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Respiratory Tract Infections
Thomas M File, Jr MD MSc MACP FIDSA FCCP
Chair, Infectious Disease Division
Summa Health System
Akron, Ohio;
Professor of Internal Medicine,
Chair ID Section
Northeast Ohio Medical University
Rootstown, Ohio
Acute Respiratory Tract Infections
• Most common reason for antimicrobials
• Many infections
Unspecified URI
Common Cold
Sinusitis
Pharyngitis
Otitis
Acute Bronchitis
Chronic Bronchitis
Pneumonia
• Challenge
– What infections warrant antimicrobial therapy?
– What etiology (viral vs bacterial)?
Use of Procalcitonin for
Antimicrobial Stewardship for RTIs
PCT < 0.1
ug/ml
Bacterial
Infection
VERY
UNLIKELY
NO
ANTIMICROBIALS
Consider repeat 6-24hrs
based on clinical status
PCT 0.10.25 ug/ml
Bacterial
infection
UNLIKELY
NO
ANTIMICROBIALS
Use of ABX based on
clinical status (‘unstable’)
& judgment
YES
ANTIMICROBIALS
Repeat PCT day 3, 5, 7 (for
Duration)
Bacterial
YES
infection
ANTIMICROBIALS
VERY LIKELY
CONSIDER STOP ABX
when 80=90% decrease; if
PCT remains high consdier
treatment failure
PCT > 0.25- Bacterial
0.5 ug/ml
infection
LIKELY
PCT > 0.5
ug/ml
File TM Jr. Clin Cherst Med. 2011; modified from
Schuetz P. et al. Eur Respir J 2011;37(2): 384–92.
20 year old afebrile college student
with non-exudative acute sore throat.
What is your approach?
Pharyngitis
• Most pharyngitis is viral
– S. pyogenes (GAS)—only common etiology of pharyngitis
for which antimicrobials are indicated
• accounts for up to 25% in children, much less in adults
– Concern for severe post-streptococcal complications
• Acute rheumatic fever (risk is low in developed
countries)
• Acute glomerulonephritis (no evidence ATB prevents)
• Local suppurative (low risk)
– Other causes: GC, Mono, Mycoplasma, Grp C/G Strep,
Arcanobacterium hemolyticus (unresponsive to PCN), Fusobacterium
necrophorum (Lemierres syndrome)
Inf Dis Soc Am Guidelines, Clin Inf Dis. 2012: available www.idsociety .org
Pharyngitis
• Indications for antimicrobial therapy
– Base on rapid antigen test or throat culture
• Newer antigen tests have sensitivity approx 90%
• No need to do culture for adults if antigen neg.
– vs syndromic approach (adenopathy, exudate,
fever, lack of cough….)
• Low predictability
• Consider if high risk; ie, history of recurrent GASpharyngitis or ARF; epidemic)
Inf Dis Soc Am Guidelines, Clin Inf Dis. 2012: available www.idsociety .org .
Grp A Strep vs Viral Pharyngitis
Grp A Strep
Viral
Inf Dis Soc Am Guidelines, Clin Inf Dis. 2012: available www.idsociety .org
IDSA Guideline: Grp A Strep therapy
b. Avoid if immediate PCN hypersensitivity; c. Resistance variable
Inf Dis Soc Am Guidelines, Clin Inf Dis. 2012: available www.idsociety .org
Pharyngitis in University Health Clinic
• 312 students (age 15-30)
• Etiology:
– Fusobacterium necrophorum
– Grp A Strep
– Grp C/G Strep
– Mycoplasma
20.5%
10.3%
9.0%
1.9%
• Infection with F necrophorum and Grp A Strep
more severe
Centor et al. Ann Intern Med 2015; 162: 241-
•F necrophorum casues pharyngitis in adolescents/young adults as
common as Grp A Strep
•Use a penicillin or cephalosporin or clindamycin (not macrolide) if
a consideration in Strept-negative pharyngitis
•Pharyngitis normally resolves in 3-5 days
•2 major flags are worsening sore throat and neck swelling
•Often bacteremic and toxic; may require surgical intevention
Centor R. Annals Intern Med. 2009; 151: 812-815 (Dec 1)
Who of the following warrant antimicrobial
therapy for sinusitis?
