Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. American Thoracic Society. Medical Section of the American Lung Association

Impact of guideline-concordant empiric antibiotic therapy in community-acquired pneumonia

PURPOSE

We evaluated the impact of guideline-concordant empiric antibiotic therapy on time to clinical stability, time to switch therapy, length of hospital stay, and mortality among patients with community-acquired pneumonia.

METHODS

This is a retrospective cohort study of all adult community-acquired pneumonia patients managed at 5 community hospitals from November 1, 1999 to April 30, 2000. Patients were stratified into guideline-concordant and discordant groups as defined by the 2001 American Thoracic Society and the 2003 Infectious Diseases Society of America guidelines. Time to clinical stability, time to switch therapy, length of hospital stay, and in-hospital mortality were evaluated in per-protocol and intention-to-treat stepwise regression models that included the outcome as the dependent variable, guideline-concordant antibiotic therapy as the independent variable, and Pneumonia Severity Index score as a covariate.

RESULTS

Of the 631 evaluable patients, 357 (57%) received guideline-concordant empiric antibiotic therapy. Groups were similar with respect to age, sex, comorbidities, severity of illness, and processes of care. Guideline-concordant antibiotic therapy was associated with a significant decrease in time to switch therapy (P < or =.01), length of hospital stay (P < or =.01), and in-hospital mortality (P=.04) for both per-protocol and intention-to-treat analyses. In addition, guideline-concordant antibiotic therapy was associated with a significant decrease in time to clinical stability for intention-to-treat analysis only (P=.03).

CONCLUSIONS

Among hospitalized community-acquired patients, guideline-concordant antibiotic therapy is associated with improved in-hospital survival and shorter time to clinical stability, time to switch therapy, and length of hospital stay.

Antibiotic therapy and 48-hour mortality for patients with pneumonia

PURPOSE

Although numerous articles have demonstrated that recommended empiric antimicrobial regimens are associated with decreased mortality at 30 days, there is controversy over whether appropriate antibiotic selection has a beneficial impact on mortality within the first 48 to 96 hours after admission. Our aim was to determine whether the use of guideline-concordant antibiotic therapy is associated with decreased mortality within the first 48 hours after admission for patients with pneumonia.

METHODS

A retrospective cohort study was conducted at two tertiary teaching hospitals in San Antonio, Texas. A propensity score was used to balance the covariates associated with the use of guideline-concordant antimicrobial therapy. A multivariable logistic regression model was used to assess the association between mortality within 48 hours and the use of guideline-concordant antibiotic therapy, after adjusting for potential confounders including the propensity score.

RESULTS

Information was obtained on 787 patients with community-acquired pneumonia. The median age was 60 years, 79% were male, and 20% were initially admitted to the intensive care unit. At presentation 52% of subjects were low risk, 34% were moderate risk, and 14% were high risk. Within the first 48 hours, 20 patients died. After adjustment for potential confounders, the use of guideline-concordant antimicrobial therapy (odds ratio 0.37, 95% confidence interval, 0.14-0.95) was significantly associated with decreased mortality at 48 hours after admission.

CONCLUSION

Using initial empiric guideline-concordant antimicrobial therapy is associated with decreased mortality at 48 hours. Further research needs to investigate methods to ensure that patients with community-acquired pneumonia are treated with appropriate antimicrobial therapies.

Pneumonia during pregnancy

BACKGROUND

We determined the incidence, clinical course, risk factors, and outcomes of community-acquired pneumonia complicating pregnancy.

METHODS

A prospective study was performed of pregnant and nonpregnant patients in the same age range who presented to any of 6 hospitals in Edmonton, Alberta, with signs and symptoms of pneumonia together with an acute infiltrate evident on chest radiography compatible with pneumonia.

RESULTS

There were 28 patients with pneumonia during pregnancy, for an incidence of 1.1 per 1000 deliveries, whereas there were 333 nonpregnant females in the 20- to 40-year age group with pneumonia, for an incidence of 1.3 per 1000. No significant differences in signs and symptoms were present between the two groups. Asthma requiring treatment was present in 46.4% of the pregnant patients, compared with 17.1% of the nonpregnant patients. No maternal or fetal deaths were noted except an abortion at 10 weeks of gestation. No anomaly was detected among newborns. Two patients had preterm deliveries.

CONCLUSIONS

Pneumonia is well tolerated during pregnancy. Asthma may be a predisposing factor for pneumonia in this group of patients.

Comparison of plain chest radiography and high-resolution CT in human immunodeficiency virus infected patients with community-acquired pneumonia: a sub-Saharan Africa study

The objective of the study was to determine the proportion of patients with missed lesions on plain chest radiographs compared with high-resolution computed tomography (HRCT) in 49 human immunodeficiency virus (HIV) infected patients with community-acquired pneumonia (CAP). Patients underwent plain chest radiography and HRCT scans of the chest at admission. Microbiological investigations for CAP were performed. An experienced radiologist, without knowledge of clinical or pathological data, reported the chest radiographs and HRCT scans. The study group included 26 females and 23 males, aged 18-53 years (mean age 36 years). Organisms were isolated from 26 patients (53%). In 40 patients (82%), the HRCT scans demonstrated lesions not visualized on the plain chest radiographs. There was 100% correlation between plain radiographic and HRCT scan findings in nine cases (18%). Lesions that were not visualized on the plain radiographs but elucidated on HRCT included: pleural effusion (n = 14), ground-glass opacification (n = 20), pericardial effusion (n = 8), cavitation (n = 4), cysts (n = 4), bullae (n = 4), abscess (n = 1) and pneumothorax (n = 1). In 20 of 23 cases, hilar lymphadenopathy, identified on HRCT, was not recognized on plain chest radiographs. In patients in whom an organism was isolated, a correct HRCT diagnosis of pulmonary tuberculosis, bacterial pneumonia and Pneumocystis carinii pneumonia (PCP) was made in 80%, 84% and 100% of cases, respectively. The proportion of patients with missed lesions on plain chest radiographs in HIV infected patients with CAP was high. This has important implications for management and prognosis. HRCT scans correlate well with the microbiological diagnosis when reported by an experienced radiologist.

Sensitivity of detection of rhinoviruses in spiked clinical samples by nucleic acid sequence-based amplification in the presence of an internal control

The objectives of the study were to determine the sensitivity of Nucleic Acid Sequence-Based Amplification (NASBA) for the detection of rhinovirus (RV) serotype 15 in water and in spiked respiratory specimens in the presence of a newly developed internal control (IC). The sensitivity of NASBA on RNA was 10 molecules per reaction. The sensitivity of RV NASBA on RV-15 in water and in respiratory specimens was equal to that in tissue culture. Addition of 10(4) molecules of rhinovirus internal control (RV IC) did not affect the sensitivity. Viral RNA should be extracted from clinical specimens as rapidly as possible after collection, since loss of detectable RNA occurs after 2 h. NASBA allows a sensitive detection of RV RNA in spiked respiratory specimens in the presence of an internal control.

Should I hospitalize my resident with nursing home-acquired pneumonia?

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.

