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Cilloniz C, Pericas JM, Curioso WH. Interventions to improve outcomes in community-acquired pneumonia. Expert Rev Anti Infect Ther 2023; 21:1071-1086. [PMID: 37691049 DOI: 10.1080/14787210.2023.2257392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) is a common infection associated with high morbimortality and a highly deleterious impact on patients' quality of life and functionality. We comprehensively review the factors related to the host, the causative microorganism, the therapeutic approach and the organization of health systems (e.g. setting for care and systems for allocation) that might have an impact on CAP-associated outcomes. Our main aims are to discuss the most controversial points and to provide some recommendations that may guide further research and the management of patients with CAP, in order to improve their outcomes, beyond mortality. AREA COVERED In this review, we aim to provide a critical account of potential measures to improve outcomes of CAP and the supporting evidence from observational studies and clinical trials. EXPERT OPINION CAP is associated with high mortality and a highly deleterious impact on patients' quality of life. To improve CAP-associated outcomes, it is important to understand the factors related to the patient, etiology, therapeutics, and the organization of health systems.
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Affiliation(s)
- Catia Cilloniz
- IDIBAPS, Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Barcelona, Spain
- Facultad de Ciencias de la Salud, Universidad Continental, Huancayo, Peru
| | - Juan Manuel Pericas
- Liver Unit, Internal Medicine Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute for Research (VHIR), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Walter H Curioso
- Facultad de Ciencias de la Salud, Universidad Continental, Huancayo, Peru
- Health Services Administration, Continental University of Florida, Margate, FL, USA
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2
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Xu S, Song Z, Han F, Zhang C. Effect of appropriate empirical antimicrobial therapy on mortality of patients with Gram-negative bloodstream infections: a retrospective cohort study. BMC Infect Dis 2023; 23:344. [PMID: 37221465 DOI: 10.1186/s12879-023-08329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/14/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Little evidence exists regarding the prevalence of pathogens in bloodstream infections (BSIs), the mortality risk, and the benefit of combination therapy over monotherapy. This study aims to describe patterns of empiric antimicrobial therapy, and the epidemiology of Gram-negative pathogens, and to investigate the effect of appropriate therapy and appropriate combination therapy on the mortality of patients with BSIs. METHODS This was a retrospective cohort study including all patients with BSIs of Gram-negative pathogens from January 2017 to December 2022 in a Chinese general hospital. The in-hospital mortality was compared between appropriate and inappropriate therapy, and between monotherapy and combination therapy for patients receiving appropriate therapy. We used Cox regression analysis to identify factors independently associated with in-hospital mortality. RESULTS We included 205 patients in the study, of whom 147 (71.71%) patients received appropriate therapy compared with 58 (28.29%) who received inappropriate therapy. The most common Gram-negative pathogen was Escherichia coli (37.56%). 131 (63.90%) patients received monotherapy and 74 (36.10%) patients received combination therapy. The in-hospital mortality was significantly lower in patients administered appropriate therapy than inappropriate therapy (16.33% vs. 48.28%, p = 0.004); adjusted hazard ratio [HR] 0.55 [95% CI 0.35-0.84], p = 0.006). In-hospital mortality was also not different in combination therapy and monotherapy in the multivariate Cox regression analyses (adjusted HR 0.42 [95% CI 0.15-1.17], p = 0.096). However, combination therapy was associated with lower mortality than monotherapy in patients with sepsis or septic shock (adjusted HR 0.94 [95% CI 0.86-1.02], p = 0.047). CONCLUSIONS Appropriate therapy was associated with a protective effect on mortality among patients with BSIs due to Gram-negative pathogens. Combination therapy was associated with improved survival in patients with sepsis or septic shock. Clinicians need to choose optical empirical antimicrobials to improve survival outcomes in patients with BSIs.
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Affiliation(s)
- Shanshan Xu
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Zhihui Song
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Furong Han
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Chao Zhang
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
- , No.1 Dongjiaomin Lane, Beijing, Dongcheng District, China.
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3
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Choi KY, Lee HJ, Lee HW, Park TY, Heo EY, Kim DK, Lee JK. Systemic corticosteroid use and cardiovascular risk in patients hospitalized for pneumonia. Steroids 2023; 191:109161. [PMID: 36572057 DOI: 10.1016/j.steroids.2022.109161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 11/30/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Limited data are available concerning cardiovascular risk with respect to adjunctive corticosteroid use in patients with pneumonia. We aimed to assess the associations between systemic corticosteroid use and the occurrence of major adverse cardiovascular events (MACEs) in patients hospitalized for pneumonia. METHODS Among study participants enrolled via surveillance for severe acute respiratory infection from July 2016 to January 2017, the clinical course of patients with pneumonia was retrospectively investigated until December 2019. We evaluated the occurrence of in-hospital and after-discharge MACEs according to steroid use during hospitalization. RESULTS Of the 424 patients hospitalized for pneumonia, 118 (28.8%) received systemic corticosteroids during hospitalization. The most common reason for steroid use was acute exacerbation of chronic lung disease (75.4%). Systemic steroid use was significantly associated with an increased risk of in-hospital MACEs; it was not associated with after-discharge MACEs. The risk of in-hospital MACEs was significantly greater in patients with more comorbidities, more severe pneumonia, and a higher inflammatory marker level; moreover, it was positively associated with duration and cumulative dose of steroid treatment. CONCLUSION Systemic corticosteroid use was associated with an increased risk of in-hospital MACEs in patients hospitalized for pneumonia.
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Affiliation(s)
- Kwang Yong Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Hyo Jin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Tae Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Eun Young Heo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jung-Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea.
