§ Diseases of the heart

§ Diseases of the vascular

system
§ Pneumonia
§ Cancer
§ Accidents
§ Tuberculosis
§ Chronic Obstructive Lung
Disease
§ Diabetes Mellitus
§ Diseases of the respiratory
system
*All Preventable with Education and Public Health
§ Kidney diseases infrastructure (DOH 2006)
 Morbidity Mortality

No. 1 Lower RTIs and No. 5 Pneumonia

Pneumonia

No. 2 No. 6 Tuberculosis

Bronchitis/Bronchiolitis
No. 6 Tuberculosis No. 8 Chronic Respiratory
Diseases (COPD,AECB)

¾ of all antibiotic consumption is for RTIs

(last updated February 11, 2008)
Source : National Epidemiology Center, DOH
Evi dence -B ased Cl in ica l Pra ctice Gui delines
in C ommu nit y Ac qui red Pneumoni a

 Ame ri can Coll eg e of Ch est Phy si cians St at eme nt:

Mx of CA P in the Home (AC CP 2 005)
 The Ph ili pp ine Cl in ical P ract ice Guid el in es
on CA P in Adul ts (PC PG 2004 )
 Brit ish Th ora cic Societ y ( BTS 2004 )
 Ame ri can Thoracic So cie ty (AT S 2001 )
 In fectious Dis ease Societ y of Ame rica (I DSA
2000 )
 Can adi an Inf ect io us D iseas e So ci et y-
Ca na dia n Thoraci c Soci et y (CI DS- CT S 2000)
 Clinical Practice Guidelines
Diagnosis, Empiric Management &
Prevention of Community Acquired Pneumonia
in Immunocompetent Adults: 2004 Update

A Joint Statement of:

• Philippine Society for Microbiology
and Infectious Diseases
• Philippine College of Chest Physicians
• Philippine Academy of Family Physicians
 Presumptive Definition of CAP
as per Phil CPG 04
 LRT I acquir ed f rom the communi ty
wit hi n 24 h to < 2 weeks
 Acut e cough
 RR > 20, H R > 1 00, fev er
 Ab norma l chest p hysi cal f ind ings
 No pa rt icul ar sympt om or a bn orma l P.E.
find in g is s uff ici ent ly sens it ive or
spec ifi c to co nfir m or ex clu de t he D x
Value of Chest X-Ray in
CAP Diagnosis
• Accuracy of predicting CAP
by physicians’ clinical judgment
is at best 60 – 76%
• All the guidelines are
unanimous in requiring a
chest radiograph to establish
the diagnosis and the presence
of complications (e.g., pleural
effusion, multilobar disease)
2007 JOINT IDSA-ATS
CAP
2009 JOINT PSMID-
PCCP-PAFP
 SITE-OF-CARE
Medical
Outpatient ICU
Ward

Guided by:
• disease-specific prognostic indicators to assess
the initial severity of pneumonia
• physician’s clinical judgement, supplemented by
objective findings
Current Approaches to CAP Therapy
 CURB 65
Score 1 point for each:
•Confusion
•Urea >7 mmol/L
•RR ≥30/min
•BP (SBP <90 mmHg or DBP ≤60
mmHg
•Age ≥65 years

0 or 1 2 >3

Home Hospital Hospital /

treatment supervisio ICU
n
 CURB 65
Risk of
Sc ore mortality/ Dis posi tio n 1 poin t each :
ICU
admission C - onfusion
0 0.7% No hospitalization
U - rea >7 mmol/l
1 3.2% Hospital referral & R - espiratory rate > 30/min
assessment: can be
outpatient B - lood pressure low,
2 13% Hospital referral & systolic <90 or diast < 60
assessment: short
inpatient or Age > 65
supervised outpatient
3 17% Sev ere
CAP
4 41.5%
Urgen t hos pit al
5 57%
ad mi ssion
Lim et al. Thorax 2003;58:377–382.
• CRB-65 omits
blood urea CRB- 65 30-Day
measurement Scor e Mor tal ity ( %)

