Management of Pneumonia

Ni Ketut Donna Prisilia Deweerdt

Global Mortality in Infectious Diseases

World Health Organization. World Health Report. 2004.

Lower Respiratory Tract Infections:The Most Common
Reason for Antibiotic Use

Arnold FW, et al. J Manag Care Pharm. 2004;10:152-158.

 Pneumonias – Classification

Nosocomial
Pneumonias

ATS/IDSA. Am J Respir Crit Care Med.

2005;171:388-416.
Community-Acquired Pneumonia (CAP):
Pneumonia which develops in the community
or within 48 hours of hospital admission
Hospital-acquired pneumonia (HAP): pneumonia occurs 48
hours or more after admission, which was not incubating at the
time of admission
Ventilator-associated pneumonia (VAP): pneumonia that arise
more than 48-72 hours after endotracheal intubation

Healthcare-associated pneumonia (HCAP) includes any patients

who was hospitalized in acute care hospital for two or more
days within 90 days of the infection; resided in a nursing home
or long-term care facility; received recent IV antibiotic therapy,
chemotherapy, or wound care within the past 30 days of the
current infection; or attended a hospital or hemodialysis clinic
 Diagnosis of Pneumonia
• New infiltrates or progressively infiltrates on
chest X ray
• with two or more:
– increased cough,
– change in sputum characteristic,
– temperature 380C or history of fever,
– sign of consolidation (bronchial sound, creackles),
– leucocyte 10.000 or ≤4.5000
 PATIENT WITH SUSPECT
CAP

DIAGNOSIS
1.
PSI
CURB-65
THE SITE OF INITIAL
2.
TREATMENT

OUT PATIENT IN PATIENT

3. EMPIRICAL ANTIMICROBIAL
(EFFECTIVITY, COMPLIANCE, COST)
 Selection of Antimicrobial Regimens

• Based on prediction of most likely

pathogens
• Knowledge of local susceptibiliy patterns
Most common etiologies of CAP
Streptococcus pneumoniae
Outpatient Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydophilia pneumoniae
Respiratory viruses
Inpatient (non- S. Pneumoniae
M. Pneumoniae
ICU)
C. Pneumoniae
H. Influenza
Legionella species
Aspiration
Respiratory viruses
Inpatient (ICU) S. Pneumoniae
Staphylococcus auereus
Legionella species
Gram-negative bacilli
H. influenza
 Etiologis of CAP
(Medan, Jakarta, Surabaya, Malang, Makasar)

Pathogen (%)
K. pneumoniae 45,18
S. pneumoniae 14,04
S. viridans 9,21
S. auereus 9
Peudomonas aerugonosa 8,58
β hemolitik 7,89
Enterobacter 5,26
Pseudomonas spp 0,9
Sudarsono, Ilmu penyakit Paru,2010
 Pathogen in sputum cultures of CAP patient in
Sanglah Hospital -2008
• 181 inpatient with CAP Pathogen N(%)
• Pathogen found in 28 S. viridan 8(28,6)
(15,5%) cases Enterobacter 5(17,9)
Pseudomonas 4(14,3)
E. cloaca 3(10,7)
E. coli 2(7,1)
S. pneumoniae 2(7,1)
Acinetobacter 1(3,6)
Chrysemo 1(3,6)
Suartini, Saji,IB Rai, 2009 Total 28(100)
 Timing and Choice of Antibiotics

• Antibiotic Timing at 4 hours cutoff: IDSA B-III

recommendation.
• Empiric Antibiotic Choice of Therapy: IDSA A-I
recommendation.
Time to first antibiotic dose.

For patients admitted through the emergency

department (ED), the first antibiotic dose should be
administered while still in the ED.

(Moderate recommendation; level III evidence)

 Community Acquired Pneumonia
Outpatient Inpatient

Previously CO-MOR In Region Inpatient In patient

Healthy BIDITIES > 25% infection Non ICU ICU
With high level Pseudomonas CA MRSA
(MIC > 16 mg/ml) infection
Macrolide resistant
S. pneumoniae

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

 Community Acquired Pneumonia
Outpatient

Previously
Healthy

No Risk DRSP
• Age < 2 or > 65
•  lactam within previous 3 mo
• Alcoholism
• Medical comorbidities
• Immunosupressive illness/therapy
• Exposure to child in day care center

Streptococcus pneumoniae
Mycoplasma pneumonia
Hemophilus influenzae
Chlamydia pneumoniae
Respiratory viruses

A macrolide (azithromycin
Clarithromycin , erythromycin)
(Strong recommendation)
OR
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
Doxycycline
 Community Acquired Pneumonia
Outpatient

