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Zhao B, Si M, Hu Z, Jiang J. Alveolar-arterial oxygen gradient: An early marker to predict the severity of community-acquired pneumonia in children. Medicine (Baltimore) 2024; 103:e37670. [PMID: 38579093 PMCID: PMC10994442 DOI: 10.1097/md.0000000000037670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/29/2024] [Indexed: 04/07/2024] Open
Abstract
To study the clinical significance of alveolar-arterial oxygen gradient (PA-aO2) for children with community-acquired pneumonia (CAP). A prospective study was carried out from January 2020 to June 2023, Overall, 100 patients were included in the study, 35 had severe pneumonia, whereas, 65 had non-severe pneumonia. Clinical and laboratory data were retrospectively collected at the time of hospital admission and during hospitalization. Patients were divided into severe and non-severe groups. PA-aO2 was significantly higher among children with severe pneumonia, as determined by WHO, PRESS (P < .001). PA-aO2 was significantly higher among children with mechanical ventilation, shock, sepsis, and mortality. Receiver operating characteristic curve (ROC) analysis for PA-aO2 showed that the area under the curve was 0.76 (P value < .05), with a sensitivity of 84.3% and a specificity of 67.9%. Our study suggests that PA-aO2 level has a predictive value for detecting community-acquired pneumonia severity in children.
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Affiliation(s)
- Baoxi Zhao
- Department of Pediatrics, The First People’s Hospital of Linping District, Hangzhou, China
| | - Mingqiang Si
- Department of Pediatrics, The First People’s Hospital of Linping District, Hangzhou, China
| | - Zhonghua Hu
- Department of Pediatrics, The First People’s Hospital of Linping District, Hangzhou, China
| | - Junsheng Jiang
- Department of Pediatrics, The First People’s Hospital of Linping District, Hangzhou, China
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Davis D, Thadhani J, Choudhary V, Nausheem R, Vallejo-Zambrano CR, Mohammad Arifuddin B, Ali M, Carson BJ, Kanwal F, Nagarajan L. Advancements in the Management of Severe Community-Acquired Pneumonia: A Comprehensive Narrative Review. Cureus 2023; 15:e46893. [PMID: 37954793 PMCID: PMC10638673 DOI: 10.7759/cureus.46893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
Pneumonia, classified as a lower respiratory tract illness, affects different parts of the bronchial system as well as alveoli and can present with varying severities depending on co-morbidities and causative pathogens. It can be broadly classified using the setting in which it was acquired, namely the community or hospital setting, the former being more common and spreading through person-to-person droplet transmission. Community-acquired pneumonia (CAP) is currently the fourth leading cause of death worldwide, and its high mortality makes continual insight into the management of the condition worthwhile. This review explores the literature specifically for severe CAP (sCAP) and delves into the diagnosis, various modalities of treatment, and management of the condition. This condition can be defined as pneumonia requiring mechanical ventilation in the ICU and/or presenting with sepsis and organ failure due to pneumonia. The disease process is characterized by inflammation of the lung parenchyma, initiated by a combination of pathogens and lowered local defenses. Acute diagnosis of the condition is vital in reducing negative patient outcomes, namely through clinical presentation, blood/sputum cultures, imaging modalities such as computed tomography scan, and inflammatory markers, identifying common causative pathogens such as Streptococcus pneumoniae, rhinovirus, Legionella, and viral influenza. Pathogens such as Escherichia coli should also be investigated in patients with chronic obstructive pulmonary disease. The mainstay of treating sCAP includes rapid ICU admission once a diagnosis has been confirmed, initiating sepsis protocol, and treatment with combined empiric antibiotic regimens consisting of beta-lactams and macrolides. Corticosteroid use alongside antibiotics shows promise in reducing inflammation, but its use has to be judged on a case-by-case basis. New drugs such as omadacycline, delafloxacin, and zabofloxacin have shown valid evidence for the treatment of resistant causative organisms. The main guidelines for preventing sCAP include maintaining a healthy lifestyle, and annual pneumococcal and influenza vaccines are recommended for the most vulnerable patient groups, such as those with COPD and immunosuppression.
