Community acquired pneumonia 2015 part 2

1. SAMIR EL ANSARY
COMMUNITY
ACQUIRED
PNEUMONIA 2015 - 2

2. Global Critical Care
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3. What defines a treatment failure?
The majority of patients receiving appropriate
therapy show a favorable clinical response within
72 hours.
Therefore initial antibiotic therapy should not be
changed before 72 hours unless indicated by
significant clinical worsening or microbiologic
data.
Remember that certain host factors, such as
advanced age, alcoholism, and chronic
obstructive pulmonary disease, have been
associated with delayed resolution despite
appropriate treatment.

4. What defines a treatment
failure?
Radiographic resolution of pneumonia
lags behind clinical improvement and
in some cases may take up to 8 to 10
weeks to clear completely.

5. Discuss the potential reasons why
a patient may not respond
favorably to empiric therapy.
Clinical deterioration or a lack of
response to empiric antimicrobial
therapy within 3 days often indicates
treatment failure, warranting
thorough reassessment and
additional investigation.

6. 1. Inappropriate antimicrobial therapy
a. Is the dosing adequate?
b. Are all potential bacterial pathogens covered by
the empiric regimen?
c. Are the organisms resistant or has a previously
sensitive pathogen developed resistance?
d. Is the pathogen bacterial? Consider other
pathogens to include viruses, endemic fungi, and
mycobacteria.
e. Is the host immunocompromised and at risk for
opportunistic infections such as Pneumocystis jiro
veci?
f. Is the disease infectious? Has the patient been
misdiagnosed?

7. 2. Complications of lung infection or
hospitalization
a. Has a lung abscess or empyema
developed?
b. Does the patient have acute respiratory
distress syndrome (ARDS)?
c. Have the bacteria seeded extrapulmonary
sites (e.g., endocarditis, septic arthritis,
meningitis)?
d. Has the patient acquired a new
nosocomial infection (e.g., urinary tract
infection, central line infection, sinusitis)?

8. How should a patient with nonresolving
pneumonia be evaluated?
The clinician should review initial culture
results and sensitivities and collect
additional lower respiratory tract and blood
cultures.
Broadening empiric therapy may be
indicated while awaiting results of
additional testing.
All patients should have a repeated chest
radiograph at this time.

9. Additional history may reveal HIV risk
factors, tick exposure, travel history, or
other diagnostic clues.
Further testing, such as a chest computed
tomographic or ultrasound scan, should
be directed at the likely cause of treatment
failure.
If the procedure can be performed safely,
a thoracentesis of a pleural effusion can
exclude a complicated effusion or
empyema.

10. Bronchoscopy has good diagnostic utility,
and specimens should be sent for
quantitative bacterial cultures and
sensitivities, as well as for stains and
cultures of unusual organisms
(mycobacteria, viruses,endemic fungi, and
P. jiroveci ).
If the diagnosis remains elusive, a trial of
corticosteroids or a thoracoscopic or
open lung biopsy may be considered in
the appropriate clinical setting.

11. Noninfectious processes present
with signs and symptoms of acute
pneumonia
include ARDS, traumatic pulmonary contusion,
pneumonitis resulting from connective tissue
disease (e.g Noninfectious conditions that can
mimic acute pneumonia., systemic lupus
erythematosus), acute hypersensitivity
pneumonitis, drug-induced pneumonitis, diffuse
alveolar hemorrhage (e.g., Goodpasture
syndrome), Wegener granulomatosis, bronchiolitis
obliterans .

12. Noninfectious processes present
with signs and symptoms of acute
pneumonia
Organizing pneumonia, acute interstitial
pneumonia (Hamman-Rich syndrome), acute
eosinophilic pneumonia, pulmonary embolism with
infarction, atelectasis, chemical pneumonitis
(aspiration), and malignancy (e.g., bronchoalveolar
carcinoma, lymphangitic carcinomatosis, Kaposi
sarcoma).

13. Hospital-acquired pneumonia (HAP),
health care associated pneumonia
(HCAP), and ventilator-associated
pneumonia (VAP)?
HAP Hospital-acquired pneumonia
is defined as pneumonia that occurs 48
hours or more after admission, which was
not incubating at the time of admission.

