Assessment of oxygenation and comorbidities improves outcome prediction in patients with community-acquired pneumonia with a low CRB-65 score

Validation of risk scores for prediction of severe pneumonia in kidney transplant recipients hospitalized with community-acquired pneumonia

PURPOSE

Risk scores for community-acquired pneumonia (CAP) are widely used for standardized assessment in immunocompetent patients and to identify patients at risk for severe pneumonia and death. In immunocompromised patients, the prognostic value of pneumonia-specific risk scores seems to be reduced, but evidence is limited. The value of different pneumonia risk scores in kidney transplant recipients (KTR) is not known.

METHODS

Therefore, we retrospectively analyzed 310 first CAP episodes after kidney transplantation in 310 KTR. We assessed clinical outcomes and validated eight different risk scores (CRB-65, CURB-65, DS-CRB-65, qSOFA, SOFA, PSI, IDSA/ATS minor criteria, NEWS-2) for the prognosis of severe pneumonia and in-hospital mortality. Risk scores were assessed up to 48 h after admission, but always before an endpoint occurred. Multiple imputation was performed to handle missing values.

RESULTS

In total, 16 out of 310 patients (5.2%) died, and 48 (15.5%) developed severe pneumonia. Based on ROC analysis, sequential organ failure assessment (SOFA) and national early warning score 2 (NEWS-2) performed best, predicting severe pneumonia with AUC of 0.823 (0.747-0.880) and 0.784 (0.691-0.855), respectively.

CONCLUSION

SOFA and NEWS-2 are best suited to identify KTR at risk for the development of severe CAP. In contrast to immunocompetent patients, CRB-65 should not be used to guide outpatient treatment in KTR, since there is a 7% risk for the development of severe pneumonia even in patients with a score of zero.

PLUS-IS-LESS project: Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments: study protocol for a pragmatic stepped-wedge cluster-randomized trial

BACKGROUND

Lower respiratory tract infections (LRTIs) are among the most frequent infections and a significant contributor to inappropriate antibiotic prescription. Currently, no single diagnostic tool can reliably identify bacterial pneumonia. We thus evaluate a multimodal approach based on a clinical score, lung ultrasound (LUS), and the inflammatory biomarker, procalcitonin (PCT) to guide prescription of antibiotics. LUS outperforms chest X-ray in the identification of pneumonia, while PCT is known to be elevated in bacterial and/or severe infections. We propose a trial to test their synergistic potential in reducing antibiotic prescription while preserving patient safety in emergency departments (ED).

METHODS

The PLUS-IS-LESS study is a pragmatic, stepped-wedge cluster-randomized, clinical trial conducted in 10 Swiss EDs. It assesses the PLUS algorithm, which combines a clinical prediction score, LUS, PCT, and a clinical severity score to guide antibiotics among adults with LRTIs, compared with usual care. The co-primary endpoints are the proportion of patients prescribed antibiotics and the proportion of patients with clinical failure by day 28. Secondary endpoints include measurement of change in quality of life, length of hospital stay, antibiotic-related side effects, barriers and facilitators to the implementation of the algorithm, cost-effectiveness of the intervention, and identification of patterns of pneumonia in LUS using machine learning.

DISCUSSION

The PLUS algorithm aims to optimize prescription of antibiotics through improved diagnostic performance and maximization of physician adherence, while ensuring safety. It is based on previously validated tests and does therefore not expose participants to unforeseeable risks. Cluster randomization prevents cross-contamination between study groups, as physicians are not exposed to the intervention during or before the control period. The stepped-wedge implementation of the intervention allows effect calculation from both between- and within-cluster comparisons, which enhances statistical power and allows smaller sample size than a parallel cluster design. Moreover, it enables the training of all centers for the intervention, simplifying implementation if the results prove successful. The PLUS algorithm has the potential to improve the identification of LRTIs that would benefit from antibiotics. When scaled, the expected reduction in the proportion of antibiotics prescribed has the potential to not only decrease side effects and costs but also mitigate antibiotic resistance.

TRIAL REGISTRATION

This study was registered on July 19, 2022, on the ClinicalTrials.gov registry using reference number: NCT05463406.

TRIAL STATUS

Recruitment started on December 5, 2022, and will be completed on November 3, 2024. Current protocol version is version 3.0, dated April 3, 2023.

[Community-acquired pneumonia]

RISK FACTORS FOR SEVERE COURSES

The CRB-65 score is recommended as a risk predictor, as well as consideration of unstable comorbidities and oxygenation.

