PNEUMONIE - lunge-eichgraben.atfür+die... · In this case-control study of Medicare ... Enteric Gram-negatives residence in nursing home ... Defining community acquired pneumonia

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K.Mühlbacher Krankenhaus Hietzing

Abteilung für Atemwegs-und Lungenerkrankungen

PNEUMONIE FIT FÜR DIE PRAXIS

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Pneumonia: still the old man’s friend? Kaplan V, Clermont G, Griffin MF, et al. Arch Intern Med 2003; 163:317–323

In this case-control study of Medicare patients with CAP, with five control subjects matched for age, sex, and race with each case, the in-hospital and 1-year mortality rates for patients with CAP were significantly higher than those for control subjects.

ALL DIFFERENCES WITH p < 0.001

0 Hospital Mortality

1 Year Mortality

5

10

15

20

25

30

35

40

45

CAP

Control

CAP ist keine selbst-limitierende Erkrankung, 1-Jahres Mortalität ist 4-fach höher als die Spitals- mortalität

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Long-term Symptom Recovery and Health-Related Quality of Life in Patients With Mild-to-Moderate-Severe Community-Acquired Pneumonia Rachida el Moussaoui et al. Chest 2006; 130: 1165-1172

Symptom recovery of patients with CAP. Top left, A: overall CAP scores, expressed as medians, IQRs, and tenth/ninetieth percentiles. Top right, B: the respiratory score contains the CAP items dyspnea, coughing and sputum. Bottom, C: the well-being score contains the CAP items fitness and general state of health. Day -30 represents the prepneumonia level, at day 0 antibiotic therapy is started, and day 540 is the end of the follow-up period.

-20

0

20

40

60

80

100

120

Day-30

83

Day0

85

Day3

73

Day7

90

Day10

58

Day14

58

Day28

81

Day180

80

Day540

53 N=

A

CAP score Respiratory score Well beeing score

-20

0

20

40

60

80

100

120

Day-30

83

Day0

85

Day3

73

Day7

90

Day10

58

Day14

58

Day28

81

Day180

80

Day540

53 N=

A

-20

0

20

40

60

80

100

120

Day-30

83

Day0

85

Day3

73

Day7

90

Day10

58

Day14

58

Day28

81

Day180

80

Day540

53 N=

A

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KLINISCHE KLASSIFIKATION

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Definition

NOSOKOMIALE PNEUMONIE (HAP)

Lungenentzündung, die weder bei der Aufnahme bestand noch in der Inkubationszeit war – eine Spitals- infektion, die sich ab dem dritten Tag nach Aufnahme und bis zu 7 Tage nach der Entlassung des Patienten manifestieren kann.

AMBULANT ERWORBENE PNEUMONIE (CAP)

Lungenentzündung eines immunkompetenten Patienten, wenn Erreger im privaten oder beruflichen Umfeld außerhalb eines Krankenhausaufenthaltes akquiriert wurden.

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Epidemiology and Outcomes of Health-care–Associated Pneumonia Marin H. Kollef, Andrew Shorr, Ying P. Tabak, Vikas Gupta, Larry Z. Liu and R. S. Johannes CHEST 2005; 128: 3854–3862

Definition

HEALTH-CARE-ASSOCIATED PNEUMONIA • Hospitalisierung > 2 Tage in den letzten 90 Tagen • Heimbewohner • ambulante Infusionstherapie • Dialyse innerhalb der letzten 30 Tage • ambulante Wundbehandlung • Kontakt mit Familienangehörige, die mit resistenten

Keimen infiziert sind

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Mean mortality rates in patients with CAP, HCAP, HAP, and VAP

0 CAP

(n=2221) HCAP

(n=988) HAP

(n=835) VAP

(n=499)

Mo

rta

lity

rate

(%

pati

en

ts)

5

10

15

20

25

30

P<0.0001

P<0.0001

P>0.05

10.0 19.8 18.8 29.3

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ANTIBIOTIKA VERBRAUCH

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Outpatient antibiotic use in Europe and association with resistance: a cross-national database study Herman Goossens, Matus Ferech, Robert Vander Stichele, Monique Elseviers Lancet 2005; 365: 579–87

Total outpatient antibiotic use in 26 European countries in 2002

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Seasonal variation of total outpatient antibiotic use in ten European countries between 1997 and 2002

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CAP

• CAP in den Industrieländern die vierthäufigste Todesursache.

• 20-30% müssen im Verlauf ihrer Erkrankung stationär aufgenommen werden – davon ca. 10% intensivmedizinisch behandelt werden.

• Die Letalität der CAP liegt bei 2% und 21% und kann bei schweren Verläufen bzw. signifikanten Komorbiditäten bis auf 50 % ansteigen.

Inzidenz: Allgemeinbevölkerung: 8-15/1000 EW/Jahr Altersgruppe >65: 25-44/1000 Pflegeheimpatienten: ca. 68-114/1000

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community acquired pneumonia

The computed-tomography scan (b) shows typical findings of consolidation, where air bronchogram is visible and blood vessels are indistinguishable from consolidated lung.

(b)

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ERREGER- SPEKTRUM

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Experten-Statement CAP (2002) F. Thalhammer et al.

Ätiologie der CAP

Das Erregerspektrum der ambulant erworbenen Pneumonie (CAP) hat sich in den letzten Jahren nicht wesentlich verändert: Immer noch stehen Pneumokokken (Streptococcus pneumoniae) mit etwa der Hälfte aller Fälle klar an der Spitze, gefolgt von Hämophilus influencae und Viren.

Analyse von 16 Studien von >3300 hospitalisierten Patienten (1960-1987)

S. aureus: 5,7

Chlamydien

3,7%

Legionellen

5,2%

Gramnegative

Stäbchen

6,8Mycoplasmen

6,7

S. pneumoniae

44,9

H. influencae

14,3

12,6viral

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Morphologie

http://de.wikipedia.org/wiki/Bild:Klebsiella-pneumoniae.jpg

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Community-acquired pneumonia: what is relevant and what is not? Arunabh Talwar, Hans Lee and Alan Fein Curr Opin Pulm Med 2007; 13: 177–185

Most common etiologies of community-acquired pneumonia

a Influenza A and B, adenovirus, Respiratory Syncitial Virus; parainfluenza.

Ambulatory patients: Streptococcus pneumoniae, Mycoplasma pneumonia, Haemophilus influenzae, Chlamydia pneumoniae, respiratory virusesa

Hospitalized patients: Strep. pneumoniae, M. pneumonia, H. influenzae, C. pneumoniae, aspiration, respiratory virusesa, Legionella spp.

Severe (ICU admission): Strep. pneumoniae, Legionella spp., Staphylococcus aureus, Gram-negative bacilli, H. influenzae

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A Worldwide Perspective of Atypical Pathogens in Community-acquired Pneumonia Forest W. Arnold et al. Am J Respir Crit Care Med 2007; 175: 1086–1093

THE INCIDENCE OF ATYPICAL PATHOGENS, AND THE PROPORTION OF PATIENTS TREATED WITH ANTIMICROBIAL THERAPY FOR ATYPICAL

PATHOGENS

Definition of abbreviation: CAP = community-acquired pneumonia

Globally Region I

United States, Canada Region II Europe

University of Louisville Infectious Diseases Atypical Pathogens Reference Laboratory Database

Total patients with CAP 4,337 3,302 501

No. patients with atypical pathogens

975 724 140

Incidence of atypical pathogens

22% 22% 28%

Mycoplasma pneumoniae 12% 11% 15%

Chlamydia pneumoniae 7% 8% 7%

Legionella pneumophila 5% 4% 9%

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THE INCIDENCE OF ATYPICAL PATHOGENS, AND THE PROPORTION OF PATIENTS TREATED WITH ANTIMICROBIAL THERAPY FOR ATYPICAL

PATHOGENS

Definition of abbreviation: CAP = community-acquired pneumonia; CAPO = Community-Acquired Pneumonia Organization.

