Clinical analysis of community-acquired pneumonia in the elderly

OBJECTIVE: To evaluate the clinical features, etiology, and outcome of patients over 65 years old hospitalized for community-acquired pneumonia. PATIENTS: Eighty-four patients (50 males, 34 females) hospitalized for community-acquired pneumonia in Kawasaki Medical School Kawasaki Hospital between April 1998 and March 2000. RESULTS: Most of the patients had respiratory symptoms or signs, but over one-third also had atypical symptoms of pneumonia such as dyspnea, consciousness disturbance, and gastrointestinal symptoms. The causative microorganisms were identified in 48% of these patients. Streptococcus pneumoniae (13%), respiratory viruses (13%), Haemophilus influenzae (8%) and Mycobacterium tuberculosis (8%) were frequently identified, but Mycoplasma pneumoniae was less frequently noted in the elderly. Double infection was recognized in 19 % and a combination of some virus and bacteria in 13%. Treatment consisted of the administration of second or third generation cephalosporin antibiotics intravenously, because antibiotics had already been preadministered in 39%. The prognosis was poor (mortality rate 9%) for the elderly with community-acquired pneumonia despite mechanical ventilation in 8%. CONCLUSIONS: Although the range of microorganisms causing community-acquired pneumonia differed slightly from that in previous reports; namely, lower frequency of Chlamydia pneumoniae and Legionella pneumophila, it is suggested that the initial antibiotic treatment should always cover S. pneumoniae and H. influenzae. In addition, since a prevalence of virus infections related to the increase in community-acquired pneumonia in the elderly was found in this study, the routine use of influenza vaccine and pneumococcal vaccines in the elderly is recommended to reduce the high mortality rate.     

老年耐药肺结核的结核杆菌药敏特点分析

目的探讨老年耐药肺结核的结核杆菌的药敏特点方法所有病例均为解放军第309医院2006年3月至2010年10的住院患者,其中28例老年耐药肺结核患者男21例,女7例,平均年龄（67±8）岁,同期随机抽取非老年耐药肺结核患者32例作为对照,其中男23例,女9例,平均年龄（32±8）岁。所有患者痰结核杆菌培养均采用L-J罗氏培养基Bactec-MGIT960快速培养及药敏试验。两组资料结果用SPSS 12.0软件包进行统计学分析结果两组病例耐药药物顺序前四位均为S,H,R,E,老年组耐2～3种药共17例,占60.71%,非老年组共10例,占31.25%;耐3～4种药非老年组共19例,占59.38%,老年组共14例,占50%,老年组以耐2～3种为主,非老年组以耐3～4种药为主,统计学分析差异显著;结果还显示两组药物敏感率均以KOP最高。结论对老年肺结核患者,应加强督导化疗,减少耐药病例的产生。对已耐药的病例,应根据药敏结果选择敏感药物进行化疗;在药敏结果未报之前,可选用包含KOP的方案进行化疗,以提高疗效。     

Clinical evaluation of the cause of death in patients with active pulmonary tuberculosis

We made a clinical analysis of the cause of death of forty deceased patients with active pulmonary tuberculosis who were admitted to Kawasaki Medical School Hospital, Kawasaki Medical School Kawasaki Hospital, and Asahigaoka Hospital during the period from January 1996 to December 2001. The age of 40 deceased patients (29 males/11 females) ranged from 55 to 93 years old, and were mostly bedridden. Underlying diseases existed in all except one case, and they were respiratory diseases in 9 patients and non-respiratory diseases in 34 patients. Laboratory findings revealed poor nutritional conditions. The diagnosis of pulmonary tuberculosis was established within one month from the appearance of symptoms in over half of these patients because most of them were smear positive for Mycobacterium tuberculosis. None of the strains of Mycobacterium tuberculosis isolated from these patients were multidrug resistant for antituberculous drugs and only one strain was completely resistant for Rifampicin. Radiological findings of the tuberculosis were bilateral in 30 patients. Consolidation shadows without cavity were noted in 22 patients, and extension within the unilateral lung field was observed in 24 patients. Regarding the cause of death, advanced pulmonary tuberculosis was the cause in 17 patients and non-tuberculous diseases were the cause in 23 patients. There were 15 patients with bacterial superinfections such as bacterial pneumonia, 4 with malignancy, and 4 with other disease. The number of pulmonary tuberculosis patients in poor general and nutritional condition has been increasing with the aging of the Japanese population. Treatment for pulmonary tuberculosis has been successful in most cases, however, the number of the deaths unrelated to tuberculosis including those due to bacterial superinfection has been increasing. Therefore, treatment should be considered against resistant microoganisms such as MRSA.     

