Evaluation of the Japanese Respiratory Society guidelines for the identification of Mycoplasma pneumoniae pneumonia

Background and objective: Community‐acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. Mycoplasma pneumoniae is one of the major causative pathogens of CAP. Early diagnosis of M. pneumoniae pneumonia is crucial for initiating appropriate antibiotic therapy. The aim of this study was to determine whether the Japanese Respiratory Society (JRS) guidelines on CAP are effective for diagnosing M. pneumoniae pneumonia. Methods: Between August 2008 and July 2009, adult outpatients with CAP were consecutively enrolled. The aetiology of CAP was determined by culture and real‐time polymerase chain reaction (PCR) methods to detect M. pneumoniae, urine antigen tests to detect Streptococcus pneumoniae and Legionella pneumoniae, blood and sputum culture for bacteria and real‐time PCR for eight common respiratory viruses. The predictive value of the JRS guidelines for differentiating M. pneumoniae pneumonia from typical bacterial and viral pneumonias was determined. Results: Data from 215 adult CAP outpatients was analyzed. An aetiological diagnosis was made for 105 patients (48.8%), including 62 patients with M. pneumoniae pneumonia, 17 patients with typical bacterial pneumonia and 23 patients with viral pneumonia. According to the JRS criteria for differential diagnosis of atypical pneumonia, 55 of 62 patients were correctly diagnosed with M. pneumoniae pneumonia (sensitivity 88.7%), and 31 of 40 patients with bacterial and viral pneumonia were correctly excluded (specificity 77.5%). Conclusions: The JRS guidelines on CAP provide a useful tool for the identification of M. pneumoniae pneumonia cases and differentiating these from cases of typical bacterial or viral pneumonia.     

Role of 'atypical pathogens' among adult hospitalized patients with community-acquired pneumonia

Background and objective: Agents such as Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella pneumophila are recognized as important causes of community‐acquired pneumonia (CAP) worldwide. This study examined the role of these ‘atypical pathogens’ (AP) among adult hospitalized patients with CAP. Methods: A prospective, observational study of consecutive adult CAP (clinico‐radiological diagnosis) patients hospitalized during 2004–2005 was conducted. Causal organisms were determined using cultures, antigen testing and paired serology. Clinical/laboratory/radiological variables and outcomes were compared between different aetiologies, and a clinical prediction rule for AP was constructed. Results: There were 1193 patients studied (mean age 70.8 ± 18.0 years, men 59.3%). Causal organisms were identified in 468 (39.2%) patients: ‘bacterial’ (48.7%), ‘viral’ (26.9%), ‘AP’ (28.6%). The AP infections comprised Mycoplasma or Chlamydophila pneumoniae (97.8%) and co‐infection with bacteria/virus (30.6%). The majority of AP infections involved elderly patients (63.4%) with comorbidities (41.8%), and more than one‐third of patients were classified as ‘intermediate’ or ‘high’ risk CAP on presentation (pneumonia severity index IV–V (35.1%); CURB‐65 2–5 (42.5%)). Patients with AP infections had disease severities and outcomes similar to patients with CAP due to other organisms (oxygen therapy 29.1% vs 29.8%; non‐invasive ventilation 3.7% vs 3.3%; admission to the intensive care unit 4.5% vs 2.7%; length of hospitalization 6 day vs 7 day; 30‐day mortality: 2.2% vs 6.0%; overall P > 0.05). Age <65 years, female gender, fever ≥38.0°C, respiratory rate <25/min, pulse rate <100/min, serum sodium >130 mmol/L, leucocyte count <11 × 10⁹/L and Hb < 11 g/dL were features associated with AP infection, but the derived prediction rule failed to reliably discriminate CAP caused by AP from bacterial CAP (area under the curve 0.75). Conclusions: M. pneumoniae and C. pneumoniae as single/co‐pathogens are important causes of severe pneumonia among older adults. No reliable clinical indicators exist, so empirical antibiotic coverage for hospitalized CAP patients may need to be considered.     

