Community-acquired pneumonia in patients with liver cirrhosis: clinical features, outcomes, and usefulness of severity scores

We performed an observational analysis of a prospective cohort of nonimmunocompromised hospitalized adults with community-acquired pneumonia (CAP) to determine the epidemiology, clinical features, and outcomes of patients with liver cirrhosis. We also analyzed the prognostic value of several severity scores. Of 3420 CAP episodes, 90 occurred in patients with liver cirrhosis. The median value of the Model for End-Stage Liver Disease (MELD) was 14 (range, 6-36). On the Child-Pugh (CP) score, 56% of patients were defined as grade B and 22% as grade C. Patients with liver cirrhosis were younger (61.8 vs. 66.8 yr; p = 0.001) than patients without cirrhosis, more frequently presented impaired consciousness at admission (33% vs. 14%; p < 0.001) and septic shock (13% vs. 6%; p = 0.011), and were more commonly classified in high-risk Pneumonia Severity Index (PSI) classes (classes IV-V) (74% vs. 58%; p = 0.002). Streptococcus pneumoniae (47% vs. 33%; p = 0.009) and Pseudomonas aeruginosa (4.4% vs. 0.9%; p = 0.001) were more frequently documented in patients with cirrhosis. Bacteremia was also more common in these patients (22% vs. 13%; p = 0.023). Areas under the curve (AUCs) from disease-specific scores (MELD, CP, PSI, and CURB-65 [confusion, urea, respiratory rate, blood pressure, and age ≥65 yr]) were comparable in predicting severe disease (30-d mortality and intensive care unit [ICU] admission). A new score based on MELD, multilobar pneumonia, and septic shock at admission (MELD-CAP) had an AUC of 0.945 (95% confidence interval [CI], 0.872-0.983) for predicting severe disease and was significantly different from other scores. Early (5.6% vs. 2.1%; p = 0.048) and overall (14.4% vs. 7.4%; p < 0.024) mortality rates were higher in cirrhotic patients than in patients without cirrhosis. Factors associated with mortality were impaired consciousness, multilobar pneumonia, ascites, acute renal failure, bacteremia, ICU admission, and MELD score. Among the severity scores, MELD-CAP was the only score associated with severe disease (odds ratio [OR], 1.33; 95% CI, 1.09-1.52) and mortality (OR, 1.21; 95% CI, 1.03-1.42). In conclusion, CAP in patients with liver cirrhosis presents a distinctive clinical picture and is associated with higher mortality than is found in patients without cirrhosis. The severity of hepatic dysfunction plays an important role in the development of adverse events. Cirrhosis-specific scores may be useful for predicting and stratifying cirrhotic patients with CAP who have a high risk of severe disease.

[Medicosocial aspects of thermal injuries in patients with hemocontact viral infection]

The social structure of patients of the burns unit in 2008 year, hospitalized with hemocontact viral infections (HVI), was analyzed. 764 patients were treated, HVI was diagnosed in 103 of them. Men had HVI two times more often then women. The possibility of HVI was higher in patients with fire burns. The lager the burn area was, the higher was the possibility of HVI detection. Patients with HVI were reliably younger with average age of 33.1 years; the majority of them were unemployed. The most socially problematic group was represented by patients with mixed HVI--unemployed youngsters of the capable age, the majority of them were drug addict.

Case of Legionella pneumonia complicated with pulmonary thromboembolism

We report a patient with community acquired Legionella pneumonia, complicated with pulmonary embolism. The patient was cured by levofloxacin and anticoagulant therapy. We performed laboratorial control and we excluded the thrombophilia and antiphospholipid syndrome. Our case report draws attention to the possible association between Legionella infection and pulmonary embolism.

Bilateral cavernous sinus thrombosis following community-acquired methicillin-resistant staphylococcus aureus infection: a case report and review of the literature

OBJECTIVES

We describe a case of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infection leading to bilateral cavernous sinus thrombosis (CST) and subsequent left eye blindness in a previously healthy, immunocompetent woman. A secondary objective is to document all published cases of MRSA induced CST.

DATA SOURCE AND STUDY SELECTION

To identify all relevant publications on MRSA-induced CST in adults.

RESULTS

Seven publications were included in this review describing patients age 19 or older. Together, with the case included in this publication, a total of 8 cases of MRSA induced CST have been documented since 2003. Of interest, to our knowledge this is the first reported case of CA-MRSA CST temporally associated with nasal H1N1 vaccination.

CONCLUSION

In selecting empiric antibiotic coverage for septic CST, the practitioner should use antibiotics that are active against CA-MRSA to help prevent morbidity and mortality.

