Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention

Benefit of adjunct corticosteroids for community-acquired pneumonia in diabetic patients

AIMS/HYPOTHESIS

We have recently shown that adjunct prednisone shortens the time taken to reach clinical stability (time to clinical stability, TTCS) in patients with community-acquired pneumonia (CAP). Considering the hyperglycaemic effects of prednisone, there are concerns about the efficacy and safety of this therapy for diabetic patients with CAP. Our objective was to evaluate whether diabetes and/or hyperglycaemia on admission to hospital has an influence on the effect of corticosteroids on outcome in a well-defined cohort of patients with CAP.

METHODS

This is a preplanned subanalysis of a prospective randomised, double-blind placebo-controlled multicentre trial. Patients aged 18 years or older with CAP were eligible and were recruited from seven tertiary care hospitals in Switzerland within 24 h of presentation. Patients were randomised (1:1 ratio) to receive either 50 mg of prednisone daily for 7 days or placebo. Allocation was concealed with a prespecified computer-generated randomisation list. Patients, treating physicians, investigators and data assessors were masked to treatment allocation. The primary endpoint was TTCS; secondary endpoints were length of stay, mortality, duration of antibiotic treatment, CAP complications and new insulin requirement at day 30. Furthermore, we analysed whether these endpoints were influenced by a glycaemic dysregulation during the study time.

RESULTS

Of 802 patients randomised (n = 402 in the prednisone, n = 400 in the placebo group), 726 patients were treated per protocol and included in this analysis (n = 362 in the prednisone, n = 364 in the placebo group). Nineteen per cent of 726 patients had diabetes mellitus (n = 66 in the prednisone group, n = 72 in the placebo group). Adjunct prednisone shortened TTCS in diabetic and non-diabetic patients (HR 1.65 [95% CI 1.16, 2.35], p = 0.007; 1.30 [95% CI 1.10, 1.53], p = 0.002) with no evidence for effect modification by diabetes in interaction analysis (p = 0.44). No difference was found in other clinically relevant endpoints. Although adjunct prednisone was associated with glycaemic dysregulation, this did not translate into worse clinical outcomes in either group, and there was no difference in secondary endpoints.

CONCLUSIONS/INTERPRETATION

The benefit of adjunct prednisone in CAP patients is also valid for those with diabetes or hyperglycaemia on admission. Hyperglycaemia in diabetic patients or due to adjunct prednisone did not have a negative effect on outcome.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00973154 FUNDING : This study was supported by a grant from the Swiss National Foundation and by the Nora van Meeuwen Häfliger Stiftung and the Gottfried Julia Bangerter-Rhyner Stiftung.

Diagnostic accuracy of lung ultrasonography combined with procalcitonin for the diagnosis of pneumonia: a pilot study

BACKGROUND

The diagnostic value of lung ultrasonography (LUS) and procalcitonin (PCT) in the diagnosis of lung infections is known. No studies evaluated the combination of LUS and PCT for the diagnosis of pneumonia in the emergency department (ED). We evaluated the diagnostic accuracy of the combination of LUS and PCT in the diagnosis of pneumonia.

METHODS

Patients with respiratory symptoms of unexplained origin who underwent a chest CT in ED were included in the study if PCT assay was available. LUS was performed before CT and was targeted to the detection of lung consolidations with the morphologic features of pneumonia. A PCT assay was performed at presentation, and cut-off of 0.25 and of 0.5 ng/ml were used to rule-out and rule-in pneumonia. The final diagnosis of pneumonia was established by independent clinicians, on the basis of clinical chart review including CT results.

RESULTS

We enrolled 128 patients and pneumonia was the final diagnosis in 61 (47.7%). In 38 patients (29.7%) LUS and PCT were negative (PCT < 0.25 ng/ml). The overall accuracy, sensitivity and negative predictive value of LUS/PCT were 88.8, 96.7 and 94.7% respectively. Sensitivity of the LUS/PCT test was significantly superior to LUS alone (85.2%) and PCT alone (73.8%) (p < 0.05 for both). Specificity and positive predictive value of the combination of positivity of LUS/PCT (PCT > 0.5 ng/ml) were 94% and 83.3% respectively. Specificity of LUS/PCT was not significantly different to LUS alone (88.1%) (p = 0.125).

CONCLUSIONS

The sensitivity of the combination of LUS with PCT for the diagnosis of pneumonia was significantly superior when compared with the sensitivity of LUS and PCT alone.

Amoxicillin-clavulanic acid prescriptions at the Greater Paris University Hospitals (AP-HP)

OBJECTIVE

We aimed to document amoxicillin-clavulanic acid prescription to improve the proper use of antibiotics in hospital settings. We used three criteria: quality of medical charts, adequacy of indications, and adequacy of treatment duration.

METHOD

This study was designed as a one-day point prevalence survey carried out by antibiotic lead specialists.

RESULTS

We included 387 prescriptions from 32 hospitals. Immunodeficiency was recorded as a risk factor in 30% of patients. Computerized prescriptions were observed in 79% of cases. The indication was mentioned in 73% of cases and a 48/78-hour re-assessment of the antibiotic therapy was performed in 54% of cases. The antibiotic indication was primarily for pneumonia and was deemed appropriate in 75% of patients. Adult mean treatment duration was 11.1 days. Use of dual combination therapy and/or treatment duration exceeding two weeks accounted for the main reasons for an inappropriate use of antibiotics. Prescriptions recorded as having been made by senior physicians were of the shortest treatment duration (P=0.0163).

CONCLUSION

Medical charts should be better filled in. Reinforcing the role of senior physicians in supervising antibiotic prescriptions is likely to result in a better control of treatment duration and ultimately in a reduced antibiotic consumption. By reinforcing the collaboration between pharmacists and antibiotic lead specialists, the improvement of computerized prescriptions at hospital level should help better detect the "at risk" prescriptions, namely those exceeding seven days or those combining antibiotics.

A case-control study of community-acquired Acinetobacter baumannii pneumonia and melioidosis pneumonia in northeast Thailand: an emerging fatal disease with unique clinical features

Acinetobacter baumannii is the emerging cause of severe and often fatal gram-negative, community-acquired pneumonia (CAP-AB) in Thailand. Due to its rarity, its specific clinical features are ill defined. In this retrospective study, we compared the demographic data, risk factors, clinical characteristics, radiographic pattern, and microbiological data between CAP-AB and Burkholderia pseudomallei CAP (CAP-BP) to identify the clinical features and risk factors of CAP-AB. CAP-AB was associated with a more productive cough and a shorter duration of symptoms, while CAP-BP was associated with more musculoskeletal symptoms. The white blood cell and neutrophil counts were significantly lower in the CAP-AB group. Gram staining of the sputum revealed a significantly higher amount of bacteria in the CAP-AB group. Lobar infiltration and unilateral right lung involvement were the most common radiographic patterns in the CAP-AB group. CAP-AB is associated with severe pneumonia and has unique clinical features that distinguish it from CAP-BP.

Characteristics of Children Hospitalized With Aspiration Pneumonia

OBJECTIVES

Unlike community-acquired pneumonia (CAP), there is a paucity of data characterizing the patient demographics and hospitalization characteristics of children with aspiration pneumonia. We used a large national database of US children's hospitals to assess the patient and hospitalization characteristics associated with aspiration pneumonia and compared these characteristics to patients with CAP.