Clinical analysis of pneumonia in the elderly in a community hospital--comparison of community-acquired pneumonia and nosocomial pneumonia]

We experienced 530 elderly cases with pneumonia among 930 patients with pneumonia in Kawasaki Medical School Kawasaki Hospital between April 1986 and September 1998. Clinical analysis of all these patients and a comparison of one group consisting of 418 patients with community-acquired pneumonia and another group composed of 112 patients with nosocomial pneumonia were performed. In all of the elderly patients with pneumonia, respiratory symptoms and inflammatory findings were less frequent, but were frequent for those in poor general and nutritional condition. The causative microorganism was isolated in 42% of these patients. Streptococcus pneumoniae, MSSA and Klebsiella pneumoniae were frequently isolated from the sputum of the patients with community-acquired pneumonia, while Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Methicillin-sensitive Staphylococcus aureus (MSSA) were frequently isolated from that of nosocomial pneumonia patients. Mycoplasma pneumoniae, Chlamydia pneumoniae and some viruses were less frequent for patients in both groups. Although many intravenous antibiotics, such as cephem or carbapenem were administered to patients in both groups, the prognosis was relatively good for those with community acquired pneumonia but was extremely poor for those with nosocomial pneumonia despite mechanical ventilation or steroid pulse therapy for many patients.     

Management of community-acquired pneumonia in the era of pneumococcal resistance: a report from the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group

OBJECTIVE: To provide recommendations for the management of community-acquired pneumonia and the surveillance of drug-resistant Streptococcus pneumoniae (DRSP). METHODS: We addressed the following questions: (1) Should pneumococcal resistance to beta-lactam antimicrobial agents influence pneumonia treatment? (2) What are suitable empirical antimicrobial regimens for outpatient treatment of community-acquired pneumonia in the DRSP era? (3) What are suitable empirical antimicrobial regimens for treatment of hospitalized patients with community-acquired pneumonia in the DRSP era? and (4) How should clinical laboratories report antibiotic susceptibility patterns for S pneumoniae, and what drugs should be included in surveillance if community-acquired pneumonia is the syndrome of interest? Experts in the management of pneumonia and the DRSP Therapeutic Working Group, which includes clinicians, academicians, and public health practitioners, met at the Centers for Disease Control and Prevention in March 1998 to discuss the management of pneumonia in the era of DRSP. Published and unpublished data were summarized from the scientific literature and experience of participants. After group presentations and review of background materials, subgroup chairs prepared draft responses, which were discussed as a group. CONCLUSIONS: When implicated in cases of pneumonia, S pneumoniae should be considered susceptible if penicillin minimum inhibitory concentration (MIC) is no greater than 1 microg/mL, of intermediate susceptibility if MIC is 2 microg/ mL, and resistant if MIC is no less than 4 microg/mL. For outpatient treatment of community-acquired pneumonia, suitable empirical oral antimicrobial agents include a macrolide (eg, erythromycin, clarithromycin, azithromycin), doxycycline (or tetracycline) for children aged 8 years or older, or an oral beta-lactam with good activity against pneumococci (eg, cefuroxime axetil, amoxicillin, or a combination of amoxicillin and clavulanate potassium). Suitable empirical antimicrobial regimens for inpatient pneumonia include an intravenous beta-lactam, such as cefuroxime, ceftriaxone sodium, cefotaxime sodium, or a combination of ampicillin sodium and sulbactam sodium plus a macrolide. New fluoroquinolones with improved activity against S pneumoniae can also be used to treat adults with community-acquired pneumonia. To limit the emergence of fluoroquinolone-resistant strains, the new fluoroquinolones should be limited to adults (1) for whom one of the above regimens has already failed, (2) who are allergic to alternative agents, or (3) who have a documented infection with highly drug-resistant pneumococci (eg, penicillin MIC > or =4 microg/mL). Vancomycin hydrochloride is not routinely indicated for the treatment of community-acquired pneumonia or pneumonia caused by DRSP.     