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Affiliation(s)
- Don Davis
- Medicine, Medical University of Varna, Varna, BGR
| | - Jainisha Thadhani
- Medicine, Royal College of Surgeons in Ireland, Medical University of Bahrain, Manama, BHR
| | | | | | | | | | - Mujahaith Ali
- Medicine, Ternopil National Medical University, Ternopil, UKR
| | - Bryan J Carson
- Emergency Medicine, Northern Health and Social Care Trust, Coleraine, GBR
| | - Fnu Kanwal
- Medical College, Chandka Medical College, Larkana, PAK
| | - Lavanya Nagarajan
- Department of Medicine, The Tamilnadu Dr.M.G.R. Medical University, Chennai, IND
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Houshmand H, Porta C, Pradelli L, Pinciroli M, Sotgiu G. Cost-Impact Analysis of a Novel Diagnostic Test to Assess Community-Acquired Pneumonia Etiology in the Emergency Department Setting: A Multi-Country European Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3853. [PMID: 36900863 PMCID: PMC10001249 DOI: 10.3390/ijerph20053853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND We aimed to estimate the economic and clinical impacts of a novel diagnostic test called LIAISON® MeMed BV® (LMMBV), which can differentiate bacterial from viral infections, in patients with community-acquired pneumonia (CAP) in emergency departments. METHODS A cost-impact simulation model was developed to investigate the financial consequences of the introduction of LMMBV into the standard of care (SOC) diagnostic process in Italy, Germany, and Spain. Clinical outcomes were expressed as antibiotic patients and days saved, reduced hospital admissions, and shortened hospital length of stay (LOS). Cost savings were evaluated from the perspectives of third-party payers and hospitals. A deterministic sensitivity analysis (DSA) was carried out. RESULTS LMMBV was associated with a reduction in antibiotic prescriptions, treatment duration, and LOS. Furthermore, the adoption of LMMBV would allow savings per patient up to EUR 364 and EUR 328 for hospitals and EUR 91 and EUR 59 for payers in Italy and Germany, respectively. In Spain, average savings per patient could reach up to EUR 165 for both payers and hospitals. Savings were most sensitive to test accuracy, with DSA confirming the robustness of the results. CONCLUSIONS Combining LMMBV with the current SOC diagnostic process is expected to provide clinical and economic benefits in Italy, Germany, and Spain.
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Affiliation(s)
| | - Camilla Porta
- AdRes Health Economics and Outcomes Research, 10121 Torino, Italy
| | - Lorenzo Pradelli
- AdRes Health Economics and Outcomes Research, 10121 Torino, Italy
| | | | - Giovanni Sotgiu
- Scienze Mediche Chirurgiche E Sperimentali, Università degli Studi di Sassari, 07100 Sassari, Italy
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Smith MD, Fee C, Mace SE, Maughan B, Perkins JC, Kaji A, Wolf SJ. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia. Ann Emerg Med 2021; 77:e1-e57. [PMID: 33349374 DOI: 10.1016/j.annemergmed.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This clinical policy from the American College of Emergency Physicians is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data.
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Eticha EM, Gemechu WD. Adherence to Guidelines for Assessment and Empiric Antibiotics Recommendations for Community-Acquired Pneumonia at Ambo University Referral Hospital: Prospective Observational Study. Patient Prefer Adherence 2021; 15:467-473. [PMID: 33658770 PMCID: PMC7920623 DOI: 10.2147/ppa.s295118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/16/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE The high incidence and substantial morbidity and mortality associated with community-acquired pneumonia necessitate an accurate assessment and appropriate management of patients. This observational prospective study aimed to evaluate the physicians' adherence to the Ethiopian Standard Treatment Guideline for assessment and an empiric antibiotic selection for Community-acquired pneumonia. RESULTS The study indicated that the pneumonia severity assessment tool, CURB-65 score, was never used. Of 141 patients referred to an admitting diagnosis of severe community-acquired pneumonia, only 50 were subsequently found to satisfy the guideline criteria, over-diagnosis of 41.9%. Large proportions of the participants (130, 60%) were prescribed antibiotics in the last three months. The most commonly prescribed single antibiotic was Ceftriaxone (47, 21.7%), while ceftriaxone plus azithromycin was the most common combination, 110 (50.7%). In general, the extent of non-adherence to the national guideline for the use of antibiotics was 36.4%. In conclusion, the use of CRB65 scores was uncommon in the study setting. Poor adherence to Ethiopian Standard Treatment Guideline regarding the decision of hospital admission (41.9%) and the antimicrobial selection (36.4%) was determined.
