are cap and hcap two separate entities? francesco blasi department pathophysiology and...
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ARE CAP AND HCAP TWO SEPARATE ENTITIES?Francesco Blasi
Department Pathophysiology and Transplantation, University of Milan, Italy
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Disclosures
• I have accepted grants, speaking and conference invitations from Almirall, Angelini, AstraZeneca, Bayer, Chiesi, GSK, Guidotti-Malesci, Menarini, Novartis, Pfizer, and Zambon
• I have had recent or ongoing consultancy with Almirall, Angelini, AstraZeneca, GSK, Menarini, Mundipharma and Novartis
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European Lung White Book
http://www.erswhitebook.org
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HEALTH CARE – ASSOCIATED STATUS The evolution of MDR pathogens as a dynamic
process
NH
Dialysis
DH Surgery
HC Services
Rehabilitation
Home IV
Hospital
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HCAP: original definition
ATS / IDSA guidelines for HA, VAP and HCAP, Am J Respir Crit Care Med 2005HCAP health care associated pneumonia
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Kollef MH, et al. Clin Inf Dis 2008;46:S296-334
HCAP health care associated pneumoniaCAP community acquired pneumoniaVAP ventilator associated pneumonia
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HCAP: what is behind ?
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HCAP: the original concept
ATS / IDSA guidelines for HA, VAP and HCAP, Am J Respir Crit Care Med 2005HCAP Health care associated pneumoniaMDR multi drug resistant
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When HCAP = resistant pathogens,predictive values of HCAP are poor
Shorr AF et al., Arch Intern Med. 2008;168(20):2205-10.(Zilberberg, Micek, Kollef)HCAP health care associated pneumonia
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Attidge RT, Frei CR. Am J Med. 2011;124: 689-97.
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Chalmers JD, et al. CID. 2011;53(2):107-13
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Chalmers JD, et al. CID. 2011;53(2):107-13
HCAP health care associated pneumoniaCAP community acquired pneumoniaCOPD chronic obstructive pulmonary disease
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Chalmers JD, et al. CID. 2011;53(2):107-13 HCAP health care associated pneumoniaCAP community acquired pneumonia
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• HCAP is common in the United Kingdom and is associated with a high mortality.
• This increased mortality was primarily related to underlying patient-related factors rather than the presence of antibiotic-resistant pathogens
• This study did not establish a clear indication to change prescribing practices in a UK cohort
HCAP health care associated pneumonia Chalmers JD, et al. CID. 2011;53(2):107-13
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HEALTH CARE-ASSOCIATED PNEUMONIA: Does therapy modify the outcome?
GC guideline-concordantHCAP health care associated pneumoniaCAP community acquired pneumonia Attridge RT et al. Eur Resp J 2011;38:878-87
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CAP HAP
Woodhead M, et al.Clin Microbiol Infect 2011; 17(Suppl. 6): E1–E59.CAP community acquired pneumoniaHAP hospital acquired pneumonia
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CAP community acquired pneumoniaMDR multi drug resistant Cilloniz C et al. Chest. 2013;144(3):999-1007
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HCAP definition: pitfalls
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The real question is:Does HCAP accurately identify MDR?
HCAP health care acquired pneumoniaMDR multi drug resistance
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A probabilistic approach
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New approach: Stratify risk factors.. In the USA
Scoring system:4: Recent hospitalization3: Long term facility2: Chronic Heart Disease1: ICU admission within 24h of evaluation in the ED
Shorr AF, et al. CID 2012;54(2):193–8ICU intensive care unitED emergency department
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cohort of patients with severe pneumonia. In fact, more than half of the patients was directly admitted to the ICU and the main pathogen isolated was methicillin-resistant S. aureus, followed by P. aeruginosa and S. pneumoniae.
New approach: Stratify risk factors.. In the USA
Shorr AF, et al. CID 2012;54(2):193–8
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New approach: Stratify risk factors.. In the USA
Shorr AF, et al. CID. 2012;54(2):193–8
HCAP health care associated pneumoniaNPV, negative predictive valuePPV, positive predictive vale
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This was an observational, prospective study of consecutive patients coming from the community who were admitted to the Policlinico Hospital, Milan, Italy, with a diagnosis of pneumonia between April 2008 and April 2010. A total of 935 consecutive patients with pneumonia were enrolled during the study period
Aliberti A, et al CID 2012;54(4):470-8.
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Risk Factors Analysis: MDR pathogens
Aliberti A, et al CID 2012;54(4):470-8.MDR multi drug resustantHCAP health care associated pneumonia
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Aliberti A, et al CID 2012;54(4):470-8.MDR multi drug resistantCOPD chronic obstructive pulmonary disease
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Sensitivity: 75%Specificity: 71% Sensitivity: 78%
Specificity: 56%
HCAP approach
Aliberti A, et al CID 2012;54(4):470-8.HCAP health care associated pneumonia
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Risk Factors Analysis for MDR pathogensA probabilistic approach
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Risk Factors Analysis for MDR pathogensA probabilistic approach
MDR multi drug resistant
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Risk Factors Analysis for MDR pathogensA probabilistic approach...for MDR
MDR multi drug resistant
Aliberti A, et al CID 2012;54(4):470-8.Shorr AF, et al. CID. 2012;54(2):193–8
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Aliberti S et al. Thorax 2013;68:997-9
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New approach: Stratify risk factors
New findings: • Different risk factors have different importance for MDR prediction
• Chronic renal failure is an independent risk factor for MDR (A window of patient’s functional status)
• Patient’s targeted approach for empiric antibiotic therapy is possible
Aliberti A, et al CID 2012;54(4):470-8MDR multi drug resistant
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22,456 patients
Sub analysis by region found that HCAP ‐performed poorly in European studies and in
prospective/high quality studies.
MRSA methicillin resistant Staphylococcus aureusAUC area under the curveHCAP health care associated pneumonia Chalmers JD, et al. CID. 2014;58(3)330-9.
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Predictive accuracy of HCAP
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Predictive accuracy of HCAP
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Predictive accuracy of HCAP
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Predictive accuracy of HCAP
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Number needed to treat
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Number needed to treat
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Empiric antibiotic therapy
HCAP healthcare associated pneumoniaCAP community-acquired pneumonia
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Empiric antibiotic therapy
A probabilistic approach for each
single pathogen
HCAP healthcare associated pneumoniaCAP community-acquired pneumonia
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