Severe community-acquired pneumonia

Although several pneumonia severity criteria have been firmly established, the exact definition of severe community-acquired pneumonia (CAP) remains elusive. Mortality from CAP remains high, reaching 50% in some series. The particular role of and spp. in severe CAP has been defined more clearly. Microbial diagnosis in the individual patient remains a difficult task. Despite promising new diagnostic tools, concerns about possible mixed origins preclude a change from the currently advocated broad-spectrum approach of antimicrobial treatment. Although there is some evidence that guidelines may optimize outcomes, their role in limiting the spread of resistance has only recently received attention. Finally, although there are promising data on the use of noninvasive positive pressure ventilation to treat pneumonia in patients without chronic obstructive pulmonary disease, its place in the management of acute respiratory failure remains to be defined in randomized studies.     

Severe pneumococcal community-acquired pneumonia admitted to medical Tunisian ICU

Streptococcus pneumoniae is the most common cause of community-acquired pneumonia (CAP). There are no available data about this disease in Tunisian intensive care patients. The objective of this study is to describe the clinical and microbiological features of pneumococcal CAP and determine the prognostic factors. This is a retrospective cohort study of all pneumococcal CAP cases hospitalized in the medical intensive care unit (ICU) of Hospital A. Mami of Ariana (Tunisia) between January 1999 and August 2008. Included were 132 patients (mean age, 49.5 years; 82.6% males); 30 patients had received antimicrobial treatment before hospital admission. The mean of the Simplified Acute Physiology Score II was 32.9. All patients had an acute respiratory failure; 34 patients (25.8%) had pneumococcal bacteremic CAP. Among the isolated strains, 125 antimicrobial susceptibility tests were performed. The use of the new Clinical and Laboratory Standards Institute breakpoints for susceptibility when testing penicillin against S. pneumoniae showed that all isolated strains were susceptible to penicillin. The mortality rate was 25%. The need of mechanical ventilation at admission [odds ratio (OR), 3.4; 95% confidence interval (CI), 1.67–6.94; P = 0.001), Sepsis-related Organ Failure Assessment (SOFA) score at admission ≥4 (OR, 3.1; 95% CI, 1.56–6.13; P = 0.001), and serum creatinine at admission ≥102 μmol/l (OR, 1.8; 95% CI, 1.02–3.17; P = 0.043) were independent factors related to ICU mortality. In conclusion, pneumococcal CAP requiring hospitalization in the ICU is associated with high mortality. All isolated stains were susceptible to penicillin.     

Severe community-acquired pneumonia: current management and future therapeutic alternatives

Introduction: Despite advances in modern medicine, severe community-acquired pneumonia (CAP) continues to be a potentially deadly disease. Mortality rate reaches up to the 50% in patients requiring admission to the Intensive Care Unit (ICU) when developing septic shock.

Areas covered: We aim to describe the optimal management of severe CAP, including antibiotic therapy, future antimicrobial options, and non-antibiotic (so-called adjunctive) therapies. A literature search was performed to identify all clinical trials, observational studies, meta-analysis, and reviews about this topic from PubMed.

Expert commentary: Antibiotic therapy, the cornerstone of the management of CAP, must be started prompt because the delay in the administration of antimicrobials is associated with mortality. Diverse observational studies have reported a lower adjusted mortality in patients with severe CAP treated with combined antibiotic therapy, especially those in septic shock or with pneumococcal bacteremia. We summarize the available information about new antibiotics in the pipeline for severe CAP. Finally, we review the available evidence about the role of corticosteroids, immunoglobulins, and statins as adjunctive for CAP.     

