Outline Introduction Site-of-Care Decisions Diagnostic Testing Antibiotic Treatment Prevention 2

Transcription

1 Community-Acquired Pneumonia in Adults 日期 ;2016/10/26 報告人 : 李怡萱 1

2 Outline Introduction Site-of-Care Decisions Diagnostic Testing Antibiotic Treatment Prevention 2

3 Introduction 3

4 Pneumonia Pneumonia is an infection of the lungs. It is a serious illness that can affect people of any age, but it is most common and most dangerous in very young children, people older than 65, and in those with underlying medical problemssuch as heart disease, diabetes, and chronic lung disease. There is seasonal variation with more cases occurring in the winter months. 圖片來源 :uptodate 4

5 Pneumonia Community-acquired pneumonia(cap): -- 肺實質的急性感染, 發生在未住院或住院未滿 48 小時之病人 -- 病患胸部 X 光片上有新出現之浸潤, 同時表現出急性感染的症狀, 如發熱 體溫過低 發抖 出汗 ( 新出現的 ) 咳嗽 ( 有痰或沒痰 ) 痰色改變 胸部不適 氣促, 其他非特定性症狀 ( 疲倦 肌痛 腹痛 食慾差 頭痛 ), 或聽診之異常 ( 支氣管音, 加上 / 或是局部囉音 ) Hospital-acquired pneumonia (HAP): -- 住院 48 小時後, 或上次住院結束後 14 天之內發生之肺實質的急性感染 -- 胸部 X 光片上有新出現或持續進展 (>24 小時 ) 之浸潤, 同時以下條件至少有兩項存在 : (1) 發熱 : 體溫之上昇 1, 或體溫 38.3, 或 <35 (2) 白血球上升 : 白血球之增加 > 原來值之 25%, 或白血球 >10,000/μl 或 < 3000 / μl (3) 膿性氣管抽吸液或痰 : 革蘭氏染色呈現 >25 嗜中性白血球 / 低倍視野 (100 )3-6 5

6 Pneumonia Ventilator-associated pneumonia (VAP): -- 為使用呼吸器 48 小時以後產生的院內肺炎 Healthcare-associated pneumonia(hcap): -- 肺炎病患有下列情況者稱之 - 在 90 天內曾在急性病醫院住院大於二天以上者 - 住在安養院或長期照護機構的患者 -30 天內接受針劑抗生素 化療 傷口照護的病患, 洗腎的病人 6

7 pical Pathogenesis Atypical iologic agent Incidence(%) Etiologic agent Incidence(%) reptococcus pneumoniae aemophilus influenzae aphylococcus aureus ebsiella pneumonia coli 23.8 ~ ~ ~ ~ ~ 1.8 Legionella spp. Mycoplasma pneumoniae Chlamydia pneumoniae Viruses Mycobacterium tuberculosis 12.2 ~ ~ ~ ~ ~ 2.0 表格來源 : 臨床肺炎指引 7

8 Common pathogens 在台灣的社區肺炎常見菌種與其他國家的文獻報告相近, 如附表 ( 一 ),Streptococcus pneumoniae 是最常見引起肺炎菌種, 尤其是大於 65 歲的病患 年輕病患的肺炎應先排除 Mycoplasma pneumoniae 中壯年的重度肺炎應考慮 Klebsiella pneumoniae 的可能性 兩種病菌或兩種以上的混合感染比率約佔社區肺炎病人的 13~16%14,15 如果嚴重到呼吸衰竭的重度肺炎病例, 則應考慮的菌種如 S. pneumoniae, K. pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus 等 在台灣 Burkholderia pseudomallei, Acinetobacter baumannii 也是重度的社區肺炎的可能病因 17 8

9 Site-of-Care Decisions HOSPITAL ADMISSION DECISION ICU ADMISSION DECISION 9

10 Hospital admission decision Assessment of severity -CURB-65 - Pneumonia Severity Index (PSI) 10

11 CURB-65 Confusion (based upon a specific mental test or disorientation to person, place, or time) Urea (blood urea nitrogen in the United States) >7 mmol/l(20 mg/dl) Respiratory rate >30 breaths/minute Blood pressure (systolic <90 mmhg or diastolic <60 mmhg) Age >65 years 11

