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Qin Q, Yu H, Zhao J, Xu X, Li Q, Gu W, Guo X. Machine learning-based derivation and validation of three immune phenotypes for risk stratification and prognosis in community-acquired pneumonia: a retrospective cohort study. Front Immunol 2024; 15:1441838. [PMID: 39114653 PMCID: PMC11303239 DOI: 10.3389/fimmu.2024.1441838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/05/2024] [Indexed: 08/10/2024] Open
Abstract
Background The clinical presentation of Community-acquired pneumonia (CAP) in hospitalized patients exhibits heterogeneity. Inflammation and immune responses play significant roles in CAP development. However, research on immunophenotypes in CAP patients is limited, with few machine learning (ML) models analyzing immune indicators. Methods A retrospective cohort study was conducted at Xinhua Hospital, affiliated with Shanghai Jiaotong University. Patients meeting predefined criteria were included and unsupervised clustering was used to identify phenotypes. Patients with distinct phenotypes were also compared in different outcomes. By machine learning methods, we comprehensively assess the disease severity of CAP patients. Results A total of 1156 CAP patients were included in this research. In the training cohort (n=809), we identified three immune phenotypes among patients: Phenotype A (42.0%), Phenotype B (40.2%), and Phenotype C (17.8%), with Phenotype C corresponding to more severe disease. Similar results can be observed in the validation cohort. The optimal prognostic model, SuperPC, achieved the highest average C-index of 0.859. For predicting CAP severity, the random forest model was highly accurate, with C-index of 0.998 and 0.794 in training and validation cohorts, respectively. Conclusion CAP patients can be categorized into three distinct immune phenotypes, each with prognostic relevance. Machine learning exhibits potential in predicting mortality and disease severity in CAP patients by leveraging clinical immunological data. Further external validation studies are crucial to confirm applicability.
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Affiliation(s)
- Qiangqiang Qin
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haiyang Yu
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jie Zhao
- Department of Hematology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xue Xu
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qingxuan Li
- Department of Respiratory and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Wen Gu
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xuejun Guo
- Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Meyer HJ, Mödl L, Unruh O, Xiang W, Berger S, Müller-Plathe M, Rohde G, Pletz MW, Rupp J, Suttorp N, Witzenrath M, Zoller T, Mittermaier M, Steinbeis F. Comparison of clinical outcomes in hospitalized patients with COVID-19 or non-COVID-19 community-acquired pneumonia in a prospective observational cohort study. Infection 2024:10.1007/s15010-024-02292-z. [PMID: 38761325 DOI: 10.1007/s15010-024-02292-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/06/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE Coronavirus disease 2019 (COVID-19) and non-COVID-19 community-acquired pneumonia (NC-CAP) often result in hospitalization with considerable risks of mortality, ICU treatment, and long-term morbidity. A comparative analysis of clinical outcomes in COVID-19 CAP (C-CAP) and NC-CAP may improve clinical management. METHODS Using prospectively collected CAPNETZ study data (January 2017 to June 2021, 35 study centers), we conducted a comprehensive analysis of clinical outcomes including in-hospital death, ICU treatment, length of hospital stay (LOHS), 180-day survival, and post-discharge re-hospitalization rate. Logistic regression models were used to examine group differences between C-CAP and NC-CAP patients and associations with patient demography, recruitment period, comorbidity, and treatment. RESULTS Among 1368 patients (C-CAP: n = 344; NC-CAP: n = 1024), C-CAP showed elevated adjusted probabilities for in-hospital death (aOR 4.48 [95% CI 2.38-8.53]) and ICU treatment (aOR 8.08 [95% CI 5.31-12.52]) compared to NC-CAP. C-CAP patients were at increased risk of LOHS over seven days (aOR 1.88 [95% CI 1.47-2.42]). Although ICU patients had similar in-hospital mortality risk, C-CAP was associated with length of ICU stay over seven days (aOR 3.59 [95% CI 1.65-8.38]). Recruitment period influenced outcomes in C-CAP but not in NC-CAP. During follow-up, C-CAP was linked to a reduced risk of re-hospitalization and mortality post-discharge (aOR 0.43 [95% CI 0.27-0.70]). CONCLUSION Distinct clinical trajectories of C-CAP and NC-CAP underscore the need for adapted management to avoid acute and long-term morbidity and mortality amid the evolving landscape of CAP pathogens.
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Affiliation(s)
- Hans-Jakob Meyer
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Pneumology, Helios Klinikum Emil Von Behring, Lungenklinik Heckeshorn, Berlin, Germany
| | - Lukas Mödl
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | | | - Weiwei Xiang
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sarah Berger
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Moritz Müller-Plathe
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Gernot Rohde
- CAPNETZ STIFTUNG, Hannover, Germany
- Department of Respiratory Medicine, Goethe University, University Hospital, Medical Clinic I, Frankfurt/Main, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Mathias W Pletz
- CAPNETZ STIFTUNG, Hannover, Germany
- Institute of Infectious Diseases and Infection Control, Jena University Hospital /Friedrich Schiller University, Jena, Germany
| | - Jan Rupp
- CAPNETZ STIFTUNG, Hannover, Germany
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Norbert Suttorp
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- CAPNETZ STIFTUNG, Hannover, Germany
- German Center for Lung Research (DZL), Berlin, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- CAPNETZ STIFTUNG, Hannover, Germany
- German Center for Lung Research (DZL), Berlin, Germany
| | - Thomas Zoller
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Mirja Mittermaier
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Fridolin Steinbeis
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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Choudhary T, Upadhyaya P, Davis CM, Yang P, Tallowin S, Lisboa FA, Schobel SA, Coopersmith CM, Elster EA, Buchman TG, Dente CJ, Kamaleswaran R. Derivation and Validation of Generalized Sepsis-induced Acute Respiratory Failure Phenotypes Among Critically Ill Patients: A Retrospective Study. RESEARCH SQUARE 2024:rs.3.rs-4307475. [PMID: 38746442 PMCID: PMC11092838 DOI: 10.21203/rs.3.rs-4307475/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Background Septic patients who develop acute respiratory failure (ARF) requiring mechanical ventilation represent a heterogenous subgroup of critically ill patients with widely variable clinical characteristics. Identifying distinct phenotypes of these patients may reveal insights about the broader heterogeneity in the clinical course of sepsis. We aimed to derive novel phenotypes of sepsis-induced ARF using observational clinical data and investigate their generalizability across multi-ICU specialties, considering multi-organ dynamics. Methods We performed a multi-center retrospective study of ICU patients with sepsis who required mechanical ventilation for ≥24 hours. Data from two different high-volume academic hospital systems were used as a derivation set with N=3,225 medical ICU (MICU) patients and a validation set with N=848 MICU patients. For the multi-ICU validation, we utilized retrospective data from two surgical ICUs at the same hospitals (N=1,577). Clinical data from 24 hours preceding intubation was used to derive distinct phenotypes using an explainable machine learning-based clustering model interpreted by clinical experts. Results Four distinct ARF phenotypes were identified: A (severe multi-organ dysfunction (MOD) with a high likelihood of kidney injury and heart failure), B (severe hypoxemic respiratory failure [median P/F=123]), C (mild hypoxia [median P/F=240]), and D (severe MOD with a high likelihood of hepatic injury, coagulopathy, and lactic acidosis). Patients in each phenotype showed differences in clinical course and mortality rates despite similarities in demographics and admission co-morbidities. The phenotypes were reproduced in external validation utilizing an external MICU from second hospital and SICUs from both centers. Kaplan-Meier analysis showed significant difference in 28-day mortality across the phenotypes (p<0.01) and consistent across both centers. The phenotypes demonstrated differences in treatment effects associated with high positive end-expiratory pressure (PEEP) strategy. Conclusion The phenotypes demonstrated unique patterns of organ injury and differences in clinical outcomes, which may help inform future research and clinical trial design for tailored management strategies.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eric A Elster
- Uniformed Services University of the Health Sciences
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Carella F, Aliberti S, Stainer A, Voza A, Blasi F. Long-Term Outcomes in Severe Community-Acquired Pneumonia. Semin Respir Crit Care Med 2024; 45:266-273. [PMID: 38395062 DOI: 10.1055/s-0044-1781426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Community-acquired pneumonia (CAP) is globally one of the major causes of hospitalization and mortality. Severe CAP (sCAP) presents great challenges and need a comprehensive understanding of its long-term outcomes. Cardiovascular events and neurological impairment, due to persistent inflammation and hypoxemia, contribute to long-term outcomes in CAP, including mortality. Very few data are available in the specific population of sCAP. Multiple studies have reported variable 1-year mortality rates for patients with CAP up to 40.7%, with a clear influence by age, comorbidities, and disease severity. In terms of treatment, the potential protective role of macrolides in reducing mortality emphasizes the importance of appropriate empiric antibiotic therapy. This narrative review explores the growing interest in the literature focusing on the long-term implications of sCAP. Improved understanding of long-term outcomes in sCAP can facilitate targeted interventions and enhance posthospitalization care protocols.
