Session: How to manage and prevent the different faces of pneumonia Severe CAP
|
|
- Geoffrey Whitehead
- 6 years ago
- Views:
Transcription
1 Athens 19, 20 November 2015 Garyfallia Poulakou Consultant, Infectious Diseases 4 th Department of Internal Medicine, Attikon University Hospital of Athens Session: How to manage and prevent the different faces of pneumonia Severe CAP
2 TRANSPARENCY DECLARATION No conflicts of interest related to this presentation
3 Definition and incidence of scap CAP is defined as An acute illness with clinical features of lower respiratory tract infection, presenting with radiological infiltrations and no other explanation of the infection For scap there is not universally accepted definition CAP that requires ICU admission (scap) represents 10 % of patients hospitalized with CAP, with an incidence that increases in recent years Woodhead M et al, Crit Care. 2006;10(2):S1 Mandell et al, Clin Infect Dis 2007; 44(S2): S27 72
4 CAP: a disease with important consequences CAP is the leading cause of morbidity and mortality from infectious diseases in developed countries It affects more than 5 million adults and accounts for more than 1 million admissions each year in the United States Despite effective antibiotic therapy, about 12 36% patients admitted to the Intensive Care Unit (ICU) with severe CAP die within a short period of time Murray CJ Lancet 1997;349: Jemal J, JAMA 2005;294: Fine M, JAMA 1996;275:134 41
5 scap is on the rise Data from 17,869 cases in UK: registered in the ICNARC Case Mix Programme Database While scap represents a small proportion of all ICU admissions, there is a progressive rise in the number of admissions with time (128%) Overall mortality (50% survive to exit hospital) remains high, especially in those admitted later in their hospital stay Woodhead H et al, Crit Care. 2006;10(2):S1
6 Mortality of scap: stable, worsening or decreasing over time? The UK database: stability ~30% ICU mortality The CAPUCI I ( ) and II ( ) studies from Spain and European centers show a significantly decrease in mortality The CAPO International cohort shows increase CAPO Study In-hospital mortality percentage and 95% confidence interval CAPUCI Studies Cavallazzi R, Respiratory Medicine (2015) 109, 743e750 Woodhead H et al, Crit Care. 2006;10(2):S1, Gattarello S, Crit Care Sep 10;19:335
7 scap is a progressive disease and the most common cause of sepsis and septic shock worldwide Infection Local extension LRTI Mild CAP Systemic inflammatory response Hypercoagulation Acute organ dysfunction Hypotension Hypoperfusion Sepsis Severe sepsis Pulmonary spread Multiorgan dysfunction Acute respiratory failure Hypotension non responsive to fluid resuscitation Ewig et al, Eur R J 2006 Beal et al, JAMA 1994 Septic shock Nystrom et al, JAC 1998 Rello J, Crit Care 2008
8 Why pneumonia remains a lethal condition? Pathogen s inherent toxicity Antimicrobial resistance Viral coinfections? Antibiotic development Most hospital deaths occur after eradication of bacteria Pathogen Bordon J, Chest. 2010;138: Iwashyna TJ, JAMA. 2010;304: Yende S, Am J Respir Crit Care Med. 2008;177: Inflammation Continuing excess mortality for more than 2 years after surviving an episode of CAP Long term impaired functional status Long term neurologic, cardiovascular, cognitive, endocrine consequences Johnstone, Medicine. 2008;87: Waterer GW, Am J Respir Crit Care Med. 2004;169:910 4
9 IDSA / ATS Criteria for ICU admission Major criteria (1 or more) Delayed ICU transfer for Invasive mechanical ventilation respiratory arrest or shock is Septic shock with the need for vasopressors associated with fold Minor criteria (3 or more) increased risk for hospital Respiratory rate 30 breaths/min PaO2/FiO2 250 mortality compared with direct Multilobar infiltrates admission from the emergency Confusion-disorientation department Uremia (BUN level 20 mg/dl) Leucopenia (WBC count <4 109/L) Thrombocytopenia (platelet count < /L) Hypothermia (core temperature <36 C) vhypotension (SBP <90 mmhg) requiring aggressive fluid resuscitation Renaud B, Crit CareMed. 2009;37: Restreppo MI, Chest. 2010;137:552 7 Leroy O, Intensive Care Med. 1995;21(1):24 31.