• Applicable to 0 0
office-based
settings 1 4.1

• Scores: 2 18.7
0=home
treatment 3 43.5
1=hospital-
supervised
4 54.6
treatment Capelastegui A et al. Eur Respir J. 2006;27:151-157.
≥2=hospitalizati
Which patient will need
hospital admission?
 Which patient will need hospital
admission?
 Pts w/ stable VS:
 RR < 30 breaths/min, PR < 125 beats/min,
 SBP > 90 mmHg or DBP > 60 mmHg &
 Temp >36oC and <40oC
 No altered mental status of acute onset (NEW)
 No or stable comorbid condition *
 No evidence of aspiration
 CXR: localized infiltrates; no evidence of pleural
effusion nor abscess
LOW Ris k C A P -- -> Ou tpa ti ent Ca re
* Comorbid conditions include:
 Diabetes mellitus (DM)
 Neoplastic disease
 Neurologic disease
 Congestive heart failure (CHF)
 Coronary artery disease (CAD)
 Renal failure
 COPD
 Chronic liver disease
 Chronic alcohol abuse
 Which patient will need hospital
admission?
ANY OF THE FOLLOWING

 Patients with unstable sign

 RR > 30/min
 PR > 125/min
 Temp > 40oC or <36oC
 SBP<90mmHg or DBP <60mmHg
 Altered mental status of acute onset
 Suspected aspiration
 Unstable comorbid conditions*
 CXR: multilobar, pleural effusion, abscess
Mode rate Ris k C A P ---> In -pat ient
 *Unstable comorbid conditions
include:
 uncontrolled diabetes mellitus (DM)
 active malignancies
 neurologic disease in evolution
 congestive heart failure (CHF) Class II-IV
 unstable coronary artery disease (CAD)
 renal failure on dialysis
 uncompensated COPD
 decompensated liver disease
 Which patient will need hospital
admission?
Any criteria under moderate risk category
plus
 Septic shock with need for vasopressor
 Need for mechanical ventilation (invasive or
non-invasive)

Hig h Ri sk C A P - --> Inten si ve ca re

 What microbiologic studies are
necessary in CAP?
Low Risk CAP High Risk CAP
• Sputum GS CS
(optional for CAP pts
with co-morbid
conditions)  Blood CS 2 sites
 Respiratory secretion GS
Moderate Risk CAP CS
 Urine Ag Test for L.
 Blood CS 2 sites pneumophila
 Sputum GS CS  DFA Test for L.
pneumophila
Treatment
 Initial Inadequate Antibiotic Therapy Increases
Mortality
Alvarez-Lerma,1996 Initial adequate
therapy
Rello, 1997
Initial inadequate
Kollef, 1999 therapy

Kollef, 1998
Anti biot ics sh oul d be ini tia ted w it hi n 4
Ibrahim, 2000
hours of D x of CAP
Luna, 1997

0 20 40 60 80 100
% Mortality
Alvarez-Lerma F, et al. Intensive Care Med. 1996;22:387-394. Kollef MH, et al. Chest. 1998;113:412-420.
Ibrahim EH, et al. Chest. 2000;118L146-155. Luna CM, et al. Chest. 1997;111:676-685.
Kollef MH, et al. Chest. 1999; 115:462-474. Rello J, et al. Am J Respir Crit Care Med. 1997;1
56:196-200.
 Antibiotic
Treatment
Major goal of therapy:
Major goal of therapy:
eradication of the infecting
organism, with resultant
resolution of clinical disease

Thus, ANTIMICROBIALS are a

mainstay of treatment
 Until more accurate and
rapid diagnostic methods are
available, the initial
treatment for most patients
is EMPIRIC

 Selection of antibiotics for

empirical therapy is based on
prediction of the most likely
pathogens and knowledge of
local susceptibility patterns
Principles of Empirical Therapy
in Management of CAP
 give antibiotics / therapy as soon as possible after the
diagnosis is considered likely (IDSA/ATS 2007)

 cannot reliably differentiate etiology on basis of clinical

findings

 Treat most likely pathogens

 S. pneumoniae; H. Influenzae
 Atypicals
 Others (local epidemiology)
 *co-morbid conditions, recent antibiotic use, recent hospitalization,
hypersensitivity
Most common etiologies
of CAP
Outpatient
Streptococcus pneumoniae
Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Respiratory viruses
Inpatient (non-ICU) Inpatient (ICU)

•S. pneumoniae
 S. pneumoniae •Staphylococcus
 M. pneumoniae
aureus
 C. pneumoniae •Legionella species
 H. influenzae
•Gram-negative bacilli
•H. influenzae
 Legionella species

 Aspiration

 Respiratory viruses
 Evidences – Aetiologic distribution of
Community-acquired pneumonia in Asian Countries

Aetiology (n=390) No. of Isolates (%)

