Management of CAP :

Recent Guideline in Daily Practis

Soedarsono

Department of Pulmonology
Faculty of Medicine, Airlangga University
Dr. Soetomo General Hospital, Surabaya

Current important issue in the management of

RTI
DEMOGRAPHY ;
PHYSICAL
FINDINGS

NEW and
RESISTANT
PATHOGEN

IDENTIFICATION
RISK FACTORS

MANAGEMENT

COMORBIDITY ;
LABORATORY

COST
EFFECTIVE
CARE

OUTCOMES
2

Numerous National Societies :

Recommendations for
the Management of CAP
ATS guidelines 1993 revised in 2001
IDSA guidelines 1998 revised in 2000
updated 2003
Canadian guidelines 1993
BTS guidelines 1993 updated 2004
3

Treat as
outpatient
or inpatient
EXTREMELY
IMPORTANT DECISION
- Nature of investigational tests
- Type & route of drugs selected of
treatment
- Cost of care
4

T
N
E
I
T
A
P
N
E
WH
P
A
C
?
D
WITH
E
Z
I
L
A
T
I
HO S P

PNEUMONIA SEVERITY INDEX (PSI)

vs OTHER CLINICAL JUDMENT
5

Computation of risk score (Pneumonia Severity Index)

Demographics

History &

Laboratory

Physical find.
Age = years (male)
Age = years 10 (female)
Nursing home resident (+10)

Neoplasia (+30)
CHF (+10)
Renal disease (+10)

pH (+30)
BUN (+20)
Na (+20)

Liver disease (+20)

Glucosa (+10)

Cerebrovasc. Dis. (+10)

Ht (+10)

Pulse (+10)
The Pneumonia Patient Outcomes Research Team (PORT)
Blood pressure (+20)

pO2 (+10)
Effusion (+10)
6
Fine MJ, 2000

STRATIFICATION OF RISK
SCORE FOR CAP
Risk Risk Class Based on

Recommendation

for site of care

Low

Algorithm

Low

II

70 total points

Outpatient
Outpatient

Low
III
71-90 tot. points
Inpatient
Moderate IV 91-130 tot.points
Inpatient
High

< 130 tot. points

Inpatient

Mortality : I (0,1%) ; II (0,6%); III (2,8%) ; IV ( 8,2%) ; V (29,2%)

8

Fine et al. NEJM 1997 336 : 243-250

Controversial in PSI
Atlas et al (1998); Marrie et al
(2000) :
Physicians often disregard &
frequency
hospitalized low risk patients
Arnold FW et al (2003) :
The PSI not be used as the
9

Any of :
Confusion*
Respiratory rate 30/min
Blood pressure (SBP < 90mmHg or DBP 60mmHg)
Age 65 years
Score 1 point for each feature present

CRB-65
score

Likely suitable for

Home treatment

1 or 2

Consider hospital
referral

3 or 4

Urgent hospital
admission

Defined as a Mental Test Score of 8 or less, or new disorientation in person, place or time

Severity assessment used to determine the management of CAP in

patients in the
community(CRB-65 score) UPDATED 2004

10

Any of :
Confusion*
Urea < 7 mmol/l
Respiratory rate 30/min
Blood pressure (SBP < 90mmHg or DBP 60mmHg)
Age 65 years
Score 1 point for each feature present
0 or 1

CURB-65
score

Consider hospital

Likely suitable for

Supervised treatment
Home treatment

3 or more

Manage in hospital as
Severe pneumonia

Options may include

Assess for ICU
a.Short stay in-patient Admission especially if
b.Hospital supervised CURB-65 score = 4 or 5
out-patient

* Defined as a Mental Test Score of 8 or less ,or new disorientation in person, place o

Severity assessment used to determine the management of CAP in

patient
11
admitted to hospital (CURB-65 score) UPDATED 2004

CAP
(The Indonesian Association of
Pulmonologists)
PORT score < 70
PORT score < 70 if one or more upon this
- respiratory rate <30/ min
- Pa O2 < 250 mmHg
- Bilateral involvement with more than
2
lobes
- Systolic pressure < 90 mmHg
- Diastolic pressure < 60 mmHg
Pneumonia drug abuse
12

 Take patients medical history &

do physical examination
Order chest radiograph to
support of CAP
Evaluate patient for possible
hospital admission

Outpatient Treatment

Hospitalize Patient

Assess patient for

cardiopulmonary disease and
modying factors

Measure oxygen saturation levels

Order chemistry profile, complete
blood cell count, blood cultures, and
sputum Gram stain and culture

Ann Intern Med 2005; 143: 881-894

13

Hospitalize Patient
Measure oxygen saturation levels
Order chemistry profile, complete
blood cell count, blood cultures, and
sputum Gram stain and culture
Mild to moderate illness

