Management of severe community-acquired pneumonia: A survey on the attitudes of 468 physicians in Iberia and South America

Purpose

The purpose of this study is to characterize the practices of pulmonary, internal medicine, and critical care physicians toward the management of patients with severe community-acquired pneumonia (CAP).

Materials and methods

A cross-sectional international anonymous survey was conducted among a convenience sample of critical care, pulmonary, emergency, and internal medicine physicians from Portugal, Spain, and South America between October and December 2008. The electronic survey evaluated physicians’ attitudes toward diagnosis, risk assessment, and therapeutic interventions for patients with severe CAP.

Results

Four hundred sixty-eight physicians responded being 84.6% from 4 countries (Brazil, Portugal, Spain, and Argentina) whom 66.9% had more than 10 years experience. Risk assessment of severe CAP was very heterogeneous being clinical evaluation the most frequent. Although blood cultures were recognized as presenting a poor diagnostic performance, they were performed by 77.1%. In opposition, the presence of urinary pneumococcal and Legionella antigen was asked by less than one-third of physicians. The great majority (95%) prescribes antibiotics according to a guideline being the combination of β-lactam plus macrolide the most frequent choice.

Conclusions

Despite the recent advances of knowledge reflected in the present study in the management of severe CAP, several of them are still incompletely translated into clinical practice. Significant variation in practice is observed among physicians and represents a potential target for future research and educational interventions.     

Impact of systemic corticosteroids on the clinical course and outcomes of patients with severe community-acquired pneumonia: a cohort study

Introduction

Our aim was to evaluate the impact of corticosteroids on clinical course and outcomes of patients with severe community-acquired pneumonia (CAP) requiring invasive mechanical ventilation.

Methods

This was a cohort study of patients with severe CAP from 2 intensive care units in tertiary hospitals in Brazil and Portugal.

Results

A total of 111 patients were included (median age, 69 years; 56% men; 34% hospital mortality). Corticosteroids were prescribed in 61 (55%) patients. Main indications for their use were bronchospasm (52.5%) and septic shock (36%). Mortality rate of patients treated with and without corticosteroids was comparable (29.5% vs 32%, P = .837). No significant differences were observed on clinical course from day 1 to day 7 as assessed by the Sequential Organ Failure Assessment score (P = .95). Furthermore, C-reactive protein declined similarly in both groups (P = .147). In a multivariate analysis, mortality was associated with older age and higher Acute Physiology and Chronic Health Evaluation II score.

Conclusions

In patients with severe CAP requiring invasive mechanical ventilation, adjunctive therapy with corticosteroids did not influence intensive care unit and hospital mortality. In addition, no changes were observed on weaning from vasopressors, on recovery from organ failure/dysfunction as assessed by the Sequential Organ Failure Assessment score, as well as on C-reactive protein course.     

Clinical characteristics of severe community-acquired pneumonia among younger patients: An analysis of 18 years at a community hospital

Unlike elderly patients with community-acquired pneumonia whose outcomes are markedly affected by their background characteristics, it appears that the severity of the infection itself contributes to outcomes in younger patients with community-acquired pneumonia. In order to identify clinical characteristics of severe community-acquired pneumonia in younger patients under 60 years old, among such cases prospectively collected at our hospital over a period of 18 years, those meeting the criteria for severe community-acquired pneumonia, as defined in the Infectious Diseases Society of America/American Thoracic Society Guidelines for community-acquired pneumonia, were retrospectively examined and compared to elderly patients with severe community-acquired pneumonia. Younger patients with severe pneumonia accounted for 12.9% of younger hospitalized patients. Although the incidence of severe pneumonia in younger patients was lower than that in elderly patients, its severity may be underestimated by severity assessment based on the conventional guidelines. Thus, attention is required. While Streptococcus pneumoniae and Legionella species were important causative pathogens, atypical pathogens and viruses were also frequently detected. There were only 11 deaths over a period of 18 years. Based on multivariate analysis, the risk factors for aggravation of community-acquired pneumonia among younger patients were age 50 years or older, diabetes mellitus, chronic liver disease, and Legionella pneumonia. Although the mortality rate from community-acquired pneumonia is extremely low in previously healthy younger patients, outcomes might be poor for patients with underlying diseases and those with rapid progression. Multimodal treatments including respiratory management may be appropriate.     

