Markers of treatment failure in hospitalised community acquired pneumonia

Severity assessment in community-acquired pneumonia: a review

Severity assessment is an important early step in the management of patients presenting with community-acquired pneumonia. Various pneumonia-specific scores, generic sepsis scores and predictive biomarkers have been proposed as tools to aid clinicians in key management decisions. However, there is no uniform agreement about the optimum severity assessment tool to use. This review provides a summary of current evidence surrounding severity assessment in adult patients presenting with community-acquired pneumonia.

Plasma transforming growth factor-beta1 level in patients with severe community-acquired pneumonia and association with disease severity

BACKGROUND/PURPOSE

Pro- and anti-inflammatory cytokines, such as interferon (IFN)-gamma, interleukin (IL)-6, IL-10, IL-12 and transforming growth factor (TGF)-beta1, have been shown to be mediators associated with severe community-acquired pneumonia (CAP). It is unknown whether plasma TGF-beta1 level can help physicians to judge disease severity. In this study, we investigated the value of predicting mortality in patients with severe CAP by the plasma levels of IFN-gamma, IL-6, IL-10, IL-12 and TGF-beta1 on admission day.

METHODS

Patients who were admitted to the emergency department and soon transferred to the ICU because of severe CAP were enrolled in this study. Plasma levels of IFN-gamma, IL-6, IL-10, IL-12 and TGF-beta1 on the day of admission were determined in 49 survivors and 14 non-survivors within 28 days by ELISA. Clinical characteristics were also recorded.

RESULTS

Plasma IL-6, IL-10 and TGF-beta1 levels on admission were significantly different between survivors and non-survivors. Conversely, there was no significant difference in plasma IFN-gamma and IL-12 levels between the survivors and non-survivors. Furthermore, the plasma TGF-beta1 level was the only independent factor associated with mortality. The value of predicting mortality in patients with severe CAP was similar for IL-6, IL-10 and TGF-beta1. Plasma IL-6 level was not related to the Acute Physiology and Chronic Health Evaluation (APACHE) II score. However, plasma IL-10 and TGF-beta1 levels were correlated with APACHE II score.

CONCLUSION

A severity scoring system, including TGF-beta1 level on admission, may be considered as a useful parameter to predict outcomes of patients with severe CAP.

The role of biomarkers in community-acquired pneumonia: predicting mortality and response to adjunctive therapy

Patients with community-acquired pneumonia (CAP) in the hospital setting exhibit markedly abnormal levels of various biomarkers of infection, inflammation and coagulation. CAP is a well characterized disease, relatively homogeneous and amenable to management according to defined protocols. Hence, this group of patients represents an opportunity to investigate further these biomarkers as a means of determining disease severity and identifying candidates for new therapies. Changes in biomarker levels during the course of disease may enable physicians to identify those patients who are most at risk for deterioration and progression toward severe CAP and who are in greatest need of early intervention. Subgroup analysis of the placebo-controlled OPTIMIST trial of tifacogin in severe sepsis revealed a trend toward benefit in patients with procalcitonin levels of 2 ng/ml or greater and in those with high baseline markers of activated coagulation. Biomarker studies are being undertaken as part of the ongoing CAPTIVATE study. This study includes patients with severe CAP and will compare the efficacy and safety of recombinant tissue factor pathway inhibitor (tifacogin) versus placebo. In the future it may also be possible to use genomic markers to identify patients at greatest risk for deterioration or complications.

Pneumonia in the emergency department

Pneumonia remains one of the most common reasons for admission of emergency department (ED) patients to the hospital. Pneumonia also remains one of the most common causes of death in our patients. As with many emergent conditions, the ED management of these patients initiated by ED physicians contributes greatly to the survival and successful management of these patients. Specifically, the recognition of severe pneumonias, precise choice of diagnostic tests, and appropriate antibiotics can have an impact on the outcome.