Severe community-acquired legionella pneumonia: treatment, complications and outcome

Legionella pneumophila is the second most common cause of severecommunity-acquired pneumonia requiring treatment with intermittentpositive pressure ventilation. The prognosis of this conditionand its complications have not been well documented. Erythromycinis the first-line antibiotic of choice based on clinical experience.Rifampicin has been recommended as an additional agent, thoughclinical experience has not been reported. We have retrospectivelyexamined 30 cases of severe community-acquired legionella pneumonia.The mean age of the patients was 53 years, 24 were male andeight died (27%, mean age 57 years). During admission 26 patientsreceived erythromycin (eight died) and 15 received rifampicinin addition (five died); four received neither drug and survived.Mean duration of intermittent positive pressure ventilationwas 15.9 days for survivors and 14.1 days for fatal cases. Acuterenal failure requiring dialysis developed in 13 (43%), of whomfive died (38%). Positive inotropic drugs were used in 10 patientsand of these six died. Jaundice occurred in 11 patients andwas significantly more common (p = 0.028) in patients who receivedrifampicin (60%) than in those who did not (17%). Excess bilirubinwas largely conjugated when measured and there was no consistenthepatitic or obstructive change in the liver enzymes. Severecommunity-acquired legionella pneumonia has a relatively goodoutcome with a mortality of 27%, though prolonged intermittentpositive pressure ventilation may be required. Acute renal failureis common but reversible in survivors, and jaundice is morecommon in those who receive rifampicin.     

Severe community-acquired pneumonia in ICUs: Prospective validation of a prognostic score

Objective To determine predictors of intensive care unit (ICU) mortality in patients with community-acquired pneumonia (CAP), to develop a pneumonia-specific prognostic index, and to evaluate this index prospectively.Design Combined retrospective and prospective clinical study over two periods: January 1987–December 1992 and January 1993–December 1994.Setting Four medical ICUs in the north of France.Patients Derivation cohort: 335 patients admitted to one ICU were retrospectively studied to determine prognosis factors and to develop a pneumonia-specific prognostic index. Validation cohort: 125 consecutive patients, admitted to four ICUs, were prospectively enrolled to evaluate this index.Results In the derivation cohort, 16 predictors of mortality were identified and assigned a value directly proportional to their magnitude in the mortality model: aspiration pneumonia (–0.37), grading of sepsis 11 (–0.2), antimicrobial combination (–0.01), Glasgow score >12+mechanical ventilation (MV) (+0.09), serum creatinine 15 mg/l (+0.22), chest involvement shown by X-ray 3 lobes (+0.28), shock (+0.29), bacteremia (+0.29), initial MV (+0.29), underlying ultimately or rapidly fatal illness (+0.31), Simplified Acute Physiology Score 12 (+0.49), neutrophil count 3500/mm³ (+0.52), acute organ system failure score 2 (+0.64), delayed MV (+0.67), immunosuppression (+1.38), and ineffective initial antimicrobial therapy (+1.5). An index was obtained by adding each patient's points. According to a receiver operating characteristic curve, the cut-off value of this index was 2.5. In the validation cohort, an index of 2.5 could predict death with a positive predictive value of 0.92, sensitivity 0.61, and specificity 0.98.Conclusion This index, which performs well in classifying patients at high-risk of death, may help physicians in initial patient care (appropriateness of the initial antimicrobial therapy) and guide future clinical research (analysis and design of therapeutic trials).     

Treatment of community-acquired pneumonia

Community-acquired pneumonia is the sixth leading cause of death in the USA. Adherence to the 2007 Infectious Diseases Society of America/American Thoracic Society community-acquired pneumonia guidelines has been associated with improved clinical outcomes. However, choice between guideline-recommended treatments is at the discretion of the prescribing clinician. This review is intended to discuss the characteristics of these treatment options including dosing frequency, dose adjustment for renal/hepatic dysfunction, serious/common adverse events, drug interactions, lung penetration, pharmacokinetic-pharmacodynamic target and effect of obesity to help guide antimicrobial selection. An increasing portion of patients are receiving expanded empiric coverage for methicillin-resistant Staphylococcus aureus as recommended by the American Thoracic Society and Infectious Diseases Society of America for healthcare-associated pneumonia. However, this expanded coverage may not be achieving the desired improvements in clinical outcomes. We expect this increasingly diverse spectrum of patients with pneumonia to eventually result in the merger of these two guidelines to include all patients with pneumonia.     

