S pneumoniae - MAPTB

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S pneumoniae - MAPTB

MANAGEMENT OFCOMMUNITY ACQUIRED PNEUMONIAIN THE ASIA PACIFIC REGIONChong-Kin LIAMDepartment of MedicineFaculty of MedicineUniversity of MalayaKuala Lumpurliamck@ummc.edu.my


COMMUNITY ACQUIRED PNEUMONIAA common disorderAnnual incidence in USA- 12 per 1000 adults- 25-44 per 1000 in those aged >65 yearsMarfarlane J. Semin Respir Infect 1994; 9:153-65


COMMUNITY ACQUIRED PNEUMONIAIn JapanAnnual incidence: 15 per 1000 adults and childrenAnnual incidence requiring hospitalisation:3.4 per 1000 adults and children6 th leading cause of death worldwideJRS guidelines (2005). Respirology 2006; 11:S79-S133


CAP: Key Bacterial Pathogens• In most studies,Streptococcus pneumoniaeis the most commonly identifiedpathogen followed byHaemophilus influenzae40%S. pneumoniaeH. influenzae20%Bartlett JG, et al. Clin Infect Dis. 1998;26:811-838; Marrie TJ. Infect Dis Clin North Am. 1998;12:723-740; Reimer LG, Carroll KC. Clin Infect Dis.1998;26:742-748.


CAP: Key Bacterial Pathogens.. and atypical pathogens:Mycoplasma pneumoniaeChlamydophila pneumoniaeand Legionella spp.S. pneumoniaeH. influenzae6%40%Legionella spp.M. pneumoniaeAtypicalpathogens:23%10%7%20%C. pneumoniaeBartlett JG, et al. Clin Infect Dis. 1998;26:811-838; Marrie TJ. Infect Dis Clin North Am. 1998;12:723-740; Reimer LG, Carroll KC. Clin Infect Dis.1998;26:742-748.


CAP: Key Bacterial PathogensOther bacteria includeMoraxella catarrhalis, Staphylococcus aureus,Klebsiella spp., andother gram-negative bacilli1%16%S. pneumoniaeH. influenzae6%40%Legionella spp.M. pneumoniaeAtypicalpathogens:23%10%7%20%C. pneumoniaeM. catarrhalisOthersBartlett JG, et al. Clin Infect Dis. 1998;26:811-838; Marrie TJ. Infect Dis Clin North Am. 1998;12:723-740; Reimer LG, Carroll KC. Clin Infect Dis.1998;26:742-748.


Clinical Practice GuidelinesAmbulatory patientsHospitalised patients(non-ICU)Severe(ICU)CAP patients are generally categorised into 3 groups• outpatients• inpatients• intensive care patients


IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72Most common microbial aetiologies of CAP (in the West)OutpatientS. pneumoniaeM. pneumoniaeH. influenzaeC. pneumoniaeRespiratory viruses*Influenza A and B, adenovirus,RSV & parainfluenzaInpatient(non-ICU)S. pneumoniaeM. pneumoniaeC. pneumoniaeH. influenzaeLegionella speciesAspirationRespiratory viruses*• For all 3 categories of patients, the number onepathogen is pneumococcusInpatient(ICU)S. pneumoniaeStaph. aureusLegionella spp.Enterobacteriaceae spp.Pseudomonas spp.H. InfluenzaeRef: File TM. Community-acquired pneumonia. Lancet 2003; 362:1991-2001[Based on collective data from recent studies]


IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72Most common microbial aetiologies of CAP (in the West)OutpatientS. pneumoniaeM. pneumoniaeH. influenzaeC. pneumoniaeRespiratory viruses*Influenza A and B, adenovirus,RSV & parainfluenzaInpatient(non-ICU)S. pneumoniaeM. pneumoniaeC. pneumoniaeH. influenzaeLegionella speciesAspirationRespiratory viruses*• For all 3 categories of patients, the number onepathogen is pneumococcus• Atypical pathogens are also prominently representedInpatient(ICU)S. pneumoniaeStaph. aureusLegionella spp.Gram-negative bacilliH. Influenzae• Legionella - an important pathogen in patients with severe CAP


Aetiologies of CAP Requiring Hospitalization in Asia 1LocationNo. ofpatientsRank order / Frequency of microbial cause (%)1 23 4 5 UnknownOkayama 1Ishida T, et al.Chest1998;114:1588-9393326S pneumoniae23H influenzae7M pneumoniae5K pneumoniae4S milleri4 39Okayama 23 hospitalsMiyashita N, et al.Chest2000;119:1295-6200S pneumoniae21H influenzae11M pneumoniae10C pneumoniae8S aureus5 42Korea 3Woo JH, et al.Korean J Infect Dis2001, 33:1-7562(588 cases)S pneumoniae22K pneumoniae15Ps aeruginosa10S aureus10S viridans6 62Hong Kong 4CHS Chan, et al.Chest1992;101:442-690M tuberculosis12S pneumoniae12Chlamydia spp6Viral6H influenzae4 59• The aetiology of CAP in Japan is quite similar to that of Western countries• High incidence of infection by Gram –ve bacilli• Infection due to M tuberculosis may commonly present as CAP incountries with a high prevalence of TB