rs1840680 single nucleotide polymorphism in Pentraxin 3: a potential protective biomarker of severe community-acquired pneumonia

ObjectiveSingle nucleotide polymorphisms (SNPs) of pentraxin 3 (PTX3) are associated with various outcomes of lung infections. This study aimed to analyze the relationship between PTX3 polymorphisms and the severity of community-acquired pneumonia (CAP).MethodsThis is a retrospective case-control study comprising 43 patients with severe CAP (SCAP) and 97 patients with non-severe CAP. Three SNPs in the PTX3 gene (rs2305619, rs3816527, and rs1840680) from peripheral blood samples were genotyped by real-time polymerase chain reaction. The association between each SNP and the CAP severity was analyzed by logistic regression analysis.ResultsWe found that the rs1840680 polymorphism was significantly associated with CAP clinical severity. However, no such association was observed for the genotypes and allele frequencies of rs2305619 or rs3816527. The PTX3 rs1840680 AG genotype was an independent factor for a lower risk of SCAP after multivariate logistic regression analysis. Male sex and coronary heart disease were associated with an increased risk of SCAP.ConclusionsThe PTX3 rs1840680 AG genotype was found to be associated with a lower risk of SCAP, and may serve as a potential protective biomarker to help clinical judgment and management.     

血小板平均体积在老年重症社区获得性肺炎中的应用价值

目的 探讨血小板平均体积在老年重症社区获得性肺炎(SCAP)中的应用价值,为老年SCAP的严重程度提供更多的依据.方法 老年SCAP组患者31例,老年非SCAP组75例,健康对照组55例,收集临床及实验室指标进行比较分析.结果 老年SCAP组血小板平均体积(MPV)较对照组明显升高(10.46±1.01) fl vs (9.77±0.91) fl(P＜0.01),老年SCAP组也较老年非SCAP组升高(10.46±1.01) fl vs (9.88±0.82) fl(P＜0.01),老年非SCAP组和正常对照组差异无统计学意义.MPV工作者特征曲线(ROC)诊断老年SCAP的最佳界值为10.25 fl,MPV大于10.25 fl时敏感度54.8%,特异度73.3%,阳性诊断价值59.0%,阴性诊断价值12.0%,曲线下面积(AUC)0.666(P<0.01).老年SCAP组MPV与白细胞计数呈正相关,与血小板计数、C反应蛋白无明显相关.结论 MPV作为一个简单指标一定程度反映了社区获得性肺炎的严重程度和炎症的程度,其在诊断老年SCAP中敏感性较低.     

老年重症肺炎的治疗和预后危险因素分析

目的探讨老年重症肺炎病死率的危险因素，以提高临床的救治率。方法参照2001年美国胸科学会（ATS）指南对重症肺炎的诊断标准，分析54例重症肺炎患者的临床资料，其中经验性抗菌治疗按指南推荐方案治疗组36例，未按指南推荐方案治疗组18例。结果54例重症肺炎病死率为66．67％（36／54），死亡患者的平均年龄为（79±4）岁，高于生存者（70±5）岁的平均年龄，P〈0．05。按指南推荐方案治疗组和未按指南推荐方案治疗组的病死率分别为55．56％（20／36）和88．89％（16／18）；36例并有1～2个脏器功能衰竭和18例有三个以上脏器功能衰竭患者的病死率分别为55．56％（20／36）和88．89％（16／18），P〈0．05。患有一种以上的基础疾病96．30％（52／54），免疫功能低下70．37％（38／54），血浆白蛋白降低77．78％（42／54），P〈0．01。结论高龄、多脏器功能衰竭、伴有多种基础疾病、免疫功能低下及血浆白蛋白降低等是重症肺炎病死率的主要影响因素，选择按指南推荐方案治疗可降低重症肺炎病死率。     

