Development of a nomogram to estimate the risk of community-acquired pneumonia in adults with acute asthma exacerbations

Objective

The aim of this study is to investigate the clinical characteristics of acute asthma exacerbations (AEs) with community-acquired pneumonia (CAP) in adults and establish a CAP prediction model for hospitalized patients with AEs.

Methods

We retrospectively collected clinical data from 308 patients admitted to Beijing Luhe Hospital, Capital Medical University, for AEs from December 2017 to August 2021. The patients were divided into CAP and non-CAP groups based on whether they had CAP. We used the Lasso regression technique and multivariate logistic regression analysis to select optimal predictors. We then developed a predictive nomogram based on the optimal predictors. The bootstrap method was used for internal validation. We used the area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA) to assess the nomogram's discrimination, accuracy, and clinical practicability.

Results

The prevalence of CAP was 21% (65/308) among 308 patients hospitalized for AEs. Independent predictors of CAP in patients hospitalized with an AE (P < 0.05) were C-reactive protein > 10 mg/L, fibrinogen > 4 g/L, leukocytes > 10 × 10⁹/L, fever, use of systemic corticosteroids before admission, and early-onset asthma. The AUC of the nomogram was 0.813 (95% CI: 0.753–0.872). The concordance index of internal validation was 0.794. The calibration curve was satisfactorily consistent with the diagonal line. The DCA indicated that the nomogram provided a higher clinical net benefit when the threshold probability of patients was 3% to 89%.

Conclusions

The nomogram performed well in predicting the risk of CAP in hospitalized patients with AEs, thereby providing rapid guidance for clinical decision-making.     

Modified IDSA/ATS Minor Criteria for Severe Community-Acquired Pneumonia Best Predicted Mortality

It is not clear whether the IDSA/ATS minor criteria for severe community-acquired pneumonia (CAP) could be simplified or even be modified to orchestrate improvements in predicting mortality.A retrospective cohort study of 1230 CAP patients was performed to simplify and to modify the scoring system by excluding 4 noncontributory or infrequent variables (leukopenia, hypothermia, hypotension, and thrombocytopenia) and by excluding these variables and then adding age ≥65 years, respectively. The simplification and modification were tested against a prospective 2-center validation cohort of 1409 adults with CAP.The increasing numbers of IDSA/ATS, simplified, and modified minor criteria present in the retrospective cohort were positively associated with the mortality, showing significant increased odds ratios for mortality of 2.711, 4.095, and 3.755, respectively. The validation cohort confirmed a similar pattern. The sensitivity, specificity, positive predictive value, and Youden index of modified minor criteria for mortality prediction were the best pattern in the retrospective cohort. High values of corresponding indices were confirmed in the validation cohort. The highest accuracy of the modified version for predicting mortality in the retrospective cohort was illustrated by the highest area under the receiver operating characteristic curve of 0.925 (descending order: modified, simplified, and IDSA/ATS minor criteria). The validation cohort confirmed a similar paradigm.The IDSA/ATS minor criteria could be simplified to 5 variables and then be modified to orchestrate improvements in predicting mortality in CAP patients. The modified version best predicted mortality. These were more suitable for clinic and emergency department.     

Performance and potential impact of a chest pain prediction rule in a large public hospital