GROUPING OF COMMUNITY-ACQUIRED PNEUMONIA

Community-acquired pneumonia is divided into 3 groups: mild pneumonia, moderate pneumonia, severe pneumonia. Whether there is a curative vs palliative treatment goal should be determined early.

DIAGNOSTIC RECOMMENDATION

An X-ray chest radiograph is recommended to confirm the diagnosis, also in the outpatient setting if possible. Sonography of the thorax is an alternative, asking for additional imaging if negative. Streptococcus pneumoniae remains the most common bacterial pathogen.

THERAPY

Community-acquired pneumonia continues to be associated with high morbidity and lethality. Prompt diagnosis and prompt initiation of risk-adapted antimicrobial therapy are essential measures. However, in times of COVID-19, as well as the current influenza and RSV epidemic, purely viral pneumonias must also be expected. At least with COVID-19, antibiotics can often be avoided. Antiviral and anti-inflammatory drugs are used here.

POST-ACUTE COURSE

Patients after community-acquired pneumonia have increased acute and long-term mortality due to cardiovascular events in particular. The focus of research is on improved pathogen identification, a better understanding of the host response with the potential of developing specific therapeutics, the role of comorbidities, and the long-term consequences of the acute illness.

Unmet needs in pneumonia research: a comprehensive approach by the CAPNETZ study group

Introduction

Despite improvements in medical science and public health, mortality of community-acquired pneumonia (CAP) has barely changed throughout the last 15 years. The current SARS-CoV-2 pandemic has once again highlighted the central importance of acute respiratory infections to human health. The “network of excellence on Community Acquired Pneumonia” (CAPNETZ) hosts the most comprehensive CAP database worldwide including more than 12,000 patients. CAPNETZ connects physicians, microbiologists, virologists, epidemiologists, and computer scientists throughout Europe. Our aim was to summarize the current situation in CAP research and identify the most pressing unmet needs in CAP research.

Methods

To identify areas of future CAP research, CAPNETZ followed a multiple-step procedure. First, research members of CAPNETZ were individually asked to identify unmet needs. Second, the top 100 experts in the field of CAP research were asked for their insights about the unmet needs in CAP (Delphi approach). Third, internal and external experts discussed unmet needs in CAP at a scientific retreat.

Results

Eleven topics for future CAP research were identified: detection of causative pathogens, next generation sequencing for antimicrobial treatment guidance, imaging diagnostics, biomarkers, risk stratification, antiviral and antibiotic treatment, adjunctive therapy, vaccines and prevention, systemic and local immune response, comorbidities, and long-term cardio-vascular complications.

Conclusion

Pneumonia is a complex disease where the interplay between pathogens, immune system and comorbidities not only impose an immediate risk of mortality but also affect the patients’ risk of developing comorbidities as well as mortality for up to a decade after pneumonia has resolved. Our review of unmet needs in CAP research has shown that there are still major shortcomings in our knowledge of CAP.

Comparison of the prognostic performance of the CURB-65 and a modified version of the pneumonia severity index designed to identify high-risk patients using the International Community-Acquired Pneumonia Collaboration Cohort

BACKGROUND

Although the PSI and CURB-65 represent well-validated prediction rules for pneumonia prognosis, PSI was designed to identify patients at low risk and CURB- 65 patients at high risk of mortality. We compared the prognostic performance of a modified version of the PSI designed to identify high-risk patients (i.e., PSI-HR) to CURB-65 in predicting short-term mortality.

METHODS

Using data from 6 pneumonia cohorts, we designed PSI-HR as a 6-class prediction rule using the original prognostic weights of all PSI variables and modifying the risk score thresholds to define risk classes. We calculated the proportion of low-risk and high-risk patients using CURB-65 and PSI-HR and 30-day mortality in these subgroups. We compared the rules' sensitivity, specificity, positive and negative predictive values for mortality at all risk class thresholds and assessed discriminatory power using areas under their receiver operating characteristic curves (AUROCs).

RESULTS

Among 13,874 patients with pneumonia, 1,036 (7.5%) died. For PSI-HR versus CURB-65, aggregate mortality was lower in low-risk patients (1.6% vs. 2.2%, p = 0.005) and higher in high-risk patients (36.5% vs. 32.2%, p = 0.27). PSI-HR had higher sensitivities than CURB-65 at all thresholds; PSI-HR also had higher specificities at the 3 lowest thresholds and specificities within 0.5% points of CURB-65 at the 2 highest thresholds. The AUROC was larger for PSI-HR than CURB- 65 (0.82 vs. 0.77, p < 0.0001).

