Exploring onset, progression and outcomes of Pneumonia from community to Hospital

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2. Dr. Parthiv MEHTA

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 “Con- solidation” of Air Cells..
Infection / Inflammation
 Pneumonia in OPD > ICU
 Arriving with Pneumonia
▪ “Community Acquired”
 Arising Pneumonia in Hospital
▪ “Nosocomial”

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 Community Acquired Pneumonia (CAP)
 Different severity
 Multivariate pathogen
 Multiple antibiotic exposures
 Multiple variables..
WARD
ICU

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 Severity
 Co-morbidities
 Age of patients
 “Affordability”
 “Perception of Severity”

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Criteria for Severe CAP…
>/=3
Mandell LA et al. IDSA /ATS consensus guidelines on the management of CAP in adults. Clin Infect Dis. 2007;44(suppl 2):S27-S72.

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Criteria for Severe CAP…
Mandell LA et al. IDSA /ATS consensus guidelines on the management of CAP in adults. Clin Infect Dis. 2007;44(suppl 2):S27-S72.
>/=3

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N Engl J Med 2015;373:415-27

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 Active population based surveillance
 Jan 2010 to June 2012
 Laboratory Methods: extensive testing for CAP
pathogens
 Bacterial Culture: Blood, Pleural, High quality
sputum,Tracheal aspirate, BAL
 PCR (for viral pathogens, bacterial pathogens) from
sputum, pleural fluid, nasopharyngeal or
oropharyngeal swab
 Urinary antigen test for Legionella, S. pneumoniae
N Engl J Med 2015;373:415-27

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N Engl J Med 2015;373:415-27

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 Despite extensive diagnostic work up, pathogens
were identified in 38%
 Viruses were detected in 27% of the patients
 Human Rhinovirus was the most commonly detected virus
in patients with pneumonia
 Influenza virus was the second most common pathogen
detected
 Bacterial pathogens were detected in 14% of the
patients
 S. pneumoniae was the most commonly detected
bacterium
 M. pneumoniae, L. pneumophila, and C. pneumoniae
combined were detected in 4% of the adults
N Engl J Med 2015;373:415-27

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Polymicrobial CAP; is a risk factor for inappropriate initial
antimicrobial treatment which in turn; independently
predicts hospital mortality.

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ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416.
Antimicrobial therapy in preceding 90 days
Current hospitalization of 5 days
High frequency of community or hospital-unit
antibiotic resistance
Presence of risk factors for HCAP
–Hospitalization for 2 days in preceding 90 days
–Residence in a nursing home or LTC facility
–Home infusion therapy (including antibiotics)
–Chronic dialysis within 30 days
–Home wound care
–Family member with MDR pathogen
Immunosuppressive disease and/or therapy

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Adapted from Kollef MH et al. Chest. 1999;115:462-474.
ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416.
“…selection of initial appropriate antibiotic therapy (ie, getting the antibiotic treatment right
the first time) is an important aspect of care for hospitalized patients with serious infections.”
– ATS/IDSA Guidelines
A Study by Kollef and Colleagues Evaluating the Impact of Inadequate Antimicrobial Therapy on Mortality
Inadequate antimicrobial treatment
(n=169)
Adequate antimicrobial treatment
(n=486)
0
10
20
30
40
50
60
All-Cause Mortality Infection-Related Mortality
24
42*
18
HospitalMortality(%)
52* *P<.001

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 Primary outcome: 30-day all-cause mortality.
 Secondary outcomes: Medicare spending and
hospital costs.
 Patient and hospital characteristics were adjusted
to account for differences between patients with
and without ICU admission.

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Results
 Among 11,12,394 Medicare beneficiaries with
pneumonia, 3,28,404 (30%) were admitted to the
ICU.
 In unadjusted analyses, patients admitted to the
ICU had significantly higher 30-day mortality,
Medicare spending, and hospital costs than
patients admitted to a general hospital ward.

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Results
 Patients living closer than the median differential
distance (<5 kms) to a hospital with high ICU
admission were significantly more likely to be
admitted to the ICU (n = 5,53,597) than patients
living farther away (n = 5,58,797)
 36% for patients living closer vs 23% for patients
living farther, (P < .001) were admitted in ICU.

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Results
 In adjusted analyses, for the 13% of patients
whose ICU admission decision appeared to be
discretionary (dependent only on distance),
▪ ICU admission was associated with a significantly
lower adjusted 30-day mortality (14.8% for ICU
admission vs 20.5% for general ward admission, P = .02;
absolute decrease, −5.7% [95% CI, −10.6%, −0.9%]),
▪ Yet there were no significant differences in Medicare
spending or hospital costs for the hospitalization.

