101
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Ewig S, Woodhead M, Torres A. Towards a sensible comprehension of severe community-acquired pneumonia. Intensive Care Med 2010; 37:214-23. [PMID: 21080155 DOI: 10.1007/s00134-010-2077-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Accepted: 10/13/2010] [Indexed: 01/20/2023]
Abstract
Four different rules have been suggested and validated for intensive care unit (ICU) admission for community-acquired pneumonia: modified American Thoracic Society (ATS) rule, Infectious Diseases Society of America (IDSA)/ATS rule, España rule, and SMART-COP. Their performance varies, with sensitivity of around 70% and specificity of around 80-90%. Only negative predictive values are consistently high. Critical methodological issues include the appropriate reference for derivation, the populations studied, the variables included, and the time course of pneumonia. Severe community-acquired pneumonia (SCAP) may evolve because of acute respiratory failure or/and severe sepsis/septic shock. Pneumonia-related complications and decompensated comorbidities may be additional or independent reasons for a severe course. All variables included in predictive rules relate to the two principal reasons for SCAP. However, taken as major criteria, they are of little value for clinical assessment. Instead, a limited set of minor criteria reflecting severity seems appropriate. However, predictive rules may not meet principal needs of severity assessment because of failure in sensitivity, ignorance of the potential contribution of complications or decompensated comorbidity to pneumonia severity, and poor sensitivity for the lower extreme in the spectrum of severe pneumonia, i.e., patients at risk of SCAP. We therefore advocate an approach that refers to the evaluation of the need for intensified treatment rather than ICU, based on a set of minor criteria and sensitive to the dynamic nature of pneumonia. Intensified treatment such as monitoring and treatment of acute respiratory failure or/and severe sepsis/septic shock is thought to improve management and possibly outcomes by setting the focus on both patients with severity criteria at admission and those at risk for SCAP.
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Affiliation(s)
- Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, Evangelisches Krankenhaus Herne und Augusta-Kranken-Anstalt Bochum, Bergstrasse 26, 44791 Bochum, Germany.
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102
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Apisarnthanarak A, Puthavathana P, Mundy L. Detection by microneutralization of antibodies against avian influenza virus in an endemic avian influenza region. Clin Microbiol Infect 2010. [DOI: 10.1111/j.1469-0691.2010.03148.x] [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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103
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Jo S, Kim K, Jung K, Rhee JE, Cho IS, Lee CC, Singer AJ. The effects of incorporating a pneumonia severity index into the admission protocol for community-acquired pneumonia. J Emerg Med 2010; 42:133-8. [PMID: 20542398 DOI: 10.1016/j.jemermed.2010.04.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2009] [Revised: 01/23/2010] [Accepted: 04/11/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a common reason for admissions in the emergency department (ED). However, patient disposition is not always standardized. OBJECTIVE To evaluate the effect of incorporating a pneumonia severity index (PSI) on admission rates and medical costs in CAP patients presenting to the ED. METHODS From April 2008 to March 2009, CAP patients presenting to the ED were prospectively screened and low-risk CAP patients (PSI I, II, or III) were enrolled (after group). Discharge and outpatient care were recommended for this group in the absence of other medical conditions requiring hospitalization. Data from low-risk CAP patients from May 2003 to October 2006 were also collected for comparative analysis (before group). RESULTS There were 365 and 174 patients in the before and after groups, respectively. The admission rate of the after group was significantly lower than that of the before group (30.4% vs. 68.2%, p < 0.01). The subsequent admission rates after ED discharge due to CAP were similar (3.2% vs. 7.7%, p = 0.10). The ultimate admission rate in the after group was significantly lower than that in the before group (32.5% vs. 70.7%, p < 0.01). Direct medical costs per patient for the before and after groups were $US 1532 and $US 1186, respectively (p = 0.03). CONCLUSIONS Incorporation of the PSI into the admission protocol for ED patients with CAP significantly reduced the admission rates and medical costs.
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Affiliation(s)
- Sion Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul, Korea
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104
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Abstract
PURPOSE OF REVIEW Community-acquired pneumonia is a significant clinical and public health problem. Defining and predicting severe pneumonia is difficult but important. RECENT FINDINGS Several new predictive models and more sophisticated approaches to describing pneumonia severity have been recently proposed, with subsequent validation in varied patient populations. Early data suggest that biomarkers may be useful in the future. SUMMARY Definitions of pneumonia severity depend on the relevant clinical or public health question. A health services reference definition seems most useful in most settings. The Infectious Disease Society of America/American Thoracic Society 2007 guidelines and SMART-COP are two recent promising methods for predicting severe pneumonia at the time of presentation. The traditional pneumonia severity index and Confusion Uremia Respiratory rate Blood pressure (CURB)-65 models are less useful. Accurate assessment of severity has important implications for triage, outcome, and defining populations for research applications. Novel biomarkers, while somewhat promising, do not yet have a validated role in pneumonia severity assessment.
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105
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Hasan A. Ventilator-Associated Pneumonia. UNDERSTANDING MECHANICAL VENTILATION 2010. [PMCID: PMC7124052 DOI: 10.1007/978-1-84882-869-8_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The area of the alveolar epithelium of the lung is approximately 70 m2. This area is constantly in contact with the ambient air and is therefore vulnerable to contamination with airborne microbes and particles of respirable size. Due to the configuration of the respiratory tract, airborne particles having diameters in the range of 0.5-2.0 μ can reach and deposit in the terminal part of the tracheobronchial tree - most bacteria are of this size. In reality, very few bacteria cause infections by spreading via the airborne route (e.g., mycobacteria, viruses, and legionella). Most bacteria cause pneumonia by first colonizing the upper respiratory tract and later descending into the tracheobronchial tree.
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Affiliation(s)
- Ashfaq Hasan
- 1 Maruthi Heights Road No. Banjara Hills, Flat 1-E, Hyderabad, 500034 India
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106
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Validation of the Infectious Disease Society of America/American Thoracic Society 2007 guidelines for severe community-acquired pneumonia. Crit Care Med 2009; 37:3010-6. [PMID: 19789456 DOI: 10.1097/ccm.0b013e3181b030d9] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Validate the Infectious Disease Society of America/American Thoracic Society 2007 (IDSA/ATS 2007) criteria for predicting severe community-acquired pneumonia (SCAP) and evaluate a health-services definition for SCAP. DESIGN Retrospective cohort study. SETTING LDS Hospital, an academic tertiary care facility in the western United States. PATIENTS Consecutive patients with International Classification of Diseases, Ninth Edition, codes and chest radiographs consistent with community-acquired pneumonia from 1996 to 2006 seen at LDS Hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We utilized the electronic medical record to examine intensive care unit admission, intensive therapies received, and predictors of severity, as well as 30-day mortality. We also developed logistic regression models of mortality and disease severity. We calculated the IDSA/ATS 2007 criteria as well as three other pneumonia severity scores. We defined SCAP as receipt of intensive therapy in the intensive care unit. In 2413 episodes of pneumonia, 1540 were admitted to the hospital, while 379 were admitted to the intensive care unit. Overall 30-day mortality was 3.7% but was 16% among intensive care patients. The IDSA/ATS 2007 minor criteria predicted SCAP with an area under the curve of 0.88 (95% confidence interval 0.85-0.90), which improved to 0.90 (95% confidence interval 0.88-0.92) with weighting. Competing models had area under the curve of 0.76 to 0.83. Using four rather than three minor criteria improved the positive predictive value from 54% to 81%, with a stable negative predictive value of 94% to 92%. CONCLUSIONS The IDSA/ATS 2007 criteria predicted pneumonia severity better than other models. Using four rather than three minor criteria may be a superior cutoff, although this will depend on institutional characteristics.