CONCLUSIONS

PSI-HR demonstrated superior prognostic accuracy to CURB-65 at the lower end of the severity spectrum and identified high-risk patients with nonsignificant higher short-term mortality at the higher end.

Procalcitonin and lung ultrasonography point-of-care testing to determine antibiotic prescription in patients with lower respiratory tract infection in primary care: pragmatic cluster randomised trial

OBJECTIVE

To assess whether point-of care procalcitonin and lung ultrasonography can safely reduce unnecessary antibiotic treatment in patients with lower respiratory tract infections in primary care.

DESIGN

Three group, pragmatic cluster randomised controlled trial from September 2018 to March 2020.

SETTING

60 Swiss general practices.

PARTICIPANTS

One general practitioner per practice was included. General practitioners screen all patients with acute cough; patients with clinical pneumonia were included.

INTERVENTIONS

Randomisation in a 1:1:1 of general practitioners to either antibiotics guided by sequential procalcitonin and lung ultrasonography point-of-care tests (UltraPro; n=152), procalcitonin guided antibiotics (n=195), or usual care (n=122).

MAIN OUTCOMES

Primary outcome was proportion of patients in each group prescribed an antibiotic by day 28. Secondary outcomes included duration of restricted activities due to lower respiratory tract infection within 14 days.

RESULTS

60 general practitioners included 469 patients (median age 53 years (interquartile range 38-66); 278 (59%) were female). Probability of antibiotic prescription at day 28 was lower in the procalcitonin group than in the usual care group (0.40 v 0.70, cluster corrected difference -0.26 (95% confidence interval -0.41 to -0.10)). No significant difference was seen between UltraPro and procalcitonin groups (0.41 v 0.40, -0.03 (-0.17 to 0.12)). The median number of days with restricted activities by day 14 was 4 days in the procalcitonin group and 3 days in the usual care group (difference 1 day (95% confidence interval -0.23 to 2.32); hazard ratio 0.75 (95% confidence interval 0.58 to 0.97)), which did not prove non-inferiority.

CONCLUSIONS

Compared with usual care, point-of-care procalcitonin led to a 26% absolute reduction in the probability of 28 day antibiotic prescription without affecting patients' safety. Point-of-care lung ultrasonography did not further reduce antibiotic prescription, although a potential added value cannot be excluded, owing to the wide confidence intervals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03191071.

[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.

Derivation and Validation of a Novel Severity Scoring System for Pneumonia at Intensive Care Unit Admission

BACKGROUND

Severity stratification scores developed in intensive care units (ICUs) are used in interventional studies to identify the most critically ill. Studies that evaluate accuracy of these scores in ICU patients admitted with pneumonia are lacking. This study aims to determine performance of severity scores as predictors of mortality in critically ill patients admitted with pneumonia.

METHODS

Prospective cohort study in a general ICU in Brazil. ICU severity scores (Simplified Acute Physiology Score 3 [SAPS 3] and Sepsis-Related Organ Failure Assessment [qSOFA]), prognostic scores of pneumonia (CURB-65 [confusion, urea, respiratory rate, blood pressure, age] and CRB-65 [confusion, respiratory rate, blood pressure, age]), and clinical and epidemiological variables in the first 6 hours of hospitalization were analyzed.

RESULTS

Two hundred patients were included between 2015 and 2018, with a median age of 81 years (interquartile range, 67-90 years) and female predominance (52%), primarily admitted from the emergency department (65%) with community-acquired pneumonia (CAP, 80.5%). SAPS 3, CURB-65, CRB-65,and qSOFA all exhibited poor performance in predicting mortality. Multivariate regression identified variables independently associated with mortality that were used to develop a novel pneumonia-specific ICU severity score (Pneumonia Shock score) that outperformed SAPS 3, CURB-65, and CRB-65. The Shock score was validated in an external multicenter cohort of critically ill patients admitted with CAP.

CONCLUSIONS

We created a parsimonious score that accurately identifies patients with pneumonia at highest risk of ICU death. These findings are critical to accurately stratify patients with severe pneumonia in therapeutic trials that aim to reduce mortality.

Limited prognostic accuracy of the CRB-65 and qSOFA in patients presenting with pneumonia and immunosuppression

BACKGROUND

Scores for risk prediction used in immunocompetent patients with sepsis or pneumonia are poorly evaluated in immunocompromised patients. Therefore, we evaluated the prognostic value of the qSOFA- and CRB-65-criteria in immunocompromised patients presenting with pneumonia.

METHODS

Retrospective cohort study including consecutive patients hospitalized with pneumonia and immunosuppression without treatment restrictions. The qSOFA and CRB-65 criteria were documented in the emergency department. Outcome was defined as need of mechanical ventilation (MV) or vasopressor support (VS) and/or hospital-mortality.