PURPOSE: To evaluate the performance of a previously validated prediction rule for patients presenting to the emergency department with chest pain and the potential impact of the rule on triage decisions. SUBJECTS AND METHODS: In a prospective cohort study, physician investigators interviewed consecutive patients admitted for suspected acute ischemic heart disease (n = 207) by emergency department attending physicians who had not used the prediction rule. We measured the accuracy of the rule in predicting cardiac complications in these patients, and compared actual triage decisions with those that might have been recommended by use of the prediction rule. We also measured comorbid illnesses among patients stratified as very low risk by the prediction rule, as well as the effect of standardizing the definition of unstable angina and interpretation of electrocardiograms (ECG) on the rule's sensitivity and specificity. RESULTS: Overall, the rate of major cardiac complications (4.3%) was similar to that reported in the original study (3.6%). The prediction rule performed well in predicting these complications in our patients (area under receiver operating characteristic curve 0.84 versus 0.80 in the original study; difference 0.04, 95% confidence interval [CI] -0.07, 0.14). Standardized definitions of unstable angina and interpretation of ECGs improved the specificity of the prediction rule in predicting complications (55% versus 47%; difference 8%, 95% CI 1.5%, 13.7%). The prediction rule recommended admission to telemetry units in 65 fewer patients than actually occurred (31% of the entire cohort). None of these patients had major complications. A substantial minority of "very low risk" patients (27%) had comorbid illnesses requiring inpatient treatment. CONCLUSIONS: This independent validation of the prediction rule suggests that it can improve triage decisions for patients admitted with suspected acute ischemic heart disease. Additional studies are needed to test prospectively the performance of the prediction rule in actual decision making, its acceptance by clinicians, and its cost effectiveness.     

Usefulness of a semi-quantitative procalcitonin test and the A-DROP Japanese prognostic scale for predicting mortality among adults hospitalized with community-acquired pneumonia

Background and objective: The solid‐phase immunoassay, semi‐quantitative procalcitonin (PCT) test (B R A H M S PCT‐Q) can be used to rapidly categorize PCT levels into four grades. However, the usefulness of this kit for determining the prognosis of adult patients with community‐acquired pneumonia (CAP) is unclear. Methods: A prospective study was conducted in two Japanese hospitals to evaluate the usefulness of this PCT test in determining the prognosis of adult patients with CAP. The accuracy of the age, dehydration, respiratory failure, orientation disturbance, pressure (A‐DROP) scale proposed by the Japanese Respiratory Society for prediction of mortality due to CAP was also investigated. Hospitalized CAP patients (n = 226) were enrolled in the study. Comprehensive examinations were performed to determine PCT and CRP concentrations, disease severity based on the A‐DROP, pneumonia severity index (PSI) and confusion, urea, respiratory rate, blood pressure, age ≥65 (CURB‐65) scales and the causative pathogens. The usefulness of the biomarkers and prognostic scales for predicting each outcome were then examined. Results: Twenty of the 170 eligible patients died. PCT levels were strongly positively correlated with PSI (ρ = 0.56, P < 0.0001), A‐DROP (ρ = 0.61, P < 0.0001) and CURB‐65 scores (ρ = 0.58, P < 0.0001). The areas under the receiver operating characteristic curves (95% CI) for prediction of survival, for CRP, PCT, A‐DROP, CURB‐65, and PSI were 0.54 (0.42–0.67), 0.80 (0.70–0.90), 0.88 (0.82–0.94), 0.88 (0.82–0.94), and 0.89 (0.85–0.94), respectively. The 30‐day mortality among patients who were PCT‐positive (≥0.5 ng/mL) was significantly higher than that among PCT‐negative patients (log–rank test, P < 0.001). Conclusions: The semi‐quantitative PCT test and the A‐DROP scale were found to be useful for predicting mortality in adult patients with CAP.     

Severe community-acquired pneumonia: use of intensive care services and evaluation of American and British Thoracic Society Diagnostic criteria

