Appropriate Antibiotics use in CAP and HCAP at Sisters Hospital in 2008. Syed Faraz Masood, MBBS...
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Transcript of Appropriate Antibiotics use in CAP and HCAP at Sisters Hospital in 2008. Syed Faraz Masood, MBBS...
Appropriate Antibiotics use in CAP and HCAP at Sisters
Hospital in 2008.Syed Faraz Masood, MBBS
Nashat H. Rabadi, MD, FCCP
Community Acquired Pneumonia
• Common : 5 to 6 million cases/year• 20% are hospitalized ( 10% in ICU)• No. 1 cause of death from infectious disease• No. 6 cause of death in adults• Mortality rates :
– Outpatients = 1-5%– Inpatients = 12% ( higher in ICU- 50%)
• Costs : 9.7 billion
: inpatient – $7,517 vs. outpatient - $264
CAPDefinition
• CXR – infiltrate
• Auscultatory findings
• Signs of RTI– Cough +/- sputum– Fever or hypothermia– WBC
Risk Factors.
• Age.
• Smoking.
• Co-morbid Conditions.
• Poor Prognosis.– Pleural Effusion.– Bacteremia.
Cultures.
• Sputum Cx– Not needed as outpatient.– May or may not be needed inpatient.
• Blood Cx
• Urinary Antigens.
CURB - 65C – Confusion
U – Urea. BUN > 20
R – Respiratory rate > 30 / min
B – Blood pressure . SBP < 90 or DBP < 60
65 – Age > 65
Number of factors Mortality Rate 0 0.7%
1 2.1% 2 9.2% 3 14.5% 4 40% 5 57%
Empirical Treatment
• Hospitalized Patients: – 2nd or 3rd generation Cephalosporins plus a Macrolide.– Floroquinolones.
• For all critically ill patients, – 2nd or 3rd generation Cephalosporin + Macrolide or
Floroquinolones – necessary to provide coverage for Legionella Pneumophilia.
– Change antibiotics – based on culture and sensitivity.
Nosocomial Pneumonia
• Hospital Acquired Pneumonia:– > 48 hours of admission to hospital.
• Ventilator associated Pneumonia.– > 48 hours of intubation.
Health-care Associated Pneumonia.
• Antimicrobial therapy in preceding 90 days.
• Hospitalization for 2 or more days in the preceding 90 days.
• Residence in a NH or an extended care facility.
• Home infusion therapy.• Chronic Dialysis within 30 days.• Immunosuppressive state and/or therapy.
Health-care Associated Pneumonia.
• Epidemiology extrapolated from HAP/VAP
• Second most common Nosocomial Infection.
• High morbidity / mortality.
• Increase hospital stay by 7-9 days.
• Excess cost of $ 40,000 per patient.
• Early VAP/HAP (<5 days)– Similarly as CAP– No MDR pathogens.
• Late VAP/HAP (>5 days) treated similarly as HCAP:– MDR pathogens.
Microbiology
• Polymicrobial.– Methicillin-resistant Staphylococcus Aureus.– Pseudomonas Aeruginosa.– Acinetobacter– E.Coli– Klebsiella Pneumoniae (ESBL).
Increased crude and attributable mortality associated with MDR pathogens.
Pathogenesis of HCAP
• Colonization: Lower Respiratory Tract.
• Aspiration; inhalation.
• Host-related: severity of illness, prior surgery.
• Environment-related: antibiotic exposure, medications, invasive devices.
• Host’s mechanical, humoral and cellular defenses.
Diagnosis
• Lower Respiratory Tract Cultures:– Sputum Cultures.– Endotracheal aspirates.– Bronchoscopy
• Broncho-alveolar Lavage (BAL).• Protected Brushed Specimen (PBS).
Empirical Treatment
• Anti-pseudomonal cephalosporins or
• Anti-pseudomonal cabrapenems or
• Beta-lactam/beta-lactamase inhibitorsAnd
• Anti-pseudomonal floroquinolones.PLUS
• Vancomycin or Linezolid.
HAP,VAP or HCAP SuspectedObtain Blood & Lower Respiratory Tract
Cultures
Early, Appropriate, Adequate Antibiotics
Assess Clinical Response Check Microbiology
Clinical Improvement (24-48 hrs)
YESNO
• Streamline Antibiotics.
• Treat Uncomplicated patients for 7 days. • Reassess & Follow up.
Search for Complications: Abscess or Empyema
Untreated Pathogen Non-Infectious Cause
ATS Consensus Statement. AJRCCM 171: 2005
Mortality in Nosocomial Pneumonia.
• Presence of MDR pathogens.
• Initial Inappropriate antibiotics.
• Co-morbidities.
