[Pediatric comments provided in blue]

Transcription

1 Infectious Diseases Society of America Emerging Infections Network Comments for Query: S. aureus Community-Acquired Pneumonia 2008 [Pediatric comments provided in blue] S. aureus colonization / Diagnosis of S. aureus pneumonia Must differentiate pneumonia from colonization/serious diagnostic issues. [CA, SC] Occasionally (~25%) see MRSA from nasal ET culture, but no patients w/ convincing clinical evidence of S. aureus (MRSA) pneumonia. [CA] SA CAP very rare in our area. Colonization of respiratory throat (upper) very common so diagnosis of MRSA CAP made on basis of circumstantial evidence often. [PA] Our hospital currently does admission screening for 100% (at least we try) of patients. ~ 1 in 12 patients admitted have MRSA nasal colonization for our area. The problem is that if the nose is colonized, it does not mean the pneumonia is from the same organism - but it has altered the way we approach many of our children, especially if they are sicker. [NC] The possibility of seeing this infection points yet again to the importance of the Gram stain in directing empirical therapy (most valuable early diagnostic test). [MA, MA, NC] The issue is VAP and MRSA or MSSA isolation from tracheal aspirates; colonization vs infection. In practice, the intensivists put everyone on vancomycin and we have to determine on clinical grounds the likelihood of MRSA or MSSA pneumonia and alter the therapy accordingly. [MD] Nasal or sputum S. aureus colonization plus pneumonia is NOT S. aureus pneumonia. A chest CT can very useful to differentiate the two. The necrotizing, nodular appearance of S. aureus pneumonia is not usually seen with other agents causing pneumonia. Also, S. aureus septic pulmonary embolism is not S. aureus pneumonia; however, to differentiate the two clinically is sometimes very difficult and I therefore implement longer duration of therapy for "possible" S. aureus septic pulmonary embolism. [OH] Much of what I see that is labeled as CA-MRSA appears to be MRSA bacteremia from a nonpulmonary focus with secondary seeding of the lungs and subsequent cavitation. I base this assumption on the presence of fever & bacteremia (and, sometimes, a soft tissue focus of MRSA infection) at the time of admission with minimal abnormalities on CXR that subsequently evolve into a DIFFUSE cavitary process. [CA] Most of what is called MRSA pneumonia in the hospital where I practice is actually not pneumonia at all but simply MRSA colonization in my opinion. Suspect this is true elsewhere too. [LA] Many w/ MRSA in sputum but questionable diagnosis of CAP vs CHF. Lots of sputa + for MRSA but clinical picture not consistent w/ severe MRSA pneumonia. Improved on therapy not containing antibiotics for MRSA before I am consulted. [MO] We see lots of other pts with cultures + for MRSA, perhaps 2 or 3 each week. But they are colonized in nares and we don't think they have real MRSA pneumonia though we cover them with vancomycin initially. If slow to respond, then we use either linezolid or daptomycin. [KS] Page 1

2 Hard to distinguish between colonization and infection. Most are the former. The cases I reported above were those I felt had features suggesting PVL+ S. aureus. Seems to be more common these days, but this is anecdotal at best. [OR] Cavitation is rare on presentation, but develops later. [OH] All patients with severe pneumonia should get either expectorated or induced sputum analysis by Gram stain in the ER. If there are GPC in clusters, they should receive anti-staph coverage (MRSA or MSSA) based on MRSA prevalence in the area. I do not think a blanket recommendation would suite the whole nation. [IL] Vastly over diagnosed based on sputum gram stain & vastly over treated on empiric therapy based on IDSA-TS guideline for HCAP. [NC] Vancomycin dosing and trough issues Would begin with a loading dose of 25 mg/kg. [MI] When using vancomycin I will routinely push for trough levels of 15 to 20. [MI] I try to maintain a vanco trough of about [NJ] Given that vancomycin's pulmonary penetration is not as adequate as we would like, we typically increase to troughs of 15 or so. [TN] Am concerned that this will become an even greater problem. I believe that vancomycin is effective treatment when careful attention paid to kinetics including target Cpmin approaching 15 mg/l. [NJ] Effect of vancomycin MIC on treatment We don't routinely do vanco MICs, so we don't know if there's "creep". Hence, linezolid gets my encouragement. I have a low threshold for empiric rx in anyone w/ "severe" pneumonia. [OK] It is CRUCIAL to know the MIC to vancomycin (not just S or R). For those who choose vanco an MIC predicts failure even for bacteremia, let alone pneumonia when vanco's lung penetration is poor. [ID] Use low-dose gentamicin for synergy to improve vancomycin's killing activity in the lung. If vancomycin's MIC value is on the high side [~2 or higher], may use linezolid