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Affiliation(s)
- Francesco Carella
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Antonio Voza
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Emergency Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesco Blasi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Méndez R, González-Jiménez P, Mengot N, Menéndez R. Treatment Failure and Clinical Stability in Severe Community-Acquired Pneumonia. Semin Respir Crit Care Med 2024; 45:225-236. [PMID: 38224700 DOI: 10.1055/s-0043-1778139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
Treatment failure and clinical stability are important outcomes in community-acquired pneumonia (CAP). It is essential to know the causes and risk factors for treatment failure and delay in reaching clinical stability in CAP. The study of both as well as the associated underlying mechanisms and host response are key to improving outcomes in pneumonia.
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Affiliation(s)
- Raúl Méndez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Paula González-Jiménez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
| | - Noé Mengot
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
| | - Rosario Menéndez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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Almutairi A, Alenezi F, Tamim H, Sadat M, Humaid FB, AlMatrood A, Syed Y, Arabi Y. The prevalence of acute kidney injury in patients with community-acquired pneumonia who required mechanical ventilation. Ann Saudi Med 2024; 44:104-110. [PMID: 38615183 PMCID: PMC11016152 DOI: 10.5144/0256-4947.2024.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 12/08/2023] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a common reason for intensive care unit (ICU) admission and sepsis. Acute kidney injury (AKI) is a frequent complication of community-acquired pneumonia and is associated with increased short- and long-term morbidity and mortality and healthcare costs. OBJECTIVE Describe the prevalence of AKI in patients with CAP requiring mechanical ventilation and evaluate its association with inhospital mortality. DESIGN Retrospective cohort. SETTING Intensive care unit. PATIENTS AND METHODS We included patients with CAP on mechanical ventilation. Patients were categorized according to the development of AKI in the first 24 hours of ICU admission using the Kidney Disease Improving Global Outcomes (KDIGO) classification from no AKI, stage 1 AKI, stage 2 AKI, and stage 3 AKI. MAIN OUTCOME MEASURES The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, hospital and ICU length of stay, ventilation duration, tracheostomy, and renal replacement therapy requirement. RESULTS Of 1536 patients included in the study, 829 patients (54%) had no AKI while 707 (46%) developed AKI. In-hospital mortality was 288/829 (34.8%) for patients with no AKI, 43/111 (38.7%) for stage 1 AKI, 86/216 (40%) for stage 2 AKI, and 196/380 (51.7%) for stage 3 AKI (P<.0001). Multivariate analysis revealed that stages 1, 2, or 3 AKI compared to no AKI were not independently associated with in-hospital mortality. Older age, vasopressor use; decreased Glasgow coma scale, PaO2/Fio2 ratio and platelet count, increased bilirubin, lactic acid and INR were associated with increased mortality while female sex was associated with reduced mortality. CONCLUSION Among mechanically ventilated patients with CAP, AKI was common and was associated with higher crude mortality. The higher mortality could not be attributed alone to AKI, but rather appeared to be related to multi-organ dysfunction. LIMITATIONS Single-center retrospective study with no data on baseline serum creatinine and the use of estimated baseline creatinine distributions based on the MDRD (Modification of Diet in Renal Disease)equation which may lead to an overestimation of AKI. Second, we did not have data on the microbiology of pneumonia, appropriateness of antibiotic therapy or the administration of other medications that have been demonstrated to be associated with AKI.
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Affiliation(s)
- Abdulmajed Almutairi
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Farhan Alenezi
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hani Tamim
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Musharaf Sadat
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Felwa Bin Humaid
- Intensive Care Unit, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Amal AlMatrood
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yadullah Syed
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yaseen Arabi
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Paraskevas T, Kantanis A, Karalis I, Michailides C, Karamouzos V, Koniari I, Pierrakos C, Velissaris D. N-acetylcysteine efficacy in patients hospitalized with COVID-19 pneumonia: a systematic review and meta-analysis. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2023; 61:41-52. [PMID: 36627753 DOI: 10.2478/rjim-2023-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND N-acetylcysteine (NAC) is a mucolytic agents with anti-inflammatory properties that has been suggested as an adjunctive therapy in patients with COVID-19 pneumonia. OBJECTIVES We conducted a systematic review and meta-analysis to evaluate available evidence on the possible beneficial effects of NAC on SARS-CoV-2 infection. METHODS In September 2022, we conducted a comprehensive search on Pubmed/Medline and Embase on randomized controlled trials (RCTs) and observational studies on NAC in patients with COVID-19 pneumonia. Study selection, data extraction and risk of bias assessment was performed by two independent authors. RCTs and observational studies were analyzed separately. RESULTS We included 3 RCTs and 5 non-randomized studies on the efficacy of NAC in patients with COVID-19, enrolling 315 and 20826 patients respectively. Regarding in-hospital mortality, the summary effect of all RCTs was OR: 0.85 (95% CI: 0.43 to 1.67, I2=0%) and for non-randomized studies OR: 1.02 (95% CI: 0.47 to 2.23, I2=91%). Need for ICU admission was only reported by 1 RCT (OR: 0.86, 95% CI:0.44-1.69, p=0.66), while all included RCTs reported need for invasive ventilation (OR:0.91, 95% CI:0.54 to 1.53, I2=0). Risk of bias was low for all included RCTs, but certainty of evidence was very low for all outcomes due to serious imprecision and indirectness. CONCLUSION The certainty of evidence in the included studies was very low, thus recommendations for clinical practice cannot be yet made. For all hard clinical outcomes point estimates in RCTs are close to the line of no effect, while observational studies have a high degree of heterogeneity with some of them suggesting favorable results in patients receiving NAC. More research is warranted to insure that NAC is both effective and safe in patients with COVID-19 pneumonia.
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Affiliation(s)
| | - Anastasios Kantanis
- Department of General Practice and Family Medicine, General University Hospital of Patras, Patras, Greece
| | - Iosif Karalis
- Department of Internal Medicine, General University Hospital of Patras, Patras, Greece
| | - Christos Michailides
- Department of Internal Medicine, General University Hospital of Patras, Patras, Greece
| | | | - Ioanna Koniari
- Cardiology Department, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Charalampos Pierrakos
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, General University Hospital of Patras, Patras, Greece
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Myristoyl lysophosphatidylcholine is a biomarker and potential therapeutic target for community-acquired pneumonia. Redox Biol 2022; 58:102556. [PMID: 36459717 PMCID: PMC9712772 DOI: 10.1016/j.redox.2022.102556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/18/2022] [Accepted: 11/24/2022] [Indexed: 11/27/2022] Open
Abstract
There is no gold standard for evaluating the severity of community-acquired pneumonia (CAP), and it is still based on a score. This study aimed to use the metabolomics method to find promised biomarkers in assessing disease severity and potential therapeutic targets for CAP. The result found that the metabolites in the plasma samples of CAP patients had significantly different between the acute phase and the remission phase, especially lysophosphatidylcholine (LPCs) in glycerophospholipids, whose levels are negatively linked to the severity of the disease. Subsequently, the two key metabolites of myristoyl lysophosphatidylcholine (LPC 14:0) and LPC 16:1 were screened. We analyzed the predictive performance of the two metabolites using Spearman-related analysis and ROC curves, and LPC14:0 showed more satisfactory diagnostic performance than LPC16:1. Then we explored the protective role and mechanism of LPC 14:0 in animal and cell models. The results showed that LPC 14:0 could inhibit the LPS-induced secretion of IL-1β, IL-6, and TNF-α, lower the ROS and MDA levels, and decreased the depletion of SOD and GSH, thereby reducing lung tissue and cell damage, such as down-regulating the protein level in BALF, lung W/D ratio, MPO activity, and apoptosis. We found that LPC 14:0 inhibited LPS-induced inflammatory response and oxidative stress, and the above protection was achieved by inhibiting LPS-induced activation of the NLRP3 inflammasome. LPC 14:0 may serve as a novel biomarker for predicting the severity of CAP. In addition, our exploration of the role of LPC 14:0 in animal and cellular models has reinforced its promise as a therapeutic target to improve the clinical efficacy for CAP.
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Prendki V, Garin N, Stirnemann J, Combescure C, Platon A, Bernasconi E, Sauter T, Hautz W. LOw-dose CT Or Lung UltraSonography versus standard of care based-strategies for the diagnosis of pneumonia in the elderly: protocol for a multicentre randomised controlled trial (OCTOPLUS). BMJ Open 2022; 12:e055869. [PMID: 35523502 PMCID: PMC9083386 DOI: 10.1136/bmjopen-2021-055869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Pneumonia is a leading cause of mortality and a common indication for antibiotic in elderly patients. However, its diagnosis is often inaccurate. We aim to compare the diagnostic accuracy, the clinical and cost outcomes and the use of antibiotics associated with three imaging strategies in patients >65 years old with suspected pneumonia in the emergency room (ER): chest X-ray (CXR, standard of care), low-dose CT scan (LDCT) or lung ultrasonography (LUS). METHODS AND ANALYSIS This is a multicentre randomised superiority clinical trial with three parallel arms. Patients will be allocated in the ER to a diagnostic strategy based on either CXR, LDCT or LUS. All three imaging modalities will be performed but the results of two of them will be masked during 5 days to the patients, the physicians in charge of the patients and the investigators according to random allocation. The primary objective is to compare the accuracy of LDCT versus CXR-based strategies. As secondary objectives, antibiotics prescription, clinical and cost outcomes will be compared, and the same analyses repeated to compare the LUS and CXR strategies. The reference diagnosis will be established a posteriori by a panel of experts. Based on a previous study, we expect an improvement of 16% of the accuracy of pneumonia diagnosis using LDCT instead of CXR. Under this assumption, and accounting for 10% of drop-out, the enrolment of 495 patients is needed to prove the superiority of LDCT over CRX (alpha error=0.05, beta error=0.10). ETHICS AND DISSEMINATION Ethical approval: CER Geneva 2019-01288. TRIAL REGISTRATION NUMBER NCT04978116.
