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Haan BJ, Blackmon SN, Cobb AM, Cohen HE, DeVier MT, Perez MM, Winslow SF. Corticosteroids in critically ill patients: A narrative review. Pharmacotherapy 2024; 44:581-602. [PMID: 38872437 DOI: 10.1002/phar.2944] [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: 02/26/2024] [Revised: 05/15/2024] [Accepted: 05/15/2024] [Indexed: 06/15/2024]
Abstract
Corticosteroids have been utilized in modern medicine for decades. Many indications have been investigated across various treatment settings with both benefit and harm observed. Given the instability of critically ill patients, the increased risk of corticosteroid-related complications, and the pervasive comorbidities, patients who receive corticosteroids must be carefully managed. Common critical care disease states in which corticosteroids have been studied and are routinely utilized include acute respiratory distress syndrome, adrenal insufficiency, angioedema, asthma, chronic obstructive pulmonary disease, community-acquired pneumonia, coronavirus disease 2019, septic shock, and spinal cord injury. Benefits of corticosteroids include an improvement in disease state-specific outcomes, decreased hospital length of stay, decreased mechanical ventilatory support, and decreased mortality. The harm of corticosteroids is well documented through adverse effects that include, but are not limited to, hyperglycemia, tachycardia, hypertension, agitation, delirium, anxiety, immunosuppression, gastrointestinal bleeding, fluid retention, and muscle weakness. Furthermore, corticosteroids are associated with increased health care costs through adverse effects as well as drug acquisition and administration costs. Given the assortment of agents, dosing, benefits, risks, and utilization in the critical care setting, there may be difficulty with identifying the appropriate places for use of corticosteroids in therapy. There currently exists no comprehensive report detailing the use of corticosteroids in the aforementioned disease states within the critical care setting. This narrative review sets out to describe these in detail.
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Affiliation(s)
- Bradley J Haan
- Department of Pharmacy, Ascension Genesys Hospital, Grand Blanc, Michigan, USA
| | - Samantha N Blackmon
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Alex M Cobb
- Department of Pharmacy, Ascension St. John Medical Center, Tulsa, Oklahoma, USA
| | - Heather E Cohen
- Department of Pharmacy, Ascension Illinois Metro Region, Chicago, Illinois, USA
| | - Margaret T DeVier
- Department of Pharmacy, Ascension Saint Thomas Hospital Midtown, Nashville, Tennessee, USA
| | - Mary M Perez
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Samuel F Winslow
- Department of Pharmacy, Ascension Providence Hospital, Southfield, Michigan, USA
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Blum CA, Roethlisberger EA, Cesana-Nigro N, Winzeler B, Rodondi N, Blum MR, Briel M, Mueller B, Christ-Crain M, Schuetz P. Adjunct prednisone in community-acquired pneumonia: 180-day outcome of a multicentre, double-blind, randomized, placebo-controlled trial. BMC Pulm Med 2023; 23:500. [PMID: 38082273 PMCID: PMC10712075 DOI: 10.1186/s12890-023-02794-w] [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: 06/25/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Several trials and meta-analyses found a benefit of adjunct corticosteroids for community-acquired pneumonia with respect to short-term outcome, but there is uncertainty about longer-term health effects. Herein, we evaluated clinical outcomes at long term in patients participating in the STEP trial (Corticosteroid Treatment for Community-Acquired Pneumonia). METHODS This predefined secondary analysis investigated 180-day outcomes in 785 adult patients hospitalized with community-acquired pneumonia included in STEP, a randomised, placebo-controlled, double-blind trial. The primary endpoint was time to death from any cause at 180 days verified by telephone interview. Additional secondary endpoints included pneumonia-related death, readmission, recurrent pneumonia, secondary infections, new hypertension, and new insulin dependence. RESULTS From the originally included 785 patients, 727 were available for intention-to-treat analysis at day 180. There was no difference between groups with respect to time to death from any cause (HR for corticosteroid use 1.15, 95% CI 0.68 to 1.95, p = 0.601). Compared to placebo, corticosteroid-treated patients had significantly higher risks for recurrent pneumonia (OR 2.57, 95% CI 1.29 to 5.12, p = 0.007), secondary infections (OR 1.94, 95% CI 1.25 to 3.03, p = 0.003) and new insulin dependence (OR 8.73, 95% CI 1.10 to 69.62, p = 0.041). There was no difference regarding pneumonia-related death, readmission and new hypertension. CONCLUSIONS In patients with community-acquired pneumonia, corticosteroid use was associated with an increased risk for recurrent pneumonia, secondary infections and new insulin dependence at 180 days. Currently, it is uncertain whether these long-term adverse effects outweigh the short-term effects of corticosteroids in moderate CAP. TRIAL REGISTRATION This trial was registered with ClinicalTrials. gov, number NCT00973154 before the recruitment of the first patient. First posted: September 9, 2009. Last update posted: April 21, 2015.
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Affiliation(s)
- Claudine A Blum
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland.
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland.
