Severe community-acquired pneumonia in ICUs: prospective validation of a prognostic score

The prevalence of acute kidney injury in patients with community-acquired pneumonia who required mechanical ventilation

BACKGROUND

Community-acquired pneumonia (CAP) is a common reason for intensive care unit (ICU) admission and sepsis. Acute kidney injury (AKI) is a frequent complication of community-acquired pneumonia and is associated with increased short- and long-term morbidity and mortality and healthcare costs.

OBJECTIVE

Describe the prevalence of AKI in patients with CAP requiring mechanical ventilation and evaluate its association with inhospital mortality.

DESIGN

Retrospective cohort.

SETTING

Intensive care unit.

PATIENTS AND METHODS

We included patients with CAP on mechanical ventilation. Patients were categorized according to the development of AKI in the first 24 hours of ICU admission using the Kidney Disease Improving Global Outcomes (KDIGO) classification from no AKI, stage 1 AKI, stage 2 AKI, and stage 3 AKI.

MAIN OUTCOME MEASURES

The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, hospital and ICU length of stay, ventilation duration, tracheostomy, and renal replacement therapy requirement.

RESULTS

Of 1536 patients included in the study, 829 patients (54%) had no AKI while 707 (46%) developed AKI. In-hospital mortality was 288/829 (34.8%) for patients with no AKI, 43/111 (38.7%) for stage 1 AKI, 86/216 (40%) for stage 2 AKI, and 196/380 (51.7%) for stage 3 AKI (P<.0001). Multivariate analysis revealed that stages 1, 2, or 3 AKI compared to no AKI were not independently associated with in-hospital mortality. Older age, vasopressor use; decreased Glasgow coma scale, PaO2/Fio2 ratio and platelet count, increased bilirubin, lactic acid and INR were associated with increased mortality while female sex was associated with reduced mortality.

CONCLUSION

Among mechanically ventilated patients with CAP, AKI was common and was associated with higher crude mortality. The higher mortality could not be attributed alone to AKI, but rather appeared to be related to multi-organ dysfunction.

LIMITATIONS

Single-center retrospective study with no data on baseline serum creatinine and the use of estimated baseline creatinine distributions based on the MDRD (Modification of Diet in Renal Disease)equation which may lead to an overestimation of AKI. Second, we did not have data on the microbiology of pneumonia, appropriateness of antibiotic therapy or the administration of other medications that have been demonstrated to be associated with AKI.

Significance of the Modified NUTRIC Score for Predicting Clinical Outcomes in Patients with Severe Community-Acquired Pneumonia

Nutritional status could affect clinical outcomes in critical patients. We aimed to determine the prognostic accuracy of the modified Nutrition Risk in Critically Ill (mNUTRIC) score for hospital mortality and treatment outcomes in patients with severe community-acquired pneumonia (SCAP) compared to other clinical prediction rules. We enrolled SCAP patients in a multi-center setting retrospectively. The mNUTRIC score and clinical prediction rules for pneumonia, as well as clinical factors, were calculated and recorded. Clinical outcomes, including mortality status and treatment outcome, were assessed after the patient was discharged. We used the receiver operating characteristic (ROC) curve method and multivariate logistic regression analysis to determine the prognostic accuracy of the mNUTRIC score for predicting clinical outcomes compared to clinical prediction rules, while 815 SCAP patients were enrolled. ROC curve analysis showed that the mNUTRIC score was the most effective at predicting each clinical outcome and had the highest area under the ROC curve value. The cut-off value for predicting clinical outcomes was 5.5. By multivariate logistic regression analysis, the mNUTRIC score was also an independent predictor of both clinical outcomes in SCAP patients. We concluded that the mNUTRIC score is a better prognostic factor for predicting clinical outcomes in SCAP patients compared to other clinical prediction rules.

A literature review of severity scores for adults with influenza or community-acquired pneumonia - implications for influenza vaccines and therapeutics

Influenza vaccination and antiviral therapeutics may attenuate disease, decreasing severity of illness in vaccinated and treated persons. Standardized assessment tools, definitions of disease severity, and clinical endpoints would support characterizing the attenuating effects of influenza vaccines and antivirals. We review potential clinical parameters and endpoints that may be useful for ordinal scales evaluating attenuating effects of influenza vaccines and antivirals in hospital-based studies. In studies of influenza and community-acquired pneumonia, common physiologic parameters that predicted outcomes such as mortality, ICU admission, complications, and duration of stay included vital signs (hypotension, tachypnea, fever, hypoxia), laboratory results (blood urea nitrogen, platelets, serum sodium), and radiographic findings of infiltrates or effusions. Ordinal scales based on these parameters may be useful endpoints for evaluating attenuating effects of influenza vaccines and therapeutics. Factors such as clinical and policy relevance, reproducibility, and specificity of measurements should be considered when creating a standardized ordinal scale for assessment.

