Causes and factors associated with early failure in hospitalized patients with community-acquired pneumonia

Treatment Failure and Clinical Stability in Severe Community-Acquired Pneumonia

Treatment failure and clinical stability are important outcomes in community-acquired pneumonia (CAP). It is essential to know the causes and risk factors for treatment failure and delay in reaching clinical stability in CAP. The study of both as well as the associated underlying mechanisms and host response are key to improving outcomes in pneumonia.

Streptococcus pneumoniae favors tolerance via metabolic adaptation over resistance to circumvent fluoroquinolones

Streptococcus pneumoniae is a major human pathogen of global health concern and the rapid emergence of antibiotic resistance poses a serious public health problem worldwide. Fluoroquinolone resistance in S. pneumoniae is an intriguing case because the prevalence of fluoroquinolone resistance does not correlate with increasing usage and has remained rare. Our data indicate that deleterious fitness costs in the mammalian host constrain the emergence of fluoroquinolone resistance both by de novo mutation and recombination. S. pneumoniae was able to circumvent such deleterious fitness costs via the development of antibiotic tolerance through metabolic adaptation that reduced the production of reactive oxygen species, resulting in a fitness benefit during infection of mice treated with fluoroquinolones. These data suggest that the emergence of fluoroquinolone resistance is tightly constrained in S. pneumoniae by fitness tradeoffs and that mutational pathways involving metabolic networks to enable tolerance phenotypes are an important contributor to the evasion of antibiotic-mediated killing.IMPORTANCEThe increasing prevalence of antibiotic resistant bacteria is a major global health concern. While many species have the potential to develop antibiotic resistance, understanding the barriers to resistance emergence in the clinic remains poorly understood. A prime example of this is fluroquinolone resistance in Streptococcus pneumoniae, whereby, despite continued utilization, resistance to this class of antibiotic remains rare. In this study, we found that the predominant pathways for developing resistance to this antibiotic class severely compromised the infectious capacity of the pneumococcus, providing a key impediment for the emergence of resistance. Using in vivo models of experimental evolution, we found that S. pneumoniae responds to repeated fluoroquinolone exposure by modulating key metabolic pathways involved in the generation of redox molecules, which leads to antibiotic treatment failure in the absence of appreciable shifts in resistance levels. These data underscore the complex pathways available to pathogens to evade antibiotic mediating killing via antibiotic tolerance.

Aetiological agents of adult community-acquired pneumonia in Japan: systematic review and meta-analysis of published data

OBJECTIVE

Epidemiological information is essential in providing appropriate empiric antimicrobial therapy for pneumonia. This study aimed to clarify the epidemiology of community-acquired pneumonia (CAP) by conducting a systematic review of published studies in Japan.

DESIGN

Systematic review.

DATA SOURCE

PubMed and Ichushi web database (January 1970 to October 2022).

ELIGIBILITY CRITERIA

Clinical studies describing pathogenic micro-organisms in CAP written in English or Japanese, excluding studies on pneumonia other than adult CAP, investigations limited to specific pathogens and case reports.

DATA EXTRACTION AND SYNTHESIS

Patient setting (inpatient vs outpatient), number of patients, concordance with the CAP guidelines, diagnostic criteria and methods for diagnosing pneumonia pathogens as well as the numbers of each isolate. A meta-analysis of various situations was performed to measure the frequency of each aetiological agent.

RESULTS

Fifty-six studies were included and 17 095 cases of CAP were identified. Pathogens were undetectable in 44.1% (95% CI 39.7% to 48.5%). Streptococcus pneumoniae was the most common cause of CAP requiring hospitalisation or outpatient care (20.0% (95% CI 17.2% to 22.8%)), followed by Haemophilus influenzae (10.8% (95% CI 7.3% to 14.3%)) and Mycoplasma pneumoniae (7.5% (95% CI 4.6% to 10.4%)). However, when limited to CAP requiring hospitalisation, Staphylococcus aureus was the third most common at 4.9% (95% CI 3.9% to 5.8%). Pseudomonas aeruginosa was more frequent in hospitalised cases, while atypical pathogens were less common. Methicillin-resistant S. aureus accounted for 40.7% (95% CI 29.0% to 52.4%) of S. aureus cases. In studies that used PCR testing for pan-respiratory viral pathogens, human enterovirus/human rhinovirus (9.4% (95% CI 0% to 20.5%)) and several other respiratory pathogenic viruses were detected. The epidemiology varied depending on the methodology and situation.

CONCLUSION

The epidemiology of CAP varies depending on the situation, such as in the hospital versus outpatient setting. Viruses are more frequently detected by exhaustive genetic searches, resulting in a significant variation in epidemiology.

Effects of Juhongtanke oral solution on alleviating the symptoms of community-acquired pneumonia: A multicenter, prospective, randomized controlled trial

Introduction: The timely alleviation of symptoms is essential for managing community-acquired pneumonia (CAP). Juhongtanke oral solution is a traditional marketed Chinese patent medicine believed to ease CAP symptoms. The currently available evidence is based on a few retrospective studies of patients with various types of pneumonia, whereas robust randomized controlled trials (RCTs) that support this notion are lacking.

Material and methods: In this multi-center, prospective RCT, patients were randomly allocated to receive routine treatment alone or a combination of Juhongtanke oral solution (20 mL q8h) for 5 days and maintained for an additional 3-day safety observation period. The primary outcome was Breathlessness, Cough, and Sputum Scale (BCSS) score evaluated on day 5. Secondary outcomes included the evaluation of cough and dyspnea items in the Visual Analogue Scale (VAS) from days 1–5, remission rate in BCSS and VAS during the treatment course, and the length of hospitalization and in-hospital mortality.

Results: Of 272 patients assessed for eligibility, 240 were enrolled in the study (n =120 per group). The mean difference in BCSS evaluated on day 5 was a median 1 point [95%CI (1.00, 2.00)], significantly lower in the treatment group compared with the control group (p < 0.001). Similar results were observed in VAS on day 5, with statistics of a median 2 points [95%CI (1.40, 2.50)] in the cough item and a median 1 point [95%CI (0.50, 2.00)] in the dyspnea item, significantly lower in the treatment group compared with the control group (both p < 0.001). The treatment group had a favorable outcome in BCSS and VAS remission rate assessments compared with the control group, with 99.50% vs. 89.17% in BCSS (p = 0.01), 98.33% vs. 75% in the cough item of VAS (p < 0.001), and 88.33% vs. 62.50% in the dyspnea item of VAS (p < 0.001), respectively. No notable adverse effects were observed during the study. No differences were observed in the length of hospitalization between groups (with a median of 7 days for both groups, p = 0.871).

Conclusion: Juhongtanke oral solution may be considered to alleviate the clinical symptoms of CAP.

Multi-Modal Data Analysis for Pneumonia Status Prediction Using Deep Learning (MDA-PSP)

Evaluating several vital signs and chest X-ray (CXR) reports regularly to determine the recovery of the pneumonia patients at general wards is a challenge for doctors. A recent study shows the identification of pneumonia by the history of symptoms and signs including vital signs, CXR, and other clinical parameters, but they lack predicting the recovery status after starting treatment. The goal of this paper is to provide a pneumonia status prediction system for the early affected patient’s discharge from the hospital within 7 days or late discharge more than 7 days. This paper aims to design a multimodal data analysis for pneumonia status prediction using deep learning classification (MDA-PSP). We have developed a system that takes an input of vital signs and CXR images of the affected patient with pneumonia from admission day 1 to day 3. The deep learning then classifies the health status improvement or deterioration for predicting the possible discharge state. Therefore, the scope is to provide a highly accurate prediction of the pneumonia recovery on the 7th day after 3-day treatment by the SHAP (SHapley Additive exPlanation), imputation, adaptive imputation-based preprocessing of the vital signs, and CXR image feature extraction using deep learning based on dense layers-batch normalization (BN) with class weights for the first 7 days’ general ward patient in MDA-PSP. A total of 3972 patients with pneumonia were enrolled by de-identification with an adult age of 71 mean ± 17 sd and 64% of them were male. After analyzing the data behavior, appropriate improvement measures are taken by data preprocessing and feature vectorization algorithm. The deep learning method of Dense-BN with SHAP features has an accuracy of 0.77 for vital signs, 0.92 for CXR, and 0.75 for the combined model with class weights. The MDA-PSP hybrid method-based experiments are proven to demonstrate higher prediction accuracy of 0.75 for pneumonia patient status. Henceforth, the hybrid methods of machine and deep learning for pneumonia patient discharge are concluded to be a better approach.