instead. If organism is susceptible to clindamycin, may use this instead of vancomycin. [IN] Choice of antibiotic for S. aureus CAP Primary Drug of Choice Working in a cancer center, there are conflicting issues of a majority of isolates with vancomycin MIC's greater than 2, but at the same time many patients have thrombocytopenia or bone marrow suppression that present a problem with linezolid use. Tigecycline has been used in these circumstances, but obviously without adequate data to justify this practice. [TX] Potent "static" linezolid vs. "cidal" vancomycin as empiric therapy?? [WY] I'll be anxious to get more info re vanco vs linezolid pneumonia in patients w/ MRSA pneumonia. FDA issued info in 2007 that seemed unhelpful since it INCLUDED GN infxns! We need vanco (tr 15-20) vs linezolid study in this population of pts. [ME] I have had several pts with MRSA pneumonia with empyema who required multiple chest tubes and decortications and did not stabilize until I changed from vanco to linezolid, so now I change MUCH earlier. [CA] Would consider using non-vancomycin-based therapy more often since vancomycin failure for pneumonia due to MRSA is unacceptable in severe disease. [TN] Way too much empiric linezolid use by my pulmonary/ccm colleagues. [TX] Use linezolid if I m highly suspicious of MRSA. Using something in addition (question 5) is because they are peds pts and could still have H. flu (rare but...) [CA] Page 2

3 This has raised interesting questions regarding antimicrobial stewardship, as the ED and others would like permission to use empiric linezolid (they don't like vanco for pneumonia) for patients presenting with CAP suspected to be due to MRSA. This was not approved at our institution however. [DE] May change to linezolid for better lung penetration if there is evidence of MRSA and no improvement on vancomycin. [MO, NY, OR] Linezolid up front for severe pneumonia. Quick switch once an isolate available to clindamycin usually or whatever is indicated ie. 3rd generation cephalosporin if more likely S. pneumoniae. [NJ] Linezolid is a very toxic compound and I have had problems with it even for short durations of treatments. [NY] It would be desirable to definitively settle the issue of linezolid vs vancomycin in pneumonia. [LA, MA] If isolate is susceptible to clinda will use it in preference to vanco, usually along with rif or fusidic acid. Have on occasion added linezolid if I cannot use two of clinda, TMP-SMX, rif or fusidic acid because of resistance. [British Columbia] I will add an aminoglycoside to vancomycin. I reserve linezolid for patients who are allergic to vancomycin. Doxycycline has the same coverage as Tygacil. Is there any advantage/reason to use Tygacil instead of doxycycline? [NY] I seen only a few cases of MRSA CAP but there is no prospective data suggesting any better treatment than vancomycin. [TX] I don't use linezolid for empiric therapy, but change to it if the pneumonia is documented to be due to MRSA. [OK] On the other hand, all severe sepsis patients should receive empiric coverage for MRSA. Unfortunately, many patients with severe sepsis have acute lung trauma which is inappropriately diagnosed as pneumonia in my opinion and my practice is not to cover these patients with what I think is the best MRSA pneumonia drug (linezolid). [MA] I am most likely to cover for staph if the patient is septic or severely ill on presentation. Then I will add vanco and clinda to ceftriaxone (which is what I usually use for CAP). If the isolate is sensitive to clinda, I drop the vanco. [NJ] Heard lots of opinions about not using vanco and going straight to linezolid. Many are doing this already. We are not but perhaps we should be. [CO] If severely ill and not improving on vancomycin, we quickly change or add linezolid. [TN] For healthcare associated pneumonia, vanco is frequently started for empiric coverage for MRSA. In patients with true CAP, no risk factors, I have been advising MRSA coverage if they have a necrotizing pneumonia or SIRS requiring ICU admission. [PA] I do consider linezolid as a potentially better drug in non-bacteremic/septic patients with bad necrotizing pneumonias over vanco. [MO] Always seems to be a debate at my institution about when and whether to change vanco to linezolid or whether to add clinda for toxin inhibition. Generally we have recommended sticking with vanco unless there is severe necrosis or is not improving on vanco with culture confirmed MRSA. [CA] Adding empiric Rx for MRSA in high risk patients seems very appropriate but de-escalation is essential to be good stewards of antibiotics. [SC] Issue of Adding a Second Drug Usually add a second drug for gram neg Rx, e.g., Zosyn, Levoquin. [CA] Never add a 2nd drug for empiric treatment. [MD] I may add a 2nd drug, but not empirically. [OR] At peds ID Board Review course there was brief mention of antagonism with high doses of vanco & clinda (230x and 50x MIC) combined. There was a study in J Appl Res 2004;4: which Page 3

