W.Pohl 08
K.Mühlbacher Krankenhaus Hietzing
Abteilung für Atemwegs-und Lungenerkrankungen
PNEUMONIE FIT FÜR DIE PRAXIS
W.Pohl 08
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
W.Pohl 08
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
W.Pohl 08
KLINISCHE KLASSIFIKATION
W.Pohl 08
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.
W.Pohl 08
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
W.Pohl 08
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
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
W.Pohl 08
ANTIBIOTIKA VERBRAUCH
W.Pohl 08
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
W.Pohl 08
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
Seasonal variation of total outpatient antibiotic use in ten European countries between 1997 and 2002
W.Pohl 08
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
W.Pohl 08
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)
W.Pohl 08
ERREGER- SPEKTRUM
W.Pohl 08
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
W.Pohl 08
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
W.Pohl 08
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%
W.Pohl 08
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; 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)
W.Pohl 08
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
W.Pohl 08
STRATIFIZIERUNG
W.Pohl 08
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
W.Pohl 08
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
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
W.Pohl 08
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.
W.Pohl 08
CAP Risikostratifizierung
beide Scoring-Systeme ermöglichen eine Abschätzung der Krankheitsschwere, jedoch aus unterschiedlichen
Perspektiven
geringes Risiko
hohes Risiko
klinische Einschätzung
PSI CURB-65
Risikostratifizierung
W.Pohl 08
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
W.Pohl 08
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
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
W.Pohl 08
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
W.Pohl 08
DIAGNOSE
W.Pohl 08
Diagnostik
• Sputum - Gram Färbung
- Zytologie
- Kultur
• Blutkultur
• Serologie - Mykoplasmen
- Legionellen
• Harn - Legionellen
- Pneumokokken
• Pleurapunktion
• CT-Lunge
Spezifität: 80% Sensitivität: 50-60%
Spezifität: 99% Sensitivität: 76-86%
Spezifität: 90% Sensitivität: 50-80%
• 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:
W.Pohl 08
Legionella pneumonia
W.Pohl 08
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.
W.Pohl 08
Influenza pneumonia
W.Pohl 08
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%)
W.Pohl 08
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
• 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.
W.Pohl 08
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§
W.Pohl 08
THERAPIE
W.Pohl 08
Therapie-Empfehlungen nach Risikogruppen
W.Pohl 08
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.
W.Pohl 08
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
W.Pohl 08
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 ?
W.Pohl 08
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
W.Pohl 08
THERAPIE- VERSAGEN
W.Pohl 08
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
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
W.Pohl 08
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
W.Pohl 08
Treatment Failure in Community-Acquired Pneumonia Rosario Menendez and Antoni Torres Chest 2007; 132; 1348-1355
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
W.Pohl 08
Bronchiolitis obliterans organizing pneumonia
W.Pohl 08
Treatment Failure in Community-Acquired Pneumonia Rosario Menendez and Antoni Torres Chest 2007; 132; 1348-1355
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
W.Pohl 08
PRÄVENTION
W.Pohl 08
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.
W.Pohl 08
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
W.Pohl 08
Differentialdiagnosen
• Maligner Prozess
• TBC typ/atyp
• Infarktpneumonie
• Lungenstauung
• Atelektase
• Pilze
W.Pohl 08
Pneumonie ja oder nein ?
W.Pohl 08
W.Pohl 08
Normalbefund
W.Pohl 08
W.Pohl 08
W.Pohl 08
Lungenstauung
W.Pohl 08
De- und Rekompensation
W.Pohl 08
W.Pohl 08
Pneumonie (Pneumokokken)
W.Pohl 08
Kulissenzeichen
W.Pohl 08
W.Pohl 08
Pneumonie ML
W.Pohl 08
W.Pohl 08
Infarktpneumonie
W.Pohl 08
Hamton Hump
W.Pohl 08
W.Pohl 08
Pneumonie (Legionella)
W.Pohl 08
W.Pohl 08
TBC (miliares Bild)
W.Pohl 08
W.Pohl 08
W.Pohl 08
Alveolarzellcarcinom
W.Pohl 08
W.Pohl 08
Pneumonie re OL
W.Pohl 08
W.Pohl 08
OL Atelektase/zentraler TU re
W.Pohl 08
Pancoast TU li
W.Pohl 08
W.Pohl 08
Pleuraempyem
W.Pohl 08
Rupturierte Abszesse
W.Pohl 08
Pneumonie UL re
W.Pohl 08
W.Pohl 08
Lymphangiose
W.Pohl 08
Strahlenpneumonitis
W.Pohl 08
Aspergillom
W.Pohl 08
Pneumonie (Clamydien)
W.Pohl 08
Pneumonie OL li
W.Pohl 08
Postpneumonische Residuen
W.Pohl 08
DANKE FÜR EURE AUFMERKSAMKEIT!