- Hormonpraxis Aarau, 5000, Aarau, Switzerland.
| | - Eva A Roethlisberger
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland
| | - Nicole Cesana-Nigro
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland
- Stoffwechselzentrum, Bürgerspital, 4500, Solothurn, Switzerland
| | - Bettina Winzeler
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Manuel R Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Matthias Briel
- CLEAR-Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, 4031, Basel, Switzerland
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Beat Mueller
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Clinic, Division of General Internal & Emergency Medicine and Division of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, 5001, Aarau, Switzerland
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Beaty W, Elnadoury O, Fridman D, Louie E, Lubinsky AS. Effects of corticosteroids in hospitalized patients with Legionella pneumonia: A retrospective cohort study. J Infect Chemother 2023; 29:849-854. [PMID: 37164062 DOI: 10.1016/j.jiac.2023.05.002] [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: 01/25/2023] [Revised: 04/03/2023] [Accepted: 05/06/2023] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Legionella pneumophila is an important cause of pneumonia, however there is scant literature assessing the therapeutic benefit of corticosteroids in treatment. We sought to investigate the association between corticosteroid use and in-hospital mortality for patients hospitalized with Legionella pneumonia. METHODS Data was collected retrospectively from January 2012 to July 2019 at a 705 bed hospital in New York City. Patients were included if they received a positive Legionella test. Exclusion criteria included age <18, concurrent immunosuppression, and HIV diagnosis. We assessed the relationship between corticosteroid use and in-hospital mortality. Statistical analyses were performed in RStudio. RESULTS The study included 160 patients, among which 32 (20%) received steroids. Overall mortality was 7.5% (12.5% among steroid recipients, 6.2% among controls). 25% of patients were admitted to the ICU (37.5% among steroid recipients, 21.9% among controls). Adjusted analysis showed steroid recipients did not have significantly different mortality (aOR = 2.56, p = 0.436). Steroid use was not significantly associated with longer LOS (p = 0.22). Steroid use was significantly associated with hyperglycemia (aOR = 2.91, p = 0.018) and GI bleed (OR = 9.0, p = 0.014). CONCLUSIONS We found that in patients hospitalized with Legionella pneumonia, corticosteroid administration was not significantly associated with longer hospitalization or mortality. All findings held true when adjusting for known predictors of pneumonia severity. Corticosteroid use was associated with increased rates of hyperglycemia and GIB requiring blood transfusion. The results of this study are consistent with guidelines recommending against routine use of corticosteroids in CAP.
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Affiliation(s)
- William Beaty
- New York University Grossman School of Medicine, 550 1st Ave, New York, NY, 10016, USA.
| | - Ola Elnadoury
- Regeneron Pharmaceuticals Inc, 777 Old Saw Mill River Rd, Tarrytown, NY, 10591, USA.
| | - David Fridman
- New York University Langone Health, 550 1st Ave, New York, NY, 10016, USA.
| | - Eddie Louie
- New York University Langone Health, 550 1st Ave, New York, NY, 10016, USA.
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Win TZ, Tabei K, Mukadi P, Edwards T, Smith C, Lee N. Corticosteroids for treatment of leptospirosis. Hippokratia 2022. [DOI: 10.1002/14651858.cd014935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tin Zar Win
- School of Tropical Medicine and Global Health; Nagasaki University; Nagasaki Japan
| | - Kozue Tabei
- School of Tropical Medicine and Global Health; Nagasaki University; Nagasaki Japan
| | - Patrick Mukadi
- Department of Clinical Medicine; Institute of Tropical Medicine, Nagasaki University; Nagasaki Japan
- Program for Nurturing Global Leaders in Tropical and Emerging Communicable Diseases; Graduate School of Biomedical Sciences, Nagasaki University; Nagasaki Japan
- Institut National de Recherche Biomedicale (INRB); Kinshasa Costa Rica
| | - Tansy Edwards
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health; London School of Hygiene & Tropical Medicine; London UK
| | - Chris Smith
- School of Tropical Medicine and Global Health; Nagasaki University; Nagasaki Japan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases; London School of Hygiene & Tropical Medicine; London UK
| | - Nathaniel Lee
- Hospital for Tropical Diseases; University College London Hospital NHS Foundation Trust; London UK
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Cortés JA, Cuervo-Maldonado SI, Nocua-Báez LC, Valderrama MC, Sánchez EA, Saavedra A, Torres JV, Forero DP, Álvarez CA, Leal AL, Pérez JE, Rodríguez IA, Guevara FO, Saavedra CH, Vergara EP, Montúfar FE, Espinosa T, Chaves W, Carrizosa JA, Meléndez SDM, Espinosa CJ, García F, Guzmán IJ, Cortés SL, Díaz JA, González N. Guía de práctica clínica para el manejo de la neumonía adquirida en la comunidad. REVISTA DE LA FACULTAD DE MEDICINA 2021. [DOI: 10.15446/revfacmed.v70n2.93814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
La neumonía sigue siendo una de las principales causas de consulta y de hospitalización a la que, además de su un alto impacto en términos de morbilidad y mortalidad, se suma la actual problemática de resistencia a los antimicrobianos, por lo que establecer directrices que permitan su adecuado diagnóstico y tratamiento es de gran importancia para obtener mejores desenlaces clínicos y promover un uso racional de antibióticos en estos pacientes. La presente guía de práctica clínica (GPC) contiene recomendaciones basadas en la evidencia para el diagnóstico y tratamiento de la neumonía adquirida en la comunidad en adultos, las cuales fueron realizadas mediante el proceso de adaptación de GPC basadas en la evidencia para el contexto colombiano.