Alvarez-Lerma F, et al. Alvarez-Lerma F, et al. Intensive Care MedIntensive Care Med. 1996;22:387-394.. 1996;22:387-394.Ibrahim EH, et al. Ibrahim EH, et al. ChestChest. 2000;118L146-155.. 2000;118L146-155.Kollef MH, et al. Kollef MH, et al. Chest.Chest. 1999; 115:462-474. 1999; 115:462-474.
Initial Inadequate Therapy Increases Mortality
Kollef MH, et al.Kollef MH, et al. Chest Chest. 1998;113:412-420.. 1998;113:412-420.Luna CM, et al. Luna CM, et al. Chest.Chest. 1997;111:676-685. 1997;111:676-685.Rello J, et al. Rello J, et al. Am J Respir Crit Care MedAm J Respir Crit Care Med. 1997;156:196-200. 1997;156:196-200..
0 20 40 60 80 100
% Mortality
Initial adequatetherapy
Initial inadequatetherapy
Luna, 1997Luna, 1997
Ibrahim, 2000Ibrahim, 2000
Kollef, 1998Kollef, 1998
Kollef, 1999Kollef, 1999
Rello, 1997Rello, 1997
Alvarez-Lerma,1996Alvarez-Lerma,1996
BAL=bronchoalveolar lavage. NS=Not significant.Luna CM, et al. Chest. 1997;111:676-685.
0
10
20
30
40
50
60
70
80
90
100
Pre-BAL Post-BAL Post-result
% M
orta
lity
No Antibiotic
Adequate Antibiotic
Inadequate Antibiotic
P<.001
P=NS
P=NS
Adequate Therapy Reduces Mortality Only If Selected Prior to Identification of the Pathogen
Research Question
• Appropriateness of CAP treatment at Sister’s Hospital.
• Appropriateness of HCAP treatment at Sister’s Hospital.
• Mortality.
• Length of Stay.
Method
• IRB approval.• HIPAA Compliance.• 248 charts reviewed with diagnosis of
pneumonia.• Retrospective analysis.• Single institution (Community Hospital setting).• 1 Calendar year. (Jan 1st – Dec 31st 2008)
Community Acquired Pneumonia
42%
58%
0%
10%
20%
30%
40%
50%
60%
< 65 years > 65 years
< 65 years
> 65 years
• Antibiotics administered in ER: 100%
• Appropriate antibiotics: 93.2%
• Cultures performed: 95.7%
• Positive Cultures: 8.1%
Cultures
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Blood Cx Sputum Cx No Cultures
Blood Cx
Sputum Cx
No Cultures
Positive Cultures
0
20
40
60
80
100
120
140
Positive Cultures 11 4 2 1
Total Cultures 67 131 82
Sputum Blood U-antigens Others
Microbiology of CAP
Stenotrophomonas (1)
MRSA (1)
Influenza (2)
MSSA (1)
P.Aerugino (2) M.Cat (1)
H. Influenzae (2)
Strep. Pneumo (4)
Choice of Initial Antibiotics
Others5%
Levaquin19%
RocephinZithromax
76%
Rocephin/Zithromax
Levaquin
Others
Health-care Associated Pneumonia.
33%
67%
0%
10%
20%
30%
40%
50%
60%
70%
< 65 years > 65 years
< 65 years
> 65 years
Multi-Drug Resistant Risk Factors
0
10
20
30
40
50
MDR risk factors
MDR riskfactors
47 24 31 9
LTCF IS PH HD
Initial Antibiotic Coverage in ER
0
20
40
60
80
Appropriate
'Partially'Appropriate
Inappropriate
Antibiotic 4 15 71
Appropriate'Partially'
AppropriateInappropriate
Initial Antibiotics Choice
Rocephin/Zithromax
(50)
Levaquin (14)
Vanco/Zosyn(1)
Vanco/ Zosyn/
Levaquin (1)Ceftriaxone
(4) Vanco/Imipenem (1)
Zyvox/Premaxin (1)
antibiotics
Other Combinations used…
• Vanco/Zithro• Levaquin/Genta/
Aztreonam.• Levaquin/Aztreonam• Levaquin/
Aztreonam/Clindamycin.
• Levaquin/Ceftazidime
• Aztreonam/Zithro• Levaquin/Zithro• Clindamycin• Primaxin/Zithromax• Levaquin/Clindamycin• Zosyn/Zithromax• Zosyn/Levaquin.
Coverage.
0
20
40
60
80
NonHousestaffCoverage
HousestaffCoverage
Coverage 65 25
NonHousestaff Coverage
Housestaff Coverage
Appropriately changed within 24 hours of admission
0
10
20
30
40
50
60
70
Antibiotics
Total Patients
Antibiotics 6 8
Total Patients 65 25
Non-housestaff Housestaff
9.2%
32%
Appropriate Change in Subgroups in Covered Patients.