Pulmonary Emergencies in the Elderly

The aging process results in changes in pulmonary physiology that make the elderly population more susceptible to pulmonary disease. These physiologic changes also alter the clinical presentation of such diseases, making the diagnosis and treatment of pulmonary disorders particularly challenging for the clinician. It is important for the clinician to have a high index of suspicion for pulmonary disorders to make the proper diagnosis. It is essential to keep in mind the subtle differences between pulmonary diseases in the elderly compared with younger patients.

Sensitivity of three serum antibody tests in a large outbreak of Legionnaires' disease in the Netherlands

In 1999, an outbreak involving 188 patients with Legionnaires' disease (LD) occurred at a flower show in the Netherlands. This large outbreak provided the opportunity to evaluate serum antibody tests to assay anti-Legionella pneumophila, since limited data are available on the sensitivity of these tests. The sensitivities of an indirect serotype 1-6 immunofluorescence antibody test (IFAT), a rapid micro-agglutination test (RMAT) IgM serotype 1 antibody assay, and an ELISA to detect IgM and IgG serotype 1-7 antibodies, were evaluated using serum samples from LD patients related to the 1999 outbreak. Sensitivity was calculated using positive culture and/or a positive urinary antigen test as the gold standard in outbreak-related patients with radiographically confirmed pneumonia who fulfilled the epidemiological criteria. The IFAT, RMAT and ELISA showed sensitivities of 61, 44 and 64%, respectively. The sensitivity of the three tests combined was 67%. In epidemic situations, however, high standing titres may be included in the laboratory evidence of LD cases. In the study population, high standing titres were found in 16% of cases. If the presence of high standing antibody titres was added to the criteria of a positive test, the sensitivities of IFAT, RMAT and ELISA were 86, 48 and 75%, respectively. The sensitivity was 91% for all tests combined. The higher sensitivity for the combined use of tests is offset by a reduction in specificity to 97.6%. The results of this study indicate that using a combination of serologic tests in pneumonia patients suspected to have LD does not substantially improve sensitivity. The results suggest that in the microbiological diagnosis of LD, both IFAT and ELISA are reasonably sensitive assays. In an epidemic situation, both tests are highly sensitive, the IFAT more so than the ELISA.

Routine use of pleural fluid cultures. Are they indicated? Limited yield, minimal impact on treatment decisions

In pleural infection, it has been recommended that Gram stain and cultures should be obtained on a routine basis. However, this recommendation has not been tested prospectively. We evaluated the yield of microbiological studies in 259 patients with parapneumonic pleural effusion. Microbiological studies were positive on the pleural fluid of 50 patients (19.3%). In 48 of the 50 patients with positive microbiological results (96%), the need for pleural drainage was correctly predicted by pleural fluid parameters. There were no differences in hospital stay (9.5+/-2.5 days versus 9.9+/-3.2 days, P=0.68) or in mortality (2 deaths in each group, P=0.58) between the group of patients in which antibiotic treatment was changed according to microbiological results and the group of patients in which it is not. In conclusion, this study demonstrates that, at least in our institution, routine microbial investigation of pleural fluid adds very little to the standard management of parapneumonic effusions.

Severe Sepsis in Community-Acquired Pneumonia

STUDY OBJECTIVES

Most natural history studies of severe sepsis are limited to ICU populations. We describe the onset and timing of severe sepsis during the hospital course for patients hospitalized with community-acquired pneumonia (CAP). We also determine the ability of the systemic inflammatory response syndrome (SIRS) and other proposed risk stratification scores measured at emergency department (ED) presentation to predict progression to severe sepsis, septic shock, or death.

DESIGN

Retrospective analysis of a prospective observational outcome study from the Pneumonia Patient Outcomes Research Team (PORT).

SETTING

Four academic medical centers in the United States and Canada between October 1991 and March 1994.

PARTICIPANTS

The 1,339 patients hospitalized for CAP in the PORT study cohort, and a random subset of 686 patients for whom we had information for SIRS criteria.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

All subjects had infection (CAP). Severe sepsis was defined as new-onset acute organ dysfunction in this cohort, using consensus criteria. Severe sepsis developed in one half of the patients (n = 639, 48%), nonpulmonary organ dysfunction developed in 520 patients (39%), and septic shock developed in 61 subjects (4.5%). Severe sepsis and septic shock were present at ED presentation in 457 patients (71% of severe sepsis cases) and 27 patients (44% of septic shock cases), respectively. While SIRS was common at presentation (82% of the subset of 686 had two SIRS criteria), it was not associated with increased odds for progression to severe sepsis (odds ratios [ORs], 0.65 and 0.89 for two or more SIRS criteria and three or more SIRS criteria, respectively), septic shock (ORs, 0.80 and 0.55), or death (ORs, 0.65 and 0.39), with poor discrimination (all receiver operating characteristic [ROC] areas under the curve < 0.5). The pneumonia severity index was associated with severe sepsis (p < 0.001) with moderate discrimination (ROC, 0.63).

CONCLUSIONS

Severe sepsis is common in hospitalized CAP patients, occurring early in the hospital course. SIRS criteria do not appear to be useful predictors for progression to severe sepsis in CAP.

Detection of rhinoviruses by tissue culture and two independent amplification techniques, nucleic acid sequence-based amplification and reverse transcription-PCR, in children with acute respiratory infections during a winter season

Five hundred seventeen consecutive nasopharyngeal aspirates were collected between October 1998 and May 1999 for episodes of acute respiratory tract infections in children presenting at the University Hospital of Antwerp. Culture and nucleic acid amplification techniques--nucleic acid sequence-based amplification (NASBA) and reverse transcription-PCR (RT-PCR)--were applied to detect rhinoviruses (RVs). Other respiratory viruses were detected by immunofluorescence (IF) analysis of the specimens and IF analysis of shell vial cultures. Among the 517 specimens, 219 viral agents were identified. They were, in decreasing order, rhinoviruses (93 [18.0%]), respiratory syncytial virus (76 [14.7%]), adenoviruses (16 [3.1%]), influenza viruses (15 [2.9%]), enteroviruses (15 [2.9%]), and herpes simplex virus (4 [0.8%]). For the evaluation of rhinovirus detection, culture positivity and/or a positive reaction in the two independent amplification methods was used as an expanded "gold standard." Based on this standard, the sensitivity, specificity, positive predictive value, and negative predictive value of culture were 44.7, 100, 100, and 99.8%, and those of NASBA and RT-PCR were 85.1, 98.3, 83.3, and 98.5% and 82.9, 93.4, 55.7, and 98.2%, respectively. NASBA and RT-PCR produced comparable results and were significantly more sensitive than virus culture. RVs showed the highest incidence in acute respiratory tract infections in children.

Cortisol levels in patients with severe community-acquired pneumonia

OBJECTIVES

To evaluate cortisol levels and prevalence of adrenal insufficiency in patients with severe community-acquired pneumonia (CAP).

DESIGN AND SETTING

Retrospective cohort study in a 24-bed medical-surgical intensive care unit (ICU).

PATIENTS

Forty patients with severe CAP admitted to the ICU from March 2003 and May 2005.