Globally Region I

United States, Canada Region II Europe

The CAPO Database

Total patients with CAP 2,878 1,408 782

No. patients with atypical pathogens

2,220 1,292 582

Proportion of patients treated for atypical pathogens

77% 91% 74%

Viral Community-Acquired Pneumonia in Nonimmunocompromised Adults Andrés de Roux, Maria A. Marcos, Elisa Garcia, Jose Mensa, Santiago Ewig, Hartmut Lode and Antoni Torres Chest 2004; 125; 1343-1351

Monthly distribution of viral infections of 338 CAP events with valid paired viral serologies.

0 J

pure viral CAP, n=26

all detected viruses

in CAP events, n=61

F M A M J J A S O N D

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

months

N=

Clinical correlates of pure viral pneumonia: • heart failure • absence of expectoration • 58% PSI IV-V (none died)

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New guidelines for the management of adult community-acquired pneumonia Kathryn Armitage and Mark Woodhead Curr Opin Infect Dis 2007; 20: 170–176

Modifying factors that increase the risk of infection with specific pathogens (American Thoracic Society guidelines)

Penicillin-resistant and drug-resistant pneumococci

age >65 years ß-lactam therapy in past 3 months alcoholism immune-suppressive illness (including steroids) multiple medical comorbidities exposure to child in day care centre

Enteric Gram-negatives residence in nursing home underlying cardiopulmonary disease multiple medical comorbidities recent antibiotic therapy

Pseudomonas aeruginosa structural lung disease corticosteroid therapy (>10mg day) broad spectrum antibiotics of >7 days in past month malnutrition

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STRATIFIZIERUNG

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Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia Drahomir Aujesky, Thomas E. Auble, Donald M. Yealy, Roslyn A. Stone, D. Scott Obrosky, Thomas P. Meehan, Louis G. Graff, Jonathan M. Fine, Michael J. Fine The American Journal of Medicine 2005; 118: 384-392

Risk Class Assignment based on the Pneumonia Severity Index

Age Men Women Nursing home resident Coexisting illnesses Neoplastic disease Liver disease Congestve heart failure Cerebrovascular disease Renal disease Physical examination findings Altered mental status Respiratory rate 30/min Systolic blood pressure < 90 mm Hg Temperature < 35ºC or 40°C Pulse 125/min. Laboratory and radiographic findings Arterial pH < 7.35 BUN 30 mg/dl (11 mmol/l) Sodium < 130 mmol/l Glucose 250 mg/dl (14 mmol/l) Hematocrit < 30% Partial pressure of arterial oxygen <60 mmHg or oxygen saturation < 90% on pulse oximetry Pleural effusion

Points assignments correspond with the following risk classes: 70 class II, 71-90 class III. 91-130 dass IV, >130 class V

Characteristic

Point Assigned

Age (yr)

Age (yr) –10 +10

+30 +20 +10 +10 +10

+20 +20 +20 +15 +10

+30 +20 +20 +10 +10 +10

+10

STEP 2 Presene of 1 of the following characteristics? Age > 50 years Neoplastic disease Congestve heart failure Cerebrovascular disease Renal disease Liver disease Altered mental status Pulse 125/min. Respiratory rate 30/min Systolic blood pressure < 90 mm Hg Temperature < 35ºC or 40°C

STEP 1

Assign patient to risk class I

NO

Assign patient to risk class

II-V according to step 2

YES

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Pneumonia Severity Index score risk classification

a Risk class I: age <50 years, no comorbidities and absence of vital sign abnormalities.

Risk class Points Mortality (%) Site of care

Group I a

0.1 Outpatient

Group II Score <70 0.6 Outpatient

Group III Score 71–90 2.8 Outpatient/Brief inpatient

Group IV Score 91–130

8.2 Hospital admission

Group V Score >130 29.2 Hospital admission

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Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study Lim WS, van der Erden MM, Laing R, et al. Thorax 2003;58:377-382

Risk Class Assignment based on the CURB Severity Scores

Characteristics CURB Severity Score

Point Assigned

CURB-65 Severity Score

Point Assigned

Respiratory rate 30/min. 1 1

diastolic blood pressure 60 mmHg or systolic blood pressure <90 mmHg

1 1

BUN > 19 mg/dl (7 mmol/l) 1 1

Presence of confusion (defind by an Abbreviated Mental Test Score 8 or disorientation in person, place, or time)

1 1

Age 65 years - 1

The CURB and CURB-65 total scores are calculated by adding the individual assigned points together. Patients with 0 points are assigned to risk stratum 0, those with 1 point to risk stratum 1, etc.

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CAP Risikostratifizierung

beide Scoring-Systeme ermöglichen eine Abschätzung der Krankheitsschwere, jedoch aus unterschiedlichen

Perspektiven

geringes Risiko

hohes Risiko

klinische Einschätzung

PSI CURB-65

Risikostratifizierung

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Cost and Incidence of Social Comorbidities in Low-Risk Patients With Community-Acquired Pneumonia Admitted to a Public Hospital Christopher H. Goss, Gordon D. Rubenfeld, David R. Park, Vandy L. Sherbin, Michelle S. Goodman and Richard K. Root Chest 2003; 124; 2148-2155

Characteristics of patients with low-risk CAP who do not have overt reasons for admission

R/O TB = ruled out for tuberculosis on admission with serial sputums for acid-fast bacilli; R/O PCP = ruled out for Pneumocystis carinii at admission with sputum induction or bronchoscopy; IVDA = Fever recent IV drug use and fever on admission; Alcohol >50 = blood alcohol level >50 mg/dL on admission; H/O alcohol = history of alcoholism as determined by the admitting physician; Tox Pos = urine toxicity screen positive for sedative hypnotic drugs or stimulants, in addition to methadone use and noninjection cocaine use; Vomit = recent vomiting prior to admission; 3 or more = three or more of the patient traits listed.

44

33

7 7

20

49

20

2833

0

10

20

30

40

50

60

Homeless Homeless Homeless IVDA Fever

Alcohol >50

H/O Alcohol.

Tox Pos.

Vomit 3 or more

% o

f P

ati

en

ts w

ith

trait

Patients Traits

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Algorithm 1: British Thoracic Society scheme for the management of community-acquired pneumonia

Prognostic Factors: Confusion Urea concentration > 7 mmol/l (19.6 mgdl) Respiratory rate > 30/min. Blood pressure (Systolic < 90 mmHg or Diastolic < 60 mmHg) > 65 yrs.

0 or 1 2 3 or more

Group 1 Low mortality

(1.5%)

Group 2 Intermediate

mortality (9.2%)

Group 3 High mortality

(22%)

Probable outpatient treatment

Consider supervised treatment: Short admission Supervised outpatient treatment.