Streptococcus 114 (29.2)
pneumoniae
Klebsiella pneumoniae 60 (15.4)
Haemophilus 59 (15.1)
influenzae
Pseudomonas 26 (6.7)
aeruginosa
Staphylococcus aureus 19 (4.9)
Mycobacterium 13 (3.3)
tuberculosis
Moraxella catarrhalis 12 (3.1)
Other pathogens 77 (19.7)
Mycoplasma 61/556 (11)
pneumoniae
Chlamydia pneumoniae 55/411 (13.4)
Epidemiology and Clinical outcomes of Community-acquired pneumonia in Adult patients in Asian countries:
A prospective study by the Asian network for Surveillance of Resistance pathogens. Jae-Hoon song et.a. International Journal of

Legionella 7 /648 (1.1) Antimicrobial Agents 31 (2008): 107-114

 Resistance pattern of
Streptococcus pneumoniae
2004 2005 2006 2007
Penicillin 5 11 6 1

Co- 15 16 14 18
trimoxazole
Chloramphe 5 4 5 5
nicol

Celia C. Carlos, ARSP, DOH

 Resistance pattern of
Haemophilus influenza
2004 2005 2006 2007
Ampicillin 10 10 9 11

Co- 36 15 16 13
trimoxazole
Chloramphe 10 20 14 8
nicol

Celia C. Carlos, ARSP, DOH

 Resistance pattern of
Moraxella catarrhalis
2004 2005 2006 2007
Ampicillin 9 16 15 19.6

Co- 1 7 5 11.4
amoxiclav
Co- 38 50 59 49.6
trimoxazole
Erythromyci 27 32 24 32.7
n
Celia C. Carlos, ARSP, DOH
What is the empiric
treatment for CAP?
IDSA/ATS Consensus Guidelines on CAP 2007
(Clinical Infectious Diseases 2007;44:S27-
OU TPAT IENT 72)
IN PAT IENT: INPA TIENT:
GENERAL W ARD ICU ( SE VERE C AP)
Previou sly heal th y, no Re spirat or y No Pseudomonal risk:
antib io ti cs th e pas t 3 Flu oroq uin olon e Beta-lactam (cefotaxime,
mont hs: (le vo, mox i or gemi) (I ) ceftriaxone, ampicillin-
A ma cro lid e (I) OR sulbactam)
Doxy cy cli ne (III ) Be ta-lac ta m* + Ma crolide PLUS
(I) IV Macrolide (II) or
Co -mor bid it y or rece nt or Dox ycyclin e (II I) IV Fquinolone (I)
anti bio tic use:
Pseudomonal risk factors present:
Re spirat or y FQ (L evo *ce fot ax im e, ce tria xo ne ,  Anti-Pseudo, Anti-pneumo
750) ampic illi n-sulbact am
Blactam (cefepime, piptazo,
(I ) ertapenem imipenem, meropenem)
Hig h-dose beta -la ct am*
PLUS
+ For ca refully selec te d Cipro or Levofloxacin (750 mg)
macrolid e (I) patie nts wit ho ut ris k  Above beta-lactam PLUS
fact or s for DRS P or GNR,
mo no the ra py w it h IV aminoglycoside or
* Amox 1g tid
azit hr omy cin ca n be IV antipneumococcal FQ
Co-am ox 2g bid
co nsid ered *Add Vanco or Linezolid for CA-
MRSA
Ce ftria xo ne,
LOW RISK CAP
 What is the empiric treatment for
Low Risk CAP?
Low Risk CAP with no co morbid conditions

2004 2009
 Recommendation  Recommendation
 Amoxicillin
 Amoxicillin OR
 Extended macrolides
 Alternative
 Extended Macrolides:
 Alternative azithromycin dihydrate,
 Co-trimoxazole clarithromycin
 What is the empiric treatment for
Low Risk CAP?
Low Risk CAP with stable co morbid conditions

Recommendation (2004/2009):

co-amoxiclav or sultamicillin

or

2nd gen cephalosporin (cefuroxime axeteil, cefaclor)

or

extended macrolide (azithromycin dihydrate, clarithromycin)

Moderate Risk CAP
 Moderate Risk CAP

Recommendation (2004/2009):

IV nonpseudomonal b-lactam +/-

b-lactamase inhibitor
+ macrolide
Alternative:
antipneumococcal FQ
 Nonpseudomonal β-lactam
 IV β-lactams
 2nd gen cephalosporin (cefuroxime sodium)
 3rd gen cephalosporins (ceftriaxone,
cefotaxime)
 those w/ anaerobic activity (cefoxitin,
ceftizoxime, ertapenem)

 IV β-lactams w/ β-lactamase inhibitor

 ampicillin-sulbactam
 amoxicillin-clavulanic acid
Antipneumococcal Fluoroquinolone