Clinical features of healthcare-associated pneumonia (HCAP) in a Japanese community hospital: comparisons among nursing home-acquired pneumonia (NHAP), HCAP other than NHAP, and community-acquired pneumonia

Background and objective: More than 100 000 Japanese die of pneumonia every year. The number of people residing in nursing homes is increasing with the ageing of the population. In 2005, the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) published important guidelines for the management of healthcare‐associated pneumonia (HCAP). In Japan, however, the optimum strategy for management of HCAP is still unclear. The purpose of this study was to clarify the clinical features of patients with HCAP. Methods: Patients (n = 202) who were consecutively admitted with a diagnosis of acute pneumonia between October 2007 and September 2009 were retrospectively evaluated. Using the ATS/IDSA guidelines, patients were divided into three groups: a community‐acquired pneumonia (CAP) group (n = 123), a nursing home‐acquired pneumonia (NHAP) group (n = 46) and a HCAP other than NHAP (O‐HCAP) group (n = 33). These groups were then compared with respect to laboratory data, microbiological findings and mortality. Results: Thirty‐day mortality in the NHAP group (10.9%) tended to be higher than that in the CAP group (3.3%) or the O‐HCAP group (0%). The pathogens most frequently identified were Streptococcus pneumoniae and Haemophilus influenzae in the CAP group, methicillin‐resistant Staphylococcus aureus and Klebsiella pneumoniae in the NHAP group, and S. pneumoniae and K. pneumoniae in the O‐HCAP group. Conclusions: The NHAP group was clinically different from the O‐HCAP group, based on bacteriological examination and mortality rates. In order to accurately diagnose, and formulate optimum treatment strategies for Japanese patients, the categories of HCAP, as specified in the ATS/IDSA guidelines, should not be applied directly either to patients with NHAP or those with O‐HCAP.     

Lower incidence of acute respiratory distress syndrome in community‐acquired pneumonia patients aged 85 years or older

Background and objective: The incidence of and risk factors for ARDS among elderly patients with community‐acquired pneumonia (CAP) have not been well characterized. Methods: The clinical details of 221 consecutive patients aged ≥65 years, who were admitted with CAP during the period April 2006 to June 2008, were investigated by review of patient charts. Clinical variables and laboratory data at admission for CAP were compared between patients with and without ARDS. Results: Eighteen patients (8.1%) developed ARDS 1–5 days after admission. The mortality rate was 44% in patients with ARDS and 10.3% in those without ARDS (P < 0.001). The incidence of ARDS was 8.5–20% among patients aged <85 years and 1.1% in patients aged ≥85 years (P < 0.001), while overall mortality rates were not significantly different among the age groups. Predictors for the development of ARDS included higher serum levels of CRP and glucose, lower PaO₂/fraction of inspired O₂ (FiO₂), PaCO₂ and HCO₃^‐, and the presence of systemic inflammatory response syndrome at admission. ARDS developed less frequently among patients with pneumonia associated with oropharyngeal aspiration (AP). Multivariate analysis indicated that lower age, serum glucose, pre‐existence of systemic inflammatory response syndrome and non‐oropharyngeal AP were significant risk factors for ARDS. The Pneumonia Severity Index and confusion, urea, respiratory rate, blood pressure, age ≥65 score were not correlated with the incidence of ARDS. Conclusions: Predictors for ARDS appeared to differ from the determinants of severity of CAP in the elderly. ARDS developed less frequently in patients aged ≥85 years and in those with oropharyngeal AP. It is important to identify subjects at high risk for ARDS upon admission and to observe them closely.     

Clinical evaluation of hemorrhagic gastroduodenal ulcer in the elderly: Is Helicobacter pylori infection a risk factor for hemorrhage?