In-hospital treatment: ICU admission for patients

with scores > 3.

CURB-65 SCORE

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The role of new therapies for severe community-acquired pneumonia Marcos I. Restrepoa and Antonio Anzuetoa Curr Opin Infect Dis 2006; 19: 557–564

American Thoracic Society modified criteria

The presence of at least one major criterion or at least two minor criteria defines a pneumonia severe enough to require ICU admission.

Major criteria

• Need for mechanical ventilation

• Requiring vasopressors (septic shock)

Minor criteria

• Respiratory rate >30 breaths per minute

• PaO2/FiO2 ratio<250

• Bilateral or multilobar infiltrates

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DIAGNOSE

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Diagnostik

• Sputum - Gram Färbung

- Zytologie

- Kultur

• Blutkultur

• Serologie - Mykoplasmen

- Legionellen

• Harn - Legionellen

- Pneumokokken

• Pleurapunktion

• CT-Lunge

Spezifität: 80% Sensitivität: 50-60%



• Keimnachweis gelingt nur in 30-50%, bei ambulanten Patienten somit nicht sinnvoll.

• Keimnachweis sinnvoll: - Auswirkung auf das

Management - Vor Entnahme noch keine

AB-Therapie - Logistik muss stimmen

(Abnahme – Lagerung – Transport – Labor)

• Indikation für Erregerdiagnostik

bei kritisch kranken Patienten (Staph. aureus, Enterobact., Pseudomonas)

Kommentar:

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Legionella pneumonia

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RADIOLOGIE

• Referenzuntersuchung für die Diagnose einer CAP.

• Limitierte Aussagekraft bezüglich kausalen Auslösern, kann aber das Ausmaß der Erkrankung und Komplikationen dokumentieren.

• Radiologische Veränderungen bilden sich meist langsamer zurück als Klinik.

„slow resolving pneumonia“ > 1 Monat. 90% von Patienten < 50 Jahre zeigen eine

Verbesserung innerhalb 4 Wochen, jedoch nur 30% der Patienten >50 Jahre.

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Influenza pneumonia

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Predicting Bacteremia in Patients with Community-Acquired Pneumonia Mark L. Metersky, Allen Ma, Dale W. Bratzler, and Peter M. Houck Am J Respir Crit Care Med 2004; 169: 342–347

BLOOD CULTURE ISOLATES FROM PATIENTS IN DERIVATION COHORT AND VALIDATION COHORT

The number of isolates is calculated on the basis of the first two blood cultures collected within 36 h of presentation. * Other contaminants include unspecified Clostridium, Micrococcus sp., Corynebacterium diptheriae, and Propionibacterium acnes.

Pathogens Streptococcus pneumoniae Escherichia coli Staphylococcus aureus Klebsiella pneumoniae Pseudomonas aeruginosa Streptococcus sp. (other) Enterococcus sp. Hemophilus influenza Viridans streptococci Other Contaminants Coagulase-negative staphylococci Corynebacterium (except C. diptheriae) Bacillus sp. Clostridium perfringens Other*

Derivation Cohort (n = 13,034)

n (%)

Validation Cohort (n = 12,771)

n(%)

Bacteria Isolated

n = 954 341 (36%) 118 (12%) 160 (17%) 35 (4%) 23 (2%) 26 (3%) 38 (4%) 27 (3%) 37 (4%)

182 (19%) n = 643

520 (89%) 28 (5%) 17 (5%) 2 (0%) 28 (5%)

n = 886 324 (37%) 121 (14%) 120 (14%) 38 (4%) 29 (3%) 27 (3%) 27 (3%) 24 (3%) 24 (3%)

195 (22%) n = 643

582 (91%) 24 (4%) 19 (3%) 13 (2%) 32 (5%)

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• Bei Patienten mit vorangegangener AB-Therapie ohne Risikofaktoren/Co-Morbiditäten scheint eine BK-Abnahme nicht erforderlich, da nur 3% der Patienten eine Bakteriämie zeigten.

• Bei Patienten ohne vorangegangener AB-Therapie ohne Co-Morbiditätten bzw. Patienten mit vorang. AB-Therapie und einem Risikofaktor sollte eine BK durchgeführt werden, da die Inzidenz einer pos BK 5%.

• Bei Patienten mit 2 Risikofaktoren (16%) oder bei Patienten mit 1 Risikofaktor und keiner vorang. AB-Therapie (9%) sollte 2 BK gemacht werden.

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Contribution of C-Reactive Protein to the Diagnosis and Assessment of Severity of Community-Acquired Pneumonia Jordi Almirall, Ignasi Bolíbar, Pere Toran, Guillem Pera, Xavier Boquet, Xavier Balanzó and Goretti Sauca Chest 2004; 125; 1335-1342

Serum CRP Values in Subjects According to Age and Sex*

*5th = 5th percentile; 95th = 95th percentile. †Men, 116 patients; women, 85 patients. ‡Men, 8 patients; women, 8 patients. Total CRP values in patients with unconfirmed CAP was based on 25 cases. §Men, 49 subjects; women, 35 subjects.

36.3

42.3

21.4

100.0

%

15-44

45-75

>75

Total

Age, yr

102.3

97.2

141.4

110.7

Median

4.0

10.9

13.6

8.0

5th

178.1

181.4

184.8

182.1

95th

Confirmed CAP†

25.0

43.8

6.3

100.0

%

31.0

33.0

149.5

31.9

Median

6.8

1.5

149.5

1.5

5th

131.3

160.1

149.5

160.1

95th

Unconfirmed CAP‡

36.9

40.5

22.6

100.0

%

1.6

1.7

5.0

1.9

Median

0.1

0.1

1.1

0.3

5th

5.4

16.7

21.7

11.0

95th

Healthy Control Subjects§

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THERAPIE

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Therapie-Empfehlungen nach Risikogruppen

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Antibiotikatherapie bei CAP nach Risikogruppen

Gruppe I Gruppe II Gruppe III

Amoxicillin

Cefadroxil

Cefalexin

Cefatamet-P.

Cefixim

Cefpodoxim

Cefuroxim-A.

3x1g

2x2g

3x1g

2x1g

1x0,4g

2x0,4g

2x1g

p.o.

p.o.

p.o.

p.o.

p.o.

p.o.

p.o.

Amoxicillin/Clac

Ampicillin/Sulb

Bacampicillin

3x1g

3x0,75g

3x0,8g

p.o.

p.o.

p.o.

Piperacillin/Taz

Cefotaxim

Cefepim

Cefpirom

Ceftriaxon

Cefodizim

Ertapenem

Azithromycin

Clarithromycin

3x4,5g

3x2g

1x1g

PLUS

1x0,5g

2x0,5g

i.v.

i.v.

i.v.

i.v.

i.v.

Azithromycin

Clarithomycin

Roxithromycin

Telithromycin

1x0,5g

2x0,5g

2x0,3g

1x0,8g

p.o.

p.o.

p.o.

p.o.

Azithromycin

Clarithomycin

Roxithromycin

Telithromycin

1x0,5g

(1-)2x0,5g

(1-)2x0,3g

1x0,8g

p.o.

p.o.

p.o.

p.o.