MEASUREMENTS AND RESULTS

Random cortisol levels were measured up to 72 h after ICU admission. A threshold of 20 microg/dl was considered for the diagnosis of adrenal insufficiency. Median cortisol levels were 15.5 microg/dl (IQR 10.8-25.1), and 26 patients (65%) met the criteria for adrenal insufficiency. Other cutoff levels of cortisol were evaluated, and 30 patients (75%) had cortisol levels below 25 microg/dl and 19 (47.5%) had cortisol levels below 15 microg/dl. When only patients with septic shock (n=19) were evaluated, 12 (63%) had adrenal insufficiency.

CONCLUSIONS

Relative adrenal insufficiency occurs in a high proportion of patients with severe CAP. This finding highlights the importance of measuring cortisol levels and may help explain the potential benefits of hydrocortisone infusion in these patients.

Prior outpatient antibacterial therapy as prognostic factor for mortality in hospitalized pneumonia patients

STUDY OBJECTIVES

To assess whether prior outpatient treatment is associated with outcome in patients hospitalized for community-acquired pneumonia (CAP).

PATIENTS AND METHODS

All patients with a first hospital admission for CAP between 1995 and 2000 were selected. Patients were divided into two groups, one of patients with use of antibacterial agents prior to hospitalization and one of patients treated as inpatient directly. The main outcome measures were duration of hospital stay and in-hospital mortality.

RESULTS

The two patient groups comprised 296 and 794 patients, respectively. The median duration of hospital stay was 10 days and was similar for both groups. In patients with respiratory diseases or heart failure, the median duration of hospital stay was 12 and 14 days, respectively. The overall in-hospital mortality was 7.2% and did not largely differ between both groups. In patients with congestive heart failure, the mortality was 9.8% for controls and 23.3% for patients hospitalized after initial outpatient treatment (adjusted OR 2.78, 95% CI 1.01-7.81).

CONCLUSIONS

Prior outpatient antibacterial therapy is not associated with outcome in hospitalized pneumonia patients. In patients with underlying chronic heart failure, prior outpatient antibiotic is associated with a significant increased mortality.

The JRS guidelines for the management of community-acquired pneumonia in adults: an update and new recommendations

Community-acquired pneumonia (CAP) continues to be a major medical problem. Since CAP is a potentially fatal disease, early appropriate antibiotic treatment is vital. Epidemiologic studies have shown that in the combined cause-of-death category, pneumonia ranks fourth as the leading cause of death in Japan. Therefore, the Japanese Respiratory Society (JRS) provided guidelines for the management of CAP in adults in 2000. Because of evolving resistance to antimicrobials and advances in diagnosis, treatment and prevention of CAP, it is felt that an update should be provided every three years so that important developments can be highlighted and pressing questions can be answered. Thus, the guidelines committee updated its guidelines in 2005. The basic policy and main purposes of the JRS guidelines include; 1) prevention of bacterial resistance and 2) effective and long-term use of medical resources. The JRS guidelines have recommended the exclusion of potential and broad spectrum antibiotics, fluoroquinolones and carbapenems, from the list of first-choice drugs for empirical treatment. In addition, the JRS guidelines have recommended short-term usage of antibiotics of an appropriate dose and pathogen-specific treatment using rapid diagnostic methods if possible.

Polmoniti

Non è semplice ordinare una materia così articolata come la patologia infettiva respiratoria. La gestione delle polmoniti si presenta complessa per le problematiche ad esse connesse (aspetti epidemiologici, microbiologici, farmacoeconomici, ecc.) per cui è necessario confrontare costantemente le conoscenze di quanti hanno dimestichezza in questo settore per proporre e condividere linee strategiche che tengano in considerazione da un lato i suggerimenti contenuti nelle linee guida più accreditate e dall’altro le esperienze prodotte dalla pratica quotidiana al fine di migliorare potenzialità e metodi di cura e razionalizzare i percorsi diagnostico-terapeutici più idonei a fronteggiarle. L’incremento costante delle infezioni respiratorie sostenute dai patogeni emergenti e interessate dal fenomeno delle resistenze batteriche è oggi un elemento preoccupante che rischia, tra l’altro, di vanificare, in carenza di un adeguamento costante, tutti gli schemi, le linee guida e i protocolli diagnostico-terapeutici elaborati in questi ultimi anni per un razionale trattamento delle patologie pneumoinfettivologiche. Il trattamento delle polmoniti acquisite in comunità (CAP) rappresenta uno degli argomenti più dibattuti in pneumologia negli ultimi anni, sottoposto a continue revisioni, aggiornamenti, precisazioni dottrinarie.

Nursing Home-Acquired Pneumonia

The management of nursing home-acquired pneumonia (NHAP) continues to be debatable because of the lack of clinical trials and controversy regarding its aetiology. The controversy regarding aetiology stems, in part, from studies that utilised sputum cultures for the diagnosis of NHAP without assessing the quality of the samples. These studies found a high proportion of Gram-negative aerobic bacilli in cultures as well as Staphylococcus aureus. However, in studies that have assessed the reliability of sputum samples, Gram-negative bacilli and S. aureus were isolated infrequently and Streptococcus pneumoniae and Haemophilus influenzae isolated most commonly. Since Gram-negative aerobic bacilli and S. aureus frequently cause hospital-acquired pneumonia, some authors have considered NHAP to be a variant of this group. Many other studies, however, have considered NHAP as part of the community-acquired pneumonia category. Depending on which categorisation is used for NHAP, the treatment recommendations have varied. There are several factors to consider in the management of NHAP in addition to choice of antibacterial: hospitalisation decision, initial route of administration of antibacterials for treatment in the nursing home, timing of switch from a parenteral to an oral agent and the duration of therapy. These factors, which have not been addressed in published guidelines, are discussed in this review. Recent guidelines recommend a fluoroquinolone (gatifloxacin, levofloxacin or moxifloxacin) or amoxicillin/clavulanic acid plus a macrolide for initial treatment of NHAP in the nursing home. For treatment in the hospital, a parenteral fluoroquinolone (as listed above) or a second- or third-generation cephalosporin plus a macrolide is recommended. A recent guideline for the treatment of healthcare-associated pneumonia (that includes NHAP) recommended an antipseudomonal cephalosporin or a carbapenem or an antipseudomonal penicillin/beta-lactamase inhibitor plus ciprofloxacin plus vancomycin or linezolid for treatment of NHAP based on findings in residents with severe pneumonia who required mechanical ventilation. However, this recommendation does not apply to the majority of residents who are hospitalised with pneumonia and not intubated. Other factors to consider when choosing an empiric regimen include recent antibacterial therapy and prior colonisation with a resistant organism, e.g. methicillin-resistant S. aureus. Recently, a group of studies by investigators in The Netherlands have focused on the concept of withholding antibacterial therapy in nursing home residents with pneumonia who have advanced dementia. These studies are reviewed in some detail because this is an approach to the management of NHAP that is uncommon but deserves more consideration given the terminal status of these people. Future studies of NHAP should focus on development of rapid (molecular) methods to identify aetiological agents, determination of the optimum antimicrobial regimen and duration of therapy, and identification of criteria that can assist physicians and families in making the decision to withhold antimicrobial therapy in residents with advanced dementia and pneumonia.

