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Iroh Tam PY, Bernstein E, Ma X, Ferrieri P. Blood Culture in Evaluation of Pediatric Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Hosp Pediatr 2015; 5:324-36. [PMID: 26034164 DOI: 10.1542/hpeds.2014-0138] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Current guidelines strongly recommend collection of blood cultures (BCs) in children requiring hospitalization for presumed moderate to severe bacterial community-acquired pneumonia (CAP). Our objective was to systematically review the international pediatric literature to evaluate how often BCs are positive in hospitalized children with CAP, identify the most commonly isolated pathogens, and determine the impact of positive BCs on clinical management. METHODS We identified articles in PubMed and Scopus published from January 1970 through December 2013 that addressed BCs in children with CAP. We extracted total number of BCs collected and prevalence of positive BCs and used meta-regression to evaluate whether subgroups had any impact on prevalence. RESULTS Meta-analysis showed that the overall prevalence of positive BCs was 5.14% (95% confidence interval 3.61-7.28). Studies focusing on severe CAP had a significant effect on prevalence (P=.008), at 9.89% (95% CI 6.79-14.19) compared with 4.17% (95% confidence interval 2.79-6.18) for studies not focusing on severe CAP. The most commonly isolated organisms were Streptococcus pneumoniae (76.7%) followed by Haemophilus influenzae (3.1%) and Staphylococcus aureus (2.1%). Contaminants accounted for 14.7%. Only 3 studies reported on BC-driven change in management, with contrasting findings. CONCLUSIONS BCs in pediatric CAP identified organisms in only a small percentage of patients, predominantly S. pneumoniae. False-positive BC rates can be substantial. The 3 studies that examined BC-driven changes in management had conflicting results. This systematic review was limited by heterogeneous case definitions, which may overestimate the true prevalence of positive BCs in hospitalized children.
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Affiliation(s)
- Pui-Ying Iroh Tam
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Immunology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota;
| | - Ethan Bernstein
- University of Minnesota Medical School, Minneapolis, Minnesota
| | - Xiaoye Ma
- Department of Biostatistics, University of Minnesota School of Public Health, Minneapolis, Minnesota; and
| | - Patricia Ferrieri
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Immunology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota; Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, Minnesota
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Tam PYI, Hanisch BR, O’Connell M. The Impact of Adherence to Pediatric Community-Acquired Pneumonia Guidelines on Clinical Outcomes. Clin Pediatr (Phila) 2015; 54:1006-8. [PMID: 25422523 PMCID: PMC4441860 DOI: 10.1177/0009922814559381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Michael O’Connell
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN
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Abstract
Recent years have witnessed the emergence of new pathogens linked to community-acquired pneumonia (CAP) along with new antibiotics designed to combat them. In this article, Dr Mandell presents an expert's view on these developments in the context of treatment guidelines for CAP. He also explores monotherapy versus combination therapy, the efficacy of rapid initiation of treatment, and short-course therapy as a hedge against antimicrobial resistance.
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Affiliation(s)
- Lionel A Mandell
- Division of Infectious Diseases, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.
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Self WH, Wunderink RG, Williams DJ, Barrett TW, Baughman AH, Grijalva CG. Comparison of clinical prediction models for resistant bacteria in community-onset pneumonia. Acad Emerg Med 2015; 22:730-40. [PMID: 25996620 DOI: 10.1111/acem.12672] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 10/24/2014] [Accepted: 12/04/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Six recently published algorithms classify pneumonia patients presenting from the community into high- and low-risk groups for resistant bacteria. Our objective was to compare performance of these algorithms for identifying patients infected with bacteria resistant to traditional community-acquired pneumonia antibiotics. METHODS This was a retrospective study of consecutive adult patients diagnosed with pneumonia in an emergency department and subsequently hospitalized. Each patient was classified as high or low risk for resistant bacteria according to the following algorithms: original health care-associated pneumonia (HCAP) criteria, Summit criteria, Brito and Niederman strategy, Shorr model, Aliberti model, and Shindo model. The reference for comparison was detection of resistant bacteria, defined as methicillin-resistant Staphylococcus aureus or Gram-negative bacteria resistant to ceftriaxone or levofloxacin. RESULTS A total of 614 patients were studied, including 36 (5.9%) with resistant bacteria. The HCAP criteria classified 304 (49.5%) patients as high risk, with an area under the receiver operating characteristic curve (AUC) of 0.63 (95% confidence interval [CI] = 0.54 to 0.72), sensitivity of 0.69 (95% CI = 0.52 to 0.83), and specificity of 0.52 (95% CI = 0.48 to 0.56). None of the other algorithms improved both sensitivity and specificity or significantly improved the AUC. Compared to the HCAP criteria, the Shorr and Aliberti models classified more patients as high risk, resulting in higher sensitivity and lower specificity. The Shindo model classified fewer patients as high risk, with lower sensitivity and higher specificity. CONCLUSIONS All algorithms for identification of resistant bacteria included in this study had suboptimal performance to guide antibiotic selection. New strategies for selecting empirical antibiotics for community-onset pneumonia are necessary.
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Affiliation(s)
- Wesley H. Self
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Richard G. Wunderink
- Division of Pulmonary and Critical Care Medicine; Department of Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL
| | - Derek J. Williams
- Department of Pediatrics; Vanderbilt University School of Medicine; Nashville TN
| | - Tyler W. Barrett
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Adrienne H. Baughman
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Carlos G. Grijalva
- Department of Health Policy; Vanderbilt University School of Medicine; Nashville TN
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Clinical outcomes and microbiological characteristics of severe pneumonia in cancer patients: a prospective cohort study. PLoS One 2015; 10:e0120544. [PMID: 25803690 PMCID: PMC4372450 DOI: 10.1371/journal.pone.0120544] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 01/23/2015] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Pneumonia is the most frequent type of infection in cancer patients and a frequent cause of ICU admission. The primary aims of this study were to describe the clinical and microbiological characteristics and outcomes in critically ill cancer patients with severe pneumonia. METHODS Prospective cohort study in 325 adult cancer patients admitted to three ICUs with severe pneumonia not acquired in the hospital setting. Demographic, clinical and microbiological data were collected. RESULTS There were 229 (71%) patients with solid tumors and 96 (29%) patients with hematological malignancies. 75% of all patients were in septic shock and 81% needed invasive mechanical ventilation. ICU and hospital mortality rates were 45.8% and 64.9%. Microbiological confirmation was present in 169 (52%) with a predominance of Gram negative bacteria [99 (58.6%)]. The most frequent pathogens were methicillin-sensitive S. aureus [42 (24.9%)], P. aeruginosa [41(24.3%)] and S. pneumonia [21 (12.4%)]. A relatively low incidence of MR [23 (13.6%)] was observed. Adequate antibiotics were prescribed for most patients [136 (80.5%)]. In multivariate analysis, septic shock at ICU admission [OR 5.52 (1.92-15.84)], the use of invasive MV [OR 12.74 (3.60-45.07)] and poor Performance Status [OR 3.00 (1.07-8.42)] were associated with increased hospital mortality. CONCLUSIONS Severe pneumonia is associated with high mortality rates in cancer patients. A relatively low rate of MR pathogens is observed and severity of illness and organ dysfunction seems to be the best predictors of outcome in this population.
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Gershengorn HB, Keene A, Dzierba AL, Wunsch H. The association of antibiotic treatment regimen and hospital mortality in patients hospitalized with Legionella pneumonia. Clin Infect Dis 2015; 60:e66-79. [PMID: 25722195 DOI: 10.1093/cid/civ157] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/13/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Guidelines recommend azithromycin or a quinolone antibiotic for treatment of Legionella pneumonia. No clinical study has compared these strategies. METHODS We performed a retrospective cohort analysis of adults hospitalized in the United States with a diagnosis of Legionella pneumonia in the Premier Perspectives database (1 July 2008-30 June 2013). Our primary outcome was hospital mortality; we additionally evaluated hospital length of stay, development of Clostridium difficile colitis, and total hospital cost. We used propensity-based matching to compare patients treated with azithromycin vs a quinolone. All analyses were repeated on a subgroup of more severely ill patients, defined as requiring intensive care unit admission or mechanical ventilation or having a predicted probability of hospital mortality in the top quartile for all patients. RESULTS Legionella pneumonia was diagnosed in 3152 adults across 437 hospitals. Quinolones alone were used in 28.8%, azithromycin alone was used in 34.0%, and 1.8% received both. Crude hospital mortality was similar: 6.6% (95% confidence interval [CI], 5.0%-8.2%) for quinolones vs 6.4% (95% CI, 5.0%-7.9%) for azithromycin (P = .87); after propensity matching (n = 813 in each group), mortality remained similar (6.3% [95% CI, 4.6%-7.9%] vs 6.5% [95% CI, 4.8%-8.2%], P = .84 for the whole cohort, and 14.9% [95% CI, 10.0%-19.8%] vs 18.3% [95% CI, 13.0%-23.6%], P = .36 for the more severely ill). There was no difference in hospital length of stay, development of C. difficile, or total hospital cost. CONCLUSIONS Use of azithromycin alone or a quinolone alone for treatment of Legionella pneumonia was associated with similar hospital mortality. Few patients receive combination therapy.
