Angiotensin-converting enzyme inhibitors reduce community-acquired pneumonia hospitalization and mortality

BACKGROUND

Pneumonia is a global disorder and a common reason for prolonged hospitalization. Angiotensin-converting enzyme inhibitors (ACEi) have pleiotropic effects that support a role in modulating pneumonia, but results have been controversial.

OBJECTIVES

The present study was conducted to elucidate an ACEi-induced pneumonia benefit in at-risk neurologically impaired population and to determine whether a mortality benefit exists.

METHODS

A cohort study using a large health-system of 29,011 unique ACEi users and 1635 case patients 65 years of age or older without neurological disorders affecting swallowing who were admitted with community-acquired pneumonia hospitalization and followed up from January 1, 2015 to December 31, 2019 (5 years). The association between ACEi use and pneumonia hospitalization and mortality were determined after propensity score matching using Cox and logistic regression.

RESULTS

The experimental cohort was 74.9 ± 7.3 years and 51% were male. ACEi users had lower odds of acquiring pneumonia versus ACEi non-users (odds ratio) 0.72 [95% Confidence Interval (CI) 0.51 to 0.99]; p = 0.048. The risk of short-term mortality (<30 days) (HR) 0.42, p < 0.001 and long-term mortality (≥30 day) (HR) 0.83, p < 0.002 was significantly lower for ACEi users compared with the ACEi non-users.

CONCLUSIONS

ACEi use in patients at risk of pneumonia without neurological swallowing disorders is associated with reduction in hospitalization and lowering of short- and long-term mortality. Given the high incidence of morbidity and mortality associated with pneumonia, and the susceptibility in older populations with underlying cardiovascular or renal disease or social dependencies, our data support the prescribing of ACEi in these populations to reduce pneumonia hospitalization risk as well as short- and long-term mortality.

Preparation and Evaluation of Low-Dose Calcitriol Dry Powder Inhalation as Host-Directed Adjunct Therapy for Tuberculosis

Background

It is unclear whether Vitamin D is efficacious as a host-directed therapy (HDT) for patients of tuberculosis (TB). We investigated pulmonary delivery of the active metabolite of Vitamin D₃, i.e., 1, 25-dihydroxy vitamin D₃ (calcitriol) in a mouse model of infection with Mycobacterium tuberculosis (Mtb).

Methods

We optimized a spray drying process to prepare a dry powder inhalation (DPI) of calcitriol using a Quality by Design (QbD) approach. We then compared outcomes when Mtb-infected mice were treated with inhaled calcitriol at 5 ng/kg as a stand-alone intervention versus DPI as adjunct to standard oral anti-tuberculosis therapy (ATT).

Results

The DPI with or without concomitant ATT markedly improved the morphology of the lungs and mitigated histopathology in both the lungs and the spleens. The number of nodular lesions on the lung surface decreased from 43.7 ± 3.1 to 22.5 ± 3.9 with the DPI alone and to 9.8 ± 2.5 with DPI + ATT. However, no statistically significant induction of host antimicrobial peptide cathelicidin or reduction in bacterial burden was seen with the DPI alone. DPI + ATT did not significantly reduce the bacterial burden in the lungs compared to ATT alone.

Conclusions

We concluded that HDT using the low dose calcitriol DPI contributed markedly to mitigation of pathology, but higher dose may be required to evoke significant induction of bactericidal host response and bactericidal activity in the lung.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11095-022-03360-5.

Real-world corticosteroid use in severe pneumonia: a propensity-score-matched study

BACKGROUND

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide despite correct antibiotic use. Corticosteroids have long been evaluated as a treatment option, but heterogeneous effects on survival have precluded their widespread implementation. We aimed to evaluate whether corticosteroids might improve clinical outcomes in patients with severe CAP and high inflammatory responses.

STUDY DESIGN AND METHODS

We analyzed two prospective observational cohorts of patients with CAP in Barcelona and Rome who were admitted to intensive care with a high inflammatory response. Propensity score (PS) matching was used to obtain balance among the baseline variables in both groups, and we excluded patients with viral pneumonia or who received hydrocortisone.

RESULTS

Of the 610 patients admitted with severe CAP, 198 (32%) received corticosteroids and 387 had major criteria for severe CAP. All patients had a baseline serum C-reactive protein above 15 mg/dL. Patients who received corticosteroids were more commonly male, had more comorbidities (e.g., cancer or chronic obstructive pulmonary disease), and presented with significantly higher sequential organ failure assessment scores. Eighty-nine patients met major severity criteria (invasive mechanical ventilation and/or septic shock) and were matched per group. Twenty-eight-day mortality was lower among patients receiving corticosteroids (16 patients, 18%) than among those not receiving them (28 patients, 31%; p = 0.037). After PS matching, corticosteroid therapy reduced the 28-day mortality risk in patients who met major severity criteria (hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.29-0.98) (p = 0.043). In patients who did not meet major severity criteria, no benefits were observed with corticosteroid use (HR 0.88 (95%CI 0.32-2.36).

CONCLUSIONS

Corticosteroid treatment may be of benefit for patients with CAP who have septic shock and/or a high inflammatory response and requirement for invasive mechanical ventilation. Corticosteroids appear to have no impact on mortality when these features are not present.

The clinical role of host and bacterial-derived extracellular vesicles in pneumonia

Pneumonia is among the leading causes of morbidity and mortality worldwide. Due to constant evolution of respiratory bacteria and viruses, development of drug resistance and emerging pathogens, it constitutes a considerable health care threat. To enable development of novel strategies to control pneumonia, a better understanding of the complex mechanisms of interaction between host cells and infecting pathogens is vital. Here, we review the roles of host cell and bacterial-derived extracellular vesicles (EVs) in these interactions. We discuss clinical and experimental as well as pathogen-overarching and pathogen-specific evidence for common viral and bacterial elicitors of community- and hospital-acquired pneumonia. Finally, we highlight the potential of EVs for improved management of pneumonia patients and discuss the translational steps to be taken before they can be safely exploited as novel vaccines, biomarkers, or therapeutics in clinical practice.

[Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]

The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.

Corticosteroids for CAP, influenza and COVID-19: when, how and benefits or harm?

PURPOSE

Corticosteroids have been considered in medicine for a long time, and they are broadly prescribed. In infectious diseases, corticosteroids have been regarded as a thread due to their immunosuppressive effects and therefore their anti-inflammatory properties. MAIN: In recent years, there have been several studies published that aimed to determine the role of corticosteroids in patients with community-acquired pneumonia (CAP), because, despite significant advances in new antibiotics and supportive care, deaths of patients with CAP remain unacceptably high. While the 2007 Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) CAP guidelines did not mention the use of corticosteroids in the management of CAP, the recently published 2019 IDSA/ATS guidelines recommended their use in patients with septic shock refractory to vasopressors and fluid resuscitation. Regarding viral infection, the use of corticosteroids in patients with influenza has shown to be associated with significantly higher mortality and higher incidence of nosocomial infection, while in patients with coronavirus disease 2019 (COVID-19) there is a good body of evidence of the benefit of corticosteroids in terms of mortality.

CONCLUSIONS

The use of corticosteroids has been considered as a potential alternative co-adjuvant treatment in patients with pneumonia. In patients with COVID-19, the evidence is quite strong and there is a clear benefit of the use of corticosteroids in those patients presenting severe forms of disease.