1. 35 year old afebrile female with signs of acute
sinusitis of three days duration
2. 40 y/o female with sinus drainage and tenderness
for 10 days
3. 25 y/o female with sinus pressure and drainage for
3 days with initial improvement followed by onset
of fever, increasing sinus drainage and tenderness
Management of Sinusitis
• Acute sinusitis is generally viral
– 0.5%-2% develop secondary bacterial sinusitis
• Predictors of bacterial sinusitis (acute
maxillary)
– Symptoms >7 days; severe
– Facial pain/tenderness, fever, dental pain,
abnormal transillumination, intranasal pus,
unresponsive to decongestants
– Imaging studies not suggested for initial Rx
• Most common bacterial pathogens: S.
pneumoniae, H. influenzae
Sinus and Allergy Health Partnership. Otolaryngol Head Neck Surg. 2004;130(Suppl 1):1-45.
New Guideline Recommendations (pending
review and approval)
The following clinical criteria (any of three) are
recommended for identifying patients with acute
bacterial vs. viral rhinosinusitis:
– Onset with persistent symptoms (nasal discharge of any
quality or daytime cough or both) lasting for >10 days
without any evidence of clinical improvement);
– Onset with severe symptoms (purulent nasal discharge and
fever or facial pain) lasting for at least 3-4 days at the
beginning of illness; or
– Onset with initial improvement followed by worsening of
respiratory symptoms (nasal discharge or cough or new
onset fever or headache) lasting for 3-4 days.
Clin Infect Dis. April, 2012
New Recommendations (pending approval)
• Amoxicillin-clavulanate rather than amoxicillin alone is
recommended as empiric therapy in both children and adults.
• “high-dose” amoxicillin-clavulanate recommended for children and
adults from geographic regions with high endemic rates of
penicillin-nonsusceptible S. pneumoniae, severe infection, a recent
history (within 3 months) of hospitalization or antibiotic use, or
those with co-morbidities
• Either doxycycline (not suitable for children) or a respiratory
fluoroquinolones (levofloxacin or moxifloxacin) are recommended
as alternative agents for empiric initial antimicrobial therapy in
patients allergic to penicillin. (macrolides or SXT/TMP NOT listed)
• Recommended duration of therapy for uncomplicated ABRS in
adults is 5-7 days. (Children 10-14d)
New Recommendations
• Intranasal saline irrigations recommended as an
adjunctive treatment in patients with ABRS. Either physiologic or
hypertonic saline is recommended.
• Intranasal corticosteroids may be used as an adjunct to antibiotics
in the empiric treatment of ABRS, particularly in those with a
history of allergic rhinitis. This recommendation places a relatively
high value on a small additional relief of symptoms and a relatively
low value on avoiding increased resource cost.
• Neither topical nor oral decongestants and/or anti-histamines
are recommended as adjunctive treatment in patients with ABRS
(in placebo trials no significant benefit and causes increase in
inflammation)
NASAL IRRIGATION:recipe
•Use a one-quart clean glass jar
•Fill with water that has been distilled, boiled, or sterilized.
Plain tap water is not recommended because it is not
sterile.
•Add 1 to 1½ heaping teaspoons of pickling/canning salt.
Do NOT use table salt because it contains a large number
of additives.
•Add 1 teaspoon baking soda (pure bicarbonate)
•Mix ingredients together and store at room temperature.
Discard after one week.
from: Diseases of the Sinuses: Diagnosis and Management. Kennedy DW,
Bolger WE, Zinreich SJ (Eds), BC Decker, Hamilton, Ontario 2001.