Treatment with Sequential Intravenous or Oral Moxifloxacin Was Associated with Faster Clinical Improvement than Was Standard Therapy for Hospitalized Patients with Community-Acquired Pneumonia Who Received Initial Parenteral Therapy

BACKGROUND

Although third-generation cephalosporins, such as ceftriaxone (CTRX), and pneumococcal fluoroquinolones, such as moxifloxacin (MXF), are currently recommended first-line antibiotics for empirical treatment of inpatients with community-acquired pneumonia, CTRX and MXF have never undergone a head-to-head comparison. We therefore compared the efficacy, safety, and speed and quality of defervescence of sequential intravenous or oral MXF and high-dose CTRX with or without erythromycin (CTRX+/-ERY) for patients with community-acquired pneumonia requiring parenteral therapy.

METHODS

In this prospective, multicenter, randomized, controlled, nonblinded study, 397 patients were randomly assigned to receive either MXF (400 mg once daily intravenously, possibly followed by oral tablets) or CTRX (2 g intravenously once daily) with or without ERY (1 g intravenously every 6-8 h) for 7-14 days.

RESULTS

Among 317 patients evaluable for efficacy and safety, 138 (85.7%) of 161 MXF-treated patients and 135 (86.5%) of 156 CTRX+/-ERY-treated patients (59 [37.8%] of whom received CTRX and ERY) achieved continued clinical resolution. Defervescence and relief of symptoms, such as chest pain, occurred significantly earlier in the MXF-treated group than in the CTRX+/-ERY-treated group. Both regimens were generally well tolerated.

CONCLUSIONS

For adult patients hospitalized with community-acquired pneumonia, sequential MXF therapy was clinically equivalent to high-dose CTRX+/-ERY therapy but led to a faster clinical improvement.

The impact of empiric antimicrobial therapy with a β-lactam and fluoroquinolone on mortality for patients hospitalized with severe pneumonia

Introduction

National clinical practice guidelines have recommended specific empiric antimicrobial regimes for patients with severe community-acquired pneumonia. However, evidence confirming improved mortality with many of these regimes is lacking. Our aim was to determine the association between the empiric use of a β-lactam with fluoroquinolone, compared with other recommended antimicrobial therapies, and mortality in patients hospitalized with severe community-acquired pneumonia.

Methods

A retrospective observational study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of community-acquired pneumonia and had a chest X-ray and a discharge ICD-9 diagnosis consistent with this. Subjects were excluded if they received 'comfort measures only' during the admission, had been transferred from another acute care hospital, did not meet criteria for severe pneumonia, or were treated with non-guideline-concordant antibiotics. A multivariable logistic regression model was used to assess the association between 30-day mortality and the use of a β-lactam antibiotic with a fluoroquinolone compared with other guideline-concordant therapies, after adjustment for potential confounders including a propensity score.

Results

Data were abstracted on 172 subjects at the two hospitals. The mean age was 63.5 years (SD 15.0). The population was 88% male; 91% were admitted through the emergency department and 62% were admitted to the intensive care unit within the first 24 hours after admission. Mortality was 19.8% at 30 days. After adjustment for potential confounders the use of a β-lactam with a fluoroquinolone (odds ratio 2.71, 95% confidence interval 1.2 to 6.1) was associated with increased mortality.

Conclusion

The use of initial empiric antimicrobial therapy with a β-lactam and a fluoroquinolone was associated with increased short-term mortality for patients with severe pneumonia in comparison with other guideline-concordant antimicrobial regimes. Further research is needed to determine the range of appropriate empiric antimicrobial therapies for patients with severe community-acquired pneumonia.

Predicted effects on antibiotic use following the introduction of British or North American guidelines for community-acquired pneumonia in The Netherlands

This study evaluated the possible changes in antibiotic use that might follow the implementation of British or North American guidelines for the treatment of community-acquired pneumonia (CAP) in The Netherlands. Patients admitted for mild, moderate and severe CAP were evaluated prospectively. Volume of antibiotic use, based upon guidelines of the British Thoracic Society (BTS), the Infectious Diseases Society of America (IDSA) or the American Thoracic Society (ATS), was estimated and compared to current practice. For 248 patients, current antibiotic use was 3087 defined daily doses. Antibiotic use would increase by 38% if based on ATS guidelines, by 23% if based on IDSA guidelines, and by 21% if based on BTS guidelines. The most significant increase in antibiotic use would occur for cases of moderate CAP, with incremental antibiotic costs of 1 750 000-3 500 000 Euros in The Netherlands.

Impact of Chisan (ADAPT-232) on the quality-of-life and its efficacy as an adjuvant in the treatment of acute non-specific pneumonia

A double-blind, placebo-controlled, randomized (simple randomisation), pilot (phase III) study of Chisan, (ADAPT-232; a standardised fixed combination of extracts of Rhodiola rosea L., Schisandra chinensis Turcz. Baill., and Eleutherococcus senticosus Maxim) was carried out on two parallel groups of patients suffering from acute nonspecific pneumonia. Sixty patients (males and females; 18-65 years old) received a standard treatment with cephazoline, bromhexine, and theophylline: in addition, one group of 30 patients was given Chisan mixture, whilst the second group of 30 patients received a placebo, each medication being taken twice daily from the beginning of the study for 10-15 days. The primary outcome measurements were the duration of antibiotic therapy associated with the clinical manifestations of the acute phase of the disease, together with an evaluation of mental performance in a psychometric test and the self-evaluation of quality-of-life (QOL) (WHOQOL-Bref questionnaires) before treatment and on the first and fifth days after clinical convalescence. The mean duration of treatment with antibiotics required to bring about recovery from the acute phase of the disease was 2 days shorter in patients treated with Chisan compared with those in the placebo group. With respect to all QOL domains (physical, psychological, social and ecological), patients in the Chisan group scored higher at the beginning of the rehabilitation period, and significantly higher on the fifth day after clinical convalescence, than patients in the control group. Clearly, adjuvant therapy with ADAPT-232 has a positive effect on the recovery of patients by decreasing the duration of the acute phase of the illness, by increasing mental performance of patients in the rehabilitation period, and by improving their QOL. Both the clinical and laboratory results of the present study suggest that Chisan (ADAPT-232) can be recommended in the standard treatment of patients with acute non-specific pneumonia as an adjuvant to increase the QOL and to expedite the recovery of patients.

Efficacy of moxifloxacin for treatment of penicillin-, macrolide- and multidrug-resistant Streptococcus pneumoniae in community-acquired pneumonia

This pooled analysis of six prospective, multicentre trials aimed to determine the efficacy of moxifloxacin in community-acquired pneumonia (CAP) due to penicillin-, macrolide- and multidrug-resistant Streptococcus pneumoniae (MDRSP). At a central laboratory, isolates were identified and antimicrobial susceptibility determined (microbroth dilution). MDRSP was defined as resistance > or =3 drug classes. Patients received oral or sequential intravenous/oral 400 mg moxifloxacin once daily for 7-14 days. The primary endpoint was clinical success at test-of-cure for efficacy-valid patients with proven pretherapy S. pneumoniae infection. Of 140 S. pneumoniae isolated (112 respiratory, 28 blood), 23 (16.4%) were penicillin resistant, 26 (18.6%) macrolide resistant and 31 (22.1%) MDRSP. The moxifloxacin MIC90 was 0.25 microg/ml. Clinical cure with moxifloxacin was 95.4% (125/131) overall, and 100% (21/21) for penicillin-, 95.7% (22/23) for macrolide- and 96.4% (27/28) for multidrug-resistant strains. Moxifloxacin provided excellent clinical and bacteriological cure rates in CAP due to drug-resistant pneumococci.