 Moxifloxacin

 Levofloxacin
 High Risk CAP with No risk for
Pseudomonas aeruginosa
Recommendation (2009):

IV nonpseudomonal antipneumococcal β-
lactam
+/- β-lactamase inhibitor
+ IV macrolide
Alternative:
IV antipneumococcal FQ
 High Risk CAP with Risk for
Pseudomonas aeruginosa
Recommendation (2009):

IV antipseudomonal antipneumococcal β-lactam

+/- β-lactamase inhibitor

+
IV macrolide or IV antipneumococcal FQ

+/-
Aminoglycosides or IV Ciprofloxacin
 Antipseudomonal
Antipneumococcal β-lactam
 IV β-lactams
 Those without anaerobic activity
 4th gen cephalosporin (cefepime)
 Those with anti-anaerobic activity
 Carbapenem (Imipenem-cilastatin, Meropenem)

 IV β-lactams w/ β-lactamase inhibitor

 Cefoperazone-sulbactam
 Ticarcillin-Clavulanic acid
 Piperacillin-tazobactam
 Risk Factor for Pseudomonas
aeruginosa CAP
 History of chronic or prolonged (>7 days
within the past month) use of broad
spectrum antibiotic therapy
 Malnutrition

 Chronic Use of steroid therapy: > 7.5

mg/day
 Severe underlying bronchopulmonary

disease (COPD, bronchiectasis)

Source: IDSA-ATS 2007
 As ses smen t of Cli nica l
Res pon se a nd D e-Es ca lat ion
Th er apy
 IV to Or al Swi tch Th er apy for
CAP
 Single most important advance in the
treatment of CAP
 Early IV to oral switch results in similar
outcomes with shorter length of hospital
stay and cheaper treatment
 Antibiotic streamlining to a narrow
spectrum antibiotic is possible as early as
72 hours of treatment
Cunha BA, Chest 125: 1913-1919, 2004
Phil CPG 2004
Switch Therapy Criteria

1. Cough and dyspnea are improving

2. Patient is afebrile for at least 8 hours

3. White blood cell count is normalizing

4. PO intake and GI absorption are adequate

ATS Guidelines
 Dur ati on of Ant ibi oti c Use
Base d o n Et iolog y

Et io lo gic Age nt Du rat ion of ther ap y

(da ys)
 Mo st b acter ial pn eumo nia 5- 7
ex cept 3 - 5
GNB, S. aur eus, P. aer ugi nosa (a zal ides )
 En te ric Gram (-) pat hoge ns,
10- 14

S. au reus, P. ae rugi no sa
10- 14
 My co pl asma & Chl am ydo ph ili a
14- 21
 Legio nel la sp .
Oral Agents with Good Bioavailability
and Convenient Dosing Schedule for
Switch Therapy
 Se cond/ Thir d Genera ti on
Cepha lo spo ri ns
 Ext ende d Mac rol ide s
 Fluo ro quinol ones

Phil CPG 2004

 Impact of CPGs on Clinical Practice

• Bef ore an d af ter obse rv at io nal cohort st udy : the

imple me nt ati on of the ATS guid eli nes re su lt ed in
red uct ion in 30- day mo rtal it y amo ng eld er ly
pa tie nt s w it h CA P
Dean NC, et. al.Am J Med Ap r 15;110(6) :451-7, 2001
• Co hort group man age d acc ording to CP G vs .
ret roact iv el y ide nti fied co ntr ol gro up : rat es of
hosp it al admis si on de cre ased wi tho ut a
de tecta ble di ffer ence in base li ne seve rit y of
ill ne ss, resu lte d i n si gn ifican t co st sa vi ng

Su chyta MR, et. al. Am J Me d 110: 306-9, 2001

Impact of CPGs on Clinical Practice

• Guid el ine s for se ver e CAP as so cia te d wit h no

redu ct ion in mo rtal it y

Hi ran i. Thorax 19 97 Ja n; 52( 1) :17-

21
Impact of CPGs on Clinical Practice

“Guide li nes are hel pf ul to tho se wh o hav e

kn owl ed ge bu t ar e dan ger ous in th e han ds of
tho se wh o do not, a gr oup to wh om gu ide li nes
may gi ve confiden ce to ex ceed their knowle dg e.
A phy sici an wi tho ut kno wle dg e but wi th
gu ide li nes is lik e a m onk ey in a t ree wi th a
mach in e gun.”
Ma rc Baltzan , CM AJ 166: 1 68, 2002.