Epidemiology and etiology of community-acquired pneumonia

Weekend admissions and outcomes in patients with pneumonia: a systematic review and meta-analysis

Background

To document pooled evidence on the association between weekend hospital admissions and the potential risks of mortality, intensive care requirements, and readmission among patients with pneumonia.

Methods

We performed a systematic search across the PubMed, EMBASE, and Scopus databases. We collected observational studies exploring the association between weekend admissions and outcomes of interest in patients with pneumonia. To analyze the data, we used a random effects model and expressed the effect sizes as pooled odds ratios (ORs) accompanied by their respective 95% confidence intervals (CIs).

Results

The analysis comprised data from 13 retrospective studies. Compared to patients admitted on weekdays, those admitted during the weekend had a non-statistically significant marginally higher risk of in-hospital mortality (OR, 1.02; 95% CI, 1.00, 1.04) but similar 30-day mortality after admission (OR, 1.03; 95% CI, 0.97, 1.10), and similar risks of admission to intensive care unit (OR, 1.04; 95% CI, 0.98, 1.11) and re-admission (OR, 0.85; 95% CI, 0.65-1.12).

Conclusion

Our findings do not support the presence of a "weekend effect" in patients with pneumonia.

Systematic review registration

PROSPERO, identifier CRD42023425802, https://www.crd.york.ac.uk/prospero/.

Short treatment duration for community-acquired pneumonia

PURPOSE OF REVIEW

Lower respiratory tract infections are one of the most common indications for antibiotic use in community and hospital settings. Usual guidelines for adults with community-acquired pneumonia (CAP) recommend 5-7 days of antibiotic treatment. In daily practice, physicians often prescribe 9-10 days of antibiotic treatment. Among available strategies to decrease antibiotic use, possibly preventing the emergence of bacterial resistance, reducing treatment durations is the safest and the most acceptable to clinicians. We aim to review data evaluating the efficacy of short antibiotic duration in adult CAP and which criteria can help clinicians to reduce antibiotic treatment.

RECENT FINDINGS

Several studies and meta-analyses demonstrated that the treatment duration of 7 days or less was sufficient for CAP. Two trials found that 3-day treatments were effective, even in hospitalized CAP.To customize and shorten duration, clinical and biological criteria have been studied and reflect patient's response. Indeed, stability criteria were recently shown to be effective to discontinue antibiotic treatment. Procalcitonin was also studied but never compared with clinical criteria.

SUMMARY

Treatment duration for CAP is still under debate, but several studies support short durations. Clinical criteria could be possibly used to discontinue antibiotic treatment.

The Role of Vitamin C: From Prevention of Pneumonia to Treatment of Covid-19

Vitamins are the main components of our diet. In our nutrition 14 vitamins are present namely A, B1 (Thiamine), B6(Pyridoxine), B12(Cyanocobalamin), C, D, E, K, niacin, folacin, choline, pantothenic acid and biotin. The main role of it is in treating common diseases like cold. Vitamin C's role in treating pneumonia or Sepsis /Septicemia has been underway for many decades. A great benefit in decreasing the duration of cold is by injecting heavy dose of ascorbic acid. So, at high dose/ risk of injection like it may be obese, diabetes, and the elderly. Vitamin C always acts as an antioxidant that can help to prevent our cells from getting any harm. Recently injection of vitamin C was used in treatment of Covid-19 patients. In this review we have primarily discussed its effects on the immune system and the treatment of pneumonia disorders using vitamin C. At the beginning we have discussed the bio-avalibility of vitamin-C followed by the synthesis of it by plants and animals and then the dietary allowance to be followed for vitamin C regularly. The level of vitamin C is very low in people having pneumonia and those with low immunity are being effected by COVID-19 virus. Kiwi is the main source of vitamin C. Preliminary observational studies show that critically sick individuals use vitamin C for the prevention of the pneumonia to the treatment of the virus COVID-19 by increasing the vitamin C levels in the body.

The Role of Vitamin C: From Prevention of Pneumonia to Treatment of Covid-19

Vitamins are the main components of our diet. In our nutrition 14 vitamins are present namely A, B1 (Thiamine), B6(Pyridoxine), B12(Cyanocobalamin), C, D, E, K, niacin, folacin, choline, pantothenic acid and biotin. The main role of it is in treating common diseases like cold. Vitamin C's role in treating pneumonia or Sepsis /Septicemia has been underway for many decades. A great benefit in decreasing the duration of cold is by injecting heavy dose of ascorbic acid. So, at high dose/ risk of injection like it may be obese, diabetes, and the elderly. Vitamin C always acts as an antioxidant that can help to prevent our cells from getting any harm. Recently injection of vitamin C was used in treatment of Covid-19 patients. In this review we have primarily discussed its effects on the immune system and the treatment of pneumonia disorders using vitamin C. At the beginning we have discussed the bio-avalibility of vitamin-C followed by the synthesis of it by plants and animals and then the dietary allowance to be followed for vitamin C regularly. The level of vitamin C is very low in people having pneumonia and those with low immunity are being effected by COVID-19 virus. Kiwi is the main source of vitamin C. Preliminary observational studies show that critically sick individuals use vitamin C for the prevention of the pneumonia to the treatment of the virus COVID-19 by increasing the vitamin C levels in the body.

The Long History of Vitamin C: From Prevention of the Common Cold to Potential Aid in the Treatment of COVID-19

From Pauling's theories to the present, considerable understanding has been acquired of both the physiological role of vitamin C and of the impact of vitamin C supplementation on the health. Although it is well known that a balanced diet which satisfies the daily intake of vitamin C positively affects the immune system and reduces susceptibility to infections, available data do not support the theory that oral vitamin C supplements boost immunity. No current clinical recommendations support the possibility of significantly decreasing the risk of respiratory infections by using high-dose supplements of vitamin C in a well-nourished general population. Only in restricted subgroups (e.g., athletes or the military) and in subjects with a low plasma vitamin C concentration a supplementation may be justified. Furthermore, in categories at high risk of infection (i.e., the obese, diabetics, the elderly, etc.), a vitamin C supplementation can modulate inflammation, with potential positive effects on immune response to infections. The impact of an extra oral intake of vitamin C on the duration of a cold and the prevention or treatment of pneumonia is still questioned, while, based on critical illness studies, vitamin C infusion has recently been hypothesized as a treatment for COVID-19 hospitalized patients. In this review, we focused on the effects of vitamin C on immune function, summarizing the most relevant studies from the prevention and treatment of common respiratory diseases to the use of vitamin C in critical illness conditions, with the aim of clarifying its potential application during an acute SARS-CoV2 infection.

Predictive and prognostic roles of electrical cardiometry in noninvasive assessments of community-acquired pneumonia patients with dyspnoea

Background:

Thoracic impedance monitoring able to detect pneumonia in the very early phase of emerging infiltration prior the patient developed remarkable clinical symptoms. However, no studies have yet been conducted on the usefulness of predicting pneumonia patient outcomes with parameters from electrical cardiometry.