莫西沙星治疗老年耐多药肺结核疗效的观察

目的评价新一代氟喹诺酮类药物莫西沙星对老年耐多药肺结核病（MDR-PTB）的治疗效果及安全性。方法将65例老年痰菌阳性的MDR-PTB患者随机分成试验组（T组）33例与对照组（H组）32例;试验组用莫西沙星0.4 g/d,对照组用左氧氟沙星0.4 g/d,疗程12个月,同时辅以其他抗结核药物治疗。观察两组痰菌阴转率、病灶吸收率、空洞闭合率等情况。结果治疗组痰菌阴转率明显高于对照组（P〈0.05）,影像吸收率、副作用两组间差异无显著性（P〉0.05）。结论莫西沙星对老年MDR-PTB的治疗是有效更安全的。     

A study on low performance status cases of pulmonary tuberculosis in the elderly

The subjects consisted of 42 patients aged over 60 years, whose performance status (PS) was grade 3 or 4, and who had been admitted for pulmonary tuberculosis at National Chiba-Higashi Hospital between 1997 and 1998. The average age (+/- SD) of the 34 men and 8 women was 77.6 (+/- 8.5) years (range, 60-91 years). The mean stay in the hospital of the improved patients was 166.6 days (range, 57-303 days), and the mean survival period from admission to death was 43.4 days (range, 2-179 days in died patients). On admission to our hospital, 26 cases were sputum smear positive, 8 cases were smear negative and culture positive, and 8 were negative both on smear and culture. The cavity was observed in 30 cases (71.4%) on the chest X-ray. The laboratory data on admission revealed low nutritional condition. The mean serum total protein, albumin, and cholesterol level on admission were 6.2 (+/- 0.82) g/dl, 2.7 (+/- 0.62) g/dl, and 143.0 (+/- 41.9) mg/dl. Most of the patients had a difficulty in taking foods, and 20 cases (47.6%) were performed parenteral nutrition by central venous catheter. 23 cases (54.8%) received oxygen therapy by facial mask or nasal tube. The most common cause of low PS on admission was pulmonary tuberculosis in 14 cases (33.3%), followed by cerebrovascular diseases in 11 cases, and orthopedic disease in 8 cases. The proportion of patients whose cause of low PS was not due to lung tuberculosis increased with age. Observing the mortality by the route of administration of antituberculosis medications on admission, 19 (55.9%) of 34 cases who could take drugs per oral route died. One (50.0%) of 2 cases who were administered drugs through gastric tube died, and all (100.0%) of 5 cases who could not take drugs per oral route and were injected isoniazid and streptomycin died. One case who could not administer any drug died. 16 cases improved and 26 cases died, of whom the most common cause of death was pulmonary tuberculosis in 11 cases (42.3%), followed by bacterial pneumonia in 5 cases, and cerebrovascular disease in 3 cases. The mortality by the PS on admission were as follows: 10 (47.6%) of 21 cases with PS 3 died. 16 (76.2%) of 21 cases with PS 4 died. 16 (6.4%) of 249 cases aged over 60 years with PS 0, 1 or 2, and were admitted for pulmonary tuberculosis at the same hospital during the same period died. This study confirms that the prognosis of low performance status patients of pulmonary tuberculosis in the elderly was significantly poor. We have to detect tuberculosis patients in the early stage, and give them antituberculosis medications per oral route as far as possible.     