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Affiliation(s)
- Virginie Prendki
- Division of Internal Medicine for the Aged, Geneva University Hospitals, Thônex, Switzerland
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Nicolas Garin
- Division of General Internal Medicine, Riviera Chablais Hospitals, Rennaz, Switzerland
- Department of Internal Medicine Specialties, Geneva University Hospitals, Geneva, Switzerland
| | - Jerome Stirnemann
- Department of Internal Medicine Specialties, Geneva University Hospitals, Geneva, Switzerland
| | - Christophe Combescure
- Department of Health and Community Medicine, Geneva University Hospitals, Geneve, Switzerland
| | - Alexandra Platon
- Diagnostic Department, Division of Radiology, Geneva University Hospitals, Geneva, Switzerland
| | - Enos Bernasconi
- Division of Infectious Diseases, Ente Ospedaliero Cantonale, University of Southern Switzerland, Lugano, Switzerland
| | - Thomas Sauter
- Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Wolf Hautz
- Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland
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Global Perspective of Legionella Infection in Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis of Observational Studies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031907. [PMID: 35162928 PMCID: PMC8835084 DOI: 10.3390/ijerph19031907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/11/2021] [Accepted: 01/20/2022] [Indexed: 01/27/2023]
Abstract
Legionnaires’ disease (LD) (Legionella) is a common cause of community-acquired pneumonia (CAP) in those requiring hospitalization. Geographical variation in the importance of Legionella species as an aetiologic agent of CAP is poorly understood. We performed a systematic review and meta-analysis of population-based observational studies that reported the proportion of Legionella infection in patients with CAP (1 January 1990 to 31 May 2020). Using five electronic databases, articles were identified, appraised and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The quality of the included studies was assessed using the Newcastle–Ottawa Scale. Univariate and multivariate meta-regression analyses were conducted using study design, WHO region, study quality and healthcare setting as the explanatory variables. We reviewed 2778 studies, of which 219 were included in the meta-analysis. The mean incidence of CAP was 46.7/100,000 population (95% CI: 46.6–46.8). The mean proportion of Legionella as the causative agent for CAP was 4.6% (95% CI: 4.4 to 4.7). Consequently, the mean Legionella incidence rate was 2.8/100,000 population (95% CI: 2.7–2.9). There was significant heterogeneity across all studies I2 = 99.27% (p < 0.0001). After outliers were removed, there was a decrease in the heterogeneity (I2 = 43.53%). Legionella contribution to CAP has a global distribution. Although the rates appear highest in high income countries in temperate regions, there are insufficient studies from low- and middle-income countries to draw conclusions about the rates in these regions. Nevertheless, this study provides an estimate of the mean incidence of Legionella infection in CAP, which could be used to estimate the regional and global burden of LD to support efforts to reduce the impact of this infection as well as to fill important knowledge gaps.
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Steuder R, Pott H, Maxheim M, Schmeck B. Pneumonie und COVID-19 bei COPD-Patienten. PNEUMO NEWS 2021; 13:30-35. [PMID: 34691274 PMCID: PMC8526095 DOI: 10.1007/s15033-021-2749-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Regina Steuder
- Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Universitätsklinikum Marburg, Hans-Meerwein-Str. 2, 35043 Marburg, Germany
| | - Hendrik Pott
- Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Universitätsklinikum Marburg, Hans-Meerwein-Str. 2, 35043 Marburg, Germany
| | - Michael Maxheim
- Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Universitätsklinikum Marburg, Hans-Meerwein-Str. 2, 35043 Marburg, Germany
| | - Bernd Schmeck
- Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Universitätsklinikum Marburg, Hans-Meerwein-Str. 2, 35043 Marburg, Germany
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Understanding the Host in the Management of Pneumonia. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2021; 18:1087-1097. [PMID: 34242148 PMCID: PMC8328365 DOI: 10.1513/annalsats.202102-209st] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Pneumonia causes a significant burden of disease worldwide. Although all populations are at risk of pneumonia, those at extremes of age and those with immunosuppressive disorders, underlying respiratory disease, and critical illness are particularly vulnerable. Although clinical practice guidelines addressing the management and treatment of pneumonia exist, few of the supporting studies focus on the crucial contributions of the host in pneumonia pathogenesis and recovery. Such essential considerations include the host risk factors that lead to susceptibility to lung infections; biomarkers reflecting the host response and the means to pursue host-directed pneumonia therapy; systemic effects of pneumonia on the host; and long-term health outcomes after pneumonia. To address these gaps, the Pneumonia Working Group of the Assembly on Pulmonary Infection and Tuberculosis led a workshop held at the American Thoracic Society meeting in May 2018 with overarching objectives to foster attention, stimulate research, and promote funding for short-term and long-term investigations into the host contributions to pneumonia. The workshop involved participants from various disciplines with expertise in lung infection, pneumonia, sepsis, immunocompromised patients, translational biology, data science, genomics, systems biology, and clinical trials. This workshop report summarizes the presentations and discussions and important recommendations for future clinical pneumonia studies. These recommendations include establishing consensus disease and outcome definitions, improved phenotyping, development of clinical study networks, standardized data and biospecimen collection and protocols, and development of innovative trial designs.
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Aliberti S, Dela Cruz CS, Amati F, Sotgiu G, Restrepo MI. Community-acquired pneumonia. Lancet 2021; 398:906-919. [PMID: 34481570 DOI: 10.1016/s0140-6736(21)00630-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/22/2021] [Accepted: 03/05/2021] [Indexed: 02/06/2023]
Abstract
Community-acquired pneumonia is not usually considered a high-priority problem by the public, although it is responsible for substantial mortality, with a third of patients dying within 1 year after being discharged from hospital for pneumoniae. Although up to 18% of patients with community-acquired pneumonia who were hospitalised (admitted to hospital and treated there) have at least one risk factor for immunosuppression worldwide, strong evidence on community-acquired pneumonia management in this population is scarce. Several features of clinical management for community-acquired pneumonia should be addressed to reduce mortality, morbidity, and complications related to community-acquired pneumonia in patients who are immunocompetent and patients who are immunocompromised. These features include rapid diagnosis, microbiological investigation, prevention and management of complications (eg, respiratory failure, sepsis, and multiorgan failure), empirical antibiotic therapy in accordance with patient's risk factors and local microbiological epidemiology, individualised antibiotic therapy according to microbiological data, appropriate outcomes for therapeutic switch from parenteral to oral antibiotics, discharge planning, and long-term follow-up. This Seminar offers an updated view on community-acquired pneumonia in adults, with suggestions for clinical and translational research.
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Affiliation(s)
- Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy.