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107
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Torralba MÁ, Amores-Arriaga B, Olivera S, Pérez-Calvo JI. [Validity of Fine and CURB scales in the treatment of community-acquired pneumonia in adults]. Med Clin (Barc) 2009; 135:624-5. [PMID: 19819503 DOI: 10.1016/j.medcli.2009.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 07/08/2009] [Accepted: 08/06/2009] [Indexed: 10/20/2022]
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108
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Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA 2009; 302:758-66. [PMID: 19690308 PMCID: PMC4818952 DOI: 10.1001/jama.2009.1163] [Citation(s) in RCA: 379] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
CONTEXT During the 1990s, antibiotic prescriptions for acute respiratory tract infection (ARTI) decreased in the United States. The sustainability of those changes is unknown. OBJECTIVE To assess trends in antibiotic prescriptions for ARTI. DESIGN, SETTING, AND PARTICIPANTS The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data (1995-2006) were used to examine trends in antibiotic prescription rates by antibiotic indication and class. Annual survey data and census denominators were combined in 2-year intervals for rate calculations. MAIN OUTCOME MEASURES National annual visit rates and antibiotic prescription rates for ARTI, including otitis media (OM) and non-ARTI. RESULTS Among children younger than 5 years, annual ARTI visit rates decreased by 17% (95% confidence interval [CI], 9%-24%), from 1883 per 1000 population in 1995-1996 to 1560 per 1000 population in 2005-2006, primarily due to a 33% (95% CI, 22%-43%) decrease in OM visit rates (950 to 634 per 1000 population, respectively). This decrease was accompanied by a 36% (95% CI, 26%-45%) decrease in ARTI-associated antibiotic prescriptions (1216 to 779 per 1000 population). Among persons aged 5 years or older, ARTI visit rates remained stable but associated antibiotic prescription rates decreased by 18% (95% CI, 6%-29%), from 178 to 146 per 1000 population. Antibiotic prescription rates for non-OM ARTI for which antibiotics are rarely indicated decreased by 41% (95% CI, 22%-55%) and 24% (95% CI, 10%-37%) among persons younger than 5 years and 5 years or older, respectively. Overall, ARTI-associated prescription rates for penicillin, cephalosporin, and sulfonamide/tetracycline decreased. Prescription rates for azithromycin increased and it became the most commonly prescribed macrolide for ARTI and OM (10% of OM visits). Among adults, quinolone prescriptions increased. CONCLUSIONS Overall antibiotic prescription rates for ARTI decreased, associated with fewer OM visits in children younger than 5 years and with fewer prescriptions for ARTI for which antibiotics are rarely indicated. However, prescription rates for broad-spectrum antibiotics increased significantly.
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Affiliation(s)
- Carlos G Grijalva
- Department of Preventive Medicine, Vanderbilt University School of Medicine, 1500 21st Ave, Ste 2600, The Village at Vanderbilt, Nashville, TN 37232-2637, USA.
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109
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Kang Y, Crogan NL. An evidence-based review of infectious diseases. Geriatr Nurs 2009; 30:272-86. [PMID: 19673155 DOI: 10.1016/j.gerinurse.2009.06.005] [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]
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110
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Sandora TJ, Desai R, Miko BA, Harper MB. Assessing Quality Indicators for Pediatric Community-Acquired Pneumonia. Am J Med Qual 2009; 24:419-27. [DOI: 10.1177/1062860609337900] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Thomas J. Sandora
- Division of Infectious Diseases, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts,
| | - Rishi Desai
- Division of Infectious Disease, Children's Hospital Los Angeles, Los Angeles, California
| | - Benjamin A. Miko
- Department of Medicine, New York Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York
| | - Marvin B. Harper
- Divisions of Infectious Diseases and Emergency Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts
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111
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Pachón J, Alcántara Bellón JDD, Cordero Matía E, Camacho Espejo Á, Lama Herrera C, Rivero Román A. Estudio y tratamiento de las neumonías de adquisición comunitaria en adultos. Med Clin (Barc) 2009; 133:63-73. [DOI: 10.1016/j.medcli.2009.01.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Accepted: 01/08/2009] [Indexed: 10/20/2022]
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112
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Noda R, Takaya J, Hasui M, Araki A, Kaneko K. Severe concurrent lung infection caused by legionella and mycoplasma in a 3-year-old patient with Down syndrome and tuberous sclerosis. Pediatr Int 2009; 51:413-4. [PMID: 19500283 DOI: 10.1111/j.1442-200x.2009.02825.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Reiko Noda
- Department of Pediatrics, Kansai Medical University, Moriguchi, Osaka 570-8506, Japan
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113
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Pneumococcal pneumonia: clinical features, diagnosis and management in HIV-infected and HIV noninfected patients. Curr Opin Pulm Med 2009; 15:236-42. [DOI: 10.1097/mcp.0b013e32832a09e0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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114
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Liu Y, Chen M, Zhao T, Wang H, Wang R, Cai B, Cao B, Sun T, Hu Y, Xiu Q, Zhou X, Ding X, Yang L, Zhuo J, Tang Y, Zhang K, Liang D, Lv X, Li S, Liu Y, Yu Y, Wei Z, Ying K, Zhao F, Chen P, Hou X. Causative agent distribution and antibiotic therapy assessment among adult patients with community acquired pneumonia in Chinese urban population. BMC Infect Dis 2009; 9:31. [PMID: 19292931 PMCID: PMC2667519 DOI: 10.1186/1471-2334-9-31] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2008] [Accepted: 03/18/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Knowledge of predominant microbial patterns in community-acquired pneumonia (CAP) constitutes the basis for initial decisions about empirical antimicrobial treatment, so a prospective study was performed during 2003-2004 among CAP of adult Chinese urban populations. METHODS Qualified patients were enrolled and screened for bacterial, atypical, and viral pathogens by sputum and/or blood culturing, and by antibody seroconversion test. Antibiotic treatment and patient outcome were also assessed. RESULTS Non-viral pathogens were found in 324/610 (53.1%) patients among whom M. pneumoniae was the most prevalent (126/610, 20.7%). Atypical pathogens were identified in 62/195 (31.8%) patients carrying bacterial pathogens. Respiratory viruses were identified in 35 (19%) of 184 randomly selected patients with adenovirus being the most common (16/184, 8.7%). The nonsusceptibility of S. pneumoniae to penicillin and azithromycin was 22.2% (Resistance (R): 3.2%, Intermediate (I): 19.0%) and 79.4% (R: 79.4%, I: 0%), respectively. Of patients (312) from whom causative pathogens were identified and antibiotic treatments were recorded, clinical cure rate with beta-lactam antibiotics alone and with combination of a beta-lactam plus a macrolide or with fluoroquinolones was 63.7% (79/124) and 67%(126/188), respectively. For patients having mixed M. pneumoniae and/or C. pneumoniae infections, a better cure rate was observed with regimens that are active against atypical pathogens (e.g. a beta-lactam plus a macrolide, or a fluoroquinolone) than with beta-lactam alone (75.8% vs. 42.9%, p = 0.045). CONCLUSION In Chinese adult CAP patients, M. pneumoniae was the most prevalent with mixed infections containing atypical pathogens being frequently observed. With S. pneumoniae, the prevalence of macrolide resistance was high and penicillin resistance low compared with data reported in other regions.
