Download Title Case, 32pt Calibri, SH Dark Blue

Update Community
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
Overview
1. Increase resistance
• Pneumococcus
• Mycoplasma
• GNR (nosocomial)
2. Pharyngitis
• Fusobacterium in adolescents
3. Sinusitis-new guidelines
• ?Watchful waiting
4. Pneumonia
• HCAP-elimination
• CAPo elimination of ‘standard’ macrolide monotherapy
o New agent (Solithromycin)
o Steroids for serious CAP
2
Trends in Susceptibility Rates for Antimicrobial Agents
Tested Against S. pneumoniae
Isolated in the United States
Susceptiblity Trends
100.0
SUSCEPTIBILITY RATES (%)
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
A/C (≤2)
PEN
(≤0.06)
PEN (≤2) CRO (≤1)
ERY
CC (≤0.25) TC (≤2)
(≤0.25)
1998 (1399)
2009 (1372)
TMP/SMX LEV (≤2)
(≤0.5)
A/C = amoxicillin/clavulanate; PEN = penicillin; CRO = ceftriaxone; LEV = levofloxacin; TC = tetracycline; TMP/SMX = trimethoprim/sulfamethoxazole;
ERY = erythromycin; CC = clindamycin
% Susceptible by agent (MIC breakpoint in μg/mL)
SENTRY Antimicrobial Surveillance Program, 1998–2009. http://dx.doi.org/10.1016/j.diagmicrobio.2010.08.024
3
Keedy et al. Poster 2016 presented at IDWeek 2016 Oct . New Orleans
4
Global Prevalence of Macrolide-Resistant
Mycoplasma pneumoniae1
Sporadic
Reports
in the US2
US City, State
Isolates, #
Resistance
Chicago, IL
23
17.4%
Kansas City, MO
40
7.5%
Hackensack, NJ
2
50%
New York, NY
5
40%
Seattle, WA
15
6.5%
Birmingham, AL
6
16.7%
91
13.2%
TOTAL
1. Cao B et al. Clin Respir J. 2015 Sept 14. [Epub ahead of print] 2. Zheng X et al. Emerg Infect Dis. 2015;21:470-472.
5
You are asked to evaluate a 20 y/o college
student who presents with a sore throat of 2
days duration. Afebrile. Pharynx-moderate
erythema. Which of the following options is
your choice of management ?
A. Pen VK 500 mg bid x 10 days
b. Oral cephalosporin Qd x 5 days
c. Z-pac
d. Rapid antigen test for S. pyogenes
e. Throat culture
6
Pharyngitis
•Most pharyngitis is viral
o S. pyogenes
(GAS)—only common etiology of pharyngitis
for which antimicrobials are indicated
• accounts for up to 25% in children, much less in adults
o 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)
o 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
7
Pharyngitis
•Indications for antimicrobial therapy
oBase on rapid antigen test or throat culture
• Newer antigen tests have sensitivity approx 90%
• No need to do culture for adults if antigen neg.
ovs syndromic approach (Centor Score*:
adenopathy, exudate, fever, lack of cough….)
• Treat 3 or 4; Variable predictability
• Low threshold if high risk; ie, history of recurrent GASpharyngitis or ARF; epidemic)
Inf Dis Soc Am Guidelines, Clin Inf Dis. 2012: available www.idsociety .org .