12 CURB-65 C U R Confusion Urea >7 mmol/l(20 mg/dl) Respiratory rate >30 breaths/minute B Blood pressure (systolic <90 mmhg or diastolic <60 mmhg) 65 Age >65 years 表格來源 :uptodate 12

13 CURB-65 points meaning recommendation 0 to 1 Points Low severity (risk of death <3 %) Outpatient therapy is usually appropriate 2 Points Moderate severity (risk of death 9 %). Hospitalization should be considered 3 to 5 Points High severity (risk of death 15 ~ 40 %) Hospitalization is indicated, and the patient should be assessed for possible intensive care unit admission, especially if the CURB-65 score is 4 or 5 表格來源 :uptodate 13

14 Pneumonia Severity Index (PSI) Sex Male female Demographic factors Age Nursing home resident Comorbid illnesses Neoplastic disease Chronic liver disease Heart failure Cerebrovascular disease Chronic renal disease (0) (-10) (1 point for each year) (+10) (+30) (+20) (+10) (+10) (+10) 表格來源 :uptodate 14

15 Pneumonia Severity Index (PSI) Physical examination findings Altered mental status Respiratory rate 30/minute Systolic blood pressure <90 mmhg Temperature <35 C (95 F) or 40 C (104 F) Pulse 125/minute (10 points) Laboratory and radiographic findings Arterial ph <7.35 Blood urea nitrogen 30 mg/dl (11 mmol/l) Sodium <130 meq/l Glucose 250 mg/dl Hematocrit <30 percent Partial pressure of arterial oxygen <60 mmhg or oxygen saturation <90 percent Pleural effusion 表格來源 :uptodate (+20) (+20) (+20) (+15) (+10) (+30) (+20) (+20) (+10) (+10) (+10) (+10) 15

16 Pneumonia Severity Index (PSI) points meaning recommendation 0 to 50 Points Class I 0.1% mortality outpatients 51 to 70 Points Class II 0.6% mortality 71 to 90 Points Class III 0.9% mortality treated in an observation unit or with a short hospitalization 91 to 130 Points Class IV 9.3% mortality require hospitalization 131 to 395 Points Class V 27.0% mortality 表格來源 :uptodate 16

17 ICU admission decision Direct admission to an ICU is required for patient with septic shock requiring vasopressors with acute respiratory failure requiring intubation and mechanical ventilation. Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP. 17

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19 ICU admission decision Major criteria Septic shockrequiring vasopressors Acute respiratory failure requiring intubation and mechanical ventilation Minor criteria Respiratory rate 30 breaths/min PaO2/FiO2 ratio 250 Multilobar infiltrates Confusion/disorientation Uremia (BUN level, 20 mg/dl) Leukopenia (WBC count, <4000 cells/mm3) Thrombocytopenia (platelet count,!100,000 cells/mm3 ) Hypothermia (core temperature, <36 ) Hypotension requiring aggressive fluid resuscitatio with 3 of the minor criteria 表格來源 :IDSAGuidelines on the Management of Community-Acquired Pneumonia in Adults 19

20 Diagnostic Testing 20

21 Diagnosis Clinical evaluation Radiologic evaluation Diagnostic testing for microbial -Outpatients -Hospitalized patients Blood cultures Sputum Urinary antigen Polymerase chain reaction -cough, fever, pleuritic chest pain, dyspnea, and sputum production -gastrointestinal symptoms (nausea, vomiting, diarrhea -mental status changes. - 21

22 Radiologic evaluation The presence of an infiltrate on plain chest radiograph is considered the gold standard for diagnosing pneumonia when clinical and microbiologic features are supportive 圖片來源 :uptodate 22