Levofloxacin

Moxifloxacin

1x0,5g

1x0,4g

p.o.

p.o.

Amoxicillin/Clac

Ampicillin/Sulb

Cefamandol

Cefotiam

Cefuroxim

Cefotaxim

Ceftriaxon

Cefodizim

Ertapenem

3x2,2g

3x3g

3x1,5g

3x2g

1x1g

i.v.

i.v.

i.v.

i.v.

i.v.

Doxycyclin 1x0,2g p.o. Levofloxacin

Moxifloxacin

1x0,5-1g

1x0,4g

i.v.

i.v.

Levofloxacin

Moxifloxacin

1x0,5g

1x0,4g

i.v.

i.v.

3x2g

1x2g

1x2g i.v.

i.v.

i.v.

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Kommentar

• Gruppe I

- Rascher Therapiebeginn mit Amoxicillin od Makrolid, statt

Penicillin Cephalosporin p.o. der Gruppen II/III.

- Bei Penicillinresistenten Pneumokokken Levofloxacin,

Moxifloxacin oder Ketolide in Erwägung ziehen

• Gruppe II (ambulant)

- Aminopenicillin plus BLI od Makrolid, bzw. Ketolid oder

Chinolon

• Gruppe II (stationär)

- Cephalosporin II, Aminopenicillin plus BLI, nach

erfolgloser ambulanter Therapie Cephalosporin IIIa

- bei atypischen Erregern: Makrolid/Chinolone

- bei PRSP: Cephalosporin IIIa oder Chinolone

- Gruppe III

- parenteral mit Cephalosporin IIIa ± Makrolid bzw. Ketolid

oder Chinolone

- bei Pseudomonas: Peneme

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Therapiedauer

Therapiedauer: 7-14 Tage, weltweit kein Konsensus 7-10 Tage Pneumokokken Pneumonie (72 Stunden nach Patient afebril) mindestens 14 Tage bei atypischer Pneumonie

Vorteile: Resistenz , Compliance , Gefahr von PRSP (nasopharyngeal)

„hit hard - stop early“

5-7 Tage ?

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Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study R el Moussaoui et al. BMJ 2006; 332: 1355-1362

Community acquired pneumonia scores (medians, interquartile ranges, 10th to 90th centiles) during treatment and follow-up. Day −30=score before pneumonia; day 0=start of treatment; day 10=test of cure; day 28=end of follow-up

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THERAPIE- VERSAGEN

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Criteria for clinical stability

a Important for discharge or oral switch decision but not necessarily for determination of nonresponse.

• Temperature 37.88°C

• Heart rate 100 beats/min

• Systolic blood pressure 90mmHg

• Respiratory rate 24 breaths/min

• PaO2 60mmHg or arterial saturation 90%

• Ability to maintain oral intakea, normal mental statusa

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Treatment Failure in Community-Acquired Pneumonia Rosario Menendez and Antoni Torres Chest 2007; 132; 1348-1355

Factors Related to Pneumonia Resolution

Factors Characteristics

Rapid resolution Host factors Severity of CAP Causal microorganisms

Youth; nonsmokers; nonhospitalized CAP Mild initial severity Mycoplasma pneumoniae; Chlamydia pneumoniae

Slow resolution Host factors Severity of CAP Causal microorganisms

Elderly; comorbid conditions; alcohol intake; smokers Higher severity; multilobar CAP; empyema; bacteremia Legionella spp; polymicrobial pneumonia

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Causes of TF

Causes Microorganisms

Infectious Resistant microorganisms CAP Nosocomial pneumonia Infrequent microorganisms

S pneumoniae; S aureus Acinetobacter; MRSA; P aeruginosa Mycobacterium tuberculosis; Nocardia spp; fungal pneumonia; Pneumocystis jiroveci

Noninfectious Neoplasia; hemorrhagic lung; eosinophilic lung; pulmonary edema; adult respiratory distress; BOOP; vasculitis

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Bronchiolitis obliterans organizing pneumonia

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Microbiological Assessment Indicated for TF

Sample Variables

Sputum Gram stain and conventional bacteria culture;

Legionella direct immunofluorescence; Ziehl

and Giemsa stain; stains for fungi

Blood Two sets for culture

Urine Legionella antigen;

Pleural fluid Cultures for anaerobes; bacterial cultures

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PRÄVENTION

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Effect of Introduction of the Pneumococcal Conjugate Vaccine on Drug-Resistant Streptococcus pneumoniae Moe H. Kyaw, Ruth Lynfield, William Schaffner, Allen S. Craig, James Hadler, Arthur Reingold, Ann R. Thomas, Lee H. Harrison, Nancy M. Bennett, Monica M. Farley, Richard R. Facklam, James H. Jorgensen, John Besser, Elizabeth R. Zell, Anne Schuchat, and Cynthia G. Whitney, N Engl J Med 2006; 354: 1455-63

Annual Incidence of Invasive Disease Caused by Penicillin- Nonsusceptible Pneumococci in Persons Two Years of Age or Older, 1996 to 2004.

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Pneumokokken-Impfung

• 23-valente Polysaccharid-Impfstoff für

Erwachsene (PNE) - Impfung mit PNE im 60. Lebensjahr vorgesehen;

bei entsprechendem Risiko alle 5 Jahre

- Reimmunisierung Alter >65 Jahre bei chronischen

Erkrankungen und Erstdosis vor dem

65. Lebensjahr

• 7-valente Konjugat-Impfstoff für Kinder (PNC) - Österreichischer Impfplan

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Differentialdiagnosen

• Maligner Prozess

• TBC typ/atyp

• Infarktpneumonie

• Lungenstauung

• Atelektase

• Pilze

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Pneumonie ja oder nein ?

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Normalbefund

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Lungenstauung

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De- und Rekompensation

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Pneumonie (Pneumokokken)

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Kulissenzeichen

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Pneumonie ML

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Infarktpneumonie

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Hamton Hump

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Pneumonie (Legionella)

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TBC (miliares Bild)

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Alveolarzellcarcinom

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Pneumonie re OL

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OL Atelektase/zentraler TU re

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Pancoast TU li

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Pleuraempyem

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Rupturierte Abszesse

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Pneumonie UL re

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Lymphangiose

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Strahlenpneumonitis

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Aspergillom

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Pneumonie (Clamydien)

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Pneumonie OL li

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Postpneumonische Residuen

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DANKE FÜR EURE AUFMERKSAMKEIT!

...ein handout folgt...

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AB - Therapie

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Procalcitonin Guidance of Antibiotic Therapy in Community-acquired Pneumonia M. Christ-Crain, D. Stolz, Roland Bingisser, Ch. Müller, David Miedinger, P. R. Huber, W. Zimmerli, St. Harbarth, M. Tamm, and B. Müller Am J Respir Crit Care Med 2006; 174: 84–93

(A) Percentage of patients receiving antibiotic therapy in the control group and the procalcitonin group on admission and during the course of the disease. AB = antibiotics. (B) Cumulative frequency distribution curve for the time to discontinuation in patients for whom antibiotic therapy was prescribed. Patients in the procalcitonin group were compared with those in the control group.