Title: Effects of Antibiotics on Respiratory Symptoms in Terminally Ill Cancer Patients With Pneumonia: A Multicenter Cohort Study

CONTEXT

Patients in the terminal stages of cancer are frequently affected by infection, especially pneumonia; but the effects of antibiotics on respiratory symptoms and factors associated with improvement are still unclear.

OBJECTIVES

This study aimed to clarify the effects of antibiotics on respiratory symptoms of terminally ill cancer patients with pneumonia, and to explore factors associated with the improvement.

METHODS

This was a prospective cohort study in which we consecutively recruited terminally ill cancer patients diagnosed with pneumonia and treated with antibiotics at one of 23 palliative care units across Japan. At the baseline and Day 3, primarily responsible palliative care specialists recorded patient backgrounds, the results of physical and laboratory examination, and patient symptoms using the Support Team Assessment Schedule. Improvement was defined as improvement of dyspnea, cough, and sputum production on Day 3.

RESULTS

Among all 1896 patients admitted during the study periods, 137 patients (7.2%) were enrolled into this study. Improvement was achieved in 65 patients (47.4%; 95% confidence intervals, 39-56). Univariate analyses revealed that the Palliative Prognostic Index (PPI), respiratory rate (RR), and oxygen requirement were significantly associated with the improvement. A multiple logistic regression analysis identified that PPI score of ≤ 6 and RR of <20 were independently associated with the improvement (odds ratios, 4.4 [1.6-12] and 2.5 [1.1-5.5], respectively).

CONCLUSION

Antibiotics may relieve respiratory symptoms from pneumonia in approximately half of the terminally ill cancer patients. PPI and respiratory rate are useful to identify the patients who received benefits of antibiotics.

Clinical effectiveness of cefoperazone-sulbactam versus piperacillin-tazobactam for the treatment of pneumonia in the elderly population

OBJECTIVES

Both cefoperazone-sulbactam (CFP-SUL) and piperacillin-tazobactam (PIP-TAZ) are β-lactam/β-lactamase inhibitor antibiotics and have a similar antimicrobial spectrum. However, comparative clinical efficacy and safety between CFP-SUL and PIP-TAZ for pneumonia treatment remain largely unknown, especially in the elderly population.

METHODS

Based on a multicenter, registry database, patients aged ≥65, diagnosed with severe community-acquired pneumonia (SCAP), hospital-acquired pneumonia (HAP), or ventilator-associated pneumonia (VAP), and given empirical therapy with CFP-SUL or PIP-TAZ were included for analysis. The primary outcome of interest was the proportion of patients achieving clinical cure. Multivariate logistic regression was conducted to compare the odds ratios (OR) for the outcome between patients received CFP-SUL and PIP-TAZ.

RESULTS

A total of 941 elderly patients, 624 with SCAP and 317 with either HAP or VAP, were included. The overall in-hospital mortality for the entire cohort was 19%. Clinical cure can be achieved in 81% and 83% of patients with SCAP and HAP/VAP, respectively. Multivariate logistic regression analysis showed similar odds for clinical cure between patients receiving CFP-SUL and PIP-TAZ whether they had SCAP (adjusted OR, 1.10; 95% CI, 0.71-1.70) or HAP/VAP (adjusted OR, 0.72; 95% CI, 0.30-1.76). Regarding the safety issue, both CFP-SUL and PIP-TAZ were generally well tolerated with few reported adverse events, even in this aged population.

CONCLUSIONS

Among the elderly patients with SCAP or HAP/VAP, empirical therapy with CFP-SUL is a viable alternative to PIP-TAZ, while considering antibiotic heterogeneity in antimicrobial stewardship.

Use of antibiotics and factors associated with treatment failure among 152,245 patients with pneumonia treated in the community - a retrospective cohort study

This study aims to evaluate risk factors associated with treatment failure and the antibiotics prescribed by primary care physicians in a large patient cohort treated for pneumonia in the community. A retrospective cohort study based on the databases of Maccabi Healthcare Services that provide healthcare to a quarter of the Israeli population. Included patients were > 12 years and diagnosed with pneumonia in the outpatient setting. Cohort 1 included patients with community-acquired pneumonia (CAP), whereas cohort 2 included patients with a documented pneumonia diagnosis following hospital discharge. Treatment failure (TF) was defined as either the use of a second line antibiotic OR hospital admission within 3-14 days OR death within 30 days of diagnosis. Risk factors for TF in the study cohorts were analyzed using multivariable logistic regression. During the study period, 148,376 patients were included in cohort 1 and 3,869 patients in cohort 2, with mean ages of 46.5 ± 20.3 and 63.8 ± 19.5 years, respectively. The most commonly used antibiotics were cephalosporins (36%) and macrolides (35.5%). TF occurred in 12% of cohort 1 and was associated with older age, comorbid conditions, use of non-respiratory fluoroquinolones, and penicillin. Atypical coverage (either macrolides or tetracyclines) was associated with a lower risk of failure. Among cohort 2, TF was higher (16.4%, p < 0.001) and was associated with older age, prior cancer, and congestive heart failure. Treatment failure was associated with comorbid conditions and increasing age. Among young patients with CAP and no comorbid conditions, macrolides or tetracyclines may suffice.

Factors Associated With Treatment Failure in Moderately Severe Community-Acquired Pneumonia: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Failure of treatment is the most serious complication in community-acquired pneumonia (CAP).

OBJECTIVE

To assess the potential risk factors for treatment failure in clinically stable patients with CAP.

DESIGN, SETTING, AND PARTICIPANTS

This secondary analysis assesses data from a randomized clinical trial on CAP (Pneumonia Short Treatment [PTC] trial) conducted from December 19, 2013, to February 1, 2018. Data analysis was performed from July 18, 2019, to February 15, 2020. Patients hospitalized at 1 of 16 centers in France for moderately severe CAP who were clinically stable at day 3 of antibiotic treatment were included in the PTC trial and analyzed in the per-protocol trial population.

INTERVENTIONS

Patients were randomly assigned (1:1) on day 3 of antibiotic treatment to receive β-lactam (amoxicillin-clavulanate [1 g/125 mg] 3 times daily) or placebo for 5 extra days.

MAIN OUTCOMES AND MEASURES

The main outcome was failure at 15 days after first antibiotic intake, defined as a temperature greater than 37.9 °C and/or absence of resolution or improvement of respiratory symptoms and/or additional antibiotic treatment for any cause. The association among demographic characteristics, baseline clinical and biological variables available (ie, at the first day of β-lactam treatment), and treatment failure at day 15 among the per-protocol trial population was assessed by univariate and multivariable logistic regressions.

RESULTS

Overall, 310 patients were included in the study; this secondary analysis comprised 291 patients (174 [59.8%] male; mean [SD] age, 69.6 [18.5] years). The failure rate was 26.8%. Male sex (odds ratio [OR], 1.74; 95% CI, 1.01-3.07), age per year (OR, 1.03; 95% CI, 1.01-1.05), Pneumonia Severe Index score (OR, 1.01; 95% CI, 1.00-1.02), the presence of chronic lung disease (OR, 1.85; 95% CI, 1.03-3.30), and creatinine clearance (OR, 0.99; 95% CI, 0.98-1.00) were significantly associated with failure in the univariate analysis. When the Pneumonia Severe Index score was excluded to avoid collinearity with age and sex in the regression model, only male sex (OR, 1.92; 95% CI, 1.08-3.49) and age (OR, 1.02; 95% CI, 1.00-1.05) were associated with failure in the multivariable analysis.

