Nonresolving pneumonia and mimics of pneumonia

Treatment Failure and Clinical Stability in Severe Community-Acquired Pneumonia

Treatment failure and clinical stability are important outcomes in community-acquired pneumonia (CAP). It is essential to know the causes and risk factors for treatment failure and delay in reaching clinical stability in CAP. The study of both as well as the associated underlying mechanisms and host response are key to improving outcomes in pneumonia.

A Single-Center Study of the Utility of Bronchoalveolar Lavage in Critically Ill Patients With Haematological Malignancy or Stem Cell Transplants

INTRODUCTION

The aim of this study was to evaluate the yield of bronchoscopy-guided bronchoalveolar lavage (BAL) and decisions on management of antimicrobials in critically ill patients with hematological malignancy and/or hematological stem cell transplant (HSCT). The safety and tolerance of bronchoscopy were also reported.

METHODS

A retrospective cohort study was conducted by reviewing health charts of all adult patients with a hematological malignancy and/or an HSCT who were admitted to the intensive care unit and underwent bronchoscopy and BAL over four years from April 2016 to April 2020 at King Abdulaziz Medical City, Riyadh.  Results: The cohort included 75 critically ill patients. Of these 75 patients, 53 (70.7%) had HSCT (allogenic 66%, autologous 32.1%, haplogenic 3.8%). Computed tomography of the chest was abnormal in all patients. Predominant findings included airspace abnormalities, ground glass opacities, and others. The positive yield was found to be 20% for bacterial, 22% for viral, 21% for fungal, and other organisms were identified in 2%. Although cytology was not performed in 18 patients, malignant cells were identified on BAL in two patients. While the overall mortality of the cohort was high (46.7%), the vast majority (94.7%) tolerated bronchoscopy and BAL without any complications. However, three patients (4%) developed a pneumothorax and one patient bled and developed the acute respiratory distress syndrome post bronchoscopy.

CONCLUSIONS

BAL can identify and detect microorganisms directly influencing the clinical care of patients who have received non-invasive diagnostic tests that yielded negative culture results. Bronchoscopy and BAL are generally safe and well tolerated by critically ill patients with hematological malignancy or HSCT.

Percutaneous CT-guided lung biopsy for the diagnosis of persistent pulmonary consolidation

PURPOSE

The primary objective of this study was to determine the diagnostic accuracy of percutaneous computed tomography (CT)-guided biopsy of persistent pulmonary consolidations. The secondary objective was to determine the complication rate and identify factors affecting diagnostic yield.

MATERIALS AND METHODS

Two radiologists retrospectively reviewed 98 percutaneous CT-guided biopsies performed in 93 patients (60 men, 33 women; mean age, 62±14.0 (SD) years; range: 18-88 years) with persistent pulmonary consolidations. Final diagnoses were based on surgical outcomes or 12 months clinical follow-up findings. Biopsy results were compared to the final diagnosis to estimate diagnostic yield.

RESULTS

A final diagnosis was obtained for all patients: 51/93 (54.8%) had malignant lesions, 12/93 (12.9%) specific definite benign lesions (including 9 infections, two pneumoconiosis and one lipoid pneumonia) and 30/93 (32.3%) non-specific benign lesions. CT-guided biopsy had an overall diagnostic yield of 60% (59/98) with a correct diagnosis for 50/51 malignant lesions (diagnostic yield of 98% for malignancy) and for 9/47 benign lesions (diagnostic yield of 19% for benign conditions). Major complications occurred in 4/98 (4%) of lung biopsies (four pneumothoraxes requiring chest tube placement).

CONCLUSION

Percutaneous CT-guided biopsy is an alternative to endoscopic or surgical biopsy for the diagnosis of persistent consolidation with a low risk of severe complication.

Clinical role, safety and diagnostic accuracy of percutaneous transthoracic needle biopsy in the evaluation of pulmonary consolidation

Background

To determine the clinical role, safety, and diagnostic accuracy of percutaneous transthoracic needle biopsy in the evaluation of pulmonary consolidation.

