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Sibila O, Soto-Gomez N, Restrepo MI. The risk and outcomes of pneumonia in patients on inhaled corticosteroids. Pulm Pharmacol Ther 2015; 32:130-6. [PMID: 25956073 PMCID: PMC5079105 DOI: 10.1016/j.pupt.2015.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 04/16/2015] [Accepted: 04/24/2015] [Indexed: 12/11/2022]
Abstract
Corticosteroids are frequently prescribed anti-inflammatory medications. Inhaled corticosteroids (ICS) are indicated for Chronic Obstructive Pulmonary Disease (COPD) and asthma. ICS are associated with a decrease in exacerbations and improved quality of life in COPD, however multiple studies have linked the chronic use of ICSs with an increased risk of developing pneumonia, though the effect on mortality is unclear. We review the association of ICS with the risk of pneumonia and the implications on clinical outcomes.
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Affiliation(s)
- Oriol Sibila
- Servei de Pneumologia, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria Claret 167, 08025 Barcelona, Spain; Institut d'Investigació Biomèdica Sant Pau (IBB Sant Pau), Sant Antoni Maria Claret, 167 Pavelló de Sant Frederic, Planta 1, 08025 Barcelona, Spain.
| | - Natalia Soto-Gomez
- South Texas Veterans Health Care System, 7400 Merton Minter Boulevard, San Antonio, TX 78229, United States; University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States.
| | - Marcos I Restrepo
- South Texas Veterans Health Care System, 7400 Merton Minter Boulevard, San Antonio, TX 78229, United States; University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States.
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52
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Lorenzo MJ, Moret I, Sarria B, Cases E, Cortijo J, Méndez R, Molina J, Gimeno A, Menéndez R. Lung inflammatory pattern and antibiotic treatment in pneumonia. Respir Res 2015; 16:15. [PMID: 25849726 PMCID: PMC4328072 DOI: 10.1186/s12931-015-0165-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 01/05/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND In community-acquired pneumonia host inflammatory response against the causative microorganism is necessary for infection resolution. However an excessive response can have deleterious effects. In addition to antimicrobial effects, macrolide antibiotics are known to possess immunomodulatory properties. METHODS A prospective study was performed on 52 admitted patients who developed an inadequate response after 72 hours of antibiotic treatment - non-responders community-acquired pneumonia - (blood and bronchoalveolar lavage), and two control groups: 1) community-acquired pneumonia control (blood) and 2) non-infection control (blood and bronchoalveolar lavage). Cytokine profiles (interleukin (IL)-6, IL-8, IL-10), tumour necrosis factor α and clinical outcomes were assessed. RESULTS Non-responders patients treated with macrolide containing regimens showed significantly lower levels of IL-6 and TNF-α in bronchoalveolar lavage fluid and lower IL-8 and IL-10 in blood than those patients treated with non-macrolide regimens. Clinical outcomes showed that patients treated with macrolide regimens required fewer days to reach clinical stability (p < 0.01) and shorter hospitalization periods (p < 0.01). CONCLUSIONS After 72 hours of antibiotic effect, patients who received macrolide containing regimens exhibited lower inflammatory cytokine levels in pulmonary and systemic compartments along with faster stabilization of infectious parameters.
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Guía de consenso para el abordaje de la neumonía adquirida en la comunidad en el paciente anciano. Rev Esp Geriatr Gerontol 2014; 49:279-91. [PMID: 24873864 PMCID: PMC7103352 DOI: 10.1016/j.regg.2014.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 04/11/2014] [Indexed: 11/29/2022]
Abstract
La incidencia de la neumonía adquirida en la comunidad se incrementa con la edad y se asocia a una elevada morbimortalidad debido a los cambios fisiológicos asociados al envejecimiento y a una mayor presencia de enfermedades crónicas. Debido a la importancia que tiene desde un punto de epidemiológico y pronóstico, y a la enorme heterogeneidad descrita en el manejo clínico, creemos que existía la necesidad de realizar un documento de consenso específico para este perfil de paciente. El propósito de este fue realizar una revisión de las evidencias en relación con los factores de riesgo para la etiología, la presentación clínica, el manejo y el tratamiento de la neumonía adquirida en la comunidad en los ancianos con el fin de elaborar una serie de recomendaciones específicas basadas en el análisis crítico de la literatura. Este documento es fruto de la colaboración de diferentes especialistas en representación de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Sociedad Española de Geriatría y Gerontología (SEGG), Sociedad Española de Quimioterapia (SEQ), Sociedad Española de Medicina Interna (SEMI), Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Sociedad Española de Hospitalización a Domicilio (SEHAD) y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC).
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Gonçalves-Pereira J, Conceição C, Póvoa P. Community-acquired pneumonia: identification and evaluation of nonresponders. Ther Adv Infect Dis 2014; 1:5-17. [PMID: 25165541 DOI: 10.1177/2049936112469017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Community acquired pneumonia (CAP) is a relevant public health problem, constituting an important cause of morbidity and mortality. It accounts for a significant number of adult hospital admissions and a large number of those patients ultimately die, especially the population who needed mechanical ventilation or vasopressor support. Thus, early identification of CAP patients and its rapid and appropriate treatment are important features with impact on hospital resource consumption and overall mortality. Although CAP diagnosis may sometimes be straightforward, the diagnostic criteria commonly used are highly sensitive but largely unspecific. Biomarkers and microbiological documentation may be useful but have important limitations. Evaluation of clinical response is also critical especially to identify patients who fail to respond to initial treatment since these patients have a high risk of in-hospital death. However, the criteria of definition of non-response in CAP are largely empirical and frequently markedly diverse between different studies. In this review, we aim to identify criteria defining nonresponse in CAP and the pitfalls associated with this diagnosis. We also aim to overview the main causes of treatment failure especially in severe CAP and the possible strategies to identify and reassess non-responders trying to change the dismal prognosis associated with this condition.
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Affiliation(s)
- João Gonçalves-Pereira
- Unidade de Cuidados Intensivos Polivalente, Hospital de Sao Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1449-005 Lisboa, Portugal
| | - Catarina Conceição
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon and CEDOC, Faculty of Medical Sciences, New University of Lisbon, Lisbon, Portugal
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55
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Takada K, Matsumoto S, Kojima E, Iwata S, Ninomiya K, Tanaka K, Goto D, Shimizu T, Nohara K. Predictors and impact of time to clinical stability in community-acquired pneumococcal pneumonia. Respir Med 2014; 108:806-12. [DOI: 10.1016/j.rmed.2014.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 01/02/2014] [Accepted: 02/11/2014] [Indexed: 10/25/2022]
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Viasus D, Simonetti A, Garcia-Vidal C, Carratalà J. Prediction of prognosis by markers in community-acquired pneumonia. Expert Rev Anti Infect Ther 2014; 11:917-29. [PMID: 24053273 DOI: 10.1586/14787210.2013.825442] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Early identification of patients with community-acquired pneumonia (CAP) at risk of poor outcome is critical for defining site of care and may impact on hospital resource consumption and prognosis. The Pneumonia Severity Index and CURB-65 are clinical rules that accurately identify individuals at risk of death. However, these scores have some limitations. Therefore in recent years, increasing attention has been being paid to research on biomarkers, since they have the potential to resolve fundamental issues regarding prognostic prediction that cannot be readily addressed using CAP-specific scores. Nevertheless, the use of biomarkers in this context needs to be validated in prospective trials so as to elucidate how they can best be applied in practice. This review examines the usefulness of biomarkers, whether used alone or in conjunction with other clinical severity of illness scores, for identifying CAP patients at risk of short- and long-term mortality and for predicting both the need for intensive care unit admission and the potential for treatment failure.