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Kukhon FR, Festic E. Adjuvant Inhaled Corticosteroids in Community-Acquired Pneumonia: A Review Article. Med Sci (Basel) 2021; 9:34. [PMID: 34071031 PMCID: PMC8162532 DOI: 10.3390/medsci9020034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 12/15/2022] Open
Abstract
Community-acquired pneumonia is still a major cause of morbidity and mortality worldwide. Since the inflammatory response induced by the immune system is often a major contributor to the lung injury, it becomes reasonable to assess the potential benefit of anti-inflammatory agents in treating community-acquired pneumonia. The role of corticosteroids as adjunct anti-inflammatory agents in treating community-acquired pneumonia is still controversial. Several studies have assessed the benefit of their use in patients with community-acquired pneumonia. In most of those studies, the route of corticosteroids administration was systemic. The aim of this article is to provide a concise review of the role of corticosteroids in treating community-acquired pneumonia when administered via inhalational route, with the potential benefit of avoiding systemic side effects of corticosteroids while exerting the same anti-inflammatory effects on the lungs. Conclusion: the use of inhaled corticosteroids may be of benefit in certain patient subsets with community-acquired pneumonia. Further randomized controlled trials are needed for better determination of such patient subsets.
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Affiliation(s)
| | - Emir Festic
- Division of Pulmonary and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL 32224, USA;
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Cui YQ, Ding XF, Liang HY, Wang D, Zhang XJ, Li LF, Kan QC, Wang LX, Sun TW. Efficacy and safety of low-dose corticosteroids for acute respiratory distress syndrome: A systematic review and meta-analysis. World J Emerg Med 2021; 12:207-213. [PMID: 34141036 DOI: 10.5847/wjem.j.1920-8642.2021.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There are conflicting results regarding whether corticosteroids have better efficacy than placebo in acute respiratory distress syndrome (ARDS) patients. Therefore, we aim to further evaluate the efficacy and safety of corticosteroids in adult ARDS patients. METHODS The databases, including Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, were searched from their inception to May 2, 2020. Randomized controlled trials (RCTs) and observational cohort studies were selected to assess the use of corticosteroids in adult ARDS patients. The quality of the results was judged by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The inverse-variance method with random or fixed effects modeling was used to compute pooled odds ratio (OR), standardized mean difference (SMD), and their 95% confidence interval (CI). RESULTS Eight eligible RCTs and six cohort studies were included. The use of corticosteroids was associated with reduced mortality (OR 0.57, 95% CI 0.43-0.76, I2=35.1%, P=0.148) in ARDS patients, and the result was confirmed in the included cohort studies (OR 0.51, 95% CI 0.27-0.95, I2=66.7%, P=0.010). The subgroup analysis stratified by the initiation time and duration of corticosteroid use showed that early ARDS and prolonged corticosteroid use had significant survival benefits in the RCTs. The low-dose corticosteroid use was also associated with significantly more ventilator-free days and a reduced rate of new infections in ARDS patients. CONCLUSIONS The low-dose corticosteroid therapy may be safe and reduce mortality, especially in patients with prolonged treatment and early ARDS.
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Affiliation(s)
- Yu-Qing Cui
- General ICU, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou 450052, China
| | - Xian-Fei Ding
- General ICU, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou 450052, China
| | - Huo-Yan Liang
- General ICU, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou 450052, China
| | - Dong Wang
- General ICU, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou 450052, China
| | - Xiao-Juan Zhang
- General ICU, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou 450052, China
| | - Li-Feng Li
- Biotherapy Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Quan-Cheng Kan
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Le-Xin Wang
- School of Biomedical Sciences, Charles Sturt University, Wagga Wagga 2650, Australia
| | - Tong-Wen Sun
- General ICU, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou 450052, China
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Odeyemi YE, Herasevich S, Chalmers SJ, Barreto EF, Frank RD, Gajic OO, Yadav H. Biomarker-Concordant Steroid Use in Critically Ill Patients with Pneumonia. Mayo Clin Proc Innov Qual Outcomes 2020; 4:649-656. [PMID: 33367210 PMCID: PMC7749267 DOI: 10.1016/j.mayocpiqo.2020.07.011] [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] [Indexed: 01/22/2023] Open
Abstract
Objectives To evaluate the frequency and consequences of prescribing corticosteroids for pneumonia in a biomarker-concordant manner. Patients and Methods This was a single-center retrospective cohort study of adults with pneumonia admitted to the medical intensive care unit (ICU) at Mayo Clinic in Rochester, Minnesota, between January 1, 2009, and June 30, 2014. Steroid use was “biomarker concordant” if given when C-reactive protein (CRP) was ≥150 mg/L or withheld when CRP was <150 mg/L, and vice versa for biomarker discordant. Results Of 3481 ICU admissions with community-acquired pneumonia, 169 (4.9%) had CRPs measured within 48 hours of admission to the ICU. Steroid use in the ICU was biomarker concordant in 88 (52%) patients and biomarker discordant in 81 (48%) patients. Biomarker-concordant steroid use was associated with faster resolution of lung injury: median fraction of inspired oxygen on day 3 (0.4 [0.3, 0.5] vs 0.3 [0.21, 0.4], P=.005), day 4 (0.35 [0.3, 0.5] vs 0.28 [0.21, 0.38], P=<.001), and day 5 (0.30 [0.24, 0.45] vs 0.28 [0.21, 0.40], P=.03), and increased ICU (3.5; 95% CI, 0.5 to 6.4, P=.02), and hospital-free days (3.6; 95% CI, 0.4 to 6.8, P=.03) on multivariate analysis. Conclusions In critically ill patients with community-acquired pneumonia, steroid use is rarely biomarker informed and often discordant with inflammatory biomarker levels. Biomarker-concordant steroid use was associated with a faster recovery of hypoxemia and increased ICU- and hospital-free days. Future well-designed prospective studies are justified to test the potential value of biomarker-concordant steroid therapy.
