ESISTONO LE HCAP? Francesco Blasi Sezione Medicina Respiratoria Dipartimento Toraco Polmonare e Cardiocircolatorio Università degli Studi di Milano
Community-acquired pneumonia (CAP): Management issues 1. 1. Diagnosis of of CAP 2. 2. Need for Hospitalisation 3. 3. Respiratory Isolation 4. 4. Microbiological Workup 5. 5. Empiric Therapy 6. 6. Switch Therapy 7. 7. Patient Education 8. 8. Satisfaction with Care 9. 9. Clinical Outcome 10. Hospital Discharge 11. Prevention of CAP
Classically pneumonia... Likely organism Community-acquired pneumonia S. pneumoniae Atypicals H. influenzae H Hospital-acquired pneumonia HA-MRSA P. aeruginosa HA-MRSA, hospital-acquired MRSA Mandell et al. Clin Infect Dis 2007;44:S27
Rapid emergence of MDR pathogens in CAP Likely organism Community-acquired pneumonia Nursing home Dialysis / home IV Hospitalisation Previous ABT S. pneumoniae Atypicals H. influenzae P. aeruginosa ESBL+ GNB CA-MRSA Hospital-acquired pneumonia HA-MRSA P. aeruginosa MDR, multi-drug resistant; ESBL, extended-spectrum beta lactamases; GNB, Gram-negative bacteria; CA-MRSA, community-acquired MRSA; HA-MRSA, hospital-acquired MRSA Mandell et al. Clin Infect Dis 2007;44:S27
ATS / IDSA guidelines for HA, VAP and HCAP, Am J Respir Crit Care Med 2005
Do we believe in HCAP? Koleff M et al., Clin Infect Dis 2008
HCAP: what is behind?
HCAP: original defintion ATS / IDSA guidelines for HA, VAP and HCAP, Am J Respir Crit Care Med 2005
HCAP: the original concept ATS / IDSA guidelines for HA, VAP and HCAP, Am J Respir Crit Care Med 2005
HCAP: bad prognosis, of course Koleff M et al., Chest 2005
HCAP: what you get is what you put in Previous hospitalization NHAP Immunosuppression Antibiotics Dialysis Infusions MDR
When HCAP = resistant pathogens, predictive values of HCAP are poor Shorr AF et al., Arch Intern Med 2008 (Zilberberg, Micek, Kollef)
The origin of the HCAP concept Notion that patients with HCAP compared with those with CAP have a different microbial pattern receive inadequate antimicrobial treatment more frequently have a significant excess mortality need to be managed aggressively in order to reduce excess mortality
HCAP is present: From a nursing home, recent hospitalisation, haemodialysis, home infusion therapy Assess severity of illness (need for mechanical ventilation, ICU admit) AND Presence of risk factors for MDR pathogens (recent antibiotics, recent hospitalisation, poor functional status, immune suppression) Severe pneumonia No Yes 0 1 Risks 2 Risks 0 Risks 1 Risk Treat for common CAP pathogens (consider oral Rx) quinolone or betalactam/macrolide Consider hospital. Treat for MDR pathogens with HAP therapy Treat for severe pneumonia in hospital. Beta-lactam PLUS macrolide or quinolone Treat for MDR pathogens with HAP recommendations. Use 3 drugs HCAP, healthcare-associated pneumonia; MDR, multi-drug resistant
Community-acquired pneumonia: Management issues 1. 1. Diagnosis of of CAP 2. 2. Need for Hospitalisation 3. 3. Respiratory Isolation 4. 4. Microbiological Workup 5. 5. Empiric Therapy 6. 6. Switch Therapy 7. 7. Patient Education 8. 8. Satisfaction with Care 9. 9. Clinical Outcome 10. Hospital Discharge 11. Prevention of of CAP
Fine class IV or V CAP patients included in a multicentre, interventional, before-and-after study: 1. retrospective phase (1443 patients) 2. guideline implementation phase 3. prospective phase (1404 patients) OR 0.73 (95% CI 0.69 1.00) p=0.049 After protocol implementation, 44% compliance with guideline recommendations (was 33%)
Favourable clinical outcomes (by initial treatment, all phases) 90 80 70 60 79.1* 70.9 68.6 72.2 78.8 76.7 75.5 73.4 66.4 70.5 50 (%) 40 30 20 10 0 Beta-lactams Other Cephalosporin + macrolide Beta-lactam + macrolide Other combinations Levofloxacin Cephalosporins Levofloxacin + Beta-lactam Levofloxacin + other Beta-lactam + other *p=0.023 (multiple logistic regression) OR for failure: 0.64 (95% IC 0.44-094) levofloxacin vs. ceftriaxone