Despite careful evaluation of changes in hospital care for community-acquired pneumonia (CAP), little is known about intensive care unit (ICU) use in the treatment of this disease. There are criteria that define CAP as "severe," but evaluation of their predictive value is limited. We compared characteristics, course, and outcome of inpatients who did (n = 170) and did not (n = 1,169) receive ICU care in the Pneumonia Patient Outcomes Research Team prospective cohort. We also assessed the predictive characteristics of four prediction rules (the original and revised American Thoracic Society criteria, the British Thoracic Society criteria, and the Pneumonia Severity Index [PSI]) for ICU admission, mechanical ventilation, medical complications, and death (as proxies for severe CAP). ICU patients were more likely to be admitted from home and had more comorbid conditions. Reasons for ICU admission included respiratory failure (57%), hemodynamic monitoring (32%), and shock (16%). ICU patients incurred longer hospital stays (23.2 vs. 9.1 days, p < 0.001), higher hospital costs (21,144 dollars vs. 5,785 dollars, p < 0.001), more nonpulmonary organ dysfunction, and higher hospital mortality (18.2 vs. 5.0%, p < 0.001). Although ICU patients were sicker, 27% were of low risk (PSI Risk Classes I-III). Severity-adjusted ICU admission rates varied across institutions, but mechanical ventilation rates did not. The revised American Thoracic Society criteria rule was the best discriminator of ICU admission and mechanical ventilation (area under the receiver operating characteristic curve, 0.68 and 0.74, respectively) but none of the prediction rules were particularly good. The PSI was the best predictor of medical complications and death (area under the receiver operating characteristic curve, 0.65 and 0.75, respectively), but again, none of the prediction rules were particularly good. In conclusion, ICU use for CAP is common and expensive but admission rates are variable. Clinical prediction rules for severe CAP do not appear adequately robust to guide clinical care at the current time.     

Severe sepsis in community-acquired pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course?

STUDY OBJECTIVES: Most natural history studies of severe sepsis are limited to ICU populations. We describe the onset and timing of severe sepsis during the hospital course for patients hospitalized with community-acquired pneumonia (CAP). We also determine the ability of the systemic inflammatory response syndrome (SIRS) and other proposed risk stratification scores measured at emergency department (ED) presentation to predict progression to severe sepsis, septic shock, or death. DESIGN: Retrospective analysis of a prospective observational outcome study from the Pneumonia Patient Outcomes Research Team (PORT). SETTING: Four academic medical centers in the United States and Canada between October 1991 and March 1994. PARTICIPANTS: The 1,339 patients hospitalized for CAP in the PORT study cohort, and a random subset of 686 patients for whom we had information for SIRS criteria. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: All subjects had infection (CAP). Severe sepsis was defined as new-onset acute organ dysfunction in this cohort, using consensus criteria. Severe sepsis developed in one half of the patients (n = 639, 48%), nonpulmonary organ dysfunction developed in 520 patients (39%), and septic shock developed in 61 subjects (4.5%). Severe sepsis and septic shock were present at ED presentation in 457 patients (71% of severe sepsis cases) and 27 patients (44% of septic shock cases), respectively. While SIRS was common at presentation (82% of the subset of 686 had two SIRS criteria), it was not associated with increased odds for progression to severe sepsis (odds ratios [ORs], 0.65 and 0.89 for two or more SIRS criteria and three or more SIRS criteria, respectively), septic shock (ORs, 0.80 and 0.55), or death (ORs, 0.65 and 0.39), with poor discrimination (all receiver operating characteristic [ROC] areas under the curve < 0.5). The pneumonia severity index was associated with severe sepsis (p < 0.001) with moderate discrimination (ROC, 0.63). CONCLUSIONS: Severe sepsis is common in hospitalized CAP patients, occurring early in the hospital course. SIRS criteria do not appear to be useful predictors for progression to severe sepsis in CAP.     

Differentiation syndrome in acute promyelocytic leukaemia

Acute promyelocytic leukaemia differentiation syndrome (APL DS) is seen when patients with APL are treated with all-trans retinoic acid (ATRA) and/or arsenic trioxide (ATO). Presenting symptoms are varied but frequently include dyspnoea, unexplained fever, weight gain >5 kg, unexplained hypotension, acute renal failure and a chest radiograph demonstrating pulmonary infiltrates or pleural or pericardial effusion. Immediate treatment with steroids at the first clinical suspicion is recommended and ATRA/ATO should be stopped in severe cases or if there is no response to treatment. The utility of steroid prophylaxis in order to prevent APL DS is less certain. Here we provide a detailed review of the pathogenesis, clinical signs and symptoms as well as management and prophylaxis strategies of APL DS.     

