Delay to ICU Admission in SCAP

Delay to ICU Admission in SCAP
> 6 hrs at ED vs. < 6 hrs at ED
A cross-sectional study using the IMPACT database
(a multicenter บ.ร database of ICU patients 200-03)
DEL
Non-DEL
(ท = 1036) (ท = 49286) p Value
Age, yrs 57.4 ± 19.7 58.4 ± 19.8 .10
Gender, % male 54.3 54.0 .82
DNR, % at admission 0.1 0.1 .61
Any advance directive, % 17.0 15.3 .14
APACHE IIs 16.3 ± 8.3 15.7 ± 8.1 .08
DEL
Non-DEL
1 เ
l (ๆ H

Chalflin DB et al.Crit Care Med 2007;35:1477-83
Conclusion on
Initial Site of Care
Admission assessment
Busy OPD/ER/Clinic
…using CURB-65 or CRB-65…
Non-busy OPD/ER lab availability
…using PSI…
SCAP need ICU admission
…by using modified ATS 2007criteria…
Rapid transfer from ED to ICU
The last but not the least
Presence of sepsis/social factors/psychogenic factors
& Physician instinct

Developed severe sepsis
Genetic
Domain
Mif-173C
10.1 ^0.0
Biomarker
Domain
TNF; IL-6 ;IL-10; pet
Clinical
Domain
Severe lung disease/age co-morbid itiy Antibiotic Rx non-antibiotic Rx
นIQ no]
eiop severe sepsis
Discharged from ED
60 120 180 240 300 360
Days from enrollment
Precaution for CURB-65 application for Hospitalization
Subsequent Evaluation
(by written- or witness- advice/telephone Visit/Home visit)
Is very important
Especially during the first 24-72 hr

Early treatment failure
Defined as = on D3 of Rx
With presence of any one of the followings

Prognostic Factors for Early Treatment Failure
A multivariate analysis
Table 2. Characteristics of patients included in the study
Characteristic
K IS ponder Early failure
n – 180 It= 80 OR 95% Cl p
Age
Pneumonia severity index score APACHE score Glasgow coma score Female gender Nursing home Mental slate change
Pleural effusioo X-ray Temperature <35°c or >K):’C
Syst๗ic BP <90 mm H»
67,9(16.0%) 69.15 (16พ) 1.01 1.00-1.02 0.57 1083 (23.9%) 123.9(26.2%) 1.03 1.01-1.04 <0.001
13.3(4.4%) 14.il (5.1%)
14.7(1.1%) 14.4(1.1%)
57(32%) 23(29%)
5(3%) 4(5%)
39 (22%) 36 (45%)
Heart rate >125/๗ท
Respiratory rate >3d/min
Arterial PaH <7.35 mm Hg
Arterial Pallh <60 mm Hg
PaOj
PH
Systolic blond pressuir Temperature Respiratory rate Heart rate Medical history’
Chronic heart failure Neoplasm
Cerebrovascular incident Kidney disease
1.07 1.01-1.13 0.03
0,80 0.62-1.02 0.07
0.87 0.49-1.55 0.69
1.80 0,48-7.05 0.37
2.% ไ.^-ว.21 <0.(M
รพ 17%» 17๓»/.) พ ttuam
J’able 5. Results of multivariate analysis
Cli a rac LerlsL L-c ExpCB) 95%CI p
A lie red menial status Arterial PaH Hearl failure 3.19
429
030 1 .75-5JS0 1 53-12.05 0.10-0.96 <O.OOl
0.006
0.04
Arterial L75 TTES
1
27(15%) 4(5%) 0.30 0.10.0.88 0.03
44(24%) 1# (23%) 1.00 0.98-1.02 0.73
13(7%) 7(9%) 1.02 0.93-1.12 0.67
17(9%) 6(8%) 0.98 0.89-1.08 0.61
Hoogerwerf M. Clin Microbiol Infect 2006;12:1097-1104

Initial Evaluation of CAP
The two most important steps for a good outcome
HOME WARD ICU
How to consider
for etiologic agent coverage?