4 demonstrated concentration dependent antagonism using these 2 drugs and MRSA. Is this something others have either experienced or tried to avoid combination of vanco & clinda? [GA] Always add dalfopristin-quinupristin as second agent. [PA] Always add a 2nd drug (levofloxacin) for other CAP pathogens pending cultures. [IN, LA] Always add a 2nd drug: list includes clinda, rifampin, TMP-SMX, doxy [NC] The reason for additional coverage is not MRSA, but the possibility of Gm neg infections instead with necrotizing lung infections. [KS] Clindamycin may be added if abscess is a concern or toxin mediated disease is associated. Useful survey. [NE] Epidemiology of SA CAP, including frequency with which it occurs My patient s risk factor - visited husband in LTCF. [NY] My colleagues have seen a few with PVL producing toxin with lethal consequences. [MS] I am curious what effect the recent expansion of routine immunization for influenza to all children up to 18yo will have on the incidence of MRSA CAP. My suspicion is that, if a high immunization rate is obtained in this age group, rates under 30 yo will drop leading to the appearance of change in disease process in the elderly. [OH] We've seen surprisingly little respiratory MRSA in patient who've not been in a hospital/chronic care facility, despite very large numbers with CA-MRSA boils (I'd estimate over 1000/year). Failures of usual outpatient Rx (azithro, moxi) are not rare but are almost never due to CA-MRSA here. [CA] We see surprisingly little of it/no confirmed cases to date. [CA, CA, CO, MS, OH PA, TX, TX] We see enormous numbers of community onset MRSA skin and soft tissue infections, bacteremia, endocarditis, osteomyelitis, epidural abscesses, etc. We also see lots of HAP or VAP due to MRSA. But we very, very rarely see adults with MRSA CAP. [CA, MI, PA] We do not specifically track CA-MRSA pneumonia, so I am unable to provide numbers. However, we have seen a steady increase in the number of patients entering with newly recognized MRSA from the community. We don't distinguish CA-MRSA vs HA-MRSA. [MA] We did see pts with MRSA pneumonia but I do not have the number of patients. My estimate is ~5 patients (post viral, DM, IVDU). [NY] Think about it in elderly patients with comorbid conditions presenting with pneumonia and respiratory distress. [ND] My three patients were all in one family; 2 died of septic shock and fulminant hemorrhagic pneumonia. Respiratory or post-mortem cultures all grew MSSA (USA 400) and tested positive for PVL, enterotoxin A, SEK, and SEQ virulence factors. [MN] The MSSA from our patient was PVL positive and was a strain that has not been seen in the US since the 1950s. [NY] Our gestalt is that we're seeing a slight increase this year, but we don't have numbers to confirm. [WA] My overall sense is that this has been decreasing over the years. [MN] MRSA in CAP almost always in elderly/immunocompromised/debilitated individuals, most coming from long term care facilities (what is often termed HCAP). Have heard about (but have not seen) cases in vigorous, otherwise healthy individuals. [GA] We teach the importance of covering Staph in the setting of a post-viral bacterial pneumonia and that means covering for MRSA. We do not cover Staph ordinarily. [CA] It involves a mixture of patient types: post influenza, injection drug use, HIV, for example. [NE] Increased number of influenza associated ICU admissions this year in late winter. In ID group of 5 physicians, several more cases of probable post-influenza MRSA pneumonia. High morbidity, mortality rate. [KY] Page 4

5 My patient presented with MRSA pneumonia after a flu like illness and was without any clear risk factor for MRSA infection. [CA] I think that CA MRSA pneumonia is often a surprise diagnosis, different in character than the MRSA pneumonia found in patients intubated for a prolonged period in an ICU. It is found in patients not typically thought to be carrying the bacteria. The risk factors for MRSA usually include having family members with MRSA and being hospitalized w/n 90 days of the presentation, and dialysis pts - but I find these patients rarely present with acute cavitary community acquired MRSA pneumonia. [ID] I don't think this survey will capture my approach to empiric therapy for CAP-MRSA. You have expressed question 3 as dichotomous variables which they are not. I also think the clinical status of the patient strongly dictates whether or not I will cover for MRSA and your survey does not permit expression of this practice. In our community, admission with clinical compromise from a condition that could be due to S. aureus should be covered empirically for MRSA, though I see so little CAP- MRSA that I do not routinely prescribe coverage for MRSA in patients who have rather classic stories for typical or atypical CAP who are not clinically compromised. [MA] Good survey. It is hard to tell if really CoMRSA due to huge overlap