Lower respiratory tract infections

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					Lower respiratory tract infections
Application de la 15è Conférence de Consensus en Thérapeutique Anti-infectieuse du 15 Mars 2006

Société de Pathologie Infectieuse de Langue Française
Avec la participation de APNET, APP, CMIT, SFM, SNFMI, SPLF, SRLF

Definitions
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In the past, it was easy…
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Community-acquired vs. hospital-acquired infections

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Now, we observe that
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Many traditional inpatient services are provided in outpatient settings  Dialysis, chemotherapy, and same-day surgery … Invasive medical therapies are now routinely administered in nursing homes and rehabilitation hospitals

Definitions
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Thus, we must distinguish
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Hospital-Acquired Pneumonia (HAP)
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Acquired > 2 days from admission

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Health-Care Associated Pneumonia (HCAP)
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Transfer from another health-care facility Long-term hemodialysis Prior hospitalization within 30 days Acquired at home
Kollef MH et al. Chest 2005;128:3854-62

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Community-Acquired Pneumonia (CAP)
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Bacterial Pathogens Associated With CAP, HCAP, HAP
50 45 40 35 30 25 20 15 10 5 0
46,7 47,1

CAP

HCAP

HAP

25,5

25,3

16,6
5,5 3,1

16,6
5,8 5,6

17,1

18,4

S.pneumoniae

Staphylococcus

H.influenzae

Pseudomonas

Kollef MH et al. Chest 2005;128:3854-62

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15ème Conférence de Consensus en Thérapeutique Anti-Infectieuse Mars 2006
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Acute bronchitis Acquired at home Pneumonia Acute Exacerbation of COPD

http://www.infectiologie.com

Questions
1. Diagnosis of an acute lower respiratory tract infection 2. Initial evaluation and management of patients 3. Initial antimicrobial therapy • CAP • AE of COPD

Acute bronchitis
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Incidence: 10 Millions episodes /year in France Etiology : viruses Diagnosis : clinical examination Investigations: unnecessary Antimicrobial treatment: none

CAP : Diagnosis
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Clinical diagnosis could be difficult
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Signs of pulmonary consolidation = high positive predictive value Respiratory rate < 30 /min., Heart rate < 100/min. et Temp. < 37.9°C = high negative predictive value Sometimes, a CT scan could be useful… C- reactive protein, hemogram, procalcitonin ???

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Chest X-ray is always necessary
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Biological investigations ???
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AE COPD: Diagnosis
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Diagnosis is difficult
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An exacerbation of COPD = progressive changes in the patient’s baseline dyspnea, cough and/or sputum

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Anthonisen’s criteria
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Impairment of dyspnea Increased volume of sputum Increased purulence of sputum

Initial evaluation and management of patients with CAP
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British Thoracic Society score: CRB 65
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Confusion Respiratory rate > 30 /min. Low Blood pressure < 90 mmHg for systolic pressure Age > 65 yrs
0 criteria = treatment at home 1 criteria or more = hospitalization

Initial evaluation and management of patients with CAP
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Fine’s score (Pneumonia Severity Index)

Fine et coll. (New. Engl. J. Med 1997 ; 336: 243-250)

Fine et coll. New. Engl. J. Med 1997 ; 336: 243-250

Fine et coll. New. Engl. J. Med 1997 ; 336: 243-250

Fine et coll. New. Engl. J. Med 1997 ; 336: 243-250

CAP at home

No Vital abnormalities Blood pressure, heart rate, respiratory rate, Sat O2 Comorbidities

No Age < 50 yrs

Yes Yes Yes
No

PSI CRB 65 I, II III, IV, V

Home

Hospitalization

Microbiological exams
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Outpatients
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No exploration Blood cultures Sputum examination and cultures Legionella urinary antigen test
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Patients admitted in ICU
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Hospitalized patients
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Blood cultures Sputum examination and cultures Pneumococcal and legionella urinary antigen tests

Outbreaks Clinical signs +++

Evaluation and management in patients with AE of COPD
Class
0 1 2 3

Spirometric data
FEV1/FVC > 70% FEV1/FVC < 70% FEV1 > 80% predicted FEV1/FVC < 70% 30% < FEV1 < 80% FEV1/FVC < 70% FEV1 < 30% predicted Respiratory Insuficiency (PaO2 < 60 mmHg)

Clinical symptoms
No dyspnea No dyspnea Dyspnea with exercise Dyspnea at rest

Evaluation and management in patients with AE of COPD
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Hospitalization required when
Impairment of previous dyspnea  Cyanosis, arrhythmias, peripheral edema  Age > 70 yrs  Social condition…
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Antimicrobial therapy in outpatients with CAP
Young patients without comorbidities

Elderly patients without comorbidities

Elderly patients with comorbidities

Amoxicillin 1g X 3 /d Pristinamycin 1g X 3 /d Telithromycin 800 mg /d

Amoxicillin clavulanate 1g X 3 /d

Failure Levofloxacin 500 mg /d Moxifloxacin 400 mg /d

Macrolides Pristinamycin 1g X 3 /d Telithromycin 800 mg /d

Antimicrobial therapy in nursinghome residents with CAP
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Amoxicillin + clavulanate Ceftriaxone 1 g IV or IM route od Levofloxacin 500 mg oral route od Moxifloxacin 400 mg oral route od

Antimicrobial therapy in inpatients with CAP
Young patients without comorbidities Elderly patients without comorbidities

Elderly patients with comorbidities

Pneumococcal CAP suspected
Yes Amoxicillin 1g X 3

Antimicrobial therapy in inpatients with CAP
No argument for pneumococcus

Young patients without comorbidities

Elderly patients without comorbidities

Elderly patients with comorbidities

Amoxicillin 1g X 3 Pristinamycin 1g X 3 Telithromycin 800 mg

Amox-clav Cefotaxime Ceftriaxone Levofloxacin, moxifloxacin Add macrolide or switch with • Pristinamycin 1g X 3 •Telithromycin 800 mg

Failure

Antimicrobial therapy in patients with severe CAP in ICU
Young patients without comorbidities Elderly patients without comorbidities Elderly patients without comorbidities

Cefotaxime + Macrolide or Levofloxacin (500 mg X 2 /d)

Cefotaxime + Levofloxacin (500 mg X 2 /d)
Piperacillin-tazobactam, cefepime, imipenem + aminoglycoside + Agent active against intracellular pathogens: Quinolone or macrolide

P.aeruginosa suspected

Antimicrobial treatment in AE of COPD
Class No dyspnea Dyspnea with exercise Indication No Antibiotic ATB if franc purulent sputum Amoxicillin, macrolide, pristinamycin, telithromycin, 2G cephalosporins (cefuroxime), 3G cephalosporin (cefpodoxime, cefotiam) Amoxicillin-clavulanate Parenteral 3G cephalosporins Respiratory quinolones Antibiotics

Dyspnea at rest

ATB in all cases

Conclusions:
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Permanent indications for amoxicillin Restricted and rational propositions for new agents such as telithromycin and respiratory quinolones No use of antimicrobial combinations, except for patients admitted in ICU


				
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