Swamy Journal Presentation

7/29/2019 Swamy Journal Presentation

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CAP IN A CAPSULE

MODERATOR:

Dr.SELVAMUTHUKUMARAN


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Introduction

William Osler once described pneumonia as

the old mans friend as death was often

quick and painless

CAP is the second most common cause of

death from infectious diseases in India

the leading cause of childhood mortality

Studies reveal that the causative organism of

CAP is identified in only 29% of cases.


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Risk factors

Case fatality with invasive pneumococcal

pneumonias in India was reported to be about

30% according to the IBIS study for a 10-year

period.

CAP incidence is the highest in winter

more in males with ratio of 1.4 : 1

increased with age (1564 years)


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Streptococcus pneumonia is more frequentlyisolated from alcoholic patients than others

There was no relationship between mortality

and alcohol, but the severity was more inthese patients.

tobacco smoking is a risk for CAP

HIV-positive patients had a higher prevalenceof Mycoplasma pneumonia in a study fromCMC Vellore


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etiology

Fang et al. conducted a prospective, multicenterstudy in 359 cases to evaluate the new andemerging causes of CAP

S. pneumoniae (15.3%), H. infuenzae (10.9%),Legionella spp. (6.7%) and C. pneumoniae (6.1%).Mortality was the highest for S. aureus (50%) andthe lowest for C. pneumoniae (4.5%).

The study concluded that empiric antibiotic

prescriptions must be infuenced by therealization that C. pneumoniae and Legionellaspp. are common etiologies for CAP


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The emerging etiologies for CAP were alsoexamined in a 12-month prospective study,which evaluated the microbiological yield with

a new diagnostic polymerase chain reaction(PCR) platform along with conventionalmethods

It was possible to establish microbial etiologyin about 67% (n=124) of patients

. A microbiological agent was identifed in 89%


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S. pneumoniae [70 patients (38%)] and

respiratory virus [53 patients (29%)] were the

most frequently detected pathogens.

Forty-three (35%) patients out of 124, were

detected with two or more pathogens.

The most common causative pathogen in Europe,

the United States, the United Kingdom, Iraq,Delhi, and Mumbai is S. pneumoniae

whereas in Singapore, it is K. pneumoniae


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Indian Data

In the Indian scenario, studies on

bacteriological etiology are a few and far

between, and are mostly confned to limited

geographical areas

S. pneumoniae predominates as etiological

agent of CAP in Shimla and Delhi

whereas, P. aeruginosa in Ludhiana


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bansal et al. conducted a study to identify the

clinical and bacteriological profle in Shimla

S. pneumoniae, S. aureus, K. pneumoniae, M.

pneumoniae, E. coli and other Gram-negative

bacteria were the most frequently isolated

pathogens


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A study by Shah5 et al. showed that factors thatcan predict mortality in a patient of CAP at thetime of admission are

Patients above 65 years of age

History of chronic obstructive pulmonary disorder

Smoking

Hypotension and altered sensorium Respiratory failure

Staphylococcal pneumonia


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Tests to Determine Etiology of CAP

Blood cultures, sputum Gram-stain andculture are the most common tests used

In addition to this, serological tests are also

performed. an adequate sputum sample is defned as >25

polymorphs and


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Serologic Tests

The Immunoglobulin M (IgM) antibodies againstmycoplasma rise 1 week after infection and remainpositive for 6 months to 1 year after infection.

This accounts for poor sensitivity and specifcity

The IgM antibodies to Chlamydia take 3 weeks tobecome detectable accounting for poor sensitivity.

Antigen detection tests for viruses in respiratorysecretions have reasonably good sensitivity andspecifcity, but are not currently available

Antibody tests for viruses have poor sensitivity/specifcity


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Limitations of Common Investigations

Gram-Stain and Culture: Microbe identifcation

is possible in 50% of patients only and

depends on quality of sputum sample.

Blood cultures give poor results

Serology requires rising titres; it is expensive

and not easily available

Viral cultures are not useful; viral antigens are

better


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General and Radiological

Investigations

The most useful signs and symptoms for thediagnosis of CAP include:

Fever

Dyspnea Tachypnea

Positive signs on respiratory examination

Studies show that traditional chest physicalexamination alone is not sufficiently accurate toconfirm or exclude the diagnosis of pneumonia


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Especially in elderly

the symptoms are less severe and at times are

replaced with nonspecifc symptoms, such as

functional failure, falls or confusion.

