IL-1β and IL-6 in community-acquired pneumonia: Bacteremic pneumococcal pneumonia versusMycoplasma pneumoniae pneumonia

Summary Interleukin-1 (IL-1) and interleukin-6 (IL-6) levels in 20 patients with bacteremicStreptococcus pneumoniae community-acquired pneumonia (CAP) were compared with these cytokine levels in 20 patients withMycoplasma pneumoniae CAP. All 40 patients survived hospitalization and underwent a follow-up examination one month later. Serum IL-1 and IL-6 levels were determined by the enzyme immunoassay (EIA) method using commercial kits. In the acute phase of CAP, IL-6 levels were significantly higher in theS. pneumoniae group (p=0.014), while IL-1 levels were higher in theM. pneumoniae group (p=0.046). In the convalescence phase, the two cytokines were detected in a considerable number of patients in both groups. In this phase, only the level of IL-1 was significantly higher in theM. pneumoniae group than in theS. pneumoniae group (p=0.03). We conclude that the levels of IL-1 and IL-6 are different between patients withS. pneumoniae-CAP andM. pneumoniae-CAP during the acute phase. In the convalescence phase, cytokine levels remain high in some of the CAP patients, but a significant difference between the groups exists only for IL-1. Further studies are required.     

Cephalosporin-resistant pneumococcal pneumonia: does it,affect outcome?

STUDY OBJECTIVES: Penicillin resistance has been reported in various studies to have no impact on the outcome of pneumococcal pneumonia. However, the importance of cephalosporin resistance has not been systematically studied. We conducted an analysis of patients with high-level cephalosporin-resistant Streptococcus pneumoniae pneumonia (H-CRSPP). DESIGN: Retrospective matched, case-control study. SETTING: Two inner-city academic hospitals. PATIENTS: Twenty-six patients with H-CRSPP admitted to the hospital between 1995 and 1999 were identified. Each patient was matched with two controls with cephalosporin-sensitive but oxacillin-resistant pneumococcal pneumonia admitted during the same time period. Matching was done based on pneumonia severity of illness index (PSI) and for other factors. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We evaluated a number of outcomes including mortality length of stay in the hospital, and time to respond to treatment. Patients with H-CRSPP took longer to respond to treatment (6.5 +/- 0.9 days vs 4.1 +/- 0.7 days, P=0.05) and had a longer length of stay in hospital (15.4 +/- 2.2 days vs 92 +/- 1.6 days, P=0.02). None of the other outcomes were different between the two groups. CONCLUSIONS: Overall, we have found that the presence of cephalosporin resistance does impact the course of pneumococcal pneumonia.     

Community-acquired pneumonia in older veterans: does the pneumonia prognosis index help?

OBJECTIVES: Mortality rates from pneumonia increase steadily with age. Recently, a disease severity model (the Pneumonia Prognosis Index (PPI)) has been developed to predict mortality from community-acquired pneumonia (CAP). PPI ranks severity of pneumonia from 1 to 5, with 5 being most severe. This retrospective study utilizes the PPI to address the prognosis of CAP in older adults. DESIGN: Retrospective review of medical charts. SETTING: Department of Veterans Affairs Medical Center. PARTICIPANTS: All adults aged 60 and older admitted to a Veterans Affairs Medical Center with CAP between January 1 and December 31, 1998. MEASUREMENTS: PPI was calculated using subjects' demographics, comorbidities, presenting symptoms, and laboratory measurements. RESULTS: Eighty-two patients aged 60 and older were admitted with 101 episodes of CAP. The mean age +/- standard deviation was 72 +/- 9. Seventy-four episodes were admitted from the emergency room, 20 from another hospital, seven from nursing homes, and five from outpatient clinics. Mean length of stay was 7.1 +/- 6 days. Comorbid conditions included coronary artery disease, diabetes mellitus, congestive heart failure, neoplasm, stroke, and renal failure. Most episodes fell into higher PPI classes, with 20% in Class 3, 46% in Class 4, and 32% in Class 5. PPI score was significantly related to length of stay (P < .001), intensity of care (P < .0001), and presence of complications (P <.001). Mortality was 14% at 30 days: 0.5% in Class 3,10.8% in Class 4, and 25% in Class 5. CONCLUSION: The PPI was effective in identifying older adults with CAP who were at risk of a poor outcome, but the practical utility of this index remains to be determined.Further prospective studies are required to elucidate the importance of comorbidities, severity at presentation, and premorbid functional status on clinical and functional outcomes of CAP in older adults.     