Community-acquired pneumonia: development of a bedside predictive model and scoring system to identify the aetiology

Although initial presentation has been commonly used to select empirical therapy in patients with community-acquired pneumonia (CAP), few studies have provided a quantitative estimation of its value. The objective of this study was to analyse whether a combination of basic clinical and laboratory information performed at bedside can accurately predict the aetiology of pneumonia. A prospective study was developed among patients admitted to the Emergency Department University Hospital Arnau de Vilanova, Lleida, Spain, with CAP. Informed consent was obtained from patients in the study. At entry, basic clinical (age, comorbidity, symptoms and physical findings) and laboratory (white blood cell count) information commonly used by clinicians in the management of respiratory infections, was recorded. According to microbiological results, patients were assigned to the following categories: bacterial (Streptococcus pneumoniae and other pyogenic bacteria), virus-like (Mycoplasma pneumoniae, Chlamydia spp and virus) and unknown pneumonia. A scoring system to identify the aetiology was derived from the odds ratio (OR) assigned to independent variables, adjusted by a logistic regression model. The accuracy of the prediction rule was tested by using receiver operating characteristic curves. One hundred and three consecutive patients were classified as having virus-like (48), bacterial (37) and unknown (18) pneumonia, respectively. Independent predictors related to bacterial pneumonia were an acute onset of symptoms (OR 31; 95% CI, 6-150), age greater than 65 or comorbidity (OR 6.9; 95% CI, 2-23), and leukocytosis or leukopenia (OR 2; 95% CI, 0.6-7). The sensitivity and specificity of the scoring system to identify patients with bacterial pneumonia were 89% and 94%, respectively. The prediction rule developed from these three variables classified the aetiology of pneumonia with a ROC curve area of 0.84. Proper use of basic clinical and laboratory information is useful to identify the aetiology of CAP. The prediction rule may help clinicians to choose initial antibiotic therapy.     

Age and alarm symptoms do not predict endoscopic findings among patients with dyspepsia: a multicentre database study

INTRODUCTION: Symptoms of dyspepsia are common but most patients do not have major upper gastrointestinal pathology. Endoscopy is recommended for dyspeptic patients over the age of 45, or those with certain "alarm" symptoms. We have evaluated the effectiveness of age and "alarm" symptoms for predicting major endoscopic findings in six practising endoscopy centres. METHODS: Clinical variables of consecutive patients with dyspepsia symptoms undergoing upper endoscopy examinations were recorded using a common endoscopy database. Patients who had no previous upper endoscopy or barium radiography were included. Stepwise multivariate logistic regression was used to identify predictors of endoscopic findings. The accuracy of these for predicting endoscopic findings was evaluated with receiver operating characteristic analysis. The sensitivity and specificity of age thresholds from 30 to 70 years were evaluated. RESULTS: Major pathology (tumour, ulcer, or stricture) was found at endoscopy in 787/3815 (21%) patients with dyspepsia. Age, male sex, bleeding, and anaemia were found to be significant but weak independent predictors of endoscopic findings. A multivariate prediction rule based on these factors had poor predictive accuracy (c statistic=0.62). Using a simplified prediction rule of age > or =45 years or the presence of any "alarm" symptom, sensitivity was 87% and specificity was 26%. Increasing or decreasing the age cut off did not significantly improve the predictive accuracy. CONCLUSIONS: Age and the presence of "alarm" symptoms are not effective predictors of endoscopic findings among patients with dyspepsia. Better clinical prediction strategies are needed to identify patients with significant upper gastrointestinal pathology.     

N-terminal pro-brain natriuretic peptide for discriminating between cardiac and non-cardiac dyspnoea

AIM: Evaluation of N-terminal pro-brain natriuretic peptide (NT-proBNP) to confirm or disprove heart failure in community patients complaining of dyspnoea. METHODS AND RESULTS: General practitioners referred 345 consecutive patients complaining of dyspnoea to our hospital-based clinic, where a diagnosis was established based on a combined programme for heart and lung diseases including echocardiography. The level of NT-proBNP in plasma was also measured. The mean (S.D.) concentration of NT-proBNP in patients with heart failure was significantly higher, 189 (270) pmol/l in patients with heart failure (n=81), than in patients with non-cardiac dyspnoea (n=264), 17 (38) pmol/l (P<0.001). In patients > or = 50 years NT-proBNP <11 pmol/l for men and <17 pmol/l for women excluded heart failure with a negative predictive value of 97% while the positive predictive value was 53%, the sensitivity 95% and the specificity 68%. Areas under receiver operator characteristic curves for men and women were 0.93 and 0.90, respectively. CONCLUSION: In a relevant setting of primary care patients complaining of dyspnoea, NT-proBNP seems promising for disproval of heart failure, and this test may reduce the need for echocardiographic screening with 50%. However, the discrimination levels of NT-proBNP found in this study may need prospective confirmation, before the test can be generally recommended.     