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Affiliation(s)
- Youning Liu
- Department of Respiratory Diseases, Chinese PLA General Hospital, Beijing, PR China
| | - Minjun Chen
- Department of Clinical Laboratory, Beijing Union Medical College Hospital, Beijing, PR China
| | - Tiemei Zhao
- Department of Respiratory Diseases, Chinese PLA General Hospital, Beijing, PR China
| | - Hui Wang
- Department of Clinical Laboratory, Beijing Union Medical College Hospital, Beijing, PR China
| | - Rui Wang
- Clinical Pharmacological Laboratory, Chinese PLA General Hospital, Beijing, PR China
| | - Baiqiang Cai
- Department of Respiratory Diseases, Beijing Union Medical College Hospital, Beijing, PR China
| | - Bin Cao
- Department of Respiratory Diseases, Beijing Union Medical College Hospital, Beijing, PR China
| | - Tieying Sun
- Department of Respiratory Diseases, Beijing Hospital, Beijing, PR China
| | - Yunjian Hu
- Department of Clinical Laboratory, Beijing Hospital, Beijing, PR China
| | - Qingyu Xiu
- Department of Respiratory Diseases, Changzheng Hospital, Second Military Medical College, Shanghai, PR China
| | - Xin Zhou
- Department of Respiratory Diseases, First People's Hospital of Shanghai, Shanghai, PR China
| | - Xing Ding
- Department of Respiratory Diseases, First People's Hospital of Shanghai, Shanghai, PR China
| | - Lan Yang
- Department of Respiratory Diseases, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, PR China
| | - Jiansheng Zhuo
- Department of Respiratory Diseases, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, PR China
| | - Yingchun Tang
- Department of Respiratory Diseases, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China
| | - Kouxing Zhang
- Department of Respiratory Diseases, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China
| | - Derong Liang
- Clinical Pharmacological Institutes, West China Hospital of Sichuan University, Sichuan, PR China
| | - Xiaoju Lv
- Clinical Pharmacological Institutes, West China Hospital of Sichuan University, Sichuan, PR China
| | - Shengqi Li
- Department of Respiratory Diseases, Second Affiliated University of China Medical University, Shenyang, PR China
| | - Yong Liu
- Department of Clinical Laboratory, Second Affiliated University of China Medical University, Shenyang, PR China
| | - Yunsong Yu
- Department of Infectious Diseases, First Affiliated Hospital of Zhejiang University, Zhejiang, PR China
| | - Zeqing Wei
- Department of Infectious Diseases, First Affiliated Hospital of Zhejiang University, Zhejiang, PR China
| | - Kejing Ying
- Department of Respiratory Diseases, Sir Run Run Shaw Hospital, Zhejiang, PR China
| | - Feng Zhao
- Department of Respiratory Diseases, Sir Run Run Shaw Hospital, Zhejiang, PR China
| | - Ping Chen
- Department of Respiratory Diseases, General Hospital of Shenyang Military Region, Shenyang, PR China
| | - Xiaona Hou
- Department of Clinical Laboratory, General Hospital of Shenyang Military Region, Shenyang, PR China
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115
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Liapikou A, Ferrer M, Polverino E, Balasso V, Esperatti M, Piñer R, Mensa J, Luque N, Ewig S, Menendez R, Niederman M, Torres A. Severe Community‐Acquired Pneumonia: Validation of the Infectious Diseases Society of America/American Thoracic Society Guidelines to Predict an Intensive Care Unit Admission. Clin Infect Dis 2009; 48:377-85. [DOI: 10.1086/596307] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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116
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117
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Wheeler DS, Wong HR, Shanley TP. Pneumonia and Empyema. THE RESPIRATORY TRACT IN PEDIATRIC CRITICAL ILLNESS AND INJURY 2009. [PMCID: PMC7123273 DOI: 10.1007/978-1-84800-925-7_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Derek S. Wheeler
- Medical Center, Div. of Critical Care Medicine, Cincinnati Children's Hospital, Burnet Avenue 3333, Cincinnati, 45229 U.S.A
| | - Hector R. Wong
- Medical Center, Div. of Critical Care Medicine, Cincinnati Children's Hospital, Burnet Avenue 3333, Cincinnati, 45229 U.S.A
| | - Thomas P. Shanley
- C.S. Mott Children's Hospital , Pediatric Critical Care Medicine , University of Michigan, E. Medical Center Drive 1500, Ann Arbor, 48109-0243 U.S.A
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118
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Bacterial community-acquired pneumonia: risk factors for mortality and supportive therapies. Intensive Care Med 2008; 35:391-3. [PMID: 19066849 DOI: 10.1007/s00134-008-1366-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Accepted: 11/27/2008] [Indexed: 01/05/2023]
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119
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Vardakas KZ, Siempos II, Grammatikos A, Athanassa Z, Korbila IP, Falagas ME. Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials. CMAJ 2008; 179:1269-77. [PMID: 19047608 PMCID: PMC2585120 DOI: 10.1503/cmaj.080358] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We investigated whether the use of respiratory fluoroquinolones was associated with better clinical outcomes compared with the use of macrolides and beta- lactams among adults with pneumonia. METHODS We searched PubMed, Current Contents, Scopus, EMBASE, ClinicalTrials.gov and Cochrane with no language restrictions. Two reviewers independently extracted data from published trials that compared fluoroquinolones (levofloxacin, moxifloxacin, gemifloxacin) with macrolides or beta-lactams or both. A meta-analysis was performed with the clinical outcomes of mortality, treatment success and adverse outcomes. RESULTS We included 23 trials in our meta-analysis. There was no difference in mortality among patients who received fluoroquinolones or the comparator antibiotics (OR 0.85, 95% CI 0.65-1.12). Pneumonia resolved in more patients who received fluoroquinolones compared with the comparator antibiotics for the included outcomes in the intention-to-treat population (OR 1.17, 95% CI 1.00-1.36), clinically evaluable population (OR 1.26, 95% CI 1.06-1.50) and the microbiologically assessed population (OR 1.67, 95% CI 1.28-2.20). Fluoroquinolones were more effective than a combination of beta-lactam and macrolide (OR 1.39, 95% CI 1.02-1.90). They were also more effective for patients with severe pneumonia (OR 1.84, 95% CI 1.02-3.29), those who required admission to hospital (OR = 1.30, 95% CI 1.04-1.61) and those who required intravenous therapy (OR = 1.44, 15% CI 1.13-1.85). Fluoroquinolones were more effective than beta-lactam and macrolide in open-label trials (OR = 1.35, 95% CI 1.08-1.69) but not in blinded randomized controlled trials (OR = 1.13, 95% CI 0.85-1.50). INTERPRETATION Fluoroquinolones were associated with higher success of treatment for severe forms of pneumonia; however, a benefit in mortality was not evident. A randomized controlled trial that includes patients with severe pneumonia with or without bacteremia is needed.
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120
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Buising KL, Thursky KA, Black JF, MacGregor L, Street AC, Kennedy MP, Brown GV. Improving antibiotic prescribing for adults with community acquired pneumonia: Does a computerised decision support system achieve more than academic detailing alone?--A time series analysis. BMC Med Inform Decis Mak 2008; 8:35. [PMID: 18667084 PMCID: PMC2527556 DOI: 10.1186/1472-6947-8-35] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Accepted: 07/31/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ideal method to encourage uptake of clinical guidelines in hospitals is not known. Several strategies have been suggested. This study evaluates the impact of academic detailing and a computerised decision support system (CDSS) on clinicians' prescribing behaviour for patients with community acquired pneumonia (CAP). METHODS The management of all patients presenting to the emergency department over three successive time periods was evaluated; the baseline, academic detailing and CDSS periods. The rate of empiric antibiotic prescribing that was concordant with recommendations was studied over time comparing pre and post periods and using an interrupted time series analysis. RESULTS The odds ratio for concordant therapy in the academic detailing period, after adjustment for age, illness severity and suspicion of aspiration, compared with the baseline period was OR = 2.79 [1.88, 4.14], p < 0.01, and for the computerised decision support period compared to the academic detailing period was OR = 1.99 [1.07, 3.69], p = 0.02. During the first months of the computerised decision support period an improvement in the appropriateness of antibiotic prescribing was demonstrated, which was greater than that expected to have occurred with time and academic detailing alone, based on predictions from a binary logistic model. CONCLUSION Deployment of a computerised decision support system was associated with an early improvement in antibiotic prescribing practices which was greater than the changes seen with academic detailing. The sustainability of this intervention requires further evaluation.
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Affiliation(s)
- Kirsty L Buising
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Karin A Thursky
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
- Centre for Clinical Research Excellence in Infectious Diseases, Department of Medicine, University of Melbourne, Parkville, Victoria 3050, Australia
| | - James F Black
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
- Centre for Clinical Research Excellence in Infectious Diseases, Department of Medicine, University of Melbourne, Parkville, Victoria 3050, Australia
- The Nossal Institute for Global Health, The University of Melbourne, Victoria, 3010, Australia
| | - Lachlan MacGregor
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Alan C Street
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Marcus P Kennedy
- Emergency Department, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Graham V Brown
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
- Centre for Clinical Research Excellence in Infectious Diseases, Department of Medicine, University of Melbourne, Parkville, Victoria 3050, Australia
- The Nossal Institute for Global Health, The University of Melbourne, Victoria, 3010, Australia
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121
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Finch R. Community-acquired pneumonia: the evolving challenge. Clin Microbiol Infect 2008. [DOI: 10.1111/j.1469-0691.2001.00052.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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122
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Buising K. Severity scores for community-acquired pneumonia. Expert Rev Respir Med 2008; 2:261-71. [PMID: 20477254 DOI: 10.1586/17476348.2.2.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
An assessment of the severity of illness of a patient is one of the most important components of their early management. It guides decisions regarding the most appropriate site of care and the selection of empiric antibiotic therapy. In recent years, prediction tools, known as severity scores, have been promoted to assist early assessments of the severity of illness for patients with community-acquired pneumonia. Several different severity scores now exist and these have been modified over time. Each tool has particular strengths and weaknesses. This article reviews the evolution of severity scores for patients with community-acquired pneumonia and compares their performance in different patient cohorts for different outcomes of interest, as described in the published literature to date. It also discusses how these tools could be evaluated more comprehensively so that their place in patient management can be better appreciated.