They also have a lesser tendency to have fever

compared to younger patients.


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Symptoms specific to organism

Streptococcus pneumoniae: Increasing age,

comorbidity, acute onset, high fever and pleuritic

chest pain.

Bacteremic pneumonia: Female sex, excess alcohol,diabetes mellitus, chronic obstructive pulmonary

disease.

Legionella pneumophila: Younger patients, smokers,

absence of comorbidity, diarrhea, neurological

symptoms, more severe infection and evidence of

multisystem involvement (e.g. abnormal liver

function tests, elevated serum creatine kinase).


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Mycoplasma pneumoniae: Younger patients,

prior antibiotics, less multisystem

involvement.

Chlamydophila pneumoniae: Longer durationof symptoms before hospital admission,

headache.

Coxiella burnetii: Males, dry cough, high fever.


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Absence of vital sign abnormalitiessubstantially reduced the probability of theinfection.

The gold standard for the diagnosis ofpneumonia is chest radiography.

Sensitivity and specifcity of chest radiograph

are not well-known and also limited data isavailable on costs of false-positive and false-negative results.


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Wipf et al.2 conducted a study to determinethe accuracy of various physical examinationmaneuvers in diagnosing pneumonia and to

compare the inter-observer reliability ofmaneuvers among three examiners.

Male patients with symptoms of lowerrespiratory tract infection (cough and changein sputum) were enrolled in this prospectivestudy (n=52).


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A standard form was used to record the

examination fndings by lung site and whether

the examiner diagnosed pneumonia.

Radiologists read the chest radiography flms.

the three examiners clinical diagnosis of

pneumonia had a sensitivity of 4769% and

specifcity of 5875%


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Vital Sign Abnormalities

Nolt et al. conducted a study which examined thestrength of the association among vital signabnormalities, advanced age and the diagnosis ofCAP in the evaluation of adults with acute cough

illness It was found that vital sign abnormality (including

fever, hypoxemia, tachycardia or tachypnea) andage greater than 50 years were the only signifcant

predictors of CAP strong association was found between hypoxemia

and CAP


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Mayaud et al. carried out an evaluation study

on data related to age and clinical and

radiological fndings.

The data showed that absolute lack of vital

signs has a good negative predictive value in

CAP.

The presence of unilateral crackles has a good

positive predictive value


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Role of Chest Radiograph

Lieberman et al. conducted a prospective,

clinical study with the aim to determine the

reliability of physiciansjudgements in

respiratory tract infections (RTIs) patients byclinical assessment alone compared with chest

radiography.

Ambulatory patients with febrile RTI wereenrolled (n=250).


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compared to the results of chest radiography,physiciansjudgements of pneumonia had asensitivity of 74%, a specifcity of 84%, a negative

predictive value of 97% and a positive predictivevalue of only 27%.

Physicians had good ability to negateradiography-confrmed pneumonia by clinical

assessment in febrile adult RTI patients. However, they had poor ability to successfully

predict the condition


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OBrien et al.9 carried out a study to develop aprediction rule for the use of chest radiographs inevaluating CAP based on presenting signs and

symptoms. The study included 350 adult patients with acute

respiratory symptoms and positive chestradiographic results

The study included an equal number of age-matched controls with acute respiratorysymptoms but negative radiographic results


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It was found that vital sign and physical

examination fndings are useful screening

parameters for CAP, demonstrating a sensitivity

of 95%, and a specifcity of 56% in the presence ofvital sign or physical examination abnormalities.

The study fndings were suggestive of non-

requirement of chest radiographs in the absenceof vital signs abnormalities or physical fndings

Chest X ray is Considered as Gold


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Chest X-ray is Considered as Gold

Standard for Diagnosis of Pneumonia:

The Netherland Study Findings In a study conducted in three hopitals in theNetherland, it was found

Pneumonia cannot be treated based on clinical fndingsalone. Manifestation of pneumonia on chest X-ray

varies considerably depending upon the degree ofinfammation and stage of the disease process.

Radiographic fndings may lag behind clinical fndingsand are poor indicators of etiological diagnosis.

