Community Acquired Pneumonia - A Malaysian Perspective

Transcription

1 CONTINUING MEDICAL EDUCATION Cmmunity Acquired Pneumnia - A Malaysian Perspective C K Liam, FRCP Department f Medicine, Faculty f Medicine, University f Malaya, Kuala Lumpur Intrductin Cmmunity acquired pneumnia (CAP) is a cmmn illness and ptentially life threatening especially in lder adults and thse with c-mrbid disease. It is a majr cause f mrbidity and death wrldwide. Recgnising the clinical imprtance f CAP, many cuntries have develped natinal guidelines fr the management f this cnditin l ",3.4.5,6.7. In Malaysia, the Malaysian Thracic Sciety tgether with the Ministry f Health and the Academy f Medicine, Malaysia are develping guidelines fr the management f CAP in adults. The micrbial aetilgy f cmmunity acquired pneumnia Althugh many micrrganisms have been assciated with CAP, it is a small range f key pathgens that cause mst cases. Streptcccus pneumniae (pneumcccus) is the mst frequently identified pathgen, with the highest incidence f this rganism reprted in studies that used urinary antigen detectin. Apart frm Streptcccus pneumniae, a great deal f literature in Western cuntries has reprted Haemphilus injluenzae, atypical pathgens Chlamydia pneumniae, Mycplasma pneumniae, Leginella pneumphila and viruses (influenza virus, adenvirus, respiratry syncytial virus, parainfluenza virus crnavirus) as the cmmn pathgens f CAP3,.8,9,lO,ll. Gram-negative bacilli (Enterbacteriaceae and pseudmnadas) are the cause f CAP in patients wh have had previus antimicrbial treatment r wh have pulmnary cmrbidities)1'. In ne study, 33% f hspitalized CAP patients with unknwn aetilgy diagnsed by rutine methds were fund t due t Streptcccus pneumniae based n findings frm transthracic needle lung aspiratin, suggesting that many patients withut a knwn pathgen have pneumcccal infectin 13 The micrbial aetilgical distributin f CAP reprted in the literature depends n the patient ppulatin, the gegraphical regin, the intensity f investigatins carried ut and the ccurrence f epidemics f infectin. Even when carefully sught fr in large prspective studies, the putative causative rganism remains unknwn in abut half f all patients with CAP. In an bservatinal study that assessed the 'real-wrld' practice frm several centres in the USA, nly 6% f utpatients and a quarter f inpatients with CAP had the cause f their disease defined l4. Reasns fr failure t identify the aetilgical agent include prir treatment with antibitics, unusual pathgens that g unrecgnized, viral infectins, nn-infectius mimic f CAP, and pathgens that are currently nt identified r recgnized.. The micrbial aetilgy f cmmunity acquired pneumnia in patients requiring hspitalisatin The results f sme studies n CAP requiring hspitalizatin frm United Kingdm, the remainder f Eurpe, Australia and New Zealand, Nrth America and Asia are cmpared in Table 1. The aetilgy f CAP in Japan and Krea des nt differ markedly when cmpared with that f Western cuntries except fr the lw incidence f Leginella pneumnial5.l6.17. The lw incidence f Leginella pneumnia is als fund in the ther Asian cuntries which culd have been due t limitatins f labratry tests used. The epidemilgic data frm Bangkk l6 indicate that the micrbial agents causing CAP in Thailand, in general, are nt different frm thse in Western cuntries. This article was accepted: 18 August 2004 Crrespnding Authr: Liam Chng Kin, Department f Medicine, Faculty f Medicine, University f Malaya, Kuala Lumpur Med J Malaysia Vl 60 N 2 June

2 CONTINUING MEDICAL EDUCATION In the Japanese series, Chlamydia pneumniae was identified in 3%15 and 7.5%20 f the cases, respectively. In the AsiACAP study" which was cnducted frm Octber December 2002 in 12 urban tertiary medical centres in Asia (Beijing, Shanghai, Seul, Taipei, Hng Kng, Bangkk, Manila, Kuala Lumpur, Petaling Jaya and Jakarta invlving 1756 ut- and inpatients aged 2 years and abve, paired sera (acute and cnvalescent) were btained frm 1374 patients (78.2%) [children up t 15 years (448 patients), adults (frm age 15 years and abve) (926 patients)]. Infectin rates based n 2:4-fld rise in antibdy titre between acute and cnvalescent sera were fund t be 9.4% fr Mycplasma pneumniae, 4.3% fr Chlamydia pneumniae and 6.2% fr Leginella pneumphila. The verall infectin rate fr atypical pathgens is 19.9%. A number f studies in Asia where the prevalence f tuberculsis is high have shwn that infectin due t Mycbacterium tuberculsis may cmmnly present as an apparent CAP'S.21,23,24. In a study cnducted in Argentina, Mycbacterium tuberculsis was identified in 2,8% f 253 patients with mderate CAp 2 6. One 22 f the Malaysian studies excluded patients with tuberculsis while in the ther tw studies, tuberculsis accunted fr 15.3% and 4.8% f the cases, respectively23,24. Althugh pulmnary tuberculsis is a chrnic respiratry infectin, it can present as CAP and it shuld be a differential diagnsis in areas where tuberculsis is endemic. In studies cnducted in Malaysia, 2 ut f %) patients in the Kuala Lumpur series had meliidsis;22 while Burkhlderia pseudmallei was nt islated in any patient in the Penang series 23. In the Bangkk study,20 Burkhlderia pseudmallei was identified in 1.4% f the cases, Hwever, in rural Nrtheastern Thailand, Burkhlderia pseudmallei was identified in 15.4% f the patients hspitalised fr CAP ' 9. Burkhlderia pseudmallei shuld be cnsidered a causative rganism in patients with CAP in rural Sutheast Asia particularly if the patient has'diabetes mellitus'9. Studies perfrmed in the Asia Pacific regin shwed that Gram-negative bacilli ther than Haemphilus injluenzae such as Klebsiella pneumniae are mre frequently islated'5,17'19,20,22,23,24, The differences in the micrbilgy f CAP as cmpared t what is reprted in the West must be taken int cnsideratin when selecting the apprpriate antibitics fr initial empirical therapy f CAP in this regin, The micrbial aetilgy f severe cmmunity acquired pneumnia There is n standard definitin fr diagnsing severe CAP. In treatment guidelines develped in the West, patients with CAP admitted t an intensive care unit (lcu) are cnsidered as having the severe frm f the disease. Hwever, plicies fr ICU admissin may vary cnsiderably between medical centres. Patients nt admitted t an ICU culd als be having severe CAP, Hst-factrs such as underlying diseases, can influence severity f presentatin f CAP. Severe CAP accunts fr apprximately 5-35% f hspital-treated cases f pneumnia with the majrity f patients having underlying cmrbidities. The American Thracic Sciety prpsed defining severe CAP n the presence f ne majr criteria r 2 minr criteria 6 The majr criteria cnsist f the need fr mechanical ventilatin and septic shck while the minr criteria include chest radigraph shwing bilateral r multilbe invlvement, a PaOz/fractin f inspired xygen (FiOz) rati less than 250 mm Hg and systlic bld pressure f 90 mm Hg r less. The micrbilgy f severe CAP patients requiring ICU admissin in varius studies are shwn in Table II. The micrbilgy f severe CAP in patients admitted t intensive care units is similar t that in ther patients admitted t hspital with CAP. Studies cnducted in the west shw that Streptcccus pneumniae t be the mst frequent causative micrrganism assciated with severe CAP and it is detected in abut 20% f cases. Other frequently identified pathgens are Haemphilus influenzae, gram-negative enteric bacilli and Staphylcccus aureus (althugh few f these cases culd be judged as definite, i.e. cnfirmed bacteraemia r islatin frm pleural fluid r lung tissue); and Leginella pneumphila 7,26,27. A review f nine studies f CAP that resulted in admissin t an ICU (seven frm Eurpe and ne each frm USA and Suth Africa) nted that Leginella spp were the secnd mst cmmnly identified pathgens 30, In an internatinal cllabrative survey f 508 patients with culturepsitive leginellsis, 92% f the islates with sergrup 1 were L pneumphila, accunting fr 84% f the ttal. L pneumphila sergrup 1 accunted fr 88% f islates in America and Eurpe but fr nly 46% in Australia and New Zealand where L lngbeachae accunted fr 30% f cases 31. In 2 studies n severe CAP cnducted in Singapre, Leginella spp was nt identified in any f the patients 2S,29. Hwever, Burkhlderia pseudmallei was a cmmn causative 250 Med J Malaysia Vl 60 N 2 June 2005