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Affiliation(s)
- Kirsty Buising
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, NHMRC Centre for Clinical Research Excellence in Infectious Diseases, University of Melbourne, 9 North, Royal Melbourne Hospital, Grattan St, Parkville, Victoria 3056, Australia.
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Schuetz P, Stolz D, Mueller B, Morgenthaler NG, Struck J, Mueller C, Bingisser R, Tamm M, Christ-Crain M. Endothelin-1 precursor peptides correlate with severity of disease and outcome in patients with community acquired pneumonia. BMC Infect Dis 2008; 8:22. [PMID: 18304365 PMCID: PMC2335111 DOI: 10.1186/1471-2334-8-22] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Accepted: 02/28/2008] [Indexed: 02/05/2023] Open
Abstract
Background Circulating levels of endothelin-1 are increased in sepsis and correlate with severity of disease. A rapid and easy immunoassay has been developed to measure the more stable ET-1 precursor peptides proET-1. The objective of this study was to assess the diagnostic and prognostic value of proET-1 in a prospective cohort of mainly septic patients with community-acquired pneumonia. Methods We evaluated 281 consecutive patients with community acquired pneumonia. Serum proET-1 plasma levels were measured using a new sandwich immunoassay. Results ProET-1 levels exhibited a gradual increase depending on the clinical severity of pneumonia as assessed by the pneumonia severity index (PSI) and the CURB65 scores (p < 0.001 and p < 0.01). The diagnostic accuracy to predict bacteraemia of procalcitonin (AUC 0.84 [95% 0.74–0.93]) was superior than C-reactive protein (AUC 0.67 [95%CI 0.56–0.78]) and leukocyte count (AUC 0.66 [95%CI 0.55–0.78]) and in the range of proET-1(AUC of 0.77 [95%CI 0.67–0.86]). ProET-1 levels on admission were increased in patients with adverse medical outcomes including death and need for ICU admission. ROC curve analysis to predict the risk for mortality showed a prognostic accuracy of proET-1 (AUC 0.64 [95%CI 0.53–0.74]), which was higher than C-reactive protein (AUC 0.51 [95%CI 0.41–0.61]) and leukocyte count (AUC 0.55 [95%CI 0.44–0.65]) and within the range of the clinical severity scores (PSI AUC 0.69 [95%CI 0.61–0.76] and CURB65 0.67 [95%CI 0.57–0.77]) and procalcitonin (AUC 0.59 [95% 0.51–0.67]). ProET-1 determination improved significantly the prognostic accuracy of the CURB65 score (AUC of the combined model 0.69 [95%CI 0.59–0.79]). In a multivariate logistic regression model, only proET1 and the clinical severity scores were independent predictors for death and for the need for ICU admission. Conclusion In community-acquired pneumonia, ET-1 precursor peptides correlate with disease severity and are independent predictors for mortality and ICU admission. If confirmed in future studies, proET-1 levels may become another helpful tool for risk stratification and management of patients with community-acquired pneumonia. Trial registration ISRCTN04176397
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Affiliation(s)
- Philipp Schuetz
- Department of Internal Medicine, University Hospital Basel, Switzerland.
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Bruns AHW, Oosterheert JJ, Prokop M, Lammers JWJ, Hak E, Hoepelman AIM. Patterns of Resolution of Chest Radiograph Abnormalities in Adults Hospitalized with Severe Community-Acquired Pneumonia. Clin Infect Dis 2007; 45:983-91. [PMID: 17879912 DOI: 10.1086/521893] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2007] [Accepted: 06/20/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Timing of follow-up chest radiographs for patients with severe community-acquired pneumonia (CAP) is difficult, because little is known about the time to resolution of chest radiograph abnormalities and its correlation with clinical findings. To provide recommendations for short-term, in-hospital chest radiograph follow-up, we studied the rate of resolution of chest radiograph abnormalities in relation to clinical cure, evaluated predictors for delayed resolution, and determined the influence of deterioration of radiographic findings during follow-up on prognosis. METHODS A total of 288 patients who were hospitalized because of severe CAP were followed up for 28 days in a prospective multicenter study. Clinical data and scores for clinical improvement at day 7 and clinical cure at day 28 were obtained. Chest radiographs were obtained at hospital admission and at days 7 and 28. Resolution and deterioration of chest radiograph findings were determined. RESULTS At day 7, 57 (25%) of the patients had resolution of chest radiograph abnormalities, whereas 127 (56%) had clinical improvement (mean difference, 31%; 95% confidence interval, 25%-37%). At day 28, 103 (53%) of the patients had resolution of chest radiograph abnormalities, and 152 (78%) had clinical cure (mean difference, 25%; 95% confidence interval, 19%-31%). Delayed resolution of radiograph abnormalities was independently associated with multilobar disease (odds ratio, 2.87; P < or = .01); dullness to percussion at physical examination (odds ratio, 6.94; P < or = .01); high C-reactive protein level, defined as >200 mg/L (odds ratio, 4.24; P < or = .001); and high respiratory rate at admission, defined as >25 breaths/min (odds ratio, 2.42; P < or = .03). There were no significant differences in outcome at day 28 between patients with and patients without deterioration of chest radiograph findings during the follow-up period (P > .09). CONCLUSIONS Routine short-term follow-up chest radiographs (obtained <28 days after hospital admission) of hospitalized patients with severe CAP seem to provide no additional clinical value.
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Affiliation(s)
- Anke H W Bruns
- Division of Medicine, Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
INTRODUCTION Pneumonia is the leading cause of mortality, morbidity, and transfers to acute care facilities among residents of nursing homes. With the expected growth of the nursing home population over the next 30 years, the annual incidence of nursing home-acquired pneumonia (NHAP) is expected to reach 1.9 million cases. Yet there is growing evidence to suggest that the transfer of nursing home residents to hospitals with NHAP results in little to no improvement in overall mortality or morbidity when compared with residents treated in the nursing home. Furthermore, recent evidence suggests that nursing home residents admitted to hospitals may be at greater risk for functional decline, delirium, and pressure ulcer formation following hospitalization. The author therefore performed a comprehensive review of the literature to consider the salient issues confronting a clinician faced with the question of whether to transfer a nursing home resident diagnosed with pneumonia to an acute care facility. METHODOLOGY A structured literature search was performed relating to the diagnosis, treatment, and triage of residents with nursing home pneumonia. Relevant key words used to conduct this search included: pneumonia, long-term care facility, nursing home, nursing home-acquired pneumonia, triage, treatment, and hospitalization. References in English dated from 1966 to the present day were considered. RESULTS One prospective observational study and 2 retrospective, case control studies have directly compared the 30-day mortality rates of residents with NHAP who are hospitalized versus those who are treated in the nursing home. A second, prospective, observational study evaluated the mortality rate in residents with any form of infection who were transferred to acute care hospitals. These studies all suggest that mortality rates are similar or reduced when residents are treated in the nursing home. Studies also suggest that considerable cost savings can be incurred when residents are treated in the nursing home. Additional literature reviews were conducted to evaluate important factors that need to be considered before making triage decisions on nursing home residents diagnosed with pneumonia. These factors include the ease of making the diagnosis of NHAP, the availability and use of antibiotics, relevant cost issues, and barriers to providing adequate care in the nursing home environment. CONCLUSION There is growing evidence to suggest that hospitalization for residents with NHAP is not required and may result in increased cost, morbidity, and mortality. To date, studies show that residents may benefit from hospitalization if their respiratory rate is over 40. Otherwise, if appropriate treatment can be initiated expeditiously in the nursing home, resident mortality and morbidity may decrease. Numerous barriers to treating acutely ill residents in the nursing home exist, including a difficulty in obtaining antibiotics quickly, inadequate staffing, and poor documentation of a resident's wishes for hospitalization. More studies need to be conducted to further identify these barriers to nursing home care.
