CAP related pathogens in Germany

Transkript

1 CAP related pathogens in Germany

2 Quotations Cultural detection of pathogens in sputum is meaningless if not guided by microscopy (Heineman et al., 1977) Initial Microbiological Studies in the Management of Nonsevere Community- Acquired Pneumonia has no value at all (Theerthakarai, R. et al. 2001)

3 Quotations With regard to BAL and fiber optic brush technique cultural detection has a sensitivity between 42 and 95% and a specificity between 45 and 100% (Sharp et al, 2004)

4 Quotations The culture of lower respiratory specimens may result in more unnecessary microbiologic effort than any other type of specimen (R.C. Bartlett)

5 Local centers and projects Local clinical centers Berlin Bonn/Köln Bochum Lübeck Hannover Magdeburg Ulm Würzburg Lüdenscheid Rotenburg/Wümme Aachen Essen Köln Lüdenscheid Freiburg Lübeck Rotenburg (Wümme( Wümme) Bremen Gießen Hannover Würzburg Ulm Braunschweig Magdeburg Jena München Berlin Dresden Projects of CAPNET Local clinical centers and recruitment of patients

6 Infrastructure and processing Private practitioner Hospitals Specimens sputum, blood, urine, pharyngeal washings Primary results Pathogens, cytology. susceptibility serology,antigen Local microbiology sputum cytology, sputum culture, susceptibility, asservation of specimens and strains, fixation for FISH uarterly Transport pathogens and specimens at 80 C Central service unit Documentation, asservation, DNA extraction Area B Projects Detection and characterization

7 Detection of respiratory pathogens Culture out of sputum, BAL, respiratory secretions, blood PCR based detection of M. pneumoniae, Legionella, Chlamydia pneumoniae PCR based detection of Influenza-, Entero-, Adeno-, RS-Virus Pneumococcal- and Legionella-Antigen-assay Antibody-assay (Legionella, Chlamydia, Mycoplasma pneumoniae)

8 Definitions of a pathogen Detection of pathogen in blood or other sterile specimens Significant bacterial growth in respiratory secretions and BAL Significant bacterial growth in purulent Sputum Positive Chlamydia pneumoniae PCR in at least two out of three laboratories Detection of IgM by Mycoplasma pneumoniae P1 immunoblot Positive Mycoplasma pneumoniae or Legionella PCR Positive Pneumococcal of Legionella urinary antigen assay Positive Influenzavirus A and B, RS-Virus, Adenovirus, Enterovirus-PCR

9 Proportion of pathogen positive CAP patients Patients with purulent sputum without squamous-epithelial cells purulent sputum sputum Proportion of patients per population

10 Study population: patients with sputum

11 Study population: patients with purulent sputum without squamous-epithelial cells

12 Candida albicans vs. S. pneumoniae detection Candida albicans S. pneumoniae age (mean, range) 65 (22,86) 60 (25,85) female chronic lung disease SCAP (<3 CURB Kriterien) antibiotic treatment within the last 4 weeks Packyears> Diabetes mellitus 8 24

13 Four out of 2279 patients received antifungal agents Prescription of antifungal agents Fluconazol+Aminopenicillin+Laktamase-Inhibitor+Cephalosporin Fluconazol+Macrolid+Aminopenicillin+Laktamase-Inhibitor Fluconazol+Metronidazol+Makrolid+Cephalosporin Ketoconazol+Tetracyclin+Aminopenicillin+Laktamase-Inhibitor Med. Mikrobiologie kein kultureller Erregernachweis aus respiratorischen Sekreten kultureller Nachweis von Klebsiella pneumoniae aus dem Sputum kein kultureller Erregernachweis aus respiratorischen Sekreten kultureller Nachweis von Proteus mirabilis aus dem Sputum

14 Improved outcome associated by limited ID Restricted ID (Yeasts) Full ID Hospital stay 10,1 days 12,1 days average cost 7,0 $ per patient 9,4 $ per patient Anti-fungal medication 21% 39% Mortality 14,30% 18,70% (Barenfanger,JCM 2003)

15 Variance of the incidence of CAP pathogens (Box-Plots (25 75 %-Quantiles; = mean line, =data point)

16 Chlamydia pneumoniae 6 h p.i. 60 h p.i. 12 h p.i.

17 C. pneumoniae case definitions PCR positive in two different assays using respiratory secretions or IgM positive by MIF

18 Applied methods Laboratory A B C Target gene/method 16S rrna-gen LightCycler PCR Pst1-Fragment (semi-nested PCR) Pst1-Fragment (nested PCR)