Pneumonia was frequently overdiagnosed clinically bygeneral practitioners.


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British Thoracic Society Guidelines

British Thoracic Society guidelines do notrecommend chest radiography in patients withsuspected CAP unless the diagnosis is not clearand chest radiograph would help in differential

diagnosis and management of acute illness. ChestX-ray is considered when

there is no satisfactory treatment progress at thetime of review or

the patient is at risk of underlying lung pathology The guidelines also recommend routine chest

radiograph 6 weeks after discharge.


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American thoracic society

The IDSA/ATS consensus guidelinesrecommend the use of chest radiograph orother technique with or without

microbiological data for the diagnosis ofpneumonia.

Identification of causative microorganismthrough microbiological studies may supportthe diagnosis of pneumonia.


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Importance of Severity Assessment

Important

Community-acquired pneumonia (CAP)represents a signifcant therapeutic challengeto physicians, as they have to decide whether

the patient is to be treated in a clinic or ahospital setting.

Therefore, it is vital to assess the severity ofthe disease

Several scoring systems are available to helpclinicians assess the severity of the illness


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there are three scoring systems available for

assessing the severity of CAP. These systems

aim to assess the mortality risk associated

with the illness and thus accurately determinethe severity. The three scoring systems are2

Pneumonia Severity Index (PSI)

CURB 65

CRB 65


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Pneumonia Severity Index

It is a mortality prediction tool that was first

introduced by Fine et al. in 1997.

It classifies CAP patients into five categories of

an increased risk for short-term mortality

based on 20 variables routinely available at

presentation.


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The PSI score is assigned after answering thefollowing three questions:3

Is the patient >50 years of age?

Does the patient have any coexistingabnormalities

Does the patient have altered mental status,

pulse rate 125 beats/min; respiratory rate30 breaths/min; systolic blood pressure


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While the PSI is a relatively reliable tool for

mortality assessment in CAP, there remain

some limitations that prevent its widespread

use.

One of the major limitations is that the tool

relies heavily on the age of the patient, which

may result in underestimation of the severityof the illness, especially in younger patients.


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CURB 65

CURB 65 is a modification of the British ThoracicSociety (BTS) rule in assessing pneumoniamortality risk.

It uses five variables to arrive at overall death riskin CAP

Lim et al. also examined the efficacy of thisscoring system after excluding BUN.

CRB 65 that effectively categorizes patientsaccording to the need for home care, hospitalassessment or urgent (ICU) hospital admission


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Bauer et al found that CURB and CRB 65 hadan equivalent predictive power for 14-daymortality.

Thus, CURB, CURB 65 and CRB 65 allow forsimilar predictions of death from CAP ascompared to the PSI.

Among these severity assessment scales, theCRB 65 is the only tool that can be applied tooutpatients as wel


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PSI vs. CURB 65

PSI is indicated for identifying low-risk patients

CURB 65 is ideal for identifying high mortalityrisk patients with severe illness.

In the Indian context, Shah et al. found thatboth PSI and CURB 65 had equal sensitivity inpredicting the risk of death from CAP.

The PSI was more sensitive in predicting ICUadmission than CURB 65, although the latterhad better overall specificity.


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Recommendations

Use CURB 65/CRB65 over PSI in India forjudging site of care and severity

both PSI and the CURB 65 have several

limitations These scoring systems are designed primarily

to predict mortality.

They are not very effective for predicting ICUadmission and are of limited use in the criticalcare environment.


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Importance of Identifying Patients in

Need of ICU Admission

Identifying appropriate patients to optimize

the use of limited ICU resources.

An increase in mortality is observed in

patients who are transferred to the ICU for

delayed respiratory failure or delayed onset of

septic shock.

Microbial etiologies for ICU patients aredifferent from that of CAP in general


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Predictive Models for Severe CAP

There are three scoring systems available for

identifying severe CAP that necessitates ICU

admission.

ATS/IDSA Criteria

SMART-COP Rule

SCAP Rule


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ATS/IDSA Criteria


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Limitations

Variables like ventilation and vasopressors, asspecifed in the ATS criteria, might not beavailable at admission in the emergency

department (ED). This might lead to errors in deciding the site-

of-care; for example, patients might beadmitted to the ward instead of the ICU.