The role of steroids in severe CAP

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality despite adequate antibiotic therapy. It is the single most common cause of infection-related mortality in the United States. An exaggerated host inflammatory response can potentially be harmful to both the lung and host, and has been associated with treatment failure and mortality. Modulation of inflammatory response may, therefore, be theoretically beneficial. The anti-inflammatory and immunosuppressive effects of steroids seem an attractive therapeutic option in severe CAP patients. Available datapoint to overall shorter time to clinical stability and decreased length-of-stay in CAP patients, with a potential mortality benefit in severe CAP. The level of evidence is, however, low to moderate regarding mortality due to high heterogeneity and insufficient power of data. Furthermore, steroids were deleterious in influenza pneumonia and in patients with pneumococcal pneumonia data suggest a lack of efficacy and potential harm. Both European and American guidelines recommend not using corticosteroids in CAP. Patients who might benefit and those that can be harmed from steroids remain to be clearly identified, as does the ideal steroid for CAP patients, based on pharmacokinetic and pharmacodynamic properties. It is essential for future studies to avoid the same methodological bias present in the available data so that high-quality evidence on the true role of steroids in CAP can be provided.

Hypervitaminosis D has no positive effects on goat tuberculosis and may cause chronic renal lesions

BACKGROUND

There is evidence for a link between vitamin D deficiency and active tuberculosis (TB). In human beings, several trials have evaluated the role of vitamin D supplementation in TB treatment with conflicting results. However, the role of vitamin D supplementation in animal TB control has received less attention. The authors evaluated the benefit of vitamin D supplementation for preventing mycobacterial infection or reducing TB lesions (TBL) in a controlled trial with goats naturally exposed to Mycobacterium caprae.

METHODS

Two groups of goats, a vitamin D-supplemented group and a non-supplemented control group, were housed for 10 months in direct contact with M caprae-infected adult goats. Upon contact with the infected adult goats, all animals were TB-tested every two months.

RESULTS

No experimental evidence of a protective effect of vitamin D supplementation based on M caprae culture prevalence, TBL prevalence, median TBL score or the proportion of single versus multiple organs presenting TBL was observed.

CONCLUSION

The results indicate that, in the conditions used in this study, vitamin D supplementation in goats does not reduce TB infection risk nor the diffusion and severity of TBL. In addition, vitamin D-supplemented goats presented hyperphosphataemia and renal injury with calcifications suggestive of vitamin D intoxication.

Calcitriol enhances pyrazinamide treatment of murine tuberculosis

Background:

Tuberculosis is a leading cause of morbidity and mortality in humans worldwide. There is an urgent need for new and effective drugs to treat tuberculosis and shorten the duration of tuberculosis therapy. 1, 25-dihydroxy vitamin D₃ (1,25 (OH)₂D₃) has been reported to have a synergistic effect with pyrazinamide (PZA) in killing tubercle bacilli in vitro. The addition of 1,25 (OH)₂D₃ to standard tuberculosis treatment should benefit patients if the adjunctive drug has a synergistic effect in vivo. Thus, in this study, calcitriol (bioactive 1,25 (OH)₂D₃) was administered to mice undergoing treatment for Mycobacterium tuberculosis (M.tb) infection with PZA, a first-line anti-tuberculosis drug, to determine whether vitamin D3 enhances the therapeutic effect.

Methods:

C57BL/6 female mice were infected with the M.tb H37Rv strain through aerosol exposure. Calcitriol and PZA, either alone or in combination, were orally administered to the M.tb infected mice. The effect of calcitriol on PZA activity was determined by evaluating the bacterial burden and analyzing the histopathological lesions in the lungs and spleen. To investigate the expression of inflammatory cytokines and anti-microbial peptide genes, we determined the transcriptional levels of interferon-γ (IFN-γ), interleukin-4 (IL-4), mouse β-defensin-2 (mBD2), and cathelicidin LL-37 through real-time quantitative polymerase chain reaction. The protein levels of IFN-γ were detected by enzyme-linked immunosorbent assay. Differences between groups were analyzed with independent samples t-test or one-way analysis of variance.

Results:

Calcitriol alone had little effect on tuberculosis infection, whereas PZA, compared with saline control treatment, decreased the bacterial burden (spleens: PZA vs. saline, 4.82 ± 0.22 vs. 5.22 ± 0.40 Log₁₀ colony-forming units [CFU]/gram, t = 2.13, P < 0.05; lungs: PZA vs. saline, 5.55 ± 0.15 vs. 6.83 ± 0.46 Log₁₀ CFU/gram, t = 6.56, P < 0.01) and pathological lesions in the lungs. Simultaneous administration of calcitriol with PZA, compared with PZA alone, decreased the bacterial load (spleen: calcitriol + PZA vs. PZA, 4.37 ± 0.13 vs. 4.82 ± 0.22 Log₁₀ CFU/gram, t = 4.36, P < 0.01; lung: calcitriol + PZA vs. PZA, 5.03 ± 0.32 vs. 5.55 ± 0.15 Log₁₀ CFU/gram, t = 3.58, P < 0.01) and attenuated the lung lesions (gross pathological score: calcitriol + PZA vs. PZA, 3.25 ± 0.50 vs. 2.50 ± 0.58, t = 1.96, P < 0.05; affected area of total lung area: calcitriol + PZA vs. PZA, 30.75% ± 6.50% vs. 21.55% ± 2.99%, t = 2.66, P < 0.05). Further studies demonstrated calcitriol significantly increased the expression of anti-inflammatory cytokine IL-4 but suppressed production of the pro-inflammatory cytokine IFN-γ (IL-4: calcitriol vs. saline, 5.69 ± 0.50 vs. 2.80 ± 0.56 fold of control, t = 6.74, P < 0.01; IFN-γ: calcitriol vs. saline, 1.36 ± 0.11 vs. 4.13 ± 0.83 fold of control, t = 5.77, P < 0.01). In addition, calcitriol alone or in combination with PZA significantly enhanced the transcriptional level of anti-microbial peptides (cathelicidin LL-37: calcitriol vs. saline, 10.59 ± 1.03 vs. 2.80 ± 0.90 fold of control, t = 9.85, P < 0.01; mBD2: calcitriol vs. saline, 7.92 ± 0.62 vs. 1.79 ± 0.45 fold of control, t = 13.82, P < 0.01), whereas PZA exerted a negative effect on anti-microbial peptide gene expression.

Conclusions:

Calcitriol as adjunctive treatment can result in beneficial treatment outcomes in M.tb infection by suppressing the inflammatory response and up-regulating the expression of anti-microbial peptides. These results indicate the feasibility of using calcitriol adjunctively with standard chemotherapy for the treatment of M.tb infection.

Challenges in severe community-acquired pneumonia: a point-of-view review

Purpose

Severe community-acquired pneumonia (SCAP) is still associated with substantial morbidity and mortality. In this point-of-view review paper, a group of experts discuss the main controversies in SCAP: the role of severity scores to guide patient settings of care and empiric antibiotic therapy; the emergence of pathogens outside the core microorganisms of CAP; viral SCAP; the best empirical treatment; septic shock as the most lethal complication; and the need for new antibiotics.

Methods

For all topics, the authors describe current controversies and evidence and provide recommendations and suggestions for future research. Evidence was based on meta-analyses, most recent RCTs and recent interventional or observational studies. Recommendations were reached by consensus of all the authors.

Results and conclusions

The IDSA/ATS criteria remain the most pragmatic tool to predict ICU admission. The authors recommend a combination of a beta-lactam/beta-lactamase inhibitor or a third G cephalosporin plus a macrolide in most SCAP patients, and to empirically cover PES (P. aeruginosa, extended spectrum beta-lactamase producing Enterobacteriaceae, methicillin-resistant S. aureus) pathogens when at least two specific risk factors are present. In patients with influenza CAP, the authors recommend the use of oseltamivir and avoidance of the use of steroids. Corticosteroids can be used in case of refractory shock and high systemic inflammatory response.