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Affiliation(s)
- Endalkachew Mekonnen Eticha
- Ambo University, College of Medicine and Health Science, School of Pharmacy, Ambo, Ethiopia
- Correspondence: Endalkachew Mekonnen Eticha Email
| | - Workineh Diriba Gemechu
- Jigjiga University, College of Medicine and Health Science, School of Medicine, Jigjiga, Ethiopia
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Florin TA, Ambroggio L, Lorenz D, Kachelmeyer A, Ruddy RM, Kuppermann N, Shah SS. Development and Internal Validation of a Prediction Model to Risk Stratify Children with Suspected Community-Acquired Pneumonia. Clin Infect Dis 2020; 73:e2713-e2721. [PMID: 33159514 DOI: 10.1093/cid/ciaa1690] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/30/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although community-acquired pneumonia (CAP) is one of the most common infections in children, no tools exist to risk stratify children with suspected CAP. We developed and validated a prediction model to risk stratify and inform hospitalization decisions in children with suspected CAP. METHODS We performed a prospective cohort study of children age 3 months to 18 years with suspected CAP in a pediatric emergency department (ED). Primary outcome was disease severity, defined as mild (discharge home or hospitalization for <24 hours with no oxygen or intravenous (IV) fluids), moderate (hospitalization <24 hours with oxygen or IV fluids, or hospitalization >24 hours), or severe (intensive care unit (ICU) stay for >24 hours, septic shock, vasoactive agents, positive-pressure ventilation, chest drainage, extracorporeal membrane oxygenation, or death). Ordinal logistic regression and bootstrapped backwards selection were used to derive and internally validate our model. RESULTS Of 1128 children, 371 (32.9%) developed moderate disease and 48 (4.3%) severe disease. Severity models demonstrated excellent discrimination (optimism-corrected c-indices of 0.81) and outstanding calibration. Severity predictors in the final model included respiratory rate, systolic blood pressure, oxygenation, retractions, capillary refill, atelectasis or pneumonia on chest radiograph, and pleural effusion. CONCLUSIONS We derived and internally validated a score that accurately predicts disease severity in children with suspected CAP. Once externally validated, this score has potential to facilitate management decisions by providing individualized risk estimates that can be used in conjunction with clinical judgment to improve the care of children with suspected CAP.
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Affiliation(s)
- Todd A Florin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine & Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado School of Medicine, Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
| | - Andrea Kachelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Richard M Ruddy
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine and UC Davis Health, Sacramento, CA
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Avci S, Perincek G. The alveolar-arterial gradient, pneumonia severity scores and inflammatory markers to predict 30-day mortality in pneumonia. Am J Emerg Med 2020; 38:1796-1801. [PMID: 32739850 DOI: 10.1016/j.ajem.2020.05.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/16/2020] [Accepted: 05/17/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the association of elevated alveolar-arterial oxygen (A-a O2) gradient with risk of mortality in hospitalized patients with community-acquired pneumonia (CAP). METHODS This prospective study included 206 patients diagnosed with CAP admitted to the ED. Demographics, comorbidities, arterial blood gas, serum electrolytes, liver-renal functions, complete blood count, NLR, PLR, CRP, CAR, procalcitonin, A-a O2 gradient, expected A-a O2 and A-a O2 difference were evaluated. PSI and CURB-65 scores were classified as follow: a) PSI low risk (I-III) and moderate-high risk (IV-V) groups; b) CURB-65; low risk (0-2) and high risk (3-5) groups. RESULTS The survival rates of the PSI class (I-III) were significantly higher than the ones of the PSI class (IV-V) (92.1% vs. 62.9%, respectively). The percentage of survivors of the CURB-65 score (0-2) group (81.9%) was higher than the survivors of CURB-65 score (3-5) group (27.8%). Creatinine, BUN, uric acid, phosphorus, RDW, CRP, CAR, procalcitonin, lactate, A-a 02 gradient, expected A-a 02 and A-a 02 difference were significantly higher and basophil was lower in non-survivors. A-a O2 gradient (AUC 0.78), A-a O2 difference (AUC 0.74) and albumin (AUC 0.80) showed highest 30-day mortality prediction. NLR (AUC 0.58) and PLR (AUC 0.55) showed lowest 30-day mortality estimation. Procalcitonin (AUC 0.65), PSI class (AUC 0.81) and PSI score (AUC 0.86) indicated statistically significant higher 30-day mortality prediction. CONCLUSION A-a O2 gradient, A-a O2 difference and albumin are potent predictors of 30-day mortality in CAP patients in the ED.