METHODS

We identified children hospitalized with a diagnosis of aspiration pneumonia or CAP at 47 hospitals included in the Pediatric Health Information System between 2009 and 2014. We evaluated whether differences exist in patient characteristics (median age and proportion of patients with a complex chronic condition), and hospital characteristics (length of stay, ICU admission, cost, and 30-day readmission rate) between children with aspiration pneumonia and CAP. Lastly, we assessed whether seasonal variability exists within these 2 conditions.

RESULTS

Over the 6-year study period, there were 12 097 children hospitalized with aspiration pneumonia, and 121 489 with CAP. Compared with children with CAP, children with aspiration pneumonia were slightly younger and more likely to have an associated complex chronic condition. Those with aspiration pneumonia had longer hospitalizations, higher rates of ICU admission, and higher 30-day readmission rates. Additionally, the median cost for hospitalization was 2.4 times higher for children with aspiration pneumonia than for children with CAP. More seasonal variation was observed for CAP compared with aspiration pneumonia hospitalizations.

CONCLUSIONS

Aspiration pneumonia preferentially affects children with medical complexity and, as such, accounts for longer and more costly hospitalizations and higher rates of ICU admission and readmission rates.

Prognostic value of on admission arterial PCO2 in hospitalized patients with community-acquired pneumonia

BACKGROUND

There is little data about the correlation between the outcome of community acquired pneumonia (CAP) and the hypercapnic type respiratory failure. In this study we prospectively investigated the prognostic significance of first arterial CO₂ tension in patients hospitalized with CAP.

METHODS

In this prospective study patients with CAP, admitted to a general hospital were included. PaCO₂ was measured for each subject in an arterial blood sample drawn in the first 2 hours and its correlations with three major outcomes were evaluated: intensive care unit (ICU) admission, duration of admission and mortality in 30 days.

RESULTS

A total of 114 patients (mean age: 60.9±18.3; male: 51.8%) diagnosed with CAP were included. Significant relationship was not found between PaCO₂ and mortality (P=0.544) or ICU admission (P=0.863). However advanced age, associated CHF, high BUN levels, high CURB-65 scores, associated pleural effusion in chest X-ray and being admitted to the ICU (P=0.012, 0.004, 0.003, <0.001, 0.045 and <0.001 respectively) were all significant prognostic factors of higher mortality risks. Prognostic factors for ICU admission were a history of malignancy (P=0.004), higher CURB-65 (P<0.001) scores and concomitant pleural effusion (P=0.028) in chest X-ray. Hypercapnic patients hospitalized for longer duration compared with normocapnic subjects. Furthermore, patients with lower pH (P=0.041) and pleural effusions (P=0.002) were hospitalized longer than the others.

CONCLUSIONS

There was less prominent prognostic value regarding on-admission PaCO₂ in comparison to other factors such as CURB-65. Considering the inconsistent results of surveys conducted on prognostic value of PaCO₂ for CAP outcomes, further investigations are required to reach a consensus on this matter.

Adherence to guidelines for hospitalized community-acquired pneumonia over time and its impact on health outcomes and mortality

Compliance with validated guidelines is crucial to guide management of patients hospitalized with community-acquired pneumonia (CAP). Data describing real-life management and treatment of CAP are limited. We aimed to evaluate the compliance with guidelines over time, and to assess its impact on all-cause mortality and clinical outcomes. We retrospectively compared two cohorts of patients admitted to the hospital, throughout 2005, just after the implementation of a local clinical pathway based on CAP international guidelines, and 7 years later over 2012. We included all patients with a diagnosis of pneumonia and/or related complications. 564 patients were included. The Pneumonia Severity Index calculation was better documented in 2012 (25.23 %) compared to 2005 (17.70 %; p = 0.032), but compliance with guideline empirical antibiotic therapy was lower in 2012 (56.70 %) than in 2005 (68.75 %; p = 0.004). Performance of guideline recommended urinary antigen tests was higher in 2012, and associated with 57.3 % lower odds of in-hospital mortality (95 % CI 15.0-78.5 %) and with 65.9 % lower odds of 30-day mortality (95 % CI 31.5-83.0 %). Compliance with empirical antibiotic therapy was associated with 2.9 days lower mean length of hospital stay (95 % CI -4.2 to -1.6 days) and with 2.0 days lower mean duration of antibiotic therapy (95 % CI -3.3 to -0.7 days). Compliance with guidelines changed over time, with some effects on mortality and with an apparent reduction in the length of hospital stay and the duration of antibiotic therapy. Specific clinical training and hospital control policies could achieve greater compliance with guidelines, and thus reduce a burden on hospital services.

The National Early Warning Score (NEWS) for outcome prediction in emergency department patients with community-acquired pneumonia: results from a 6-year prospective cohort study

OBJECTIVE

To investigate the accuracy of the National Early Warning Score (NEWS) to predict mortality and adverse clinical outcomes for patients with community-acquired pneumonia (CAP) compared to standard risk scores such as the pneumonia severity index (PSI) and CURB-65.

DESIGN

Secondary analysis of patients included in a previous randomised-controlled trial with a median follow-up of 6.1 years.

SETTINGS

Patients with CAP included on admission to the emergency departments (ED) of 6 tertiary care hospitals in Switzerland.

PARTICIPANTS

A total of 925 patients with confirmed CAP were included. NEWS, PSI and CURB-65 scores were calculated on admission to the ED based on admission data.

MAIN OUTCOME MEASURE

Our primary outcome was all-cause mortality within 6 years of follow-up. Secondary outcomes were adverse clinical outcome defined as intensive care unit (ICU) admission, empyema and unplanned hospital readmission all occurring within 30 days after admission. We used regression models to study associations of baseline risk scores and outcomes with the area under the receiver operating curve (AUC) as a measure of discrimination.

RESULTS

6-year overall mortality was 45.1% (n=417) with a stepwise increase with higher NEWS categories. For 30 day and 6-year mortality prediction, NEWS showed only low discrimination (AUC 0.65 and 0.60) inferior compared to PSI and CURB-65. For prediction of ICU admission, NEWS showed moderate discrimination (AUC 0.73) and improved the prognostic accuracy of a regression model, including PSI (AUC from 0.66 to 0.74, p=0.001) and CURB-65 (AUC from 0.64 to 0.73, p=0.015). NEWS was also superior to PSI and CURB-65 for prediction of empyema, but did not well predict rehospitalisation.

CONCLUSIONS

NEWS provides additional prognostic information with regard to risk of ICU admission and complications and thereby improves traditional clinical-risk scores in the management of patients with CAP in the ED setting.

TRIAL REGISTRATION NUMBER

ISRCTN95122877; Post-results.

The Usefulness of the Delta Neutrophil Index for Predicting Superimposed Pneumonia in Patients with Acute Decompensated Heart Failure in the Emergency Department

Background

Although respiratory infections, such as pneumonia, have long been recognized as precipitators of exacerbation in patients with acute decompensated heart failure (ADHF), identifying signs of concomitant pneumonia in ADHF is a clinical diagnostic challenge. We evaluated the predictive value of the delta neutrophil index (DNI), a new indicator for immature granulocytes, for diagnosing superimposed pneumonia in patients presenting with ADHF in the emergency department (ED).

Methods

This was a retrospective and observational study of consecutive patients (>18 years old) diagnosed with an ADHF in the ED over a 7-month period. Patients were categorized into either the ADHF group or the ADHF with pneumonia group. DNI, serum white blood cell (WBC), C-reactive protein (CRP), and β-natriuretic peptide (BNP) were measured upon ED arrival.