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Affiliation(s)
- Diego Viasus
- Department of Infectious Diseases, Hospital Universitari de Bellvitge - IDIBELL, Barcelona, Spain
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Shindo Y, Hasegawa Y. Reply: Isolation of Drug-Resistant Pathogens Does Not Always Require Use of Broad-Spectrum Antibiotics in Pneumonia. Am J Respir Crit Care Med 2014; 189:757-8. [DOI: 10.1164/rccm.201401-0029le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Yuichiro Shindo
- Nagoya UniversityNagoya, Japanand
- Nagoya University Graduate School of MedicineNagoya, Japan
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58
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Mbata GC, Chukwuka CJ, Onyedum CC, Onwubere BJC. The CURB-65 scoring system in severity assessment of Eastern Nigerian patients with community-acquired pneumonia: a prospective observational study. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2014; 22:175-80. [PMID: 23633130 PMCID: PMC6443104 DOI: 10.4104/pcrj.2013.00034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in Nigeria. Severity assessment is a major starting point in the proper management of CAP. The BTS guideline for managing this condition is simple and does not require sophisticated equipment. Adherence to this guideline will improve CAP management in Nigeria. Aims: To assess the usefulness of the CURB-65 score in the management of CAP patients in Nigeria and to determine the outcome in relation to the degree of severity using CURB-65. Methods: A prospective observational study of 80 patients with CAP was carried out in the University of Nigeria Teaching Hospital Enugu, Nigeria from December 2008 to June 2009. The patients were classified into three risk groups and the ability of the CURB-65 score to predict the 30-day mortality rate and the need for ICU admission was determined. Results: Eighty patients were recruited, 39 of whom were men, giving a male to female ratio of 1:1.05. The mean age was 56±18 years. Thirty-seven patients (46.3%) were outpatients, 13 with CURB score 0, 21 with CURB score 1, two with CURB score 2, and one with CURB score 3. Of the 43 patients (53.7%) admitted to hospital, six, 13, 14, and 10 had scores of 4, 3, 2, and 1, respectively. The ICU admission rate was 10%. Twelve patients died, 2.2% in the low-risk group, 12.5% in the intermediate-risk group, and 45% in the high-risk group. Conclusions: The CURB-65 score is a simple method of assessing and risk stratifying CAP patients. It is particularly useful in a busy emergency department because of its ability to identify a reasonable proportion of low-risk patients for potential outpatient care.
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Affiliation(s)
- Godwin C Mbata
- Department of Medicine, Federal Medical Centre, Owerri, Nigeria
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60
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Procalcitonin versus C-reactive protein for guiding antibiotic therapy in sepsis: a randomized trial. Crit Care Med 2013; 41:2336-43. [PMID: 23921272 DOI: 10.1097/ccm.0b013e31828e969f] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE We sought to evaluate whether procalcitonin was superior to C-reactive protein in guiding antibiotic therapy in intensive care patients with sepsis. DESIGN Randomized open clinical trial. SETTING Two university hospitals in Brazil. PATIENTS Patients with severe sepsis or septic shock. INTERVENTIONS Patients were randomized in two groups: the procalcitonin group and the C-reactive protein group. Antibiotic therapy was discontinued following a protocol based on serum levels of these markers, according to the allocation group. The procalcitonin group was considered superior if the duration of antibiotic therapy was at least 25% shorter than in the C-reactive protein group. For both groups, at least seven full-days of antibiotic therapy were ensured in patients with Sequential Organ Failure Assessment greater than 10 and/or bacteremia at inclusion, and patients with evident resolution of the infectious process had antibiotics stopped after 7 days, despite biomarkers levels. MEASUREMENTS AND MAIN RESULTS Ninety-four patients were randomized: 49 patients to the procalcitonin group and 45 patients to the C-reactive protein group. The mean age was 59.8 (SD, 16.8) years. The median duration of antibiotic therapy for the first episode of infection was 7.0 (Q1-Q3, 6.0-8.5) days in the procalcitonin group and 6.0 (Q1-Q3, 5.0-7.0) days in the C-reactive protein group (p=0.13), with a hazard ratio of 1.206 (95% CI, 0.774-1.3; p=0.13). Overall, protocol overruling occurred in only 13 (13.8%) patients. Twenty-one patients died in each group (p=0.836). CONCLUSIONS C-reactive protein was as useful as procalcitonin in reducing antibiotic use in a predominantly medical population of septic patients, causing no apparent harm.
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Sialer S, Liapikou A, Torres A. What is the best approach to the nonresponding patient with community-acquired pneumonia? Infect Dis Clin North Am 2013; 27:189-203. [PMID: 23398874 DOI: 10.1016/j.idc.2012.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Treatment failure in community-acquired pneumonia (CAP) is the failure to normalize the clinical features (eg, fever, cough, sputum production), or nonresolving image in chest radiograph, despite antimicrobial therapy. The incidence of treatment failure in CAP has not been clearly established; according to several studies it ranges between 6% and 15%. The rate of mortality increases significantly, especially in those patients with severe CAP. It is important to be able to identify what patients are at risk for progressive or treatment failure pneumonia that may make them candidates for a more careful monitoring.
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Affiliation(s)
- Salvador Sialer
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Barcelona 08036, Spain
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Mbata GC, Chukwuka CJ, Onyedum CC, Onwubere BJC, Aguwa EN. The role of complications of community acquired pneumonia on the outcome of the illness: a prospective observational study in a tertiary institution in eastern Nigeria. Ann Med Health Sci Res 2013; 3:365-9. [PMID: 24116315 PMCID: PMC3793441 DOI: 10.4103/2141-9248.117952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Community acquired pneumonia (CAP) is a major cause of mortality and morbidity in our environment. Recent data on the role of complications on outcome of CAP are not readily available in Nigeria. AIM This study aims to analyze the influence of complications on the outcome of CAP in a tertiary health center in Eastern Nigeria. SUBJECTS AND METHODS A prospective observational study was carried out on 80 patients with CAP, who met the inclusion criteria. Data relating to their age, gender, and clinical details; severity assessment using CURB 65 (C- confusion, Serum urea > 7mmol/L, R-respiratory rate > 30, B-systolic BP > 90 and diastolic BP ≤ 60, age > 65 years.) scoring system, laboratory results, complications, and outcome (mortality) were collected. The statistical package used for data analysis is SPSS version 17.0 (Chicago IL USA). Data were presented in tables and charts. Sample means, standard deviation, and Chi-square test were used for statistical significance. Severity was assessed using CURB65 scoring system. Outcome of interest was 30 day mortality. In all P value of 0.05 was regarded as significant. RESULTS Eighty patients were recruited for the study, 39 males and 41 females; giving male:female ratio of 1:1.05. The mean age range was 56 (18.0) years. A total of 37 patients were managed as out-patients while 43 were managed as in-patients. Complications were observed in 25 patients. Severe hemodynamic changes and pleural effusion 8/25 (32%) were the most common complications observed. Total mortality was 12/80 (15%). Mortality was higher in in-patients than out-patients however, this was not statistically significant. Mortality in those with complications was 6/25 (24%) compared to 6/55 (11%) in those without complications (P = 0.10). CONCLUSION Mortality rate in patients with CAP though higher in patients with complications numerically were not found to be significantly higher than in those without complications. We posit that other factors like presence of higher severity assessment scores (CURB-65 scores) and co-morbidities may be more important predictors of mortality in CAP patients and should be further studied.