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Affiliation(s)
- Hayley B Gershengorn
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx
| | - Adam Keene
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx
| | - Amy L Dzierba
- Department of Pharmacy, Columbia University, New York Presbyterian Hospital, New York
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto Department of Anesthesiology Interdepartmental Division of Critical Care, University of Toronto, Ontario, Canada Department of Anesthesiology, Columbia University, New York, New York
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Chien YF, Chen CY, Hsu CL, Chen KY, Yu CJ. Decreased serum level of lipoprotein cholesterol is a poor prognostic factor for patients with severe community-acquired pneumonia that required intensive care unit admission. J Crit Care 2015; 30:506-10. [PMID: 25702844 DOI: 10.1016/j.jcrc.2015.01.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 12/15/2014] [Accepted: 01/05/2015] [Indexed: 01/28/2023]
Abstract
PURPOSE The purpose of this study is to investigate the prognostic values of the serum levels of lipids in patients with severe community-acquired pneumonia (CAP) that required intensive care unit (ICU) admission. MATERIALS AND METHODS Patients who had severe CAP that required ICU admission were included. Serum lipid level was collected on the days 1 and 7 of ICU stay. Clinical outcome, including length of ICU stay, hospital stay, and death, were monitored prospectively. RESULTS A total of 40 patients were enrolled in this study. Lower high-density lipoprotein (HDL) and low-density lipoprotein (LDL) were found in nonsurvival group on ICU admission day 7 (survivors vs nonsurvivors; mean HDL, 41.8 vs 13.0 mg/dL, P = .002; LDL, 62.3 vs 30.3 mg/dL, P = 0.006, respectively). High-density lipoprotein cholesterol level of less than or equal to 17 mg/dL on day 7 (odds ratio, 1.23) and LDL cholesterol level of less than or equal to 21 mg/dL on day 7 (odds ratio, 1.10) could be a predictor of hospital mortality. The mean change in levels of HDL cholesterol in nonsurvivors decreased significantly than those in survivors from days 1 to 7 (8.5 vs -17.4 mg/dL, P = .04) but not LDL cholesterol. CONCLUSIONS Decreased serum HDL cholesterol level from days 1 to 7 may be of prognostic value.
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Affiliation(s)
- Yu-Fen Chien
- Department of Laboratory Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Chung-Yu Chen
- Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Chia-Lin Hsu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kuan-Yu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chong-Jen Yu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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Perplexing pneumonia: Early anticipation and outcome. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2014.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Mercante JW, Winchell JM. Current and emerging Legionella diagnostics for laboratory and outbreak investigations. Clin Microbiol Rev 2015; 28:95-133. [PMID: 25567224 PMCID: PMC4284297 DOI: 10.1128/cmr.00029-14] [Citation(s) in RCA: 214] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Legionnaires' disease (LD) is an often severe and potentially fatal form of bacterial pneumonia caused by an extensive list of Legionella species. These ubiquitous freshwater and soil inhabitants cause human respiratory disease when amplified in man-made water or cooling systems and their aerosols expose a susceptible population. Treatment of sporadic cases and rapid control of LD outbreaks benefit from swift diagnosis in concert with discriminatory bacterial typing for immediate epidemiological responses. Traditional culture and serology were instrumental in describing disease incidence early in its history; currently, diagnosis of LD relies almost solely on the urinary antigen test, which captures only the dominant species and serogroup, Legionella pneumophila serogroup 1 (Lp1). This has created a diagnostic "blind spot" for LD caused by non-Lp1 strains. This review focuses on historic, current, and emerging technologies that hold promise for increasing LD diagnostic efficiency and detection rates as part of a coherent testing regimen. The importance of cooperation between epidemiologists and laboratorians for a rapid outbreak response is also illustrated in field investigations conducted by the CDC with state and local authorities. Finally, challenges facing health care professionals, building managers, and the public health community in combating LD are highlighted, and potential solutions are discussed.
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Affiliation(s)
- Jeffrey W Mercante
- Pneumonia Response and Surveillance Laboratory, Respiratory Diseases Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonas M Winchell
- Pneumonia Response and Surveillance Laboratory, Respiratory Diseases Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Webb BJ, Dascomb K, Stenehjem E, Dean N. Predicting risk of drug-resistant organisms in pneumonia: moving beyond the HCAP model. Respir Med 2014; 109:1-10. [PMID: 25468412 DOI: 10.1016/j.rmed.2014.10.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/19/2014] [Accepted: 10/27/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical management of community-acquired pneumonia (CAP) is increasingly complicated by antibiotic resistance. CAP due to pathogens resistant to guideline-recommended drugs (CAP-DRP) has increased. 2005 ATS/IDSA guidelines introduced a new category, healthcare-associated pneumonia (HCAP), and recommend extended-spectrum antibiotic treatment for patients meeting HCAP criteria. However, the predictive value of the HCAP model is limited and data suggest that outcomes are not improved using HCAP guideline-concordant therapy. Better methods to predict risk of CAP-DRP are needed. METHODS We reviewed currently published literature on the performance status of HCAP as a predictive tool and studies describing additional risk factors for CAP-DRP. We also summarize the performance characteristics of the currently published alternative clinical prediction scores and compare them to that of the HCAP model. RESULTS In addition to the five risk factors incorporated in HCAP, at least 13 other factors have been identified. The independent predictive value of any single factor is low, but accumulating factors results in increased risk of CAP-DRP. The performance characteristics of 9 clinical prediction scores are reviewed. Nearly all of the scores outperformed HCAP in their study populations. However, no single model has yet demonstrated adequate specificity to minimize unnecessary antibiotic use, while retaining sufficient sensitivity to prevent inadequate initial empiric antibiotic therapy when validated across a wide range of CAP-DRP prevalence. CONCLUSIONS Additional development and validation of prediction scores based upon more refined risk factors for CAP-DRP is needed. Once an accurate, adequately validated prediction score is available, an interventional trial will be needed to determine clinical impact.
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Affiliation(s)
- Brandon J Webb
- Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA; Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Salt Lake City, UT, USA.
| | - Kristin Dascomb
- Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA; Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Edward Stenehjem
- Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA; Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Nathan Dean
- Division of Pulmonary and Critical Care Medicine, at Intermountain Medical Center and the University of Utah, Salt Lake City, UT, USA
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Iroezindu MO, Chima EI, Isiguzo GC, Mbata GC, Onyedum CC, Onyedibe KI, Okoli LE. Sputum bacteriology and antibiotic sensitivity patterns of community-acquired pneumonia in hospitalized adult patients in Nigeria: a 5-year multicentre retrospective study. ACTA ACUST UNITED AC 2014; 46:875-87. [PMID: 25288384 DOI: 10.3109/00365548.2014.954263] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND A clear knowledge of the pathogens responsible for community-acquired pneumonia (CAP) in a given region and their antibiotic sensitivity patterns is necessary for optimal treatment. We determined the common bacterial pathogens causing CAP in Nigeria and further reviewed their antibiotic senstivity patterns with a view to providing recommendations to improve antibiotic management of CAP. METHODS Case notes of all adult patients who were 18 years or more admitted to four major tertiary hospitals in South East Nigeria with a diagnosis of CAP between 2008 and 2012 were retrospectively studied. To be eligible, patients were required to have sputum culture and sensitivity results available. Socio-demographic, clinical, pre-admission and in-hospital treatment data were also obtained. RESULTS Of 400 patients with a radiologically confirmed diagnosis of CAP, 232 fulfilled the study criteria; 122 (52.6%) were women and the mean age was 50.6 ± 18.8 years. Aetiological agents were identified from sputum in 189 (81.5%) patients. Streptococcus pneumoniae (n = 90, 47.6%) was the most frequent isolate followed by Klebsiella pneumoniae (n = 62, 32.8%), Staphylococcus aureus (n = 24, 12.7%) and Streptococcus pyogenes (n = 13, 6.9%). The pathogens were most sensitive to levofloxacin (77%), ceftazidime (75.5%) and ofloxacin (55.8%). The susceptibility of the isolates to antibiotics most frequently presecribed for empirical therapy was low (co-amoxiclav, 47.6%; ciprofloxacin, 45.9% and ceftriaxone, 47.6%) and this was associated with higher mortality and/or longer duration of hospital stay in survivors. CONCLUSION Strep. pneumoniae and K. pneumoniae were the most common causes of CAP. The pathogens were most sensitive to levofloxacin and ceftazidime. We suggest that these antibiotics should increasingly be considered as superior options for empirical treatment of CAP in Nigeria.