Aim: In this study, the aim was to determine the demographic characteristics of elderly patients with gastroduodenal ulcer who had undergone endoscopic hemostasis by comparing them with younger patients. Methods: A total of 353 patients with Forrest class I–IIa hemorrhagic gastroduodenal ulcer who underwent endoscopic hemostasis at our hospital between December 2004 and May 2010 were divided into two groups: one for those 75 years or older (old‐old group; n = 71; age ≥75 years) and one for those younger than 75 years (younger group; n = 282; age <75 years). Then, their demographic characteristics were compared. Results: There were significantly more female patients, patients with underlying chronic renal failure and patients using non‐steroidal anti‐inflammatory drugs in the old‐old group than in the younger group. In addition, the prevalence of open‐type atrophy in the background gastric mucosa was significantly higher in the old‐old group. Although more than half the patients in each group were infected with Helicobacter pylori, the prevalence was significantly higher in the younger group. Of the patients who underwent endoscopic hemostasis only once, those in the old‐old group constituted a significantly higher medical cost than those in the younger group. Comparison of deaths between the two groups revealed that the old‐old patients were more likely to develop severe complications associated with hematemesis, such as aspiration pneumonia. Conclusions: The observed lower prevalence of Helicobacter pylori infection among the elderly patients compared to the younger patients with hemorrhagic gastroduodenal ulcer suggests that other factors, such as non‐steroidal anti‐inflammatory drugs use and chronic renal failure, predispose the elderly to hemorrhagic ulcer.     

Aetiology of community-acquired pneumonia in hospitalized adult patients in New Caledonia

Objective To describe the aetiology of community‐acquired pneumonia (CAP) in hospitalized adult patients in New Caledonia, a French archipelago in the South Pacific. Methods Confirmed CAP patients (n = 137) were enrolled prospectively. Pathogens were detected by culture, molecular methods, serology on paired sera, immunofluorescence on nasopharyngeal swabs and antigen detection in urine. Results The aetiology of CAP was determined in 82 of 137 cases (59.8%), of which 31 exhibited two or more pathogens (37.8%). Hundred and seventeen pathogens were detected: Streptococcus pneumoniae was the most common one (41.0%), followed by influenza virus A (22.1%) and Haemophilus influenzae (10.2%). The frequency of atypical bacteria was low (6.0%). The most frequent and significant coinfection was S. pneumoniae with influenza A virus (P = 0.004). Influenza virus was detected from nasopharyngeal swabs in four patients (15.4% of patients tested for influenza) and by PCR from pulmonary specimens in 15 patients (57.7%). Conclusions Streptococcus pneumoniae is the leading cause of CAP in New Caledonian adults. Viral–bacterial co‐infections involving S. pneumoniae and influenza virus are very common during the winter. Such adult patients hospitalized with CAP are a clear sentinel group for surveillance of influenza. Vaccination against influenza and S. pneumoniae should be strengthened when risk factors are identified.     

Nationwide survey on the 2005 Guidelines for the Management of Community-Acquired Adult Pneumonia: Validation of severity assessment

IntroductionThe Japanese Respiratory Society Guidelines for the Management of Community-Acquired Pneumonia (CAP) in Adults (JRS 2005) were published to revise the Basic Concept for the Management of CAP in Adults (JRS 2000). Revisions in JRS 2005 mainly focused on the criteria for the assessment of pneumonia severity and the differentiation between bacterial pneumonia and atypical pneumonia. To evaluate the JRS 2005 criteria for the assessment of pneumonia severity, we conducted a prospective survey.Subjects and methodsThe survey was conducted from July 2006 to March 2007 as a nationwide joint study by 200 institutions. The study subjects included patients aged ≥16 years of age who had CAP. The severity at initial consultation was determined using the criteria established by JRS 2005, JRS 2000, and Infectious Diseases Society of America Guidelines (IDSA-GLs). The survival outcome 30 days after the start of the initial antimicrobial agent treatment was confirmed.ResultsA total of 1875 patients were analyzed. The numbers of cases of pneumonia assessed as being moderate and severe were significantly lower when the JRS 2005 criteria were used than when the JRS 2000 criteria were used. Thus, the severity of pneumonia could be determined more appropriately using the JRS 2005 criteria. Furthermore, the severity-dependent prediction of fatal outcomes or mortality according to these criteria was similar to that determined using the IDSA-GLs.ConclusionsDetermining severity on the basis of JRS 2005 can resolve nearly all the problems encountered with JRS 2000; these criteria were found to be useful and rapidly and easily applicable in clinical practice.     