Severe illness

Admit patient to
general medical floor

Admit patient to
intensive care unit

Assess patient for risk

factors for drug-resistant
Streptoccocus pneumoniae
& enteric gram-negative
pathogens

Assess patient for risk

factors for Pseudomonas
infection
Ann Intern Med 2005; 143: 881-894

14

Summary of Guideline Recommendation for the Initial Site

of Treatment & Processes of Care for Patients with CAP

Ann Intern Med 2005; 143: 881-894

15

Summary of Guideline Recommendation for the Initial Site

of Treatment & Processes of Care for Patients with CAP

Ann Intern Med 2005; 143: 881-894

16

Summary of Guideline Recommendation for the Initial Site

of Treatment & Processes of Care for Patients with CAP

Ann Intern Med 2005; 143: 881-894

17

The Indonesian Association of

Pulmonologists Guidelines CAP- Outpatient
Without modifying factors
-lactam or -lactam + -lactam inhibitor

With modifying factors

-lactam + -lactam inhibitor or respiratory

fluoroquinolone (levofloxacin, moxifloxacin,
gatifloxacin
Note : suspect atypical : + New macrolide
(roxithromycin,clarithromycin, azithromycin)

18

The Indonesian Association of

Pulmonologists Guidelines CAP-Inpt (Ward)
Without modifying factors
-lactam + -lactam inhibitor iv or
2nd G, 3rd G Cephalosporin iv or
Respiratory fluoroquinolone iv
With modifying factors
2nd G, 3rd G Cephalosporin iv or
Respiratory fluoroquinolone iv
Note : suspect atypical : + New macrolide
(roxithromycin, clarithromycin, azithromycin)

19

The Indonesian Association of

Pulmonologists Guidelines CAP - ICU
Non Pseudomonas
3 rd G Cephalosporin non pseudomonas iv + New
macrolide or respiratory fluoroquinolone iv

Pseudomonas

antipseudomonal Cephalosporin iv or carbapenem +

antipseudomonal fluoroquinolone (ciprofloxacin) iv or
aminoglycoside iv
Suspect atypical : antipseudomonal Cephalosporin iv or
carbapenem + aminoglycoside iv + new macrolide or
respiratory fluoroquinolone iv

20

Preferred and alternative initial empirical treatment regimens and

parenteral to oral switch regimens for community acquired pneumonia
UPDATED BTS 2004

PREFERRED

ALTERNATIVE

(1) Home-treated,not severe

amoxicillin 500mg-1.0 g tds po erythromycin 500mg qds po or
clarithromycin 500mg bd po
(2i) Hospital-treated,not severe
[admitted for non-clinical reasons or
previously untreated in the community]
As under Home-treated ,not severe
(2ii) Hospital-treated,not severe
Either oral Amoxicillin 500mg-1.0 g tds po Fluoroquinolone with enchaned
plus erythromycin 500mg qds po or pneumococcal activity
clarithromycin 500mg bd po e.g.levofloxacin 500mg od OR moxiOr if IV needed, ampicillin 500mg qds iv or floxacin 400mg od po (the only such
benzylpenicillin 1.2g qds iv licensed agents in UK at time writing)
plus erythromycin 500mg qds iv or
levofloxacine 500mg od iv
clarithromycin 500mg bd iv

21

PREFERRED ALTERNATIVE
(3) Hospital-treated,severe
co-amoxiclav 1.2 g tds iv
Fluoroquinolone with
or cefuroxime 1.5 g tds iv or
enhanced pneumococcal
cefotaxime 1 g tds iv or
activity
ceftriaxone 2 g od iv
eg. Levofloxacin 500 mg bd iv or po
plus erythromycin 500 mg
plus
qds iv or clarithromycin 500mg benzylpenicillin 1.2 g qds iv
bd iv
(with or without rifampicin
600mg od or bd iv)

22

CAP: Empiric Therapy Principles

TREAT EARLY consensus in
guidelines
TREAT MOST LIKELY
PATHOGENS
Consider :
Local antibiotic resistance patterns
Infection incidence data
Patient demographic features
We cannot differentiate the etiology reliably based only on clinical findings
ATS. Am J Respir Crit Care Med. 2001;163:1730-1754; Bartlett
23
JG, et al. CID. 2000;31:347-382; Heffelfinger JD, et al. Arch Intern
Med. 2000;160:1399-1408.

Why would anyone ever use empiric

treatment ?
The pathogen : difficulty
in finding pathogen
Limitations
of diagnostic
testing

EMPIRIC
Bact. profile
Resistance pattern

The
diseases itself
mortality

30-60 % no identifiable
pathogens
Mandell LA. Clinics in Chest Medicine 1999; 20 : 589-598

24

What is Appropriate
Antimicrobial Therapy?
The chosen antimicrobial agent is:
on the formulary
in the treatment guideline or clinical pathway
The pathogen is:
susceptible to the antimicrobial agent
The patient:
is not allergic to the prescribed antimicrobial
agent
has not had a previous adverse event to the
prescribed agent
Paladino, 2004 25

Other factors to consider in

defining appropriate therapy
l
l
l
l
l
l
l
l

Microbiologic data
Monotherapy vs combination thpy
Dose and dosing frequency
Penetration
Timing
Toxicity
Risk of influencing resistance
Prior antibiotic use

Kollef MH. Clin Infect Dis 2000;31(Suppl 4):S131-S138.