Analysis of systemic corticosteroid usage and survival in patients requiring mechanical ventilation for severe community-acquired pneumonia

We evaluated the clinical data in patients who required mechanical ventilation for severe community-acquired pneumonia (CAP) and compared survival with and without the use of systemic corticosteroids. This retrospective study examined 97 patients with severe CAP in the MICU of the Asan Medical Center in Korea between January 2002 and November 2006. We collected data from medical charts about clinical and laboratory data, as well as 28-day and 3-month survival rates. Clinical baseline characteristics and scores on the Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment were similar in the corticosteroid and noncorticosteroid groups. The 28-day and 3-month survival rates were 59.8% and 47.4% in all patients (56.7% and 45% in corticosteroid group and 64.9% and 54.3% in noncorticosteroid group, P > 0.05, respectively). Multivariate logistic regression analysis revealed that female sex [odds ratio (OR) 24.052], younger age (OR, 0.714), absence of acute respiratory distress syndrome (ARDS) (OR, 1.019e⁴), and absence of neoplasm (OR, 0.002) were associated with increased survival at 3 months. However, systemic corticosteroid was not associated with improving 28-day and 3-month survival rates.     

应用右美托咪定及丙泊酚在重症肺炎使用有创机械通气患者中的镇静疗效研究

目的比较右美托咪定及丙泊酚应用于重症肺炎有创机械通气患者的镇静效果及安全性。 方法前瞻性分析2015年1月至2017年12月江苏大学附属人民医院重症监护治疗病房（ICU）收治的重症肺炎有创机械通气患者100例,将患者随机分为右美托咪定镇静组（50例）及丙泊酚镇静组（50例）。对两组患者均给予抗感染、有创机械通气、集束化治疗,并予瑞芬太尼镇痛。在镇痛基础上,对两组患者分别给予右美托咪定和丙泊酚镇静治疗。维持患者Richmond躁动-镇静量表评分在-2~0分之间。对于右美托咪定组和丙泊酚组两组患者年龄、APACHEⅡ评分、临床肺部感染评分（CPIS）、机械通气时间、拔管时间、住ICU时间,以及应用镇静药物前和应用镇静药物15 min后平均动脉压（MAP）、心率（HR）、呼吸频率（RR）等资料,其中应用镇静药物前后资料的比较采用配对样本t检验,组间资料的比较采用两组独立样本t检验。对于两组患者的性别分布,谵妄、VAP发生情况以及30 d内死亡情况的比较采用χ²检验。 结果右美托咪定组和丙泊酚组两组患者在性别、年龄、APACHEⅡ评分、CPIS方面相比较,差异无统计学意义（P均>0.05）。两组患者应用镇静药物前的MAP、HR、RR差异无统计学意义（P均>0.05）。与用药前比较,应用镇静药物15 min后两组患者的MAP、HR、RR均下降,差异具有统计学意义（P均<0.01）。与右美托咪定组比较,应用镇静药物15 min后丙泊酚组患者MAP、RR下降更为显著,差异具有统计学意义（P均<0.05）。右美托咪定组患者与丙泊酚组比较,应用镇静药物15 min后HR下降更为显著,差异具有统计学意义（P<0.05）。与丙泊酚组比较,右美托咪定组的机械通气时间、拔管时间及住ICU时间均减少,差异具有统计学意义（P均<0.05）。与丙泊酚组比较,右美托咪定组患者谵妄发生率较低,差异具有统计学意义（P<0.05)。两组患者VAP发生率及30 d病死率差异无统计学意义（P均>0.05）。 结论将右美托咪定应用于重症肺炎有创机械通气患者,可减少机械通气时间及住ICU时间,谵妄的发生率低于丙泊酚治疗组。     

社区获得性重症肺炎患者预后的影响因素分析

目的 分析影响社区获得性重症肺炎患者预后的因素,以期为病情的评估及治疗方案的及时调整提供参考.方法 回顾性选取2015年1月至2021年1月我院69例社区获得性重症肺炎患者的临床资料.按照治疗28 d预后情况将患者分为生存组(45例)及死亡组(24例).比较两组的一般资料及实验室指标,采用多因素Logistic回归分析...     