Infectious Lung Diseases and Endogenous Oxidative Stress

Lower respiratory tract infections, according to the World Health Organization, account for nearly one third of all deaths from infectious diseases. They account for approximately 4 million deaths annually including children and adults and provide a greater disease burden than HIV and malaria. Among the common respiratory diseases, tuberculosis, influenza, and pneumonia are very common and can be life threatening if not treated properly. The causative agent of tuberculosis is the slow-growing bacilli Mycobacterium tuberculosis, while the causative agent of influenza is a segmented genome RNA virus. Pneumonia can be caused by a number of different microorganisms like bacteria, virus, and mycoplasma. In case of the entry of a pathogen in our body, the immune system gets activated, and the phagocytic cells try to eliminate it by generating reactive oxygen and nitrogen species (ROS and RNS) inside the phagosome. These reactive species or respiratory bursts are sufficient to eliminate most of the pathogens, except a few. M. tuberculosis is one such microorganism that has evolved mechanisms to escape this respiratory burst-mediated killing and thus survive and grow inside the macrophages. Infection with M. tuberculosis leads to the destruction of macrophages and release of cytokines, which lead to prolonged immune activation and oxidative stress. In some cases, the bacilli remain dormant inside macrophages for a long time. Flu viruses infect the epithelial cells present in respiratory tract, and the infection site is dependent on the hemagglutinin protein present on their capsid. Destruction of epithelial cells promotes secretion of mucus and activation of immune system leading to the oxidative damage. Community-acquired pneumonia is more serious and difficult to treat. In all these infections, ROS/RNS are developed as a defense mechanism against the pathogen. Persistence of the pathogen for a long time would lead to the uncontrolled production of ROS/RNS which will lead to oxidative stress and tissue damage to the host. Administration of antioxidants along with conventional treatments can be useful in the elimination of the reactive oxygen and nitrogen species.

Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia

Community-acquired pneumonia is common and important infectious disease in adults. This work represents an update to 2009 treatment guideline for community-acquired pneumonia in Korea. The present clinical practice guideline provides revised recommendations on the appropriate diagnosis, treatment, and prevention of community-acquired pneumonia in adults aged 19 years or older, taking into account the current situation regarding community-acquired pneumonia in Korea. This guideline may help reduce the difference in the level of treatment between medical institutions and medical staff, and enable efficient treatment. It may also reduce antibiotic resistance by preventing antibiotic misuse against acute lower respiratory tract infection in Korea.

Steroids and Survival in Critically Ill Adult Patients: A Meta-analysis of 135 Randomized Trials

OBJECTIVE

Corticosteroids have important effects on intermediate outcomes in critically ill patients, but their effect on survival is unknown. The objective of this meta-analysis was to analyze the effect on mortality of corticosteroids in critical and perioperative settings.

DESIGN

A meta-analysis of randomized trials.

SETTING

PubMed, Embase, BioMed Central, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched to February 1, 2018, for randomized trials comparing corticosteroids with placebo or standard care.

PARTICIPANTS

Critically ill or surgical adult patients.

INTERVENTIONS

Corticosteroids compared with placebo or standard care.

MEASUREMENTS AND MAIN RESULTS

A total of 44,553 patients from 135 studies were included. Overall, mortality in the corticosteroid group and in the control group were similar (16% v 16%; p = 0.9). Subanalyses identified a beneficial effect of corticosteroids on survival in patients with respiratory system diseases (9% v 13%; p < 0.001) and bacterial meningitis (28% v 32%; p= 0.04), and a detrimental effect on survival in patients with traumatic brain injury (22% v 19%; p < 0.001). No differences in mortality were found in patients with cardiac diseases (7% v 6%; p = 0.7), in patients undergoing cardiac surgery (2.8% v 3.2% p = 0.14), and when treatment duration or patient age were considered.

CONCLUSIONS

This meta-analysis documents the safety of corticosteroids in the overall critically ill population with the notable exception of brain injury patients, a setting where the authors confirmed their detrimental effect on survival. A possible beneficial effect of corticosteroids on survival was found among patients with respiratory diseases and in patients with bacterial meningitis.

Pneumonia as a cardiovascular disease

Community-acquired pneumonia (CAP) is an important cause of death around the globe. Up to 30% of patients admitted to hospital for CAP develop cardiovascular complications (i.e. new/worsening heart failure, new/worsening arrhythmias, myocardial infarctions and/or strokes), acutely and up to 10 years thereafter. Cardiac complications result from complex interactions between preexisting conditions, relative ischaemia, upregulation of the sympathetic system, systemic inflammation and direct pathogen-mediated damage to the cardiovascular system. The exact mechanisms underlying the direct host-pathogen interactions are of great interest to identify potential therapeutic and preventative targets for CAP. In this review, we summarize the epidemiological data, risk factors and the pathogen-driven cardiovascular damage affecting patients with CAP.

The dilemma of monotherapy or combination therapy in community-acquired pneumonia

SCOPE

To study the factors associated with mortality in hospitalized patients with community-acquired pneumonia treated with monotherapy or combination therapy.

METHODS

PubMed and Scopus were searched. Patients receiving macrolides, β-lactams and fluoroquinolones, as monotherapy or in combination, were included. Meta-analyses and meta-regressions were performed.

RESULTS

Fifty studies were included. Overall, monotherapy was not associated with higher mortality than combination (RR 1.14, 95% CI 0.99-1.32, I² 84%). Monotherapy was associated with higher mortality than combination in North American and retrospective studies. β-lactam monotherapy was associated with higher mortality than β-lactam/macrolide combination in the primary (1.32, 1.12-1.56, I² 85%) and most sensitivity analyses. There was no difference in mortality between fluoroquinolone monotherapy and β-lactam/macrolide combination (0.98, 0.78-1.23, I² 73%). In meta-regressions, the moderators that could partially explain the observed statistical heterogeneity were the frequency of cancer patients (P = .03) and Pneumonia Severity Index score IV (P = .008).

CONCLUSION

Due to the considerable heterogeneity and inclusion of unadjusted data, it is difficult to recommend a specific antibiotic regimen over another. Specific antibiotic regimens, study design and the characteristics of the population under study seem to influence the reported outcomes.

Multicenter Osteopathic Pneumonia Study in the Elderly: Subgroup Analysis on Hospital Length of Stay, Ventilator-Dependent Respiratory Failure Rate, and In-hospital Mortality Rate

CONTEXT

Osteopathic manipulative treatment (OMT) is a promising adjunctive treatment for older adults hospitalized for pneumonia.

OBJECTIVE

To report subgroup analyses from the Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) relating to hospital length of stay (LOS), ventilator-dependent respiratory failure rate, and in-hospital mortality rate.

DESIGN

Multicenter randomized controlled trial.

SETTING

Seven community hospitals.

PARTICIPANTS

Three hundred eighty-seven patients aged 50 years or older who met specific criteria for pneumonia on hospital admission.

INTERVENTIONS

Participants were randomly assigned to 1 of 3 groups that received an adjunctive OMT protocol (n=130), a light touch (LT) protocol (n=124), or conventional care only (CCO) (n=133).

MAIN OUTCOME MEASURES

Outcomes for subgroup analyses were LOS, ventilator-dependent respiratory failure rate, and in-hospital mortality rate. Subgroups were age (50-74 years or ≥75 years), Pneumonia Severity Index (PSI) class (I-II, III, IV, or V), and type of pneumonia (community-acquired or nursing-home acquired). Data were analyzed by intention-to-treat and per-protocol analyses using stratified Cox proportional hazards models and Cochran-Mantel-Haenszel tests for general association.

RESULTS

By per-protocol analysis of the younger age subgroup, LOS was shorter for the OMT group (median, 2.9 days; n=43) than the LT (median, 3.7 days; n=45) and CCO (median, 4.0 days; n=65) groups (P=.006). By intention-to-treat analysis of the older age subgroup, in-hospital mortality rates were lower for the OMT (1 of 66 [2%]) and LT (2 of 68 [3%]) groups than the CCO group (9 of 67 [13%]) (P=.005). By per-protocol analysis of the PSI class IV subgroup, the OMT group had a shorter LOS than the CCO group (median, 3.8 days [n=40] vs 5.0 days [n=50]; P=.01) and a lower ventilator-dependent respiratory failure rate than the CCO group (0 of 40 [0%] vs 5 of 50 [10%]; P=.05). By intention-to-treat analysis, in-hospital mortality rates in the PSI class V subgroup were lower (P=.05) for the OMT group (1 of 22 [5%]) than the CCO group (6 of 19 [32%]) but not the LT group (2 of 15 [13%]).

