SAMIR EL ANSARY

COMMUNITYACQUIREDPNEUMONIA 2015 - 2

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9555/ Wellcome in our new group ..... Dr.SAMIR EL ANSARY

What defines a treatment failure?The majority of patients receiving appropriate

therapy show a favorable clinical response within

72 hours.

Therefore initial antibiotic therapy should not be

changed before 72 hours unless indicated by

significant clinical worsening or microbiologic

data.

Remember that certain host factors, such as

advanced age, alcoholism, and chronic

obstructive pulmonary disease, have been

associated with delayed resolution despite

appropriate treatment.

What defines a treatment

failure?

Radiographic resolution of pneumonia

lags behind clinical improvement and

in some cases may take up to 8 to 10

weeks to clear completely.

Discuss the potential reasons why

a patient may not respond

favorably to empiric therapy.

Clinical deterioration or a lack of

response to empiric antimicrobial

therapy within 3 days often indicates

treatment failure, warranting

thorough reassessment and

additional investigation.

1. Inappropriate antimicrobial therapya. Is the dosing adequate?

b. Are all potential bacterial pathogens covered by

the empiric regimen?

c. Are the organisms resistant or has a previously

sensitive pathogen developed resistance?

d. Is the pathogen bacterial? Consider other

pathogens to include viruses, endemic fungi, and

mycobacteria.

e. Is the host immunocompromised and at risk for

opportunistic infections such as Pneumocystis jiro

veci?

f. Is the disease infectious? Has the patient been

misdiagnosed?

2. Complications of lung infection or

hospitalization

a. Has a lung abscess or empyema

developed?

b. Does the patient have acute respiratory

distress syndrome (ARDS)?

c. Have the bacteria seeded extrapulmonary

sites (e.g., endocarditis, septic arthritis,

meningitis)?

d. Has the patient acquired a new

nosocomial infection (e.g., urinary tract

infection, central line infection, sinusitis)?

How should a patient with nonresolving

pneumonia be evaluated?

The clinician should review initial culture

results and sensitivities and collect

additional lower respiratory tract and blood

cultures.

Broadening empiric therapy may be

indicated while awaiting results of

additional testing.

All patients should have a repeated chest

radiograph at this time.

Additional history may reveal HIV risk

factors, tick exposure, travel history, or

other diagnostic clues.

Further testing, such as a chest computed

tomographic or ultrasound scan, should

be directed at the likely cause of treatment

failure.

If the procedure can be performed safely,

a thoracentesis of a pleural effusion can

exclude a complicated effusion or

empyema.

Bronchoscopy has good diagnostic utility,

and specimens should be sent for

quantitative bacterial cultures and

sensitivities, as well as for stains and

cultures of unusual organisms

(mycobacteria, viruses,endemic fungi, and

P. jiroveci ).

If the diagnosis remains elusive, a trial of

corticosteroids or a thoracoscopic or

open lung biopsy may be considered in

the appropriate clinical setting.

Noninfectious processes present

with signs and symptoms of acute

pneumonia

include ARDS, traumatic pulmonary contusion,

pneumonitis resulting from connective tissue

disease (e.g Noninfectious conditions that can

mimic acute pneumonia., systemic lupus

erythematosus), acute hypersensitivity

pneumonitis, drug-induced pneumonitis, diffuse

alveolar hemorrhage (e.g., Goodpasture

syndrome), Wegener granulomatosis, bronchiolitis

obliterans .

Noninfectious processes present

with signs and symptoms of acute

pneumonia

Organizing pneumonia, acute interstitial

pneumonia (Hamman-Rich syndrome), acute

eosinophilic pneumonia, pulmonary embolism with

infarction, atelectasis, chemical pneumonitis

(aspiration), and malignancy (e.g., bronchoalveolar

carcinoma, lymphangitic carcinomatosis, Kaposi

sarcoma).

Hospital-acquired pneumonia (HAP),

health care associated pneumonia

(HCAP), and ventilator-associated

pneumonia (VAP)?

HAP Hospital-acquired pneumonia

is defined as pneumonia that occurs 48

hours or more after admission, which was

not incubating at the time of admission.