0 AB

started

10

20

30

40

50

60

70

80

90

100

Pati

en

ts o

n A

nti

bio

tics (

%)

Control group Procalcitonin group

>4d >6d >8d >10d >14d >21d

Duration of Antibiotic Therapy (days)

A

0

25

50

75

100

Cu

mu

lati

ve P

ercen

t

B

Procalcitonin group

Control group

P<0.001

Time to antibiotic discontinuation (days)

0 10 20 30

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Antibiotic therapy in nonsevere community-acquired pneumonia

Advanced-generation macrolide: azithromycin or clarythromycin. b-Lactam: oral cefpodoxime, cefuroxime, high-dose amoxicillin, amoxicillin/clavulanate or intravenous ceftriaxone then oral cefpodoxime. Respiratory fluoroquinolone: levofloxacin, moxifloxacin. aPenicillin allergic/intolerant. Admitted for nonclinical reasons or previously untreated in community.

European Respiratory Society

British Thoracic Society

Outpatient: no cardiopulmonary disease or modifying factors (Group 1)

amoxicillin or tetracycline

amoxicillin or erythromycin/ clarithromycina

Outpatient: cardiopulmonary disease ± modifying factors (Group 2)

as above as above

Inpatient: cardiopulmonary disease ± modifying factors (Group 3a)

penicillin G or aminopenicillin or coamoxiclav or second/third-generation cephalosporin ± macrolide or respiratory fluoroquinolone

(a) as home treated (b) amoxicillin + macrolide or respiratory fluoroquinolone

Inpatient: no cardiopulmonary disease ± modifying factors (Group 3b)

as above

as above

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Antibiotic therapy in severe community-acquired pneumonia

ICU, intensive care unit. Antipseudomonal ß-lactam: cefepime, imipenem, meropenem, piperacillin/ tazobactam. Second-generation cephalosporin: cefuroxime. Thrid-generation cephalosporin: cefotaxime, ceftriaxone. Respiratory fluoroquinolone: levofloxacin, moxifloxacin (moxifloxacin not licensed in the UK for severe community-acquired pneumonia).

European Respiratory Society

British Thoracic Society

ICU: risk of Pseudomonas

antipseudomonal cephalosporin + ciprofloxacin carbapenem or acylureidopenpenicillin/ ß-lactamase inhibitor + ciprofloxacin

coamoxiclav or second/third- generation cephalosporin + macrolide ± rifampicin or respiratory fluoroquinolone + benzylpenicillin

ICU: no risk of Pseudomonas

third-generation cephalosporin + macrolide or third-generation cephalosporin + respiratory fluoroquinolone

Nursing home respiratory fluoroquinolone or amoxicillin/clavulantate + macrolide or second-generation cephalosporin + macrolide (o/p)

same treatment as per severity

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Nosocomial gram-negative (Pseudomonas) pneumonia

(b)

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HAP

• Zweithäufigste nosokomiale Infektion mit der höchsten Letalität 33-50%.

• 18% postoperative Patienten. • VAP ist die häufigste ICU-akquirierte Infektion

(Inzidenz 10-20%) mit der höchsten Mortalität 24-76%. Bei Pseudomonas oder Acinetobacter verursachten Pneumonie steigt Mortalität auf 50-70%. Der stationäre Aufenthalt verlängert sich um 2-9 Tage.

Inzidenz: 5-15 Patienten/1000 EW

Soto J, 2007 Burgmann, 2007

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Risikofaktoren für die Entwicklung einer nosokomialer Pneumonie

• Hohes Lebensalter

• Schwere Grunderkrankung

• Morbidität (Hoher APACHE-II oder SAPS II Score-Wert)

• Bewusstseinseintrübung

• Vorangegangener thorakoabdomineller Eingriff

• Prolongierte Hospitalisierung

• Prolongierte Beatmung

• Re-Intubation

• Subglottischer Sekretstau

• Antimikrobielle Vortherapie

• Horizontale Lage des Patienten

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Erregerspektrum: Early onset versus late onset

Early Onset Late Onset

Staphylococcus aureus

Streptococcus pneumoniae

Haemophilus influencae

Pseudomonas aeruginosa

Acinetobacter baumannii

Stenotrophomonas maltophilia

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Punktebewertung von Risikofall-Patienten mit nosokomialer Pneumonie

Risikofaktor Punkte

Alter >65 Jahre •

Strukturelle Lungenerkrankung • •

Antiinfektive Vorbehandlung • •

Beginn der Pneumonie ab dem 5. Krankenhaustag

• • •

Schwere respiratorische Insuffizienz mit oder ohne Beatmung

• • •

Extrapulmonales Organversagen • • • •

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Kalkulierte Initialtherapie der nosokomialen Pneumonie unter Berücksichtigung von Risikofaktoren (adaptiert nach PEG 2004)

Gruppe I:

bis 2 Punkte

Gruppe II:

3 bis 5 Punkte

Gruppe III:

6 Punkte

Aminopenicillin/BLI

Cephalosporin 2

Cephalosporin 3a

Fluorchinolon 3

Fluorchinolon 4

Carbapenem 2

Acylaminopenicillin/BLI

Cephalosporin 3b

Cephalosporin 4

Carbapenem 1

Fluorchinolon 2

Fluorchinolon 3

Acylaminopenicillin/BLI oder

Cephalosporin 3b oder

Cephalosporin 4 oder

Carbapenem Gruppe 1 jeweils

+ Fluorchinolon 2 oder

+ Fluorchinolon 3 oder

+ Aminoglykosid

± Fosfomycin

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Risikofaktoren, an der nosokomialen Pneumonie zu versterben

Risikofaktor Odds Ratio

• Alter

• Fatale Grundkrankheit

• Progrediente Ateminsuffizienz

• Neoplasie

• Beidseitige Pneumonie

• Septischer Schock

• Resistenter Erreger

• Inadäquate antimikrobielle Therapie

• Antimikrobielle Vorbehandlung

1,1 - 4,6

4,8 - 8,8

11,9

1,6

6,3

2,8

2,5 - 8,7

5,8 - 32,5

9,2

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„Clinical Pulmonary-Infection-Score“ (CPIS)

Parameter 0 Punkte 1 Punkt 2 Punkte

Temperatur (°C) 36,5-38,4 38,5-38,9 39,0 oder 36,0

Leukozytenzahl (mm³) 4000-11 000 <4000 od

>11 000

<4000 od. >11 000

<50% unreife Formen

Trachealsekret kein

Trachealsekret

nicht purulentes

Trachealsekret

purulentes

Trachealsekret

Oxygenation: paO2/FiO2

(mmHg)

>240 oder

ARDSa

240 und kein ARDSa

Röntgen-Thorax kein Infiltrat diffuse Infiltrate lokalisierte Infiltrate

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Punktebewertung von Risikofall-Patienten mit nosokomialer Pneumonie

Risikofaktor Sensitivität (%) Spezifität (%)

Sputum 50 50

Endotracheale

Aspiration (EA)

90 50

Quantitative

Kultur EA

80 90

Protected brush 60 85

BAL 89 90

Feinnadelbiopsie 70 95

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Risikofaktoren für die Entwicklung resistenter Keime

• Antimikrobielle Therapie innerhalb der letzten 90 Tage

• Hospitalisation innerhalb der letzten 90 Tage

• Derzeitiger stationärer Aufenthalt 5 Tage

• Dauer der Beatmung 7 Tage

• Dialyse

• Altenheim

• Immunsupprimierende Erkrankung oder Therapie

• Hohe antimikrobielle Resistenz in der Community oder in der EU

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Umgang mit diagnostischer Unsicherheit bei VAP

