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Outpatient Management of Outpatient Management of CAP, Sinusitis, AECB and CAP, Sinusitis, AECB and Pharyngitis Pharyngitis David A. Pegues, MD Division of Infectious Diseases David Geffen School of Medicine at UCLA

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Page 1: Cap Sinusitis Pharyngitis Im0306.Ppt

Outpatient Management of CAP, Outpatient Management of CAP, Sinusitis, AECB and PharyngitisSinusitis, AECB and Pharyngitis

David A. Pegues, MD

Division of Infectious Diseases

David Geffen School of Medicine at UCLA

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Etiologic Agents in Community-Etiologic Agents in Community-acquired Respiratory Tract Infectionsacquired Respiratory Tract Infections

* Also Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila, and rarely Staphylococcus aureus.

10% - 15%

8% - 12%

23% - 25%

2% - 8%

20% - 25%

20% - 25%

30% - 35%

15% - 25%

30% - 35%

25% - 30%

7% - 10%

35% - 55%

Acute otitis media

Acute maxillary sinusitis

AECB

CAP*

Moraxella catarrhalis

Haemophilus influenzae

Streptococcus pneumoniaeDisease

Zeckel ML, et al. Clin Ther. 1992;14(2):214-229.Hoberman A, et al. Pediatr Infect Dis J. 1996;15(10)955-962.Bartlett JG, et al. N Engl J Med. 1995;333(24):1618-1624.

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CAP Statistics--United StatesCAP Statistics--United States

• Influenza and pneumonia--leading infectious cause of death:– 5th leading cause of death in persons aged > 65 y

• 5.6 million cases of CAP per year:– 1.1 million cases hospitalized– average LOS 2 days longer for those aged >65 y vs. <65 y

• Mortality:– overall--1-5%; hospitalized cases--25%

• Cost: – $14 billion/y in healthcare costs and $9 billion/y in lost wages

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CAP Probabilities in CAP Probabilities in Ambulatory CareAmbulatory Care

Metlay JP, Fine MJ. Ann Intern Med 2003;138:109-18.

• Baseline CAP prevalence 5%• Scenario 1:

– patient with cough only

– 1%-13% probability of CAP

• Scenario 2:– cough, fever, tachycardia,

crackles

– 18%-42% probability of CAP

• Scenario 3:– CAP prevalence 10%

– 32%-60% probability of CAP if all 4 signs present

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120

100

80

60

40

20

0

18–34 35–49 50–64 65–79 =80Age Group, Years

Cas

es p

er 1

00,0

00 P

op

ula

tio

n

Chlamydia pneumoniae *

Legionella spp *

Mycoplasma pneumoniae *

Streptococcus pneumoniae †

Chlamydia pneumoniae *

Legionella spp *

Mycoplasma pneumoniae *

Streptococcus pneumoniae †

, , Age-Specific Rates of Hospital Age-Specific Rates of Hospital Admission for CAP, by PathogenAdmission for CAP, by Pathogen

Marston BJ, et al. Arch Intern Med 1997:157:1709-18.

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37 y.o. father with 2 children in daycare, 37 y.o. father with 2 children in daycare, cough, fever, and altered mental statuscough, fever, and altered mental status

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Modifying Factors that Increase the Risk of Modifying Factors that Increase the Risk of Infection with Specific PathogensInfection with Specific Pathogens

• Drug-resistant pneumococci:

– age > 65 yr

-Lactam therapy w/in 3 mo

– alcoholism

– immune-suppressive illness

– multiple medical comorbidities

– exposure to a child in day care

– Enteric gram-negatives – residence in a nursing home

– cardiopulmonary disease

– multiple medical comorbidities

– recent antibiotic therapy

– Pseudomonas aeruginosa – structural lung disease

– >10 mg of prednisone/day

– broad spectrum abx. for >7 d in the past month

– malnutritionAmer Rev Resp Dis 2001;163:1730-54.