10 PSI for admission decisions in CAP DEMOGRAPHICS Age Gender Nursing home COMORBIDITIES Neoplasia Liver Disease CHF Cerebrovascular disease Renal Disease PHYSICAL EXAM Mental confusion Respiratory Rate SBP Heart Rate Temperature LABORATORY/ IMAGING BUN,Glucose Sodium, Hematocrit Pleural effusion Arterial Ph Oxygenation Risk Class Mortality Admission recommendation I 0.1 Outpatient II 0.6 Outpatient III 2.8 Outpatient or Brief Inpatient IV 8.2 Inpatient V 29.2 Inpatient Woodhead Eur R J 2005 Fine, NEJM 1997 Restrepo and Anzueto Curr Opin Infect Dis 2006
11 CURB 65 for admission decisions in CAP C onfusion U rea (>7mmol/L) R espiratory rate 30/min B P (SBP 90mmHg or DBP 60mmHg 65 (Age 65 years) 1 point each McFarlane et al, Thorax 2001; 56(S IV): 1 96 Score/ Risk Class Mortality Outpatient Outpatient Admission recommendation Short Hospital stay/supervised outpatient Hospital, assess for ICU admission 4 40 Hospital, assess for ICU admission 5 57 Hospital, assess for ICU admission
12 Comparison of PSI and CURB 65 PSI Well validated Reduces admissions and costs Rather complex to calculate Not based on severity of disease Age bias against young without comorbidities CURB 65 Easy to remember Easy to calculate Disease severity; no comorbidities BUN? Underestimates risk in elderly with comorbidities Mandell et al, Clin Infect Dis 2007; 44(S2): S27 72 Woodhead Eur R J 2005, Rello J Crit Care 2009
13 Adapted PIRO score for scap The PIRO concept Analogy to the TNM cancer classification P redisposition I nfection R esponse O rgan dysfunction Rello J, et al, Crit Care Med Rello J et al, Eur Respir J. 2006;27: Opal S, Pediatr Crit Care Med. 2005;6(suppl):S55 S60
14 PIRO score for community acquired pneumonia: results fro the CAPUCI I study Rello J et al, Critical Care Medicine 2009; 37(2): Twenty eight day mortality rate according PIRO score Length of stay (LOS) in intensive care unit (ICU) and mechanical ventilation (MV) days on survivors according to PIRO score
15 The SMART COP score A tool developed in the Australian CAP Study for the prediction of which patients will require intensive respiratory or vasopressors support. Systolic blood pressure, Multilobar chest radiography, low Albumin levels, Respiratory rate (age adjusted), Tachycardia, Confusion, low Oxygen (age adjusted), and arterial ph (<7.35) Charles PG, Clin Infect Dis 2008;47(3):375-84
16 Newly introduced scores aiming to predict ICU referral The SCAP score Variables of the score grouped in six minor criteria (confusion, urea >30 mg/dl, respiratory rate >30/ min, multilobar bilateral infiltrates, PaO2 <54 mmhg or PaO2/FiO2 <250 and age >80 years) and two major criteria (arterial ph <7.35 or systolic blood pressure <90 mmhg) At least, two minor criteria or one major criterion predicted SCAP with sensitivity of 84% and specificity of 60% The REA ICU index 11 criteria : male gender, age <80 years, comorbid conditions, respiratory rate >30 breaths/min, heart rate >125 beats/min, multilobar infiltrate or pleural effusion, WBC <3 or >20 G/l, hypoxemia [SO2 <90% or PaO2<60 mmhg], blood urea nitrogen >11 mmol/l, ph < 7.35 and Na<130 meq/l. Espan a PP, J Infect 2010;60(2): Renaud et al Crit Care Med 2009;37(11):
17 Microbiology of scap Streptococcus pneumoniae* Legionella pneumophila* Haemophilus influenza Klebsiella pneumoniae Viral infections (up to 1/3) Mixed infections (up to 20%) Anaerobes Pseudomonas aeruginosa* Neuhaus and Ewig, Med Clin North Am. 2001;85: Rello et al Chest. 2003;123: Liapikou and Torres 2014 Alcoholics Account for 85% of CAP causes 2/3 of deaths are attributed to pneumococcus * Lethal pathogens Risk factors Severe COPD with frequent hospitalizations, Bronchiectasis, Cystic fibrosis, Those taking antibiotics for a long time(>10 mg for >1 month) Immunosuppressed patients (HIV, corticosteroid therapy, malnutrition)
18 Antibiotic treatment in scap Speed matters Antimicrobial treatment for scap remains largely empirical, targeting the most likely pathogens Before the initiation of antibiotics, at least two samples of blood cultures should be obtained, one intravenous and the other from a vascular catheter Total duration of 7 10 days Woodhead CMI 2011
19 Recommended treatment for scap Patients without pseudomonal risk: an intravenous β lactam plus either a macrolide or a respiratory fluoroquinolone Patients with pseudomonas risk: an antipseudomonal β lactam combined with either levofloxacin or ciprofloxacin or the antipseudomonal β lactam can be combined with both an aminoglycoside and either azithromycin or a respiratory quinolone Anaerobic coverage (a cephalosporin with clindamycin) is indicated only in patients with a risk for aspiration, such as alcoholism, loss of consciousness and oropharyngeal dysphagia due to neurological disease Mandell LA, et al Clin InfectDis. 2007;44 Suppl 2:S27 72 Woodhead et al, Clin Microbiol Infect. 2011;17(6):E1 59
20 Combination treatments and the role of macrolides From several studies, it has been reported that the benefit of combination therapy in patients with SCAP and septic shock is seen only when a macrolide is part of the regimen This effect is probably attributed to the anti inflammatory properties of macrolides In one US study of patients with Pneumonia Severity Index class V, quinolone monotherapy had twice as high a mortality as the use of a b lactam/macrolide combination Eur Respir J 2009;33(1): 153-9, Intensive Care Med 2010;36(4): Am J Respir Crit Care Med 2004;170(4): Antimicrob Agents Chemother 2007;51(11):
