PNEUMONIA

Augustine Lee, MD

Mayo Clinic Florida

Lee.augustine@mayo.edu

Top causes of death (2011)

United States Chile (& the World)

1. Ischemic heart

2. Cancer

3. Stroke

…

8. Pneumonia

1. Ischemic heart

2. Stroke

3. Pneumonia

United States

Incidence

2-3 million cases/y

500,000 admissions

Mortality >60,000 deaths/y

Outpatient <1%

Ward 10-14%

ICU 30-40%

Where can we impact ?

Diagnosis

Treatment

Death

Diagnostic aids

Prediction algorithms

Triage tools

Predicting the bugs

Timely antibiotics

Things that we do to

patients

Some pathogens by risks

Alcoholism S. pneumoniae, anaerobes,

Klebsiella, (TB)

COPD, smoking S. pneumonia, H. influenzae,

M. catarrhalis, Legionella

Nursing home S. pneumoniae, GNB, H.

influenzae, S. aureus, C. pneumoniae, (TB)

Poor dental hygiene Anaerobes

Hotel, cruise Legionella

Birds, soil, caves Histoplasma, C. psittaci

Rabbits Francisella tularensis

Farm animals, cats Coxiella (Q-fever)

SW USA Hantavirus, coccidioides

Structural lung disease Pseudomonas, S. aureus,

Burkoholderia cepaci, (NTM)

SE and East Asia Pseumolmallei, SARS,

Bartlett, Clin Infect Dis 2003

ATS/IDSA 2007

Adult CAP in Chile (N=365)

Bacteria (42.7% of cases) % of cases

Streptococcus pneumoniae 21.1%

Mycoplasma pneumoniae 9.0%

Chlamydia pneumoniae 7.9%

Legionella 5.07%

Staphylococcus aureus 2.2%

Moraxella catarrhalis 1.7%

Gram-negative bacillus 1.4%

Haemophilus influenzae 0.8%

Luchsinger, Avendano, Thorax 2013

Barcelona, 1042 CAP/Ward patients

Leading Ward Pathogens

43% S. pneumoniae

13% Mixed

12% Viral

8% Legionella

5% H. influenzae

4% Pseudomonas

3% Mycoplasma pneumoniae

3% Chlamydia pneumoniae

2% each of S. aureus, GNEB, Coxiella burnetti

Cilloniz, Thorax 2011

Barcelona, 260 CAP/ICU patients

Leading ICU Pathogens

42% S. pneumoniae

22% Mixed

8% Legionella

5% Pseudomonas

4% Viral

3% H. influenzae

3% Chlamydia pneumoniae

2% Mycoplasma pneumoniae

2% S. aureus

1% each GNEB, Coxiella burnetti

Cilloniz, Thorax 2011

7% mortality

(highest total deaths)

16% mortality

24% mortality

30% mortality

11% mortality

Septic shock & Pneumococcus

1041 prospective cohort (Spain)

10.9% will develop septic shock

41% bacteremic, 37% MV

25% mortality

Independent risk factors for septic shock

Serotype 3 (Also more necrotizing pneumonia)

Chronic steroid use

Active smoking

Garcia-Vidal, Thorax 2010

Indications for testing (ATS/IDSA)

ICU

Failure of therapy

Cavitary

Leukopenia

Active alcohol abuse

Chronic liver disease

Chronic lung disease

Asplenia

Recent travel

Pleural effusion

Clinical

Judgment

Other considerations

Outpatient Optional

Seasonal variations Influenza +/- RSV

Urinary antigen testing: Specificity > Sens. Legionella, serogroup 1

Streptococcus

Intubated Tracheal aspirate in most is fine

?Bronchoscopy: opportunistic organisms, alternative diagnoses, immunocompromised

PSI / PORT

Low risk class (I) or not (II-V)

Age

Physiologic parameters

Comorbidities

High risk class (II-V)

Age

Physiologic parameters

Comorbidities

Labs & Imaging

Fine, NEJM 1997

30-day Mortality

(I) 0.1%

(II) 0.6%

(III)0.9%

(IV)9.3%

(V) 27%

PSI / PORT, Risk Class I

Age >50

Altered mental status

HR ≥ 125

RR >30

SBP <90

Temp <35 or ≥40 C

History of:

Cancer, CHF, stroke, kidney disease, liver disease

CURB-65

Confusion

Urea >7 mmol/L (19 mg/dL)

Respiratory rate ≥30

BP, systolic <90

Age ≥65

Score

Mortality

0, 1 1.5%

Home?

2 9.2%

Inpatient?

3+ 22%

ICU?