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ImpactImpact ofof PenicillinPenicillin SusceptibilitySusceptibility onon MedicalMedical

OutcomesOutcomes forfor AdultAdult PatientsPatients withwith BacteremicBacteremic

PneumococcalPneumococcal PneumoniaPneumonia

• Retrospective cohort study conducted in the greater Atlanta

region during 1994

• 192 adult patients with bacteremic pneumococcal pneumonia

Pen-NS Pen-S RR

(n=44) (n=148) (95% CI)

PSI risk class IV or V 20 (46) 46 (31) P=0.05

Death from pneumonia 10 (23) 16 (11) 2.1 (1-4.3)

Suppurative complications 4 (9) 3 (2) 4.5 (1-19.3)Metaly JP, et al. Clin Infect Dis 2000;30:520-28

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A healthy 30 y.o. female with insidious onset of A healthy 30 y.o. female with insidious onset of fever, malaise, HA and non-productive coughfever, malaise, HA and non-productive cough

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Group 1:Group 1: Outpatients, No Cardiopulmonary Outpatients, No Cardiopulmonary Disease, No Modifying FactorsDisease, No Modifying Factors

Organism• Streptococcus pneumonia• Mycoplasma pneumoniae • Chlamydia pneumoniae• Hemophilus influenzae • Respiratory viruses • Legionella spp. • Mycobacterium tuberculosis • Endemic fungi

Therapy• azithromycin or

clarithromycin

or• doxycycline

Amer Rev Resp Dis 2001;163:1730-54.

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Group 2:Group 2: Outpatients, with Cardiopulmonary Outpatients, with Cardiopulmonary Disease, and/or Modifying FactorsDisease, and/or Modifying Factors

Organism• S. pneumoniae (incl. DRSP)• M. pneumonia, C. pneumoniae• Mixed infection • H. influenzae• Enteric gram negatives • Respiratory viruses• M. catarrhalis• Legionella spp.• Aspiration (anaerobes)• M. tuberculosis• Endemic fungi

Therapy -lactam

– cefpodoxime– cefuroxime– high-dose amoxicillin– amoxicillin/clavulanate– ceftriaxone then cefpodoxime

plus• macrolide or doxycycline

or• antipneumococcal FQ alone

Amer Rev Resp Dis 2001;163:1730-54.

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Initial Empiric Therapy for CAP in Initial Empiric Therapy for CAP in Adult Outpatients, IDSA 2003Adult Outpatients, IDSA 2003

Patient variable Preferred treatment optionsPreviously healthy

No recent antibiotic therapy macrolide or doxycyclineRecent antibiotic therapy respiratory fluoroquinolonealone,

advanced macrolide + high-dose amoxicillin, oradvanced macrolide + high-dose amoxicillin-clavulanate

Comorbidities (COPD, diabetes, renal or congestive heart failure, or malignancy)

No recent antibiotic therapy advanced macrolide or a respiratory fluoroquinoloneRecent antibiotic therapy respiratory fluoroquinolone alone, or

advanced macrolide plus a beta-lactamSuspected aspiration Amoxicillin-clavulanate or clindamycinInfluenza with superinfection beta-lactam or a respiratory fluoroquinolone

Mandell LA, et al. Clin Infect Dis 2003;37:1405-33.

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Pneumonia Pneumonia Severity IndexSeverity Index

• Risk classes I and II:– low risk of death

– treat as outpatients

• Elderly or risk class III:– consider short

hospitalization (1 day)

• Risk class IV and V– hospitalize

• Inpatient treatment:– O2 saturation <90

– hemodynamic instability

– co-morbid conditions

– inability to take PO meds

Halm EA, Teirstein AS. NEJM 2002:347:2039-45.

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Score 0 –1: Low risk. Suitable for outpatient treatment.

Score 2: Intermediate risk. Consider hospitalization.

Score =3: High risk. Urgent hospitalization.

Lim WS et al. Thorax. 2003;58:377–382.

• Confusion*

• Urea >7 mmol /L

• Respiration >30/min

• Systolic BP <90 mmHg or diastolic BP <60 mm Hg

• Age >65 years•

Mortality predictors

-

0

5

10

15

20

25

Mortality, %

CURB -65 SCORE

0–1 2 =3

Risk groups

*Mental Test Score of <8 or new disorientation in person, place, or time.

1.5

9.2

22

Risk Assessment: CURB-65Risk Assessment: CURB-65

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Decreased LOS 6Early mobilization

Decreased LOS 4

No difference in LOS, decreased cost and mortality* ,5

Critical pathway

Decreased LOS/cost 3

Decreased 30 - day mortality 2Appropriate antimicrobials

Decreased 30 - day mortality* ,1Blood cultures within 24 hr

Decreased 30 - day mortality* ,1,2Early antimicrobials

OutcomeFactors

Decreased LOS 6Early mobilization

Decreased LOS 4

No difference in LOS, decreased cost and mortality* ,5

Critical pathway

Decreased LOS/cost 3Early IV to PO switch

Decreased 30 - 2Appropriate antimicrobials

Decreased 30 - day mortality* ,1Blood cultures within 24 hr

Decreased 30 - day mortality* ,1,2

OutcomeFactors

1.Meehan TP et al. JAMA . 1997;278:2080 – 2084.2.Gleason PP et al. Arch Intern Med . 1999;159:2562 – 2572.3. Ramirez JA et al. Arch Intern Med . 1999;159:2449 – 2454.4.Marrie TJ et al. JAMA . 2000;283:749 – 755.5. Dean NC et al. Am J Med. 2001;110:451 – 457.6.Mundy LM et al. Chest . 2003;124:883 – 889.