CONCLUSION

Subgroup analyses suggested adjunctive OMT for pneumonia reduced LOS in adults aged 50 to 74 years and lowered in-hospital mortality rates in adults aged 75 years or older. Adjunctive OMT may also reduce LOS and in-hospital mortality rates in older adults with more severe pneumonia. Interestingly, LT also reduced in-hospital mortality rates in adults aged 75 years or older relative to CCO. (ClinicalTrials.gov number NCT00258661).

Efficacy and Safety of Adjunctive Corticosteroids Therapy for Severe Community-Acquired Pneumonia in Adults: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Adjunctive corticosteroids therapy is an attractive option for community-acquired pneumonia (CAP) treatment. However, the effectiveness of adjunctive corticosteroids on mortality of CAP remains inconsistent, especially in severe CAP. We performed a meta-analysis to evaluate the efficacy and safety of adjunctive corticosteroids in severe CAP patients.

METHODS

Three databases of PubMed, EMBASE and Cochrane Library were searched for related studies published in English up to December, 2015. Randomized controlled trials (RCTs) of corticosteroids in hospitalized adults with severe CAP were included. Meta-analysis was performed by a random-effect model with STATA 11.0 software. We estimated the summary risk ratios (RRs) or effect size (ES) with its corresponding 95% confidence interval (95%CI) to assess the outcomes.

RESULTS

We included 8 RCTs enrolling 528 severe CAP patients. Adjunctive corticosteroids significantly reduced all-cause mortality (RR = 0.46, 95%CI: 0.28 to 0.77, p = 0.003), risk of adult respiratory distress syndrome (ARDS) (RR = 0.23, 95%CI: 0.07 to 0.80, p = 0.02) and need for mechanical ventilation (RR = 0.50, 95%CI: 0.27 to 0.92, p = 0.026). Adjunctive corticosteroids did not increase frequency of hyperglycemia requiring treatment (RR = 1.03, 95%CI: 0.61 to 1.72, p = 0.91) or gastrointestinal hemorrhage (RR = 0.66, 95%CI: 0.19 to 2.31, p = 0.52). In subgroup analysis by duration of corticosteroids, we found that prolonged corticosteroids therapy significantly reduced all-cause mortality (RR = 0.41, 95%CI: 0.20 to 0.83, p = 0.01) and length of hospital stay (-4.76 days, 95% CI:-8.13 to -1.40, p = 0.006).

CONCLUSIONS

Results from this meta-analysis suggested that adjunctive corticosteroids therapy was safe and beneficial for severe CAP. In addition, prolonged corticosteroids therapy was more effective. These results should be confirmed by adequately powered studies in the future.

Inpatient rehabilitation improves functional capacity, peripheral muscle strength and quality of life in patients with community-acquired pneumonia: a randomised trial

QUESTION

Among people who are hospitalised for community-acquired pneumonia, does an inpatient exercise-based rehabilitation program improve functional outcomes, symptoms, quality of life and length of hospital stay more than a respiratory physiotherapy regimen?

DESIGN

Randomised trial with concealed allocation, intention-to-treat analysis and blinding of some outcomes.

PARTICIPANTS

Forty-nine adults hospitalised for community-acquired pneumonia.

INTERVENTION

The experimental group (n=32) underwent a physical training program that included warm-up, stretching, peripheral muscle strength training and walking at a controlled speed for 15 minutes. The control group (n=17) underwent a respiratory physiotherapy regimen that included percussion, vibrocompression, respiratory exercises and free walking. The intervention regimens lasted 8 days.

OUTCOME MEASURES

The primary outcome was the Glittre Activities of Daily Living test, which assesses the time taken to complete a series of functional tasks (eg, rising from a chair, walking, stairs, lifting and bending). Secondary outcomes were distance walked in the incremental shuttle walk test, peripheral muscle strength, quality of life, dyspnoea, lung function, C-reactive protein and length of hospital stay. Measures were taken 1 day before and 1 day after the intervention period.

RESULTS

There was greater improvement in the experimental group than in the control group on the Glittre Activities of Daily Living test (mean between-group difference 39 seconds, 95% CI 20 to 59) and the incremental shuttle walk test (mean between-group difference 130 m, 95% CI 77 to 182). There were also significantly greater improvements in quality of life, dyspnoea and peripheral muscle strength in the experimental group than in the control group. There were no between-group differences in lung function, C-reactive protein or length of hospital stay.

CONCLUSION

The improvement in functional outcomes after an inpatient rehabilitation program was greater than the improvement after standard respiratory physiotherapy. The exercise training program led to greater benefits in functional capacity, peripheral muscle strength, dyspnoea and quality of life.

REGISTRATION

ClinicalTrials.gov, NCT02103400.

Epidemiology, Seasonality and Treatment of Hospitalized Adults and Adolescents with Influenza in Jingzhou, China, 2010-2012

BACKGROUND

After the 2009 influenza A (H1N1) pandemic, we conducted hospital-based severe acute respiratory infection (SARI) surveillance in one central Chinese city to assess disease burden attributable to influenza among adults and adolescents.

METHODS

We defined an adult SARI case as a hospitalized patient aged ≥ 15 years with temperature ≥38.0°C and at least one of the following: cough, sore throat, tachypnea, difficulty breathing, abnormal breath sounds on auscultation, sputum production, hemoptysis, chest pain, or chest radiograph consistent with pneumonia. For each enrolled SARI case-patient, we completed a standardized case report form, and collected a nasopharyngeal swab within 24 hours of admission. Specimens were tested for influenza viruses by real-time reverse transcription polymerase chain reaction (rRT-PCR). We analyzed data from adult SARI cases in four hospitals in Jingzhou, China from April 2010 to April 2012.

RESULTS

Of 1,790 adult SARI patients enrolled, 40% were aged ≥ 65 years old. The median duration of hospitalization was 9 days. Nearly all were prescribed antibiotics during their hospitalization, less than 1% were prescribed oseltamivir, and 28% were prescribed corticosteroids. Only 0.1% reported receiving influenza vaccination in the past year. Of 1,704 samples tested, 16% were positive for influenza. Influenza activity in all age groups showed winter-spring and summer peaks. Influenza-positive patients had a longer duration from illness onset to hospitalization and a shorter duration from hospital admission to discharge or death compared to influenza negative SARI patients.

CONCLUSIONS

There is substantial burden of influenza-associated SARI hospitalizations in Jingzhou, China, especially among older adults. More effective promotion of annual seasonal influenza vaccination and timely oseltamivir treatment among high risk groups may improve influenza prevention and control in China.

Efficacy and safety of glucocorticoids in the treatment of community-acquired pneumonia: A meta-analysis of randomized controlled trials

BACKGROUND

Community-acquired pneumonia (CAP) is pneumonia acquired infectiously from normal social contact as opposed to being acquired during hospitalization. CAP is a leading cause of illness and death. This review aims to determine the efficacy and safety of glucocorticoids in the treatment of community-acquired pneumonia (CAP).

DATA SOURCES

We searched randomized controlled trials (RCTs) from Pubmed, EMBASE, Cochrane Library, Chinese Journal Full-text Database, and Chinese Biomedical Literature Database to obtain the information by using steroids, glucocorticoids, cortisol, corticosteroids, community-acquired pneumonia and CAP as key words. The quality of RCTs was evaluated. A Meta-analysis was made using RevMan 5.0 provided by the Cochrance Collaboration.