Comparison of prognostic factors between bacteraemic and non-bacteraemic critically ill immunocompetent patients in community-acquired severe pneumococcal pneumonia: a STREPTOGENE sub-study

Background

The presence of bacteraemia in pneumococcal pneumonia in critically ill patients does not appear to be a strong independent prognostic factor in the existing literature. However, there may be a specific pattern of factors associated with mortality for ICU patients with bacteraemic pneumococcal community-acquired pneumonia (CAP). We aimed to compare the factors associated with mortality, according to the presence of bacteraemia or not on admission, for patients hospitalised in intensive care for severe pneumococcal CAP.

Methods

This was a post hoc analysis of data from the prospective, observational, multicentre STREPTOGENE study in immunocompetent Caucasian adults admitted to intensive care in France between 2008 and 2012 for pneumococcal CAP. Patients were divided into two groups based on initial blood culture (positive vs. negative) for Streptococcus pneumoniae. The primary outcome was hospital mortality, which was compared between the two groups using odds ratios according to predefined variables to search for a prognostic interaction present in bacterial patients but not non-bacteraemic patients. Potential differences in the distribution of serotypes between the two groups were assessed. The prognostic consequences of the presence or not of initial bi-antibiotic therapy were assessed, specifically in bacteraemic patients.

Results

Among 614 included patients, 274 had a blood culture positive for S. pneumoniae at admission and 340 did not. The baseline difference between the groups was more frequent leukopaenia (26% vs. 14%, p = 0.0002) and less frequent pre-hospital antibiotic therapy (10% vs. 16.3%, p = 0.024) for the bacteraemic patients. Hospital mortality was not significantly different between the two groups (p = 0.11). We did not observe any prognostic factors specific to the bacteraemic patient population, as the statistical comparison of the odds ratios, as an indication of the association between the predefined prognostic parameters and mortality, showed them to be similar for the two groups. Bacteraemic patients more often had invasive serotypes but less often serotypes associated with high case fatality rates (p = 0.003). The antibiotic regimens were similar for the two groups. There was no difference in mortality for patients in either group given a beta-lactam alone vs. a beta-lactam combined with a macrolide or fluoroquinolone.

Conclusion

Bacteraemia had no influence on the mortality of immunocompetent Caucasian adults admitted to intensive care for severe pneumococcal CAP, regardless of the profile of the associated prognostic factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00936-z.

Kidney disease and mortality in patients with respiratory tract infections: a systematic review and meta-analysis

BACKGROUND

Respiratory tract infections (RTIs) are a common reason for people to seek medical care. RTIs are associated with high short-term mortality. Inconsistent evidence exists in the association between the presence of kidney disease and the risk of death in patient with RTIs.

METHODS

We searched the PubMed, Cochrane Library and Embase databases from inception through April 2019 for cohort and case-control studies investigating the presence of kidney disease (defined as medical diagnosis of kidney disease, reduced estimated glomerular filtration rate or creatinine clearance, elevated serum creatinine and proteinuria) on mortality in adults with RTIs in different settings including community, inpatient and intensive care units. We assessed the quality of the included studies using Cochrane Collaboration's tool and conducted a meta-analysis on the relative risk (RR) of death.

RESULTS

Of 5362 records identified, 18 studies involving 16 676 participants met the inclusion criteria, with 15 studies investigating pneumonia and 3 studies exploring influenza. The risk of bias in the available evidence was moderate. Most [17/18 (94.5%)] of studies reported positive associations of underlying chronic kidney disease with mortality. The pooled adjusted risk for all-cause mortality in patients with RTIs almost doubled [RR 1.96 (95% confidence interval 1.48-2.59)] in patients with kidney disease. Associations were consistent across different timings of kidney disease assessment and provenances of RTIs (community-acquired or healthcare-associated).

CONCLUSIONS

The presence of kidney disease is associated with higher mortality among people with RTIs, especially in those with pneumonia. The presence of kidney disease might be taken into account when considering admission for patients who present with RTIs.

Long-Term Mortality and Prognostic Factors in Aspiration Pneumonia

OBJECTIVES

Aspiration pneumonia is a leading cause of death among older patients; however, little is known about the long-term mortality in aspiration pneumonia. The purpose of this study was to evaluate long-term mortality and its associated factors in patients with aspiration pneumonia.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

In total, 550 patients with aspiration pneumonia (median age: 78.0 years, 66.4% male) with compatible clinical symptoms and chest computed tomography images were enrolled at a single tertiary center from 2006 to 2016.

MEASURES

The 1-, 3-, and 5-year mortality rates were evaluated for all patients. The prognostic factors for 1-year and 5-year mortality were also evaluated using Cox proportional hazard models.

RESULTS

A total of 441 (80.2%) patients died during a median follow-up of 50.7 weeks. The 1-, 3-, and 5-year mortality rates were 49.0%, 67.1%, and 76.9%, respectively. Multivariate analysis identified 5 risk factors for 1-year mortality of male sex [hazard ratio (HR) 1.533, P = .003], low body mass index (HR 0.934, P = .002), hypoalbuminemia, anemia (0.973, P = .032), and mechanical ventilation (HR 2.052, P < .001), which were also independent prognostic factors for 5-year mortality. During the follow-up period, 133 (24.2%) patients experienced recurrent aspiration pneumonia. However, Kaplan-Meier analysis showed no significant differences in survival curves between patients with single and recurrent aspiration pneumonia (P = .371).