Objective:

In the present study, we evaluated whether parameters measured by electrical cardiometry can predict clinical outcomes including mortality and length of hospital stay in patients with community-acquired pneumonia in the emergency department.

Methods:

Demographic, clinical and laboratory data were collected from enrolled patient. Electrical cardiometry monitoring was done with a portable electrical cardiometry device connected to the body surface sensor. The continuous data from electrical cardiometry were recorded, and parameters were stored on the electrical cardiometry device automatically and then the data were downloaded for further analysis.

Results:

Thoracic fluid content has shown to be significantly higher in the intensive care unit admission group and in the death group. Expired patients had higher value of thoracic fluid content at emergency department admission. From a receiver operating characteristics curve analysis, thoracic fluid content presented fair AUC values of 0.72 (95% confidence interval, 0.71–0.74) and 0.73 (0.62–0.82) for prediction of 28-day mortality and intensive care unit admission. Arterial partial pressure of oxygen (PaO2), the ratio of arterial partial pressure of oxygen to inspired oxygen fraction (PaO2/FiO2 ratio) also showed excellent AUC value for prediction of mortality and intensive care unit admission.

Conclusion:

Electrical cardiometry monitoring indicated new possibility to anticipate prognosis of community-acquired pneumonia patient. Increased thoracic fluid content value would relate worse outcome of the patient like mortality and intensive care unit admission. Electrical cardiometry monitoring allows real-time measurements of thoracic fluid content without restraining the patient or invasive catheters.

Impact of emergency physician experience on decision-making in patients with suspected community-acquired pneumonia and undergoing systematic thoracic CT scan

Objectives

To determine whether the impact of a thoracic CT scan on community-acquired pneumonia (CAP) diagnosis and patient management varies according to emergency physician’s experience (≤10 vs >10 years).

Methods

Early thoracic CT Scan for Community-Acquired Pneumonia at the Emergency Department is an interventional study conducted from November 2011 to January 2013 in four French emergency departments, and included suspected patients with CAP. We analysed changes in emergency physician CAP diagnosis classification levels before and after CT scan; and their agreement with an adjudication committee. We performed univariate analysis to determine the factors associated with modifying the diagnosis classification level to be consistent with the radiologist’s CT scan interpretation.

Results

319 suspected patients with CAP and 136 emergency physicians (75% less experienced with ≤10 years, 25% with >10 years of experience) were included. The percentage of patients whose classification was modified to become consistent with CT scan radiologist’s interpretation was higher among less-experienced than experienced emergency physicians (54.2% vs 40.2%; p=0.02). In univariate analysis, less emergency physician experience was the only factor associated with changing a classification to be consistent with the CT scan radiologist’s interpretation (OR 1.77, 95% CI 1.01 to 3.10, p=0.04). After CT scan, the agreement between emergency physicians and adjudication committee was moderate for less-experienced emergency physicians and slight for experienced emergency physicians (k=0.457 and k=0.196, respectively). After CT scan, less-experienced emergency physicians modified patient management significantly more than experienced emergency physicians (36.1% vs 21.7%, p=0.01).

Conclusions

In clinical practice, less-experienced emergency physicians were more likely to accurately modify their CAP diagnosis and patient management based on thoracic CT scan than more experienced emergency physicians.

Trial registration number

NCT01574066

Etiology and epidemiology of community-acquired pneumonia in adults requiring hospital admission: A prospective study in rural Central Philippines

BACKGROUND

Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality among adults worldwide. However, the distribution of the etiology of CAP varies from one country to another, with limited data from rural areas.

METHODS

A prospective hospital-based study on adult CAP was conducted in Leyte, Central Philippines from May 2010 to May 2012. Blood, sputum, and nasopharyngeal samples obtained from patients were used to identify pathogens using standard microbiological culture methods and PCR.

RESULTS

Of the 535 patients enrolled, 38% were younger than 50 years old. More than half of the patients had an underlying disease, including pulmonary tuberculosis (22%). The detection rate was higher for bacteria (40%) than viruses (13%). Haemophilus influenzae (12%) was the most commonly detected bacterium and influenza virus (5%) was the most commonly detected virus. The proportion of CAP patients with Mycobacterium tuberculosis infection was higher in the younger age group than in the older age group. Among CAP patients, 14% died during hospitalization, and drowsiness on admission and SpO₂ <90% were independent risk factors for mortality.

CONCLUSIONS

Bacterial infections contribute substantially to the number of hospitalizations among CAP patients in rural Philippines. This study also highlights the importance of treatment of tuberculosis in reducing the burden of adult CAP in the country.

Disease burden of hospitalized community-acquired pneumonia in South Korea: Analysis based on age and underlying medical conditions

Pneumonia is a leading cause of hospitalization and mortality worldwide. Despite recognition of the importance of community-acquired pneumonia (CAP) in adults, limited epidemiologic information is available in South Korea. This study aimed to evaluate the disease burden of hospitalized CAP in adults aged ≥19 years and its epidemiologic trend using Health Insurance and Review Assessment (HIRA) data.This is a retrospective study using the HIRA database from year 2009 to 2013. We estimated the incidence rate and direct medical cost of hospitalized CAP in adults aged ≥19 years in South Korea. These were further analyzed with respect to age and underlying medical conditions.During 2009 to 2013, 1216,916 hospitalizations were recorded. On average, the annual age-adjusted incidence rate of hospitalized CAP was 626 per 100,000 persons, with the rate increasing with age. When stratified by age- and risk groups, elderly people ≥75 years showed the highest incidence rate of hospitalized CAP over 5-year study periods. With respect to the risk groups based on underlying medical conditions, incidence rate ratios were 2.04 to 5.86 for the high-risk group versus the low-risk group and 1.28 to 5.49 for the moderate-risk group versus the low-risk group. Overall, mean direct medical cost for hospitalized CAP was 1851 USD per capita during the 5-year period: 1263 USD in the low-risk group, 2353 USD in the moderate-risk group, and 2841 USD in the high-risk group.This study shows that the incidence and medical cost of hospitalized CAP were consistently high over the 5-year study period. In particular, elderly people and adults with underlying medical conditions were at increased risk for hospitalized CAP.

The etiology and bacteriology of healthcare-associated empyema are quite different from those of community-acquired empyema

OBJECTS

Changes in patients' background and life environment could contribute to increase healthcare-associated (HCA) empyema. There are no guidelines and statements for HCA empyema.

METHODS

We retrospectively reviewed all patients with empyema who were admitted to the Aichi Medical University Hospital, Japan between 2008 and 2015. We evaluated patients' characteristics, microbial profiles, treatment and outcomes, and analyzed prognostic factors for 90-day mortality.