Treatment of community-acquired pneumonia

Lower respiratory tract infections are the major cause of death due to infectious disease in the developed and developing world. Despite substantial progress in defining pathogens and in therapeutic options, there continues to be major controversies in the clinical management of these infections. This report reviews the guidelines for community-acquired pneumonia from the Infectious Diseases Society of America (IDSA), updated from the initial publication. Diagnosis should include a chest X-ray to differentiate acute bronchitis from pneumonia. The decision for hospitalization should be based on social factors and evaluation of severity of illness. Identification of an etiological agent for inpatients should include two pretreatment cultures, one pretreatment sputum specimen, with seriously ill patients requiring studies for Legionella spp. Recommendations for empiric treatment of outpatients are doxycycline, a macrolide or a fluoroquinolone. Recommendations for empiric treatment of hospitalized patients are a cephalosporin plus a macrolide, or a fluoroquinolone alone. Recommendations for ICU patients are a beta-lactam combined with either a macrolide or a fluoroquinolone. While concern has arisen about increasing resistance to fluoroquinolones, arguments in favor of these agents include the fact that they have good in vitro activity against nearly all treatable pathogens except some anaerobes. Clinical trials have shown equivalence or superiority compared to other standard agents. They are well tolerated, and can be administered intravenously or orally, once daily. A recent retrospective review has shown superior outcome with fluoroquinolone treatment compared to cephalosporins, including a 36% reduction in mortality.     

社区获得性肠杆菌肺炎与普通肺炎的比较

目的通过对社区获得性肠杆菌肺炎与普通肺炎的临床对比研究,探讨社区获得性肠杆菌肺炎新的流行病学变化趋势及其特点。方法10例社区获得性肠杆菌肺炎与20例社区获得性普通肺炎进行配对研究,回顾性分析其临床特点、易患因素、病原学检查特点以及抗生素治疗特点。结果(1)社区获得性肠杆菌肺炎的临床症状、生化检查、胸部X线表现等无特殊性,两组病死率比较差异无显著性。(2)患有基础疾病者易发生社区获得性肠杆菌肺炎。(3)不适合抗生素使用时间的过度延长引起一个复杂的疾病过程,而适合抗生素使用的延迟未引起患者病死率的明显增加。结论(1)对因社区获得性肺炎住ICU的患者,如果具备年老,至少有一种基础疾病存在,有既往住院史,有既往抗菌素使用史等特点,应警惕社区获得性肠杆菌肺炎的可能。(2)对疑诊患者早期病原学检查有助于抗生素的合理的选择。     

Bronchial capacity in community-acquired pneumonia

AIM: To examine bronchial capacity (BC) in patients with community pneumonia (CP) by speed characteristics of pulmonary ventilation function (PVF) and bronchial resistance (Raw). MATERIAL AND METHODS: Monitoring of a peak expiration speed (PES) was made in 99 CP patients. In addition, 46 of them have undergone spirometry and bodyplethysmography (Masterlab pro device) with measurement of airflow speed, Raw and structure of total lung capacity. RESULTS: In 88.9% patients with CP the initial PES was subnormal but its normalization occurred (in 79.7%) within 3 days of stable normalization of body temperature. This was confirmed by a strong negative correlation between the initial PES and body temperature in admission of CP patients to hospital (r = -0.73, p = 0.001). Raw in 86.9% patients with CP is normal (74.53 +/- 4.50%) both in moderate and acute fall of PVF speed characteristics. If these characteristics in CP patients are low, Raw should be examined. High Raw in this case justifies the diagnosis of latent chronic obstructive pulmonary disease. CONCLUSION: Raw in 86.9% CP patients is normal, thus indicating no impairment of bronchial capacity. Obstructive disorder of lung ventilation in acute CP detected at spirometry is explained by non-pulmonary causes. For diagnosis of BC affection in patients with CP and low speed characteristics of PVF, bronchial resistance must be examined. High bronchial resistance in such cases indicates latent chronic obstructive pulmonary disease.     