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Affiliation(s)
- Michael O Iroezindu
- From the Department of Medicine, College of Medicine, University of Nigeria Enugu Campus , Nigeria
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Mohamed KAE, Ahmed DAE. Prognostic value of lactate clearance in severe community acquired pneumonia. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2014.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Patterns of initial antibiotic therapy for community-acquired pneumonia in U.S. hospitals, 2000 to 2009. Am J Med Sci 2014; 347:347-56. [PMID: 24029796 DOI: 10.1097/maj.0b013e318294833f] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although clinical guidelines for management of community-acquired pneumonia (CAP) in non-intensive care unit ("non-ICU") hospitalized patients have changed substantially over the last decade, it is unknown how treatment of this disease has evolved over this period. METHODS Using data from >100 U.S. hospitals, we identified all adults (aged ≥18 years) hospitalized for CAP between January 1, 2000, and June 30, 2009 ("study period"). We excluded patients admitted to ICU <24 hours of admission, those not starting antibiotics <24 hours of admission, those not receiving antibiotics for ≥48 hours (if alive), and those with probable healthcare-associated pneumonia. We defined "initial therapy" as all parenteral antibiotics received ≤24 hours of admission, and we examined changes in such therapy over the study period. The statistical significance of changes in initial therapy was ascertained using 2-tailed χ tests. RESULTS We identified 40,392 patients who met all selection criteria. In 2000, the most frequently used initial regimens were levofloxacin (24.0% of all such admissions), ceftriaxone (9.0%), cefotaxime (7.3%), ceftriaxone plus levofloxacin (3.2%) and azithromycin plus cefotaxime (3.0%); in 2009, they were ceftriaxone plus azithromycin (18.5%), levofloxacin (12.7%), ceftriaxone (6.6%), moxifloxacin (4.7%) and ceftriaxone + levofloxacin (3.2%). Use of single-agent regimens declined between 2000 and 2009 (from 48.2%-30.0%); use of vancomycin almost doubled (13.1%-23.3%). All findings were statistically significant (P < 0.01). CONCLUSIONS Initial antibiotic therapy for non-ICU CAP has changed substantially in the United States over the past decade, in line with evidence of widespread antibiotic resistance, evolving treatment guidelines and, most recently, quality improvement initiatives that tie hospital payments to guideline-based care.
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Majhi A, Kundu K, Adhikary R, Banerjee M, Mahanti S, Basu A, Bishayi B. Combination therapy with ampicillin and azithromycin in an experimental pneumococcal pneumonia is bactericidal and effective in down regulating inflammation in mice. JOURNAL OF INFLAMMATION-LONDON 2014; 11:5. [PMID: 24565171 PMCID: PMC3936873 DOI: 10.1186/1476-9255-11-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 02/17/2014] [Indexed: 12/21/2022]
Abstract
Objectives Emergence of multidrug resistance among Streptococcus pneumoniae (SP), has limited the available options used to treat infections caused by this organism. The objective of this study was to compare the role of monotherapy and combination therapy with ampicillin (AMP) and azithromycin (AZM) in eradicating bacterial burden and down regulating lung inflammation in a murine experimental pneumococcal infection model. Methods Balb/C mice were infected with 106 CFU of SP. Treatments with intravenous ampicillin (200 mg/kg) and azithromycin (50 mg/kg) either alone or in combination was initiated 18 h post infection, animals were sacrificed from 0 – 6 h after initiation of treatment. AMP and AZM were quantified in serum by microbiological assay. Levels of TNF-α, IFN-γ IL-6, and IL-10 in serum and in lungs, along with myeloperoxidase, inflammatory cell count in broncho alveolar lavage fluid, COX-2 and histopathological changes in lungs were estimated. Results Combination therapy down regulated lung inflammation and accelerated bacterial clearance. This approach also significantly decreased TNF-α, IFN-γ, IL-6 and increased IL-10 level in serum and lungs along with decreased myeloperoxidase, pulmonary vascular permeability, inflammatory cell numbers and COX-2 levels in lungs. Conclusions Combinatorial therapy resulted in comparable bactericidal activity against the multi-drug resistant isolate and may represent an alternative dosing strategy, which may help to alleviate problems with pneumococcal pneumonia.
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Affiliation(s)
| | | | | | | | | | | | - Biswadev Bishayi
- Department of Physiology, Immunology laboratory, University of Calcutta, University Colleges of Science and Technology, 92 APC Road, Calcutta 700009, West Bengal,India.
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Therapeutic effects of mosapride citrate and lansoprazole for prevention of aspiration pneumonia in patients receiving gastrostomy feeding. J Gastroenterol 2013; 48:1105-10. [PMID: 23238778 DOI: 10.1007/s00535-012-0725-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 11/23/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Aspiration pneumonia is an emerging problem in patients receiving gastrostomy feeding. This study is designed to clarify the therapeutic effects of mosapride citrate and lansoprazole for prevention of aspiration pneumonia in patients receiving gastrostomy feeding. METHODS The study subjects were 119 patients with dysphasia who required gastrostomy feeding. They were randomly assigned to the control (without medication), lansoprazole (15 mg, 1/day), and mosapride (5 mg, 3/day) groups. The number of days with fever (≥37.8 °C), vomiting, and antibiotics administration, as well as the occurrence of pneumonia were investigated during the 6-month observation period. RESULTS The incidence of pneumonia during the observation period was significantly lower in the mosapride group as compared to the control (7/38 vs. 16/40, p = 0.038) and lansoprazole (vs. 20/41, p = 0.005) groups. The mosapride group also showed a significant decrease in days with fever and antibiotics administration as compared to the other groups. Multivariate analysis revealed that the presence of hiatal hernia was a significant risk factor and administration of mosapride was a significant preventive factor for pneumonia. CONCLUSION Mosapride has a preventive effect on occurrence of pneumonia in patients receiving gastrostomy feeding.
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Johnstone J, Mandell L. Guidelines and quality measures: do they improve outcomes of patients with community-acquired pneumonia? Infect Dis Clin North Am 2013; 27:71-86. [PMID: 23398866 DOI: 10.1016/j.idc.2012.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Community-acquired pneumonia (CAP) has a significant impact in terms of morbidity, mortality, and cost of care. Guidelines play an important role in the management of this disease, and evidence supporting the positive effects of guidelines on outcomes in patients with CAP is substantial. However, evidence supporting many of the CAP quality indicators is low, and pay-for-performance measures do not seem to influence clinically important outcomes. Future CAP quality indicators should incorporate evidence-based interventions.
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Affiliation(s)
- Jennie Johnstone
- Department of Medicine, McMaster University, West Hamilton, Ontario, Canada
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Ovetchkine P, Rieder MJ. Azithromycin use in paediatrics: A practical overview. Paediatr Child Health 2013. [DOI: 10.1093/pch/18.6.311] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Musher DM, Roig IL, Cazares G, Stager CE, Logan N, Safar H. Can an etiologic agent be identified in adults who are hospitalized for community-acquired pneumonia: results of a one-year study. J Infect 2013; 67:11-8. [PMID: 23523447 PMCID: PMC7132393 DOI: 10.1016/j.jinf.2013.03.003] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 03/07/2013] [Accepted: 03/13/2013] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Determining the cause of community-acquired pneumonia (CAP) remains problematic. In this observational study, we systematically applied currently approved diagnostic techniques in patients hospitalized for CAP in order to determine the proportion in which an etiological agent could be identified. METHODS All patients admitted with findings consistent with CAP were included. Sputum and blood cultures, urine tests for pneumococcal and Legionella antigens, nasopharyngeal swab for viral PCR, and serum procalcitonin were obtained in nearly every case. Admission-related electronic medical records were reviewed in entirety. RESULTS By final clinical diagnosis, 44 patients (17.0%) were uninfected. A causative bacterium was identified in only 60 (23.2%) cases. PCR identified a respiratory virus in 42 (16.2%), 12 with documented bacterial coinfection. In 119 (45.9%), no cause for CAP was found; 69 (26.6%) of these had a syndrome indistinguishable from bacterial pneumonia. Procalcitonin was elevated in patients with bacterial infection and low in uninfected patients or those with viral infection, but with substantial overlap. CONCLUSIONS Only 23.2% of 259 patients admitted with a CAP syndrome had documented bacterial infection; another 26.6% had no identified bacterial etiology, but findings closely resembled those of bacterial infection. Nevertheless, all 259 received antibacterial therapy. Careful attention to the clinical picture may identify uninfected patients or those with viral infection, perhaps with reassurance by a non-elevated procalcitonin. Determining an etiologic diagnosis remains elusive. Better discriminators of bacterial infection are sorely needed.