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Affiliation(s)
- Yewande E. Odeyemi
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
- Correspondence: Address to Yewande Odeyemi, MBBS, MS, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
| | - Svetlana Herasevich
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Sarah J. Chalmers
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Ryan D. Frank
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ognjen O. Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Hemang Yadav
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2020; 200:e45-e67. [PMID: 31573350 PMCID: PMC6812437 DOI: 10.1164/rccm.201908-1581st] [Citation(s) in RCA: 1837] [Impact Index Per Article: 459.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia. Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions. Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.
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MESH Headings
- Adult
- Ambulatory Care
- Anti-Bacterial Agents/therapeutic use
- Antigens, Bacterial/urine
- Blood Culture
- Chlamydophila Infections/diagnosis
- Chlamydophila Infections/drug therapy
- Chlamydophila Infections/metabolism
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/drug therapy
- Culture Techniques
- Drug Therapy, Combination
- Haemophilus Infections/diagnosis
- Haemophilus Infections/drug therapy
- Haemophilus Infections/metabolism
- Hospitalization
- Humans
- Legionellosis/diagnosis
- Legionellosis/drug therapy
- Legionellosis/metabolism
- Macrolides/therapeutic use
- Moraxellaceae Infections/diagnosis
- Moraxellaceae Infections/drug therapy
- Moraxellaceae Infections/metabolism
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Mycoplasma/diagnosis
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/metabolism
- Pneumonia, Pneumococcal/diagnosis
- Pneumonia, Pneumococcal/drug therapy
- Pneumonia, Pneumococcal/metabolism
- Pneumonia, Staphylococcal/diagnosis
- Pneumonia, Staphylococcal/drug therapy
- Pneumonia, Staphylococcal/metabolism
- Radiography, Thoracic
- Severity of Illness Index
- Sputum
- United States
- beta-Lactams/therapeutic use
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CE: Infection in Acute Care: Evidence for Practice. Am J Nurs 2020; 119:24-32. [PMID: 31567249 DOI: 10.1097/01.naj.0000586160.03391.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Infection may be either a cause for admission to an acute care hospital or health care associated, a complication of receiving care for another illness in the acute care environment. In recent years, there has been significant research investigating risk factors for infection in the hospital setting, best practices for diagnosis and treatment, and ways to prevent many health care-associated infections. Multidrug-resistant organisms are a consequence of antibiotic overuse, poor environmental hygiene, and our increasing ability to keep chronically ill patients alive longer through invasive intensive care support. This article reviews the evidence on infection in acute care settings, with a focus on community- and hospital-acquired pneumonia, surgical site infections, and Clostridioides difficile infection. Recommendations for integrating this evidence into nursing practice are offered.
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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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Abstract
Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality despite adequate antibiotic therapy. It is the single most common cause of infection-related mortality in the United States. An exaggerated host inflammatory response can potentially be harmful to both the lung and host, and has been associated with treatment failure and mortality. Modulation of inflammatory response may, therefore, be theoretically beneficial. The anti-inflammatory and immunosuppressive effects of steroids seem an attractive therapeutic option in severe CAP patients. Available datapoint to overall shorter time to clinical stability and decreased length-of-stay in CAP patients, with a potential mortality benefit in severe CAP. The level of evidence is, however, low to moderate regarding mortality due to high heterogeneity and insufficient power of data. Furthermore, steroids were deleterious in influenza pneumonia and in patients with pneumococcal pneumonia data suggest a lack of efficacy and potential harm. Both European and American guidelines recommend not using corticosteroids in CAP. Patients who might benefit and those that can be harmed from steroids remain to be clearly identified, as does the ideal steroid for CAP patients, based on pharmacokinetic and pharmacodynamic properties. It is essential for future studies to avoid the same methodological bias present in the available data so that high-quality evidence on the true role of steroids in CAP can be provided.
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Affiliation(s)
- David Nora
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Wagner Nedel
- Intensive Care Unit, Hospital Nossa Senhora Da Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Hospital De Clínicas De Porto Alegre, Post-Graduation Program (PPG) Pneumology,Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Jorge Salluh
- D'or Institute for Research and Education, Rio De Janeiro, Brazil
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
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Fitzgerald DB, Waterer GW, Read CA, Fysh ET, Shrestha R, Stanley C, Muruganandan S, Lan NSH, Popowicz ND, Peddle-McIntyre CJ, Rahman NM, Gan SK, Murray K, Lee YCG. Steroid therapy and outcome of parapneumonic pleural effusions (STOPPE): Study protocol for a multicenter, double-blinded, placebo-controlled randomized clinical trial. Medicine (Baltimore) 2019; 98:e17397. [PMID: 31651842 PMCID: PMC6824804 DOI: 10.1097/md.0000000000017397] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a major global disease. Parapneumonic effusions often complicate CAP and range from uninfected (simple) to infected (complicated) parapneumonic effusions and empyema (pus). CAP patients who have a pleural effusion at presentation are more likely to require hospitalization, have a longer length of stay and higher mortality than those without an effusion. Conventional management of pleural infection, with antibiotics and chest tube drainage, fails in about 30% of cases. Several randomized controlled trials (RCT) have evaluated the use of corticosteroids in CAP and demonstrated some potential benefits. Importantly, steroid use in pneumonia has an acceptable safety profile with no adverse impact on mortality. A RCT focused on pediatric patients with pneumonia and a parapneumonic effusion demonstrated shorter time to recovery. The effects of corticosteroid use on clinical outcomes in adults with parapneumonic effusions have not been tested. We hypothesize that parapneumonic effusions develop from an exaggerated pleural inflammatory response. Treatment with systemic steroids may dampen the inflammation and lead to improved clinical outcomes. The steroid therapy and outcome of parapneumonic pleural effusions (STOPPE) trial will assess the efficacy and safety of systemic corticosteroid as an adjunct therapy in adult patients with CAP and pleural effusions. METHODS STOPPE is a pilot multicenter, double-blinded, placebo-controlled RCT that will randomize 80 patients with parapneumonic effusions (2:1) to intravenous dexamethasone or placebo, administered twice daily for 48 hours. This exploratory study will capture a wide range of clinically relevant endpoints which have been used in clinical trials of pneumonia and/or pleural infection; including, but not limited to: time to clinical stability, inflammatory markers, quality of life, length of hospital stay, proportion of patients requiring escalation of care (thoracostomy or thoracoscopy), and mortality. Safety will be assessed by monitoring for the incidence of adverse events during the study. DISCUSSION STOPPE is the first trial to assess the efficacy and safety profile of systemic corticosteroids in adults with CAP and pleural effusions. This will inform future studies on feasibility and appropriate trial endpoints. TRIAL REGISTRATION ACTRN12618000947202 PROTOCOL VERSION:: version 3.00/26.07.18.