3 Cmmunity Acquired Pneumnia - A Malaysian Perspective rganism identified (Table II). MelIidsis shuld be cnsidered a diagnstic pssibility especially if the patient has diabetes mellitus. Pseudmnas aeruginsa shuld be cnsidered in patients with underlying structural lung disease, fr example in patients with brnchiectasis r chrnic bstructive pulmnary disease. Apart frm these pathgens, ther pathgens assciated with severe CAP are als frequently islated frm patients with nn-severe CAP. The micrbial aetilgy f cmmunity acquired pneumnia in patients treated n an ambulatry basis The mst cmmn pathgens identified frm recent studies f mild (Le. in ambulatry patients) CAP are Streptcccus pneumniae, Mycplasma pneumniae, Chlamydia spp, and viruses (mstly influenza virus) (Table III)8,2,26,32,33. In ne study, Mycplasma pneumniae is the mst cmmn pathgen in patients yunger than 50 years and withut imprtant cmrbid cnditins, whereas Streptcccus pneumniae is the mst cmmn pathgen fr lder patients r thse with significant underlying disease 34. The high infectin rates caused by Chlamydia pneumniae (36.7%) and Mycplasma pneumniae (29.6%) in ambulatry patients in the Bangkk study 20 culd be explained by many factrs. First, paired sera cllected frm mst the patients fr the diagnsis f atypical pathgens in the study prbably imprved the diagnstic yield. Secnd, Chlamydia pneumniae and Mycplasma pneumniae ften cause a mild clinical disease, therefre patients are mre likely t be seen as utpatients. Mrever, the infectin by the atypical micrrganisms is mre cmmn amng persns in a yunger age grup, as was seen in the utpatients. Initial site and antibitic fr empirical treatment The selectin f the initial site f treatment and the initial empirical antibitic therapy is based n (1) risk stratificatin f the patient accrding t (a) the presence f c-mrbid cnditins; (b) the severity f the pneumnia at presentatin (based n' physical findings, chest radigraph changes and labratry findings); and (c) the presence f identified clinical risk factrs fr drug-resistant and unusual pathgens ; and (2) the lcal epidemilgy and resistance pattern. Bth the 2001 American Thracic Sciety6 and the 2000 Infectius Disease Sciety f America3 guidelines indicate that age alne is nt a reasn fr hspitalizatin. Studies have shwn that age alne, in the absence f cmrbid illness, has little impact n the bacterial etilgy f CAP Practice guidelines usually categrise CAP patients based n the site f treatment (utpatient, general ward, r intensive care unit), the presence f cmrbidity and mdifying factrs (e.g., risk fr penicillin-resistant Streptcccus pneumniae)1,2,3.4,5,6. Each patient grup is assigned a list f likely pathgens and suggested antimicrbial therapy. Guidelines advcate the use f thse antimicrbials that prvide cverage f bth the likely pathgens and resistant strains. Determining the initial site f treatment Mst patients with CAP can be safely treated as utpatients. Hwever, abut 20% f CAP patients need hspitalizatin and apprximately 1% require treatment in an ICU38,39. Patients shuld be admitted if they require clse bservatin, intravenus antibitics, respiratry supprt, r there are ther cncerns. Risk factrs fr increased mrtality assciated with CAP include extremes f age; cmrbid cnditins such as malignant disease, cngestive cardiac failure, crnary artery disease and alchlism; vital sign abnrmalities; and certain labratry and chest radigraphic findings 40. The decisin whether r nt t admit a patient depends n the clinician's judgment which is an "art f medicine". Hwever, prgnstic scring rules are available which prvide supprt fr this decisin7, A pneumnia severity index (PSI) scre r the "pneumnia predictin rule", has been develped frm studies f the pneumnia Patient Outcmes Research Team (PORT)". This predictin rule r index can be used t stratify patients t ne f five risk categries with a scre r pint system based n 7 labratry and chest radigraphic parameters after an initial evaluatin f three factrs: age (yunger than 50 years r 50 years r lder), presence f 5 cmrbid cnditins (neplastic disease, liver disease, cngestive heart failure, cerebrvascular disease and renal disease), and mental status and vital signs n admissin. This methd has been validated fr identifying patients at risk f dying within 30 days. The risk f death is lw fr risk classes I-III ( %), intermediate fr class IV ( %), and high fr class V (27-31%). Apart frm being an effective methd fr triaging patients, this methd is particularly useful fr identifying lw-risk patients wh may be safely treated as utpatients Befre calculating the severity index scre, patients shuld be assessed fr any pre-existing cnditin that may cmprmise the safety f hme care, which includes haemdynamic instability, acute hypxaemia, active cmrbid cnditins that warrant hspital admissin, scial r psychiatric prblems Med J Malaysia Vl 60 N 2 June