RESULTS

A total of 48 patients were enrolled in this study. They were categorized into community-acquired (CA) empyema (16 patients) and healthcare-associated (HCA) empyema (32 patients). HCA empyema patients had higher Charlson comorbidity index (CCI) scores, and poorer performance status (PS) than CA empyema patients. Potentially-drug resistant (PDR) pathogens were seen more frequently in HCA empyema than in CA empyema. Compared with survival and death groups, the death group showed higher CCI scores and poorer PSs than the survival group. The death group had more malignancy than the survival group. PDR pathogens were detected more frequently in the death group than in the survival group. Multivariate analysis showed that emergence of PDR pathogens and malignancies were independent poor prognostic factors for 90-days mortality among empyema.

CONCLUSION

The etiology and bacteriology of HCA empyema are quite different from those of CA empyema. Especially, the mortality of HCA empyema was higher than the one of CA empyema. Emergence of PDR pathogens in the pleural fluid detected by culture, pulmonary disease and malignancies were independent poor prognostic factors among CA and HCA empyema by multivariate logistic regression analysis.

Patterns of C-reactive protein ratio predicts outcomes in healthcare-associated pneumonia in critically ill patients with cancer

PURPOSE

Describe the patterns of C-reactive protein relative changes in response to antibiotic therapy in critically ill cancer patients with healthcare-associated pneumonia (HCAP) and its ability to predict outcome.

METHODS

Secondary analysis of a prospective cohort of critically ill cancer patients with HCAP. CRP was sampled every other day from D0 to D6 of antibiotic therapy. Patients were classified according to an individual pattern of CRP-ratio response: fast - CRP at D4 of therapy was <0.4 of D0 CRP; slow - a continuous but slow decrease of CRP; non - CRP remained ≥0.8 of D0 CRP; biphasic - initial CRP decrease to levels <0.8 of the D0 CRP followed by a secondary rise ≥0.8.

RESULTS

129 patients were included and septic shock was present in 74% and invasive mechanical ventilation was used in 73%. Intensive care unit (ICU) and hospital mortality rates were 47% and 64%, respectively. By D4, both CRP and CRP-ratio of survivors were significantly lower than in nonsurvivors (p<0.001 and p=0.004, respectively). Both time-dependent analysis of CRP-ratio of the four previously defined patterns (p<0.001) as ICU mortality were consistently different [fast 12.9%, slow 43.2%, biphasic 66.7% and non 71.8% (p<0.001)].

CONCLUSION

CRP-ratio was useful in the early prediction of poor outcomes in cancer patients with HCAP.

Treatment of Community-Acquired Pneumonia: A Case Report and Current Treatment Dilemmas

Resistance to macrolides is rising in the USA and warrants careful consideration when confronted with a patient with suspected pneumonia in the urgent care clinic. This case study exemplifies the potentially serious consequences of treatment failure following prescription of a macrolide for community-acquired bacterial pneumonia. Furthermore, the consequential treatment dilemmas currently faced by physicians are briefly discussed.

Mannose-binding lectin and l-ficolin polymorphisms in patients with community-acquired pneumonia caused by intracellular pathogens

Community-acquired pneumonia (CAP) is the leading infectious disease requiring hospitalization in the western world. Genetic variability affecting the host response to infection may play a role in susceptibility and outcome in patients with CAP. Mannose-binding lectin (MBL) and l-ficolin (l-FCN) are two important activators of the complement system and they can enhance phagocytosis by opsonization. In a prospective cohort of 505 Dutch patients with CAP and 227 control participants we studied whether polymorphisms in the MBL (MBL2) and FCN (FCN2) genes influenced susceptibility and outcome. No difference in frequency of these genotypes was found between patients with CAP in general and controls. However, the +6424G>T single nucleotide polymorphism (SNP) in FCN2 was more common in patients with a Coxiella burnetii pneumonia (P = 0·014). Moreover, the haplotypes coding for the highest MBL serum levels (YA/YA and YA/XA) predisposed to atypical pneumonia (C. burnetii, Legionella or Chlamydia species or Mycoplasma pneumoniae) compared with controls (P = 0·016). Furthermore, patients with these haplotypes were more often bacteraemic (P = 0·019). It can therefore be concluded that MBL2 and FCN2 polymorphisms are not major risk factors for CAP in general, but that the +6424G>T SNP in the FCN2 gene predisposes to C. burnetii pneumonia. In addition, patients with genotypes corresponding with high serum MBL levels are at risk for atypical pneumonia, possibly caused by enhanced phagocytosis, thereby promoting cell entry of these intracellular bacteria.

Diagnostic accuracy of C-reactive protein and procalcitonin in suspected community-acquired pneumonia adults visiting emergency department and having a systematic thoracic CT scan

Introduction

Community-acquired pneumonia (CAP) requires prompt treatment, but its diagnosis is complex. Improvement of bacterial CAP diagnosis by biomarkers has been evaluated using chest X-ray infiltrate as the CAP gold standard, producing conflicting results. We analyzed the diagnostic accuracy of biomarkers in suspected CAP adults visiting emergency departments for whom CAP diagnosis was established by an adjudication committee which founded its judgment on a systematic multidetector thoracic CT scan.

Methods

In an ancillary study of a multi-center prospective study evaluating the impact of systematic thoracic CT scan on CAP diagnosis, sensitivity and specificity of C-reactive protein (CRP) and procalcitonin (PCT) were evaluated. Systematic nasopharyngeal multiplex respiratory virus PCR was performed at inclusion. An adjudication committee classified CAP diagnostic probability on a 4-level Likert scale, based on all available data.

Results

Two hundred patients with suspected CAP were analyzed. The adjudication committee classified 98 patients (49.0 %) as definite CAP, 8 (4.0 %) as probable, 23 (11.5 %) as possible and excluded in 71 (35.5 %, including 29 patients with pulmonary infiltrates on chest X-ray). Among patients with radiological pulmonary infiltrate, 23 % were finally classified as excluded. Viruses were identified by PCR in 29 % of patients classified as definite. Area under the curve was 0.787 [95 % confidence interval (95 % CI), 0.717 to 0.857] for CRP and 0.655 (95 % CI, 0.570 to 0.739) for PCT to detect definite CAP. CRP threshold at 50 mg/L resulted in a positive predictive value of 0.76 and a negative predictive value of 0.75. No PCT cut-off resulted in satisfactory positive or negative predictive values. CRP and PCT accuracy was not improved by exclusion of the 25 (25.5 %) definite viral CAP cases.

Conclusions

For patients with suspected CAP visiting emergency departments, diagnostic accuracy of CRP and PCT are insufficient to confirm the CAP diagnosis established using a gold standard that includes thoracic CT scan. Diagnostic accuracy of these biomarkers is also insufficient to distinguish bacterial CAP from viral CAP.

Trial registration

ClinicalTrials.gov registry NCT01574066 (February 7, 2012)

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1083-6) contains supplementary material, which is available to authorized users.

