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Aetiology and treatment of community acquired pneumonia

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Aetiology and treatment of community acquired pneumonia Powered By Docstoc
					E-Communication Session                                                                                                                       Room C9c - 08:30-10:30

                                                             T UESDAY, S EPTEMBER 15 TH 2009

                                                                                        Results: The HIRA-TAN identified the causative pathogens in 93% of pneumonias
                                                                                        caused by S. pneumoniae, 93% of those by H. influenzae and 100% of those by
                                                                                        Pseudomonas spp. Together with the results for non-commensal organisms, the
                                                                                        HIRA-TAN identified the therapeutic target in 70% of the patients with pneumonia.
                                                                                        Conclusions: By the use of the HIRA-TAN, the rapid identification of the causative
                                                                                        pathogens is accelerated, which will promote targeted treatments for pneumonias.
                                                                                        (UMIN000001118.)


                                                                                        E3185
                                                                                        Fast replicating strains of streptococcus pneumoniae are associated with
                                                                                        severe community-acquired pneumonia
                                                                                        Mathias Pletz 1 , Daniel Rudolf 1 , Mark van der Linden 2 , Ludwig Hoy 3 ,
                                                                                        Tobias Welte 1 , CAPNETZ Study Group. 1 Department of Pulmonary Medicine,
                                                                                        Hannover Medical School, Hannover, Germany; 2 Nationales Referenz-Zentrum
                                                                                        Für Streptokokken, Institut für Mikrobiologie am RWTH Aachen, Aachen,
                                                                                        Germany; 3 Institute of Biometrics, Hannover Medical School, Hannover,
                                                                                        Germany

                                                                                        Background: Clinical outcome in pneumonia depends on treatment, host and
                                                                                        pathogen factors. Pathogen factors include virulence factors and replication rate.
                                                                                        To date the impact of bacterial replication rate on the clinical course of pneumo-
                                                                                        coccal pneumonia has not been analyzed.
                                                                                        Aims: We measured the replication rates of pneumococci isolated from blood or
                                                                                        sputum of adult patients with pneumonia. Strains and clinical data were collected
                                                                                        by the German surveillance study CAPNETZ.
                                                                                        Methods: Replication rate was defined as the maximal slope of the bacterial
                                                                                        growth curve. Growth curves were determined in three independent experiments
                                                                                        with three replicates each by measuring optical density at 600 nm. We analyzed the
                                                                                        replication rate of 157 strains, which were divided according to their replication
                                                                                        rate into three equally sized groups (slow, medium, fast). We compared the clinical
                                                                                        data (demographics, pneumonia severity index (PSI), outcome) of patients infected
                                                                                        by fast (n=52) and slowly replicating strains (n=52).
                                                                                        Results: Patients infected by fast replicating strains exhibited more frequently PSI
                                                                                        class IV or V (38 versus 20%, p<0.05), had more often purulent sputum (85 versus
                                                                                        71%, p<0.05), were more frequently admitted to hospital (75 vs 58%, p<0.05)
                                                                                        and experienced more frequently a switch in antibiotic treatment (39 versus 23%,
                                                                                        p<0.05) than patients infected by slowly replicating strains.
                                                                                        In contrast to slowly replicating strains, the majority of fast replicating strains
                                                                                        belonged to one of the global pneumococcal clones defined by the Pneumococcus
                                                                                        Molecular Epidemiology Network.
                                                                                        Conclusions: Bacterial replication rate has an impact on the clinical course of
                                                                                        pneumococcal pneumonia.


                                                                                        E3186
                                                                                        Mortality and bacteriology in pleural empyema
                                                                                        Jannie Nielsen 1 , Christian Niels Meyer 1 , Alice Friis-Møller 2 , Signe Rosenlund 1 .
                                                                                        1
                                                                                          Internal Medicine, Roskilde Hospital, Roskilde, Denmark; 2 Clinical
                                                                                        Microbiology, Hvidovre Hospital, Hvidovre, Denmark