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Affiliation(s)
- Sema Avci
- Department of Emergency Medicine, Amasya University Sabuncuoglu Serefeddin Research and Training Hospital, Amasya, Turkey.
| | - Gokhan Perincek
- Department of Pulmonology, Kars Harakani State Hospital, Kars, Turkey
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XueBiJing Injection Versus Placebo for Critically Ill Patients With Severe Community-Acquired Pneumonia: A Randomized Controlled Trial. Crit Care Med 2020; 47:e735-e743. [PMID: 31162191 PMCID: PMC6727951 DOI: 10.1097/ccm.0000000000003842] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Supplemental Digital Content is available in the text. Objectives: To investigate whether XueBiJing injection improves clinical outcomes in critically ill patients with severe community-acquired pneumonia. Design: Prospective, randomized, controlled study. Setting: Thirty-three hospitals in China. Patients: A total of 710 adults 18–75 years old with severe community-acquired pneumonia. Interventions: Participants in the XueBiJing group received XueBiJing, 100 mL, q12 hours, and the control group received a visually indistinguishable placebo. Measurements and Main Results: The primary outcome was 8-day improvement in the pneumonia severity index risk rating. Secondary outcomes were 28-day mortality rate, duration of mechanical ventilation and total duration of ICU stay. Improvement in the pneumonia severity index risk rating, from a previously defined endpoint, occurred in 203 (60.78%) participants receiving XueBiJing and in 158 (46.33%) participants receiving placebo (between-group difference [95% CI], 14.4% [6.9–21.8%]; p < 0.001). Fifty-three (15.87%) XueBiJing recipients and 84 (24.63%) placebo recipients (8.8% [2.4–15.2%]; p = 0.006) died within 28 days. XueBiJing administration also decreased the mechanical ventilation time and the total ICU stay duration. The median mechanical ventilation time was 11.0 versus 16.5 days for the XueBiJing and placebo groups, respectively (p = 0.012). The total duration of ICU stay was 12 days for XueBiJing recipients versus 16 days for placebo recipients (p = 0.004). A total of 256 patients experienced adverse events (119 [35.63%] vs 137 [40.18%] in the XueBiJing and placebo groups, respectively [p = 0.235]). Conclusions: In critically ill patients with severe community-acquired pneumonia, XueBiJing injection led to a statistically significant improvement in the primary endpoint of the pneumonia severity index as well a significant improvement in the secondary clinical outcomes of mortality, duration of mechanical ventilation and duration of ICU stay.
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Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2020; 200:e45-e67. [PMID: 31573350 PMCID: PMC6812437 DOI: 10.1164/rccm.201908-1581st] [Citation(s) in RCA: 1764] [Impact Index Per Article: 441.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia. Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions. Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.