Suspected SARS patients hospitalised in French isolation units during the early SARS epidemic: the French experience

During the SARS epidemic, many patients were screened according to WHO criteria but never went on to develop SARS. In May 2003, early in the epidemic, we conducted a retrospective study to describe suspected SARS patients hospitalised in France and compared them with documented cases of patients with SARS to evaluate the screening strategy. A total of 117 patients were studied. Only 3.4% had been in close contact with a SARS patient but 73.5% came from an affected area. 67.5% had fever and respiratory symptoms on their admission to hospital. 49.6% had fever and non specific symptoms. Clinical symptoms that were significantly more common among patients with SARS were fever, myalgia, dyspnoea, and nausea or vomiting. Presumed viral fever and respiratory tract infection were the most common diagnosis. Symptoms cannot be distinguished from an early stage of SARS confirming the usefulness of the WHO case definitions in isolation decision to avoid further transmission.     

Use of the NOBLADS Score to Predict Endoscopic Treatment in Patients with Colonic Diverticular Bleeding by Age Stratification

Objective A high NOBLADS score reflecting the severity of lower gastrointestinal bleeding contributes to the identification of stigmata of recent hemorrhage (SRH) in colonic diverticular bleeding (CDB). The burden of colonoscopy is particularly high in elderly patients; therefore, we investigated the utility of the NOBLADS score for managing CDB by age stratification. The NOBLADS score performance in SRH prediction was estimated by the area under the receiver operating characteristic calculation and a multiple logistic regression model.Methods This was a single-center, retrospective cohort study. Patients who underwent initial colonoscopy with CDB between April 2008 and December 2019 were divided into a young group (＜65 years old) and an elderly group (≥65 years old). We further categorized patients according to colonoscopy findings as SRH-positive, with successful endoscopic hemostasis performance, and SRH-negative, with suspected CDB. The main outcome measure was successful SRH identification.Results Four-hundred and seventeen CDB patients were included, of whom 250 (60.0%) were elderly. There were 72 (43.1%) SRH-positive patients in the young group and 94 (37.6%) in the elderly group. The areas under the receiver operating characteristic curves of the NOBLADS score predicting SRH identification were 0.76, 0.71, and 0.81 for all ages, young patients, and elderly patients, respectively. A multiple logistic regression analysis showed that SRH identification was significantly associated with NOBLADS scores in both groups. Eighty-one patients (32.4%) scored ≥4 in the elderly group, and 60 of those were SRH-positive (74.1%). All 27 patients (10.8%) who scored ≥4 with extravasation on computed tomography were found to have SRH.Conclusion The NOBLADS score is useful for predicting SRH identification, especially in elderly patients.     

Validation of IDSA/ATS Guidelines for ICU Admission in Adults Over 80 Years Old With Community-Acquired Pneumonia

