Download William Maher, MD - The Ohio State University

#1005 Hospital & Community Acquired
Pneumonias
October 19 to October 22
Stephen Hoffmann, MD
Clinical Instructor of Internal Medicine
Division of Pulmonary & Critical Care Medicine
The Ohio State University Medical Center
William Maher, MD
Associate Professor of Clinical Internal Medicine
Division of Infectious Diseases
The Ohio State University Medical Center
William Maher, MD
Associate Professor of Clinical Internal Medicine
Division of Infectious Diseases
The Ohio State University Medical Center
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Profile
Chuck
• Healthy 46 year old physician
• Well until he developed a flu-like illness
prior to a business trip
• Felt better with non-specific treatments
• Returned home, then developed a productive
cough and high fevers, coughed up phlegm
and parts of lungs
• Ultimately hospitalized
Diagnosis: Bacterial Pneumonia due to
Staphylococcus Aureus
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Pathogens
Typical Pneumonia
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Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Legionellae
Staph. aureus
• Aerobic gram-negative bacilli
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Pathogens
Atypical Pneumonia
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Mycoplasma pneumoniae
Chlamydia pneumoniae
Influenza, adenovirus, RSV
Q-fever
Chlamydia psittaci
• TB, Endemic Fungi
• Pneumocystis carinii
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Pneumonia
Therapeutic Categories
• Age < 60 years; no comorbidity
• Age > 60 years; or with
comorbidity
• Requires hospitalization
• Severe pneumonia
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Age < 60 Years;
No Comorbidity
• Streptococcus pneumoniae
• Mycoplasma pneumoniae
• Chlamydia pneumoniae
• Respiratory viruses
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Age > 60 Years;
Or With Comorbidity
• Streptococcus pneumoniae
• Respiratory viruses
• b-lactamase produces
(H. flu etc.)
• S. aureus
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Community Acquired
Requiring Admission
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Streptococcus pneumoniae
Haemophilus influenzae
Aspiration / polymicrobic
Legionellae
S. aureus (post influenza)
Gram-negative bacilli
ECF: as per comorbidity,
except influenza, TB, MRSA
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Severe Pneumonia
• Streptococcus pneumoniae
• Legionella
• Viruses
• Aerobic gram-negative bacilli
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More Specific
CXR Patterns
• Cavities
- Aspiration, GNB, Staph. Aureus, TVE
- TB, Histoplasma, aspergillus
• Segmental
- Post-obstructive, aspergillus
- Pulmonary embolism
• Hilar / mediastinal adenopathy
- Primary TB, fungal infection
- Malignancy, sarcoid
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More Specific
CXR Patterns
• Diffuse Interstitial
- Viral, Pneumocystis carinii
- CHF, allergic, etc.
• Nodules
- Fungal, TB, septic emboli
- May cavitate
- Metastatic Ca
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Prescribing Practices
• 1968 antibiotics prescribed for:
- 51% patients with Dx:
“common cold”
• 1997 antibiotics prescribed for:
- 51% with Dx: “cold”
- 52% with Dx: “URI”
- 66% with Dx: “Acute
Bronchitis” (no COPD)
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Summary
Chuck
• Had a flu-like illness
• Diagnosed with Bacterial Pneumonia
due to Staphylococcus Aureus
Treatment
• Prolonged course of IV and oral
antibiotics
• Was very ill but recovered completely
• Annual flu shots expected
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Stephen Hoffmann, MD
Clinical Instructor of Internal Medicine
Division of Pulmonary & Critical Care Medicine
The Ohio State University Medical Center
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Case
• 37 year old male
1st Day
• Underwent a CT scan
• Fiberoptic bronchoscopy with BAL
• Transbronchial biopsy
• Results were negative
• That evening, had an aspiration event
• Developed fevers to 103 degrees
• Started on pipercillin / tazobactum but
condition worsened
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Case
3rd Day
• Ciprofloxcin added to antibiotic regimen
• A CXR showed worsening infiltrate and
pleurl effusion
• Thoracentesis was performed but no
evidence of empyema
4th Day
• Developing significant hypoxemia and
respiratory insufficiency
• Required intubation and ventilation
24 A
Case
• Repeat fiberoptic bronchoscopy was
performed
• Gram stain of the BAL revealed gram
positive cocci
• Due to high incidence of MRSA, started on
vancomyocin
• He developed ARDS with severe respiratory
failure requiring 100% oxygen and
significant amounts of PEEP
• Enrolled in Liquid Ventilation Study
24 B
Case
• Over 5 days, he improved
• Peflubron was discontinued
• Patient was extubated
• One day later, patient was transferred to
floor
24 C
Hospital Acquired Pneumonia
• Pneumonia occurring greater than 48 hours
after hospital admission
• Accounts for 13-18% of all nosocomial infections
• 5-10m cases per 1000 hospital admissions
• Incidence increases 6-20 fold in mechanically
ventilated patients
• Up to 25% of ICU patients develop pneumonia
• Associated mortality 20-50%
• Attributable mortality more difficult to define but
may be in excess of 10%
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Pathogenesis
Respiratory Infections
• Impaired host defenses
• Sufficient innoculum to
overwhelm the host defense
• Virulent organisms
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Routes Of Bacterial Entry
• Microaspiration of oropharyngeal secretions colonized
with pathogenic organisms
• Aspiration of esophageal / gastric contents
• Inhalation of infected aerosols
• Hematogenous spread
• Contiguous spread from infected site
• Direct inoculation into airways
of intubated patients
• Translocation from GI tract
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Etiology
• Type of infection largely determined by the
bacteria colonizing the oropharynx
- Hospitalized patients may become colonized
with aerobic gram negative bacteria within
several days
- 75% of severely ill patients become
colonized within 48 hours
• Overgrowth of the near sterile environment of
the stomach and UGI tract may occur due to
alterations in gastric pH
- Illness, drugs, enteral feedings
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Common Bacteria
• Pseudomonas aeruginosa - 17%
• Enterobacteriaceae - 11%
• Klebsiella species - 7%
• Escheichia coli - 6%
• Haemophilus influenzae - 6%
• Serratia marcens - 5%
• Staphylococcus aureus - 16%
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Other Pathogens
• Less common pathogens include:
- Streptococcus pneumoniae, anaerobes, influenza A
and other viruses, Legionella species, Candida sp.,
Aspergillus sp.