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Affiliation(s)
- GC Mbata
- Department of Medicine, Federal Medical Centre, Owerri, Nigeria
| | - CJ Chukwuka
- Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - CC Onyedum
- Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - BJC Onwubere
- Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - EN Aguwa
- Department of Community Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
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Crisafulli E, Menéndez R, Huerta A, Martinez R, Montull B, Clini E, Torres A. Systemic Inflammatory Pattern of Patients With Community-Acquired Pneumonia With and Without COPD. Chest 2013; 143:1009-1017. [DOI: 10.1378/chest.12-1684] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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64
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Sibila O, Restrepo MI, Anzueto A. What is the Best Antimicrobial Treatment for Severe Community-Acquired Pneumonia (Including the Role of Steroids and Statins and Other Immunomodulatory Agents). Infect Dis Clin North Am 2013; 27:133-47. [DOI: 10.1016/j.idc.2012.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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65
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POLVERINO EVA, CILLÓNIZ CATIA, DAMBRAVA POVILAS, GABARRÚS ALBERT, FERRER MIQUEL, AGUSTÍ CARLOS, PRINA ELENA, MONTULL BEATRIZ, MENENDEZ ROSARIO, NIEDERMAN MICHAELS, TORRES ANTONI. Systemic corticosteroids for community-acquired pneumonia: Reasons for use and lack of benefit on outcome. Respirology 2013; 18:263-71. [DOI: 10.1111/resp.12013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/09/2012] [Accepted: 08/25/2012] [Indexed: 12/16/2022]
Affiliation(s)
- EVA POLVERINO
- Respiratory Disease Department; Hospital Clínic i Provincial de Barcelona; IDIBAPS; CIBER de Enfermedades Respiratorias (Ciberes)
| | - CATIA CILLÓNIZ
- Respiratory Disease Department; Hospital Clínic i Provincial de Barcelona; IDIBAPS; CIBER de Enfermedades Respiratorias (Ciberes)
| | - POVILAS DAMBRAVA
- Respiratory and Sleep Disorders Unit; Hospital of Vendrell; Barcelona
| | - ALBERT GABARRÚS
- Respiratory Disease Department; Hospital Clínic i Provincial de Barcelona; IDIBAPS; CIBER de Enfermedades Respiratorias (Ciberes)
| | - MIQUEL FERRER
- Respiratory Disease Department; Hospital Clínic i Provincial de Barcelona; IDIBAPS; CIBER de Enfermedades Respiratorias (Ciberes)
| | - CARLOS AGUSTÍ
- Respiratory Disease Department; Hospital Clínic i Provincial de Barcelona; IDIBAPS; CIBER de Enfermedades Respiratorias (Ciberes)
| | - ELENA PRINA
- Emergency Care Department; Policlinic - University of Milan; Milan; Italy
| | - BEATRIZ MONTULL
- Respiratory Disease Department; Hospital La Fe; Valencia; Spain
| | | | | | - ANTONI TORRES
- Respiratory Disease Department; Hospital Clínic i Provincial de Barcelona; IDIBAPS; CIBER de Enfermedades Respiratorias (Ciberes)
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66
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Are circulating levels of CRP compared to IL-6 and PCT still relevant in intensive care unit patients?1). ACTA ACUST UNITED AC 2013. [DOI: 10.1515/labmed-2013-0029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
AbstractC-reactive protein (CRP) currently constitutes one of the most widely used parameters for the diagnosis of infections and inflammatory processes, due to simple methods and low costs. However, in recent years, other parameters, such as interleukin 6 (IL-6) and procalcitonin (PCT), have gained in importance. Although these parameters are presently not established everywhere in clinical routine, they provide significant advantages in the diagnosis and monitoring of inflammatory diseases. For instance, in intensive care, the increase in IL-6 levels may indicate inflammatory complications 24 to 48 h prior to the increase in circulating CRP levels. In contrast to CRP, PCT shows a higher specifity for bacterial infections, which facilitates the diagnosis of bacterial infections and sepsis. PCT measurements further allow assessment of therapeutic success and indicate necessary changes in antibiotic therapy. These points raise the question whether CRP measurements should at least in part be replaced by PCT and/or IL-6. Thus, this review seeks to examine the value of CRP in relation to PCT and IL-6 for the diagnosis of bacterial infections, in therapeutic monitoring, and regarding prognosis in critical care patients.
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67
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Khan AR, Riaz M, Bin Abdulhak AA, Al-Tannir MA, Garbati MA, Erwin PJ, Baddour LM, Tleyjeh IM. The role of statins in prevention and treatment of community acquired pneumonia: a systematic review and meta-analysis. PLoS One 2013; 8:e52929. [PMID: 23349694 PMCID: PMC3538683 DOI: 10.1371/journal.pone.0052929] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 11/22/2012] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Emerging epidemiological evidence suggests that statins may reduce the risk of community-acquired pneumonia (CAP) and its complications. PURPOSE Performed a systematic review to address the role of statins in the prevention or treatment of CAP. DATA SOURCE Ovid MEDLINE, Cochrane, EMBASE, ISI Web of Science, and Scopus from inception through December 2011 were searched for randomized clinical trials, cohort and case-control studies. STUDY SELECTION Two authors independently reviewed studies that examined the role of statins in CAP. DATA EXTRACTION Data about study characteristics, adjusted effect-estimates and quality characteristics was extracted. DATA SYNTHESIS Eighteen studies corresponding to 21 effect-estimates (eight and 13 of which addressed the preventive and therapeutic roles of statins, respectively) were included. All studies were of good methodological quality. Random-effects meta-analyses of adjusted effect-estimates were used. Statins were associated with a lower risk of CAP, 0.84 (95% CI, 0.74-0.95), I(2) = 90.5% and a lower short-term mortality in patients with CAP, 0.68 (95% CI, 0.59-0.78), I(2) = 75.7%. Meta-regression did not identify sources of heterogeneity. A funnel plot suggested publication bias in the treatment group, which was adjusted by a novel regression method with a resultant effect-estimate of 0.85 (95% CI, 0.77-0.93). Sensitivity analyses using the rule-out approach showed that it is unlikely that the results were due to an unmeasured confounder. CONCLUSIONS Our meta-analysis reveals a beneficial role of statins for the risk of development and mortality associated with CAP. However, the results constitute very low quality evidence as per the GRADE framework due to observational study design, heterogeneity and publication bias.