0
2
4
6
8
10
Appropriate
Total
Appropriate 5 2 1 0
Total 10 10 2 3
LTCF IS PH HD
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Blood Cx
Sputum Cx
No cultures
Cultures. 95.50% 45.50% 2.22%
Blood Cx Sputum Cx No cultures
Positive Cultures
0
20
40
60
80
100
Positive Cultures
Total Cultures
Positive Cultures 11 4 5 1
Total Cultures 41 86 46
Sputum Blood U.Antigens Other
MicrobiologyCMV (1)Stenotropho
monas (1)Actinobacter (1)
MSSA (1)
P.Aerugino (3)
MRSA (6)
S.Pneumo (8)
• Appropriate antibiotics in ER: 4.4%
• Partially appropriate in ER: 15.5%
• Inappropriate antibiotics in ER: 78.8%
• Appropriate change in 24 hours: 16.27%
• Cultures performed: 97.7%
• Positive cultures: 18.1%
• Average Length of Stay: 9.5 days
• Average age: 71.2 years
Mortality
• Total Number of Deaths: 11/90
• Mortality Rate: 12.2%
• Deaths on Inappropriate Antibiotics: 9/11
Comparison
Variables HCAP CAPAge 71.2 years 69 years
Females 71.5% 54.5%
Sputum Cx yield 26.8% 16.2%
Blood Cx yield 4.6% 3.2%
Urinary Ag yield 10.8% 2.4%
Mortality 12.4% 4.2%
LOS 9.5 days 5.8 days
Housestaff covered
27.7% 29.3%
HAP,VAP or HCAP SuspectedObtain Blood & Lower Respiratory Tract
Cultures
Early, Appropriate, Adequate Antibiotics
Assess Clinical Response Check Microbiology
Clinical Improvement (24-48 hrs)
YESNO
• Streamline Antibiotics.
• Treat Uncomplicated patients for 7 days. • Reassess & Follow up.
Search for Complications: Abscess or Empyema
Untreated Pathogen Non-Infectious Cause
ATS Consensus Statement. AJRCCM 171: 2005
Strategies to Improve HCAP Outcomes
• Education.
• Order Sheets.
• De-escalation.
• Consultation.
• Re-evaluation.
References• National Center for Health Statistics. Health, United States, 2006, with chart book on trends in
the health of Americans. Available at: http://www.cdc.gov/nchs/data/hus/hus06.pdf. Accessed 17 January 2007.
• American Thoracic Society; Infectious Diseases Society of America. (2005). "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". Am. J. Respir. Crit. Care Med. 171 (4): 388–416.
• Alvarez-Lerma F, et alAlvarez-Lerma F, et al. . Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. Intensive Care MedIntensive Care Med. 1996;22:387-394. 1996;22:387-394
• Ibrahim EH, et al.Ibrahim EH, et al. The Influence of Inadequate Antimicrobial Treatment of Bloodstream Infections on Patient Outcomes in the ICU Setting*. ChestChest. 2000;118L146-155.. 2000;118L146-155.
• Kollef MH, et al.Kollef MH, et al. Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Mortality Among Critically III Patients.Mortality Among Critically III Patients. Chest.Chest. 1999; 115:462-474. 1999; 115:462-474.
• Kollef MH, et al.Kollef MH, et al. The Influence of Mini-BAL Cultures on Patient Outcomes*: Implications for The Influence of Mini-BAL Cultures on Patient Outcomes*: Implications for the Antibiotic Management of Ventilator-Associated Pneumonia the Antibiotic Management of Ventilator-Associated Pneumonia ChestChest. 1998;113:412-420.. 1998;113:412-420.
• Luna CM, et al. Luna CM, et al. Impact of BAL Data on the Therapy and Outcome of Ventilator-Associated Impact of BAL Data on the Therapy and Outcome of Ventilator-Associated Pneumonia*.Pneumonia*. Chest.Chest. 1997;111:676-685. 1997;111:676-685.
• Rello J, et al. Rello J, et al. The Value of Routine Microbial Investigation in Ventilator-Associated The Value of Routine Microbial Investigation in Ventilator-Associated PneumoniaPneumonia Am J Respir Crit Care MedAm J Respir Crit Care Med. 1997;156:196-200.. 1997;156:196-200.
Acknowledgement
• Dr. Nashat Rabadi.
• Cliff Gadra and the Medical Records team.
• Dr. Varuna Nargunan.
• Danielle Casucci.
• Dr. Sateesh Satchidanand
• IRB team.