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4
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Meduri GU, Shih MC, Bridges L, Martin TJ, El-Solh A, Seam N, Davis-Karim A, Umberger R, Anzueto A, Sriram P, Lan C, Restrepo MI, Guardiola JJ, Buck T, Johnson DP, Suffredini A, Bell WA, Lin J, Zhao L, Uyeda L, Nielsen L, Huang GD. Low-dose methylprednisolone treatment in critically ill patients with severe community-acquired pneumonia. Intensive Care Med 2022; 48:1009-1023. [PMID: 35723686 PMCID: PMC9208259 DOI: 10.1007/s00134-022-06684-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/16/2022] [Indexed: 12/15/2022]
Abstract
Purpose Severe community-acquired pneumonia (CAP) requiring intensive care unit admission is associated with significant acute and long-term morbidity and mortality. We hypothesized that downregulation of systemic and pulmonary inflammation with prolonged low-dose methylprednisolone treatment would accelerate pneumonia resolution and improve clinical outcomes. Methods This double-blind, randomized, placebo-controlled clinical trial recruited adult patients within 72–96 h of hospital presentation. Patients were randomized in 1:1 ratio; an intravenous 40 mg loading bolus was followed by 40 mg/day through day 7 and progressive tapering during the 20-day treatment course. Randomization was stratified by site and need for mechanical ventilation (MV) at the time of randomization. Outcomes included a primary endpoint of 60-day all-cause mortality and secondary endpoints of morbidity and mortality up to 1 year of follow-up. Results Between January 2012 and April 2016, 586 patients from 42 Veterans Affairs Medical Centers were randomized, short of the 1420 target sample size because of low recruitment. 584 patients were included in the analysis. There was no significant difference in 60-day mortality between the methylprednisolone and placebo arms (16% vs. 18%; adjusted odds ratio 0.90, 95% CI 0.57–1.40). There were no significant differences in secondary outcomes or complications. Conclusions In patients with severe CAP, prolonged low-dose methylprednisolone treatment did not significantly reduce 60-day mortality. Treatment was not associated with increased complications. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06684-3.
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Affiliation(s)
- G Umberto Meduri
- Pulmonary, Critical Care and Sleep Medicine Services, Memphis VA Medical Center, Memphis, USA. .,University of Tennessee Health Science Center, Memphis, USA.
| | - Mei-Chiung Shih
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA.,Department of Biomedical Data Sciences, Stanford University, Stanford, USA
| | - Lisa Bridges
- Pulmonary, Critical Care and Sleep Medicine Services, Memphis VA Medical Center, Memphis, USA.,University of Tennessee Health Science Center, Memphis, USA
| | - Thomas J Martin
- Salem VA Health Care System, Salem, USA.,Virginia Tech Carilion School of Medicine, Roanoke, USA.,Edward Via Virginia College of Osteopathic Medicine, Blacksburg, USA
| | - Ali El-Solh
- VA Western New York Health Care System, Buffalo, USA.,University at Buffalo, Buffalo, USA
| | - Nitin Seam
- National Institutes of Health Clinical Center, Bethesda, USA
| | - Anne Davis-Karim
- VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, USA
| | - Reba Umberger
- University of Tennessee Health Science Center, Memphis, USA
| | - Antonio Anzueto
- South Texas Veterans Health San Antonio, San Antonio, USA.,University of Texas Health Science Center, Houston, USA
| | | | - Charlie Lan
- Michael E Debakey VA Medical Center, Houston, USA
| | - Marcos I Restrepo
- South Texas Veterans Health San Antonio, San Antonio, USA.,University of Texas Health Science Center, Houston, USA
| | - Juan J Guardiola
- Robley Rex VA Medical Center, Louisville, USA.,University of Louisville, Louisville, USA
| | - Teresa Buck
- Bay Pines VA Healthcare Center, Bay Pines, USA
| | | | | | | | - Julia Lin
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Lan Zhao
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Lauren Uyeda
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Lori Nielsen
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Grant D Huang
- Office of Research and Development, Department of Veterans Affairs, Baltimore, USA
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Han X, Chen L, Li H, Zhou F, Xing X, Zhang C, Suo L, Wang J, Liu X, Cao B. Prognostic Factors for Cardiovascular Events in Elderly Patients with Community Acquired Pneumonia: Results from the CAP-China Network. Clin Interv Aging 2022; 17:603-614. [PMID: 35497052 PMCID: PMC9047947 DOI: 10.2147/cia.s356925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/18/2022] [Indexed: 02/05/2023] Open
Affiliation(s)
- Xiudi Han
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital Group, Qingdao City, Shandong Province, 266011, People’s Republic of China
| | - Liang Chen
- Department of Infectious Diseases, Nanjing Lishui People’s Hospital, Nanjing City, Jiangsu Province, 211213, People’s Republic of China
| | - Hui Li
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital; Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, 100020, People’s Republic of China
| | - Fei Zhou
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital; Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, 100020, People’s Republic of China
| | - Xiqian Xing
- Department of Respiratory Medicine, Yan’an Hospital Affiliated to Kunming Medical University, Kunming City, Yunnan Province, 652199, People’s Republic of China
| | - Chunxiao Zhang
- Department of Respiratory Medicine, Beijing Huimin Hospital, Beijing, 100054, People’s Republic of China
| | - Lijun Suo
- Department of Pulmonary and Critical Care Medicine, Zibo Municipal Hospital, Zibo City, Shandong Province, 255000, People’s Republic of China
| | - Jinxiang Wang
- Department of Respiratory Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, 101149, People’s Republic of China
| | - Xuedong Liu
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital Group, Qingdao City, Shandong Province, 266011, People’s Republic of China
- Correspondence: Xuedong Liu, Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital Group, Jiaozhou Road, Qingdao City, Shandong Province, 266011, People’s Republic of China, Tel +86-18661678256, Fax +86-532-82789055, Email
| | - Bin Cao
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital; Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, 100020, People’s Republic of China
- Bin Cao, Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-Yang District, Beijing, 100020, People’s Republic of China, Tel +86-13911318339, Fax +86-10-84206264, Email
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6
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Ceccato A, Russo A, Barbeta E, Oscanoa P, Tiseo G, Gabarrus A, Di Giannatale P, Nogas S, Cilloniz C, Menichetti F, Ferrer M, Niederman M, Falcone M, Torres A. Real-world corticosteroid use in severe pneumonia: a propensity-score-matched study. Crit Care 2021; 25:432. [PMID: 34915895 PMCID: PMC8674860 DOI: 10.1186/s13054-021-03840-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/24/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide despite correct antibiotic use. Corticosteroids have long been evaluated as a treatment option, but heterogeneous effects on survival have precluded their widespread implementation. We aimed to evaluate whether corticosteroids might improve clinical outcomes in patients with severe CAP and high inflammatory responses. STUDY DESIGN AND METHODS We analyzed two prospective observational cohorts of patients with CAP in Barcelona and Rome who were admitted to intensive care with a high inflammatory response. Propensity score (PS) matching was used to obtain balance among the baseline variables in both groups, and we excluded patients with viral pneumonia or who received hydrocortisone. RESULTS Of the 610 patients admitted with severe CAP, 198 (32%) received corticosteroids and 387 had major criteria for severe CAP. All patients had a baseline serum C-reactive protein above 15 mg/dL. Patients who received corticosteroids were more commonly male, had more comorbidities (e.g., cancer or chronic obstructive pulmonary disease), and presented with significantly higher sequential organ failure assessment scores. Eighty-nine patients met major severity criteria (invasive mechanical ventilation and/or septic shock) and were matched per group. Twenty-eight-day mortality was lower among patients receiving corticosteroids (16 patients, 18%) than among those not receiving them (28 patients, 31%; p = 0.037). After PS matching, corticosteroid therapy reduced the 28-day mortality risk in patients who met major severity criteria (hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.29-0.98) (p = 0.043). In patients who did not meet major severity criteria, no benefits were observed with corticosteroid use (HR 0.88 (95%CI 0.32-2.36). CONCLUSIONS Corticosteroid treatment may be of benefit for patients with CAP who have septic shock and/or a high inflammatory response and requirement for invasive mechanical ventilation. Corticosteroids appear to have no impact on mortality when these features are not present.