Atypical Bacterial Pneumonia and Asthma Risk

The role of respiratory infections in asthma is poorly understood. Atypical bacteria Mycoplasma pneumoniae and Chlamydia pneumoniae are present in the lower airways of approximately 50% of asthmatics. This study tested the hypothesis that early life community‐acquired pneumonia caused by Mycoplasma pneumoniae or Chlamydia pneumoniae is associated with increased asthma prevalence. Thirty‐five subjects with a history of community‐acquired pneumonia (22 due to atypical bacteria, 13 due to nonatypical pathogens) were evaluated by questionnaire 7–9 years after the episode of pneumonia. Subjects with a history of either typical or atypical pneumonia demonstrated increased asthma prevalence. Current or past asthma prevalence was 55% in subjects with atypical bacterial pneumonia and 61.5% in subjects with nonatypical bacterial pneumonia. Significant between‐group differences were not demonstrated with regard to asthma prevalence (risk ratio = 0.89; 95% confidence interval = 0.49–1.61), current bronchodilator use [1.18 (0.44–3.17)], and family history of atopy [1.18 (0.73–1.91)], or asthma [1.63 (0.68–3.88)]. These data suggest that atypical bacterial pneumonia confers a risk of asthma similar to that seen with nonatypical bacterial pneumonia. Prospective studies are warranted to more fully evaluate the importance of atypical bacterial pneumonia as an asthma risk factor.     

Epidemiology and clinical manifestations of children with macrolide‐resistant Mycoplasma pneumoniae pneumonia in Taiwan

Mycoplasma pneumoniae accounts for 10–30% of community‐acquired pneumonia (CAP) in children. This study reveals the epidemiology and clinical manifestations of children with macrolide‐resistant (ML^r) M. pneumoniae pneumonia in Taiwan. Respiratory tract specimens were collected from children hospitalized with CAP for evaluation via PCR followed by DNA sequencing for several point mutations related to the ML^r character. Of the 412 specimens collected during the study period, 60 (15%) were positive for M. pneumoniae, 14 (23%) of which presented point mutation (all A2063G) in 23S rRNA. Clinical symptoms and chest X‐ray findings between the ML^s and ML^r groups were not significantly different. However, the ML^r group had longer mean duration of fever after azithromycin treatment (3.2 days vs. 1.6 days, P = 0.02) and significantly higher percentage of changing antibiotics for suspected ML^r strain (42% vs. 13%, P = 0.04). Although 58% of children in the ML^r group did not receive effective antibiotics, all children were discharged without sequelae. In conclusion, 15% of CAP in children is caused by M. pneumoniae and the macrolide‐resistance rate is 23% in Taiwan. Despite ineffective antibiotics, children with ML^r M. pneumoniae pneumonia recover completely. Pediatr Pulmonol. 2013; 48:904–911. © 2012 Wiley Periodicals, Inc.     

Pneumonia in a nursing home

The authors studied nursing home residents serologically to determine whether atypical organisms were causes of radiologic pneumonia. The study was conducted at the Wisconsin Veterans Home, a facility with on-site microbiology and x-ray. Over one year, serologic examinations for Legionella, Mycoplasma, and Chlamydia were conducted for the residents who had pneumonia. Cultures and mortality were reviewed. Fifty-six episodes were studied (mean resident age 78 years). There was no fourfold titer change. Seventeen quality sputum specimens revealedStreptococcus pneumoniae (5), normal flora (4),Hemophilus influenzae (4),Moraxella catarrbalis (3),Staphylococcus aureus (1), and beta-hemolytic Streptococcus, not group A (1). The two-month mortality was 21%. This study did not result in serologic confirmation of atypical organisms’ causing pneumonia. Antibiotic choice should be based on coverage of prevalent organisms, includingHemophilus influenzae, Moraxella, and Staphylococcus, as well as clinical features.     