RESULTS

41 of 198 (21%) patients reached the outcome and 10% died. Both, the CRB-65 and qSOFA- were independently associated with the outcome (all p<0.01), but age was not predictive. ROC curve analysis showed moderate predictive potential for both scores (CRB-65: AUC 0.63 and qSOFA: 0.69). With scores of 0, the negative predictive values were below 90% (CRB-65: 9/60 and qSOFA: 12/105 missed patients). With scores > 1, the positive predictive values were 36% (CRB-65) and 58% (qSOFA), respectively.

CONCLUSIONS

Both, the qSOFA and the CRB-65 only showed moderate prognostic value, and negative predictive values were inadequate to exclude organ failure or death in patients with immunosuppression. In this population, age was not a predictive parameter. Patients with > 1 positive vital sign criterion measured by both scores should be assessed for organ failure.

[Fatal severe community-acquired pneumonia: risk factors, clinical characteristics and medical errors of hospital patients]

Community-acquired pneumonia (CAP) is the most common disease and potentially life-threatening infection in the worldwide. In the Nizhny Novgorod region, no analysis of the causes of mortality and medical errors of severe CAP patients.

AIM

To analyze the patients structure who died severe CAP in hospitals of the Nizhny Novgorod region, to identify the leading risk factors, to assess the clinical characteristics of fatal severe CAP and medical errors according to medical records of patients from 20152016.

MATERIALS AND METHODS

This was a retrospective study of medical records of 139 patients with fatal severe CAP from medical organizations of the Nizhny Novgorod region. The 72 patients died in 2015. The mortality rate from pneumonia was 67 cases in 2016.

RESULTS

The key predictors of the fatal severe CAP in patients of the Nizhny Novgorod region identified: socio-demographic status (men of working age, unemployed, smoking, alcohol and drug dependence), late treatment and hospitalization, tachypnea, hypotension, tachycardia, confusion, leukocytosis or leukopenia, thrombocytopenia, anemia, hyperglycemia, bilateral lung damage, pleural effusion, acute respiratory failure. The leading medical errors in fatal CAP were incorrect assessment of the severity of the patients condition, untimely CAP, non-monitoring of SpO2 on the first day of hospitalization, late transfer of patients to the intensive care unit, there was no influenza therapy, inadequate starting antibacterial therapy.

CONCLUSION

The main ways to avoid or minimize medical errors and reduce the mortality of patients with TVP is strict adherence to clinical recommendations, active preventive measures, diagnosis and treatment of chronic diseases.

Initial diagnosis and management of adult community-acquired pneumonia: a 5-day prospective study in Shanghai

Background

Despite the release of a national guideline in 2016, the actual practices with respect to adult community-acquired pneumonia (CAP) remain unknown in China. We aimed to investigate CAP patient management practices in Shanghai to identify potential problems and provide evidence for policy making.

Methods

A short-period, 5-day prospective cross-sectional study was performed with sampled pulmonologists from 36 hospitals, encompassing all the administrative districts of Shanghai, during January 8–12, 2018. The medical information was recorded and analyzed for the patients with the diagnosis of CAP who were cared for by 46 pulmonologists during the study period.

Results

Overall, 435 patients were included in the final analysis, and 94.3% had a low risk of death in terms of CRB-65 criteria (C: disturbance of consciousness, R: respiratory rate, B: blood pressure, 65: age). When diagnosed with CAP, 70.1% of patients were not evaluated using the CURB-65 score (CRB-65 + U: urea nitrogen), but most patients (95.4%) were evaluated using CRB-65. Time to achieve clinical stability was longer in patients with hypoxemia than in those without hypoxemia (8.42±6.36 vs. 5.53±4.12 days, P=0.004). Overall, 84.4% of patients with a CRB-65 score of 0 were administered antibiotics intravenously, and 19.4% were still hospitalized after excluding hypoxemia and comorbidities. The average duration of antibiotic treatment was 10.4±4.9 days. Overall, 72.6% of patients received antibiotics covering atypical pathogens whose time to clinical stability was significantly shortened compared with those without coverage, but the antibiotic duration was similar and not correspondingly shortened.

Conclusions

CRB-65 seems to be more practical than CURB-65 for the initial evaluation of CAP in the context of local practice, and oxygenation assessment should be included in the evaluation of severity. Overtreatment may be relatively common in patients at low risk of death, including unreasonable hospitalization, intravenous administration, and antibiotic duration.

