PROBLEMS IN THE DIAGNOSIS AND MANAGEMENT OF LOWER RESPIRATORY INFECTIONS IN TUNISIA

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PROBLEMS IN THE DIAGNOSIS AND MANAGEMENT OF LOWER
RESPIRATORY INFECTIONS IN TUNISIA

• Pr DRIRA Ikram
• Pr BEN KHEDER Ali
• FEMTOS SESSION
• TTS 10th ANNUAL MEETING
• 26 April 2007

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FEMTOS
Gürcistan Azerbeycan Kazakistan Kirgizistan
Georgia Kyrgyzstan
Yunanistan Bulgaristan Makedonya Sirbistan
Fas Tunus Misir Iran
Yunanistan Bulgaristan Makedonya Sirbistan
Fas Tunus Misir Iran
Turkey Bulgaria Macedonia Serbia
Morocco Tunisia Egypt Iran
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Are Lower respiratory infections a Public Health
problem in Tunisia??

• Public Health problem is defined by
• frequency
• gravity
• cost

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TUNISIAN DATA?
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TUNISIAN DATA
Very fragmentary !!!
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National Data

• Lower respiratory infections among children lt 5
  years
• 56.33 of pediatric consultations (2004)
• 54.52 of pediatric consultations (2003)
• Antibiotic prescription
• 76.5 (2004)
• 81.65 (2003)

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Retrospective study in adultsCommunity
Acquired PneumoniaInpatients
Tritar F.

• Retrospective study 2003 - 2004
• Tunis 8 departments of Pulmonology
• Patients hospitalized for CAP
• 557 patients

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Community Acquired Pneumonia InpatientsStudied
population
282 men - 275 women (SR 1.O2)
Age 52 20 years (15-91)
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Community Acquired PneumoniaInpatientsepidemiolo
gical characteristics

• HABITS nb
• Tobacco (36PA) 223 40
• Neffa 45 8
• Chicha 7 1,5
• Alcohol 23 4
• Drug addiction 2 0,3

49.5
10

• COPD 12
• Asthma 6
• Bronchectasies 5
• Tb 5
• CRF 2
• BPcancer 1

Total 40
Respiratory antecedents
11
AHT 17
Diabetes 15
Cardiopathies 7
Renal diseases 2
psy desorders 4
Digest 3
Tumors 2
Anemia 1
Total 47
Risk factors
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Community Acquired PneumoniaInpatientsBacteriolo
gical data
Nb
Sputum 211 70
Bloodculture 107 35
Pleural liquid 18 6
ECBU 19 6
PDP 25 8
LBA 7 2
PDP
LBA
ECBU
L.P
bloodculture
Sputum
Samples 302 (54)
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Bacteriological data
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Positive samples 68 (23)
211
107
11
25
18
7
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Community Acquired PneumoniaInpatientsBac
teriological data
HC ECBC PDP LBA LP Nb
S. pneumo 7 4 5 2 18 26
S.aureus 1 1 1
H Influenzae 1 18 6 2 27 40
K.Pneumoniae 1 5 1 7 10
P.aeruginosa 6 1 7 10
B.Catharalis 4 4 6
Other BGN 2 2 4 6
Total 10 39 13 4 2 68 100
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Community Acquired PneumoniaInpatients
Antibiotic treatment
Nb Duration
1 ATB 398 71 10.43 j
2 ATB 168 30 12.51 j
3 ATB 22 4 13.38 j
Middle Duration 12 days
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Community Acquired PneumoniaInpatientsAntibiot
ic treatment
ATB nb
Ampicillin 188 34
Amox clav ac 141 25
Amoxicillin 60 11
Penicillin 19 3
Cephalosporin 77 14
Macrolides 32 6
F.quinolones 28 5
ß Lactams
87
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Community Acquired PneumoniaInpatientsOutcome

• nb
• Favorable 533 95.5
• Unfavorable 25 4.5
• Death 9 2
  
• Delay of pyrexia 3.45 days (1 to 13)

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Community Acquired PneumoniaInpatients Fine
Score
Class I II III IV V
nb 211 152 113 76 5
38 27 20 14 1
557 Patients Classes I et II 65
ABUSE OF HOSPITALIZATION
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CAUSATIVE PATHOGENS

• 221 cases of community acquired pneumonia
  (January 2002- June 2004)
• 150 men et 71 women,
• Average age 42.7 years,
• 117 patients from the Pneumology departments and
  104 from the ICU.

