#1005 Hospital & Community Acquired Pneumonias

October 19 to October 22

Stephen Hoffmann, MDClinical Instructor of Internal MedicineDivision of Pulmonary & Critical Care MedicineThe Ohio State University Medical Center

William Maher, MDAssociate Professor of Clinical Internal MedicineDivision of Infectious DiseasesThe Ohio State University Medical Center

William Maher, MDAssociate Professor of Clinical Internal Medicine

Division of Infectious DiseasesThe Ohio State University Medical Center 1

Profile Profile

Chuck• Healthy 46 year old physician• Well until he developed a flu-like illness prior to a business trip• Felt better with non-specific treatments• Returned home, then developed a productive cough and high fevers, coughed up phlegm and parts of lungs• Ultimately hospitalizedDiagnosis: Bacterial Pneumonia due to Staphylococcus Aureus

Chuck• Healthy 46 year old physician• Well until he developed a flu-like illness prior to a business trip• Felt better with non-specific treatments• Returned home, then developed a productive cough and high fevers, coughed up phlegm and parts of lungs• Ultimately hospitalizedDiagnosis: Bacterial Pneumonia due to Staphylococcus Aureus

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PathogensTypical Pneumonia

PathogensTypical Pneumonia

• Streptococcus pneumoniae• Haemophilus influenzae• Moraxella catarrhalis

• Legionellae

• Staph. aureus• Aerobic gram-negative bacilli

• Streptococcus pneumoniae• Haemophilus influenzae• Moraxella catarrhalis

• Legionellae

• Staph. aureus• Aerobic gram-negative bacilli

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PathogensAtypical Pneumonia

PathogensAtypical Pneumonia

• Mycoplasma pneumoniae• Chlamydia pneumoniae• Influenza, adenovirus, RSV• Q-fever• Chlamydia psittaci• TB, Endemic Fungi• Pneumocystis carinii

• Mycoplasma pneumoniae• Chlamydia pneumoniae• Influenza, adenovirus, RSV• Q-fever• Chlamydia psittaci• TB, Endemic Fungi• Pneumocystis carinii

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PneumoniaTherapeutic Categories

PneumoniaTherapeutic Categories

• Age < 60 years; no comorbidity

• Age > 60 years; or with comorbidity

• Requires hospitalization

• Severe pneumonia

• Age < 60 years; no comorbidity

• Age > 60 years; or with comorbidity

• Requires hospitalization

• Severe pneumonia

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Age < 60 Years;No ComorbidityAge < 60 Years;No Comorbidity

• Streptococcus pneumoniae

• Mycoplasma pneumoniae

• Chlamydia pneumoniae

• Respiratory viruses

• Streptococcus pneumoniae

• Mycoplasma pneumoniae

• Chlamydia pneumoniae

• Respiratory viruses

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Age > 60 Years;Or With Comorbidity

Age > 60 Years;Or With Comorbidity

• Streptococcus pneumoniae

• Respiratory viruses

• -lactamase produces (H. flu etc.)

• S. aureus

• Streptococcus pneumoniae

• Respiratory viruses

• -lactamase produces (H. flu etc.)

• S. aureus9

Community AcquiredRequiring AdmissionCommunity AcquiredRequiring Admission

• Streptococcus pneumoniae• Haemophilus influenzae • Aspiration / polymicrobic• Legionellae• S. aureus (post influenza)• Gram-negative bacilli• ECF: as per comorbidity, except influenza, TB, MRSA

• Streptococcus pneumoniae• Haemophilus influenzae • Aspiration / polymicrobic• Legionellae• S. aureus (post influenza)• Gram-negative bacilli• ECF: as per comorbidity, except influenza, TB, MRSA 10

Severe Pneumonia Severe Pneumonia

• Streptococcus pneumoniae

• Legionella

• Viruses• Aerobic gram-negative bacilli

• Streptococcus pneumoniae

• Legionella

• Viruses• Aerobic gram-negative bacilli

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More SpecificCXR PatternsMore SpecificCXR Patterns

• Cavities - Aspiration, GNB, Staph. Aureus, TVE - TB, Histoplasma, aspergillus

• Segmental - Post-obstructive, aspergillus - Pulmonary embolism • Hilar / mediastinal adenopathy - Primary TB, fungal infection - Malignancy, sarcoid

• Cavities - Aspiration, GNB, Staph. Aureus, TVE - TB, Histoplasma, aspergillus

• Segmental - Post-obstructive, aspergillus - Pulmonary embolism • Hilar / mediastinal adenopathy - Primary TB, fungal infection - Malignancy, sarcoid 12

More SpecificCXR PatternsMore SpecificCXR Patterns

• Diffuse Interstitial - Viral, Pneumocystis carinii - CHF, allergic, etc.