Comparison between pathogen directed antibiotic treatment and empirical broad spectrum antibiotic treatment in patients with community acquired pneumonia: a prospective randomised study

BACKGROUND

There is much controversy about the ideal approach to the management of community acquired pneumonia (CAP). Recommendations differ from a pathogen directed approach to an empirical strategy with broad spectrum antibiotics.

METHODS

In a prospective randomised open study performed between 1998 and 2000, a pathogen directed treatment (PDT) approach was compared with an empirical broad spectrum antibiotic treatment (EAT) strategy according to the ATS guidelines of 1993 in 262 hospitalised patients with CAP. Clinical efficacy was primarily determined by the length of hospital stay (LOS). Secondary outcome parameters for clinical efficacy were assessment of therapeutic failure on antibiotics, 30 day mortality, duration of antibiotic treatment, resolution of fever, side effects, and quality of life.

RESULTS

Three hundred and three patients were enrolled in the study; 41 were excluded, leaving 262 with results available for analysis. No significant differences were found between the two treatment groups in LOS, 30 day mortality, clinical failure, or resolution of fever. Side effects, although they did not have a significant influence on the outcome parameters, occurred more frequently in patients in the EAT group than in those in the PDT group (60% v 17%, 95% CI -0.5 to -0.3; p<0.001).

CONCLUSIONS

An EAT strategy with broad spectrum antibiotics for the management of hospitalised patients with CAP has comparable clinical efficacy to a PDT approach.

The spectrum of practice in the diagnosis and management of pneumonia in patients requiring mechanical ventilation. Australian and New Zealand practice in intensive care (ANZPIC II)

This study of ventilated patients investigated current clinical practice in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units (ICUs) within Australia and New Zealand. Diagnostic methods and confidence, disease severity, microbiology and antibiotic use were assessed. All pneumonia types had similar mortality (community-acquired pneumonia 33%, hospital-acquired pneumonia 37% and ventilator-associated pneumonia 24%, P=0.15) with no inter-hospital differences (P=0.08-0.91). Bronchoscopy was performed in 26%, its use predicted by admission hospital (one tertiary: OR 9.98, CI 95% 5.11-19.49, P< 0.001; one regional: OR 6.29, CI 95% 3.24-12.20, P<0.001), clinical signs of consolidation (OR 3.72, CI 95% 2.09-6.62, P<0.001) and diagnostic confidence (OR 2.19, CI 95% 1.29-3.72, P=0.004). Bronchoscopy did not predict outcome (P=0.11) or appropriate antibiotic selection (P=0.69). Inappropriate antibiotic prescription was similar for all pneumonia types (11-13%, P=0.12) and hospitals (0-16%, P=0.25). Blood cultures were taken in 51% of cases. For community-acquired pneumonia, 70% received a third generation cephalosporin and 65% a macrolide. Third generation cephalosporins were less frequently used for mild infections (OR 0.38, CI 95% 0.16-0.90, P=0.03), hospital-acquired pneumonia (OR 0.40, CI 95% 0.23-0.72, P<0.01), ventilator-associated pneumonia (OR 0.04, CI 95% 0.02-0.13, P<0.001), suspected aspiration (OR 0.20, CI 95% 0.04-0.92, P=0.04), in one regional (OR 0.26, CI95% 0.07-0.97, P=0.05) and one tertiary hospital (OR 0.14, CI 95% 0.03-0. 73, P=0.02) but were more commonly used in older patients (OR 1.02, CI 95% 1.01-1.03, P=0.01). There is practice variability in bronchoscopy and antibiotic use for pneumonia in Australian and New Zealand ICUs without significant impact on patient outcome, as the prevalence of inappropriate antibiotic prescription is low. There are opportunities for improving microbiological diagnostic work-up for isolation of aetiological pathogens.

Evaluation of infections in non-small cell lung cancer patients treated with radiotherapy

PURPOSE

We aim to determine infections occurring in patients with non-small cell lung cancer during radiotherapy (RT).

METHODS AND MATERIALS

A total of 181 patients had been treated with thoracic radiotherapy between October 1995 and December 1999. Radiotherapy was given using 1.8-3Gray (Gy) fraction daily, five fractions a week for a total dose of 59.4Gy (30-70.2Gy). A complete history was collected retrospectively for each patient. All microbiological examinations were performed according to the routine procedures of the hospital laboratory. Numeric and categoric variables were employed such as sex, age, performance status, histology, stage, chemotherapy, usage of corticosteroids, neutropenia, surgery, hospitalization, associated diseases, smoking during treatment, package per year of cigarette smoking, dose of radiotherapy, and response rates.

RESULTS

Infections developed in 84 patients (46%, 84/181) during thoracic radiotherapy. A 101 episodes of infections developed in these patients. Most patients suffered from sputum production (65%), cough (59%), auscultation findings (31%) and fever (31%). Gram-negative bacteria were the most frequently isolated pathogens in the cultures of specimens (70%, 16/23 samples). Neoadjuvant chemotherapy (OR=4.81; 95% CI, 1.57-9.12; p=0.003) and neutropenia (OR=4.25; 95% CI, 1.44-6.89; p=0.009) were found as risk factors for influencing infection based on logistic regression analyses. Package per year of cigarette smoking was found statistically significantly higher in patients with infections than patients without infections (p=0.001). A slight increase in infections, which was of borderline statistical significance (p=0.07), was observed in patients age over 70. Ciprofloxacin and clarithromycin were the most frequently used agents in treatment. Median survival was 9 months in the patients with infection and 13 months in the 97 patients without infection. Overall survival seemed to be statistically significantly better in patients without infection than patients with infection (p=0.042) calculated using Kaplan-Meier method. Based on Cox regression analyses; overall survival was not correlated to presence of infection but associated with poor performance status (</=80) (OR=2.35; 95% CI, 0.85-8.93; p=0.03), and usage of corticosteroids (OR=2.68; 95% CI, 0.98-6.72; p=0.01). The dose of radiation therapy >5940 cGy (OR=2.06; 95% CI, 0.72-7.18; p=0.007) and the absence of response to treatment (OR=2.45; 95% CI, 0.89-14.23; p<0.001) were also found to be risk factors for survival.

CONCLUSIONS

Infections are important causes of morbidity and mortality in lung cancer patients. The control of infection in these patients may improve the survival. Predisposing factors and treatment management approaches in non-small cell lung cancer should be defined carefully.

Pneumonia in hospitalized children

Pneumonia is one of the most common infections in the pediatric age group and one of the leading diagnoses that results in overnight hospital admission for children. Various micro-organisms can cause pneumonia, and etiologies differ by age. Clinical manifestations vary, and diagnostic testing is frequently not standardized. Hospital management should emphasize timely diagnosis and prompt initiation of antimicrobial therapy when appropriate. Issues of particular relevance to inpatient management are emphasized in this article.

Total Antioxidant Status and Severity of Community-Acquired Pneumonia: Are They Correlated?