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Affiliation(s)
- David Dosa
- Division of Geriatrics and Department of Medicine and Community Health, Brown University, Providence, RI, USA.
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Banker PD, Jain VR, Haramati LB. Impact of chest CT on the clinical management of immunocompetent emergency department patients with chest radiographic findings of pneumonia. Emerg Radiol 2007; 14:383-8. [PMID: 17701235 DOI: 10.1007/s10140-007-0659-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 07/17/2007] [Indexed: 11/26/2022]
Abstract
The purpose of this study is to assess the impact on clinical decision making of chest computed tomography (CT) in immunocompetent emergency department (ED) patients with chest radiographic (CXR) findings of pneumonia. We retrospectively identified 1,373 patients from our ED who underwent chest CT between 7/05 and 6/06. Report of CXR within 24 h before CT were reviewed to identify patients with findings of pneumonia. The following were the exclusion criteria: recommendation of CT on CXR report and immunocompromised status on chart review. Fifty-one patients met the inclusion criteria: 26 women and 25 men, with a mean age of 60 (range 29-103) years. Age- and sex-matched controls from the ED with CXR findings of pneumonia who did not undergo CT were identified. Charts were reviewed for clinical presentation, management, and follow-up. Patient and control groups were compared using Fisher exact and paired Student's t tests. The patients were sicker than the controls with more signs and symptoms including auscultation abnormalities, 64 (33 of 51) vs 47% (24 of 51), abnormal sputum 32 (16 of 51) vs 0%, hypoxemia 22 (11 of 51) vs 2% (1 of 51), weight loss, 20 (10 of 51) vs 4% (2 of 51), and night sweats, 16 (8 of 51) vs 2% (1 of 51; p < 0.05 each). Clinical management, (based on CT findings in 31% [16 of 51]), was more extensive for patients than controls: antibiotics initiated 82 (41 of 51) vs 47% (24 of 51), antibiotics changed 29 (15 of 31) vs 0%, procedures performed 24 (12 of 51) vs 0%, and mean length of stay was 8 days vs less than 1 (p < 0.05, each). Sixteen percent (8 of 51) of the patients had alternative/additional diagnosis based on CT: pulmonary embolism, lung cancer, hypersensitivity pneumonitis, multiple myeloma, renal cell carcinoma, small bowel obstruction, lung nodule, and endobronchial mass (n = 1, each). Eight percent (4 of 51) of the patients and no controls were diagnosed with tuberculosis (p = 0.06). Immunocompetent ED patients with CXR findings of pneumonia who underwent chest CT were sicker than those who were not imaged with CT. Chest CT was often useful in guiding therapy or providing an alternative diagnosis.
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Affiliation(s)
- Piyush D Banker
- Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210 Street, Bronx, NY 10467, USA
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Affiliation(s)
- Christoph Wenisch
- Medizinische Abteilung mit Infektions- und Tropenmedizin, SMZ-Süd-KFJ Spital, Wien, Osterreich.
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128
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van de Garde EMW, Oosterheert JJ, Bonten M, Kaplan RC, Leufkens HGM. International classification of diseases codes showed modest sensitivity for detecting community-acquired pneumonia. J Clin Epidemiol 2007; 60:834-8. [PMID: 17606180 DOI: 10.1016/j.jclinepi.2006.10.018] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Revised: 10/09/2006] [Accepted: 10/17/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To estimate the sensitivity of International Classification of Diseases (ICD-9-CM) coding for detecting hospitalized community-acquired pneumonia and to assess possible determinants for misclassification. STUDY DESIGN AND SETTING Based on microbiological analysis data, 293 patients with a principal diagnosis of community-acquired pneumonia at seven hospitals in the Netherlands were assigned to three categories (pneumococcal pneumonia, pneumonia with other organism, or pneumonia with no organism specified). For these patients, the assigned principal and secondary ICD-9-CM codes in the hospital discharge record were retrieved and the corresponding sensitivity was calculated. Furthermore, pneumonia-related patient characteristics were compared between correctly and incorrectly coded subjects. RESULTS The overall sensitivity was 72.4% for the principal code and 79.5% for combined principal and secondary codes. For pneumococcal pneumonia (ICD-9-CM code 481) and pneumonia with specified organism (ICD-9-CM code 482-483), the sensitivities were 35% and 18.3%, respectively. Patient characteristics were not significantly different between correctly and incorrectly coded subjects except for duration of hospital stay, which correlated negatively with coding sensitivity (P=0.01). CONCLUSION ICD-9-CM codes showed modest sensitivity for detecting community-acquired pneumonia in hospital administrative databases, leaving at least one quarter of pneumonia cases undetected. Sensitivity decreased with longer duration of hospital stay.
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Affiliation(s)
- Ewoudt M W van de Garde
- Division of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO Box 80082, 3506 TB Utrecht, The Netherlands
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Reyes Calzada S, Martínez Tomas R, Cremades Romero MJ, Martínez Moragón E, Soler Cataluña JJ, Menéndez Villanueva R. Empiric treatment in hospitalized community-acquired pneumonia. Impact on mortality, length of stay and re-admission. Respir Med 2007; 101:1909-15. [PMID: 17628462 DOI: 10.1016/j.rmed.2007.04.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Revised: 03/27/2007] [Accepted: 04/23/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate adherence to guidelines when choosing an empirical treatment and its impact upon the prognosis of community-acquired pneumonia (CAP). METHODS A prospective multicentre study was conducted in 425 CAP patients hospitalized on ward. Initial empirical treatment was classified as adhering or not to Spanish guidelines. Adherent treatment was defined as an initial antimicrobial regimen consisting of beta-lactams plus macrolides, beta-lactam monotherapy and quinolones. Non-adherent treatments included macrolide monotherapy and other regimens. Initial severity was graded according to pneumonia severity index (PSI). The end point variables were mortality, length of stay (LOS) and re-admission at 30 days. RESULTS Overall 30-day mortality was 8.2%, the mean LOS was 8+/-5 days, and the global re-admission rate was 7.6%. Adherence to guidelines was 76.5%, and in most cases the empirical treatment consisted of beta-lactam and macrolide in combination (57.4%). Logistic regression analysis showed that other regimens were associated with higher mortality OR=3 (1.2-7.3), after adjusting for PSI and admitting hospital. Beta-lactam monotherapy was an independent risk factor for re-admission. LOS was independently associated with admitting hospital and not with antibiotics. CONCLUSIONS A high adherence to CAP treatment guidelines was found, though with considerable variability in the empirical antibiotic treatment among hospitals. Non-adherent other regimens were associated with greater mortality. Beta-lactam monotherapy was associated with an increased re-admission rate.
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Affiliation(s)
- S Reyes Calzada
- Service of Pneumology, Hospital Universitario La Fe, Valencia, Spain.
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Abstract
Pulmonary and cardiac infections in the athlete can have a wide range of presentations and complications. These infections may present few problems for the training athlete or become life threatening. The team physician must be able to make an accurate diagnosis, give the appropriate treatment, understand the potential complications, and ensure proper follow-up and return-to-play protocols.
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Affiliation(s)
- Roger J. Kruse
- Sports Care/Sports Medicine Fellowship, The Toledo Hospital, Promedica Health System, 2865 N. Reynolds Road, Suite 130, Toledo, OH 43615, USA
- University of Toledo, 2801 W. Bancroft, Toledo, OH 43606, USA
| | - Cathy L. Cantor
- Sports Care/Sports Medicine Fellowship, The Toledo Hospital, Promedica Health System, 2865 N. Reynolds Road, Suite 130, Toledo, OH 43615, USA
- University of Toledo, 2801 W. Bancroft, Toledo, OH 43606, USA
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Abstract
PURPOSE OF REVIEW Community-acquired pneumonia is associated with significant morbidity and mortality and is the most common cause of death from infectious diseases in North America. The purpose of this review is to highlight recent advances in epidemiology, risk factors, severity criteria and antibiotic therapeutic regimens used for community-acquired pneumonia management. RECENT FINDINGS All guidelines recommend early and appropriate empiric therapy directed against common typical organisms, such as Streptococcus pneumoniae, and other atypical organisms, but clinicians should be aware of newer emerging pathogens such as community-acquired methicillin-resistant Staphylococcus aureus and Gram-negative pathogens. SUMMARY The optimum outcome in community-acquired pneumonia can be achieved by careful risk stratification using prediction rules together with appropriate antibiotic regimens. The mainstay of community-acquired pneumonia prevention is influenza and pneumococcal immunization. Promotion of smoking cessation will also help curtail the incidence of pneumococcal disease.