LOS=length of stay.*Retrospective studies with patients at least aged 65 years.

LOS=length of stay.*Retrospective studies with patients at least aged 65 years.

Factors Improving Outcome in CAPFactors Improving Outcome in CAP

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Timing of Antibiotic Administration and Outcomes Timing of Antibiotic Administration and Outcomes for Medicare Patients Hospitalized With CAPfor Medicare Patients Hospitalized With CAP

• Retrospective study of a national random sample of 18,209 Medicare patients:– >65 years hospitalized with CAP from 7/98-3/99

– 75.6% did not receive outpatient antibiotics

• Antibiotic within 4 hours of arrival at the hospital: in-hospital mortality (6.8% vs 7.4%; AOR, 0.85), 30 d mortality (11.6% vs 12.7%; AOR, 0.85) LOS exceeding 5-day median (42.1% vs 45.1%; AOR, 0.90)

Houck, PM, et al. Arch Intern Med. 2004;164:637-44.

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Recommendations for the Use of Recommendations for the Use of 23-Valent Pneumococcal Vaccine 23-Valent Pneumococcal Vaccine

Group Strength of evidence

Revaccination

Immunocompetent Age >65 y

A

2nd dose if vaccinated >5 y ago and were <65 y old then

Age 2-64 y and chronic disease

A, B Not recommended

Age 2-64 y and asplenic

A Age >10 y: 2nd dose if vaccinated >5 y ago

Age 2-64 y and living in special environment

C Not recommended

Immunosuppressed C Age >10 y: 2nd dose if vaccinated >5 y ago

MMWR 1997; 46 (RR8).

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Efficacy of Pneumococcal Polysaccharide Vaccine in Efficacy of Pneumococcal Polysaccharide Vaccine in Patients at Moderate to High Risk of Serious DiseasePatients at Moderate to High Risk of Serious Disease

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Effect of Empiric Therapy with Macrolides on Effect of Empiric Therapy with Macrolides on Length of Stay in Patients Hospitalized with CAPLength of Stay in Patients Hospitalized with CAP

Stahl JE, et al. Arch Intern Med. 1999;159:2576-80.

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FailureFailure ofof MacrolideMacrolide AntibioticAntibiotic TreatmentTreatment inin

PatientsPatients withwith BacteremiaBacteremia DueDue toto

Erythromycin-ResistantErythromycin-Resistant S.S. pneumoniaepneumoniae

• Matched case-control study at 4 hospitals:– bacteremic pneumococcal infection– case patients (n = 86)--erythromycin-I or -R S. pneumoniae– controls (n = 141)--erythromycin-susceptible S. pneumoniae

• Taking a macrolide at time blood culture obtained: – 18/76 (24%) cases vs. 0/136 controls (P <<0.001)

• Low-level-R efflux/M phenotype (mef): – 5/21 (24%) cases vs. 0/40 controls (P = .002)

• Breakthrough bacteremia during macrolide Rx: risk among patients infected with an erythromycin-R pneumococcus

– associated with both efflux and methylase mechanism

Lonks, JR, et al. Clin Infect Dis 2002;35:556-64

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In Vitro*In Vitro* MIC MIC9090 Activity Against Activity Against

Lower Respiratory PathogensLower Respiratory Pathogens

20.2516<0.250.120.030.06M. catarrhalis (ß-lac+ )

0.5<0.12<0.12<0.250.120.030.06M. catarrhalis (ß-lac-)

22>16160.030.0150.03H. influenzae (ß-lac+)

21180.030.0150.03H. influenzae (ß-lac-)

82280.510.25S. pneumoniae

Cefurmg/L

Amox/Clavmg/L

Amoxmg/L

Clarimg/L

Gatimg/L

Levomg/L

Moximg/L

Felmingham et al. J Antimicrob Chemother. 2002 Sep;50 Suppl S1:25-37. Hoban & Felmingham. J Antimicrob Chemother. 2002 Sep;50 Suppl S1:49-59. Fung-Tomc JC, et al. J Antimicrob Chemother. 2000 Apr;45(4):437-46