                                                                                        Traditionally, pleural empyema has been considered caused mainly by pneumo-
                                                                                        cocci/other streptococci, which has influenced the choice of antibiotics. As most
                                                                                        international guidelines suggest a rather wide coverage by empirical antibiotic
                                                                                        treatment, it was our aim to evaluate the correlation of bacteriology to mortality.
                                                                                        Methods: Patients with positive culture in pleural fluids were identified in the
   294. Aetiology and treatment of community-                                           database of the department of clinical microbiology in the period 1996-2004.
                                                                                        Relevance of culture finding was evaluated retrospectively by audit of the medical
               acquired pneumonia                                                       records. Statistics: Univariate analyses.
                                                                                        Results: 113 patients with empyema. The bacteriology in the pleural fluids was
                                                                                        dominated by other streptococci (24%), s. aureus (18%), anaerobics (18%), and
                                                                                        enterobactericeae (11%). Pneumococci constituted 6%. Mixed bacteriology in
E3184                                                                                   35%. Overall 30% died.
HIRA-TAN: a real-time PCR-based diagnostic test for the pathogens of                    60% (n=68) of the empyemas were community acquired infections, 28% (n=32)
pneumonia                                                                               nosocomial, 12% unknown. Mortality was higher among the patients with nosoco-
Takashi Hirama, Shohei Minezaki, Tomohiko Mio, Minoru Kanazawa,                         mial infection (50% vs. 28%, p= 0.005). Among patients with mixed bacteriology
Koichi Hagiwara. Respiratory Medicine, Saitama Medical University, Moroyama,            the mortality was 37%, among patients with enterobactericeae 56%, s. aureus
Saitama, Japan                                                                          41%, anaerobic 11% and pneumo/streptococci 21%, which did not reach signif-
                                                                                        icant difference (p=0.08). The initial antibiotic treatment covered the bacteria in
Background: Pneumonia is one of the most frequent causes of death worldwide.            45% of the patients. Theoretically, 74% of the patients’ bacteria would be covered,
The identification of the causative pathogen allows the selection of effective antibi-   if cefuroxim and metronidazol had been administrated, as recommended of BTS.
otics and reduces the mortality rate and the emergence of drug resistant pathogens.     Conclusion: Nosocomial infection (but not aetiology) correlated to adverse
However, current clinical tests often fail to identify the causative pathogen.          outcome. Pnemonocci (6%) did not dominate, thus the bacteriology of pleu-
Methods: Commensal organisms, which are colonizing in healthy respiratory tract         ral empyema may have changed over time. The empirical treatment of pleural
and lead to pneumonia at specific situation, cause more than half of pneumonias          empyema should be revised according to BTS.
and thus detection of commensal organisms by PCR is unable to conclude that
they are causative pathogens. We developed a PCR-based test for sputum that
is able to identify the commensal organisms that are likely to be the causative         E3187
pathogens. The conditions for four commensal organisms, S. pneumoniae, H. in-           Immunolocalization of surfactant protein-a (SP-A) in the lungs of
fluenzae, M. catarrhalis and Pseudomonas spp., were determined from the results          pneumocystis pneumonia
of retrospective 223 patients. We combined this test with the PCR reactions for         Makoto Kobayashi 1 , Sachiko Hirose 1 , Takao Kitagawa 1 , Yuji Ohtsuki 2 .
                                                                                        1
non-commensal organisms, i.e. M. pneumoniae, and established the HIRA-TAN,                Department of Respiratory Medicine, Hosogi Hospital, Kochi, Kochi, Japan;
                                                                                        2
a system that allows the rapid identification of the pathogens that should be thera-       Division of Pathology, Matsuyama Shimin Hospital, Matsuyama, Ehime, Japan
peutically targeted. The system was validated by a prospective study that enrolled
174 patients.                                                                           Background: Pneumocystis pneumonia (PCP) is caused by Pneumocystis jiroveci


                                                                                    552s
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E-Communication Session                                                                                                                       Room C9c - 08:30-10:30