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Affiliation(s)
- Daniel M Musher
- Medical Care Line (Infectious Disease Section), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
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69
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Prina E, Ferrer M, Ranzani OT, Polverino E, Cillóniz C, Moreno E, Mensa J, Montull B, Menéndez R, Cosentini R, Torres A. Thrombocytosis Is a Marker of Poor Outcome in Community-Acquired Pneumonia. Chest 2013. [DOI: 10.1378/chest.12-1235] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Oster G, Berger A, Edelsberg J, Weber DJ. Initial treatment failure in non-ICU community-acquired pneumonia: risk factors and association with length of stay, total hospital charges, and mortality. J Med Econ 2013; 16:809-19. [PMID: 23574431 DOI: 10.3111/13696998.2013.794805] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To identify risk factors for initial treatment failure in patients with community-acquired pneumonia (CAP) in non-intensive care unit (non-ICU) settings, and to characterize the association between initial treatment failure and length of stay, total hospital charges, and mortality. METHODS Retrospective cohort study. Using data from >100 US hospitals, this study identified all adults (age ≥18 years) hospitalized for pneumonia between January 1, 2000 and June 30, 2009 who began antibiotic therapy within 24 h of admission and were treated for at least 48 h if alive; patients admitted to intensive care within the first 24 h in hospital were excluded. Initial therapy was defined as all parenteral antibiotics administered within the first 24 h in hospital. Treatment failure was assessed based on subsequent receipt of new antibiotic(s), excluding agents of similar/narrower spectrum and those begun at discharge. Multivariate logistic regression was used to identify risk factors for treatment failure, and multivariate linear and logistic regression to compare length of stay, total hospital charges, and in-hospital mortality between patients experiencing initial treatment failure and those who did not. RESULTS Among 32,324 patients with non-ICU CAP, 4695 (14.6%) experienced initial treatment failure, most often within 72 h of hospital admission. Significant predictors of initial treatment failure included malnourishment (OR = 1.87; 95% CI = 1.60-2.18), receipt of vasoactive medications within 24 h of admission (1.51 [1.17-1.94]), and renal failure (1.45 [1.32-1.59]). Treatment failure was associated with higher case fatality (8.5% vs 3.3%), longer hospital stays (mean [SD] = 10.1 [8.1] days vs 4.9 [3.3] days), and higher total hospital charges ($37,602 [$71,876] vs $14,371 [$21,633]) (all comparisons, p < 0.01). Study limitations include possible inclusion of patients with healthcare-associated pneumonia (HCAP) in the study sample, our focus on the 40 most commonly used antibiotic regimens, and indirect measurement of treatment failure. CONCLUSIONS Approximately one in seven non-ICU CAP patients experience failure of initial antibiotic therapy. Risk of failure is higher for patients with significant comorbidities and/or severe infections. Non-ICU patients who experience initial treatment failure have significantly longer hospital stays, higher total hospital charges, and higher rates of mortality.
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Affiliation(s)
- Gerry Oster
- Policy Analysis Inc. (PAI), Brookline, MA 02445, USA.
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Rosengarten B, Krekel D, Kuhnert S, Schulz R. Early neurovascular uncoupling in the brain during community acquired pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R64. [PMID: 22520083 PMCID: PMC3681393 DOI: 10.1186/cc11310] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 03/28/2012] [Accepted: 04/20/2012] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Sepsis leads to microcirculatory dysfunction and therefore a disturbed neurovascular coupling in the brain. To investigate if the dysfunction is also present in less severe inflammatory diseases we studied the neurovascular coupling in patients suffering from community acquired pneumonia. METHODS Patients were investigated in the acute phase of pneumonia and after recovery. The neurovascular coupling was investigated with a simultaneous electroencephalogram (EEG)-Doppler technique applying a visual stimulation paradigm. Resting EEG frequencies, visual evoked potentials as well as resting and stimulated hemodynamic responses were obtained. Disease severity was characterized by laboratory and cognitive parameters as well as related scoring systems. Data were compared to a control group. RESULTS Whereas visually evoked potentials (VEP) remained stable a significant slowing and therefore uncoupling of the hemodynamic responses were found in the acute phase of pneumonia (Rate time: control group: 3.6 ± 2.5 vs. acute pneumonia: 1.6 ± 2.4 s; P < 0.0005). In the initial investigation, patients who deteriorated showed a decreased hemodynamic response as compared with those who recovered (gain: recovered: 15% ± 4% vs. deteriorated: 9% ± 3%, P < 0.05; control: 14% ± 5%). After recovery the coupling normalized. CONCLUSIONS Our study underlines the role of an early microcirculatory dysfunction in inflammatory syndromes that become evident in pre-septic conditions with a gradual decline according to disease severity.
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Affiliation(s)
- Bernhard Rosengarten
- Department of Neurology, Justus-Liebig University of Giessen, Klinikstrasse 33, 35392 Giessen, Germany.
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Neuman MI, Hall M, Hersh AL, Brogan TV, Parikh K, Newland JG, Blaschke AJ, Williams DJ, Grijalva CG, Tyler A, Shah SS. Influence of hospital guidelines on management of children hospitalized with pneumonia. Pediatrics 2012; 130:e823-30. [PMID: 23090342 PMCID: PMC9923563 DOI: 10.1542/peds.2012-1285] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Clinical practice guidelines (CPGs) assist clinicians in making appropriate diagnostic and treatment decisions based on available evidence. The objective of this study was to describe the availability and content of institutional community-acquired pneumonia (CAP) CPGs, and to evaluate the association between institutional CPGs and care utilization, antibiotic administration, and outcomes among children hospitalized with CAP. METHODS This multicenter retrospective cohort study included children aged 1 to 18 years hospitalized with CAP from July 1, 2009, to June 30, 2011. CPGs from each institution were reviewed to abstract information regarding diagnostic testing and antimicrobial selection. We compared overall and specific utilization patterns, antimicrobial use, and hospital length of stay (LOS) for children with CAP between hospitals with and without CPGs. RESULTS Thirteen (31.7%) of 41 hospitals had an institutional CPG for nonsevere CAP. There was marked heterogeneity among CPGs. Among the 19,710 children hospitalized with CAP, cost of care, hospital LOS, and 14-day readmission rate were not associated with the presence of a CPG. CPGs did not influence ordering patterns for most diagnostic tests, including blood culture and chest radiographs. Penicillin or aminopenicillins were prescribed to 46.3% of children at institutions where a CPG recommended the use of these antibiotics as first-line agents compared with 23.9% of children at institutions without a CPG (odds ratio = 2.7; 95% confidence interval = 1.4-5.5). CONCLUSIONS The availability of a CAP CPG had minimal impact on resource utilization and was not associated with cost or hospital LOS. Institutional CPGs, however, did influence patterns of antimicrobial use.
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Affiliation(s)
- Mark I. Neuman
- Division of Emergency Medicine, Children’s Hospital Boston, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;,Address correspondence to Mark I. Neuman, MD, MPH, Children’s Hospital, Division of Emergency Medicine, 300 Longwood Ave, Boston, MA 02115. E-mail:
| | - Matt Hall
- The Children’s Hospital Association, Overland Park, Kansas
| | - Adam L. Hersh
- Division of Pediatric Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah
| | - Thomas V. Brogan
- Division of Critical Care, Seattle Children’s Hospital, and the Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Kavita Parikh
- Division of Hospital Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Jason G. Newland
- Division of Infectious Diseases, Children's Mercy Hospital & Clinics and University of Missouri-Kansas City, Kansas City, Missouri
| | - Anne J. Blaschke
- Division of Pediatric Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah
| | - Derek J. Williams
- Division of Hospital Medicine, The Monroe Carell, Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee;,Departments of Pediatrics and
| | - Carlos G. Grijalva
- Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Amy Tyler
- Division of Pediatric Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado; and
| | - Samir S. Shah
- Divisions of Infectious Diseases and Hospital Medicine, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Chen YH, Keller J, Wang IT, Lin CC, Lin HC. Pneumonia and pregnancy outcomes: a nationwide population-based study. Am J Obstet Gynecol 2012; 207:288.e1-7. [PMID: 23021691 PMCID: PMC7093888 DOI: 10.1016/j.ajog.2012.08.023] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 06/15/2012] [Accepted: 08/14/2012] [Indexed: 12/14/2022]
Abstract
Objective Using 2 nationwide population-based datasets, this study aimed to assess the risk of adverse pregnancy outcomes, including low birthweight (LBW), preterm birth, small for gestational age (SGA), cesarean section (CS), lower Apgar score, and preeclampsia/eclampsia, between women with and without pneumonia. Study Design This study included 1462 women who had been hospitalized with pneumonia during pregnancy and used 7310 matched women without pneumonia as a comparison group. Results Compared to women without pneumonia, conditional logistic regression analyses showed that the adjusted odds ratios for LBW, preterm birth, SGA, CS, Apgar scores <7 at 5 minutes, and preeclampsia/eclampsia in women with pneumonia were 1.73 (95% confidence interval [CI], 1.41–2.12), 1.71 (95% CI, 1.42–2.05), 1.35 (95% CI, 1.17–1.56), 1.77 (95% CI, 1.58–1.98), 3.86 (95% CI, 1.64–9.06), and 3.05 (95% CI, 2.01–4.63), respectively. Conclusion Women with pneumonia during pregnancy had significantly higher risk of LBW, preterm birth, SGA, low Apgar scores infants, CS, and preeclampsia/eclampsia, compared to unaffected women.
