Adult CAP. How to approach for diagnosis. Natpatou Sanguanwongse, MD. Bureau of Emerging Infectious Disease July Sunday, July 8, 12

Transcription

1 Adult CAP How to approach for diagnosis Natpatou Sanguanwongse, MD. Bureau of Emerging Infectious Disease July 2012

2 Community-acquired pneumonia (CAP) one of several disease in which individuals (who have not recently been hospitalized) develop an infection of the lung Nosocomial pneumonia (NP), Hospital-acquired pneumonia (HAP) any pneumonia contracted by a patient in a hospital at least hours after being admitted Ventilator-associated pneumonia (VAP) a sub-type of HAP which occurs in people who are receiving mechanical ventilator Healthcare-associated pneumonia (HCAP) any pneumonia in patients with recent close contact with the health care system

3 Community-acquired pneumonia (CAP) one of several disease in which individuals (who have not recently been hospitalized) develop an infection of the lung Nosocomial pneumonia (NP), Hospital-acquired pneumonia (HAP) any pneumonia contracted by a patient in a hospital at least hours after being admitted Ventilator-associated pneumonia (VAP) a sub-type of HAP which occurs in people who are receiving mechanical ventilator Healthcare-associated pneumonia (HCAP) any pneumonia in patients with recent close contact with the health care system

4 CAP immunocompetent host immunocompromised host - HIV/AIDS - non-hiv asplenia hematologic malignancy post-organ transplantation others eg. CMT, XRT, steroid

5 CAP immunocompetent host immunocompromised host - HIV/AIDS - non-hiv asplenia hematologic malignancy post-organ transplantation others eg. CMT, XRT, steroid

6 Community Acquired Pneumonia (CAP) Diagnosis 1. acute onset (duration > 4 days and < 2 weeks) 2. symptoms and signs of LRI (3 in 5) Fever Cough, ± productive sputum Dyspnea Pleuritic chest pain Consolidation or crackles on P.E. 3. new pulmonary infiltration 4. in a patient not hospitalized or residing in a long term care facility for > 14 days before onset of symptoms. แนวทางการร กษาโรคปอดอ กเสบช มชนในประเทศไทย (ส าหร บผ ใหญ ) สมาคมอ รเวชช แห งประเทศไทย ต ลาคม 2544 Modified from Bartlett. Clin Infect Dis 2000;31:

7 Minor criteria Criteria for severe CAP 1. Respiratory rate > 30 breaths/min 2. PaO2/FiO2 ratio < Multilobar infiltrates 4. Confusion/disorientation 5. Uremia (BUN > 20 mg/dl) 6. Leukopenia (WBC count < 4000 cells/mm 3 ) 7. Thrombocytopenia (platelet count < 100,000 cells/mm 3 ) 8. Hypothermia (core temperature < 36 o C) 9. Hypotension requiring aggressive fluid resuscitation Major criteria 1. Invasive mechanical ventilation 2. Septic shock with the need for vasopressors

8 CRB-65 CURE-65 CURB-65 criteria Confusion Uremia (BUN > 20 mg/dl) Respiratory rate > 30 breaths/min Blood pressure; (SBP < 90 or DBP < 60 mm.hg) age > 65 years BTS guidelines for the management of CAP in adults: update Thorax 2009: 64 (suppl 3)

9 Table 1. Pneumonia severity index (PSI) scoring Patient Characteristics Points Demographics Age(years): Male: age Female: age Nursing home resident +10 Co-morbidities Neoplastic disease +30 Liver disease +20 Congestive heart failure +10 Cerebrovascular disease +10 Renal disease +10 Examination findings Altered mental status +20 Respiratory rate ³30/minute +20 Systolic blood pressure <90 mmhg +20 Temperature <35 o C or ³40 o C +15 Pulse ³125/minute +10 Laboratory findings ph <7.35 (do ABG only if hypoxic +30 or COPD) BUN >10.7 mmol/ L +20 Sodium <130 meq/l +20 Glucose ³13.9 mmol/l +10 Hematocrit < PaO 2 <60mmHg or oxygen saturation <90% +10 Pleural effusion +30 PSI Risk Class Score Mortality Low I <51 0.1% Low II % Low III % Medium IV % High V > % Hospitalization is recommended for class IV and V. Class III is based on clinical judgement