Initial antibiotic regimen
started at ED or <4 hrs

Recommended Atb. treatment options
^ ATS/IDS A 2007 guidelines ; ERS-ESCMID guideline 2005
|)pAP
Initial oral antibiotic
e.g. oral resp. cephalosporin/Amoxicillin/macrolide/FQ
IPD (MODERATE) CAP
Initial systemic antibiotic
e.g. Ceftriasone + macroiide or FQ monotherapy Switch to the oral antibiotic
e.g. oral resp. cephaiosporin/macrolide
IPD (SEVERE) CAP
Initial systemic antibiotic
e.g. No p.aeru risk: Ceftriasone + macroiide or + FQ
p.aeru risk: Anti-pneumo,anti-pseudo B-lactam + CPX or LVXor + AMG
How about the other risks?
CA-MRSA;CA-A.baumannii; Influenza active; Scrub typhus, TB pneumonia, Melioidosis, Leptospirosis,etc

CAP-Etiologic Agents
In Thailand
Is it the same spectrum as worldwide reports?
Pre- Novel Influenza epidemic era
2002-2005

Can we use the IDSA/ATS 2007 guideline antibiotic
without any modifications?

CAP Etiology เท BBAgkok
(j (Sep1998-Apr2000)
เท? 3 hospitals(i university 1 private 1 community)
^ OPD(N=98)
I ■ ‘ 29.6 IPD(N=147)
%
13.3
13.3
*p<0.001
Spn
Cp
Mp
Lp
GNB Mixed
Wattanathum A et al. Chest 2003;123:1512-91
In Bangkok
CAP-Etiologic Agents
It seem to be the same spectrum as worldwide reports

CAP Etiology in Northeast
IPD(N=254)** SCAP(N=62)***
31 8 Retrospective chart review
_ 29.4
* Reechaipichitkul พ, et al. Southeast Asian J Trop Med Public Health 2005(in print)
**Reechaipichitkul พ. et al. Southeast Asian J Trp Med Public Health 2005; 26: 156-61
***Reechaipichitkul พ. et al. Southeast Asian ช Trp Med Public Health 2004; 35: 430- 3
In Northeast
CAP-Etiologic Agents
to be the same spectrum as worldwide report
Except
in Severe CAP/Hospitaiized CAP The ร. pseudomallei pneumonia
napH Kp cprjoiKlv ronrerned
(The mostionรร5™๔“mmon cause)

 
In Northeast
CAP-Etiologic Agents
to be the same spectrum as worldwide report
Except
in Severe CAP/ possibly Hospitalized CAP
The Endemic organisms, especially Scrub typhus pneumonia, Tuberculous pneumonia
need be seriously concerned
Impact of Endemic Agents of CAP
On Initial Empirical Antibiotic Guideline
Chaidiarn Pothirat 75th Western meeting of JAID 2005

1JbRecommended Atb. treatment options
jS? ATS/IDS A 2007 guidelines ; ERS-ESCMID guideline 2005
ชุ^nitial oral antibiotic
^ e.g. oral resp. cephalosporin/Amoxiciilin/macrolide/FQ
IPD (MODERATE) CAP
Initial systemic antibiotic
e.gj Ceftriasone ± macro tide far FQ monotherapy Switch to the oral antibiotic
e.g. oral resp. cephalosporin/macrolide
IPD (SEVERE) CAP
Initial systemic antibiotic
e.g. No P.aeru risk\ Ceftriasone + macroiide Ior + FQ
p. aeru risk: Anti-pneumo,anv-pseudo b-lactam + CPX or LVXor + AMG
How about the other risks?
CA-MRSA;CA-A.baumannii; Influenza active; Scrub typhus, TB pneumonia, Melioidosis, Leptospirosis,etc
Combination Therapy in CAP
Who need? Why need?
The evidences