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Affiliation(s)
- Yi-Hua Chen
- School of Public Health, Taipei Medical University Hospital, Taipei, Taiwan
| | - Joseph Keller
- School of Public Health, Taipei Medical University Hospital, Taipei, Taiwan
| | - I-Te Wang
- Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ching-Chun Lin
- School of Health Care Administration, Taipei Medical University Hospital, Taipei, Taiwan
| | - Herng-Ching Lin
- School of Health Care Administration, Taipei Medical University Hospital, Taipei, Taiwan
- Reprints: Herng-Ching Lin, PhD, School of Health Care Administration, Taipei Medical University, 250 Wu-Hsing St., Taipei 110, Taiwan
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Reasons for choice of antibiotic for the empirical treatment of CAP by Canadian infectious disease physicians. Can J Infect Dis 2012; 10:337-45. [PMID: 22346393 DOI: 10.1155/1999/928438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/1998] [Accepted: 12/18/1998] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Previous studies have documented substantial variation in physician prescribing practices for the treatment of community-acquired pneumonia. Much of this variation is the result of empirical treatment, in which physicians must choose antibiotics in the a8bsence of culture and sensitivity data. OBJECTIVE To explore the factors that influence antibiotic choice for the empirical treatment of community-acquired pneumonia. MATERIALS AND METHODS Case-based questionnaires were mailed to all 157 members of the Canadian Infectious Disease Society in June 1996. The questionnaires presented three clinical cases and asked respondents which antibiotics they would most likely prescribe. Half the questionnaires were closed-ended, and half were open-ended. In the former, respondents were asked to explain their antibiotic choice by assigning weights to a list of clinical factors. In the latter, respondents were asked to explain their antibiotic choice by providing a short written answer. Respondents were grouped by the class of antibiotics they selected. These groups were then compared with regards to respondent characteristics (age, years of infectious disease experience, adult versus pediatric practice, country of training, province of practice) and rationale for the treatment chosen. Rationale for drug choice was analyzed statistically for the closed-ended questionnaires and qualitatively for the open-ended questionnaires. RESULTS A response rate of 84.6% was obtained. For the first clinical case, in which the patient was young and had no underlying illness, the majority of respondents chose a macrolide (74.7%). In the second case, in which the patient was older and had evidence of comorbidity, the most common choice of antibiotic was a penicillin (40.8%). In the third case, in which the patient had intensive care unit-requiring pneumonia, the most popular choice was combination therapy of a third-generation cephalosporin and a macrolide (43.2%). There was decreasing consensus regarding the choice of antibiotics as the complexity of the cases increased. There was evidence that prescribing variation could occasionally be attributed to both respondent characteristics and the use of different decision-making strategies. CONCLUSIONS Despite the relative homogeneity of the physicians studied, considerable variation in antibiotic choice was observed. In the first case, this variation was based on the issue of whether the patient had a typical or atypical infection. In the second case, the choice of antibiotic was related to the issue of infection by Haemophilus influenzae, although the results of the Gram stain suggested a pneumococcal infection. In the third case, variance appeared to be based more on the respondent's age and province of practice than on any difference in decision-making strategy.
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75
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de Castro FR, Torres A. Optimizing Treatment Outcomes in Severe Community-Acquired Pneumonia. ACTA ACUST UNITED AC 2012; 2:39-54. [PMID: 14720021 DOI: 10.1007/bf03256638] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Severe community-acquired pneumonia (CAP) is a life-threatening condition that requires intensive care unit (ICU) admission. Clinical presentation is characterized by the presence of respiratory failure, severe sepsis, or septic shock. Severe CAP accounts for approximately 5-35% of hospital-treated cases of pneumonia with the majority of patients having underlying comorbidities. The most common pathogens associated with this disease are Streptococcus pneumoniae, Legionella spp., Haemophilus influenzae, and Gram-negative enteric rods. Microbial investigation is probably helpful in the individual case but is likely to be more useful for defining local antimicrobial policies. The early and rapid initiation of empiric antimicrobial treatment is critical for a favorable outcome. It should include intravenous beta-lactam along with either a macrolide or a fluoroquinolone. Modifications of this basic regimen should be considered in the presence of distinct comorbid conditions and risk factors for specific pathogens. Other promising nonantimicrobial new therapies are currently being investigated. The assessment of severity of CAP helps physicians to identify patients who could be managed safely in an ambulatory setting. It may also play a crucial role in decisions about length of hospital stay and time of switching to oral antimicrobial therapy in different groups at risk. The most important adverse prognostic factors include advancing age, male sex, poor health of patient, acute respiratory failure, severe sepsis, septic shock, progressive radiographic course, bacteremia, signs of disease progression within the first 48-72 hours, and the presence of several different pathogens such as S. pneumoniae, Staphylococcus aureus, Gram-negative enteric bacilli, or Pseudomonas aeruginosa. However, some important topics of severity assessment remain controversial, including the definition of severe CAP. Prediction rules for complications or death from CAP, although far from perfect, should identify the majority of patients with severe CAP and be used to support decision-making by the physician. They may also contribute to the evaluation of processes and outcomes of care for patients with CAP.
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Affiliation(s)
- Felipe Rodríguez de Castro
- Servicio de Neumología, Hospital Universitario de Gran Canaria "Dr Negrín", Universidad de Las Palmas de Gran Canaria, Las Palmas, Spain
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Periodontal infections and community-acquired pneumonia: a case–control study. Eur J Clin Microbiol Infect Dis 2012; 32:27-32. [DOI: 10.1007/s10096-012-1710-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 07/18/2012] [Indexed: 10/28/2022]
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Wilson BZ, Anzueto A, Restrepo MI, Pugh MJV, Mortensen EM. Comparison of two guideline-concordant antimicrobial combinations in elderly patients hospitalized with severe community-acquired pneumonia. Crit Care Med 2012; 40:2310-4. [PMID: 22622401 PMCID: PMC4066649 DOI: 10.1097/ccm.0b013e31825151a8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Two of the guideline-concordant therapies for severe community-acquired pneumonia are either a beta-lactam and fluoroquinolone or beta-lactam and macrolide. However it is unclear if there is a benefit for one vs. the other for elderly patients with severe community-acquired pneumonia. DESIGN A retrospective population-based cohort study of patients with community-acquired pneumonia. SETTING Patients admitted to an intensive care unit of any Department of Veterans Affairs hospital during 5-yr period. PATIENTS We included only those patients>65 yrs of age admitted to the intensive care unit with community-acquired pneumonia who received either beta-lactam+fluoroquinolone or beta-lactam+macrolide antibiotic therapy for pneumonia. INTERVENTION Not applicable. MEASUREMENTS We used multilevel regression models to examine the effect of beta-lactam+fluoroquinolone vs. beta-lactam+macrolide on each of the outcomes after adjusting for potential confounders using propensity scores. MAIN RESULTS The cohort consisted of 1,989 patients: 98.5% male and a mean age of 74 yrs. For treatment, 44% of subjects received beta-lactam+fluoroquinolone and 56% received beta-lactam+macrolide. Unadjusted 30-day mortality was 27% for beta-lactam+fluoroquinolone and 24% for beta-lactam+macrolide (p=.11). In the multilevel models, the use of beta-lactam+fluoroquinolone was not significantly associated with 30-day mortality (odds ratio 1.05, 95% confidence interval 0.85-1.30). However, the use of beta-lactam+fluoroquinolone was significantly associated with increased mean length of stay (incidence rate ratio 1.30, 95% confidence interval 1.27-1.33). CONCLUSIONS We found no significant difference for 30-day mortality but did demonstrate an association with increase in length of stay associated with the use of beta-lactam + fluoroquinolone. Randomized controlled trials are needed to determine the most effective antibiotics regimes for patients with severe pneumonia.