Results

The ADHF with pneumonia group included 30 patients (20.4%). Median initial DNI, WBC, and CRP were significantly higher in the ADHF with pneumonia group [0% vs. 1.8%, p<0.001, 8,200 cells/mL vs. 10,470 cells/mL, p<0.001, and 0.56 mg/dL vs. 6.10 mg/dL, p<0.001]. Multiple logistic regression analyses showed that only initial DNI significantly predicted the presence of superimposed pneumonia in patients with ADHF. In the receiver operating characteristic curves for initial DNI, WBC, and CRP for differentiating superimposed pneumonia in ADHF patients, the area under curve (AUC) of DNI (0.916 [95% confidence interval 0.859–0.955]) was good. AUC of DNI was significantly higher than AUC of CRP and WBC [0.828 and 0.715] (DNI vs. CRP, p = 0.047 and DNI vs. WBC, p<0.001).

Conclusions

Initial DNI, which was measured upon ED arrival, was significantly higher in the ADHF with pneumonia group than in the ADHF group. The initial DNI’s ability of prediction for ADHF with superimposed pneumonia in the ED was good and it was better than those of serum WBC and CRP. Therefore, DNI may serve as a convenient and useful marker for early diagnosis of superimposed pneumonia in patients with ADHF in the ED.

Prediction model for mortality in cancer patients with pneumonia: comparison with CURB-65 and PSI

INTRODUCTION AND OBJECTIVES

We aimed to develop a new prediction model of mortality in cancer patients with pneumonia and to compare its performance with CURB-65 and the Pneumonia Severity Index (PSI).

METHODS

Active cancer patients who were diagnosed with pneumonia at the Emergency Department (ED) from 7/1/2014 to 12/31/2014 were consecutively included. Clinical data were collected through a medical chart review. The primary outcome was the 28-day mortality, and clinical factors were analyzed using logistic regression analysis.

RESULTS

Among a total of 218 analyzed patients with a median age of 64.0 years (IQR, 56.8-71.0) and a male proportion of 72%, 42 (19.3%) died within 28 days of ED admission. By multivariate logistic regression analysis, an ECOG performance status (PS) 3 (OR: 8.54, 95% CI: 3.42-21.33) or 4 (OR: 13.17, 95% CI: 3.19-54.32), SpO₂ <90% (OR: 3.06, 95% CI: 1.17-8.00), and elevated lactic acid levels (OR: 1.42, 95% CI: 1.12-1.81) were significantly associated with mortality. With these three variables, a new prediction model with total scores ranged from 0 to 6 was generated. The area under the curve of the new prediction model was 0.840, compared with 0.673 and 0.586 for CURB-65 and PSI, respectively.

CONCLUSION

In cancer patients with pneumonia, a poor ECOG PS, SpO₂ <90%, and lactic acid elevation are independent predictors of mortality. The new prediction model, comprising three predictors, performs better in predicting mortality in cancer patients than CURB-65 or PSI.

Getting Physicians to Make “The Switch”: The Role of Clinical Guidelines in the Management of Community-Acquired Pneumonia

The authors sought to assess physician awareness and usage of American Thoracic Society guidelines for early conversion from intravenous to oral antibiotics ("switch therapy") in those with community-acquired pneumonia (CAP). We then determined if adoption of a CAP guideline would improve either. Patients (N = 510) hospitalized with CAP from June 2002 to May 2003 were identified retrospectively, and chart reviews were done on a random sample (130 [25%]) of these. Physicians were surveyed before and after guideline adoption. Community-acquired pneumonia guideline implementation increased physician awareness of American Thoracic Society recommendations (5% to 40%) and use of switch therapy (60% to 86%). Such use resulted in decreased overall length of stay from 3.6 to 2.4 days (P < .05) and from 2.91 to 2.41 days (P < .05) among early-switch candidates. Early-switch therapy was not optimally used prior to implementation of this CAP guideline. Adoption of the guideline increased awareness and reduced length of stay among inpatients with CAP.

Role of Atypical Bacteria in Hospitalized Patients With Nursing Home-Acquired Pneumonia

Background: Nursing home-acquired pneumonia (NHAP) has been identified as one of the leading causes of mortality and hospitalization for long-term care residents. However, current and previous pneumonia guidelines differ on the appropriate management of NHAP in hospitalized patients, specifically in regard to the role of atypical bacteria such as Chlamydiae pneumonia, Mycoplasma pneumoniae, and Legionella. Objectives: The purpose of this review is to evaluate clinical trials conducted in hospitalized patients with NHAP to determine the prevalence of atypical bacteria and thus the role for empiric antibiotic coverage of these pathogens in NHAP. Methods: Comprehensive MEDLINE (1966-April 2016) and Embase (1980-April 2016) searches were performed using the terms "atypical bacteria", "atypical pneumonia", "nursing-home acquired pneumonia", "pneumonia", "elderly", "nursing homes", and "long term care". Additional articles were retrieved from the review of references cited in the collected studies. Thirteen published clinical trials were identified. Results: In the majority of studies, atypical bacteria were infrequently identified in patients hospitalized with NHAP. However, when an active community-acquired pneumonia (CAP) cohort was available, the rate of atypical bacteria between NHAP and CAP study arms was similar. Only 3 studies in this review adhered to recommended strategies for investigating atypical bacteria; in 2 of these studies, C. pneumoniae was the most common pathogen identified in NHAP cohorts. Conclusion: Although atypical bacteria were uncommon in most NHAP studies in this review, suboptimal microbial investigations were commonly performed. To accurately describe the role of atypical bacteria in NHAP, more studies using validated diagnostic tests are needed.

Neumonía aguda extrahospitalaria

La neumonía aguda extrahospitalaria sigue estando asociada a una elevada morbimortalidad. Durante estos últimos años, y gracias al desarrollo de técnicas de biología molecular, se han realizado importantes progresos en los métodos diagnósticos. Estas técnicas permiten mejorar la detección de bacterias atípicas y de virus respiratorios estacionales. Han permitido asimismo subrayar el lugar de los virus respiratorios en su aparición. El protocolo terapéutico se basa siempre en la instauración precoz de una antibioticoterapia que casi siempre es empírica. Las recomendaciones europeas para el tratamiento de las neumonías extrahospitalarias han sido puestas al día en 2011, como también lo han sido recientemente las pautas vacunales frente al neumococo. En este artículo, se resumen las etiologías de las neumonías, su diagnóstico, las escalas que permiten evaluar su gravedad y orientar el tratamiento del paciente, los datos sobre la sensibilidad a los antibióticos y las recomendaciones terapéuticas resultantes, así como las estrategias de prevención.

Severe community-acquired pneumonia: timely management measures in the first 24 hours

Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.