IntroductionThe 2007 IDSA/ATS guidelines for community-acquired pneumonia (CAP) recommended intensive care unit (ICU) admission for adults meeting severe CAP criteria. We aimed to validate the accuracy of IDSA/ATS criteria in patients ≥ 80 years old (very elderly patients, VEP) with CAP.MethodsProspective cohort study of VEP with CAP admitted to three Spanish hospitals between 1996 and 2019. We compared patients who did and did not require ICU admission. We also assessed factors independently associated with ICU admission, as well as the accuracy of severe CAP criteria for ICU admission and mortality. Major criteria include septic shock and invasive mechanical ventilation while minor criteria encompass other variables related to hemodynamics and respiratory insufficiency as well as level of consciousness, renal function, blood parameters indicative of sepsis and body temperature.ResultsOf the 2006 VEP with CAP, 519 (26%) met severe CAP criteria, while 204 (10%) required ICU admission. Concordance between severe CAP criteria and the decision to admit the patient to the ICU occurred in 1591 (79%) cases (k coefficient, 0.33), with a sensitivity of 75% and specificity of 80% in predicting ICU admission. All patients with invasive mechanical ventilation received care in ICUs, while 45 (44%) patients with septic shock—previously stabilized in the emergency room—did not. Thirty-day mortality of ICU-admitted patients with septic shock was lower than that of patients in wards (30% vs. 60%, p = 0.013). In contrast, patients with severe CAP and only minor criteria had similar mortality.ConclusionsIDSA/ATS criteria for severe CAP predict ICU admission in VEP moderately well. While patients with septic shock and invasive mechanical ventilation warrant ICU admission, severe CAP without major severity criteria in VEP may be acceptably manageable in wards.     

Correlation between the macroscopic severity of Crohn’s disease in resected intestine and bowel wall thickness evaluated by water-immersion ultrasonography

Abstract

Objectives: Transabdominal ultrasonography is a common and accurate tool for managing Crohn’s disease (CD); however, the significance of the resulting data is poorly understood. This study was performed to determine the association between bowel wall thickness evaluated by water-immersion ultrasonography and macroscopic severity, namely, refractory inflammation and subsequent fibrosis in CD surgical specimens.

Materials and methods: We retrospectively evaluated 100 segments of colon and small intestine from 27 patients with CD. The resected specimens were placed in saline postoperatively, and bowel wall thickness was measured by water-immersion ultrasonography and compared with macroscopic findings. Correlations between bowel wall thickness and macroscopic findings were assessed using analysis of variance and receiver operating characteristic curves.

Results: According to the progression of macroscopic severity, the mean bowel wall thickness was increased as follows: macroscopically intact: 4.1?mm, longitudinal ulcer scars: 5.4?mm, longitudinal open ulcers: 6.0?mm, large ulcers: 6.4?mm, cobblestone-like lesions: 7.1?mm, and fibrotic strictures: 7.4?mm. For all lesions except longitudinal ulcer scars, the bowel wall thickness was significantly thicker than that of macroscopically-intact areas (p?<?.001). According to receiver operating characteristic curves, bowel wall thickness >4.5?mm was associated with CD lesions, and thickness >5.5?mm was associated with more severe lesions.

Conclusions: The bowel wall thickness of CD lesions was evaluated by water-immersion ultrasonography correlated with macroscopic disease severity.     

Escherichia coli: an unknown and infrequent cause of community acquired pneumonia

Our aim was to describe the incidence, clinical characteristics and outcome of community acquired pneumonia (CAP) caused by Escherichia coli through the analysis of a cohort of patients with this condition. This study includes all the patients who were admitted to our hospitals because of CAP caused by E. coli, diagnosed with highly reliable microbiological techniques, such as blood culture, bronchoscopic protected specimen brush (PSB) or transthoracic needle aspiration (TNA). 29 patients were enrolled, representing 0.4% of CAP cases admitted. Main symptoms were fever and dyspnoea. 18 patients were classified into class IV and class V of the Pneumonia Severity Index (PSI). Diagnosis was based on blood culture in 24 cases, PSB in 4 cases and by TNA in 1 case. Three of the patients died, the longer time evolution of the symptoms being the only factor related to higher mortality (p<0.05). Mean hospitalization time was 7.1+/-3.1 d, and correlated with severity at admission (r=0.43; p<0.003). This study demonstrates that CAP caused by E. coli is infrequent. It has an unspecific presentation and mortality rate is 10.3%, associated with longer time before admission to hospital.     