What is healthcare-associated pneumonia, and how should it be treated?

PURPOSE OF REVIEW: In contrast to patients at risk for hospital-acquired pneumonia or mechanically ventilated patients at risk for ventilator-associated pneumonia, healthcare-associated pneumonia is a relatively new clinical entity that includes a spectrum of adult patients who have close association with acute care hospitals or reside in chronic care settings that increase their risk for pneumonia caused by multi-drug-resistant bacteria. Multi-drug-resistant pathogens include methicillin-resistant Staphylococcus aureus and Gram-negative bacilli, such as Pseudomonas aeruginosa, extended-spectrum beta-lactamase-producing Klebsiella pneumoniae, and Acinetobacter species. New guidelines for the management and prevention of hospital-acquired pneumonia, ventilator-associated pneumonia and healthcare-associated pneumonia from the American Thoracic Society and the Infectious Diseases Society of America were published in 2005 and are highlighted in this article. RECENT FINDINGS: Recent data indicate that types of multi-drug-resistant pathogens may vary in different healthcare settings, and that individuals infected with multi-drug-resistant pathogens are more likely to receive inappropriate initial antibiotic therapy, which may result in poorer outcomes in terms of patient morbidity, mortality and increased length of hospital stay. SUMMARY: This review highlights key points in the new recommendations and principles for initiating, de-escalating and stopping antibiotic therapy in individuals with healthcare-associated pneumonia. Widespread implementation of these guidelines is needed in healthcare institutions in order to reduce patient morbidity, mortality, and healthcare costs.     

Is it possible to distinguish between atypical pneumonia and bacterial pneumonia?: evaluation of the guidelines for community-acquired pneumonia in Japan

The Japanese Respiratory Society (JRS) published the guidelines for the management of community-acquired pneumonia in 2000. The guidelines set up nine parameters and criteria for the differential diagnosis of atypical pneumonia and bacterial pneumonia based on clinical symptoms, physical signs and laboratory data. To evaluate the performance of these guideline criteria, 91 cases of Chlamydia pneumoniae (53 cases were pure-C. pneumoniae and 38 cases were mixed-C. pneumoniae pneumonia), 103 cases of Mycoplasma pneumoniae (86 cases were pure-M. pneumoniae and 17 cases were mixed-M. pneumoniae pneumonia) and 144 cases of bacterial (Streptococcus pneumoniae and/or Haemophilus influenzae) pneumonia were analyzed. The accordance rate for a suspected atypical pneumonia with the guideline criteria was 84.8% for pure-M. pneumoniae pneumonia and 60.3% for pure-C. pneumoniae pneumonia, but only 9.0% for bacterial pneumonia, 12.1% for mixed-C. pneumoniae pneumonia and 16.6% for mixed-M. pneumoniae pneumonia. Overall, the sensitivity and specificity of the criteria in the JRS guidelines were 75.5% and 90.9%, respectively. Our results indicated that the differentiation of pneumonia in the JRS guidelines is useful for the diagnosis of M. pneumoniae pneumonia, but difficult to apply to the diagnosis of C. pneumoniae pneumonia.     

Effect of COVID 19 pneumonia on hyperglycemia: Is it different from non COVID pneumonia?