14. HCAP
{health care associated pneumonia}
Refers to pneumonia that develops in a
patient who lives in a nursing home or long-
term care facility; undergoes hemodialysis;
has received IV antimicrobial therapy,
chemotherapy, or wound care within the
preceding 30 days
or has been hospitalized for at least 2 days
within the preceding 90 days.

15. The causative pathogens in
these patients are similar to
those responsible for HAP and
VAP and are often
Multidrug resistant (MDR).

16. VAP:
Universally agreed-on diagnostic criteria for VAP do
not exist; however, commonly used criteria include the
presence of all of the following:
1. Mechanical ventilation for > 48 hours.
2. A new and persistent infiltrate on chest radiograph or
ARDS; in the setting of ARDS, it may be impossible to
visualize a new infiltrate on chest radiograph.
3. Two of the following three findings:
a. Fever (temperature >38.3" C)
b. Leukocytosis or leukopenia
c. Purulent tracheal secretions
4. Quantitative cultures of a lower respiratory tract
specimen at or above the threshold defined as consistent
with lung infection.
The use of clinical criteria alone without microbiologic
data tends to overdiagnose lung infection.

17. How do you decide on the initial
empiric antibiotic therapy for
HAP,HCAP, or VAP?
If the patient has late-onset pneumonia
development (25 days) or risk factors for MDR
pathogens, then broad-spectrum antibiotic
therapy is indicated.
If neither of these criteria is met,limited-
spectrum antibiotic therapy is appropriate. If
HAP, VAP, or HCAP is suspected, disease
severity is not considered in the initial empiric
antibiotic decision.

18. Risk factors for MDR pathogens
causing HAP, HCAP,and VAP?
Riskfactors for MDR causing HAP, HCAP,
and VAP include antimicrobial therapy in
the preceding 90 days, current
hospitalization of 5 days or more, high
frequency of antibiotic resistance in the
community or in the specific hospital unit,
immunosuppressive disease
and/or therapy, or presence of risk factors
for HCAP

19. Risk factors for MDR pathogens
causing HAP, HCAP,and VAP?
and/or therapy, or presence of risk factors
for HCAP (hospitalization for 2 days or
more in the preceding 90 days,residence
in a nursing home or extended-care facility,
home infusion therapy [including
antibiotics], long-term dialysis within 30
days, home wound care, family member
with MDR pathogen).

20. What initial empiric antibiotic therapy is
recommended for HAP, HCAP, or VAP in
patients with no known risk factors for
MDR, early onset pneumonia
development, and any disease severity?
Recommended antibiotics include
ceftriaxone, levofloxacin (moxifloxacin or
ciprofloxacin can replace levofloxacin),
ampicillin-sulbactam, or ertapenem.

21. What initial empiric antibiotic therapy is
recommended for HAP, HCAP, or VAP in
patients with no known risk factors for
MDR, early onset pneumonia
development, and any disease severity?
Potential pathogens include S.pneumoniae,
H. influenzae, methicillin-sensitive S. aureus,
and antibiotic-sensitive enteric gram negative
bacilli
(Escherichia coli, Klebsiella pneumoniae,
Enterobacter, Proteus, Serratia marcescens).

22. What initial empiric antibiotic therapy is
recommended for HAP, HCAP, or VAP in patients with
known risk factors for MDR, late-onset disease
development, and any disease severity?
Recommended combination antibiotic therapy includes
an :
Antipseudomonal cephalosporin
(cefepime or ceftazidime)
Antipseudomonal carbapenems
(imipenem or Meropenem)
or p-lactam-p-lactamase inhibitor
(piperacillin-tazobactam)
plus an antipseudomonal fluoroquinolone
(ciprofloxacin or levofloxacin)
or an aminoglycoside
(amikacin, gentamicin, or tobramycin).

23. What initial empiric antibiotic therapy is
recommended for HAP, HCAP, or VAP in
patients with known risk factors for MDR,
late-onset disease development, and any
disease severity?
Linezolid or vancomycin should be added if
MRSA risk factors are present or there is a
high incidence locally.
Potential MDR pathogens include P.
aeruginosa, K. pneumoniae, Acinetobacter
species, and MRSA

24. Some specific treatment strategies for MDR
Pseudomonas, Acinetobacter, and MRSA VAP?
Combination therapy for P. aeruginosa pneumonia
remains controversial.
Resistance is mediated partly by multiple efflux
pumps.
Acinetobacter species are most sensitive to
the carbapenems, sulbactam, colistin, and
polymyxin.