* Centor R Anna Intern med 2009; 151: 812
8
Grp A Strep vs Viral Pharyngitis
Grp A Strep
9
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
10
17 year old male: story
•
•
•
•
•
•
•
Normal 17-year-old
Day 1 – sore throat
Day 2 – doc started Z-pack
Day 3-6 – fevers to 102 pain & swelling Right neck
Admitted for metastatic lung abscesses
Day 9 – blood grew Fusobacterium necrophorum
He died after 3 weeks in the ICU
From Robert Centor MD
Lemierre’s Presentation
Sore
throat
4-5 days
Fever &
rigors
Repeated
rigors
Metastatic
abscesses
From Robert Centor MD
Pharyngitis in University Health Clinic
•312 students (age 15-30)
•Etiology:
o Fusobacterium necrophorum20.5%
o Grp A Strep10.3%
o Grp C/G Strep 9.0%
o Mycoplasma
1.9%
•Infection with F necrophorum and Grp A Strep
more severe
Centor et al. Ann Intern Med 2015; 162: 24113
Centor Score by Bacteria (n=312)
100%
Any p < 0.001
74%
75%
50%
41%
43%
27%
25%
15%
0%
0
1
GAS
2
GCS
Fuso
3
Any
4
Centor
Score
Chi square for trend
From Robert Centor MD
•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)
15
Pharyngitis in the 21st century
Pre-adolescents
• Group A strep relatively
frequent
• Group C/G rare
• Fusobacterium very rare
• No infectious mono
From Robert Centor MD
Adolescents/young adults
• Group A strep less common
• Group C/G less common than
A but still significant
• Fusobacterium necrophorum
most frequent bacteria
• Inf mono frequent
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.
17
Pathophysiology of Bacterial
Sinusitis
– Viral URI most
common
preceding
cause
Adapted from Gwaltney: Clin Infect Dis 23:1209-1225, 1996; Reilly: Otoloaryngol Head Neck Surg 103:856-862,
1990.
18
Radiologic Imaging: CT
Photo courtesy J. Hadley, 19MD.
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
20
Rosenfeld NEJM 2016; 375: 962-
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)
22
Augmentin XR™
• Pharmacokinetic design
o
o
Bilayer tablets with immediate release layer of amoxicillin
and clavulanate, and extended release layer of amoxicillin
Each tablet contains 1 gm amox and 62.5 gm clavulanate
• Increases daily dose of amoxicillin—2000 mg BID = 4000 mg/day
• Maintains daily dose of clavulanate—125 mg BID = 250 mg/day
• Extends coverage to include S. pneumoniae with
elevated amoxicillin MICs
•
Indications (When PRSP is a concern): CAP; Acute Bacterial
Sinusitis
• Tolerability
Similar to Augmentin 875 (clavulanate dose is the same)
o Diarrhea approx 10% (most are mild)
• Cost: 10day course $118; vs 875 mg BID X 10 d23$12.60
o
Pharmacokinetic Profile
Comparison: Augmentin XR™ vs.
Amox/Clav 875/125
Mean amoxicillin
concentration (µg/mL)
20
Amox/Clav 875/125
Augmentin XR 1000/62.5 mg, 2 tabs
Augmentin XR
15
Maintains extended plasma concentrations
875mg
10
5
S. pneumoniae with amox
0
4.8 hours
7.2 hours
40%
60%
MIC = 2 µg/mL
Goal= 4.8 hours
0
1
2
3
4
5
6
7
Time (hours)
40% of 12-hour dosing interval = 4.8 hours
24
8
9
10
11
12
New Recommendations
25
Other 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.
• 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)
26
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 numbe
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
27 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
28
A Vicious Cycle of Infection
and Inflammation in AECB
Microbial
Infection
Impaired Lung
Defences
Inflammation
Tissue
Damage
Cole and Wilson
29
GOLD Recommendation for Antibiotic
Use in Exacerbations of COPD
•Antibiotics recommendations:
oPatients with 3 cardinal symptoms
o2 symptoms if increased purulence is one
oLength 5-10 days.