COPD
Airflow limitation/
obstruction present
Bronchiectasis
Emphysema
Chronic bronchitis
• Chronic productive cough for 3 months
in each of 2 successive years
• 85% of COPD
AECB
• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence
COPD = chronic obstructive pulmonary disease;
AECB = acute exacerbations of chronic bronchitis
McCrory et al. Chest. 2001 Apr;119(4):1190-209
A vicious cycle of infection
and inflammation in AECB
Microbial
Infection
Impaired Lung
Defences
Inflammation
Tissue
Damage
Cole and Wilson
GOLD Recommendation for antibiotic
use in Exacerbations of COPD
• Antibiotics recommendations:
– Patients with 3 cardinal symptoms
– 2 symptoms if increased purulence is
one
– Length 5-10 days.
– Choice based on local bacterial
resistance pattern.
Global Initiative for Chronic Obstructive Lung Disease
Vestbo J et al. Am J Resp Crit Care Med. 2013 187: 347-65
Guidelines for management of
AECB
I, Chronic bronchitis w/o
risk factors (Simple)
II, Chronic bronchitis w III, Chronic suppurative
Risk factors (Complicated)bronchitis
< 4 exacerbations/yr
>4 exacerbations/yr
As in group II
No comorbid illness
Cardiac disease
FEV1 usually <35%
FEV1 >50%
FEV1 <50%
Multiple risk factors
Home O2
Chronic oral steroids
Ab use in past 3 mo
Hemophilus, S. pneumoniae,
Moraxella
2nd generation macrolide
2nd/3rd cephalosporin,
Amoxicillin; Doxycycline
Trimethoprim/sulfameth
Plus GNRs
Fluoroquinolone
b-lactam/b-lactamase
inhibitor
Plus Pseudomonas
Tailor to pathogen
Ciprofloxacin
Balter et al Can Respir J 2003; 10 (Suppl B): 3B-32B
From Sethi S.
personal
communication
Community-acquired Pneumonia (CAP)
• Leading cause of morbidity and mortality
– 40,000 deaths/year in US
– Esp. elderly and patients with comorbidities
– No. I cause due to infection
• Incidence
– General pop.: 1−12/1000/year
– > 65 years: 25−44/1000/year
• 5-6 million cases/year
– Approx. 1 million admissions/year (40% one year mortality; Kaplan et al. Arch
Intern Med 2003; 163: 317-323)
– > 75% treated as outpatients
• Cost of treating CAP exceeds $17 billion/year
• Performance Measures
File T. Lancet 2003; File and Tan JAMA 2005
File T and Marrie T Postgrad Med. 2010
Types and Spectrum of Pneumonia
Risk of MDR Pathogens
Community
-acquired
pneumonia
(CAP)
Craven D. Curr Opin Infect Dis. 2006;19:153-160.
Healthcareassociated
pneumonia
(HCAP)
Hospitalacquired
pneumonia
(HAP)/
ventilatoracquired
pneumonia
(VAP)
Morbidity and Mortality
HCAP: are all at risk for MDRO?
• Inclusion of healthcare related pneumonia1
–
–
–
–
Hospitalized in the preceding 90 days
Nursing home/extended care facility residence
Home infusion therapy (including antibiotics)
Chronic dialysis; Home wound care
• Treat for MDR pathogens, regardless of when in hospital
stay pneumonia begins1 (But this is overgeneralization)
• Increasing evidence many NOT at risk for MDRO2-4
– 23.5% of HCAP patients over treated for MDRO5
– Underlying patient characteristics important independent
determinants
• New guidelines pending
1. Am J respir Crit Care Med. 2005; 171: 388; 2.Chambers et al. Clin Infect Dis 2014;
58:330; 3. Gross et al AAC 2014; 58:5262; 4. Yap et al. Inf Dis Clinics NA 2013; 27: 1;
5. Webb, BJ et al. IDWeek Poster #47798, 2014
• Inclusion of healthcare related pneumonia1
– Hospitalized in the preceding 90 days
– Nursing home/extended care facility residence
– Home infusion therapy (including antibiotics)
– Chronic dialysis
– Home wound care
– Family member with multidrug-resistant pathogen
• Treat for MDR pathogens, regardless of when
in hospital stay pneumonia begins1 (But this is
overgeneralization)
1.