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Conclusions and Relevance
 Among Medicare beneficiaries hospitalized with
pneumonia, ICU admission of patients for whom the
decision appeared to be discretionary was
associated with improved survival and no
significant difference in costs.
 More liberal ICU admission policies improve mortality
for patients with pneumonia.

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 A prospective observational study of 119
consecutive patients who were admitted to
the ICU with diagnoses of
 CAP (n = 89) or HAP (n = 30)
 from May 2011 until December 2012.

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 The most commonly isolated pathogens were
 H1N1 (23%) and Streptococcus pneumonia (17%) in the
patients with CAP and
 Acinetobacter baumannii (37%) in the patients with
HAP.
 Multidrug resistant (MDR) organisms were
detected in 32 (39%) isolates.
 The median time for receiving antibiotics was
2 hours.
 Most of the patients (82%) received double
antibiotic coverage.

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 The overall ICU and hospital mortality rates
for CAP was 25% and HAP was 30%
 There were no significant differences
between the patients with CAP and HAP in
terms of ICU mortality or the average length
of hospital stay.
 Multiple regression analysis identified septic
shock, ARDS and the Pneumonia Severity
Index [PSI] as significant predictors of
mortality.

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Conclusion
 The outcomes of patients with severe pneumonia
who were admitted to the ICU were better than
those of previous reports.
 Early administration of combination antibiotics was
practiced with vigilance.
 MDR organisms and respiratory viruses were the
commonly isolated pathogens.
 The presence of septic shock, ARDS and high PSI
were independent predictors of mortality.

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 Adjunctive corticosteroids in CAP reduces the morbidity
with modest mortality benefit ([RR] 0.67, 95% CI 0.45-1.01)
 Steroid recipient patients had lower rates of mechanical
ventilation and ARDS, time to clinical stability and duration
of hospitalization; while rates of hyperglycemia requiring
treatment were high
 Clinicians should make the decision using glucocorticoids on
a case-by-case basis
 Limited evidence suggests that infections caused by certain
pathogens (influenza virus, Aspergillus spp) may be
associated with worse outcomes on use of glucocorticoid
CorticosteroidTherapy for Patients Hospitalized With CAP: A Systematic Review and Meta-analysis.
Siemieniuk RA, Meade MO, et al Ann Intern Med. 2015;163(7):519.

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• Fungal pneumonia is classically found in neutropenic
patients. There is increase in concern about this
entity in non- neutropenic critically ill patients.
– Aspergillus is the main offending organism.
– Although Candida is frequently found in respiratory
sample in intensive care unit (ICU) it is always colonization
rather than pneumonia.

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 Other than neutropenia,
 COPD and long-term steroid use are the main
risk factors for invasive pulmonary aspergillosis in
an ICU setting.
 Treatment in a non- neutropenic patient is
only considered if the culture of Aspergillus
comes positive in respiratory sample in the
background of risk factors.
We treat ALL!

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The Journal of Association of Chest Physicians | Jul-Dec 2015 |Vol 3 | Issue 2

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“HIGH RISK”!!
The Journal of Association of Chest Physicians | Jul-Dec 2015 |Vol 3 | Issue 2

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Diagnosis of Aspergillus Pneumonia :
 Collection of BAL sample is recommended for culture
and galactomannan determination. BAL has Highest
sensitivity (50%) and specificity (97% ) - which increase if
Aspergillus colony count is performed.
 Probability of IPA increases by the number of positive
cultures to Aspergillus : 6% (1 culture), 18% (2 cultures)
and 38% (≥3 cultures)
 However, only 61% patients with confirmed IPA present
with positive culture and 30–50% patients with IPA also
have bacterial isolation in respiratory tract cultures
The Journal of Association of Chest Physicians | Jul-Dec 2015 |Vol 3 | Issue 2

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Diagnosis of Aspergillus Pneumonia :
 Identification of Aspergillus in respiratory samples may
represent a simple colonization or be suggestive of IPA.
 The probability of being a true infection depends on the
type of patient:
 72% for patients with neutropenia
 55% for solid organ transplant recipients
 22% for COPD patients
 10% for general ICU cases only.
 The presence of Aspergillus in blood culture is not
considered diagnostic since it usually means
contamination - with the exception of A. terreus
The Journal of Association of Chest Physicians | Jul-Dec 2015 |Vol 3 | Issue 2

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Diagnosis of Aspergillus Pneumonia :
The Journal of Association of Chest Physicians | Jul-Dec 2015 |Vol 3 | Issue 2

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 ICU treatment for CAP is not Expensive…
 ALI / VAC precede Pneumonia
 High index of suspicion
 Early detection is key to success
 Hit Hard First time
 De-escalation is must to consider
 Fungi need to be defined
 Not every patient is High risk for fungus

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