# Presentation: 012346

## Community-acquired Pneumonia 

- Thomas J. Marrie
- University of Alberta
- Edmonton, AB

## Definition - CAP

- Two or more of fever, chills, cough, purulent sputum, pleuritic chest pain,plus a new opacity on CXR
- Problems with definition –CXR – neither sensitive or specific

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## Previous slide

- Pt with BPP – CXR reported as atelectasis and not as pneumonia.
- Clinical features were those of pneumonia.

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## Age specific hospitalization rate/1000 for CAP in Alberta

## Age specific length of stay (days) for CAP in Alberta – overall 9.15

## In hospital and one year age specific mortality rates CAP – Alberta.

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## Pneumonia in elderly in US – Kaplan et al AJRCCM 2002; 165: 766-772

- 1997 – 623,718 medicare recip hosp for CAP
- 18.3/1,000
- 4.3% - from a NH; 10.6% died
- 22.4% to ICU; 7.2% mechanical ventil
- $4.4 billion of which 2.1 was for ICU care
- Mean LOS 7.6 d at a cost $6,949
- Men younger than women, more likely to suffer from Gm Neg infection and more likely to die.

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## Total pneumonia admission rate 

**Total pneumonia admission rate **
**in year 1 and year 2**

## ICU admission rate  in year 1 and year 2

**ICU admission rate  in year 1 and year 2**

## Percent of patients who were admitted according to age group

## Percent of patients in each age group who were admitted to ICU

## Pneumonia monthly distribution

**from  Nov 15, 2000 to Nov 14, 2002**

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## Outpatients vs inpatients PORT-outcomes according to risk class

- 		Outpts			Inpts
- 	N		deaths			N 	deaths
- 1.	587	0			185	1(0.5%)
- 2.	244	1(0.4%)		233	2 (0.9%)
- 72	0			254	3(1.2%)
- 40	5(12.5%)		446	40(9%)
- 1		0			225	61(27%)
- 	944	6(0.6%)		1343  107(8%)

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## Evolution of antibiotic therapy for ambulatory pneumonia – results from various Can studies

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## Etiology CAP – Ohio study Arch Intern Med 1997; 157: 1709-18

- Jan 1 – Dec 31, 1994 - > 14,000 adm dx CAP; 3881 met initial eligibility criteria; 812 met clinical criteria but had neg CXR; 60 met x-ray criteria but not clinical criteria; 71 – neither. 2776 patients were the subject of the paper
- 				Definite	   Probable   Possible     Total
- S. pneumoniae		154	   33	      164	          351 (12.6%)
- H. influenzae		10	    31           143            184 (6.6%)
- GNB			24	    26            74	          124 (4.5%)
- S. aureus		12	    4              78               94  (3.4%)
- M. Pneumoniae		67		       337	           404( 32.5%)
- C. Pneumoniae		29		       143            172  (8.9%)
- Legionella spp		47		       16	             63 (3%)

## Etiology CAP requiring hospitalization using pneumococcal urinary antigen plus other tests

- Nottingham, UK – 1998 – 271 pts	S. pneumoniae 	126 	46%
- Hamilton, NZ- 420 pts with CAP; 169 controls	S. pneumoniae 	120	29%	Controls were negative
- High false positive rate in children [ due to high carriage rate of S. pneumoniae
- In adults sensitivity 80% and specificity 97 – 100%

## Blood culture done

**793 (20%)**

**Positive blood culture **
**41 (5.2%)**

**S. pneumoniae **
**24 (59%)**

**Total number of patients with CAP**
**(9558)**

**Pathway**
**7734 (81%)**

**Excluded**
**1824 (19%)**

**Outpatient**
**4259 (55%)**

**Inpatient**
**3475 (45%)**

**Unique visit**
**4033 (95%)**

**Blood culture done**
**2239 (66%)**

**Positive blood culture **
**154 (6.9%)**

**S. pneumoniae **
**76 (49%)**

**Unique visit**
**3395 (98%)**

## CAP pathway

**Total**
**7738**

**Outpatient**
**4259 (55%)**

**Inpatient**
**3479 (45%)**

**Unique**
**4032 **
**(95%)**

**Unique**
**3394**
**(98%)**

**Sputum done**
**199**
**(5%)**

**Positive sputum culture**
**87**
**(44%)**

**Sputum done**
**1190**
**(35%)**

**Positive sputum culture**
**343**
**(29%)**

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| Microorganism isolated from sputum | Admission type |  |  |  |
| --- | --- | --- | --- | --- |
|  | Outpatient |  | Inpatient |  |
|  | No. | % | No. | % |
| STREPTOCOCCUS PNEUMONIAE | 28 | 32.2 | 108 | 31.5 |
| STAPHYLOCOCCUS AUREUS | 9 | 10.3 | 54 | 15.7 |
| HAEMOPHILUS INFLUENZAE | 27 | 31.0 | 53 | 15.5 |
| PSEUDOMONAS AERUGINOSA | 4 | 4.6 | 28 | 8.2 |
| MORAXELLA CATARRHALIS | 7 | 8.0 | 27 | 7.9 |
| HAEMOPHILUS SPECIED | 3 | 3.4 | 19 | 5.5 |
| STREPTOCOCCUS  PYOGENES | 4 | 4.6 | 9 | 2.6 |
| KLEBSIELLA PNEUMONIAE | 1 | 1.1 | 9 | 2.6 |
| ENTEROCOCCUS SPECIES |   |   | 8 | 2.3 |
| E.COLI |   |   | 8 | 2.3 |
| STAPHYLOCOCCUS SPECIES |   |   | 7 | 2.0 |
| HAEMOPHILUS PARAINFLUENZAE | 6 | 6.9 | 7 | 2.0 |
| CORYNEBACTERIUM PSEUDODIPHTHERITICUM | 1 | 1.1 | 7 | 2.0 |
| SERRATIA MARCESCENS | 1 | 1.1 | 7 | 2.0 |

## Associations Between Initial Antimicrobial Therapy and Medical Outcomes for Hospitalized Elderly Patients With Pneumonia

- Review of records of 12,945 Medicare pts >65 y hospitalized with CAP
- Initial treatment associated with a lower 30-day mortality
- 2nd-generation cephalosporin + macrolide [HR-0.71 (0.52-0.96)]
- Non-pseudomonal 3rd generation ceph [HR 0.74 (0.6-0.92)] + macrolide
- FQ alone [HR 0.64 (0.3-0.94)]

## Associations Between Initial Antimicrobial Therapy and Medical Outcomes for Hospitalized Elderly Patients With Pneumonia (cont’d)

- Increased 30-day mortality associated with
- Beta-lactam/beta-lactamase inhibitor plus macrolide [HR 1.77]
- Aminoglycoside plus another agent [HR 1.43]

- Gleason et al. *Arch Intern Med*. 1999;159:2562.

## Associations Between Initial Antimicrobial Therapy and Medical Outcomes for Hospitalized Elderly Patients With Pneumonia (cont’d)

- Ceftriaxone, cefotaxime, ceftizoxime – 26.5%
- Cefuroxime – 12.3%
- Non-pseudomonal 3rd gen ceph + macrolide – 8.8%

## Associations Between Initial Antimicrobial Therapy and Medical Outcomes for Hospitalized Elderly Patients With Pneumonia (cont’d)

- 30 day mortality – 15.3% (11.2% CAP; 27.5% lTCF)
- Mortality with
- 2nd gen ceph + macrolide – 8.9%
- BL/BLI + macro – 24%

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