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Affiliation(s)
- A Ceccato
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
| | - A Russo
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - E Barbeta
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - P Oscanoa
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - G Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Gabarrus
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - P Di Giannatale
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - S Nogas
- Dipartimento Scienze Chirurgiche E Diagnostiche Integrate (DISC), Università Degli Studi Di Genova, Genova, Italy
| | - C Cilloniz
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - F Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Ferrer
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - M Niederman
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - M Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Torres
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain.
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
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Violi F, Cammisotto V, Pignatelli P. Thrombosis in Covid-19 and non-Covid-19 pneumonia: role of platelets. Platelets 2021; 32:1009-1017. [PMID: 34097572 PMCID: PMC8204311 DOI: 10.1080/09537104.2021.1936478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 02/09/2023]
Abstract
Platelets may be a target of bacteria and viruses, which can directly or indirectly activate them so promoting thrombosis. In accordance with this, community-acquired pneumonia (CAP) is complicated by ischemia-related vascular disease (myocardial infarction and stroke) in roughly 10% of patients while the incidence of venous thrombosis is uncertain. In CAP platelet biosynthesis of TxA2 is augmented and associated with myocardial infarction; however, a cause-effect relationship is still unclear as unclear is if platelet activation promotes thrombosis or functional changes of coronary tree such vasospasm. Retrospective studies suggested a potential role of aspirin in reducing mortality but the impact on vascular disease is still unknown. Coronavirus disease 2019 (Covid-19) is complicated by thrombosis in roughly 20% of patients with an almost equivalent localization in arterial and venous circulation. Platelet activation seems to have a pivot role in the thrombotic process in Covid-19 as consistently evidenced by its involvement in promoting Tissue Factor up-regulation via leucocyte interaction. Until now, antiplatelet treatment has been scarcely considered for the treatment of Covid-19; interventional trials, however, are in progress to explore this issue. The aim of this review is 1) to compare the type of vascular diseases complicating CAP and Covid-19 2) to assess the different role of platelets in both diseases and 3) to discuss if antiplatelet treatment is potentially useful to improve clinical outcomes.
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Affiliation(s)
- Francesco Violi
- I Clinica Medica, Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Vittoria Cammisotto
- Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Mediterranea Cardiocentro, Naples, Italy
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Cangemi R, Calvieri C, Falcone M, Cipollone F, Ceccarelli G, Pignatelli P, D'Ardes D, Pirro M, Alessandri F, Lichtner M, D'Ettorre G, Oliva A, Aronica R, Rocco M, Venditti M, Romiti GF, Tiseo G, Taliani G, Menichetti F, Pugliese F, Mastroianni CM, Violi F. Comparison of thrombotic events and mortality in patients with community-acquired pneumonia and COVID-19: a multicentre observational study. Thromb Haemost 2021; 122:257-266. [PMID: 34758488 DOI: 10.1055/a-1692-9939] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND It is still unclear if patients with community-acquired pneumonia (CAP) and coronavirus disease 2019 (COVID-19) have different rate, typology, and impact of thrombosis on survival. METHODS In this multicentre observational cohort study 1.138 patients, hospitalized for CAP (n=559) or COVID-19 (n=579) from 7 clinical centres in Italy, were included in the study. Consecutive adult patients (age ≥18 years) with confirmed COVID-19 related pneumonia, with or without mechanical ventilation, hospitalized from 1st March 2020 to 30 April 2020, were enrolled. Covid-19 was diagnosed based on the WHO interim guidance. Patients were followed-up until discharge or in-hospital death, registering the occurrence of thrombotic events including ischemic/embolic events. RESULTS During the in-hospital stay, 11.4% of CAP and 15.5% of COVID-19 patients experienced thrombotic events (p=0.046). In CAP patients all the events were arterial thromboses, while in COVID-19 patients 8.3% were venous and 7.2% arterial thromboses. During the in-hospital follow-up, 3% of CAP patients and 17% of COVID-19 patients died (p<0.001). The highest mortality rate was found among COVID-19 patients with thrombotic events (47.6% vs 13.4% in thrombotic-event free patients; p<0.001). In CAP, 13.8% of patients experiencing thrombotic events died vs. 1.8% of thrombotic event-free ones (p<0.001). A multivariable COX-regression analysis confirmed a higher risk of death in COVID-19 patients with thrombotic events (HR 2.1; 95% CI: 1.4-3.3; p<0.001). CONCLUSIONS Compared with CAP, COVID-19 is characterized by a higher burden of thrombotic events, different thrombosis typology and higher risk of thrombosis-related in-hospital mortality.
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Affiliation(s)
| | - Camilla Calvieri
- I Clinica Medica, Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy, Sapienza University of Rome, Rome, Italy
| | | | - Francesco Cipollone
- Department of Medicine and Aging, "G. D'Annunzio" University of Chieti-Pescara, Ita, G. D'Annunzio" University of Chieti-Pescara, Ita, Chieti, Italy
| | | | | | - Damiano D'Ardes
- 3. Department of Medicine and Aging, "G. D'Annunzio" University of Chieti-Pescara, Italy, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | | | | | | | - Gabriella D'Ettorre
- I Clinica Medica, Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy, Sapienza University of Rome, Rome, Italy
| | - Alessandra Oliva
- I Clinica Medica, Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy, Sapienza University of Rome, Rome, Italy
| | - Raissa Aronica
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Monica Rocco
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | | | | | - Gloria Taliani
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | - Francesco Pugliese
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | - Francesco Violi
- Policlinico Umberto I, I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Roma, Italy
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9
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Tiseo G, Arena F, Borrè S, Campanile F, Falcone M, Mussini C, Pea F, Sganga G, Stefani S, Venditti M. Diagnostic stewardship based on patient profiles: differential approaches in acute versus chronic infectious syndromes. Expert Rev Anti Infect Ther 2021; 19:1373-1383. [PMID: 33970746 DOI: 10.1080/14787210.2021.1926986] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: New diagnostics may be useful in clinical practice, especially in contexts of high prevalence of multidrug-resistant organisms (MDRO). However, misuse of diagnostic tools may lead to increased costs and worse patient outcome. Conventional and new techniques should be appropriately positioned in diagnostic algorithms to guide an appropriate use of antimicrobial therapy.Areas covered: A panel of experts identified 4 main areas in which the implementation of diagnostic stewardship is needed. Among chronic infections, bone and prosthetic joint infections and subacute-chronic intravascular infections and endocarditis represent common challenges for clinicians. Among acute infections, bloodstream infections and community-acquired pneumonia may be associated with high mortality and require appropriate diagnostic approach.Expert opinion: Diagnostic stewardship aims to improve the appropriate use of microbiological diagnostics to guide therapeutic decisions through appropriate and timely diagnostic testing. Here, diagnostic algorithms based on different patient profiles are proposed for chronic and acute clinical syndromes. In each clinical scenario, combining conventional and new diagnostic techniques is crucial to make a rapid and accurate diagnosis and to guide the selection of antimicrobial therapy. Barriers related to the implementation of new rapid diagnostic tools, such as high initial costs, may be overcome through their rational and structured use.
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Affiliation(s)
- Giusy Tiseo
- Infectious Disease Unit, Azienda Ospedaliera Universitaria Pisana, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabio Arena
- Infectious Disease Unit, Azienda Ospedaliera Universitaria Pisana, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Silvio Borrè
- Infectious Diseases Unit, Sant'Andrea Hospital Vercelli, Vercelli, Italy
| | - Floriana Campanile
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Marco Falcone
- Infectious Disease Unit, Azienda Ospedaliera Universitaria Pisana, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Cristina Mussini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, Policlinico of Modena, Modena, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, University Hospital IRCCS Policlinico Sant'Orsola, Bologna, Italy
| | - Gabriele Sganga
- Emergency Surgery, Fondazione Policlinico Agostino Gemelli IRCCS of Rome, Rome, Italy
| | - Stefania Stefani
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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10
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Card TR, Zittan E, Nguyen GC, Grainge MJ. Disease Activity in Inflammatory Bowel Disease Is Associated With Arterial Vascular Disease. Inflamm Bowel Dis 2021; 27:629-638. [PMID: 32618340 DOI: 10.1093/ibd/izaa156] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS There is evidence that several inflammatory diseases are associated with increased cardiovascular risk. Whether this is true for inflammatory bowel diseases remains controversial. We aimed to assess this risk, corrected for the effects of conventional vascular risk factors and IBD disease activity. METHODS We conducted a cohort study in British general practice and hospital records from the Clinical Practice Research Datalink. We extracted the records of subjects with IBD and matched controls from 1997 to 2017. We conducted Cox proportional hazards and self-controlled case series analyses to examine the associations of IBD, disease activity, and hospitalization with the risk of myocardial infarction, stroke, and cardiovascular death in a manner attempting to remove the effect of likely confounders. RESULTS We identified 31,175 IBD patients (16,779 UC, 10,721 Crohn's disease, and 3675 unclassifiable cases) and 154,412 matched controls. Five hundred thirty-two myocardial infarctions, 555 strokes, and 469 cardiovascular deaths were observed in IBD cases. Our Cox regression models, adjusted for potential confounders, showed no significant excess of vascular events for IBD patients overall. There was, however, an increased hazard of myocardial infarction in ambulatory patients for acute disease (hazard ratio, 1.83 [1.28-2.62]) and chronic activity (hazard ratio, 1.69 [1.24-2.30]). This effect of disease activity was confirmed in our case series analysis. CONCLUSIONS Though we have found no evidence of an overall excess of vascular events in IBD patients, our findings of increased risk with more active disease suggest the potential for anti-inflammatory therapies to reduce cardiovascular risk in this patient group.
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Affiliation(s)
- Timothy R Card
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.,National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK
| | - Eran Zittan
- Ellen and Pinchas Mamber Institute of Gastroenterology and Liver Diseases, IBD Unit, Emek Medical Center, Afula, Israel
| | - Geoffrey C Nguyen
- Department of Medicine, Mount Sinai Inflammatory Bowel Disease Centre, University of Toronto, Toronto, Canada
| | - Matthew J Grainge
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
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11
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Chen L, Han X, Li Y, Zhang C, Xing X. Complications of Cardiovascular Events in Patients Hospitalized with Influenza-Related Pneumonia. Infect Drug Resist 2021; 14:1363-1373. [PMID: 33859482 PMCID: PMC8043795 DOI: 10.2147/idr.s305509] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/25/2021] [Indexed: 02/05/2023] Open
Abstract
Purpose Influenza virus infections are a key cause of community-acquired pneumonia (CAP). Cardiovascular events (CVEs) are common among CAP and influenza patients, but there have been few population-based studies of influenza-related pneumonia (Flu-p) patients published to date. Methods A retrospective analysis of 1191 immunocompetent hospitalized adult Flu-p patients from January 2012 to December 2018 in five teaching hospitals in China was conducted. Results A total of 24.6% (293/1191) of patients developed at least one form of CVE-related complication while hospitalized. In a multivariate logistic regression analysis, hypertension, cerebrovascular disease, coronary artery disease, preexisting heart failure, systolic blood pressure <90 mmHg, respiratory rates ≥30 breaths/min, a lymphocyte count <0.8×109/L, PaO2/FiO2 <300 mmHg, and systemic corticosteroid administration were independently associated with the incidence of CVEs; while early neuraminidase inhibitor treatment and angiotensin converting enzyme inhibitors/angiotensin II receptor blocker treatment were associated with a lower risk of CVEs. After controlling for potential confounding variables, we determined that CVEs were linked to a higher risk of 30-day mortality (OR 3.307, 95% CI 2.198–4.975, p < 0.001) in Flu-p patients. Conclusion CVE-related complications are common among hospitalized Flu-p patients and are associated with negative patient outcomes. Clarifying these CVE-related risk factors can aid in their clinical prevention and management.
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Affiliation(s)
- Liang Chen
- Department of Infectious Diseases, Beijing Jishuitan Hospital, 4th Medical College of Peking University, Beijing, People's Republic of China
| | - Xiudi Han
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital, Qingdao City, People's Republic of China
| | - YanLi Li
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chunxiao Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Huimin Hospital, Beijing, People's Republic of China
| | - Xiqian Xing
- Department of Pulmonary and Critical Care Medicine, The 2nd People's Hospital of Yunnan Province, Kunming City, People's Republic of China
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12
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Narota A, Puri G, Singh VP, Kumar A, Naura AS. COVID-19 and ARDS: Update On Preventive And Therapeutic Venues. Curr Mol Med 2021; 22:312-324. [PMID: 33829971 DOI: 10.2174/1566524021666210408103921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 01/08/2023]
Abstract
A novel coronavirus SARS-CoV-2 which initially originated in China has outstretched to all nations and turned out to be an intense global concern for both the governments and the public. In addition to the health concerns, COVID-19 pandemic has caused tremendous impact on economic and political conditions of every nation. Ever since the start of pandemic the physicians were constrained to rely on the management strategies due to lack of clear understanding of the disease pathogenesis caused by SARS-CoV-2 infection. Scientists are working tirelessly to gather maximum information about the deadly virus and come up with various strategies which can be used against COVID-19 infection in terms of therapeutics and vaccine development. It is quite evident that virus infection leads to acute respiratory distress syndrome (ARDS) and most of the deaths occur due to respiratory failure. As the virus spread through respiratory droplets, the strenuous exercise of preventive measures and large scale diagnosis has been in practice across the globe to prevent the transmission. This review amalgamates the various updates and acts as an umbrella to provide insights on SARS-CoV-2 mediated ARDS pathogenesis, impact of co-morbidities, diagnostics, current progress in vaccine development, and promising therapeutics and immuno-modulatory strategies highlighting various concerns and gaps that need to be addressed to fight current and future pandemics effectively.
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Affiliation(s)
- Arun Narota
- Department of Biochemistry, Panjab University, Chandigarh-160014. India
| | - Gayatri Puri
- Department of Biochemistry, Panjab University, Chandigarh-160014. India
| | - Vikram Pal Singh
- Department of Cardiothoracic Vascular Surgery, Dayanand Medical College & Hospital, Ludhiana. India
| | - Ashwani Kumar
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh-160014. India
| | - Amarjit S Naura
- Department of Biochemistry, Panjab University, Chandigarh-160014. 0
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13
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Resl M, Heinzl MW, Klammer C, Egger M, Feldbauer R, Pohlhammer J, Dieplinger B, Clodi M. Storm of Cardiovascular Markers After LPS Administration in Human Volunteers. J Cardiovasc Transl Res 2021; 14:941-947. [PMID: 33751402 PMCID: PMC7983963 DOI: 10.1007/s12265-021-10109-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 02/15/2021] [Indexed: 12/01/2022]
Abstract
Acute infections are associated with an elevated cardiovascular risk. However, little is known about the interactions of acute inflammatory responses and the cardiovascular system. We therefore aimed to evaluate effects of acute inflammatory stimuli mediated by LPS administration on a set of 89 cardiovascular biomarkers. A single-blinded, placebo-controlled cross-over study using the human endotoxin model was performed. Ten healthy men were administered lipopolysaccharide (LPS) or placebo on two different study days after an overnight fast. Eighty-nine different cardiovascular biomarkers were measured repetitively over 48 h. Out of 89 cardiovascular biomarkers, 54 markers were significantly influenced by LPS infusion. The observed biomarker response to inflammation was more pronounced and complex than anticipated. In conclusion, our data show that the cardiovascular system is under enormous distress in response to experimental low-dose inflammation in humans, as demonstrated by a significant effect on 54 of the 89 biomarkers tested.
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Affiliation(s)
- Michael Resl
- Department of Medicine, St. John of God Hospital Linz, Seilerstaette 2, 4021, Linz, Austria
| | | | - Carmen Klammer
- Department of Medicine, St. John of God Hospital Linz, Seilerstaette 2, 4021, Linz, Austria
| | - Margot Egger
- Department of Laboratory Medicine, St. John of God Hospital Linz, ICMR - Institute for Cardiovascular and Metabolic Research, JKU Linz, Linz, Austria
| | - Roland Feldbauer
- Department of Medicine, St. John of God Hospital Linz, Seilerstaette 2, 4021, Linz, Austria
| | - Johannes Pohlhammer
- Department of Medicine, St. John of God Hospital Linz, Seilerstaette 2, 4021, Linz, Austria
| | - Benjamin Dieplinger
- Department of Laboratory Medicine, St. John of God Hospital Linz, ICMR - Institute for Cardiovascular and Metabolic Research, JKU Linz, Linz, Austria
| | - Martin Clodi
- Department of Medicine, St. John of God Hospital Linz, Seilerstaette 2, 4021, Linz, Austria.
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14
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Community-acquired Pneumonia Owing to Multidrug-Resistant Pathogens: A Step toward an Early Identification. Ann Am Thorac Soc 2021; 18:211-213. [PMID: 33522876 PMCID: PMC7869783 DOI: 10.1513/annalsats.202009-1207ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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Rombauts A, Abelenda-Alonso G, Cuervo G, Gudiol C, Carratalà J. Role of the inflammatory response in community-acquired pneumonia: clinical implications. Expert Rev Anti Infect Ther 2021; 20:1261-1274. [PMID: 33034228 DOI: 10.1080/14787210.2021.1834848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Despite adequate antibiotic coverage, community-acquired pneumonia (CAP) remains a leading cause of hospitalization and mortality worldwide. It induces both a local pulmonary and a systemic inflammatory response, particularly significant in severe cases. The intensity of the dysregulated host response varies from patient to patient and has a negative impact on survival and other outcomes. AREAS COVERED This comprehensive review summarizes the pathophysiological aspects of the inflammatory response in CAP, briefly discusses the usefulness of biomarkers, and assesses the clinical evidence for modulating the inflammatory pathways. We searched PubMed for the most relevant studies, reviews, and meta-analysis until August 2020. EXPERT OPINION Notable efforts have been made to identify biomarkers that can accurately differentiate between viral and bacterial etiology, and indeed, to enhance risk stratification in CAP. However, none has proven ideal and no recommended biomarker-guided algorithms exist. Biomarker signatures from proteomic and metabolomic studies could be more useful for such assessments. To date, most studies have produced contradictory results concerning the role of immunomodulatory agents (e.g. corticosteroids, macrolides, and statins) in CAP. Adequately identifying the population who may benefit most from effective modulation of the inflammatory response remains a challenge.
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Affiliation(s)
- Alexander Rombauts
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Gabriela Abelenda-Alonso
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Guillermo Cuervo
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Carlota Gudiol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain.,Institut Català d'Oncologia (ICO), Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain
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16
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Feldman C, Anderson R. Platelets and Their Role in the Pathogenesis of Cardiovascular Events in Patients With Community-Acquired Pneumonia. Front Immunol 2020; 11:577303. [PMID: 33042161 PMCID: PMC7527494 DOI: 10.3389/fimmu.2020.577303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/24/2020] [Indexed: 12/21/2022] Open
Abstract
Community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality throughout the world with much recent and ongoing research focused on the occurrence of cardiovascular events (CVEs) during the infection, which are associated with adverse short-term and long-term survival. Much of the research directed at unraveling the pathogenesis of these events has been undertaken in the settings of experimental and clinical CAP caused by the dangerous, bacterial respiratory pathogen, Streptococcus pneumoniae (pneumococcus), which remains the most common bacterial cause of CAP. Studies of this type have revealed that although platelets play an important role in host defense against infection, there is also increasing recognition that hyperactivation of these cells contributes to a pro-inflammatory, prothrombotic systemic milieu that contributes to the etiology of CVEs. In the case of the pneumococcus, platelet-driven myocardial damage and dysfunction is exacerbated by the direct cardiotoxic actions of pneumolysin, a major pore-forming toxin of this pathogen, which also acts as potent activator of platelets. This review is focused on the role of platelets in host defense against infection, including pneumococcal infection in particular, and reviews the current literature describing the potential mechanisms by which platelet activation contributes to cardiovascular complications in CAP. This is preceded by an evaluation of the burden of pneumococcal infection in CAP, the clinical features and putative pathogenic mechanisms of the CVE, and concludes with an evaluation of the potential utility of the anti-platelet activity of macrolides and various adjunctive therapies.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, Institute of Cellular and Molecular Medicine, University of Pretoria, Pretoria, South Africa
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17
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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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18
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The Interplay Between Antioxidants and the Immune System: A Promising Field, Still Looking for Answers. Nutrients 2020; 12:nu12061550. [PMID: 32466603 PMCID: PMC7352790 DOI: 10.3390/nu12061550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/20/2020] [Indexed: 12/14/2022] Open
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19
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Feldman C. Cardiac complications in community-acquired pneumonia and COVID-19. Afr J Thorac Crit Care Med 2020; 26:10.7196/AJTCCM.2020.v26i2.077. [PMID: 34235421 PMCID: PMC7221539 DOI: 10.7196/ajtccm.2020.v26i2.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2020] [Indexed: 12/11/2022] Open
Abstract
Community-acquired pneumonia (CAP) remains a global health problem with significant morbidity and mortality. Much recent published literature about the infection has indicated that a substantial number of patients with CAP, particularly those ill enough to be admitted to hospital, will suffer a cardiovascular event. While these may include events such as deep venous thrombosis and stroke, most of the events involve the heart and include the occurrence of an arrhythmia (most commonly atrial fibrillation), new onset or worsening of heart failure and acute myocardial infarction. While such cardiac events may occur, for example, in all-cause CAP and CAP due to influenza virus infection, and more recently described with the SARS-CoV-2 pandemic, a significant amount of research work has been investigating the pathogenic mechanisms of these cardiac events in patients with CAP due to Streptococcus pneumoniae (pneumococcus) and, more recently, COVID-19 infections. Such research has identified a number of mechanisms by which these microorganisms may cause cardiovascular events. Importantly, these cardiac events appear not only to be associated with in-hospital mortality, but they also appear to contribute to longer-term mortality of patients with CAP, even after their discharge from hospital. This review will focus initially on studies of cardiovascular events in all-cause CAP and pneumococcal CAP, excluding COVID-19 infection, and then address similar issues in the latter infection.
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Affiliation(s)
- C Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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20
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Abstract
Infection with the severe acute respiratory syndrome novel coronavirus produces a clinical syndrome known as 2019 novel coronavirus disease (COVID-19). When severe, COVID-19 is a systemic illness characterized by hyperinflammation, cytokine storm, and elevations of cardiac injury biomarkers. Here, we review what is known about the pathophysiology of COVID-19, its cardiovascular manifestations, and emerging therapeutic prospects. In this rapidly moving field, this review was comprehensive as of April 3, 2020.
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Affiliation(s)
- Akbarshakh Akhmerov
- From the Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Eduardo Marbán
- From the Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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21
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Niederman MS, Nair GB, Matt U, Herold S, Pennington K, Crothers K, Cummings M, Schluger NW. Update in Lung Infections and Tuberculosis 2018. Am J Respir Crit Care Med 2020; 200:414-422. [PMID: 31042415 DOI: 10.1164/rccm.201903-0606up] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Michael S Niederman
- 1Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Girish Balachandran Nair
- 2Division of Pulmonary and Critical Care Medicine, Beaumont Health, William Beaumont School of Medicine, Oakland University, Royal Oak, Michigan
| | - Ulrich Matt
- 3Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center, member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Susanne Herold
- 3Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center, member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Kelly Pennington
- 4Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kristina Crothers
- 5Pulmonary, Critical Care and Sleep Medicine, VA Puget Sound Health Care System, Seattle, Washington.,6University of Washington, Seattle, Washington; and
| | | | - Neil W Schluger
- 7Columbia University Irving Medical Center, New York, New York
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22
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Tralhão A, Póvoa P. Cardiovascular Events After Community-Acquired Pneumonia: A Global Perspective with Systematic Review and Meta-Analysis of Observational Studies. J Clin Med 2020; 9:E414. [PMID: 32028660 PMCID: PMC7073946 DOI: 10.3390/jcm9020414] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/28/2020] [Accepted: 01/31/2020] [Indexed: 12/12/2022] Open
Abstract
Acute cardiovascular disease after community-acquired pneumonia is a well-accepted complication for which definitive treatment strategies are lacking. These complications share some common features but have distinct diagnostic and treatment approaches. We therefore undertook an updated systematic review and meta-analysis of observational studies reporting the incidence of overall complications, acute coronary syndromes, new or worsening heart failure, new or worsening arrhythmias and acute stroke, as well as short-term mortality outcomes. To set a framework for future research, we further included a holistic review of the interplay between the two conditions. From 1984 to 2019, thirty-nine studies were accrued, involving 92,188 patients, divided by setting (inpatients versus outpatients) and clinical severity (low risk versus high risk). Overall cardiac complications occurred in 13.9% (95% confidence interval (CI) 9.6-18.9), acute coronary syndromes in 4.5% (95% CI 2.9-6.5), heart failure in 9.2% (95% CI 6.7-12.2), arrhythmias in 7.2% (95% CI 5.6-9.0) and stroke in 0.71% (95% CI 0.1-3.9) of pooled inpatients. During this period, meta-regression analysis suggests that the incidence of overall and individual cardiac complications is decreasing. After adjusting for confounders, cardiovascular events taking place after community-acquired pneumonia independently increase the risk for short-term mortality (range of odds-ratio: 1.39-5.49). These findings highlight the need for effective, large trial based, preventive and therapeutic interventions in this important patient population.
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Affiliation(s)
- António Tralhão
- Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1449-005 Lisbon, Portugal;
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Avenida Professor Doutor Reinaldo dos Santos, 2790-134 Carnaxide, Portugal
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1449-005 Lisbon, Portugal;
- NOVA Medical School, CHRH, New University of Lisbon, 1069-056 Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, DK-5000 Odense C, Denmark
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23
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Use of glucocorticoids in the critical care setting: Science and clinical evidence. Pharmacol Ther 2020; 206:107428. [DOI: 10.1016/j.pharmthera.2019.107428] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
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24
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Falcone M, Bassetti M, Tiseo G, Giordano C, Nencini E, Russo A, Graziano E, Tagliaferri E, Leonildi A, Barnini S, Farcomeni A, Menichetti F. Time to appropriate antibiotic therapy is a predictor of outcome in patients with bloodstream infection caused by KPC-producing Klebsiella pneumoniae. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:29. [PMID: 32000834 PMCID: PMC6993311 DOI: 10.1186/s13054-020-2742-9] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/14/2020] [Indexed: 12/15/2022]
Abstract
Background Bloodstream infections (BSIs) by Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (Kp) are associated with high mortality. The aim of this study is to assess the relationship between time to administration of appropriate antibiotic therapy and the outcome of patients with BSI due to KPC-Kp hospitalized in intensive care unit (ICU). Methods An observational study was conducted in the ICUs of two academic centers in Italy. Patients with KPC-Kp bacteremia hospitalized between January 2015 to December 2018 were included. The primary outcome was the relationship between time from blood cultures (BC) collection to appropriate antibiotic therapy and 30-day mortality. The secondary outcome was to evaluate the association of different treatment regimens with 30-day mortality and a composite endpoint (30-day mortality or nephrotoxicity). A Cox regression analysis to identify factors independently associated with 30-day mortality was performed. Hazard ratio (HR) and 95% confidence interval (CI) were calculated. Results A total of 102 patients with KPC-Kp BSI were included. The most common sources of infection were intra-abdominal (23.5%), urinary tract (20.6%), and skin and skin structure (17.6%). The 30-day mortality was 45%. Median time to appropriate antibiotic therapy was shorter in patients who survived (8.5 h [IQR 1–36]) versus those who died (48 h [IQR 5–108], p = 0.014). A propensity score matching showed that receipt of an in vitro active therapy within 24 h from BC collection was associated with lower 30-day mortality (HR = 0.36, 95% CI: 0.188–0.690, p = 0.0021). At Cox regression analysis, factors associated with 30-day mortality were primary bacteremia (HR 2.662 [95% CI 1.118–6.336], p = 0.027), cardiovascular disease (HR 2.196 [95% CI 1.082–4.457], p = 0.029), time (24-h increments) from BC collection to appropriate therapy (HR 1.382 [95% CI 1.132–1.687], p = 0.001), SOFA score (HR 1.122 [95% CI 1.036–1.216], p = 0.005), and age (HR 1.030 [95% CI 1.006–1.054], p = 0.012). Ceftazidime-avibactam-containing regimens were associated with reduced risk of composite endpoint (30-day mortality OR nephrotoxicity) (HR 0.231 [95% CI 0.071–0.745], p = 0.014) compared to colistin-containing regimens. Conclusions Time to appropriate antibiotic therapy is an independent predictor of 30-day mortality in patients with KPC-Kp BSI. Appropriate antibiotic therapy should begin within 24 h from the collection of BC. Electronic supplementary material The online version of this article (10.1186/s13054-020-2742-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marco Falcone
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa, 2, 56124, Pisa, PI, Italy.
| | - Matteo Bassetti
- Infectious Diseases Clinic Department of Health Science, University of Genoa and Hospital Policlinico San Martino - IRCCS, Genoa, Italy
| | - Giusy Tiseo
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa, 2, 56124, Pisa, PI, Italy
| | - Cesira Giordano
- Microbiology Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Elia Nencini
- Emergency Medicine Department, University of Pisa, Pisa, Italy
| | - Alessandro Russo
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa, 2, 56124, Pisa, PI, Italy
| | - Elena Graziano
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Enrico Tagliaferri
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa, 2, 56124, Pisa, PI, Italy
| | | | - Simona Barnini
- Microbiology Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Alessio Farcomeni
- Department of Economics and Finance, University of Rome "Tor Vergata", Rome, Italy
| | - Francesco Menichetti
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa, 2, 56124, Pisa, PI, Italy
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Violi F, Calvieri C, Cangemi R. Effect of corticosteroids on myocardial injury among patients hospitalized for community-acquired pneumonia: rationale and study design. The colosseum trial. Intern Emerg Med 2020; 15:79-86. [PMID: 31152308 PMCID: PMC7223724 DOI: 10.1007/s11739-019-02117-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/24/2019] [Indexed: 02/08/2023]
Abstract
Community-acquired pneumonia (CAP) is often complicated by elevation of cardiac troponin, a marker of myocardial injury that can be isolated or associated with myocardial infarction (MI). A retrospective study showed that corticosteroid treatment lowers the incidence of MI during the hospital stay. No data exist so far on the effect of corticosteroids on myocardial injury in CAP patients. The primary objective of the study is to evaluate if methylprednisolone is able to reduce myocardial injury, as assessed by serum high-sensitivity cardiac T Troponin (hs-cTnT), in a cohort of patients hospitalized for CAP. Secondary aims are to evaluate the potential effect of methylprednisolone on cardiovascular events during hospitalization, at 30 days from hospital admission and during 2 years' follow-up. The trial will also examine whether the potential protective effects of methylprednisolone might be due to platelet activation down-regulation. Double-blind randomized placebo-controlled trial. One hundred twenty-two eligible patients will be randomized to a week treatment with iv methylprednisolone (20 mg b.i.d) or placebo from hospital admission. Serum hs-cTnT will be measured at admission and every day until up 3 days from admission. ECG will be monitored every day until discharge. After discharge, all patients will be followed-up 2 years. This is the first clinical trial aimed at examining whether methylprednisolone treatment may reduce myocardial injury. The results of this trial may constitute the basis for conducting a larger multicenter trial aimed to evaluate the effect of corticosteroid on cardiovascular events in this setting.
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Affiliation(s)
- Francesco Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Camilla Calvieri
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, La Sapienza University, Rome, Italy
| | - Roberto Cangemi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Davidson JA, Warren-Gash C. Cardiovascular complications of acute respiratory infections: current research and future directions. Expert Rev Anti Infect Ther 2019; 17:939-942. [PMID: 31684779 DOI: 10.1080/14787210.2019.1689817] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Jennifer A Davidson
- Department of Non-communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Warren-Gash
- Department of Non-communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Cangemi R, Calvieri C, Taliani G, Pignatelli P, Morelli S, Falcone M, Pastori D, Violi F. Left Atrium Dilatation and Left Ventricular Hypertrophy Predispose to Atrial Fibrillation in Patients With Community-Acquired Pneumonia. Am J Cardiol 2019; 124:723-728. [PMID: 31266594 DOI: 10.1016/j.amjcard.2019.05.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/09/2019] [Accepted: 05/16/2019] [Indexed: 01/27/2023]
Abstract
Atrial fibrillation (AF) is one of the most common cardiovascular complications in patients hospitalized with community-acquired pneumonia (CAP). However, predisposing clinical factors associated with AF in CAP patients have not been fully elucidated. We enrolled 545 patients consecutively hospitalized for CAP. Data on demographic characteristics and co-morbidities were collected and all patients underwent ECG, echocardiography, and laboratory measurements. During the in-hospital stay, 9.5% of patients experienced a new episode of AF within 24 to 72 hours from admission. CAP patients who experienced AF had a higher indexed left atrial area (LAAi) and a higher proportion of concentric left ventricular hypertrophy than those not presenting AF. Univariate logistic regression analysis showed that hypertension, history of coronary heart disease, high Pneumonia Severity Index classes, history of paroxysmal AF, systolic heart failure, concentric left ventricular hypertrophy, and an enlarged LAAi were associated with a new episode of AF. A multivariable logistic analysis showed that history of paroxysmal AF (odds ratio [OR] 11.7; 95% confidence interval [CI] 5.8 to 23.7; p <0.001), enlarged LAAi (OR 5.4; 95% CI 2.5 to 11.9; p <0.001), and concentric left ventricular hypertrophy (OR 2.2; 95 CI 1.1 to 4.6; p = 0.034) remained independently associated with AF occurrence. In conclusion, in this large cohort of CAP patients, history of paroxysmal AF, enlarged LAAi, and concentric left ventricular hypertrophy are independent predictors of AF occurrence during the early stages of pneumonia.
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Corticosteroids for Community-Acquired Pneumonia: Overstated Benefits and Understated Risks. Chest 2019; 156:1049-1053. [PMID: 31287999 DOI: 10.1016/j.chest.2019.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 01/13/2023] Open
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