Meta-analysis ofRCTs comparing
p-lactam vs Agent active against atypical pathogens
Outcome =Failure to achieve clinical cure
Macrolides
Mao-Dlldeoi telolISs Eiymianycri11
NO falling 10 acnlare cllnltal Dire
nrlmprmsmml’Ki) receding diug
Jiilltiln lies aillve 39a ins I
ar/pltal pamogens
R Blame nstiiirad’i
(95S,CI)
T
Test lor heterogmeit/: x^-aag. UI^P-O.IS, TKttorOVeralemti 5.12a P-0.33
Aztthronqcl ท11 T«lltoromrehJ< Sublalil |95V= Oil
p lactam
aolllilollis
นโร.15
weigm Raiattw list HUM I rs] imcii
225 1.12 (062 10208)
OjOS 6.0c (0.30 to 121.8}
73ว่ OJB (04310 1.01)
966 0,51,058 to 1.14
Quinolones
Quinolones
vs.
Macorlides
Mills et al 6MJ2005;330:456-460
oulnaune
TetralfcMtin^ 19123 24*’120 ■— 4.07 0.77,0.45101.335
Sparta: เท 26.156 2S1J0 1 421 1.071)a® 101.78)
QpiEllaxdn14 17,107 201*110 * 330 0£7 (048 to 1.58)
GrapfltaiclT* 2?.ฯ14 2&’111 4.41 1.01 «.63 to 1.62)
Lewlfcorin Qinpitilalial) ฬ! 4/41 ■- 059 0.75 (122 to 2.51)
นพท*!๙’ 6S34B 24.‘168 HI— 5.42 125(181101.521
stall®* ท^ 46,168 4J,’162 8.02 0.94. (067101.331
SreHffwjch t’lupudlsiirfi 72235 »‘240 10.94 1.11.0.54 to 1.48)
TrorafliHKln8 11,162 1&ฯ80 1— 2.94 0.54,0.31 to 1.32)
ผทท:# I ■: ท”: 30228 arm 7|01 0.71,0.4810 1.10)
GreMtl:«iCh I’uiDublstirii S&190 31,’100 533 1.10,0.71 to 1.70,
MmdnoKieti13 27,200 <Bim 6>J5 0.7s 10.48 to 1.20)
Gsmltotadn11, 24.167 •ร/153 *- 437 0.55,0.3 to 1.47)
GammonIIIIPJDIMI 8&’b19 72532 11.91 122(0.92101.63)
Subtolil (SEfA Cli 2782 2=83 1 \ 78.9S 0.99,0.58 to1.11)
Ttsl tor heteraflพส์เy:x’-l0i5i, 01-13, P-Q.t5, lJ-0S.
TKI tor overai ervtt 1.030, p-0 81
Oulnobne or matrollite
Stall main or er/lhrom^tf 191,«99 4๓99 1137 0.96 (0.71 to 1.28)
sumotu \<&k CII 609 188 ♦ 1137 0.95,0.71 to 1.3)
TRI tor heterogeneity: net astKitts
Ttstlorowral tffect 1-033, P-0.74
Tohl (96% Cl) 3881 3088 { * moo 0.97 ,0.37 to 1.07)
Total events; 667(irrtlDWIcs act».>0 agamsl jljirlMl pihcqffls).
S6i เ:^ Udam dirtibloiH»i 0.1 0.2 0.5 i 2 5 10
Ttsl tor heterogeneity:dl.17, p.0,56, ,’;.0S. fj,01115 Jirtflirtfcs .rilve Fiwursplistim
Te6l1orowral eftett 1-0.65, F-0.S2 igSna^pfalpiDioflws arttofctfci

Shidy
KiWAMVTf/ [1$]
MACFAHIANE [17] OOhOlVITZ|t1]
O’O0K«ty|14]
SA^VAHIOIAIIS)
PETrn>wETz[1J]:
Cvorai
Atypica
SF$**ty|18J RMaR£z|19) hOtfFttM |12| Gotfhico [ฉ่เ Scmcx |20|
Overall
Macrolides vs. Qiiiinolones
%,«12,, . FOCAftTrflQ]
Overall
Cephalc 4
I
«
4

1
i
1
sporins vs. BL/BLI
DJ 1.0 1,ร RR

The RCT-meta-analysis
Clinical success / OPDRxCAP
Maimon et al.ERJ2008;31:1068-76