oChoice 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
30
Guidelines for Management of
AECB
II, Chronic bronchitis w
Risk factors (Complicated)
III, Chronic suppurative
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
I, Chronic bronchitis w/o
risk factors (Simple)
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; 1031(Suppl B): 3B-32B
Community-acquired Pneumonia (CAP)
• Leading cause of morbidity and mortality
o 40,000 deaths/year in US
o Esp. elderly and patients with comorbidities
o No. I cause due to infection
• Incidence
o General pop.: 1−12/1000/year
o > 65 years: 25−44/1000/year
• 5-6 million cases/year
o Approx. 1 million admissions/year (40% one year mortality;
Kaplan et al. Arch Intern Med 2003; 163: 317-323)
o > 75% treated as outpatients
• Cost of treating CAP exceeds $17 billion/year
• Performance Measures: now Only outcome-30 day
mortality and readmission rate
File T. Lancet 2003; File and Tan JAMA 2005
File T and Marrie T Postgrad Med. 2010
32
Types and Spectrum of Pneumonia
Risk of MDR Pathogens
Community
-acquired
pneumonia
(CAP)
Healthcareassociated
pneumonia
(HCAP)
Hospital-acquired
pneumonia (HAP)/
ventilator-assoc
pneumonia (VAP)
Morbidity and Mortality
Craven D. Curr Opin Infect Dis. 2006;19:153-160.
HCAP:
are all at risk for MDRO?
• Inclusion of healthcare related pneumonia1
o
o
o
o
o
o
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
• Prior Guideline: Treat all for MDR pathogens (But this is
overgeneralization)
• Increasing evidence many with HCAP NOT at risk for
MDRO2-4
Large % of HCAP patients over treated for MDRO5
o Underlying patient characteristics important independent determinants
o
1. Am J Respir Crit Care Med. 2005; 171: 388; 2.Chambers et al. Clin Infect Dis 2014;
58:330; Gross et al AAC 2014; 58:5262; 4. Yap et al. Inf Dis Clinics NA 2013; 27: 1;
Webb, BJ et al. IDWeek Poster #47798, 2014
Elimination of HCAP from HAP/VAP Guidelines
Risk Factors for Multidrug-Resistant Pathogens
“…coverage
for MDR
pathogens…would likely be
based on validated risk
factors for MDR pathogens,
not solely on whether or not
the patient had previous
contacts with the healthcare
system…the panel
unanimously decided that
HCAP should not be
included in the HAP/VAP
guidelines.”
Risk factors for MDR VAP
Prior intravenous antibiotic use within 90 days
Septic shock at time of VAP
ARDS preceding VAP
Five or more days of hospitalization prior to the
occurrence of VAP
Acute renal replacement
therapy prior to VAP
YES
onset
Risk factors for MDR HAP
Prior intravenous antibiotic use within 90 days
Risk factors for MRSA VAP/HAP
Prior intravenous antibiotic use within 90 days
Kalil AC, et al. Clin Infect Dis.
2016;63:e61-111.
Risk factors for MDR Pseudomonas VAP/HAP
Prior intravenous antibiotic use within 90 days
Community-acquired Pneumonia (CAP): Case
• 26 Y/O FEMALE
o
Healthy
• Headache, Fever, Nonproductive C
for 7 days
• T-100.80 F; P-100; RR-24; Ausc-Bil
hi-pitched rhonchi
• O2 sat-98% Room Air
• SHOULD SHE BE ADMITTED?
• What antimicrobial(s)
36
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
Demographic
variables
(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
Class IV
(91–130 points)
Class V
(>130 points)
Class I
Fine MJ, et al. N Engl J Med. 1997;336:243-50.
37
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 20
Temp <35ºC, >50ºC
15
Pulse, beats/min
10
BUN; Sodium <130 mmol/l
Glucose >250 mg/dl; Hct < 30%
pO2 < 60 mmHg
20
10
10
38
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.
39
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)
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
Lim WS, et al. Thorax. 2003;58:377-82.
40
CAP: EMPIRICAL THERAPY
Principles
•TREAT EARLY
•TREAT MOST LIKELY PATHOGENS
o S. pneumoniae (?Drug resistance*); H. influenzae
o Atypicals—studies in North America show high prevalence
(even though may not be severe, therapy reduces illness)
o Others (local epidemiology)
o Cannot differentiate etiology based on initial findings
• FUTURE: Pathogen directed
*Recent ATB (Following of ? Relevance: Recent Hospitalization;
DayCare; Multiple comorbidities; Age)
41
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.