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a randomized clinical trial, among patients with CAP who reached clinical stability after 3 days of antibiotic treatment, only male sex and age were associated with higher risk of failure, independent of antibiotic treatment duration and biomarker levels. Another randomized clinical trial is needed to evaluate the impact of treatment duration in populations at higher risk for treatment failure.

Pneumococcal vaccine uptake and vaccine effectiveness in older adults with invasive pneumococcal disease in Germany: A retrospective cohort study

Background

Invasive pneumococcal disease (IPD) in people ≥60 years old is on the rise in Germany. There has been a recommendation for pneumococcal vaccination in this age group since 1998.

Methods

We determined the vaccination status of people ≥60 years old with IPD in Germany. We assessed vaccine effectiveness (VE) of the recommended 23-valent polysaccharide vaccine (PPV23) against IPD using the indirect cohort method.

Results

The rate of pneumococcal vaccination in older adults with IPD is low, 26%, with only 16% of people receiving a pneumococcal vaccine within five years of the IPD episode. Age- and gender- adjusted vaccine effectiveness (VE) for PPV23 was 37% (95% confidence interval 12% - 55%). For people vaccinated with PPV23 less than two years prior to IPD, VE was -20% (-131% - 34%), between two and four years prior to IPD, VE was 56% (20% - 76%), and 47% (17% - 63%) for those vaccinated ≥5 five years ago. Excluding serotype 3, overall VE for the remaining serotypes in PPV23 was 63% (49% - 74%). For people receiving PPV23 within the past two years, VE against all serotypes except 3 was 49% (12% - 71%); for people vaccinated between two and four years prior to IPD 66% (37% - 82%); for those vaccinated ≥five years ago, 69% (50% - 81%). VE of PPV23 against serotype 3 IPD only was -110% (-198% - -47%).

Conclusions

To reduce IPD in older adults in Germany, we must increase the rate of pneumococcal vaccine uptake. For 22/23 serotypes, PPV23 was effective. Serotype 3 remains a major problem.

Funding

This work was supported by an investigator-initiated research grant from Pfizer.

[Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]

The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.

Empiric antibiotics for community-acquired pneumonia in adult patients: a systematic review and a network meta-analysis

OBJECTIVE

The main aim of this network meta-analysis is to identify the empiric antibiotic (Em-ATB) with the highest probability of being the best (HPBB) in terms of (1) cure rate and (2) mortality rate in hospitalised patients with community acquired pneumonia (CAP) .

METHOD

Inclusion criteria: (1) adult patients (>16 years old) diagnosed with CAP that required hospitalisation; (2) randomised to at least two different Em-ATBs, (3) that report cure rate and (4) are written in English or Spanish.

EXCLUSION CRITERIA

(1) ambiguous antibiotics protocol and (2) published exclusively in abstract or letter format.

DATA SOURCES

Medline, Embase, Cochrane and citation reviews from 1 January 2000 to 31 December 2018. Risk of bias: Cochrane's tool. Quality of the systematic review (SR): A MeaSurement Tool to Assess systematic Reviews-2. Certainity of the evidence: Grading of Recommendations Assessment, Development and Evaluation.

STATISTICAL ANALYSES

frequentist method performed with the 'netmeta' library, R package.

RESULTS

27 randomised controlled trials (RCTs) from the initial 41 307 screened citations were included. Regarding the risk of bias, more than one quarter of the studies presented low risk and no study presented high risk in all domains. The SR quality is moderate. For cure, two networks were constructed. Thus, two Em-ATBs have the HPBB: cetaroline 600 mg (two times a day) and piperacillin 2000 mg (two times a day). For mortality, three networks were constructed. Thus, three Em-ATBs have the HPBB: ceftriaxone 2000 mg (once a day) plus levofloxacin 500 (two times a day), ertapenem 1000 mg (two times a day) and amikacin 250 mg (two times a day) plus clarithromycin 500 mg (two times a day). The certainity of evidence for each results is moderate.

CONCLUSION

For cure rate, ceftaroline and piperaciline are the options with the HPBB. However, for mortality rate, the options are ceftriaxone plus levofloxacin, ertapenem and amikacin plus clarithromycin. It seems necessary to conduct an RCT that compares treatments with the HPBB for each event (cure or mortality) (CRD42017060692).

"Difficult" pneumonia

The article considers the issues of therapeutic management of patients with so-called difficult pneumonia, particularly, patients with diagnosed syndrome slowly resolving / nonresolving pneumonia, who do not respond to the treatment. The reasons and significant risk factors potentially affecting the effectiveness of therapy are analyzed, the therapeutic tactics of managing patients with no response to treatment are considered, the list of necessary diagnostic methods and directions of antibiotic therapy is updated. The article analyses the tactics of managing patients with pneumonia during a pandemic caused by SARS-CoV-2 coronavirus. It also provides directions of diagnostics with priority discussion of biological markers of the inflammatory response as well as antimicrobial therapy strategy.

Detection of Viruses by Multiplex Real-Time Polymerase Chain Reaction in Bronchoalveolar Lavage Fluid of Patients with Nonresponding Community-Acquired Pneumonia

Background

Nonresponding pneumonia is responsible for the most mortality of community-acquired pneumonia (CAP). However, thus far, it is not clear whether viral infection plays an important role in the etiology of nonresponding CAP and whether there is a significant difference in the clinical characteristics between viral and nonviral nonresponding CAP.

Methods

From 2016 to 2019, nonresponding CAP patients were retrospectively enrolled in our study. All patients received bronchoalveolar lavage (BAL) and virus detection in BAL fluid by multiplex real-time polymerase chain reaction (PCR), and clinical, laboratory, and radiographic data were collected.

Results

A total of 43 patients were included. The median age was 62 years, and 65.1% of patients were male. Overall, 20 patients (46.5%) were identified with viral infection. Of these viruses, influenza virus (n = 8) and adenovirus (n = 7) were more frequently detected, and others included herpes simplex virus, human enterovirus, cytomegalovirus, human coronavirus 229E, rhinovirus, and parainfluenza virus. Compared with nonviral nonresponding CAP, only ground-glass opacity combined with consolidation was a more common imaging manifestation in viral nonresponding CAP. However, no obvious differences were found in clinical and laboratory findings between the presence and the absence of viral infections.

Conclusions

Viral infections were particularly frequent in adults with nonresponding CAP. The ground-glass opacity combined with consolidation was a specific imaging manifestation for viral nonresponding CAP, while the clinical and laboratory data showed no obvious differences between viral and nonviral nonresponding CAP.

Procalcitonin as a predictor of early antibiotic treatment failure in patients with gram-negative bloodstream infections caused by urinary tract infections

We retrospectively evaluated whether initial procalcitonin (PCT) levels can predict early antibiotic treatment failure (ATF) in patients with gram-negative bloodstream infections (GN-BSI) caused by urinary tract infections from January 2018 to November 2019. Early ATF was defined as the following: (1) hemodynamically unstable or febrile at Day 3; (2) the need for mechanical ventilation or continuous renal replacement therapy at Day 3; (3) patients who died within 3 days (date of blood culture: Day 0). The study included 189 patients; 42 showed early ATF. Independent risk factors for early ATF were initial admission to the intensive care unit (odds ratio: 7.735, 95% confidence interval: 2.567-23.311; P < 0.001) and PCT levels ≥30 ng/mL (odds ratio: 5.413, 95% confidence interval: 2.188-13.388; P < 0.001). Antibiotic factors were not associated with early ATF. Initial PCT levels may be helpful to predict early ATF in these patients.

Disease burden and prognostic factors for clinical failure in elderly community acquired pneumonia patients

Background

The study was to evaluate initial antimicrobial regimen and clinical outcomes and to explore risk factors for clinical failure (CF) in elderly patients with community-acquired pneumonia (CAP).