10 Incidence of radiographically confirmed CAP by age --- the incidence the max. incidence adjusted for complete ascertainment of CXR and health-seeking behavior The incidence of pneumonia in rural Thailand. International Journal of Infectious Diseases (2006) 10,

11 Risk factors related to the host and the environment that affect incidence of adult clinical CAP aged > 65 year co-morbid diseases smoking > P-Y / ex-smoker malnutrition URT infection in prior 1 month crowding; long term care facilities, military camp, etc (indoor air pollution)

12 Causative organisms of adult CAP in Europe

13 Viral pneumonia In immunocompetent host Human influenza virus (A, B) Respiratory syncytial virus Adenovirus Parainfluenza virus (1, 2, 3) In immunocompromised host Cytomegalovirus Herpesviruses Measles virus Adenovirus Others; Rhinovirus, Human metapneumovirus RadioGraphics 2002; 22:S137-S149.

14 Atypical pneumonia M. pneumoniae C. pneumoniae Legionella spp. Clamydophila. psittaci Coxiella burnetti Francisella tularensis

15 Common etiologies of CAP depend on - age - immune status - co-morbid diseases - severity of CAP - geography

16 Epidemiology of Pneumonia Caused by L. longbeachae, M. pneumoniae and C. pneumoniae: 1-Year, Population-Based Surveillance in Thailand

17 Resp Med 2004; 98(10);

18

19

20 Clinical conditions related to specific pathogens in CAP Alcoholism - S. pneumoniae - K. pneumoniae - Oral anaerobes - Acinetobacter spps. - M. tuberculosis Clinical: Chronic obstructive pulmonary disease - H. influenzae - P. aeruginosa (COPD), Smokers - M. catarrhalis - C. pneumoniae - Legionella spp. - Enterobacteriaceae - S. pneumoniae Structural lung disease (bronchiectasis, - P. aeruginosa - S. aureus cystic fibrosis etc.) - B. cepacia Cough >2 weeks with whoop or post-tussive - B. pertussis vomiting Aspiration (patients with history of alcohol - Anaerobes - P. aeruginosa abuse, drug overdose, or oesophageal motility - Enterobacteriaceae - Mixed infections disorders). Lung abscess - CA-MRSA 2 - M. tuberculosis - oral anaerobes - Atypical mycobacteria - endemic fungi Necrotizing pneumonia - CA-MRSA Cavitary infiltrates - M. tuberculosis - CA-MRSA - Fungi HIV infection (early) - S. pneumoniae - M. tuberculosis - H. influenzae Recent antibiotic therapy or hospitalization - Enterobacteriaceae - P. aeruginosa Chronic treatment with steroids - P. aeruginosa - Aspergillus spp. - Enterobacteriaceae New Microbiologica 2008:31:1-18. Modified from IDSA/ATS Guidelines for CAP in adults. CID 2007:44 (suppl 2)

21 The most frequent etiologies of CAP according to treatment setting Non-hospitalized patients Non-ICU hospitalized patients ICU-hospitalized patients S. pneumoniae S. pneumoniae S. pneumoniae M. pneumoniae M. pneumoniae Legionella spp. H. influenzae C. pneumoniae H. influenzae C. pneumoniae H. influenzae S. aureus Respiratory viruses a Legionella spp. Gram-negative bacilli Respiratory viruses* NEW MICROBIOLOGICA, 31, 1-18, 2008