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Affiliation(s)
- Abdur Rahman Khan
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio, United States of America
| | - Muhammad Riaz
- Research and Scientific Publication Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Aref A. Bin Abdulhak
- Department of Internal Medicine, University of Missouri – Kansas City, Kansas City, Missouri, United States of America
| | - Mohamad A. Al-Tannir
- Research and Scientific Publication Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Musa A. Garbati
- Department of Internal Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Patricia J. Erwin
- Mayo Medical Library, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Larry M. Baddour
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Imad M. Tleyjeh
- Department of Internal Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, United States of America
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Torres A, Barberán J, Falguera M, Menéndez R, Molina J, Olaechea P, Rodríguez A. [Multidisciplinary guidelines for the management of community-acquired pneumonia]. Med Clin (Barc) 2012; 140:223.e1-223.e19. [PMID: 23276610 DOI: 10.1016/j.medcli.2012.09.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 09/06/2012] [Indexed: 11/16/2022]
Abstract
Community-acquired pneumonia (CAP) is an infectious respiratory disease with an incidence that ranges from 3 to 8 cases per 1,000 inhabitants per year. This incidence increases with age and comorbidities. Forty per cent of CAP patients require hospitalization and around 10% of these patients are admitted in an Intensive Care Unit (ICU). Several studies have suggested that the implementation of clinical guidelines has a positive impact in the outcome of patients including mortality and length of stay. The more recent and used guidelines are those from Infectious Diseases Society of America/American Thoracic Society, published in 2007, the 2009 from the British Thoracic Society, and that from the European Respiratory Society/European Society of Clinical Microbiology and Infectious Diseases, published in 2010. In Spain, the most recently released guideline is the Sociedad Española de Neumología y Cirugía Torácica-2011 guideline. The present guidelines GNAC are designed to be used by the majority of health-care professionals that can participate in the care of CAP patients including diagnosis, decision of hospital and ICU admission, treatment and prevention. The Centro Cochrane Iberoamericano (CCIB) has participated in summarizing the previous guidelines and in the bibliography search. For each one of the following sections the panel of experts has developed a table with recommendations classified according to its evidence, strength and practical applicability using the Grading of Recommendations of Assessment Development and Evaluations (GRADE) system: 1. Epidemiology, microbiological etiology and antibiotic resistances.2. Clinical and microbiological diagnosis.3. Prognostic scales and decision of hospital admission.4. ICU admission criteria. 5. Empirical and definitive antibiotic treatment.6. Treatment failure. 7. Prevention.
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69
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Upadhyay S, Niederman MS. Biomarkers: what is their benefit in the identification of infection, severity assessment, and management of community-acquired pneumonia? Infect Dis Clin North Am 2012; 27:19-31. [PMID: 23398863 DOI: 10.1016/j.idc.2012.11.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Biomarkers have been proposed as tools that can guide the management of patients with community-acquired pneumonia, providing information that supplements the usually available clinical data. Among the available biomarkers, procalcitonin has been studied extensively and seems promising for several purposes. The use of biomarkers needs further study, to validate their utility in daily practice, especially given the limitations of the current tools for identifying the need for antibiotic therapy in patients with influenza and secondary bacterial pneumonia, in patients with aspiration syndromes, and in those infected with atypical pathogens.
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Affiliation(s)
- Shweta Upadhyay
- Pulmonary and Critical Care Medicine, Winthrop-University Hospital, Mineola, NY 11501, USA
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Malave A, Laserna E, Sibila O, Mortensen EM, Anzueto A, Restrepo MI. Impact of prior systemic corticosteroid use in patients admitted with community-acquired pneumonia. Ther Adv Respir Dis 2012. [PMID: 23179232 DOI: 10.1177/1753465812458985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Limited information is available regarding the impact of prior outpatient use of systemic corticosteroids (SCS) in patients subsequently developing community-acquired pneumonia (CAP). We investigate the effects of prior SCS on severity of illness, microbiology and clinical outcomes for patients hospitalized with CAP. METHODS A retrospective cohort study of subjects with CAP (according to International Classification of Diseases, 9th edition codes) was conducted over a 3-year period at two tertiary teaching hospitals. Subjects were considered to be SCS users if they received oral corticosteroids prior to admission. Primary outcomes were severity of illness, microbiology and 30-day mortality. RESULTS Data were abstracted on 698 patients [prior SCS users, 75 (10.7%) versus prior non-SCS users 623 (89.3%)]. Prior SCS users were more likely to have chronic obstructive pulmonary disease. No differences were found in severity of disease at admission, microbiological etiology including opportunistic and drug-resistant pathogens and clinical outcomes, including 30-day mortality, intensive care unit admission, length of hospital stay, need for mechanical ventilation and need for vasopressors. CONCLUSION Prior SCS use is not associated with increased 30-day mortality for patients hospitalized with CAP. In addition, no differences were found in either the severity of the disease at the time of presentation or in the presence of the resistant or opportunistic pathogens among groups.
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Affiliation(s)
- Adriel Malave
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX, USA
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Ruiz-Rodríguez J, Caballero J, Ruiz-Sanmartin A, Ribas V, Pérez M, Bóveda J, Rello J. Usefulness of procalcitonin clearance as a prognostic biomarker in septic shock. A prospective pilot study. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.medine.2012.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Foushee JA, Hope NH, Grace EE. Applying biomarkers to clinical practice: a guide for utilizing procalcitonin assays. J Antimicrob Chemother 2012; 67:2560-9. [DOI: 10.1093/jac/dks265] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Blasi F, Bocchino M, Di Marco F, Richeldi L, Aliberti S. The role of biomarkers in low respiratory tract infections. Eur J Intern Med 2012; 23:429-35. [PMID: 22726371 DOI: 10.1016/j.ejim.2012.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Low respiratory tract infections (LRTI) represent the leading infectious cause of death worldwide and account for substantial use of healthcare resources. Physicians must adopt practices focused on improving outcomes and serum biomarker can help them in the management of patients with LRTI. Several studies have been carried out or are currently ongoing to evaluate the role of various biomarkers for the differential diagnosis, definition of prognosis, treatment and duration of antibiotic therapy in respiratory infections. The objective of this position paper of the Italian Society of Respiratory Diseases (SIMER) is to provide evidence-based recommendations for the use of biomarkers in routine clinical practice in the management of adult patients with LRTI. These guidelines capture the use of biomarkers both outside and inside the hospital, focused on community-acquired pneumonia, acute exacerbations of chronic obstructive pulmonary disease, hospital-acquired and ventilator-acquired pneumonia.
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Affiliation(s)
- Francesco Blasi
- Dipartimento Toraco-Polmonare e Cardio-Circolatorio, University of Milan, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy.