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Affiliation(s)
- Bryan Z Wilson
- VERDICT/South Texas Veterans Health Care System, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Marti C, Garin N, Grosgurin O, Poncet A, Combescure C, Carballo S, Perrier A. Prediction of severe community-acquired pneumonia: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R141. [PMID: 22839689 PMCID: PMC3580727 DOI: 10.1186/cc11447] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 07/27/2012] [Indexed: 02/07/2023]
Abstract
Introduction Severity assessment and site-of-care decisions for patients with community-acquired pneumonia (CAP) are pivotal for patients' safety and adequate allocation of resources. Late admission to the intensive care unit (ICU) has been associated with increased mortality in CAP. We aimed to review and meta-analyze systematically the performance of clinical prediction rules to identify CAP patients requiring ICU admission or intensive treatment. Methods We systematically searched Medline, Embase, and the Cochrane Controlled Trials registry for clinical trials evaluating the performance of prognostic rules to predict the need for ICU admission, intensive treatment, or the occurrence of early mortality in patients with CAP. Results Sufficient data were available to perform a meta-analysis on eight scores: PSI, CURB-65, CRB-65, CURB, ATS 2001, ATS/IDSA 2007, SCAP score, and SMART-COP. The estimated AUC of PSI and CURB-65 scores to predict ICU admission was 0.69. Among scores proposed for prediction of ICU admission, ATS-2001 and ATS/IDSA 2007 scores had better operative characteristics, with a sensitivity of 70% (CI, 61 to 77) and 84% (48 to 97) and a specificity of 90% (CI, 82 to 95) and 78% (46 to 93), but their clinical utility is limited by the use of major criteria. ATS/IDSA 2007 minor criteria have good specificity (91% CI, 84 to 95) and moderate sensitivity (57% CI, 46 to 68). SMART-COP and SCAP score have good sensitivity (79% CI, 69 to 97, and 94% CI, 88 to 97) and moderate specificity (64% CI, 30 to 66, and 46% CI, 27 to 66). Major differences in populations, prognostic factor measurement, and outcome definition limit comparison. Our analysis also highlights a high degree of heterogeneity among the studies. Conclusions New severity scores for predicting the need for ICU or intensive treatment in patients with CAP, such as ATS/IDSA 2007 minor criteria, SCAP score, and SMART-COP, have better discriminative performances compared with PSI and CURB-65. High negative predictive value is the most consistent finding among the different prediction rules. These rules should be considered an aid to clinical judgment to guide ICU admission in CAP patients.
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Epidemiologic Assessment of Mortality, Building Collapse Pattern, and Medical Response after the 1992 Earthquake in Turkey. Prehosp Disaster Med 2012. [DOI: 10.1017/s1049023x0003764x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Post-earthquake engineering and epidemiologic assessments are important for the development of injury prevention strategies. This paper describes mortality and its relationship to building collapse patterns and initial medical responses following the 1992 earthquake in Erzincan, Turkey.Methods:The study consisted of: 1) background data collection and review; 2) design and implementation of a field survey; and 3) site inspection of building collapse patterns. The survey included: 1) national (n = 11) and local (n = 17) officials; 2) medical and search and rescue (SAR) workers (n = 38); and 3) a geographically stratified random sample of lay survivors (n = 105). The survey instruments were designed to gather information regarding location, injuries, initial actions and prior training of survivors and responders, and the location, injuries, and management of dead and dying victims. A case-control design was constructed to assess the relationship between mortality, location, and building collapse pattern.Results:There was extensive structural damage throughout the region, especially in the city where mid-rise, unreinforced masonry buildings (MUMBs) incorporating a “soft” first floor design (large store windows for commercial use) and one story adobe structures were most vulnerable to collapse. Of 526 people who died in the city, 87% (n = 456) were indoors at the time of the earthquake. Of these, 92% (n = 418) died in MUMBs. Of 54 witnessed deaths, 55% (n = 28) of victims died slowly, the majority of whom (n = 26) were pinned or trapped (p <0.05). Of 42 MUMB occupants identified through the survey, those who died (n = 25) were more likely to have been occupying the ground floor when compared with survivors (n = 28) (p <0.01). Official medical and search and rescue responders arrived after most deaths had occurred. Prior first-aid or rescue training of lay, uninjured survivors was associated with a higher likelihood of rescuing and resuscitating others (p <0.001).Conclusion:During an earthquake, MUMBs with soft ground floor construction are highly lethal, especially for occupants on the ground floor, suggesting that this building type is inappropriate for areas of seismic risk. The vulnerability of MUMBs appears due to a lack of lateral force resistance as a result of the use of glass store fiont windows and the absence of shear walls. The prevalence of this building type in earthquake-prone regions needs to be investigated further. A large portion of victims dying in an earthquake die slowly at the scene of injury. Prior public first-aid and rescue training programs increase participation in rescue efforts in major earthquakes and may improve survival.
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Abstract
AbstractIntroduction:A mass casualty disaster (MCD) never has occurred in the United States, but such an event remains a fearful possibility. The purpose of this study was to establish baseline information concerning the perceptions relative to the capabilities of the United States to respond to a MCD of persons most likely to involved in the responses to such an event when it does occur.Methods:A survey was constructed in 1995 to query the perceptions of persons in authority in federal, state, and local agencies who would participate in the medical responses to a MCD. Participants were asked to select the most likely scenario, a hurricane or earthquake, that could generate 30,000 casualties within their respective region. The survey requested respondent's perceptions as to the timing of the federal responses and the quality and sufficiency of these responses. The survey also sought information about the availability of plans to meet such a catastrophe in the region, and the frequency with which such plans have been exercised.Responses were grouped by phase of the responses and whether the respondents were employed by federal, state, or local agencies. Descriptive statistics were used to summarize the data. When appropriate, a one-tailed t-test was used to compare the responses of the groups. A p-value = 0.05 was considered statistically significant.Results:A total of 104 surveys were distributed of which 88 were completed and returned (85%). Both the federal and state respondents had considerable experienced in this area.Overall, the federal respondents were more optimistic about the availability, utility, and timely arrival of federal resources to assist regions in meeting the medical needs. In each of the three phases of MCD responses evaluated (medical response, patient evacuation, and definitive care), there was concern that there were insufficient resources to meet the requirements. States and local respondents perceived that initially, they will be on their own for field rescue, life-supporting first-aid, and casualty evacuation. Respondents acknowledged that a combination of local, state, federal, and private resources eventually would be needed to meet the huge demand. Only 31% federal and 26% state/local respondents believed that there will be sufficient combined local, state, federal, and private resources to meet the requirements for the evacuation of casualties to definitive care facilities outside of the region, and another 50% acknowledged the resources would only partially meet these requirements. Sixty-eight percent of state/local respondents believed that there would be insufficient local, state, federal, and private definitive care resources to meet the requirements for definitive care.Conclusion:While three years have elapsed since the survey was conducted and there have been some improvements in preparedness and responses, concerns center around the perceived lack of resource capability or lack of ability to get the resources to the MCD scene in time to meet requirements. Such perceptions by experienced professionals warrant further review by those at all levels of government responsible for planning and responding to mass casualty disasters.
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Delgado M, Alvarez MM, Carrascosa I, Rodríguez-Velasco M, Barrios JL, Canut A. [The routine use of the Pneumonia Severity Index in the emergency department: effect on process-of-care indicators and results in community acquired pneumonia]. Enferm Infecc Microbiol Clin 2012; 31:289-97. [PMID: 22728072 DOI: 10.1016/j.eimc.2012.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 04/24/2012] [Accepted: 04/27/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate process-of-care indicators (inappropriate hospitalisation, suitability and early antibiotic treatment) and outcome indicators (length of hospital stay, hospital readmission, ICU admission, and mortality) in the management of community-acquired pneumonia (CAP) when the SEPAR/IDSA guidelines were applied. PATIENTS AND METHODS An observational retrospective study conducted on patients diagnosed with CAP during the first semester of 2007 and 2008 (186 and 161 patients, respectively) in the emergency unit of a general hospital. Differences in the process-of-care and outcome indicators between 2007 and 2008 (with and without the Pneumonia Severity Index [PSI]) were evaluated. Moreover, the indicators were compared with those obtained in 2006 (110 patients), when the current guidelines were those of SEQ/ATS. RESULTS The SEPAR/IDSA guidelines improved the following process-of-care indicators: appropriateness of treatment, unjustified hospital readmission (39.4% in 2006 vs. 8.5% in 2007 [P<.001], and 17,2% in 2008 [P=.005]), and early treatment. However, outcome indicators did not change. In 2008, a decrease in the mortality of the patients of risk classes IV-V in which the PSI had been estimated was observed in comparison with the patients in which the PSI was not estimated (2.3% vs. 28.3%; P<.001). Moreover, the mortality rate of the patients of risk classes IV-V in which the PSI had been estimated was lower than those measured using the SEQ/ATS guidelines (22.7%; P=.003). CONCLUSION SEPAR/IDSA guidelines decreased the unjustified hospital readmission. In the second year of its application an increase in the number of patients who received early treatment, and a decrease of the mortality rate of the patients of risk classes IV-V in which the PSI had been estimated, were also observed.