Association of hypoglycemia with mortality for subjects hospitalized with pneumonia

BACKGROUND

Previous research has shown that hypoglycemia is associated with worse outcomes for the elderly, in sepsis, and in children with pneumonia. The purpose of this study was to examine whether hypoglycemia (<70 mg/dL) is associated with increased 30-day mortality, after adjusting for potential confounders, for adults hospitalized with pneumonia.

METHODS

A retrospective cohort study conducted at 2 tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of, and had a chest x-ray consistent with, community-acquired pneumonia. Our primary analysis was a multivariable logistic regression with the dependent variable of 30-day mortality and with independent variable of hypoglycemia, diabetes, severity of illness determined using the pneumonia severity index, and pneumonia-related processes of care.

RESULTS

Data were abstracted on 787 subjects at the 2 hospitals. Mortality was 8.1% at 30 days. At presentation, 55% of subjects were at low risk, 33% were at moderate risk, and 12% were at high risk. In our cohort, 2.8% (n = 22) had hypoglycemia at presentation. Unadjusted mortality for those who were hypoglycemic was 27.3% versus 8.6% for those who were not (P = 0.0003). In the multivariable analysis, hypoglycemia (odds ratio: 4.1, 95% confidence interval: 1.4-11.7) was significantly associated with 30-day mortality.

CONCLUSIONS

After adjusting for severity of illness and other potential confounders, hypoglycemia is significantly associated with 30-day mortality for patients hospitalized with pneumonia. Patients with hypoglycemia should be placed in closely monitored settings even when by pneumonia specific risk systems they would normally be discharged.

[Septic pylephlebitis associated with Enterobacter cloacae septicemia]

Septic pylephlebitis or purulent thrombosis of the portal venous system generally results from a progressive extension of suppurated thrombophlebitis, secondary to an intrabdominal infection. Germs most often found are Escherichia coli and Streptococcus, isolation of Enterobacter cloacae is unusual. We report a particular observation of septic pylephlebitis associated with E. cloacae bacteremia, without biliary, digestive or pancreatic lesion on the CT-scan. The antibiotic sensitivity pattern of the isolated germ and the negative epidemiologic investigation pled in favour of community acquired infection. The infection resolved with antibiotics and anticoagulation, followed by total repermeation of the portal system.

Community-acquired pneumonia due to pandemic A(H1N1)2009 influenzavirus and methicillin resistant Staphylococcus aureus co-infection

BACKGROUND

Bacterial pneumonia is a well described complication of influenza. In recent years, community-onset methicillin-resistant Staphylococcus aureus (cMRSA) infection has emerged as a contributor to morbidity and mortality in patients with influenza. Since the emergence and rapid dissemination of pandemic A(H1N1)2009 influenzavirus in April 2009, initial descriptions of the clinical features of patients hospitalized with pneumonia have contained few details of patients with bacterial co-infection.

METHODOLOGY/PRINCIPAL FINDINGS

Patients with community-acquired pneumonia (CAP) caused by co-infection with pandemic A(H1N1)2009 influenzavirus and cMRSA were prospectively identified at two tertiary hospitals in one Australian city during July to September 2009, the period of intense influenza activity in our region. Detailed characterization of the cMRSA isolates was performed. 252 patients with pandemic A(H1N1)2009 influenzavirus infection were admitted at the two sites during the period of study. Three cases of CAP due to pandemic A(H1N1)2009/cMRSA co-infection were identified. The clinical features of these patients were typical of those with S. aureus co-infection or sequential infection following influenza. The 3 patients received appropriate empiric therapy for influenza, but inappropriate empiric therapy for cMRSA infection; all 3 survived. In addition, 2 fatal cases of CAP caused by pandemic A(H1N1)2009/cMRSA co-infection were identified on post-mortem examination. The cMRSA infections were caused by three different cMRSA clones, only one of which contained genes for Panton-Valentine Leukocidin (PVL).

CONCLUSIONS/SIGNIFICANCE

Clinicians managing patients with pandemic A(H1N1)2009 influenzavirus infection should be alert to the possibility of co-infection or sequential infection with virulent, antimicrobial-resistant bacterial pathogens such as cMRSA. PVL toxin is not necessary for the development of cMRSA pneumonia in the setting of pandemic A( H1N1) 2009 influenzavirus co-infection.