• Nodules - Fungal, TB, septic emboli - May cavitate - Metastatic Ca

• Diffuse Interstitial - Viral, Pneumocystis carinii - CHF, allergic, etc.

• Nodules - Fungal, TB, septic emboli - May cavitate - Metastatic Ca

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Prescribing Practices Prescribing Practices

• 1968 antibiotics prescribed for: - 51% patients with Dx: “common cold”

• 1997 antibiotics prescribed for: - 51% with Dx: “cold” - 52% with Dx: “URI” - 66% with Dx: “Acute Bronchitis” (no COPD)

• 1968 antibiotics prescribed for: - 51% patients with Dx: “common cold”

• 1997 antibiotics prescribed for: - 51% with Dx: “cold” - 52% with Dx: “URI” - 66% with Dx: “Acute Bronchitis” (no COPD) 14

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Summary Summary

Chuck• Had a flu-like illness• Diagnosed with Bacterial Pneumonia due to Staphylococcus Aureus

Treatment• Prolonged course of IV and oral antibiotics• Was very ill but recovered completely• Annual flu shots expected

Chuck• Had a flu-like illness• Diagnosed with Bacterial Pneumonia due to Staphylococcus Aureus

Treatment• Prolonged course of IV and oral antibiotics• Was very ill but recovered completely• Annual flu shots expected

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Stephen Hoffmann, MDClinical Instructor of Internal Medicine

Division of Pulmonary & Critical Care MedicineThe Ohio State University Medical Center 23

Case Case

• 37 year old male

1st Day• Underwent a CT scan• Fiberoptic bronchoscopy with BAL• Transbronchial biopsy• Results were negative• That evening, had an aspiration event• Developed fevers to 103 degrees• Started on pipercillin / tazobactum but condition worsened

• 37 year old male

1st Day• Underwent a CT scan• Fiberoptic bronchoscopy with BAL• Transbronchial biopsy• Results were negative• That evening, had an aspiration event• Developed fevers to 103 degrees• Started on pipercillin / tazobactum but condition worsened 24

Case Case

3rd Day• Ciprofloxcin added to antibiotic regimen• A CXR showed worsening infiltrate and pleurl effusion• Thoracentesis was performed but no evidence of empyema

4th Day• Developing significant hypoxemia and respiratory insufficiency• Required intubation and ventilation

3rd Day• Ciprofloxcin added to antibiotic regimen• A CXR showed worsening infiltrate and pleurl effusion• Thoracentesis was performed but no evidence of empyema

4th Day• Developing significant hypoxemia and respiratory insufficiency• Required intubation and ventilation

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Case Case

• Repeat fiberoptic bronchoscopy was performed• Gram stain of the BAL revealed gram positive cocci• Due to high incidence of MRSA, started on vancomyocin• He developed ARDS with severe respiratory failure requiring 100% oxygen and significant amounts of PEEP• Enrolled in Liquid Ventilation Study

• Repeat fiberoptic bronchoscopy was performed• Gram stain of the BAL revealed gram positive cocci• Due to high incidence of MRSA, started on vancomyocin• He developed ARDS with severe respiratory failure requiring 100% oxygen and significant amounts of PEEP• Enrolled in Liquid Ventilation Study

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Case Case

• Over 5 days, he improved

• Peflubron was discontinued

• Patient was extubated

• One day later, patient was transferred to floor

• Over 5 days, he improved

• Peflubron was discontinued

• Patient was extubated

• One day later, patient was transferred to floor

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Hospital Acquired Pneumonia Hospital Acquired Pneumonia

• Pneumonia occurring greater than 48 hours after hospital admission

• Accounts for 13-18% of all nosocomial infections

• 5-10m cases per 1000 hospital admissions• Incidence increases 6-20 fold in mechanically ventilated patients

• Up to 25% of ICU patients develop pneumonia

• Associated mortality 20-50%• Attributable mortality more difficult to define but may be in excess of 10%

• Pneumonia occurring greater than 48 hours after hospital admission

• Accounts for 13-18% of all nosocomial infections

• 5-10m cases per 1000 hospital admissions• Incidence increases 6-20 fold in mechanically ventilated patients

• Up to 25% of ICU patients develop pneumonia

• Associated mortality 20-50%• Attributable mortality more difficult to define but may be in excess of 10% 25

PathogenesisRespiratory Infections

PathogenesisRespiratory Infections

• Impaired host defenses

• Sufficient innoculum to overwhelm the host defense

• Virulent organisms

• Impaired host defenses

• Sufficient innoculum to overwhelm the host defense

• Virulent organisms

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Routes Of Bacterial Entry Routes Of Bacterial Entry