This might lead to an increase in the risk ofmortality.


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SMART COP score


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SMART COP is the result of an extensive studyon CAP called the Australian CAP Study

(ACAPS). The tool was designed to overcome the

limited ability of PSI and CURB 65 to predictwhich patients will require intensiverespiratory or vasopressor support (IRVS).

Th i i f SMART COP


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The interpretation of SMART-COP

score

0-2 points: Low risk of needing intensive

respiratory or vasopressor support (IRVS)

3-4 points: Moderate risk (1 in 8) of needing

IRVS

5-6 points: High risk (1 in 3) of needing IRVS

7 or more points: Very high risk (2 in 3) of

needing IRVS


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SCAP rule


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advantage of this model is its ability to identifyseriously ill patients with CAP who are at risk for anadverse outcome.

The variables are easy to interpret and access in

causality The sensitivity of SCAP to identify severe CAP is 92%

it is more sensitive but not specific when compared toPSI or CURB 65

In the study, SCAP was found to be effective inpredicting adverse outcomes such as ICU admission,mechanical ventilation, development of severe sepsisand therapeutic failure.


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Keeping in view the limitations of the ATS and

the SMART-COP scoring systems, SCAP may be

more suited in the Indian scenario.

More practical in predicting ICU admission

Cost-effective

Accessible

Useful in taking quick decision for ICU

admission.


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Role of Biomarkers

Three prognostic markers, C-reactive protein(CRP), procalcitonin (PCT) and cortisol, have beeninvestigated to assess CAP severity and predictoutcome

Biomarkers can help differentiate patients withpneumonia from heart failure and chronicobstructive pulmonary disease (COPD)

exacerbation, with the latter not requiringantibiotics.

can be used to assess the treatment response.


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Procalcitonin

Significantly higher PCT levels have been observed inpatients with a higher PSI score or with complications ordeath than those with an uncomplicated clinical course.

In the CAPNETZ study, Krger et al. Nonsurvivors hadsignificantly higher median PCT levels than survivors (1.2 vs.

0.3 mmol/L; p=0.0001) Even in patients with high CRB 65, low PCT was able to

accurately predict patients who are at very low risk ofdeath.

Procalcitonin has a high negative predictive potential(98.9% with PCT level of


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advantages

Identifying need for aggressive management

Identifying patients to be treated on

outpatient basis

When PCT is used as a prognostic marker,

patients can be counseled appropriately for

adverse events.


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limitations

Cost

Availability

Reporting time

Serial assessment


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C-reactive protein is an acute-phase proteinsynthesized in the liver.

Chalmers et al. carried out a prospective study andfound that admission CRP


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PCT vs. CRP

Simon et al. compared the predictive value of PCT andCRP in assessing the severity of CAP and found thatPCT (88%) was more sensitive than CRP (75%) in thedistinction of bacterial and noninfective causes ofinfammation.

Also, PCT (81%) was more specifc than CRP (67%) indifferentiating bacterial from noninfective causes ofinfammation.

SCAP criteria with the use of biomarkers is one

potential solution. Procalcitonin seems to offer the greatest potential

among all biomarkers

Management of Community Acquired


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Management of Community-Acquired

Pneumonia


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Indian Setting

An important concern in India is tuberculosis.

Tuberculosis accounts for 7% cases of CAP.

Newer fuoroquinolones have excellent

activity against Mycobacterium tuberculosis.

There is a delay in the initiation of appropriate

antituberculosis treatment (21 days vs. 5

days), thus increasing the risk of spread oftuberculosis in the community.


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The widespread and indiscriminate use of these broad-spectrum quinolones (often in subtherapeutic doses) canenhance the quinolone resistance of organisms, includingmycobacteria.

Based on this, with the use of newer fuoroquinolones,

there may be: Potential masking of active tuberculosis

Probability of an emerging epidemic of extensively drug-resistant tuberculosis

Therefore, in areas of tuberculosis endemicity, restricteduse of newer fuoroquinolones may be considered.Macrolides may have an extended role in these endemicareas.


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Recommendation

Amoxicillin remains the preferred agent to initiateempiric antibiotic therapy in clinic/ outpatientsettings.

Macrolides such as clarithromycin andazithromycin are recommended in those patientswho are hypersensitive to penicillins.