Ibrahim EH et al. Chest 2000;118:146-155.
26

HEALTH ECONOMICS
STREAMLINING
COMBINATION

MONO-TX

PARENTERAL

BROAD

ORAL

NARROW SPECTR.

DOSE REDUCTION
27

COMBINED
ONLY INDICATION:
IF NO SINGLE AGENT
COVERS ALL PROBABLE
PATHOGENS

MONO IS PREFERED :
LESS
LESS
LESS
LESS

DRUG INTERACTION
ADVERSE EFFECTS
EXPENSIVE
CHANCE OF FORGETTING

MONO TX
CAP
(ATS-guideline)
BETA LACT.
+
MACROL

COVERED by
MONO

RESPIR.QUIN !!
28

SWITCH THERAPY

REPLACING A PARENTERAL
ANTIBIOTIC WITH AN EFFECTIVE
ORAL ANTIBIOTIC IN THE TREATMENT
OF A SERIOUS INFECTION.
Rhew DC , Weingarten SR. The Medical Clinics of North America 2001;Vol 85 : 1427-1440
29

Community-Acquired Pneumonia
High risk
High Risk Pneumonia
- IV antibiotic treatment
- Hospital admission
Complicated pneumonia
- Prolonged IV antibiotic
treatment
Continued instability

Low risk
Low Risk Pneumonia
- Oral antibiotic treatment
- Out patient therapy
Unstable Pneumonia
- IV antibiotic
treatment
Observation
24 - 72 hours

Clinical Stability
Siegel RE. Strategies for early discharge - Rapid switch to oral antibiotic
of the hospitalized patient with CAP.
- Hospital discharge 30
Clinics in Chest Medicine . 1999

CRITERIA: IV to ORAL

STABLE CLINICAL
CONDITION

IMPROVING COUGH & S.O.B.

AFEBRILE < 8 hrs
NORMALIZING WBC
ORAL INTAKE & G.I.
ABSORPTION :
ADEQUATE
RAMIREZ J.A.: 21 st IUATLD, MANILA, 2001
31

GOAL

SWITCH day 3
DISCHARGE day 4

I.V.
to
ORAL
SWITCH

SWITCH
THERAPY

SEQUENTIAL STEP-DOWN
THERAPY
THERAPY
32

VARIOUS TERMS USED TO DESCRIBE CONVERSION

FROM PARENTERAL TO ORAL ANTIBIOTICS

TERMS

DEFINITION

Switch therapy

Conversion from parenteral therapy with 1

drug to an oral formulation of a different
medication, without losing potency (e.g., IV
ceftazidime to oral ciprofloxacin)

Sequential therapy Conversion from IV to oral formulation of the

same medication (maintaining equivalent
potency) (e.g., levofloxacin, gati, moxi)
Step-down therapy Conversion from an IV to an oral agent of the
same class or different class of agent, with
reduction in potency (e.g., IV cefuroxime to
oral cefuroxime axetil)
33
Rhew DC , Weingarten SR. The Medical Clinics of North America 2001;Vol 85 : 1427-1440

5 - 14 days
DURATION of TREATMENT
SHORT TREATMENT
CLINICAL CURE
RESISTANCE
(dead bugs do not mutate)

BACTERIAL
ERADICATION ?

34

CRITERIA FOR DETERMINING THE

APPROPRIATENESS OF DISCHARGE
Patients vital signs are stable for 24-hour periode
Patient is able to take oral antibiotics
Patient is able to maintain adequate hydration and
nutrition
Patients mental status is normal (or at his/her base-line
level)
Patient has no other active clinical or psychosocial
problems requiring hospitalization

Halm EA, Teirstein AS. NEJM 2002 ; 347 : 2039-45

35

An updated of the IDSA

2003 guideline for
management CAP

Discharge criteria during

24 hours to discharge to
home patients should not
have more than 1 of the
following:
- elevated temp < 37,80
C
- pulse < 100/ minute

36

SUMMARY
Severity assessment

n the key to deciding the site of care

l guiding both general management & antibiotic
treatment

Empiric therapy : early & appropriate

Variations among the guidelines usually
depends on when the guideline were released
Management CAP daily practice in Indonesia
The Indonesian Association of
Pulmonologist Guidelines 2003 ATS
2001/IDSA 2000 guidelines

37

Thanks
for
Your

38