Calculated parenteral initial treatment of bacterial infections: Respiratory infections

This is the fifth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. It provides recommendations for the empirical and targeted antimicrobial treatment of lower respiratory tract infections, with a special emphasis on the treatment of acute exacerbation of COPD, community-acquired pneumonia and hospital-acquired pneumonia.

Management Of Community-Acquired Pneumonia: An Observational Study In UK Primary Care

Purpose

In primary care, initial diagnosis of community-acquired pneumonia (CAP) is made on clinical judgment without radiological confirmation or knowledge of the causative organism. Use of CRB65 score has been recommended for assessing the severity of CAP and thereby determining clinical management, but it is not known how frequently these scores are used in primary care.

Patients and methods

Primary care consultations in adults with a diagnostic code for CAP between 1 January 2009 and 31 December 2016 were extracted from the Optimum Patient Care Research Database, which at the time of data extraction had over 3.4 million patients in the UK. Episodes without antibiotic prescription on day of diagnosis were excluded, as were records describing past events. Patients admitted to hospital on day of diagnosis were excluded, but were included in exploratory analysis of CRB65 recording.

Results

In total, 4734 episodes of CAP in adults managed in primary care between 1 January 2009 and 31 December 2016 were included. A range of investigations/observations were recorded, including pulse rate (10.7%), chest examinations (9.1%) and blood tests (5.4%). CRB65 scores were recorded in 19 (0.4%) episodes of CAP, 17 of which were after the publication of the NICE guidelines in December 2014. CRB65 recording was no more frequent in 3819 episodes referred to hospital (12, 0.3%; p=0.63), but where recorded, CRB65 scores were higher (Median: 1.0 [interquartile range: 0.5–1.0] vs 2.0 [interquartile range: 1.0–2.0], p=0.04). The most commonly prescribed antibiotic was amoxicillin (40.3%), and 85.9% of episodes had a prescription length of seven days.

Conclusion

CRB65 scores are seldom recorded in UK primary care. Given that these scores are embedded in UK guidelines, further work is required to assess feasibility and barriers to use of CRB65 scores in primary care.

Systematic review with meta-analysis: high mortality in patients with non-severe alcoholic hepatitis

BACKGROUND

Alcoholic hepatitis is a serious complication of alcohol misuse. Severe alcoholic hepatitis with its high mortality, has been investigated in detail but 'nonsevere alcoholic hepatitis' is poorly characterised. Survival of this group of patients is unknown.

AIM

To conduct a systematic review and meta-analysis to determine 28-day, 90-day and 1-year mortality of patients with nonsevere alcoholic hepatitis.

METHODS

The protocol was registered on the PROSPERO database (CRD42018107451). Embase, Medline and Cochrane Central databases were searched until July 2018. All study designs reporting mortality rates in patients with nonsevere alcoholic hepatitis were eligible. Mortality data were extracted and meta-analysis performed using a random effects model. Risk of bias was assessed by Cochrane risk of bias or National Institutes of Health quality assessment tool for case series studies.

RESULTS

Twenty-five studies (n = 1372 patients; 12 prospective) met criteria. Nonsevere was variably defined based on bilirubin, prothrombin time, and creatinine. Twenty-eight day mortality (17 studies; n = 993) was 6% (95% CI 3%-9%; I2  = 67.3%; P < 0.001), 90-day mortality (15 studies; n = 755) was 7% (4%-11%, I2  = 64.2%; P < 0.001) and 1-year mortality (five studies; n = 234) was 13% (4%-24%; I2  = 72%; P = 0.006). Subgroup analyses by method of diagnosis (histological vs clinical) or study design (prospective vs retrospective) did not reveal differences in mortality.

CONCLUSION

Nonsevere alcoholic hepatitis is not benign with 6% and 13% 28-day and 1-year mortality, respectively. This systematic review demonstrates the paucity of high quality studies in patients with nonsevere alcoholic hepatitis. Our analysis suggests that patients who do not meet criteria for severe alcoholic hepatitis are an important and hitherto overlooked clinical group. Full characterisation of clinical outcome and development of treatment strategies to reduce mortality in this group is a priority.

Meta-analysis of Calibration, Discrimination, and Stratum-Specific Likelihood Ratios for the CRB-65 Score

BACKGROUND

The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients.

OBJECTIVE

To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios.

DESIGN

Meta-analysis of accuracy, discrimination, and calibration.

METHODS

We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported.

KEY RESULTS

Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95% CI 0.71-0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95% CI 0.91-1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70-0.81) and 0.88 (0.69-1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients.

CONCLUSIONS

The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4% overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5%.