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MESH Headings
- Adult
- Ambulatory Care
- Anti-Bacterial Agents/therapeutic use
- Antigens, Bacterial/urine
- Blood Culture
- Chlamydophila Infections/diagnosis
- Chlamydophila Infections/drug therapy
- Chlamydophila Infections/metabolism
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/drug therapy
- Culture Techniques
- Drug Therapy, Combination
- Haemophilus Infections/diagnosis
- Haemophilus Infections/drug therapy
- Haemophilus Infections/metabolism
- Hospitalization
- Humans
- Legionellosis/diagnosis
- Legionellosis/drug therapy
- Legionellosis/metabolism
- Macrolides/therapeutic use
- Moraxellaceae Infections/diagnosis
- Moraxellaceae Infections/drug therapy
- Moraxellaceae Infections/metabolism
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Mycoplasma/diagnosis
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/metabolism
- Pneumonia, Pneumococcal/diagnosis
- Pneumonia, Pneumococcal/drug therapy
- Pneumonia, Pneumococcal/metabolism
- Pneumonia, Staphylococcal/diagnosis
- Pneumonia, Staphylococcal/drug therapy
- Pneumonia, Staphylococcal/metabolism
- Radiography, Thoracic
- Severity of Illness Index
- Sputum
- United States
- beta-Lactams/therapeutic use
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Eekholm S, Ahlström G, Kristensson J, Lindhardt T. Gaps between current clinical practice and evidence-based guidelines for treatment and care of older patients with Community Acquired Pneumonia: a descriptive cross-sectional study. BMC Infect Dis 2020; 20:73. [PMID: 31973742 PMCID: PMC6979078 DOI: 10.1186/s12879-019-4742-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 12/27/2019] [Indexed: 02/03/2023] Open
Abstract
Background Community acquired pneumonia (CAP) remains a significant cause of morbidity and in-hospital mortality, and readmission rates are rising for older persons (> 65 years). Optimized treatment and nursing care will benefit patients and the health economy. Hence, there is a need to describe gaps between current clinical practice and recommendations in evidence-based guidelines for diagnostic procedures, medical treatment and nursing interventions for older patients with CAP. Methods Structured observations, individual ad hoc interviews and audits of patient records were carried out in an emergency department and three medical units. Data were analysed by manifest content analysis and descriptive statistics. Results Thirty patients (median age 74 years) admitted with CAP and 86 physicians, nurses, physiotherapists were included. The median length of stay (LOS) was 6.5 days, in-hospital mortality was10 and 40.7% were readmitted within one month. The severity assessment tool (CURB-65) was used in 16.7% of the patients, correct antibiotic treatment prescribed for 13.3% and chest radiography (≤6 weeks post-discharge) prescribed for 22.2%. Fluid therapy, nutrition support and mobilisation plans were found to be developed sporadically, and interventions to be performed unsystematically and sparingly. Positive Expiratory Pressure therapy and oral care were the nursing interventions with lowest adherence, ranging from 18.2 to 55.6%. Conclusions Adherence to recommendations was low for several central treatment and nursing care interventions for patients with CAP with possible consequences for patients and the use of resources. Thus, there is an urgent need to identify and remove barriers to adherence to recommendations in the neglected areas in view of the potential to improve patient outcomes.
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Affiliation(s)
- Signe Eekholm
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, SE-221 00, Lund, Sweden. .,Research Unit for Clinical Nursing, Department of Internal Medicine, Copenhagen University Hospital Herlev and Gentofte, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Gerd Ahlström
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, SE-221 00, Lund, Sweden
| | - Jimmie Kristensson
- Department of Health Sciences, Lund University, P.O. Box 157, SE-221 00, Lund, Sweden
| | - Tove Lindhardt
- Research Unit for Clinical Nursing, Department of Internal Medicine, Copenhagen University Hospital Herlev and Gentofte, Herlev Ringvej 75, 2730, Herlev, Denmark
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Usefulness of blood and cerebrospinal fluid laboratory testing to predict bacterial meningitis in the emergency department. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Abstract
The emergency department (ED) is the hub of the US health care system. Acute infectious diseases are frequently encountered in the ED setting, making this a critical setting for antimicrobial stewardship efforts. Systems level and behavioral stewardship interventions have demonstrated success in the ED setting but successful implementation depends on institutional support and the presence of a physician champion. Antimicrobial stewardship efforts in the ED should target high-impact areas: antibiotic prescribing for nonindicated respiratory tract conditions, such as bronchitis and sinusitis; overtreatment of asymptomatic bacteriuria; and using two antibiotics (double coverage) for uncomplicated cases of cellulitis or abscess.