Aetiologies of CAP Requiring Hospitalization in Asia 2LocationKhon Kaen 5Reechaipichitkul W,et al. SoutheastAsian J Trop MedPublic Health2005; 36:156-6161Bangkok 5a3 hospitalsWattanathum, et al.Chest2003;123:1512-9Singapore 6Hui KP, et al.Singapore Med J1992;101:442-6No. ofpatients25414796Rank order / Frequency of microbial cause (%)1 23 4 5 UnknownS pneumoniae11S pneumoniae22M tuberculosis21B pseudomallei111.4% in Bangkok 5aGram -vebacilli18(K.pneum 10)S pneumoniae12K pneumoniae10C. pneumoniae16Gram -vebacilli10M pneumoniae9M pneumoniae7H influenzae5C pneumoniae4L pneumophila5 29M pneumoniae54342K. Lumpur 7Liam CK, et al.Respirology2001;6:259-6464127K pneumoniae10S pneumoniae6H influenzae6M pneumoniae4Ps aeruginosa458Penang 8Hooi LN, et al.Med J Malaysia2001;56:275-8398M tuberculosis15K pneumoniae7Ps aeruginosa6S aureus5S pneumoniae• Studies in Singapore and Malaysia (countries with a high prevalence of TB)also show pulmonary TB commonly presents as CAP357


LocationAetiologies of Severe CAP Requiring ICU AdmissionUnitedKingdom(4 studies)Other partsof Europe(10 studies)SingaporeNUH Lee KH,Lee KH, et al.Singapore Med J1996;37:374-7777SingaporeSGH Tan YK,Tan YK, et al.Eur Respir J1998;12:113-1515Khon KaenReechaipichitkul W,et al.Southeast AsianJ Trop Med PublicHealth 2004;35:430-3No. ofpatients18511485957105Rank order / Frequency of microbial cause (%)1 23 4 5 UnknownS pneumoniae22S pneumoniae22K pneumoniae15B pseudomallei18B pseudomallei29Legionella spp18Gram –veenteric bacilli9H influenzae8M tuberculosis16S pneumoniae21Patients who met ATS criteria for severe CAPViruses10S aureus7S aureus7Klebsiella spp9K pneumoniae19S aureus9C pneumoniae7B pseudomallei7S aureus9H influenzae12Influenza A& B5 32Legionella spp6 43S pneumoniae5 32M pneumoniae7 28S aureus6 4191.4% of patients had co-morbidity, most common was diabetes mellitus; Mortality: 21%


LocationAetiologies of Severe CAP Requiring ICU AdmissionNo. ofpatientsRank order / Frequency of microbial cause (%)1 23 4 5 UnknownS pneumoniaeLegionella sppVirusesS aureusInfluenza ABurkholderia pseudomallei should be considered a& BUnitedKingdom185(4 studies)causative 22organism 18in patients 10with 9severe CAP 5 32Other partsof Europe(10 studies)SingaporeNUH Lee KH,Lee KH, et al.Singapore Med J1996;37:374-7777SingaporeSGH Tan YK,Tan YK, et al.Eur Respir J1998;12:113-1515Khon KaenReechaipichitkul W,et al.Southeast AsianJ Trop Med PublicHealth 2004;35:430-311485957S pneumoniae22K pneumoniae15B pseudomallei18in Gram Southeast –veS aureusAsia C pneumoniaeenteric bacilli9H influenzae8M tuberculosis167S aureus7Klebsiella spp97B pseudomallei7S aureus9Legionella sppparticularly if the patient has diabetes mellitus105B pseudomallei29S pneumoniae21K pneumoniae19H influenzae126 43S pneumoniae5 32M pneumoniae7 28S aureus6 41


LocationNova Scotia 1Marrie TJ, et al.Am J Med1996;101:508-1515ArgentinaErard PH, et al.Am Soc Microbiol1991;108:56ALausanneBochud PY, et al.Medicine2001;80:752-8787Aetiologies of CAP treated on an ambulatory basisNo. ofpatients14954170Rank order / Frequency of microbial cause (%)1 23 4 5 UnknownM pneumoniae23S pneumoniae13S pneumoniae23C pneumoniae11M pneumoniae7M pneumoniae14M pneumoniae&C pneumoniae3C pneumoniae4Influenza virus12Influenza A3Influenza A4C pneumoniae5C burnetii3 48Cryptococcusspp4 65C burnetii2 46FinlandJokinen C, et al.Clin Infect Dis2001;15:1141-5454169S pneumoniae37M pneumoniae14Chlamydiae9Viruses8H influenzae4 45