CONCLUSIONS/IMPLICATIONS

Long-term prognosis of aspiration pneumonia was poor as a result of underlying morbidity instead of the aspiration pneumonia itself. Our findings suggest that prognostic indices for patients with aspiration pneumonia including the patient's underlying conditions should be devised.

Prognostic implications of aspiration pneumonia in patients with community acquired pneumonia: A systematic review with meta-analysis

Aspiration pneumonia is thought to be associated with a poor outcome in patients with community acquired pneumonia (CAP). However, there has been no systematic review regarding the impact of aspiration pneumonia on the outcomes in patients with CAP. This review was conducted using the MOOSE guidelines: Patients: patients defined CAP. Exposure: aspiration pneumonia defined as pneumonia in patients who have aspiration risk. Comparison: confirmed pneumonia in patients who were not considered to be at high risk for oral aspiration. Outcomes: mortality, hospital readmission or recurrent pneumonia. Three investigators independently identified published cohort studies from PubMed, CENTRAL database, and EMBASE. Nineteen studies were included for this systematic review. Aspiration pneumonia increased in-hospital mortality (relative risk, 3.62; 95% CI, 2.65–4.96; P < 0.001, seven studies) and 30-day mortality (3.57; 2.18–5.86; P < 0.001, five studies). In contrast, aspiration pneumonia was associated with decreased ICU mortality (relative risk, 0.40; 95% CI, 0.26–0.60; P < 0.00001, four studies). Although there are insufficient data to perform a meta-analysis on long-term mortality, recurrent pneumonia, and hospital readmission, the few reported studies suggest that aspiration pneumonia is also associated with these poor outcomes. In conclusion, aspiration pneumonia was associated with both higher in-hospital and 30-day mortality in patients with CAP outside ICU settings.

Applicability of Prediction Rules in Patients With Community-Acquired Pneumonia Requiring Intensive Care: A Pilot Study

Little attention has been paid to developing prediction rules that could assist in deciding which patients with community-acquired pneumonia (CAP) need intensive care. Four existing prediction rules were examined to determine if any could predict the need for intensive care in these patients. The prediction rules studied were British Thoracic Society (BTS), Conte et al, Leroy et al, and Fine et al. Thirty-two patients admitted to the medical or coronary intensive care unit (ICU) during 1 year with pneumonia Diagnosis Related Group 079 or 089 were evaluated. The sensitivity of each rule for identifying a need for ICU admission in our group was BTS .72 using both rules together, Conte et al .47, Leroy et al .56, and Fine et al .84. It was concluded that these rules poorly identify the need for ICU admission for patients with severe CAP. Of the 4 rules tested, the BTS rule was the simplest, and the Fine et al rule was the most sensitive. None of them performed well enough to be used for decision making in individual patients.

Community Acquired Pneumonia in Internal Medicine: A One-Year Retrospective Study Based on Pneumonia Severity Index

Community acquired pneumonia (CAP) represents the sixth cause of death and the first cause of death for an infectious disease in the USA. The aim of the present study is to evaluate how CAP is managed in a hospital setting, with particular attention to the wards of internal medicine, compared to the recommendations based and validated PSI (Pneumonia Severity Index). 42 subjects were included in the study, 25 males and 17 females. According to the PSI, nine (21%) patients were classified in class I, two (5%) in class II, ten (24%) in class III, fifteen (36%) in class IV and six (14%) in class V. Three patients died during the stay in the hospital (2 males and 1 female), all in the highest PSI class (V). According to the criteria used to evaluate the adequacy of the admission to the hospital, twentyeight patients were classified in the HRG, with an appropriate admission, whilst fourteen (33%) were in the LRG, with an inappropriate admission to the hospital. The data of the study confirm the validity of a PSI based strategy for the management of CAP since admittance to the hospital. This approach is not yet widely implemented in Italy, and a better dialogue between hospital and health system representatives would be convenient, to reduce costs and ensure the safety of patients affected by CAP.

[Severe community-acquired pneumonia admitted at the intensive care unit: main clinical and bacteriological features and prognostic factors: a Tunisian experience]

INTRODUCTION

Severe community-acquired pneumonia (SCAP) remains a major cause of death. The aim of this study was to describe the main clinical and bacteriological features and to determine predictive factors for death in patients with SCAP who were admitted in intensive care unit (ICU) in a Tunisian setting.

METHOD

It is a retrospective study conducted between March 2005 and December 2010 at the intensive care unit of the University Hospital of Mahdia (Tunisia). All patients hospitalized at the ICU with a SCAP diagnosis according to the American Thoracic Society criteria were included.

RESULTS

Two hundred and nine patients (mean age: 64±16 years, and mean SAPS II: 42±17) were included. Overall, 24% had a bacteriological diagnosis. Streptococcus pneumoniae was the most frequently detected. Use of mechanical ventilation was required in 57% of patients and 45% experimented septic shock upon admission. The mortality rate at ICU was 29% (n=60). In multivariate analysis, a septic shock at admission and the use of mechanical ventilation were both associated with death.