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Affiliation(s)
- Miriam Delgado
- Servicio de Medicina Interna, Hospital Universitario de Álava-Sede Hospital Santiago, Osakidetza-Servicio Vasco de Salud, Vitoria-Gasteiz, Spain
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Asai N, Motojima S, Ohkuni Y, Matsunuma R, Nakasima K, Iwasaki T, Nakashita T, Otsuka Y, Kaneko N. Non-HIV Pneumocystis pneumonia: do conventional community-acquired pneumonia guidelines under estimate its severity? Multidiscip Respir Med 2012; 7:2. [PMID: 22958656 PMCID: PMC3415119 DOI: 10.1186/2049-6958-7-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 06/11/2012] [Indexed: 11/24/2022] Open
Abstract
Background Non-HIV Pneumocystis pneumonia (PCP) can occur in immunosuppressed patients having malignancy or on immunosuppressive agents. To classify severity, the A-DROP scale proposed by the Japanese Respiratory Society (JRS), the CURB-65 score of the British Respiratory Society (BTS) and the Pneumonia Severity Index (PSI) of the Infectious Diseases Society of America (IDSA) are widely used in patients with community-acquired pneumonia (CAP) in Japan. To evaluate how correctly these conventional prognostic guidelines for CAP reflect the severity of non-HIV PCP, we retrospectively analyzed 21 patients with non-HIV PCP. Methods A total of 21 patients were diagnosed by conventional staining and polymerase chain reaction (PCR) for respiratory samples with chest x-ray and computed tomography (CT) findings. We compared the severity of 21 patients with PCP classified by A-DROP, CURB-65, and PSI. Also, patients’ characteristics, clinical pictures, laboratory results at first visit or admission and intervals from diagnosis to start of specific-PCP therapy were evaluated in both survivor and non-survivor groups. Results Based on A-DROP, 18 patients were classified as mild or moderate; respiratory failure developed in 15 of these 18 (83.3%), and 7/15 (46.7%) died. Based on CURB-65, 19 patients were classified as mild or moderate; respiratory failure developed in 16/19 (84.2%), and 8 of the 16 (50%) died. In contrast, PSI classified 14 as severe or extremely severe; all of the 14 (100%) developed respiratory failure and 8/14 (57.1%) died. There were no significant differences in laboratory results in these groups. The time between the initial visit and diagnosis, and the time between the initial visit and starting of specific-PCP therapy were statistically shorter in the survivor group than in the non-survivor group. Conclusions Conventional prognostic guidelines for CAP could underestimate the severity of non-HIV PCP, resulting in a therapeutic delay resulting in high mortality. The most important factor to improve the mortality of non-HIV PCP is early diagnosis and starting of specific-PCP therapy as soon as possible.
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Affiliation(s)
- Nobuhiro Asai
- Department of Pulmonology, Kameda Medical Center, 296-8602, 929 higashi-cho, Kamogawa-city, Chiba, Japan.
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Neuman MI, Ting SA, Meydani A, Mansbach JM, Camargo CA. National study of antibiotic use in emergency department visits for pneumonia, 1993 through 2008. Acad Emerg Med 2012; 19:562-8. [PMID: 22594360 DOI: 10.1111/j.1553-2712.2012.01342.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) developed guidelines for the management of community-acquired pneumonia (CAP); however, there are sparse data on actual rates of antibiotic use in the emergency department (ED) setting. METHODS Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for ED visits during 1993 through 2008 for adults with a diagnosis of pneumonia. RESULTS During the study period there were an estimated 23,252,000 pneumonia visits, representing 1.8% of all ED visits. The visit rate for pneumonia during this 16-year period may have increased (p trend = 0.055). Overall, 66% of adult patients with a primary diagnosis of pneumonia had documentation of an antibiotic administered while in the ED. There was an increase in antibiotic administration for adults with pneumonia from 1993 through 2008 (49% to 80%; p trend < 0.001). Specifically, there was an increase in use of macrolides from 1993 to 2006 (20% to 30%, p trend < 0.001) and a marked increase in use of quinolones from 0% to 39% from 1993 through 2008 (p trend < 0.001). Penicillin and cephalosporin use remained stable. Use of an antibiotic consistent with 2007 IDSA/ATS guidelines increased from 22% (95% confidence interval [CI] = 16% to 27%) of cases in 1993-1994 to 68% (95% CI = 63% to 73%) of cases in 2007-2008 (p trend < 0.001). CONCLUSIONS ED visit rates for pneumonia increased slightly from 1993 through 2008. Although antibiotic administration in the ED has increased for adults with CAP, guideline-concordant antibiotics may not be consistently administered.
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Affiliation(s)
- Mark I Neuman
- Division of Emergency Medicine, Children's Hospital, Boston, MA, USA.
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84
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Abstract
Patients admitted to the intensive care unit (ICU) often have significant underlying morbidities that require complex treatment plans. Because of these complexities, numerous guidelines have been developed to facilitate the management of the critically ill patient. Some of these guidelines include sepsis, community-acquired and ventilator-associated pneumonia, sedation, and glycemic control. Once guidelines are written, a treatment protocol must be developed and implemented within the critical care unit. Our medical center has implemented multiple treatment protocols, often with preprinted order sets with various degrees of success. In 2003, we implemented and later evaluated a sedation order form and protocol. Patients whose sedation was initiated with a standardized order form had more frequent sedation score assessment, less time between sedation vacations, reduced ICU length of ICU stay, and a trend in reduction of ventilator days. However, only 37% of eligible patients were treated using the order form and the protocol, despite the potentially beneficial effects. Some recommendations within guidelines are based on sound clinical evidence supported by randomized controlled trials, although others are based on expert opinion only. The most often-cited reason for protocol noncompliance is disagreement with the published clinical trial data. This paper examines both infectious and noninfectious treatment guidelines and the supportive evidence that they improved patient outcomes. In addition, strategies for successful implementation of a treatment guideline are discussed for clinicians to follow in order to maximize clinical outcomes.
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Affiliation(s)
- Stephen W Nissen
- Department of Pharmaceutical Services, The Nebraska Medical Center, 981090 Nebraska Medical Center, Omaha, NE, USA
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Ferrer M, Menendez R, Amaro R, Torres A. The impact of guidelines on the outcomes of community-acquired and ventilator-associated pneumonia. Clin Chest Med 2012; 32:491-505. [PMID: 21867818 DOI: 10.1016/j.ccm.2011.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The correct implementation of the current guidelines for the management of community-acquired pneumonia is associated with less mortality, faster clinical stabilization, and lower costs in these patients. By contrast, implementing the current guidelines for the management of hospital-acquired pneumonia has been followed by an increase in initially adequate antibiotic treatment but has not been accompanied by a consistently improved outcome in patients.
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Affiliation(s)
- Miquel Ferrer
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Villarroel, Spain
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86
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Epidemiology of community-acquired pneumonia in children of Latin America and the Caribbean: a systematic review and meta-analysis. Int J Infect Dis 2012; 16:e5-15. [DOI: 10.1016/j.ijid.2011.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 09/08/2011] [Accepted: 09/12/2011] [Indexed: 11/22/2022] Open
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Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH, Moore MR, St Peter SD, Stockwell JA, Swanson JT. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011; 53:e25-76. [PMID: 21880587 PMCID: PMC7107838 DOI: 10.1093/cid/cir531] [Citation(s) in RCA: 974] [Impact Index Per Article: 74.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 07/08/2011] [Indexed: 02/07/2023] Open
Abstract
Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.
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Affiliation(s)
- John S Bradley
- Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, San Diego, California, USA.
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Sala H, Roca JS, Zerbo C, Garcia R, Cabral G, Fernandez A, Tummino C, Baldini M, Rizzo O. Initial Clinical Management of Symptomatic Adult Patients during Influenza A (H1N1) Epidemics. J Emerg Med 2011; 41:435-40. [DOI: 10.1016/j.jemermed.2010.05.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 03/07/2010] [Accepted: 05/28/2010] [Indexed: 10/19/2022]
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Dean NC, Jones JP, Aronsky D, Brown S, Vines CG, Jones BE, Allen T. Hospital admission decision for patients with community-acquired pneumonia: variability among physicians in an emergency department. Ann Emerg Med 2011; 59:35-41. [PMID: 21907451 DOI: 10.1016/j.annemergmed.2011.07.032] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 07/11/2011] [Accepted: 07/25/2011] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes. METHODS We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined "low severity" as PaO(2)/FiO(2) ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics. RESULTS Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions. CONCLUSION We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data.
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Affiliation(s)
- Nathan C Dean
- Pulmonary and Critical Care Medicine Division at Intermountain Medical Center and the University of Utah, Salt Lake City, UT, USA.