RESULTS

Seven RCTs involving 944 patients were included in the meta-analysis. The mean length of hospital stay in glucocorticoids treatment group was significantly shorter than that in standard treatment group (WMD=-1.70, 95%CI 2.01-1.39, Z=10.81, P<0.00001). No statistically significant differences were found in the mortality rate (RR=0.77,95%CI 0.46-1.27, Z=1.03, P=0.30), the mean length of hospital stay in ICU (WMD=1.17, 95%CI 1.68-4.02, Z=0.81, P=0.42), the incidence of super infection (RR=1.32, 95%CI 0.66-2.63, Z=0.79, P=0.43), the incidence of hyperglycemia (RR=1.84, 95%CI 0.76-4.41, Z=1.36, P=0.17), the incidence of upper gastrointestinal bleeding (RR=1.98, 95%CI 0.37-10.59, Z=0.80, P=0.42) between the standard treatment group and the glucocorticoids treatment group.

CONCLUSIONS

The use of glucocorticoids in patients with community-acquired pneumonia can significantly shorten the duration of illness and have a favorable safety profile. However, it could not reduce the overall mortality.

Adjunctive Systemic Corticosteroids for Hospitalized Community-Acquired Pneumonia: Systematic Review and Meta-Analysis 2015 Update

Previous randomized controlled trials (RCTs) and meta-analyses evaluated the efficacy and safety of adjunctive corticosteroids for community-acquired pneumonia (CAP). However, the results from them had large discrepancies. The eligibility criteria for the current meta-analysis were original RCTs written in English as a full article that evaluated adjunctive systemic corticosteroids adding on antibiotic therapy targeting typical and/or atypical pathogen for treating hospitalized human CAP cases. Four investigators independently searched for eligible articles through PubMed, Embase, and Cochrane databases. Random model was used. The heterogeneity among original studies and subgroups was evaluated with the I(2) statistics. Of 54 articles that met the preliminary criteria, we found 10 eligible RCTs comprising 1780 cases. Our analyses revealed following pooled values by corticosteroids. OR for all-cause death: 0.80 (95% confidence interval (95% CI) 0.53-1.21) from all studies; 0.41 (95% CI 0.19-0.90) from severe-case subgroup; 0.21 (95% CI 0.0-0.74) from intensive care unit (ICU) subgroup. Length of ICU stay: -1.30 days (95% CI (-3.04)-0.44). Length of hospital stay: -0.98 days (95% CI (-1.26)-(-0.71)). Length to clinical stability: -1.16 days (95% CI (-1.73)-(-0.58)). Serious complications do not seem to largely increase by steroids. In conclusion, adjunctive systemic corticosteroids for hospitalized patients with CAP seems preferred strategies.

Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial

BACKGROUND

Clinical trials yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of community-acquired pneumonia. We assessed whether short-term corticosteroid treatment reduces time to clinical stability in patients admitted to hospital for community-acquired pneumonia.

METHODS

In this double-blind, multicentre, randomised, placebo-controlled trial, we recruited patients aged 18 years or older with community-acquired pneumonia from seven tertiary care hospitals in Switzerland within 24 h of presentation. Patients were randomly assigned (1:1 ratio) to receive either prednisone 50 mg daily for 7 days or placebo. The computer-generated randomisation was done with variable block sizes of four to six and stratified by study centre. The primary endpoint was time to clinical stability defined as time (days) until stable vital signs for at least 24 h, and analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00973154.

FINDINGS

From Dec 1, 2009, to May 21, 2014, of 2911 patients assessed for eligibility, 785 patients were randomly assigned to either the prednisone group (n=392) or the placebo group (n=393). Median time to clinical stability was shorter in the prednisone group (3·0 days, IQR 2·5-3·4) than in the placebo group (4·4 days, 4·0-5·0; hazard ratio [HR] 1·33, 95% CI 1·15-1·50, p<0·0001). Pneumonia-associated complications until day 30 did not differ between groups (11 [3%] in the prednisone group and 22 [6%] in the placebo group; odds ratio [OR] 0·49 [95% CI 0·23-1·02]; p=0·056). The prednisone group had a higher incidence of in-hospital hyperglycaemia needing insulin treatment (76 [19%] vs 43 [11%]; OR 1·96, 95% CI 1·31-2·93, p=0·0010). Other adverse events compatible with corticosteroid use were rare and similar in both groups.

INTERPRETATION

Prednisone treatment for 7 days in patients with community-acquired pneumonia admitted to hospital shortens time to clinical stability without an increase in complications. This finding is relevant from a patient perspective and an important determinant of hospital costs and efficiency.

FUNDING

Swiss National Science Foundation, Viollier AG, Nora van Meeuwen Haefliger Stiftung, Julia und Gottfried Bangerter-Rhyner Stiftung.

Corticosteroid treatment for community-acquired pneumonia--the STEP trial: study protocol for a randomized controlled trial

BACKGROUND

Community-acquired pneumonia (CAP) is the third-leading infectious cause of death worldwide. The standard treatment of CAP has not changed for the past fifty years and its mortality and morbidity remain high despite adequate antimicrobial treatment. Systemic corticosteroids have anti-inflammatory effects and are therefore discussed as adjunct treatment for CAP. Available studies show controversial results, and the question about benefits and harms of adjunct corticosteroid therapy has not been conclusively resolved, particularly in the non-critical care setting.

METHODS/DESIGN

This randomized multicenter study compares a treatment with 7 days of prednisone 50 mg with placebo in adult patients hospitalized with CAP independent of severity. Patients are screened and enrolled within the first 36 hours of presentation after written informed consent is obtained. The primary endpoint will be time to clinical stability, which is assessed every 12 hours during hospitalization. Secondary endpoints will be, among others, all-cause mortality within 30 and 180 days, ICU stay, duration of antibiotic treatment, disease activity scores, side effects and complications, value of adrenal function testing and prognostic hormonal and inflammatory biomarkers to predict outcome and treatment response to corticosteroids. Eight hundred included patients will provide an 85% power for the intention-to-treat analysis of the primary endpoint.

DISCUSSION

This largest to date double-blind placebo-controlled multicenter trial investigates the effect of adjunct glucocorticoids in 800 patients with CAP requiring hospitalization. It aims to give conclusive answers about benefits and risks of corticosteroid treatment in CAP. The inclusion of less severe CAP patients will be expected to lead to a relatively low mortality rate and survival benefit might not be shown. However, our study has adequate power for the clinically relevant endpoint of clinical stability. Due to discontinuing glucocorticoids without tapering after seven days, we limit duration of glucocorticoid exposition, which may reduce possible side effects.

TRIAL REGISTRATION

7 September 2009 on ClinicalTrials.gov: NCT00973154.

Corticosteroids in the treatment of severe community-acquired pneumonia

Controversy surrounds the use of adjunctive corticosteroids in severe community acquired pneumonia (CAP) as current guidelines either do not address or discourage their use. Double-blind, placebo-controlled, randomized controlled trials examining systemic corticosteroids in the treatment of severe CAP were summarized and their impacts on patient-important outcomes assessed. Four trials describing systemic corticosteroid use in adults with severe CAP were identified. One trial had a significant mortality difference favoring corticosteroids. However, this may be the result of a CAP severity imbalance within the trial and the mortality benefit was not confirmed in a larger trial conducted in a similar critical care setting. Pneumonia severity, mortality assessment timing, comorbidities, corticosteroid and antibiotic choice and timing in the CAP disease course, and bias risks varied across the four trials. Because of the clinical heterogeneity of available studies and the unknowns pertaining to clinical efficacy and safety, we do not recommend the use of adjunctive corticosteroids in severe CAP.

Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults

BACKGROUND

Cough is often distressing for patients with pneumonia. Accordingly they often use over-the-counter (OTC) cough medications (mucolytics or cough suppressants). These might provide relief in reducing cough severity, but suppression of the cough mechanism might impede airway clearance and cause harm.