4 CONTINUING MEDICAL EDUCATION cmprmlsmg hme care, r the inability t take medicatin rall)"'7. Nrth American practice guidelines advcate the use f PSI as an bjective measure f risk stratificatin t help determine the initial site f CAP treatment 3,'. Easy-tuse versins f the PSI are nw available n handheld cmputers and the Internet: CAPcalc/default.htm, and emedhme.cm/dbase,cfm. Mrtality predictin rules shuld be used t supprt, but nt replace, clinician decisin making, Whether r nt a patient is admitted has an effect n the extent f diagnstic evaluatin and the chice f empirical antibitic therapy. Mrtality frm CAP The mrtality frm CAP in patients treated as utpatients is less than 1%, while that fr hspitalised patients as a whle is 13.7%, in elderly patients 17.6%, patients with bacteraemia 19.6%, and patients admitted t ICU 36.5%40. In a recent study cnducted in Malaysia (unpublished data), the verall in-hspital mrtality rate in adult patients hspitalised fr CAP was 11.1% while that fr patients aged 30 years r yunger was 0%, fr patients aged 31 t 64 years was 7%, fr patients aged 65 t 80 years was 12% and fr patients aged 81 years and lder was 41%24, The clinical features independently assciated with an increased risk f dying frm. CAP in these patients were age lder than 50 years, c-existing cngestive cardiac failure, multilbar pneumnia, tachycardia f 125/min r mre n admissin, admissin serum creatinine greater than 130 [!mlll, and acute respiratry failure. Initial empirical antibitic therapy fr CAP In mst instances, a quick micrbilgical diagnsis is nt pssible and the micrbial aetilgy f CAP is unknwn, As the micrbial aetilgy cannt be reliably predicted frm the clinical, labratry and radilgical features, initial antibitic treatment has t be empiricai 48 -'. An awareness f the likely causative rganism f CAP treated in different settings is imprtant t allw the start f apprpriate empirical antimicrbial treatment. Table IV shws the mst cmmn pathgens assciated with CAP as derived frm cllective results f varius studies cnducted in the west and in the Asia Pacific regin7,8,12,13,15-29,32,33. Nrth American and Eurpean guidelines3,4,6,7 recmmend initial empirical therapy cnsisting f a macrlide cmbined with a brad-spectrum betalactam antibitic r mntherapy with a newer flurquinlne which has antipneumcccal activity ("respiratry fluquinlne") in all CAP patients requiring hspitalisatin. Retrspective large ppulatin studies have fund that cmbinatins f beta-iactam antibitics plus macrlides r mntherapy with respiratry flurquinlnes, as initial therapy fr nn-severe CAP, reduce length f stay and mrtality, even when Streptcccus pneumniae is the causative micrrganism 51 -'6. These favrable utcmes may,be explained by the rle f atypical pathgens as aetilgical agents f CAP, the anti-inflammatry effects f macrlides r resistance t beta-iactam antibitics f the mst imprtant pathgens. The respiratry flurquinlnes can als be used t treat severe CAP'7,'8. Finch et at" shwed mxiflxacin t have better clinical and bacterilgical success when cmpared with c-amxiclav with r withut a macrlide in the treatment f patients hspitalised with CAP and severe CAP, Hwever, the develpment f resistance t these respiratry flurquinlnes has already been reprted'9,60. Despite a high levd f activity against Streptcccus pneumniae and atypical rganisms, flurquinlnes, are nt advcated by the Centers fr Disease Cntrl (CDC) Drug-Resistant Streptcccus pneumniae Therapeutic Wrking Grup (DRSPTWG) because f their verextended spectrum f cverage (inclusive f gram negative bacteria) and cncern abut the emergence f resistant Streptcccus pneumniae, The use f a thirdgeneratin cephalsprin and a macrlide antibitic prvides a mre apprpriate spectrum f cverage fr CAP withut carrying the added risk nt nly, f resistant Streptcccus pneumniae but als f the emergence f many resistant gram-negative rganisms that have nthing t d with the patient's pneumnia. The DRSPTWG recmmends reserving the use f flurquinlnes fr patients wh are allergic t firstline agents, in whm first-line therapy has failed, r wh have prven resistance t penicillin 2. CAP caused by penicillin resistant Streptcccus pneumdniae (minimum inhibitry cncentratin less than 4 j.1g/ml), can still be adequately treated with betalactams at the right dsage 61, The prpsed initial empirical antibitic therapy f bacterial CAP in immuncmpetent adults accrding t the treatment setting in Malaysia is shwn in Table V. 252 Med J Malaysia Vl 60 N 2 June 2005

5 Cmmunity Acquired Pneumnia - A Malaysian Perspective Empirical antibitic therapy fr hspitalized nnsevere cmmunity acquired pneumnia Antibitic therapy shuld be initiated prmptly as this is assciated with better utcmes 62,63, Antibitic therapy shuld cver fr Streptcccus pneumniae and atypical pathgens which have been shwn t be prevalent as causative agents, The antibitic ptins include: A macrlide plus a penicillin r secnd generatin cephalsprin r a nn-pseudmnal third generatin cephalsprin A macrlide plus a B-Iactam / B-Iactamase inhibitr Mntherapy with a flurquinlne with enhanced antipneumcccal activity, Epidemilgical clues that may lead t diagnstic cnsideratins are listed in Table VP, In patients with the fllwing c-mrbidities: COPD - antibitic treatment shuld cver fr Haemphilus irifluenzae and Mraxella catarrhalis, Brnchiectasis - antibitic treatment shuld cver fr Pseudmnas aerginsa, Examples f antibitic regimens - a B-Iactam plus an aminglycside r a B lactam plus ciprflxacin Patients n lng-term crticsterids (dse exceeding 10 mglday f prednislne) - shuld cver fr Pseudmnas aerginsa Empirical antibitic therapy fr severe cmmunity acquired pneumnia Since Streptcccus pneumniaeis the mst frequently identified pathgen in severe CAP and Leginella pneumphila is feared fr the ptential severity f infectin empirical antibitic therapy shuld cver fr these tw pathgens 64, The early and rapid initiatin f empiric antibitic treatment is critical fr a favrable utcme, It shuld include an intravenus beta-iactam tgether with either a macrlide r a flurquinlne, Mdificatins f this basic regimen shuld be cnsidered in the presence f distinct cmrbid cnditins and risk factrs fr specific pathgens, Fr example, empirical therapy fr Pseudmnas aeruginsa is recmmended if the patient has brnchiectasis and antibitic cver fr Burhldena pseudmallei shuld be cnsidered if the patient has diabetes mellitus, Failure t define a pathgen in patients with severe CAP has nt been assciated with a different utcme than if a pathgen is identified39,65, Pathgen-specific therapy If a specific pathgen can be identified within hurs then cntinued treatment can be guided by this infrmatin, Fr example, if penicillin-susceptible Streptcccus pneumniae is islated, treatment shuld be mdified by selecting a narrw spectrum antibitic (such as penicillin r amxicillin), which will help t reduce the selective pressure fr resistance, This infrmatin is ften available at the time f switching frm parenteral t ral therapy, Duratin f antibitic therapy Mst experts recmmend the ttal duratin f antibitic therapy shuld be days, depending n the severity f the pneumnia and the respnse t therapy66, An extended curse f intravenus antibitics is generally recmmended fr bacteraemia due t high-risk rganisms (Staphylcccus aureus r gram-negative bacilli) r suppurative cmplicatins 67, Antibitic treatment fr 21 days has been recmmended fr infectin due t Leginella pneumphila, The American Thracic Sciety recmmends that patients switched t ral antibitics can be discharged n the same day if ther medical and psychscial factrs permit 6, Evidence frm bservatinal studies suggests that there is n need t bserve patients fr 24 hurs after a switch frm intravenus t ral therapy67,68, Susceptibility f Streptcccus pneumniae t cmmnly used antimicrbial agents stratified by susceptibility t penicillin In-vitr activities f 6 antibitics against 92 strains f Streptcccus pneumniae islated frm patients in Malaysia is shwn in Table VII69, The data is frm a study cnducted between , Specimens were referred by labratries in hspitals thrughut the cuntry t bacterilgy departments at the Institute fr Medical Research and the University f Malaya Medical Centre, 61.9% f the strains were islated frm respiratry tract specimens, Minimum inhibitry cncentratins (MICs) were determined by the Etest methd, Ten (10,9%) islates, all frm respiratry tract specimens, were nn-susceptible t penicillin (5 exhibiting intermediate susceptibility and anther 5 resistance), The mst active drug was c-amxiclav (96,8% f islates, including 2 that were resistant t penicillin being susceptible) fllwed by ceftriaxne, cefurxime and azithrmycin, As the MIC breakpint fr susceptibility t cefaclr has nt been recmmended by United States Natinal Cmmittee fr Clinical Labratry Standards (NCCLS), the percentage f islates susceptible t this agent culd nt be calculated, Of the 6 strains resistant t ceftriaxne, 5 were resistant t penicillin and ne exhibited Med J Malaysia Vl 60 N 2 June