重症肺炎患者机械通气期间气道分级管理的效果分析

目的评价重症肺炎患者机械通气期间采用气道分级管理的干预效果。方法采用前瞻性队列研究,将76例重症肺炎患者随机分为研究组和对照组。对照组（36例）按常规每2h一次胸部物理治疗;研究组（40例）根据气道分级评分将气道管理级别分为A、B、C、D四级,实施不同频次的胸部物理治疗。比较两组患者机械通气期间潮气量（VT）、呼吸频率（D、氧合指数（PaO2／FiO2）、急性病生理学和长期健康评价（APACHE）Ⅱ评分、机械通气时间及ICU住院时间。结果机械通气第7天,研究组患者VT、f、PaO2/FiO2均优于对照组（P均〈0．001）,APACHEⅡ评分低于对照组（P〈0．05）,研究组患者机械通气时间明显少于对照组（P〈0．001）。结论基于不同频次胸部物理治疗的气道分级管理有助于减少重症肺炎患者机械通气期间物理治疗产生的副作用,改善其呼吸功能,缩短机械通气时间。     

Epidemiological features and prognosis of severe community-acquired pneumococcal pneumonia

Objective: To describe risk factors of severe pneumococcal community-acquired pneumonia and to study variables influencing outcome. Design: Retrospective (1987–1992) and prospective (1993–1995) study. Setting: Three participating ICUs from primary care hospitals. Patients: Five hundred and five patients (mean age: 63 ± 17 years) with severe community-acquired pneumonia (CAP). Three groups of patients were defined: pneumococcal CAP (group 1), CAP with microbial diagnosis other than Streptococcus pneumoniae (group 2), CAP from group 2 and CAP without microbial diagnosis (group 3). Measurements and results: Admission data and data on the disease's course were recorded. The mean Simplified Acute Physiologic Score (SAPS) was 12.5 ± 5.4. On admission 288 (57 %) patients were mechanically ventilated (mv) and 82 (16.2 %) required inotropic support. A microbial diagnosis was established for 309 (61.2 %) patients. S. pneumoniae was isolated in 137 (27.1 %) patients. Severe pneumococcal CAP was independently associated with male sex (p = 0.01), lack of antibiotics use before admission (p = 0.0001), non-aspiration pneumonia (p = 0.01) and septic shock (p = 0.0001). The overall mortality rate was 27.5 % (29.2 % in group 1). In patients with severe pneumococcal CAP, multivariate analysis showed that leukopenia less than 3,500/mm³ (p = 0.0004), age over 65 years (p = 0.01), septic shock (p = 0.01), sepsis related complications (p = 0.0001), ICU complications (p = 0.001) and inadequacy of antimicrobial therapy (p = 0.002) worsened the prognosis. Conclusions: Few features facilitate the identification of pneumococcal CAP on ICU admission. The prognosis is mostly related to severity of illness (leukopenia, septic shock) while comorbidities do not seem to influence outcome. Sepsis-related disorders, ICU complications and adequate antimicrobial chemotherapy are the major variables affecting the outcome during an ICU stay. Received: 11 May 1998 Final revision received: 11 December 1998 Accepted: 18 December 1998     

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.     

Predictors of failure of noninvasive ventilation in patients with severe community-acquired pneumonia

Purpose

The study aimed to investigate cardiorespiratory parameters potentially predictive of failure of noninvasive ventilation (NIV) in severe community-acquired pneumonia (CAP).

Patients and Methods

Sixty-four consecutive patients with severe CAP entered the study and underwent NIV with a helmet. Arterial blood gases, Pao₂/FIo₂, and oxygenation index (OI; mean airway pressure × FIo₂ × 100/Pao₂) were determined before and after a 1-hour trial of NIV.