Increased soluble and membrane-bound PD-L1 contributes to immune regulation and disease progression in patients with tuberculous pleural effusion

Soluble and membrane-bound programmed death ligand-1 (sPD-L1 and mPD-L1, respectively) have been demonstrated to participate in the immune suppression of non-small cell lung cancer. However, the contribution of sPD-L1 and mPD-L1 to immune regulation and disease progression in patients with pleural effusions remains unknown. The present study evaluated the levels of sPD-L1 and membrane-bound PD-1/PD-L1 in the peripheral blood and pleural effusions of patients with tuberculous pleural effusion (TPE), malignant pleural effusion (MPE) and non-tuberculous non-malignant pleural effusion (n-TB n-M). Furthermore, selected T lymphocytes and cluster of differentiation (CD)14⁺ monocytes were co-cultured to investigate the potential effect of the PD-1/PD-L1 pathway in TPE. Levels of sPD-L1 and PD-L1 on CD14⁺ monocytes were increased in the TPE group, as compared with the MPE and n-TB n-M groups. Furthermore, sPD-L1 levels and the expression levels of PD-L1 on CD14⁺ monocytes were demonstrated to be positively correlated with interferon (IFN)-γ concentration in pleural effusions. Therefore, IFN-γ may increase the expression of PD-L1 on CD14⁺ monocytes in vitro. Cell counting kit-8 analysis demonstrated that anti-PD-L1 antibody was able to partially reverse the proliferation of T lymphocytes in the co-culture system. The results of the present study indicated that sPD-L1 or mPD-L1 are associated with the immune regulation and disease progression of TPE, and may serve as possible biomarkers of TPE. Furthermore, sPD-L1 and the PD-1/PD-L1 pathway of TPE may be associated with the Th1 immune response; therefore, an anti-PD-1/PD-L1 pathway suggests a potential immune therapy strategy for the treatment of TPE.

Cardiovascular autonomic alterations in hospitalized patients with community-acquired pneumonia

Background

Alterations of cardiac autonomic control (CAC) are associated with poor outcomes in patients with infectious and non-infectious diseases. No evaluation of CAC in patients with community-acquired pneumonia (CAP) has been performed so far. The aim of the study was to assess CAC in patients with CAP and evaluate the impact of its alterations on disease severity and clinical outcomes in a multicenter, prospective, observational study.

Methods

Consecutive patients hospitalized for CAP were enrolled between 2011 and 2013 two university hospitals in Italy. CAC was assessed by linear spectral and non-linear symbolic analysis of heart rate variability. The presence of severe CAP was evaluated on hospital admission. The primary study outcome was time to clinical stability (TCS) during hospitalization.

Results

Among the 75 patients enrolled (median age: 75 years; 57 % males), a significantly lower total variability and reduction of sympathetic rhythmical component with predominant respiratory modulation was detected in comparison to controls. Among CAP patients affected by a severe CAP on admission, CAC showed a lower sympathetic modulation and predominant parasympathetic oscillatory rhythm. At the multivariate analysis, variables independently correlated with a TCS >7 days were total power, as marker of total variability, [OR (95 % CI): 0.997 (0.994–1.000), p = 0.0454] and sympathetic modulation [OR (95 % CI): 0.964 (0.932–0.998), p = 0.0367].

Conclusions

Loss of sympathetic rhythmical oscillation is associated with a more severe disease and worse early clinical outcome in hospitalized patients with CAP.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-016-0414-8) contains supplementary material, which is available to authorized users.

Is inhaled prophylactic heparin useful for prevention and management of pneumonia in ventilated ICU patients?

PURPOSE

The purpose was to determine the efficacy of prophylactic inhaled heparin for the prevention and treatment of pneumonia in patients receiving mechanical ventilation (MV).

METHODS

A phase 2, double-blind, randomized controlled trial stratified for study center and patient type (nonoperative, postoperative) was conducted in 3 university-affiliated intensive care units. Patients aged at least 18 years and requiring invasive MV for more than 48 hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 U in 2 mL), or nebulization with 0.9% sodium chloride (2 mL) 4 times daily with the main outcome measures, the development of ventilator-associated pneumonia (VAP), ventilator-associated complication, and Sequential Organ Failure Assessment scores in patients with admission pneumonia or developing VAP.

TRIAL REGISTRATION

ACTRN12612000038897.

RESULTS

A total of 214 patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP using either Klompas criteria (6%-7%, P=1.00) or clinical diagnosis (24%-26%, P=.85).

CONCLUSION

Low-dose nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.

Diagnostic and prognostic value of soluble CD14 subtype (Presepsin) for sepsis and community-acquired pneumonia in ICU patients

Background

The soluble CD14 subtype, Presepsin, appears to be an accurate sepsis diagnostic marker, but data from intensive care units (ICUs) are scarce. This study was conducted to evaluate the diagnostic and prognostic value of Presepsin in ICU patients with severe sepsis (SS), septic shock (SSh) and severe community-acquired pneumonia (sCAP).

Methods

Presepsin and procalcitonin (PCT) levels were determined for patients at admission to ICU. Four groups have been differentiated: (1) absence or (2) presence of systemic inflammatory response syndrome, (3) SS or (4) SSh; and 2 groups, among the patients admitted for acute respiratory failure: absence or presence of sCAP. Biomarkers were tested for diagnosis of SS, SSh and sCAP and for prediction of ICU mortality.

Results

One hundred and forty-four patients were included: 44 SS and 56 SSh. Plasma levels of Presepsin and PCT were significantly higher in septic than in non-septic patients and in SSh as compared to others. The sepsis diagnostic accuracy of Presepsin was not superior to that of PCT (AUC: 0.75 vs 0.80). In the 72/144 patients admitted for acute respiratory failure, the capability of Presepsin to diagnose sCAP was significantly better than PCT. Presepsin levels were also predictive of ICU mortality in sepsis and in sCAP patients.

Conclusion

Plasma levels of Presepsin were useful for the diagnosis of SS, SSh and sCAP and may predict ICU mortality in these patients.

Short-Course Antimicrobial Therapy for the Treatment of Pneumonia

Duration of antimicrobial therapy for the treatment of pneumonia has been inconsistent and is typically at the discretion of the prescriber. Themost common durations of therapy are 7, 10, or 14 days, but courses of 14 days or longer have also been used. Newer data support the use of clinical data to identify resolution of infection, such as defervescence, normalizing white blood cell count, and absence of infiltrate on chest radiograph. Discontinuation of antimicrobials 48 to 72 hours after such clinical resolution may allow for shorter courses of therapy with equivalent efficacy as the more arbitrary end points of 7 to 14 days. The intent of this article is to review the rationale, potential benefit, and relevant studies pertaining to the use of short-course antimicrobial regimens for the treatment of community-acquired and ventilatorassociated pneumonia.

Community Acquired Pneumonia in Internal Medicine: A One-Year Retrospective Study Based on Pneumonia Severity Index

Community acquired pneumonia (CAP) represents the sixth cause of death and the first cause of death for an infectious disease in the USA. The aim of the present study is to evaluate how CAP is managed in a hospital setting, with particular attention to the wards of internal medicine, compared to the recommendations based and validated PSI (Pneumonia Severity Index). 42 subjects were included in the study, 25 males and 17 females. According to the PSI, nine (21%) patients were classified in class I, two (5%) in class II, ten (24%) in class III, fifteen (36%) in class IV and six (14%) in class V. Three patients died during the stay in the hospital (2 males and 1 female), all in the highest PSI class (V). According to the criteria used to evaluate the adequacy of the admission to the hospital, twentyeight patients were classified in the HRG, with an appropriate admission, whilst fourteen (33%) were in the LRG, with an inappropriate admission to the hospital. The data of the study confirm the validity of a PSI based strategy for the management of CAP since admittance to the hospital. This approach is not yet widely implemented in Italy, and a better dialogue between hospital and health system representatives would be convenient, to reduce costs and ensure the safety of patients affected by CAP.