LocationNova Scotia 1Marrie TJ, et al.Am J Med1996;101:508-1515ArgentinaErard PH, et al.Am Soc Microbiol1991;108:56ALausanneBochud PY, et al.Medicine2001;80:752-8787Aetiologies of CAP treated on an ambulatory basisNo. ofpatients14954170Rank order / Frequency of microbial cause (%)1 23 4 5 UnknownM pneumoniae23S pneumoniae13S pneumoniae23C pneumoniae11M pneumoniae7M pneumoniae14M pneumoniae&C pneumoniae3C pneumoniae4Influenza virus12Influenza A3Influenza A4C pneumoniae5C burnetii3 48Cryptococcusspp4 65C burnetii2 46FinlandJokinen C, et al.Clin Infect Dis2001;15:1141-5454169S pneumoniae37M pneumoniae14Chlamydiae9Viruses8H influenzae4 45Bangkok3 hospitalsWattanathum, et al.Chest2003;123:1512-9Japan3 hospitals (Okayama)Miyashita N, et al.J Med Microbiol2005; 54:395-40040098106C pneumoniae37M pneumoniae27M pneumoniae30S pneumoniae12S pneumoniae13C pneumoniae11L pneumophila8H influenzae5Mixed infection13Viruses 2Mcatarrhalis22547


AsiA-CAP StudyNgeow YF, et al. Int J Infect Dis 2005 May;9:144-53 Results from 1374 patients with paired sera showedinfection rates forMycoplasma pneumoniae 12.2%Chlamydophila pneumoniae 4.7%Legionella pneumophila 6.6%Overall infection rate by atypicalrespiratory pathogens = 23.5%


Severity AssessmentThe key to deciding initial site of care Outpatient Medical ward Critical care ward / ICUSeverity assessment is made on the basis of prognostic criteria:• patients’ age• comorbidities• physical, laboratory and radiographic findings


Severity assessment& Prognostication Severity of illness score (e.g., CURB-65) Prognostic models (e.g., PSI)can be used to identify patients who may betreated as outpatients (Strong recommendation;level I evidence)IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72


Severity AssessmentPneumonia Severity Index (PSI)Requires computation of a score based on 20 variablesFine MJ, et al. A prediction rule to identify low-risk patients with CAP. N Engl J Med 1997;336:243-50


Severity AssessmentPneumonia Severity Index (PSI)stratifies patients into 5 mortality risk classes:Risk Risk class Score 30-day mortalityLow I No predictors 0.1%Low II < 70 0.6%Low III 71 – 90 0.9%Moderate IV 91 – 130 9.3%High V > 130 27.0%Fine MJ, et al. A prediction rule to identify low-risk patients with CAP. N Engl J Med 1997;336:243-50


Severity AssessmentPneumonia Severity Index (PSI)On the basis of associated mortality rates, patients inRisk class30-day mortalityI 0.1%II 0.6%III 0.9%IV 9.3%V 27.0%Treat as outpatientsTreat in an observation unitor short hospitalisationTreat as inpatientsFine MJ, et al. A prediction rule to identify low-risk patients with CAP. N Engl J Med 1997;336:243-50


Severity AssessmentCURB-65 score (6-point) – adopted by BTSScore 1 point for each feature present Confusion Urea > 7 mmol/L Respiratory rate > 30/min Blood pressure (SBP < 90 mmHg or DBP < 60 mmHg) Age > 65 yrsLim WS, et al. Thorax 2003;58:377-382


CURB-65 score Risk of mortality Score 0 0.7% Score 1 3.2%RecommendationsPatients who have a CURB-65score of 0 or 1 are at low risk ofdeath - can be treated as havingnon-severe pneumonia and maybe suitable for home treatment Score 2 13% Score 3 17% Score 4 41.5% Score 5 57%At increased risk of death - shouldbe considered for short stay inpatienttreatment or hospital supervisedoutpatient treatment (use clinicaljudgement)Patients who have a CURB-65score of 3 or more are at high riskof death and should be managedas severe pneumoniaLim WS, et al. Thorax 2003;58:377-382


There is growing evidence that CURB,CURB-65 and CRB-65 all allow for similarpredictions of death from CAP as comparedto the PSI


A prospective observational study of 1016consecutive inpatients with CAP in an Emergency Department mean (SD) age: 72 (+ 17) yrs The ability of the three rules to predict 30 daymortality was comparedYan Man S, et al. Prospective comparison of 3 predictive rules (PSI, CURB-65, CRB-65) for assessingseverity of CAP (and to predict 30-day mortality) in Hong Kong. Thorax 2007; 62: 348-53


PSI class 30-day mortality (%)I 0II 0.8III 5IV 9.3V 22.1CURB-650 0.91 3.62 7.33 16.44 26.65 37.5CRB-650 2.31 5.12 11.23 23.2All 3 predictive rules showed thesame trend of increasing mortalitywith worsening risk groups (p


Sensitivity, specificity, positive and negative predictivevalues of 30 day mortality of the different predictive rulesAll 3 clinical decision rules had high negative predictive values but low positivepredictive values at all cut-off points and are therefore more useful in ruling outserious illnessYan Man S, et al. Prospective comparison of 3 predictive rules forassessing severity of CAP in Hong Kong. Thorax 2007; 62: 348-53


Sensitivity, specificity, positive and negative predictivevalues of 30 day mortality of the different predictive rules• PSI : complicated computation of a score may not bepractical for routine application in busy hospital emergencydepartments or primary care settings• CURB-65 : simpler to apply• CRB-65 : is also easily applicable in primary care settingsAll 3 clinical decision rules had high negative predictive values but low positivepredictive values at all cut-off points and are therefore more useful in ruling outserious illnessYan Man S, et al. Prospective comparison of 3 predictive rules forassessing severity of CAP in Hong Kong. Thorax 2007; 62: 348-53