A prospective study of community-acquired pneumonia in Hong Kong.

A prospective study of community-acquired pneumonia in Hong Kong was carried out between January and December, 1988. Ninety adults (57 male) with a mean age of 57.3 years were admitted to the Prince of Wales Hospital with community-acquired pneumonia. The etiologic diagnosis of pneumonia was made in 37 cases (41 percent). Pneumococcal infection was diagnosed in 11 patients (12 percent). The same number of patients had pulmonary tuberculosis presenting as acute pneumonia. It could not be differentiated from other causes of pneumonia on clinical and radiologic grounds, although pleural effusion and upper lobe involvement were more common in patients with tuberculosis. Chlamydia species were identified in five patients (6 percent) and Mycoplasma pneumoniae was identified in three patients (3 percent). There was no case of Legionnaires' disease. The etiologic agent could not be identified in 59 percent of cases. The low incidence of etiologic diagnosis of community-acquired pneumonia was probably related to the widespread use of antibiotics in private practice. Tuberculosis is an important cause of community-acquired pneumonia in Hong Kong and this diagnosis should be considered in patients who fail to respond to first-line antibiotics.     

厄他培南治疗老年社区获得性肺炎的疗效观察

目的比较厄他培南与莫西沙星治疗老年社区获得性肺炎的有效性和安全性。方法 80例老年(≥65岁)社区获得性肺炎患者随机分为两组,治疗组给予厄他培南注射液(商品名怡万之,默沙东公司),每次1g,每日一次静脉滴注,总疗程5天;对照组给予莫西沙星(商品名拜复乐,拜尔公司)注射液400mg/250ml静脉滴注,每日一次,总疗程5天。进行治疗前后两组间的疗效比较。结果厄他培南组40例,治疗有效率为90.0%,细菌清除率为83.3%;莫西沙星组40例,治疗有效率为81.7%,细菌清除率为72.1%;两组间差异有显著性;两组均无不良反应发生,差异无统计学意义。结论厄他培南相比莫西沙星能更好地改善临床症状,厄他培南治疗老年社区获得性肺炎疗效良好,安全性高,不良反应较少,是治疗老年社区获得性肺炎的理想药物。     

Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia

BACKGROUND: Although medical practice guidelines exist, there have been no large-scale studies assessing the relationship between initial antimicrobial therapy and medical outcomes for patients hospitalized with pneumonia. OBJECTIVE: To determine the associations between initial antimicrobial therapy and 30-day mortality for these patients. METHODS: Hospital records for 12945 Medicare inpatients (> or = 65 years of age) with pneumonia were reviewed. Associations between initial antimicrobial regimens and 30-day mortality were assessed with Cox proportional hazards models, adjusting for baseline differences in patient characteristics, illness severity, and processes of care. Comparisons were made with patients treated with a non-pseudomonal third-generation cephalosporin alone (the reference group). RESULTS: Initial treatment with a second-generation cephalosporin plus macrolide (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.52-0.96), a non-pseudomonal third-generation cephalosporin plus macrolide (HR, 0.74; 95% CI, 0.60-0.92), or a fluoroquinolone alone (HR, 0.64; 95% CI, 0.43-0.94) was independently associated with lower 30-day mortality. Adjusted mortality among patients initially treated with these 3 regimens became significantly lower than that in the reference group beginning 2, 3, and 7 days, respectively, after hospital admission. Use of a beta-lactam/beta-lactamase inhibitor plus macrolide (HR, 1.77; 95% CI, 1.28-2.46) and an aminoglycoside plus another agent (HR, 1.21; 95% CI, 1.02-1.43) were associated with an increased 30-day mortality. CONCLUSIONS: In this study of primarily community-dwelling elderly patients hospitalized with pneumonia, 3 initial empiric antimicrobial regimens were independently associated with a lower 30-day mortality. The more widespread use of these antimicrobial regimens is likely to improve the medical outcomes for elderly patients with pneumonia.     