6 CONTINUING MEDICAL EDUCATION intermediate susceptibility. Of the 7 strains that were resistant t cefurxime, 5 and 2 islates, respectively, were resistant and intermediately susceptible t penicillin. Twelve strains were resistant t azithrmycin and 7 f these exhibited reduced susceptibility t penicillin. Penicillin-resistant Streptcccus pneumniae The risk factrs fr penicillin-resistant Streptcccus pneumniae (PRSP) include age yunger than 2 years r lder than 65 years, beta-lactam antibitic treatment within the past 3 mnths, alchlism, multiple medical cmrbidities, immunsuppressive illness r treatment, and expsure t a child in a day-care centre,". Several studies shwed that age lder than 65 years is, by itself, a specific epidemilgical risk fr CAP due t PRSP, but is nt an indep1ndent risk factr fr ther rganisms"'". Under the frmer NCCLS criteria, Streptcccus pneumniae infectins treated with beta-lactam antibitics t which islates had intermediate resistance were assciated with wrse clinical utcmes fr meningitis but nt fr pneumnia. This difference might be related t the attainable cncentratins f beta-lactam antibitics in cerebrspinal fluid (CSF), cmpared with plasma and interstitial fluid, Betalactam antibitic cncentratins in the lung interstitia are similar t thse measured simultaneusly in serum, and levels in CSF are lwer than thse in serum 73, The presence f penicillin resistance itself has nt been shwn t adversely affect utcme in CAP treatment unless penicillin MIC vales are 4 mg/ml r higher 3,74, As f January 2002, the NCCLS increased the MIC breakpints fr ceftaxime and ceftriaxne. Islates with MICs f :::;1 pg/ml are nw cnsidered susceptible, thse with MICs f 2 pg/ml are intermediate, and thse with MICs f?4 pg/ml are resistant. The new breakpints apply t nn-meningeal Streptcccus pneumniae infectins and such infectins by strains frmerly cnsidered t be intermediately susceptible and even sme that were regarded as resistant can be treated successfully with the usual dses f beta-lactam antibitics. Antibitic ptins in the treatment f penicillinsusceptible and penicillin-resistant Streptcccus pneumniae are shwn in Table VIII. Fr patients admitted t the general ward, high-dse benzylpenicillin shuld be adequate, as lng as the MICs f islates in the lcal cmmunity is <2 pg/ml. Alternatively, ceftriaxne r ceftaxime (nt available in Malaysia) can be used fr strains f pneumcccus with an MIC f <2 pg/mu. If the patient has a histry f anaphylactic allergic reactin t penicillin r is allergic t cephalsprins, intravenus vancmycin r an antipneumcccal flurquinlne are acceptable substitutes. Current guidelines fof treating PRSP pneumnia recmmend chsing ne f the fllwing antibitics based n susceptibility testing results: ceftriaxne, ceftaxime, antipneumcccal flurquinlnes, r, if the islate is resistant t flurquinlne and cephalsprin, vancmycin 4, Treatment guidelines cannt capture every clinical situatin and it is therefre the respnsibility f the clinician t balance the histry and clinical features, assess the imprtance f risk factrs and interpret lcal epidemilgy and labratry data in rder t make the best judgement fr an individual patient. 254 Med J Malaysia Vl 60 N 2 June 2005

7 cnt'd... next page () 3 3c :J..z...0 c [ ":J (J) c 3 :J ' I» c "75i ' :J (;l r 1CiS 0-0" '< V>' (). Z tv ' C :::J (J) tv 01 Table I: Micrbilgy f cmmunity acquired pneumnia in patients requiring hspitalisatin Lcatin N. f Frequency / Rank rder f micrbial cause (%) patients Unknwn United Kingdm? pneumniae C pneumniae M pneumniae Influenza A & B H influenzae Leginella spp (5 studies) (mean %) Other parts C M Influenza Leginella spp Gram negative f Eurpe? pneumniae pneumniae pneumniae A &B enteric bacilli (23 studies) (mean %) Australia & M H Leginella Gram negative C New Zealand? pneumniae pneumniae influenzae spp enteric bacilli pneumniae (3 studies) (mean %) Nrth America? H C Influenza Gram negative Leginella (4 studies) pneumniae influenzae pneumniae A&B enteric bacilli spp (mean %) Okayama S H M K S milleri C (326 episdes) pneumniae influenzae pneumniae pneumniae pneumniae Okayama S H M C 5 aureus Anaerbes pneumniae influenzae pneumniae pneumniae Krea 1? 562 S K Ps S aureus Streptcccus Enterbacter (588 cases) pneumniae pneumniae aeruginsa viridans clacae Hng Kng M S Chlamydia Viral H M tuberculsis pneumniae spp influenzae pneumniae Khn Kaen S K B H M S aureus pneumniae pneumniae pseudmallei influenzae pneumniae Bangkk 2O Chlamydia K. M. L H (TB cases were pneumniae pneumniae pneumniae pneumniae pneumphila influenzae excluded) tv 01 01

8 n Ẕ I Z c: Z G) 3: rn n» e- rn c: n z '" 0- tjl cnt'd... Table I Lcatin N. f Frequency / Rank rder f micrbial ca e (%) patients Unknwn Singapre M 5 Gram negative H M 5 tuberculsis pneumniae bacilli influenzae pneumniae aureus K. Lumpur K 5 H M Ps Burkhlderia (Fr atypical pneumniae pneumniae influenzae pneumniae aeruginsa pseudmallei pathgens: nly serlgy fr Mycplasma was dne) Penang M K Ps 5 aureus 5 Acinetbacter (Fr atypical tuberculsis pneumniae aeruginsa pneumniae spp pathgens: serlgy fr Mycplasma and Leginella was dne) K. Lumpur K M M 5 aureus 5 H influenzae (unpublished data) pneumniae pneumniae tuberculsis pneumniae CD 0... Q Q ' Q: 0 Z '- '" C ::l CD '" tjl