The Change of Asthma-associated Immunological Parameters in Children with Mycoplasma pneumoniae Infection

Background. Mycoplasma pneumoniae (M. pneumoniae), an atypical pathogen, is increasingly recognized as a common and important pathogen. Previous studies showed that M. pneumoniae infection may play a role in asthmatic mechanisms based on evidence collected from peripheral blood or sputum of patients or animal models. However, evidence reported from the airways of patients has been rare. Objective. To estimate the role of M. pneumoniae infection in asthma by measuring the immunological parameters from peripheral blood and bronchoalveolar lavage fluid (BALF) in pediatric patients with mycoplasma pneumonia. Methods. A total of 30 patients with mycoplasma pneumonia and 37 patients without M. pneumoniae infection undergoing fiberoptic bronchoscopy were reviewed. The peripheral blood cell count, immunoglobulins (Ig), BALF cell count, and other clinical and laboratory data were reviewed and analyzed. Results. There were significantly more patients with raised basophil counts in the M. pneumoniae group than that in the control group (p = 0.033). Serum immunoglobulin (Ig) A, IgM, and IgG levels in the M. pneumoniae group were significantly higher than those in the control group (p = 0.008, p = 0.011, and p = 0.019, respectively). The percentage of eosinophils in BALF cells was in the range 0 to 10% in M. pneumoniae patients, while it ranged between 0 and 4% in the control group with a significant difference (p = 0.043). In the M. pneumoniae group, we found that the percentage of eosinophils in the BALF cells was positively correlated with age, the percentage of peripheral eosinophils, and BALF lymphocytes (r = 0.298, p = 0.030; r = 0.341, p = 0.014; r = 0.387, p = 0.006; respectively) and negatively correlated with total peripheral white blood cell (r = ?0.387, p = 0.005). Conclusion. These results suggest that M. pneumonia infection is associated with the asthma mechanism, especially in older children.     

Inhaled corticosteroids increase the risk of oropharyngeal colonization by Streptococcus pneumoniae in children with asthma

Background and objective: Recent studies have raised concerns about the link between use of inhaled corticosteroids (ICS) and risk of pneumonia in patients with chronic obstructive pulmonary disease. This cross‐sectional study aimed to investigate the association between ICS and oropharyngeal colonization by Streptococcus pneumoniae (S. pneumoniae) among children (up to 18 years old) with asthma. Methods: Two age‐matched groups of patients were consecutively recruited: (i) exposed group: children who had persistent asthma and were being treated with daily ICS for at least 30 days and (ii) non‐exposed group: children who had asthma and were not being treated with ICS at study entry. Oropharyngeal specimens from the tonsillar area and posterior pharyngeal wall were collected. S. pneumoniae was identified according to National Committee for Clinical Laboratory Standards recommendations. Results: A total of 200 consecutive patients were recruited and 192 (96 in each group) were included in the analysis. In the exposed group, the mean daily dose of ICS was 400 µg of beclomethasone or equivalent and the mean duration of treatment was 8.6 months. The prevalence of oropharyngeal colonization by S. pneumoniae was higher in the exposed group compared with the non‐exposed group (27.1% vs 8.3%, P = 0.001). After adjusting for potential confounders, use of ICS was an independent risk factor for oropharyngeal carriage of S. pneumoniae, with an adjusted prevalence ratio of 3.75 (95% confidence interval: 1.72–8.18, P = 0.001). Conclusions: Regular use of ICS is associated with an increased risk of having oropharyngeal colonization by S. pneumoniae in children with asthma.     

Use of proton pump inhibitors is associated with increased mortality due to nosocomial pneumonia in bedridden patients receiving tube feeding

Aim

To investigate the association between the use of proton pump inhibitors (PPI) and nosocomial pneumonia and gastrointestinal bleeding in bedridden patients receiving tube feeding.