ICU admission rates also increased with the risk levels of each rule, but were onlystatistically significant in CURB-65 and CRB-65Yan Man S, et al. Prospective comparison of 3 predictive rules forassessing severity of CAP in Hong Kong. Thorax 2007; 62: 348-53


Sensitivity and specificity for high-risk group ofthe 3 predictive rules in identifying ICU admissionSensitivity (%) Specificity (%)PSI 29.3 82.7CURB-65 41.5 75.0CRB-65 24.4 90.3Because of their low sensitivities, none of the 3 rules appears to be useful foridentifying patients requiring ICU careModified ATS 90.2 59.1rule ††Ewig S, et al. Severe CAP: assessment of severity criteria.Am J Respir Crit Care Med 1998;158:1102–8.Yan Man S, et al. Prospective comparison of 3 predictive rules forassessing severity of CAP in Hong Kong. Thorax 2007; 62: 348-53


Sensitivity and specificity for high-risk group ofthe 3 predictive rules in identifying ICU admissionSensitivity (%) Specificity (%)PSI 29.3 82.7CURB-65 41.5 75.0CRB-65 24.4 90.3Although far from being perfect, the modified AmericanThoracic Society score is currently the best tool in identifyingBecause of their low sensitivities, none of the 3 rules appears to be useful foridentifying patients requiring patients ICU for care ICU admissionModified ATS 90.2 59.1rule ††Ewig S, et al. Severe CAP: assessment of severity criteria.Am J Respir Crit Care Med 1998;158:1102–8.Yan Man S, et al. Prospective comparison of 3 predictive rules forassessing severity of CAP in Hong Kong. Thorax 2007; 62: 348-53


Site-of-care decisions 1Prediction rules give an indication of disease severityPrediction rules have not been found to be useful inpredicting ICU admissionGenerally, patients of higher risk classes have higher ratesof ICU admissionUnlike 30 day mortality, the association is not strong enoughto allow for individual predictions and decisionsCriteria for ICU admission vary from country to country andfrom hospital to hospitalCriteria for ICU admission: disease severity is not the onlyfactor to consider; other factors to consider: diseaseprognosis, pre-morbid status, age of patient, and theavailability of ICU resources


Site-of-care decisions 2 All predictive rules serve only as a guide to clinicalmanagement Severity of illness is not the only factor to beconsidered when deciding on admission Social and home circumstances must beconsidered as well Physicians should always exercise clinicaljudgment and common sense in making thesedecisions


Criteria for severe CAPMajor criteria Need for mechanical ventilation Septic shock requiring vasopressors2007 IDSA / ATS Consensus Guidelines


Criteria for severe CAPMajor criteria Need for mechanical ventilation Septic shock requiring vasopressorsMinor criteria Respiratory rate >30 breaths/min PaO 2 /FiO 2 ratio 20 mg/dL) Leukopenia (WBC count,


ICU admission decisionDirect admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation andmechanical ventilation(Strong recommendation; level II evidence)Direct admission to an ICU or high-level monitoring unit isrecommended for patients with 3 of the minor criteria for severe CAP(Moderate recommendation; level II evidence)Mandell LA, et al. IDSA / ATS Consensus Guidelines on the management of CAP in adults.Clin Infect Dis 2007; 44:S27-72


ICU admission decisionDirect admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation andmechanical ventilation(Strong recommendation; level II evidence)Direct admission to an ICU or high-level monitoring unit isrecommended for patients with 3 of the minor criteria for severe CAP(Moderate recommendation; level II evidence)This recommendation requires prospective validationMandell LA, et al. IDSA / ATS Consensus Guidelines on the management of CAP in adults.Clin Infect Dis 2007; 44:S27-72


Effects of antibiotic administration within 4 hrs of arrivalat the hospital on in-hospital & 30-day mortality *181614121086420OR:0.86OR:0.62Hosp Fine II-III Hospital IV-V 30 days Fine II-IIIOR:0.8730 days FineIV-V< 4h> 4 h*In Medicare patients older than 65 yrs who had not receivedpre-hospital antibiotic therapy (n = 13,771)Houck PM, et al. A retrospective study on Medicare patients.Arch Intern Med 2004;164:637–44


Effects of antibiotic administration within 4 hrs of arrivalat the hospital on in-hospital & 30-day mortality *OR:0.8715% 18 reduction in both in-hospital and 30-day mortality1614121086420OR:0.86OR:0.62Hosp Fine II-III Hospital IV-V 30 days Fine II-III30 days FineIV-V< 4h> 4 h*In Medicare patients older than 65 yrs who had not receivedpre-hospital antibiotic therapy (n = 13,771)Houck PM, et al. A retrospective study on Medicare patients.Arch Intern Med 2004;164:637–44


Treat earlyInitiation of antimicrobial therapy within 4 hrs of arrival at the hospital was associated with a0.4 day shorter mean LOSHouck PM, et al. A retrospective study on Medicare patients.Arch Intern Med 2004; 164:637-44