                                                              T UESDAY, S EPTEMBER 15 TH 2009

(PJ) in immuno-compromised hosts. PCP is pathologically characterized by the             but significantly correlated with RPI (r = 0.476, p = 0.006). However, RPI was not
presence of abundant foamy eosinophilic material in the alveolar space by H-E            significantly correlated with blood leucocyte count and ESR (r = 0,011, p = 0,952
stain. PJ cysts are demonstrated by Grocott stain. Recently, SP-A is elucidated to       ve r = 0,102, p = 0,580, respectively). Although both ESR and hsCRP can detect
play an important role in the host defense against microorganisms.                       infection only hsCRP was correlated with the extent of parenchymal infiltration.
Objectives: We attempted to investigate the distribution of SP-A in the alveolar         So, as a parameter sCRP can be used to evaluate the severity of CPP but larger
space of the lung of PCP and its interaction with PJ cysts.                              series are needed to confirm this finding.
Methods: Seven autopsy lung specimens from patients with confirmed PCP
were examined. The localization of SP-A was investigated by immunohistochem-
istry using anti-SP-A or anti-Krebs von Lungen-6 (KL -6) monoclonal antibody.            E3190
Concomitant in situ hybridization using digoxigenin-labeled PCR probe for Pneu-          Long term survival and risk factors for gram-negative bacillary aetiology in
mocystis 5S ribosomal RNA was carried out on some of the tissues.                        patients with community-acquired pneumonia
Results: SP-A was localized not only in the alveolar epithelia but also in foamy         Henning Kothe 1 , Annette Wulff 1 , Petra Heyer 1 , Jan Rupp 2 , Peter Zabel 1 ,
materials of the alveolar space. The staining pattern in the latter was classified into   Klaus Dalhoff 1 . 1 Department of Medicine III, University of Lübeck, Lübeck, SH,
3 types. Circumferential linear pattern (3/7), circumferential linear and internal       Germany; 2 Institute of Medical Microbiology and Hygiene, University of Lübeck,
granular pattern (2/7), and internal reticular pattern (2/7) were observed.              Lübeck, SH, Germany
Discussion: Three staining patterns for SP-A were observed in the alveolar space
in patients with PCP. It seemed that the extent of the occupation by PJ cysts in the     Background: Several guidelines have advocated targeted initial antibiotic treat-
eosinophilic foamy material is related to the distribution of PJ cysts. Moreover,        ment in CAP patients with specific risk factors for gram-negative aetiology.
some of the alveoli surrounding the heavy infected alveoli were occupied by SP-A         However evidence to support this recommendation is scarce.
positive granules but free of PJ cysts. It is suggested that SP-A is at least in part    Objectives: To identify specific risk factors and clinical outcome of CAP caused
released into alveolar space as the results of inflammation due to PCP.                   by gram-negative bacilli including Pseudomonas aeruginosa (GNB), we compared
                                                                                         the clinical features, short and long term outcome of patients with CAP due to
                                                                                         GNB with those of patients with non-GNB pneumonia.
E3188                                                                                    Methods: 116 patients with CAP requiring hospitalization and availability of
Usefulness of alveoloscopy in the diagnosis PF Pneumocystis jiroveci                     respiratory samples were included. Clinical history and residence status were
pneumonia in HIV+ patients                                                               documented. Microbiologic investigations included cultures and C pneumoniae
Ana Kersul 1 , Jaume Sauleda 1,2 , Borja G. Cosio 1,2 , Luc Thiberville 3 ,              PCR detection from respiratory samples, blood cultures, virus serology and L.
Melchor Riera 4 , Cristina Gómez 5 , Alvar Agusti 6,2,7 . 1 Department of Respiratory    pneumophila urine antigen test and an aspiration index was calculated from BAL
Medicine, Hospital Son Dureta, Palma de Mallorca, Spain; 2 Respiratory                   slides. Host derived factors associated with GNB infections and mortality were
Diseases, CIBER, Palma de Mallorca, Spain; 3 Department of Respiratory                   included in multivariate analysis.
Medicine, Rouen Universitary Hospital, Rouen, France; 4 Department of internal           Results: In 58 cases potential pathogenic microorganisms were detected. Longterm
Medicine, Hospital Son Dureta, Palma de Mallorca, Spain; 5 Department of                 mortality was independently associated with the PSI-score, chronic heart failure
Pathology, Hospital Son Dureta, Palma de Mallorca, Spain; 6 Institut del Tórax,          and presence of GNB infections. Elderly patients showed a higher incidence of
Hospital Clínic i Provincial, Barcelona, Spain; 7 Epidemiology and Clinical              infections with GNB (14% v.s. 5%, p< 0.05). Furthermore, elderly patients with
Research, Fundación Caubet- Cimera, Bunyola, Spain                                       GNB infection had a lower probability of survival during follow up over 3 years
                                                                                         compared with other aetiologies (OR 7.0, p< 0.005). Advanced age was associated
Introduction: Pneumocystis jiroveci pneumonia (PJP) is a frequent and severe             with a higher aspiration index (p< 0.01).
respiratory complication in HIV+ patients. It is characterised by the presence of        Conclusion: Our data suggest that an initial empirical antimicrobial coverage of
intra-alveolar exudates at microscopical examination. Fibered confocal fluoresces-        GNB including P. aeruginosa should be seriously considered in elderly patients.
cence microscopy (FCMF) during bronchoscopy enables to explore the alveoli
in-vivo (alveoloscopy).
Hypothesis: Alveoloscopy is useful in the immediate diagnosis of PJP in HIV+             E3191
patients.                                                                                16S ribosomal RNA gene sequencing analysis of microbial flora in
Aim: to evaluate the sensitivity, specificity, positive and negative predictive values    bronchoalveolar lavage fluids in intubated patients with pneumonia
of alveoloscopy in the diagnosis of PJP in HIV+ patients.                                Toshinori Kawanami 1 , Kazuhiro Yatera 1 , Kazumasa Fukuda 2 , Chiharu Yoshii 1 ,
Method: Patients with acute respiratory infection and radiological infiltrates un-        Hatsumi Taniguchi 2 , Masamitsu Kido 1 . 1 Department of Respiratory Disease,
derwent fibrebronchoscopy with bronchoalveolar lavage and alveoloscopy with               University of Occupational and Environmental Health, Japan, Kitakyushu City,
analysis of at least 4 segments in the area of maximal radiological impairment.          Japan; 2 Department of Microbiology, University of Occupational and
Diagnosis of PJP by alveoloscopy was based on the presence of alveolar exudates.         Environmental Health, Japan, Kitakyushu City, Japan
Respiratory samples were processed for bacteria, fungi, virus and pneumocystis
jiroveci.                                                                                Objectives. Approximately 50% cases of severe pneumonia have been reported to
Results: Eleven HIV+ patients (44±10 yrs, X±SD) were analysed. Microbiologi-             be intractable or cryptogenic. In order to evaluate causative bacteria in severe pneu-
cal cultures were positive for: M. tuberculosis (n=4), E. coli (n=2), Cytomegalovirus    monia, we analyzed microbial flora of BALFs from intubated patients using 16S
(n=2), S. pneumoniae (n=1) and Pneumocystis jiroveci (n=2). We obtained one              ribosomal RNA (rRNA) gene sequencing method, and compared this molecular
false positive and none false negatives. The sensitivity was 100%, specifictiy 89%,       information with the results from ordinary culture method.
positive predictive and negative values 66% and 100%, respectively.                      Materials and Methods. Twenty BALFs were analyzed by both conventional
Conclusions: Our preliminary data suggest that alveoloscopy might be useful in           culture and culture-independent methods, which were as follows. Approximately
the immediate diagnosis of PJP.                                                          600bp of 16S rRNA gene was amplified by PCR using universal primers and clone
Supported in part by: Grant 2008 Unidad de Investigacion, Hospital Son Dureta            library was constructed. Nucleotide sequences of randomly chosen approximately
and Funds for research from Conselleria Economia 2008-2009, Balearic Gover-              90 clones for each specimen were determined and the homology with in-house
ment.                                                                                    data base was searched.
                                                                                         Results. This molecular analysis detected causative bacteria in all the 20 cases, and
                                                                                         culture method identified 13 cases. Only 8 cases showed consistent results, and 12
E3189                                                                                    cases were inconsistent. Of 12 inconsistent cases, 3 cases contained predominant
The relation between blood leucocyte count, erythrocyte sedimentation rate,              bacteria differed from those of culture method and 2 cases showed additional
high sensitive C-reactive protein and pulmonary parenchymal infiltration in               agents to culture method. In 7 inconsistent cases, molecular method revealed
young male patients with Chlamydia pneumoniae pneumonia                                  Prevotella spp. (2 cases),Staphylococcus sp., Streptococcus sp.,Haemophillus sp.,
Dilaver Tas 1 , Erdogan Kunter 1 , Haldun Sevketbeyoglu 2 , Ahmet Fakih Aydin 3 ,        Legionella sp., and unknown bacterium, whereas culture method could detect no
Oguzhan Okutan 1 , Zafer Kartaloglu 1 . 1 Department of Chest Diseases, GATA             bacteria.
Haydarpasa Training Hospital, Istanbul, Turkey; 2 Department of Chest Diseases,          Conclusion: In 60% BALFs (12/20) from severe pneumonia patients, microbial
Van Asker Hastanesi, Van, Turkey; 3 Department of Infectious Diseases, Izmir             flora analyzed using 16S rRNA gene sequencing-clone library method indicated
Asker Hastanesi, Izmir, Turkey                                                           causative bacteria which could not be detected by culture method. This molecular
                                                                                         method provides us useful etiological information for diagnosis and treatment of
We aimed to describe the levels of leucocyte count, erythrocyte sedimentation            pneumonia.
rate (ESR) and high sensitive C-Reactive Protein (hsCRP), and to investigate the
relation of these biomarkers with the ratio of parenchymal infiltration (RPI) in
patients with Chlamydia pneumoniae pneumonia (CPP).                                      E3192
We looked for the blood leucocyte counts, ESR and hsCRP levels. The parenchymal          Nocardia community-acquired pneumonia in immunocompetent and
infiltration ratio, given as percent, was calculated from the high resolution com-        immunocompromised host
puterized tomography (HRCT) images using the following formula. Pulmonary                Elisa Mincholé 1 , Ana Betran 2 , Elisabeth Vera 1 , Cruz Villuendas 2 , María
infiltration ratio = number of images showing infiltration in HRCT × 100/number            José Revillo 2 , Salvador Bello 1 . 1 Respiratory Medicine Service, Miguel Servet
of all images × 2. The relation of the extent of the infiltrated lung parenchyma,         Universitary Hospital, Zaragoza, Spain; 2 Microbiology Service, Miguel Servet
shown by HRCT, with the leucocyte count, ESR and sCRP was investigated.                  Universitary Hospital, Zaragoza, Spain
Increments of blood leucocyte counts in 14 (43.7%), ESR in 27 (84.3%) and
hsCRP in 26 (81.2%) patients were observed. High sensitive CRP was moderately            Nocardia spp is considered a respiratory pathogen mainly in individuals with im-


