• New antibiotics
Antibiotics
– Cephalosporins – Macrolides/ketolides – Fluoroquinolones
• Route ofvenous – Intramuscular
• Pharmacology
Fine MJ, et al. NEJM 1997;336(4)243-250
Associated Mortality by Age and Treatment
Age 18-64 yr 65-74 yr 75-84 yr > 85 yr Untreated Mortality 10% - 15% 20% 30% 40% 50% - 90%
How many cases of pneumonia have you cared for in the last year?
1. None 2. 1-5 3. 6-10 4. 11-20 5. More
Community-acquired pneumonia
• Symptoms consistent with lung infection • New pulmonary infiltrate • Acquired outside the hospital
5/25/2016
Ho, Pak-Leung AAC, May, 1999
Possible Diagnostic Tests
• • • • Gram Stain WBC Chest x-ray Pulse oximetry
I routinely use a Gram stain
1. Yes 2. No
Applications of New Insights
• Analysis of risk factors • Guidelines for evaluation • Guidelines for management
• Antibiotic resistance tracking
Prediction model for C A P
• • • • • • ANTIBIOTIC Penicillin (MIC>0.06) Ceftriaxone (MIC>0.5) Ciprofloxacin (MIC>2) Levofloxacin (MIC>2) Trovafloxacin (MIC>1) • • • • • • RESISTANCE 69.1 % 44.2 % 12.1 % 5.5 % 2.2 %
Patient Points characteristics assigned Demographic factors Age: males age (in yrs) females age (in yrs) -10 Nursing home resident +10 Comorbid illnesses Neoplastic disease +30 Liver disease +20 Congestive heart failure +10 Cerebrovascular disease +10 Renal disease +10 Physical examination findings Altered mental status Respiratory rate ≥ 30/min Systolic blood pressure < 90 mmHg Temp. < 35°C or ≥ 40°C Pulse >125 / min +20 +20 +20 +15 +10
I routinely do a CBC
1. Yes 2. No
I often do a Chest x-ray
1. Yes 2. No
I commonly use pulse oximetry
1. Yes 2. No
Rapid Diagnostic studies
• • • • Gram stain - bacteria Acid fast - mycobacteria DFA - Pneumocystis, influenza, legionella PCR - chlamydia, mycoplasma, mycobacteria, legionella, hantavirus • EIA - influenza, RSV
Community-Acquired Pneumonia
• 2-3 million cases/year • 500,000 hospitalizations/year • 45,000 deaths/year
– the most lethal infection – 14% of those hospitalized die
– Once daily
Managed Care
• Reduce costs
– Antibiotic – Hospitalization – Personnel
• Quality assurance • Accountability • Clinical pathways
• Large databases
Fine MJ, et al. NEJM 1997;336(4)243-250
Risk-Class Mortality Rates for Patients with Pneumonia
Risk class I II III IV V No. of points No predictors < 70 71- 90 91 - 130 > 130 No. of Mortality Recommendations patients (%) for site of care 3,304 5,778 6,790 13,104 9,333 0.1 0.6 2.8 8.2 29.2 Outpatient Outpatient Inpatient (briefly) Inpatient Inpatient
Primary Patient Care Site
1. Hospital 2. Intensive Care 3. Clinic 4. Skilled nursing facility 5. Home care
How young are you?
1. 30-40 years 2. 40-50 3. 50-60 4. 60-70 5. 70-80
Microbiology of C. A. P.
• Pathogens
– Broad range – Many still unknown – Coinfections
• Rapid diagnostic testing • Susceptibility reporting
– Alexander project, others
Hospital Discharge Decisions
• 418 patients • Stable for last 2.5 days • Stay due to co morbid conditions, “standard” course of therapy, or delay in home arrangements • OPAT would have allowed earlier discharge in 26% and home care nursing in 20%
Do you routinely use an algorithm or guideline in decision making with C A P?
1. Yes 2. No
Hospital Admission Decisions
• 472 low risk patients (<4% mortality) • Admission decisions related to
Fine MJ, et al. Arch Intern Med 1997;157:47-56
Causative pathogens in 5,961 adults admitted to hospital with CAP identified in 26 prospective studies from 10 European countries
S pneumoniae C pneumoniae Viral Mycoplasma pneumoniae Legionella sp H influenzae
Community-acquired Pneumonia
Alan D Tice, MD, FACP Infections Limited Tacoma, Washington
University of Washington
What is Your Specialty?
1. Primary care 2. Medical specialist 3. Surgery 4. Gynecology 5. Nurse 6. Physician assistant
• 10 million physician visits/year • Frequent reason for antibiotic use
Recent Developments in C. A. P.
• • • • • Antimicrobial resistance New antibiotics New microbiology/technology Managed care Information management
Information Management
– Pneumonia Patient Outcomes Research Team (PORT) study (38,000 patients) – Medicare/HCFA