Given the endemic nature of tuberculosis in India,

macrolides such as clarithromycin andazithromycin may be preferred to quinolones/doxycycline as the initial empiric therapy.


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Most of the bacteria causing community-

acquired pneumonia are found to be resistant

to doxycycline. Hence, doxycycline is not

recommended. In the presence of comorbidities, a respiratory

fuoroquinolone or a -lactam plus a macrolide

or amoxicillinclavulanate is preferred.


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Coverage of Atypical Pathogen

Restrepo et al. compared clinical outcomes ofpatients with CAP treated with and withoutatypical coverage. In the study, the long-term (90days) and short-term (30 days) mortality was

assessed with the use of macrolides in patientswith severe sepsis due to pneumonia.

The use of macrolide was associated withreduced mortality at 30 as well as at 90 days.

The study concluded that empiric therapy with aregimen that covers atypical pathogens might beconsidered for all hospitalized patients with CAP.


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Monotherapy vs. Dual Therapy

Waterer et al. confirmed that monotherapy may not beoptimal for CAP patients hospitalized.

On the basis of culture results, empirical therapy in thisstudy was classified as single effective therapy (SET), dualeffective therapy (DET) or more than DET (MET).

Multivariate analysis confirmed that SET was anindependent predictor of worse outcome. Among patientswho were given coverage for atypical pathogen, 9.9% diedas compared to 22.6% without atypical coverage (p=0.02).

Subjects who did not receive coverage for atypicalorganisms had a significantly higher predicted mortalitythan those who received it (27.3% vs. 21.8%, respectively;p=0.047);


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It was observed that subjects receiving SET were

6.4 times more likely to die of their illness after

adjusting for the severity of pneumonia.

The same premise was also evaluated in a reviewby Weiss and Tillotson.

This review also suggested that for hospitalized

patients, dual therapy combining a -lactam andan advanced macrolide represents a good choice

potental benefts of combinaton


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ptherapy include

Better atypical microorganisms coverage The combination regimen that acts at two different

sites in the bacteria (cell wall for -lactams and theinhibition of protein synthesis for macrolides),

Demonstrated effective antiinfammatory properties ofmacrolides via reduced production of interleukin-8 andtumor necrosis factor-.

Beta-lactams and fuoroquinolones that might beresponsible for perpetrating the inflammation process

because they are known to kill a large number ofbacteria in a short amount of time, thus releasingnumerous intracellular components.


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Agents Used in Combination Therapy

Anderson et al. compared the effects of subinhibitoryconcentrations of antibiotics

on pneumolysin production by a macrolide-susceptiblestrain and two macrolide-resistant strains [erm(B) or

mef(A)] of S. pneumoniae This study indicated that only macrolides and

macrolide-like antibiotics were found to inhibit theproduction of pneumolysin by all three strains of thepneumococcus, with clarithromycin, erythromycin,

telithromycin and clindamycin exhibiting comparableactivities, whereas azithromycin was generallysomewhat less active..


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Furthermore, in comparison with the otherclasses of antibiotics tested, macrolides atsub-MICs effectively antagonize the

production of pneumolysin by both macrolide-susceptible and macrolide-resistant strains ofthe pneumococcus

compatible with a role for these agents as

adjuncts to p-lactams in the treatment ofsevere pneumococcal disease


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Recommendations

Combination therapy is the way forward in patientshospitalized with moderate severity CAP.

Amoxicillin plus macrolides like clarithromycin orally is thepreferred regimen in these cases. In patients hypersensitiveto penicillins oral doxycycline, levofoxacin or moxifoxacin isrecommended.

If oral administration is not possible IV amoxicillin orbenzylpenicillin plus macrolide like clarithromycin IV isrecommended.

For hospitalized patients, the necessary change inantibiotics can be done only after the sputum culture test,till then empiric therapy is continued.

Empirical Antibiotic Choice for Adults


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Empirical Antibiotic Choice for Adults

Admitted in ICU with CAP

Macrolides may contribute to better

outcomes in patients with severe sepsis due to

CAP, as they have

A synergistic antibacterial mechanism

Atypical pathogen coverage

An immunomodulatory effect

If the specific pathogen has been isolated,

then the choice is relatively straightforward.