• Microaspiration of oropharyngeal secretions colonized with pathogenic organisms

• Aspiration of esophageal / gastric contents

• Inhalation of infected aerosols• Hematogenous spread

• Contiguous spread from infected site

• Direct inoculation into airways of intubated patients

• Translocation from GI tract

• Microaspiration of oropharyngeal secretions colonized with pathogenic organisms

• Aspiration of esophageal / gastric contents

• Inhalation of infected aerosols• Hematogenous spread

• Contiguous spread from infected site

• Direct inoculation into airways of intubated patients

• Translocation from GI tract 27

Etiology Etiology

• Type of infection largely determined by the bacteria colonizing the oropharynx - Hospitalized patients may become colonized with aerobic gram negative bacteria within several days - 75% of severely ill patients become colonized within 48 hours

• Overgrowth of the near sterile environment of the stomach and UGI tract may occur due to alterations in gastric pH - Illness, drugs, enteral feedings

• Type of infection largely determined by the bacteria colonizing the oropharynx - Hospitalized patients may become colonized with aerobic gram negative bacteria within several days - 75% of severely ill patients become colonized within 48 hours

• Overgrowth of the near sterile environment of the stomach and UGI tract may occur due to alterations in gastric pH - Illness, drugs, enteral feedings

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Common Bacteria Common Bacteria

• Pseudomonas aeruginosa - 17%

• Enterobacteriaceae - 11%

• Klebsiella species - 7%

• Escheichia coli - 6%

• Haemophilus influenzae - 6%

• Serratia marcens - 5%

• Staphylococcus aureus - 16%

• Pseudomonas aeruginosa - 17%

• Enterobacteriaceae - 11%

• Klebsiella species - 7%

• Escheichia coli - 6%

• Haemophilus influenzae - 6%

• Serratia marcens - 5%

• Staphylococcus aureus - 16% 29

Other PathogensOther Pathogens

• Less common pathogens include: - Streptococcus pneumoniae, anaerobes, influenza A and other viruses, Legionella species, Candida sp., Aspergillus sp.

• Acinetobacter species have emerged as significant pathogens in some centers

• The incidence of anaerobic bacteria as the cause of HAP may be overestimated: - Marik et al evaluated 185 patients with anaerobic cultures of PSB and BAL specimens - Only 1, nonpathogenic anaerobic species was isolated• Frequently polymicrobial

• Less common pathogens include: - Streptococcus pneumoniae, anaerobes, influenza A and other viruses, Legionella species, Candida sp., Aspergillus sp.

• Acinetobacter species have emerged as significant pathogens in some centers

• The incidence of anaerobic bacteria as the cause of HAP may be overestimated: - Marik et al evaluated 185 patients with anaerobic cultures of PSB and BAL specimens - Only 1, nonpathogenic anaerobic species was isolated• Frequently polymicrobial 30

Etiology Based OnEpidemiology 1995 ATS Criteria

Etiology Based OnEpidemiology 1995 ATS Criteria

• Severity of pneumonia

• Presence of coexisting illness

• Prior therapy

• Length of hospitalization prior to pneumonia

• Severity of pneumonia

• Presence of coexisting illness

• Prior therapy

• Length of hospitalization prior to pneumonia 31

Core OrganismsCore Organisms

• E. coli• Klebsiella

• Proteus

• Serratia

• Hemophilus influenza

• Methicillin - sensitive S. aureus

• Streptococcus pneumoniae

• E. coli• Klebsiella

• Proteus

• Serratia

• Hemophilus influenza

• Methicillin - sensitive S. aureus

• Streptococcus pneumoniae 32

Late Onset Severe HospitalAcquired Pneumonia: GreaterThan 5 Days After Admission

Late Onset Severe HospitalAcquired Pneumonia: GreaterThan 5 Days After Admission

• Core organisms plus• P. auriginosa• Acinetobacter species• Methicillin resistant staph aureus• Candida

• Core organisms plus• P. auriginosa• Acinetobacter species• Methicillin resistant staph aureus• Candida 33

Risk Factors ForSpecific Pathogens

Risk Factors ForSpecific Pathogens

• Anaerobes (witnessed aspiration, recent abdominal surgery)

• S. Aureus (coma, head trauma, IVDA, renal failure, DM)

• Legionella (high dose steroids)

• Pseudomonas aeruginosa (steroids, structural lung disease, prolonged ICU stay, mechanical ventilation)

• Anaerobes (witnessed aspiration, recent abdominal surgery)

• S. Aureus (coma, head trauma, IVDA, renal failure, DM)

• Legionella (high dose steroids)

• Pseudomonas aeruginosa (steroids, structural lung disease, prolonged ICU stay, mechanical ventilation) 34

