Management of Pneumonia in

General Ward

Arto Yuwono Soeroto

Divisi Respirologi dan Penyakit Kritis Respirasi
Departemen Ilmu Penyakit Dalam
RS Hasan Sadikin – FK Unpad
aysoeroto@yahoo.co.id
Case 3 : 76-year-old man bedridden man transferred
from a nursing home for an acute pneumonia
pneumonia
FDA USA 2009 Draft
Time to first antibiotic dose.

For patients admitted through the emergency

department (ED), the first antibiotic dose should be
administered while still in the ED.

(Moderate recommendation; level III evidence)

 Community Acquired Pneumonia
Outpatient Inpatient

Previously CO-MOR In Region Inpatient In patient

Healthy BIDITIES > 25% infection Non ICU ICU
With high level Pseudomonas CA MRSA
(MIC > 16 mg/ml) infection
Macrolide resistant
S. pneumoniae

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

 Community Acquired Pneumonia
Outpatient

Previously
Healthy

No Risk DRSP
• Age < 2 or > 65
•  lactam within previous 3 mo
• Alcoholism
• Medical comorbidities
• Immunosupressive illness/therapy
• Exposure to child in day care center

Streptococcus pneumoniae
Mycoplasma pneumonia
Hemophilus influenzae
Chlamydia pneumoniae
Respiratory viruses

A macrolide (azithromycin
Clarithromycin , erythromycin)
(Strong recommendation)
OR
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
Doxycycline
 Community Acquired Pneumonia
Outpatient

CO-MOR
BIDITIES

Age < 2 or > 65  lactam within previous 3 mo, Alcoholism

Medical comorbidities, Immunosupressive illness/therapy,
Exposure to child in day care center
+ Comorbid (Chronic heart, Lung Liver, renal disease DM,
Alcoholism, malignancy etc

Streptococcus pneumoniae,Mycoplasma Pneumoniae,

Hemophilus influenzae, Chlamydia pneumoniae, Respiratory viruses
+ Gram negative + DRSP

 A respiratory fluoroquinoloe (moxifloxacin, Gemifloxacin

Levofloxacin 750 mg) (strong recommendation)
 A  lactam + a macrolide (strong recommendation) Amoxicillin
(3x1gr). Co amoxyclave (2x2gr). Cefriaxone, cefodoxime,
cefuroxime. Doxy (alternative)
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
 Community Acquired Pneumonia
Outpatient

In Region
> 25% infection
With high level
(MIC > 16 mg/ml)
Macrolide resistant
S. pneumoniae

 a respiratory fluoroquinolone (moxifloxacin,

Gemifloxacin, Levofloxacin 750 mg)
(strong recommendation)
 a B lactam + a macrolide (strong recommendation)
Amoxicillin (3x1gr). Co amoxyclave
(2x2gr). Cefriaxone, cefrodoxime,
ceforoxime. Doxy (alternative)

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

 Community Acquired Pneumonia
Inpatient

Inpatient
Non ICU

• S. pneumoniae
• M. pneumoniae
• C. pneumoniae
• H. Influenzae
• Legionella species
• Aspiration
• Respiratory
viruses

 a respiratory
Fluoroquinolonoe
(strong recommendation)
 a B lactam + A macrolide
(strong recommendation)
Prefered : cefotaxime
Ceftrioxone, ertapenem
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
 Doxycyclin  alternative
for macrolide
 Community Acquired Pneumonia
Inpatient

In patient
ICU

S. Pneumoniae
Staph aureus
Legionella spesies
Gram negative bacilli
H. Influenzae

 a B lactam
(cefotaxime, cefriaxone
or ampicillin sulbactam)
+
Azythromycin
or
Fluoroquinolone
(strong recommendation)
 Penicillin allergic
Fluoroquinolone
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
+
Azetreonam
 Community Acquired Pneumonia
Inpatient

In patient
ICU
Pseudomonas
infection

• Structural lung disease

• Severe COPD with frequent
Steroid and/or antibiotic use
• prior Antibiotic therapy

Antipneumococcal, antipseudomonal
B lactam (piperacillin-tazobactam
cefepime, imipenem, meropenem)
+
Ciprofloxacin or levofloxacin750mg
OR
The above B lactam +
an aminoglycoside
And an antipneumococcal
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2) Fluoroquinolone/azithromycin
(moderate recommendation)
 Community Acquired Pneumonia
Inpatient

In patient
ICU
CA MRSA

• ESRD
• Injection drug abuser
• Prior influenzae
• Prior antibiotic th/
(especially fluoroquinolone)

Add vancomycin or
Linezolid
(moderate recommendation)

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Piperacillin/tazobactam plus azithromycin
Switch from intravenous to oral therapy

Patients should be switched from intravenous to oral

therapy when they are hemodynamically stable and
improving clinically, are able to ingest medications, and
have a normally functioning gastrointestinal tract.