Methods

A total of 116 bedridden hospitalized patients receiving tube feeding, of which 80 were supported by percutaneous endoscopic gastrostomy and 36 by nasogastric tube, were included in the present study. The patients were divided into two groups: 62 patients treated with PPI (PPI group) and 54 patients without PPI (non‐PPI group). Mortality due to nosocomial pneumonia was evaluated using the Kaplan–Meier approach and the log–rank test.

Results

A total of 36 patients (31%) died of nosocomial pneumonia during the observation period; the mortality rate due to nosocomial pneumonia was significantly higher in the PPI group than in the non‐PPI group (P = 0.0395). Cox proportional hazard analysis showed that the use of PPI and lower levels of serum albumin were independent predictors of 2‐year mortality due to nosocomial pneumonia. Gastrointestinal bleeding was observed in four patients in the non‐PPI group (7.7%) and in one patient in the PPI group (1.6%); there was no significant difference between the two groups.

Conclusion

The use of PPI in bedridden tube‐fed patients was independently associated with mortality due to nosocomial pneumonia, and the PPI group had a non‐significant lower incidence of gastrointestinal bleeding than the non‐PPI group. Geriatr Gerontol Int 2018; 18: 1215–1218 .     

高龄脑梗死患者并发肺炎的危险因素及其对预后的影响

目的 分析高龄脑梗死患者并发肺炎的危险因素,探讨其对脑梗死预后的影响。方法 回顾性分析2020年1月至2022年12月南京医科大学第一附属医院收治的275例高龄脑梗死患者的临床资料,根据脑梗死后是否并发肺炎将患者分为肺炎组(n=41)和非肺炎组(n=234),比较两组患者一般资料、临床表现及辅助检查结果。采用SPSS 22.0统计软件进行数据分析。根据数据类型,分别采用t检验或χ²检验进行组间比较。采用多因素logistic回归分析影响高龄脑梗死患者并发肺炎的危险因素。结果 肺炎组患者年龄、10年吸烟史、心力衰竭、心房颤动、心肌梗死、慢性肺部疾病、脑卒中史、吞咽障碍、意识障碍、呕吐、留置胃管、气管侵入性操作、呼吸机辅助呼吸、胸部X线检查、胸部CT检查、脑干或小脑梗死的比率及入院时美国国立卫生研究院脑卒中量表(NIHSS)评分均显著高于非肺炎组,差异有统计学意义(P<0.05)。肺炎组患者住院时间、住院费用、治疗后NIHSS评分、1个月及3个月病死率均显著高于非肺炎组,差异有统计学意义(P<0.05)。10年吸烟史(OR=3.432,95%CI 1.170~10.065)、慢性肺部疾病(OR=15.580,95%CI 2.744~88.461)、吞咽障碍(OR=2.757,95%CI 1.319~5.760)、脑干或小脑梗死(OR=2.036,95%CI 1.282~3.233)及高NIHSS评分(OR=1.328,95%CI 1.231~1.434)均是高龄脑梗死并发肺炎的独立危险因素。结论 在高龄脑梗死并发肺炎患者中,应重点关注吸烟史、慢性肺部疾病、吞咽障碍、脑干或小脑梗死及高NIHSS评分等因素,以减少梗死患者并发肺炎的发生。     

Diagnostic value and utility of the simplified International Autoimmune Hepatitis Group criteria in acute‐onset autoimmune hepatitis