Re-evaluation of the therapy of severe pneumonia caused by Streptococcus pneumoniae

Pneumonia caused by Streptococcus pneumoniae is the most deadly form of community-acquired pneumonia. The death rate of bacteremic pneumococcal pneumonia has remained constant over the past 50 years. Several retrospective reviews of bacteremic pneumococcal pneumonia suggest that dual therapy with a beta-lactam and a macrolide antimicrobial agent is associated with a lower case fatality rate than therapy with a beta-lactam alone. These studies are reviewed, potential mechanisms are suggested, and future studies are discussed.     

Clinical analysis of patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents--including a comparative study of an infectious group with monomicrobial agents and an infectious group with unknown agents

We clinically analyzed 83 patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents who we have treated during the past 15 years. A comparative study among three groups; an infectious group with polymicrobial agents (83 cases), an infectious group with monomicrobial agents (335 cases), and an infectious group with unknown agents (599 cases) was performed. The results were as follows; (1) The highest percentage of patients were elderly and bedridden. (2) Striking atypical pneumonic symptoms, including dyspnea, consciousness disturbance, gastrointestinal symptoms and hypotension (shock) were present. (3) Laboratory findings of poor nutritional conditions, including decreases in serum protein, albumin, and cholineesterase, and hypoxia remarkably increased. (4) The prognosis was poor because the mortality rate (15.7%) was higher. (5) There were two polymicrobial agents for 75 patients and three agents for 8 patients. The coupling of polymicrobial agents was most frequent in five patients with Haemophilus influenzae + MSSA and five with H. influenzae + respiratory virus. These results suggest that the patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents had clinical features and causative microorganisms resembling those of elderly patients with community-acquired pneumonia. We recommended that treatment with antibiotics for them was adequate if the treatment resemble that of elderly patients.     

Clinical analysis of pulmonary tuberculosis detected during follow-up of other underlying diseases

OBJECTIVE: The objects of this study were to analyze clinically the outpatients and inpatients who were diagnosed as pulmonary tuberculosis during the follow-up of other underlying diseases at our affiliated hospitals and to review the past problems and to discuss how to improve the situation. METHODS: Sixty five outpatients or inpatients diagnosed as pulmonary tuberculosis during the follow-up of other underlying diseases were collected from 508 patients with pulmonary tuberculosis at our affiliated hospitals over the past 10 years. RESULTS: The proportion of elderly patients over 65 years old among 65 index cases was significantly higher as compared to the control group. Forty three of these index patients were outpatients and 22 were inpatients. The most frequent underlying diseases excluding respiratory diseases were malignant diseases followed by diabetes mellitus, gastrointestinal diseases and psychosomatic diseases in order. Pulmonary tuberculosis without clinical symptoms was detected by periodic chest X-ray in 21 cases (32%). There were some severe TB cases caused by the doctor's delay who were followed for malignant or psychosomatic diseases. CONCLUSION: Although many doctors except for respiratory specialists tended to pay attention to pulmonary tuberculosis as a possible complication during periodic health examination, further intensive education regarding pulmonary tuberculosis is required for doctors who treat malignant or psychosomatic diseases at special hospitals because TB patients who were smear positive when they were detected may cause outbreak of tuberculosis in the hospital.     