Community-acquired methicillin-resistant Staphylococcus aureus meningitis complicated by cerebral infarction. Role of antibiotic combination of linezolid plus levofloxacin

The therapeutic options available for central nervous system (CNS) infections due to resistant Gram-positive cocci remain limited. We report an unusual case of community-acquired methicillin-resistant Staphylococcus aureus meningitis complicated by cerebral infarction in the middle cerebral artery territory in a previously healthy young male. After an initial vancomycin-based regimen, treatment was completed with a seven-week course of linezolid and levofloxacin. The potential role of such a combination and, particularly, linezolid as a first-line therapy in serious CNS infections is also discussed.

Is there an association between wheezing and pneumonia?

OBJECTIVE

The aim of this study was to investigate whether there is a relationship in school aged children between wheezing and pneumonia prior, during, or following the pneumonia episode.

PATIENTS-METHODS

One hundred and three children with community acquired pneumonia who were hospitalised were recruited along with 55 controls.

RESULTS

During hospitalisation wheezing was audible in 11/103 (10.6%) patients with pneumonia and in none of the controls (p=0.009). Wheezing ever or asthma was elicited in 29/103(28%) patients with pneumonia and in 8/55 (14.5%) of the controls and this difference was not significant. Two years after the hospitalisation with pneumonia, wheezing episodes occurred in 12/103 with pneumonia and 1/55 of the controls (p=0.034). Among those who developed asthma following pneumonia 11/12 also had wheezing prior to pneumonia.

CONCLUSION

There is an excess of wheezing prior, during, and after an episode of pneumonia in school aged children and therefore children with pneumonia should be followed up carefully.

[Nutritional status and mortality in community acquired pneumonia]

Pneumonias are a major cause of morbidity and mortality and their prognosis depends on many factors including nutritional status. This study analyzed the relationship between malnutrition and the risk of death in Community Acquired Pneumonia (CAP) patients. This is a prospective observational study. The Subjective Global Assessment (SGA) was used as a screening tool to appraise the nutritional status. Ninety-eight patients with CAP requiring hospitalization were included consecutively from October 2004 to September 2006. The clinical, bacteriological and laboratory features were recorded. Patient's nutritional condition was assessed using the SGA. The monitoring was performed until discharge, death or shunt. Persistent cough or fever, the presence of pleural effusion, malignancies or long hospitalization were associated with worse prognosis. Mortality increased in proportion to the degree of malnutrition. Thirty two CAP patients (32.65%) were classified as SGA-category A; 44 (44.90%) as SGA-B, and 22 (22.45%) as SGA-C. Pneumonia resulted in death in 3/32 SGA-A (9.37%), 8/44 SGA-B (18.18%) and 10/22 SGA-C patients. SGA-C patients showed significantly higher odds ratios for death in comparison to SGA-A patients (OR = 6.085, CI95%: 1.071-34.591; p = 0.042). Considering death as the outcome variable, SGA-A class had the highest negative predictive value (0.906), while SGA-C class showed the highest positive predictive value (0.455). These results link the nutritional status to the NAC evolution prognostic. SGA provides a simple estimation of the nutritional status and it is a good predictor of the risk of death in CAP patients.

Community-acquired methicillin-resistant Staphylococcus aureus mycotic aneurysm

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) continues to emerge as a cause of serious infections. We present the first case of abdominal mycotic aneurysm caused by Panton-Valentine leukocidin-positive CA-MRSA. This case adds another presentation to the clinical spectrum of CA-MRSA infections, and highlights the problem encountered in the choice of the therapy of serious community-acquired infections in an era of increasing CA-MRSA infections.

[The influence of community-acquired pneumonia to the clinical course in COPD cases admitted to intensive care unit with acute respiratory failure]

In this study the influence of community-acquired pneumonia to the clinical course in 173 COPD patients admitted to ICU with acute respiratory failure (ARF) was evaluated. In prospective descriptive study, patients with pneumonia at admission to ICU were grouped as Group 1, others Group 2. The demographics, "Acute Physiology Assessment and Chronic Health Evaluation (APACHE) II" scores, body mass index (BMI), comorbidities, steroid use, admission arterial blood gases (ABG), leucocyte and CRP, utilization and duration of non-invasive and invasive mechanical ventilation (NIMV and IMV), development of ventilator associated pneumonia (VAP) and septic shock, length of stay (LOS) in ICU and mortality of groups were recorded and compared. No differences were found between demographics, but leucocyte and CRP levels were determined higher in Group 1(p= 005, 0.001). NIMV, IMV ratio and IMV days are similar (respectively p= 0.419, 0.170, 0.459); NIMV was applied longer in Group 2 (p= 0.019). 4 (17.6%) patients in group 1 and 7 (6.3%) patients in Group 2 were switched to IMV(p= 0.083) due to NIMV failure.While VAP was detected in 8 (17.7%) cases of intubated 45 (26%) patients, rate of VAP was similar in both groups (p= 0.657). 2 (6.7%) patients in Group 1 and 12 (8.3%) patients in Group 2 died and no difference was found in terms of LOS in ICU. Mortality was found 3 times higher (26.7%) than overall mortality (8.1%) in patients with IMV. Mortality risk factors are higher CRP levels (p< 0.016, OR: 1.01 CI 95%: 1.00-1.02), NIMV application determined to reduce the mortality. In conclusions, the presence of pneumonia, on admission to ICU in COPD patients with ARF, didn't influence IMV duration, LOS and mortality in ICU. Although mortality can be higher in COPD patients with high CRP levels, but NIMV is thought to be a mortality reducing treatment approach.