W. Mahjoubi, E. Mhiri Zghal, L. Slim Saidi
Microbiology Laboratory - Ariana
Hospital Congress of the Tunisian Society of
Respiratory Disease December 2004
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CAUSATIVE PATHOGENS

• 221 cases of community acquired pneumonia
  (January 2002- June 2004)
• 150 men et 71 women,
• Average age 42.7 years,
• 117 patients from the Pneumology departments and
  104 from the ICU.

Causative Pathogens
Streptococcus pneumoniae 38,5
Haemophilus influenzae 15
Staphylococcus aureus 4,5
Klebsiella pneumoniae 4,5
Moraxella catarrhalis 2,5
Legionella pneumophila 2
Mycoplasma pneumoniae 8,5
Chlamydiae pneumoniae 3,5
Coxiella burnetti 1
94 patients
W. Mahjoubi, E. Mhiri Zghal, L. Slim Saidi
Microbiology Laboratory - A. Mami Hospital -
Ariana Congress of the Tunisian Society of
Respiratory Disease December 2004
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RESISTANCE TO PENICILLIN OF S.PNEUMONIAE
ISOLATED IN TUNISIA

• 964 samples
• Study period 2000 2004
• Respiratory tract infections

Penicillin Susceptible S.Pneumonia
Penicillin Low Susceptible S. Pneumonia
W. Mahjoubi, E. Mhiri Zghal, L. Slim Saidi
Microbiology Laboratory Ariana Hospital RICAI
2005
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ANTIBIOTIC RESISTANCE
Streptococcus Pneumoniae
Penicillin Resistance S. Pneumoniae 35
Amoxicillin Resistance S. Pneumoniae 24.5
High level 3.6
Intermediate level 18.9
Cefotaxim Resistance S. Pneumoniae 14
High level 4
Intermediate level 10
Erythromycin Resistance S. Pneumoniae 28
Cyclin Resistance S. Pneumoniae 23
Cotrimoxazole Resistance S. Pneumoniae 28
BEN REJEB S., BEN HASSEN A, HAMMAMI A, KECHRID A.
(HCN)
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ANTIBIOTIC RESISTANCE
Haemophilus Influenzae
Amoxicillin Resistance H. Influenzae 24.5
Erythromycin Resistance H. Influenzae 67
Cyclin Resistance H. Influenzae 17
Cefotaxim Resistance H. Influenzae 0
Amoxicillin/Clavulanate Resistance H. Influenzae 0
BEN REJEB S., BEN HASSEN A, HAMMAMI A, KECHRID A.
(HCN)
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CAP TUNISIAN PROPOSED GUIDELINES
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CAP TUNISIAN PROPOSED GUIDELINES
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CAP TUNISIAN PROPOSED GUIDELINES
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CAP TUNISIAN PROPOSED GUIDELINES
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PAL Study
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     Diagnosis establish before and after training
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     Diagnosis establish before and after training
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Antibiotic prescription (ATBP) among the
respiratory patients who received drug
prescription
ATBP Baseline
Impact Variation p-value
study
study in ------------------------
--------------------------------------------------
----------------------------- Proportion of
1670/2341 822/1422 - 19.0 lt
0.0001 patients who (71.3) (57.8) received
ATBP   Nb of antibiotics prescribed per
0.73 0.58 -
20.0 lt 0.0001 patient who received a
DP   ---------------------------------------------
--------------------------------------------------
--------

• Proportion of patients who were prescribed
  antibiotics and the number
• of antibiotics per drug prescription decreased
  in the impact study.

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Are Lower respiratory infections a Public Health
problem in Tunisia??
frequency ? in children (Health policy
vaccination, PMI, school medicine) gravity
Death 2 (inpatients) cost - direct
cost is high (overprescription of antibiotics)
- Indirect cost (abuse of hospitalization)
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Are Lower respiratory infections a Public Health
problem in Tunisia??
frequency ? in children (Health policy
vaccination, PMI, school medicine) gravity
Death 2 (inpatients) cost - direct
cost is high (overprescription of antibiotics)
- Indirect cost (abuse of hospitalization)
34
Are Lower respiratory infections a Public Health
problem in Tunisia??
frequency ? in children (Health policy
vaccination, PMI, school medicine) gravity
Death 2 (inpatients) cost - direct
cost is high (overprescription of
antibiotics) - Indirect cost (abuse of
hospitalization)
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PROBLEMS

• The lack of epidemiological study among children
  and adults to establish frequency, morbidity and
  mortality data
• Overdiagnosis of suppurated acute bronchitis and
  underdiagnosis of CAP

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PROBLEMS

• Overprescription of antibiotics
• - High cost
• - Emergence of resistance
• Abuse of hospitalizations for CPA (Social
  considerations)

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In Summary

• Epidemiological problem (data)
• Emergence of pathogens resistance
• Management