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Interleukin 6, lipopolysaccharide-binding protein and interleukin 10 in the prediction of risk and etiologic patterns in patients with community-acquired pneumonia: results from the German competence network CAPNETZ. BMC Pulm Med 2012; 12:6. [PMID: 22348735 PMCID: PMC3311562 DOI: 10.1186/1471-2466-12-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 02/20/2012] [Indexed: 11/29/2022] Open
Abstract
Background The aim of our study was to investigate the predictive value of the biomarkers interleukin 6 (IL-6), interleukin 10 (IL-10) and lipopolysaccharide-binding protein (LBP) compared with clinical CRB and CRB-65 severity scores in patients with community-acquired pneumonia (CAP). Methods Samples and data were obtained from patients enrolled into the German CAPNETZ study group. Samples (blood, sputum and urine) were collected within 24 h of first presentation and inclusion in the CAPNETZ study, and CRB and CRB-65 scores were determined for all patients at the time of enrollment. The combined end point representative of a severe course of CAP was defined as mechanical ventilation, intensive care unit treatment and/or death within 30 days. Overall, a total of 1,000 patients were enrolled in the study. A severe course of CAP was observed in 105 (10.5%) patients. Results The highest IL-6, IL-10 and LBP concentrations were found in patients with CRB-65 scores of 3-4 or CRB scores of 2-3. IL-6 and LBP levels on enrollment in the study were significantly higher for patients with a severe course of CAP than for those who did not have severe CAP. In receiver operating characteristic analyses, the area under the curve values for of IL-6 (0.689), IL-10 (0.665) and LPB (0.624) in a severe course of CAP were lower than that of CRB-65 (0.764) and similar to that of CRB (0.69). The accuracy of both CRB and CRB-65 was increased significantly by including IL-6 measurements. In addition, higher cytokine concentrations were found in patients with typical bacterial infections compared with patients with atypical or viral infections and those with infection of unknown etiology. LBP showed the highest discriminatory power with respect to the etiology of infection. Conclusions IL-6, IL-10 and LBP concentrations were increased in patients with a CRB-65 score of 3-4 and a severe course of CAP. The concentrations of IL-6 and IL-10 reflected the severity of disease in patients with CAP. The predictive power of IL-6, IL-10 and LBP for a severe course of pneumonia was lower than that of CRB-65. Typical bacterial pathogens induced the highest LBP, IL-6 and IL-10 concentrations.
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Ruiz-Rodríguez JC, Caballero J, Ruiz-Sanmartin A, Ribas VJ, Pérez M, Bóveda JL, Rello J. Usefulness of procalcitonin clearance as a prognostic biomarker in septic shock. A prospective pilot study. Med Intensiva 2012; 36:475-80. [PMID: 22257436 DOI: 10.1016/j.medin.2011.11.024] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 11/21/2011] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To evaluate procalcitonin clearance as a prognostic biomarker in septic shock. DESIGN Prospective, observational pilot study. SETTING Intensive care unit. PATIENTS Patients admitted to the ICU due to septic shock and multiorgan dysfunction. INTERVENTIONS Serum concentrations of procalcitonin were determined within 12h of onset of septic shock and multiorgan dysfunction (coinciding with admission to the ICU), and the following extractions were obtained after 24, 48 and 72h in patients who survived. DATA COLLECTED Demographic data, Acute Physiology and Chronic Health Evaluation II score, and Sequential Organ Failure Assessment score, data on the primary focus of infection, and patient outcome (ICU mortality). RESULTS Procalcitonin clearance was higher in survivors than in non-survivors, with significant differences at 24h (73.9 [56.4-83.8]% vs 22.7 [-331-58.4], p<0.05) and 48h (81.6 [71.6-91.3]% vs -7.29 [-108.2-82.3], p<0.05). The area under the ROC curve was 0.74 (95%CI, 0.54-0.95, p<0.05) for procalcitonin clearance at 24h, and 0.86 (95%CI, 0.69-1.0, p<0.05) at 48h. CONCLUSIONS ICU mortality was associated to sustained high procalcitonin levels, suggesting that procalcitonin clearance at 48h may be a valuable prognostic biomarker.
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Affiliation(s)
- J C Ruiz-Rodríguez
- Servei de Medicina Intensiva, Universitat Autònoma de Barcelona, Barcelona,, Spain.
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Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--summary. Clin Microbiol Infect 2012; 17 Suppl 6:1-24. [PMID: 21951384 DOI: 10.1111/j.1469-0691.2011.03602.x] [Citation(s) in RCA: 192] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.
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Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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Procalcitonin improves the differentiation between infectious and cryptogenic/secondary organizing pneumonia. J Infect 2011; 64:122-4. [PMID: 22079501 DOI: 10.1016/j.jinf.2011.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Accepted: 10/31/2011] [Indexed: 11/20/2022]
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Arinzon Z, Peisakh A, Schrire S, Berner Y. C-reactive protein (CRP): An important diagnostic and prognostic tool in nursing-home-associated pneumonia. Arch Gerontol Geriatr 2011; 53:364-9. [DOI: 10.1016/j.archger.2011.01.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 01/17/2011] [Accepted: 01/19/2011] [Indexed: 11/17/2022]
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Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--full version. Clin Microbiol Infect 2011; 17 Suppl 6:E1-59. [PMID: 21951385 PMCID: PMC7128977 DOI: 10.1111/j.1469-0691.2011.03672.x] [Citation(s) in RCA: 586] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.
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Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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Procalcitonin-guided interventions against infections to increase early appropriate antibiotics and improve survival in the intensive care unit: a randomized trial. Crit Care Med 2011; 39:2048-58. [PMID: 21572328 DOI: 10.1097/ccm.0b013e31821e8791] [Citation(s) in RCA: 256] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE For patients in intensive care units, sepsis is a common and potentially deadly complication and prompt initiation of appropriate antimicrobial therapy improves prognosis. The objective of this trial was to determine whether a strategy of antimicrobial spectrum escalation, guided by daily measurements of the biomarker procalcitonin, could reduce the time to appropriate therapy, thus improving survival. DESIGN Randomized controlled open-label trial. SETTING Nine multidisciplinary intensive care units across Denmark. PATIENTS A total of 1,200 critically ill patients were included after meeting the following eligibility requirements: expected intensive care unit stay of ≥ 24 hrs, nonpregnant, judged to not be harmed by blood sampling, bilirubin <40 mg/dL, and triglycerides <1000 mg/dL (not suspensive). INTERVENTIONS : Patients were randomized either to the "standard-of-care-only arm," receiving treatment according to the current international guidelines and blinded to procalcitonin levels, or to the "procalcitonin arm," in which current guidelines were supplemented with a drug-escalation algorithm and intensified diagnostics based on daily procalcitonin measurements. MEASUREMENTS AND MAIN RESULTS The primary end point was death from any cause at day 28; this occurred for 31.5% (190 of 604) patients in the procalcitonin arm and for 32.0% (191 of 596) patients in the standard-of-care-only arm (absolute risk reduction, 0.6%; 95% confidence interval [CI] -4.7% to 5.9%). Length of stay in the intensive care unit was increased by one day (p = .004) in the procalcitonin arm, the rate of mechanical ventilation per day in the intensive care unit increased 4.9% (95% CI, 3.0-6.7%), and the relative risk of days with estimated glomerular filtration rate <60 mL/min/1.73 m was 1.21 (95% CI, 1.15-1.27). CONCLUSIONS Procalcitonin-guided antimicrobial escalation in the intensive care unit did not improve survival and did lead to organ-related harm and prolonged admission to the intensive care unit. The procalcitonin strategy like the one used in this trial cannot be recommended.