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Declining Susceptibility of Declining Susceptibility of S. pneumoniaeS. pneumoniae to Levofloxacin to Levofloxacin

•Between 1997 and 2002, 26 US hospitals collected susceptibility data for community-acquired S pneumoniae isolates

•6 FQs tested: ciprofloxacin, gatifloxacin, levofloxacin, moxifloxacin, ofloxacin, and trovafloxacin

•Increase in levofloxacin use associated with decreased susceptibility to S pneumoniae across all geographical regions

•Levofloxacin MIC90 1.0; range <0.5 to >4.0

Bhavnani SM et al. ICAAC 2003, Chicago, Ill. Abstract A 2017.

50%0.4 to >3.0Southwest

0.4 to 1.5-3.0

Levofloxacin use increase (Rx/10

0 persons)

126%West

MIC increase

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Pathophysiology of Pathophysiology of Acute Maxillary SinusitisAcute Maxillary Sinusitis

• Ostial obstruction is a primary factor pO2 Clearance of debris

• Predisposing conditions– Allergic rhinitis

– Upper respiratory infections

– Malformations

– Polyps

– Septal deviation

– Foreign bodies

– Tumors

– Upper tooth infections

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Pathophysiology—RhinosinusitisPathophysiology—Rhinosinusitis

Adapted from: Kennedy DW, ed. Sinus Disease: Guide to First-Line Management. Darien CT, Health Communications, 1994.

Secretions thicken;

pH changes.

Ostiumis closed.

Mucosal gas metabolism

changes.

Cilia and epithelium

are damaged.

Change in host milieu creates culture medium for bacterial growth in

closed cavity.

Retained secretions cause

tissueinflammation.

Bacterial infection develops in the

sinus cavity.

Mucosal thickening creates further blockage.

Secretions stagnate.

Mucosal congestion or anatomic

obstruction blocks airflow and drainage.

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*Facial pain or pressure alone does not constitute a suggestive history in the absence of other findingsin the Major category. Osguthorpe JD. Am Fam Physician. 2001;63:69-76.

Major

Facial pain/pressure/fullness*

Nasal obstruction/blockage

Nasal discharge/purulence

Hyposmia/anosmia

Fever (acute phase)

Minor

Headaches

Halitosis

Fatigue

Dental pain

Cough

Ear pain/pressure/fullness

Signs and Symptoms Associated Signs and Symptoms Associated with the Diagnosis of Sinusitiswith the Diagnosis of Sinusitis

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26 Piccirillo, J. F. N Engl J Med 2004;351:902-910

Plain Radiograph and CT Scans of Plain Radiograph and CT Scans of the Paranasal Sinusesthe Paranasal Sinuses

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27 Piccirillo, J. F. N Engl J Med 2004;351:902-910

Various Signs and Symptoms Used Various Signs and Symptoms Used to Predict the Presence of Sinusitisto Predict the Presence of Sinusitis

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Principles of Appropriate Antibiotic Use for Principles of Appropriate Antibiotic Use for Acute Sinusitis in AdultsAcute Sinusitis in Adults

Snow V, et al, Ann Intern Med 2001;134:495-7.Snow V, et al, Ann Intern Med 2001;134:495-7.

• Most cases of acute rhinosinusitis in ambulatory care are caused by viral URIs

• Viral and bacterial rhinosinusitis are difficult to differentiate on clinical or radiographic grounds

• Clinical Dx of bacterial rhinosinusitis should be reserved for patients with Sx >7 days

• Sinus radiography is not routinely recommended

• Acute bacterial sinusitis does not require antimicrobial treatment when symptoms are mild to moderate:– Up to 2/3 of patients improve with symptomatic management

• Patients with severe or moderate persistent symptoms should be treated with and antimicrobial

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AAOHNS Rhinosinusitis AAOHNS Rhinosinusitis GuidelinesGuidelines

Anon JB et al. Otolaryngol Head Neck Surg. 2004;130(suppl 1):1-45.