An Autopsy Case of Fulminant Amebic Colitis in a Patient with a History of Rheumatoid Arthritis

Generally, amebic colitis is localized around the mucosal membrane and often accompanied by diarrhea and abdominal pain. We describe a patient with a history of rheumatoid arthritis who had received prolonged steroid therapy. The patient complained of breathing difficulties because of rheumatoid lung disease. Although the patient was given antibacterial agent, the symptoms did not improve until death. We did an autopsy and found that he had fulminant amebic colitis, although the patient was not previously examined. Histochemical analysis revealed severe inflammation and full-thickness necrosis of the colon by ameba, suggesting the involvement of ameba in the progression of the overall condition.

Community-acquired pneumonia related to intracellular pathogens

Community-acquired pneumonia (CAP) is associated with high rates of morbidity and mortality worldwide; the annual incidence of CAP among adults in Europe has ranged from 1.5 to 1.7 per 1000 population. Intracellular bacteria are common causes of CAP. However, there is considerable variation in the reported incidence between countries and change over time. The intracellular pathogens that are well established as causes of pneumonia are Legionella pneumophila, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Chlamydophila psittaci, and Coxiella burnetii. Since it is known that antibiotic treatment for severe CAP is empiric and includes coverage of typical and atypical pathogens, microbiological diagnosis bears an important relationship to prognosis of pneumonia. Factors such as adequacy of initial antibiotic or early de-escalation of therapy are important variables associated with outcomes, especially in severe cases. Intracellular pathogens sometimes appear to cause more severe disease with respiratory failure and multisystem dysfunction associated with fatal outcomes. The clinical relevance of intracellular pathogens in severe CAP has not been specifically investigated. We review the prevalence, general characteristics, and outcomes of severe CAP cases caused by intracellular pathogens.

Antimicrobial drug prescribing patterns for community-acquired pneumonia in hospitalized patients: A retrospective pilot study from New Delhi, India

OBJECTIVE

The objective of this study was to determine patterns and frequency of antimicrobial drug use among hospitalized patients with community-acquired pneumonia (CAP).

METHODOLOGY

A retrospective 5 years (April 2007-March 2012) detailed medical record review of patients diagnosed with CAP and discharged to home from Non-Intensive Care Unit respiratory medicine wards of two public hospitals in Delhi.

RESULTS

A total of 261 medical records were analyzed. Over the 5 years, 82.0% (2007-08), 78.6% (2008-09), 59.5% (2009-10), 64.7% (2010-11), and 67.8% (2011-12) patients were prescribed two antimicrobials. In the last two study years, the proportion of patients receiving three antimicrobials increased (from 2.0% to 26.5% and 28.8%), while the proportion receiving monotherapy decreased (from 16.0% to 8.8% and 3.4%). In accordance with guidelines, beta-lactams and macrolides were the two most frequently prescribed antimicrobials (34.1%). However, newer generation beta-lactams were prescribed. A total of 37 patients were prescribed beta-lactam-tazobactam combination preparations. Overall, beta-lactams constituted more than 40% of prescriptions while macrolides were the second most prescribed class. Cephalosporin prescriptions significantly increased (P < 0.01) and penicillin prescriptions significantly decreased over study periods. The prescription of fluoroquinolones also decreased (21.5-6.0%, P < 0.01) and aminoglycoside prescription ranged from 9.7% to 16.4%, over 5 years. Reasons for prescribing three antimicrobials, use of aminoglycosides, or higher-end/reserve antibiotics were not mentioned in the medical records. There were no hospital-specific guidelines for doctors to follow in the treatment of CAP.

CONCLUSIONS

These findings suggest the need for implementing antimicrobial treatment guidelines. Adequate documentation and monitoring of antibiotic use for feedback are also lacking. An antimicrobial stewardship program may offer the most comprehensive solution for appropriate use of antimicrobials.

Non-infectious mimics of community-acquired pneumonia

Community-acquired pneumonia (CAP) is a common cause of presentation to healthcare facilities. The diagnosis of CAP is usually made in patients with suggestive symptoms, signs, and radiological features. A number of non-infectious conditions, including neoplastic lesions, pulmonary oedema, pulmonary embolism, drug-induced pneumonitis, diffuse alveolar haemorrhage syndromes, cryptogenic organising pneumonia and acute eosinophilic pneumonia, may present in a similar way and mimic CAP. These other conditions are often only thought of after patients that are being treated as CAP fail to respond to therapy. The non-infectious mimics of CAP require early diagnosis and appropriate treatment to decrease patient morbidity and mortality. This article is intended to create an awareness of the non-infectious mimics of CAP and highlight some of the more frequent conditions as well as those that require early diagnosis and treatment to prevent a poor outcome.

Is inhaled prophylactic heparin useful for prevention and Management of Pneumonia in ventilated ICU patients?: The IPHIVAP investigators of the Australian and New Zealand Intensive Care Society Clinical Trials Group

PURPOSE

To determine whether prophylactic inhaled heparin is effective for the prevention and treatment of pneumonia patients receiving mechanical ventilation (MV) in the intensive care unit.

METHODS

A phase 2, double blind randomized controlled trial stratified for study center and patient type (non-operative, post-operative) was conducted in three university-affiliated intensive care units. Patients aged ≥18years and requiring invasive MV for more than 48hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 units in 2mL) or placebo nebulization with 0.9% sodium chloride (2mL) four times daily with the main outcome measures of the development of ventilator associated pneumonia (VAP), ventilator associated complication (VAC) and sequential organ failure assessment scores in patients with pneumonia on admission or who developed VAP.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12612000038897.

RESULTS

Two hundred and fourteen patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP, using either Klompas criteria (6-7%, P=1.00) or clinical diagnosis (24-26%, P=0.85). There was no difference in the clinical consistency (P=0.70), number (P=0.28) or the total volume of secretions per day (P=.54). The presence of blood in secretions was significantly less in the usual care group (P=0.005).

CONCLUSION

Nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.

Cefepime shows good efficacy and no antibiotic resistance in pneumonia caused by Serratia marcescens and Proteus mirabilis - an observational study

Background

Many antibiotics have no effect on Gram-positive and Gram-negative microbes, which necessitates the prescription of broad-spectrum antimicrobial agents that can lead to increased risk of antibiotic resistance. These pathogens constitute a further threat because they are also resistant to numerous beta-lactam antibiotics, as well as other antibiotic groups. This study retrospectively investigates antimicrobial resistance in hospitalized patients suffering from pneumonia triggered by Gram-negative Serratia marcescens or Proteus mirabilis.

Methods

The demographic and clinical data analyzed in this study were obtained from the clinical databank of the HELIOS Clinic, Witten/Herdecke University, Wuppertal, Germany, for inpatients presenting with pneumonia triggered by S. marcescens or P. mirabilis from 2004 to 2014. An antibiogram was conducted for the antibiotics utilized as part of the management of patients with pneumonia triggered by these two pathogens.