Guidelines for managing CAPPrinciples of empirical therapy Treat earlyInitiation of antimicrobial therapy within 4 hrs of arrival at the hospital was associated with a0.4 day shorter mean LOSHouck PM, et al. A retrospective study on Medicare patients.Arch Intern Med 2004; 164:637-44In the 2003 IDSA guidelines (also JRS guidelines 2005), initiating antibiotic therapywithin 4 hrs after registration for hospitalised patients was a performance indicator2007 IDSA / ATS Consensus Guidelines: Rather than designating aspecific window in which to initiate treatment, hospitalized patients withCAP should receive the first antibiotic dose in the ED


Guidelines for managing CAPPrinciples of empirical therapy Treat early Cannot reliably differentiate aetiology based onclinical and radiological findings


Guidelines for managing CAPPrinciples of empirical therapy Treat early Cannot reliably differentiate aetiology based onclinical and radiological findings Treat the most likely pathogens– S. pneumoniae (?DRSP*); H. influenzae– Atypicals– Others (co-morbidity and local epidemiology)


Guidelines for managing CAPPrinciples of empirical therapy Treat early Cannot reliably differentiate aetiology based onclinical and radiological findings Treat the most likely pathogens– S. pneumoniae (?DRSP*); H. influenzae– Atypicals– Others (co-morbidity and local epidemiology) Likely antibiotic sensitivity of presumed pathogens


Antibiotic Resistance Issues Resistance to commonly used antibiotics for CAP is majorconsideration in choosing empirical therapy Resistance patterns vary by geography Therefore, antibiotic recommendations must be modifiedbased on local susceptibility patterns


Mandell Mandell LA, LA, et et al. al. IDSA IDSA // ATS ATS Consensus Consensus Guidelines. Guidelines. Clin ClinInfect Dis Dis2007; 44:S27-72 44:S27-72American American Thoracic Thoracic Society Society Guidelines Guidelines Am Am J J Respir RespirCrit CritCare Care Med Med2001; 163:1730-54163:1730-54Risk factors for infection with β-lactam-resistantStreptococcus pneumoniae•Age 65 yrs•β-lactam therapy within the previous 3 months•Alcoholism•Medical comorbidities•Immunosuppressive illness or therapy•Exposure to a child in a day care centreProbably related to greater exposure to antibiotics among these categories ofindividuals and increased selection of antibiotic-resistant strainsMandell LA, et al. IDSA / ATS Consensus Guidelines on the management of CAP in adults.Clin Infect Dis 2007; 44:S27-72


Risk factors for infection with β-lactam-resistantStreptococcus pneumoniae•Age 65 yrs•β-lactam therapy within the previous 3 months•Alcoholism•MedicalRecent treatment comorbiditieswith antimicrobials - the mostsignificant:•Immunosuppressive illness or therapy•Exposure Recent therapy to a or child repeated in a courses day care of therapy centrewithβ-lactams, macrolides, , or fluoroquinolones are riskfactors for pneumococcal resistance to the sameclass of antibioticMandell LA, et al. IDSA / ATS Consensus Guidelines on the management of CAP in adults.Clin Infect Dis 2007; 44:S27-72


Prevalence of penicillin-resistantS. pneumoniae*in 12 Asian countries (1996-1997 1997 and 2000-2001)2001)Asian Network for Surveillance of Resistant Pathogens (ANSORP)China (Beijing, Shanghai)9.8% → 19.8%0% → 23.4%Vietnam28.2% → 20.6%Saudi Arabia32.6% → 71.4%NA → 20.5%NA → 10.3% India3.8% → 7.8%0% → 0%Thailand35.7% → 26.9%22.2% → 26.9%Penicillin-intermediate intermediate (MIC 0.12–1 1 mg/L)Penicillin-resistant (MIC ≥2 mg/L)Malaysia6.0% → 9.1%3.0% → 29.5%Hong KongNA → 24.1%NA → 43.8%South Korea24.3% → 9.7%55.4% → 54.8%* Clinical isolatesTaiwan9.3% → 24.6%29.4% → 38.6%PhilippinesNA → 27.3%NA → 0%Singapore4.9% → 28.6 %18.2 % → 17.1%Song JH, et al. ANSORP. Antimicrob Agents Chemother June 2004; 48:2101-7


Prevalence of penicillin-resistantS. pneumoniae*in 12 Asian countries (1996-1997 1997 and 2000-2001)2001)Asian Network for Surveillance of Resistant Pathogens (ANSORP)China (Beijing, Shanghai)South Korea9.8% → 19.8%24.3% → 9.7%0% → 23.4%55.4% → 54.8%Vietnam28.2% → 20.6%TaiwanSaudi Arabia32.6% → 71.4%9.3% → 24.6%NA → 20.5%Hong Kong29.4% → 38.6%NA → 10.3% IndiaNA → 24.1%3.8% → 7.8%PhilippinesNA → 43.8%0% → 0%NA → 27.3%and 29.4% were penicillin-resistant NA → 0%Thailand35.7% → 26.9%Singapore22.2% → 26.9%IDSA / ATS Consensus Guidelines on the management of CAP in adults. CID 4.9% 2007; → 28.6 44:S27-72 %18.2 % → 17.1%The available data suggest that the clinically relevant level ofMalaysiapenicillin resistance 6.0% is → 9.1% a MIC of at least 4 mg/L3.0% → 29.5%Penicillin-intermediate intermediate (MIC 0.12–1 1 mg/L)Penicillin-resistant (MIC ≥2 mg/L)* Clinical isolatesOverall, 23% of S pneumoniae isolates were penicillin-intermediateFeikin DR,, et al. Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995–1997.Am J Public Health 2000; 90:223–9.Song JH, et al. ANSORP. Antimicrob Agents Chemother June 2004; 48:2101-7