Moxi/gati/levoRifampin+clindamycin

Moxi/gati/levoAmox/clavCeftriaxoneCombination therapy

Reevaluate patient

Mild disease with no recent antimicrobial use (past 4-6 weeks)

TMP/SMXDoxycyclineAzithro, clarithro, erythro

Amox/clavAmoxCefpodoximeCefuroximeCefdinir

Mild disease with recent antimicrobial use (past 4-6 weeks) or moderate disease

Severity

Reevaluate patient

Moxi/gati/levoAmox/clavCeftriaxone

Moxi/gati/levo Clindamycin and rifampin

β-Lactam Allergic

No

Yes

No

Initial Therapy Switch Therapy Options

Reevaluate patientYes

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30 y.o. female with HSP and 30 y.o. female with HSP and chronic nasal dischargechronic nasal discharge

• 30 yo F• Henoch Schonlein

purpura, Dx 2001– CellCept 500 bid– prior prednisone

• >12 mths Hx:– anosmia, altered taste,

post nasal drip, sinus pressure

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Chronic Sinusitis: HistoryChronic Sinusitis: History

• Primary symptom:– nasal congestion or obstruction; duration >6-12 wks

• Secondary symptoms:– pain, pressure, and postnasal discharge.

• Symptoms are poorly localized and mild:– may be extremely difficult to recognize.

• In children:– purulent rhinorrhea with or without postnasal drip.

• Cough and occasional wheezing episodes.

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Chronic Sinusitis: TherapyChronic Sinusitis: Therapy

• Sinus irrigation:• buffered saline (e.g., Sinus Rinse--NeilMed)• antimicrobial, betadine, acetic acid• at least BID

• Decongestants:• topical, systemic

• Corticosteroids:• topical, systemic

• Surgery

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A 15-year-old boy with sinusitis causing right A 15-year-old boy with sinusitis causing right proptosis, telecanthus, and malar flatteningproptosis, telecanthus, and malar flattening

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Allergic Fungal Sinusitis (AFS)Allergic Fungal Sinusitis (AFS)

• ~ 5-10% of patients with chronic rhinosinusitis have AFS. • History of atopy:

– ~2/3 allergic rhinitis and 50% asthma.

– 90% elevated specific IgE to one or more fungal antigens.

• Geography:– temperate regions of relatively high humidity

– US--most commonwithin the Mississippi basin, the Southeast, and the Southwest.

• Demographics:– Adolescents and young adults; mean age at Dx--21.9 years

– M/F ratio ~50/50

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AFS Lab StudiesAFS Lab Studies• Total IgE:

– > 1000 U/mL (normal, <50 U/mL).– indicator of AFS clinical activity.

• RAST versus skin testing – positive skin tests and in vitro (RAST) responses to fungal and

nonfungal antigens. – broad sensitivity to a number of fungal and nonfungal antigens. – generally, only a single fungus is isolated by culture of allergic

fungal mucin

• Nonspecific allergy testing – Gell and Coombs type I hypersensitivity

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AFS TreatmentAFS Treatment

• Corticosteroids:– oral, intranasal

• Immunotherapy:– RAST or quantitative skin test:

• typical panel of nonfungal antigens

• all relevant molds (fungi) available.

– Duration of Rx--3-5 years.

• Antifungal therapy:– systemic, topical.

• Surgery

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Initiating Factors (e.g., Smoking, Childhood Respiratory Disease)

Bacterial Products(LOS)

Alteration of Elastase–Anti-Elastase

Balance

Increased ElastolyticActivity in Lung

Progression of COPD

Impaired MucociliaryClearance

Inflammatory Response

(Cytokines, Enzymes, etc.)

LOS = lipooligosaccharideMurphy et al, 1992.

BacterialColonization

Damage to AirwayEpithelium

Infection and Inflammation of Acute Bacterial Infection and Inflammation of Acute Bacterial Exacerbations of Chronic BronchitisExacerbations of Chronic Bronchitis

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38 Sethi, S. et al. N Engl J Med 2002;347:465-471

New Strains of Bacteria and New Strains of Bacteria and Exacerbations of COPDExacerbations of COPD

• The role of bacterial pathogens in AECB is controversial

• Studied 81 outpatients with COPD over 56 months– collected clinical information and sputum samples monthly and during

exacerbations– performed molecular typing of sputum isolates

• 1975 clinic visits, 374 for AECB

• Risk of exacerbation: new (33.0%) vs. no new strains (15.4%); (RR = 2.15)

• New strain of H. influenzae, M. catarrhalis, or S. pneumoniae increased risk of an exacerbation

• Supports the causative role of bacteria in AECB

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Likely PathogensH influenzae

Haemophilus sppM catarrhalis

S pneumoniaeKlebsiella spp

Other GNBProbability of -lactam resistance

Treatment: 1st Line1. Fluoroquinolone 2. -lactam/-lactamase inhibitor

Alternative Treatment1. May require parenteral Rx2. Consider referral to specialist; hospitalization

Anthonisen Type 1

Increased sputum volumeIncreased sputum purulence

Increased dyspnea

Complicated

FEV1 < 50% > 4 AECB/y

Cardiac diseaseUse of home O2

Chronic oral steroid useAntibiotic use in the past 3 mo

Balter MS et al. Can Respir J. 2003;10:3B-32B.