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Affiliation(s)
- Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
| | - Robert Redwood
- Department of Family Medicine and Community Health, University of Wisconsin Madison School of Medicine and Public Health, 1100 Delaplaine Ct, Madison, WI 53715
| | - Larissa May
- Department of Emergency Medicine, University of California Davis, 4150 V Street, Suite 2100, Sacramento, CA 95817, USA
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López‐Alcalde J, Rodriguez‐Barrientos R, Redondo‐Sánchez J, Muñoz‐Gutiérrez J, Molero García JM, Rodríguez‐Fernández C, Heras‐Mosteiro J, Marin‐Cañada J, Casanova‐Colominas J, Azcoaga‐Lorenzo A, Hernandez Santiago V, Gómez‐García M. Short-course versus long-course therapy of the same antibiotic for community-acquired pneumonia in adolescent and adult outpatients. Cochrane Database Syst Rev 2018; 9:CD009070. [PMID: 30188565 PMCID: PMC6513237 DOI: 10.1002/14651858.cd009070.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a lung infection that can be acquired during day-to-day activities in the community (not while receiving care in a hospital). Community-acquired pneumonia poses a significant public health burden in terms of mortality, morbidity, and costs. Shorter antibiotic courses for CAP may limit treatment costs and adverse effects, but the optimal duration of antibiotic treatment is uncertain. OBJECTIVES To evaluate the efficacy and safety of short-course versus longer-course treatment with the same antibiotic at the same daily dosage for CAP in non-hospitalised adolescents and adults (outpatients). We planned to investigate non-inferiority of short-course versus longer-term course treatment for efficacy outcomes, and superiority of short-course treatment for safety outcomes. SEARCH METHODS We searched CENTRAL, which contains the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE, Embase, five other databases, and three trials registers on 28 September 2017 together with conference proceedings, reference checking, and contact with experts and pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing short- and long-courses of the same antibiotic for CAP in adolescent and adult outpatients. DATA COLLECTION AND ANALYSIS We planned to use standard Cochrane methods. MAIN RESULTS Our searches identified 5260 records. We did not identify any RCTs that compared short- and longer-courses of the same antibiotic for the treatment of adolescents and adult outpatients with CAP.We excluded two RCTs that compared short courses (five compared to seven days) of the same antibiotic at the same daily dose because they evaluated antibiotics (gemifloxacin and telithromycin) not commonly used in practice for the treatment of CAP. In particular, gemifloxacin is no longer approved for the treatment of mild-to-moderate CAP due to its questionable risk-benefit balance, and reported adverse effects. Moreover, the safety profile of telithromycin is also cause for concern.We found one ongoing study that we will assess for inclusion in future updates of the review. AUTHORS' CONCLUSIONS We found no eligible RCTs that studied a short-course of antibiotic compared to a longer-course (with the same antibiotic at the same daily dosage) for CAP in adolescent and adult outpatients. The effects of antibiotic therapy duration for CAP in adolescent and adult outpatients remains unclear.
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Affiliation(s)
- Jesús López‐Alcalde
- Universidad Francisco de Vitoria (UFV) MadridFaculty of MedicineCtra. Pozuelo‐Majadahonda km. 1,800MadridSpain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS)Clinical Biostatistics UnitCtra. Colmenar, km. 9.100MadridSpain28034
| | - Ricardo Rodriguez‐Barrientos
- Gerencia Asistencial de Atención Primaria, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC)Unidad de apoyo a la InvestigaciónJátiva Nº23 2ºcMadridSpain28007
| | - Jesús Redondo‐Sánchez
- Gerencia Asistencial Atención PrimariaCentro de Salud Ramon y CajalJabonería 67MadridSpain28921
| | - Javier Muñoz‐Gutiérrez
- Gerencia Asistencial Atención PrimariaCentro de Salud Buenos AiresPio FelipeMadridSpain28038
| | - José María Molero García
- Gerencia Asistencial Atención PrimariaCentro de Salud San AndrésAlberto Palacios, nº 22MadridMadridSpain28021
| | | | - Julio Heras‐Mosteiro
- Rey Juan Carlos UniversityDepartment of Preventive Medicine and Public Health & Immunology and MicrobiologyAvda. Atenas s/nAlcorcónMadridSpain28922
| | - Jaime Marin‐Cañada
- Gerencia Asistencial Atencion Primaria de MadridCentro de Salud Villarejo de SalvanesCalle Hospital 7Villarejo de SalvanesMadridSpain28590
| | - Jose Casanova‐Colominas
- Gerencia Asistencial de Atención PrimariaCentro de Salud Ciudad de los PeriodistasValencia de don Juan 1028034 MadridMadridSpain28034