Methods

3011 hospitalized elderly patients were enrolled from 13 national teaching hospitals between January 1, 2014 and December 31, 2014 initiated by the CAP-China network. Risk factors for CF were screened by multivariable logistic regression analysis.

Results

The incidence of CF in elderly CAP patients was 13.1%. CF patients were older, longer hospital stays and higher treatment costs than clinical success (CS) patients. The CF patients were more prone to present hyperglycemia, hyponatremia, hypoproteinemia, pleural effusion, respiratory failure and cardiovascular events. Inappropriate initial antimicrobial regimens in CF group were significantly higher than CS group. Undertreatment, CURB-65, PH < 7.3, PaO₂/FiO₂ < 200 mmHg, sodium < 130 mmol/L, healthcare-associated pneumonia, white blood cells > 10,000/mm³, pleural effusion and congestive heart failure were independent risk factors for CF in multivariable logistic regression analysis. Male and bronchiectasis were protective factors.

Conclusions

Discordant therapy was a cause of CF. Early accurate detection and management of prevention to potential causes is likely to improve clinical outcomes in elderly patients CAP.

Trial registration

A Retrospective Study on Hospitalized Patients With Community-acquired Pneumonia in China (CAP-China) (RSCAP-China), NCT02489578. Registered 16 March 2015, https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0005E5S&selectaction=Edit&uid=U0000GWC&ts=2&cx=1bnotb

Prognosis of pathogen-proven acute respiratory distress syndrome diagnosed from a protocol that includes bronchoalveolar lavage: a retrospective observational study

Background

To treat patients with acute respiratory distress syndrome (ARDS), it is important to diagnose specific lung diseases and identify common risk factors. Our facility focuses on using bronchoalveolar lavage (BAL) to identify precise risk factors and determine the causative pathogen of ARDS within 24 h of intensive care unit (ICU) admission. This study evaluated the prognoses of pathogen-proven ARDS patients who were diagnosed or identified with risk factors using a diagnostic protocol, which included BAL, compared with the prognoses of pathogen-unproven ARDS patients.

Methods

This retrospective observational study was conducted in the ICU at a tertiary hospital from October 2015 to January 2019. We enrolled patients with respiratory distress who were on mechanical ventilation for more than 24 h in the ICU and who were subjected to our diagnostic protocol. We compared the disease characteristics and mortality rates between pathogen-proven and pathogen-unproven ARDS patients.

Results

Seventy ARDS patients were included, of whom, 50 (71%) had pathogen-proven ARDS as per our protocol. Mortality rates in both the ICU and the hospital were significantly lower among pathogen-proven ARDS patients than among pathogen-unproven ARDS patients (10% vs. 50%, p = 0.0006; 18% vs. 55%, p = 0.0038, respectively). Pathogen-proven ARDS patients were independently associated with hospital survival (adjusted hazard ratio, 0.238; 95% confidence interval, 0.096–0.587; p = 0.0021).

Conclusions

Our diagnostic protocol, which included early initiation of BAL, enabled diagnosing pathogen-proven ARDS in 71% of ARDS patients. These patients were significantly associated with higher hospital survival rates. The diagnostic accuracy of our diagnostic protocol, which includes BAL, remains unclear.

Progression of the Radiologic Severity Index is associated with increased mortality and healthcare resource utilisation in acute leukaemia patients with pneumonia

Background

Pneumonia is a major cause of mortality and morbidity, but the development of new antimicrobials is lacking. Radiological assessment of pneumonia severity may serve as an effective intermediate endpoint to reduce barriers to successful completion of antimicrobial trials. We sought to determine whether the Radiologic Severity Index (RSI) correlated with mortality and healthcare resource utilisation in patients with acute leukaemia undergoing induction chemotherapy.

Methods

We measured RSI (range 0–72) on all chest radiographs performed within 33 days of induction chemotherapy in 165 haematological malignancy patients with pneumonia. Peak RSI was defined as the highest RSI score within 33 days of induction. We used extended Cox proportional hazards models to measure the association of time-varying RSI with all-cause mortality within the first 33 days after induction chemotherapy, and logistic regression or generalised models to measure the association of RSI with total daily cost and healthcare resource utilisation.

Results

After adjustment for clinical variables, each one-point increase in RSI was associated with a 7% increase in all-cause 33-day mortality (HR 1.07, 95% CI 1.05 to 1.09, p<0.0001). Peak RSI values of 37.5 or higher were associated with 86% higher daily direct costs (p<0.0001), more days in intensive care unit (9.9 vs 4.8 days, p=0.001) and higher odds for mechanical ventilation (OR 12.1, p<0.0001).

Conclusions

Greater radiological severity as measured by RSI was associated with increased mortality and morbidity in acute leukaemia patients with pneumonia. RSI is a promising intermediate marker of pneumonia severity and is well suited for use in antimicrobial trials.

Incidence and Mortality of Adults Hospitalized With Community-Acquired Pneumonia According to Clinical Course

BACKGROUND

After hospitalization for community-acquired pneumonia (CAP), patients' clinical course may progress to clinical improvement, clinical failure, or nonresolving pneumonia. The epidemiology and outcomes of patients with CAP according to clinical course has not been well studied. The objective of this study was to characterize the incidence and outcomes for each clinical course of hospitalized patients with CAP.

METHODS

This was a secondary data analysis of the University of Louisville Pneumonia Study. Clinical course was classified as improvement, failure, and nonresolving. Objective criteria were used to define improvement and failure during the first week of hospitalization. If neither group of criteria were met, the course was classified as nonresolving. Incidence for each clinical course was calculated. Mortality was evaluated at different time points through the first year. P < .05 was considered statistically significant.

RESULTS

A total of 7,449 patients were hospitalized with CAP during the study period. Improvement was documented in 5,732 patients (77%), failure was documented in 1,458 patients (20%), and nonresolving CAP was documented in 259 patients (3%). Mortality at 30 days was 6% for those who improved, 34% for those who failed, and 34% for those with nonresolving pneumonia. Mortality at 1 year was 23%, 52%, and 51%, respectively.

CONCLUSIONS

This study shows that > 75% of hospitalized patients with CAP will reach clinical improvement. One of two patients with clinical failure or nonresolving CAP may die 1 year after hospitalization. Understanding the pathogenesis of long-term mortality is critical to developing interventions.

Optimal approaches to preventing severe community-acquired pneumonia

Introduction: Community-acquired pneumonia (CAP) has the highest rate of mortality of all infectious diseases, especially among the elderly. Severe CAP (sCAP) is defined as a CAP in which intensive care management is required and is associated with an unfavorable clinical course. Areas covered: This review aims to identify prevention strategies for reducing the incidence of CAP and optimized management of sCAP. We highlight the main prevention approaches for CAP, focusing on the latest vaccination plans and on the influence of health-risk behaviors. Lastly, we report the latest recommendations about the optimal approach for sCAP when CAP has already been diagnosed, including prompt admission to ICU, early empirical antibiotic therapy, and optimization of antibiotic use. Expert opinion: Despite improvements in the diagnosis and treatment of sCAP, more efforts are needed to combat preventable causes, including the implementation and improvement of vaccine coverage, anti-tobacco campaigns and correct oral hygiene. Moreover, future research should aim to assess the benefits of early antimicrobial therapy in primary care. Pharmacokinetic studies in the target population may help clinicians to adjust dosage regimens in critically ill patients with CAP and thus reduce rates of treatment failure.

The association of prior hospitalization with clinical outcomes among patients admitted with pneumonia: a propensity score matching study

Background

Although prior hospitalization (PH) has been considered as a risk factor for infection with potentially drug-resistant (PDR) pathogens in patients admitted with pneumonia, the evidence is limited. We aimed to elucidate the clinical impact of PH on these patients.