42
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.
43
US FDA Issues New Warnings [Posted 05/12/2016]
Fluoroquinolone Antibacterial Drugs:
Drug Safety Communication – FDA Advises
Restricting Use for Certain Uncomplicated
Infections
ISSUE:
•FDA is advising that the serious side effects associated with fluoroquinolone
antibacterial drugs generally outweigh the benefits for patients with sinusitis,
bronchitis, and uncomplicated urinary tract infections who have other treatment
options.
– For patients with these conditions, fluoroquinolones should be reserved for
those who do not have alternative treatment options
•An FDA safety review has shown that fluoroquinolones when used systemically
(i.e. tablets, capsules, and injectable) are associated with disabling and potentially
permanent serious side effects that can occur together
– These side effects can involve the tendons, muscles, joints, nerves, and
central nervous system
44
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm500665.htm
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.
45
Azithromycin and Cardiovascular
Events (QT effect)
• NEJM 2012 (Ray et al. Tennessee, USA)
o
Older population; Azithro associated with higher mortality
• NEJM 2013 (Svanstrom et al. Denmark)
o
General population; no association with mortality
• JAMA 2014 (Mortensen et al. VA database, USA)
o
Azithro associated with slight increase of MI but overall reduced mortality
in hospitalized patients
• MY TAKE: 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)
46
• New Macrolide:
• First Fluoroketolide; Interacts at 3
sites of Ribosome
• Completed clinical trials
• Oral vs moxi:
•
Barrera Lancet Inf Dis 2016; 16:421
• IV to oral vs moxi:
•
File Clin Infect Dis 2016; 63: 1007
• AEs: mild, transient LFTs; Mild IV
site irritation; NO QTc, NO
accommodation effect
Community-acquired Pneumonia (CAP): Case
• 66 Y/O MALE
oSmoke, Diabetes, CHF
oTreated with macrolide
for ‘sinusitis’ 8 weeks
ago
• Headache, Fever, Cough for 3
days, New Confusion
• T-101.80 F; P-110; RR-28; Auscrhonchi RLL
• O2 sat-92% Room Air
• SHOULD HE BE ADMITTED?
• WHAT ANTIMICROBIAL
CXR courtesy of T. File MD
48
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.
o 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
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: UpToDate
• For hospitalized patients, we suggest adjunctive
glucocorticoids.
o 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
o 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
51
SWITCH THERAPY (IV to po) and
DISCHARGE CRITERIA
• Switch Therapy
oWhen good clinical response, comobidities stabilized, can take po
oIf pathogen identified, ‘Directed’ Therapy
oIf empiric, can utilize ‘negative’ lab results to simplify therapy
(e.g. if urinary antigen and blood cultures negative)
•Discharge
oIf VS and O2 status stable, and no unresolved comorbidities, can
discharge at time of oral switch
oNo value to observe in hospital for 24 h after switch
• (Dunn et al. Am J Med. 1999; 106:6)
52
Short- vs Long-course Therapy for CAP
•Meta-analysis (≤ 7 days vs longer)
Conclusion: No difference in efficacy and safety
•Based on available data
o
o
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
o
Reduced resistance, AE, cost
Dimopoulos 2008, p1848; Drugs; 2008: 68: 184153
Respiratory Tract Infections:
Prevention
•Smoking cessation
•Vaccines
oPneumococcal
oInfluenza
•Reducing effect of comorbidities*
oControlling CHF, Hyperglycemia (higher mortality)
oReducing swallowing disorders etc.
• Brushing teeth
*File and Tan JAMA 2005; 294: 2760-63.
54
Community RTIs
Take-home Messages
•Pharyngitis: Base therapy on antigen test (check
susceptibility if erythromycin used)
oConsider Lemierre’s in adolescent if really sick
and with rigors
•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.
55