21 13 studies 5 prospective 7 included ICU patients O Brien E et al, Respir Investigation 2015
22 Combined therapy provided a survival benefit in CAPUCI study Gatarello S et al, Chest 2014 Jul 1;146(1):22e31
23 Early initiation of treatment was associated with a survival benefit in the CAPUCI study Gatarello S et al, Chest 2014 Jul 1;146(1):22e31
24 Combination therapy is associated with better survival in scap: CAPUCI study, non pneumococcal scap Gattarello S et al Crit Care 2015 Courtesy S. Gattarello and J. Rello
25 Prompt administration of antibiotics is associated with better survival curves : CAPUCI study, non pneumococcal scap Gattarello S et al Crit Care 2015
26 Biomarkers as tools for treatment duration and prognosis in scap The SCC and ESCMID guidelines now include the use of biomarkers, especially PCT, to assist in decisions regarding discontinuation of empiric antibiotics (grade 2C). The largest randomized trial published to date reported that a PCT guided strategy to treat suspected bacterial infections could reduce antibiotic exposure Moreover, PCT kinetics could be a tool for assessing the evolution of severe sepsis and septic shock In their study, Schuetz and colleagues concluded that for ICU and inhospital mortality, a 72 h PCT decrease >80% had a negative predictive value of 91%, and no decrease or an increase in PCT over 72 h had a positive predictive value of 48%. Bouadma L et al, Lancet 2010;375(9713): Schuez P et al, Care 2013;17(3):R115
27 Corticosteroids in scap For patients with scap, risk assessment should take into consideration patients with severe chronic obstructive pulmonary disease and asthma that may have received intermittent treatment with steroids before their septic episode, and, therefore, have iatrogenic adrenal insufficiency, needing steroid replacement Mandel L, Clin Infect Dis 2007; 44(S2); S27 72
28 Author / year Confalonieri et al./ 2005 Mikami et al./ 2007 (open label) Snijders et al./ 2010 Fernandez Serrano/ 2011 Sabry et al. / 2011 Meijvis et al./ 2011 Torres et al/ 2015 Blum et al/ 2015 SUMMARY OF RANDOMISED CONTROLLED TRIALS OF CORTICOSTEROIDS IN CAP Adapted from Sibila O, Minerva Anestesiol 2014;80: No patients Disease 48 CAP requiring ICU 31 Hospitalized CAP 213 Hospitalized CAP 56 Hospitalized CAP 80 Hospitalized CAP 304 Hospitalized CAP 112 scap and high inflammatory response Type of corticosteroid, dosage Hydrocortisone, 240 mg/d Duration of treatment Main outcome 7 days Decrease mortality Prednisolone 40 mg/d 3 days Early stabilization vital signs Prednisolone 40 mg/d 7 days Increase late failure Methylprednisolone, 620 mg 9 days Gradual withdrawal Decrease length of stay Hydrocortisone 300 mg/d 7 days Decreased duration of mechanical ventilation Dexamethasone 5 mg/d 4 days Reduced length of stay Hyperglycemia 0.5 mg/kg per 12 hours of methylprednisolone 5 days Decreased treatment failure 785 Mild and scap Prednisone 50 mg daily 7 days Shorter median time to clinical stability Hyperglycemia
29 Results of the most recent meta analysis (10 eligible RCTs comprising 1780 cases) (i) corticosteroids shorten length of hospital stay for CAP, (ii) corticosteroids shorten length to clinical stability for CAP, and (iii) corticosteroids lower mortality for severe CAP Horita N et al, Sci Rep Sep 16;5:14061.
30 According to the most recent meta analysis corticosteroids lower mortality for severe CAP The incidence of major complications was not greatly increased Horita N et al, Sci Rep Sep 16;5:14061.
31 A large scale observational study from Japan Low dose* corticosteroid use may be associated with reduced 28 day mortality in patients with septic shock complicating CAP *[defined as intravenous infusion of methylprednisolone mg kg 1 day 1 (or an equivalent dose of dexamethasone, hydrocortisone, prednisolone or betamethasone)] Tagami T, Eur Respir J 2015; 45:
32 Conclusions Despite the advent of new antibiotics and better treatment modalities in the ICU, scap still carries a significant mortality The use of severity scores to guide ICU admission remains a priority, because delayed ICU admission is associated with higher mortality; however still do not have the ideal score for this purpose Clinical experience and judgment should not be underestimated in this setting Early administration of combination antibiotic treatment represents a milestone in the management of scap; the combination of a β lactam plus a macrolide showed survival benefits in the recent literature Although several RCTs have been performed in the last years with promising results, the use of corticosteroids in CAP remains controversial in clinical practice Patients with severe CAP, septic shock and a high inflammatory response could be the most likely to benefit of adjuvant corticosteroid treatment
33 Thank you for your attention Athena, the ancient Greek Goddess of wisdom and justice
Pneumonia Community-Acquired Healthcare-Associated
Pneumonia Community-Acquired Healthcare-Associated Edwin Yu Clin Infect Dis 2007;44(S2):27-72 Am J Respir Crit Care Med 2005; 171:388-416 IDSA / ATS Guidelines Microbiology Principles and Practice of Infectious
More informationPneumonia in the Hospitalized
Pneumonia in the Hospitalized Patient: Use of Steroids Nicolette Myers, MD Pulmonary/Sleep/Critical Care November 9, 2018 Park Nicollet Clinic Facts About Pneumonia CAP is the 8 th most common cause of