Clinical and economic burden of community-acquired pneumonia in the Veterans Health Administration, 2011: a retrospective cohort study

Purpose

The burden of community-acquired pneumonia (CAP) is not well described in the US Veterans Health Administration (VHA).

Methods

CAP was defined as having a pneumonia diagnosis with evidence of chest X-ray, and no evidence of prior (90 days) hospitalization/long-term care. We calculated incidence rates of adult CAP occurring in inpatient or outpatient VHA settings in 2011. We also estimated the proportion of VHA CAP patients who were hospitalized, were readmitted within 30 days of hospital discharge, and died (any cause) in the year following diagnosis. Incremental costs during the 90 days following a CAP diagnosis were estimated from the perspective of the VHA.

Results

In 2011, 34,101 Veterans developed CAP (35,380 episodes) over 7,739,757 VHA person-years. Median age of CAP patients was 65 years (95 % male). CAP incidence rates were higher for those aged ≥50 years. A majority of Veterans aged 50–64 (53 %) and ≥65 (66 %) years had ≥1 chronic medical (moderate risk) or immunocompromising (high risk) condition. Compared to those at low-risk (healthy), moderate- and high-risk Veterans were >3 and >6 times more likely to develop CAP, respectively. The percentage of CAP patients who were hospitalized was 45 %, ranging from 12 % (age 18–49, low risk) to 57 % (age ≥65, high risk). One-year all-cause mortality rates ranged from 1 % (age 18–49, low risk) to 36 % (age ≥65, high risk). Annual VHA medical expenditure related to CAP was estimated to be $750 million (M) ($415M for those aged ≥65 years).

Conclusion

A focus on CAP prevention among older Veterans and those with comorbid or immunocompromising conditions is important.

Electronic supplementary material

The online version of this article (doi:10.1007/s15010-015-0789-3) contains supplementary material, which is available to authorized users.

Clinical outcomes and microbiological characteristics of severe pneumonia in cancer patients: a prospective cohort study

INTRODUCTION

Pneumonia is the most frequent type of infection in cancer patients and a frequent cause of ICU admission. The primary aims of this study were to describe the clinical and microbiological characteristics and outcomes in critically ill cancer patients with severe pneumonia.

METHODS

Prospective cohort study in 325 adult cancer patients admitted to three ICUs with severe pneumonia not acquired in the hospital setting. Demographic, clinical and microbiological data were collected.

RESULTS

There were 229 (71%) patients with solid tumors and 96 (29%) patients with hematological malignancies. 75% of all patients were in septic shock and 81% needed invasive mechanical ventilation. ICU and hospital mortality rates were 45.8% and 64.9%. Microbiological confirmation was present in 169 (52%) with a predominance of Gram negative bacteria [99 (58.6%)]. The most frequent pathogens were methicillin-sensitive S. aureus [42 (24.9%)], P. aeruginosa [41(24.3%)] and S. pneumonia [21 (12.4%)]. A relatively low incidence of MR [23 (13.6%)] was observed. Adequate antibiotics were prescribed for most patients [136 (80.5%)]. In multivariate analysis, septic shock at ICU admission [OR 5.52 (1.92-15.84)], the use of invasive MV [OR 12.74 (3.60-45.07)] and poor Performance Status [OR 3.00 (1.07-8.42)] were associated with increased hospital mortality.

CONCLUSIONS

Severe pneumonia is associated with high mortality rates in cancer patients. A relatively low rate of MR pathogens is observed and severity of illness and organ dysfunction seems to be the best predictors of outcome in this population.

Sputum bacteriology and antibiotic sensitivity patterns of community-acquired pneumonia in hospitalized adult patients in Nigeria: a 5-year multicentre retrospective study

BACKGROUND

A clear knowledge of the pathogens responsible for community-acquired pneumonia (CAP) in a given region and their antibiotic sensitivity patterns is necessary for optimal treatment. We determined the common bacterial pathogens causing CAP in Nigeria and further reviewed their antibiotic senstivity patterns with a view to providing recommendations to improve antibiotic management of CAP.

METHODS

Case notes of all adult patients who were 18 years or more admitted to four major tertiary hospitals in South East Nigeria with a diagnosis of CAP between 2008 and 2012 were retrospectively studied. To be eligible, patients were required to have sputum culture and sensitivity results available. Socio-demographic, clinical, pre-admission and in-hospital treatment data were also obtained.

RESULTS

Of 400 patients with a radiologically confirmed diagnosis of CAP, 232 fulfilled the study criteria; 122 (52.6%) were women and the mean age was 50.6 ± 18.8 years. Aetiological agents were identified from sputum in 189 (81.5%) patients. Streptococcus pneumoniae (n = 90, 47.6%) was the most frequent isolate followed by Klebsiella pneumoniae (n = 62, 32.8%), Staphylococcus aureus (n = 24, 12.7%) and Streptococcus pyogenes (n = 13, 6.9%). The pathogens were most sensitive to levofloxacin (77%), ceftazidime (75.5%) and ofloxacin (55.8%). The susceptibility of the isolates to antibiotics most frequently presecribed for empirical therapy was low (co-amoxiclav, 47.6%; ciprofloxacin, 45.9% and ceftriaxone, 47.6%) and this was associated with higher mortality and/or longer duration of hospital stay in survivors.

CONCLUSION

Strep. pneumoniae and K. pneumoniae were the most common causes of CAP. The pathogens were most sensitive to levofloxacin and ceftazidime. We suggest that these antibiotics should increasingly be considered as superior options for empirical treatment of CAP in Nigeria.

Microbiological Profile and Drug Sensitivity Pattern among Community Acquired Pneumonia Patients in Tertiary Care Centre in Mangalore, Coastal Karnataka, India

BACKGROUND

Community Acquired Pneumonia (CAP) is the most common respiratory tract infection in day to day practice. The knowledge of organism commonly causative of CAP helps in early empirical treatment initiation.

AIM

To study the microbiological profile of patients with community acquired pneumonia and to study drug sensitivity pattern.

METHODS

Hospital based cross sectional study among 100 patients with CAP was conducted in a tertiary care hospital of Southern India. Sputum culture showed that out of 100 patients 39 had an identifiable etiology with 12 patients having evidence of mixed infection.

RESULT

Micro-organisms isolated in sputum culture were Streptococcus pneumoniae (31%) followed by, Pseudomonas pyogens (15%), Klebsiella pneumoniae (13%). AFB smear was found to be positive in 6 patients. Organisms were found to be sensitive for piperacillin plus tazobactum (41%), aminoglycocides (amikacin-46%, gentamicin-31%), third generation cephalosporins (Cefotaxim-36%, Ceftriaxone-18%) and macrolides (Erythromicin-31%, Azithromycin-18%). Sensitivity to chloramphenicol was observed in 31% sputum culture positive patients. Ciprofloxacin sensitivity was seen among 49%.