...ein handout folgt...
W.Pohl 08
AB - Therapie
W.Pohl 08
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
W.Pohl 08
New guidelines for the management of adult community-acquired pneumonia Kathryn Armitage and Mark Woodhead Curr Opin Infect Dis 2007; 20: 170–176
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
W.Pohl 08
New guidelines for the management of adult community-acquired pneumonia Kathryn Armitage and Mark Woodhead Curr Opin Infect Dis 2007; 20: 170–176
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
W.Pohl 08
W.Pohl 08
Nosocomial gram-negative (Pseudomonas) pneumonia
(b)
W.Pohl 08
W.Pohl 08
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
W.Pohl 08
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
W.Pohl 08
Erregerspektrum: Early onset versus late onset
Early Onset Late Onset
Staphylococcus aureus
Streptococcus pneumoniae
Haemophilus influencae
Pseudomonas aeruginosa
Acinetobacter baumannii
Stenotrophomonas maltophilia
W.Pohl 08
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 • • • •
W.Pohl 08
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
W.Pohl 08
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
W.Pohl 08
„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
W.Pohl 08
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
W.Pohl 08
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
W.Pohl 08
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
W.Pohl 08
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.
W.Pohl 08
MRSA Management
Therapie
• Vancomycin
• Teicoplanin
• Linezolid
• Daptomycin
Dekontamination
• Nasensalbe - Mupirocin, Octenidin
- Betaisodona
• Augensalbe - Fucithalmic
• Desinfizierende Seife
• Antiinfektivum - Rifampicin
- Minocyclin
- Cotrimoxazol
- Fusidinsäure
- Fosfomycin
W.Pohl 08
Staphylokokken Therapie
kurz & heftig
• HD-Laktame
• Vancomycin
• Linezolid
• Fosfomycin
lang & geduldig
• Teicoplanin
• Fusidinsäure
• Minocyclin
• Rifampicin
• Trimethoprim
• ...
W.Pohl 08
Lunge und Candida
• Häufig Kolonisation bei kritisch Kranken
• Histologisch verifizierte Candida-Pneumonie ist sehr selten
• Nachweis von Candida im Respirationstrakt ist keine Behandlungsindikation
W.Pohl 08
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
W.Pohl 08
Treatment Failure in Community-Acquired Pneumonia Rosario Menendez and Antoni Torres Chest 2007; 132; 1348-1355
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)
W.Pohl 08
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
No antibiotic therapy 9.8 1.0 3.5
Noncompliant therapy 7.5 7.0 3.8
Partially compliant therapy 2.3 2.8 2.0
Compliant therapy 80.5 89.2 90.7
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
W.Pohl 08
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
No antibiotic therapy 8.3 5.9 3.7
Noncompliant therapy 40.1 32.4 19.4
Partially compliant therapy 1.6 2.1 2.6
Compliant therapy 50.0 59.6 74.3
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
W.Pohl 08
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.
W.Pohl 08
KATEGORIEN
W.Pohl 08
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
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
W.Pohl 08
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)
W.Pohl 08
Radiological imaging in pneumonia: recent innovations Sat Sharma, Bruce Maycher and Gregg Eschun Curr Opin Pulm Med 2007; 13: 159–169
Left lower-lobe cavitation in a patient with nosocomial Gram-negative (Pseudomonas) pneumonia
(b)
W.Pohl 08
Radiological imaging in pneumonia: recent innovations Sat Sharma, Bruce Maycher and Gregg Eschun Curr Opin Pulm Med 2007; 13: 159–169
Bilateral, multilobar consolidations of community acquired Legionella pneumonia led to acute respiratory failure
W.Pohl 08
Radiological imaging in pneumonia: recent innovations Sat Sharma, Bruce Maycher and Gregg Eschun Curr Opin Pulm Med 2007; 13: 159–169
Influenza pneumonia in a debilitated elderly patient who did not receive influenza vaccine
W.Pohl 08
Radiological imaging in pneumonia: recent innovations Sat Sharma, Bruce Maycher and Gregg Eschun Curr Opin Pulm Med 2007; 13: 159–169
Bronchiolitis obliterans organizing pneumonia of idiopathic etiology
W.Pohl 08
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
W.Pohl 08
VERLAUF
W.Pohl 08
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.
W.Pohl 08
Treatment Failure in Community-Acquired Pneumonia Rosario Menendez and Antoni Torres Chest 2007; 132; 1348-1355
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
W.Pohl 08
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)
W.Pohl 08
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
W.Pohl 08
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 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%)
W.Pohl 08
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
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
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
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
W.Pohl 08
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
W.Pohl 08
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)
W.Pohl 08
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
W.Pohl 08
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
W.Pohl 08
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
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.
W.Pohl 08
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
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
W.Pohl 08
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%)
W.Pohl 08
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
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
W.Pohl 08
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