                                                                                     553s
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                                                             T UESDAY, S EPTEMBER 15 TH 2009

munity alterations and/or undergoing prolonged oral corticoid therapy. We studied        adjusted for age, gender, presence of comorbidities, pneumococcal vaccination
the relevance of Nocardia spp in community-acquired pneumonia (CAP), either              status, living conditions and smoking habits.
in immunocompetent and immunocompromised population. Between 1998 and                    Results: In the season cohort (2368 patients) CAP in vaccinated patients was
2006, every quality sputum samples from patients with CAP were systematically            significantly less severe in almost all analyzed parameters (adjusted OR for CURB
cultured in BCYE medium and incubated for 10 days. Retrospectively, we an-               [≥ 1] 0.763; for procalcitonin [≥2.0 ng/ml] 0.530, for procalcitonin [≥ 0.5] 0.709
alyzed which patients were either immunocompetent and immunocompromised,                 and these patients showed a significantly better overall survival within the 6 months
and the comorbilities or potential risk factors that could be present. We found          follow-up period (adjusted HR 0.630). This beneficial effect of vaccination was
51 patients with Nocardia spp CAP. 15 were immunocompromised (4 AIDS, 4                  more pronounced in patients aged ≥ 60 years. Within the off-season cohort (2632
solid active neoplasms, 5 haematologic active neoplasms, 1 autoimmune disease            patients) there was no significant influence of influenza vaccination status on CAP
with immunosuppresive therapy, and 1 organ solid transplantation), and 36 were           severity or disease outcome.
immunocompetents. The only significant risk factor was the presence of COPD               Conclusion: Prior influenza vaccination is associated with less severe clinical
(p=0.029) with a relative risk (RR) of 4.86 (1.28-18.4). We didn’t find any differ-       course and improved overall survival in patients with CAP during influenza
ence in the rest of parameters. There was an important higher prevalence of lobar        seasons.
or multilobar affectation.