CONCLUSION

Most of the organisms were found to be sensitive to monotherapy with extended spectrum beta lactamases, third generation cephalosporins, fluroquinolones, macrolides.

Duration of antimicrobial therapy in community acquired pneumonia: less is more

Community acquired pneumonia (CAP) represents the most common cause of infection-related morbidity and mortality worldwide. Appropriate treatment of CAP is challenging and sometimes limited by the availability to obtain rapid and timely identification of the etiologic agent in order to initiate or deescalate the correct antimicrobial therapy. As a consequence, prescribers frequently select empiric antimicrobial therapy using clinical judgment, local patterns of antimicrobial resistance, and, sometimes, individual patient expectations. These issues may contribute to prolonged courses of inappropriate therapy. In this review, we discuss the evidence and recommendations from international guidelines for the management of CAP and the clinical trials that specifically addressed duration of antimicrobial therapy for CAP in adults. In randomized controlled trials comparing the clinical efficacy of a short-course antimicrobial regimen versus an extended-course regimen, no differences in terms of clinical success, bacterial eradication, adverse events, and mortality were observed. The use of biomarkers, such as procalcitonin, to guide the initiation and duration of antimicrobial therapy may reduce total antibiotic exposure and treatment duration, healthcare costs, and the risk of developing antimicrobial resistance. In clinical practice, antimicrobial stewardship interventions may improve the management of CAP and may help in reducing treatment duration. Sometimes “less is more” in CAP.

Diagnosis of pneumococcal pneumonia: current pitfalls and the way forward

Streptococcus pneumoniae is the most common cause of community-acquired pneumonia. However, it can also asymptomatically colonize the upper respiratory tract. Because of the need to distinguish between S. pneumoniae that is simply colonizing the upper respiratory tract and S. pneumoniae that is causing pneumonia, accurate diagnosis of pneumococcal pneumonia is a challenging issue that still needs to be solved. Sputum Gram stains and culture are the first diagnostic step for identifying pneumococcal pneumonia and provide information on antibiotic susceptibility. However, these conventional methods are relatively slow and insensitive and show limited specificity. In the past decade, new diagnostic tools have been developed, particularly antigen (teichoic acid and capsular polysaccharides) and nucleic acid (ply, lytA, and Spn9802) detection assays. Use of the pneumococcal antigen detection methods along with biomarkers (C-reactive protein and procalcitonin) may enhance the specificity of diagnosis for pneumococcal pneumonia. This article provides an overview of current methods of diagnosing pneumococcal pneumonia and discusses new and future test methods that may provide the way forward for improving its diagnosis.

The value of signs and symptoms in differentiating between bacterial, viral and mixed aetiology in patients with community-acquired pneumonia

Current diagnostics for community-acquired pneumonia (CAP) include testing for a wide range of pathogens, which is costly and not always informative. We compared clinical and laboratory parameters of patients with CAP caused by different groups of pathogens to evaluate the potential for targeted diagnostics and directed treatment. In a prospective study, conducted between April 2008 and April 2009, adult patients with CAP were tested for the presence of a broad range of possible respiratory pathogens using bacterial cultures, PCR, urinary antigen testing and serology. Of 408 patients with CAP, pathogens were detected in 263 patients (64.5%). Streptococcus pneumoniae and influenza A virus were the most frequently identified bacterial and viral pathogens, respectively. Age had a significant effect on the prediction of aetiology (P = 0.054), with an increase in the relative contribution of viruses with advancing age. Multivariate analyses further showed that the presence of cough increased the likelihood of detecting a viral pathogen [odds ratio (OR) 5.536, 95% confidence interval (CI) 2.130-14.390], the presence of immunodeficiency decreased the likelihood of detecting a bacterial pathogen (OR 0.595, 95 % CI 0.246-1.437) and an increase in pneumonia severity index score increased the likelihood of detecting a pathogen in general. Although several variables were independently associated with the detection of a pathogen group, substantial overlap meant there were no reliable clinical predictors to distinguish aetiologies. Therefore, testing for common respiratory pathogens is still necessary to optimize treatment.

Antimicrobial activity of the pleuromutilin antibiotic BC-3781 against bacterial pathogens isolated in the SENTRY antimicrobial surveillance program in 2010

BC-3781 is a novel semisynthetic pleuromutilin antibiotic inhibiting bacterial protein synthesis. BC-3781 has completed a phase 2 clinical trial in acute bacterial skin and skin structure infections (ABSSSI). Its antibacterial spectrum additionally covers the predominant pathogens causing community-acquired bacterial pneumonia (CABP). In this study, the antibacterial activity of BC-3781 was evaluated against a contemporary collection of 10,035 bacterial isolates predominately causing ABSSSI and CABP, among other infections, collected within the SENTRY Antimicrobial Surveillance Program worldwide in 2010. BC-3781 exhibited potent activity against organisms commonly isolated from ABSSSI such as Staphylococcus aureus (MIC50/90, 0.12/0.12 μg/ml; 99.8% inhibited at ≤0.5 μg/ml), beta-hemolytic streptococci (MIC50/90, 0.03/0.03 μg/ml; 99.3% inhibited at ≤0.5 μg/ml), and coagulase-negative staphylococci (CoNS; MIC50/90, 0.06/0.12 μg/ml; 97.8% inhibited at ≤1 μg/ml). BC-3781 displayed similar MIC distributions among methicillin-susceptible (MSSA) and methicillin-resistant (MRSA) S. aureus strains. BC-3781 was also active against Enterococcus faecium, with 76.3% of vancomycin-susceptible and 97.0% of vancomycin-resistant isolates being inhibited at BC-3781 concentrations of ≤1 μg/ml. Beta-hemolytic and viridans group streptococci were highly susceptible to BC-3781, with 99.3% and 96.7% of isolates inhibited at ≤0.5 μg/ml, respectively. Further, activity of BC-3781 against Streptococcus pneumoniae (MIC50/90, 0.12/0.25 μg/ml), Haemophilus influenzae (MIC50/90, 1/2 μg/ml), and Moraxella catarrhalis (MIC50/90, 0.12/0.25 μg/ml) was not negatively influenced by β-lactamase production or resistance to other antimicrobial classes tested. In all, BC-3781 displayed a very potent antibacterial profile including the most prevalent bacterial pathogens causing ABSSSI and CABP, thus warranting further clinical development of this antibiotic in these and possibly other indications.

Etiological analysis and predictive diagnostic model building of community-acquired pneumonia in adult outpatients in Beijing, China

BACKGROUND

Etiological epidemiology and diagnosis are important issues in adult community-acquired pneumonia (CAP), and identifying pathogens based on patient clinical features is especially a challenge. CAP-associated main pathogens in adults include viruses as well as bacteria. However, large-scale epidemiological investigations of adult viral CAP in China are still lacking. In this study, we analyzed the etiology of adult CAP in Beijing, China and constructed diagnostic models based on combinations of patient clinical factors.