Results

Pneumonia was caused by Gram-negative bacteria in 115 patients during the study period from January 1, 2004, to August 12, 2014. Of these, 43 (37.4 %) hospitalized patients [26 males (60.5 %, 95 % CI 45.9 %–75.1 %) and 17 females (39.5 %, 95 % CI 24.9 %–54.1 %)] with mean age of 66.2 ± 13.4 years had pneumonia triggered by S. marcescens, while 20 (17.4 %) patients [14 males (70 %, 95 % CI 49.9 %–90.1 %) and 6 females (30 %, 95 % CI 9.9 %–50.1 %)] with a mean age of 64.6 ± 12.8 years had pneumonia caused by P. mirabilis. S. marcescens showed an increased antibiotic resistance to ampicillin (100 %), ampicillin-sulbactam (100 %), and cefuroxime (100 %). P. mirabilis had a high resistance to tetracycline (100 %) and ampicillin (55 %). S. marcescens (P < 0.0001) and P. mirabilis (P = 0.0003) demonstrated no resistance to cefepime in these patients with pneumonia.

Conclusions

S. marcescens and P. mirabilis were resistant to several commonly used antimicrobial agents, but showed no resistance to cefepime.

Expanded CURB-65: a new score system predicts severity of community-acquired pneumonia with superior efficiency

Aim of this study was to develop a new simpler and more effective severity score for community-acquired pneumonia (CAP) patients. A total of 1640 consecutive hospitalized CAP patients in Second Affiliated Hospital of Zhejiang University were included. The effectiveness of different pneumonia severity scores to predict mortality was compared, and the performance of the new score was validated on an external cohort of 1164 patients with pneumonia admitted to a teaching hospital in Italy. Using age ≥ 65 years, LDH > 230 u/L, albumin < 3.5 g/dL, platelet count < 100 × 10⁹/L, confusion, urea > 7 mmol/L, respiratory rate ≥ 30/min, low blood pressure, we assembled a new severity score named as expanded-CURB-65. The 30-day mortality and length of stay were increased along with increased risk score. The AUCs in the prediction of 30-day mortality in the main cohort were 0.826 (95% CI, 0.807–0.844), 0.801 (95% CI, 0.781–0.820), 0.756 (95% CI, 0.735–0.777), 0.793 (95% CI, 0.773–0.813) and 0.759 (95% CI, 0.737–0.779) for the expanded-CURB-65, PSI, CURB-65, SMART-COP and A-DROP, respectively. The performance of this bedside score was confirmed in CAP patients of the validation cohort although calibration was not successful in patients with health care-associated pneumonia (HCAP). The expanded CURB-65 is objective, simpler and more accurate scoring system for evaluation of CAP severity, and the predictive efficiency was better than other score systems.

Xuebijing injection in the treatment of severe pneumonia: study protocol for a randomized controlled trial

Background

Severe pneumonia (SP) is a major complication of respiratory system diseases that is associated with high mortality and morbidity. If not treated correctly, it may rapidly lead to sepsis and multiple organ dysfunction syndrome. Despite continuous developments in antibiotic treatments for SP, the mortality rate remains high. Both basic and clinical research show that Xuebijing injection (XBJ) can improve the symptoms of SP. The aim of this study is to evaluate the effectiveness and safety of XBJ compared with placebo.

Methods/design

This multicenter, blinded, randomized controlled trial will be conducted with a total of 700 participants with SP. Using a central randomization system, participants will be randomized (1:1) into groups receiving either XBJ or placebo (within 24 h of diagnosis of SP) for 5–7 days with a 28-day follow-up. All participants will receive conventional treatment simultaneously. Both XBJ and placebo will be administered using a photophobic infusion set to avoid bias. The primary outcome is improvement of Pneumonia Severity Index risk rate. Adverse events will be monitored throughout the trial.

Discussion

This is the first and largest randomized trial done in China on SP treatment using a Chinese herbal extract. In this trial, we will use central randomization and an electronic case report form, and we have designed an innovative blinding method for the traditional Chinese medicine injection. The results of this trial may help to provide evidence-based recommendations to clinicians for treatment of SP.

Trial registration

Chinese Clinical Trials Registry ChiCTR-TRC-13003534. Registered 24 June 2013.

Cost effectiveness of adherence to IDSA/ATS guidelines in elderly patients hospitalized for Community-Aquired Pneumonia

BACKGROUND

Adherence to guidelines for the treatment of hospitalized elderly patients with community-acquired pneumonia (CAP) has been associated with improved clinical outcomes. This study evaluated the cost-effectiveness of adherence to guidelines for the treatment of CAP in an elderly hospitalized patient cohort.

METHODS

Data from an international, multicenter observational study for patients age 65 years or older hospitalized with CAP from 2001 to 2007 were used to estimate transition probabilities for a multi-state Markov model traversing multiple health states during hospitalization for CAP. Empiric antibiotic therapy was classified as adherent, over-treated, and under-treated according to 2007 Infectious Disease Society of America/American Thoracic Society IDSA/ATS guidelines. Utilities were estimated from an expert panel of active clinicians. Costs were estimated from a tertiary referral hospital and adjusted for inflation to 2013 US dollars. Costs, utilities, and transition probabilities were all modeled using probability distributions to handle their inherit uncertainty. Cost-effectiveness analysis was based on the first 14 days of hospitalization. Patients admitted to the intensive care unit (ICU) were analyzed separately from those admitted to the ward. Sensitivity analyses with regards to time frame (out to 30 days hospitalization), cost estimates, and willingness to pay values were performed.

RESULTS

The model parameters were estimated using data from 1635 patients (1438 admitted to the ward and 197 admitted to the ICU). For the ward model, adherence to antibiotic guidelines was the dominant strategy and associated with lower costs (-$1379 and -$799) and improved quality of life compared to over- and under-treatment. In the ICU model, however, adherence to guidelines was associated with greater costs (+$13,854 and + $3461 vs. over- and under-treatment, respectively) and lower quality of life. Acceptance rates across the willingness to pay ranges evaluated were 42-48 % for guideline adherence on the ward and 61-64 % for over-treatment on the ICU. Results were robust over sensitivity analyses concerning cost and utility estimates.

CONCLUSIONS

While adherence to antibiotic guidelines was the most cost-effective strategy for elderly patients hospitalized with CAP and admitted to the ward, in the ICU over-treatment of patients relative to the guidelines was the most cost-effective strategy.

High Lung Cancer Incidence in Heavy Smokers Following Hospitalization due to Pneumonia

INTRODUCTION

The rate of lung cancer incidence following pneumonia in heavy smokers is unknown. Heavy smokers hospitalized due to community-acquired pneumonia might be at high risk for subsequent lung cancer. The primary objective of this study was to determine lung cancer incidence in this high-risk population.

PATIENTS AND METHODS

This was a single-center, retrospective cohort study that included heavy smokers hospitalized due to community-acquired pneumonia between January 1, 2007 and December 31, 2011 in Beilinson hospital, a large community hospital and tertiary center. Patients were identified by International Classification of Diseases, Ninth Revision coding from the hospital's registry. Two physicians reviewed every patient's medical file for patient demographics, smoking history, lung cancer risk factors, and anatomical location of pneumonia. Data were cross-checked with the database at the national cancer registry for new diagnoses of cancer.

RESULTS

There were 381 admissions for community-acquired pneumonia included in the final analysis. Thirty-one cases (8.14%; 95% confidence interval [CI], 5.9%-11.2%) of lung cancer were diagnosed during the first year after hospitalization. Lung cancer incidence was significantly higher in patients who had upper-lobe pneumonia (23.8%; 95% CI, 14.9%-40%). Lung cancer was located within the lobe involved by the pneumonia in 75.8% of patients.