Methods

PH was defined as hospitalization for two or more days in the preceding 90 days. Patients with PH-associated pneumonia (PHAP) or community-acquired pneumonia (CAP) were matched using the propensity score matching method, and the clinical outcomes were compared. We also conducted subgroup analyses based on intravenous antibiotic use during PH, duration of PH, and time to re-admission.

Results

A total of 704 patients were identified; the PHAP group included 97 patients (13.7%). After matching according to propensity scores, the baseline characteristics of the PHAP group were similar to those of the CAP group. The isolation rate of PDR pathogens as well as the 30-day and total in-hospital mortality did not differ between propensity score-matched PHAP and CAP patients (13.6% vs. 10.2%, P = 0.485; 10.2% vs. 14.8%, P = 0.362; and 13.6% vs. 15.9%, P = 0.671, respectively). In subgroup analyses, only intravenous antibiotic use during PH was associated with the isolation rate of PDR pathogens (adjusted OR: 5.066; 95% CI: 1.231–20.845).

Conclusions

PH itself might not be related with higher isolation rates of PDR pathogens or mortality in patients admitted with pneumonia. Therefore, it seems reasonable that broad spectrum antibiotic therapy for PDR pathogens should be selectively applied to PHAP patients with intravenous antibiotic use during PH.

Risk Factors for Severe Community-aquired Pneumonia Among Children Hospitalized With CAP Younger Than 5 Years of Age

BACKGROUND

Community-acquired pneumonia (CAP) causes great morbidity and mortality as well as enormous economic burden worldwide. This study intended to describe the clinical characteristics of CAP and explore the risk factors of severe CAP among children in downtown Suzhou, China.

METHODS

This was a retrospective study of childhood hospitalizations in Soochow University Affiliated Children's Hospital from January 1, 2010, to December 31, 2014. Children who were residents of downtown Suzhou, 29 days to < 5 years of age, with discharge diagnosis codes J09 to J18 and J20 to J22 were included. Medical charts and chest radiograph reports were reviewed for included children to collect clinical information. CAP with intensive care unit (ICU) admission and poor clinical outcome were categorized as severe CAP.

RESULTS

A total of 28,043 children were identified with CAP; 17,501 (62.4%) of these children were male, and 20,747 (74.0%) children were less than 2 years of age. The common clinical symptoms at admission were cough (94.8%), fever (52.9%), wheezing (37.7%) and respiratory distress (9.5%). In total, 21,898 (78.1%) children had radiologic evidence of pneumonia, and 1,403 (5.0%) children developed at least 1 complication. Multivariate regression analysis showed that younger age, congenital heart disease and abnormal white blood cells, and C-reactive protein results were independent risk factors for both ICU admission and poor clinical outcome (odds ratio [OR] > 1 for all). Respiratory distress symptoms at admission (OR = 12.10) greatly increased the risk for ICU admission, while ICU admission (OR = 8.87) and complications (OR = 2.55) increased the risk of poor outcome. However, cough was a protective factor for ICU admission, so were wheezing, antibiotic and antiviral therapies for clinical failure.

CONCLUSION

Pediatric CAP hospitalizations of those of younger age, with congenital heart diseases, respiratory distress symptoms/tachypnea, abnormal white blood cells and C-reactive protein results as well as complications were at higher risk for progressing to severe CAP.

Etiology and epidemiology of community-acquired pneumonia in adults requiring hospital admission: A prospective study in rural Central Philippines

BACKGROUND

Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality among adults worldwide. However, the distribution of the etiology of CAP varies from one country to another, with limited data from rural areas.

METHODS

A prospective hospital-based study on adult CAP was conducted in Leyte, Central Philippines from May 2010 to May 2012. Blood, sputum, and nasopharyngeal samples obtained from patients were used to identify pathogens using standard microbiological culture methods and PCR.

RESULTS

Of the 535 patients enrolled, 38% were younger than 50 years old. More than half of the patients had an underlying disease, including pulmonary tuberculosis (22%). The detection rate was higher for bacteria (40%) than viruses (13%). Haemophilus influenzae (12%) was the most commonly detected bacterium and influenza virus (5%) was the most commonly detected virus. The proportion of CAP patients with Mycobacterium tuberculosis infection was higher in the younger age group than in the older age group. Among CAP patients, 14% died during hospitalization, and drowsiness on admission and SpO₂ <90% were independent risk factors for mortality.

CONCLUSIONS

Bacterial infections contribute substantially to the number of hospitalizations among CAP patients in rural Philippines. This study also highlights the importance of treatment of tuberculosis in reducing the burden of adult CAP in the country.

Progression of the Radiologic Severity Index predicts mortality in patients with parainfluenza virus-associated lower respiratory infections

Background

Radiologic severity may predict adverse outcomes after lower respiratory tract infection (LRI). However, few studies have quantified radiologic severity of LRIs. We sought to evaluate whether a semi-quantitative scoring tool, the Radiologic Severity Index (RSI), predicted mortality after parainfluenza virus (PIV)-associated LRI.

Methods

We conducted a retrospective review of consecutively-enrolled adult patients with hematologic malignancy or hematopoietic stem cell transplantation and with PIV detected in nasal wash who subsequently developed radiologically-confirmed LRI. We measured RSI (range 0–72) in each chest radiograph during the first 30 days after LRI diagnosis. We used extended Cox proportional hazards models to identify factors associated with mortality after onset of LRI with all-cause mortality as our failure event.

Results

After adjustment for patient characteristics, each 1-point increase in RSI was associated with an increased hazard of death (HR 1.13, 95% confidence interval [CI] 1.05–1.21, p = 0.0008). Baseline RSI was not predictive of death, but both peak RSI and the change from baseline to peak RSI (delta-RSI) predicted mortality (odds ratio for mortality, peak: 1.11 [95%CI 1.04–1.18], delta-RSI: 1.14 [95%CI 1.06–1.22]). A delta-RSI of ≥19.5 was 89% sensitive and 91% specific in predicting 30-day mortality.

Conclusions

We conclude that the RSI offers precise, informative and reliable assessments of LRI severity. Progression of RSI predicts 30-day mortality after LRI, but baseline RSI does not. Our results were derived from a cohort of patients with PIV-associated LRI, but can be applied in validated in other populations of patients with LRI.

Management of community-acquired pneumonia in immunocompetent adults: updated Swedish guidelines 2017

Based on expert group work, Swedish recommendations for the management of community-acquired pneumonia in adults are here updated. The management of sepsis-induced hypotension is addressed in detail, including monitoring and parenteral therapy. The importance of respiratory support in cases of acute respiratory failure is emphasized. Treatment with high-flow oxygen and non-invasive ventilation is recommended. The use of statins or steroids in general therapy is not found to be fully supported by evidence. In the management of pleural infection, new data show favourable effects of tissue plasminogen activator and deoxyribonuclease installation. Detailed recommendations for the vaccination of risk groups are afforded.

Medical mishap as a cause of non-resolving pneumonia

A 15-year old boy was referred for evaluation of fever, productive cough, and recurrent/persistent right lower lobe (RLL) pneumonia of 1-month duration. Chest computed tomography scan showed RLL consolidation, with minimal pleural effusion and a liver abscess with sharp borders, containing a solid calcification in the lower portion. History revealed acute appendicitis with laparoscopic appendectomy 6 months prior to presentation, during which a fecalith dropped to the peritoneal cavity. Following laparoscopically guided drainage of the abscess the patient improved. Herein we describe a rare case of non-resolving RLL pneumonia secondary to pyogenic liver abscess caused by dropped appendicolith.

Initial empiric antibiotic therapy for community-acquired pneumonia in Chinese hospitals

OBJECTIVES

Studies on treatment of community-acquired pneumonia (CAP) in China are scarce. We performed a study to investigate empiric antibiotic practices for patients hospitalized with CAP in China and the risk factors for treatment failure.