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Lacoma A, Rodríguez N, Prat C, Ruiz-Manzano J, Andreo F, Ramírez A, Bas A, Pérez M, Ausina V, Domínguez J. Usefulness of consecutive biomarkers measurement in the management of community-acquired pneumonia. Eur J Clin Microbiol Infect Dis 2011; 31:825-33. [PMID: 21870054 DOI: 10.1007/s10096-011-1381-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 08/03/2011] [Indexed: 02/05/2023]
Abstract
The aim of this study was to investigate whether procalcitonin (PCT), neopterin, C-reactive protein (CRP), and mid regional pro-atrial natriuretic peptide (MR-proANP) levels at admission and during the clinical course can be useful for the management of patients with pneumonia. The study population consisted of 75 patients with clinical and radiological diagnosis of pneumonia. Serum samples were collected at admission and during hospitalization. Complications were defined as intensive care unit (ICU) admission or death. The levels of PCT were significantly higher in pneumonia of definite bacterial origin in comparison to probable bacterial or unknown origin. The PCT levels were higher in pneumococcal pneumonia. The PCT and MR-proANP levels increased significantly according to the Pneumonia Severity Index (PSI). All biomarkers levels are higher in patients developing complications and who were dying. The serial levels of MR-proANP remain significantly elevated in patients developing complications and in patients classified in PSI and CURB-65 risk groups. In patients not developing complications, there is a significant decrease in the PCT levels. PCT can be useful for identifying pneumonia etiology. PCT and MR-proANP levels correlate with pneumonia severity rules. PCT and MR-proANP serial measurements can be useful for predicting short-term prognosis. Systemic biomarkers can provide additional information regarding clinical evolution, because these are dynamic and can be measured daily.
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Affiliation(s)
- A Lacoma
- Servei de Microbiologia, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autònoma de Barcelona, Carretera del Canyet s/n, 08916, Barcelona, Spain
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Singanayagam A, Singanayagam A, Wood V, Chalmers JD. Factors associated with severe illness in pandemic 2009 influenza a (H1N1) infection: implications for triage in primary and secondary care. J Infect 2011; 63:243-51. [PMID: 21839111 DOI: 10.1016/j.jinf.2011.07.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 07/29/2011] [Accepted: 07/29/2011] [Indexed: 10/17/2022]
Abstract
Pandemic (H1N1) 2009 influenza virus (pH1N1/09) infection spread rapidly around the globe, leading to a phase 6 pandemic level of alert declared in June 2009. The WHO declared the end of the pandemic in August 2010. Although for the majority of infected patients, it manifest as a mild, self-limiting illness, a proportion appeared to follow an adverse clinical course, requiring higher level care and aggressive management strategies. Experience with previous pandemics suggests that H1N1 will continue to circulate for many years. The aim of this review is to evaluate data from published case series reporting patients with pH1N1/09 influenza to identify clinical markers of severe disease. Comorbid illnesses including chronic lung disease, obesity and pregnancy have been shown to confer increased risk of severe infection. Admission vital signs, laboratory investigations and chest radiographic features can guide admitting clinicians to stratify patients' risk of severe disease, however, the currently available severity scoring tools have only a limited role in risk assessment. Knowledge of high risk parameters remains important for clinicians triaging patients with suspected pH1N1/09 influenza and to inform strategies for future pandemics.
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Affiliation(s)
- Anika Singanayagam
- Department of Respiratory Medicine, Barnet and Chase Farm Hospitals NHS Trust, London EN28JL, United Kingdom.
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Póvoa P, Teixeira-Pinto AM, Carneiro AH. C-reactive protein, an early marker of community-acquired sepsis resolution: a multi-center prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R169. [PMID: 21762483 PMCID: PMC3387609 DOI: 10.1186/cc10313] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 06/03/2011] [Accepted: 07/15/2011] [Indexed: 01/26/2023]
Abstract
Introduction C-reactive protein (CRP) has been shown to be a valuable marker in the diagnosis of infection and in monitoring its response to antibiotics. Our objective was to evaluate serial CRP measurements after prescription of antibiotics to describe the clinical course of Community-Acquired Sepsis admitted to intensive care units (ICU). Methods During a 12-month period a multi-center, prospective, observational study was conducted, segregating adults with Community-Acquired Sepsis. Patients were followed-up during the first five ICU days, day of ICU discharge or death and hospital outcome. CRP-ratio was calculated in relation to Day 1 CRP concentration. Patients were classified according to the pattern of CRP-ratio response to antibiotics: fast response if Day 5 CRP-ratio was < 0.4, slow response if Day 5 CRP-ratio was between 0.4 and 0.8, and no response if Day 5 CRP-ratio was > 0.8. Comparison between survivors and non-survivors was performed. Results A total of 891 patients (age 60 ± 17 yrs, hospital mortality 38%) were studied. There were no significant differences between the CRP of survivors and non-survivors until Day 2 of antibiotic therapy. On the following three days, CRP of survivors was significantly lower (P < 0.001). After adjusting for the Simplified Acute Physiology Score II and severity of sepsis, the CRP course was significantly associated with mortality (ORCRP-ratio = 1.03, confidence interval 95%= (1.02, 1.04), P < 0.001). The hospital mortality of patients with fast response, slow response and no response patterns was 23%, 30% and 41%, respectively (P = 0.001). No responders had a significant increase on the odds of death (OR = 2.5, CI95% = (1.6, 4.0), P < 0.001) when compared with fast responders. Conclusions Daily CRP measurements after antibiotic prescription were useful as early as Day 3 in identification of Community-Acquired Sepsis patients with poor outcome. The rate of CRP decline during the first five ICU days was markedly associated with prognosis. The identification of the pattern of CRP-ratio response was useful in the recognition of the individual clinical course.
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Affiliation(s)
- Pedro Póvoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, CHLO, Estrada do Forte do Alto do Duque, 1449-005 Lisbon, Portugal.
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Corticoides en la neumonía: argumentos a favor. Arch Bronconeumol 2011; 47:222-3. [DOI: 10.1016/j.arbres.2011.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 03/01/2011] [Accepted: 03/03/2011] [Indexed: 11/24/2022]
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Risk factors and severity scores in hospitalized patients with community-acquired pneumonia: prediction of severity and mortality. Eur J Clin Microbiol Infect Dis 2011; 31:33-47. [PMID: 21533875 DOI: 10.1007/s10096-011-1272-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 04/12/2011] [Indexed: 12/27/2022]
Abstract
Morbidity and mortality in patients with moderate to severe community-acquired pneumonia (CAP) is a global problem, and CAP is a leading cause of death due to infectious diseases. Prompt initiation of expanded-spectrum antimicrobials is essential for the prevention of unnecessary mortality and complications in patients, particularly in the elderly and other at-risk populations, and the treatment decisions made by practitioners have important implications for healthcare systems when hospitalization is required. Empirical antimicrobial treatment and the appropriate management of CAP patients will initially require the proper assessment of severity and patient risk for increased mortality, as well as risk factors for difficult-to-treat bacteria. This review will examine risk factors and scoring systems that may be predictive of moderate to severe CAP, which is often linked to increased risk of mortality. Understanding and recognizing potential risk factors will allow practitioners to proactively identify patients at the highest risk for severe illness or complications, thereby, guiding site-of-care decisions, as well as the choices for empiric antibiotic regimens. The decision to hospitalize a patient with CAP should include not only a clinical perspective and laboratory and radiographic findings, but also at least one objective tool of risk assessment, all in combination with sound clinical judgment.