Background: The diagnosis of autoimmune hepatitis (AIH) is already difficult, and that of acute‐onset AIH with atypical features is even more challenging, even though the revised original diagnostic criteria created by an international AIH group were widely accepted and incorporated into clinical practice. Aims: Recently, simplified diagnostic criteria were proposed. We compared the performance parameters of the simplified scoring system in patients with acute‐onset AIH and examined its usefulness and limitations. Methods: Fifty‐five patients with acute‐onset AIH (29 non‐severe, 14 severe and 12 fulminant) were assessed according to the simplified scoring system and compared with the revised original one. Results: Of the 55 patients, 22 (40%) were diagnosed as ‘definite’ AIH, 28 (51%) as ‘probable’ and five (9%) as ‘non‐diagnostic’ based on the revised original scoring system. By the simplified scoring system, six (11%) were diagnosed as ‘definite’ AIH, 16 (29%) as ‘probable’ and 33 (60%) as ‘non‐diagnostic’. Anti‐nuclear antibody titres did not differ among the three groups. The immunoglobulin G level was higher in fulminant than in non‐severe patients (P=0.01). Sixty‐five per cent showed acute hepatitis (massive necrosis, submassive necrosis and severe acute hepatitis) and 35% showed chronic hepatitis. Conclusions: The revised original scoring system performed better in patients with acute‐onset AIH than the simplified scoring system.     

Radiological patterns and prognosis in elderly patients with acute Klebsiella pneumoniae pneumonia: A retrospective study

Although Klebsiella pneumoniae pneumonia is an insidious threat among the elderly, the role of radiological features has not been elucidated. We aimed to evaluate thin-section chest computed tomography (CT) features and assess its associations with disease prognosis in elderly patients with acute K. pneumoniae pneumonia.We retrospectively included elderly patients, admitted for acute K. pneumoniae pneumonia, and investigated thin-section CT findings to determine whether bronchopneumonia or lobar pneumonia was present. The association between the radiological pattern of pneumonia and in-hospital mortality was analyzed.Eighty-six patients with acute K. pneumoniae pneumonia were included, and among them, the bronchopneumonia pattern was observed in 70 (81%) patients. Twenty-five (29%) patients died in hospital, and they had a greater incidence of lobar pneumonia pattern (40% in nonsurvivors vs 10% in survivors; P = .008), low albumin level (2.7 g/dL, range, 1.6–3.8 in nonsurvivors vs 3.0 g/dL, range, 1.7–4.2 in survivors; P = .026) and higher levels of aspartate aminotransferase (30 U/L, range, 11–186 in nonsurvivors vs 23 U/L, range, 11–102 in survivors, P = .017) and C-reactive protein (8.0 mg/dL, range, 0.9–26.5 in nonsurvivors vs 4.7 mg/dL, range, 0.0–24.0 in survivors; P = .047) on admission. Multivariate analysis showed that lobar pneumonia pattern was independently associated with increased in-hospital mortality (adjusted hazard ratio, 3.906; 95% CI, 1.513–10.079; P = .005).In elderly patients with acute K. pneumoniae pneumonia, the lobar pneumonia pattern may be less commonly observed, and this pattern could relate to poor prognosis.     

Predictors of length of stay between the young and aged in hospitalized community‐acquired pneumonia patients

Aim: To determine the factors that may prolong the length of stay (LOS) for older patients hospitalized for community‐acquired pneumonia (CAP) and also to see if they are applicable to the younger patients. Methods: A retrospective case record review was conducted of all adult patients who were discharged from the general medical service or the geriatric medicine service of an acute care hospital over 6 months. Results: During the study period, 393 patients were discharged with the diagnosis of pneumonia. Based on the study criteria, 200 patients were included in the study. Of the elderly patients, 39% had severe pneumonia compared to 9.3% in the younger group (P < 0.001), resulting in a higher mortality rate. All patients with severe pneumonia had serum albumin levels of less than 3.7 g/dL. The median LOS was significantly shorter in the younger patients (4 days) compared to the elderly patients (9 days, P < 0.001). Severe pneumonia, dysphagia, chronic renal disease, hypoalbuminemia and older age group were found to be significantly associated with longer LOS. Conclusion: Compared to younger patients, older subjects aged 65 years and above hospitalized with CAP were more likely to have severe pneumonia and longer LOS. Presence of severe pneumonia, dysphagia, chronic renal disease, hypoalbuminaemia and age of more than 65 years were significantly associated with longer LOS for all patients. However, in the younger group, only hypoalbuminaemia remained a significant factor. In the elderly patients, severe pneumonia, dysphagia and type of residence were important factors predicting longer LOS.     