Klinische Konstellation Strategie Rationale

Klinischer Verdacht auf VAP Quantitative Kulturen,

kalkulierte antimikrobielle

Therapie

Gesicherter

prognostischer Vorteil

Re-Evaluation nach 72h; vier mögliche Konstellationen

1. V. a. VAP bestätigt Fortführung der

antimikrobielle Therapie,

Adjustierung bzw. Deeskalation

nach Kulturergebnissen

Gesicherter

prognostischer Vorteil

2. VAP klinisch wahrscheinlich,

Kulturergebnisse nicht signifikant;

keine schwere Sepsis

Individuelle Abwägung Vorgehen nicht gesichert

3. VAP klinisch unwahrscheinlich,

Kulturergebnisse nicht signifikant;

keine schwere Sepsis

Absetzen der

antimikrobielle Therapie

Reduktion des Selektionsdrucks

und der Letalität durch

antimikrobielle Übertherapie

4. VAP ausgeschlossen,

alternative Infektionsquelle

und/oder schwere Sepsis

Fortsetzen bzw. adjustieren der

antimikrobielle Therapie

Vorgehen evident

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Antibiotikatherapie bei CAP nach Risikogruppen

Kinder

Säuglinge & Kinder bis drei Monate

Amoxicillin

Kinder drei Monate bis 14 Jahre

Amoxicillin

Cefadroxil

Cefalexin

Cefatamet-P.

Cefixim

Cefpodoxim

Cefuroxim-A.

50-100mg/Kg

20mg/kg

8mg/kg

5-12mg/kg

20-30mg/kg

3 ED p.o.

2 EDp.o.

1 ED p.o.

2 ED p.o.

2 ED p.o.

Azithromycin

Clarithomycin

Roxithromycin

Telithromycin

10mg/kg

15mg/kg

5mg/kg

ab dem 12. Lj.

1 ED p.o.

2 ED p.o.

1 ED p.o.

1 ED p.o.

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MRSA Management

Therapie

• Vancomycin

• Teicoplanin

• Linezolid

• Daptomycin

Dekontamination

• Nasensalbe - Mupirocin, Octenidin

- Betaisodona

• Augensalbe - Fucithalmic

• Desinfizierende Seife

• Antiinfektivum - Rifampicin

- Minocyclin

- Cotrimoxazol

- Fusidinsäure

- Fosfomycin

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Staphylokokken Therapie

kurz & heftig

• HD-Laktame

• Vancomycin

• Linezolid

• Fosfomycin

lang & geduldig

• Teicoplanin

• Fusidinsäure

• Minocyclin

• Rifampicin

• Trimethoprim

• ...

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Lunge und Candida

• Häufig Kolonisation bei kritisch Kranken

• Histologisch verifizierte Candida-Pneumonie ist sehr selten

• Nachweis von Candida im Respirationstrakt ist keine Behandlungsindikation

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Microbiology of severe aspiration pneumonia in institutionalized elderly. El Solh AA, Pietrantoni C, Bhat A, et al. Am J Respir Crit Care Med 2003; 167: 1650–1654

Results of nonbronchoscopic BAL fluid cultures collected within 4 h of ICU admission in 95 elderly nursing-home patients with aspiration pneumonia admitted to the ICU. The dominant organism group was enteric Gram-negative pathogens, and anaerobes were less common and often part of a mixed infection.

0 Anaerobes Gram

Negatives S. Aureus

5

10

15

20

25

30

35

40

45

50

Perc

ent

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Independent Factors Related to TF and Early Failure*

*Data are presented as odds ratio (95% confidence interval).

Factors

Early Failure

Age > 65 Influenza vaccination COPD Legionella Gram negative Pleural effusion Multilobar CAP Cavitation Discordant therapy Fluoroquinolone treatment Fine risk class Leukopenia Hyponatremia

TF

0.3 (0.2-0.6) 0.6 (0.4-0.9) 2.7 (1.8-4.2) 2.1 (1.4-2.9) 4.1 (1.3-13.5) 0.5 (0.3-0.9) 1.3 (1.1-1.5) 3.7 (1.4-10.2)

Roson et al

0.35 (0.21-0.6) 2.7 (1.4-5.3) 4.3 (1.04-18) 2.7 (1.8-4.2) 2.15 (1.4-3.4) 2.51 (1.61-3.94) 1.8 (1.11-2.9)

Menendez et al

0.2 (0.1-0.4) 2.6 (1.6-4.3) 2.2 (1.4-3.2) 5.2 (1.4-18.2) 1.2 (1.1-1.5) 5.9 (2.2-15.3) 1.6 (1.1-2.4)

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Effect of Increasing the Intensity of Implementing Pneumonia Guidelines Donald M. Yealy et al. Ann Intern Med. 2005; 143: 881-894

Performances of Processes of Care by Intervention Group for Outpatients

Process of Care Guideline Implementation Group P Value*

Low Intensity Moderate Intensity High Intensity

Patients, n 174 498 453

Oxygenation assessment at presentation, % 94.8 95.6 96.7 0.83

First dose of antibiotic therapy in the emergency department, %

64.9 70.1 90.9 <0.001

Antibiotic therapy administered in the emergency department, %

<0.001

No antibiotic therapy 35.1 29.9 9.1

Noncompliant therapy 17.8 20.7 3.8

Partially compliant therapy 17.8 18.7 21.6

Compliant therapy 29.3 30.7 65.6

Antibiotic therapy prescribed at discharge from the emergency department, %

0.02





Recommended process of care performed, % <0.001

0-1 9.2 4.8 2.0

2 37.4 33.1 13.0

3 28.2 33.7 24.1

4 25.3 28.3 60.9

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Effect of Increasing the Intensity of Implementing Pneumonia Guidelines Donald M. Yealy, Thomas E. Auble, Roslyn A. Stone, Judith R. Lave, Thomas P. Meehan, Louis G. Graff, Jonathan M. Fine, D. Scott Obrosky, Maria K. Mor, Jeff Whittle and Michael J. Fine Ann Intern Med. 2005; 143: 881-894

Performances of Processes of Care by Intervention Group for Inpatients

* P values compare the proportion of patients who are fully compliant with the recommended processes of care across intervention groups. P values for the number of processes of care performed for outpatients and inpatients were based on an ordinal scale. Analyses accounted for the clustering of patients within providers and emergency departments.

Process of Care Guideline Implementation Group P Value*

Low Intensity Moderate Intensity High Intensity

Patients, n 566 661 849

Oxygenation assessment at presentation, % 96.3 99.1 97.4 0.180

Performance of 2 blood cultures before antibiotic administration, %

53.5 57.6 74.2 0.001

Administration of antibiotic therapy within 4h of presentation, %

77.0 79.7 78.8 0.82

Antibiotic therapy administered in the emergency department, %

0.002





Recommended process of care performed, % <0.001

0-1 7.8 6.7 2.9

2 30.0 20.6 13.5

3 39.2 42.7 39.2

4 23.0 30.1 44.3

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A Randomized Trial Comparing the Cardiac Rhythm Safety of Moxifloxacin vs Levofloxacin in Elderly Patients Hospitalized With Community-Acquired Pneumonia Michael S. Niederman and Shurjeel Choudhri CHEST 2005; 128: 3398–3406

Conclusions

IV/oral moxifloxacin, although known to

cause QTc interval prolongation, has a

comparable cardiac rhythm safety profile to

IV/oral levofloxacin in high-risk elderly

patients with CAP.