METHODS

A multicenter cohort was established with 500 adult CAP outpatients enrolled in Beijing between November 2010 to October 2011. Multiplex and quantitative real-time fluorescence PCR were used to detect 15 respiratory viruses and mycoplasma pneumoniae, respectively. Bacteria were detected with culture and enzyme immunoassay of the Streptococcus pneumoniae urinary antigen. Univariate analysis, multivariate analysis, discriminatory analysis and Receiver Operating Characteristic (ROC) curves were used to build predictive models for etiological diagnosis of adult CAP.

RESULTS

Pathogens were detected in 54.2% (271/500) of study patients. Viruses accounted for 36.4% (182/500), mycoplasma pneumoniae for 18.0% (90/500) and bacteria for 14.4% (72/500) of the cases. In 182 of the patients with viruses, 219 virus strains were detected, including 166 single and 53 mixed viral infections. Influenza A virus represented the greatest proportion with 42.0% (92/219) and 9.1% (20/219) in single and mixed viral infections, respectively. Factors selected for the predictive etiological diagnostic model of viral CAP included cough, dyspnea, absence of chest pain and white blood cell count (4.0-10.0) × 10(9)/L, and those of mycoplasma pneumoniae CAP were being younger than 45 years old and the absence of a coexisting disease. However, these models showed low accuracy levels for etiological diagnosis (areas under ROC curve for virus and mycoplasma pneumoniae were both 0.61, P < 0.05).

CONCLUSIONS

Greater consideration should be given to viral and mycoplasma pneumoniae infections in adult CAP outpatients. While predictive etiological diagnostic models of viral and mycoplasma pneumoniae based on combinations of demographic and clinical factors may provide indications of etiology, diagnostic confirmation of CAP remains dependent on laboratory pathogen test results.

Viral and bacterial aetiology of community-acquired pneumonia in adults

BACKGROUND

Modern molecular techniques reveal new information on the role of respiratory viruses in community-acquired pneumonia. In this study, we tried to determine the prevalence of respiratory viruses and bacteria in patients with community-acquired pneumonia who were admitted to the hospital.

METHODS

Between April 2008 and April 2009, 408 adult patients (aged between 20 and 94 years) with community-acquired pneumonia were tested for the presence of respiratory pathogens using bacterial cultures, real-time PCR for viruses and bacteria, urinary antigen testing for Legionella and Pneumococci and serology for the presence of viral and bacterial pathogens.

RESULTS

Pathogens were identified in 263 (64·5%) of the 408 patients. The most common single organisms in these 263 patients were Streptococcus pneumoniae (22·8%), Coxiella burnetii (6·8%) and influenza A virus (3·8%). Of the 263 patients detected with pathogens, 117 (44·5%) patients were positive for one or more viral pathogens. Of these 117 patients, 52 (44·4%) had no bacterial pathogen. Multiple virus infections (≥2) were found in 16 patients.

CONCLUSION

In conclusion, respiratory viruses are frequently found in patients with CAP and may therefore play an important role in the aetiology of this disease.

Economic burden and epidemiology of pneumonia in Korean adults aged over 50 years

This study was performed to estimate the direct medical costs and epidemiology of pneumonia in adults of Korea. We conducted a multi-center, retrospective, observational study and collected data targeting for community-acquired pneumonia patients ( ≥ 50 yr) from 11 hospitals. Costs attributable to the treatment of pneumonia were estimated by reviewing resource utilization and epidemiology data (distribution of pathogen, hospital length of stay, overall outcome) were also collected. A total 693 patients were included; average 70.1 ( ± 10.5) aged, 57.3% male and average 1.16 CURB-65 (confusion, blood urea nitrogen, respiratory rate, blood pressure, age > 65 yr) scored. The pathogen was identified in the 32.9% (228 patients); Streptococcus pneumoniae accounted for 22.4% (51 patients) of identified pathogens. The hospital mortality was 3.2% (especially, for S. pneumoniae was 5.9%) and average length of stay was 9 days. The mean total cost for the treatment of pneumonia was US dollar (USD) 1,782 (SD: USD 1,501). Compared to the cost of all caused pneumonia, that of pneumococcal pneumonia was higher, USD 2,049 ( ± USD 1,919), but not statistically significant. Charge of hospitalization accounted the greatest part of total medical costs. The economic burden of pneumonia was high in Korea, and the prevention of pneumonia should be considered as effective strategy.

Morbidity and mortality of pneumonia in adults in six Latin American countries

OBJECTIVE

To estimate the morbidity and mortality of pneumonia in adults over 50 years of age in Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela.

METHODS

Local data sources were queried to estimate the number of hospitalized and outpatient pneumonia cases and deaths in the year 2009. Pneumonia cases were identified in adults aged ≥50 years using ICD-10 codes. The hospital case fatality rate (HCFR) by age corresponds to the percentage of mortality per hospitalization.

RESULTS

Cases of hospitalized pneumonia (incidence per 100 000 inhabitants/year) in adults ≥50 years were: Argentina 39 674 (401.1); Brazil 225 341 (611.6); Chile 30 434 (738.5); Colombia 26 955 (326.6); Mexico 82 397 (413.1); Venezuela 31 601 (640.1). The number of hospital deaths (CFR%) were: Argentina 5099 (13%); Brazil 47 287 (21%); Chile 3072 (10%); Colombia 2981 (11%); Mexico 13 312 (16%); Venezuela 11 101 (35%). Cases of outpatient pneumonia (incidence per 100 000 inhabitants/year) were: Argentina 54 093 (546.8); Brazil 260 277 (706.4); Chile 33 173 (804.9); Colombia 27 713 (335.8); Mexico 83 354 (417.9); Venezuela 39 645 (803.0). The percentage of episodes treated as outpatient was 64% (range 57-80%) among those aged 50-64 years and 39% (range 8-56%) among those ≥85 years. Across countries, 51% of hospitalizations (range 42-63%) and 69% of deaths (range 65-72%) were in adults ≥75 years.

CONCLUSIONS

Pneumonia is a common cause of hospitalization and mortality in adults in Latin America. Incidence increases substantially with increasing age, as does the likelihood of hospitalization and mortality.

Streptococcus pneumoniae: susceptibility to penicillin and moxifloxacin

OBJECTIVE

To determine the minimum inhibitory concentrations (MICs) of parenteral penicillin and moxifloxacin against Streptococcus pneumoniae strains isolated at a hospital center.

METHODS

In-vitro, prospective study involving 100 S. pneumoniae isolates collected from patients who had been treated, between October of 2008 and July of 2010, at the Hospital das Clínicas complex of the University of São Paulo School of Medicine, located in the city of São Paulo, Brazil. The isolates were obtained from respiratory tract cultures or blood samples unrelated to meningeal infections, and they were tested for penicillin and moxifloxacin susceptibility by E-test. The MIC category interpretations were based on updated standards.