Methods

A retrospective review of all computed tomography (CT)-guided percutaneous transthoracic needle biopsies (PTNB) at a tertiary care hospital over a 4-year period was performed to identify all cases of PTNB performed for pulmonary consolidation. For each case, CT Chest images were reviewed by two thoracic radiologists. Histopathologic and microbiologic results were obtained and clinical follow-up was performed.

Results

Thirty of 1090 (M:F 17:30, mean age 67 years) patients underwent PTNB for pulmonary consolidation (2.8% of all biopsies). A final diagnosis was confirmed in 29 patients through surgical resection, microbiology, or clinicoradiologic follow-up for at least 18 months after biopsy. PTNB had an overall diagnostic accuracy of 83%. A final diagnosis of malignancy was made in 20/29 patients, of which 19 were correctly diagnosed by PTNB, resulting in a sensitivity of 95% and specificity of 100% for malignancy. In all cases of primary lung cancer, adequate tissue for molecular testing was obtained. A benign final diagnosis was made in 9 patients, infection in 5 cases and non-infectious benign etiology in 4 cases. PTNB correctly diagnosed all cases of infection. Minor complications occurred in 13% (4/30) of patients.

Conclusions

Pulmonary consolidation can be safely evaluated with CT-guided percutaneous needle biopsy. Diagnostic yield is high, especially for malignancy. PTNB of pulmonary consolidation should be considered following non-diagnostic bronchoscopy.

N-acetylcysteine improves oxidative stress and inflammatory response in patients with community acquired pneumonia: A randomized controlled trial

Oxidative stress is considered to be part of the pathogenic mechanism for community-acquired pneumonia (CAP) and is closely linked to inflammation. Attenuation of oxidative stress would be expected to reduce pulmonary damage. Antioxidants have been found to be effective in alleviating lung injury and protecting against damage of other organs.The aim of the study was to compare the effect of adding N-acetylcysteine (NAC) to conventional treatment versus conventional treatment on oxidative stress, inflammatory factors, and radiological changes in CAP patients.Eligible CAP patients at Weihai Municipal Hospital were stratified and randomly assigned to either NAC group or non-NAC group between August 2016 and March 2017. The NAC group received conventional treatment for pneumonia and NAC (1200 mg/d). Thenon-NAC group received conventional therapy. malondialdehyde (MDA), superoxide dismutase (SOD), total antioxidant capacity (TAOC), tumor necrosis factor-α (TNF-α), and computed tomography (CT) images were evaluated at baseline and after treatment. The primary endpoint indicators were the changes in oxidative stress parameters (MDA, TAOC, SOD) and TNF-α after treatment in the NAC group compared with those in the non-NAC group. The secondary endpoint indicator was any difference in CT scores after treatment in the NAC group compared with the non-NAC group.Baseline levels of MDA, TAOC, SOD, and TNF-α were similar between the 2 groups before treatment. Plasma levels of MDA and TNF-α decreased more (P < .05 MDA:p 0.004, TNF-α:p <0.001) in the NAC group than the non-NAC group, and there was a reliable increase in TAOC content (p 0.005). There was no significant difference in increased plasma SOD activity between the groups (p 0.368), and the NAC group did not show a greater improvement from CT scores. No NAC-related adverse effects were observed.Addition of NAC therapy for CAP patients reduced MDA and TNF-α and increased TAOC. Treatment with NAC may help to reduce oxidative and inflammatory damage in pneumonia patients.

Management of community-acquired pneumonia in immunocompetent adults: updated Swedish guidelines 2017

Based on expert group work, Swedish recommendations for the management of community-acquired pneumonia in adults are here updated. The management of sepsis-induced hypotension is addressed in detail, including monitoring and parenteral therapy. The importance of respiratory support in cases of acute respiratory failure is emphasized. Treatment with high-flow oxygen and non-invasive ventilation is recommended. The use of statins or steroids in general therapy is not found to be fully supported by evidence. In the management of pleural infection, new data show favourable effects of tissue plasminogen activator and deoxyribonuclease installation. Detailed recommendations for the vaccination of risk groups are afforded.

Risk factors for slowly resolving pneumonia in the intensive care unit

BACKGROUND

Slowly resolving pneumonia (SRP) poses early challenges for identification and medical expense for clinicians in intensive care units (ICUs); to date, the literature has been very limited in this regard.