Development and verification of a prediction model using serum tumor markers to predict the response to chemotherapy of patients with metastatic or recurrent breast cancer

Purpose  The aim of this study was to develop a prediction model using serum tumor markers to predict the response to chemotherapy of patients with metastatic or recurrent breast cancer. Methods  We retrospectively analyzed a training set of 105 patients with metastatic or recurrent breast cancer. Their chemotherapeutic response had been evaluated according to the World Health Organization (WHO)’s response criteria. Our model for predicting response using carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 15-3, and NCC-ST-439 was determined using the area under the receiver operating characteristic curve (ROC-AUC) and the overall misclassification rate (OMR) in a random cross-validation. The prediction model was then verified in a consecutive set of 64 patients. Their response had been evaluated using the response evaluation criteria in solid tumors (RECIST) criteria. Results  The best prediction model consisted of the serum CEA, CA15-3, and NCC-ST-439 levels, but the prediction formula varied according to the baseline CA15-3 level (elevated or normal). The overall ROC-AUC and OMR in the training set were 0.83 and 0.19, respectively. The overall ROC-AUC and OMR in the verification set were 0.72 and 0.28, respectively. When the verification set was stratified according to either the objective response or the predicted response, the time-to-progression, but not the overall survival, was significantly different. Conclusion  Our model for predicting the response to first-line chemotherapy of patients with metastatic or recurrent breast cancer may be valid because it predicted the outcome of more than 70% of the patients in an independent verification set.     

Non-infectious and unusual infectious mimics of community-acquired pneumonia

Noninfectious or unusual infectious diseases may present with clinical, radiological and laboratorial characteristics of community-acquired pneumonia (CAP). Usually their presence is only suspected after treatment failure, leading to inappropriate interventions, unnecessary costs and risks related to the untreated potentially life-threatening disease. The present study aimed to assess the noninfectious or unusual infectious diseases that may be misdiagnosed as CAP that progresses with treatment failure. Sixteen hospitalized patients with presumptive diagnosis of CAP and treatment failure were described. The most prevalent symptoms were fever and cough. Radiological pattern of air-space disease was observed in 10 (62%) patients. The diagnosis was established by autopsy (12%) or invasive procedures (88%), as follows: open lung biopsy (nine), flexible fiberoptic bronchoscopy (two), transthoracic fine needle aspiration (two) and bone marrow aspiration (one). Eight patients had noninfectious diseases: pulmonary embolism, cryptogenic organizing pneumonia, Wegener's granulomatosis, hypersensitivity pneumonitis, bronchocentric granulomatosis, neoplastic disease and acute leukemia. The unusual infectious diseases were: tuberculosis, cryptococcosis, actinomycosis, histoplasmosis and paracoccidioidomycosis. Patients with noninfectious or unusual infectious diseases may present with symptoms and radiological findings that mimic CAP. These diseases should always be suspected in patients who do not respond to initial empirical antimicrobial treatment, especially young patients or those without comorbidity.     

Risk factors for pulmonary embolism in patients preliminarily diagnosed with community-acquired pneumonia: a prospective cohort study

D-dimer levels are increased in patients with acute pulmonary embolism (PE). However, D-dimer levels are also increased in patients with community-acquired pneumonia (CAP). The aim of this prospective cohort study was to examine the incidence and clinical features of patients preliminarily diagnosed with CAP and with increased D-dimer levels, and who finally were diagnosed with PE. Patients diagnosed with CAP and hospitalized in the Respiratory Department of the Tenth People’s Hospital Affiliated to Tongji University between May 2011 and May 2013 were enrolled. D-dimer levels were measured routinely after admission. For patients with increased D-dimer levels, those suspected with PE underwent computed tomography pulmonary angiography (CTPA). A total of 2387 patients with CAP was included: 724 (30.3 %) had increased D-dimer levels (median of 0.91 mg/L). CTPA was performed for 139 of the 724 patients (median D-dimer levels of 1.99 mg/L). Among the 139 patients, 80 were diagnosed with PE, and 59 without PE; D-dimer levels were 2.83 and 1.41 mg/L, respectively (p < 0.05). Multivariate analysis showed that age, coronary heart disease, chronic obstructive pulmonary disease (COPD), lower limb varicosity, chest pain, shortness of breath, hemoptysis, fever, and increased levels of troponin I were independent risk factors for PE. Presentation of PE and CAP are similar. Nevertheless, these results indicated that for hospitalized patients with CAP and elevated D-dimer levels, PE should be considered for those >60 years; with CHD, COPD, or lower limb varicosity; with chest pain, shortness of breath, hemoptysis, increased troponin I, or low fever.     