| | - Charles S Dela Cruz
- Department of Internal Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale School of Medicine, New Haven, CT, USA
| | - Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy
| | - Giovanni Sotgiu
- Department of Medical, Surgical and Experimental Sciences, Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | - Marcos I Restrepo
- Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
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Ewig S, Kolditz M, Pletz M, Altiner A, Albrich W, Drömann D, Flick H, Gatermann S, Krüger S, Nehls W, Panning M, Rademacher J, Rohde G, Rupp J, Schaaf B, Heppner HJ, Krause R, Ott S, Welte T, Witzenrath M. [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)]. Pneumologie 2021; 75:665-729. [PMID: 34198346 DOI: 10.1055/a-1497-0693] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta-Kranken-Anstalt Bochum
| | - M Kolditz
- Universitätsklinikum Carl-Gustav Carus, Klinik für Innere Medizin 1, Bereich Pneumologie, Dresden
| | - M Pletz
- Universitätsklinikum Jena, Institut für Infektionsmedizin und Krankenhaushygiene, Jena
| | - A Altiner
- Universitätsmedizin Rostock, Institut für Allgemeinmedizin, Rostock
| | - W Albrich
- Kantonsspital St. Gallen, Klinik für Infektiologie/Spitalhygiene
| | - D Drömann
- Universitätsklinikum Schleswig-Holstein, Medizinische Klinik III - Pulmologie, Lübeck
| | - H Flick
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Lungenkrankheiten, Graz
| | - S Gatermann
- Ruhr Universität Bochum, Abteilung für Medizinische Mikrobiologie, Bochum
| | - S Krüger
- Kaiserswerther Diakonie, Florence Nightingale Krankenhaus, Klinik für Pneumologie, Kardiologie und internistische Intensivmedizin, Düsseldorf
| | - W Nehls
- Helios Klinikum Erich von Behring, Klinik für Palliativmedizin und Geriatrie, Berlin
| | - M Panning
- Universitätsklinikum Freiburg, Department für Medizinische Mikrobiologie und Hygiene, Freiburg
| | - J Rademacher
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - G Rohde
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Pneumologie und Allergologie, Frankfurt/Main
| | - J Rupp
- Universitätsklinikum Schleswig-Holstein, Klinik für Infektiologie und Mikrobiologie, Lübeck
| | - B Schaaf
- Klinikum Dortmund, Klinik für Pneumologie, Infektiologie und internistische Intensivmedizin, Dortmund
| | - H-J Heppner
- Lehrstuhl Geriatrie Universität Witten/Herdecke, Helios Klinikum Schwelm, Klinik für Geriatrie, Schwelm
| | - R Krause
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Infektiologie, Graz
| | - S Ott
- St. Claraspital Basel, Pneumologie, Basel, und Universitätsklinik für Pneumologie, Universitätsspital Bern (Inselspital) und Universität Bern
| | - T Welte
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - M Witzenrath
- Charité, Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie, Berlin
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Chen D, Yuan H, Cao C, Liu Z, Jiang L, Tan Y, Ding J, Ma M, Huang W, Wan X. Impact of acute kidney injury on in-hospital outcomes in Chinese patients with community acquired pneumonia. BMC Pulm Med 2021; 21:143. [PMID: 33933054 PMCID: PMC8088559 DOI: 10.1186/s12890-021-01511-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 04/21/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent complication of community acquired pneumonia (CAP). However, the impact of AKI on in-hospital outcomes of patients with CAP in the Chinese population remains unclear. METHODS Patients diagnosed with CAP were evaluated in this retrospective observational study. Multiple Cox regression models were employed to identify the association between AKI and in-hospital mortality and 30-day mortality, respectively. RESULTS A total of 4213 patients were recruited; 950 (22.5%) patients were diagnosed with AKI. Independent risk factors for AKI were age, male gender, hypertension, cardiac dysfunction, diabetes, chronic kidney disease, acute respiratory failure, use of diuretics, use of vasoactive drugs, and CURB-65. Cox proportional hazards regression revealed AKI, use of angiotensin receptor blocker, hypertension, CURB-65, acute respiratory failure, and use of vasoactive drugs to be independent risk factors for both in-hospital and 30-day mortality. Compared to patients without AKI, those suffering AKI were found to have 1.31-fold (HR 1.31, 95% CI, 1.04-1.66; P = 0.023) and 1.29-fold (HR 1.29, 95% CI, 1.02-1.62; P = 0.033) increased in-hospital and 30-day mortality risks, respectively. In addition, patients with AKI were likely to require admission to intensive care unit (ICU) (42.9% versus 11.4%; P < 0.001), mechanical ventilation (33.8% versus 9.3%; P < 0.001), invasive mechanical ventilation (25.9% versus 5.8%; P < 0.001), non-invasive mechanical ventilation (25.4% versus 7.1%; P < 0.001), and experienced a longer duration of hospital stay (14 days versus 10 days; P < 0.001) than those without AKI. However, no significant difference in ICU stay (11 days versus 10 days; P = 0.099) and duration of mechanical ventilation (8 days versus 8 days; P = 0.369) between AKI and non-AKI groups was found. CONCLUSION AKI was common in Chinese patients with CAP. Patients with CAP who developed AKI had worse in-hospital outcomes.
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Affiliation(s)
- Dawei Chen
- Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, China
| | - Hongbo Yuan
- Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, China
| | - Changchun Cao
- Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhihe Liu
- Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, China
| | - Linglin Jiang
- Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, China
| | - Yan Tan
- Department of Respiratory Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ji Ding
- Department of Cardiothoracic Surgery, Yizheng People's Hospital, Yangzhou, Jiangsu, China
| | - Mengqing Ma
- Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Wenjuan Huang
- Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, China
| | - Xin Wan
- Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, China. .,Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.
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Admission lysophosphatidylethanolamine acyltransferase level predicts the severity and prognosis of community-acquired pneumonia. Infection 2021; 49:877-888. [PMID: 33694084 DOI: 10.1007/s15010-021-01585-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 02/06/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Early diagnosis and prognosis of patients with community-acquired pneumonia (CAP) are still difficult clinical challenges. This study aimed to investigate the role of lysophosphatidylethanolamine acyltransferase (LPEAT) in CAP and to evaluate the effectiveness of this enzyme as an indicator of disease severity and risk of death in CAP. METHODS This retrospective, multi-center study was conducted in 2017. A total of 267 patients with CAP were included. Of these 267 patients, 175 patients had non-severe CAP (non-SCAP) and 92 patients had severe CAP (SCAP). In addition, we recruited 15 healthy volunteers and 42 hospitalized disease controls in our study. The demographic and clinical characteristics were recorded for all participants. Admission levels of LPEAT were determined by quantitative enzyme-linked immunosorbent assay. RESULTS Admission levels of LPEAT in patients with SCAP were significantly higher, particularly in non-survivors and were not affected by the causative etiology. Furthermore, when the patients were stratified according to PSI and CURB-65 scores, the patients with high severity scores had higher LPEAT levels upon admission than patients with low severity scores. LPEAT also performed well in predicting SCAP in patients with CAP. Moreover, LPEAT could predict the 30-day mortality rate of patients with CAP, and combining LPEAT with the clinical severity score further improved the accuracy of mortality prediction. CONCLUSION Elevated LPEAT levels can reliably predict the severity of illness in patients with CAP at the time of admission. Adding LPEAT to clinical scoring methods could improve prognostic accuracy. Trial registration ClinicalTrials.gov, NCT03093220. Registered on March 28th, 2017.
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de Miguel-Díez J, Jiménez-García R, Hernández-Barrera V, Puente-Maestu L, Ji Z, de Miguel-Yanes JM, Méndez-Bailón M, López-de-Andrés A. Ventilatory Support Use in Hospitalized Patients With Community-Acquired Pneumonia. Fifteen-year Trends in Spain (2001–2015). Arch Bronconeumol 2020; 56:792-800. [DOI: 10.1016/j.arbres.2019.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/17/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022]
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Crisafulli E, Manco A, Ferrer M, Huerta A, Micheletto C, Girelli D, Clini E, Torres A. Pneumonic versus Nonpneumonic Exacerbations of Chronic Obstructive Pulmonary Disease. Semin Respir Crit Care Med 2020; 41:817-829. [PMID: 32726837 DOI: 10.1055/s-0040-1702196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) often suffer acute exacerbations (AECOPD) and community-acquired pneumonia (CAP), named nonpneumonic and pneumonic exacerbations of COPD, respectively. Abnormal host defense mechanisms may play a role in the specificity of the systemic inflammatory response. Given the association of this aspect to some biomarkers at admission (e.g., C-reactive protein), it can be used to help to discriminate AECOPD and CAP, especially in cases with doubtful infiltrates and advanced lung impairment. Fever, sputum purulence, chills, and pleuritic pain are typical clinical features of CAP in a patient with COPD, whereas isolated dyspnea at admission has been reported to predict AECOPD. Although CAP may have a worse outcome in terms of mortality (in hospital and short term), length of hospitalization, and early readmission rates, this has only been confirmed in a few prospective studies. There is a lack of methodologically sound research confirming the impact of severe AECOPD and COPD + CAP. Here, we review studies reporting head-to-head comparisons between AECOPD and CAP + COPD in hospitalized patients. We focus on the epidemiology, risk factors, systemic inflammatory response, clinical and microbiological characteristics, outcomes, and treatment approaches. Finally, we briefly discuss some proposals on how we should orient research in the future.
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Affiliation(s)
- Ernesto Crisafulli
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy.,Department of Medicine, Section of Internal Medicine, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Alessandra Manco
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Miquel Ferrer
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERES (CB06/06/0028), University of Barcelona, Barcelona, Spain
| | - Arturo Huerta
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERES (CB06/06/0028), University of Barcelona, Barcelona, Spain
| | - Claudio Micheletto
- Department of Cardiovascular and Thoracic, Pneumology Unit, Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Domenico Girelli
- Department of Medicine, Section of Internal Medicine, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Enrico Clini
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia and University Hospital of Modena Policlinico, Modena, Italy
| | - Antoni Torres
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERES (CB06/06/0028), University of Barcelona, Barcelona, Spain
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Abstract
Purpose of review Pneumonia is a frequent disease mainly affecting older and multimorbid patients. Symptoms and signs lack sensitivity and specificity, and chest X-ray has poor accuracy. Hence, an initial diagnosis of pneumonia has limited predictive value for the presence of pneumonia. Overdiagnosis of pneumonia leads to inappropriate antibiotic use and may delay the appropriate management of mimicking diseases. Alternative imaging strategies including computed tomography (CT)-scan or lung ultrasonography may improve the diagnosis of pneumonia. We review the recent evidence and perspectives regarding their contribution to the diagnosis and management of patients with suspected pneumonia. Recent findings Two studies assessed the diagnostic accuracy of CT-scan in emergency department or hospitalized patients suspected of pneumonia. CT-scan led to a net reclassification improvement of 8 and 18% of patients, and was particularly helpful to rule out the diagnosis, allowing a lowering of the number of inappropriate antibiotic prescriptions. Summary CT-scan reduces overdiagnosis of pneumonia and allows a better identification of alternative diagnoses. The impact on clinical outcomes of a strategy incorporating CT-scan for patients suspected of pneumonia should be evaluated, along with its cost-effectiveness.