METHODS

Data were collected from a national Chinese hospitalization database. Adult patients who were diagnosed with CAP between 1 October 2014 and 30 September 2015 were identified. We studied initial empiric antibiotic regimens, microbiologic sampling, treatment failure, in-hospital mortality and length of hospital stay.

RESULTS

We included 18 043 adult patients from 185 hospitals who met all the study inclusion criteria. The most common initial antibiotic regimen for CAP was monotherapy with a fluoroquinolone (14.8%, 2671/18 043). The most common initial antibiotic (used alone or in combination with other antibiotics) was levofloxacin (15.7%, 4597/29 278 (this denominator represents the total number of initial antibiotics)). The microbiologic sampling rate was 26.9% (4851/18 043). A total of 4050 (22.4%) of 18 043 patients experienced treatment failure. Multivariate logistic regression demonstrated that older age, male sex, coexisting lung cancer and use of regimens not covering atypical pathogens were risk factors for treatment failure. In-hospital mortality was 2.1% (380/18 043). The median hospital length of stay was 11 days (interquartile range, 8-15 days).

CONCLUSIONS

Patients receiving Chinese guideline-adherent regimens had better outcomes, and atypical pathogen active regimens were associated with a lower treatment failure rate and shorter length of hospital stay.

Diagnosis and treatment of community-acquired pneumonia in adults: 2016 clinical practice guidelines by the Chinese Thoracic Society, Chinese Medical Association

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.

Association Between the Order of Macrolide and Cephalosporin Treatment and Outcomes of Pneumonia

Background

Many patients hospitalized with pneumonia are treated with combination macrolide/cephalosporin therapy. Macrolides have immunomodulatory effects and do not directly cause bacterial lysis. These effects suggest the possibility that initial treatment with a macrolide before a cephalosporin could improve patient outcomes by preventing the inflammatory response to rapid bacterial lysis that can be caused by cephalosporin treatment. This study explores whether initial treatment for pneumonia with a macrolide before a cephalosporin is associated with better patient outcomes than treatment with a cephalosporin before a macrolide.

Methods

This is a retrospective cohort study using a clinically rich database derived from electronic health records of 71 hospitals. We compared outcomes for pneumonia patients who received intravenous treatment with a macrolide at least 1 hour before a cephalosporin, versus patients who received a cephalosporin at least 1 hour before a macrolide. Propensity matching was performed for 527 patients in each group.

Results

Among the propensity-matched cohorts, for the macrolide first group, in-hospital mortality was 4.2% vs 5.5% for the cephalosporin first group (P = .31), combined in-hospital mortality/hospice discharge was 6.3% vs 9.3% (P = .06), median hospital length of stay was 101.5 hours vs 109.5 hours (P = .09), and 30-day readmission was 12.9% vs 10.6% (P = .27).

Conclusions

Treatment of pneumonia with a macrolide before a cephalosporin was not associated with significantly improved outcomes when compared with treatment with a cephalosporin first; however, the lower rate of mortality/discharge to hospice and the large confidence intervals allow for the possibility of a clinically significant benefit.

Predictors for individual patient antibiotic treatment effect in hospitalized community-acquired pneumonia patients

OBJECTIVE

Our objective was to identify clinical predictors of antibiotic treatment effects in hospitalized patients with community-acquired pneumonia (CAP) who were not in the intensive care unit (ICU).

METHODS

Post-hoc analysis of three prospective cohorts (from the Netherlands and Spain) of adult patients with CAP admitted to a non-ICU ward having received either β-lactam monotherapy, β-lactam + macrolide, or a fluoroquinolone-based therapy as empirical antibiotic treatment. We evaluated candidate clinical predictors of treatment effects in multiple mixed-effects models by including interactions of the predictors with empirical antibiotic choice and using 30-day mortality, ICU admission and length of hospital stay as outcomes.

RESULTS

Among 8562 patients, empirical treatment was β-lactam in 4399 (51.4%), fluoroquinolone in 3373 (39.4%), and β-lactam + macrolide in 790 (9.2%). Older age (interaction OR 1.67, 95% CI 1.23-2.29, p 0.034) and current smoking (interaction OR 2.36, 95% CI 1.34-4.17, p 0.046) were associated with lower effectiveness of fluoroquinolone on 30-day mortality. Older age was also associated with lower effectiveness of β-lactam + macrolide on length of hospital stay (interaction effect ratio 1.14, 95% CI 1.06-1.22, p 0.008).

CONCLUSIONS

Older age and smoking could influence the response to specific antibiotic regimens. The effect modification of age and smoking should be considered hypothesis generating to be evaluated in future trials.

No Room for Error: Empiric Treatment for Fulminant Pneumonia

Early antibiotic administration is critical in cases of sepsis and severe community-acquired pneumonia, which is frequently due to Streptococcus pneumoniae, Staphylococcus aureus, Legionella species, or influenza. We describe the case of a 29-year-old previously healthy man who presented to an urban emergency department (ED) in the North Central U.S. with fever, hip pain, severe hypoxemia, and diffuse pulmonary infiltrates. He was intubated and received piperacillin/tazobactam, levofloxacin, vancomycin, and oseltamivir; given his fulminant presentation and predicted high mortality, doxycycline, methylprednisolone, and amphotericin B were also administered empirically in the ED. A respiratory culture eventually grew Blastomyces dermatitidis, and the patient survived. Severe acute respiratory distress syndrome due to fulminant pneumonitis carries a high mortality. Faced with this scenario and no room for error, it is important that the emergency physician cover for all possible pathogens, including zoonotic bacteria and endemic fungi.

Microbial Etiology of Pneumonia: Epidemiology, Diagnosis and Resistance Patterns

Globally, pneumonia is a serious public health concern and a major cause of mortality and morbidity. Despite advances in antimicrobial therapies, microbiological diagnostic tests and prevention measures, pneumonia remains the main cause of death from infectious disease in the world. An important reason for the increased global mortality is the impact of pneumonia on chronic diseases, along with the increasing age of the population and the virulence factors of the causative microorganism. The increasing number of multidrug-resistant bacteria, difficult-to-treat microorganisms, and the emergence of new pathogens are a major problem for clinicians when deciding antimicrobial therapy. A key factor for managing and effectively guiding appropriate antimicrobial therapy is an understanding of the role of the different causative microorganisms in the etiology of pneumonia, since it has been shown that the adequacy of initial antimicrobial therapy is a key factor for prognosis in pneumonia. Furthermore, broad-spectrum antibiotic therapies are sometimes given until microbiological results are available and de-escalation cannot be performed quickly. This review provides an overview of microbial etiology, resistance patterns, epidemiology and microbial diagnosis of pneumonia.

Factors affecting treatment success in community-acquired pneumonia

BACKGROUND/AIM

Treatment failure in hospitalized patients with community-acquired pneumonia is a major cause of mortality. The aim of this study was to evaluate the factors affecting treatment success in community-acquired pneumonia.

MATERIALS AND METHODS

A total of 537 patients (mean age: 66.1 ± 15.8 years, 365 males) registered to the Turkish Thoracic Society Pneumonia Database were analyzed. Of these, clinical improvement or cure, defined as treatment success, was achieved in 477, whereas 60 patients had treatment failure and/or died.

RESULTS

Lower numbers of neutrophils (5989.9 ± 6237.3 vs. 8495.6 ± 7279.5/mm³), higher blood urea levels (66.1 ± 42.1 vs. 51.2 ± 38.2 mg/dL), higher Pneumonia Severity Index (PSI) scores (123.3 ± 42.6 vs. 96.3 ± 32.9), higher CURB-65 scores (2.7 ± 1.2 vs. 2.2 ± 0.9), lower PaO₂/FiO₂ ratios (216.3 ± 86.8 vs. 269.9 ± 65.6), and the presence of multilobar (33.3% vs. 16.4%) and bilateral (41.7% vs. 18.9%) radiologic infiltrates were related to treatment failure. The PSI score and PaO₂/FiO₂ ratio were independent parameters affecting treatment results in multivariate linear regression analysis (P < 0.001).