RESULTS

All isolates were fully susceptible to parenteral penicillin (MIC < 2 µg/mL), and, consequently, they were also susceptible to amoxicillin, ampicillin, third/fourth generation cephalosporins, and ertapenem. Of the S. pneumoniae strains, 99% were also susceptible to moxifloxacin, and only one strain showed an MIC = 1.5 µg/mL (intermediate).

CONCLUSIONS

Our results showed high susceptibility rates to parenteral penicillin and moxifloxacin among S. pneumoniae isolates unrelated to meningitis, which differs from international reports. Reports on penicillin resistance should be based on updated breakpoints for non-meningitis isolates in order to guide the selection of an antimicrobial therapy and to improve the prediction of the clinical outcomes.

Serotype emergence and genotype distribution among macrolide-resistant invasive Streptococcus pneumoniae isolates in the postconjugate vaccine (PCV-7) era

We conducted population-based surveillance for pneumococcal bacteremia within a 5-county region surrounding Philadelphia from October 2001 through September 2008, the period following introduction of the seven-valent pneumococcal conjugate vaccine. Erythromycin resistance increased from 14.7% in 2001-2002 to 20.3% in 2007-2008, while the resistance rate to penicillin (MIC, ≥2 μg/ml) decreased from 7.2% to 4.2% during the same period. The most predominant serotypes associated with erythromycin resistance in 2007-2008 included 19A (29.7%), 15A (29.2%), 6C (10.1%), 3 (5.6%), and 6A (4.5%). The molecular mechanisms for the increasing erythromycin resistance were mainly due to the growing presence of mef(A) negative erm(B)(+) and mef(A)(+) erm(B)(+) genotypes, which increased from 20.0% to 46.1% and from 1.8% to 19.1%, respectively, from 2001-2002 to 2007-2008. However, mef(A)-mediated erythromycin resistance decreased from 72.7% in 2001-2002 to 34.8% in 2007-2008. Serotypes related to the erm(B) gene were 15A (45.6%), 19A (20.9%), 3 (10.1%), and 6B (6.3%); serotypes related to the mef(A) gene were 6A (18.6%), 19A (15.0%), 6C (9.3%), and 14(8.4%); serotypes associated with the presence of both erm(B) and mef(A) were 19A (81.5%), 15A (7.7%), and 19F (6.2%). Pulsed-field gel electrophoresis analysis demonstrated that erythromycin-resistant isolates within the 19A serotype were genetically diverse and related to several circulating international clones. In contrast, erythromycin-resistant isolates within the 15A serotype consisted of clonally identical or closely related isolates.

Longitudinal analysis of pneumococcal antibodies during community-acquired pneumonia reveals a much higher involvement of Streptococcus pneumoniae than estimated by conventional methods alone

In up to half of all cases of community-acquired pneumonia (CAP), no pathogen can be identified with conventional diagnostic methods. The most common identified causative agent is Streptococcus pneumoniae. In this study, pneumococcal antibody responses during CAP were analyzed to estimate the contribution of the pneumococcus to all cases of CAP for epidemiological purposes. Pneumococcal antibodies against 14 different serotypes were measured in serum of hospitalized CAP patients. Patients participated in one of two consecutive clinical trials in a general 600-bed teaching hospital in the Netherlands (between October 2004 and June 2009). A significant pneumococcal immune response was defined as at least a 2-fold increase in antibody concentrations against a single serotype between an early (day 1) and a late (day 30) serum sample of each patient with an end concentration above 0.35 μg/ml. A total of 349 adult CAP patients participated in two consecutive clinical trials. For 200 patients, sufficient serum samples were available to determine antibody responses: 62 pneumococcal pneumonia patients, 57 nonpneumococcal pneumonia patients, and 81 patients with an unidentified causative agent. A significant immune response was detected in 45% (28/62 patients) of pneumococcal pneumonia patients, in 5% (3/57) of nonpneumococcal pneumonia patients, and in 28% (23/81) of patients with an unidentified causative agent. The estimated contribution of pneumococci in patients with an unidentified causative agent was calculated to be 57% (95% confidence interval, 36 to 86%). A substantial fraction of pneumococcal pneumonia patients do not elicit a serotype-specific immune response.

Demographics, guidelines, and clinical experience in severe community-acquired pneumonia

Mortality in patients with community-acquired pneumonia (CAP) who require intubation or support with inotropes in an intensive care unit setting remains extremely high (up to 50%). Systematic use of objective severity-of-illness criteria, such as the Pneumonia Severity Index (PSI), British Thoracic Society CURB-65 (an acronym meaning Confusion, Urea, Respiratory rate, Blood pressure, age ≥65 years), or criteria developed by the Infectious Diseases Society of America/American Thoracic Society, to aid site-of-care decisions for pneumonia patients is emerging as a step forward in patient management. Experience with the Predisposition, Infection, Response, and Organ dysfunction (PIRO) score, which incorporates key signs and symptoms of sepsis and important CAP risk factors, may represent an improvement in staging severe CAP. In addition, it has been suggested that implementing a simple care bundle in the emergency department will improve management of CAP, using five evidence-based variables, with immediate pulse oxymetry and oxygen assessment as the cornerstone and initial step of treatment.

Comparative analysis of length of stay, total costs, and treatment success between intravenous moxifloxacin 400 mg and levofloxacin 750 mg among hospitalized patients with community-acquired pneumonia

OBJECTIVE

This study aimed to evaluate the length of stay (LOS), costs, and treatment consistency among patients hospitalized with community-acquired pneumonia (CAP) initially treated with intravenous (IV) moxifloxacin 400 mg or IV levofloxacin 750 mg.

METHODS

Adults with CAP receiving IV moxifloxacin or IV levofloxacin for > or =3 days were identified in the Premier Perspective comparative database. Primary outcomes were LOS and costs. Secondary outcomes included treatment consistency, which was defined as 1) no additional IV moxifloxacin or levofloxacin after > or =1 day off study drug; 2) no switch to another IV antibiotic; and 3) no addition of another IV antibiotic.

RESULTS

A total of 7720 patients met inclusion criteria (6040 receiving moxifloxacin; 1680 receiving levofloxacin). Propensity matching created two cohorts (1300 patients each) well matched for demographic, clinical, hospital, and payor characteristics. Before the patients were matched, mean LOS (5.87 vs. 5.46 days; P = 0.0004) and total costs per patient ($7302 vs. $6362; P < 0.0001) were significantly greater with moxifloxacin. After the patients were matched, mean LOS (5.63 vs. 5.51 days; P = 0.462) and total costs ($6624 vs. $6473; P = 0.476) were comparable in both cohorts. Treatment consistency was higher for moxifloxacin before (81.0% vs. 78.9%; P = 0.048) and after matching (82.8% vs. 78.0%; P = 0.002).