More informationPneumonia Severity Scores:
Pneumonia Severity Scores: Are they Accurate Predictors of Mortality? JILL McEWEN, MD FRCPC Clinical Professor Department of Emergency Medicine University of British Columbia Vancouver, BC Canada President,
More informationCommunity-Acquired Pneumonia OBSOLETE 2
Community-Acquired Pneumonia OBSOLETE 2 Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate
More informationCorticosteroids in Severe CAP. Mervyn Mer Department of Medicine & ICU Johannesburg Hospital University of the Witwatersrand
Corticosteroids in Severe CAP Mervyn Mer Department of Medicine & ICU Johannesburg Hospital University of the Witwatersrand Introduction Much controversy and debate regarding the use of corticosteroids
More informationRepeated Pneumonia Severity Index Measurement After Admission Increases its Predictive Value for Mortality in Severe Community-acquired Pneumonia
ORIGINAL ARTICLE Repeated Pneumonia Severity Index Measurement After Admission Increases its Predictive Value for Mortality in Severe Community-acquired Pneumonia Chiung-Zuei Chen, 1 Po-Sheng Fan, 2 Chien-Chung
More informationCare Guideline DRAFT for review cycle 08/02/17 CARE OF THE ADULT PNEUMONIA PATIENT
Care Guideline DRAFT for review cycle 08/02/17 CARE OF THE ADULT PNEUMONIA PATIENT Target Audience: All MHS employed providers within Primary Care, Urgent Care, and In-Hospital Care. The secondary audience
More informationUPDATE IN HOSPITAL MEDICINE
UPDATE IN HOSPITAL MEDICINE FLORIDA CHAPTER ACP MEETING 2016 Himangi Kaushal, M.D., F.A.C.P. Program Director Memorial Healthcare System Internal Medicine Residency DISCLOSURES None OBJECTIVES Review some
More informationCharles Krasner, M.D. University of NV, Reno School of Medicine Sierra NV Veterans Affairs Medical Center
Charles Krasner, M.D. University of NV, Reno School of Medicine Sierra NV Veterans Affairs Medical Center Kathy Peters is a 63 y.o. patient that presents to your urgent care office today with a history
More informationSupplementary Appendix
Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for
More informationCARE OF THE ADULT PNEUMONIA PATIENT
Care Guideline CARE OF THE ADULT PNEUMONIA PATIENT Target Audience: The target audience for this Care Guideline is all MultiCare providers and staff, including those associated with our clinically integrated
More informationCommunity Acquired & Nosocomial Pneumonias
Community Acquired & Nosocomial Pneumonias IDSA/ATS 2007 & 2016 Guidelines José Luis González, MD Clinical Assistant Professor of Medicine Outline Intro - Definitions & Diagnosing CAP treatment VAP & HAP
More informationKAISER PERMANENTE OHIO COMMUNITY ACQUIRED PNEUMONIA
KAISER PERMANENTE OHIO COMMUNITY ACQUIRED PNEUMONIA Methodology: Expert opinion Issue Date: 8-97 Champion: Pulmonary Medicine Most Recent Update: 6-08, 7-10, 7-12 Key Stakeholders: Pulmonary Medicine,
More informationPolmoniti: Steroidi sì, no, quando. Alfredo Chetta Clinica Pneumologica Università degli Studi di Parma
Polmoniti: Steroidi sì, no, quando Alfredo Chetta Clinica Pneumologica Università degli Studi di Parma Number of patients Epidemiology and outcome of severe pneumococcal pneumonia admitted to intensive
More informationPneumonia. Dr. Rami M Adil Al-Hayali Assistant professor in medicine
Pneumonia Dr. Rami M Adil Al-Hayali Assistant professor in medicine Definition Pneumonia is an acute respiratory illness caused by an infection of the lung parenchyma, associated with recently developed
More informationAntimicrobial Stewardship in Community Acquired Pneumonia
Antimicrobial Stewardship in Community Acquired Pneumonia Medicine Review Course 2018 Dr Lee Tau Hong Consultant Department of Infectious Diseases National Centre for Infectious Diseases Scope 1. Diagnosis
More informationA Comparative Study of Community-Acquired Pneumonia Patients Admitted to the Ward and the ICU*
CHEST Original Research A Comparative Study of Community-Acquired Pneumonia Patients Admitted to the Ward and the ICU* Marcos I. Restrepo, MD, MSc, FCCP; Eric M. Mortensen, MD, MSc; Jose A. Velez, MD;
More informationMAJOR ARTICLE. (See the editorial commentary by Mandell on pages 386 8)
MAJOR ARTICLE Severe Community-Acquired Pneumonia: Validation of the Infectious Diseases Society of America/ American Thoracic Society Guidelines to Predict an Intensive Care Unit Admission Adamantia Liapikou,
More informationCommunity Acquired Pneumonia. Abdullah Alharbi, MD, FCCP
Community Acquired Pneumonia Abdullah Alharbi, MD, FCCP A 68 y/ male presented to the ED with SOB and productive coughing for 2 days. Reports poor oral intake since onset due to nausea and intermittent
More informationWORKSHOP. The Multiple Facets of CAP. Community acquired pneumonia (CAP) continues. Jennifer s Situation
Practical Pointers pointers For for Your your Practice practice The Multiple Facets of CAP Dr. George Fox, MD, MSc, FRCPC, FCCP Community acquired pneumonia (CAP) continues to be a significant health burden
More informationCommunity Acquired Pneumonia: Measures to Improve Management and Healthcare Quality
Community Acquired Pneumonia: Measures to Improve Management and Healthcare Quality Gonzalo Bearman MD, MPH Assistant Professor of Internal Medicine Divisions of Quality Health Care & Infectious Diseases
More informationHow do we define pneumonia?