BACKGROUND

Oxidant/antioxidant imbalance has been reported in various respiratory diseases including pneumonia. However, the role of blood antioxidants has not been fully discussed.

OBJECTIVES

The aim of this exploratory study was to assess serum total antioxidant status (TAS) in patients with community-acquired pneumonia (CAP) and the probable correlation with the severity of the disease.

METHODS

Thirty patients (22 men, 8 women; mean age of 48 +/- 21 years) and 10 healthy nonsmokers (mean age 44 +/- 16 years) were studied. Clinical, laboratory and radiological findings were recorded on the day of admission and on the 7th day. A severity score was calculated using the Fine scale. Serum TAS was measured at the same time points using a colorimetric method.

RESULTS

On admission, TAS (TAS1) was significantly lower than on the 7th day (TAS2) (0.84 +/- 0.13 mmo/l vs. 1.00 +/- 0.17 mmo/l; p = 0.0001) and compared with the healthy subjects (0.84 +/- 0.13 vs. 1.19 +/- 0.09 mmol/l; p < 0.001). TAS change (TAS2 - TAS1) was statistically significantly more marked in smokers (0.17 vs. 0.28, p = 0.001), in patients with factors predisposing to CAP (0.12 vs. 0.37; p = 0.000) and in patients with gram-negative pneumonia (0.16 vs. 0.35; p = 0.000). On the other hand, change in TAS was statistically significantly less marked in patients with lobar pneumonia (0.27 vs. 0.17; p = 0.001). Additionally, TAS change was positively correlated to white blood count on admission (r = 0.39; p = 0.029).

CONCLUSIONS

It is concluded that serum TAS is decreased in patients with CAP, suggesting the presence of oxidative stress, and that change in TAS seems to be influenced by disease severity. TAS measurement may be useful in estimating the severity of CAP and is a probable indication for the administration of antioxidants in the management of the disease.

Pleural Fluid Parameters Identifying Complicated Parapneumonic Effusions

BACKGROUND

Controversy exists regarding the clinical utility of pleural fluid parameters as prognosticators of complicated parapneumonic effusions that require drainage.

OBJECTIVES

The purpose of this prospective study is to further assess the utility of these parameters in the management of a larger series of parapneumonic effusions and to determine appropriate binary decision thresholds.

METHODS

We studied 238 consecutive patients with parapneumonic effusions who underwent diagnostic thoracentesis.

RESULTS

We found that pleural fluid pH had the highest diagnostic accuracy (area under the curve, AUC: 0.928; 95% confidence interval, CI: 0.894-0.963) compared with pleural fluid glucose (AUC: 0.835; 95% CI: 0.773-0.897), LDH (AUC: 0.824; 95% CI: 0.761-0.887) or pleural fluid volume (AUC: 0.706; 95% CI: 0.634-0.777). The optimal binary decision threshold for pleural fluid pH identifying complicated effusions requiring drainage was 7.15. Binary, multilevel and continuous likelihood ratios (LRs) for pH were calculated to estimate the likelihood of complication of the pleural effusion. Values for the LRs were compared for each of the three strategies, and relative clinical and statistical significances were assessed. Binary LRs provided significantly less information than continuous strategies.

CONCLUSION

The pH has the highest diagnostic accuracy for identifying complicated parapneumonic pleural effusions. The binary decision threshold determining the need for chest drainage is 7.15 in our patient series. We recommend continuous LRs to estimate the post-test probability of the complication as they provide the most information compared with binary LRs. Our results do not support the use of pleural fluid LDH as independent predictor of complicated parapneumonic effusions.

Comparison of Levofloxacin and Cefotaxime Combined With Ofloxacin for ICU Patients With Community-Acquired Pneumonia Who Do Not Require Vasopressors

STUDY OBJECTIVES

To evaluate the efficacy and tolerability of levofloxacin (L) as monotherapy in patients with severe community-acquired pneumonia (CAP) in comparison with therapy using a combination of cefotaxime (C) plus ofloxacin (O).

DESIGN

Prospective, randomized 1:1, comparative, open, parallel-group study.

SETTING

Multinational study with 149 sites.

PATIENTS

A total of 398 randomized patients who had been admitted to the ICU with severe CAP without shock, including 308 patients in a modified intent-to-treat population and 271 patients in the per-protocol (PP) population (L group, 139 patients; C + O group, 132 patients).

INTERVENTIONS

Therapy with levofloxacin (500 mg IV, q12h) vs therapy with a C + O combination (C, 1g IV, q8h; O, 200 mg IV, q12h) for 10 to 14 days.

MEASUREMENTS AND RESULTS

The main end point was the clinical efficacy at the end of treatment (ie, the test-of-cure [TOC] visit). The statistical hypothesis was the noninferiority of L therapy to C + O therapy with a 2.5% alpha risk (unilateral) and a 15% maximum set difference. At the TOC visit, a clinical success was observed in 79.1% of patients (L group) and 79.5% of patients (C + O group) in the PP population (difference, -0.4%; 95% confidence interval [CI], -10.79 to 9.97% without adjustment for simplified acute physiology score [SAPS] II at inclusion; difference, -0.3%; 95% CI, -10.13 to 9.58% with adjustment for SAPS II). A satisfactory bacteriologic response was present in 73.7% of L group patients and 77.5% of C + O group patients, including responses of 75.7% and 70.3%, respectively, in the L group and C + O group in the Streptococcus pneumoniae-documented population. In the safety analysis, 20 patients in the L group (10.3%) and 16 patients in the C + O group (8.0%) experienced at least one adverse event that was considered to be treatment-related.

CONCLUSION

L therapy was at least as effective as the combination therapy of C + O in the treatment of a subset of patients with CAP requiring ICU admission. This conclusion cannot be extrapolated to patients requiring mechanical ventilation or vasopressors (ie, those patients in shock).

Severe community-acquired pneumonia in an intensive care unit: risk factors for mortality

OBJECTIVE

To evaluate severe community-acquired pneumonia (SCAP) patients in an intensive care unit (ICU) with regard to risk factors for mortality and to compare ICU patients with matched non-ICU patients to evaluate whether our judgement for ICU admission was appropriate or not.

MATERIALS AND METHODS

During a 7-year period, all patients with CAP who were admitted to the ICU were examined. They underwent clinical and radiographic evaluations, and two commonly used severity of illness scores were also calculated using the Simplified Acute Physiological Score (SAPS) and the Acute Physiology and Chronic Health Evaluation (APACHE) II methods. To detect risk factors for ICU admission using existing guidelines, each study patient was matched with two patients hospitalized in a general medical ward.

RESULTS

Seventy-two patients were identified during the study period. Their mean age was 72.9 years, and 35 patients (48.6%) subsequently died. For the univariate analysis, there were significant differences with the pulse rate > or = 130/min, blood urea nitrogen > or = 30 mg/dl, multilobar shadow, SAPS > or = 13, APACHE II > or = 23, and the occurrence of septic shock between the survivors and those who died. For the multivariate analysis, septic shock (p = 0.0005, odds ratio of 26.6) and blood urea nitrogen > or = 30 mg/dl (p = 0.037, odds ratio of 5.38) were associated with mortality. Regarding the characteristics of different clinical predictions for ICU admission, the revised American Thoracic Society criteria might have been the most accurate.

