Community-acquired Pneumonia Alan D Tice, MD, FACP Infections Limited Tacoma, Washington University of Washington What is Your Specialty? Primary care Medical specialist Surgery Gynecology Nurse Physician assistant Primary Patient Care Site Hospital Intensive Care Clinic Skilled nursing facility Home care How young are you? 30-40 years 40-50 50-60 60-70 70-80 How many cases of pneumonia have you cared for in the last year? None 1-5 6-10 11-20 More Community-acquired pneumonia • Symptoms consistent with lung infection • New pulmonary infiltrate • Acquired outside the hospital Community-Acquired Pneumonia • 2-3 million cases/year • 500,000 hospitalizations/year • 45,000 deaths/year – the most lethal infection – 14% of those hospitalized die • 10 million physician visits/year • Frequent reason for antibiotic use Recent Developments in C A P • • • • • Antimicrobial resistance New antibiotics New microbiology/technology Managed care Information management Microbiology of C A P • Pathogens – Broad range – Many still unknown – Coinfections • Rapid diagnostic testing • Susceptibility reporting – Alexander project, others Causative pathogens in 5,961 adults admitted to hospital with CAP identified in 26 prospective studies from 10 European countries S pneumoniae C pneumoniae Viral Mycoplasma pneumoniae Legionella sp H influenzae G-neg enterobacteria C psittacii Coxiella burnetii Staph aureus M catarrhalis Other Woodhead M Chest 1998;183S-187S 10 15 20 25 30 Future Therapy of C A P • Rapid access to information – About patient – Likely pathogens and susceptibilities • Microbiology laboratory – Identification of pathogen – Susceptibility testing • Antibiotic – One dose – Good penetration • Real time decision making I D Resources • PubMed • ProMed • IDLinks.com – CDC – WHO – IDSA • Medscape • icanPREVENT IDSA Empirical Antibiotic Selection for Patients with C.A.P Outpatients – Generally preferred: Macrolides, fluoroquinolones, or doxycycline – Modifying factors • Suspected penicillin-resistant Streptococcus pneumoniae: fluoroquinolones • Suspected aspiration: amoxicillin/clavulanate • Young adult (>17-40 y): doxycycline IDSA Empirical Antibiotic Selection for Patients with C.A.P Hospitalized patients – General medical ward • Generally preferred: β-lactam with or without a macrolide or a fluoroquinolone (alone) • Alternatives: cefuroxime with or without a macrolide or azithromycin (alone) – Hospitalized in the intensive care unit for serious pneumonia • Generally preferred: erythromycin, azithromycin, or a fluoroquinolone plus cefotaxime, ceftriaxone, or a β -lactam/β lactamase inhibitor – Modifying factors • Structural disease of the lung: antipseudomonal penicillin, a carbapenem, or cefepime plus a macrolide or a fluoroquinolone plus an aminoglycoside • Penicillin allergy: a fluoroquinolone with or without clindamycin • Suspected aspiration: a fluoroquinolone plus either clindamycin or metronidazole or a β -lactam/β -lactamase inhibitor (alone) Community-Acquired Pneumonia: Incidence Description Annual Cases in US Outpatient 3.5 million Requires hospitalization 0.5 million S pneumoniae bacterium 75,000 Stratification of Risk Score Risk Risk class I Low II III Moderate High V Based on Algorithm < 70 total points 71-90 total points IV 91-130 total points > 130 total points Bacteriology of Hospital-Acquired Pneumonia Early-Onset Pneumonia Late-Onset Pneumonia Other S pneumoniae P aeruginosa Anaerobic bacteria H influenzae Enterobacter sp Legionella pneumophilia Moraxella cattarrhalis Acinetobacter SP Influenza A and B S aureus K pneumoniae Respiratory syncitial virus Aerobic gram-negative bacilli S marcenscens E coli Other gram-negative bacilli S aureus Fungi Algorithm Patient with community-acquired pneumonia Is the patient > 50 years of age Yes No Does the patient have a history of any of the following comorbid conditions ? Neoplastic disease Congestive heart failure Cerebrovascualr disease Renal disease Liver disease Yes No Does the patient have a history of any of the following abnormalities on physical examination Altered mental status Pulse ≥ 125 / minute Respiratory rate ≥30 / minute Systolic blood pressure < 90 mmHg Temp < 35° C or ≥40° C No Assign patient to risk class I Yes Assign patient to risk class II-V based on prediction mosel scoring system Relationship of Performance of Quality Indicators to 30-Day Mortality Study Set Unadjusted OR (95% Confidence P Quality Indicator interval P Value Adjusted OR (95% Confidence Interval) Initial antibiotics within h 0.85 (0.76-0.95)