                       Immunocompetent          Immunocompromised           p (Fisher)   E3195
                                                                                         Assessment of antibiotic prescribing practises for hospitalised patients with
Age                        70.6±14.6                 63.2±18.5                 0.18      suspected sepsis using a score of “likelihood of infection”
Oral corticoids               6/36                      3/15                   0.69      Murugapathy Veerasamy, Lucy Aldridge, George Antunes, Stephen Murphy.
COPD                         23/36                      4/15                  0.029
                                                                                         Respiratory Medicine, James Cook University Hospital, Middlesbrough, United
Diabetes Mellitus             6/36                      2/15                   0.99
                                                                                         Kingdom

Most of our cases of Nocardia CAP were diagnosed in immunocompetent patients,            Background: Previous studies suggest up to 50% of antibiotic prescriptions for
and COPD was an important risk factor. It is likely that Nocardia CAP is much            inpatients are inappropriate. Suboptimal prescribing includes: inadequate recog-
more frequent than it is usually suspected in immunocompetent hosts, and a               nition of sepsis, unnecessary use of IV route and protracted treatment duration.
systematic Nocardia culture could be suitable in every quality sputum sample form        The purpose of this study was to evaluate an audit tool for monitoring antibiotic
CAP hospitalized patient.                                                                prescribing.
                                                                                         Methods: Audit tool included 5 point “likelihood of infection score” (LIS) based
                                                                                         on clinical, radiological and bacteriological evidence. LIS: 0 nil, 1 very unlikely, 2
E3193                                                                                    unlikely, 3 likely, 4 definite. Antibiotics (AB) were appropriate if LIS ≥ 3. Choice
Inhaled corticosteroid therapy and risk of hospitalization with pneumonia:               of route (IVAB/PO), treatment duration, length of stay and adverse events were
a population-based case-control study from Denmark                                       assessed.
Reimar W. Thomsen, Anders Riis, Claire Andrejak, Jette B. Kornum,                        Results: 50 inpatients were given AB for: AECOPD 34%, pneumonia (PN) 18%,
Steffen Christensen, Mette Nørgaard. Department of Clinical Epidemiology,                UTI 18%, LRTI 12%, bronchiectasis 12%, other 6%. AB were appropriate in
Aarhus University and Aalborg Hospital, Aalborg, Denmark                                 38.9% (PN 74% v: AECOPD 15% OR 15.4 p< 0.005, LRTI 33% OR 5.5 p<0.05,
                                                                                         UTI 36% OR 7.7 p<0.01). IVAB were given unnecessarily in 10/17 cases. Use
Background: Randomized trials have reported that inhaled corticosteroid (ICS)            of IVAB and duration of treatment varied between physicians (% IVAB: 33%
therapy may be a risk factor for pneumonia. Data from clinical practice are              v 77.7% OR 10.5 p<0.03; mean duration (SD) days: 3.9 (3.4) v 7.44 (2.65)
sparse.                                                                                  p<0.02). AB related adverse events (18% of patients) were associated with longer
Objective: To examine if ICS use is associated with an elevated risk of hospitalized     hospitalisation (mean (SD) days: 17 (10.5) v 7.46 (5.8) p< 0.001).
pneumonia in a population-based case-control study in Northern Denmark.                  Conclusion: 1. Antibiotics are frequently prescribed for inpatients, particularly
Methods: We identified 34,239 patients with a first-time pneumonia hospitalization         with AECOPD, with little evidence of infection and IVAB are often used unnec-
and 342,390 sex- and age-matched population controls between 1997 and 2005,              essarily.
using health care databases. We used conditional logistic regression to compute          2. Antibiotic related adverse effects are associated with longer hospitalisation.
relative risk (odds ratio, OR) for pneumonia among persons with and without ICS          3. A simple score of likelihood of infection is a useful tool in auditing antibiotic
use within 365 days, controlling for comorbidities and stratifying by ICS type,          prescribing practise for hospitalised patients with suspected sepsis.
dose and duration.
Results: The adjusted OR for pneumonia-related hospitalization among persons
with ICS therapy was 2.4 (95% CI 2.3-2.5) compared with non-users of ICS.                E3197
Fluticason was associated with higher pneumonia risk (adj. OR 2.5; 95% CI                Switching of antimicrobial agents in the therapy of community acquired
2.3-2.6) than Budenosid (adj. OR 2.0; 95% CI 1.9-2.1) and Beclometason (adj. OR          pneumonia
2.0; 95% CI 1.7-2.3). Subgroup analyses showed an increased risk of pneumonia            Takao Shimizu 1 , Tomoyoshi Nagira 1 , Kohei Ueda 1 , Tomohiro Hirata 1 ,
in the following groups: Users of ICS in combination with beta-agonists (adj. OR         Kanzo Kijima 2 , Takashi Shimbo 1 , Ken Sano 3 . 1 Department of Medicine,
2.7; 95% CI 2.5-2.9), users who started ICS therapy within 6 months of admission         Matsubara Tokusyukai Hospital, Atsubara, Osaka, Japan; 2 Department of
(adj. OR 3.1; 95% CI 2.8-3.5), and users of the highest ICS dose: adj. OR 2.8            Nutrition, Matsubara Tokusyukai Hospital, Matsubara, Osaka, Japan;
(95% CI 2.5-3.0) for daily dose of >1000 mg as compared to adj. OR 1.9 (95%              3
                                                                                           Department of Surgery, Matsubara Tokusyukai Hospital, Matsubara, Osaka,
CI 1.8-2.0) for ICS dose <400 mg.                                                        Japan
Conclusions: ICS therapy is a risk factor for hospitalized pneumonia consis-
tent with results from randomized trials. However, confounding by underlying             Background: Intravenous administration of antimicrobial agents is recommended
COPD/asthma severity may have impact on our risk estimates.                              to be switched to oral administration after a few days in the patients with com-
                                                                                         munity acquired pneumonia (CAP). However, the switching of the agents is not
                                                                                         necessarily successful. In this preliminary study, which factor is important in the
E3194                                                                                    switching of antimicrobial agents in CAP was investigated.
Impact of influenza vaccination in patients with CAP                                      Subjects and methods: Thirty six patients with CAP admitted in our department
Antje Tessmer 1 , Tobias Welte 2 , Ruprecht Schmidt-Ott 3 , Sonja Eberle 3 ,             from April 1 to September 30, 2008 were subjected. They were diagnosed CAP by
Norbert Suttorp 1 , Reinhard Marre 4 , Tom Schaberg 5 . 1 Dept. of Infectious Disease    clinical symptoms, radiographic examinations and laboratory data. The treatment
and Respiratory Medicine, Charité-University Medicine, Berlin, Germany; 2 Dept.          was started with intravenous administration of antimicrobial agents. In three or
of Pulmonary Medicine, Medical University Hannover, Hannover, Germany;                   four days after intravenous administration of the drugs, the laboratory analysis was
3
  Medical Department GlaxoSmithKline, GlaxoSmithKline, Munich, Germany;                  performed again to assess the efficacy of the agents. When the white blood cell
4
  Dept. of Medical Microbiology & Hygiene, University of Ulm, Ulm, Germany;              count (WBC) was reduced and clinical symptoms were ameliorated, it was judged
5
  Dept. of Pulmonary Medicine, Diakonie Hospital Rotenburg, Rotenburg,                   that the intravenous administration of the agents was effective. Then, antimicrobial
Germany                                                                                  agents were switched to oral administration of antimicrobial agents.
                                                                                         Results: In seventeen cases, switching was successful (Group A) and in another
Background: Pneumonia is an important cause of influenza-associated morbidity             nineteen cases, it was not successful (Group B). The mean ages were 75±15
and mortality. Influenza vaccination has been shown to reduce morbidity and               in Group A and 72±16 in Group B, the laboratory data on admission of WBC
mortality during influenza seasons.                                                       were 11982±4436 and 13000±7553, C-reactive protein (CRP) 7.46±7.35 and
Aims and objectives: Protection from severe pneumonia may contribute to the              15.33±11.44 (p=0.010328), hemoglobin 13.14±1.31 and 12.11±2.15 and albu-
beneficial effect of influenza vaccination. We therefore evaluated the impact of           min 4.00±0.42 and 3.16±0.76 (p=0.000159), respectively.
prior influenza vaccination on disease severity, outcome and health economic              Conclusion: It appears that albumin on admission was an important factor for the
parameters in patients with CAP.                                                         switching of antimicrobial agents. The strategy in the therapy of CAP in the aged
Methods: Analyses from an observational study initiated by CAPNETZ were                  should be focused on the nutritional aspects.
performed. Between 2002 and 2006 all consecutive patients with CAP aged ≥ 18
years were enrolled and analysed separately as a Season (December to April) and
off-Season (Mai to November) cohort. Association between vaccination status and
severity of CAP, mortality and health economic parameters were evaluated and