CONCLUSION

Septic shock was associated with high mortality, which is a more accurate and higher predictor of mortality than was physical examination, laboratory or radiographic findings.

Hidden epidemic of macrolide-resistant pneumococci

Community-acquired respiratory tract infections (RTIs) account for a substantial proportion of outpatient antimicrobial drug prescriptions worldwide. Concern over the emergence of multidrug resistance in pneumococci has largely been focused on penicillin-resistant Streptococcus pneumoniae. Macrolide antimicrobial drugs have been widely used to empirically treat community-acquired RTIs because of their efficacy in treating both common and atypical respiratory pathogens, including S. pneumoniae. However, increased macrolide use has been associated with a global increase in pneumococcal resistance, which is leading to concern over the continued clinical efficacy of the macrolides to treat community-acquired RTIs. We provide an overview of macrolide-resistant S. pneumoniae and assess the impact of this resistance on the empiric treatment of community-acquired RTIs.

Antimicrobial treatment of community-acquired pneumonia

Community-acquired pneumonia (CAP) is a clinical diagnosis that has a significant impact on health care management around the world. Early clinical suspicion and prompt empiric antimicrobial therapies are mandatory in patients with CAP. This article provides a review of recent studies and guidelines addressing antimicrobial therapy for hospitalized patients with CAP.

[Clinical picture and prognostic factors for severe community-acquired pneumonia in adults admitted to the intensive care unit]

OBJECTIVE

In Chile very little information is available on severe community-acquired pneumonia treated in intensive care units. This study describes the clinical picture, prognostic factors, and treatment of adult patients admitted to the intensive care unit for severe community-acquired pneumonia.

PATIENTS AND METHODS

A total of 113 consecutive patients were included in this prospective, descriptive study.

RESULTS

The mean (SD) age of the 113 patients was 73 (15). Of these, 95% had associated comorbidity, and 81% were in the high-risk classes of the Pneumonia Severity Index. Etiology was identified in 31%, and the most common pathogens were Streptococcus pneumoniae (40%), gram negative bacilli (17%), and Mycoplasma pneumoniae (6%). The main complications were the need for mechanical ventilation (45%), septic shock (26%), heart failure (24%), and arrhythmias (15%). Mortality at 30 days was 16.8%, and multivariate analysis revealed the following factors to be associated with a greater risk of death: acute renal failure (odds ratio: 5.1), and glycemia above 300 mg/dL (odds ratio: 7.2).

CONCLUSIONS

The patients with severe pneumonia admitted to the intensive care unit are elderly, with a high level of comorbidity and complications, but most survive.

High prevalence of respiratory viral infections in patients hospitalized in an intensive care unit for acute respiratory infections as detected by nucleic acid-based assays

Forty-seven bronchoalveolar lavages (BAL) were obtained from 41 patients with acute pneumonia attending an intensive care unit. By molecular diagnosis, 30% of total BAL and 63% of bacteria-negative BAL were positive for respiratory viruses. Molecular detection allows for high-rate detection of respiratory viral infections in adult patients suffering from severe pneumonia.

Management of community-acquired pneumonia and secular trends at different hospitals

STUDY OBJECTIVES

The goal of this study was to assess variability in the management of patients admitted to hospitals with community-acquired pneumonia (CAP), and changes in secular trends of this condition.

METHODS

Observational study carried out, in 5 teaching hospitals, in northern Spain of patients admitted with CAP between March 1,1998 and March 1,1999 (baseline period), and between March 1, 2000 and September 30, 2001 (follow-up period). Clinical histories were analyzed retrospectively for relevant parameters for process-of-care and outcome performance. Those parameters among hospitals during the baseline period were compared. For each hospital, changes in these parameters between baseline and follow-up were also measured. All parameters were adjusted for disease severity.

RESULTS

A total of 844 patients were included in the baseline period, and 654 in the follow-up period. During the baseline period, adjusted analyses revealed statistically significant differences in all process-of-care parameters except the coverage of atypical pathogens. With regard to clinical outcomes, however, only the 30-day readmission rate was significantly different (P=0.03). Adjusted mean length of stay ranged from 6.3 to 9.2 days (P<0.0001). In adjusted analyses of temporal changes within hospitals for process-of-care and outcome performance, revealed few statistically significant differences.

CONCLUSIONS

Variability discovered between hospitals in the management of patients in the absence of relevant secular changes in each hospital points out the necessity to implement measures designed to reduce such variability between hospitals and to improve the quality of medical treatment.

Severity scoring in community-acquired pneumonia caused by Streptococcus pneumoniae: a 5-year experience

Multiple severity scoring systems have been devised and evaluated in community-acquired pneumonia (CAP), but a simplified set of prognostic indicators has not yet been developed. Streptococcus pneumoniae is the most frequent aetiological agent of CAP. Our aim was to characterise the outcome in the light of different severity scoring systems and to compare the predictive values of different sets of clinical parameters, using available clinical data for pneumococcal CAP patients. This is a case series retrospective analysis that included consecutive adult pneumococcal CAP patients admitted to Danbury Hospital between 1 January 1996 and 31 December 2000. The aetiology was confirmed by positive sputum and/or blood cultures. The severity assessment included the Pneumonia Outcome Research Trial (PORT) and British Thoracic Society (BTS) scoring systems and other additional parameters. Primary end-points were in-hospital CAP-attributable deaths and length of hospitalisation. N = 151 patients with S. pneumoniae CAP were identified. The mean (+/- standard deviation) age at the time of diagnosis was 68 (+/-15) years. Thirty-three patients (22%) were admitted to the medical intensive care unit. The mean (median) hospitalisation duration was 7.5 (+/-5) days. Door-to-antibiotic mean (median) administration time was 3.7 (2) hours. Most frequent antibiotics used initially were cephalosporins plus/minus macrolides or fluoroquinolones. The mean (+/- standard deviation) PORT score was 105 (+/-37). The observed CAP-related mortality was 9/151 (5.9%, 95% confidence interval: 3-9%). The mortality rate in ICU was 18% (6/33). Sixty-nine patients (45%) had S. pneumoniae bacteraemia an admission. The bacteraemic and non-bacteraemic patients had similar PORT scores (107 vs. 104, P = 0.66), length of hospitalisation (8 vs. 7 days, P = 0.41) and mortality rates (9% vs. 4%, P = 0.30). In conclusion, patients admitted with pneumococcal CAP, although severe and with multiple co-morbidities had low in-hospital mortality rates and lengths of hospitalisation. Neither prior antimicrobial use (or failure) nor antimicrobial resistance contributed to an adverse outcome. S. pneumoniae bacteraemia failed to correlate with need for ICU, length of stay, higher morbidity index or fatal outcome. Low rates of empirical antibiotic use for non-bacterial infections in the local community, implementation of an emergency department protocol for CAP therapy, early recognition of higher risk patients and placement in ICU, use of broad spectrum antibiotics, infectious disease approval or critical pathway restriction for admission orders, could all have combined to effect a good outcome for these patients.