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KATEGORIEN

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Definitions of Pneumonia Categories

*All pneumonia cases with primary or secondary ICD-9-CM codes for pneumonia and positive respiratory culture finding treated in a hospital that collected at least 5 days of culture data. †Eligible bacteria include: Acinetobacter, Bacillus, Bacteroides, Bordetella, Brucella, Chlamydia, Enterobacter, Escherichia, Haemophilus, Klebsiella, Legionella, Listeria, MRSA, Mycoplasma, Proteus, Pseudomonas, Salmonella, Serratia, Shigella, S aureus, Streptobacillus, Streptococcus A, Streptococcus B, Streptococcus C, Streptococcus D, Streptococcus F, Streptococcus G, Streptococcus nongroup, S pneumoniae, Yersinia.

VAP Patients receiving mechanical ventilation for at least 24 h with a first positive bacterial† respiratory culture finding after ventilator start date

HAP Patients with a first positive bacterial† respiratory culture finding > 2 days from admission who do not meet VAP definition

HCAP Patients with a first positive bacterial† respiratory culture finding within 2 days of admission and any of the following: (1) admission source indicates a transfer from another health-care facility; (2) receiving long-term hemodialysis (ICD-9-CM codes); and (3) prior hospitalization within 30 days who do not meet VAP definition

CAP Patients with a first positive bacterial† respiratory culture finding who do not meet VAP or HCAP definition

Pneumonia Category*

Definition

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Radiological imaging in pneumonia: recent innovations Sat Sharma, Bruce Maycher and Gregg Eschun Curr Opin Pulm Med 2007; 13: 159–169

Right upper-lobe consolidation in a patient with community- acquired pneumonia

The computed-tomography scan (b) shows typical findings of consolidation, where air bronchogram is visible and blood vessels are indistinguishable from consolidated lung.

(b)

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Left lower-lobe cavitation in a patient with nosocomial Gram-negative (Pseudomonas) pneumonia

(b)

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Bilateral, multilobar consolidations of community acquired Legionella pneumonia led to acute respiratory failure

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Influenza pneumonia in a debilitated elderly patient who did not receive influenza vaccine

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Bronchiolitis obliterans organizing pneumonia of idiopathic etiology

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Antibiotic duration. The duration of antibiotic courses in the procalcitonin group and in the control group is given overall (top), in patients classified according to Pneumonia Severity Index risk class (middle), and blood culture result (bottom). Squares denote mean values, boxes the SEM, and whiskers 1.96 ± SEM. Results of the procalcitonin group are shown in the solid boxes, and results of the control group are in the hatched boxes.

Procalcitonin Guidance of Antibiotic Therapy in Community-acquired Pneumonia M. Christ-Crain, D. Stolz, Roland Bingisser, Ch. Müller, David Miedinger, P. R. Huber, W. Zimmerli, St. Harbarth, M. Tamm, and B. Müller Am J Respir Crit Care Med 2006; 174: 84–93

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VERLAUF

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Effect of Increasing the Intensity of Implementing Pneumonia Guidelines Donald M. Yealy, Thomas E. Auble, Roslyn A. Stone, Judith R. Lave, Thomas P. Meehan, Louis G. Graff, Jonathan M. Fine, D. Scott Obrosky, Maria K. Mor, Jeff Whittle and Michael J. Fine Ann Intern Med. 2005; 143: 881-894

Mehr Patienten mit niedrigem Risiko konnten auf Abteilungen mit Richtlinien-konformen Therapie- strategien sicher ambulant betreut werden.

• Mortalitätsrate

• Hospitalisierungsrate nach initialer ambulanter Tx

• Komplikationsrate

wurden nicht beeinflußt.

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BAL Processing in TF

Microbiological studies

Stains

Gram stain

Ziehl and modified Ziehl

Fungi

Opportunists

Colony count for bacteria

Specific cultures for mycobacteria, Legionella, fungi, virus

Histologic and cytologic studies

Giemsa stain for cell count and differential

Macrophages and hemosiderin-loaded macrophages

Leukocytes

Eosinophils

Lymphocytes

Malignancy

Lymphocyte subpopulation

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The role of new therapies for severe community-acquired pneumonia Marcos I. Restrepoa and Antonio Anzuetoa Curr Opin Infect Dis 2006; 19: 557–564

Empiric antimicrobial regimen to treat severe community-acquired pneumonia in the ICU

DRSP, drug-resistant Streptococcus pneumoniae.

Empiric treatment Comments

Intravenous ß-lactam Third-generation cephalosporins (ceftriaxone or cefotaxime) or Beta-lactam/ß-lactamase inhibitor (ampicillin- sulbactam or piperacillin-tazobactam) plus either Intravenous macrolide (azithromycin or clarithromycin) or Intravenous fluoroquinolone (levofloxacin, or moxifloxacin)

Covers well Streptococcus pneumoniae, Haemophilus influenzae, enteric Gram-negative bacilli (Klebsiella spp.) Fluoroquinolones also cover these pathogens including DRSP Legionella spp., Mycoplasma pneumoniae, Chlamydiophila pneumoniae and Chlamydiophila psittaci

Intravenous ß-lactam Antipseudomonal ß-lactam/ß-lactamase inhibitor (aztreonam, ceftazidime, cefepime, piperacillin-tazobactam, imipenem, meropenem) plus either Intravenous aminoglycoside or intravenous ciprofloxacin plus Intravenous macrolide (azithromycin or clarithromycin) if aminoglycoside used,but not with the use of ciprofloxacin

Pseudomonas aeruginosa (and the other pathogens above)

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Comparison between pathogen directed antibiotic treatment and empirical broad spectrum antibiotic treatment in patients with community acquired pneumonia: a prospective randomised study. Van der Eerden MM, Vlaspolder F, de Graaff CS, et al. Thorax 2005; 60: 672–678

A randomized trial of pathogen-directed therapy (PDT) compared with empiric therapy in 262 adults with CAP found no significant differences in length of stay (LOS), mortality rate, or rate of therapeutic failure.

ALL DIFFERENCES NOT SIGNIFICANT

0

LOS (Days)

EMPIRIC

PDT

5

10

15

20

25

%Mortality %Failure

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THE FOUR MOST COMMON ANTIMICROBIAL REGIMENS USED IN PATIENTS WITH AND WITHOUT COVERAGE FOR ATYPICAL PATHOGENS

Definition of abbreviation: TMP/SMX = trimethoprim/sulfamethoxazole.

Antimicrobial Regimen

Atypical Coverage (n = 2,878)

No Atypical Coverage (n = 658)

Regimen 1 ß-Lactam + macrolide, 1,130 (51%)

ß-Lactam, 553 (84%)

Regimen 2 Quinolone, 681 (31%)

ß-Lactam + clindamycin, 34 (5%)

Regimen 3 ß-Lactam + quinolone, 240 (11%)

ß-Lactam + TMP/SMX, 18 (3%)

Regimen 4 Macrolide, 54 (2%)

ß-Lactam + gentamicin, 16 (2%)

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Time to clinical stability for patients with (red line) and without (blue line) coverage for atypical pathogens (p < 0.01). The p value is an expression of the log-rank test comparing the two Kaplan-Meier curves.