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Bonnesen B, Baunbæk Egelund G, Vestergaard Jensen A, Andersen S, Trier Petersen P, Rohde G, Ravn P. Is chronic obstructive pulmonary disease a risk factor for death in patients with community acquired pneumonia? Infect Dis (Lond) 2019; 51:340-347. [PMID: 30938220 DOI: 10.1080/23744235.2019.1565416] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND It is still a matter of debate whether the outcome of community acquired pneumonia is more severe in patients with chronic obstructive pulmonary disease. We aimed to determine whether chronic obstructive pulmonary disease was associated with increased mortality and to identify risk-factors for mortality in patients with community acquired pneumonia and chronic obstructive pulmonary disease. METHODS Retrospective cohort study comparing patients with community acquired pneumonia and chronic obstructive pulmonary disease to patients without chronic obstructive pulmonary disease. We included 1309 patients with community acquired pneumonia admitted from 2011 until 2012 (243 patients with chronic obstructive pulmonary disease and 1066 without chronic obstructive pulmonary disease). RESULTS At admission patients with community acquired pneumonia and chronic obstructive pulmonary disease presented with more severe pneumonia as measured by CURB-65 score compared to patients without chronic obstructive pulmonary disease. Mortality on day 30 was generally high, and higher among patients with community acquired pneumonia and chronic obstructive pulmonary disease compared to those without chronic obstructive pulmonary disease (16.0% versus 11.3%, p = .04). In an adjusted analysis, however, chronic obstructive pulmonary disease was not independently associated with 30-d mortality (odds ratio 0.94, confidence interval 95% 0.59-1.50). Factors related to mortality in patients with community acquired pneumonia and chronic obstructive pulmonary disease were age, premorbid condition, severity of pneumonia as determined by CURB-65 score, and pleural effusion and multi-lobular infiltrate on chest X-ray. CONCLUSIONS Chronic obstructive pulmonary disease was not independently associated with 30-d mortality in patients with community acquired pneumonia.
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Affiliation(s)
- Barbara Bonnesen
- a Department of Pulmonary and Infectious Diseases , Nordsjaelland Hospital , Hillerød , Denmark.,b Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Gertrud Baunbæk Egelund
- a Department of Pulmonary and Infectious Diseases , Nordsjaelland Hospital , Hillerød , Denmark.,b Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Andreas Vestergaard Jensen
- a Department of Pulmonary and Infectious Diseases , Nordsjaelland Hospital , Hillerød , Denmark.,b Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Stine Andersen
- a Department of Pulmonary and Infectious Diseases , Nordsjaelland Hospital , Hillerød , Denmark.,b Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Pelle Trier Petersen
- a Department of Pulmonary and Infectious Diseases , Nordsjaelland Hospital , Hillerød , Denmark.,b Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Gernot Rohde
- c Department of Respiratory Medicine , Medical Clinic I, Goethe University Hospital , Frankfurt/Main , Germany.,d CAPNETZ-Stiftung, Hannover Medical School , Hannover , Germany
| | - Pernille Ravn
- b Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark.,e Department of Medicine , Herlev Gentofte Hospital , Hellerup , Denmark
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Abstract
PURPOSE OF REVIEW The primary challenges in the field of clinical research include a lack of support within existing infrastructure, insufficient number of clinical research training programs and a paucity of qualified mentors. Most medical centers offer infrastructure support for investigators working with industry sponsors or government-funded clinical trials, yet there are a significant amount of clinical studies performed in the field of pneumonia which are observational studies. For this type of research, which is frequently unfunded, support is usually lacking. RECENT FINDINGS In an attempt to optimize clinical research in pneumonia, at the University of Louisville, we developed a clinical research coordinating center (CRCC). The center manages clinical studies in the field of respiratory infections, with the primary focus being pneumonia. Other activities of the CRCC include the organization of an annual clinical research training course for physicians and other healthcare workers, and the facilitation of international research mentoring by a process of connecting new pneumonia investigators with established clinical investigators. SUMMARY To improve clinical research in pneumonia, institutions need to have the appropriate infrastructure in place to support investigators in all aspects of the clinical research process.
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Vanoni NM, Carugati M, Borsa N, Sotgiu G, Saderi L, Gori A, Mantero M, Aliberti S, Blasi F. Management of Acute Respiratory Failure Due to Community-Acquired Pneumonia: A Systematic Review. Med Sci (Basel) 2019; 7:medsci7010010. [PMID: 30646626 PMCID: PMC6359640 DOI: 10.3390/medsci7010010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/03/2019] [Accepted: 01/08/2019] [Indexed: 01/15/2023] Open
Abstract
Community-acquired pneumonia (CAP) is a leading cause of mortality worldwide. CAP mortality is driven by the development of sepsis and acute respiratory failure (ARF). We performed a systematic review of the available English literature published in the period 1 January 1997 to 31 August 2017 and focused on ARF in CAP. The database searches identified 189 articles—of these, only 29 were retained for data extraction. Of these 29 articles, 12 addressed ARF in CAP without discussing its ventilatory management, while 17 evaluated the ventilatory management of ARF in CAP. In the studies assessing the ventilatory management, the specific treatments addressed were: high-flow nasal cannula (HFNC) (n = 1), continuous positive airway pressure (n = 2), non-invasive ventilation (n = 9), and invasive mechanical ventilation (n = 5). When analyzed, non-invasive ventilation (NIV) success rates ranged from 20% to 76% and they strongly predicted survival, while NIV failure led to an increased risk of adverse outcome. In conclusion, ARF in CAP patients may require both ventilatory and non-ventilatory management. Further research is needed to better evaluate the use of NIV and HFNC in those patients. Alongside the prompt administration of antimicrobials, the potential use of steroids and the implementation of severity scores should also be considered.
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Affiliation(s)
- Nicolò Maria Vanoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory unit and Adult Cystic Fibrosis Center, 20122 Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy.
| | - Manuela Carugati
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Infectious Diseases Unit, 20122 Milan, Italy.
- Division of Infectious Diseases, Duke University, 27710 Durham, NC, USA.
| | - Noemi Borsa
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory unit and Adult Cystic Fibrosis Center, 20122 Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy.
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy.
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy.
| | - Andrea Gori
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy.
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Infectious Diseases Unit, 20122 Milan, Italy.
| | - Marco Mantero
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory unit and Adult Cystic Fibrosis Center, 20122 Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy.
| | - Stefano Aliberti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory unit and Adult Cystic Fibrosis Center, 20122 Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy.
| | - Francesco Blasi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory unit and Adult Cystic Fibrosis Center, 20122 Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy.
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Brambilla AM, Prina E, Ferrari G, Bozzano V, Ferrari R, Groff P, Petrelli G, Scala R, Causin F, Noto P, Bresciani E, Voza A, Aliberti S, Cosentini R. Non-invasive positive pressure ventilation in pneumonia outside Intensive Care Unit: An Italian multicenter observational study. Eur J Intern Med 2019; 59:21-26. [PMID: 30528840 DOI: 10.1016/j.ejim.2018.09.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 09/26/2018] [Accepted: 09/28/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVE Non-Invasive Ventilation (NIV) represents a standard of care to treat some acute respiratory failure (ARF). Data on its use in pneumonia are lacking, especially in a setting outside the Intensive Care Unit (ICU). The aims of this study were to evaluate the use of NIV in ARF due to pneumonia outside the ICU, and to identify risk factors for in-hospital mortality. METHODS Prospective, observational study performed in 19 centers in Italy. Patients with ARF due to pneumonia treated outside the ICU with either continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) were enrolled over a period of at least 3 consecutive months in 2013. Independent factors related to in-hospital mortality were evaluated. RESULTS Among the 347 patients enrolled, CPAP was applied as first treatment in 176 (50.7%) patients,NPPV in 171 (49.3%). The NPPV compared with CPAP group showed a significant higher PaCO2 (55 [47-78] vs 37 [32-43] mmHg, p < 0.001), a lower arterial pH (7.30 [7.21-7.37] vs 7.43 [7.35-7.47], p < 0.001), higher HCO3- (28 [24-33] vs 24 [21-27] mmol/L, p < 0.001). De-novo ARF was more prevalent in CPAP group than in NPPV group (86/176 vs 31/171 patients,p < 0.001). In-hospital mortality was 23% (83/347). Do Not Intubate (DNI) order and Charlson Comorbidity Index (CCI) ≥3 were independent risk factors for in-hospital mortality. CONCLUSIONS Outside ICU setting, CPAP was used mainly for hypoxemic non-hypercapnic ARF, NPPV for hypercapnic ARF. In-hospital mortality was mainly associated to patients' basal status (DNI status, CCI) rather than the baseline degree of ARF.