DiagnosisDiagnosis• Clinical definition - A new or progressive infiltrate in a patient with fever, leukocytosis and tracheobronchial secretion

• Mimics - CHF - Atelectasis - Pulmonary embolism - Drug reaction - Pulmonary hemorrhage - ARDS

• Clinical definition - A new or progressive infiltrate in a patient with fever, leukocytosis and tracheobronchial secretion

• Mimics - CHF - Atelectasis - Pulmonary embolism - Drug reaction - Pulmonary hemorrhage - ARDS

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Microbiologic EvaluationMicrobiologic Evaluation

• Blood cultures• Sputum

• Endotracheal aspirates

• Fiberoptic bronchoscopy - Protected brush specimen - Bronchoalveolar lavage

• Blood cultures• Sputum

• Endotracheal aspirates

• Fiberoptic bronchoscopy - Protected brush specimen - Bronchoalveolar lavage

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DiagnosisDiagnosis

• Purulent sputum

• A significant respiratory pathogen predominating on gram stain

• Peripheral leukocytosis

• Fever• New or persistent infiltrate on chest x-ray, with a concurrent deterioration in gas exchange

• Purulent sputum

• A significant respiratory pathogen predominating on gram stain

• Peripheral leukocytosis

• Fever• New or persistent infiltrate on chest x-ray, with a concurrent deterioration in gas exchange

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TreatmentTreatment

• Adequacy of initial treatment crucial• Patients suspected of having HAP and particularly VAP should be treated with broad spectrum antibiotics aimed at covering all likely bacterial pathogens

• Knowledge of local bacterial spectra and antimicrobial resistance patterns are essential in formulating initial coverage

• Treatment then should be narrowed based on the results of microbiologic data

• Usual duration of treatment is 10-14 days

• Adequacy of initial treatment crucial• Patients suspected of having HAP and particularly VAP should be treated with broad spectrum antibiotics aimed at covering all likely bacterial pathogens

• Knowledge of local bacterial spectra and antimicrobial resistance patterns are essential in formulating initial coverage

• Treatment then should be narrowed based on the results of microbiologic data

• Usual duration of treatment is 10-14 days38

Antibiotic Regimens:Core Coverage

Antibiotic Regimens:Core Coverage

• Extended spectrum penicillins - Pipercillin / tazobactam - Ticarcillin / clavulanate

• Third / fourth generation cephalosporins - Cefepime - Not ceftazidime

• Fluroquinolones - Levafloxcin

• Extended spectrum penicillins - Pipercillin / tazobactam - Ticarcillin / clavulanate

• Third / fourth generation cephalosporins - Cefepime - Not ceftazidime

• Fluroquinolones - Levafloxcin

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Antibiotic Regimens:Late Onset CoverageAntibiotic Regimens:Late Onset Coverage

• Common regimens include two of the following classes plus / minus Vancomyocin - Extended spectrum penicillins - Pipercillin / tazobactam - Ticarcillin / clavulanate

- Third / Fourth generation cephalosporins - Cefepime - Not ceftazidime

- Fluroquinolones - Levafloxcin - Ciprofloxcin

- Aminiglycosides - Imipenem-cilastin

- Aztreonam

• Common regimens include two of the following classes plus / minus Vancomyocin - Extended spectrum penicillins - Pipercillin / tazobactam - Ticarcillin / clavulanate

- Third / Fourth generation cephalosporins - Cefepime - Not ceftazidime

- Fluroquinolones - Levafloxcin - Ciprofloxcin

- Aminiglycosides - Imipenem-cilastin

- Aztreonam 40

Antibiotic Regimens: Coverage For Patients With Risk Factors

Antibiotic Regimens: Coverage For Patients With Risk Factors

• Prolonged ICU stay, mechanical ventilation, structural lung disease - double coverage for pseudomonas plus / minus vancomyocin

• Steroids therapy - macrolide

• Witnessed aspiration, recent abdominal surgery - anerobic coverage - Clindamyocin - Metronidazole - Extended spectrum penicillins - Imipenem-cilastin

• Prolonged ICU stay, mechanical ventilation, structural lung disease - double coverage for pseudomonas plus / minus vancomyocin

• Steroids therapy - macrolide

• Witnessed aspiration, recent abdominal surgery - anerobic coverage - Clindamyocin - Metronidazole - Extended spectrum penicillins - Imipenem-cilastin

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#1006 New Approaches to Cardio Re-vascularization

October 26 to October 29

Robert E. Michler, MDProfessor of SurgeryChief, Division of Thoracic and Cardiovascular SurgeryThe Ohio State University Medical Center

Gregory M. Eaton, MDAssistant Professor of Clinical Internal MedicineDivision of CardiologyThe Ohio State University Medical Center

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