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                                                                 T UESDAY, S EPTEMBER 15 TH 2009

E3198                                                                                    a developing country where antibiotics can be purchased over the counter without
Antimicrobial-resistance in streptococcus pneumoniae isolates causing                    doctor’s prescription.We feel that if antibiotics are not prescribed by doctors it
pneumonia in Spanish people over 50 years                                                may lead to inappropriate usage of antibiotics leading to resistant pathogens.
Imma Hospital-Guardiola, Angel Vila-Corcoles, Mar Juarez-Laiz,                           Methods: We reviewed, patients admitted to chest ICU, HDU and ward with a
Izaskun Guinea-Oruechevarria, Olga Ochoa-gondar, EPIVAC Study Group. servei              diagnosis of hospital acquired pneumonia.Microbiology results of sputum, blood
d’atencio Primaria Tarragona-valls, institut catala de la salut, Tarragona, Spain        cultures and tracheal aspirates.Clinical improvement in these patients were re-
                                                                                         viewed by looking at clinical and radiological improvements and change in
Background: Pneumococcus is a major cause of morbidity and mortality world-              leukocyte counts.
wide. Updated data on drug-resistance from different populations may be important        Results: Of 57 patients, 48 noted suitable, The mortality rate was 6%. 21 had
to recognize changes in disease patterns. This study assessed current levels of peni-    Hospital Acquired Pneumonia.17 microbiological investigations were done, of
cillin resistance among Streptococcus pneumoniae causing pneumonia in Spanish            which 13 were positive.
patients over 50 years.                                                                  Total (n=21): no growth seen 4, Acenitobacter = 7, S.pneumonia = 2 , Mix Flora
Methods: Antimicrobial susceptibility was tested for 104 consecutive isolates of         = 2, Moraxella = 1 , Klebsiella = 1
Streptococcus pneumoniae recovered from patients >=50 yrs with x-ray proved              Among these 21 patients the response to Antibiotics was as follows:
pneumonia in Tarragona (Spain) between 2002-2007. According to the minimum               Response to 1st line antibiotics 28% , 2nd line 24% ,3rd line 24% ,4th line 24%
inhibitory concentration (MIC) of tested antimicrobials (penicillin, erythromycin,       Inference: Concluding that the organisms causing pneumonia in our setup have
cefotaxime and levofloxacin), strains were classified as susceptible or resistant          marked resistance against antibiotics used,requiring change of strategy in pre-
according to classical breakpoints. In addition, according to new break point            scribing antibiotics i.e not without physician consultation.Other factors could be
criteria for intravenous penicillin, the cases were also re-classified as susceptible,    involved i.e hygienic conditions or lack of standardization of antibiotics.This
intermediate or resistant to penicillin when MIC was <= 2, 4, and >= 8 μg/ML,            emerging problem in the developing countries has to be looked now or we will
respectively.                                                                            end up with multiple drug resistant pathogens with no antibiotics treating them
Results: Given classical break points, 27 (25.9%) were penicillin-resistant strains      successfully.
(19 strains with intermediate resistance and 8 strains with high resistance). Con-
sidering the new pneumonia breakpoints, 100 (96.2%) of the 104 cases in our
study would be penicillin-susceptible, 4 (3.8%) would be penicillin intermediate-        E3201
resistant, and none would be high resistance. Of the 27 initially penicillin-resistant   A clinical and aetiological evaluation of community acquired pneumonia-are
strains, 10 (37%) were resistant to erythromycin, 8 (29.6%) to cefotaxime, 2             we following guidelines in prescribing antibiotics?
(7.4%) to levofloxacin, and 4 (14.8%) were identified as multidrug resistant.              Nizar A. Naji 1 , Haithem Muhammed 1 , Brian McCullagh 2 , Rita Obaze 1 ,
Conclusions: Given new pneumonia breakpoint for susceptibility, percentages of           Paul O’Brien 1 . 1 Dept of Medicine, Naas General Hospital, Naas, Co.Kildare,
strains resistant to penicillin have greately decreased.                                 Ireland; 2 Dept of Respiratory Medicine, The Mater Misericordiae Hospital,
                                                                                         Dublin, Ireland