Clinicopathological study of miliary tuberculosis in patients with hematologic disease

Seven cases of miliary tuberculosis in patients with hematologic disease were analyzed clinicopathologically. Mean age of the patients was 65 years, and the hematologic diseases were CML, AML, ALL, MDS and malignant lymphoma. Diabetes mellitus was present as a complication in three patients. Miliary tuberculosis was found in 5 cases during the first admission to our hospital owing to hematologic problems. In 4 of 6 cases, fever had started more than two months before admission, consequently, the tuberculosis probably began about that time. After admission, chemotherapy was administered in 5 cases, and steroid in 6 cases for hematologic disease. The mean total quantity of steroid administered was 2,134 mg of prednisolone and average treatment duration was 69 days. The chest roentgenographic shadow was so atypical that miliary tuberculosis was suspected in only one case. The initial chest roentgenogram showed hilar and mediastinal lymph node swelling as well as the shadow of pulmonary tuberculosis in two cases. It was thought that the hilar and mediastinal lymph node swelling could be explained by primary complex, although the patients were of advanced age, or by "secondary complex" reported by Terplan, K in 1940. The diagnosis of tuberculosis was made in two patients before their death by smear of aspirated fluid of cervical lymph node and by bone marrow cell block in one patients, and by pathological examination of mediastinal lymph node biopsy in the other patients. Tubercles were found from bone marrow cell block in 2 out of 5 patients and from bone marrow biopsy in 1 out of 3 patients, but the positive results were reported in 2 patients following death. Smears of sputum, gastric juice, urine, spinal fluid and pleural effusion were negative in all cases. One patient diagnosed as miliary tuberculosis also had pneumocystis carinii pneumonia. This case was treated with antituberculosis drugs for 20 days without improvement. Another patient diagnosed as miliary tuberculosis improved under treatment with antituberculosis drugs, but died of cytomegalovirus pneumonia. Autopsy in 5 cases revealed non-reactive miliary tuberculosis, and pulmonary hemorrhage probably due to DIC was present as a complication in two cases. In these cases, severe immunosuppression, which is a major precipitating factor of miliary tuberculosis, is thought to be induced by hematologic disease itself, chemotherapy, steroid or other underlying disease such as diabetes mellitus. Miliary tuberculosis in such compromised host is cryptic and progresses rapidly. Consequently, early diagnosis is very important. Retrospectively, the unexplained pyrexia was most important to suspect tuberculosis.(ABSTRACT TRUNCATED AT 400 WORDS)     

老年社区获得性肺炎237例临床分析

目的总结老年社区获得性肺炎（CAP）的临床资料,分析其临床特点。方法分析我科2005年1月-2008年1月收治的237例老年社区获得性肺炎住院患者的临床资料。结果237例中男性136例（57.4％）,女性101例（42.6％）;年龄65-95岁,有基础疾病者174例（73.4％）,出现并发症者96例（40.5％）;173例（73％）有呼吸道症状;影像学检查多呈片斑片状模糊阴影;白细胞总数升高（≥10×10^9／L）仅66例（27.85％）。结论老年社区获得性肺炎临床表现不典型,病情重,基础疾病多,并发症多,容易漏诊及误诊,应该引起重视。     

Problems about the management of active pulmonary tuberculosis patients undergoing haemodialysis--our experiences and nation-wide questionnaire survey