19 Patient No Clinical data of PCR positive patients Age (years) Sex female male male male female Smoker 30 py no 24 py no no COPD no no yes no no Pleural effusion no no no no no Pleuritic chest pain no no yes no yes Dyspnoea yes yes yes yes yes Requirement of hospitalization C-reactive protein (mg/l) Total white blood cells per nl yes no yes no yes n.a n.a Sputum cytology: Leukocytes per 100x field > n.a. >25 <10 Sample material for PCR sputum sputum BAL/BS sputum sputum

20 PID-Ari.network C. pneumoniae incidence

21 Mycoplasma pneumoniae infection case definitions Confirmed Infection Detection of specific DNA by PCR and/or Detection of specific IgM-Antibodies by Immunoblot (P1 = 160 kda Ahhäsin sin) Presumptive infection Detection of specific IgA-Antibodies Antibodies by Immunoblot (P1 = 160 kda Ahhäsin sin)

22 M. pneumoniae diagnostic in CAP Parameter Number of specimens Valid Test Positive PCR resp. samples (5,5%) Serum IgA-Blot (17,0%) Serum IgM-Blot (2,1%) Confirmed infection (3,7%)

23 M. pneumoniae infections Parameter Mp confirmed PCR PCR+IgM n=34 n=61 Mp presumptive n=268 Mp negative n=1357 Average age 37 38,6 60,5 62,7 CRP 112, ,9 143,3 Leukocytes 9,62 10,2 12,4 13,1 Out patients 47% 50% 27,6% 27,1% male 41% 36% 61,9% 55,6%

24 Sensitivity and Specificity of M. pneumoniae IgM and IgA antibodies Wert IgM Blot PCR positiv PCR negativ PCR alle Sensitivität 0,25 IgM Blot positiv Spezifität 0,99 IgM Blot negativ pos VW 0,6 IgM Blot alle neg VW 0,97 Wert IgA Blot PCR positiv PCR negativ PCR alle Sensitivität 0,50 IgA Blot positiv Spezifität 0,85 IgA Blot negativ pos VW 0,13 IgA Blot alle neg VW 0,97 Conclusion: IgA and IgM- Antibody assays do not increase the diagnostic accuracy

25 Legionella in Acanthamoeba castelanii

26 Case definitions for Legionella infections Confirmed infection Detection by culture Detection by PCR Positive L.-pneumophila urinary antigen-assay assay Presumptive infection Significant Legionella-Antibody titer by IFT

27 Legionella diagnostic in 2656 adults with CAP Parameter Patients tested Positiv PCR of respiratory specimens (2,6%) Antigen in urine (2,2%) Serum antibody by IFAT (1,4%) Confirmed Infection (4,2%)

28 Validity of Legionella diagnostic in 112 confirmed Legionella-infections infections 100% 90% 80% 70% 57 negativ positiv 60% 50% 40% 30% 20% 10% 0% PCR resp. specimens Urinary antigen Serum antibody

29 Summary Pathogen detection succeeds in only 25% of the patients Streptoccocus pneumoniae is the leading pathogen in CAP The incidence of C. pneumoniae is less than 2% The incidence of M. pneumoniae is less than 4% The incidence of Legionella infections is about 4%

30 However, is that the whole truth? We do know nothing at all about the aetiology of the remaining 60 % of the patients We cannot extend the findings from positive patients to pathogen negative patients Additional methods (e.g. FISH) might reveal additional pathogens of significance -

31 Quotations The major goal of the clinical microbiologic laboratory is to provide information of maximal clinical usefulness as rapidly as consistent with acceptable accuracy and minimal cost (J.P. Sanford)

32 Acknowledgements E. Straube, Jena M. Maass,Lübeck P.C. Lück, E. Jacobs, Dresden B. Schweiger, Berlin H. v. Baum, A. Essig, N. Wellinghausen, Ulm

33

34 Frequency of pathogen combinations in CAP Species A Species B Frequency Streptococcus pneumoniae Haemophilus influenzae 29 Streptococcus pneumoniae Staphylococcus aureus 11 Haemophilus influenzae E.coli 7 Haemophilus spp E.coli 6 Staphylococcus aureus Pseudomonas aeruginosa 6 Streptococcus pneumoniae Influenza -Virus 5 Streptococcus pneumoniae Enteroviren 5 Mycoplasma pneumoniae Haemophilus influenzae 5 Mycoplasma pneumoniae Enteroviren 5 RS-Viren Adenoviren 5 Streptococcus pyogenes Pseudomonas aeruginosa 4 Streptococcus pneumoniae Legionella spp. 3 Legionella spp. Adenoviren 2 Legionella spp. RS-Viren 2