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Affiliation(s)
- Anna Maria Brambilla
- Department of Emergency Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Elena Prina
- Servei de Pneumologia, Hospital Corporació Parc Tauli de Sabadell, Barcelona, Spain
| | | | - Viviana Bozzano
- University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rodolfo Ferrari
- U.O. Medicina d'Urgenza e Pronto Soccorso, Policlinico Sant'Orsola, Malpighi Azienda Ospedaliero, Universitaria di Bologna, Italy
| | - Paolo Groff
- ASUR Marche Area Vasta 5 U.O., Pronto Soccorso-Medicina d'urgenza Ospedale Civile di San Benedetto del Tronto, Italy
| | - Giuseppina Petrelli
- ASUR Marche Area Vasta 5 U.O., Pronto Soccorso-Medicina d'urgenza Ospedale Civile di San Benedetto del Tronto, Italy
| | - Raffaele Scala
- Unita' Operativa di Pneumologia e UTIP, Ospedale S Donato Arezzo, Italy
| | - Fabio Causin
- Pronto Soccorso e Medicina d'Urgenza ULSS 9, Treviso, Italy
| | - Paola Noto
- U.O.C. M.C.A.U. Azienda Ospedaliero, Universitaria Policlinico Vittorio Emanuele di Catania, Italy
| | | | - Antonio Voza
- Pronto Soccorso-EAS, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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24
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Ning P, Zheng Y, Luo Q, Liu X, Kang Y, Zhang Y, Zhang R, Xu Y, Yang D, Xi W, Wang K, Chen Y, An S, Gao Z. Metabolic profiles in community-acquired pneumonia: developing assessment tools for disease severity. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:130. [PMID: 29759075 PMCID: PMC5952829 DOI: 10.1186/s13054-018-2049-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 04/23/2018] [Indexed: 01/11/2023]
Abstract
Background This study aimed to determine whether community-acquired pneumonia (CAP) had a metabolic profile and whether this profile can be used for disease severity assessment. Methods A total of 175 individuals including 119 CAP patients and 56 controls were enrolled and divided into two cohorts. Serum samples from a discovery cohort (n = 102, including 38 non-severe CAP, 30 severe CAP, and 34 age and sex-matched controls) were determined by untargeted ultra-high-performance liquid chromatography with tandem mass spectrometry (LC-MS/MS)-based metabolomics. Selected differential metabolites between CAP patients versus controls, and between the severe CAP group versus non-severe CAP group, were confirmed by targeted mass spectrometry assays in a validation cohort (n = 73, including 32 non-severe CAP, 19 severe CAP and 22 controls). Pearson’s correlation analysis was performed to assess relationships between the identified metabolites and clinical severity of CAP. The area under the curve (AUC), sensitivity and specificity of the metabolites for predicting the severity of CAP were also investigated. Results The metabolic signature was markedly different between CAP patients and controls. Fifteen metabolites were found to be significantly dysregulated in CAP patients, which were mainly mapped to the metabolic pathways of sphingolipid, arginine, pyruvate and inositol phosphate. The alternation trends of five metabolites among the three groups including sphinganine, p-Cresol sulfate, dehydroepiandrosterone sulfate (DHEA-S), lactate and l-arginine in the validation cohort were consistent with those in the discovery cohort. Significantly lower concentrations of sphinganine, p-Cresol sulfate and DHEA-S were observed in CAP patients than in controls (p < 0.05). Serum lactate and sphinganine levels were positively correlated with confusion, urea level, respiratory rate, blood pressure, and age > 65 years (CURB-65), pneumonia severity index (PSI) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, while DHEA-S inversely correlated with the three scoring systems. Combining lactate, sphinganine and DHEA-S as a metabolite panel for discriminating severe CAP from non-severe CAP exhibited a better AUC of 0.911 (95% confidence interval 0.825–0.998) than CURB-65, PSI and APACHE II scores. Conclusions This study demonstrates that serum metabolomics approaches based on the LC-MS/MS platform can be applied as a tool to reveal metabolic changes during CAP and establish a metabolite signature related to disease severity. Trial registration ClinicalTrials.gov, NCT03093220. Registered retrospectively on 28 March 2017. Electronic supplementary material The online version of this article (10.1186/s13054-018-2049-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pu Ning
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Yali Zheng
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Qiongzhen Luo
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Xiaohui Liu
- National Protein Science Technology Center, Tsinghua University, Beijing, China.,School of Life Sciences, Tsinghua University, Beijing, China
| | - Yu Kang
- CAS Key Laboratory of Genome Sciences and Information, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
| | - Yan Zhang
- National Engineering Research Center for Beijing Biochip Technology, Beijing, China
| | - Rongbao Zhang
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Yu Xu
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Donghong Yang
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Wen Xi
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Keqiang Wang
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Yusheng Chen
- Department of Respiratory Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Shuchang An
- Department of Respiratory Medicine, First Hospital of Tsinghua University, Beijing, China
| | - Zhancheng Gao
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China.
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26
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Restrepo MI, Reyes LF. Pneumonia as a cardiovascular disease. Respirology 2018; 23:250-259. [PMID: 29325222 DOI: 10.1111/resp.13233] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/05/2017] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Marcos I Restrepo
- Division of Pulmonary Diseases and Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Medicine, University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Luis F Reyes
- Division of Pulmonary Diseases and Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Medicine, University of Texas Health at San Antonio, San Antonio, TX, USA
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27
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Bermejo-Martin JF, Cilloniz C, Mendez R, Almansa R, Gabarrus A, Ceccato A, Torres A, Menendez R. Lymphopenic Community Acquired Pneumonia (L-CAP), an Immunological Phenotype Associated with Higher Risk of Mortality. EBioMedicine 2017; 24:231-236. [PMID: 28958655 PMCID: PMC5652132 DOI: 10.1016/j.ebiom.2017.09.023] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/17/2017] [Accepted: 09/18/2017] [Indexed: 10/26/2022] Open
Abstract
The role of neutrophil and lymphocyte counts in blood as prognosis predictors in Community Acquired Pneumonia (CAP) has not been adequately studied. This was a derivation-validation retrospective study in hospitalized patients with CAP and no prior immunosuppression. We evaluated by multivariate analysis the association between neutrophil and lymphocyte counts and mortality risk at 30-days post hospital admission in these patients. The derivation cohort (n=1550 patients) was recruited in a multi-site study. The validation cohort (n=2846 patients) was recruited in a single-site study. In the derivation cohort, a sub-group of lymphopenic patients, those with <724lymphocytes/mm3, showed a 1.93-fold increment in the risk of mortality, independently of the CURB-65 score, critical illness, and receiving an appropriate antibiotic treatment. In the validation cohort, patients with <724lymphocytes/mm3 showed a 1.86-fold increment in the risk of mortality. The addition of 1 point to the CURB-65 score in those patients with <724lymphocytes/mm3 improved the performance of this score to identify non-survivors in both cohorts. In conclusion, lymphopenic CAP constitutes a particular immunological phenotype of the disease which is associated with an increased risk of mortality. Assessing lymphocyte counts could contribute to personalized clinical management in CAP.
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Affiliation(s)
- Jesus F Bermejo-Martin
- Group for Biomedical Research in Sepsis (Bio Sepsis), Hospital Clínico Universitario de Valladolid/IECSCYL, Av. Ramón y Cajal, 3, 47003 Valladolid, Spain
| | - Catia Cilloniz
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911- Ciber de Enfermedades Respiratorias (Ciberes), Carrer de Villarroel, 170, 08036 Barcelona, Spain
| | - Raul Mendez
- Pulmonology Service, University and Polytechnic Hospital La Fe, Ciber de Enfermedades Respiratorias (Ciberes), Avinguda de Fernando Abril Martorell, 106, 46026 València, Spain; PhD program in Medicine and Traslational Research, University of Barcelona, Gran Via de les Corts Catalanes, 585, 08007 Barcelona, Spain
| | - Raquel Almansa
- Group for Biomedical Research in Sepsis (Bio Sepsis), Hospital Clínico Universitario de Valladolid/IECSCYL, Av. Ramón y Cajal, 3, 47003 Valladolid, Spain
| | - Albert Gabarrus
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911- Ciber de Enfermedades Respiratorias (Ciberes), Carrer de Villarroel, 170, 08036 Barcelona, Spain
| | - Adrian Ceccato
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911- Ciber de Enfermedades Respiratorias (Ciberes), Carrer de Villarroel, 170, 08036 Barcelona, Spain
| | - Antoni Torres
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911- Ciber de Enfermedades Respiratorias (Ciberes), Carrer de Villarroel, 170, 08036 Barcelona, Spain.
| | - Rosario Menendez
- Pulmonology Service, University and Polytechnic Hospital La Fe, Ciber de Enfermedades Respiratorias (Ciberes), Avinguda de Fernando Abril Martorell, 106, 46026 València, Spain
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Berk Takir H, Esquinas AM, Glossop AJ. Inclusion of sepsis and hypoxaemia in mortality prediction of hospitalized patients with community-acquired pneumonia. Respirology 2017; 23:113-114. [PMID: 28905465 DOI: 10.1111/resp.13169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 06/13/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Huriye Berk Takir
- Department of Intensive Care Unit, Sureyyapasa Chest Disease and Research Hospital, Istanbul, Turkey
| | - Antonio M Esquinas
- Intensive Care and Non Invasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, Spain
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29
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Frenzen FS, Kutschan U, Meiswinkel N, Schulte-Hubbert B, Ewig S, Kolditz M. Admission lactate predicts poor prognosis independently of the CRB/CURB-65 scores in community-acquired pneumonia. Clin Microbiol Infect 2017; 24:306.e1-306.e6. [PMID: 28710027 DOI: 10.1016/j.cmi.2017.07.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/06/2017] [Accepted: 07/04/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Community-acquired pneumonia (CAP) is associated with a high risk of respiratory failure or septic organ dysfunction. Lactate is an established early marker of prognosis and sepsis severity, but few data exist in patients with CAP. METHODS We performed a retrospective cohort study of consecutive adult CAP patients without treatment restrictions or direct intensive care unit admission. Lactate was measured as a point-of-care test within the capillary admission blood gas analysis, and its prognostic value was compared to the CRB/CURB-65 criteria by multivariate and receiver operating characteristic (ROC) curve analysis. The primary endpoint was the combination of need for mechanical ventilation, vasopressors, intensive care unit admission or hospital mortality. RESULTS Of 303 included patients, 75 (25%) met the primary endpoint. After ROC analysis, lactate predicted the primary endpoint (area under the curve 0.67) with an optimal cutoff of >1.8 mmol/L. Of the 76 patients with lactate above this threshold, 35 (46%) met the primary endpoint. After multivariate analysis, the predictive value of lactate was independent of the CRB/CURB-65 scores. The addition of lactate >1.8 mmol/L to the CRB/CURB-65 scores resulted in significantly improved area under the curves (0.69 to 0.74, p 0.005 and 0.71 to 0.75, p 0.008 respectively). Fourteen (42%) of 33 and 11 (39%) of 28 patients meeting the endpoint despite presenting with 0 or 1 CRB/CURB-65 criteria had lactate >1.8 mmol/L. CONCLUSIONS Admission lactate levels significantly improved the prognostic value of the CRB/CURB-65 scores in CAP patients. Lactate may therefore be considered a rapid, cheap and broadly available additional criterion for the assessment of risk in patients with CAP.
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Affiliation(s)
- F S Frenzen
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - U Kutschan
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - N Meiswinkel
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - B Schulte-Hubbert
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - S Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, EVK Herne and Augusta-Kranken-Anstalt Bochum, Bochum, Germany
| | - M Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Bi J, Yang J, Wang Y, Yao C, Mei J, Liu Y, Cao J, Lu Y. Efficacy and Safety of Adjunctive Corticosteroids Therapy for Severe Community-Acquired Pneumonia in Adults: An Updated Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0165942. [PMID: 27846240 PMCID: PMC5113003 DOI: 10.1371/journal.pone.0165942] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 10/20/2016] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Jirui Bi
- Department of Respiratory Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jin Yang
- Department of Respiratory Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ying Wang
- Department of Respiratory Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Cijiang Yao
- School of Public Health, Anhui Medical University, Hefei, China
| | - Jing Mei
- Department of Respiratory Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ying Liu
- School of Public Health, Anhui Medical University, Hefei, China
| | - Jiyu Cao
- The Teaching Center for Preventive Medicine, School of Public Health, Anhui Medical University, Hefei, China
| | - Youjin Lu
- Department of Respiratory Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, China
- * E-mail:
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31
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Phua J, Dean NC, Guo Q, Kuan WS, Lim HF, Lim TK. Severe community-acquired pneumonia: timely management measures in the first 24 hours. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:237. [PMID: 27567896 PMCID: PMC5002335 DOI: 10.1186/s13054-016-1414-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.
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Affiliation(s)
- Jason Phua
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nathan C Dean
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Qi Guo
- Department of Respiratory Medicine, Affiliated Futian Hospital, Guangdong Medical College, Shenzhen, Guangdong, China.,Guangzhou Institute of Respiratory Diseases (State Key Laboratory of Respiratory Diseases), First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Win Sen Kuan
- Department of Emergency Medicine, National University Hospital, National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hui Fang Lim
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tow Keang Lim
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore. .,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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Pneumonia presenting with organ dysfunctions: Causative microorganisms, host factors and outcome. J Infect 2016; 73:419-426. [PMID: 27506395 DOI: 10.1016/j.jinf.2016.08.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/25/2016] [Accepted: 08/02/2016] [Indexed: 11/23/2022]
Abstract
Community-acquired pneumonia (CAP) is a serious infection that may occasionally rapidly evolve provoking organ dysfunctions. We aimed to characterize CAP presenting with organ dysfunctions at the emergency room, with regard to host factors and causative microorganisms, and its impact on 30-day mortality. 460 of 4070 (11.3%) CAP patients had ≥2 dysfunctions at diagnosis, with a 30-day mortality of 12.4% vs. 3.4% in those with one or no dysfunctions. Among them, the most frequent causative microorganisms were Streptococcus pneumoniae, gram-negatives and polymicrobial etiology. Independent host risk factors for presenting with ≥2 dysfunctions were: liver (OR 2.97) and renal diseases (OR 3.91), neurological disorders (OR 1.86), and COPD (OR 1.30). Methicillin-resistant Staphylococcus aureus (OR 6.41) and bacteraemic episodes (OR 1.68) had the higher independent risk among microorganisms. The number of organ dysfunctions vs. none increased at 30-day mortality: three organs (OR 11.73), two organs (OR 4.29), and one organ (OR 2.42) whereas Enterobacteria (OR 3.73) were also independently related to mortality. The number of organ dysfunctions was the strongest 30-day mortality risk factor while Enterobacteriaceae was also associated with poorer outcome. The assessment of organ dysfunctions in CAP should be implemented for management, allocation and treatment decisions on initial evaluation.
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Liapikou A, Cillóniz C, Gabarrús A, Amaro R, De la Bellacasa JP, Mensa J, Sánchez M, Niederman M, Torres A. Multilobar bilateral and unilateral chest radiograph involvement: implications for prognosis in hospitalised community-acquired pneumonia. Eur Respir J 2016; 48:257-61. [PMID: 27103390 DOI: 10.1183/13993003.00191-2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/08/2016] [Indexed: 12/16/2022]
Affiliation(s)
| | - Catia Cillóniz
- Dept of Pneumology, Institut Clinic del Tórax, Hospital Clínic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) Barcelona, Spain
| | - Albert Gabarrús
- Dept of Pneumology, Institut Clinic del Tórax, Hospital Clínic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) Barcelona, Spain
| | - Rosanel Amaro
- Dept of Pneumology, Institut Clinic del Tórax, Hospital Clínic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) Barcelona, Spain
| | | | - Josep Mensa
- Infectious Diseases Dept, Hospital Clínic, Barcelona, Spain
| | | | - Michael Niederman
- Pulmonary and Critical Care Division, Weill Cornell Medical College, New York, NY, USA
| | - Antoni Torres
- Dept of Pneumology, Institut Clinic del Tórax, Hospital Clínic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) Barcelona, Spain
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Pletz MW, Rohde GG, Welte T, Kolditz M, Ott S. Advances in the prevention, management, and treatment of community-acquired pneumonia. F1000Res 2016; 5. [PMID: 26998243 PMCID: PMC4786904 DOI: 10.12688/f1000research.7657.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2016] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
- Mathias W Pletz
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Gernot G Rohde
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Martin Kolditz
- Division of Pulmonology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Sebastian Ott
- Department of Pulmonary Medicine, Inselspital, University Hospital, Bern, Switzerland
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Kolditz M, Bauer TT, König T, Rohde G, Ewig S. 3-day mortality in hospitalised community-acquired pneumonia: frequency and risk factors. Eur Respir J 2016; 47:1572-4. [PMID: 26917605 DOI: 10.1183/13993003.00113-2016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/19/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Martin Kolditz
- Division of Pulmonology, Medical Dept I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Torsten T Bauer
- HELIOS Klinikum Emil von Behring, Lungenklinik Heckeshorn, Berlin, Germany
| | | | - Gernot Rohde
- Dept of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands CAPNETZ Stiftung, Hannover, Germany Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Dept of Respiratory and Infectious Diseases, EVK Herne and Augusta-Kranken-Anstalt Bochum, Bochum, Germany
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36
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Aliberti S, Ramirez J, Cosentini R, Valenti V, Voza A, Rossi P, Stolz D, Legnani D, Pesci A, Richeldi L, Peyrani P, Massari FM, Blasi F. Acute myocardial infarction versus other cardiovascular events in community-acquired pneumonia. ERJ Open Res 2015; 1:00020-2015. [PMID: 27730139 PMCID: PMC5005139 DOI: 10.1183/23120541.00020-2015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/21/2015] [Indexed: 11/29/2022] Open
Abstract
The aim of the present study was to define the prevalence, characteristics, risk factors and impact on clinical outcomes of acute myocardial infarction (AMI) versus other cardiovascular events (CVEs) in patients with community-acquired pneumonia (CAP). This was an international, multicentre, observational, prospective study of CAP patients hospitalised in eight hospitals in Italy and Switzerland. Three groups were identified: those without CVEs, those with AMI and those with other CVEs. Among 905 patients, 21 (2.3%) patients experienced at least one AMI, while 107 (11.7%) patients experienced at least one other CVE. Patients with CAP and either AMI or other CVEs showed a higher severity of the disease than patients with CAP alone. Female sex, liver disease and the presence of severe sepsis were independent predictors for the occurrence of AMI, while female sex, age >65 years, neurological disease and the presence of pleural effusion predicted other CVEs. In-hospital mortality was significantly higher among those who experienced AMI in comparison to those experiencing other CVEs (43% versus 21%, p=0.039). The presence of AMI showed an adjusted odds ratio for in-hospital mortality of 3.57 (p=0.012) and for other CVEs of 2.63 (p=0.002). These findings on AMI versus other CVEs as complications of CAP may be important when planning interventional studies on cardioprotective medications. Acute myocardial infarction is associated with specific risk factors and accounts for worse outcomes in CAP patientshttp://ow.ly/QhT2t
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Affiliation(s)
- Stefano Aliberti
- Health Science Department, University of Milan Bicocca, Respiratory Unit, AO San Gerardo, Monza, Italy
| | - Julio Ramirez
- Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Roberto Cosentini
- Emergency Medicine Unit, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda, Milan, Italy
| | - Vincenzo Valenti
- Pulmonary Unit, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Paolo Rossi
- Internal Medicine Department, Azienda Ospedaliero-Universitaria "S. Maria della Misericordia", Udine, Italy
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Delfino Legnani
- Department of Biomedical and Clinical Sciences, University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Alberto Pesci
- Health Science Department, University of Milan Bicocca, Respiratory Unit, AO San Gerardo, Monza, Italy
| | - Luca Richeldi
- National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK; Centre for Rare Lung Disease, University of Modena and Reggio Emilia, AO Policlinico, Modena, Italy
| | - Paula Peyrani
- Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Fernando Maria Massari
- UOC Malattie Cardiovascolari, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda, Milan, Italy
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Kolditz M, Ewig S, Schütte H, Suttorp N, Welte T, Rohde G. Assessment of oxygenation and comorbidities improves outcome prediction in patients with community-acquired pneumonia with a low CRB-65 score. J Intern Med 2015; 278:193-202. [PMID: 25597400 DOI: 10.1111/joim.12349] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Addition of assessment of comorbid diseases ('D') and oxygen saturation ('S') to the CRB-65 score has been recommended to improve its accuracy for risk stratification in community-acquired pneumonia (CAP). The aim of this study was to validate the resulting DS-CRB-65 score in a large cohort of patients with CAP. METHODS A total of 4432 patients prospectively enrolled in the CAPNETZ cohort were included in this study. Predefined end points were 28-day mortality, requirement for mechanical ventilation or vasopressors (MV/VS) and requirement for MV/VS or intensive care unit admission (MV/VS/ICU). Receiver operating characteristic curve analysis was used to determine the accuracy of the CRB-65 score and the addition of D (extra-pulmonary comorbidities) and S (oxygen saturation <90% or partial pressure of oxygen <8 kPa). Binary logistic regression and the method of Hanley and McNeil were used to compare the criteria. RESULTS The mortality rate was 4.0%, and 4.2% of patients required MV/VS and 6.6% required MV/VS/ICU. After multivariate analysis, D and S independently were added to the CRB-65 criteria for mortality prediction, but only S improved prediction of MV/VS and MV/VS/ICU (P < 0.001 for all). The area under the curve of the CRB-65 score was significantly improved by adding D and S for all end points (P < 0.02). Amongst patients who died or required MV/VS despite a CRB-65 score of 0, 64-80% would have been identified by the DS-CRB-65 score. CONCLUSIONS The addition of assessment of oxygenation and comorbidities significantly improved the prognostic accuracy of the CRB-65 score. Consequently, the DS-CRB-65 score may have a useful role in risk stratification algorithms for CAP.
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Affiliation(s)
- M Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technical University, Dresden, Germany
| | - S Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, EVK Herne and Augusta-Kranken-Anstalt, Bochum, Germany
| | - H Schütte
- Department of Pulmonology, Klinikum Ernst von Bergmann, Potsdam, Germany.,Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,CAPNETZ STIFTUNG, Hannover, Germany
| | - N Suttorp
- Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,CAPNETZ STIFTUNG, Hannover, Germany
| | - T Welte
- CAPNETZ STIFTUNG, Hannover, Germany.,Department of Respiratory Medicine, Medizinische Hochschule, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), The German Center for Lung Research (DZL), Hannover, Germany
| | - G Rohde
- CAPNETZ STIFTUNG, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), The German Center for Lung Research (DZL), Hannover, Germany.,Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Confalonieri M, Trevisan R, Demsar M, Lattuada L, Longo C, Cifaldi R, Jevnikar M, Santagiuliana M, Pelusi L, Pistelli R. Opening of a respiratory intermediate care unit in a general hospital: impact on mortality and other outcomes. Respiration 2015; 90:235-42. [PMID: 26160422 DOI: 10.1159/000433557] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 05/16/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Respiratory intermediate care units (RICUs) are specialized areas aimed at optimizing the cost-benefit ratio of care. No data exist about the impact of opening a RICU on hospital outcomes. OBJECTIVES We wondered if opening a RICU may improve the outcomes of patients with acute respiratory failure (ARF), acute exacerbation of chronic obstructive pulmonary disease (AECOPD), or community-acquired pneumonia (CAP). METHODS We analyzed the discharge abstracts of 2,372 admissions to the RICU and internal medicine units (IMUs) for ARF, AECOPD, and CAP. The IMUs at the Hospital of Trieste comprise emergency and internal wards. In order to investigate the determinants of outcomes, a matched case-control study was performed using clinical records. RESULTS The in-hospital mortality rate was lower in the RICU vs. IMUs (5.4 vs. 19.1%, p = 0.0001). Statistical differences did not change when comparing the RICU with the emergency and internal wards. After adjusting for potential confounders, the risk of death for patients with CAP, AECOPD, or ARF was significantly higher in the IMUs than in the RICU (OR 6.90, 3.19, and 6.7, respectively, p < 0.04). Both the frequency of transfer to the ICU (6 vs. 12%, p = 0.0001, OR 0.38) and the hospital stay (9.3 vs. 12.1 days, p = 0.0001) were reduced in patients admitted to the RICU compared to those admitted to non-RICUs. Significant differences were found in care management concerning chest physiotherapy, mechanical ventilation, antibiotics, and corticosteroids. CONCLUSIONS The opening of a RICU may be advantageous to reduce in-hospital mortality, the need for ICU admission, and the hospital stay of patients with AECOPD, CAP, and ARF. Better use of care resources contributed to better patient management in the RICU.
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Affiliation(s)
- Marco Confalonieri
- Department of Pneumology and Respiratory Intermediate Care Unit, University Hospital of Cattinara, Trieste, Italy
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Kolditz M, Ewig S, Klapdor B, Schütte H, Winning J, Rupp J, Suttorp N, Welte T, Rohde G. Community-acquired pneumonia as medical emergency: predictors of early deterioration. Thorax 2015; 70:551-8. [PMID: 25782758 DOI: 10.1136/thoraxjnl-2014-206744] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/26/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Early organ dysfunction determines the prognosis of community-acquired pneumonia (CAP), and recognition of CAP as a medical emergency has been advocated. OBJECTIVE To characterise patients with 'emergency CAP' and evaluate predictors for very early organ failure or death. METHODS 3427 prospectively enrolled patients of the CAPNETZ cohort were included. Emergency CAP was defined as requirement for mechanical ventilation or vasopressor support (MV/VS) or death within 72 h and 7 days after hospital admission, respectively. To determine independent predictors, multivariate Cox regression was employed. The ATS/IDSA 2007 minor criteria were evaluated for prediction of emergency CAP in patients without immediate need of MV/VS. RESULTS 140 (4%) and 173 (5%) patients presented with emergency CAP within 3 and 7 days, respectively. Hospital mortality of patients presenting without immediate need of MV/VS was highest. Independent predictors of emergency CAP were the presence of focal chest signs, home oxygen therapy, multilobar infiltrates, altered mental status and altered vital signs (hypotension, raised respiratory or heart rate, hypothermia). The ATS/IDSA 2007 minor criteria showed a high sensitivity and negative predictive value, whereas the positive predictive value was low. Reduction to 6 minor criteria did not alter accuracy. CONCLUSIONS Emergency CAP is a rare but prognostic relevant condition, mortality is highest in patients presenting without immediate need of MV/VS. Vital sign abnormalities and parameters indicating acute organ dysfunction are independent predictors, and the ATS/IDSA 2007 minor criteria show a high negative predictive value.
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Affiliation(s)
- Martin Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Santiago Ewig
- Department of Respiratory and Infectious Diseases, Thoraxzentrum Ruhrgebiet, EVK Herne and Augusta-Kranken-Anstalt Bochum, Bochum, Germany
| | - Benjamin Klapdor
- Department of Respiratory and Infectious Diseases, Thoraxzentrum Ruhrgebiet, EVK Herne and Augusta-Kranken-Anstalt Bochum, Bochum, Germany
| | - Hartwig Schütte
- Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany Department of Pulmonology, Klinikum Ernst von Bergmann, Potsdam, Germany CAPNETZ Stiftung, Hannover, Germany
| | - Johannes Winning
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Jena, Jena, Germany
| | - Jan Rupp
- CAPNETZ Stiftung, Hannover, Germany Division of Molecular and Clinical Infectious Diseases, Med. Clinic III, University of Lübeck, Lübeck, Germany
| | - Norbert Suttorp
- Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany CAPNETZ Stiftung, Hannover, Germany
| | - Tobias Welte
- CAPNETZ Stiftung, Hannover, Germany Department of Respiratory Medicine, Medizinische Hochschule Hannover, Hannover, Germany Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL)
| | - Gernot Rohde
- CAPNETZ Stiftung, Hannover, Germany Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL) Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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