End-stage renal failure patients on chronic dialysis are high risk groups of tuberculosis due to attenuated cellular immunity. Patients receiving haemodialysis stay prolonged time inside the health-care facilities, thereby increased risk of tuberculosis transmission if a patient has active disease. So management of active pulmonary tuberculosis undergoing haemodialysis is important, however, the number of hospitals which are capable of taking care of such patients is estimated to be few in Japan. METHODS: From August 1994 through July 2002, 1059 active pulmonary tuberculosis patients (mean age; 57 +/- 19, male/female = 773/286) were admitted to Nishi-Kobe Medical Center, a 500-bed teaching hospital. Out of them, patients undergoing haemodialysis were retrospectively studied to describe the clinical characteristics of such cases. Then we conducted a questionnaire survey regarding the management of active pulmonary tuberculosis patients undergoing haemodialysis for 86 self-governing bodies in Japan. RESULTS: (1) Clinical characteristics of active pulmonary tuberculosis undergoing haemodialysis. We encountered 14 cases (mean age; 65 +/- 11, male/female = 7/7) of pulmonary tuberculosis undergoing haemodialysis during 8 years. In addition to pulmonary involvement, 3 pleural, one knee joint and one lymph node involvement was detected. Primary renal disease included diabetic nephropathy (n = 3), chronic glomerulonephritis (n = 3), congenital anomaly (n = 1), and unknown (n = 7). Nine cases were referred to our hospital from health-care facilities located out of city or prefecture. In five cases it took more than three months from the onset or detection of abnormal chest X-ray findings to the admission to our hospital. Five cases developed pulmonary tuberculosis within the first year after the initiation of dialysis. None of the patients had a past history of tuberculosis. Cavitary lesion on chest X-ray was observed in only one case. Triple antituberculosis therapy was used in 9 patients, and 4 antituberculosis drugs were used in 5 patients. Antituberculosis therapy was successfully done in all cases except two patients who died of apoplexy and cerebral infarction. (2) The nation-wide questionnaire survey. Of the 86 self-governing bodies we mailed, 66 self-governing bodies replied. Of them, 31% reported that they have experienced difficulties in the management of active pulmonary tuberculosis patients undergoing haemodialysis, and 25% reported the lack of health-care facilities to take care of such cases in their territory. They have referred such patients to hospitals located in the nearby prefectures or they have recommended antituberculosis therapy visiting a local haemodialysis facility. CONCLUSION: There are sometimes difficulties to manage active pulmonary tuberculosis patients undergoing haemodialysis in Japan. Health-care facilities to take care of such patients should be arranged and the formation of the network is necessarily.     

Community-acquired pneumonia in the elderly.

Pneumonia in the elderly is a common and serious problem with a clinical presentation that can differ from that in younger patients. Older patients with pneumonia complain of significantly fewer symptoms than do younger patients, and delirium commonly occurs. Indeed, delirium may be the only manifestation of pneumonia in this group of patients. Alcoholism, asthma, immunosuppression, and age >70 years are risk factors for community-acquired pneumonia in the elderly. Among nursing home residents, the following are risk factors for pneumonia: advanced age, male sex, difficulty in swallowing, inability to take oral medications, profound disability, bedridden state, and urinary incontinence. Streptococcus pneumoniae is the most common cause of pneumonia among the elderly. Aspiration pneumonia is underdiagnosed in this group of patients, and tuberculosis always should be considered. In this population an etiologic diagnosis is rarely available when antimicrobial therapy must be instituted. Use of the guidelines for treatment of pneumonia issued by the Infectious Diseases Society of America, with modification for treatment in the nursing home setting, is recommended.     

Clinical analysis of pulmonary tuberculosis in association with corticosteroid therapy

OBJECTIVE: Due to the increased incidence of pulmonary tuberculosis in association with corticosteroid therapy during the last five years in our associated hospitals, we studied the clinical characteristics of these patients. PATIENTS: Fourteen cases of pulmonary tuberculosis were collected which occurred in association with corticosteroid drugs in our associated hospitals during the last 10 years; four patients (2.1%) from April 1991 to March 1996 and 10 patients (4.3%) from April 1996 to March 2001. RESULTS: The average age of the 14 patients was 74.1 years old and the male:female ratio was 9:5. Regarding underlying diseases, respiratory diseases (7 patients) were the most frequent and a past history of pulmonary tuberculosis was recognized in six patients. The duration of corticosteroid administration ranged from two months to seven years and the total dose of corticosteroids ranged from 1.20 g to 12.05 g. Pulmonary tuberculosis was detected by chance during a health examination in eight patients and radiological findings showed an infiltration shadow without cavity located in a portion other than the predominant location in four patients. A microbiological examination was smear positive in eight patients but tolerance was not shown to any antituberculous drugs. The prognosis was poor because the mortality rate was high, but the cause of death was not related to the progress of pulmonary tuberculosis. CONCLUSION: Careful observation of patients is considered to be important because pulmonary tuberculosis in association with corticosteroid drugs was found among inpatients, there was no relationship to the total dose or duration of administration of corticosteroid drugs, there were no clinical symptoms, and the patients exhibited atypical radiographic findings.     