35 S. pneumonia S. pneum oniae. Influen za A Mycopl asma Kombinationen Legion ella Haemo philus S. aureus E.coli Häufigkeiten von 2-fach- RS- Viren Entero viren e Influen za-b Adenov iren Pseudo monas Influenza A 1 Mycoplasm a 12 5 Legionella Haemophil us S. aureus 11 6 E.coli 13 RS-Viren 2 5 Enteroviren 5 5 Influenza B 5 1 Adenoviren 2 5 P. aeruginosa 6

36 Erregerhäufigkeit bei der CAP Häufigkeiten von 2-fach-Kombinationen (definite) Σ: Streptococcus pneumoniae: Influenza A-Viren: Mycoplasma pneumoniae: Legionella spp: Haemophilus influenzae: Staphylococcus aureus: E.coli: RS-Viren: Enteroviren: Influenza B-Viren: Haemophilus spp.: Adenoviren: Pseudomonas aeruginosa: Staphylococcus haemolyticus: Streptococcus pyogenes:

37 Häufigkeit von Erregerkombinationen bei der CAP Erreger A Erreger B Frequenz Streptococcus pneumoniae Haemophilus influenzae 29 Streptococcus pneumoniae Staphylococcus aureus 11 Haemophilus influenzae E.coli 7 Haemophilus spp E.coli 6 Staphylococcus aureus Pseudomonas aeruginosa 6 Streptococcus pneumoniae Influenza B-Viren 5 Streptococcus pneumoniae Enteroviren 5 Mycoplasma pneumoniae Haemophilus influenzae 5 Mycoplasma pneumoniae Enteroviren 5 RS-Viren Adenoviren 5 Streptococcus pyogenes Pseudomonas aeruginosa 4 Streptococcus pneumoniae Legionella spp. 3 Legionella spp. Adenoviren 2 Legionella spp. RS-Viren 2 Influenza A-Viren Influenza B-Viren 1

38 Studienpopulation: Verfügbarkeit von Chlamydia pneumoniae Ergebnissen

39 Studienpopulation: Verfügbarkeit von eitrigem, respiratorischem Sekret

40 Studienpopulation: Verfügbarkeit von Legionellen u. Mykoplasmen - Nachweisen

41 Studienpopulation: Verfügbarkeit von Rachenspülwasser

42 Studienpopulation: Verfügbarkeit von S. pneumoniae Antigennachweis im Urin

43 Penicillin- und Makrolid Resistenz bei S. pneumoniae (Alexander Projekt 1997) Penicilin (MHK > 0,06) Makrolid (MHK > 0.25) % der Stämme Deutschland Niederlande Italien Polen Schweiz Portugal Gross Britanien Griechenland Irland Spanien Slowakei Frankreich Tschechien

44 Number of leukocytes in sputum and pathogen spectrum > < Streptococcus pneumoniae Haemophilus influenzae Candida albicans Enterobacteria Escherichia coli Hem. Streptococci Staphylococcus aureus Streptococcus pyogenes Klebsiella pneumoniae Pseudomonas aeruginosa Non-aeruginosa Moraxella catarrhalis Stenotrophomonas maltophilia

45 S3-Leitlinie Als Therapie der Wahl für die unkomplizierte acap im ambulanten Bereich bei Patienten ohne Risikofaktoren wird eine Monotherapie mit einem hochdosierten Aminopenicillinpräparat, alternativ ein neueres Makrolid oder Doxycyclin empfohlen. Fluorchinolone werden bei dieser Patientengruppe nicht empfohlen (Empfehlungsgrad A). Als Therapie der Wahl für die komplizierte acap bei Patienten mit Risikofaktoren wird eine Monotherapie mit einem hochdosierten Aminopenicillin/ Betalaktamaseinhibitor, alternativ mit pneumokokkenwirksamen Fluorchinolonen empfohlen. Bei Verdacht auf eine Infektion durch Mykoplasmen, Chlamydien oder Legionellen kann auch eine Kombinationstherapie in Form einer Betalaktam-Makrolid- Kombination durchgeführt werden (Empfehlungsgrad A).

46 Positivität der Legionella PCR in verschiedenen respiratorischen Materialien 100% 90% 80% 70% negativ positiv 60% 50% % 30% 20% 10% 0% BAL Sputum andere