23 Diagnostic testing for microbial Outpatients -Routine diagnostic tests are optional Hospitalized patients -Pretreatment blood samples for culture and an expectorated sputum sample for stain and culture should be obtained from hospitalized patients with the clinical indications -Patients with severe CAP, as defined above, should at least have blood samples drawn for culture, urinary antigen tests for Legionella pneumophila and Streptococcus pneumoniae performed, and expectorated sputum samples collected for culture 23

24 表格來源 :IDSAGuidelines on the Management of Community-Acquired Pneumonia in Adults 24

25 Testing for microbial Blood cultures - Easy to obtain blood samples, simple, cheap, high specificity - The blood culture positivity rate is relatively low. Sputum Gram stain -If a good quality sputum can be obtained -The sensitivity of Gram stain microscopy in S. pneumoniae pneumonia can be as high as 85% -not for diagnosis of atypical pneumonia (Legionellaspp, M. pneumoniae, C. pneumoniae) Urinary antigen - detect S. pneumoniae and Legionella - Only useful for the diagnosis of L. pneumophila group 1 infection Polymerase chain reaction - For some difficult to cultivate or slow growth of pathogens 25

26 Antibiotic Treatment EMPIRICAL ANTIMICROBIAL THERAPY PATHOGEN-DIRECTED THERAPY 26

27 Empirical antimicrobial therapy Outpatient treatment Inpatients, non-icu treatment Inpatients, ICU treatment Special concerns 27

28 Empirical antimicrobial therapy Outpatient treatment S. pneumoniae/ M. pneumoniae/ C. pneumoniae /H. influenzae /S. aureus Previously healthy and no use of antimicrobials within the previous three months 1.Macrolide(azithromycin, clarithromycin, erythromycin) 2.Doxycyline Presence of comorbidities such as chronic heart, lung, liver, orrenal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditionsor use of immunosuppressing drugs; or use of antimicrobials within the previous three months 1.respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin) 2. beta-lactam(high-dose amoxicillin, amoxicillin-clavulanate//ceftriaxone, cefuroxime) + macrolide(azithromycin, clarithromycin, erythromycin) In regions with a high rate (>25 percent) of infection with high-level (MIC 16 mcg/ml) macrolideresistant Streptococcus pneumoniae, consider use of alternative agents listed in (2) above. 表格來源 :IDSAGuidelines on the Management of Community-Acquired Pneumonia in Adults 28

29 Empirical antimicrobial therapy Outpatient treatment Previously healthy and no use of antimicrobials within the previous three months QT prolong 1.Macrolide -azithromycin 500 mg on day 1 followed by four days of 250 mg a day or500 mg QDfor 3 days -clarithromycin 500 mg twice daily for 5 days 2.Doxycyline* Pregnancy X 100 mg twice daily *:Doxycycline may be used as an alternative to a macrolide, but there is stronger evidence to support the use of a macrolide than doxycycline for CAP. 表格來源 :IDSAGuidelines on the Management of Community-Acquired Pneumonia in Adults 29

30 Empirical antimicrobial therapy Outpatient treatment Presence of comorbidities such as chronic heart, lung, liver, orrenal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditionsor use of immunosuppressing drugs; or use of antimicrobials within the previous three months QT prolong 1.respiratory fluoroquinolone -moxifloxacin 400 mg QD -gemifloxacin 320 mg QD - levofloxacin 750 mg QD 2.beta-lactam - high-dose amoxicillin 1 g TID - amoxicillin-clavulanate 2g BID -cefuroxime 500mg BID - + macrolide(azithromycin, clarithromycin, erythromycin) For 5 day 表格來源 :IDSAGuidelines on the Management of Community-Acquired Pneumonia in Adults 30

31 Empirical antimicrobial therapy- Inpatients, non-icu treatment S. pneumoniae /H. influenzae /Other GNB/ Legionella spp./ C. pneumoniae 1.respiratory fluoroquinolone -moxifloxacin 400mg QD IV or PO -levofloxacin 750mg QD IV or PO 2.antipneumococcal beta-lactam -cefotaxime 1~2g IVQ8H -ceftriaxone 1~2g IV QD - ampicillin-sulbactam 1.5~3g IV Q6H -ertapenem 1g IV QD +macrolide(azithromycin, clarithromycin, or erythromycin) 3.tigecycline IInitial: 100 mg IV as a single dose; then 50 mg Q12h for 7 to 14 days *An increase in all-cause mortality has been observed, Tigecycline should be reserved for use in situations when alternative treatments are not suitable. 表格來源 :IDSAGuidelines on the Management of Community-Acquired Pneumonia in Adults 31