Role of Antimicrobial Therapy in AECBRole of Antimicrobial Therapy in AECB

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40

0

20

40

60

80

100

Moxifloxacin

Comparator

ITT PP(95% CI; 1.40, 14.87) (95% CI; 0.26, 15.95)

71%

63%70%

62%

Wilson R et al. Chest. 2004;125:953-964.

MOSAIC Study: Clinical Cure of MOSAIC Study: Clinical Cure of ABECB at 7-10 Days PosttherapyABECB at 7-10 Days Posttherapy

Moxifloxacin 400 mg QD for 5 days vs. Amox 500 gm tid for 7 days, clarithromycin 500mg bid for 7 days, or cefuroxime 250 mg bid for 7 days

Clin

ica

l Cu

re (

%)

191/274 185/298 P < .02251/354 236/376

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41 Bisno. N Engl J Med. 2001;344:205-211.

Bacterial Pharyngitis: GABHSBacterial Pharyngitis: GABHS

• Group A -hemolytic streptococci (GABHS)/S pyogenes –Most common bacterial cause

• Accounts for approximately 15%–30% of all pediatric and adult pharyngitis cases–Affects primarily school-aged children

• Peak incidence: winter to early spring

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Clinical PredictorsClinical Predictors

• Physicians, are not able to reliably predict which patients will have a positive throat culture for GAS

– Sensitivity (55-74%) and specificity (58-76%)

• Centor criteria: tonsillar exudates, tender anterior cervical adenopathy, fever by history, absence of cough

• 3 of 4 criteria: PPV 40 to 60 %; <1 of criteria: NPV 80%

– Sensitivity and specificity: 75 % vs. throat cultures

• Some consider the clinical criteria to be too liberal:

– overtreatment of 50 %

– restrict Rx to those with positive rapid antigen testing (RAT) or culture

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GABHS = Group A -hemolytic streptococci.Bisno et al. Clin Infect Dis. 1997;25:574-583.

Throat Culture vs Rapid Throat Culture vs Rapid Antigen Detection TestsAntigen Detection Tests

• Throat culture– Gold standard for

diagnosis of GABHS– Sensitivity: 90%–95%– Throat swab: both tonsils

and posterior pharyngeal wall

– Results: 24 hours

• Rapid antigen detection tests– Rapid results– More expensive than

culture– Specificity: 95%– Sensitivity: 80%–90%– Negative result: confirm

with blood agar-plate culture

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Diagnostic and Treatment Diagnostic and Treatment Algorithm of Acute PharyngitisAlgorithm of Acute Pharyngitis

GABHS = Group A -hemolytic streptococci.Bisno et al. Clin Infect Dis. 1997;25:574-583.

Clinical and epidemiologic features

Not suggestive of GABHS

Symptomatic therapy

Antimicrobial therapy

Possible GABHS

Throat culture

Rapid antigendetection test

– –

+ +

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Management strategiesManagement strategies

• Four reasons to treat a GABHS with antibiotics; none are very compelling in adults: To prevent rheumatic fever — treatment works, but this

complication has nearly disappeared in North America

To prevent peritonsillar abscess — again a vanishing complication

To reduce symptoms — there is a modest (~ 1 day) reduction in symptoms with early treatment

To prevent transmission — this is important in pediatrics due to extensive exposures but not in adults

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RecommendationsRecommendations

Empirically treat patients who have all four clinical criteria

Do not treat with antibiotics or perform diagnostic tests on patients with zero or one criterion.

Perform RAT on those with two or three criteria and use antibiotic treatment only for patients with positive RAT results.

• Another approach is to treat empirically those adults with three or four of the clinical criteria

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TherapyTherapy

• Penicillin--remains first-line therapy for GAS infections – Pen V 500 tid for 10 days

– benzanthine PCN G 300,000 units + procaine IM

– 5-30% Rx failure rate

• Erythromycin--alternative if PCN-allergic

• Empiric, broad spectrum antibiotic therapy for the treatment of sore throat:– e.g., newer macrolides, cephalosporins, or Augmentin

– increased cost and potential to increase antibiotic resistance among respiratory pathogens