Role of beta-lactam agents in the treatment of community-acquired pneumonia

Community-acquired pneumonia (CAP) is a common illness associated with high rates of morbidity and mortality worldwide. The beta-lactam antibacterial agents have been the mainstay of therapy for CAP for over four decades and remain as first-line therapy. However, the impact of the substantial prevalence of resistance seen among the common respiratory pathogens, particularly penicillin and macrolide resistance among Streptococcus pneumoniae, is now an area for concern. CAP treatment guidelines often recommend the use of a macrolide or fluoroquinolone in conjunction with, or as an alternative to, beta-lactam agents, but whether this is necessary is uncertain. This review outlines the historical use of beta-lactam antibacterial agents in the treatment of CAP along with their ongoing therapeutic utility.

[Guidelines for the management of community pneumonia in adult who needs hospitalization]

Community acquired pneumonia is still an important health problem. In Spain the year incidence is 162 cases per 100,000 inhabitants with 53,000 hospital admission costing 115 millions of euros per year. In the last years there have been significant advances in the knowledge of: aetiology, diagnostic tools, treatment alternatives and antibiotic resistance. The Spanish Societies of Intensive and Critical Care (SEMICYUC), Infectious Diseases and Clinical Microbiology (SEIMC) and Pulmonology and Thoracic Surgery (SEPAR) have produced these evidence-based Guidelines for the management of community acquired pneumonia in Adults. The main objective is to help physicians to make decisions about this disease. The different points that have been developed are: aetiology, diagnosis, treatment and prevention.

Hydrocortisone Infusion for Severe Community-acquired Pneumonia

We hypothesize that hydrocortisone infusion in severe community-acquired pneumonia attenuates systemic inflammation and leads to earlier resolution of pneumonia and a reduction in sepsis-related complications. In a multicenter trial, patients admitted to the Intensive Care Unit (ICU) with severe community-acquired pneumonia received protocol-guided antibiotic treatment and were randomly assigned to hydrocortisone infusion or placebo. Hydrocortisone was given as an intravenous 200-mg bolus followed by infusion at a rate of 10 mg/hour for 7 days. Primary end-points of the study were improvement in Pa(O(2)):FI(O(2)) (Pa(O(2)):FI(O(2)) > 300 or >/= 100 increase from study entry) and multiple organ dysfunction syndrome (MODS) score by Study Day 8 and reduction in delayed septic shock. Forty-six patients entered the study. At study entry, the hydrocortisone group had lower Pa(O(2)):FI(O(2)), and higher chest radiograph score and C-reactive protein level. By Study Day 8, treated patients had, compared with control subjects, a significant improvement in Pa(O(2)):FI(O(2)) (p = 0.002) and chest radiograph score (p < 0.0001), and a significant reduction in C-reactive protein levels (p = 0.01), MODS score (p = 0.003), and delayed septic shock (p = 0.001). Hydrocortisone treatment was associated with a significant reduction in length of hospital stay (p = 0.03) and mortality (p = 0.009).

Nonresponses and treatment failures with conventional empiric regimens in patients with community-acquired pneumonia

Although most patients with suspected CAP respond to empiric therapy,a small number of patients do not respond in the expected fashion. Age and underlying comorbid conditions have a strong influence on the course of illness. Less common causes of treatment failures include overwhelming infection, antimicrobial resistance, and misdiagnosis. It is a common practice for empiric antimicrobial treatment of CAP to be initiated without microbiologic studies. Clinicians carefully should observe these patients for unusual or slow responses and should be ready to pursue a more extensive search for the cause of treatment failure.

Community-acquired pneumonia: severity of illness evaluation

Severity-of-illness assessment is now an accepted part of clinical practice and clinical research for the management of adults who have community-acquired pneumonia. Several approaches to this issue have been devised based on severity-of-illness scores or rules, some related to site of management. No single approach has been found to be superior to others, but further research into their effect on outcome in clinical practice is required. It is likely that different approaches may suit different populations and health care systems.

Validation of the 2001 American Thoracic Society criteria for severe community-acquired pneumonia

STUDY OBJECTIVE

Ewig et al. proposed a new definition of severe community-acquired pneumonia in 1999, which was adopted by the American Thoracic Society in 2001. We evaluated this definition in an independent population of emergency department patients.

DESIGN

We compared the 2001 American Thoracic Society definition of severe community-acquired pneumonia using emergency department data to intensive care unit (ICU) admission, use of mechanical ventilation, and administration of vasopressors.

SETTING

LDS Hospital, a tertiary care, university-affiliated hospital with 520 total beds and 68 ICU beds in Salt Lake City, UT.

PATIENTS

We studied 980 consecutive emergency department patients with a radiographically confirmed diagnosis of pneumonia between June 1995 and June 1999. Of these patients, 498 were admitted to the hospital, immunocompetent, and without a "do-not-resuscitate" order within 24 hrs of admission.

MEASUREMENTS AND MAIN RESULTS

Forty-seven patients met the criteria for severe community-acquired pneumonia in the emergency department and were admitted to the ICU. Three hundred eighty patients did not meet the criteria and were admitted to a hospital unit. Nineteen patients met the definition but were admitted to a hospital unit; only one required subsequent ICU admission. Two of the 19 died after a do-not-resuscitate order was entered >24 hrs after admission; the remainder recovered. Fifty-two patients were triaged to the ICU but did not initially meet the definition of severe pneumonia. Sixteen of these 52 patients required mechanical ventilation, 13 of the 16 within 24 hrs of admission to the ICU. The sensitivity for the 2001 American Thoracic Society definition in our population was 44%, specificity was 95%, positive predictive value was 71%, and negative predictive value was 88%.

CONCLUSION

The 2001 American Thoracic Society definition of severe community-acquired pneumonia had high specificity but lower sensitivity in our population compared with the derivation population. Additional factors not reflected in the definition may contribute to ICU admission and the need for mechanical ventilation.

Antimicrobial therapy in community-acquired pneumonia among emergency patients in a university hospital in Japan

As antimicrobial therapy for pneumonia has not been well established in Japan, this study was designed to obtain a more definitive standard for antimicrobial treatment of this condition. Two hundred and thirty-one emergency patients admitted to Kyorin University Hospital between January 1998 and December 2000 were retrospectively analyzed in respect to their age, underlying disease, causative organism, and primary treatment with antimicrobial agent. Furthermore, the severity and prognosis were analyzed for those patients who had not responded to initial treatment with antimicrobial agents. The majority of the patients were elderly (over 65 years old; mean overall age 66.7 +/- 15.2 years) and had severe pneumonia; underlying diseases were recognized at a high rate in patients with severe pneumonia (P < 0.05) and in those classified as elderly (P < 0.0001). The most common underlying conditions in elderly patients were respiratory, cardiovascular (P < 0.01), and cerebrovascular (P < 0.05) diseases. The most common causative organisms were Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae, and Mycoplasma pneumoniae. In patients with severe pneumonia, S. aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa were identified as the most common causative organisms. Complications associated with antimicrobial treatment were observed in those patients with K. pneumoniae isolates who also had severe pneumonia and were frequently treated with penicillin. Furthermore, increased mortality rates were observed in patients not responding well to the initial treatment with antimicrobial agents. Thus, the selection of appropriate initial antimicrobial agents is an important factor affecting the prognosis of patients with community-acquired pneumonia.