HCAP

{health care associated pneumonia}Refers to pneumonia that develops in a

patient who lives in a nursing home or long-

term care facility; undergoes hemodialysis;

has received IV antimicrobial therapy,

chemotherapy, or wound care within the

preceding 30 days

or has been hospitalized for at least 2 days

within the preceding 90 days.

The causative pathogens in

these patients are similar to

those responsible for HAP and

VAP and are often

Multidrug resistant (MDR).

VAP:

Universally agreed-on diagnostic criteria for VAP do

not exist; however, commonly used criteria include the

presence of all of the following:

1. Mechanical ventilation for > 48 hours.

2. A new and persistent infiltrate on chest radiograph or

ARDS; in the setting of ARDS, it may be impossible to

visualize a new infiltrate on chest radiograph.

3. Two of the following three findings:

a. Fever (temperature >38.3" C)

b. Leukocytosis or leukopenia

c. Purulent tracheal secretions

4. Quantitative cultures of a lower respiratory tract

specimen at or above the threshold defined as consistent

with lung infection.

The use of clinical criteria alone without microbiologic

data tends to overdiagnose lung infection.

How do you decide on the initial

empiric antibiotic therapy for

HAP,HCAP, or VAP?If the patient has late-onset pneumonia

development (25 days) or risk factors for MDR

pathogens, then broad-spectrum antibiotic

therapy is indicated.

If neither of these criteria is met,limited-

spectrum antibiotic therapy is appropriate. If

HAP, VAP, or HCAP is suspected, disease

severity is not considered in the initial empiric

antibiotic decision.

Risk factors for MDR pathogens

causing HAP, HCAP,and VAP?

Riskfactors for MDR causing HAP, HCAP,

and VAP include antimicrobial therapy in

the preceding 90 days, current

hospitalization of 5 days or more, high

frequency of antibiotic resistance in the

community or in the specific hospital unit,

immunosuppressive disease

and/or therapy, or presence of risk factors

for HCAP

Risk factors for MDR pathogens

causing HAP, HCAP,and VAP?

and/or therapy, or presence of risk factors

for HCAP (hospitalization for 2 days or

more in the preceding 90 days,residence

in a nursing home or extended-care facility,

home infusion therapy [including

antibiotics], long-term dialysis within 30

days, home wound care, family member

with MDR pathogen).

What initial empiric antibiotic therapy is

recommended for HAP, HCAP, or VAP in

patients with no known risk factors for

MDR, early onset pneumonia

development, and any disease severity?

Recommended antibiotics include

ceftriaxone, levofloxacin (moxifloxacin or

ciprofloxacin can replace levofloxacin),

ampicillin-sulbactam, or ertapenem.

What initial empiric antibiotic therapy is

recommended for HAP, HCAP, or VAP in

patients with no known risk factors for

MDR, early onset pneumonia

development, and any disease severity?

Potential pathogens include S.pneumoniae,

H. influenzae, methicillin-sensitive S. aureus,

and antibiotic-sensitive enteric gram negative

bacilli

(Escherichia coli, Klebsiella pneumoniae,

Enterobacter, Proteus, Serratia marcescens).

What initial empiric antibiotic therapy is

recommended for HAP, HCAP, or VAP in patients with

known risk factors for MDR, late-onset disease

development, and any disease severity?

Recommended combination antibiotic therapy includes

an :

Antipseudomonal cephalosporin

(cefepime or ceftazidime)

Antipseudomonal carbapenems

(imipenem or Meropenem)

or p-lactam-p-lactamase inhibitor

(piperacillin-tazobactam)

plus an antipseudomonal fluoroquinolone

(ciprofloxacin or levofloxacin)

or an aminoglycoside

(amikacin, gentamicin, or tobramycin).

What initial empiric antibiotic therapy is

recommended for HAP, HCAP, or VAP in

patients with known risk factors for MDR,

late-onset disease development, and any

disease severity?

Linezolid or vancomycin should be added if

MRSA risk factors are present or there is a

high incidence locally.

Potential MDR pathogens include P.

aeruginosa, K. pneumoniae, Acinetobacter

species, and MRSA

Some specific treatment strategies for MDR

Pseudomonas, Acinetobacter, and MRSA VAP?