CONCLUSIONS

A high lung cancer rate was found in heavy smokers admitted due to community-acquired pneumonia. The association was especially strong for patients with upper-lobe pneumonia. Screening with chest computed tomography should be strongly considered for these patients.

External Validation of Prediction Models for Pneumonia in Primary Care Patients with Lower Respiratory Tract Infection: An Individual Patient Data Meta-Analysis

Background

Pneumonia remains difficult to diagnose in primary care. Prediction models based on signs and symptoms (S&S) serve to minimize the diagnostic uncertainty. External validation of these models is essential before implementation into routine practice. In this study all published S&S models for prediction of pneumonia in primary care were externally validated in the individual patient data (IPD) of previously performed diagnostic studies.

Methods and Findings

S&S models for diagnosing pneumonia in adults presenting to primary care with lower respiratory tract infection and IPD for validation were identified through a systematical search. Six prediction models and IPD of eight diagnostic studies (N total = 5308, prevalence pneumonia 12%) were included. Models were assessed on discrimination and calibration. Discrimination was measured using the pooled Area Under the Curve (AUC) and delta AUC, representing the performance of an individual model relative to the average dataset performance. Prediction models by van Vugt et al. and Heckerling et al. demonstrated the highest pooled AUC of 0.79 (95% CI 0.74–0.85) and 0.72 (0.68–0.76), respectively. Other models by Diehr et al., Singal et al., Melbye et al., and Hopstaken et al. demonstrated pooled AUCs of 0.65 (0.61–0.68), 0.64 (0.61–0.67), 0.56 (0.49–0.63) and 0.53 (0.5–0.56), respectively. A similar ranking was present based on the delta AUCs of the models. Calibration demonstrated close agreement of observed and predicted probabilities in the models by van Vugt et al. and Singal et al., other models lacked such correspondence. The absence of predictors in the IPD on dataset level hampered a systematical comparison of model performance and could be a limitation to the study.

Conclusions

The model by van Vugt et al. demonstrated the highest discriminative accuracy coupled with reasonable to good calibration across the IPD of different study populations. This model is therefore the main candidate for primary care use.

Composition and dynamics of the respiratory tract microbiome in intubated patients

BACKGROUND

Lower respiratory tract infection (LRTI) is a major contributor to respiratory failure requiring intubation and mechanical ventilation. LRTI also occurs during mechanical ventilation, increasing the morbidity and mortality of intubated patients. We sought to understand the dynamics of respiratory tract microbiota following intubation and the relationship between microbial community structure and infection.

RESULTS

We enrolled a cohort of 15 subjects with respiratory failure requiring intubation and mechanical ventilation from the medical intensive care unit at an academic medical center. Oropharyngeal (OP) and deep endotracheal (ET) secretions were sampled within 24 h of intubation and every 48-72 h thereafter. Bacterial community profiling was carried out by purifying DNA, PCR amplification of 16S ribosomal RNA (rRNA) gene sequences, deep sequencing, and bioinformatic community analysis. We compared enrolled subjects to a cohort of healthy subjects who had lower respiratory tract sampling by bronchoscopy. In contrast to the diverse upper respiratory tract and lower respiratory tract microbiota found in healthy controls, critically ill subjects had lower initial diversity at both sites. Diversity further diminished over time on the ventilator. In several subjects, the bacterial community was dominated by a single taxon over multiple time points. The clinical diagnosis of LRTI ascertained by chart review correlated with low community diversity and dominance of a single taxon. Dominant taxa matched clinical bacterial cultures where cultures were obtained and positive. In several cases, dominant taxa included bacteria not detected by culture, including Ureaplasma parvum and Enterococcus faecalis.

CONCLUSIONS

Longitudinal analysis of respiratory tract microbiota in critically ill patients provides insight into the pathogenesis and diagnosis of LRTI. 16S rRNA gene sequencing of endotracheal aspirate samples holds promise for expanded pathogen identification.

Precision medicine for the treatment of severe pneumonia in intensive care

Despite advances in its management, community-acquired pneumonia (CAP) remains the most important cause of sepsis-related mortality and the reason for many ICU admissions. Severity assessment is the cornerstone of CAP patient management and the attempts to ensure the best site of care and therapy. Survival depends on a combination of host factors (genetic, age, comorbidities, defenses), pathogens (virulence, serotypes) and drugs. To reduce CAP mortality, early adequate antibiotic therapy is fundamental. The use of combination therapy with a macrolide seems to improve the clinical outcome in the subset of patients with high inflammation due to immunomodulation. Guidelines on antibiotic therapy have been associated with beneficial effects, and studies of newer adjunctive drugs have produced promising results. This paper discusses the current state of knowledge regarding of precision medicine and the treatment of severe CAP patients.

In-hospital mortality risk factors in community acquired pneumonia: evaluation of immunocompetent adult patients without comorbidities

OBJECTIVE

several scores were developed in order to improve the determination of community acquired pneumonia (CAP) severity and its management, mainly CURB-65 and SACP score. However, none of them were evaluated for risk assessment of in-hospital mortality, particularly in individuals who were non-immunosuppressed and/or without any comorbidity. In this regard, the present study was carried out.

METHODS

we performed a cross-sectional study in 272 immunocompetent patients without comorbidities and with a diagnosis of CAP. Performance of CURB- 65 and SCAP scores in predicting in-hospital mortality was evaluated. Also, variables related to death were assessed. Furthermore, in order to design a model of in-hospital mortality prediction, sampled individuals were randomly divided in two groups. The association of the variables with mortality was weighed and, by multiple binary regression, a model was constructed in one of the subgroups. Then, it was validated in the other subgroup.

RESULTS

both scores yielded a fair strength of agreement, and CURB-65 showed a better performance in predicting in-hospital mortality. In our casuistry, age, white blood cell counts, serum urea and diastolic blood pressure were related to death. The model constructed with these variables showed a good performance in predicting in-hospital mortality; moreover, only one patient with fatal outcome was not correctly classified in the group where the model was constructed and in the group where it was validated.

CONCLUSION

our findings suggest that a simple model that uses only 4 variables, which are easily accessible and interpretable, can identify seriously ill patients with CAP.

A novel method for rapid detection of Streptococcus pneumoniae antigens in blood

In this study, we used "RAPIRUN(®)Streptococcus pneumoniae HS (otitis media/sinusitis) (RAPIRUN-HS)," a rapid S. pneumoniae antigen detection kit, to investigate methods for detecting S. pneumoniae antigens in blood of 32 bacterial pneumonia patients. We simultaneously performed PCR to detect S. pneumoniae in blood samples. The results of these tests were compared based on pneumonia severity, determined using the Pneumonia Severity Index (PSI) score classification. Four S. pneumoniae PCR-positive patients of the six severe pneumococcal pneumonia patients (PSI risk class IV/V) also tested positive using RAPIRUN-HS. Twenty-four mild to moderate pneumonia patients (PSI risk class I-III) were S. pneumoniae PCR-negative; of these, 21 tested negative using RAPIRUN-HS. The pneumococcal pneumonia patients testing positive using RAPIRUN-HS had low leukocyte counts and elevated C-reactive protein and procalcitonin levels, indicating that RAPIRUN-HS results were correlated with pneumonia severity. The time course evaluations of the laboratory tests for severe pneumococcal pneumonia patients showed that RAPIRUN-HS and S. pneumoniae PCR yielded positive results earlier than the changes in procalcitonin and IL-6. Thus, concomitant pneumococcal bacteremia was strongly suspected in patients testing positive using RAPIRUN-HS. In conclusion, RAPIRUN-HS may be useful for determining whether to admit patients into hospitals and selecting the appropriate antimicrobial agents.