25. More than 85% of
Acinetobacter species isolates are
susceptible to carbapenems, but resistance is
increasing because of either integral membrane
protein (IMP)-type metalloenzymes or
carbapenemases of the oxacillinase (OXA) type.
MRSA produces a penicillin-binding protein with
reduced affinity for p-lactam antibiotics.
Linezolid is an alternative to
vancomycin for the treatment of
MRSA VAP.

26. Measures which can be taken to
decrease the risk of VAP?
1. Avoid intubation when possible, and apply
noninvasive positive-pressure ventilation when
appropriate.
2. Use orotracheal tubes preferentially over
nasotracheal tubes.
3. Minimize the duration of mechanical ventilation
with the aid of weaning protocols.
4. Apply continuous aspiration of subglottic
secretions.
5. Maintain an endotracheal tube cuff pressure >20
cm H20 to prevent leakage of oropharyngeal
secretions containing bacteria into the lungs.

27. 6. Avoid unnecessary manipulation of the ventilator
circuit.
7. Carefully discard contaminated condensate from
the ventilator circuit.
8. Keep the head of the bed elevated by 30
degrees.
9. Avoid heavy sedation and paralytics because
they impair the patient's ability to cough.
10. It does not appear that sucralfate or
therapies that decrease gastric acid increase
the incidence of nosocomial pneumonia.

28. When to continue, de-escalate, and
discontinue the use of antibiotic treatment
on the basis of clinical response and culture
data?
When HAP, VAP, or HCAP is suspected,
consider obtaining lower respiratory tract
samples for culture
(quantitative or semiquantitative) and
microscopy.
Unless there is both a low clinical suspicion
for pneumonia and negative microscopy of
the lower respiratory tract sample
Begin empiric antimicrobial therapy.

29. At day 2 and 3, check cultures and
assess clinical response
(temperature, white blood cell [WBC] count,
chest radiograph, oxygenation, purulent sputum
,hemodynamic changes, and organ function).
If no clinical improvement is seen after 2 to
3 days with negative cultures, search for
other pathogens, complications, diagnoses,
or sites of infection.

30. If clinical improvement is noted after 2 to 3 days
but cultures are negative
consider stopping antibiotics.
If clinical improvement is noted
and cultures are positive, de-
escalate antibiotics, and consider
treating selected patients for 7 to
8 days and reassess

31. How long should you continue
antibiotic management for HAP,
HCAP, or VAP?
In a prospective, randomized clinical trial, an 8-
day treatment strategy for culture-proved
VAP resulted in a significant decrease in
multiresistant bacteria and more antibiotic-free
days with no differences in mortality, ICU length of
stay, or mechanical ventilator-free days when
compared with a 15-day regimen.

32. A higher rate of recurrence was
documented with the 8-day regimen
when the infection was due to
Acinetobacter or Pseudomonas
therefore VAP due to these
organisms should be treated for 15
days.
Because the infecting pathogens are
similar, HAP and HCAP can be treated
similarly.

33. Extended therapy
(14-21 days) may be
indicated in the setting of
Multilobar disease,
Cavitation, Malnutrition, or
Necrotizing gram-negative
infection

34. SUMMARY
1. Treat empirically if pneumonia is clinically
suspected.
2. Select the initial empiric therapy on the basis of
the current bacteriology and resistance patterns
at each institution.
3. Obtain cultures of respiratory tract specimens
to identify pathogen(s), preferably before initiation
of antibiotics.
However, the administration of antibiotic therapy
should not be delayed for diagnostic testing.

35. 4. Narrow the initial antibiotic regimen on the
basis of quantitative culture results and clinical
response (de-escalation).
5. Avoid excessive antibiotic use by de-escalating
therapy when appropriate and prescribing the
minimal duration of therapy required for efficacy.

36. SAMIR EL ANSARY
ICU PROFESSOR
AIN SHAMS
CAIRO
elansarysamir@yahoo.com
GOOD LUCK
Global Critical Care
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9555/
Wellcome in our new group ..... Dr.SAMIR EL ANSARY