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Treatment of pneumonia in immunocompromised host

Treatment of pneumonia in immunocompromised host. Prof. Dr. Volkan Korten Marmara Univ. School of Medicine Dept. of Infectious Diseases. Pneumonia in immunocompromised host. Community acquired Noso c omial Aspiration Rea ctivation Environmental exposure.

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Treatment of pneumonia in immunocompromised host

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  1. Treatment of pneumonia in immunocompromised host Prof. Dr. Volkan Korten Marmara Univ. School of Medicine Dept. of Infectious Diseases

  2. Pneumonia in immunocompromised host • Community acquired • Nosocomial • Aspiration • Reactivation • Environmental exposure

  3. Pneumonia in immunocompromised host - Etiology • Conventional bacteria % 37 • Fungi % 14 • Viruses % 15 • Pneumocystis carinii/jirovecii % 8 • Nocardia asteroides % 7 • Mycobacterium tuberculosis % 1 • Mixed infections % 20

  4. Community acquired pneumonia • Etiology – not changed in imm.comp. host • Focal – segmental infiltrates suggest bacterial etiology. • Typical - atypical pneumonia S.pneumoniae, H.influenzaeor L.pneumophila etc • Severely impaired cellular immunity: • CMV, Tbc, MAI CAP guidelines are valid – according to severity / empiric treatment - similar to pts with underlying diseases

  5. + PCP ? + Mycoplasma – legionella ? + Viral ? Empiric Ab (antipseudomonal beta-lactams), MRSA ? Legionella ? Empiric Ab + empiric antifungal

  6. Antipseudomonal beta-lactams • Antipseudomonal cephalosporins • Cefepime 2 g tid • Ceftazidime ? 2 g tid • Carbapenems • Imipenem 500 mg qid, 1 g tid • Meropenem 1-2 g tid • Doripenem 0.5-1 g tid • Beta-lactam/beta-lactamase inhibitors • Piperacilin-tazobactam 4.5 g qid • Cefoperazone-sulbactam 2 g tid • Combinations ? • (shock – MDR) • FQ • Aminoglicosides

  7. Risk classification for invasive aspergillosis • Allo BMT + GVHD • Allo BMT ± GVHD • PNL <500/mm3 + Hematological malignancies + Auto BMT + Aplastic Anemia + MDS • SOT, AIDS • High dose steroids

  8. Invasive pulmonary aspergillosis Normal lung IPA IPA occurs in ~7% of acute leukaemia patients, 10-15% allogeneic BMT patients www.aspergillus.man.ac.uk

  9. Invasive fungal disease - Definitions II tissue Host factors Clinical features Mycology + + = Proven Host factors Clinical features Mycology + = Probable Host factors Clinical features Negative or Not done + = Possible Host factors Clinical features Negative or Not done + = De Pauw B, Definitions of Invasive Fungal Disease, CID2008;46:1813-21

  10. Host factors for IA • Recent history of neutropenia (< 500/mm3 for > 10 days) • Allogeneic stem cell transplant • Prolonged use of corticosteroids • T cell immunosuppressants, such as cyclosporine, TNF-a blockers, specific monoclonalantibodies (such as alemtuzumab), or nucleoside analogues during the past 90 days • Inherited severe immunodeficiency (such as chronic granulomatous disease or severe combined immunodeficiency)

  11. Microbiological criteria • Culture • Cytology • Galactomannan, Beta-glucan • Clinical criteria CT • Halo sign • Air - crescent sign • Cavity in consolidation

  12. nodules halo sign air crescent sign cavity Specific pulmonary infiltrates on CT scan

  13. IDSA Clinical Practice Guidelines for Aspergillosis 2008 Walsh TJ, et al. Clin Infect Dis 2008;46:327-60

  14. Risk factors for Pneumocystis pneumonia • HIV infection - CD4 < 200 • Non-HIV • Glucocorticoid use • Other immunosuppressive drugs: Antirejection medications, Purine analogs (eg, fludarabine), Infliximab • Defects in cell-mediated immunity • Cancer (particularly hematologic malignancy) • HSCT; especially allo • Solid organ transplantation • Treatment for rejection • Treatment for inflammatory conditions (eg, Wegener's granulomatosis) • Severe malnutrition (especially protein malnutrition) • Primary immunodeficiencies (particularly severe combined immunodeficiency) • Prematurity

  15. Anti-inflammation Therapy:Prednisone:needs definitive diagnosis • Shown to improve survival in patients with paO2 < 70 or Aa gradient >35 mm Hg. • Decreases the risk of respiratory failure and death by 50%. • Tapered dose (40 mg BID x 7, 40mg QD x 7, 20 mg QD x 7).

  16. Nocardia • TMP-SMZ 15 mg/kg/d TMP iv or po – first 4 wks, • 10 mg/kg/d TMP equivalent 5 months /  1 year in imm. compromised pts. • cranial imaging • Imipenem 500 mg qid or Ceftriaxone 2 g/d + Amikacin 1 g/d 3-4 wks, followed by TMP-SMZ • Linezolid 600 mg bid, po

  17. RSV / Influenza • Ribavirin aerosol or po • Ribavirin + palivizumab (monoclonal antibody developed against RSV) • Oseltamivir / zanamivir

  18. Treatment duration • Community acquired:  7 days after defervescence • Nosocomial:  14 days after defervescence • Neutropenic pts: till PNL > 500/mm3 ?

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