CONCLUSION

SCAP were associated with high mortality in the ICU.

A comparison between time to clinical stability in community-acquired aspiration pneumonia and community-acquired pneumonia

Antimicrobial therapy has been the main stay of therapy of community-acquired aspiration pneumonia (CAAP), but the duration of treatment has not been established. The objective of this study was to describe the time to reach clinical stability in patients with aspiration pneumonia compared to community-acquired pneumonia (CAP). A retrospective case control study at two university affiliated centers encompassing 329 consecutive patients admitted with CAAP and 329 consecutive patients with CAP was conducted between 2007 and 2011. While the median time to stability for patients with CAP was distributed around a median of 4 days, there was a bimodal distribution for time to clinical stability in patients with CAAP with dual peaks at days 2 and 5, respectively. CAAP patients who required more than 2 days to achieve clinical stability had a higher mortality rate compared to those with 2 days or less [odds ratio (OR) 5.95, 95% CI 2.85-12.4], and a longer hospital stay (6.6 ± 5.8 vs. 3.9 ± 1.2 days; p < 0.001). None of the CAAP patients who achieved clinical stability in 2 days or less was transferred to a higher level of care. In a multivariate analysis, time to clinical stability was found to be an independent predictor of outcome in patients with CAAP (OR 2.59, 95% CI 2.02-3.32). Normalization of vital signs in aspiration pneumonia follows a distinct pattern from that of patients with CAP. Time to achieve clinical stability may assist in identifying CAAP patients who are likely to require a shorter hospital stay and a shorter course of antimicrobial therapy.

Risk prediction models for mortality in community-acquired pneumonia: a systematic review

BACKGROUND

Several models have been developed to predict the risk of mortality in community-acquired pneumonia (CAP). This study aims to systematically identify and evaluate the performance of published risk prediction models for CAP.

METHODS

We searched MEDLINE, EMBASE, and Cochrane library in November 2011 for initial derivation and validation studies for models which predict pneumonia mortality. We aimed to present the comparative usefulness of their mortality prediction.

RESULTS

We identified 20 different published risk prediction models for mortality in CAP. Four models relied on clinical variables that could be assessed in community settings, with the two validated models BTS1 and CRB-65 showing fairly similar balanced accuracy levels (0.77 and 0.72, resp.), while CRB-65 had AUROC of 0.78. Nine models required laboratory tests in addition to clinical variables, and the best performance levels amongst the validated models were those of CURB and CURB-65 (balanced accuracy 0.73 and 0.71, resp.), with CURB-65 having an AUROC of 0.79. The PSI (AUROC 0.82) was the only validated model with good discriminative ability among the four that relied on clinical, laboratorial, and radiological variables.

CONCLUSIONS

There is no convincing evidence that other risk prediction models improve upon the well-established CURB-65 and PSI models.

Time to intubation is associated with outcome in patients with community-acquired pneumonia

Introduction

It has been suggested that delayed intensive care unit (ICU) transfer is associated with increased mortality for patients with community-acquired pneumonia (CAP). However, ICU admission policies and patient epidemiology vary widely across the world depending on local hospital practices and organizational constraints. We hypothesized that the time from the onset of CAP symptoms to invasive mechanical ventilation could be a relevant prognostic factor.

Methods

One hundred patients with a CAP and necessitating invasive mechanical ventilation were included. Prospectively collected data were retrospectively analysed. Two study groups were identified based on the time of the initiation of invasive mechanical ventilation (rapid respiratory failure requiring mechanical ventilation within 72 h of the onset of CAP and progressive respiratory failure requiring invasive mechanical ventilation 4 or more days after the onset of CAP).

Results

Excepting more COPD patients in the rapid respiratory failure group and more patients with diabetes in the progressive respiratory failure group, these patients had similar characteristics. The overall in-hospital mortality rate was 28% in the rapid respiratory failure group and 51% in the progressive respiratory failure group (P = 0.03). The ICU and the day 30 mortality rates were higher in the progressive respiratory failure group (47% vs. 23%, P = 0.02; and 37.7% vs. 21.3%, P = 0.03; respectively). After adjusting for the propensity score and other potential confounding factors, progressive respiratory failure remained associated with hospital mortality only after 12 days of invasive mechanical ventilation.

Conclusions

This study suggested that the duration or delay in the time to intubation from the onset of CAP symptoms was associated with the outcomes in those patients who ultimately required invasive mechanical ventilation.

Aspiration pneumonia in old patients with dementia. Prognostic factors of mortality

BACKGROUND

Prognostic factors of mortality in elderly patients with dementia with aspiration pneumonia (AP) are scarcely known. We determined the mortality rate and prognostic factors in old patients with dementia hospitalized due to AP.

METHODS

We prospectively studied 120 consecutive patients aged ≥ 75 years with dementia admitted with AP to two tertiary university hospitals. We collected data on demographic and clinical variables and comorbidities. Oropharyngeal swallowing was assessed by the water swallow test.