Background and aimsGlycemic control in critical illness has been linked to outcomes. We sought to investigate if COVID pneumonia was causing disrupted glycemic control compared to historically similar diseases.MethodsAt Intermountain Healthcare, a 23-hospital healthcare system in the intermountain west, we performed a multicenter, retrospective cohort observational study. We compared 13,268 hospitalized patients with COVID pneumonia to 6673 patients with non -COVID-pneumonia.ResultsPatients with COVID-19 were younger had fewer comorbidities, had lower mortality and greater length of hospital stay. Our regression models demonstrated that daily insulin dose, indexed for weight, was associated with COVID-19, age, diabetic status, HgbA1c, admission SOFA, ICU length of stay and receipt of corticosteroids. There was significant interaction between a diagnosis of diabetes and having COVID-19. Time in range for our IV insulin protocol was not correlated with having COVID after adjustment. It was correlated with ICU length of stay, diabetic control (HgbA1C) and prior history of diabetes. Among patients with subcutaneous (SQ) insulin only percent of glucose checks in range was correlated with diabetic status, having Covid-19, HgbA1c, total steroids given and Elixhauser comorbidity score even when controlled for other factors.ConclusionsHospitalized patients with COVID-19 pneumonia who receive insulin for glycemic control require both more SQ and IV insulin than the non-COVID-19 pneumonia counterparts. Patients with COVID-19 who received SQ insulin only had a lower percent of glucose checks in range.     

Interstitial pneumonia complicated by Sjögren's syndrome, Hashimoto's disease, rheumatoid arthritis and primary biliary cirrhosis

A 66-year-old woman diagnosed as having Hashimoto's disease and rheumatoid arthritis manifested interstitial pneumonia. We diagnosed Sj?gren's syndrome and primary biliary cirrhosis as complications in this case. Steroid therapy was relatively effective for the interstitial pneumonia which was in an active state; however, during tapering of the steroid, there was a relapse and also severe dry throat. Cyclophosphamide was added and was effective in the prevention of recurrence. Even after discontinuation of steroid therapy, her general condition is stabilized. It is very important to carefully investigate other organ involvement as a prognostic factor in cases in which there are multiple autoimmune diseases.     

Can chest X-ray predict pneumonia severity?

Predictors of the severity of pneumonia have not been thoroughly evaluated among children in developed countries. We investigate whether chest radiographic findings could be used as predictors of severity of childhood pneumonia. The study included 167 children, aged more than 12 months, hospitalized in our department during a 4-year period with unilateral lobar or segmental pneumonia. The durations of fever and of hospitalization were considered indicators of severity of the disease. The size of the consolidation and its location in the left hemithorax were independently associated with severity of the disease. Univariate analysis showed that the mean duration of fever and of hospitalization as well as the prevalence of pleural effusion was significantly higher among children with left-sided pneumonia. A multiple logistic regression analysis revealed that only the presence of pleural effusion was significantly more likely in left-sided pneumonia (odds ratio, 2.65; 95% confidence interval, 1.09-6.47; P = 0.031). We conclude that the size of consolidation and the side of its location can be used as predictors of severity of pneumonia, with left-sided pneumonia running a more severe course, possibly due to increased risk for the development of pleurisy.     

Diagnostic value of HBP,PCT combined with APACHE Ⅱ score respectively in ventilator-associated pneumonia

<正>Objective To evaluate the diagnostic value of the heparin-binding protein (HBP),procalcitonin (PCT)and acute physiology and chronic health evaluationⅡ(APACHEⅡ) score in ventilator-associated pneumonia(VAP). Methods A total of 160 patients who required     

Performance measures for pneumonia: are they valuable, and are process measures adequate?

PURPOSE OF REVIEW: Pneumonia has been the target of large national initiatives to measure and report quality of care. Measures of pneumonia care are now being used for public reporting and pay-for-performance in an effort to increase provider accountability for healthcare quality in the USA. Increasingly, concerns have been raised about the potential for unintended consequences of performance measurement and reporting that might lead to patient harm. RECENT FINDINGS: Since 1999, there have been substantial improvements in performance on measures of pneumonia processes of care, and patient clinical outcomes have improved. The association between improved clinical outcomes and processes of care for pneumonia, however, is not clear based on available national data. The increasing use of process measures for hospital accountability has created the continual need to re-evaluate the relationship between processes being measured and desired patient outcomes. While there is little direct evidence of unintended consequences of performance measurement, concerns have been raised about the potential for direct or indirect harm to patients. SUMMARY: Measuring processes of care for pneumonia is feasible and appears to have accelerated the pace of quality improvement. There is an ongoing need to develop new measures of pneumonia quality that focus on patient outcomes, care transitions, and efficiency of care.