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Jung JY, Park MS, Kim YS, Park BH, Kim SK, Chang J, Kang YA. Healthcare-associated pneumonia among hospitalized patients in a Korean tertiary hospital. BMC Infect Dis 2011; 11:61. [PMID: 21396096 PMCID: PMC3063837 DOI: 10.1186/1471-2334-11-61] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 03/11/2011] [Indexed: 11/20/2022] Open
Abstract
Background Healthcare-associated pneumonia (HCAP) has more similarities to nosocomial pneumonia than to community-acquired pneumonia (CAP). However, there have only been a few epidemiological studies of HCAP in South Korea. We aimed to determine the differences between HCAP and CAP in terms of clinical features, pathogens, and outcomes, and to clarify approaches for initial antibiotic management. Methods We conducted a retrospective, observational study of 527 patients with HCAP or CAP who were hospitalized at Severance Hospital in South Korea between January and December 2008. Results Of these patients, 231 (43.8%) had HCAP, and 296 (56.2%) had CAP. Potentially drug-resistant (PDR) bacteria were more frequently isolated in HCAP than CAP (12.6% vs. 4.7%; P = 0.001), especially in the low-risk group of the PSI classes (41.2% vs. 13.9%; P = 0.027). In-hospital mortality was higher for HCAP than CAP patients (28.1% vs. 10.8%, P < 0.001), especially in the low-risk group of PSI classes (16.4% vs. 3.1%; P = 0.001). Moreover, tube feeding and prior hospitalization with antibiotic treatment within 90 days of pneumonia onset were significant risk factors for PDR pathogens, with odds ratios of 14.94 (95% CI 4.62-48.31; P < 0.001) and 2.68 (95% CI 1.32-5.46; P = 0.007), respectively. Conclusions For HCAP patients with different backgrounds, various pathogens and antibiotic resistance of should be considered, and careful selection of patients requiring broad-spectrum antibiotics is important when physicians start initial antibiotic treatments.
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Affiliation(s)
- Ji Ye Jung
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Institute of Chest Disease, Yonsei University College of Medicine, Seoul, Republic of Korea
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Ruiz-González A, Falguera M, Porcel JM, Martínez-Alonso M, Cabezas P, Geijo P, Boixeda R, Dueñas C, Armengou A, Capdevila JA, Serrano R. C-reactive protein for discriminating treatment failure from slow responding pneumonia. Eur J Intern Med 2010; 21:548-52. [PMID: 21111942 DOI: 10.1016/j.ejim.2010.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Revised: 03/12/2010] [Accepted: 09/13/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND The management of patients with community-acquired pneumonia (CAP) who fail to improve constitutes a challenge for clinicians. This study investigated the usefulness of C-reactive protein (CRP) changes in discriminating true treatment failure from slow response to treatment. METHODS This prospective multicenter observational study investigated the behavior of plasma CRP levels on days 1 and 4 in hospitalized patients with CAP. We identified non-responding patients as those who had not reached clinical stability by day 4. Among them, true treatment failure and slow response situations were defined when initial therapy had to be changed or not after day 4 by attending clinicians, respectively. RESULTS By day 4, 78 (27.4%) out of 285 patients had not reached clinical stability. Among them, 56 (71.8%) patients were cured without changes in initial therapy (mortality 0.0%), and in 22 (28.2%) patients, the initial empirical therapy needed to be changed (mortality 40.9%). By day 4, CRP levels fell in 52 (92.9%) slow responding and only in 7 (31.8%) late treatment failure patients (p<0.001). A model developed including CRP behavior and respiratory rate at day 4 identified treatment failure patients with an area under the Receiver Operating Characteristic curve of 0.87 (CI 95%, 0.78-0.96). CONCLUSION Changes in CRP levels are useful to discriminate between true treatment failure and slow response to treatment and can help clinicians in management decisions when CAP patients fail to improve.
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Affiliation(s)
- Agustín Ruiz-González
- Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida, Lleida, Spain.
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Menéndez R, Torres A, Aspa J, Capelastegui A, Prat C, Rodríguez de Castro F. Community-Acquired Pneumonia. New Guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). ACTA ACUST UNITED AC 2010. [DOI: 10.1016/s1579-2129(11)60008-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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90
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Menéndez R, Torres A, Aspa J, Capelastegui A, Prat C, Rodríguez de Castro F. [Community acquired pneumonia. New guidelines of the Spanish Society of Chest Diseases and Thoracic Surgery (SEPAR)]. Arch Bronconeumol 2010; 46:543-58. [PMID: 20832928 DOI: 10.1016/j.arbres.2010.06.014] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 06/18/2010] [Indexed: 10/19/2022]
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91
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Christ-Crain M, Schuetz P, Müller B. Biomarkers in the management of pneumonia. Expert Rev Respir Med 2010; 2:565-72. [PMID: 20477291 DOI: 10.1586/17476348.2.5.565] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A novel approach to improve diagnosis and prognosis of pneumonia is the use of biomarkers. An ideal diagnostic biomarker for pneumonia should allow an early diagnosis and differential diagnosis from other, noninfectious conditions. Procalcitonin (PCT) has emerged as a reliable diagnostic marker in pneumonia, and is better when compared with other markers, namely C-reactive protein, leukocyte count and proinflammatory cytokines. A PCT-based diagnostic and therapeutic strategy can reduce antibiotic usage in patients with pneumonia, mainly by reducing the duration of antibiotic courses. However, PCT should not be used as a substitute for a careful clinical assessment. PCT levels may remain low in localized infections in the context of pneumonia, especially in patients with localized empyema. An ideal prognostic biomarker should be informative about the course and outcome of a disease. Various biomarkers, namely pro-adrenomedullin, natriuretic peptides, endothelin-1 precursor peptides, as well as copeptin and cortisol levels, are promising in this respect. Future studies will show whether an assessment with those novel biomarkers is able to guide prognostic decision-making and improve the allocation of healthcare resources and hospitalization costs.
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92
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Bewick T, Lim WS. Diagnosis of community-acquired pneumonia in adults. Expert Rev Respir Med 2010; 3:153-64. [PMID: 20477309 DOI: 10.1586/ers.09.3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Community-acquired pneumonia (CAP) is a common presentation to both primary and secondary care, representing approximately 5% of the acute medical intake in the UK. Treatment is often based on an empirical approach, using broad-spectrum antibiotic regimens, with which the majority of patients will achieve clinical cure. However, in cases of severe CAP, initial treatment failure or severe comorbidity, a more rigorous diagnostic approach is required. This review assesses the evidence base behind the common diagnostic methods for CAP, and presents the case for a rapid and accurate microbiological and radiological diagnosis in improving management and outcomes of this common condition.
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Affiliation(s)
- Thomas Bewick
- Nottingham University Hospitals NHS Trust, David Evans Building, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK.