The pneumonia severity index and the CRB-65 in cancer patients with community-acquired pneumonia

SETTING

The ability of the pneumonia severity index (PSI) and the CRB-65 to identify patients with low vs. high risk for mortality among cancer patients with CAP has not been evaluated.

DESIGN

Subjects with cancer, CAP/Ca(+), and without cancer, CAP/Ca(-), were identified from the Community-Acquired Pneumonia Organization database. Mortality for both groups was analyzed by comparing low vs. high risk for mortality for the PSI (Risk Class I, II and III vs. IV and V) and the CRB-65 score (scores 0 and 1 vs. 2, 3 and 4).

RESULTS

A total of 2621 patients were included in the CAP/Ca(-) group and 280 in the CAP/Ca(+) group. In the CAP/Ca(+) group, no significant difference in mortality was detected in low vs. high risk populations, either for the PSI (P = 0.288) or for the CRB-65 score (P = 0.281). Analyzing the receiver operator characteristic curves, the concordance indexes for the CAP/Ca(+) group were respectively 0.53 and 0.54 for PSI and CRB-65. By fitting a multivariable logistic regression model, a significantly different trend in mortality was found between the CAP/Ca(-) and CAP/Ca(+) groups for both scoring systems.

CONCLUSION

Clinical judgment will continue to be the physicians' primary tool in defining the site of care for cancer patients with CAP.

Successful Treatment of Disseminated Cerebritis Complicating Methicillin-resistant Staphylococcus aureus Endocarditis Unresponsive to Vancomycin Therapy with Linezolid

A unique case of community acquired methicillin resistant Staphylococcus aureus (MRSA) sepsis, with endocardial and cerebral metastatic seeding, caused by a strain representative of the Italian clone, is described. The patient was a 47-y-old man without apparent risk factors for endocarditis and for MRSA infection who developed coma with multiple cerebritis lesions under vancomycin plus amikacin therapy. He was eventually cured with the addition of linezolid to the initial antimicrobial regimen. This observation seems to confirm previous reports of the efficacy of linezolid for the treatment of central nervous system infections caused by multidrug resistant Gram-positive bacteria. To our knowledge, this is the first report of MRSA disseminated cerebritis, a nearly always fatal disease, cured with this oxazolidinone drug. The increase in community acquired MRSA may have some impact on empirical treatment of serious infections caused by this organism.

Adverse outcomes in patients with community acquired pneumonia discharged with clinical instability from Internal Medicine Department

There are well established admission criteria for patients suffering from community-acquired pneumonia, yet the clinical tool for decision to discharge the hospitalized patient is lacking. Continuous pressure to reduce hospital expenditures can lead to a premature discharge of unstable patients. The current study assessed the impact of clinical instability at discharge on short-term outcomes. Demographic data, background disease, laboratory tests results and PORT score were assessed prospectively. On the last day of the hospitalization 7 physiological parameters of instability were evaluated. 60 d composite mortality and readmission rate was a primary outcome measure. Of the 373 patients, 22% were discharged with 1 or more instabilities, of whom 26.8% reached primary outcome within 60 d, compared to 8.2% of patients with no instabilities. 60 d death rate was 2.1% in the former group, compared to 14.6% in the unstable patients (p<0.001). Instability on discharge remained a significant prognosticator of adverse outcome (odds ratio 3.5; 95% CI 1.8-6.8) after adjustment for pneumonia severity and baseline comorbidity. We concluded that discharging an unstable patient hospitalized with pneumonia is associated with elevated risk of death or readmission within 60 d. Pneumonia guidelines should include objective criteria for judging patients' stability and promptness for discharge.