Robert L. Keith MD FCCP Associate Professor of Medicine Division of Pulmonary Sciences & Critical Care Medicine Denver VA Medical Center University of Colorado Denver How do we define pneumonia? Fever
More informationSupplementary appendix
Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Blum CA, Nigro N, Briel M, et al. Adjunct prednisone
More informationBack to the Future: Updated Guidelines for Evaluation and Management of Adrenal Insufficiency in the Critically Ill
Back to the Future: Updated Guidelines for Evaluation and Management of Adrenal Insufficiency in the Critically Ill Joe Palumbo PGY-2 Critical Care Pharmacy Resident Buffalo General Medical Center Disclosures
More informationSepsis is an important issue. Clinician s decision-making capability. Guideline recommendations
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 Clinicians decision-making capability Guideline recommendations Sepsis is an important issue 8.7%
More informationValidation and clinical implications of the IDSA/ATS minor criteria for severe community-acquired pneumonia
1 Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore; 2 Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore,
More informationSepsis new definitions of sepsis and septic shock and Novelities in sepsis treatment
Sepsis new definitions of sepsis and septic shock and Novelities in sepsis treatment What is sepsis? Life-threatening organ dysfunction caused by a dysregulated host response to infection A 1991 consensus
More informationBrice Taylor Assistant Professor Division of Pulmonary and Critical Care Medicine
Brice Taylor Assistant Professor Division of Pulmonary and Critical Care Medicine Discuss advances in predicting prognosis Understand dwhat we know (and don t know) about the Microbiology Recognize important
More informationCommunity-Acquired Pneumonia. Lisa G. Winston, MD University of California, San Francisco San Francisco General Hospital. Nothing to disclose.
Community-Acquired Pneumonia Lisa G. Winston, MD University of California, San Francisco San Francisco General Hospital Nothing to disclose. Community-Acquired Pneumonia Talk will focus on adults Guideline
More informationAcute Respiratory Infection. Dr Anthony Gibson
Acute Respiratory Infection Dr Anthony Gibson Range of Conditions Upper tract Common Cold coryza Sore Throat- Pharyngitis Sinusitis Epiglottitis Range of Conditions Lower Acute Bronchitis Acute Exacerbation
More informationThe IDSA/ATS consensus guidelines on the management of CAP in adults
The IDSA/ATS consensus guidelines on the management of CAP in adults F. Piffer F. Tardini R. Cosentini U.O. Medicina d'urgenza, Gruppo NIV, Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina
More informationSepsis: Identification and Management in an Acute Care Setting
Sepsis: Identification and Management in an Acute Care Setting Dr. Barbara M. Mills DNP Director Rapid Response Team/ Code Resuscitation Stony Brook University Medical Center SEPSIS LECTURE NPA 2018 OBJECTIVES
More informationSeptic Shock. Rontgene M. Solante, MD, FPCP,FPSMID
Septic Shock Rontgene M. Solante, MD, FPCP,FPSMID Learning Objectives Identify situations wherein high or low BP are hemodynamically significant Recognize complications arising from BP emergencies Manage
More informationUse of surrogate inflammatory markers in the diagnosis & monitoring of patients with severe sepsis
Thursday 11 th June 2015 Use of surrogate inflammatory markers in the diagnosis & monitoring of patients with severe sepsis Dr Duncan Wyncoll Guy s & St Thomas NHS Trust, London Conflicts of Interest In
More informationSupplementary Online Content
Supplementary Online Content Uranga A, España, Bilbao A, et al. Duration of antibiotic treatment in communityacquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. ublished online
More informationSimplification of the IDSA/ATS criteria for severe CAP using meta-analysis and observational data
ORIGINAL ARTICLE RESPIRATORY INFECTIONS Simplification of the IDSA/ATS criteria for severe CAP using meta-analysis and observational data Waleed Salih, Stuart Schembri and James D. Chalmers Affiliations:
More informationPNEUMONIA. Patient Case: Chief Complaint: I have been short of breath and have been coughing up rust-colored phlegm for the past 3 days.
PNEUMONIA Relevant Guidelines: 2008 IDSA CAP guidelines: http://www.idsociety.org/guidelines/patient_care/idsa_practice_guidelines/infections_by_org an_system/lower/upper_respiratory/community-acquired_pneumonia_(cap)/
More informationK L Buising, K A Thursky, J F Black, L MacGregor, A C Street, M P Kennedy, G V Brown...
419 RESPIRATORY INFECTION A prospective comparison of severity scores for identifying patients with severe community acquired pneumonia: reconsidering what is meant by severe pneumonia K L Buising, K A
More informationSubclinical Problems in the ICU:
Subclinical Problems in the ICU: Corticosteroid Insufficiency C. S. Cutillar, M.D., FPCP, FPSEM Associate Professor Cebu Institute of Medicine H-P-A Axis during Critical Illness CRH ACTH H-P-A Axis during
More informationPULMONARY EMERGENCIES
EMERGENCIES I. Pneumonia A. Bacterial Pneumonia (most common cause of a focal infiltrate) 1. Epidemiology a. Accounts for up to 10% of hospital admissions in the U.S. b. Most pneumonias are the result
More informationSepsis Early Recognition and Management. Therese Hughes, PhD, MPA, RN
Sepsis Early Recognition and Management Therese Hughes, PhD, MPA, RN 1 Sepsis a Deadly Progression Affects millions around the world each year, killing one in four Contributes to approximately 50% of all
More informationCommunity Acquired Pneumonia. Background & Rationale to North American Guidelines. Lionel Mandell MD FRCPC Brussels Belgium
Community Acquired Pneumonia Background & Rationale to North American Guidelines Lionel Mandell MD FRCPC Brussels Belgium Consider Impact of the disease Issues to reflect upon Impact of the Disease 3-4
More informationAndrea Blotsky MDCM FRCPC General Internal Medicine, McGill University Thursday, October 15, 2015
The TIMES Project: (Time to Initiation of Antibiotic Therapy in Medical Patients Presenting to the Emergency Department with Sepsis) - Preliminary Findings Andrea Blotsky MDCM FRCPC General Internal Medicine,
More informationSteroids in Community-Acquired Pneumonia: Should the Idea be Suppressed or Standard of Care?