Lim, Thorax 2003

Independent predictors of death

CAPNETZ (German cohort, N=660,594)

Bedridden functional status OR 2.93

Nursing home residents OR 1.27

Age, decades OR 1.38

CRB OR 1.73

CRB-50

CRB-65

CRB-80

Ewig, Thorax 2013

Other biomarkers of poor prognosis

Hypoglycemia (Gamble, Am J Med 2010)

Short & long-term

~20% mortality, with HR 2.96

Platelets (Mirsaeidi, Chest 2010)

Both low and high

Better predictor than WBC

Hyper > Hypo-capnea (Laserna, Chest 2012)

NT-proBNP in Pneumonia Nowak, Chest 2012

www.thoracic.org/statements

2007 Guidelines (Being updated…)

Procalcitonin Meta-analysis 14 RCT’s of 4211 patients

Schuetz, JAMA 2013 (Cochrane review)

RCT in 302 with suspected CAP Christ-Crain, AJRCCM 2006

Reduction of antibiotics Schuetz, JAMA 2013 (Cochrane review)

Shorten antibiotics?: 401 VAP RCBT Chastre, JAMA 2003

Procalcitonin

Increased in infection

Quantity correlates with severity

Evolving role:

Stopping antibiotics

(Initiating antibiotics)

Caveats:

Increased in trauma, burns, neuroendocrine tumors, ?viral infections, unclear role in fungus, PCP, HIV, TB, immunocompromised, etc.

Schuetz, Chest 2012

Schuetz, Chest 2012

Timing is key

18209 Medicare patients >65yo, admitted

Houck, Arch Int Med 2004

Antibiotics

≤4hours

Antibiotics

>4hours

Adjusted

OR

P-value

Mortality,

30day

11.6% 12.7% 0.85 0.005

Mortality,

hospital

6.8% 7.4% 0.85 0.03

LOS >5days 42.1% 45.1% 0.90 0.003

Re-admit,

30-day

13.1% 13.9% 0.90 0.34

Antibiotic choice: Considerations

Likely pathogen

Season

Clinical, epidemiologic features

Local microbiology in your practice

Local resistance patterns

Exposure to prior antibiotics

Healthcare contact or institutionalization

Severity of illness

2007 ATS/IDSA guidelines

Outpatient

Macrolide alone

Doxycycline alone

Adjustments pending comorbidities, community

prevalence of resistant S. pneum.

Inpatient

Advanced macrolide + Beta-lactam

Respiratory fluoroquinolones alone

Adjust based on prior exposure, etc.

ICU (ATS/IDSA 2007)

Always two drugs:

+ Beta-lactam

Cefotaxime, ceftriaxone, amp./sulbactam

+ Azithromycin or a respiratory

fluoroquinolone

ICU with risk for pseudomonas

Expanding coverage for Pseudomonas:

+ Anti-pseudomonal Beta-lactam

Pip./tazobactam, cefipime, meropenem

+ Either of the two: Anti-pseudomonal fluoroquinolone

Aminoglycoside + azithromycin

If PCN allergy

Aztreonam, fluoroquinolone, aminoglycoside

ICU: Penicillin Allergy

Aztreonam + Respiratory fluoroquinolone

If pseudomonas risk:

Aztreonam

Respiratory fluoroquinolone

Aminoglycoside

Adherence to guidelines

780 prospective cohort of CAP (exclude NH)

Independent associations of Mortality:

Dambrava, ERJ 2008

Variable OR

Obtundation 7.04 (p=0.001)

Shock 5.89 (p=0.011)

Acute renal failure 3.28 (NS: p=0.075)

Arterial saturation <90% 2.86 (NS: p=0.056)

Aspiration 2.69 (p=0.046)

Adherence to ATS guideline 0.69 (NS)

51% at risk for MDR bacteria

Comorbidities

Prior antibiotics within 90 days

Wound care

Home infusion therapy

Nursing home or extended care facility

Hospitalization for >1day within 90 days

Chronic renal failure

Aliberti, Clin Infect Dis 2012

Schorr, Arch Int Med 2008

“Late onset” HAP/HCAP/VAP

S. pneumoniae

H. influenzae

S. aureus

GNEB

MDR

Pseudomonas

ESBL+ Klebsiella

Acinetobacter

MRSA

Legionella

Antibiotics (3 drugs)

Anti-pseudomonal cephalosporins

Anti-pseudomonal carbepenems

B-lactam/BL-inhibitor

Anti-pseudomonal fluoroquinolone

Aminoglycoside

Linezolid

Vancomycin

Prevention ? Case study: VAP

Education, Hand-washing, Environmental decontamination

Early removal enteral feed

Reduce patient transport

Oral care (chlorhexidine)

Sedation vacation, extubation readiness

Semi-recumbent position

Minimize intubation

Oral intubation

ETT

Subglottic aspiration from ETT

Silver coated

Tracheal cuff pressure

(Reduce unnecessary ulcer prophylaxis)

Morrow, ERJ 2011

O’Grady, JAMA 2012

What you do matter… Boudama, Clin Infect Dis 2010

Summary

Be aware of your local bugs and issues

Risk prognosticate to help you decide on appropriate resource usage (clinical, biomarkers)

Consider MDR risks, and start appropriate empiric antibiotics (guidelines can be helpful)

Give it as quickly as you diagnose pneumonia

Biomarkers might help you limit antibiotic over-usage without harm

How you handle patients once in the hospital makes a difference (for worse, and for better)

Look for upcoming updates in guidelines