Results

Noninvasive ventilation succeeded in 28 patients (43%) and failed in 36 patients (56%). Patients who avoided intubation had significantly (P < .05) shorter stays in ICU and lower rates of mortality in ICU and in hospital. Patients who failed NIV had higher Simplified Acute Physiology Score II at ICU admission (33 ± 11 versus 29 ± 9) and lower pH before NIV trial (7.37 versus 7.44). Furthermore, patients who required intubation failed to improve or worsened arterial blood gases during NIV trial and, by the end of the trial, had lower (P < .05) pH (7.34 versus 7.44) and Pao₂/FiO₂ (177 versus 228) and higher OI (8.6 versus 5.0) and respiratory rate (28 versus 23 breaths/min). In a multivariate analysis, post-NIV to pre-NIV deltas of Pao₂/FiO₂ and of OI were independent predictors of NIV failure, with OI delta being significantly more accurate.

Conclusions

Noninvasive ventilation failed in approximately half patients with severe CAP. Posttrial to pretrial deltas of Pao₂/FiO₂ and OI may help to guide decision about endotracheal intubation.     

Prognosis factors and outcome of community-acquired pneumonia needing mechanical ventilation

PURPOSE: To evaluate the variables associated with mortality of patients with community-acquired pneumonia who require mechanical ventilation and to determine the attributable morbidity and intensive care unit (ICU) mortality of community-acquired pneumonia. MATERIAL AND METHODS: Retrospective cohort study carried out in 361 ICUs from 20 countries including 124 patients who required mechanical ventilation on the first day of admission to the hospital due to acute respiratory failure secondary to severe community-acquired pneumonia. To assess the factors associated with outcome, a forward stepwise logistic regression analysis was performed, and to determine the attributable mortality of community-acquired pneumonia, a matched study design was used. RESULTS: We found 3 independent variables significantly associated with death in patients with community-acquired pneumonia requiring mechanical ventilation: simplified acute physiological score greater than 45 (odds ratio, 5.5 [95% confidence interval, 1.7-12.3]), shock (odds ratio, 5.7 [95% confidence interval, 1.7-10.1]), and acute renal failure (odds ratio, 3.0 [95% confidence interval, 1.1-4.0]). There was no statistically significant difference in ICU mortality among patients with or without community-acquired pneumonia (32% vs 35%; P=.59). CONCLUSIONS: Community-acquired pneumonia needing mechanical ventilation is not a disease associated with higher mortality. The main determinants of patient outcome were initial severity of illness and the development of shock and/or acute renal failure.     

机械通气患者贫血的临床观察研究

目的 观察贫血对机械通气患者预后的影响.方法 采用前瞻性研究方法,收集入住重症监护病房(ICU)预计机械通气时间≥72 h,血红蛋白(Hb)浓度≥100 g/L的患者.根据患者机械通气第3日的Hb浓度分为贫血组和非贫血组.比较两组患者1、3、7d血清促红细胞生成素(EPO)、Fe3+、转铁蛋白(TRF)水平,14 d 内人均输血量,3、7、14 d内人均日采血量以及机械通气时间、28 d脱机存活率、住院时间和28 d病死率.结果 共入选40例患者,贫血组18例,非贫血组22例.与非贫血组比较,贫血组患者血清Fe3+较低,血清EPO、TRF较高;贫血组患者14 d内人均输血量(U)较多[4.0(2.0,6.0)比2.0 (0.0,2.0),P＜0.01],ICU病死率较高(44.4％比13.6％,P＜0.05),住院时间(d)较长[35.0( 16.5,51.6)比24.5( 10.0,35.8),P＜ 0.05 ],28 d脱机存活率较低(44.4％比72.7％,P＜ 0.05).而贫血组和非贫血组机械通气时间(d:18.3±10.8比11.6±8.2,P＞0.05)、ICU住院时间[d:16.5(8.0,21.5)比11.0(5.8,18.3),P＞0.05]和住院病死率(61.1％比31.8％,P＞0.05)比较差异无统计学意义.结论 贫血患者机械通气时间及住院时间较长,ICU病死率较高,28 d脱机存活率较低.     