RESULTS

Sixty-one (50.8%) patients were female, and mean age was 86 ± 9 years. The swallow test was performed in 68 patients, revealing aspiration in 92.6%. Patients with repeat AP (28.3%) were more-frequently taking thickeners (61.8% vs.11.6%, p<0.0001) and were less-frequently prescribed angiotensin-converting-enzyme (ACE) inhibitors (8.8% vs. 27.9%, p<0.001) than patients with a first episode. Hospital mortality was 33.3%; these patients had lower lymphocyte counts and higher percentage of multilobar involvement. In the multivariate model, involvement of ≥ 2 pulmonary lobes was associated with hospital mortality (OR 3.051, 95% CI 1.248 to 7.458, p<0.01). Six-month mortality was 50.8%; these patients were older and had worse functional capacity and laboratory data indicative of malnutrition. In the multivariate model, lower albumin levels were associated with six-month mortality (OR 1.129, 95% CI 1.008 to 1.265, p<0.03).

CONCLUSION

In-hospital and 6-month mortality were high (one-third and one-half patients, respectively). Multilobar involvement and lower lymphocyte counts were associated with hospital mortality, and older age, greater dependence and malnutrition with six-month mortality.

In vitro activity of cefepime against multidrug-resistant Gram-negative bacilli, viridans group streptococci and Streptococcus pneumoniae from a cross-Canada surveillance study

OBJECTIVE

To determine the in vitro activity of cefepime against multidrug-resistant Gram-negative bacilli and Gram-positive cocci obtained from an ongoing cross-Canada surveillance study.

DESIGN

Clinical isolates of aerobic Gram-negative bacilli with inducible and constitutive chromosomally mediated cephalosporinases, viridans group streptococci and Streptococcus pneumoniae were collected from laboratories serving hospitals, nursing homes and physician offices in the community from across Canada during 1996 and 1997. Laboratories were asked to submit only clinically relevant nonduplicate isolates for susceptibility testing. In vitro antimicrobial susceptibility testing was carried out on all isolates of Gram-negative and viridans group streptococci. S pneumoniae were characterized as penicillin susceptible, intermediately resistant or highly resistant. Nonsusceptible isolates were defined as being intermediately or highly resistant (minimal inhibitory concentrations [MIC] greater than 0.06 mg/L). Only isolates of S pneumoniae that were nonsusceptible to penicillin were selected for further study. MICs were determined using a microbroth dilution technique according to the National Committee of Clinical Laboratory Standards.

RESULTS

A total of 727 Gram-negative bacilli samples were collected. No resistance to cefepime was detected with Citrobacter freundii, Serratia marcescens, Morganella morganii and Enterobacter species. Of these strains, Enterobacter species and C freundii were the most resistant to ceftazidime, cefotaxime and ceftriaxone with MIC(90S) of 32 mg/L or greater and resistance rates of 6% or greater. Resistance rates of Pseudomonas aeruginosa and Acinetobacter species to cefepime were 4.8% and 3%, respectively. The two organisms had similar rates of resistance to ceftazidime. Less than 3% of the Gram-negative bacilli were resistant to imipenem and meropenem. There were 153 viridans group streptococci, of which 22 (14.4%) were resistant to penicillin. Of 1287 S pneumoniae samples, 193 (15%) were nonsusceptible to penicillin. Cefepime, ceftriaxone and cefotaxime had comparable activity against all isolates of viridans group streptococci and S pneumoniae.

CONCLUSIONS

Cefepime demonstrated excellent in vitro activity against Gram-negative bacilli with inducible and constitutive chromosomally mediated cephalosporinases, and had equal or superior activity versus comparator beta-lactams against all isolates of viridans group streptococci and S pneumoniae.

Optimizing Treatment Outcomes in Severe Community-Acquired Pneumonia

Severe community-acquired pneumonia (CAP) is a life-threatening condition that requires intensive care unit (ICU) admission. Clinical presentation is characterized by the presence of respiratory failure, severe sepsis, or septic shock. Severe CAP accounts for approximately 5-35% of hospital-treated cases of pneumonia with the majority of patients having underlying comorbidities. The most common pathogens associated with this disease are Streptococcus pneumoniae, Legionella spp., Haemophilus influenzae, and Gram-negative enteric rods. Microbial investigation is probably helpful in the individual case but is likely to be more useful for defining local antimicrobial policies. The early and rapid initiation of empiric antimicrobial treatment is critical for a favorable outcome. It should include intravenous beta-lactam along with either a macrolide or a fluoroquinolone. Modifications of this basic regimen should be considered in the presence of distinct comorbid conditions and risk factors for specific pathogens. Other promising nonantimicrobial new therapies are currently being investigated. The assessment of severity of CAP helps physicians to identify patients who could be managed safely in an ambulatory setting. It may also play a crucial role in decisions about length of hospital stay and time of switching to oral antimicrobial therapy in different groups at risk. The most important adverse prognostic factors include advancing age, male sex, poor health of patient, acute respiratory failure, severe sepsis, septic shock, progressive radiographic course, bacteremia, signs of disease progression within the first 48-72 hours, and the presence of several different pathogens such as S. pneumoniae, Staphylococcus aureus, Gram-negative enteric bacilli, or Pseudomonas aeruginosa. However, some important topics of severity assessment remain controversial, including the definition of severe CAP. Prediction rules for complications or death from CAP, although far from perfect, should identify the majority of patients with severe CAP and be used to support decision-making by the physician. They may also contribute to the evaluation of processes and outcomes of care for patients with CAP.