| | - Amaya Azcoaga‐Lorenzo
- Gerencia Asistencial Atención PrimariaCentro de Salud Los PintoresC/Prolongación Cordoba s/nParlaMadridSpain29981
| | - Virginia Hernandez Santiago
- University of St AndrewsDivision of Population and Behavioural Sciences, School of MedicineNorth HaughDundeeUKKY16 9TF
| | - Manuel Gómez‐García
- Gerencia Asistencial Atención PrimariaCentro de Salud MirasierraC/ Mirador de la Reina nº 117MadridSpain28035
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Usefulness and prognostic value of biomarkers in patients with community-acquired pneumonia in the emergency department. Med Clin (Barc) 2017; 148:501-510. [PMID: 28391994 DOI: 10.1016/j.medcli.2017.02.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/08/2017] [Accepted: 02/16/2017] [Indexed: 01/10/2023]
Abstract
Between all patients treated in the Emergency Department (ED), 1.35% are diagnosed with community-acquired pneumonia (CAP). CAP is the main cause of death due to infectious disease (10-14%) and the most frequent reason of sepsis-septic shock in the ED. In the last decade, the search for objective tools to help establishing an early diagnosis, bacterial aetiology, severity, suspicion of bacteremia and the prognosis of mortality has increased. Biomarkers have shown their usefulness in this matter. Procalcitonin (obtains the highest accuracy for CAP diagnosis, bacterial aetiology and the presence of bacteremia), lactate (biomarker of hypoxia and tissue hypoperfusion) and proadrenomedullin (which has the greatest accuracy to predict mortality which in combination with the prognostic severity scales obtains even better results). The aim of this review is to highlight recently published scientific evidence and to compare the utility and prognostic accuracy of the biomarkers in CAP patients treated in the ED.
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Julián-Jiménez A, Morales-Casado MI. Usefulness of blood and cerebrospinal fluid laboratory testing to predict bacterial meningitis in the emergency department. Neurologia 2016; 34:105-113. [PMID: 27469578 DOI: 10.1016/j.nrl.2016.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 05/05/2016] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION The classic clinical presentation of bacterial meningitis (BM) is observed in less than half of the cases in adults, and symptoms are less specific in children, the elderly or immunocompromised, and other chronic patients. The usual signs and symptoms do not provide optimal sensitivity and specificity for distinguishing possible BM from viral meningitis (VM), which may lead to a delay in the appropriate antimicrobial therapy. Society therefore stands to benefit from the development of effective, objective, and rapid tools able to predict and identify patients with BM. These tools include laboratory tests for blood and cerebrospinal fluid (CSF). The aim of this review is to summarise recently published scientific evidence in order to clarify existing controversies and compare the usefulness and diagnostic ability of the different parameters used to predict BM. DEVELOPMENT Systematic search of the main bibliographic databases and platforms to identify articles published between January 2000 and January 2016. We selected 59 articles that meet the objectives of this review. CONCLUSIONS CSF lactate, proportion of polymorphonuclear leukocytes, and CSF glucose, as well as serum procalcitonin (PCT), are the independent factors most predictive of bacterial aetiology. The model that combines serum PCT and CSF lactate achieves the highest predictive power for BM, with a sensitivity and specificity exceeding 99%. We should consider BM when CSF lactate >33 md/dL and/or PCT>0.25ng/mL.
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Affiliation(s)
- A Julián-Jiménez
- Servicio de Urgencias, Complejo Hospitalario de Toledo, Toledo, España.
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Xuebijing injection in the treatment of severe pneumonia: study protocol for a randomized controlled trial. Trials 2016; 17:142. [PMID: 26983754 PMCID: PMC4794896 DOI: 10.1186/s13063-016-1282-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 03/05/2016] [Indexed: 12/19/2022] Open
Abstract
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.
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Julián-Jiménez A, García Tercero E, García Del Palacio JI. Mortality in elderly patients with community-acquired pneumonia. Arch Bronconeumol 2016; 52:450-1. [PMID: 26905775 DOI: 10.1016/j.arbres.2015.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 11/29/2015] [Accepted: 12/10/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Agustín Julián-Jiménez
- Servicio de Urgencias/Medicina Interna, Complejo Hospitalario de Toledo, Toledo, España.