METHODS

This was a retrospective and cohort-based study in the ICU of a university-affiliated hospital in Shanghai. Medical records of pneumonia patients in the ICU between April 2008 and February 2011were reviewed retrospectively to evaluate the risk factors for SRP.

RESULTS

In all, 106 pneumonia patients in the ICU were identified as immune-competent with a diagnosis of bacterial pneumonia. There were 62 (58.49%) patients who showed SRP and their radiographic infiltrations were completely resolved between 5 weeks and 8 weeks. Multivariate logistic regression analysis demonstrated that initial treatment with an inappropriate antibiotic, multilobar infiltration, and a high CURB-65 score were independent risk factors for SRP, with odds ratio (OR) values of 8.338 [95% confidence interval (CI) 2.117-32.848], 11.184 (95% CI 2.526-49.514), and 2.329 (95% CI 1.172-4.626), respectively. The length of the ICU stay in the SRP group was twice as long as that of the normally resolving pneumonia (NRP) group (62.27 ± 73.73 vs. 32.25 ± 23, p = 0.002). The 28-day and 60-day mortality rates in the SRP group were 17.74% and 25.81%, respectively. In addition, the 60-day mortality rate was significantly higher in the SRP group than the NRP group (25.81% vs. 6.82%, respectively; p = 0.012). Moreover, SRP was an independent risk factor for 60-day mortality (OR 5.687, 95% CI 1.334-24.240).

CONCLUSION

Treatment with an inappropriate antibiotic, multilobar infiltration, and a high CURB-65 score were independent risk factors for SRP.

Outcome of recommendations for radiographic follow-up of pneumonia on outpatient chest radiography

OBJECTIVE

Follow-up chest radiographs are frequently recommended by radiologists to document the clearing of radiographically suspected pneumonia. However, the clinical utility of follow-up radiography is not well understood. The purpose of this study was to examine the incidence of important pulmonary pathology revealed during follow-up imaging of suspected pneumonia on outpatient chest radiography.

MATERIALS AND METHODS

Reports of 29,138 outpatient chest radiography examinations performed at an academic medical center in 2008 were searched to identify cases in which the radiologist recommended follow-up chest radiography for presumed community-acquired pneumonia (n = 618). Descriptions of index radiographic abnormalities were recorded. Reports of follow-up imaging (radiography and CT) performed during the period from January 2008 to January 2010 were reviewed to assess the outcome of the index abnormality. Clinical history, demographics, microbiology, and pathology reports were reviewed and recorded.

RESULTS

Compliance with follow-up imaging recommendations was 76.7%. In nine of 618 cases (1.5%), a newly diagnosed malignancy corresponded to the abnormality on chest radiography initially suspected to be pneumonia. In 23 of 618 cases (3.7%), an alternative nonmalignant disease corresponded with the abnormality on chest radiography initially suspected to be pneumonia. Therefore, in 32 of 618 patients (5.2%), significant new pulmonary diagnoses were established during follow-up imaging of suspected pneumonia.

CONCLUSION

Follow-up imaging of radiographically suspected pneumonia leads to a small number of new diagnoses of malignancy and important nonmalignant diseases, which may alter patient management.

A study on non-resolving pneumonia with special reference to role of fiberoptic bronchoscopy

Context:

Non-resolving pneumonia is often an area of concern for pulmonologists. Fiber optic bronchoscopy (FOB) may have a special role in etiologic evaluation of non-resolving pneumonias. There is paucity of recent studies in this field.

Aims:

This study aimed to assess the patients of non-resolving or slowly resolving pneumonia with special emphasis on efficacy of FOB and computed tomography (CT)-guided fine needle aspiration cytology (FNAC) in diagnosis.

Settings and Design:

Prospective, observational study conducted in a tertiary care institute over a period of one year.

Materials and Methods:

After fulfilling the definition of non-resolving pneumonia by clinical and radiological parameters, patients were evaluated by FOB with relevant microbiological, cytological, histopathological investigations and CT scan of thorax. CT-guided FNAC was done in selected cases where FOB was inconclusive.