Prevalence of resistance of S. pneumoniae to otherβ-lactamsand erythromycin in Asia Jan 2000 – Jun 2001China (Beijing, Shanghai)Co-amoxiclav2.7%, 7.3%Cefuroxime 4.5%, 19.8%Ceftriaxone 0.0%, 1.1%Erythromycin 0.9%,73.9%South KoreaCo-amoxiclav6.5%, 9.7%Cefuroxime 3.2%, 61.3%Ceftriaxone 3.2%, 3.2%Erythromycin 0.0%,80.6%Jun 2001 ANSORPTaiwanCo-amoxiclav 3.5%, 1.8%Cefuroxime 8.8%, 40.4%Ceftriaxone 1.8%, 0.0%Erythromycin 1.8%, 86.0%VietnamCo-amoxiclav14.3%, 22.2%Cefuroxime 4.8%, 74.2%Ceftriaxone 9.5%, 3.2%Erythromycin 1.6%,92.1%Hong KongCo-amoxiclav0.9%, 3.6%Cefuroxime 10.0%, 50.0%Ceftriaxone 3.7%, 0.0%Erythromycin 0.0%,76.8%IntermediateResistantSong JH, et al. ANSORP. Antimicrob Agents Chemother June 2004; 48:2101-7


Prevalence of resistance of S. pneumoniae to otherβ-lactamsand erythromycin in Asia Jan 2000 – Jun 2001Jun 2001 ANSORPSaudi ArabiaCo-amoxiclav0.0%, 0.0%Cefuroxime 2.6%, 12.8%Ceftriaxone 0.0%, 0.0%Erythromycin 0.0%,10.3%IndiaCo-amoxiclav0.0%, 0.0%Cefuroxime 0.0%, 1.3%Ceftriaxone 0.0%, 0.0%Erythromycin 0.0%,1.3%ThailandCo-amoxiclav0.0%, 0.0%Cefuroxime 1.9%, 36.5%Ceftriaxone 1.9%, 0.0%Erythromycin 5.8%,36.5%IntermediateResistantMalaysiaCo-amoxiclav 2.3%, 0.0%Cefuroxime 2.3%, 29.5%Ceftriaxone 0.0%, 2.3%Erythromycin 6.8%, 34.1%SingaporeCo-amoxiclav0.0%, 0.0%Cefuroxime 5.7%, 28.6%Ceftriaxone 0.0%, 0.0%Erythromycin 2.9%,40.0%PhilippinesCo-amoxiclav 0.0%, 0.0%Cefuroxime 0.0%, 0.0%Ceftriaxone 0.0%, 0.0%Erythromycin 4.5%, 18.2%Song JH, et al. ANSORP. Antimicrob Agents Chemother June 2004; 48:2101-7


Susceptibilities of S. pneumoniae isolates tofluoroquinolones in 11 Asian countries Jan 2000Jan 2000 – Jun 2001China (Beijing, Shanghai)South KoreaTaiwanLevofloxacin 0.0%, 0.0%Levofloxacin 0.0%, 0.0%Levofloxacin 0.0%, 1.8%Gatifloxacin 0.0%, 0.0%Gatifloxacin 0.0%, 0.0%Gatifloxacin 1.8%, 1.8%Moxifloxacin 0.0%, 0.0%Moxifloxacin 0.0%, 0.0%Moxifloxacin 1.8%, 0.0%Ciprofloxacin 3.6%Ciprofloxacin 6.5%Ciprofloxacin 7.0%Saudi ArabiaIndiaHong KongLevofloxacin 0.0%, 0.0%Levofloxacin 0.0%, 1.3%Levofloxacin 0.0%, 8.0%Gatifloxacin 0.0%, 0.0%Gatifloxacin 0.0%, 1.4%Gatifloxacin 0.9%, 8.3%Moxifloxacin 0.0%, 0.0%Moxifloxacin 1.3%, 0.0%CiprofloxacinMoxifloxacin 6.3%, 1.8%2.6%Ciprofloxacin 4.0%Ciprofloxacin 11.8%ThailandVietnamPhilippinesLevofloxacin 0.0%, 0.0%Levofloxacin 0.0%, 0.0%Levofloxacin 0.0%, 0.0%Gatifloxacin 0.0%, 0.0%Gatifloxacin 0.0%, 0.0%Gatifloxacin 0.0%, 0.0%Moxifloxacin 0.0%, 0.0%Moxifloxacin 0.0%, 0.0%Moxifloxacin 0.0%, 0.0%Ciprofloxacin 3.8%Ciprofloxacin 4.8%Ciprofloxacin 9.1%MalaysiaSingaporeLevofloxacin 0.0%, 0.0%Levofloxacin 2.9%, 0.0%Gatifloxacin 0.0%, 0.0%Gatifloxacin 0.0%, 0.0%Moxifloxacin 0.0%, 0.0%Moxifloxacin 0.0%, 0.0%IntermediateCiprofloxacin 4.6%Ciprofloxacin 5.9%ResistantSong JH, et al. ANSORP. Antimicrob Agents Chemother June 2004; 48:2101-7