22 CAP at Srinagarind Hospital, Khon Kaen, Thailand type (No) year mean age M:F etiology outcome OPD (44) Feb 03 to Dec (SD 18.2) 1:1.4 (1/2 healthy) Atypical pathogens, H. influenzae (31.8% each) S. pneumoniae, H. parainfluenzae (27.3% each) 50% multiple pathogens; (C. pneumoniae was the most) 90.9% improved, averaging 6.4 d hospitalized (254) Jan 01 to Dec (SD 19.8) 1:1...? S. pneumoniae 11.4% 33.8% severe CAP B. pseudomallei 11% K. pneumoniae 10.2% C. pneumoniae 8.7% M. pneumoniae 3.9% 6.3% dual infections; C. pneumoniae was the most 83.9% improved, hospital stay 12.9 d 5.9% died hospitalized, severe (105) Jan 99 to Dec (SD 18.2) 1.6:1 91.4% co-morbidity; DM B. pseudomallei 29.4% S. pneumoniae 20.6% K. pneumoniae 19.1% H. influenzae 11.8% Other; E. coli 5.9%, S. aureus 5.9%, M. pneumoniae 1.5%, M. catarrhalis 1.5%, P. aeruginosa 1.5%, P. fluorescens 1.5%, and S. stercoralis 1.5% hospital stay 14.7d 81.9% required MV 57.1% septic shock 21% died 1. Southeast Asian J Trop Med Public Health Jan;36(1): Southeast Asian J Trop Med Public Health Jan;36(1): Southeast Asian J Trop Med Public Health Sep;35(3):664-9.

23 Etiologies of adult CAP in Europe by treatment setting

24 Diagnostic approach to CAP clinical evaluation special interest radiological evaluation diagnostic testing for microbial etiology

25 Viral pneumonia clinical manifestation: mild and self-limited illness to life-threatening disease severity depend on: - virulence of the organisms - age, co-morbidities, immune status of the patients radiographic findings reflect the variable extents of the histopathologic features patchy infiltrate, focal reticular infiltrates to ground-glass opacity with/without consolidation mixed infection RadioGraphics 2002; 22:S137-S149.

26 C. pneumoniae pneumonia at Srinagarind Hospital, Khon Kaen, Thailand. Oct 2000 to Dec 02, a prospective study among hospitalized CAP prevalence of C. pneumoniae 8.7% (24/276) mean age 42.7 (17-79), M:F = 1: % without underlying disease 52.4% non-productive cough 62.5% leukocytosis most common CXR; localized patchy alveolar infiltration, parapneumonic effusions complicated 20.8% 45.8% dual infection, mostly with Streptococcus spp or K. pneumoniae 16.7% severe CAP; 3 of 4 had a dual infection average hospital stay was 11.5 (range 1-45) two patients (8.3%) did not improve clinically Southeast Asian J Trop Med Public Health Jun;35(2):430-3.

27 Extrapulmonary manifestations of M. pneumoniae infection Braz J Infect Dis vol.11 no.5 Salvador Oct available at

28 Extrapulmonary manifestations of C. pneumoniae infection Meningoencephalitis Guillain-Barré syndrome Reactive arthritis Myocarditis a potential etiologic factor in atherosclerosis UpToDate online

29 Some complications associated with specific infections BTS guidelines for the management of CAP in adults: update Thorax 2009: 64 (suppl 3)

30 Diagnostic testing for microbial etiology CAP in immunocompromised hosts chronic severe liver disease asplenia severe pneumonia / ICU admission risk factors or clinical manifestations suggesting tuberculosis pleural effusion failure of empirical antibiotic therapy specific epidemiological conditions Modified from New Microbiologica 2008:31:1-18.

31 Expectorated sputum for Gram stain only for hospitalized CAP with a good quality sputum + appropriate measures for collection, transport and processing obtaining the specimen prior to antibiotics and rinsing the mouth prior to expectoration reject specimen with > SECs/LPF predict a likely etiologic agent by identification of a predominant bacterial morphology in an adequate (purulent) specimens less utility in the diagnosis of atypical pathogens UpToDate online July 2012 BTS guidelines for the management of CAP in adults: update Thorax 2009: 64 (suppl 3)

32 Lower respiratory tract infection (LRTI) - An acute febrile illness (< 21 days), usually with cough, with at least one other LRT symptom (sputum production, dyspnoea, wheeze or chest discomfort/ pain) and no alternative explanation (e.g. sinusitis or asthma) Clin Microbiol Infect 2011; 17 (Suppl. 6): 1 24

33 Epidemiological conditions associated to specific pathogens in CAP Characteristics Pathogens Epidemiologic: Alcohol abuse - S. pneumoniae - Acinetobacter spp. - Anaerobes - M. tuberculosis - K. pneumoniae Injecting drug abuse - S. aureus - M. tuberculosis - Anaerobes - S. pneumoniae Hotel stay or ship cruise in previous - Legionella spp. 2 weeks, especially in Mediterranean coast Influenza outbreak in community - Influenza viruses - S. aureus/ca-mrsa 2 - S. pneumoniae - H. influenzae Exposure to bat or bird droppings - H. capsulatum Exposure to birds - C. psittaci (if poultry: avian influenza virus) Specific epidemiologic conditions - SARS 1 associated coronavirus - Avian influenza virus (H5N1) Exposure to farm animals or parturient cats - C. burnetii (Q fever) - Hantavirus Travel to or residence in south-western - Coccidioides spp. United States Travel to or residence in Southeast - B. pseudomallei - Avian influenza and East Asia In context of bioterrorism - B. anthracis - F. tularensis - Y. pestis New Microbiologica 2008:31:1-18.

34 Clinical indications for more extensive diagnostic testing

35 Urinary antigen test (for S. pneumoniae, Legionella spps.) Advantages available for patients who cannot expectorate sputum validity ever after antibiotic therapy FDA-cleared available immediate result more sensitivity and specificity than sputum Gram stain Disadvantages sens. and spec. may be less in patients without bacteremia antibiotic sensitivity test is not available required a licensed technician UpToDate online July 2012

36 Molecular diagnosis not point-of-care test beware contamination cannot R/O colonization none of molecular methods to detect bacteria are FDA-cleared sensitivity and specificity are consequently highly variable UpToDate online July 2012

37

38 The clinical response depends on host factors (e.g., immune status and co-morbid illness) bacteriologic factors (e.g., virulence, susceptibility to available therapies, and inoculum) disease factors (e.g., the degree of disease progression at the time of diagnosis and the extent of illness and physiologic compromise) therapy factors (e.g., the timing and adequacy of therapy, as well as the pharmacokinetics of the selected agent)

39 CAP in the elderly should be suspected in all elderly patients who have fever, altered mental status, or a sudden decline in functional status, with or without lower respiratory tract symptoms Adherence to the IDSA/ATS guidelines has been found to improve all; in-hospital mortality (adherence vs non-adherence) 8% (95% CI, 7-10%) vs 17% (95% CI, 14-20%; P< 0.01) length of hospital stay (IQR) 8 days (5-15) vs 10 days (6-24) days; P < 0.01) percentage of stable patients by day 7 71% (95% CI, 68-74%) vs 57% (95% CI, 53-61%), P < 0.01) all elderly patients should be vaccinated against pneumococcal disease and influenza lifestyle modifications and nutritional support are also important elements in the prevention of pneumonia in the elderly. Am J Geriatr Pharmacother Feb;8(1):47-62

40 Reasons for failure to improve as expected improvement expected too soon overwhelming infection unexpected pathogen or pathogens not covered by antibiotic choice antibiotic ineffective or causing allergic reaction local or distant complications of CAP nosocomial infection other non-infectious complications/causes impaired local or systemic defenses slow response in the elderly patient Adapted from BTS guidelines for the management of CAP in adults: update Thorax 2009: 64 (suppl 3)

41 Incorrect diagnosis Uncommon Common Pulmonary embolism/ infarction Pulmonary edema Bronchial carcinoma Bronchiectasis Pulmonary eosinophilia/ eosinophilic pneumonia Cryptogenic organising pneumonia Pulmonary alveolar haemorrhage Foreign body Congenital pulmonary abnormality (eg, lobar sequestration) BTS guidelines for the management of CAP in adults: update Thorax 2009: 64 (suppl 3)

42 Thank You