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Affiliation(s)
- Arunabh Talwar
- Department of Medicine, North Shore University Hospital, Manhasset, New York 11030, USA.
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Kohlhammer Y, Raspe H, Marre R, Suttorp N, Welte T, Schäfer T. Antibiotic treatment of community acquired pneumonia varies widely across Germany. J Infect 2007; 54:446-53. [PMID: 17007933 DOI: 10.1016/j.jinf.2006.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 08/04/2006] [Accepted: 08/12/2006] [Indexed: 10/24/2022]
Abstract
UNLABELLED Community Acquired Pneumonia (CAP) is a frequent and potentially fatal infectious disease which, in the majority of cases, needs an antibiotic intervention. OBJECTIVES Aim was to evaluate antibiotic treatment patterns regarding all types of mono- and combination-therapy throughout the local clinical centres (LCCs) represented in the German competence network CAPNETZ (=Community Acquired Pneumonia Network) and to identify clinical indicators for regional differences. METHODS We analysed outpatients and inpatients recruited between March 2003 and April 2005. Patient and treatment details were registered online using standardised data entry forms. A logistic regression model was issued for the 4 most frequently applied antibiotics, adjusting for potentially relevant confounders. RESULTS The study sample consisted of 3221 patients at the age of 18 to 102 years. Overall, aminopenicillins plus betalactamase inhibitor (20.4%), fluoroquinolone (17.0%), macrolides combined with cephalosporins third generation (10.6%) and cephalosporins third generation (8.9%) were most frequently prescribed. After control for potential confounders, significant treatment differences remained between study sites. Regional variability of antibiotic CAP-treatment could not be attributed to a number of clinical or sociodemographic factors. CONCLUSIONS The presented treatment variability ranges within given guidelines, but indicates the need for an ongoing implementation of evidence-based guidelines in order to avoid potential negative clinical or economic consequences.
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Affiliation(s)
- Yvonne Kohlhammer
- Institute of Social Medicine, Medical University Schleswig-Holstein, Campus Luebeck, Beckergrube 43-47, 23552 Luebeck, Germany.
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Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27-72. [PMID: 17278083 PMCID: PMC7107997 DOI: 10.1086/511159] [Citation(s) in RCA: 4077] [Impact Index Per Article: 239.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Cheng AC, Stephens DP, Currie BJ. Granulocyte-colony stimulating factor (G-CSF) as an adjunct to antibiotics in the treatment of pneumonia in adults. Cochrane Database Syst Rev 2007:CD004400. [PMID: 17443546 DOI: 10.1002/14651858.cd004400.pub3] [Citation(s) in RCA: 27] [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
BACKGROUND Granulocyte colony stimulating factor (G-CSF) is a naturally-occurring cytokine that has been shown to increase neutrophil function and number. Exogenous administration of recombinant G-CSF (filgrastim, pegfilgrastim or lenograstim) has found extensive use in the treatment of febrile neutropenia, but its role in the treatment of infection in non-neutropenic hosts is less well defined. OBJECTIVES We explored the role of G-CSF as an adjunct to antibiotics in the treatment of pneumonia in non-neutropenic adults. SEARCH STRATEGY For this updated review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2006); MEDLINE (1950 to January 2007); EMBASE (1988 to January 2007); and online databases of clinical trials (www.controlled-trials.com, updated 10 November, 2006). SELECTION CRITERIA We considered randomized controlled trials (RCTs) which included hospitalized adult patients with either community-acquired pneumonia or hospital-acquired pneumonia. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trial quality. The primary outcome measure was 28-day mortality. Secondary outcome measures included other markers of mortality as well as markers of adverse events, including organ dysfunction. An assessment of methodological quality was made for each study. MAIN RESULTS Six studies with a total of 2018 people were identified. G-CSF use appeared to be safe with no increase in the incidence of total serious adverse events (pooled odds ratio (OR) 0.91; 95% confidence interval (CI): 0.73 to 1.14) or organ dysfunction. However, the use of G-CSF was not associated with improved 28-day mortality (pooled OR 0.81; 95% CI: 0.52 to 1.27). AUTHORS' CONCLUSIONS There is no current evidence supporting the routine use of G-CSF in the treatment of pneumonia. Studies in which G-CSF is administered prophylactically or earlier in therapy may be of interest.
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Affiliation(s)
- A C Cheng
- University of Melbourne, c/-Victorian Infectious Diseases Service, Department of Medicine, 9th floor, Royal Melbourne Hospital, Parkville, Victoria, Australia, 3052.
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135
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Abstract
Despite substantial progress in therapeutic options, severe community-acquired pneumonia (CAP) remains a significant cause of morbidity and mortality worldwide. Recognising the clinical importance of CAP over the past several years, different medical societies and health organisations in different countries have proposed specific guidelines for the management of CAP. Early and rapid initiation of antimicrobial therapy has been advocated for a favourable outcome. Treatment is empirical as the diagnostic yield for potential pathogens does not exceed 50%. Dual therapy is emerging as the preferred therapy for severe CAP. The regimen is based on an epidemiological approach with emphasis on covering both typical and atypical pathogens. Non-antimicrobial adjuvant therapies including non-invasive ventilation and immunomodulatory agents are emerging as promising area for future development.
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Affiliation(s)
- Lilibeth Pineda
- Western New York Respiratory Research Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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Armitage K, Woodhead M. New guidelines for the management of adult community-acquired pneumonia. Curr Opin Infect Dis 2007; 20:170-6. [PMID: 17496576 DOI: 10.1097/qco.0b013e3280803d70] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Community-acquired pneumonia is a major cause of morbidity and mortality, and is the leading cause of death from an infectious disease. International societies have published and revised guidelines aiming to improve the management of adult community-acquired pneumonia, based on the best available evidence. The aim of this review is to compare the current guideline recommendations. RECENT FINDINGS Aspects of guidelines differ based on local factors including resources and antimicrobial factors, as well as the differences in interpretation of existing evidence. SUMMARY The lack of robust evidence behind aspects of guideline recommendations as well as the lack of adherence to published guidelines both need to be addressed if the management of community-acquired pneumonia is to be improved.
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Affiliation(s)
- Kathryn Armitage
- Department of Respiratory Medicine, University of Manchester, Manchester Royal Infirmary, Manchester, UK
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Neuman MI, Kelley M, Harper MB, File TM, Camargo CA. Factors associated with antimicrobial resistance and mortality in pneumococcal bacteremia. J Emerg Med 2007; 32:349-57. [PMID: 17499686 PMCID: PMC2034392 DOI: 10.1016/j.jemermed.2006.08.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2005] [Revised: 12/01/2005] [Accepted: 08/03/2006] [Indexed: 11/24/2022]
Abstract
We conducted a multicenter, retrospective cohort study of patients with Streptococcus pneumoniae bacteremia to determine factors associated with antibiotic resistance and mortality. Risk factors were identified using multivariate logistic regression. There were 1574 patients at 34 sites enrolled. Compared to isolates from patients not receiving an antibiotic before the index blood culture, patients receiving an antibiotic were less likely to harbor an antibiotic susceptible organism. Susceptibility to penicillin decreased from 78% (95% confidence interval [CI] 75-80) to 49% (95% CI 39-59); to cefotaxime/ceftriaxone, from 92% (95% CI 90-93) to 82% (95% CI 72-89); and to macrolide, from 84% (95% CI 82-87) to 55% (95% CI 41-68). Factors associated with macrolide non-susceptibility include: > 24 h of antibiotic therapy at time of the index culture (odds ratio [OR] 4.0), residing in southern U.S. (OR 1.7), and having an antibiotic allergy (OR 1.7). Harboring an antibiotic non-susceptible strain (OR 1.4) and male sex (OR 1.4) were associated with increased risk of mortality, whereas black race (OR 0.6) and evidence of focal infection (OR 0.6) were associated with decreased risk.