Steroids in Community-Acquired Pneumonia: Should the Idea be Suppressed or Standard of Care? http://www.drugs.com/health-guide/pneumonia.html 1 Emily Brysch, Pharm.D. PGY-1 Pharmacotherapy Resident Controversies
More informationInitial Resuscitation of Sepsis & Septic Shock
Initial Resuscitation of Sepsis & Septic Shock Dr. Fatema Ahmed MD (Critical Care Medicine) FCPS (Medicine) Associate professor Dept. of Critical Care Medicine BIRDEM General Hospital Is Sepsis a known
More informationSupplementary Online Content
Supplementary Online Content Torres A, Sibila O, Ferrer M, et al. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory
More informationHospital-acquired Pneumonia
Hospital-acquired Pneumonia Hospital-acquired pneumonia (HAP) Pneumonia that occurs at least 2 days after hospital admission. The second most common and the leading cause of death due to hospital-acquired
More informationUnderstand the scope of sepsis morbidity and mortality Identify risk factors that predispose a patient to development of sepsis Define and know the
Understand the scope of sepsis morbidity and mortality Identify risk factors that predispose a patient to development of sepsis Define and know the differences between sepsis, severe sepsis and septic
More informationKey Points. Angus DC: Crit Care Med 29:1303, 2001
Sepsis Key Points Sepsis is the combination of a known or suspected infection and an accompanying systemic inflammatory response (SIRS) Severe sepsis is sepsis with acute dysfunction of one or more organ
More informationWeight of the IDSA/ATS minor criteria for severe community-acquired pneumonia *
Respiratory Medicine (2011) 105, 1543e1549 available at www.sciencedirect.com journal homepage: www.elsevier.com/locate/rmed Weight of the IDSA/ATS minor criteria for severe community-acquired pneumonia
More informationMDR AGENTS: RISK FACTORS AND THERAPEUTIC STRATEGIES
MDR AGENTS: RISK FACTORS AND THERAPEUTIC STRATEGIES 1 Marin H. Kollef, MD Professor of Medicine Virginia E. and Sam J. Golman Chair in Respiratory Intensive Care Medicine Washington University School of
More informationImpact of pre-hospital antibiotic use on community-acquired pneumonia
ORIGINAL ARTICLE INFECTIOUS DISEASE Impact of antibiotic use on community-acquired pneumonia A. F. Simonetti 1, D. Viasus 1,2, C. Garcia-Vidal 1,2, S. Grillo 1, L. Molero 1, J. Dorca 3,4 and J. Carratala
More informationThe Usefulness of Sepsis Biomarkers. Dr Vineya Rai Department of Anesthesiology University of Malaya
The Usefulness of Sepsis Biomarkers Dr Vineya Rai Department of Anesthesiology University of Malaya 1 What is Sepsis? Whole Body Inflammatory State + Infection 2 Incidence and Burden of Sepsis in US In
More informationGuess or get it right?
Guess or get it right? Antimicrobial prescribing in the 21 st century Robert Masterton Traditional Treatment Paradigm Conservative start with workhorse antibiotics Reserve more potent drugs for non-responders
More informationGuidelines 2017 for the management of hospitalacquired pneumonia (HAP) and. ventilator-associated. pneumonia (VAP)
Guidelines 2017 for the management of hospitalacquired pneumonia (HAP) and ventilator-associated Modifiez le style des sous-titres du masque pneumonia (VAP) Filip Moerman Présentation pour les soins int
More informationObjectives. Pneumonia. Pneumonia. Epidemiology. Prevalence 1/7/2012. Community-Acquired Pneumonia in infants and children
Objectives Community-Acquired in infants and children Review of Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America - 2011 Sabah Charania,
More informationEpidemiology of Infectious Complications of H1N1 Influenza Virus Infection
Epidemiology of Infectious Complications of H1N1 Influenza Virus Infection Lyn Finelli, DrPH, MS Lead, Influenza Surveillance and Outbreak Response Epidemiology and Prevention Branch Influenza Division
More informationAn evaluation of clinical stability criteria to predict hospital course in community-acquired pneumonia
ORIGINAL ARTICLE EPIDEMIOLOGY An evaluation of clinical stability criteria to predict hospital course in community-acquired pneumonia A. R. Akram 1, J. D. Chalmers 1, J. K. Taylor 2, J. Rutherford 2, A.
More informationStability in community-acquired pneumonia: one step forward with markers?
1 Servicio de Neumología. Universitary Hospital La Fe, Ciber de enfermedades respiratorias (CIBERES),Valencia, Spain; 2 Servicio de Infecciosas, Hospital Clinic, IDIBAPS, Barcelona, Spain; 3 Servicio de
More informationTo develop guidelines for the use of appropriate antibiotics for adult patients with CAP and guidance on IV to PO conversion.