成人社区获得性支原体肺炎32例临床分析

目的探讨成人社区获得性支原体肺炎的临床特点。方法收集并分析2004年1月至2009年1月我院确诊的肺炎支原体肺炎32例患者的临床资料。结果支原体肺炎最常见症状有发热、顽固性咳嗽、咽痛伴有胸腔积液,另外还有皮疹、溶血性贫血等肺外损害。1例因明显接触感染。所有患者肝功能无损害,亦无电解质异常。发病初期周围血象中白细胞均<10×109/L。32例诊断肺炎,2例合并肺炎伴胸腔积液。血清特异性抗体阳性仍是诊断支原体感染的主要手段。结论支原体感染易引起肺炎,并可伴有肺外器官的损害。治疗应考虑支原体合并其他病原体混合感染。呼吸喹诺酮类及新大环内酯类抗菌药物是治疗支原体肺炎的一线药物。     

Levofloxacin for the treatment of community-acquired pneumonia

New respiratory fluoroquinolones (FQs), such as levofloxacin, offer many improved qualities over older agents, such as ciprofloxacin. These include retaining excellent Gram-negative bacilli activity, with improved Gram-positive activity. New FQ-like levofloxacin possesses greater bioavailabilty and a longer serum half-life compared with ciprofloxacin, allowing for once-daily dosing, which may improve patient adherence. The high bioavailability of levofloxacin allows for rapid step-down from intravenous administration to oral therapy, minimizing unnecessary hospitalization, which may decrease costs and improve patient quality of life. Levofloxacin has been evaluated for the treatment of community-acquired pneumonia (CAP) in numerous randomized clinical trials. Most published studies have used the 500 mg dose, although more recent studies have investigated the 750 mg dose once daily. These trials demonstrate that levofloxacin is effective and safe for the treatment of CAP, displaying relatively mild adverse effects that are more or less comparable with ciprofloxacin. Levofloxacin has much to offer in terms of bacterial eradication, including for resistant respiratory pathogens. However, ciprofloxacin-resistant organisms are becoming more prevalent so prudence must be exercised when prescribing this agent.     

Sequential treatment of severe pneumonia with respiratory failure and its influence on respiratory mechanical parameters and hemodynamics

BACKGROUNDThe pathophysiological characteristics of severe pneumonia complicated by respiratory failure comprise pulmonary parenchymal changes leading to ventilation imbalance, alveolar capillary injury, pulmonary edema, refractory hypoxemia, and reduced lung compliance. Prolonged hypoxia can cause acid-base balance disorder, peripheral circulatory failure, blood-pressure reduction, arrhythmia, and other adverse consequences.AIMTo investigate sequential mechanical ventilation’s effect on severe pneumonia complicated by respiratory failure. METHODSWe selected 108 patients with severe pneumonia complicated by respiratory failure who underwent mechanical ventilation between January 2018 and September 2020 at the Luhe Hospital’s Intensive Care Unit and divided them into sequential and regular groups according to a randomized trial, with each group comprising 54 patients. The sequential group received invasive and non-invasive sequential mechanical ventilation, whereas the regular group received invasive mechanical ventilation. Blood-gas parameters, hemodynamic parameters, respiratory mechanical parameters, inflammatory factors, and treatment outcomes were compared between the two groups before and after mechanical-ventilation treatment. RESULTSThe arterial oxygen partial pressure and stroke volume variation values of the sequential group at 24, 48, and 72 h of treatment were higher than those of the conventional group (P < 0.05). The carbon dioxide partial pressure value of the sequential group at 72 h of treatment and the Raw value of the treatment group at 24 and 48 h were lower than those of the conventional group (P < 0.05). The pH value of the sequential group at 24 and 72 h of treatment, the central venous pressure value of the treatment at 24 h, and the Cst value of the treatment at 24 and 48 h were higher than those of the conventional group (P < 0.05). The tidal volume in the sequential group at 24 h of treatment was higher than that in the conventional group (P < 0.05), the measured values of interleukin-6 and tumor necrosis factor-α in the sequential group at 72 h of treatment were lower than those in the conventional group (P < 0.05), and the total time of mechanical ventilation in the sequential group was shorter than that in the conventional group, with a statistically significant difference (P < 0.05).CONCLUSIONTreating severe pneumonia complicated by respiratory failure with sequential mechanical ventilation is more effective in improving respiratory system compliance, reducing inflammatory response, maintaining hemodynamic stability, and improving patient blood-gas levels; however, from this study’s perspective, it cannot reduce patient mortality.     