(Strong recommendation; level II evidence)

Criteria for clinical stability

Temperature 37.8C
Heart rate 100 beats/min
Respiratory rate 24 breaths/min
Systolic blood pressure >90 mm Hg
Arterial oxygen saturation >90% or pO2>60 mm
Hg on room air
Ability to maintain oral intake
Normal mental status

NOTE. Criteria are from [268, 274, 294]. pO2, oxygen partial pressure. a
Important for discharge or oral switch decision but not necessarily for
determination of nonresponse.
Duration of antibiotic therapy

Patients with CAP should be treated for a minimum of

5 days (level I evidence), should be afebrile for 48–72
h, and should have no more than 1 CAP-associated
sign of clinical instability (previous table) before
discontinuation of therapy

(level II evidence; Moderate recommendation)

 Antibiotic Resistance

• A worldwide problem
• Associated with increased
morbidity, mortality, and
hospital costs
• Occurs in both hospitals and
the community
• Results from factors such as
antibiotic misuse

Adapted from Infectious Diseases Society of American (IDSA). Available at http://www.idsociety.org/pa/IDSA_Paper4_final_web.pdf. Accessed July 2005;
Cosgrove SE et al Arch Intern Med 2002;162:185–190; Ben-David D, Rubenstein E Curr Opin Infect Dis 2002;15:151–156; Colodner R et al Eur J Clin Microbiol Infect
Dis 2004;23:163–167.
Slide 37
 Increasing Antimicrobial Resistance Among
Pathogens Causing Hospital-Onset Infections
Third-generation cephalosporin- Fluoroquinolone-resistant
resistant Klebsiella pneumoniae Pseudomonas aeruginosa
30
14
25
12

Resistance (%)
Resistance (%)

10 20
8
15
6
10
4
2 5
0 0

Non–intensive care unit patients

Intensive care unit patients

Source: US National Nosocomial Infections Surveillance System (NNIS)

Adapted from Centers for Disease Control and Prevention (CDC). Available at http://www.cdc.gov/drugresistance/healthcare/ha/HASlideSet.ppm. Accessed
August 2005.
Slide 38
 Increasing Fluoroquinolone Use
and Resistance Rates
US surveillance study of gram-negative aerobic isolates from ICU patients

Fluoroquinolone use (kg)

35 250,000

30
Strains resistant to

200,000
ciprofloxacin (%)

25

20 150,000
15
P. aeruginosa 100,000
10
Gram-negative bacilli
5 50,000
Fluoroquinolone use
0 0
1994 1995 1996 1997 1998 1999 2000

Years
ICU=intensive care unit
Adapted from Neuhauser MM et al JAMA 2003;289:885–888.
Slide 39
 Multidrug-Resistant P. aeruginosa Linked to
Overuse of Traditional Antibiotics with
Antipseudomonal Activity

• In a two-year case-control study of patients (N=2613) admitted

to three ICUs in a large teaching hospital in Paris, France
– Prolonged receipt of antibiotics with specific antipseudomonal activity
(most notably ciprofloxacin) was associated with the emergence of
multidrug-resistant P. aeruginosa
– These data suggest that “if treatment with an antibiotic active against
gram-negative bacteria is needed, agents with little antipseudomonal
activity should be preferred over those with specific antipseudomonal
activity to limit the emergence of MDRPA [multidrug-resistant P.
aeruginosa].”

Adapted from Paramythiotou E et al Clin Infect Dis 2004;38:670–677.

Slide 40
 Recent Publications Confirm Community
Spread of ESBL-Producing Bacteria
• Now disseminating outside hospitals
– Reported in Europe and Israel
– Dramatic increase in prevalence of fecal carriage during non outbreak
situation demonstrated in Spain
 Outpatients: 0.7% in 1991 vs. 5.5% in 2003 in a study in Spain
• These organisms are usually multidrug-resistant to beta-lactams (except
carbapenem) and non–beta-lactams
– Frequency of co-resistance in ESBL-producing isolates in 2003 in a study
in Spain: sulfonamides 75%; tetracycline 64%; streptomycin 57%;
quinolones 54%; and trimethoprim 50%

ESBL=extended-spectrum beta-lactamase
Adapted from Munday CJ et al J Antimicrob Chemother 2004;54:628–633; Rodriguez-Baño J et al J Clin Microbiol 2004;42:1089–1094; Woodford N et al J Antimicrob
Chemother 2004;54:735–743; Colodner R et al Eur J Clin Microbiol Infect Dis 2004;23:163–167; Valverde A et al J Clin Microbiol 2004;42:4769–4775.
Slide 41
 Resistance Linked to Overuse of Traditional
Antibiotics in Recent Publication
Collateral Damage=ecological adverse effects of antibiotic therapy,
including
• Selection of drug-resistant organisms
• Unwanted development of colonization or infection with multidrug-resistant organisms

Summary of potential “collateral damage” from use

of cephalosporins and quinolones
Class of agent, pathogen(s) selected for
Third-generation cephalosporins Neither third-generation
Vancomycin-resistant enterococci cephalosporins nor
Extended-spectrum beta-lactamase–producing Klebsiella species
quinolones appear
Beta-lactam–resistant Acinetobacter species
suitable for sustained
use in hospitals
Clostridium difficile
Quinolones
as “workhorse”
Methicillin-resistant Staphylococcus aureus
antibiotic therapy
Quinolone-resistant gram-negative bacilli, including P. aeruginosa

Adapted from Paterson DL Clin Infect Dis 2004;38(suppl 4):S341–S345.

Slide 42
TERIMA KASIH

Slide 44