Defining severe pneumonia

Pneumonia is an important clinical and public health problem. Identification and prediction of severe pneumonia are significant concerns. Attempts to define severe pneumonia should recognize that different purposes are served by different definitions; no single definition meets all needs. At present, several prediction models have been proposed or validated. Biomarkers are not yet ready for routine use. The authors recommend careful consideration of the implications of any given definition of pneumonia severity. Outcome studies are needed to integrate human and health care system factors with the application of pneumonia severity definitions.

Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study

RATIONALE

Accurate, early identification of patients at risk for developing acute lung injury (ALI) provides the opportunity to test and implement secondary prevention strategies.

OBJECTIVES

To determine the frequency and outcome of ALI development in patients at risk and validate a lung injury prediction score (LIPS).

METHODS

In this prospective multicenter observational cohort study, predisposing conditions and risk modifiers predictive of ALI development were identified from routine clinical data available during initial evaluation. The discrimination of the model was assessed with area under receiver operating curve (AUC). The risk of death from ALI was determined after adjustment for severity of illness and predisposing conditions.

MEASUREMENTS AND MAIN RESULTS

Twenty-two hospitals enrolled 5,584 patients at risk. ALI developed a median of 2 (interquartile range 1-4) days after initial evaluation in 377 (6.8%; 148 ALI-only, 229 adult respiratory distress syndrome) patients. The frequency of ALI varied according to predisposing conditions (from 3% in pancreatitis to 26% after smoke inhalation). LIPS discriminated patients who developed ALI from those who did not with an AUC of 0.80 (95% confidence interval, 0.78-0.82). When adjusted for severity of illness and predisposing conditions, development of ALI increased the risk of in-hospital death (odds ratio, 4.1; 95% confidence interval, 2.9-5.7).

CONCLUSIONS

ALI occurrence varies according to predisposing conditions and carries an independently poor prognosis. Using routinely available clinical data, LIPS identifies patients at high risk for ALI early in the course of their illness. This model will alert clinicians about the risk of ALI and facilitate testing and implementation of ALI prevention strategies. Clinical trial registered with www.clinicaltrials.gov (NCT00889772).

Defining and predicting severe community-acquired pneumonia

PURPOSE OF REVIEW

Community-acquired pneumonia is a significant clinical and public health problem. Defining and predicting severe pneumonia is difficult but important.

RECENT FINDINGS

Several new predictive models and more sophisticated approaches to describing pneumonia severity have been recently proposed, with subsequent validation in varied patient populations. Early data suggest that biomarkers may be useful in the future.

SUMMARY

Definitions of pneumonia severity depend on the relevant clinical or public health question. A health services reference definition seems most useful in most settings. The Infectious Disease Society of America/American Thoracic Society 2007 guidelines and SMART-COP are two recent promising methods for predicting severe pneumonia at the time of presentation. The traditional pneumonia severity index and Confusion Uremia Respiratory rate Blood pressure (CURB)-65 models are less useful. Accurate assessment of severity has important implications for triage, outcome, and defining populations for research applications. Novel biomarkers, while somewhat promising, do not yet have a validated role in pneumonia severity assessment.

Predictors of timely antibiotic administration for patients hospitalized with community-acquired pneumonia from the cluster-randomized EDCAP trial

INTRODUCTION

To identify factors associated with timely initiation of antibiotic therapy for patients hospitalized with pneumonia.

DESIGN

Secondary analysis of a cluster-randomized, controlled trial.

SETTING

Thirty- two emergency departments (EDs) in Pennsylvania and Connecticut.

SUBJECTS

Patients with a clinical and radiographic diagnosis of community-acquired pneumonia.

INTERVENTIONS

From January to December 2001, EDs were randomly allocated to guideline implementation strategies of low (n = 8), moderate (n = 12), and high intensity (n = 12) to improve the initial site of treatment and the performance of evidence-based processes of care. Our primary outcome was antibiotic initiation within 4 hours of presentation, which at that time was the recommended process of care for inpatients.

RESULTS

Of the 2076 inpatients enrolled, 1632 (78.6%) received antibiotic therapy within 4 hours of presentation. Antibiotic timeliness ranged from 55.6% to 100% (P < 0.001) by ED and from 77.0% to 79.7% (P = 0.2) across the 3 guideline implementation arms. In multivariable analysis, heart rate > or =125 per minute (OR = 1.6, 95% CI 1.1-2.3), respiratory rate > or =30 per minute (OR = 2.3, 95% CI 1.6-3.4), and aspiration pneumonia (OR = 3.7, 95% CI 1.1-12.7) were positively associated with timely initiation of antibiotic therapy, whereas a hematocrit <30% (OR = 0.6, 95% CI 0.4-1.0) was negatively associated with this outcome.