Sequential organ failure assessment score is an excellent operationalization of disease severity of adult patients with hospitalized community acquired pneumonia - results from the prospective observational PROGRESS study

BACKGROUND

CAP (Community acquired pneumonia) is frequent, with a high mortality rate and a high burden on health care systems. Development of predictive biomarkers, new therapeutic concepts, and epidemiologic research require a valid, reproducible, and quantitative measure describing CAP severity.

METHODS

Using time series data of 1532 patients enrolled in the PROGRESS study, we compared putative measures of CAP severity for their utility as an operationalization. Comparison was based on ability to correctly identify patients with an objectively severe state of disease (death or need for intensive care with at least one of the following: substantial respiratory support, treatment with catecholamines, or dialysis). We considered IDSA/ATS minor criteria, CRB-65, CURB-65, Halm criteria, qSOFA, PSI, SCAP, SIRS-Score, SMART-COP, and SOFA.

RESULTS

SOFA significantly outperformed other scores in correctly identifying a severe state of disease at the day of enrollment (AUC = 0.948), mainly caused by higher discriminative power at higher score values. Runners-up were the sum of IDSA/ATS minor criteria (AUC = 0.916) and SCAP (AUC = 0.868). SOFA performed similarly well on subsequent study days (all AUC > 0.9) and across age groups. In univariate and multivariate analysis, age, sex, and pack-years significantly contributed to higher SOFA values whereas antibiosis before hospitalization predicted lower SOFA.

CONCLUSIONS

SOFA score can serve as an excellent operationalization of CAP severity and is proposed as endpoint for biomarker and therapeutic studies.

TRIAL REGISTRATION

clinicaltrials.gov NCT02782013 , May 25, 2016, retrospectively registered.

[Epidemiology and management of community acquired pneumonia: more than 10 years experience]

OBJECTIVE

To describe the characteristics of patients diagnosed with Community Acquired Pneumonia in this basic health area, their management, outcomes, and use of prognostic scales driven by the few studies carried out from Primary Care on these aspects.

MATERIAL AND METHODS

Descriptive cross-sectional study on a population diagnosed with Community Acquired Pneumonia if three urban health centres, during the period January 2000 to 31 July 2103.

RESULTS

Out of a sample of 1,290 patients obtained, 56.1% were men, and the mean age of the population was 61.9 years. There were 22.7% smokers. More than half (59.9%) had a disease in the prognostic scales, with Diabetes Mellitus present in 20%, and 36.1% with pulmonary disease (17.6% COPD, 11.8% asthma). Just under half (43.2%) of the total patients were diagnosed in Primary Care. There was a diagnostic X-ray in 92.7% of the cases, and a follow-up X-ray in 59.4%. Prognostic scales were recorded in 2% of the cases. The most commonly used antibiotics were amoxicillin-clavulanic (30.7%) and levofloxacin (30.4%). Having prior disease increases the risk of re-treatment by 1.6 (95% CI; 1.1-2.2)]. The mortality risk is multiplied by 5.3 on having a previous disease (95% CI; 1.3-19.2).

CONCLUSIONS

In the Primary Care setting, Community Acquired Pneumonia is a common and potentially serious disease which, in half the cases, occurs in patients with associated comorbidity. As regards treatment and management, is highlighted the wide use made of amoxicillin-clavulanic, compared to the low use of amoxicillin, combined therapy, and prognostic scales.

The Differential Diagnosis of Dyspnea

BACKGROUND

Dyspnea is a common symptom affecting as many as 25% of patients seen in the ambulatory setting. It can arise from many different underlying conditions and is sometimes a manifestation of a life-threatening disease.

METHODS

This review is based on pertinent articles retrieved by a selective search in PubMed, and on pertinent guidelines.

RESULTS

The term dyspnea refers to a wide variety of subjective perceptions, some of which can be influenced by the patient's emotional state. A distinction is drawn between dyspnea of acute onset and chronic dyspnea: the latter, by definition, has been present for more than four weeks. The history, physical examination, and observation of the patient's breathing pattern often lead to the correct diagnosis, yet, in 30-50% of cases, more diagnostic studies are needed, including biomarker measurements and other ancillary tests. The diagnosis can be more difficult to establish when more than one underlying disease is present simultaneously. The causes of dyspnea include cardiac and pulmonary disease (congestive heart failure, acute coronary syndrome; pneumonia, chronic obstructive pulmonary disease) and many other conditions (anemia, mental disorders).

CONCLUSION

The many causes of dyspnea make it a diagnostic challenge. Its rapid evaluation and diagnosis are crucial for reducing mortality and the burden of disease.