Changing needs of community-acquired pneumonia

Community-acquired pneumonia (CAP) is a serious condition associated with significant morbidity and potential long-term mortality. Although the majority of patients with CAP are treated as outpatients, the greatest proportion of pneumonia-related mortality and healthcare expenditure occurs among the patients who are hospitalized. There has been considerable interest in determining risk factors and severity criteria assessments to assist with site-of-care decisions. For both inpatients and outpatients, the most common pathogens associated with CAP include Streptococcus pneumoniae, Haemophilus influenzae, group A streptococci and Moraxella catarrhalis. Atypical pathogens, Gram-negative bacilli, methicillin-resistant Staphylococcus aureus (MRSA) and viruses are also recognized aetiological agents of CAP. Despite the availability of antimicrobial therapies, the recent emergence of drug-resistant pneumococcal and staphylococcal isolates has limited the effectiveness of currently available agents. Because early and rapid initiation of empirical antimicrobial treatment is critical for achieving a favourable outcome in CAP, newer agents with activity against drug-resistant strains of S. pneumoniae and MRSA are needed for the management of patients with CAP.     

Antibiotic stewardship in community-acquired pneumonia

Introduction: Community-acquired pneumonia (CAP) continues to be associated with significant mortality and morbidity. As with other infectious diseases, in recent years there has been a marked increase in resistance to the antibiotics commonly used against the pathogens that cause CAP. Antimicrobial stewardship denotes coordinated interventions to improve and measure the appropriate use of antibiotics by encouraging the selection of optimal drug regimens.

Areas covered: Several elements can be applied to antibiotic stewardship strategies for CAP in order to maintain or improve patient outcomes. In this regard, antibiotic de-escalation, duration of antibiotic treatment, adherence to CAP guidelines recommendations about empirical treatment, and switching from intravenous to oral antibiotic therapy may each be relevant in this context. Antimicrobial stewardship strategies, such as prospective audit with intervention and feedback, clinical pathways, and dedicated multidisciplinary teams, that have included some of these elements have demonstrated improvements in antimicrobial use for CAP without negatively affecting clinical outcomes.

Expert commentary: Although there are a limited number of randomized clinical studies addressing antimicrobial stewardship strategies in CAP, there is evidence that antibiotic stewardship initiatives can be securely applied, providing benefits to both healthcare systems and patients.     

Severe community-acquired pneumonia as a cause of severe sepsis: data from the PROWESS study

OBJECTIVE: To investigate community-acquired pneumonia (CAP) as a cause of severe sepsis in the PROWESS (Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis) trial and to evaluate the effect of drotrecogin alfa (activated) (DrotAA) in this subgroup. DESIGN: Retrospective analysis of the severe CAP subgroup in the PROWESS trial. SETTING: Tertiary care institutions in 11 countries. INTERVENTIONS: DrotAA (n = 850), 24 microg.kg.hr for 96 hrs, or placebo (n = 840). PARTICIPANTS: The 1,690 patients with severe sepsis enrolled in the PROWESS trial. MEASUREMENTS AND MAIN RESULTS: Patients were classified as having CAP if lung was the primary site of infection and if they were enrolled directly from home (private residence) with /=25, Pneumonia Severity Index score of >/=4, or CURB-65 (confusion, urea, respiratory rate, blood pressure, age) score of >/=3. CONCLUSIONS: CAP associated with a high Pneumonia Severity Index score, bacteremia, or an intense coagulation and inflammatory response requiring intensive care unit care were indicators of a high risk of death from severe sepsis. In patients with severe sepsis resulting from CAP, a readily identifiable disease, DrotAA, improved survival compared with placebo.