CONCLUSIONS

Timely initiation of antibiotic therapy is associated primarily with patient-related factors that reflect severity of illness at presentation. Although this study demonstrates an opportunity to improve performance on this quality measure in nearly one quarter of inpatients with pneumonia, we failed to identify any modifiable patient, provider, or hospital level factors to target in such quality improvement efforts.

Validation of the Infectious Disease Society of America/American Thoracic Society 2007 guidelines for severe community-acquired pneumonia

OBJECTIVES

Validate the Infectious Disease Society of America/American Thoracic Society 2007 (IDSA/ATS 2007) criteria for predicting severe community-acquired pneumonia (SCAP) and evaluate a health-services definition for SCAP.

DESIGN

Retrospective cohort study.

SETTING

LDS Hospital, an academic tertiary care facility in the western United States.

PATIENTS

Consecutive patients with International Classification of Diseases, Ninth Edition, codes and chest radiographs consistent with community-acquired pneumonia from 1996 to 2006 seen at LDS Hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We utilized the electronic medical record to examine intensive care unit admission, intensive therapies received, and predictors of severity, as well as 30-day mortality. We also developed logistic regression models of mortality and disease severity. We calculated the IDSA/ATS 2007 criteria as well as three other pneumonia severity scores. We defined SCAP as receipt of intensive therapy in the intensive care unit. In 2413 episodes of pneumonia, 1540 were admitted to the hospital, while 379 were admitted to the intensive care unit. Overall 30-day mortality was 3.7% but was 16% among intensive care patients. The IDSA/ATS 2007 minor criteria predicted SCAP with an area under the curve of 0.88 (95% confidence interval 0.85-0.90), which improved to 0.90 (95% confidence interval 0.88-0.92) with weighting. Competing models had area under the curve of 0.76 to 0.83. Using four rather than three minor criteria improved the positive predictive value from 54% to 81%, with a stable negative predictive value of 94% to 92%.

CONCLUSIONS

The IDSA/ATS 2007 criteria predicted pneumonia severity better than other models. Using four rather than three minor criteria may be a superior cutoff, although this will depend on institutional characteristics.

Late admission to the ICU in patients with community-acquired pneumonia is associated with higher mortality

BACKGROUND

Limited data are available on the impact of time to ICU admission and outcomes for patients with severe community acquired pneumonia (CAP). Our objective was to examine the association of time to ICU admission and 30-day mortality in patients with severe CAP.

METHODS

A retrospective cohort study of 161 ICU subjects with CAP (by International Classification of Diseases, 9th edition, codes) was conducted over a 3-year period at two tertiary teaching hospitals. Timing of the ICU admission was dichotomized into early ICU admission (EICUA, direct admission or within 24 h) and late ICU admission (LICUA, >or= day 2). A multivariable analysis using Cox proportional hazard model was created with the primary outcome of 30-day mortality (dependent measure) and the American Thoracic Society (ATS) severity adjustment criteria and time to ICU admission as the independent measures.

RESULTS

Eighty-eight percent (n = 142) were EICUA patients compared with 12% (n = 19) LICUA patients. Groups were similar with respect to age, gender, comorbidities, clinical parameters, CAP-related process of care measures, and need for mechanical ventilation. LICUA patients had lower rates of ATS severity criteria at presentation (26.3% vs 53.5%; P = .03). LICUA patients (47.4%) had a higher 30-day mortality compared with EICUA (23.2%) patients (P = .02), which remained after adjusting in the multivariable analysis (hazard ratio 2.6; 95% CI, 1.2-5.5; P = .02).

CONCLUSION

Patients with severe CAP with a late ICU admission have increased 30-day mortality after adjustment for illness severity. Further research should evaluate the risk factors associated and their impact on clinical outcomes in patients admitted late to the ICU.

Validation of a prediction rule for prognosis of severe community-acquired pneumonia

In a previous study, we developed a prognostic prediction rule, based on nine prognostic variables, capable to estimate and to adjust the mortality rate of patients admitted in intensive care unit for severe community-acquired pneumonia. A prospective multicenter study was undertaken to evaluate the performance of this rule. Five hundred eleven patients, over a 7-year period, were studied. The ICU mortality rate was 29.0%. In the 3 initial risk classes, we observed significantly increasing mortality rates (8.2% in class I, 22.8% in class II and 65.0% in class III) (p<0.001). Within each initial risk class, the adjustment risk score identified subclasses exhibiting significantly different mortality rates: 3.9% and 33.3% in class I; 3.1%, 12.9% and 63.3% in class II; and 55.8% and 82.5% in class III. Compared with mortality rates predicted by our previous study, only a few significant differences were observed. Our results demonstrate the performance and reproductibility of this prognostic prediction rule.