• Acinetobacter species have emerged as significant
pathogens in some centers
• The incidence of anaerobic bacteria as the cause of
HAP may be overestimated:
- Marik et al evaluated 185 patients with anaerobic
cultures of PSB and BAL specimens
- Only 1, nonpathogenic anaerobic species was
isolated
• Frequently polymicrobial
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Etiology Based On
Epidemiology 1995 ATS Criteria
• Severity of pneumonia
• Presence of coexisting illness
• Prior therapy
• Length of hospitalization
prior to pneumonia
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Core Organisms
• E. coli
• Klebsiella
• Proteus
• Serratia
• Hemophilus influenza
• Methicillin - sensitive S. aureus
• Streptococcus pneumoniae
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Late Onset Severe Hospital
Acquired Pneumonia: Greater
Than 5 Days After Admission
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Core organisms plus
P. auriginosa
Acinetobacter species
Methicillin resistant staph
aureus
• Candida
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Risk Factors For
Specific Pathogens
• Anaerobes (witnessed aspiration,
recent abdominal surgery)
• S. Aureus (coma, head trauma,
IVDA, renal failure, DM)
• Legionella (high dose steroids)
• Pseudomonas aeruginosa (steroids,
structural lung disease, prolonged ICU
stay, mechanical ventilation)
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Diagnosis
• Clinical definition
- A new or progressive infiltrate in a
patient with fever, leukocytosis and
tracheobronchial secretion
• Mimics
- CHF
- Atelectasis
- Pulmonary embolism
- Drug reaction
- Pulmonary hemorrhage
- ARDS
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Microbiologic Evaluation
• Blood cultures
• Sputum
• Endotracheal aspirates
• Fiberoptic bronchoscopy
- Protected brush specimen
- Bronchoalveolar lavage
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Diagnosis
• Purulent sputum
• A significant respiratory pathogen
predominating on gram stain
• Peripheral leukocytosis
• Fever
• New or persistent infiltrate on chest
x-ray, with a concurrent deterioration
in gas exchange
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Treatment
• Adequacy of initial treatment crucial
• Patients suspected of having HAP and
particularly VAP should be treated with broad
spectrum antibiotics aimed at covering all
likely bacterial pathogens
• Knowledge of local bacterial spectra and
antimicrobial resistance patterns are essential
in formulating initial coverage
• Treatment then should be narrowed based on
the results of microbiologic data
• Usual duration of treatment is 10-14 days
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Antibiotic Regimens:
Core Coverage
• Extended spectrum penicillins
- Pipercillin / tazobactam
- Ticarcillin / clavulanate
• Third / fourth generation cephalosporins
- Cefepime
- Not ceftazidime
• Fluroquinolones
- Levafloxcin
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Antibiotic Regimens:
Late Onset Coverage
• Common regimens include two of the
following classes plus / minus Vancomyocin
- Extended spectrum penicillins
- Pipercillin / tazobactam
- Ticarcillin / clavulanate
- Third / Fourth generation cephalosporins
- Cefepime
- Not ceftazidime
- Fluroquinolones
- Levafloxcin
- Ciprofloxcin
- Aminiglycosides
- Imipenem-cilastin
- Aztreonam
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Antibiotic Regimens: Coverage For
Patients With Risk Factors
• Prolonged ICU stay, mechanical ventilation,
structural lung disease - double coverage for
pseudomonas plus / minus vancomyocin
• Steroids therapy - macrolide
• Witnessed aspiration, recent abdominal
surgery - anerobic coverage
- Clindamyocin
- Metronidazole
- Extended spectrum penicillins
- Imipenem-cilastin
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NEXT WEEK
#1006 New Approaches to
Cardio Re-vascularization
October 26 to October 29
Robert E. Michler, MD
Professor of Surgery
Chief, Division of Thoracic and Cardiovascular Surgery
The Ohio State University Medical Center
Gregory M. Eaton, MD
Assistant Professor of Clinical Internal Medicine
Division of Cardiology
The Ohio State University Medical Center