with health care exposure in our VA patients. [SC] Cannot believe prevalence of MRSA in Kollef's HCAP study. [SC] CA-MRSA seems severe and requires a prolonged hospital stay. [VT] California now requires reporting of all severe CA-MRSA and MSSA ICU admissions or deaths since January Since January we have had 3 admissions due to CA-MRSA infections. [CA] Becoming a flashpoint for plaintiff attorneys; have already reviewed and testified for the defense in 2 cases in the past year. [SC] Almost all our SA is MRSA. By sensitivity patterns, we believe it is all USA300 clone. We add doxycycline instead of macrolide. [CA] My 2 cases were both necrotizing pneumonia requiring wks of treatment. Both initially on vancomycin. One was switched to clindamycin after 2 wks. One was HIV+, the other was cirrhotic. [IL] The patients who receive ID consults in our hospital usually have necrotizing pneumonia and require either chest tubes or thoracic surgical intervention. This is a skewed sample. These patients receive longer antibiotic courses (often 4-6 weeks). [MO] I was not on the Infectious Diseases service this winter, thus I was not treating patients with MRSA CAP during the time interval specified in the survey. My colleagues were seeing MRSA CAP. [WI] The time may be coming where all pneumonias will need CAP MRSA coverage. [IL] Presentation of SA CAP I have never seen CA-MRSA CAP before the past year. Recently a 30 year old asthmatic, otherwise healthy, presented with bilat cavitating pneumonia, developed empyema with bronchopleural fistula and required VATS drainage. MRSA in blood as well. [NJ] We see this in young healthy people in the middle of summer also. It presents with severe pleuritic pain in many cases and progresses rapidly to empyema requiring lengthy management with chest tubes etc. This is the most overlooked public health issue in this country. The amount of money being directed to this killer problem is pitiful. The EIP survey published on invasive MRSA is misleading because it oversampled wealthy northern states, and is already out of date. We need all states to be performing systematic active surveillance on this as with all other reportables. Invasive MRSA will then exceed all other reportables combined. [NM] Seems like we are seeing more empyemas also. [TX] My only case was a young patient (28 y/o) with no risk factors that would have suggested MRSA; however, the severity of his clinical presentation prompted coverage for MRSA. Bronchoscopy Page 5

6 confirmed CA-MRSA. The patient improved on oral Zyvox (14 day course). It took about 4 weeks for him to completely improve secondary to significant residual bronchospasm. [FL] Other Causes of CAP This season I saw TWO cases of influenza complicated by bacteremic group A strep pneumonia. [OK] SA CAP has been rare mostly pneumococcus /culture+ S. pneumoniae with bacteremia [CA, PA] We have not seen that much S. aureus pneumonia this season, but have seen very severe pneumococcal pneumonia. Multilobar involvement, some with cavitation. Some complicating influenza as a flu vaccine failure. It has been extremely frustrating to have CDC refuse to serotype the pneumococcal isolates, claiming that if it's not part of a population-based surveillance effort, it's not valuable information. Valuable to whom? Can no hypotheses be generated other than those in population-based surveillance? Are we creating a second class of epidemiologic citizenry? [RI] In pediatrics we have isolated pneumococci in various patients with necrotizing pneumonia. [FL] Pediatric-specific Issues We really don't use the term community acquired pneumonia in our pediatric population as it has become an antiquated term. We continue to see CAP in the setting of sepsis/osteo or alone post viral. The major change is the shift to MRSA from MSSA. The answers above require nearly prospective data collection. My answers are based on quick review of consult lists and medical records. [AR] We have a good number of children admitted with empyema/necrotizing per CT/pleural effusions that either get better with therapy or have sterile cultures at the time of their procedure. These children are not included in the numbers for this survey, as although we suspect SA as the underlying organism we often cannot prove it unless the blood culture or respiratory sample is positive. [NC] We had two pediatric patients die with MRSA post influenza pneumonia at my hospital, making an impressive ripple in our community. I did not care for them [TN] Our hospital had two deaths in January-February 2008, in teenagers who had MRSA pneumonia following documented influenza infections. [TN] This seems geared toward management of adults. For peds, I often cover for MRSA, but need to cover for pneumococcus, etc. pending a lab diagnosis. [MD] Our fellows made the following comments: 1) 3 of our 4 patients required ECMO (the surviving patient did not). 