CO-MOR
BIDITIES

Age < 2 or > 65  lactam within previous 3 mo, Alcoholism

Medical comorbidities, Immunosupressive illness/therapy,
Exposure to child in day care center
+ Comorbid (Chronic heart, Lung Liver, renal disease DM,
Alcoholism, malignancy etc

Streptococcus pneumoniae,Mycoplasma Pneumoniae,

Hemophilus influenzae, Chlamydia pneumoniae, Respiratory viruses
+ Gram negative + DRSP

 A respiratory fluoroquinoloe (moxifloxacin, Gemifloxacin

Levofloxacin 750 mg) (strong recommendation)
 A  lactam + a macrolide (strong recommendation) Amoxicillin
(3x1gr). Co amoxyclave (2x2gr). Cefriaxone, cefodoxime,
cefuroxime. Doxy (alternative)
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
 Community Acquired Pneumonia
Outpatient

In Region
> 25% infection
With high level
(MIC > 16 mg/ml)
Macrolide resistant
S. pneumoniae

 a respiratory fluoroquinolone (moxifloxacin,

Gemifloxacin, Levofloxacin 750 mg)
(strong recommendation)
 a B lactam + a macrolide (strong recommendation)
Amoxicillin (3x1gr). Co amoxyclave
(2x2gr). Cefriaxone, cefrodoxime,
ceforoxime. Doxy (alternative)

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

 Community Acquired Pneumonia
Inpatient

Inpatient
Non ICU

• S. pneumoniae
• M. pneumoniae
• C. pneumoniae
• H. Influenzae
• Legionella species
• Aspiration
• Respiratory
viruses

 a respiratory
Fluoroquinolonoe
(strong recommendation)
 a B lactam + A macrolide
(strong recommendation)
Prefered : cefotaxime
Ceftrioxone, ertapenem
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
 Doxycyclin  alternative
for macrolide
 Community Acquired Pneumonia
Inpatient

In patient
ICU

S. Pneumoniae
Staph aureus
Legionella spesies
Gram negative bacilli
H. Influenzae

 a B lactam
(cefotaxime, cefriaxone
or ampicillin sulbactam)
+
Azythromycin
or
Fluoroquinolone
(strong recommendation)
 Penicillin allergic
Fluoroquinolone
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
+
Azetreonam
 Community Acquired Pneumonia
Inpatient

In patient
ICU
Pseudomonas
infection

• Structural lung disease

• Severe COPD with frequent
Steroid and/or antibiotic use
• prior Antibiotic therapy

Antipneumococcal, antipseudomonal
B lactam (piperacillin-tazobactam
cefepime, imipenem, meropenem)
+
Ciprofloxacin or levofloxacin750mg
OR
The above B lactam +
an aminoglycoside
And an antipneumococcal
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2) Fluoroquinolone/azithromycin
(moderate recommendation)
 Community Acquired Pneumonia
Inpatient

In patient
ICU
CA MRSA

• ESRD
• Injection drug abuser
• Prior influenzae
• Prior antibiotic th/
(especially fluoroquinolone)

Add vancomycin or
Linezolid
(moderate recommendation)

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Switch from intravenous to oral therapy

Patients should be switched from intravenous to

oral therapy when they are hemodynamically
stable and improving clinically, are able to ingest
medications, and have a normally functioning
gastrointestinal tract.

(Strong recommendation; level II evidence)

Criteria for clinical stability

Temperature 37.8C
Heart rate 100 beats/min
Respiratory rate 24 breaths/min
Systolic blood pressure >90 mm Hg
Arterial oxygen saturation >90% or pO2>60
mm Hg on room air
Ability to maintain oral intake
Normal mental status

NOTE. Criteria are from [268, 274, 294]. pO2, oxygen partial pressure.
a Important for discharge or oral switch decision but not necessarily for
determination of nonresponse.
Duration of antibiotic therapy

Patients with CAP should be treated for a

minimum of 5 days (level I evidence), should be
afebrile for 48–72 h, and should have no more
than 1 CAP-associated sign of clinical instability
(previous table) before discontinuation of
therapy

(level II evidence; Moderate recommendation)

 HAP, VAP or HCAP Suspected

Obtain Lower Respiratory Tract (LRT) Sample for Culture

(Quantitative or Semi-quantitative) & Microscopy

High Clinical Suspicion for Pneumonia

Begin Empiric Antimicrobial Therapy Using Algorithm & Local Microbiologic Data

Days 2 & 3: Check Cultures & Assess Clinical Response

(Temperature, WBC, Chest X-ray, Oxygenation, Purulent Sputum,
Hemodynamic Changes & Organ Function)