30 days mortality and initial antibiotics in non-ICU inpatient
A retrospective cohort
Odd ratio
One side: prefer to combat to
atypical pathogen?
Favours monotherapy
Favours dual therapy
Gleason 1999
Dudas 2000
Houck2001
Arch Intern Med. 1999; 159:2562-2572 Ann Pharmacother 2000; 34:446-52 Chest 2001; 119;1420-1426
MORTALITY AND INITIAL ANTIBIOTIC
A meta-analysis RCTs of Adults with hospitalized CAP
0 I Favours Non-atypical
! f– 1.1.11*
1 T Favours Atypical
‘///yy?/s
พ////’/
Robenshtok et al Cochrane Database of Systematic Reviews 2009;iss 3:CD004418

Mortality เท jBacteremic Pneumococcal Pneumonia
f A retrospective studies
Favor monotherapy
0.33(0.13-0.83)
0.4(0.17-0.92)
0.23(0.07-0.74)

Fgtvor combination therapy
Waterer 2001 Martinez2003 Weiss2004
Arch Intern Med2001;161:1837-1842
CID 2003;36:389-395
Can Resp J 2004;11:589-593

Probability of survival j
A Comparative Survival of Non-Critically Ills Bacteremic Pneumococcal Pneumonia
A prospective observational study
Combination therapy, ท=155
Monotherapy, ท=343
Days post blood culture
Criterion
Points
Fever (oral temperature) ==35°c or s=40°c
35.1- 36.0“C or 39.0-39.9’C
36.1- 38.9°c
Hypotension Acute hypotensive event with drop in systolic blood pressure > 30 mm Hg and diastolic blood pressure > 20 mm Hg
Requirement for intravenous vasopressor
agents
or
Systolic blood pressure <90 mm Hg Mechanical ventilation
Cardiac arrest Mental status Alert
Disoriented
Stuporous
Comatose
* All criteria are graded within 48 hours before or on the day of first positive blood
culture The highest point soore during that time is recorded.
Baddour et al. Am J Respir Crit Care Med 2004; 170: 440-444

A Comparative Survival of Critically Ills Bacteremic Pneumococcal Pneumonia
A prospective observational study
1,0
0.8
is 0 6
1 04 CL 0.2
Combination therapy, ท=47
otherapy, ท=47
0 7 14 21 28 35
Days post blood culture
Baddour et al. Am J Respir Crit Care Med 2004; 170:440-444

Antibiotics for Bacteremic Pneumonia Improved Outcomes With Macrolides but Not FQs
Odd ration 30-day mortality
30-Day Mortality •Macroiide 0.61(0.43—0.87) •Quinolone 0.82(0.62—1.07) •Tetracycline 1.28(0.42—3. 92)
Metersky. Chest 2007; 131,466-473
Impact of macrolide therapy in mortality for patients with severe sepsis due to pneumonia
30 days mortality
90 days mortality
34%
29% p=0.001
12%

– macrolide X non macrolide
Restrepo et al. Eur Res J 2009; 33:153-159

0
3 t*0-
0.9 – 0.8 0.7 –
0,0 – 04
20 40 60 Tim« days
SO
Culture pos
I
15 4{} 65 IS”
Time days
100
: ro macrcfodes;
mac ‘นิ de-3
bj
I

0
«*) 1,0 ๅ
I
f
I
0.8 –
0.6-
0.4 J
20 40 60
Time days
80
Macrolide resist
iSo ร ร iB is 3) &
Restrepo et al. Eur Res J 2^5^33; 153-159

Effect of combination therapy
with B-lactam and macroiide drugs
Hospitalized patients with CAP
Addition of a Macroiide to the B-lactam
Decreased Patient Mortality
Inf
Atyj ว Jrr au.3|Jens Atyp ^๒เ^๒^^
Syn
Anti nation Anti-inflammatory Beneficial Effect
Nowadays, CAP in Thailand
Don’t forget to suspect
SARS-Corona virus
Avian Influenza
Human Seasonal Influenza
Novel H1N1 Influenza
And the other
Newly Emerging causative agents in the near future
CAP-Etiologic Agents
In Thailand
same spectrum as worldwide reports?
Pre- Novel Influenza epidemic year 2007
Vs.
Novel Influenza epidemic year 2009( July-Oct)
Can we use the IDSA/ATS 2007 guideline antibiotic
without any modifications?