Community-Acquired Pneumonia in Adults

BACKGROUND

The clinical spectrum of community-acquired pneumonia ranges from infections that can be treated on an outpatient basis, with 1% mortality, to those that present as medical emergencies, with a mortality above 40%.

METHODS

This article is based on pertinent publications and current guidelines retrieved by a selective search of the literature.

RESULTS

The radiological demonstration of an infiltrate is required for the differentiation of pneumonia from acute bronchitis regardless of whether the patient is seen in the outpatient setting or in the emergency room. For risk prediction, it is recommended that the CRB-65 criteria, unstable comorbidities, and oxygenation should be taken into account. Amoxicillin is the drug of choice for mild pneumonia; it should be given in combination with clavulanic acid if there are any comorbid illnesses. The main clinical concerns in the emergency room are the identification of acute organ dysfunction and the management of sepsis. Intravenous beta-lactam antibiotics should be given initially, in combination with a macrolide if acute organ dysfunction is present. The treatment should be continued for 5-7 days. Cardiovascular complications worsen the patient's prognosis and should be meticulously watched for. Structured followup care includes the follow-up of comorbid conditions and the initiation of recommended preventive measures such as antipneumococcal and anti-influenza vaccination, the avoidance of drugs that increase the risk, smoking cessation, and treatment of dysphagia, if present.

CONCLUSION

Major considerations include appropriate risk stratification and the implementation of a management strategy adapted to the degree of severity of the disease, along with the establishment of structured follow-up care and secondary prevention, especially for patients with comorbidities.

Functional status and mortality prediction in community-acquired pneumonia

BACKGROUND AND OBJECTIVE

Poor functional status (FS) has been suggested as a poor prognostic factor in both pneumonia and severe pneumonia in elderly patients. However, it is still unclear whether FS is associated with outcomes and improves survival prediction in community-acquired pneumonia (CAP) in the general population.

METHODS

Data on hospitalized patients with CAP and FS, assessed by the Eastern Cooperative Oncology Group (ECOG) scale were prospectively collected between January 2008 and December 2012. The independent association of FS with 30-day mortality in CAP patients was evaluated using multivariable logistic regression. Improvement in mortality prediction when FS was added to the CRB-65 (confusion, respiratory rate, blood pressure and age 65) score was evaluated for discrimination, reclassification and calibration.

RESULTS

The 30-day mortality of study participants (n = 1526) was 10%. Mortality significantly increased with higher ECOG score (P for trend <0.001). In multivariable analysis, ECOG ≥3 was strongly associated with 30-day mortality (adjusted OR: 5.70; 95% CI: 3.82-8.50). Adding ECOG ≥3 significantly improved the discriminatory power of CRB-65. Reclassification indices also confirmed the improvement in discrimination ability when FS was combined with the CRB-65, with a categorized net reclassification index (NRI) of 0.561 (0.437-0.686), a continuous NRI of 0.858 (0.696-1.019) and a relative integrated discrimination improvement in the discrimination slope of 139.8 % (110.8-154.6).

CONCLUSION

FS predicted 30-day mortality and improved discrimination and reclassification in consecutive CAP patients. Assessment of premorbid FS should be considered in mortality prediction in patients with CAP.

Penicillin treatment for patients with Community-Acquired Pneumonia in Denmark: a retrospective cohort study

BACKGROUND

Community-acquired pneumonia (CAP) is a severe infection, with high mortality. Antibiotic strategies for CAP differ across Europe. The objective of the study was to describe the epidemiology of CAP in Denmark and evaluate the prognosis of patients empirically treated with penicillin-G/V monotherapy.

METHODS

Retrospective cohort study including hospitalized patients with x-ray confirmed CAP. We calculated the population-based incidence, reviewed types of empiric antibiotics and duration of antibiotic treatment. We evaluated the association between mortality and treatment with empiric penicillin-G/V using logistic regression analysis.

RESULTS

We included 1320 patients. The incidence of hospitalized CAP was 3.1/1000 inhabitants. Median age was 71 years (IQR; 58-81) and in-hospital mortality was 8%. Median duration of antibiotic treatment was 10 days (IQR; 8-12). In total 45% were treated with penicillin-G/V as empiric monotherapy and they did not have a higher mortality compared to patients treated with broader-spectrum antibiotics (OR 0.92, CI 95% 0.55-1.53).

CONCLUSION

The duration of treatment exceeded recommendations in European guidelines. Empiric monotherapy with penicillin-G/V was commonly used and not associated with increased mortality in patients with mild to moderate pneumonia. Our results are in agreement with current conservative antibiotic strategy as outlined in the Danish guidelines.