2) All of our MRSA CAP patients presented with significantly low WBC/ANC. [MA] Our policy in peds now is to cover PICU patients with severe pneumonia with ceftriaxone and vancomycin if they have a pleural effusion. Our patient with MRSA pneumonia actually had a pleural effusion that grew MRSA and grp A strep. Grandmother was hospitalised at the same time (different hospital) with an unspecified MRSA infection and mother had cellulitis of leg (not cultured). [NY] The only patient we have treated since 10/07 with S aureus in the lungs was a child who had septic pulmonary emboli from vascular (adjacent to an osteomyelitis) thrombus--didn't include her above, since was not "pneumonia" in the sense you are querying. [TN] Not common/ have not seen any pediatric CAP [GA, OH] Most (>90%) of our co-mrsa in pediatric (non-nicu) patients remains sensitive to clindamycin; for non-mrsa isolates, clindamycin resistance is higher (about 25%). [OR] It may be helpful to sort pediatric providers from adult providers, since our patient population tends to have somewhat different risk factors. [NY] When the child has empyema we refer them surgery for VATS procedure and put a PICC line in [CA] In our children's hospital, we see mostly severe CA-MRSA disseminated infection w/o pneumonia. [OK] I'm a pediatrician and our recommendations may differ from those of adult ID docs. [MI] I was not attending on service during the peak influenza season. However, there were patients on our clinical service with suspected necrotizing CAP...most often, however, blood and sputum cultures are Page 6

7 negative in pediatric patients, and empiric coverage includes coverage for S. aureus (including MRSA) as well as S. pneumoniae, Group A Strep, etc... Although I don't have the numbers, it did seem like there were fewer hospitalized patients with severe CAP where Peds ID was consulted overall. [CA] I only see pediatric patients and in our institution we often suspect S. aureus pneumonia, but do not frequently get positive cultures (either samples not obtained or obtained after antibiotics started). [Manitoba] I don't see much but I'm in pediatrics. Most of our SA pneumonia is post-influenza or in patients with unusual circumstances (immunocompromised, etc.). [NC] I deal with pediatrics only and was not on inpatient assignment during flu season, but we have seen a gradual increase in documented MRSA CAP over the past 2-3 years (with caveat that most of our pediatric patients don't have an etiologic diagnosis). [DC] If the patient had another source of infection such as a significant SSTI or osteo, that would prompt me to add MRSA coverage. Another factor that would influence adding MRSA coverage (but would not automatically prompt me to add it) is pneumonia with empyema or necrotizing pneumonia. Other factors noted above may sway my decision, but would not prompt automatic MRSA coverage. [NJ] I am a pediatric ID consultant, so only see severe cases, and only when on service. Numbers do not reflect volume that is actually seen at the hospital. [MA] Despite a very high incidence of complicated pneumonia and empyema in our pediatric population, we have seen very little S. aureus pneumonia, and only rarely MRSA. [UT] A severe pneumonia year in children. We often have no organism but did see more Staph and S. pneumo empyemas that we or the surgeons have ever seen. [SC] Other Issues Appropriate survey [NY] It is very difficult to collect this type of data without doing a retrospective chart review. [CA, CA. MN, MO, TN] I could provide much more data if this request were made at the beginning of the season. [CA, MN] The choices as presented do not reflect the individual variation among patients and present a more rigid picture than is actually practiced. [WI] Survey is looking for black and white answers to situations that are usually in the gray. [MA] Question 1C is tough because if they meet that criteria they are not CAP [how many had healthcare associated risk factors]. [OH] Question 1e (mechanical ventilation w/in 48 hrs of hospitalization) will be hard to answer for cases who were transferred or already in the ICU when symptoms began, so replies may not meaningfully reflect the urgency of the symptomatology, if that s what you were trying to get at. [IA] Upcoming PROPHYLACTIC pre-op guidelines should be EFFECTED using present micro data 80% of our neurosurgical and orthopedic infections are S. aureus, 60% of those MRSA. Awareness of the aggressive nature of S. aureus in our community difficult to impart to all physicians. [LA] Don t mix up questions about MRSA pneumonias in patients with healthcare exposure (likely HA- MRSA in long term care pts) and those with real CA-MRSA pneumonias. You are going to get lot of people answering with high number of patients with potential HA-MRSA infections in column for CA-MRSA. [MO] Do you test for PVL? if suspect necrotizing CAP, and where do you send the test to? There are no specific guidelines regarding duration of treatment and that would be helpful. [FL] Page 7