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93
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Abstract
IMPORTANCE OF THE FIELD Community-acquired pneumonia (CAP) is a common and potentially life-threatening illness that continues to be a major medical problem. Among infectious diseases, CAP is the leading cause of death in the world and is associated with a substantial economic burden to health are systems around the globe. AREAS COVERED IN THIS REVIEW Recently identified clinical and biochemical tools promise to improve the assessment of CAP severity. Various prognostic scoring systems and predictive biomarkers have been proposed as tools to aid clinicians in key management decisions. This review provides a summary of current evidence about the use of prognostic scoring systems and biomarkers in the management of patients presenting with CAP. According to the existing guidelines, until more accurate and rapid diagnostic methods are available, the initial treatment for most patients with CAP will remain empirical. Some novel antibiotic and nonantibiotic therapies have recently been tested; some empirical antimicrobial regimens are still being debated. This review summarizes the recent advances in the field of therapy and novel approaches. We searched PubMed for English-language references published from 1997 to 2009 using combinations of the following terms: 'community acquired pneumonia', 'community acquired bacterial pneumonia', 'therapy', 'antibiotics', 'antimicrobials', 'prognostic scoring systems', 'biomarkers', 'diagnostic testing', 'guidelines' 'etiological diagnosis'. WHAT THE READER WILL GAIN A thorough description about recent advances in the field of therapy and novel approaches of CAP, as well as a summary of current evidence about the use of prognostic scoring systems and biomarkers in the management of patients presenting with CAP, is presented. TAKE HOME MESSAGE Recent developments have made significant contributions to the management of CAP patients. However, various hot topics remain open and urgently require prospective studies in order to optimize the outcomes of CAP.
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Affiliation(s)
- Stavros Anevlavis
- Department of Pneumonology, University Hospital of Alexandroupolis, Democritus University of Thrace, Medical School, Alexandroupolis 68100, Greece
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94
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Corrêa RDA, Lundgren FLC, Pereira-Silva JL, Frare e Silva RL, Cardoso AP, Lemos ACM, Rossi F, Michel G, Ribeiro L, Cavalcanti MADN, de Figueiredo MRF, Holanda MA, Valery MIBDA, Aidê MA, Chatkin MN, Messeder O, Teixeira PJZ, Martins RLDM, da Rocha RT. Brazilian guidelines for community-acquired pneumonia in immunocompetent adults - 2009. J Bras Pneumol 2010; 35:574-601. [PMID: 19618038 DOI: 10.1590/s1806-37132009000600011] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2009] [Accepted: 04/23/2009] [Indexed: 01/30/2023] Open
Abstract
Community-acquired pneumonia continues to be the acute infectious disease that has the greatest medical and social impact regarding morbidity and treatment costs. Children and the elderly are more susceptible to severe complications, thereby justifying the fact that the prevention measures adopted have focused on these age brackets. Despite the advances in the knowledge of etiology and physiopathology, as well as the improvement in preliminary clinical and therapeutic methods, various questions merit further investigation. This is due to the clinical, social, demographical and structural diversity, which cannot be fully predicted. Consequently, guidelines are published in order to compile the most recent knowledge in a systematic way and to promote the rational use of that knowledge in medical practice. Therefore, guidelines are not a rigid set of rules that must be followed, but first and foremost a tool to be used in a critical way, bearing in mind the variability of biological and human responses within their individual and social contexts. This document represents the conclusion of a detailed discussion among the members of the Scientific Board and Respiratory Infection Committee of the Brazilian Thoracic Association. The objective of the work group was to present relevant topics in order to update the previous guidelines. We attempted to avoid the repetition of consensual concepts. The principal objective of creating this document was to present a compilation of the recent advances published in the literature and, consequently, to contribute to improving the quality of the medical care provided to immunocompetent adult patients with community-acquired pneumonia.
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Affiliation(s)
- Ricardo de Amorim Corrêa
- Universidade Federal de Minas Gerais - UFMG, Federal University of Minas Gerais - School of Medicine, Belo Horizonte, Brazil
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Christ-Crain M, Opal SM. Clinical review: the role of biomarkers in the diagnosis and management of community-acquired pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:203. [PMID: 20236471 PMCID: PMC2875480 DOI: 10.1186/cc8155] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In patients with community-acquired pneumonia, traditional criteria of infection based on clinical signs and symptoms, clinical scoring systems, and general inflammatory indicators (for example, leukocytosis, fever, C-reactive protein and blood cultures) are often of limited clinical value and remain an unreliable guide to etiology, optimal therapy and prognosis. Procalcitonin is superior to other commonly used markers in its specificity for bacterial infection (allowing alternative diagnoses to be excluded), as an indicator of disease severity and risk of death, and mainly as a guide to the necessity for antibiotic therapy. It can therefore be viewed as a diagnostic, prognostic, and perhaps even theragnostic test. It more closely matches the criteria for usefulness than other candidate biomarkers such as C-reactive protein, which is rather a nonspecific marker of acute phase inflammation, and proinflammatory cytokines such as plasma IL-6 levels that are highly variable, cumbersome to measure, and lack specificity for systemic infection. Elevated levels of pro-adrenomedullin, copeptin (which is produced in equimolar amounts to vasopressin), natriuretic peptides and cortisol are significantly related to mortality in community-acquired pneumonia, as are other prohormones such as pro-atrial natriuretic peptide, coagulation markers, and other combinations of inflammatory cytokine profiles. However, all biomarkers have weaknesses as well as strengths. None should be used on its own; and none is anything more than an aid in the exercise of clinical judgment based upon a synthesis of available clinical, physiologic and laboratory features in each patient.
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Affiliation(s)
- Mirjam Christ-Crain
- Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
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96
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Cabezas P, Ruiz-González A, Falguera M. Factores que modifican la producción de proteína C reactiva en pacientes con neumonía adquirida en la comunidad. Arch Bronconeumol 2010; 46:48-9. [DOI: 10.1016/j.arbres.2009.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 05/04/2009] [Accepted: 05/09/2009] [Indexed: 10/20/2022]
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97
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Viasus D, Garcia-Vidal C, Gudiol F, Carratalà J. Statins for community-acquired pneumonia: current state of the science. Eur J Clin Microbiol Infect Dis 2009; 29:143-52. [DOI: 10.1007/s10096-009-0835-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 10/17/2009] [Indexed: 01/13/2023]
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98
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Hohenthal U, Hurme S, Helenius H, Heiro M, Meurman O, Nikoskelainen J, Kotilainen P. Utility of C-reactive protein in assessing the disease severity and complications of community-acquired pneumonia. Clin Microbiol Infect 2009; 15:1026-32. [DOI: 10.1111/j.1469-0691.2009.02856.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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100
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Abstract
Severity assessment is an important early step in the management of patients presenting with community-acquired pneumonia. Various pneumonia-specific scores, generic sepsis scores and predictive biomarkers have been proposed as tools to aid clinicians in key management decisions. However, there is no uniform agreement about the optimum severity assessment tool to use. This review provides a summary of current evidence surrounding severity assessment in adult patients presenting with community-acquired pneumonia.
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Affiliation(s)
- A Singanayagam
- Department of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.
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