Results:

Sixty patients were enrolled in the study. Mean age was 51.33 ± 1.71 years with male to female ratio 2:1. Right lung was more commonly involved (65%), and right upper lobe was the commonest site (25%). Pyogenic infection was the commonest etiology (53.3%), bronchogenic carcinoma and tuberculosis accounted for 26.7% and 16.7% cases, respectively. Both, FOB (85.7%) and CT-guided FNAC (91.67%) were very useful for etiological diagnosis of non-resolving pneumonia. Both the procedures were safe, and no major complication was observed.

Conclusions:

Because of the high yield of FOB, it is very useful and safe diagnostic tool for evaluation of non-resolving pneumonia. CT-guided FNAC also gives good yield when cases are properly selected.

Swedish guidelines on the management of community-acquired pneumonia in immunocompetent adults--Swedish Society of Infectious Diseases 2012

This document presents the 2012 evidence based guidelines of the Swedish Society of Infectious Diseases for the in- hospital management of adult immunocompetent patients with community-acquired pneumonia (CAP). The prognostic score 'CRB-65' is recommended for the initial assessment of all CAP patients, and should be regarded as an aid for decision-making concerning the level of care required, microbiological investigation, and antibiotic treatment. Due to the favourable antibiotic resistance situation in Sweden, an initial narrow-spectrum antibiotic treatment primarily directed at Streptococcus pneumoniae is recommended in most situations. The recommended treatment for patients with severe CAP (CRB-65 score 2) is penicillin G in most situations. In critically ill patients (CRB-65 score 3-4), combination therapy with cefotaxime/macrolide or penicillin G/fluoroquinolone is recommended. A thorough microbiological investigation should be undertaken in all patients, including blood cultures, respiratory tract sampling, and urine antigens, with the addition of extensive sampling for more uncommon respiratory pathogens in the case of severe disease. Recommended measures for the prevention of CAP include vaccination for influenza and pneumococci, as well as smoking cessation.

[Follow-up criteria for community acquired pneumonias and acute exacerbations of chronic obstructive pulmonary disease]

The follow-up of Community Acquired Pneumonias (CAP) and Acute Exacerbations of Chronic Obstructive Pulmonary Diseases (AECOPD) differs with the setting of care, but overall calls upon the same investigations as the initial evaluations. In the event of initial ambulatory care, the evaluation is carried out primarily on clinical data, at the 2 or 3rd day for the CAP, at the 2nd to 5th day for the AECOPD. In the event of unfavourable evolution, or from the start in the most severe cases, the follow-up is carried out in hospital; clinical evaluation is readily daily, and all the more frequent that the clinical condition is worrying because of the severity or risk factors. The investigations will be limited to those initially abnormal in the event of favourable evolution; on the contrary, unfavourable evolution can justify new investigations which depend on clinical characteristics. Remotely, i.e. 4 to 8 weeks later, must be checked the return at the baseline clinical state, a chest X-ray (CAP), spirometry and arterial blood gas (AECOPD), even bronchoscopy and thoracic CT-scan.

Swedish guidelines for the management of community-acquired pneumonia in immunocompetent adults

This document presents the evidence-based guidelines of the Swedish Society of Infectious Diseases for the management of adult immunocompetent patients with community-acquired pneumonia (CAP), who are assessed at hospital. The prognostic score 'CURB-65' is recommended for all CAP patients in the emergency room. The score provides an assessment tool for the decision regarding outpatient treatment or level of hospital supervision, the choice of microbiological investigations, and empirical antibiotic treatment. In patients with non-severe CAP (CURB-65 score 0-2) we recommend initial narrow-spectrum antibiotic treatment, orally or intravenously, primarily directed at Streptococcus pneumoniae. In those with CURB-65 score 3, penicillin G or a cephalosporin intravenously is recommended. For CURB-65 score 0-3 atypical pathogens should be covered only when they are suspected on clinical or epidemiological grounds. In patients with CURB-65 score 4-5 intravenous combination therapy with either cephalosporin/macrolide or penicillin G/fluoroquinolone is recommended. Efforts should be made to identify the CAP aetiology in order to support the ongoing antibiotic treatment or to suggest treatment alterations. Recommended measures for prevention of CAP include influenza -- and pneumococcal -- vaccination to risk groups and efforts for smoking cessation.

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

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

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

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