OBJECTIVES

To evaluate the efficacy of OTC cough medications as an adjunct to antibiotics in children and adults with pneumonia.

SEARCH METHODS

We searched CENTRAL 2013, Issue 12, MEDLINE (January 1966 to January week 2, 2014), OLDMEDLINE (1950 to 1965), EMBASE (1980 to January 2014), CINAHL (2009 to January 2014), LILACS (2009 to January 2014) and Web of Science (2009 to January 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in children and adults comparing any type of OTC cough medication with placebo, or control medication, with cough as an outcome and where the cough is secondary to acute pneumonia.

DATA COLLECTION AND ANALYSIS

We independently selected trials for inclusion. We extracted data from these studies, assessed them for methodological quality without disagreement and analyzed them using standard methods.

MAIN RESULTS

There are no new trials to include in this review update. Previously, four studies with a total of 224 participants were included; one was performed exclusively in children and three in adolescents or adults. One using an antitussive had no extractable pneumonia-specific data. Three different mucolytics (bromhexine, ambroxol, neltenexine) were used in the remaining studies, of which only two had extractable data. They demonstrated no significant difference for the primary outcome of 'not cured or not improved' for mucolytics. A secondary outcome of 'not cured' was reduced (odds ratio (OR) for children 0.36, 95% confidence interval (CI) 0.16 to 0.77; number needed to treat to benefit (NNTB) at day 10 = 5 (95% CI 3 to 16) and OR 0.32 for adults (95% CI 0.13 to 0.75); NNTB at day 10 = 5 (95% CI 3 to 19)). In a post hoc analysis combining data for children and adults, again there was no difference in the primary outcome of 'not cured or not improved' (OR 0.85, 95% CI 0.40 to 1.80) although mucolytics reduced the secondary outcome 'not cured' (OR 0.34, 95% CI 0.19 to 0.60; NNTB 4, 95% CI 3 to 8). The risk of bias was low or unclear.

AUTHORS' CONCLUSIONS

There is insufficient evidence to decide whether OTC medications for cough associated with acute pneumonia are beneficial. Mucolytics may be beneficial but there is insufficient evidence to recommend them as an adjunctive treatment for acute pneumonia. This leaves only theoretical recommendations that OTC medications containing codeine and antihistamines should not be used in young children.

Adjunctive corticosteroid therapy improves lung immunopathology and survival during severe secondary pneumococcal pneumonia in mice

Secondary bacterial pneumonia is a significant cause of morbidity and mortality during influenza, despite routine use of standard antibiotics. Antibiotic-induced immunopathology associated with bacterial cell wall lysis has been suggested to contribute to these poor outcomes. Using Streptococcus pneumoniae in a well-established murine model of secondary bacterial pneumonia (SBP) following influenza, we stratified disease severity based on pneumococcal load in the lungs via in vivo bioluminescence imaging. Ampicillin treatment cured mice with mild pneumonia but was ineffective against severely pneumonic mice, despite effective bacterial killing. Adjunctive dexamethasone therapy improved ampicillin-induced immunopathology and improved outcomes in mice with severe SBP. However, early dexamethasone therapy during primary influenza infection impaired lung adaptive immunity as manifest by increased viral titers, with an associated loss of its protective functions in SBP. These data support adjunctive clinical use of corticosteroids in severe cases of community-acquired pneumonia.

Corticosteroids in the treatment of community-acquired pneumonia in adults: a meta-analysis

Background

The benefit of corticosteroids in community-acquired pneumonia (CAP) remains controversial. We did a meta-analysis to include all the randomized controlled trials (RCTs) which used corticosteroids as adjunctive therapy, to examine the benefits and risks of corticosteroids in the treatment of CAP in adults.

Methods

Databases including Pubmed, EMBASE, the Cochrane controlled trials register, and Google Scholar were searched to find relevant trials. Randomized and quasi-randomized trials of corticosteroids treatment in adult patients with CAP were included. Effects on primary outcome (mortality) and secondary outcomes (adverse events) were accessed in this meta-analysis.

Results

Nine trials involving 1001 patients were included. Use of corticosteroids did not significantly reduce mortality (Peto odds ratio [OR] 0.62, 95% confidence interval [CI] 0.37–1.04; P = 0.07). In the subgroup analysis by the severity, a survival benefit was found among severe CAP patients (Peto OR 0.26, 95% CI 0.11–0.64; P = 0.003). In subgroup analysis by duration of corticosteroids treatment, significant reduced mortality was found among patients with prolonged corticosteroids treatment (Peto OR 0.51, 95% CI 0.26–0.97; P = 0.04; I² = 37%). Corticosteroids increased the risk of hyperglycemia (Peto OR 2.64, 95% CI 1.68–4.15; P<0.0001), but without increasing the risk of gastroduodenal bleeding (Peto OR 1.67, 95% CI 0.41–6.80; P = 0.47) and superinfection (Peto OR 1.36, 95% CI 0.65–2.84; P = 0.41).

Conclusion

Results from this meta-analysis did not suggest a benefit for corticosteroids treatment in patients with CAP. However, the use of corticosteroids was associated with improved mortality in severe CAP. In addition, prolonged corticosteroids therapy suggested a beneficial effect on mortality. These results should be confirmed by future adequately powered randomized trials.

Vitamin D accelerates resolution of inflammatory responses during tuberculosis treatment

Calcidiol, the major circulating metabolite of vitamin D, supports induction of pleiotropic antimicrobial responses in vitro. Vitamin D supplementation elevates circulating calcidiol concentrations, and thus has a potential role in the prevention and treatment of infection. The immunomodulatory effects of administering vitamin D to humans with an infectious disease have not previously been reported. To characterize these effects, we conducted a detailed longitudinal study of circulating and antigen-stimulated immune responses in ninety-five patients receiving antimicrobial therapy for pulmonary tuberculosis who were randomized to receive adjunctive high-dose vitamin D or placebo in a clinical trial, and who fulfilled criteria for per-protocol analysis. Vitamin D supplementation accelerated sputum smear conversion and enhanced treatment-induced resolution of lymphopaenia, monocytosis, hypercytokinaemia, and hyperchemokinaemia. Administration of vitamin D also suppressed antigen-stimulated proinflammatory cytokine responses, but attenuated the suppressive effect of antimicrobial therapy on antigen-stimulated secretion of IL-4, CC chemokine ligand 5, and IFN-α. We demonstrate a previously unappreciated role for vitamin D supplementation in accelerating resolution of inflammatory responses during tuberculosis treatment. Our findings suggest a potential role for adjunctive vitamin D supplementation in the treatment of pulmonary infections to accelerate resolution of inflammatory responses associated with increased risk of mortality.

Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: systematic review and meta-analysis

OBJECTIVE

To systematically review longitudinal studies evaluating use of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and risk of pneumonia.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline through PubMed, Web of Science with conference proceedings (inception to June 2011), and US Food and Drug Administration website (June 2011). Systematic reviews and references of retrieved articles were also searched.

STUDY SELECTION

Two reviewers independently selected randomised controlled trials and cohort and case-control studies evaluating the use of ACE inhibitors or ARBs and risk of pneumonia and retrieved characteristics of the studies and data estimates.

DATA SYNTHESIS

The primary outcome was incidence of pneumonia and the secondary outcome was pneumonia related mortality. Subgroup analyses were carried according to baseline morbidities (stroke, heart failure, and chronic kidney disease) and patients' characteristics (Asian and non-Asian). Pooled estimates of odds ratios and 95% confidence intervals were derived by random effects meta-analysis. Adjusted frequentist indirect comparisons between ACE inhibitors and ARBs were estimated and combined with direct evidence whenever available. Heterogeneity was assessed using the I(2) test.

RESULTS

37 eligible studies were included. ACE inhibitors were associated with a significantly reduced risk of pneumonia compared with control treatment (19 studies: odds ratio 0.66, 95% confidence interval 0.55 to 0.80; I(2) = 79%) and ARBs (combined direct and indirect odds ratio estimate 0.69, 0.56 to 0.85). In patients with stroke, the risk of pneumonia was also lower in those treated with ACE inhibitors compared with control treatment (odds ratio 0.46, 0.34 to 0.62) and ARBs (0.42, 0.22 to 0.80). ACE inhibitors were associated with a significantly reduced risk of pneumonia among Asian patients (0.43, 0.34 to 0.54) compared with non-Asian patients (0.82, 0.67 to 1.00; P<0.001). Compared with control treatments, both ACE inhibitors (seven studies: odds ratio 0.73, 0.58 to 0.92; I(2)=51%) and ARBs (one randomised controlled trial: 0.63, 0.40 to 1.00) were associated with a decrease in pneumonia related mortality, without differences between interventions.

CONCLUSIONS

The best evidence available points towards a putative protective role of ACE inhibitors but not ARBs in risk of pneumonia. Patient populations that may benefit most are those with previous stroke and Asian patients. ACE inhibitors were also associated with a decrease in pneumonia related mortality, but the data lacked strength.

Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults

BACKGROUND

Cough is often distressing for patients with pneumonia. Accordingly they often use over-the-counter (OTC) cough medications (mucolytics or cough suppressants). These might provide relief in reducing cough severity, but suppression of the cough mechanism might impede airway clearance and cause harm.

OBJECTIVES

To evaluate the efficacy of OTC cough medications as an adjunct to antibiotics in children and adults with pneumonia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3) which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1966 to July week 4, 2011), OLDMEDLINE (1950 to 1965), EMBASE (1980 to August 2011), CINAHL (2009 to August 2011), LILACS (2009 to August 2011) and Web of Science (2009 to August 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in children and adults comparing any type of OTC cough medication with placebo, or control medication, with cough as an outcome and where the cough is secondary to acute pneumonia.

DATA COLLECTION AND ANALYSIS

We independently selected trials for inclusion. We extracted data from these studies, assessed them for methodological quality without disagreement and analyzed using standard methods.

MAIN RESULTS

Four studies with a total of 224 participants were included; one was performed exclusively in children and three in adolescents or adults. One using an antitussive had no extractable pneumonia-specific data. Three different mucolytics (bromhexine, ambroxol, neltenexine) were used in the remaining studies, of which only two had extractable data. They demonstrated no significant difference for the primary outcome of 'not cured or not improved' for mucolytics. A secondary outcome of 'not cured' was reduced (odds ratio (OR) for children 0.36, 95% confidence interval (CI) 0.16 to 0.77; number needed to treat to benefit (NNTB) at day 10 = 5 (95% CI 3 to 16) and OR 0.32 for adults (95% CI 0.13 to 0.75); NNTB at day 10 = 5 (95% CI 3 to 19). In a post hoc analysis combining data for children and adults, again there was no difference in the primary outcome of 'not cured or not improved' (OR 0.85, 95% CI 0.40 to 1.80) although mucolytics reduced the secondary outcome 'not cured' (OR 0.34, 95% CI 0.19 to 0.60; NNTB 4, 95% CI 3 to 8).

AUTHORS' CONCLUSIONS

There is insufficient evidence to decide whether OTC medications for cough associated with acute pneumonia are beneficial. Mucolytics may be beneficial but there is insufficient evidence to recommend them as an adjunctive treatment for acute pneumonia. This leaves only theoretical recommendations that OTC medications containing codeine and antihistamines should not be used in young children.

Guidelines for the management of adult lower respiratory tract infections--summary

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Guidelines for the management of adult lower respiratory tract infections--full version

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

PPARα mediates the anti-inflammatory effect of simvastatin in an experimental model of zymosan-induced multiple organ failure

BACKGROUND AND PURPOSE

Zymosan-induced non-septic shock is a multi-factorial pathology that involves several organs including the kidneys, liver and lungs. Its complexity and diversity presents a continuing therapeutic challenge. Given their pleiotropic effect, statins could be beneficial in non-septic shock. One of the molecular mechanisms underlying the anti-inflammatory effect of statins involves the peroxisome proliferator-activated receptor (PPAR) α. We used a zymosan-induced non-septic shock experimental model to investigate the role of PPARα in the anti-inflammatory effects of simvastatin.

EXPERIMENTAL APPROACH

Effects of simvastatin (5 or 10 mg·kg(-1) i.p.) were analysed in PPARα knock-out (KO) and PPARα wild type (WT) mice after zymosan or vehicle administration. Organ injury in lung, liver, kidney and intestine was evaluated by immunohistology. PPARα mRNA expression and nuclear factor-κB activation were evaluated in all experimental groups, 18 h after study onset. Cytokine levels were measured in plasma, and nitrite/nitrate in plasma and peritoneal exudate. Nitric oxide synthase, nitrotyrosine and poly ADP-ribose were localized by immunohistochemical methods.

KEY RESULTS

Simvastatin significantly and dose-dependently increased the zymosan-induced expression of PPARα levels in all tissues analysed. It also dose-dependently reduced systemic inflammation and the organ injury induced by zymosan in lung, liver, intestine and kidney. These effects were observed in PPARαWT mice and in PPARαKO mice.

CONCLUSIONS AND IMPLICATIONS

Simvastatin protected against the molecular and cellular damage caused by systemic inflammation in our experimental model. Our results also provide new information regarding the role of PPARα in the anti-inflammatory effects of statins.

Severe pneumococcal pneumonia: impact of new quinolones on prognosis

BACKGROUND

Most guidelines have been proposing, for more than 15 years, a β-lactam combined with either a quinolone or a macrolide as empirical, first-line therapy of severe community acquired pneumonia (CAP) requiring ICU admission. Our goal was to evaluate the outcome of patients with severe CAP, focusing on the impact of new rather than old fluoroquinolones combined with β-lactam in the empirical antimicrobial treatments.

METHODS

Retrospective study of consecutive patients admitted in a 16-bed general intensive care unit (ICU), between January 1996 and January 2009, for severe (Pneumonia Severity Index > or = 4) community-acquired pneumonia due to non penicillin-resistant Streptococcus pneumoniae and treated with a β-lactam combined with a fluoroquinolone.

RESULTS

We included 70 patients of whom 38 received a β-lactam combined with ofloxacin or ciprofloxacin and 32 combined with levofloxacin. Twenty six patients (37.1%) died in the ICU. Three independent factors associated with decreased survival in ICU were identified: septic shock on ICU admission (AOR = 10.6; 95% CI 2.87-39.3; p = 0.0004), age > 70 yrs. (AOR = 4.88; 95% CI 1.41-16.9; p = 0.01) and initial treatment with a β-lactam combined with ofloxacin or ciprofloxacin (AOR = 4.1; 95% CI 1.13-15.13; p = 0.03).

CONCLUSION

Our results suggest that, when combined to a β-lactam, levofloxacin is associated with lower mortality than ofloxacin or ciprofloxacin in severe pneumococcal community-acquired pneumonia.

Diagnosis, management and prevention of ventilator-associated pneumonia: an update

Ventilator-associated pneumonia (VAP) affects 10-20% of mechanically ventilated patients and is associated with increased morbidity and mortality and high costs. Early diagnosis is crucial for rapid appropriate antimicrobial therapy to be instituted, but debate remains as to the optimal diagnostic strategy. Noninvasive clinical-based diagnosis is rapid but may not be as accurate as invasive techniques. Increased use of biomarkers and advances in genomics and proteomics may help speed up diagnosis. Management of VAP relies principally on appropriate antimicrobial therapy, which should be selected according to individual patient factors, such as previous antibacterial therapy and length of hospitalization or mechanical ventilation, and local infection and resistance patterns. In addition, once bacterial culture and sensitivity results are available, broad-spectrum therapy should be de-escalated to provide a more specific, narrower-spectrum cover. Optimum duration of antibacterial therapy is difficult to define and should be tailored to clinical response. Biomarker levels may be useful to monitor response to therapy. With the high morbidity and mortality, prevention of VAP is important and several strategies have been shown to reduce the rates of VAP in mechanically ventilated patients, including using noninvasive ventilation where possible, and semi-recumbent positioning. Other potentially beneficial preventive techniques include subglottal suctioning, oral decontamination strategies and antimicrobial-coated endotracheal tubes, although further study is needed to confirm the cost effectiveness of these strategies.

Progress in the field of probiotics: year 2011

PURPOSE OF REVIEW

The interest and scope for research in the field of probiotics has significantly widened in recent years. This brief review covers the significant advances in the field of probiotics.

RECENT FINDINGS

These include conclusive evidence for the benefits of probiotics in preventing all cause mortality and necrotizing enterocolitis (NEC) in preterm very low birth weight (VLBW) neonates, understanding the role of probiotics as vaccine adjuvants, and in modulating inflammatory bowel diseases, bowel cancer, type 1 diabetes mellitus, obesity, high cholesterol levels, and bacterial resistance. Other areas of progress include understanding the role of probiotics in oral health and ageing.

SUMMARY

Current evidence will lead to routine probiotic supplementation to prevent all cause mortality and NEC in preterm VLBW neonates. Probiotics may also become novel agents as vaccine adjuvants, and in dealing with major public health issues such as obesity, type I diabetes mellitus, and poor oral health. Research in applications of probiotics in food products will rationalize product development, and health claims. As new frontiers continue to be explored the challenges to the basis of the hygiene hypothesis will influence further developments in the field of probiotics.

Impact of the administration of probiotics on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials

BACKGROUND

Previous reviews showed no benefit for the administration of probiotics in critically ill patients, but they did not focus on ventilator-associated pneumonia.

DESIGN

Meta-analysis of randomized controlled trials comparing probiotics and control in patients undergoing mechanical ventilation and reporting on incidence of ventilator-associated pneumonia.

METHODS

PubMed, Scopus, Current Contents, Cochrane Central Register of Controlled Trials, and reference lists were searched. Weighted mean differences, pooled odds ratios, and 95% confidence intervals were calculated, implementing both the Mantel-Haenszel fixed effect and the DerSimonian-Laird random effects model.

RESULTS

Five randomized controlled trials were included. Administration of probiotics, compared with control, was beneficial in terms of incidence of ventilator-associated pneumonia (689 patients; fixed effect model: odds ratio, 0.61; 95% confidence interval, 0.41-0.91; random effects model: odds ratio, 0.55, 95% confidence interval, 0.31-0.98), length of intensive care unit stay (fixed effect model: weighted mean difference, -0.99 days; 95% confidence interval, -1.37--0.61), and colonization of the respiratory tract with Pseudomonas aeruginosa (odds ratio, 0.35; 95% confidence interval, 0.13-0.93). However, no difference was revealed between comparators regarding intensive care unit mortality (odds ratio, 0.75; 95% confidence interval, 0.47-1.21), in-hospital mortality (odds ratio, 0.75; 95% confidence interval, 0.46-1.24), duration of mechanical ventilation (weighted mean difference, -0.01 days; 95% confidence interval, -0.31--0.29), and diarrhea (odds ratio, 0.61; 95% confidence interval, 0.28-1.34).

CONCLUSION

Administration of probiotics is associated with lower incidence of ventilator-associated pneumonia than control. Given the increasing antimicrobial resistance, this promising strategy deserves consideration in future studies, which should have active surveillance for probiotic-induced diseases.

Principles of source control in the management of sepsis

The term "source control" encompasses all those physical measures used to control a focus of invasive infection and to restore the optimal function of the affected area. Source-control measures can be categorized into 3 broad modalities: drainage controls the liquid component of an infection by converting a closed space infection to a controlled sinus or fistula; debridement is the physical removal of solid necrotic tissue (removal of an infected device can be considered a form of debridement); definitive measures seek to restore optimal function to the involved area. This article discusses specific approaches to source control in the abdomen, chest, and skin and soft tissues.

Tigecycline for the treatment of patients with community-acquired pneumonia requiring hospitalization

Pneumonia, along with influenza, is the leading cause of mortality associated with infectious diseases in the USA. Tigecycline is a novel antimicrobial agent that is active against a broad spectrum of pathogens. Our objective is to review the literature about the efficacy of tigecycline in community-acquired pneumonia (CAP). Data from various sources, including Pubmed, the European Medicines Agency (EMEA) and the US FDA were appraised. Tigecycline was found to be noninferior compared with levofloxacin for the treatment of patients with bacterial CAP requiring hospitalization. Recently, the drug was approved for the treatment of these patients by the FDA, but owing to some concerns, its application in the EMEA has been withdrawn. In addition, in a recent study concerns were expressed about the efficacy of tigecycline in the lungs using the current dosage. More data are needed about the pharmacokinetics of tigecycline in the lungs and its efficacy in severe CAP.

Treatment of acute bacterial exacerbations of chronic bronchitis

BACKGROUND

Controversies persist regarding the optimal management of patients with acute exacerbations of chronic bronchitis (AECB).

OBJECTIVE

To evaluate the available evidence on relevant issues, namely the need for administering antimicrobials in patients with AECB, the identification of the subgroup of patients with AECB needing antibiotics, the antimicrobial regimen of choice and its optimal duration, the existence of new agents, and the value of non-antimicrobial regimens for AECB.

METHODS

Data from various sources of evidence, including recent relevant meta-analyses, were appraised.

CONCLUSION

Administration of antimicrobial agents, combined with bronchodilators and systemic corticosteroids, is warranted in approximately half of AECBs (i.e., in bacterial exacerbations) to achieve a survival benefit. Simple clinical parameters, mainly sputum purulence, and biomarkers, such as procalcitonin, are useful in identifying patients requiring antibiotics. Advanced antibiotics (quinolones, macrolides, or amoxicillin/clavulanic acid) are more effective than 'old' antibiotics in AECB; regimens of short duration (for 5 days) are preferred. There is no difference between several classes of advanced antibiotics regarding their short-term effectiveness; however, quinolones are associated with better long-term outcomes than macrolides. Newer quinolones and new formulations of macrolides enrich clinicians' armamentarium against AECB.

Statins for sepsis: a critical and updated review

There is increasing discussion of a potential role for statins in the management of sepsis. A search of PubMed, Embase, Scopus and the Cochrane Library databases was performed by combining the terms 'statins', 'infection', 'sepsis', 'bacteraemia', 'pneumonia', and 'ICU infections'. A total of 22 studies were retrieved, which included 177,260 people and compared clinical outcomes between 51,193 statin users and 126,067 non-statin users. Nineteen were cohort studies (seven prospective and 12 retrospective), two were retrospective case-control studies, and one was a randomized controlled study. Nine studies examined the use of statins in sepsis, four in community-acquired pneumonia (CAP), three in bacteraemia, and three in post-operative patients. Mortality data were presented in 15 studies; in ten, mortality was lower among statin users (three of six sepsis studies, five of six CAP studies, and two of three bacteraemia studies). In four studies, there was no difference in mortality (two of six sepsis studies, one of six CAP studies, and one of three bacteraemia studies) and in one study there was increased mortality among septic intensive-care unit patients receiving statins. Five of the nine studies that examined the risk of developing sepsis/infection as a primary outcome (six of nine sepsis studies and all studies in the postoperative setting) found a decreased risk among statin users, whereas the remaining studies found no difference. Irrespective of their design (matched vs. non-matched), the majority of the studies suggested that statins have a beneficial effect on the outcome of infection; however, their observational design does not allow us to draw firm conclusions. The clinical benefit of statin therapy in sepsis remains to be determined by ongoing randomized controlled trials.