[Short-course antibiotic regimens: Up-to-date]

Antibiotic treatment durations are not well documented. Yet, dramatic emergence of multi-drug resistant organisms should lead to tend to decrease antibiotic selection pressure. Furthermore, it could lower health costs and reduce associated adverse events. Unfortunately, only few studies with rigorous methodology have been performed. We present the available data on frequent infections such as urinary tract infections, community acquired pneumonia, bone and joint infections and intra-abdominal infections. We underline the difficulties to perform such trials and discuss original options to a better evaluation of treatment duration.

Prospective evaluation of biomarkers for prediction of quality of life in community-acquired pneumonia

Background:

Most clinical research investigated prognostic biomarkers for their ability to predict cardiovascular events or mortality. It is unknown whether biomarkers allow prediction of quality of life (QoL) after survival of the acute event. Herein, we investigated the prognostic potential of well-established inflammatory/cardiovascular blood biomarkers including white blood cells (WBC), C-reactive protein (CRP), procalcitonin (PCT), pro-adrenomedullin (proADM) and pro-atrial natriuretic peptide (proANP) in regard to a decline in QoL in a well-defined cohort of patients with community-acquired pneumonia (CAP).

Methods:

Within this secondary analysis including 753 patients with a final inpatient diagnosis of CAP from a multicenter trial, we investigated associations between admission biomarker levels and decline in QoL assessed by the EQ-5D health questionnaire from admission to day 30 and after 6 years.

Results:

Admission proADM and proANP levels significantly predicted decline of the weighted EQ-5D index after 30 days (n=753) with adjusted odds ratios (ORs) of 2.0 ([95% CI 1.1–3.8]; p=0.027) and 3.7 ([95% CI 2.2–6.0]; p<0.001). Results for 6-year outcomes (n=349) were similar with ORs of 3.3 ([95% CI 1.3–8.3]; p=0.012) and 6.2 ([95% CI 2.7–14.2]; p<0.001). The markers were associated with most of the different QoL dimensions including mobility, self-care, and usual activities, but not pain/discomfort and to a lesser degree anxiety/depression and the visual analogue scale (VAS). Initial WBC, PCT and CRP values did not well predict QoL at any time point.

Conclusions:

ProADM and proANP accurately predict short- and long-term decline in QoL across most dimensions in CAP patients. It will be interesting to reveal underlying physiopathology in future studies.

Sustainability of professionals' adherence to clinical practice guidelines in medical care: a systematic review

OBJECTIVES

To evaluate (1) the state of the art in sustainability research and (2) the outcomes of professionals' adherence to guideline recommendations in medical practice.

DESIGN

Systematic review.

DATA SOURCES

Searches were conducted until August 2015 in MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and the Guidelines International Network (GIN) library. A snowball strategy, in which reference sections of other reviews and of included papers were searched, was used to identify additional papers.

ELIGIBILITY CRITERIA

Studies needed to be focused on sustainability and on professionals' adherence to clinical practice guidelines in medical care. Studies had to include at least 2 measurements: 1 before (PRE) or immediately after implementation (EARLY POST) and 1 measurement longer than 1 year after active implementation (LATE POST).

RESULTS

The search retrieved 4219 items, of which 14 studies met the inclusion criteria, involving 18 sustainability evaluations. The mean timeframe between the end of active implementation and the sustainability evaluation was 2.6 years (minimum 1.5-maximum 7.0). The studies were heterogeneous with respect to their methodology. Sustainability was considered to be successful if performance in terms of professionals' adherence was fully maintained in the late postimplementation phase. Long-term sustainability of professionals' adherence was reported in 7 out of 18 evaluations, adherence was not sustained in 6 evaluations, 4 evaluations showed mixed sustainability results and in 1 evaluation it was unclear whether the professional adherence was sustained.

CONCLUSIONS

(2) Professionals' adherence to a clinical practice guideline in medical care decreased after more than 1 year after implementation in about half of the cases. (1) Owing to the limited number of studies, the absence of a uniform definition, the high risk of bias, and the mixed results of studies, no firm conclusion about the sustainability of professionals' adherence to guidelines in medical practice can be drawn.

Limited utility of blood cultures in the management of febrile outpatient kidney transplant recipients

BACKGROUND/PURPOSE

Blood cultures for patients suspected of having bacteremia are standard practice, although several studies demonstrate that blood cultures have limited utility because of a low true-positive rate and infrequent resultant changes in antibiotic treatment. However, most reports exclude immunocompromised patients such as transplant recipients. We assessed the utility of blood cultures in transplant recipients hospitalized for community-acquired infections and evaluated clinical characteristics to predict bacteremia.

METHODS

This retrospective study included 136 febrile cases in 97 kidney transplant recipients admitted to our hospital for whom blood cultures were performed between February 2001 and March 2013.

RESULTS

Among the 136 cases, blood cultures were positive, contaminated, and negative in seven (5.1%) cases, 12 (8.8%) cases, and 117 cases (86.1%), respectively. All bacteria detected in the seven cases were sensitive to the initial empirical antibiotics. Antibiotic treatment was changed based on the blood culture results only in one case for which the coverage was narrowed. The white blood cell count and C-reactive protein level were significantly higher in the patients with bacteremia. The predictive model based on these two factors successfully identified the high-risk group with a sensitivity and specificity of 86% and 91%, respectively.

CONCLUSION

Among the outpatient kidney transplant recipients, positive blood cultures were uncommon and scarcely affected antibiotic therapy, especially in patients with upper respiratory tract or urinary tract infections. Therefore, it may be reasonable to perform blood cultures only for patients with marked leukocytosis and high C-reactive protein level, even among transplant recipients.

No Resistance to Penicillin, Cefuroxime, Cefotaxime, or Vancomycin in Pneumococcal Pneumonia

OBJECTIVES

Group B Streptococcus is a primary source of pneumonia, which is a leading cause of death worldwide. During the last few decades, there has been news of growing antibiotic resistance in group B streptococci to penicillin and different antibiotic agents. This clinical study retrospectively analyzes antimicrobial resistance in inpatients who were diagnosed with group B streptococcal pneumonia.

METHODS

All of the required information from inpatients who were identified to have group B streptococcal pneumonia was sourced from the database at the Department of Internal Medicine of HELIOS Clinic Wuppertal, Witten/Herdecke University, in Germany, from 2004-2014. Antimicrobial susceptibility testing was performed for the different antimicrobial agents that were regularly administered to these inpatients.

RESULTS

Sixty-six inpatients with a mean age of 63.3 ± 16.1 years (45 males [68.2%, 95% CI 60.0%-79.4%] and 21 females [31.8%, 95% CI 20.6%-43.0%]) were detected to have group B streptococcal pneumonia within the study period from January 1, 2004, to August 12, 2014. Group B Streptococcus had a high resistance rate to gentamicin (12.1%), erythromycin (12.1%), clindamycin (9.1%), and co-trimoxazole (3.0%), but it was not resistant to penicillin, cefuroxime, cefotaxime, or vancomycin (P < 0.0001).

CONCLUSION

No resistance to penicillin, cefuroxime, cefotaxime, or vancomycin was detected among inpatients with pneumonia caused by group B streptococci.