16.2% 9.1% 15.9% 5.7% 12.2%
p<0.001 In-hospital mortality, % p<0.001 p<0.001 p=0.7 5 p<0.001 p=0.6 7 Pneumonia Severity Index Class McCabe et al. Arch Intern Med 2009;169:1525
Less likely to reach clinical stability within 1 week Antimicrobial treatment More likely to reach clinical stability within 1 week HR (95% CI) p value Adherence vs. undertreatment Adherence vs. overtreatment Antimicrobial treatment Higher risk class Admitted to ICU Multilobar infiltrate Pulmonary effusion Altered mental status Tachypnea Hypotension Antimicrobial treatment Antibiotics within 8 hours Pneumococcal vaccine evaluation Blood cultures obtained Oxygen assessment Arnold et al. Arch Intern Med 2009;169:1515 Relative risk of reaching clinical stability within 1 week (95% CI) 1.44 (1.25 1.65) 1.33 (1.08 1.63) <0.01 <0.01 0.81 (0.71 0.94) <0.01 0.60 (0.46 0.77) <0.01 0.82 (0.70 0.95) <0.01 0.96 (0.83 1.12) 0.65 0.64 (0.53 0.77) <0.01 0.82 (0.70 0.96) 0.02 1.02 (0.76 1.38) 0.88 1.25 (1.08 1.44) 1.17 (1.04 1.32) 0.98 (0.86 1.11) 0.82 (0.62 1.08) <0.01 0.10 0.73 0.15
Antimicrobial treatment Adherence vs. undertreatment Adherence vs. overtreatment Antimicrobial treatment Higher risk class Admitted to ICU Multilobar infiltrate Pulmonary effusion Altered mental status Tachypnea Hypotension Antimicrobial treatment Antibiotics within 8 hours Pneumococcal vaccine evaluation Blood cultures obtained Oxygen assessment Relative risk of death (95% CI) HR (95% CI) 0.62 (0.43 0.89) 0.51 (0.33 0.79) 3.13 (1.50 6.52) 1.37 (0.92 2.03) 1.43 (1.03 2.00) 1.56 (1.09 2.24) 3.45 (2.47 4.82) 1.49 (1.07 0.84 2.09) (0.54 1.32) 1.91 (1.12 0.59 2.36) (0.41 0.84) 0.89 (0.63 1.27) 1.71 (0.47 6.24) P value <0.01 <0.01 <0.01 0.12 0.04 0.02 <0.01 0.02 0.49 0.02 <0.01 0.53 0.41 Arnold et al. Arch Intern Med 2009;169:1515
STRATIFYING RISK FACTORS FOR MULTI-DRUG RESISTANT PATHOGENS IN HOSPITALIZED PATIENTS COMING FROM THE COMMUNITY WITH PNEUMONIA Authors Stefano Aliberti, Marta Di Pasquale, Anna Maria Zanaboni, Roberto Cosentini, Anna Maria Brambilla, Sonia Seghezzi, Paolo Tarsia, Marco Mantero and Francesco Blasi Clinical Infectious Diseases in press
Among the 935 patients enrolled in the study, 473 (51%) had at least one risk factor for MDR on admission. Among all the risk factors for MDR, previous hospitalization in the preceding 90 days (OR: 4.87, 95%CI: 1.90-12.4, p=0.001) and residency in a nursing home (OR: 3.55; 95% CI: 1.12-11.24, p=0.031) were independent predictors for an actual infection with a resistant pathogen.
Hospitalization in the preceding 90 days and residency in a nursing home were also independent predictors for inhospital mortality. Risk factors for MDR should be weighted differently and a probabilistic approach in identifying resistant pathogens among patients coming from the community with pneumonia should be embraced.
Community-acquired pneumonia: Management issues 1. 1. Diagnosis of of CAP 2. 2. Need for Hospitalisation 3. 3. Respiratory Isolation 4. 4. Microbiological Workup 5. 5. Empiric Therapy 6. 6. Switch Therapy 7. 7. Patient Education 8. 8. Satisfaction with Care 9. 9. Clinical Outcome 10. Hospital Discharge 11. Prevention of of CAP
CAPNETZ Hospital mortality 2006: Mortality during course of hospital stay Hazard-Ratio for different CRB-65-Classes in 2006 22% 20% 18% 16% HR 14% 12% 10% 8% 6% 4% 2% CRB-65=0 CRB-65=1 CRB-65=2 CRB-65=3 CRB-65=4 0% 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Hospital Stay (days)
Alberti. Chest 2008;134:955
Clinical failure in CAP CHF, congestive heart failure; AECB, acute exacerbation of chronic bronchitis; CVC, central venous catheter; ARF, acute renal failure; GI, gastrointestinal Alberti. Chest 2008;134:955
Ramirez. Clin Infect Dis 2008;47:182 Cardiovascular events in CAP
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