The intensive care management,mortality and prognostic indicators in severe community-acquired pneumococcal pneumonia

Objective To determine mortality and factors that might predict outcome in severe community-acquired pneumococcal pneumonia treated by a standard protocol.Design Prospective, nonconcurrent study.Setting Respiratory intensive care unit (ICU) in a teaching hospital by positive blood culture.Patients 63 patients who were diagnosed by positive blood culture or Gram stain and culture of sputum or tracheal aspirate were included.Measurements and results Clinical features, severity scores including Acute Physiology and Chronic Health Evaluation (APACHE) II, organ failure and lung injury scores, and the clinical course in the ICU were documented; 79% of patients required mechanical ventilation. Bacteraemia was present in 34 patients (54%); there were no distinguishing clinical features between bacteraemic and non-bacteraemic cases. The overall mortality was 21%, with only 5 deaths (15% mortality) in the bacteraemic group. Shock and a very low serum albumin (<26 g/l) were the only clinical features that differentiated survivors from non-survivors; lung injury, APACHE II and multiple organ failure scores were all predictive of outcome. The positive predictive value and specificity in predicting death in individuals for the modified British Thoracic Society rule 1 were 26 and 64%; APACHE II>20 57 and 88%; >2 organ failure 64 and 92%; and lung injury >2 33 and 73%, respectively.Conclusions These results suggest that even in bacteraemic cases mortality should be below 25% with intensive care management and that conventional scoring systems, while predictive of group mortality, are unreliable in individuals.     

A comparative study of meropenem and ceftazidime in the treatment of patients hospitalized with community-acquired pneumonia

This multicenter, open-label, randomized clinical trial compared the efficacy and tolerability of intravenous (IV) meropenem 0.5 g every 8 hours (n = 147) and IV ceftazidime 1 g every 8 hours (n = 148) as empiric monotherapy for 295 patients hospitalized with community-acquired pneumonia. Seventy-four meropenem recipients and 81 ceftazidime recipients with pneumonia were assessable both clinically and bacteriologically. In these patients, no statistically significant differences were reported in the satisfactory clinical (95% with meropenem vs 90% with ceftazidime) or bacteriologic (95% with meropenem vs 93% with ceftazidime) response rates with the two agents at the end of treatment. High satisfactory clinical (95% with meropenem vs 92% with ceftazidime) and bacteriologic (97% with meropenem vs 89% with ceftazidime) response rates were maintained at follow-up (2 to 4 weeks later). In 90 patients who were clinically assessable but bacteriologically unassessable (no pretreatment pathogen isolated), both agents produced a satisfactory clinical response rate of 87% at the end of therapy. Streptococcus pneumoniae was the most frequently isolated pretreatment pathogen (28%), but nosocomial-type pathogens such as Escherichia coli (5%), Pseudomonas aeruginosa (11%), and Klebsiella pneumoniae (6%) were also frequently isolated. Both medications were well tolerated, and the types of treatment-related adverse events were similar in the two treatment groups. These findings indicate that meropenem 0.5 g every 8 hours is a useful option for the empiric treatment of patients hospitalized with community-acquired pneumonia.