Page 1 of 5 TITLE: COMMUNITY-ACQUIRED PNEUMONIA (CAP) EMPIRIC MANAGEMENT OF ADULT PATIENTS AND IV TO PO CONVERSION GUIDELINES: These guidelines serve to aid clinicians in the diagnostic work-up, assessment
More informationManagement of Acute Exacerbations
15 Management of Acute Exacerbations Cenk Kirakli Izmir Dr. Suat Seren Chest Diseases and Surgery Training Hospital Turkey 1. Introduction American Thoracic Society (ATS) and European Respiratory Society
More informationMANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN THE ASIA PACIFIC REGION
MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN THE ASIA PACIFIC REGION Chong-Kin LIAM Department of Medicine Faculty of Medicine University of Malaya Kuala Lumpur liamck@ummc.edu.my COMMUNITY ACQUIRED PNEUMONIA
More informationTreatment of febrile neutropenia in patients with neoplasia
Treatment of febrile neutropenia in patients with neoplasia George Samonis MD, PhD Medical Oncologist Infectious Diseases Specialist Professor of Medicine The University of Crete, Heraklion,, Crete, Greece
More information4/5/2018. Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY. I have no financial disclosures
Update on Sepsis NIKHIL JAGAN PULMONARY AND CRITICAL CARE CREIGHTON UNIVERSITY I have no financial disclosures 1 Objectives Why do we care about sepsis Understanding the core measures by Centers for Medicare
More informationEfficacy of Pseudomonas aeruginosa eradication regimens in bronchiectasis
Efficacy of Pseudomonas aeruginosa eradication regimens in bronchiectasis Vallières, E., Tumelty, K., Tunney, M. M., Hannah, R., Hewitt, O., Elborn, J. S., & Downey, D. G. (2017). Efficacy of Pseudomonas
More informationCommunity-acquired pneumonia in adults
Prim Care Clin Office Pract 30 (2003) 155 171 Community-acquired pneumonia in adults Julio A. Ramirez, MD a,b, * a Department of Medicine, University of Louisville School of Medicine, 512 S. Hancock Street,
More informationSepsis Management: Past, Present, and Future
Sepsis Management: Past, Present, and Future Benjamin Ferrell, MD Tennessee ACP Meeting October 28, 2017 Learning Objectives Identify the most updated definition and clinical criteria for sepsis Describe
More informationEarly mortality in patients with communityacquired pneumonia: causes and risk factors
Eur Respir J 2008; 32: 733 739 DOI: 10.1183/09031936.00128107 CopyrightßERS Journals Ltd 2008 Early mortality in patients with communityacquired : causes and risk factors C. Garcia-Vidal*, N. Fernández-Sabé*,
More informationThe McMaster at night Pediatric Curriculum
The McMaster at night Pediatric Curriculum Community Acquired Pneumonia Based on CPS Practice Point Pneumonia in healthy Canadian children and youth and the British Thoracic Society Guidelines on CAP Objectives
More information6-horas 24 horas Coleta de lactato Hemoculturas. Corticosteróides. Controle glicêmico. Fluidos/vasopressores. Otimização de SvO 2
Novas diretrizes da Surviving Sepsis Campaign 2012 o que foi atualizado? Os pacotes da sepse 6-horas 24 horas Coleta de lactato Hemoculturas Corticosteróides Antibióticos Proteína C ativdada Fluidos/vasopressores
More informationMædica - a Journal of Clinical Medicine
Mædica - a Journal of Clinical Medicine ORIGINAL PAPERS Mortality Risk and Etiologic Spectrum of Community-acquired Pneumonia in Hospitalized Adult Patients Cornelia TUDOSE, Assistant Professor of Pneumology;
More informationVAP in COPD patients. Ignacio Martin-Loeches. St James s University Hospital. Trinity Centre for Health Sciences. Dublin Ireland.
VAP in COPD patients Ignacio Martin-Loeches St James s University Hospital. Trinity Centre for Health Sciences. Dublin Ireland. Outline Pathophysiology Is enough information? COPD trends in ICU How do
More informationSeverity and outcomes of hospitalised community-acquired pneumonia in COPD patients
Eur Respir J 2012; 39: 855 861 DOI: 10.1183/09031936.00067111 CopyrightßERS 2012 Severity and outcomes of hospitalised community-acquired pneumonia in COPD patients A. Liapikou*, E. Polverino #,S.Ewig
More informationPneumococcal pneumonia
Pneumococcal pneumonia Wei Shen Lim Consultant Respiratory Physician & Honorary Professor of Medicine Nottingham University Hospitals NHS Trust University of Nottingham Declarations of interest Unrestricted
More informationSetting The setting was secondary care. The economic study was carried out in the USA.
Cost-effectiveness of IV-to-oral switch therapy: azithromycin vs cefuroxime with or without erythromycin for the treatment of community-acquired pneumonia Paladino J A, Gudgel L D, Forrest A, Niederman
More informationBest of Pulmonary Jennifer R. Hucks, MD University of South Carolina School of Medicine
Best of Pulmonary 2012-2013 Jennifer R. Hucks, MD University of South Carolina School of Medicine Topics ARDS- Berlin Definition Prone Positioning For ARDS Lung Protective Ventilation In Patients Without
More informationSepsis Awareness and Education
Sepsis Awareness and Education Meets the updated New York State Department of Health (NYSDOH) requirements for Infection Control and Barrier Precautions coursework Element VII: Sepsis Awareness and Education
More informationStaging Sepsis for the Emergency Department: Physician
Staging Sepsis for the Emergency Department: Physician Sepsis Continuum 1 Sepsis Continuum SIRS = 2 or more clinical criteria, resulting in Systemic Inflammatory Response Syndrome Sepsis = SIRS + proven/suspected
More informationCAP, HCAP, HAP, VAP. 1. In 1898, William Osler described community-acquired pneumonia as:
1. In 1898, William Osler described community-acquired pneumonia as: Brad Sharpe, M.D. Professor of Clinical Medicine Department of Medicine UCSF sharpeb@medicine.ucsf.edu I have no relevant financial
More informationPneumonia 2017 OMAR PIRZADA
Pneumonia 2017 OMAR PIRZADA Pneumonia Pneumonia is common 0.5-1% of adults per year, 5-12% presenting to GP with LRTi 22-42% will be admitted to hospital Symptoms and signs Case 1 26 year old man Sudden
More informationSepsis 3.0: The Impact on Quality Improvement Programs
Sepsis 3.0: The Impact on Quality Improvement Programs Mitchell M. Levy MD, MCCM Professor of Medicine Chief, Division of Pulmonary, Sleep, and Critical Care Warren Alpert Medical School of Brown University
More informationSepsis: What Is It Really?