CONCLUSION

The risk of treatment failure is high in patients with severe pneumonia and with respiratory failure. Effective treatment and close monitoring are required for these cases.

An antibiotic decision-making tool for patients with pneumonia admitted to a medical intensive care unit

Pneumonia is a leading cause of death in medical intensive care units (MICUs). Delayed or inappropriate antibiotic therapy largely increases morbidity and mortality. Multidrug-resistant (MDR) micro-organisms are major reasons for inappropriate antibiotic use. Currently there is no good antibiotic decision-making tool designed for critically ill patients. The objective of this study was to develop a convenient MDR prediction scoring system for patients admitted to MICUs with pneumonia. A retrospective cohort study was conducted using databases and chart reviews of pneumonia patients admitted to a 30-bed MICU from 2012 to 2013. Forward logistic regression was applied to identify independent MDR risk factors for prediction tool development. A total of 283 pneumonia episodes from 263 patients with positive cultures from blood or respiratory secretions were recruited, of which 154 (54.4%) were MDR episodes. Long-term ventilation (OR = 11.09; P = 0.026), residence in a long-term care facility (OR = 2.50; P = 0.005), MDR infection/colonisation during the preceding 90 days (OR = 2.08; P = 0.041), current hospitalisation ≥2 days (OR = 1.98; P = 0.019) and stroke (OR = 1.81; P = 0.035) were identified as independent predictors for MDR pneumonia. The area under the ROC curve of this prediction tool was much higher than that of ATS/IDSA classification (0.69 vs. 0.54; P <0.001). The prediction accuracy of this tool with risk score ≥1 for MDR infections was 63.7%. This simple five-item, one-step scoring tool for critically ill patients admitted to the MICU could help physicians provide timely appropriate empirical antibiotics.

Predictors and Implications of Early Clinical Stability in Patients Hospitalized for Moderately Severe Community-Acquired Pneumonia

Background

Assessment of early response to treatment is crucial for the management of community-acquired pneumonia (CAP).

Objective

To describe the predictors and the outcomes of early clinical stability

Methods

We did a secondary analysis of a multicentre randomized controlled trial on CAP treatment in which 580 patients hospitalized for moderately severe CAP were included. The association between demographic, clinical and biological variables available at inclusion and early clinical stability (stabilization of vital signs within 72 hours with predetermined cut-offs) was assessed by multivariate logistic regression. The association between early clinical stability and mortality, severe adverse events, and length of stay was also tested.

Results

Younger age (OR 0.98, 95% CI 0.96–0.99), lower platelet count (OR per 10 G/L increment 0.96, 95% CI 0.94–0.98), lower respiratory rate (OR 0.94, 95% CI 0.90–0.97), absence of hypoxemia (OR 0.58, 95% CI 0.40–0.85), lower numbers of co-morbid conditions (OR 0.82, 95% CI 0.69–0.98) and signs or symptoms (OR 0.78, 95% CI 0.68–0.90) were significantly associated with early clinical stability. Patients with early clinical stability had lower 90-days mortality (3.4% vs. 11.9%, p<0.001), fewer admissions to the intensive care unit (2.7% vs. 8.0%, p = 0.005) and a shorter length of stay (6.0 days, IQR 4.0–10.0 vs. 10.0 days, IQR 7.0–15.0, p<0.001).

Conclusions

Patients with younger age, less co-morbidity, fewer signs or symptoms, less respiratory compromise, and a lower platelet count are more likely to reach early clinical stability. Patients without early clinical stability have a worse prognosis and warrant close scrutiny.

The clinical management of lower respiratory tract infections

The 2010 Global Burden of Disease Study reported that lower respiratory tract infections, including pneumonia, are the fourth most common cause of death globally. The etiology of acute bronchitis and asthma exacerbations is mostly viral and the therapy is symptomatic. Management decisions in community acquired pneumonia regarding site of care, extent of assessment, and level of treatment are based primarily on disease severity (outpatient, inpatient, ICU admission). Antibiotics are the main choice of treatment for patients with pneumonia, acute exacerbations (AE) of COPD (including increased sputum purulence and worsening shortness of breath) and AE of non-CF bronchiectasis. Inhaled antibiotics may represent a more optimal approach for the treatment and prevention of AE of non-CF bronchiectasis. Approved strategies for the prevention of exacerbations include smoking cessation and rehabilitation programs, drug therapy and vaccination.

An audit and feedback intervention study increased adherence to antibiotic prescribing guidelines at a Norwegian hospital

Background

Appropriate antibiotic prescribing is associated with favourable levels of antimicrobial resistance (AMR) and clinical outcomes. Most intervention studies on antibiotic prescribing originate from settings with high level of AMR. In a Norwegian hospital setting with low level of AMR, the literature on interventions for promoting guideline-recommended antibiotic prescribing in hospital is scarce and requested. Preliminary studies have shown improvement potentials regarding antibiotic prescribing according to guidelines. We aimed to promote appropriate antibiotic prescribing in patients with community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD) at a respiratory medicine department in a Norwegian University hospital. Our specific objectives were to increase prescribing of appropriate empirical antibiotics, reduce high-dose benzylpenicillin and reduce total treatment duration.

Methods

We performed an audit and feedback intervention study, combined with distribution of a recently published pocket version of the national clinical practice guideline. We included patients discharged with CAP or AECOPD and prescribed antibiotics during hospital stay, and excluded those presenting with aspiration, nosocomial infection and co-infections. The pre- and post-intervention period was 9 and 6 months, respectively. Feedback was provided orally to the department physicians at an internal-educational meeting. To explore the effect of the intervention on appropriate empirical antibiotics and mean total treatment duration we applied before-after analysis (Student’s t-test) and interrupted time series (ITS). We used Pearson’s χ2 to compare dose changes.

Results

In the pre-and post-intervention period we included 253 and 155 patients, respectively. Following the intervention, overall mean prescribing of appropriate empirical antibiotics increased from 61.7 to 83.8 % (P < 0.001), overall mean total treatment duration decreased from 11.2 to 10.4 days (P = 0.015), and prescribing of high-dose benzylpenicillin decreased from 48.8 to 38.6 % (P = 0.125). With ITS we found that six months post-intervention, the effect on appropriate empirical antibiotic prescribing had increased and sustained, while the effect on treatment duration was at pre-intervention level.

Conclusion

The combination of audit and feedback plus distribution of a pocket version of guideline recommendations led to a substantial increase in prescribing of appropriate empirical antibiotics, which is important due to favourable effect on AMR and clinical outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1426-1) contains supplementary material, which is available to authorized users.

Impact of an Educational Program to Reduce Healthcare Resources in Community-Acquired Pneumonia: The EDUCAP Randomized Controlled Trial

BACKGROUND

Additional healthcare visits and rehospitalizations after discharge are frequent among patients with community-acquired pneumonia (CAP) and have a major impact on healthcare costs. We aimed to determine whether the implementation of an individualized educational program for hospitalized patients with CAP would decrease subsequent healthcare visits and readmissions within 30 days of hospital discharge.

METHODS

A multicenter, randomized trial was conducted from January 1, 2011 to October 31, 2014 at three hospitals in Spain. We randomly allocated immunocompetent adults patients hospitalized for CAP to receive either an individualized educational program or conventional information before discharge. The educational program included recommendations regarding fluid intake, adherence to drug therapy and preventive vaccines, knowledge and management of the disease, progressive adaptive physical activity, and counseling for alcohol and smoking cessation. The primary trial endpoint was a composite of the frequency of additional healthcare visits and rehospitalizations within 30 days of hospital discharge. Intention-to-treat analysis was performed.

RESULTS

We assigned 102 patients to receive the individualized educational program and 105 to receive conventional information. The frequency of the composite primary end point was 23.5% following the individualized program and 42.9% following the conventional information (difference, -19.4%; 95% confidence interval, -6.5% to -31.2%; P = 0.003).