Multi-drug resistant S pneumoniaeclasses of antibiotics) in 12 Asian countries Jan 2000pneumoniae (i.e., resistance to at least 3Jan 2000 – Jun 2001Overall rate of multi-drug resistant S pneumoniae was26.8%MDR S pneumoniae : 71.4% of isolates from Vietnam 44.9% of isolates from Hong Kong 42.5% of isolates from Korea 30.9% of isolates from TaiwanSong JH, et al. ANSORP. Antimicrob Agents Chemother 2004; 48:2101-7


eofce toeedishedsestiveam.e.,osesaeis astedccalvitro,es.Drug-resistantresistant S. pneumoniae (DRSP) The clinical relevance of DRSP for pneumonia is uncertain Current levels of β-lactam resistance do not generally result inCAP treatment failures when appropriate agents (amoxicillin,ceftriaxone, or cefotaxime) and doses are used (even inbacteremia) There are data to suggest that resistance to macrolides andolder FQs (ciprofloxacin and levofloxacin) results in clinicalfailure To date, no failures have been reported for the newerfluoroquinolones (moxifloxacin and gemifloxacin)Mandell LA, et al. IDSA / ATS Consensus Guidelines on the management of CAP in adults.Clin Infect Dis 2007; 44:S27-72


ERS, ATS 2001 , IDSA 2003 , IDSA/ATS 2007algorithm for CAPCAPOutpatient treatmentInpatient treatmentNocardiopulmonarydiseaseHistory ofcardiopulmonarydiseaseMild to moderateillnessSevere CAPNo modifiers+/- modifiersRisksfor Ps aeruginosaNo C/PdiseaseNoModifier+ C/Pdisease+/orModifierYesNo


CAP: empirical antibiotic therapyIDSA/ATS 2007Empirical antibiotic recommendations have not changedsignificantly from those of previous guidelinesIDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientInpatient, non-ICUPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [strong recommendation, level 1 evidence] orDoxycycline III [weak recommendation, , level 3 evidence]ICUMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IInpatient, non-ICUComorbidities: chronic heart,lung, liver or renal disease;diabetes mellitus; alcoholism;malignancies; asplenia;immunosuppressing conditions oruse of immunosuppressive drugsUse of antimicrobials within theprevious 3 months: an alternativefrom a different class should beselectedICUIncrease thelikelihood ofinfection withDRSP andenteric gramnegativebacteriaMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IInpatient, non-ICUICUMoxifloxacin, gemifloxacin or levofloxacin [750 mg]High-dose amoxicillin 1 g 3 times daily, orhigh-dose amoxicillin-clavulanate 2 g 2 times daily orcefuroxime 500 mg 2 times dailyMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IInpatient, non-ICUIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III [moderate recommendation, level 3 evidence] orβ-lactam+ macrolide III [moderate recommendation, level 3 evidence]ICU


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ alone Iorβ-lactam+ macrolide IICUThe major discriminatingfactor between the 2regimens is the patient’sprior antibiotic exposure(within the past 3 months).Preferred β-lactamsinclude cefotaxime,ceftriaxone, and ampicillin;ertapenem for selectedpatientsMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ alone Iorβ-lactam+ macrolide IICUPreferred β-lactamsinclude cefotaxime,ceftriaxone, and ampicillin;ertapenem for selectedpatientsMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ alone Iorβ-lactam+ macrolide IICUPreferred β-lactamsinclude cefotaxime,ceftriaxone, and ampicillin;ertapenem for selectedpatientsDoxycycline is analternative to the macrolide[level III evidence]Mandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ alone Iorβ-lactam+ macrolide IFor penicillin-allergicpatientsRespiratory FQ IICUMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ Iorβ-lactam+ macrolide IFor penicillin-allergicpatientsRespiratory FQ IICUFor all patients admitted tothe ICU, coverage for S.pneumoniae and Legionellaspecies should be ensuredby using a potentantipneumococcal β-lactamand either a macrolide or aFQMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA / ATS Consensus Guidelines on the management of CAP in adults. Clin Infect Dis 2007; 44:S27-72Most common microbial aetiologies of CAPOutpatientS. pneumoniaeM. pneumoniaeH. influenzaeC. pneumoniaeRespiratory virusesInpatient(non-ICU)S. pneumoniaeM. pneumoniaeC. pneumoniaeH. influenzaeLegionella speciesAspirationRespiratory virusesInpatient(ICU)S. pneumoniaeLegionella spp.H. InfluenzaeEnterobacteriaceae spp.Staph. aureusPseudomonas spp.A review of 9 recent studies (that included 890 patients with CAP admitted to the ICU):the most common pathogens in the ICU population were (in descending order of frequency)S. pneumoniae, Legionella species, H. influenzae, Enterobacteriaceae species, S. aureus,and Pseudomonas species.The atypical pathogens collectively account for 20% of severe CAP episodes. The dominantatypical pathogen in severe CAP is Legionella.File TM. Community-acquired pneumonia. Lancet 2003; 362:1991-2001