E3199                                                                                    Background: British thoracic society (BTS) guidelines recommond using CURB
Frequency of antibiotic resistance and outcomes in severe community                      65 score to assess severity and treatment of Community Acquired Pneumonia
acquired pneumonia due to Streptococcus pneumoniae                                       (CAP). Intravenous antibiotics should not be given when CURB 65 score <3.
Pallavi Mandal, James Chalmers, Adam Hill. Respiratory Medicine, Royal                   Inappropriate antibiotics is costy and lead to various complications.
Infirmary Edinburgh, Edinburgh, United Kingdom                                            Method: Data obtained from our medical record and included all patients with
                                                                                         CAP admitted during 2008.
Introduction: Streptococcus pneumoniae is the most common cause of                       Results: We reviewed 120 patients. Male/female (N=60/60) 50% each, median
community-acquired pneumonia (CAP). Clinical significance of in vitro resis-              age 76 (40,92) yrs, Smokers (45.8%), Ex smokers (48.3%) Non smokers (5%).
tance to penicillins and macrolides merits further study. Aim of our study was           Consolidation in CXR= 75 (62.5%). Left lower lobe, RLL then RML were the
to assess frequency and outcomes of antibiotic resistance in severe CAP due to           commonost sites (61%). Only 16.6% had Bilobar pneumonia.
Streptococcus pneumoniae.                                                                Sputum C/S sent for 76 (63.3%), No growth in 78(65%), MRSA in 14 (12%)
Methods: We prospectively collected data on 48 patients admitted with severe             followed by Candida (9.2%), E coli and H influenza 6% and the rest had others.
CAP (CURB65 ≥ 3) with pneumococcal bacteraemia (between March 2005 and                   CURB 65 score retrospectively calculated as none of the patients had this recorded.
May 2007). Pneumococcal isolates were serotyped, minimum inhibitory concen-              CURB score 1 (40%), score 2 (35.8%), score 0 (15.8%),score 3 (5.8%) and score
tration (MIC) to Penicillin and Macrolide were tested. The main outcomes were            4 (2.5%).
30-day mortality, requirement for mechanical ventilation and/or inotropic support        (Augmentin and klacid) used in 32%, (Augmentin)only 18.3%,(Tazocin) 13.3%
(MV/IS) and development of empyema or lung abscess.                                      then (Ciproxin and Rocephin) 8.3% each. The majority had IV antibiotics 96(80%)
Results: 22 males,median age 62.Penicillin isolates were sensitive to penicillin         versus 23(20%) despite the fact that only 8.3% had CURB score=>3.
(MIC<2mg/L) in 47 cases (97.9%) and resistant (MIC ≥8mg/L) in 1 (2.1%). Peni-            Length of stay (LOS) for 115 patients was 10(±17.5)days, 5 died from septicaemia
cillin isolates were sensitive to macrolides (MIC≤0.25mg/L) in 43 cases (89.6%)          and 66(55%) readmitted within 6 months.
and resistant (MIC≥1mg/L) in 5(10.4%). Outcomes are shown in table 1.                    CURB score was significantly associated with the LOS (p value <0.001)
                                                                                         Conclusion: Despite the BTS and local guidelines, IV antibiotics are still being
Table1                                                                                   used inappropriately which may contribute to morbidity and mortality.Severity and
                                        Number   Lung Abscess/     MV/IS   30 day MR     length of stay are closely associated with CURB 65 score and this should be used
                                                 Empyema (%)        (%)        (%)       in the assessment of patients with CAP.
No Penicillin or Macrolide Resistance     43        13.9%          25.5%      11.6%
Penicillin Resistance                     1           0            100%         0
                                                                                         E3202
Macrolide Resistance                      5          20%            40%        40%
                                                                                         Antimicrobial activity of various antibiotics against pathogens of ventilator
Penicillin and Macrolide Resistance       1           0            100%         0
                                                                                         associated pneumonia in a tertiary care hospital of Pakistan
                                                                                         Tayyaba Ijaz, Sadia Ijaz, Muhammad K. Shahzad. Microbiology Diagnostoc and
38.1% of the isolated serotypes were covered by the 7-valent currently available         Research Lab, Mayo Hospital, Lahore, Pakistan; Medical Sciences, Services
pneumococcal vaccination (19F, 14, 6B, 23F, 9V, 18C and 4).6 had no serotype             Institute of medical Sciences, Lahore, Pakistan; Pathology Department,
specified.                                                                                University of veterinary and Animal Sciences, Lahore, Pakistan
Conclusion: In our cohort study to date, the prevalence of pneumococcal resistance
is low. A larger cohort is needed to determine whether in vitro resistance impacts       Background: The of antibiotic therapy is marked with continuous developments
on outcom.                                                                               of new antimicrobial agents. These drugs are highly effective against a variety of
                                                                                         bacteria and are known as Broad Spectrum and life saving drugs. On the basis of
                                                                                         survival, the bacteria has also developed an inverse response, and evolved into the
E3200                                                                                    multi drug resistant strains.
Pattern of antibiotic resistance in hospital acquired pneumonia in a country             Aims and objectives: A prospective antimicrobial susceptibility testing study of
where antibiotics are available over the counter without doctors prescription            pathogens from ventilator associated pneumonia was performed to evaluate the
Aneel Roy Bhagwani 3 , Syed Arshad Husain 1 , Fatima Noman 2 , Ali Nadeem 2 ,            efficacy of antibiotics using disc diffusion method in a large tertiary care hospital
Sheeba Mahjabeen 1 , Sana Sehar 4 , Hafsa Haroon 4 . 1 Respiratory Medicine,             of Lahore, Pakistan.
Liaquat National Hospital for Post Graduate Medical Studies and Health                   Materials and methods: During a period of year 2008,a total of 988 different
Sciences, Karachi, Sindh, Pakistan; 2 Microbiology, Liaquat National Hospital for        nosocomial pathogens from ventilator associated pneumonia were processed for
Post Graduate Medical Studies and Health Sciences, Karachi, Sindh, Pakistan;             antibiogram assay.
3
  Medical College, Liaquat National Hospital for Post Graduate Medical Studies           Results: All of the isolates including Staphylococci, Streptococci, Enterococci,
and Health Sciences, Karachi, Sindh, Pakistan; 4 Medical College, Dow                    Pseudomonas, Enterobacter, Klebsiella, Proteus, Escherichia, Serratia and of
University of Health Sciences, Karachi, Sindh, Pakistan                                  Haemophilus, presented variable resistance (10-80%) against the tested antibi-
                                                                                         otics. Most of the isolates were found resistant (>30%) to,Augmentin,Cefotoxime,
Noticing increasing amount of resistance against the antibiotics in hospital ac-         Cefoparazone,Ceftriaxone, Ciprofloxacin and Doxycylin.The maximum antimi-
quired pneumonias in our set up.Study was conducted in a tertiary care centre in         crobial activity was observed for Avelox, Sparaxin, Klaricid, Fucidin, Tienam,