Am
J respir Crit Careevidence
Med. 2005; 171:many
388; 2.Chambers
etHCAP
al. Clin Infect
Dis at
2014;
•58:330;
Increasing
with
NOT
3. Gross et al AAC 2014; 58:5262; 4. Yap et al. Inf Dis Clinics NA 2013; 27: 1;
2-4
riskBJfor
5. Webb,
et al.MDRO
IDWeek Poster #47798, 2014
Community-acquired pneumonia (CAP): Case
• 26 Y/O FEMALE
– Healthy
• Headache, Fever, Nonproductive
Cough for 7 days
• T-100.80 F; P-100; RR-24; AuscBilateral hi-pitched rhonchi
• O2 sat-98% Room Air
• SHOULD SHE BE ADMITTED?
• What antimicrobial(s)
Site of Care Decision
• Determines
– Cost of care
– Intensity of diagnostic testing
– Empiric choice of antibiotics
• Advantages of outpatient therapy
– Cost
– Patient preference
– Faster convalescence and avoidance of nosocomial
complications
• Science and Art
– Mortality prediction rules (PSI, CURB-65)
– Social circumstances
– Co-existing conditions
Pneumonia Prediction Rule for
Mortality Risk Assessment
STEP 1
STEP 2
Yes
Is the patient >50 years of age?
Class II
(70 points)
No
Does the patient have any of the
following coexisting conditions:
Assign points for:
Yes
Neoplastic disease; congestive heart
failure; cerebrovascular disease; renal
disease; liver disease
No
Does the patient have any of the
following abnormalities:
Class III
(71–90 points)
Comorbid conditions
Physical
observations
Laboratory and
Yes radiographic findings
Altered mental status; pulse 125/min;
respiratory rate 30/min; systolic blood
No
pressure <90 mm Hg; temperature
<35ºC or 40ºC
Fine MJ, et al. N Engl J Med. 1997;336:243-50.
Demographic
variables
Class IV
(91–130 points)
Class V
(>130 points)
Class I
Prediction Rule Step 2: Algorithm
Pt Characteristic
Age
Points
No. of years (-10 for female)
Cancer
Liver disease
CHF, CVD, Renal disease
30
20
10
RR >30/min, SBP <90 mmHg, Confusion
Temp <35ºC, >50ºC
Pulse, beats/min
20
15
10
BUN; Sodium <130 mmol/l
Glucose >250 mg/dl; Hct < 30%
pO2 < 60 mmHg
20
10
10
Prediction Rule: Risk Categories
Total Points
Class
Mortality %
How to Treat
I
0.1
Outpatient
 70
II
0.6
Outpatient
71-90
III
0.9-2.8
Brief hospital
observation
91-130
IV
8.2-9.3
Inpatient
>130
V
27.0-29.2
Inpatient ICU
Risk categories according to two validation cohorts (38,039 inpatients and 2287 in- and outpatients)
Fine MJ, et al. N Engl J Med. 1997;336:243-50.
Applying the CURB-65 Rule
Group 1
CURB-65 Score
Any of:
Confusion*
Urea >7 mmol/l
Respiratory Rate
≥30/min
Blood pressure (SBP
<90 mmHg or DBP
≤60 mm Hg)
Age ≥65 years
0 or 1
Mortality Low
(1.5%)
(n=324, died=5)
Group 2
2
Mortality
Intermediate (9.2%)
(n=184, died=17)
3+
Group 3
Mortality High
(22%)
(n=210, died=47)
Lim WS, et al. Thorax. 2003;58:377-82.