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IDSA/ATS recommends a respiratory fuoroquinolone ora combination of b-lactam plus a macrolide for non-ICUinpatients (strong recommendation, Level 1 evidencefor both regimens).

IDSA/ATS recommends a b-lactam plus eitherazithromycin (Level II) or a respiratory fuoroquinolone(Level I) for ICU-admitted inpatients.

BTS recommends an I.V. combination of a broad-spectrum b-lactamase-stable antibiotic such as co-

amoxiclav plus a macrolide like clarithromycin. Inpatients allergic to penicillin, cephalosporins can beused in combination with clarithromycin.


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Recommendations

Dual or combination therapy should beconsidered for severe CAP.

Macrolides were found to be compatible asadjuncts to broad-spectrum -lactamase stable

antibiotic in severe CAP. An intravenous combination of a broad-spectrum

b-lactamase stable antibiotic such as co-amoxiclav together with a macrolide such as

clarithromycin may be preferred overfouroquinolones or their combinations in Indiaconsidering the tuberculosis endemicity.


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Timing of antibiotic

an important performance indicator in

community-acquired pneumonia (CAP).

The European guidelines recommend initiation

of antibiotics within the first two hours ofhospitalization,

whereas the current Infectious Disease Society of

America/ American Thoracic Society consensusguidelines advise the initiation of the first

antibiotic dose in the emergency department.


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A prospective observational study conducted bySilber et al. reported that there was no reductionin the time to clinical stability with theadministration of antibiotics within 4 hours

Bruns et al. conducted a study to evaluate theeffect of minimizing the TFAD on the early clinicaloutcome

Time to first antibiotic dose was however, not

associated with early clinical failure. Hence, it is not advisable to consider TFAD as a

performance indicator


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Metersky et al. determined the frequency of medicarepatients who are discharged with a diagnosis ofpneumonia with atypical presentation.

This could lead to diagnostic uncertainty and a

resultant appropriate delay in antibiotic administration. A fnding from a retrospective study of 548 patients by

Welker et al. reported that there was a reduction in theaccuracy of the initial diagnosis of CAP when the

required TFAD was changed from 8 hours to 4 hours.

Concerns with the Administration of


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Concerns with the Administration of

Antibiotics within 4 Hours

Overdiagnosis/misdiagnosis of CAP,

inappropriate utilization of antibiotics,

no association to mortality,

length of hospital stay, time to clinical stability

and pressure on clinicians to start the first

dose of antibiotic despite diagnostic

uncertainty, were the concerns with theadministration of antibiotics within 4 hours


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Rhew et al. investigated the effectiveness ofearly switch and early discharge strategies in CAPpatients

Ten prospective, interventional, CAP-specifcstudies that evaluated length of stay wereincluded in the study.

Early switch and early discharge strategies may

signifcantly and safely reduce the mean length ofstay (LOS) when the recommended LOS is shorterthan the actual length of stay


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Athanassa et al. conducted a meta-analysis There was no difference in the treatment success,

mortality and recurrence of CAP between thegroups

Shorter duration of hospitalization was observedin the early switch group.

It was concluded that early switch to oral

antibiotics can be as effective as continuousintravenous treatment in patients with moderate-to-severe CAP


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Ramirez and Bordon conducted a study to evaluate theclinical outcomes while switching from intravenous tooral therapy in hospitalized patients with CAP. He usedfour criteria

Improvement of cough and shortness of breath

Patient being afebrile for a minimum of 8 hours

White blood cell count reaching normal levels

Adequate oral intake and gastrointestinal tractabsorption

It was concluded that it was safe to switch fromintravenous to oral therapy in hospitalized patientswith CAP after the patient was clinically stable


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R d i


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Recommendations

The timing of antibiotic therapy depends on theseverity of the CAP at the time of hospital admission.Severe cases of CAP require immediate institution oftherapy, which must be adjusted after confrmingmicrobiological etiology.

Switch from intravenous antibiotics to oral treatment isrecommended in case of observed improvement insymptoms, improved respiratory rate and oxygensaturations, patient being afebrile for >24 hours,

hemodynamic stability, reduction in white blood cellcount (if elevated earlier) and absence of nausea/vomiting.