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Linezolid, Vancomycin, and Tazocin.The sensitivity pattern of Tigecycline were
found superior as compared to others.The antimicrobial susceptibility patterns of
different isolates varied widely against tested antibiotics (P<0.005).
Conclusion: The result of this study would be helpful for managing antibiotic
resistance in hospitals and policy formulation.


E3203
Management of community acquired pneumonia audit
Wadih Habeichi, Rory Grierson, Samantha Devenny, Keiumars Maleki. Medicine,
Furness General Hospital, Barrow In Furness, Cumbria, United Kingdom

Introduction: The University Hospital of Morecambe Bay Hospitals NHS Trust
guidelines states that the treatment of community acquired pneumonia [CAP]
should be based on its severity which can be calculated depending on the CURB
socre.
CURB scores between 0 and 2 indicates a non severe CAP that can be treated
orally with Amoxicillin and Erythromycin
CURB score of 3 or more indicates a severe CAP that should be treated with
intravenous [IV] Co-amoxiclav and Clarythromycin.
Aims and objectives: To find out if the management of CAP is in line with the
guidelines; whether CURB score is being documented in the notes and whether
the documented score similar to the audited one.
Methodology: This is a retrospective study done on 50 patients.
Results: 16 out of the 50 patients were excluded.
26 patients had their audited CURB score in the range 0-2: 16 of them were given
IV antibiotics and six were given oral Doxycycline
7 patients had CURB score of 3 or more. 4 of them were given IV Antibiotics.
Five of these seven patients were admitted to general wards.
In one case CURB score could not be calculated due to lack in documentation.
CURB score was documented in patients notes in five cases only in all of which it
was similar to the audited score.
Conclusions: CURB score is being poorly documented in notes. Management of
CAP is, generally, not in line with the trust guidelines:
62% of patients with CURB score between 0-2 were treated with IVantibiotics.
29% of patients with CURB score of 3 or more were treated with oral antibiotics
Recommendations: As a result the audit, recommended improving documenta-
tions and having check lists for CURB score in MAU. It is also recommended to
repeat the audit in six months to check for the implantation of the recommendations.




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Description: Aetiology and treatment of community acquired pneumonia