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90
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Shah BA, Singh G, Naik MA, Dhobi GN. Bacteriological and clinical profile of Community acquired pneumonia in hospitalized patients. Lung India 2011; 27:54-7. [PMID: 20616935 PMCID: PMC2893425 DOI: 10.4103/0970-2113.63606] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The aim of our study was to obtain comprehensive insight into the bacteriological and clinical profile of community-acquired pneumonia requiring hospitalization. The patient population consisted of 100 patients admitted with the diagnosis of community-acquired pneumonia (CAP), as defined by British Thoracic society, from December 1998 to Dec 2000, at the Sher- i-Kashmir institute of Medical Sciences Soura, Srinagar, India. Gram negative organisms were the commonest cause (19/29), followed by gram positive (10/29). In 71 cases no etiological cause was obtained. Pseudomonas aeruginosa was the commonest pathogen (10/29), followed by Staphylococcus aureus (7/29), Escherichia coli (6/29), Klebsiella spp. (3/29), Streptococcus pyogenes (1/29), Streptococcus pneumoniae (1/29) and Acinetobacter spp. (1/29). Sputum was the most common etiological source of organism isolation (26) followed by blood (6), pleural fluid (3), and pus culture (1). Maximum number of patients presented with cough (99%), fever (95%), tachycardia (92%), pleuritic chest pain (75%), sputum production (65%) and leucocytosis (43%). The commonest predisposing factors were smoking (65%), COPD (57%), structural lung disease (21%), diabetes mellitus (13%), and decreased level of consciousness following seizure (eight per cent) and chronic alcoholism (one per cent). Fourteen patients, of whom, nine were males and five females, died. Staphylococcus aureus was the causative organism in four, Pseudomonas in two, Klebsiella in one, and no organism was isolated in seven cases. The factors predicting mortality at admission were - age over 62 years, history of COPD or smoking, hypotension, altered sensorium, respiratory failure, leucocytosis, and staphylococcus pneumonia and undetermined etiology. The overall rate of identification of microbial etiology of community-acquired pneumonia was 29%, which is very low, and if serological tests for legionella, mycoplasma and viruses are performed the diagnostic yield would definitely be better. This emphasizes the need for further studies (including the serological tests for Legionella, mycoplasma and viruses) to identify the microbial etiology of CAP.
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Abstract
Pneumonia is an important clinical and public health problem. Identification and prediction of severe pneumonia are significant concerns. Attempts to define severe pneumonia should recognize that different purposes are served by different definitions; no single definition meets all needs. At present, several prediction models have been proposed or validated. Biomarkers are not yet ready for routine use. The authors recommend careful consideration of the implications of any given definition of pneumonia severity. Outcome studies are needed to integrate human and health care system factors with the application of pneumonia severity definitions.
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Affiliation(s)
- Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.
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92
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Corticosteroid treatment in severe community-acquired pneumonia: duration of treatment affects control of systemic inflammation and clinical improvement. Intensive Care Med 2011; 37:1553-4. [PMID: 21688102 DOI: 10.1007/s00134-011-2274-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2011] [Indexed: 01/24/2023]
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93
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Grenier C, Pépin J, Nault V, Howson J, Fournier X, Poirier MS, Cabana J, Craig C, Beaudoin M, Valiquette L. Impact of guideline-consistent therapy on outcome of patients with healthcare-associated and community-acquired pneumonia. J Antimicrob Chemother 2011; 66:1617-24. [PMID: 21586592 DOI: 10.1093/jac/dkr176] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A new category of healthcare-associated pneumonia (HCAP) has been added in the most recent American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines, since multidrug-resistant (MDR) pathogens are more common in patients with HCAP than in those with community-acquired pneumonia (CAP). The optimal empirical management of patients with HCAP remains controversial and adherence to guidelines is inconsistent. METHODS A retrospective cohort study of 3295 adults admitted for pneumonia in an academic centre of Canada, between 1997 and 2008. RESULTS MDR pathogens were more common among patients with HCAP than in those with CAP, but less so than in other studies. Compared with patients with CAP, those with HCAP had a higher all-cause 30 day mortality [68/563 (12%) versus 201/2732 (7%); P < 0.001] and more frequent need for mechanical ventilation [78/563 (14%) versus 276/2732 (10%); P = 0.01]. In patients with CAP, mortality was lower when treatment was concordant with guidelines [86/1557 (6%) versus 109/1097 (10%) if discordant; adjusted odds ratio 0.6 (0.4-0.8); P < 0.001]. In HCAP, mortality was similar whether or not empirical treatment was concordant with guidelines [6/35 (17%) versus 18/148 (12%) if discordant; P = 0.4]. However, 30 day mortality tended to be higher when the empirical treatment was microbiologically ineffective [4/22 (18%) versus 17/187 (9%) when effective; P = 0.3]. CONCLUSIONS HCAP is associated with worse outcomes than CAP. MDR pathogens were implicated in only a small fraction of HCAP cases. In our study, unlike CAP, non-respect of current HCAP guidelines had no adverse effect on the ultimate outcome. Strategies for the empirical management of HCAP should be tailored to the local epidemiological context.
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Affiliation(s)
- Cynthia Grenier
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Québec, Canada
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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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95
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Association between the number of blood cultures and appropriateness of care for suspected bacteremic urinary tract infection in the elderly. J Infect Chemother 2011; 17:341-50. [PMID: 21437681 DOI: 10.1007/s10156-011-0229-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Accepted: 02/17/2011] [Indexed: 10/18/2022]
Abstract
The objective of this study was to evaluate the association between the number of blood cultures collected and the appropriateness of care for suspected bacteremic community-acquired urinary tract infection (UTI) in the elderly. We retrospectively evaluated the medical records of 129 patients with UTI > 65 years old admitted to a large community-based training hospital in Japan from 1 January 2006 to 31 December 2009. We assessed the association between the number of blood cultures collected and the appropriateness of care received, as well as other factors. Two-thirds of the patients were women, and patients > 85 years old accounted for 45.0% of the cases. Most of the organisms isolated from the urine and blood were Escherichia coli (65.4-67.0%). More than two blood cultures were collected 79.1% of the time, and 66.7% of the cases were evaluated as having been treated appropriately. The appropriateness of care was not significantly related to the number of blood cultures. The appropriateness of care received in the general internal medicine department was significantly higher (p = 0.016) than that in other departments. Thus, the appropriateness of care for suspected bacteremic UTI in the elderly was not significantly associated with the number of blood cultures. However, the department of hospitalization may have influenced the appropriateness of care.
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Ruhnke GW, Coca-Perraillon M, Kitch BT, Cutler DM. Marked reduction in 30-day mortality among elderly patients with community-acquired pneumonia. Am J Med 2011; 124:171-178.e1. [PMID: 21295197 PMCID: PMC3064506 DOI: 10.1016/j.amjmed.2010.08.019] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 08/26/2010] [Accepted: 08/31/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Community-acquired pneumonia is the most common infectious cause of death in the US. Over the last 2 decades, patient characteristics and clinical care have changed. To understand the impact of these changes, we quantified incidence and mortality trends among elderly adults. METHODS We used Medicare claims to identify episodes of pneumonia, based on a validated combination of diagnosis codes. Comorbidities were ascertained using the diagnosis codes located on a 1-year look back. Trends in patient characteristics and site of care were compared. The association between year of pneumonia episode and 30-day mortality was then evaluated by logistic regression, with adjustment for age, sex, and comorbidities. RESULTS We identified 2,654,955 cases of pneumonia from 1987-2005. During this period, the proportion treated as inpatients decreased, the proportion aged ≥80 years increased, and the frequency of many comorbidities rose. Adjusted incidence increased to 3096 episodes per 100,000 population in 1999, with some decrease thereafter. Age/sex-adjusted mortality decreased from 13.5% to 9.7%, a relative reduction of 28.1%. Compared with 1987, the risk of mortality decreased through 2005 (adjusted odds ratio, 0.46; 95% confidence interval, 0.44-0.47). This result was robust to a restriction on comorbid diagnoses assessing for the results' sensitivity to increased coding. CONCLUSIONS These findings show a marked mortality reduction over time in community-acquired pneumonia patients. We hypothesize that increased pneumococcal and influenza vaccination rates as well as wider use of guideline-concordant antibiotics explain a large portion of this trend.
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Affiliation(s)
- Gregory W Ruhnke
- Section of Hospital Medicine, University of Chicago, IL 60637, USA.
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97
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Bui H, Vargas F, Gruson D, Hilbert G. Où traiter une pneumopathie aiguë communautaire : évaluation de la sévérité ? Rev Mal Respir 2011; 28:240-53. [DOI: 10.1016/j.rmr.2010.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 08/04/2010] [Indexed: 10/18/2022]
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Park E, Park JH, Hong MJ, Kim WD, Lee KY, Kim SJ, Kim HJ, Ha KW, Chon GR, Kim HA, Yoo KH. Usefulness of Vibration Response Imaging (VRI) for Pneumonia Patients. Tuberc Respir Dis (Seoul) 2011. [DOI: 10.4046/trd.2011.71.1.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Eugene Park
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jung Hee Park
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Mi-Jin Hong
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Won Dong Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kye Young Lee
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Sun Jong Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hee Joung Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kyoung-Won Ha
- Department of Internal Medicine, Konkuk University Chungju Hospital, Chungju, Korea
| | - Gyu Rak Chon
- Department of Internal Medicine, Konkuk University Chungju Hospital, Chungju, Korea
| | - Hyun Ai Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kwang Ha Yoo
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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Berdyev D, Scapin R, Labille C, Lambin L, Fartoukh M. Infections communautaires graves — Les pneumonies aiguës communautaires bactériennes de l’adulte. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0031-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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