Clinical Improvement at 48-72 Hours

No Yes

Cultures - Cultures + Cultures - Cultures +

Search for other Adjust antibiotic Consider stopping De-escalate

pathogens, therapy, search for antibiotics. antibiotics, if possible.
complications, other other pathogens, Treat selected patients
diagnoses or other complications, other for 7-8 days &
sites of infection. diagnoses or other reassess.
sites of infection.
 Antibiotic Selection
• General Approach (clinical decision  initiate therapy)

HAP or VAP Suspected

(All Disease Severity)

Late Onset or Risk Factors for

Multi-drug Resistant (MDR) Pathogens

No Yes

Limited Spectrum Broad Spectrum

Antibiotic Therapy Antibiotic Therapy
For MDR Pathogens

American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416

 RISK FACTORS FOR MDR PATHOGENS
CAUSING HAP, HCAP, AND VAP
• Antimicrobial therapy in preceding 90 d
• Current hospitalization of 5 d or more
• High frequency of antibiotic resistance in the community
or in the specific hospital unit
• Presence of risk factors for HCAP:
– Hospitalization for 2 d or more in the preceding 90 d
– Residence in a nursing home or extended care facility
– Home infusion therapy (including antibiotics)
– Chronic dialysis within 30 d
– Home wound care
– Family member with MDR pathogen
– Immunosuppressive disease and/or therapy
 INITIAL EMPIRIC ANTIBIOTIC THERAPY FOR HAP, VAP IN
PATIENTS WITH NO KNOWN RISK FACTORS FOR MDR, EARLY
ONSET, AND ANY DISEASE SEVERITY

POTENTIAL PATHOGEN RECOMMENDED ANTIBIOTIC

♣ Streptococcus pneumoniae Ceftriaxone

♣ Haemophilus influenza or
♣ Methicillin-sensitive Levofloxacin,
Staphylococcus aureus moxifloxacin,
♣ Antibiotic-sensitive enteric or ciprofloxacin
gram-negative bacillii or
Escherichia coli Klebsiella Ampicillin/sulbactam
pneumoniae or
Enterobacter species Ertapenem
Serratia marcessens

ATS. AJRCCM 2005; 171:388-416

INITIAL EMPIRIC ANTIBIOTIC THERAPY FOR HAP, VAP, AND HCAP IN PATIENTS WITH
LATE-ONSET DISEASE OR RISK FACTORS FOR MDR PATHOGENS AND ALL DISEASE
SEVERITY
POTENTIAL PATHOGEN COMBINATION ANTIBIOTIC TH/
Antipseudomonal cephalosporin
♣ Pathogens list in table A and MDR (cefepime, ceftazidime)
pathogens or
Pseudomonas aeruginosa Antipseudomonal carbepenem
Klebsiella pneumoniae (ESBL) (imipenem or meropenem)
Acinetobacter species or
-Lactam/-lactamase inhibitor
(piperacillin-tazobactam)
plus
Antipseudomonal
fluiroquinolone (ciprofloxacin or
levofloxacin)
or
Aminoglycoside (amikacin,
gentamicin. or tobramycin)
Methicillin-resistant Staphylococcus plus
aureus (MRSA) Linezolid or vancomycin
♣ Legionella pneumophila ATS. AJRCCM 2005; 171:388-416
INITIAL IV, ADULTS DOSES OF ANTIBIOTICS FOR EMPIRIC THERAPY OF HAP, INCLUDING
VAP, AND HCAP IN PATIENTS WITH LATE ONSET DISEASES OR RISK FACTORS FOR MDR
PATHOGENS
Antibiotic Dosage
Antipseudomonals cephalosporin
Cefepime 1-2 g every 8-12h
Ceftazidine 2 g every 8 h
Carbepenems
Imipenem 500 every 6 h or 1 g every 8h
Meropenem 1 g every 8 h
Beta-lactam/beta-lactamase inhibitor
Piperacillin-tazobactam 4.5 g every 6 h
Aminoglycosides
Gentamicin 7 mg/kg per d
Tobramycin 7 mg/kg per d
Amicain 20 mg/kg per d
Antipseudomonal quinolones
Levofloxacin 750 mg every d
Ciprofloxacin 400 mg every 8 h
Vancomycin 15 mg/kg every 12 h
Linezolid 600 mg every 12 h

ATS. AJRCCM 2005; 171:388-416

THANK YOU
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