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Extended-Infusion versus standard-infusion piperacillin-tazobactam for sepsis syndromes at a tertiary medical center. Antimicrob Agents Chemother 2014; 58:4470-5. [PMID: 24867975 DOI: 10.1128/aac.02759-14] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Piperacillin-tazobactam (PTZ) is frequently used as empirical and targeted therapy for Gram-negative sepsis. Time-dependent killing properties of PTZ support the use of extended-infusion (EI) dosing; however, studies have shown inconsistent benefits of EI PTZ treatment on clinical outcomes. We performed a retrospective cohort study of adult patients who received EI PTZ treatment and historical controls who received standard-infusion (SI) PTZ treatment for presumed sepsis syndromes. Data on mortality rates, clinical outcomes, length of stay (LOS), and disease severity were obtained. A total of 843 patients (662 with EI treatment and 181 with SI treatment) were available for analysis. Baseline characteristics of the two groups were similar, except for fewer female patients receiving EI treatment. No significant differences between the EI and SI groups in inpatient mortality rates (10.9% versus 13.8%; P = 0.282), overall LOS (10 versus 12 days; P = 0.171), intensive care unit (ICU) LOS (7 versus 6 days; P = 0.061), or clinical failure rates (18.4% versus 19.9%; P = 0.756) were observed. However, the duration of PTZ therapy was shorter in the EI group (5 versus 6 days; P < 0.001). Among ICU patients, no significant differences in outcomes between the EI and SI groups were observed. Patients with urinary or intra-abdominal infections had lower mortality and clinical failure rates when receiving EI PTZ treatment. We did not observe significant differences in inpatient mortality rates, overall LOS, ICU LOS, or clinical failure rates between patients receiving EI PTZ treatment and patients receiving SI PTZ treatment. Patients receiving EI PTZ treatment had a shorter duration of PTZ therapy than did patients receiving SI treatment, and EI dosing may provide cost savings to hospitals.
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Julián-Jiménez A, Timón Zapata J, Laserna Mendieta EJ, Parejo Miguez R, Flores Chacartegui M, Gallardo Schall P. Capacidad de la procalcitonina para predecir bacteriemia en pacientes con neumonía adquirida en la comunidad. Med Clin (Barc) 2014; 142:285-92. [DOI: 10.1016/j.medcli.2013.05.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 05/11/2013] [Accepted: 05/16/2013] [Indexed: 10/26/2022]
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Julián-Jiménez A, Parejo-Miguez R, Laín-Terés N, Palomo de Los Reyes MJ. Consideraciones respecto a la epidemiología de la neumonía adquirida en la comunidad. Aten Primaria 2014; 46:224-5. [PMID: 24365450 PMCID: PMC6983639 DOI: 10.1016/j.aprim.2013.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 09/30/2013] [Indexed: 12/03/2022] Open
Affiliation(s)
- Agustín Julián-Jiménez
- Medicina Familiar y Comunitaria, Servicio de Urgencias, Complejo Hospitalario de Toledo, Toledo, España.
| | - Raquel Parejo-Miguez
- Medicina Familiar y Comunitaria, Centro de Salud de Madridejos, Madridejos, Toledo, España
| | - Natividad Laín-Terés
- Medicina Familiar y Comunitaria, Servicio de Urgencias, Complejo Hospitalario de Toledo, Toledo, España
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Irizar Aramburu MI. Respuesta de los autores. Aten Primaria 2014; 46:225-6. [PMID: 24656758 PMCID: PMC6983637 DOI: 10.1016/j.aprim.2013.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 11/24/2013] [Indexed: 11/05/2022] Open
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La implantación de una guía clínica mejora la adecuación de la prescripción del antibiótico. Enferm Infecc Microbiol Clin 2014; 32:208. [DOI: 10.1016/j.eimc.2013.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 09/23/2013] [Indexed: 11/21/2022]
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Julián-Jiménez A, Flores Chacartegui M, Piqueras-Martínez AN. Etiological pattern of community-acquired pneumonia: importance of the geographical factor. Arch Bronconeumol 2013; 50:156-7. [PMID: 24074965 DOI: 10.1016/j.arbres.2013.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 08/09/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Agustín Julián-Jiménez
- Servicio de Urgencias-Medicina Interna, Complejo Hospitalario de Toledo, Toledo, España.
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