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

CAP - Pathogenesis

• Aspiration

• Inhalation

• Hematogenous

• Direct extension

• Reactivation

RESPIRATORY PATHOGENS IN CAP

Respiratory Pathogens in CAP

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%

Management.

• Site of Care:– Inpatient vs. outpatient.– Floor vs. ICU.

• PSI

• CURB 65

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)

Classification

0

50

100

150

Patients

Patients 143 90 10 2 3

CAP HCAP HAP VAPNo

PNA

Community Acquired Pneumonia

42%

58%

0%

10%

20%

30%

40%

50%

60%

< 65 years > 65 years

< 65 years

> 65 years

Gender

54.5%

45.5%

40%

42%

44%

46%

48%

50%

52%

54%

56%

females males

females

males

Annual Frequency.

0

5

10

15

20

25

J F M A M J J A S O N D

Frequency

• Antibiotics administered in ER: 100%

• Appropriate antibiotics: 93.2%

• Cultures performed: 95.7%

• Positive Cultures: 8.1%

Coverage

101

42

0

20

40

60

80

100

120

NonHousestaff Housestaff

NonHousestaff

Housestaff

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

Urinary Antigens for S.pneumo/Legionella

55%45% U-Ag done

U-Ag not done

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

Mortality

– Number of Deaths: 6/143

– Mortality Rate: 4.2%

– Average Length of Stay: 5.8 days.

Health-care Associated Pneumonia.

33%

67%

0%

10%

20%

30%

40%

50%

60%

70%

< 65 years > 65 years

< 65 years

> 65 years

Gender

71%

29%

0%

10%

20%

30%

40%

50%

60%

70%

80%

females males

females

males

Annual Frequency

0

2

4

6

8

10

12

14

J F M A M J J A S O N D

Months.

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

Urinary Antigens for S.pneumo/Legionella

51%49% U-Ag done

U-Ag not done

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%

Where’s the problem?

Pneumonia

CAP HCAP

RECOGNIZE THE

DIFFERENCE

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.

Thank You!