Radiofrequency ablation therapy for hepatocellular carcinoma in elderly patients

Background and Aim: With the aging of society, the number of elderly patients with hepatocellular carcinoma (HCC) has been increasing in Japan. The Government of Japan defines elderly as being over 65 and has divided the elderly into two stages: the first elderly stage (< 75 years old) and the second elderly stage (≥ 75). We investigated the efficacy and safety of radiofrequency ablation therapy (RFA) in patients in the second elderly stage in comparison with other HCC patients, retrospectively. Methods: Two hundred six patients with HCC, who were within the Milan criteria, with low‐grade performance status (0 or 1) and a Child‐Pugh classification of A or B were enrolled. All were treated with RFA from January 2000 to December 2008 as an initial therapy and were divided into elderly HCC group (e‐HCC group; ≥ 75, n = 63) and non e‐HCC group (< 75, n = 143), and their clinical data and survival rates were compared. Results: Age and the level of protein induced by vitamin K absence or antagonist (PIVKA‐II) were higher in the e‐HCC group as compared with the non e‐HCC group (78.3 ± 3.2 vs 64.2 ± 7.5 years, 676.3 ± 2643.7 vs 142.4 ± 442.2 mAU/mL: P < 0.01, respectively). There were no significant differences for Child‐Pugh class, tumor node metastasis stage, and Japan Integrated Stage score and in survival rates after 3, and 5 years between the groups (e‐HCC group: 82.5% and 49.7%, respectively; non e‐HCC group: 78.3% and 57.5%, respectively). There were no severe complications in the e‐HCC group. Conclusions: Elderly HCC patients, who have good performance status, should be treated in the same manner and with the same strategy as young HCC patients.     

Nationwide survey on the 2005 Guidelines for the Management of Community-Acquired Adult Pneumonia: Validation of differentiation between bacterial pneumonia and atypical pneumonia

IntroductionThe Japanese Respiratory Society Guidelines for the Management of Community-Acquired Pneumonia (CAP) in Adults (JRS 2005) was published as a revision of the Basic Concept for the Management of CAP in Adults (JRS 2000). To evaluate the JRS 2005 criteria for differentiating between disease types and assessing the status of antimicrobial agent use in initial treatment, we conducted a prospective survey.Subjects and methodsThe survey was conducted from July 2006 to March 2007 as a nationwide joint study by 200 institutions. The study subjects included patients aged ≥16 years of age who had CAP, and patients who met the inclusion criteria were consecutively enrolled. Disease type differentiation based on JRS 2005 and JRS 2000 was conducted. Disease type diagnosis was also performed based on test results. The sensitivity and specificity of disease type differentiation were calculated. The antimicrobial agents used in the initial treatment were classified as recommended or non-recommended based on JRS 2005. The validity of non-recommended antimicrobial agent use was investigated.ResultsA total of 1875 patients were analyzed. Differentiation of atypical pneumonia using the JRS 2005 criteria had higher sensitivity and lower specificity than differentiation using the JRS 2000 criteria. The antimicrobial agents recommended by JRS 2005 were used as initial treatment in a low number of cases. The efficacy of the recommended antimicrobial agents was similar to that of the non-recommended agents.ConclusionsJRS 2005 is advantageous in terms of reducing the number of items used in disease type differentiation. The recommended antimicrobial agents used for the initial treatment are believed to be appropriate.     

Chest computed tomography for the diagnosis of Mycoplasma pneumoniae infection

We analysed 53 cases of laboratory‐confirmed Mycoplasma pneumoniae infection with cough lasting ≥7 days and chest radiography showing no abnormal findings. Twenty‐two (41%) of those patients showed abnormal findings on chest high‐resolution computed tomography. In the daily clinical setting, for assessment of acute cough, physicians should be aware that it is difficult to confirm bronchiolitis or bronchopneumonia due to M. pneumoniae by chest radiography.