Treatment Options
Likely suitable for home
treatment
Consider hospital
supervised treatment
Options may include:
Short stay inpatient;
Hospital-supervised
outpatient
Manage in hospital as
severe pneumonia
Assess for ICU
admission especially if
CURB-65 score = 4 or 5
Diagnostic Tests for Etiology
in CAP Management
• Standard culture methods (blood, sputum)
– Low yield, time to results
• Gram stain, urinary antigen testing
– S pneumoniae, Legionella spp
• Newer molecular tests (PCR,
MALDI-TOF)
– Potential for more rapid diagnosis, greater sensitivity
– Allows for pathogen-directed therapy
• Biomarkers (Procalcitonin)
• Differentiate Bacterial vs virus
• Timely response to bacterial load
32
PCR, polymerase chain reaction; MALDI-TOF, matrix-assisted laser desorption/ionization Time of Flight mass spectrometry
CAP: EMPIRICAL THERAPY
Principles
• TREAT EARLY
• TREAT MOST LIKELY PATHOGENS
– S. pneumoniae (?Drug resistance*); H. influenzae
– Atypicals—studies in North America show high
prevalence (even though may not be severe, therapy
reduces illness)
– Others (local epidemiology)
– Cannot differentiate etiology based on initial findings
*Recent ATB (Following of ? Relevance: Recent Hospitalization; DayCare; Multiple
comorbidities; Age)
Most Common Etiologies of CAP
Ambulatory
Patients
Hospitalized
(non-ICU)†
Severe
(ICU)†
S. pneumoniae
S. pneumoniae
S. pneumoniae
M. pneumoniae
M. pneumoniae
S. aureus
H. influenzae
C. pneumoniae
Legionella spp.
C. pneumoniae
H. influenzae
Gram-negative bacilli
Respiratory viruses††
Legionella spp.
H. influenzae
Aspiration
Respiratory viruses‡
Based on collective data from recent studies; †Excluding Pneumocystis spp.
‡ Influenza A and B, adenovirus, respiratory syncytial virus, parainfluenza
File TM. Lancet. 2003;362:1991-2001.
35
Empiric Therapy in CAP: IDSA/ATS
Healthy
Outpatient
Outpatient at
Risk
for DRSP*
Inpatient, nonICU
Inpatient, ICU†
Macrolide
OR
Doxycycline
Respiratory
fluoroquinolone
OR
Beta-lactam plus
macrolide
Respiratory
fluoroquinolone
OR
Beta-lactam plus
macrolide
Beta-lactam plus
azithromycin
OR
Beta-lactam plus
fluoroquinolone
*Includes healthy patients in regions with high rates of macrolide resistance.
†Treatment of Pseudomonas or MRSA is the main reason to modify standard therapy for ICU patients.
ICU = intensive care unit
Mandell L, et al. Clin Infect Dis. 2007;44(Suppl 2):S27-S72.
Azithromycin Cardiovascular events (QT effect)
• NEJM 2012 (Ray et al. Tennessee, USA)
– Older population; Azithro associated with higher mortality
• NEJM 2013 (Svanstrom et al. Denmark)
– General population; no association with mortality
• JAMA 2014 (Mortensen et al. VA database, USA)
– Azithro associated with slight increase of MI but overall reduced
mortality in hospitalized patients
• J AM Coll Cardiology 2015 ( Cheng et al)
– Metaanalysis: higher risk sudden cardiac death
• MY TAKE: Risk small; Azithro safe for general population
and associated with better outcomes for hospitalized
patients. Need to consider risk-benefit for patients with CV
disease (QT prolongation). Avoid 2 drugs that prolong QT 36
Clinical
Infectious
Diseases 2010;
51(2):189–194
CAP in 24 y/o female from China
• 3 days of progressive
cough, fever, chills,
dyspnea
• T-103.2 F (39.5 C); R24; HR-128
• WBC 9,100; 21%
bands
• Pulse Ox-94%
38
CAP: Ceftaroline vs Ceftriaxone
•Meta-analysis 3 Phase 3 RCT, DB; 1900+ patients; PORT III or IV1
•Clinical Cure for S. pneumoniae (FOCUS):
Ceftaroline 59/69 (85.5%); Ceftriaxone 48/70 (68.6%)2
(Ceftaroline has greater affinity for PBP 2X)
1. Taboada M et al. L-1748a ICAAC 2014; 2. File TM Jr. et al. Clin Infect Dis. 2010; 51; 1395-405
39
Community-acquired pneumonia (CAP): Case
• 66 Y/O MALE
– Smoke, Diabetes, CHF
– Treated with macrolide for
‘sinusitis’ 8 weeks ago
• Headache, Fever, Cough
for 3 days, New Confusion
• T-101.80 F; P-110; RR-28;
Ausc-rhonchi RLL
• O2 sat-92% Room Air
• SHOULD HE BE
ADMITTED?