Impact of Influenza2009 epidemic Agents
\f)ท Initial Empirical Antibiotic Guideline for CAP
‘ Antibiotic treatment Protocol
Ceftriazone
+
Azithromycin or Doxycycline

yg f Atb. As 2007
I +
Oseltamivir

Novel vs. Seasonal Influenza
CAP
CHEST CMU-CAP Study’ ,
iM
ะ, A
*
T’ & L
1 [V ใ -4*01
•- -V ‘ I
Impact of Bacterial Agents of CAP
On Initial Empirical Antibiotic Guideline
Agents/Resistant pattern
Chaidiarn Pothirat 75th Western meeting of JAID 2005

Antimicrobial treatment failure in CAP
215/1424 (15.1%) no response to Atb 134(62.3%) early failure 81(37.7%) late failure
11 fold increase เท nsjsjgf dooth
Most often found ir<5j»SI class V(35%
86(40%) infectious etiology of Rx. failure
could be established
Cl5/86(2Q%) resistant bacteria were fouocP
p.aerul A.oaumz.K.bimuniul,ร. mmvusc&fts 1, Mhti>A4, DRSP6
<40/86(11%) uncommon organises
M. tuberculosis 4, น rever z, L. pneumophila 4
Menendez R et al. Thorax2004;59:960-5

Practical Management of Community-acquired Pneumonia
Think globally
Act locally

Practical Management of Community-acquired Pneumonia
Think globally
Chaicharn Pothirat MD FCCP
Associate Professor Division of Pulmonary, Critical Care and Allergy
Faculty of Medicine Chiangmai University

Initial Evaluation of CAP
l-3 The two most important steps for a good outcome
\.y Site of Care
First step to be considered How shouk^^ivaluated \)r initial stiebkcare
HOME
WARD
ICU
Hown\comider for et\ologic agenj/coverage?
Initial antibiotic regimen
started at ED or <4 hrs

Site of Care
First step to be considered
Initial Evaluation of CAP
The two most important steps for a good outcome

How should we evaluated for initial site of care
HOME WARD
ICU

Mortality rate {% patients)
Predictors OR 95% Cl p Value
Age 1.02 1.01-1.03 < 0.0001
Coma 1.58 1.32-1.89 < 0.0001
ร aureus 1.58 1.32-1.89 < 0.0001
Pneumonia sepsis* 1.77 1.35-2.32 < 0.0001
Albumin < 2.4 g/dL 1.68 1.32-2.14 < 0.0001
pH arterial < 7.3 2.40 1.87-3.08 <0.0001
Creatinine >1.5 mg/dL, 1.38 1.10-1.73 < 0.0001
WBC < 4.3 or > 39.8 X lOfyxL 1.50 1.22-1.84 0.0057
Platelets < 115,00(yjiJLi 2.10 1.57-2,82 0.0001
Bands > 32% 1.ซ4 1,18-2.27 < 0.0001
BUN > 55 mg/dL 1.54 1.16-2.05 0.0034
BUN 40 to 55 mg’dL 1.47 1.10-1.96 0.0033
Temperature < 35.6°C 1.37 1,09-1.70 0.0092
Respiration > 39 breaths/min 1.55 1,15-2,08 0.005S
Metastatic cancer 3.45 2,41-4.92 0.0039
HCAP 1.65 1,31-2,08 < 0.0001
HAP 2.07 1.63-2.64 < 0.0001
VAP 3.24 2.48-4.25 < 0.0001
*Same pathogen found in the Tie the blood culture. spiratoiy culture was also found in
Kollef MH Chest2005:128:3854-62
Severe Pneumonia
= AII HCAP/HAPA/AP
Table 4—Results of Logistic Regression Analysis for Risk Factors Associated ‘With Mortality in Patients (ท = 4j543) พ’*Pneumonia

Community-acquired Pneumonia
variety of severity
Moderate
(1-5%)
M ode rate 4fc§eve re (5-10%) ^—
Very severe (>15%)
Kollef MH Chest2005; 128:3854-62