CONCLUSIONS

The implementation of an individualized educational program for hospitalized patients with CAP was effective in reducing subsequent healthcare visits and rehospitalizations within 30 days of discharge. Such a strategy may help optimize available healthcare resources and identify post-acute care needs in patients with CAP.

TRIAL REGISTRATION

Controlled-Trials.com ISRCTN39531840.

The Value of Macrolide-Based Regimens for Community-Acquired Pneumonia

Macrolide antimicrobials are commonly prescribed, specifically for the treatment of respiratory tract infections. Although still effective, the development of widespread macrolide resistance has limited their use. Aside from their antimicrobial effects, macrolides are also known to possess immune-modulatory properties which may confer a survival benefit in both acute and chronic inflammatory states. This review discusses the efficacy, potential mechanisms, and adverse effects of macrolide therapy specifically in community-acquired pneumonia in outpatients, hospitalized ward patients, and those requiring intensive care unit admission. Challenges for ongoing research in this field are discussed and treatment recommendations offered.

Modified IDSA/ATS Minor Criteria for Severe Community-Acquired Pneumonia Best Predicted Mortality

It is not clear whether the IDSA/ATS minor criteria for severe community-acquired pneumonia (CAP) could be simplified or even be modified to orchestrate improvements in predicting mortality.A retrospective cohort study of 1230 CAP patients was performed to simplify and to modify the scoring system by excluding 4 noncontributory or infrequent variables (leukopenia, hypothermia, hypotension, and thrombocytopenia) and by excluding these variables and then adding age ≥65 years, respectively. The simplification and modification were tested against a prospective 2-center validation cohort of 1409 adults with CAP.The increasing numbers of IDSA/ATS, simplified, and modified minor criteria present in the retrospective cohort were positively associated with the mortality, showing significant increased odds ratios for mortality of 2.711, 4.095, and 3.755, respectively. The validation cohort confirmed a similar pattern. The sensitivity, specificity, positive predictive value, and Youden index of modified minor criteria for mortality prediction were the best pattern in the retrospective cohort. High values of corresponding indices were confirmed in the validation cohort. The highest accuracy of the modified version for predicting mortality in the retrospective cohort was illustrated by the highest area under the receiver operating characteristic curve of 0.925 (descending order: modified, simplified, and IDSA/ATS minor criteria). The validation cohort confirmed a similar paradigm.The IDSA/ATS minor criteria could be simplified to 5 variables and then be modified to orchestrate improvements in predicting mortality in CAP patients. The modified version best predicted mortality. These were more suitable for clinic and emergency department.

What Is New in Antibiotic Therapy in Community-Acquired Pneumonia? An Evidence-Based Approach Focusing on Combined Therapy

Despite all published literature, controversies remain about the optimal antibiotic treatment in community-acquired pneumonia. The most debated issue is whether it is necessary to empirically start one or two antibiotics, i.e. whether or not to cover atypical agents. A review of the literature published from 2005 to present was completed, searching for new insights in antibiotic treatment in community-acquired pneumonia (CAP) focusing on monotherapy versus combined therapy. Forty-one articles were identified enrolling outpatients, and patients admitted to the ward and to the intensive care unit: 11 were meta-analyses, 8 clinical trials and 22 observational-prospective and retrospective-studies. Although controversies remain in the treatment of CAP, the use of combination therapy seems to be associated with a lower mortality in case of severe CAP that requires intensive care unit (ICU) admission, especially when a beta-lactam-macrolide association is delivered. Moreover, combination therapy is associated with better outcomes-although not always with a lower mortality-in cases of non-ICU patients with risk factors for a poor outcome, bacteraemic pneumococcal pneumonia and high suspicion of infection by atypical agents. In this setting, it appears that the best choice of treatment may be a beta-lactam-macrolide regimen.

Mortality among severe community-acquired pneumonia patients depends on combinations of 2007 IDSA/ATS minor criteria

OBJECTIVES

The individual 2007 Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) minor criteria for severe community-acquired pneumonia (CAP) are of unequal weight in predicting mortality. It is not clear whether the combinations of predictive findings might imply diverse severities or different mortalities.

METHODS

A prospective two centre cohort study was performed of 385 severe CAP patients fulfilling three or more IDSA/ATS minor criteria amongst 1430 patients.

RESULTS

Hospital mortality rose sharply from 5.7%, 9.9%, and 16.5%, respectively, for patients with none of three predictive findings most strongly associated to mortality (PaO2/FiO2 ≤ 250mm Hg, confusion and uraemia), one of those, and two of those to 38.6% for patients with all those (p<0.001). The number of three predictive findings present had a significantly increased odds ratio for mortality of 2.796 (p<0.001), and had the degree of positive association with sequential organ failure assessment scores at 72hours, incurring significantly longer hospital stay and higher costs.

CONCLUSIONS

Different combinations of 2007 IDSA/ATS minor criteria for severe CAP were associated to diverse severities and different mortalities. The combination of PaO2/FiO2 ≤ 250mm Hg, confusion and uraemia predicted more severity and higher mortality compared with others.

In vivo efficacy and molecular docking of designed peptide that exhibits potent antipneumococcal activity and synergises in combination with penicillin

We have previously designed a series of antimicrobial peptides (AMPs) and in the current study, the in vivo therapeutic efficacy and toxicity were investigated. Among all the peptides, DM3 conferred protection to a substantial proportion of the lethally infected mice caused by a strain of penicillin-resistant Streptococcus pneumoniae. Synergism was reported and therapeutic efficacy was significantly enhanced when DM3 was formulated in combination with penicillin (PEN). No toxicity was observed in mice receiving these treatments. The in silico molecular docking study results showed that, DM3 has a strong affinity towards three protein targets; autolysin and pneumococcal surface protein A (pspA). Thus AMPs could serve as supporting therapeutics in combination with conventional antibiotics to enhance treatment outcome.

Microbiology and outcomes of community acquired pneumonia in non cystic-fibrosis bronchiectasis patients

BACKGROUND

It is general belief that Non-cystic fibrosis bronchiectasis (NCFB) is characterized by frequent community-acquired pneumonia. Nonetheless, the knowledge on clinical characteristics of CAP in NCFBE is poor and no specific recommendations are available. We aim to investigate clinical and microbiological characteristics of NCFBE patients with CAP.

METHODS

Prospective observational study of 3495 CAP patients (2000-2011).

RESULTS

We found 90 (2.0%) NCFBE-CAP that in comparison with non-bronchiectatic CAP (n, 3405) showed older age (mean ± [SD], NCFBE-CAP 73 ± 14 vs. CAP 65 ± 19yrs), more vaccinations (pneumococcal: 35% vs. 14%; influenza: 60% vs. 42%), comorbidities (n ≥ 2: 43% vs. 25%), previous antibiotics (38% vs. 22%), and inhaled steroids (53% vs. 16%) (p < 0.05 each). Streptococcus pneumoniae was the most frequent isolate in both groups (NCFBE-CAP 44.4% vs. CAP 42.7%; p = 0.821) followed by respiratory virus, mixed infections and atypical bacteria. Considering overall frequencies of the main pathogens (including monomicrobial and mixed infections) Pseudomonas aeruginosa (15.5% vs. 2.9%; p < 0.001) and Enterobacteriaceae (8.8% vs. 2.4%; p = 0.025) were more prevalent in NCFBE-CAP patients than in CAP. Despite these clinical and microbiological differences, NCFBE-CAP showed similar outcomes to CAP patients (mortality, length of hospital stay, etc.).

CONCLUSIONS

NCFBE-CAP patients are usually older and have more comorbidities but similar outcomes than general CAP population. Usual CAP pathogens, such as S. pneumoniae, are also involved in NCFBE-CAP but P. aeruginosa and other Enterobacteriaceae were globally more frequent than in CAP. Therefore, a wide microbiological investigation should be recommended in all NCFBE-CAP cases as well as routine pneumococcal vaccination for prevention of pneumonia.