• WHAT ANTIMICROBIAL
CXR courtesy of T. File MD
CMS 2014 CAP Quality Measures for Inpatients
• Empiric antimicrobials according to guidelines
― Exceptions: pathogen-directed therapy,
clinical trials, diagnostic uncertainty
• CAP mortality
• 30-d readmission rate for pneumonia*
*Complements
Core Measures as part of the Hospital Readmissions Reduction Program—hospitals
with higher
than expected 30-d readmission rates for AMI, heart failure, and pneumonia will incur penalties
against their
total Medicare payments beginning in FFY 2013.
http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/2014_ClinicalQualityMeasures.html
File TM Jr, personal communication, Sept. 2013. CMS community-acquired pneumonia Technical Expert Panel,
9/19/13.
41
CAP CASE:
Assuming this patient does not have bronchiectasis or
advanced COPD, which of the following regimens is NOT
recommended in the IDSA/ATS guidelines and is considered in
variance with the CMS Performance Indicator?
A.
B.
C.
D.
E.
Moxifloxacin
Cefriaxone plus azithromycin
Piperacillin/tazobactam plus azithromycin
Ampicillin/sulbactam plus azithromycin
Levofloxacin
CAP CASE:
Assuming this patient does not have bronchiectasis or
advanced COPD, which of the following regimens is NOT
recommended in the IDSA/ATS guidelines and is considered in
variance with the CMS Performance Indicator?
A. Moxifloxacin
B. Cefriaxone plus azithromycin
C. Piperacillin/tazobactam plus azithromycin
D. Ampicillin/sulbactam plus azithromycin
E. Levofloxacin
CAP: JC/CMS Antimicrobial
Recommendations by Site of Care1,2
Inpatient, Non-ICU
Inpatient, ICU
β-lactama (IV or IM) + macrolide
(IV or po) –OR–
Macrolide (IV) + β-lactam (IV) –OR–
antipneumococcal + antipseudomonal β-lactam (IV)
–OR–
Anti-pneumococcal quinolone
monotherapy (IV or po) –OR–
Antipneumococcal quinolone (IV) –OR–
antipseudomonal quinolone (IV) + either
β-lactam (IV) –OR–
antipneumococcal/antipseudomonal β-lactam (IV) –
OR–
β-lactama (IV or IM) + doxycycline
(IV or po) –OR–
Tigecycline monotherapy (IV) –OR–
Macrolide monotherapy (IV or po)b
Antipneumococcal/antipseudomonal β-lactam (IV) +
aminoglycoside (IV) + either antipneumococcal
quinolone (IV) –OR– macrolide (IV)
aceftriaxone,
cefotaxime, amp/sulbactam, ertapenem, ceftaroline
b If aged <65 y with no risk factors for drug-resistant Pneumococcus.
1. JC, CMS. http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx.
44
Good through 12/31/2013. 2. File TM Jr et al. Clin Infect Dis. 2011;53(suppl 1):S15-S22, by permission of Oxford University
Press.
CAP Case: Assuming he was treated with ceftriaxone +
azithromycin and it is now Day 3-Afebrile, other VS stable,
alert, no unstable comorbidity; O2 sat-96%; sputum culture
obtained on admission + for S. pneumoniae ( PCN
susceptible). What is your course of action?
A.
B.
C.
D.
E.