0.0

0 1 2 3 4 5 6 7

Time to Clinical Stability (Days)

0.2

0.4

1.0

0.6

0.8

Pro

port

ion o

f Clinic

ally U

nsta

ble

Patients

W.Pohl 08


Total and community-acquired pneumonia (CAP)–related inhospital mortality for patients with (orange bars, n = 2,220) and without (blue bars, n = 658) coverage for atypical pathogens.

0% 217/2,220

2%

4%

6%

8%

10%

12%

14%

16%

18%

20% P

rop

orti

on

of

pati

en

ts w

ho

die

d

110/658

Total Mortality

p<0.01

101/2,220 41/658

CAP-related Mortality

p=0.05

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Antibiotics for Bacteremic Pneumonia Improvement Outcomes With Macrolides but Not Fluoroquinolones Mark L. Metersky et al. CHEST 2007; 131: 466-473

Pneumonie mit Bakteriämie

OR bei initialer Therapie mit Makrolid, Chinolon und Tetracyclin

0,59

0,94 0,95

0,61

0,82

1,28

0,59

0,82

0,98

0

0,2

0,4

0,6

0,8

1

1,2

1,4

In-Hospital Mortality 30-Day Mortality 30-Day Hospital

Readmission

Makrolid Chinolon Tetracyclin

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Effectiveness of early switch from intravenous to oral antibiotics in severe

community acquired pneumonia: multicentre randomised trial J J Oosterheert et al BMJ 2006; 333; 1193-1198

Outcomes in multicentre randomised trial of early switch from intravenous to oral antibiotics in severe community acquired pneumonia.

Intention to treat analysis. Values are number of patients (percentage) unless stated otherwise

Clincal outcome

Treatment group Mean difference

(95% CI) Intervention (n=132)

Control (n=133)

Death after day 3 5 (4) 8 (6) 2% (-3% to 8%)

Clinical cure 110 (83) 113 (85) 2% (-7% to 10%)

Clinical failure: 22 (17) 20 (15) -2% (-10% to 7%)

Clinical cure but still in hospital 9 (7) 6 (5) -2% (-4% to 7%)

Clinical deterioration 8 (6) 6 (5) -1% (-3% to 8%)

Death 5 (4) 8 (6) 2% (-3% to 8%)

Clinical deterioration and death 13 (10) 14 (11) 1% (-1% to 8%)

Mean (SD) lenght of hospital stay (days)

9.6 (5.0) 11.5 (4.9) 1.9 (0.6 to 3.2)

Mean (SD) duration of intravenous treatment (days)

3.6 (1.5) 7.0 (2.0) 3.4 (2.8 to 3.9)

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Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial J J Oosterheert, M J M Bonten, Ma M E Schneider, E Buskens, J-W J Lammers, W M N Hustinx, M H H Kramer, J M Prins, P H Th J Slee, K Kaasjager and A I M Hoepelman BMJ 2006; 333; 1193-1198

What this study adds

Early transition to oral antibiotics can safely be implemented in clinical practice in patients with severe community acquired pneumonia who do not need treatment in intensive care

Such a strategy leads to a reduced length of hospital stay

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Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study R el Moussaoui et al. BMJ 2006; 332: 1355-1362

Proportion of patients considered clinical successes in intention to treat population. Day 3=day of randomisation

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Recommendations for vaccine prevention of community-acquired pneumonia

a Avoid use in persons with asthma, reactive airways disease or other chronic disorders of the pulmonary or cardiovascular systems, persons with other underlying medical conditions, including diabetes, renal dysfunction, and hemoglobinopathies, persons with immunodeficiencies or who receive immunosuppressive therapy; children or adolescents receiving salicylates, and persons with a history of Guillain–Barre´ syndrome; and pregnant women.

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Correlation between penicillin use and prevalence of penicillin non-susceptible S pneumoniae

AT, Austria

BE, Belgium

HR, Croatia

CZ, Czech Republic

DK, Denmark

FI, Finland

FR, France

DE, Germany

HU, Hungary

IE, Ireland

IT, Italy

LU, Luxembourg

NL, The Netherlands

PL, Poland

PT, Portugal

SI, Slovenia;

ES, Spain

UK, England only

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Viral Community-Acquired Pneumonia in Nonimmunocompromised Adults Andrés de Roux, Maria A. Marcos, Elisa Garcia, Jose Mensa, Santiago Ewig, Hartmut Lode and Antoni Torres Chest 2004; 125; 1343-1351

Distribution of RVs Detected in 338 CAP Cases With Valid Paired Viral Serologies

*Influenza B + parainfluenza, influenza A + parainfluenza, or parainfluenza + RSV.

Influenza A

Influenza B

Parainfluenza (1, 2, or 3)

RSV

Adenovirus

More than one virus*

Excluded for cohort

analysis because of

missing data

Virus

27

10

11

5

5

3

9

Any RV Detected

(n=61; 18%)

16

7

2

4

2

5

Only RV´s Detected

(n=31; 9%)

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INDEPENDENT PREDICTORS OF BACTEREMIA IN COMMUNITY-ACQUIRED PATIENTS WITH PNEUMONIA

Definition of abbreviations: CI = confidence interval; OR = odds ratio; WBC = white blood cell.

Prior antibiotics Comorbidities Liver disease Vital signs Systolic blood pressure < 90 mm Hg Temperature < 35° C or 40°C Pulse 125/min Laboratory and radiographic data Blood urea nitrogen 30 mg/dl (11 mmol/L) Sodium <130 mmol/L WBC < 5,000/mm3 or > 20,000/mm3

Derivation Cohort OR (95% CI)

0.5 (0.5–0.6) 2.3 (1.6–3.4) 1.7 (1.3–2.3) 1.9 (1.4–2.6) 1.9 (1.6–2.3) 2.0 (1.8–2.3) 1.6 (1.3–2.1) 1.7 (1.4–2.0)

Validation Cohort OR (95% CI)

0.5 (0.5–0.6) 1.4 (1.0–2.2) 1.8 (1.4–2.3) 1.5 (1.1–2.1) 1.7 (1.4–2.0) 2.2 (1.9–2.5) 1.8 (1.4–2.2) 1.9 (1.6–2.2)

Characteristic

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Gruppeneinteilung verschiedener Antiinfektiva

Sustanzengruppe Beispiele

Cephalosporine

Gruppe 1 Cephazolin

Gruppe 2 Cefuroxim, Cefotiam

Gruppe 3a Cefotaxim, Ceftriaxon, Cefodizim

Gruppe 3b Ceftazidim

Gruppe 4 Cefpirom, Cefepim

Fluorchinolone

Gruppe 2

Gruppe 3

Gruppe 4

Ciprofloxacin

Levofloxacin

Moxifloxacin

Carbapeneme

Gruppe 1 Imipenem/Cilastatin, Meropenem

Gruppe 2 Ertapenem

Documents

PNEUMONIE - lunge-eichgraben.atfür+die... · In this case-control study of Medicare ... Enteric Gram-negatives residence in nursing home ... Defining community acquired pneumonia