Combination therapy for P. aeruginosa pneumonia

remains controversial.

Resistance is mediated partly by multiple efflux

pumps.

Acinetobacter species are most sensitive to

the carbapenems, sulbactam, colistin, and

polymyxin.

More than 85% of

Acinetobacter species isolates are

susceptible to carbapenems, but resistance is

increasing because of either integral membrane

protein (IMP)-type metalloenzymes or

carbapenemases of the oxacillinase (OXA) type.

MRSA produces a penicillin-binding protein with

reduced affinity for p-lactam antibiotics.

Linezolid is an alternative to

vancomycin for the treatment of

MRSA VAP.

Measures which can be taken to

decrease the risk of VAP?1. Avoid intubation when possible, and apply

noninvasive positive-pressure ventilation when

appropriate.

2. Use orotracheal tubes preferentially over

nasotracheal tubes.

3. Minimize the duration of mechanical ventilation

with the aid of weaning protocols.

4. Apply continuous aspiration of subglottic

secretions.

5. Maintain an endotracheal tube cuff pressure >20

cm H20 to prevent leakage of oropharyngeal

secretions containing bacteria into the lungs.

6. Avoid unnecessary manipulation of the ventilator

circuit.

7. Carefully discard contaminated condensate from

the ventilator circuit.

8. Keep the head of the bed elevated by 30

degrees.

9. Avoid heavy sedation and paralytics because

they impair the patient's ability to cough.

10. It does not appear that sucralfate or

therapies that decrease gastric acid increase

the incidence of nosocomial pneumonia.

When to continue, de-escalate, and

discontinue the use of antibiotic treatment

on the basis of clinical response and culture

data?

When HAP, VAP, or HCAP is suspected,

consider obtaining lower respiratory tract

samples for culture

(quantitative or semiquantitative) and

microscopy.

Unless there is both a low clinical suspicion

for pneumonia and negative microscopy of

the lower respiratory tract sample

Begin empiric antimicrobial therapy.

At day 2 and 3, check cultures and

assess clinical response(temperature, white blood cell [WBC] count,

chest radiograph, oxygenation, purulent sputum

,hemodynamic changes, and organ function).

If no clinical improvement is seen after 2 to

3 days with negative cultures, search for

other pathogens, complications, diagnoses,

or sites of infection.

If clinical improvement is noted after 2 to 3 days

but cultures are negative

consider stopping antibiotics.

If clinical improvement is noted

and cultures are positive, de-

escalate antibiotics, and consider

treating selected patients for 7 to

8 days and reassess

How long should you continue

antibiotic management for HAP,

HCAP, or VAP?

In a prospective, randomized clinical trial, an 8-

day treatment strategy for culture-proved

VAP resulted in a significant decrease in

multiresistant bacteria and more antibiotic-free

days with no differences in mortality, ICU length of

stay, or mechanical ventilator-free days when

compared with a 15-day regimen.

A higher rate of recurrence was

documented with the 8-day regimen

when the infection was due to

Acinetobacter or Pseudomonas

therefore VAP due to these

organisms should be treated for 15

days.

Because the infecting pathogens are

similar, HAP and HCAP can be treated

similarly.

Extended therapy

(14-21 days) may be

indicated in the setting of

Multilobar disease,

Cavitation, Malnutrition, or

Necrotizing gram-negative

infection

SUMMARY

1. Treat empirically if pneumonia is clinically

suspected.

2. Select the initial empiric therapy on the basis of

the current bacteriology and resistance patterns

at each institution.

3. Obtain cultures of respiratory tract specimens

to identify pathogen(s), preferably before initiation

of antibiotics.

However, the administration of antibiotic therapy

should not be delayed for diagnostic testing.

4. Narrow the initial antibiotic regimen on the

basis of quantitative culture results and clinical

response (de-escalation).

5. Avoid excessive antibiotic use by de-escalating

therapy when appropriate and prescribing the

minimal duration of therapy required for efficacy.

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamir@yahoo.com

GOOD LUCK

Global Critical Carehttps://www.facebook.com/groups/1451610115129555/#!/groups/145161011512

9555/ Wellcome in our new group ..... Dr.SAMIR EL ANSARY