Change to po amoxicillin discharge on next day
Change to po fluoroquinolone and discharge now
Change to po amoxicillin and discharge now
Continue IV ATB
Add IV Vancomycin
SWITCH THERAPY (IV to po) and
DISCHARGE CRITERIA
• Switch Therapy
–When good clinical response, comobidities stabilized,
can take po
–If pathogen identified, ‘Directed’ Therapy
–If empiric, can utilize ‘negative’ lab results to simplify
therapy (e.g. if urinary antigen and blood cultures
negative)
•Discharge
–If VS and O2 status stable, and no unresolved
comorbidities, can discharge at time of oral switch
–No value to observe in hospital for 24 h after switch
•
(Dunn et al. Am J Med. 1999; 106:6)
CAP Case:
A.
B.
C.
D.
How long do you treat?
5-7 days
7-10 days
10-14 days
14-21 days
Short- vs Long-course Therapy for CAP
•Meta-analysis (≤ 7 days vs longer)
Conclusion: No difference in efficacy and safety
•Based on available data
– Minimum of 5 days if afebrile by 48-72 hrs for ‘core pathogens’
– Longer for other pathogens or evidence of extrapulmonary
infection
• S. aureus, Pseudomonas
•Shorter course Therapy
– Reduced resistance, AE, cost
Dimopoulos 2008, p1848; Drugs; 2008: 68: 1841-
Adjunctive Therapy:
Glucocorticoids for CAP
• Systemic adjunctive corticosteroid therapy may
attenuate the inflammatory response, and by
doing so decrease the frequency of ARDS,
reduce the length of illness and of hospital stay,
and possibly even reduce mortality.
– Previous systematic reviews of randomized clinical
trials have, however, failed to establish a conclusive
benefit and current clinical practice guidelines do not
recommend systemic corticosteroid therapy for CAP
49
49
Adjunctive Therapy:
Glucocorticoids for CAP
Impact of corticosteroids on all-cause mortality in patients hospitalized with
community-acquired pneumonia , by severity of pneumonia
Siemieniuk R et al. Ann Intern Med. 2015; 163: 519-28
50
Glucocorticoids for CAP
• Blum et al (Lancet; 2015; 385; 1511-18)
– RCT, 785 patients, Swiss; 50 mg prednisone/day vs placebo X 7 days
• 50% PSI IV or V
– Time to Clinical Stability: 3 d Pred; 4.4 d placebo (HR 1.33; 1.15-1.50)
– NO difference complications (including mortality)
• 3% Pred; 6% plscebo
• Torres et al (JAMA 2015; 303)
– RCT, 120 patients, Spain; methylprednisolone 0.5 mg/kg Q 12h X 5
days
• Severe CAP and high inflammatory response (CRP > 150 mg/L)
– Less treatment failure in steroid group (13 vs 31%; OR 0.34, 0.14-0.87)
• Primary driver: radiographic progression
– NO difference mortality
• Pending questions: Who, How (what dose, duration), AEs51
Glucocorticoids for CAP:
UpToDate
• For hospitalized patients, we suggest adjunctive
glucocorticoids.
– We are more likely to give glucocorticoids to more
severely ill patients, and we are less likely to give
glucocorticoids to patients at increased risk of
adverse effects due to glucocorticoids
– When we give glucocorticoids, we use
methylprednisolone 0.5 mg/kg IV every 12 hours for
ICU patients and prednisone 50 mg daily for general
ward patients for 5 days
52
Respiratory Tract Infections: Prevention
• Smoking cessation
• Vaccines
– Pneumococcal
– Influenza
• Reducing effect of comorbidities*
– Controlling CHF, Hyperglycemia (higher mortality)
– Reducing swallowing disorders etc.
• Brushing teeth
*File and Tan JAMA 2005; 294: 2760-63.
Community RTIs
Take home messages
• Pharyngitis: Base therapy on antigen test (check
susceptibiity if erythromycin used)
• Sinusitis: New clinical guidelines; use
antimicrobials only if warranted; amox/clav 1st
line therapy; saline irrigation
• Pneumonia: Stratify by risk factors; Newer
molecular tests; treat 5 days if good response
by 3 days.