9 n 33 c ::l...c c[ --0 ::l CD c 3 ::l c' I» c' ::l r 1 CD c.. Q Q c' 0 Z '- '" c: :::> CD '" Table II: Micrbilgy f severe cmmunity acquired pneumnia requiring leu admissin Lcatin pneumphila N. f Frequency 7Rank rder f micrbial cause (%) patients Unknwn United Kingdm S pneumniae Leginefla spp Viruses Staph aureus Influenza A & B (4 studies) (mean %) Other parts 1148 S pneumniae Gram- negative Staph C pneumniae Leginella sp f Eurpe 7 enteric bacilli aureus (10 studies) (mean %) New Yrk S pneumniae Gram- negative Leginella sp H influenzae Staph aureus (all patients 75 enteric bacilli years f age r lder) Argentina S pneumniae C pneumniae Staph aureus M pneumniae Leginefla Singapre K. pneumniae H influenzae Staph aureus Burkhlderia S pneumniae pseudmallei Singapre Burkhlderia M tuberculsis Klebsiella spp Staph aureus M pneumniae pseudmallei '" 'I U'1

10 n Z --l Z C Z G) 3:: en n» r- en c n z U1 (Xl Table III: Micrbilgy f cmmunity acquired pneumnia in patients treated n an ambulatry basis Lcatin N. Of Frequency 7Rank rder f micrbial cause (%J patients Unknwn Lausanne M Influenza C Cxiel/a H influenzae pneumniae pneumniae virus pneumniae burnettii Finland M Chlamydiae Viruses H influenzae Mraxel/a pneumniae pneumniae catarrhalis Argentina M C Influenza A Cryptcccus H influenzae ('mild' CAP) pneumniae pneumniae pneumniae virus spp Nva Sctia M C M pneumniae C burnettii Influenza Other pneumniae pneumniae and A virus C pneumniae Bangkk 2O 98 C M 5 Leginel/a H influenzae - (n study n pneumniae pneumniae pneumniae pneumniae viral aetilgy) Q... 0 C 0 Z ' c: :::> CD

11 Cmmunity Acquired Pneumnia - A Malaysian Perspective Table IV: Cmmn causative rganisms in cmmunity acquired pneumnia accrding t site f care (severity) 1,8,12,13,15-29,32,33 Outpatient - Streptcccus pneumniae - Mycplasma pneumniae - Haemphilus influenzae - Chlamydia pneumniae - Mycbacterium tuberculsis - respiratry viruses (Influenza A and B, adenvirus, respiratry syncytial virus, parainfluenza) Nn-ICU inpatient - Streptcccus pneumniae - Mycplasma pneumniae - Chlamydia pneumniae - Haemphilus influenzae - Klebsiella pneumniae - Mycbacterium tuberculsis - Staphylcccus aureus - Burkhlderia pseudmallei - Leginella species - aspiratin (anaerbes) - respiratry viruses ICU Streptcccus pneumniae Leginella species Haemphilus influenzae Gram-negative bacilli (Pseudmnas aeruginsa, Klebsiella pneumniae) Staphylcccus aureus Burkhlderia pseudmallei Mycbacterium tuberculsis Table V: Prpsed initial empirical antibitic therapy f bacterial cmmunity acquired pneumnia in immuncmpetent adults accrding t the treatment setting Site f treatment Cmmn rganisms Preferred antibitic treatment ptins Out- Risk categry I Risk categry I Patient N c-mrbidity (a) N recent antibitic therapy (mild CAP) Shuld cver fr Macrlide (erythrmycin 500 mg QID x 10 Streptcccus pneumniae days, azithrmycin 500 mg 00 x 3 days, r Mycplasma pneumniae c1arithrmycin 500 mg BD x 10 days) (b) Recent antibitic therapy Advanced macrlide (azithrmycin r c1arithrmycin) plus either (i) high dse amxicillin r (ii) high dse amxiicillinc1avulate Or Antipneumcccal f1urquinlne alne (mxiflxacin 400 mg 00, gatiflxacin 400 mg 00 r levflxacin 50000) Risk categry II Presence f c-mrbidity As in risk categry I Haemphilus influenzae Risk categry II (a) N recent antibitic therapy Advanced macrlide Or Antipneumcccal f1urquinlne (b) Recent antibitic therapy Advanced macrlide plus either (i) high dse amxicillin r (ii) high dse amxiicillin-c1avulate r (iii)2nd generatin cephalsprin (cefurxime r cefprzil) Or Antipneumcccal f1urquinlne alne Med J Malaysia Vl 60 N 2 June

12 CONTINUING MEDICAL EDUCATION Site f treatment General ward (mderate CAP) ICU/high dependency unit (severe CAP) Cmmn rganisms Risk categry III Shuld cver fr As in risk categry I Klebsiella pneumniae Haemphilus influenzae Leginella Staphylcccus aureus Other Gram-negatve bacilli - Enterbacter - Escherichia cli penicillin-resistant Streptcccus pneumniae Risk categry IV Shuld cver fr As in risk categry I including PRSP Klebsiella pneumniae Haemphilus influenzae Leginella Pseudmnas aeruginsa Staphylcccus aureus Burkhlderia pseudmallei Preferred antibitic treatment ptins Risk categry III (a) N recent antibitic therapy Macrlide plus either (i) ceftriaxne 1 gm ad r (ii) cefurxime 750 mg TDS r (iii) -Iactam/-Iactamase inhibitr (amxicillin-c1avulanate r ampicillinsulbactam) Or Antipneumcccal f1urquinlne alne (b) Recent antibitic therapy same as in (a) (regimen selected depends n nature f recent antibitic therapy) Fr treatment f penicillin-resistant Streptcccus pneumniae refer t Table VIII Risk categry IV (a) Pseudmnas infectin is nt an issue (i) Ceftriaxne 1 gm BD r (ii) -Iactam/lactamase inhibitr plus either (i) macrlide r (ii) Antipneumcccal f1urquinlne (b) Pseudmnas infectin is an issue Either (I) an antipseudmnal agent (piperacillin, piperacillin-tazbactam, imipenem, merpenem r cefepime) plus ciprflxacin Or (II) An antipseudmnal agent plus aminglycside plus either (i) antipneumcccal flurquinlne r (ii) macrlide Clxacillin r vancmycin High dse ceftazidime Or Imipenem Fr treatment f penicillin-resistant Streptcccus pneumniae refer t Table VIII *Mycbacterium tuberculsis shuld be cnsidered in all risk categries OD = nce daily, BD = twice daily, TDS = thrice daily, OlD = fur times a day 260 Med J Malaysia Vl 60 N 2 June 2005