Sepsis: What Is It Really? Steven D. Burdette, MD, FIDSA, FACP Professor of Medicine Wright State University Boonshoft School of Medicine Director of Antimicrobial Stewardship for Premier Health and Miami
More informationSurviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 Mitchell M. Levy MD, MCCM Professor of Medicine Chief, Division of Pulmonary, Sleep, and Critical Care
More informationCommunity Acquired Pneumonia
April 2014 References: 1. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL Mace SE, McCracken Jr. GH, Moor MR, St. Peter SD, Stockwell JA, and Swanson JT. The Management of
More informationby author ESCMID Online Lecture Library Steroids in acute bacterial meningitis
Steroids in acute bacterial meningitis Javier Garau, MD, PhD University of Barcelona Spain ESCMID Summer School, Porto, July 2009 Dexamethasone treatment in childhood bacterial meningitis in Malawi: a
More informationChapter 22. Pulmonary Infections
Chapter 22 Pulmonary Infections Objectives State the incidence of pneumonia in the United States and its economic impact. Discuss the current classification scheme for pneumonia and be able to define hospital-acquired
More informationSevere β-lactam allergy. Alternative (use for mild-moderate β-lactam allergy) therapy
Recommended Empirical Antibiotic Regimens for MICU Patients Notes: The antibiotic regimens shown are general guidelines and should not replace clinical judgment. Always assess for antibiotic allergies.
More informationCOPD exacerbation. Dr. med. Frank Rassouli
Definition according to GOLD report: - «An acute event - characterized by a worsening of the patients respiratory symptoms - that is beyond normal day-to-day variations - and leads to a change in medication»
More informationBC Sepsis Network Emergency Department Sepsis Guidelines
The provincial Sepsis Clinical Expert Group developed the BC, taking into account the most up-to-date literature (references below) and expert opinion. For more information about the guidelines, and to
More informationNew Strategies in the Management of Patients with Severe Sepsis
New Strategies in the Management of Patients with Severe Sepsis Michael Zgoda, MD, MBA President, Medical Staff Medical Director, ICU CMC-University, Charlotte, NC Factors of increases in the dx. of severe
More informationSteroids in ARDS: if, when, how much? John Fowler, MD, FACEP Dept. of Emergency Medicine Kent Hospital, İzmir, Türkiye
Steroids in ARDS: if, when, how much? John Fowler, MD, FACEP Dept. of Emergency Medicine Kent Hospital, İzmir, Türkiye Steroids in ARDS: conclusion Give low-dose steroids if indicated for another problem
More informationPneumonia. Definition of pneumonia Infection of the lung parenchyma Usually bacterial
Pneumonia Definition of pneumonia Infection of the lung parenchyma Usually bacterial Epidemiology of pneumonia Commonest infectious cause of death in the UK and USA Incidence - 5-11 per 1000 per year Worse
More informationADVANCES IN BIOMARKER TESTING FOR SEPSIS AND BACTERIAL INFECTIONS
ADVANCES IN BIOMARKER TESTING FOR SEPSIS AND BACTERIAL INFECTIONS ERIC H GLUCK MD JD FCCP FCCM DIRECTOR OF CRITICAL SERVICES SWEDISH COVENANT HOSPTIAL DISCLOSURES: Speaking engagements and consulting:
More informationDisclosures. Case 1. Acute Bronchitis. Acute Bronchitis. Community-Acquired Pneumonia and other Respiratory Tract Infections. What do you recommend?
Community-Acquired Pneumonia and other Respiratory Tract Infections none Disclosures Joel T. Katz, M.D. Associate Professor of Medicine Division of Infectious Diseases Brigham and Women s Hospital Case
More informationPneumonia: The Forgotten Killer
Pneumonia: The Forgotten Killer David Glenn Weismiller, MD, ScM, FAAFP Department of Family and Community Medicine University of Nevada, Las Vegas School of Medicine Disclosure Statement It is the policy
More informationThorax Online First, published on May 20, 2008 as /thx
Thorax Online First, published on May 20, 2008 as 10.1136/thx.2008.095562 Systolic Blood Pressure is Superior to Other Haemodynamic Predictors of Outcome in Community Acquired Pneumonia James D Chalmers
More information10/2/2017. Pneumonia: Are We Missing the Mark? Objectives. Pneumonia
Pneumonia: Are We Missing the Mark? LaDawna Goering, DNP, APN, ANP-BC Nick Van Hise, Pharm. D, BCPS Objectives Diagnose Pneumonia Evaluate severity of illness tools and site of care decisions Review diagnostic
More informationAdmissions with severe sepsis in adult, general critical care units in England, Wales and Northern Ireland
Admissions with severe sepsis in adult, general critical care units in England, Wales and Northern Ireland Question For all admissions to adult, general critical care units in the Case Mix Programme Database
More informationCommunity Acquired Pneumonia in Adults Clinical Practice Guideline Antibiotic Stewardship
Community Acquired Pneumonia in Adults Clinical Practice Guideline Antibiotic Stewardship These guidelines are provided to assist physicians and other clinicians in making decisions regarding the care
More informationDisclosures. Objectives. Procalcitonin: Pearls and Pitfalls in Daily Practice
Procalcitonin: Pearls and Pitfalls in Daily Practice Sarah K Harrison, PharmD, BCCCP Clinical Pearl Disclosures The author of this presentation has no disclosures concerning possible financial or personal
More information