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Affiliation(s)
- Deirdre B. Fitzgerald
- Respiratory Medicine, Sir Charles Gairdner Hospital
- Medical School, Faculty of Health & Medical Sciences
- Pleural Medicine Unit, Institute for Respiratory Health
| | - Grant W. Waterer
- Medical School, Faculty of Health & Medical Sciences
- Respiratory Medicine, Royal Perth Hospital
| | - Catherine A. Read
- Medical School, Faculty of Health & Medical Sciences
- Pleural Medicine Unit, Institute for Respiratory Health
| | | | | | | | | | | | - Natalia D. Popowicz
- Respiratory Medicine, Sir Charles Gairdner Hospital
- Medical School, Faculty of Health & Medical Sciences
- Pleural Medicine Unit, Institute for Respiratory Health
- School of Allied Health, University of Western Australia
| | - Carolyn J. Peddle-McIntyre
- Pleural Medicine Unit, Institute for Respiratory Health
- School of Medical and Health Sciences, Edith Cowan University
| | | | - Seng Khee Gan
- Medical School, Faculty of Health & Medical Sciences
- Endocrinology and Diabetes, Royal Perth Hospital, Perth
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Western Australia, Australia
| | - Yun Chor Gary Lee
- Respiratory Medicine, Sir Charles Gairdner Hospital
- Medical School, Faculty of Health & Medical Sciences
- Pleural Medicine Unit, Institute for Respiratory Health
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15
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Severiche-Bueno D, Parra-Tanoux D, Reyes LF, Waterer GW. Hot topics and current controversies in community-acquired pneumonia. Breathe (Sheff) 2019; 15:216-225. [PMID: 31508159 PMCID: PMC6717612 DOI: 10.1183/20734735.0205-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Community-acquired pneumonia (CAP) is one of the most common infectious diseases, as well as a major cause of death both in developed and developing countries, and it remains a challenge for physicians around the world. Several guidelines have been published to guide clinicians in how to diagnose and take care of patients with CAP. However, there are still many areas of debate and uncertainty where research is needed to advance patient care and improve clinical outcomes. In this review we highlight current hot topics in CAP and present updated evidence around these areas of controversy. Community-acquired pneumonia is the most frequent cause of infectious death worldwide; however, there are several areas of controversy that should be addressed to improve patient care. This review presents the available data on these topics.http://bit.ly/2ShnH7A
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Affiliation(s)
- Diego Severiche-Bueno
- Infectious Diseases and Critical Care Depts, Universidad de La Sabana, Chía, Colombia
| | - Daniela Parra-Tanoux
- Infectious Diseases and Critical Care Depts, Universidad de La Sabana, Chía, Colombia
| | - Luis F Reyes
- Infectious Diseases and Critical Care Depts, Universidad de La Sabana, Chía, Colombia
| | - Grant W Waterer
- Royal Perth Bentley Hospital Group, University of Western Australia, Perth, Australia
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16
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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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17
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Lansbury L, Rodrigo C, Leonardi‐Bee J, Nguyen‐Van‐Tam J, Lim WS. Corticosteroids as adjunctive therapy in the treatment of influenza. Cochrane Database Syst Rev 2019; 2:CD010406. [PMID: 30798570 PMCID: PMC6387789 DOI: 10.1002/14651858.cd010406.pub3] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Specific treatments for influenza are limited to neuraminidase inhibitors and adamantanes. Corticosteroids show evidence of benefit in sepsis and related conditions, most likely due to their anti-inflammatory and immunomodulatory properties. Although commonly prescribed for severe influenza, there is uncertainty over their potential benefits or harms. This is an update of a review first published in 2016. OBJECTIVES To systematically assess the effectiveness and potential adverse effects of corticosteroids as adjunctive therapy in the treatment of influenza, taking into account differences in timing and doses of corticosteroids. SEARCH METHODS We searched CENTRAL (2018, Issue 9), which includes the Cochrane Acute Respiratory infections Group's Specialised Register, MEDLINE (1946 to October week 1, 2018), Embase (1980 to 3 October 2018), CINAHL (1981 to 3 October 2018), LILACS (1982 to 3 October 2018), Web of Science (1985 to 3 October 2018), abstracts from the last three years of major infectious disease and microbiology conferences, and references of included articles. We also searched the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and the ISRCTN registry on 3 October 2018. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and observational studies that compared corticosteroid treatment with no corticosteroid treatment for influenza or influenza-like illness. We did not restrict studies by language of publication, influenza subtypes, clinical setting, or age of participants. We selected eligible studies in two stages: sequential examination of title and abstract, followed by full text. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. We pooled estimates of effect using a random-effects model, where appropriate. We assessed heterogeneity using the I2 statistic and assessed the certainty of the evidence using the GRADE framework. MAIN RESULTS This updated review includes 30 studies (one RCT with two arms and 29 observational studies) with a total of 99,224 participants. We included 19 studies in the original review (n = 3459), all of which were observational, with 13 studies included in the meta-analysis for mortality. We included 12 new studies in this update (one RCT and 11 observational studies), and excluded one study in the original review as it has been superceded by a more recent analysis. Twenty-one studies were included in the meta-analysis (9536 individuals), of which 15 studied people infected with 2009 influenza A H1N1 virus (H1N1pdm09). Data specific to mortality were of very low quality, based predominantly on observational studies, with inconsistent reporting of variables potentially associated with the outcomes of interest, differences between studies in the way in which they were conducted, and with the likelihood of potential confounding by indication. Reported doses of corticosteroids used were high, and indications for their use were not well reported. On meta-analysis, corticosteroid therapy was associated with increased mortality (odds ratio (OR) 3.90, 95% confidence interval (CI) 2.31 to 6.60; I2 = 68%; 15 studies). A similar increase in risk of mortality was seen in a stratified analysis of studies reporting adjusted estimates (OR 2.23, 95% CI 1.54 to 3.24; I2 = 0%; 5 studies). An association between corticosteroid therapy and increased mortality was also seen on pooled analysis of six studies which reported adjusted hazard ratios (HRs) (HR 1.49, 95% CI 1.09 to 2.02; I2 = 69%). Increased odds of hospital-acquired infection related to corticosteroid therapy were found on pooled analysis of seven studies (pooled OR 2.74, 95% CI 1.51 to 4.95; I2 = 90%); all were unadjusted estimates, and we graded the data as of very low certainty. AUTHORS' CONCLUSIONS We found one RCT of adjunctive corticosteroid therapy for treating people with community-acquired pneumonia, but the number of people with laboratory-confirmed influenza in the treatment and placebo arms was too small to draw conclusions regarding the effect of corticosteroids in this group, and we did not include it in our meta-analyses of observational studies. The certainty of the available evidence from observational studies was very low, with confounding by indication a major potential concern. Although we found that adjunctive corticosteroid therapy is associated with increased mortality, this result should be interpreted with caution. In the context of clinical trials of adjunctive corticosteroid therapy in sepsis and pneumonia that report improved outcomes, including decreased mortality, more high-quality research is needed (both RCTs and observational studies that adjust for confounding by indication). The currently available evidence is insufficient to determine the effectiveness of corticosteroids for people with influenza.
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Affiliation(s)
- Louise Lansbury
- The University of NottinghamDepartment of Epidemiology and Public HealthCity Hospital CampusHucknall RoadNottinghamUKNG5 1PB
| | - Chamira Rodrigo
- Nottingham University Hospitals TrustDepartment of Respiratory MedicineCity CampusHucknall RoadNottinghamNottinghamshireUKNG5 1PB
| | - Jo Leonardi‐Bee
- The University of NottinghamDivision of Epidemiology and Public HealthClinical Sciences BuildingNottingham City Hospital NHS Trust Campus, Hucknall RoadNottinghamUKNG5 1PB
| | - Jonathan Nguyen‐Van‐Tam
- The University of NottinghamFaculty of Medicine and Health SciencesRoom A40DClinical Sciences Building City Hospital Campus, Hucknall RoadNottinghamNottinghamshireUKNG5 1PB
| | - Wei Shen Lim
- Nottingham University Hospitals TrustDepartment of Respiratory MedicineCity CampusHucknall RoadNottinghamNottinghamshireUKNG5 1PB
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18
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Soumagne T, Rabbat A. [Corticosteroids in community acquired pneumonia: Where are we in 2018?]. Rev Mal Respir 2018; 35:813-827. [PMID: 30217573 DOI: 10.1016/j.rmr.2018.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/23/2018] [Indexed: 12/15/2022]
Abstract
Community-acquired pneumonia (CAP) is a common infectious disease and one of the main causes of mortality worldwide. Despite an improvement in management globally, mortality remains high especially in severe forms of CAP. Adequate early antibiotics remain the cornerstone of the treatment but adjuvant corticosteroid administration is being considered to counterbalance the systemic inflammatory reaction and modulate the immune response. In the last ten years, several clinical trials and meta-analyses have been conducted in severe and non-severe CAP to assess the efficacy of corticosteroids. The benefits on the duration of hospitalization and the time to clinical stability are quite small and early mortality does not seem to be improved. Corticosteroids should not, therefore, be used routinely in patients with CAP, even in severe cases. However, new therapeutic trials are currently underway.
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Key Words
- Community acquired pneumonia, Severe, Corticosteroids, Mortality, Duration of hospitalization, Side effects
- Pneumopathie aiguë communautaire, Sévère, Corticostéroïdes, Mortalité, Durée d’hospitalisation, Effets secondaires
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Affiliation(s)
- T Soumagne
- Service de pneumologie et soins intensifs respiratoires, hôpital Cochin, hôpitaux universitaires, Paris centre, AP-HP, 75679 Paris cedex 14, France; Service de pneumologie, hôpital Jean-Minjoz, CHU de Besançon, 25030 Besançon cedex, France; Service de physiologie-explorations fonctionnelles, hôpital Jean-Minjoz, CHU de Besançon, 25030 Besançon cedex, France.
| | - A Rabbat
- Service de pneumologie et soins intensifs respiratoires, hôpital Cochin, hôpitaux universitaires, Paris centre, AP-HP, 75679 Paris cedex 14, France
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19
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Badiei A, Chan KP, Lee YCG, Waterer GW. Corticosteroids in Lung and Pleural Infections. CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0197-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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20
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Arumugam SK, Mudali I, Strandvik G, El-Menyar A, Al-Hassani A, Al-Thani H. Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis. World J Emerg Med 2018; 9:203-210. [PMID: 29796145 DOI: 10.5847/wjem.j.1920-8642.2018.03.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. METHODS Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients' demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. RESULTS Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. CONCLUSION In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.
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Affiliation(s)
| | - Insolvisagan Mudali
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Gustav Strandvik
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar.,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Ammar Al-Hassani
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
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21
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Adjuvant therapies in critical care: steroids to treat infectious diseases. Intensive Care Med 2017; 44:1306-1309. [DOI: 10.1007/s00134-017-5020-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
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22
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Rueda-Camino J, Bernal-Bello D, Canora-Lebrato J, Velázquez-Ríos L, García de Viedma-García V, Guerrero-Santillán M, Duarte-Millán M, Cristóbal-Bilbao R, Zapatero-Gaviria A. High doses of systemic corticosteroids in patients hospitalized for exacerbation of chronic obstructive pulmonary disease. A cohort study. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2017.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Cao B, Huang Y, She DY, Cheng QJ, Fan H, Tian XL, Xu JF, Zhang J, Chen Y, Shen N, Wang H, Jiang M, Zhang XY, Shi Y, He B, He LX, Liu YN, Qu JM. Diagnosis and treatment of community-acquired pneumonia in adults: 2016 clinical practice guidelines by the Chinese Thoracic Society, Chinese Medical Association. CLINICAL RESPIRATORY JOURNAL 2017; 12:1320-1360. [PMID: 28756639 PMCID: PMC7162259 DOI: 10.1111/crj.12674] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 07/25/2017] [Indexed: 02/05/2023]
Abstract
Community‐acquired pneumonia (CAP) in adults is an infectious disease with high morbidity in China and the rest of the world. With the changing pattern in the etiological profile of CAP and advances in medical techniques in diagnosis and treatment over time, Chinese Thoracic Society of Chinese Medical Association updated its CAP guideline in 2016 to address the standard management of CAP in Chinese adults. Extensive and comprehensive literature search was made to collect the data and evidence for experts to review and evaluate the level of evidence. Corresponding recommendations are provided appropriately based on the level of evidence. This updated guideline covers comprehensive topics on CAP, including aetiology, antimicrobial resistance profile, diagnosis, empirical and targeted treatments, adjunctive and supportive therapies, as well as prophylaxis. The recommendations may help clinicians manage CAP patients more effectively and efficiently. CAP in pediatric patients and immunocompromised adults is beyond the scope of this guideline. This guideline is only applicable for the immunocompetent CAP patients aged 18 years and older. The recommendations on selection of antimicrobial agents and the dosing regimens are not mandatory. The clinicians are recommended to prescribe and adjust antimicrobial therapies primarily based on their local etiological profile and results of susceptibility testing, with reference to this guideline.
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Affiliation(s)
- Bin Cao
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China
| | - Yi Huang
- Department of Respiratory and Critical Care Medicine, Changhai Hospital, the Second Military Medical University, Shanghai 200433, China
| | - Dan-Yang She
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Qi-Jian Cheng
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Sichuan 610041, China
| | - Xin-Lun Tian
- Department of Pulmonary Medicine, Peking Union Medical College Hospital, Beijing 100730, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yu Chen
- Department of Respiratory and Critical Care Medicine, Shengjing Hospital, China Medical University, Shenyang 110004, China
| | - Ning Shen
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Hui Wang
- Department of Laboratory Medicine, Peking University People's Hospital, Beijing 100044, China
| | - Mei Jiang
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Diseases, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Xiang-Yan Zhang
- Department of Respiratory and Critical Care Medicine, Guizhou Provincial People's Hospital, Guizhou 550002, China
| | - Yi Shi
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing 210002, China
| | - Bei He
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Li-Xian He
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - You-Ning Liu
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie-Ming Qu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
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24
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Rueda-Camino JA, Bernal-Bello D, Canora-Lebrato J, Velázquez-Ríos L, García de Viedma-García V, Guerrero-Santillán M, Duarte-Millán MA, Cristóbal-Bilbao R, Zapatero-Gaviria A. High doses of systemic corticosteroids in patients hospitalised for exacerbation of chronic obstructive pulmonary disease. A cohort study. Rev Clin Esp 2017; 217:504-509. [PMID: 28865758 DOI: 10.1016/j.rce.2017.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/06/2017] [Accepted: 07/30/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To assess the effect of high doses of corticosteroids in patients hospitalised for exacerbation of chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS A prospective cohort study was conducted on patients hospitalized with COPD between January and March 2015, grouped according to the glucocorticoid dosage administered (cutoff, 40mg of prednisone/day). We compared the results of hospital stay, readmission and mortality at 3 months of discharge. RESULTS We analysed 87 patients. The median daily dose was 60mg of prednisone (interquartile range, 46.67-82.33mg/day), and the administration route was intravenous in 96.6% of the cases. We established a relative risk (RR) for hospital stays longer than 8 days of 1.095 (95% CI 0.597-2.007; P=.765) when steroid dosages greater than 40mg/day were employed. In these patients, the hazard ratio (HR) for readmission in the 3 months after discharge was 0.903 (95% CI 0.392-2.082; P=.811), and the mortality was 1.832 (95% CI 0.229-16.645; P=.568). Neither the RR nor the HR varied in a statistically significant manner after adjusting for confounding factors. CONCLUSIONS A daily dose greater than 40mg of prednisone in patients hospitalised for COPD exacerbation was not associated with a shorter hospital stay or a reduction in readmissions or mortality at 3 months.
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Affiliation(s)
- J A Rueda-Camino
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España.
| | - D Bernal-Bello
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - J Canora-Lebrato
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - L Velázquez-Ríos
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | | | - M Guerrero-Santillán
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - M A Duarte-Millán
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - R Cristóbal-Bilbao
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - A Zapatero-Gaviria
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
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Boyles TH, Brink A, Calligaro GL, Cohen C, Dheda K, Maartens G, Richards GA, van Zyl Smit R, Smith C, Wasserman S, Whitelaw AC, Feldman C. South African guideline for the management of community-acquired pneumonia in adults. J Thorac Dis 2017; 9:1469-1502. [PMID: 28740661 DOI: 10.21037/jtd.2017.05.31] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Tom H Boyles
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adrian Brink
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa
| | - Greg L Calligaro
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Cheryl Cohen
- Centre for Respiratory Disease and Meningitis, National Institute for Communicable Diseases, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Guy A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard van Zyl Smit
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | | | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew C Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Charles Feldman
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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26
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Chahin A, Opal SM. Severe Pneumonia Caused by Legionella pneumophila: Differential Diagnosis and Therapeutic Considerations. Infect Dis Clin North Am 2017; 31:111-121. [PMID: 28159171 PMCID: PMC7135102 DOI: 10.1016/j.idc.2016.10.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Severe legionella pneumonia poses a diagnostic challenge and requires early intervention. Legionnaire's disease can have several presenting signs, symptoms, and laboratory abnormalities that suggest that Legionella pneumophila is the pathogen, but none of these are sufficient to distinguish L pneumophila pneumonia from other respiratory pathogens. L pneumophila is primarily an intracellular pathogen and needs treatment with antibiotics that efficiently enter the intracellular space.
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Affiliation(s)
- Abdullah Chahin
- Critical Care Division, Miriam Hospital, Brown University Alpert School of Medicine, Providence, RI, USA; Infectious Disease Division, Rhode Island Hospital, Brown University Alpert School of Medicine, Providence, RI, USA.
| | - Steven M Opal
- Critical Care Division, Miriam Hospital, Brown University Alpert School of Medicine, Providence, RI, USA; Infectious Disease Division, Rhode Island Hospital, Brown University Alpert School of Medicine, Providence, RI, USA
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27
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Corticothérapie systémique et pneumopathies communautaires : où en est-on ? MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1254-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Singh K, Jagadeesan R. Controversies in the Management of Community-Acquired Pneumonia. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016. [DOI: 10.1007/s40138-016-0107-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Feldman C, Anderson R. Corticosteroids in the adjunctive therapy of community-acquired pneumonia: an appraisal of recent meta-analyses of clinical trials. J Thorac Dis 2016; 8:E162-71. [PMID: 27076965 PMCID: PMC4805802 DOI: 10.21037/jtd.2016.02.43] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/20/2016] [Indexed: 12/12/2022]
Abstract
Improving the outcome of patients with community-acquired pneumonia (CAP) is an ongoing challenge, even in the setting of significant advances in antimicrobial chemotherapy and critical care. Recognition of the underlying involvement of inflammation-mediated organ dysfunction as a determinant of adverse outcomes in CAP has aroused intense interest in the protective potential of adjunctive anti-inflammatory therapies in CAP, particularly the role of corticosteroids (CS). This is the primary topic of the current review which is focused on an evaluation of the latest meta-analyses encompassing both recent and earlier clinical trials, with particular emphasis on the stringent meta-analysis undertaken by Siemieniuk and colleagues (Ann Intern Med 2015;163:519-528). The review highlights the findings and recommendations of these and related published commentaries/critiques, while providing a brief description of those sub-groups of patients who seemingly stand to benefit most from CS therapy. This is preceded by an overview of the mechanisms of the anti-inflammatory activities of CS, the interactions of these agents with macrolide antibiotics, and the potential benefits and risks of short-term administration of CS, concluding with a succinct appraisal of priority issues for ongoing and future research.
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Waterer G. Systemic corticosteroids and community-acquired pneumonia-cautious optimism or wishful thinking? J Thorac Dis 2016; 7:E622-4. [PMID: 26793375 DOI: 10.3978/j.issn.2072-1439.2015.12.22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Grant Waterer
- 1 University of Western Australia, Crawley WA, Australia ; 2 Northwestern University, Chicago, USA
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