Mortality & Severity Assessment
28 D-Mortality by PSI/CURB-65 & Modified ATS 2007
PSI(OPD vs. IPD) CURB-65
I <51 0.2 0 0.6
II <51-70 0.5 1 2.7
III <71-90 2.6 2 6.8
IV <91-130 9.3 3 14.0
V >130 24.9 4-5 27.8 CRB-65
0 0.9
1 5.2
2 12.0 3-4 31.2
Modified ATS 2007
>1/2 major criteria on MV
Septic shock
>3/9 minor criteria
Confusion
Ps< 9ommHg need fluid Rx Hypothermia, T <36 c RR>30,or on NIV Pa02/Fi02<250, or on NIV Muti-lobar WBC <4,000 Platelet <100,000 BUN>20 mg/dL

Two Scoring systems For hospitalization consideration
step 1
Does the patient have any of the following coexisting conditions’?
• Neoplastic disease
■ Congestive heart failure
* Cerebrovascular disease
■ Renal disease
■ Liver disease
No
Step2b
Is the patient >‘ 50 years ol age?
1 No
Yes
Yes
DuKb ttie patient have any of น(ษ following abiiLmiialifes?
* Altered mental status
* Pulse >125/min
* Respiratory late >30/min
* Systolic blood piessure <90 mmHg
* Temperature <35 ๐c or >40 °c
Assign points for:
Demographic vaiiables
Comorbld conditions
Physical observations
Laboratory and radiographic findings
–»( (91-ไ,ะspเน.3 j
j *{^ (71-90 points)2.6^
(<7Qapoil)0.5%]|
Class V
(>130 points24.9(j
No
ะr
Class I
yAdapted from: Fine MJ, Auble IE, Yeaty DM fit al. N Engl J Med. 1997:336(i):213-50.10
pftjini scoring system for step 2 of the Prediction Rule for assignment to Risk classes if, HI, IV, and V includes the Joliowing:
Demographic factor (Age): men (Age (year/), women (Age (year}—10)
|« Nursing home resident; +20
I* Coexisting iliness: neoplastic disease (+30), Kva-disease (+20\ rongssfive heart Jb’lure (+10), cerebrovascular disease (+20), renal disease (+10)
Physical examination Jlndings: altered mental status (+20), respiratory rate z30fmin (+20), systolic blood pressure <90 mmHg (+20), temperature <35°c or 2 40°c (+15), pulse i 125/irin (+10)
Laboratory and radiographic f indings: arterial pH < 7.35 (+30), blood urea nitrogen i30 mg!dL (+20), sodium < 130 mmol/L (+20), giticose 3:250 mg/dL (+10), hemat¬ocrit <30% f+JO), partial pressure of arterial oxygen < 60 เพทH? (+10), pleural effusion (+10)
Two Scoring systems For hospitalization consideration
2. CURB-65 or CRB-65
Comparative Predictive Rules
PSI vs. 2-CURB
Mortality & Severity assessment
28 D-Mortality by CURB/PSI/modified ATS
PSI(OPD vs. IPD) CURB-65
I <51 0.2 0 0.6
II <51-70 0.5 1 2.7
III <71-90 2.6 2 6.8
IV <91-130 9.3 3 14.0
V >130 24.9 4-5 27.8 CRB-65
0 0.9
1 5.2
2 12.0 Z-4 31.2
Modified ATS 2007
>1/2 major criteria on เพ
Septic shock
>3/9 minor criteria
Confusion
Ps< 9ommHg need fluid Rx Hypothermia, T <36 c RR>301or on NIV Pa02/Fi02<250, or on Nl\i Muti-lobar WBC <4,000 Platelet <100,000 BUN>20 mg/dL

ชาทีมิกซ์

Posted on กุมภาพันธ์ 3, 2014, in บทความ. Bookmark the permalink. ใส่ความเห็น.

ใส่ความเห็น

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / เปลี่ยนแปลง )

Twitter picture

You are commenting using your Twitter account. Log Out / เปลี่ยนแปลง )

Facebook photo

You are commenting using your Facebook account. Log Out / เปลี่ยนแปลง )

Google+ photo

You are commenting using your Google+ account. Log Out / เปลี่ยนแปลง )

Connecting to %s

%d bloggers like this: