New guidelines for the management of adult community-acquired pneumonia

Red Blood Cell Distribution Width and Pediatric Community-Acquired Pneumonia Disease Severity

BACKGROUND AND OBJECTIVES

No standardized risk assessment tool exists for community-acquired pneumonia (CAP) in children. This study aims to investigate the association between red blood cell distribution width (RDW) and pediatric CAP.

METHODS

Data prospectively collected by the Etiology of Pneumonia in the Community study (2010-2012) was used. Study population was pediatric patients admitted to tertiary care hospitals in Nashville and Memphis, Tennessee with clinically and radiographically confirmed CAP. The earliest measured RDW value on admission was used, in quintiles and also as a continuous variable. Outcomes analyzed were: severe CAP (requiring ICU, mechanical ventilation, vasopressor support, or death) or moderate CAP (hospital admission only). Analysis used multivariable logistic regression and restricted cubic splines modeling.

RESULTS

In 1459 eligible children, the median age was 29 months (interquartile range: 12-73), median RDW was 13.3% (interquartile range: 12.5-14.3), and 289 patients (19.8%) developed severe disease. In comparison with the lowest RDW quintile (Q1), the adjusted odds ratio (95% CI) for severe CAP in subsequent quintiles were, Q2: 1.20 (0.72-1.99); Q3: 1.28 (0.76-2.14); Q4: 1.69 (1.01-2.82); Q5: 1.25 (0.73-2.13). Consistently, RDW restricted cubic splines demonstrated an independent, nonlinear, positive association with CAP severity (P = .027), with rapid increases in the risk of severe CAP with RDW values up to 15%.

CONCLUSIONS

Higher presenting RDW was associated with an increased risk of severe CAP in hospitalized children. Widely available and inexpensive, RDW can serve as an objective data point to help with clinical assessments.

Heparin-binding protein and procalcitonin in the diagnosis of pathogens causing community-acquired pneumonia in adult patients: a retrospective study

The performance of inflammatory markers in community-acquired pneumonia (CAP) caused by different pathogens has not been fully studied. We sought to find the differences in the concentrations of procalcitonin (PCT) and heparin-binding protein (HBP) between patients with CAP caused by different pathogens. We enrolled 162 patients with CAP, divided into three groups on the basis of bacterial (n = 108), fungal (n = 21) and viral (n = 33) infection. Complete leukocyte counts and the concentration of HBP and PCT were measured, and the differences were compared with nonparametric tests. The receiver operating characteristic (ROC) curve was used to evaluate the significant differences in the sensitivity and specificity of the indicators. The leukocyte and neutrophils counts and the concentrations of HBP and PCT in the viral group were significantly lower than those in the other two groups (p < 0.001). The area under the ROC curve (AUC) of the concentration of HBP and PCT as well as leukocyte and neutrophils counts were 0.927, 0.892, 0.832 and 0.806 for distinguishing bacterial from viral infection, respectively. The best cut-off value was 20.05 ng/mL for HBP, with a sensitivity of 0.861 and specificity of 0.939. The best cut-off value was 0.195 ng/mL for PCT, with a sensitivity of 0.991 and specificity of 0.636. The best cut-off value was 5.195 × 10⁹/L and 4.000 × 10⁹/L for leukocyte and neutrophils counts, with sensitivity of 0.694 and 0.880 and specificity of 0.667 and 0.636, respectively. The AUC of HBP, PCT and leukocyte and neutrophil counts for distinguishing fungal from viral infection were 0.851, 0.883, 0.835 and 0.830, respectively. The best cut-off values were 29.950 ng/mL, 0.560 ng/mL, 5.265 × 10⁹/L and 3.850 × 10⁹/L, with sensitivity of 0.667, 0.714, 0.905 and 0.952 and specificity of 0.970, 0.879 0.667 and 0.606, respectively. There were no significant differences in the three indicators between the bacterial and fungal infection groups. The concentration of CRP showed no significant differences among the three groups. Consequently, the stronger immune response characterized by higher inflammation markers including HBP and PCT can help distinguish bacterial and fungal CAP from viral CAP.

Poverty as an independent risk factor for in-hospital mortality in community-acquired pneumonia: A study in a developing country population

BACKGROUND

Community-acquired pneumonia (CAP) is one of the most severe lower respiratory tract infections with a high in-hospital mortality. The aim of this study was to investigate the socioeconomic and medical risk factors affecting the prognosis of acute pneumonia. The results of this study can mention the value of socioeconomic backgrounds like poverty and illiteracy in clinical practice, even in a well-known biological phenomenon (eg acute pneumonia).

METHODS

In this cross-sectional study, all admitted patients to a tertiary teaching hospital with a diagnosis of community acquired pneumonia in a 12-month period were enrolled. Socioeconomic and demographic characteristics, underlying conditions, clinical manifestations and para-clinical test results at admission registered prospectively. A logistic regression model was conducted using in-hospital mortality as the dependent variable.

RESULTS

A total of 621 patients was included in this study. Among them, 47 patients (7.6%) died during the hospitalisation period. In multiple logistic regression analysis, pleural effusion, a higher CURB-65 score, hyponatremia, hyperglycaemia and poverty (being in the lower economic class) were identified as independent risk factors for in-hospital mortality in community-acquired pneumonia.

CONCLUSION

Numerous factors can influence the prognosis of CAP. In addition to the CURB-65 score and some other medical risk factors, socioeconomic backgrounds can also affect the early outcome in CAP. In this study, being in the lower economic class (as an indicator of poverty) is interpreted as an independent risk factor for a poor prognosis in CAP.

Application of vibration response imaging technology in patients with community-acquired pneumonia before and after the treatment

The value of vibration response imaging (VRI) technology in patients with community-acquired pneumonia (CAP) was assessed. The VRI images of 62 cases of CAP patients with normal lung functions before and after treatment were observed and the changes in images before and after treatment were compared. The maximum vibration energy value of CAP patients was 1.64±0.32, patients with unsmoothed vibration energy curve accounted for 88.71%, 41 cases (66.12%) had unordered dynamic images, 56 cases (90.32%) jumping images, 54 cases (87.10%) desynchrony, 58 cases (93.55%) delay and 52 cases (83.87%) showed contrary events. The maximum vibration energy value after treatment was 1.59±0.29 and the difference was not statistically significant (P=0.93). Patients with unsmoothed vibration energy curve accounted for 20.97%, 11 cases (17.74%) appeared as unordered dynamic images, 28 cases (45.16%) of jumping images, 21 cases (33.87%) desynchrony, 18 cases (29.03%) delay and 10 cases (16.13%) with contrary events. The differences of these symptoms before and after treatment were statistically significant. The image scores of CAP patients before treatment were 10.33±1.95, higher (P<0.001) than after treatment (3.49±2.29). In conclusion, the changes of VRI images of CAP patients are relatively obvious and this technology can be used for the evaluation of CAP curative effects.

Antibiotic treatment patterns, costs, and resource utilization among patients with community acquired pneumonia: a US cohort study

OBJECTIVES

The current treatment options for patients with community-acquired pneumonia (CAP) often present a trade-off between the potential for treatment failure and safety concerns. We set out to investigate real-world outcomes associated with the use of currently available antimicrobial treatment options for CAP in both the outpatient and inpatient (non-intensive care unit [ICU]) settings.

METHODS

This claims-based retrospective study included adult patients diagnosed with CAP and treated with antibiotic therapies, including any oral fluoroquinolone, macrolide, or beta-lactam monotherapy in the outpatient setting, and intravenous (IV) levofloxacin or IV azithromycin/ceftriaxone in the inpatient setting. Generalized linear model (GLM) regression was used to determine total charges for inpatient stay, the length of stay, and days of inpatient therapy. For outpatients, rates of adverse events (AEs), treatment failure, and hospitalization were compared by type of initial antibiotic therapy using logistic regression multivariate models that controlled for baseline characteristics.

RESULTS

A total of 441,820 outpatients and 33,287 inpatients treated for CAP between 2007 and 2012 were included in this analysis. In the outpatient setting, fluoroquinolone therapy led to a higher rate of documented AEs (adjusted odds ratio [OR]: 1.23; 95% confidence interval [CI]: 1.20-1.25; p < 0.0001) but a lower rate of retreatment (adjusted OR: 0.9; 95% CI: 0.87-0.94; p < 0.0001) compared with macrolides. Both AEs and retreatment in these patients were associated with increased costs. For patients treated with the IV macrolide/beta-lactam combination compared with IV fluoroquinolone in the inpatient setting, a significantly longer length of stay in hospital (4.71 vs. 4.38 days; p < 0.0001) and greater overall costs ($3,535 more per stay; p < 0.0001) were observed.

CONCLUSION

In both the inpatient and outpatient settings, the development of additional efficacious treatment options that have a reduced AE burden for patients with CAP may be warranted.

Antimicrobial drug prescribing patterns for community-acquired pneumonia in hospitalized patients: A retrospective pilot study from New Delhi, India

OBJECTIVE

The objective of this study was to determine patterns and frequency of antimicrobial drug use among hospitalized patients with community-acquired pneumonia (CAP).

METHODOLOGY

A retrospective 5 years (April 2007-March 2012) detailed medical record review of patients diagnosed with CAP and discharged to home from Non-Intensive Care Unit respiratory medicine wards of two public hospitals in Delhi.

RESULTS

A total of 261 medical records were analyzed. Over the 5 years, 82.0% (2007-08), 78.6% (2008-09), 59.5% (2009-10), 64.7% (2010-11), and 67.8% (2011-12) patients were prescribed two antimicrobials. In the last two study years, the proportion of patients receiving three antimicrobials increased (from 2.0% to 26.5% and 28.8%), while the proportion receiving monotherapy decreased (from 16.0% to 8.8% and 3.4%). In accordance with guidelines, beta-lactams and macrolides were the two most frequently prescribed antimicrobials (34.1%). However, newer generation beta-lactams were prescribed. A total of 37 patients were prescribed beta-lactam-tazobactam combination preparations. Overall, beta-lactams constituted more than 40% of prescriptions while macrolides were the second most prescribed class. Cephalosporin prescriptions significantly increased (P < 0.01) and penicillin prescriptions significantly decreased over study periods. The prescription of fluoroquinolones also decreased (21.5-6.0%, P < 0.01) and aminoglycoside prescription ranged from 9.7% to 16.4%, over 5 years. Reasons for prescribing three antimicrobials, use of aminoglycosides, or higher-end/reserve antibiotics were not mentioned in the medical records. There were no hospital-specific guidelines for doctors to follow in the treatment of CAP.

CONCLUSIONS

These findings suggest the need for implementing antimicrobial treatment guidelines. Adequate documentation and monitoring of antibiotic use for feedback are also lacking. An antimicrobial stewardship program may offer the most comprehensive solution for appropriate use of antimicrobials.

Community-acquired pneumonia: impact of empirical antibiotic therapy without respiratory fluoroquinolones nor third-generation cephalosporins

Guidelines for inpatients with community-acquired pneumonia (CAP) propose to use respiratory fluoroquinolone (RFQ) and/or third-generation cephalosporins (Ceph-3). However, broad-spectrum antibiotic therapy is associated with the emergence of drug-resistant bacteria. We established a guideline in which RFQ and Ceph-3 were excluded as a first course. Our aim was to evaluate the impact of our therapeutic choices for CAP on the length of hospital stay (LOS) and patient outcome. This was a cohort study of patients with CAP from July 2005 to June 2014. We compared patients benefiting from our guideline established in 2008 to those receiving non-consensual antibiotics. Disease severity was evaluated through the Pneumonia Severity Index (PSI). The empirical treatment for PSI III to V was a combination therapy of amoxicillin-clavulanic acid (AMX-C) + roxithromycin (RX) or AMX + ofloxacin. Adherence to guidelines was defined by the prescription of one of these antibiotic agents. Requirement for intensive care or death defined unfavorable outcome. Among 1,370 patients, 847 were treated according to our guideline (61.8 %, group 1) and 523 without concordant therapy (38.2 %, group 2). The mean PSI was similar: 82 vs. 83, p > 0.5. The mean LOS was lower in group 1: 7.6 days vs. 9.1 days, p < 0.001. An unfavorable outcome was less frequent in group 1: 5.4 % vs. 9.9 %, p = 0.001. In logistic regression models, concordant therapy was associated with a favorable outcome: adjusted odds ratio (AOR) [95 % confidence interval (CI)] 1.85 [1.20-2.88], p = 0.005. CAP therapy without RFQ and Ceph-3 use was associated with a shorter LOS and fewer unfavorable outcomes.

Epidemiology, etiology, x-ray features, importance of co-infections and clinical features of viral pneumonia in developing countries

Pneumonia is still the number one killer of young children globally, accounting for 18% of mortality in children under 5 years of age. An estimated 120 million new cases of pneumonia occur globally each year. In developing countries, management and prevention efforts against pneumonia have traditionally focused on bacterial pathogens. More recently however, viral pathogens have gained attention as a result of improved diagnostic methods, such as polymerase chain reaction, outbreaks of severe disease caused by emerging pathogens, discovery of new respiratory viruses as well as the decrease in bacterial pneumonia as a consequence of the introduction of highly effective conjugate vaccines. Although the epidemiology, etiology and clinical characterization of viral infections are being studied extensively in the developed world, little data are available from low- and middle-income countries. In this paper, we review the epidemiology, etiology, clinical and radiological features of viral pneumonia in developing countries.

The diagnosis of pneumonia requires a chest radiograph (x-ray)-yes, no or sometimes?

Community-acquired pneumonia (CAP) remains a common condition associated with considerable morbidity and mortality. Outcome is improved by early recognition and rapid institution of empirical antibiotic therapy. A number of international guidelines recommend a chest radiograph (x-ray) is obtained when pneumonia is suspected; the argument forwarded is that chest radiographs are relatively inexpensive and enable pneumonia (lung consolidation) to be confirmed or excluded. But, radiographs are not available in the community setting and introduce a delay in diagnosis and treatment. For these reasons, in mild CAP treated by primary care, guidelines suggest criteria for clinical diagnosis. However, there is debate as to whether clinical features alone are sufficiently reliable to support a diagnosis of CAP with some suggesting diagnostic precision is improved by chest radiographs. Conversely, several studies have demonstrated a lack of agreement in the interpretation of chest radiographs bringing their role as the ultimate arbiter of diagnosis into question. Below we debate the diagnostic role of the humble chest radiograph in the context of suspected CAP.

Treating pneumonia in critical care in the United Kingdom following failure of initial antibiotic: a cost-utility analysis comparing meropenem with piperacillin/tazobactam

BACKGROUND

Treating patients admitted to critical care with severe pneumonia requires timely intervention with an effective antibiotic. This reduces the risk of dying of pneumonia and minimises complications associated with a prolonged stay in critical care.

OBJECTIVE

To compare the cost-effectiveness of meropenem 1 g/8 h with piperacillin/tazobactam 4.5 g/8 h for treating pneumonia in UK critical care.

METHODS

A Markov model was built to estimate lifetime costs and quality-adjusted life years (QALYs) of using meropenem versus piperacillin/tazobactam to treat severe pneumonia. Estimates of effectiveness, utility weights and costs were obtained from published sources. Probabilistic sensitivity analysis was conducted to address uncertainty in the model results.

RESULTS

Cost of treating a patient with severe pneumonia was estimated as £19,026 with meropenem and £19,978 with piperacillin/tazobactam, respectively. QALYs gained were 4.768 with meropenem and 4.654 with piperacillin/tazobactam. Probabilistic sensitivity analysis showed meropenem to be consistently less costly and more effective than piperacillin/tazobactam.

CONCLUSION

The additional efficacy of meropenem translates into more patients surviving critical care and leaving this high-cost service more quickly than if they had been treated with piperacillin/tazobactam. As meropenem is more effective and less expensive than piperacillin/tazobactam at treating patients with severe pneumonia, it is the dominant treatment option.

Prescription of antibiotics for adults hospitalized with community-acquired pneumonia in Korea in 2004: a population-based descriptive study

BACKGROUND AND OBJECTIVE

Community-acquired pneumonia (CAP) is generally considered to be a major cause of morbidity and mortality. There is much controversy regarding the optimal choice of antibiotics for patients with CAP. The aim of this study was to identify the antibiotics prescribed for adults hospitalized with CAP in Korea during a calendar year.

METHODS

This population-based, descriptive epidemiological study was performed using data from nationwide health insurance claims from 1 January 2004 to 31 December 2004. The study population was adults (≥18 years old), who had been hospitalized with CAP as determined by discharge diagnosis, and who had been treated with antibiotics for ≥3 days. The exclusion criteria were tuberculosis, underlying malignancies and potential nosocomial pneumonia, based on the department providing care, or surgery reports during the admission.

RESULTS

Of the 5592 adults hospitalized with CAP, data for 3662 (65.5%) patients was eligible for inclusion in the analysis. This included data for 1899 (51.9%) males, and 2045 (55.8%) patients ≥65 years of age. The most frequently prescribed antimicrobial regimen was β-lactam/β-lactamase inhibitors and fluoroquinolones in combination (31.0%), followed by β-lactam/β-lactamase inhibitors plus macrolides (30.2%), monotherapy (17.0%), β-lactam/β-lactamase inhibitors plus aminoglycosides (12.9%), β-lactam/β-lactamase inhibitors plus clindamycin (4.9%), and cephalosporins plus fluoroquinolones (2.5%). Monotherapy included, in decreasing order of use, cephalosporins (6.0%), fluoroquinolones (3.5%), β-lactam/β-lactamase inhibitors (2.3%) and macrolides (2.2%).

CONCLUSIONS

In this study, patterns of antimicrobial prescription for patients hospitalized with CAP were assessed for the first time in Korea. There was divergence from the 2009 Korean guidelines for the treatment of CAP, reinforcing the need for assessment of physicians' adherence to the guidelines.

Risk factors for mortality in cirrhotic patients with sepsis

BACKGROUND

Patients with cirrhosis and sepsis had increased mortality.

AIM

Determine factors associated with increased in-hospital mortality in cirrhotic patients admitted for sepsis.

METHODS

All cirrhotic patients admitted from 2004 to 2007 for sepsis were identified from hospital electronic database. Patients were included if they had liver cirrhosis and sepsis, defined as identified sources of infection, and at least one of fever, altered total white cell count, or raised C-reactive protein. Baseline characteristics, investigations, infections, and outcomes were collected. Main outcome measure was in-hospital mortality.

RESULTS

A total of 205 admissions in 153 patients were included. In-hospital mortality rate was 24.4%. In predicting in-hospital death, area under the receiver-operating-characteristic curve for Child-Pugh score was 0.934, with optimum cut-off at 10 and above, while for model for end-stage liver disease (MELD) score was 0.751, with optimum cut-off at 17 and above. Four factors were significantly associated with in-hospital mortality on multivariate analysis: presence of >1 site of infection, pneumonia, Child's C status, and MELD score 17 and above. In-hospital mortality rate increased with more factors: 0% with no factor, 7% with one factor, 21% with two factors, 87% with three factors, and 100% with four factors. The mortality of those with <3 risk factors was significantly lower than those with three or more risk factors (7 vs. 91%, p = 0.000).

CONCLUSIONS

Septic cirrhotic patients with pneumonia, >1 site of infection, Child's C cirrhosis, and high MELD score had a high mortality risk.

Severity scores for community-acquired pneumonia

An assessment of the severity of illness of a patient is one of the most important components of their early management. It guides decisions regarding the most appropriate site of care and the selection of empiric antibiotic therapy. In recent years, prediction tools, known as severity scores, have been promoted to assist early assessments of the severity of illness for patients with community-acquired pneumonia. Several different severity scores now exist and these have been modified over time. Each tool has particular strengths and weaknesses. This article reviews the evolution of severity scores for patients with community-acquired pneumonia and compares their performance in different patient cohorts for different outcomes of interest, as described in the published literature to date. It also discusses how these tools could be evaluated more comprehensively so that their place in patient management can be better appreciated.