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Affiliation(s)
- Mark I Neuman
- Division of Emergency Medicine, Children's Hospital, Boston, Massachusetts 02115, USA
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Apisarnthanarak A, Puthavathana P, Mundy LM. Risk factors and outcomes of influenza A (H3N2) pneumonia in an area where avian influenza (H5N1) is endemic. Infect Control Hosp Epidemiol 2007; 28:479-82. [PMID: 17385156 DOI: 10.1086/513724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Accepted: 12/12/2006] [Indexed: 11/03/2022]
Abstract
We conducted a cohort study to identify the risks and outcomes of influenza A (H3N2) pneumonia. Of the 145 patients studied, 10 (7%) had influenza A pneumonia. Logistic regression identified multiple comorbidities (P<.001) and diarrhea at the initial presentation (P=.001) as associated risks. Infection with influenza A (P=.01) and receipt of inadequate antimicrobial therapy (P=.005) were predictors of mortality.
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Affiliation(s)
- Anucha Apisarnthanarak
- Division of Infectious Diseases, Deptartment of Medicine, Thammasart University Hospital, Pratumthani, Thailand.
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139
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Mufson MA, Chan G, Stanek RJ. Penicillin Resistance Not a Factor in Outcome from Invasive Streptococcus pneumoniae Community-Acquired Pneumonia in Adults When Appropriate Empiric Therapy Is Started. Am J Med Sci 2007; 333:161-7. [PMID: 17496734 DOI: 10.1097/maj.0b013e3180312cd5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Invasive Streptococcus pneumoniae pneumonia among adults due to penicillin-resistant or intermediate resistant strains was investigated to determine whether these patients responded poorly to common antibiotic regimens compared to pneumonia due to susceptible strains. METHODS During a 21-year period (1983-2003), clinical outcome was analyzed among 3 groups of adults, 19 with resistant, 33 with intermediate, and 133 with susceptible invasive S pneumoniae pneumonia admitted to hospitals in Huntington, West Virginia. Adults with resistant and intermediate infections were matched by age and month of admission to a group of 133 adults with penicillin-susceptible infections. All isolates of resistant and intermediate infections were capsular serotypes/serogroups 6, 9, 14, 19, and 23, and isolates of susceptible infections included 24 different serotypes/serogroups. Case fatality rates were calculated for deaths that occurred during the first 7, first 14, and first 21 days of hospitalization. Minimal inhibitory concentration (MIC) was determined by E-test and capsular serotype by Quellung procedures. RESULTS The resistant and susceptible groups did not differ in several measures of severity of illness, including admission vital signs, duration of fever, mean total leukocyte count, number of lobes involved, preexisting underlying diseases, and antibiotic treatment regimens. There were no significant differences in case fatality rates between the 3 groups of pneumonia by days in hospital, age, severity of illness, and empiric antibiotic treatment regimen with a cephalosporin and a macrolide, the most common antibiotic regimen. CONCLUSIONS These findings provide evidence that combination antibiotic regimens effective in the treatment of invasive susceptible S pneumoniae pneumonia are equally effective in the treatment of invasive resistant (MIC = 2-4 microg/mL) and of intermediate (MIC = 0.1-1 microg/mL) S pneumoniae pneumonia.
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Affiliation(s)
- Maurice A Mufson
- Department of Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, West Virginia 25701-3655, USA.
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140
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Sogstad MKR, Littauer P, Aaberge IS, Caugant DA, Høiby A. Rapid Spread in Norway of an Erythromycin-Resistant Pneumococcal Clone, Despite Low Usage of Macrolides. Microb Drug Resist 2007; 13:29-36. [PMID: 17536931 DOI: 10.1089/mdr.2006.9994] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
During the last 4 years, Norway has experienced an increase in macrolide resistance among systemic isolates of Streptococcus pneumoniae. The Norwegian reference laboratory for pneumococci received the isolates from over 85% of the Norwegian cases of systemic pneumococcal disease in the period studied. To study the details of the increased macrolide resistance, all macrolide-resistant systemic pneumococcal isolates (410 isolates) collected in the period from 1995 to 2005 were characterized phenotypically, and a representative selection of 68 strains was also studied genotypically. The serogroups most frequently associated with macrolide resistance in the studied period were 14, 6, 23, 19, and 9. The resistance M-type was expressed in 85% of the resistant isolates. Of the 68 isolates analyzed by multilocus sequence typing, 19 different sequence types (STs) were represented, including several of the international resistant clones. All but one of the clones appeared at a low frequency; mainly as isolated cases. The increase in macrolide resistance seen from 2001 to 2005 proved to be caused by ST-9, defined as the England(14)-9 clone by the Pneumococcal Molecular Epidemiology Network. All ST-9 isolates tested, carried the mef(A) gene and expressed the resistance M-type. This clone first appeared in the Oslo region in 1993, but was by 2005 isolated from all over the country. Children were overrepresented among the cases caused by this clone; however, people aged 20-29, possibly involving the parent generation, were also represented at an increased frequency. The England(14)-9 clone has been able to spread successfully in the Norwegian population despite a relatively low consumption of macrolides.
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Affiliation(s)
- Maren K R Sogstad
- Division of Infectious Disease Control, Norwegian Institute of Public Health, Nydalen, NO-0403 Oslo, Norway
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141
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Aagaard E, Maselli J, Gonzales R. Physician practice patterns: chest x-ray ordering for the evaluation of acute cough illness in adults. Med Decis Making 2007; 26:599-605. [PMID: 17099198 DOI: 10.1177/0272989x06295357] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The authors examine which clinical factors contribute to the clinician suspicion of pneumonia, as well as the relationship between clinical factors, clinician suspicion of pneumonia, and ordering chest X-rays (CXR). METHODS Three hundred consecutive adults presenting to the clinic with acute cough in the winter of 2003 were studied. Using standardized encounter forms, data were collected on sociodemographics, illness impact, symptoms, tobacco use, past medical history, vital signs, physical examination findings, chest X-ray result, and clinician diagnoses. Clinicians rated their suspicion of pneumonia on a 5-point Likert scale. Multivariable logistic regression analysis was used to determine independent predictors of clinician suspicion of pneumonia and of ordering of CXRs. RESULTS Clinician suspicion of pneumonia was low in the majority of patients presenting for evaluation of cough (63%). Higher clinician suspicion of pneumonia was predicted by advanced patient age (odds ratio [OR]: 4.6; 95% confidence interval [CI] [1.2-18.1]), shortness of breath (2.4; [1.0-6.0]), fever (5.5; [1.8-17.5]), tachycardia (3.8; [1.1-13.1]), rales (23.8; [5.7-98.7]), and rhonchi (14.6; [5.2-40.5]). CXRs were ordered in 19% of patients presenting with acute cough. Intermediate clinician suspicion of pneumonia (OR: 7.9; 95% CI: [2.8, 22.5]) (v. low suspicion), advanced patient age ([.greaterequal] 65 years) (9.2; [2.7, 31.6]) (v. ages 18-44 years), and decreased breath sounds on examination (5.1; [1.8, 14.3]) are independent predictors of ordering a CXR. Among patients with a clinical diagnosis of pneumonia (n = 31), CXRs were ordered in only 61%. CONCLUSIONS Advanced patient age and physical findings on chest examination influence clinician practice in obtaining CXRs, beyond their contribution to clinician suspicion of pneumonia. Physicians do not appear to endorse recommendations that the diagnosis of community-acquired pneumonia be based on or confirmed by CXR.
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Affiliation(s)
- Eva Aagaard
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, USA
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142
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Apisarnthanarak A, Puthavathana P, Kitphati R, Thavatsupha P, Chittaganpitch M, Auewarakul P, Mundy LM. Avian influenza H5N1 screening of intensive care unit patients with community-acquired pneumonia. Emerg Infect Dis 2007; 12:1766-9. [PMID: 17283633 PMCID: PMC3372342 DOI: 10.3201/eid1211.060443] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
From February 1, 2005, to January 31, 2006, we screened 115 adults for avian influenza (H5N1) and influenza A if admitted to an intensive care unit with pneumonia. Using reverse transcription-PCR, viral culture, and serologic testing for anti-H5 antibody, we identified 8 (7%) patients with influenza A (H3N2); none had H5N1. Estimated costs for H5N1 screening were $7,375.