13 Cmmunity Acquired Pneumnia - A Malaysian Perspective Table VI: Cnditin Alchlism COPD and/r smking Nursing hme residency Pr dental hygiene Suspected large-vlume aspiratin Brnchiectasis Intravenus drug abuse Diabetes mellitus Epidemilgical cnditins related t specific pathgens 3 Cmmn encuntered pathgen(s) Streptcccus pneumniae and anaerbes Streptcccus pneumniae, Haemphilus influenzae, Mraxella catarrhalis, and Leginella species Streptcccus pneumniae, gram-negative bacilli, Haemphilus influenzae, Staphylcccus aureus, anaerbes and Chlamydia pneumniae Anaerbes Anaerbes, gram-negative enteric bacilli Pseudmnas aeruginsa, Pseudmnas cepacia, Staphylcccus aureus Staphylcccus aureus, anaerbes, Mycbacterium tuberculsis and Streptcccus pneumniae Mycbacterium tuberculsis, Bukhlderia pseudmallei Table VII: In-vitr activities f 6 antibitics against 92 strains f Streptcccus pneumniae islated frm patients in Malaysia 69 Antibitic MICs (mg/l) MIC90 Range f MICs Susceptible islates (%)* C-amxiclav Azithrmycin > Cefaclr >256 - Ceftriazne Cefurxime Penicillin 'Accrding t the fllwing MIC breakpints recmmended by the Natinal Cmmittee fr Clinical labratry Standards (NCClS): c-amxiclav, $,0.5/0.25 mg/l; azithrmycin, $,0.5 mg/l; ceftriazne, $,0.5 mg/l; cefurxime, $,0.5 mg/l; and penicillin, $,0.06 mg/l Table VIII: Antibitic ptins in the case f penicillin-resistant Streptcccus pneumniae Site f treatment Penicillin susceptibility Antibitic ptin Out-patient Penicillin-susceptible strains (MIC <2 fjg/ml) Oral amxicillin, cefurxime, cefprzil,. macrlide, r antipneumcccal f1urquinlne (mxiflxacin, gatiflxacin r levflxacin) General ward Intravenus benzylpenicillin 2 mega units 4 hurly,75 ampicillin 1 g 6 hurly, r ceftriaxne 1 nce daily ICU Penicillin-resistant Vancmycin, antipneumcccal strains (MIC;::2 fjg/ml) f1urquinlne r linezlid (high dse amxicillin 3 g/day shuld be effective fr strains with MIC 2-4 fjg/ml)76... Med J Malaysia Vl 60 N 2 June

14 CONTINUING MEDICAL EDUCATION 1. Task Frce n CAP, Philippine Practice Guidelines Grup in Infectius Diseases. Cmmunity-acquired pneumnia: clinical practice guideline. PPGG-ID Philippine Sciety fr Micrbilgy and Infectius Diseases. 1998; 1(2). 2. Heffelfinger ]D, Dwell SF, Jrgensen ]H, et al. Management f cmmunity-acquired pneumnia in the era f pneumcccal resistance: a reprt frm the drugresistant Streptcccus pneumniae Therapeutic Wrking Grup. Arch Intern Med 2000; 160: Bartlett ]G, Dwell SF, Mandell LA, File TM ]r, Musher DM, Fine M]. Guidelines frm the Infectius Diseases Sciety f America. Practice guidelines fr the management f cmmunity-acquired pneumnia in adults. Clin Infect Dis 2000; 31: Mandell LA, Bartlett ]G, Dwell SF, File TM ]r, Musher DM, Whitney C. Update f practice guidelines fr the management f cmmunity-acquired pneumnia in immuncmpetent adults. Clin Infect Dis 2003; 37: Mandell LA, Marrie T], Grssman RE, et al. Canadian guidelines fr the initial management f cmmunityacquired pneumnia: an evidence-based update by the Canadian Infectius Diseases Sciety and the Canadian Thracic Sciety. Clin Infect Dis 2000; 31: Niederman MS, Mandell LA, Anzuet A, et al. Guidelines fr the management f adults with cmmunity-acquired pneumnia. Am] Respir Crit Care Med 2001; 163: British Thracic Sciety. Guidelines fr the management f cmmunity-acquired pneumnia in adults. Thrax 2001; 56 (suppl 4): ivl Jkinen C, Heiskanen L, ]uvnen H, et al. Micrbial aetilgy f cmmunity-acquired pneumnia in the adult ppulatin f fur municipalities in eastern Finland. Clin Infect Dis 2001; 15: Dwell SF, Andersn L], Gary HE ]r, et al. Respiratry syncytial virus is an imprtant cause f cmmunityacquired lwer respiratry infectin amng hspitalized adults. ] Infect Dis 1996; 174: Marx A, Gary HE, ]r, Marstn B], et al. Parainfluenza virus infectin amng adults hspitalized fr lwer respiratry tract infectin. Clin Infect Dis 1999; 29: Peiris ]SM, Lai ST, Pn LLM, et al. Crnavirus as a pssible cause f severe acute respiratry syndrme. Lancet 2003; 361: Arancifia F, Bauer TT, Ewig S, et al. Cmmunity-acquired pneumnia due t gram-negative bacteria and Pseudmnas aeruginsa. Arch Intern Med 2002; 162: Ruiz-Gnzalez, A, Falguera, M, Ngues, A, et al Is Streptcccus pneumniae the leading cause f pneumnia f unknwn etilgy? A micrbilgic study f lung aspirates in cnsecutive patients with cmmunityacquired pneumnia. Am] Med 1999; 106: Fine M], Stne RA, Singer DE, et al. Prcesses and utcmes f care fr patients with cmmunity-acquired pneumnia: results frm the Pneumnia Patient Outcmes Research Team (PORT) chrt study. Arch Intern Med 1999; 159: Ishida T, Hashimt T, Arita M, It I, Osawa M. Etilgy f cmmunity-acquired pneumnia in hspitalized patients: a 3year prspective study in Japan. Chest 1998; 114: Miyashita N, Fukan H, Niki Y, Matsushima T, Okimt N. Etilgy f cmmunity-acquired pneumnia requiring hspitalizatin in Japan. Chest 2000; 119: W ]H, Kang ]M, Kim YS, et al. A prspective multicenter study f cmmunity-acquired pneumnia in adults with emphasis n bacterial etilgy. Krean ] Infect Dis 2001; 33: Chan CH, Chen M, Pang ]. A prspective study f cmmunity-acquired pneumnia in Hng Kng. Chest 1992; 101: Reechaipichitkul W, Tantiwng P. Clinical features f cmmunity-acquired pneumnia treated at Srinagarind Hspital, Khn Kaen, Thailand. Sutheast Asian] Trp Med Public Health 2002; 33: Wattanathum A, Chaprasng C, Nunthapisud P, et al. Cmmunity-acquired pneumnia in Sutheast Asia. Chest 2003; 123: Hui KP, Chin NK, Chw K, et al. Prspective study f the aetilgy f adult cmmunity acquired bacterial pneumnia needing hspitalisatin in Singapre. Singapre Med] 1993; 34: Liam CK, Lim KH, Wng CMM. Cmmunity acquired pneumnia in patients requiring hspitalisatin. Respirlgy 2001; 6: Hi LN, Li I, Ng A]. A study n cmmunity acquired pneumnia in adults requiring hspital admissin in Penang. Med] Malaysia 2001; 56: Med J Malaysia Vl 60 N 2 June 2005