CONCLUSIONS

In-hospital treatment of CAP with IV moxifloxacin 400 mg or IV levofloxacin 750 mg was associated with similar hospital LOS and costs in propensity-matched cohorts.

Para-aortic arch abscess secondary to Staphylococcus aureus pneumonia

Staphylococcus aureus is a relatively common pathogen causing pneumonia in the community, hospital ward and intensive care unit. Although pneumonia is responsible for significant morbidity and mortality, especially in elderly and immunocompromised patients, it is usually uncomplicated and resolves without complications. The case of a woman who developed a para-aortic abscess after a community-acquired S aureus pneumonia infection is presented. A number of diagnostic imaging modalities were used to reach the diagnosis. This complication has not been reported previously and it is likely secondary to suppurative lymphadenitis of a station 5 or 6 node. The patient was successfully managed nonsurgically with computed tomography-guided drainage and intravenous antibiotics.

Bacteraemic pneumococcal pneumonia in COPD patients: better outcomes than expected

The purpose of the study was to compare the clinical characteristics and outcomes of bacteraemic pneumococcal pneumonia (BPP) in chronic obstructive pulmonary disease (COPD) and non-COPD patients. A case-control study was conducted. Cases were any adult with BPP and forced expiratory volume in 1 second (FEV(1)) <80% and FEV(1)/forced expiratory vital capacity (FVC) <70%. Controls were patients with BPP without clinical diagnosis of COPD matched 1:2 by age, gender and date of isolation. Variables included co-morbidities, serotypes, pneumonia severity index (PSI), treatment and mortality. There were 45 cases and 90 controls. No significant differences were found in Charlson scores, antibiotic treatment, serotype distribution and severity. Malignancy, shock and mechanical ventilation were less frequent in COPD patients. One patient died vs 14 controls (p = 0.02). In univariate analysis, shock, multilobar involvement, Charlson score, heart failure and absence of COPD were associated with mortality. After adjustment for the presence of shock there were no differences in mortality. BPP presents less frequently with shock and has a lower mortality rate in COPD patients than in non-COPD patients.

Clinical features predicting failure of pathogen identification in patients with community acquired pneumonia

Community acquired pneumonia (CAP) is caused by a variety of microorganisms. By identifying patients at risk for failure of pathogen identification, it is possible to make an early decision on the extent of diagnostic procedures to be performed. This is especially important in patients with severe CAP. The aim of this study was to identify these patients by using clinical and laboratory features. In 201 patients hospitalized for CAP, clinical and laboratory variables were collected. Pathogen identification was performed by culture of sputum and blood, urine antigen tests, polymerase chain reaction of sputum, serological testing and viral culture of the pharynx. In 128 patients a respiratory microorganism was identified. In both univariate and multivariate analysis, failure of pathogen identification was predicted by pre-hospital antibiotic therapy, a medical history of hypertension and a low C-reactive protein. We conclude that patients with pre-hospital antibiotic therapy, a medical history of hypertension and a relatively low C-reactive protein are at risk for failure of pathogen identification. These predictors should be confirmed in a larger population. Invasive testing in high-risk patients with CAP in the presence of these predictors should be considered at an early phase of hospitalization.

Clinical end points of therapy for patients with mild community-acquired pneumonia

Approximately 80% of patients with community-acquired pneumonia receive treatment as outpatients. The question is what are valid, reproducible, and quantifiable clinical end points that can be used in prospective clinical trials of the safety and efficacy of antibacterials. Patient-reported outcomes and measurements of time to end point are reasonable methods that, according to the limited data available, appear to work in clinical trials of therapy for mild-to-moderate community-acquired pneumonia among outpatients.

[Diagnostic procedures for patients with community acquired pneumonia]

The diagnosis of community acquired pneumonia (CAP) is based on a patient history with respiratory symptoms and additional symptoms and signs such as fever over more than 4 days, dyspnea and tachypnea and/or a positive lung auscultation. Despite recently developed tests, radiology is a key diagnostic procedure for confirming CAP. Importantly, the first treating physician must judge whether to hospitalize a patient or not. Two major scoring systems allow judgement of severity and short-term prognosis. In general, in patients with mild or moderate pneumonia who can be treated on an ambulatory basis, no specific microbiological diagnosis must be performed. If, for clinical or epidemiological reasons a gram stain is done, it must be obtained from purulent sputum. Recent tests may help in discriminating between viral and bacterial pneumonia (procalcitonin test) or determine the bacteria responsible for acute disease (pneumococcal antigen test using urine).

Diagnosis and Management of Community-Acquired Pneumonia: Evidence-Based Practice

The purpose of this article is to evaluate the new Infectious Diseases Society of America and the American Thoracic Society Guideline for Community-Acquired Pneumonia in Adults for nurse practitioner (NP) practice using evidence-based practice principles. The major recommendations for diagnosis, treatment, site of care, and prevention are also summarized. In general, the guideline meets the criteria of evaluation of practice guidelines, although the methods used for the literature search are not adequately described. The guideline was not developed with the input from primary care providers; however, it is appropriate for NPs who work in a variety of settings, including primary care.

Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis

PURPOSE

There is little consensus on the most appropriate duration of antibiotic treatment for community-acquired pneumonia. The goal of this study is to systematically review randomized controlled trials comparing short-course and extended-course antibiotic regimens for community-acquired pneumonia.

METHODS

We searched MEDLINE, Embase, and CENTRAL, and reviewed reference lists from 1980 through June 2006. Studies were included if they were randomized controlled trials that compared short-course (7 days or less) versus extended-course (>7 days) antibiotic monotherapy for community-acquired pneumonia in adults. The primary outcome measure was failure to achieve clinical improvement.

RESULTS

We found 15 randomized controlled trials matching our inclusion and exclusion criteria comprising 2796 total subjects. Short-course regimens primarily studied the use of azithromycin (n=10), but trials examining beta-lactams (n=2), fluoroquinolones (n=2), and ketolides (n=1) were found as well. Of the extended-course regimens, 3 studies utilized the same antibiotic, whereas 9 involved an antibiotic of the same class. Overall, there was no difference in the risk of clinical failure between the short-course and extended-course regimens (0.89, 95% confidence interval [CI], 0.78-1.02). In addition, there were no differences in the risk of mortality (0.81, 95% CI, 0.46-1.43) or bacteriologic eradication (1.11, 95% CI, 0.76-1.62). In subgroup analyses, there was a trend toward favorable clinical efficacy for the short-course regimens in all antibiotic classes (range of relative risk, 0.88-0.94).

CONCLUSIONS

The available studies suggest that adults with mild to moderate community-acquired pneumonia can be safely and effectively treated with an antibiotic regimen of 7 days or less. Reduction in patient exposure to antibiotics may limit the increasing rates of antimicrobial drug resistance, decrease cost, and improve patient adherence and tolerability.