Approaches to treatment of community-acquired pneumonia in the emergency department and the appropriate role of fluoroquinolones

Can we recognize severe community-acquired pneumonia without pneumonia severity index? Use of modified qSOFA with procalcitonin

Objective

The aim of this study is to analyze the diagnostic value of Quick Sequential Organ Failure Assessment (qSOFA), modified qSOFA, National Early Warning Score (NEWS) and NEWS + Lactate (NEWS + L) scores in the detection of severe community-acquired pneumonia (CAP).

Methods

This research is a retrospective cohort study. Patients admitted to the Emergency Department (ED) with the diagnosis of CAP were divided into severe and mild pneumonia regarding their Pneumonia Severity Index (PSI) scores. The accuracies of lactate, procalcitonin (PCT) values, NEWS and qSOFA scores, as well as score combinations (NEWS + L and qSOFA + PCT) in predicting patients with severe CAP were analyzed.

Results

Median qSOFA value in the severe CAP group (0 [IQR 0-1]) was found to be higher than median qSOFA value (0 [IQR 0-0]) in the mild CAP group (p < 0.001). The rate of qSOFA positivity (qSOFA ≥ 2) was significantly higher in the severe CAP group (17.1%, n = 21) compared to the mild CAP group (1.3%, n = 1) (p < 0.001). Median qSOFA + PCT for the severe CAP group (2 [IQR 1-2]) was higher than the mild CAP group (1 [IQR 0-1]) (p < 0.001). Mean NEWS score for severe CAP (4.95 ± 3.09) was found to be 1.69 (95% CI 0.92-2.46) higher than mean NEWS score of the mild CAP group (3.26 ± 2.39) (p < 0.001). The severe CAP NEWS + L score (6.97 ± 3.71) was higher than the mild CAP NEWS + L score (4.94 ± 2.48) (p < 0.001). Blood lactate level was not significant in the evaluation of severe CAP (p = 0.221). PCT (AUROC = 0.685 [95% CI 0.610-0.760]; p = 0.038), NEWS score (AUROC = 0.658 95% CI [0.582-0.733]; p < 0.001), qSOFA (AUROC = 0.686) were calculated to have adequate accuracy for the detection of severe CAP. [95% CI 0.613-0.759]; p = 0.037), NEWS + L score (AUROC = 0.665 [95% CI 0.589-0.740]; p = 0.038). The qSOFA + PCT score (AUROC = 0.758 [95% 0.691-0.825]; p = 0.034) was also found to be a highly accurate predictor of severe CAP.

Conclusion

In this study, we found a combination of qSOFA and PCT to be the most reliable method of detecting severe CAP.

Pharmacokinetics of fluoroquinolones in critical care patients: A bio-analytical HPLC method for the simultaneous quantification of ofloxacin, ciprofloxacin and moxifloxacin in human plasma

A high-performance liquid chromatographic (HPLC) method with fluorescence detection was developed and validated for the simultaneous quantification of ofloxacin, ciprofloxacin and moxifloxacin in human plasma. Sarafloxacin was used as internal standard. Chromatography was carried out using a Waters XBridge C(18) HPLC column and a gradient mobile phase consisting of CH(3)CN/MeOH/0.025M TBA.Cl/TFA (eluent A at 75/25/899/1 (v/v); eluent B at 150/50/799/1 (v/v); both at pH 3.5). Excitation/emission wavelengths were 279/442nm for ciprofloxacin and 290/500nm for ofloxacin, moxifloxacin and internal standard. Prior to chromatography, plasma samples were treated with acetonitrile for protein precipitation, followed by evaporation of the liquid layer and reconstitution in eluent A. The method was validated for the three fluoroquinolones over the clinically relevant concentration range from 0.02 to 7.50mug/ml. The method showed acceptable linearity with correlation coefficients, r(2)>0.995, as well as high precision (RSD% <7% in each case), accuracy (90.4-105.4%) and selectivity. The limit of quantification for the three fluoroquinolones was established at 0.02mug/ml. Ofloxacin, ciprofloxacin and moxifloxacin were extracted from plasma with a mean recovery of 95%, 86.4% and 94.2%, respectively. During validation, the concentration of the three fluoroquinolones was found to be stable after 3 freeze-thaw cycles and for at least 15h after extraction. This bio-analytical method was finally applied to the analysis of samples which have been obtained from patients, participating in a pharmacokinetic study on moxifloxacin.

Diagnosis and management of pneumonia in the emergency department

Pneumonia is a condition that is often treated by emergency physicians. This article reviews the diagnosis and management of pneumonia in the emergency department and highlights dilemmas in diagnostic testing, use of blood and sputum cultures, hospital admission decisions, infection control, quality measures for pneumonia care, and empiric antimicrobial therapy.

New guidelines for the management of adult community-acquired pneumonia

PURPOSE OF REVIEW

Community-acquired pneumonia is a major cause of morbidity and mortality, and is the leading cause of death from an infectious disease. International societies have published and revised guidelines aiming to improve the management of adult community-acquired pneumonia, based on the best available evidence. The aim of this review is to compare the current guideline recommendations.

RECENT FINDINGS

Aspects of guidelines differ based on local factors including resources and antimicrobial factors, as well as the differences in interpretation of existing evidence.

SUMMARY

The lack of robust evidence behind aspects of guideline recommendations as well as the lack of adherence to published guidelines both need to be addressed if the management of community-acquired pneumonia is to be improved.