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143
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Torres A. The new American Thoracic Society/Infectious Disease Society of North America guidelines for the management of hospital-acquired, ventilator-associated and healthcare-associated pneumonia: a current view and new complementary information. Curr Opin Crit Care 2007; 12:444-5. [PMID: 16943723 DOI: 10.1097/01.ccx.0000244124.46871.0d] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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144
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Aisenberg G, Rolston KV, Dickey BF, Kontoyiannis DP, Raad II, Safdar A. Stenotrophomonas maltophilia pneumonia in cancer patients without traditional risk factors for infection, 1997–2004. Eur J Clin Microbiol Infect Dis 2007; 26:13-20. [PMID: 17200840 DOI: 10.1007/s10096-006-0243-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In order to elucidate the spectrum of Stenotrophomonas maltophilia pneumonia in cancer patients without traditional risk factors, 44 cancer patients (cases) with S. maltophilia pneumonia in whom S. maltophilia pneumonia risk factors were not present were compared with two S. maltophilia pneumonia risk groups (controls) including 43 neutropenic non-intensive care unit (ICU) and 21 non-neutropenic ICU patients. The case and control patients had similar demographic and underlying clinical characteristics. Compared with case patients with S. maltophilia pneumonia, neutropenic patients had higher exposure to carbapenem antibiotics (58 vs. 41%; p < 0.03), more frequent hematologic malignancy (95 vs. 64%; p < 0.0003), and they presented with concurrent bacteremia more often (23 vs. 0%; p < 0.0005). Patients with S. maltophilia pneumonia in the ICU needed vasopressor therapy more frequently than cases (62 vs. 5%; p < 0.0001). Hospital-acquired S. maltophilia pneumonia was more common among controls than cases (98 vs. 61%; p < 0.000002). Among the cases, 15 (34%) received outpatient oral antimicrobial therapy, while 29 were hospitalized and eight (28%) were subsequently admitted to the ICU. The mean duration of ICU stay, even among these eight patients (19 +/- 40 days), was comparable to that of patients with neutropenia (23 +/- 26 days) and those who developed S. maltophilia pneumonia during their ICU stay (34 +/- 22 days; p = 0.46). The overall infection-associated mortality in the 108 patients with S. maltophilia pneumonia was 25%. Twenty percent of patients without traditional risk factors for S. maltophilia pneumonia died due to progressive infection. In a multivariate logistic regression analysis, only admission to the ICU predicted death (odds ratio 33; 95% confidence interval, 4.51-241.2; p < 0.0006). The results of this study indicate S. maltophilia pneumonia is a serious infection even in non-neutropenic, non-ICU patients with cancer.
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Affiliation(s)
- G Aisenberg
- Department of Infectious Diseases, Infection Control, and Employee Health, Unit 402, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Yum HY, Kim WK, Kim JT, Kim HH, Rha YH, Park YM, Sohn MH, Ahn KM, Lee SY, Hong SJ, Lee HR. The causative organisms of pediatric empyema in Korea. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.1.33] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hye-yung Yum
- Department of Pediatrics, Pochon Cha University, Korea
| | - Woo Kyung Kim
- Department of Pediatrics, College of Medicine, Inje University, Korea
| | - Jin Tak Kim
- Department of Pediatrics, College of Medicine, Catholic University of the Korea, Korea
| | - Hyun Hee Kim
- Department of Pediatrics, College of Medicine, Catholic University of the Korea, Korea
| | - Yeong Ho Rha
- Department of Pediatrics, College of Medicine, Kyunghee University, Korea
| | - Yong Min Park
- Department of Pediatrics, College of Medicine, Eulji University, Korea
| | - Myung Hyun Sohn
- Department of Pediatrics, College of Medicine, Yonsei University, Korea
| | - Kang Mo Ahn
- Department of Pediatrics, College of Medicine, Sungkyunkwan University, Korea
| | - Soo Young Lee
- Department of Pediatrics, College of Medicine, Ajou University, Korea
| | - Su Jong Hong
- Department of Pediatrics, College of Medicine, Ulsan University, Korea
| | - Hae Ran Lee
- Department of Pediatrics, College of Medicine, Hallym University, Korea
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146
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Advances in lower respiratory tract infections in critically ill patients. Enferm Infecc Microbiol Clin 2007. [DOI: 10.1016/s0213-005x(07)75792-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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147
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Fujiki R, Kawayama T, Ueyama T, Ichiki M, Aizawa H. The risk factors for mortality of community-acquired pneumonia in Japan. J Infect Chemother 2007; 13:157-65. [PMID: 17593502 DOI: 10.1007/s10156-007-0512-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 02/07/2007] [Indexed: 10/23/2022]
Abstract
Community-acquired pneumonia remains one of the most important diseases associated with mortality. The aim of this study was to identify the risk factors for mortality in patients with community-acquired pneumonia in Japan. This prospective study was carried out at the Social Insurance Tagawa Hospital, Fukuoka, Japan. All patients were managed according to the 1993 American Thoracic Society guidelines for community-acquired pneumonia, after an evaluation of the risk class by the pneumonia Patient Outcome Research Team (PORT) study. A comparison of several factors, including demographic findings, clinical signs, underlying diseases, results of medical examinations, severity of diseases, and causative pathogens in both survival and fatal groups, was carried out from 227 episodes of community-acquired pneumonia in 208 hospitalized patients (128 men, mean age 67.7 years). The presence of a risk of aspiration, low systolic blood pressure, low PaO(2)/FIO(2) ratio, a high pneumonia score, and the presence of severe congestive heart failure were found to be independent risk factors for mortality from community-acquired pneumonia. The mortality in risk classes IV and V was 17.5% and 54.2%, respectively, and there was a significant correlation between risk classes. The risk factors we identify here are generally similar to those given in previous reports in Western countries. According to the prediction rule of the pneumonia PORT study, the risk classes were strongly associated with the mortality, and would be suitable and helpful for the management of patients with community-acquired pneumonia in Japan.
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Affiliation(s)
- Rei Fujiki
- First Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan.
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Community-Acquired Respiratory Complications in the Intensive Care Unit: Pneumonia and Acute Exacerbations of COPD. INFECTIOUS DISEASES IN CRITICAL CARE 2007. [PMCID: PMC7121741 DOI: 10.1007/978-3-540-34406-3_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This chapter will review the two most common lower respiratory tract infections in the intensive care unit (ICU), community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In addition we will provide an overview of the topics including recommendations for the diagnosis and treatment.
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149
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Abstract
PURPOSE OF REVIEW Community-acquired pneumonia (CAP) is associated with significant morbidity and mortality and is the most common cause of death from infectious diseases. CAP patients requiring intensive care unit (ICU) admission carry the highest mortality rates. This paper aims to review the current literature regarding epidemiology, risk factors, severity criteria and reasons for admitting the hospitalized patient to the ICU, and the empiric and specific antibiotic therapeutic regimens employed. RECENT FINDINGS Multiple sets of clinical practice guidelines have been published in the past few years addressing the treatment of CAP. The guidelines all agree that CAP patients admitted to the hospital represent a major concern, and appropriate empiric therapy should be instituted to improve clinical outcomes. SUMMARY The cost, morbidity and mortality of CAP patients requiring ICU admission remain unacceptably high. These are heterogeneous groups of patients, so it is important to use risk-stratification based on clinical parameters and prediction tools. Appropriate antibiotic therapy is an important component in the management of both groups of patients. In particular, it is essential to administer an appropriate antimicrobial agent from the initiation of therapy, so that the risks of treatment failure and the morbidity of CAP may be minimized.
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Affiliation(s)
- Marcos I Restrepo
- Division of Pulmonary and Crit Care Med, South Texas Veterans Healthcare System, Audie L. Murphy Division, University of Texas Health Science Center at San Antonio 78229, USA
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Adverse Events in Patients With Community-Acquired Pneumonia at an Academic Tertiary Emergency Department. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2006. [DOI: 10.1097/01.idc.0000227713.81012.ae] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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