[CAPNETZ. The competence network for community-acquired pneumonia (CAP)]

CAPNETZ is a medical competence network for community-acquired pneumonia (CAP), which was funded by the German Ministry for Education and Research. It has accomplished seminal work on pneumonia over the last 15 years. A unique infrastructure was established which has so far allowed us to recruit and analyze more than 11,000 patients. The CAPNETZ cohort is the largest cohort worldwide and the results obtained relate to all relevant aspects of CAP management (epidemiology, risk stratification via biomarkers or clinical scores, pathogen spectrum, pathogen resistance, antibiotic management, prevention and health care research). Results were published in more than 150 journals and informed the preparation and update of the national S3-guideline. CAPNETZ was also the foundation for further networks like the Pneumonia Research Network on Genetic Resistance and Susceptibility for the Evolution of Severe Sepsis) (PROGRESS), the Systems Medicine of Community Acquired Pneumonia Network (CAPSyS) and SFB-TR84 (Sonderforschungsbereich - Transregio 84). The main recipients (Charité Berlin, University Clinic Ulm and the Hannover Medical School) founded the CAPNETZ foundation and transferred all data and materials rights to this foundation. Moreover, the ministry granted the CAPNETZ foundation the status of being eligible to apply for research proposals and receive research funds. Since 2013 the CAPNETZ foundation has been an associated member of the German Center for Lung Research (DZL). Thus, a solid foundation has been set up for CAPNETZ to continue its success story.

Tools for outcome prediction in patients with community acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is one of the most common causes of mortality world-wide. The mortality rate of patients with CAP is influenced by the severity of the disease, treatment failure and the requirement for hospitalization and/or intensive care unit (ICU) management, all of which may be predicted by biomarkers and clinical scoring systems. Areas covered: We review the recent literature examining the efficacy of established and newly-developed clinical scores, biological and inflammatory markers such as C-Reactive protein (CRP), procalcitonin (PCT) and Interleukin-6 (IL-6), whether used alone or in conjunction with clinical severity scores to assess the severity of CAP, predict treatment failure, guide acute in-hospital or ICU admission and predict mortality. Expert commentary: The early prediction of treatment failure using clinical scores and biomarkers plays a developing role in improving survival of patients with CAP by identifying high-risk patients requiring hospitalization or ICU admission; and may enable more efficient allocation of resources. However, it is likely that combinations of scoring systems and biomarkers will be of greater use than individual markers. Further larger studies are needed to corroborate the additive value of these markers to clinical prediction scores to provide a safer and more effective assessment tool for clinicians.

Improving outcomes in community-acquired pneumonia

PURPOSE OF REVIEW

Community-acquired pneumonia (CAP) is a pervasive disease that is encountered in outpatient and inpatient settings. CAP is the leading cause of death from an infectious disease and accounts for significant worldwide morbidity and mortality. This update reviews current advances that can be used to promote improved outcomes in CAP.

RECENT FINDINGS

Early recognition of CAP and its severe presentations, with appropriate site of care decisions, leads to reduced patient mortality. In addition to traditional prognostic tools, certain serum biomarkers can assist in defining disease severity and guide treatment and management strategies. The use of macrolides as part of combination antibiotic therapy has shown beneficial mortality effects across the CAP disease spectrum, especially for those with severe illness. When treating community-associated, methicillin-resistant Staphylococcus aureus pneumonia, use of an antitoxin antibiotic is likely to be valuable. Adjunctive therapy with corticosteroids may prevent delayed clinical resolution in selected patients with severe CAP. Recent data expand on the interaction of CAP with comorbid disease, particularly cardiovascular disease, and its impact on mortality in CAP patients.

SUMMARY

Improved diagnostic tools, optimized treatment regimens, and enhanced understanding of CAP-induced perturbations in comorbid disease states hold promise to improve patient outcomes.

Advances in the prevention, management, and treatment of community-acquired pneumonia

Community-acquired pneumonia (CAP) is the infectious disease with the highest number of deaths worldwide. Nevertheless, its importance is often underestimated. Large cohorts of patients with CAP have been established worldwide and improved our knowledge about CAP by far. Therefore, current guidelines are much more evidence-based than ever before. This article discusses recent major studies and concepts on CAP such as the role of biomarkers, appropriate risk stratification to identify patients in need of hospitalisation or intensive care, appropriate empiric antibiotic therapy (including the impact of macrolide combination therapy and antibiotic stewardship), and CAP prevention with novel influenza and pneumococcal vaccines.