At i l i


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Atypical organisms

Streptococcus pneumoniae causes up to 70% ofcommunity-acquired pneumonia cases andatypical pathogens are responsible for 3040% ofcases

Legionella, Mycoplasma pneumoniae andChlamydia pneumoniae are the atypical agents

the other bacteria which cause community-

acquired pneumonia besides Streptococcuspneumoniae are Haemophilus infuenzae,Staphylococcus aureus and Gram-negative bacilli.


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Zaki and Godal reported that Chlamydiapneumoniae, Mycoplasma pneumoniae,Legionella pneumophila, Coxiella burnetii,adenovirus, and infuenza virus were the

pathogens responsible for CAP. Streptococcus pneumoniae (22%)

Haemophilus infuenzae (18%).

Mycoplasma pneumoniae (5%) and

Legionella pneumophila (5%) were the mostcommon isolated bacteria.


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Appropriate oral medications should be usedwithout compromising on the spectrum of coverof the bacterial fora by the antibiotic.

In the absence of a culture/sensitivity report

identifying an organism and an appropriate oralantibiotic, following oral replacements aresuggested.

Special care and intensive management is

required in some special population of patientslike those with severe CAP, sepsis, hypotensionand respiratory failure.


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In an Indian study conducted by Udwadia etal, the most common atypical organism

causing CAP were Chlamydia pneumoniae and

Mycoplasma pneumoniae


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Therapy for pneumonia is empiric because specifcpathogens usually are not identifed at the time thetreatment is initiated.

C. pneumonia and Legionella spp. are intracellularorganisms and M. pneumonia lacks a cell wall, p-lactams are not effective.

In Legionell infection erythromycin is effective asdemonstrated in some trials and in case ofMycoplasma pneumonia, erythromycin and

tetracycline are effective. They also reduce symptom duration in Chlamydia

pneumonia infection.


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Azithromycin and clarithromycin are very effectiveagainst Mycoplasma pneumoniae, Chlamydiapneumoniae and Legionella spp. and show bettertolerability profle as compared to erythromycin.

Doxycycline is also effective and is associated withfewer gastrointestinal side-effects.

Fluoroquinolones are highly effective againstMycoplasma pneumoniae, Chlamydia pneumoniae and

Legionella spp. The advantage of fuoroquinolones is once-daily dosing

and excellent bioavailability


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The combination of rifampin plus a macrolideor a quinolone can be used for initial

treatment in severely ill patients with

Legionnaires disease

Impact of Empirical Therapy of CAPon Treatment of M t berc losis


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on Treatment of M. tuberculosis

Infections Initiation of empirical therapy of CAP is known to

have two important concerns:

Delayed initiation of anti-TB treatment

Resistance to fuoroquinolone

Dooley et al. , Yoon et al. Conducted studies

indicate that newer fuoroquinolones should be

restricted in tuberculosis endemicity because ofits potential to mask active tuberculosis and

emerging drug-resistant tuberculosis.

Recommendations


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Recommendations

Atypical coverage is a must in moderate-to-severely ill patients withpneumonia requiring hospitalization and intensive care unit care.

The only acute respiratory tract infection in which delayed antibiotic

treatment has been associated with increased risk of death is CAP,

hence prompt and accurate diagnosis of CAP is important.

Tuberculosis should always be considered while treating CAP in India.

Therefore fuoroquinolones (levofoxacin and moxifoxacin) though

effective in the treatment of CAP should be used cautiously.

Newer macrolides are the drug of choice for the treatment of CAP.

Viral pneumonias, especially infuenza and H1N1 should be consideredin the clinical setting.


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INSPECTION OF SRI THIRUAVINANKUDI SWAMY ... OF SRI THIRUAVINANKUDI SWAMY THIRUKKOIL PALANI THE DEITY OF THE temple Sri Arulmighu Kulandai VELAYUDHA SWAMY faces west and the entrance

Sri bakthavaraprasada anjaneyar swamy, salem

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Mahesh Swamy Tsuneo Kume - Control Design€¦ · Mahesh Swamy Yaskawa Electric America, Inc. Waukegan, IL, U.S.A. Email: [email protected] Tsuneo Kume Yaskawa Electric Corporation

Prof Swamy

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SWAMY SARANAM TRAVANCORE DEVASWOM BOARD

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