32 Empirical antimicrobial therapy- Inpatients, ICU treatment K. pneumoniae/ S. pneuomniae /Legionella spp./ Other GNB /P. aeruginosa/ Acinetobacter spp 1.antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) azithromycin + respiratory fluoroquinolone (moxifloxacin,levofloxacin) 2. penicillin-allergic patients respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin) +aztreonam 表格來源 :IDSAGuidelines on the Management of Community-Acquired Pneumonia in Adults 32

33 Empirical antimicrobial therapy- Special concerns Pseudomonas aeruginosa 1.antipneumococcal, antipseudomonal beta-lactam - piperacillin-tazobactam 4.5g Q6H -cefepime 2 g Q8H - ceftazidime 2g Q8H -imipenem 500mg IV Q6H - meropenem 1g Q8H either ciprofloxacin or levofloxacin aminoglycoside PLUS azithromycin aminoglycoside PLUS a respiratory fluoroquinolone for penicillin-allergic patients, substitute aztreonam for above beta-lactam + CA-MRSA Add vancomycin or linezolid 表格來源 :IDSAGuidelines on the Management of Community-Acquired Pneumonia in Adults 33

34 Drug-resistant S. pneumoniae(drsp) Risk factors for drug-resistant S. pneumoniae in adults include: Age >65 years Beta-lactam, macrolide, or fluoroquinolone therapy within the past three to six months Alcoholism Medical comorbidities Immunosuppressive illness or therapy Exposure to a child in a daycare center 34

35 Pathogen-directed therapy. 表格來源 :uptodate 35

36 表格來源 :uptodate 36

37 表格來源 :uptodate 37

38 Duration of antibiotic therapy Patients with CAP should be treated for a minimum of 5 days Should be afebrile for h, and should have no more than 1 CAP-associated sign of clinical instability 表格來源 :IDSAGuidelines on the Management of Community-Acquired Pneumonia in Adults 38

39 Prevention 39

40 Vaccine tor Pneumococcal polysaccharide vaccine Inactivatedinfluenza vaccine inistration Intramuscular injection Intramuscular injection e of vaccine ommended groups Bacterial component (polysaccharide capsule) Killed virus 1. All persons 65 years of age 2. High-risk persons 2 64 years of age 3. Current smokers accination schedule One-time revaccination after 5 years for (1) adults 65 years of age, if the first dose is received before age 65 years (2) persons with asplenia (3) immunocompromised persons 1.All persons 50 years of age 2.High-risk persons 6 months 49 years of a 3. Household contacts of high-risk persons 4. Health care providers 5. Children 6 23 months of age Annual revaccinatio 表格來源 :IDSAGuidelines on the Management of Community-Acquired Pneumonia in Adults 40

41 Pneumococcal vaccination Pneumococcal polysaccharide vaccine (PPSV) PPSV23 -All persons 65 years of age - High-risk persons 2 64 years of age (Chronic heart disease. Chronic lung disease. Diabetes mellitus.alcoholism. Chronic liver disease, cirrhosis. Cigarette smoking) Pneumococcal conjugate vaccine (PCV) PCV7 PCV10 PCV13 - For infants and children 41

