1. Appropriate Antibiotics use in CAP and HCAP at Sisters Hospital in 2008. Syed Faraz Masood, MBBS Nashat H. Rabadi, MD, FCCP

2. Community Acquired Pneumonia Common : 5 to 6 million cases/year 20% are hospitalized ( 10% in ICU) No. 1 cause of death from infectious disease No. 6 cause of death in adults Mortality rates : –Outpatients = 1-5% –Inpatients = 12% ( higher in ICU- 50%) Costs : 9.7 billion : inpatient – $7,517 vs. outpatient - $264

3. CAP Definition CXR – infiltrate Auscultatory findings Signs of RTI –Cough +/- sputum –Fever or hypothermia –WBC

4. CAP - Pathogenesis Aspiration Inhalation Hematogenous Direct extension Reactivation

5. RESPIRATORY PATHOGENS IN CAP Respiratory Pathogens in CAP

6. Risk Factors. Age. Smoking. Co-morbid Conditions. Poor Prognosis. –Pleural Effusion. –Bacteremia.

7. Cultures. Sputum Cx –Not needed as outpatient. –May or may not be needed inpatient. Blood Cx Urinary Antigens.

8. CURB - 65 C – Confusion U – Urea. BUN > 20 R – Respiratory rate > 30 / min B – Blood pressure. SBP < 90 or DBP < 60 65 – Age > 65 Number of factors Mortality Rate 0 0.7% 1 2.1% 2 9.2% 3 14.5% 4 40% 5 57%

9. Management. Site of Care: –Inpatient vs. outpatient. –Floor vs. ICU. PSI CURB 65

10. Empirical Treatment Hospitalized Patients: –2 nd or 3 rd generation Cephalosporins plus a Macrolide. –Floroquinolones. For all critically ill patients, –2 nd or 3 rd generation Cephalosporin + Macrolide or Floroquinolones – necessary to provide coverage for Legionella Pneumophilia. –Change antibiotics – based on culture and sensitivity.

11. Nosocomial Pneumonia Hospital Acquired Pneumonia: –> 48 hours of admission to hospital. Ventilator associated Pneumonia. –> 48 hours of intubation.

12. Health-care Associated Pneumonia. Antimicrobial therapy in preceding 90 days. Hospitalization for 2 or more days in the preceding 90 days. Residence in a NH or an extended care facility. Home infusion therapy. Chronic Dialysis within 30 days. Immunosuppressive state and/or therapy.

13. Health-care Associated Pneumonia. Epidemiology extrapolated from HAP/VAP Second most common Nosocomial Infection. High morbidity / mortality. Increase hospital stay by 7-9 days. Excess cost of $ 40,000 per patient.

14. Early VAP/HAP (<5 days) –Similarly as CAP –No MDR pathogens. Late VAP/HAP (>5 days) treated similarly as HCAP: –MDR pathogens.

15. Microbiology Polymicrobial. –Methicillin-resistant Staphylococcus Aureus. –Pseudomonas Aeruginosa. –Acinetobacter –E.Coli –Klebsiella Pneumoniae (ESBL). Increased crude and attributable mortality associated with MDR pathogens.

16. Pathogenesis of HCAP Colonization: Lower Respiratory Tract. Aspiration; inhalation. Host-related: severity of illness, prior surgery. Environment-related: antibiotic exposure, medications, invasive devices. Host’s mechanical, humoral and cellular defenses.

17. Diagnosis Lower Respiratory Tract Cultures: –Sputum Cultures. –Endotracheal aspirates. –Bronchoscopy Broncho-alveolar Lavage (BAL). Protected Brushed Specimen (PBS).

18. Empirical Treatment Anti-pseudomonal cephalosporins or Anti-pseudomonal cabrapenems or Beta-lactam/beta-lactamase inhibitors And Anti-pseudomonal floroquinolones. PLUS Vancomycin or Linezolid.

19. HAP,VAP or HCAP Suspected Obtain Blood & Lower Respiratory Tract Cultures Early, Appropriate, Adequate Antibiotics Assess Clinical Response Check Microbiology Clinical Improvement (24-48 hrs) YES NO Streamline Antibiotics. Treat Uncomplicated patients for 7 days. Reassess & Follow up. Search for Complications: Abscess or Empyema Untreated Pathogen Non-Infectious Cause ATS Consensus Statement. AJRCCM 171: 2005

20. Mortality in Nosocomial Pneumonia. Presence of MDR pathogens. Initial Inappropriate antibiotics. Co-morbidities.

21. Alvarez-Lerma F, et al. Intensive Care Med. 1996;22:387-394. Ibrahim EH, et al. Chest. 2000;118L146-155. Kollef MH, et al. Chest. 1999; 115:462-474. Initial Inadequate Therapy Increases Mortality Kollef MH, et al. Chest. 1998;113:412-420. Luna CM, et al. Chest. 1997;111:676-685. Rello J, et al. Am J Respir Crit Care Med. 1997;156:196-200. Luna, 1997 Ibrahim, 2000 Kollef, 1998 Kollef, 1999 Rello, 1997 Alvarez-Lerma,1996

22. BAL=bronchoalveolar lavage. NS=Not significant. Luna CM, et al. Chest. 1997;111:676-685. P<.001 P=NS Adequate Therapy Reduces Mortality Only If Selected Prior to Identification of the Pathogen

23. Research Question Appropriateness of CAP treatment at Sister’s Hospital. Appropriateness of HCAP treatment at Sister’s Hospital. Mortality. Length of Stay.

24. Method IRB approval. HIPAA Compliance. 248 charts reviewed with diagnosis of pneumonia. Retrospective analysis. Single institution (Community Hospital setting). 1 Calendar year. (Jan 1 st – Dec 31 st 2008)

25. Classification

26. Community Acquired Pneumonia

27. Gender

28. Annual Frequency.

29. Antibiotics administered in ER: 100% Appropriate antibiotics: 93.2% Cultures performed: 95.7% Positive Cultures: 8.1%

30. Coverage

31. Cultures

33. Positive Cultures

34. Microbiology of CAP

35. Choice of Initial Antibiotics

36. Mortality –Number of Deaths:6/143 –Mortality Rate:4.2% –Average Length of Stay:5.8 days.

37. Health-care Associated Pneumonia.

38. Gender

39. Annual Frequency

40. Multi-Drug Resistant Risk Factors

41. Initial Antibiotic Coverage in ER

42. Initial Antibiotics Choice

43. Other Combinations used… Vanco/Zithro Levaquin/Genta/Aztre onam. Levaquin/Aztreonam Levaquin/Aztreonam/ Clindamycin. Levaquin/Ceftazidime Aztreonam/Zithro Levaquin/Zithro Clindamycin Primaxin/Zithromax Levaquin/Clindamycin Zosyn/Zithromax Zosyn/Levaquin.

44. Coverage.

45. Appropriately changed within 24 hours of admission 9.2%32%

46. Appropriate Change in Subgroups in Covered Patients.

49. Positive Cultures

50. Microbiology

51. Appropriate antibiotics in ER:4.4% Partially appropriate in ER:15.5% Inappropriate antibiotics in ER:78.8% Appropriate change in 24 hours:16.27%

52. Cultures performed:97.7% Positive cultures: 18.1% Average Length of Stay: 9.5 days Average age: 71.2 years

53. Mortality Total Number of Deaths: 11/90 Mortality Rate: 12.2% Deaths on Inappropriate Antibiotics: 9/11

54. Comparison Variables HCAPCAP Age71.2 years69 years Females71.5%54.5% Sputum Cx yield26.8%16.2% Blood Cx yield4.6%3.2% Urinary Ag yield10.8%2.4% Mortality12.4%4.2% LOS9.5 days5.8 days Housestaff covered 27.7%29.3%

55. Where’s the problem? Pneumonia CAPHCAP RECOGNIZE THE DIFFERENCE

56. HAP,VAP or HCAP Suspected Obtain Blood & Lower Respiratory Tract Cultures Early, Appropriate, Adequate Antibiotics Assess Clinical Response Check Microbiology Clinical Improvement (24-48 hrs) YES NO Streamline Antibiotics. Treat Uncomplicated patients for 7 days. Reassess & Follow up. Search for Complications: Abscess or Empyema Untreated Pathogen Non-Infectious Cause ATS Consensus Statement. AJRCCM 171: 2005

57. Strategies to Improve HCAP Outcomes Education. Order Sheets. De-escalation. Consultation. Re-evaluation.

58. References National Center for Health Statistics. Health, United States, 2006, with chart book on trends in the health of Americans. Available at: http://www.cdc.gov/nchs/data/hus/hus06.pdf. Accessed 17 January 2007.http://www.cdc.gov/nchs/data/hus/hus06.pdf. Accessed 17 January 2007 American Thoracic Society; Infectious Diseases Society of America. (2005). "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". Am. J. Respir. Crit. Care Med. 171 (4): 388–416. Alvarez-Lerma F, et al. Intensive Care Med. 1996;22:387-394Alvarez-Lerma F, et al. Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. Intensive Care Med. 1996;22:387-394 Ibrahim EH, et al. Chest. 2000;118L146-155.Ibrahim EH, et al. The Influence of Inadequate Antimicrobial Treatment of Bloodstream Infections on Patient Outcomes in the ICU Setting*. Chest. 2000;118L146-155. Kollef MH, et al. Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Mortality Among Critically III Patients. Chest. 1999; 115:462-474.Kollef MH, et al. Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Mortality Among Critically III Patients. Chest. 1999; 115:462-474. Kollef MH, et al. The Influence of Mini-BAL Cultures on Patient Outcomes*: Implications for the Antibiotic Management of Ventilator-Associated Pneumonia Chest. 1998;113:412-420.Kollef MH, et al. The Influence of Mini-BAL Cultures on Patient Outcomes*: Implications for the Antibiotic Management of Ventilator-Associated Pneumonia Chest. 1998;113:412-420. Luna CM, et al. Impact of BAL Data on the Therapy and Outcome of Ventilator-Associated Pneumonia*. Chest. 1997;111:676-685.Luna CM, et al. Impact of BAL Data on the Therapy and Outcome of Ventilator-Associated Pneumonia*. Chest. 1997;111:676-685. Rello J, et al. The Value of Routine Microbial Investigation in Ventilator-Associated Pneumonia Am J Respir Crit Care Med. 1997;156:196-200.Rello J, et al. The Value of Routine Microbial Investigation in Ventilator-Associated Pneumonia Am J Respir Crit Care Med. 1997;156:196-200.

59. Acknowledgement Dr. Nashat Rabadi. Cliff Gadra and the Medical Records team. Dr. Varuna Nargunan. Danielle Casucci. Dr. Sateesh Satchidanand IRB team.

60. Thank You!