15 Cmmunity Acquired Pneumnia - A Malaysian Perspective 24. Liam CK, Fauzi AAA, Wng CMM, Pang YK. (unpublished data) Cmmunity acquired pneumnia requiring hspitalizatin in a Malaysian ppulatin. PP6-07 In Abstract Bk f the 8th Asian Pacific Sciety f Respirlgy Cngress, 1-4 December 2003, Petaling ]aya, 1-4 December 2003; Ngew YF. Asian study n the rle f atypical pathgens in cmmunity acquired pneumnia. In Abstract Bk f the 8th Asian Pacific Sciety f Respirlgy Cngress, 1 4 December 2003, Petaling]aya, 1-4 December 2003; Luna CM, Famiglietti A, Absi R, Videla A], Ngueira F], Fuenzalida AD, Gene RJ. Cmmunity-acquired pneumnia: etilgy, epidemilgy, and utcme at a teaching hspital in Argentina.Chest. 2000; 118: EI Slh AA, Sikka P, Ramadan F, Davies J. Etilgy f severe pneumnia in the very elderly. Am] Respir Crit Care Med 2001; 163: Lee KH, Hui KP, Tan WC, Lim TK. Severe cmmunityacquired pneumnia in Singapre. Singapre Med] 1996; 37: Tan YK, Kh KL, Chin SP, Ong YY. Aetilgy and utcme f severe cmmunity-acquired pneumnia in Singapre. Eur Respir] 1998; 12: Vergis EN, Akbas E, Yu VL. Leginella as a cause f severe pneumnia. Seminars in Respir Crit Care Med 2000; 21: Yu VL, Pluffe ]F, Pastris MC, et al. Distributin f Leginella species and sergrups islated by culture in patients with spradic cmmunity-acquired leginellsis: an internatinal cllabrative survey. ] Infect Dis 2002; 186: Bchud PY, Mser F, Erard P, et al. Cmmunity-acquired pneumnia. A prspective utpatient study. Medicine 2001; 80: Marrie T], Peeling RW, Fine M], Singer DE, Cley CM, Kapr WN. Ambulatry patients with cmmunityacquired pneumnia: the frequency f atypical agents and clinical curse. Am] Med 1996; 101: Falguera M, Sacristan 0, Ngues A, et al. Nn-severe cmmunity-acquired pneumnia: crrelatin between cause and severity r cmrbidity. Arch Int Med 2001; 161: Riquelme R, Trres A, el-ebiary M, et al. Cmmunityacquired pneumnia in the elderly: clinical and nutritinal aspects. Am] Respir Crit Care Med 1997; 156: Rell ], Rdriguez R, ]ubert P, Alvarez B. Severe cmmunity-acquired pneumnia in the elderly: epidemilgy and prgnsis. Study Grup fr Severe Cmmunit-Acquired Pneumnia. Clin Infect Dis 1996; 23: Lieberman D, Lieberman D, Schlaeffer F, Prath A. Cmmunity-acquired pneumnia in ld age : a prspective study f 91 patients admitted frm hme. Age Aging 1997; 26: Mine P, Vercken ]B, Chevret S, et al. Severe cmmunityacquired pneumnia. Etilgy, epidemilgy, and prgnsis factrs. French Study Grup fr Cmmunity Acquired Pneumnia in the Intensive Care Unit. Chest 1994; 105: Trres A, Serra-Batlles ], Ferrer A, et al. Severe cmmunity-acquired pneumnia. Epidemilgy and prgnstic factrs. Am Rev Respir Dis 1991; 144: Fine M], Smith MA, Carsn CA, et al. Prgnsis and utcmes f patients with cmmunity-acquired pneumnia. ]AMA 1996; 275: Fine M], Auble TE, Yealy DM, et al. A predictin rule t identify lw-risk patients with cmmunity-acquired pneumnia. N Engl] Med 1997; 336: Lim WS, van der Ecrden MM, Laing R, et al. Defining cmmunity-acquired pneumnia severity n presentatin t hspital: an internatinal derivatin and validatin study. Thrax 2003; 58: Auble TE, Yealy DM, Fine MJ. Assessing prgnsis and selecting an initial site f care fr adults with cmmunityacquired pneumnia. Inf Disease Clin N America 1998; 12: Atlas S], Benzer TI, Brwsky LH, et al. Safely increasing the prprtin f patients with cmmunity-acquired pneumnia treated as utpatients: an interventinal trial. Arch Intern Med 1998; 158: Marras TK, Gutierrez C, Chan CK. Applying a predictin rule t identify lw-risk patients with cmmunityacquired pneumnia. Chest 2000; 118: Chan SS, Yuen EH, Kew ], Cheung WL, Ccks RA. Cm.munity-acquired pneumnia-implementatin f a predictin rule t guide selectin f patients fr utpatient treatment. Eur] Eur Med 2001; 8: Metlay ]P, Fine MJ. Testing strategies in the initial management f patients with cmmunity-acquired pneumnia. Ann Intern Med 2003; 138: Wdhead MA, Macfarlane ]T. American Thracic Sciety: Cmparative clinical and labratry features f leginella with pneumcccal and mycplasma pneumnias. Br] Dis Chest 1987; 81: Med J Malaysia Vl 60 N 2 June

16 CONTINUING MEDICAL EDUCATION 49. Farr BM, Kaiser DL, Harrisn BDW, Cnnlly CK. Predictin f micrbial aetilgy at admissin t hspital fr pneumnia frm the presenting clinical features. Thrax 1989; 44: Macfarlane JT, Miller AC, Rderick Smith WH, et al. Cmparative radigraphic features f cmmunityacquired leginnaires' disease, pneumcccal pneumnia, mycplasma pneumnia and psittacsis. Thrax 1984; 39: Waterer GW, Smes GW, Wunderink RG. Mntherapy may be subptimal fr severe pneumcccal pneumnia. Arch Intern Med 2001; 161: Gleasn PP, Meehan TP, Fine JM, Galusha DH, Fine MJ. Assciatins between initial antimicrbial therapy and medical utcmes fr hspitalized elderly patients with pneumnia. Arch Intern Med 1999; 159: Stahl JE, Barza M, Desjardin J, et al. Effect f macrlides as part f initial empiric therapy n length f stay in patients hspitalized with cmmunity-acquired pnuemnia. Arch.Intern. Med 1999; 159: Huck PM, MacLehse RF, Niederman MS, Lwery JK. Empiric antibitic therapy and mrtality amng medicare pneumnia inpatients in 10 western states. Chest 2001; 119: Mufsn MA, Stanek R]. Bacteriemic pneumcccal pneumnia in ne American city: a 20-year lngitudinal study, Am J Med 1999; 107: 34S-43S. 56. Dudas V, Hpefl A, Jacbs R, Guglielm B]. Antimicrbial selectin fr hspitalized patients with presumed cmmunity-acquired pneumnia: a survey f nnteaching US cmmunity hspitals. Ann Pharmacther 2000; 34: Guthrie R. Cmmunity-acquired lwer respiratry tract infectins, etilgy and treatment. Chest 2001; 120: Finch R, Schurmann D, Cllins 0, et al. Randmized cntrlled trial f sequential intravenus (Lv.) and ral mxiflxacin cmpared with sequential Lv. and ral camxiclav with r withut clarithrmycin in patients with cmmunity-acquired pneumnia requiring initial parenteral treatment. Antimicrb Agents Chemther 2002; 46: Davidsn R, Cavalcanti R, Bruntn J, et al. Resistance t levflxacin and failure f treatment f pneumcccal pneumnia. N Engl J Med 2002; 346: Bruggemann AB, Cffmann SL, Rhmberg P, et al. Flurquinlne resistance in Streptcccus pneumniae in United States since Antimicb Agents Chemther 2002; 46: Garau ]. Treatment f drug-resistant pneumcccal pneumnia. Lancet Infect Dis 2002; 2: Battleman DS, Callahan M, Thaler HT. Rapid antibitic delivery and apprpriate antibitic selectin reduce length f hspital stay f patients with cmmunityacquired pneumnia. Arch Intern Med 2002; 162: Meehan TP, Fine MJ, Krumhlz HM, et al. Quality f care, prcess, and utcmes in elderly patients with pneumnia. JAMA 1997; 278: Restrep MI, Jrgensen JH,Mrtensen EM, Anzuet A. Severe cmmunity-acquired pneumnia: current utcmes, epidemilgy, etilgy, and therapy. Curr Opin Infect Dis 2001; 14: Lery 0, Santre C, Beuscart C, et al. A five-year study f severe cmmunity-acquired pneumnia with emphasis n prgnsis in patients admitted t an intensive care unit. Intensive Care Med 1995; 21: Halm EA, Teirstein AS. Management f cmmunityacquired pneumnia. N Engl J Med 2002; 347: Rhew DC, Hackner D, Hendersn L, Ellrdt AG, Weingarten SR. The clinical benefit f in-hspital bservatin in 'lw risk' pneumnia patients after parenteral t ral antimicrbial therapy. Chest 1998; 113: Dunn AS, Petersn KL, Schechter CB, Rabit P, Gtlin AD, Smith LG. The utility f an in-hspital bservatin perid after discntinuing intravenus antibitics. Am J Med 1999; 106: Rhani MY, Parasakthi N, Raudzah A, Yasim MY. In-vitr susceptibilities f Streptcccus pneumniae strains islated in Malaysia t six antibitics. J Antimicrb Chemther 1999; 44: Campbell GD Jr, Silberman R. Drug-resistant Streptcccus pneumniae. Clin Infect Dis 1998; 26: Clav-Sanchez AJ, Girn-Gnzalez JA, Lpez-Priet D, et al. Multivariate analysis f risk factrs fr infectin due t penicillin-resistant and multidrug resistant Streptcccus pneumniae: a multicenter study. Clin Infect Dis 1997; 24: Ewig S Ruiz M, Trres A, et al. Pneumnia acquired in the cmmunity thrugh drug-resistant Streptcccus pneumniae. Am J Respir Crit Care Med 1999; 159: Med J Malaysia Vl 60 N 2 June 2005

17 Cmmunity Acquired Pneumnia - A Malaysian Perspective 73. Craig WA. Pharmackinetic/pharmacdynamic parameters: ratinale fr antibacterial dsing f mice and men. Clin Infect Dis 1998; 26: Harwell JI, Brwn RE. The drug-resistant pneumcccus: clinical relevance, therapy, and preventin. Chest 2000; 117: Friedland IR, McCracken GH. Management f infectin caused by antibitic-resisatnt Streptcccus pneumniae. N Engl J Med 1994 ; 331: File TM Jr. Cmmunity-acquired pneumnia. Lancet 2003; 362: Med J Malaysia Vl 60 N 2 June

18 CONTINUING MEDICAL EDUCATION MCQs n Cmmunity Acquired Pneumnia - A Malaysian Perspective 1. The fllwing statements n the micrbial aetilgy fcmmunity acquired pneumnia are true: a. In 'real wrld' practice the aetilgical micrrganism is identified in mre than 50% f cases. b. Streptcccus pneumniae is the mst cmmnly identified causative rganism. c. Mycplasma pneumniae is mre frequently identified in yunger patients withut cmrbitiy. d. Burkhlderia pseudmallei shuld be cnsidered a pssible causative rganism in rural Sutheast Asia particularly if the patient has diabetes mellitus. e. There is a lw incidence f Leginella pneumnia in studies cnducted in Asian cuntries. 2. The fllwing statements n cmmunity acquired pneumnia are true: a. Infectin due t Mycbacterium tuberculsis may present as cmmunity acquired pneumnia in Malaysia. b. Culture f expectrated sputum is a reliable test fr identificatin f the causative rganism. c. Recent findings shw that less than 5% f Haemphilus influenzae islates in Malaysia are -lactamase prducing. d. Bld cultures are psitive in 40% r mre f cases. e. Sme Streptcccus pneumniae strains are resistant t penicillins thrugh the prductin f -lactamase. 3. The fllwing f"mdings in patients with pneumnia indicate that the stated rganism is def"mitely the aetilgical agent: a. Bld culture psitive fr Streptcccus pneumniae. b. Presence f Leginella pneumphila sergrup 1 antigen in the urine. c. Sputum culture yields mderate grwth f Haemphilus influenzae. d. A furfld rise in IgM antibdy titre t Mycplasma pneumniae. e. Islatin f Pseudmnas aeruginsa frm pleural fluid cllected frm chest drain. 4. The fllwing statements n the treatment f cmmunity acquired pneumnia are true: a. The newer flurquinlnes are effective against Streptcccus pneumniae. b. Antipseudmnal third generatin cephalsprins are the antibitic f chice in the treatment f mst cases f cmmunity acquired pneumnia. c. The antibitic f chice in the empirical treatment f Mycplasma pneumnia is a flurquinlne. d. Pneumnia due t aspiratin f rpharyngeal cntents can be effectively treated with penicillin. e. Metrnidazle prvides excellent cverage fr Gram-psitive anaerbes. 5. The fllwing statements n the utcme fcmmunity acquired pneumnia treatment are true: a. Antibitic therapy that cvers fr bth Streptcccuspneumniae and atypical pathgens in hspitalised patients results in mre favurable utcmes. b. Mrtality is higher in elderly patients. c. High-level penicillin resistance is assciated with increased mrtality in Streptcccus pneumniae pneumnia d. Failure t identify a pathgen in patients with severe CAP has been assciated with a wrse utcme than if a pathgen is identified. e. The implementatin f treatment guidelines has been shwn t reduce mrtality and health care csts. 266 Med J Malaysia Vl 60 N 2 June 2005