42 肺炎鏈球菌感染高危險群 : (1) 脾臟功能缺損或脾臟切除者 (2) 先天或後天免疫功能不全者 ( 包括愛滋病毒感染者 ) (3) 人工耳植入者 (4) 慢性疾病 : 慢性腎病變 慢性心臟疾病 慢性肺臟病 糖尿病 慢性肝病與肝硬化患者 酒癮者 菸癮者等 (5) 腦脊髓液滲漏者 (6) 接受免疫抑制劑或放射治療的惡性腫瘤者或器官移植者 高危險群之接種方式 : (1) 未曾接種 PCV13 或 PPV23 者 : 接種 1 劑 PCV13, 間隔至少 8 週再接種 1 劑 PPV23 (2) 曾接種 PPV23 者 : 接種 1 劑 PCV13, 與前劑 PPV23 應間隔至少 8 週 完成上述接種之高危險群,5 年後可經醫師評估再追加 1 劑 PPV23 42

43 公費疫苗 兒童 (PCV13) - 實施對象 : 出生滿 2 個月以上至未滿 60 個月, 未曾接種或尚未完成 PCV13 之幼童 - 常規接種採 3 劑時程 ( 出生滿 2 個月 4 個月分別接種 1 劑, 滿 12~15 個月追加 1 劑 ) 老人 (PPCV23) 一 75 歲以上從未接種肺炎鏈球菌疫苗者, 公費提供 1 劑 PPV 二 75 歲以上曾經接種肺炎鏈球菌疫苗者, 依下列原則接種 : (1) 65 歲以後曾接種 PPV 者, 無需再接種 PPV (2) 65 歲以前曾接種 PPV 者, 經醫師評估可再接種 1 劑 PPV (3) 曾接種 13 價結合型肺炎鏈球菌疫苗 (PCV13) 者且 65 歲以後從未接種 PPV 者, 間隔 1 年以上, 可經醫師評估再接種 1 劑 PPV 43

44 Reference 1. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults 2.Uptodate 3. 肺炎臨床診療指引 4. 衛生福利部疾病管制署 44

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47 Vaccine Pneumococcal polysaccharide vaccine(ppsv) -PPSV23 不適合兩歲以下兒童 Pneumococcal conjugate vaccine(pcv) -PCV7 -PCV10 -PCV13 47

48 No comorbidities, no recent antibiotic use, and low rate of resistance For uncomplicated pneumonia in patients who do not require hospitalization, have no significant comorbidities and/or use of antibiotics within the last three months, and where there is not a high prevalence of macrolide-resistant S. pneumoniae strains, we recommend any one of the following oral regimens: Azithromycin 500 mg on day 1 followed by four days of 250 mg a dayor500 mg daily for three days Clarithromycin 500 mg twice daily for five days ClarithromycinXL Two 500 mg tablets (1000 mg per dose) once daily for five days Doxycycline 100 mg twice daily 48

49 Comorbidities, recent antibiotic use, or high rate of resistance chronic obstructive pulmonary disease [COPD], liver or renal disease, cancer, diabetes, congestive heart failure, alcoholism, asplenia, or immunosuppression A respiratory fluoroquinolone (levofloxacin750 mg daily ormoxifloxacin400 mg daily or gemifloxacin 320 mg daily) for five days. Combination therapy with a beta-lactam effective against S. pneumoniae(highdoseamoxicillin1 g three times dailyoramoxicillin-clavulanatexr 2 g twice dailyorcefpodoxime200 mg twice dailyorcefuroxime500 mg twice daily)pluseither a macrolide (azithromycin500 mg on day 1 followed by four days of 250 mg a dayorclarithromycin500 mg twice dailyorclarithromycin XL 1000 mg once daily) or doxycycline(100 mg twice daily). Treatment should generally be continued for five days 49

50 Empiric therapy Antibiotics should be started as soon as possible once the diagnosis of CAP is established The most likely pathogen(s Clinical trials proving efficacy Risk factors for antimicrobial resistance. The choice of empirictherapy must take into account the emergence of antibiotic resistance amongs. pneumoniae, one of the most common bacteria responsible for CAP. Medical comorbidities that may influence the likelihood of a specific pathogen and that may be a risk factor for treatment failure 50

51 Risk factors for drug resistance Age >65 years Beta-lactam, macrolide, or fluoroquinolone therapy within the past three to six months Alcoholism Medical comorbidities Immunosuppressive illness or therapy Exposure to a child in a daycare center 51