Recurrent Community-acquired Pneumonia in Patients Starting Acid-suppressing Drugs

Background

Several studies suggest that proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H2s) increase risk of community-acquired pneumonia. To test this hypothesis, we examined a prospective population-based cohort predisposed to pneumonia: elderly patients (≥65 years) who had survived hospitalization for pneumonia.

Methods

This study featured a nested case-control design where cases were patients hospitalized for recurrent pneumonia (≥30 days after initial episode) and controls were age, sex, and incidence-density sampling matched but never had recurrent pneumonia. PPI/H2 exposure was classified as never, past, or current use before recurrent pneumonia. The association between PPI/H2s and pneumonia was assessed using multivariable conditional logistic regression.

Results

During 5.4 years of follow-up, 248 recurrent pneumonia cases were matched with 2476 controls. Overall, 71 of 608 (12%) current PPI/H2 users had recurrent pneumonia, compared with 130 of 1487 (8%) nonusers (adjusted odds ratio [aOR] 1.5; 95% confidence interval [CI], 1.1-2.1). Stratifying the 608 current users according to timing of PPI/H2 initiation revealed incident current-users (initiated PPI/H2 after initial pneumonia hospitalization, n = 303) bore the entire increased risk of recurrent community-acquired pneumonia (15% vs 8% among nonusers, aOR 2.1; 95% CI, 1.4-3.0). The 305 prevalent current-users (PPI/H2 exposure before and after initial community-acquired pneumonia hospitalization) were equally likely to develop recurrent pneumonia as nonusers (aOR 0.99; 95% CI, 0.63-1.57).

Conclusion

Acid-suppressing drug use substantially increased the likelihood of recurrent pneumonia in high-risk elderly patients. The association was confined to patients initiating PPI/H2s after hospital discharge. Our findings should be considered when deciding to prescribe these drugs in patients with a recent history of pneumonia.     

Predictive factors of etiologic agents of community-acquired pneumonia presenting at a district general hospital]

Community-acquired pneumonia is one of the major respiratory diseases causing hospital admission in previously healthy patients. Prompt and appropriate antibiotic selection is essential for recovery. The authors tried to determine the distribution of the etiologic agents of community-acquired pneumonias and to analyze predictive factors. Out of 188 cases of community-acquired pneumonia presenting to our hospital, etiologic agents were determined in 106 cases (56%). Twenty-nine cases were due to Streptococcus pneumoniae, 27 cases due to Mycoplasma, 17 cases due to Haemophilus influenzae and 21 cases due to Mycobacterium tuberculosis. M. tuberculosis was the cause in 11% of all cases and the importance of pulmonary tuberculosis must be emphasized as a community-acquired pneumonia. Out of 58 cases under 50 years old, Mycoplasma pneumoniae was the etiologic agent in 23 cases (40%) and S. pneumoniae in 7 cases (12%). Out of 62 cases not less than 70 years old. M. tuberculosis was the most common etiologic agent (15 cases, 24%). S. pneumoniae followed, being causative in 13 cases (21%). M. tuberculosis was the cause in 10 cases out of 31 cases who did not complain of fever at presentation. In 86 cases who did not show leukocytosis on admission, 21 cases were due to Mycoplasma (24%) and 15 cases were due to M. tuberculosis (17%). In particular 17 cases were due to Mycoplasma among 28 cases under 50 years old without leukocytosis (61%), and 11 cases were due to M. tuberculosis in the 27 cases no less than 70 years old without leukocytosis (41%).(ABSTRACT TRUNCATED AT 250 WORDS)