qSOFA评分和NLCR预测成人社区获得性肺炎严重程度的价值

目的探讨快速序贯器官衰竭评估(qSOFA)评分、中性粒细胞-淋巴细胞比值(NLCR),预测成人社区获得性肺炎(CAP)为重症CAP和死亡的价值。方法回顾性研究299名CAP住院患者,依据患者肺炎的严重程度分为重症CAP组与非重症CAP组,依据患者28d内是否死亡,分为死亡组与存活组,比较各组之间qSOFA评分、NLCR值的差异,并通过绘制受试者工作特征(ROC)曲线,计算曲线下面积(AUC值),分析qSOFA评分、NLCR以及两者联合预测CAP患者为重症CAP、28d内死亡的价值。结果重症CAP组的qSOFA评分和NLCR值高于非重症CAP组,死亡组高于存活组(P<0.05)。qSOFA评分、NLCR和qSOFA评分联合NLCR预测重症CAP的AUC值分别为0.92、0.83、0.85;预测死亡的AUC值分别为0.89、0.78、0.79;qSOFA评分预测患者为重症CAP和死亡的AUC值均大于NLCR和两者联合的AUC值(P<0.05)。qSOFA评分、NLCR以及两者联合预测重症肺炎敏感度分别为54.3%、69.5%和83.7%;特异度分别为99.0%、87.4%和86.5%;三者预测患者死亡的敏感度分别为60.4%、66.0%和83.0%;特异度分别为92.8%、77.6%和75.2%。结论qSOFA评分和NLCR均可用于预测成人CAP的严重程度,qSOFA评分预测CAP严重程度的特异度较高,但敏感度较低,将其与NLCR联合可提高预测的敏感度。     

Treatment of community-acquired pneumonia in outpatients: randomized study of clarithromycin alone versus clarithromycin and cefuroxime.

OBJECTIVE: To evaluate the efficacy of clarithromycin alone in comparison with the combination of clarithromycin and cefuroxime in the treatment of nonhospitalized patients with community-acquired pneumonia (CAP) in a Mediterranean population. METHODS: CAP was defined as the acute onset of fever (>38 degrees C) with pulmonary opacity on chest roentgenogram. The American Thoracic Society (ATS) criteria (1993) were used to decide on patient hospitalization. Ninety subjects, of whom 53 (59%) were men, with a mean age (+/-SD) of 38+/-15 years, were randomized: 45 received clarithromycin 500 mg b.i.d. orally for 14 days (CL group), and 45 received clarithromycin plus cefuroxime 500 mg b.i.d. orally for 7 days (CLCE group). Patients were monitored with clinical, radiological, and laboratory controls at 3 and 21 days. There were no significant differences between the two groups with regard to demographic, clinical, physical and laboratory data. RESULTS: The mean time to defervescence was 2.4+/-1.4 and 2.4+/-1.5 days, respectively. Chest roentgenogram clearance was complete in all cases, without statistically significant differences in the time to resolution between both arms. Side effects were mild (no significant differences between groups): 5 patients in the CL group and 3 in the CLCE group showed gastrointestinal symptoms. Two patients (2.2%), both in the CLCE group, needed hospital admission during follow-up, but all 90 patients showed an excellent outcome. A causative agent was determined in 25 cases (28%). Legionella pneumophila, Streptococcus pneumoniae, and Mycoplasma pneumoniae were the most frequent pathogens. CONCLUSION: Empirical treatment of outpatient CAP with clarithromycin can be considered adequate in the Mediterranean area, independently of the microbiological etiology. ATS criteria for admitting patients with CAP are appropriate in this population.