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ Iorβ-lactam+ macrolide IFor penicillin-allergicpatientsRespiratory FQ IICUThe recommendedstandard empiricalregimen should routinelycover the 3 most commonpathogens that causesevere CAP, all of theatypical pathogens, andmost of the relevantEnterobacteriaceaespecies.Mandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ Iorβ-lactam+ macrolide IFor penicillin-allergicpatientsRespiratory FQ I*β-lactamcefotaxime, ceftraxone,ampicillin/sulbactam,ICUβ-lactam* + azithromycin IIorβ-lactam* + respiratory FQ IMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ Iorβ-lactam+ macrolide IFor penicillin-allergicpatientsRespiratory FQ IICUβ-lactam* + azithromycin IIorβ-lactam* + respiratory FQ IFor penicillin-allergicpatientsRespiratory FQ + aztreonamMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ Iorβ-lactam+ macrolide IFor penicillin-allergicpatientsRespiratory FQ IICUβ-lactam* + azithromycin IIorβ-lactam* + respiratory FQ IFor penicillin-allergicpatientsRespiratory FQ + aztreonamIf Pseudomonas is aconsideration IIIAnti-pneumococcalpneumococcal, , anti-pseudomonal β-lactam(piperacillin-tazobactam, cefepime,imipenem, , or meropenem) + eitherciprofloxacin or levofloxacin(750 mg) orMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ Iorβ-lactam+ macrolide IFor penicillin-allergicpatientsRespiratory FQ IICUβ-lactam* + azithromycin IIorβ-lactam* + respiratory FQ IFor penicillin-allergicpatientsRespiratory FQ + aztreonamIf Pseudomonas is aconsideration IIIAnti-pneumococcalpneumococcal, , anti-pseudomonal β-lactam+ aminoglycoside +azithromycin orMandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ Iorβ-lactam+ macrolide IFor penicillin-allergicpatientsRespiratory FQ IICUβ-lactam* + azithromycin IIorβ-lactam* + respiratory FQ IFor penicillin-allergicpatientsRespiratory FQ + aztreonamIf Pseudomonas is aconsideration IIIAnti-pneumococcalpneumococcal, , anti-pseudomonal β-lactam+ aminoglycoside + anti-pneumococcal FQ (forpenicillin-allergic patients,substitute the β-lactamwithaztreonam)Mandell LA, et al. Clin Infect Dis 2007; 44:S27-72


IDSA/ATS Consensus Guidelines on the management of CAP in adultsSite oftreatmentIDSA /ATSGuidelines2007Recommended empirical antibiotics for CAPOutpatientPreviously healthy andno antimicrobial usewithin previous 3 mthsMacrolide I [level 1 evidence] orDoxycycline III [level 3 evidence]Presence ofcomorbidities orantimicrobial use withinprevious 3 mths or otherrisks for DRSP infectionRespiratory FQ I orβ-lactam+ macrolide IIn regions with high rate(>25%) of infection withhigh-level (MIC >16 µg/mL)macrolide-resistant S.pneumoniaeRespiratory FQ III orβ-lactam+ macrolide IIIInpatient, non-ICURespiratory FQ Iorβ-lactam+ macrolide IFor penicillin-allergicpatientsRespiratory FQ IICUβ-lactam* + azithromycin IIorβ-lactam* + respiratory FQ IFor penicillin-allergicpatientsRespiratory FQ + aztreonamIf Pseudomonas is aconsideration IIIAnti-pneumococcalpneumococcal, , anti-pseudomonal β-lactam+ aminoglycoside + anti-pneumococcal FQ (forpenicillin-allergic patients,substitute the β-lactamwithaztreonam)If CA-MRSA is aconsiderationAdd vancomycin or linezolid III


2007 IDSA / ATS Consensus GuidelinesDuration of antibiotic therapy Patients with CAP should be treated for a minimum of5 days (level I evidence) Before discontinuation of therapy- should be afebrile for 48–72 h- should have no more than 1 CAP-associated sign ofclinical instability (level II evidence)Criteria for clinical stabilityTemperature 90 mm HgArterial oxygen saturation > 90% or pO 2> 60 mm Hg on room airAbility to maintain oral intake*Normal mental status*


Adjusted OR for 30-day all-cause mortality plotted againstcompliance with guideline-recommended antibioticsat Intermountain Healthcare hospitalsAdjustedOR for30-dayall-causemortalityCircle area reflects the number of admissions per hospitalThe odds of mortality are 0.92 (p = 0.007) foreach 10% increase in complianceDean, N. C. et al. Chest 2006;130:794-799


Any advantages in following guidelines? Reduction in hospital admission rate Shortens length of hospital stay (LOS) Reduction in in-hospital and 30-day mortality ? Help control bacterial resistance in thecommunity (minimise use of excessive antibiotics and improvesaccuracy of therapy) – However, the impact of guidelines onresistance remains to be shown


THANK YOUliamck@ummc.edu.my

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