Imaging of Bacterial Pulmonary Infection in the Immunocompetent Patient

Pulmonary infection is a common reason for imaging of the lung and a common incidental finding in immunocompetent patients. Findings on chest radiography are nonspecific in defining acute infection; however, the radiologist should be aware of classically described patterns of infection, including air space, bronchopneumonia, and interstitial patterns. The radiologist must also be aware of potential limitations of the sensitivity of chest radiography. Imaging findings at computed tomography in acute infection have been poorly studied but may be more specific. Aspiration and septic emboli are additional potential radiographic patterns of infection that may be very characteristic in appearance. In the setting of nonresolving pneumonia, the differential diagnosis includes noninfectious causes as well as a variety of atypical infectious agents, specifically, mycobacterial and fungal agents, which have overlapping but distinctive clinical and radiographic presentations.

Évaluation des soins et pneumopathies aiguës communautaires

INTRODUCTION

Evaluations of care strategies for patients with community acquired pneumonia (CAP) tend to focus more on their necessity (variation in practice...) than on efficacy (adherence, impact of markers of disease severity or medico-economic factors...).

STATE OF THE ART

A number of studies are reported in the literature based on a simple evaluation of practice at a given moment on time or else on the impact of guidelines. These evaluations relate either to outcome criteria (mortality, and duration of stay especially) or the economic impact of CAP (rate of hospitalization, duration of stay, costs of the treatments or hospitalizations...), or on process of care (evaluation of initial severity, delay in administration of antibiotics, appropriateness of antibiotic therapy, evaluation of oxygenation and taking of specimens prior to treatment).

PERSPECTIVES AND CONCLUSIONS

Taken together these studies demonstrate the need to improve and standardise care. Where studies have not found a benefit from guidelines this can often be attributed to problems with assessment or study design and there are many studies showing the benefit of guideline based management and the introduction of standardised care pathways.

[Managing lower respiratory tract infections in immunocompetent patients. Definitions, epidemiology, and diagnostic features]

Les infections respiratoires basses sont une des principales cause de mortalité dans le monde et les pneumopathies représentent en France la première cause de décès d'origine infectieuse. Trois entités nosologiques distinctes sont habituellement isolées en fonction de la localisation infectieuse : la bronchite aiguë, la pneumopathie et la bronchopneumopathie (atteignant les bronches et le parenchyme pulmonaire). En cas d'infections de l'arbre bronchique dans le cadre d'une bronchopathie chronique on parle de décompensation infectieuse de la maladie bronchique. Les deux principales difficultés diagnostiques de ces infections sont de déterminer la présence d'une participation alvéolaire au processus infectieux et de définir l'agent (ou les agents) pathogènes. Ces deux éléments vont conditionner la prise en charge thérapeutique. En dehors de l'examen physique, indispensable dans ce contexte, seule la radiographie thoracique pourra, en cas de persistance d'un doute, permettre de confirmer la présence d'une participation alvéolaire. Le diagnostic microbiologique pose la question de sa nécessité systématique et celui de sa valeur. Il n'est pas indispensable de réaliser un diagnostic microbiologique de certitude dans tous les cas. La décision de documentation doit répondre à deux impératifs : faisabilité et valeur diagnostique. La valeur d'un prélèvement dépend de son aptitude à mettre en évidence l'agent pathogène et dans certains cas de la possibilité d'en déterminer le profil de sensibilité (qui reste une indication majeure à la réalisation de ces prélèvements).

Development and validation of a clinical prediction rule for severe community-acquired pneumonia

RATIONALE

Objective strategies are needed to improve the diagnosis of severe community-acquired pneumonia in the emergency department setting.

OBJECTIVES

To develop and validate a clinical prediction rule for identifying patients with severe community-acquired pneumonia, comparing it with other prognostic rules.

METHODS

Data collected from clinical information and physical examination of 1,057 patients visiting the emergency department of a hospital were used to derive a clinical prediction rule, which was then validated in two different populations: 719 patients from the same center and 1,121 patients from four other hospitals.

MEASUREMENTS AND MAIN RESULTS

In the multivariate analyses, eight independent predictive factors were correlated with severe community-acquired pneumonia: arterial pH < 7.30, systolic blood pressure < 90 mm Hg, respiratory rate > 30 breaths/min, altered mental status, blood urea nitrogen > 30 mg/dl, oxygen arterial pressure < 54 mm Hg or ratio of arterial oxygen tension to fraction of inspired oxygen < 250 mm Hg, age > or = 80 yr, and multilobar/bilateral lung affectation. From the beta parameter obtained in the multivariate model, a score was assigned to each predictive variable. The model shows an area under the curve of 0.92. This rule proved better at identifying patients evolving toward severe community-acquired pneumonia than either the modified American Thoracic Society rule, the British Thoracic Society's CURB-65, or the Pneumonia Severity Index.

CONCLUSIONS

A simple score using clinical data available at the time of the emergency department visit provides a practical diagnostic decision aid, and predicts the development of severe community-acquired pneumonia.

Routine use of pleural fluid cultures. Are they indicated? Limited yield, minimal impact on treatment decisions

In pleural infection, it has been recommended that Gram stain and cultures should be obtained on a routine basis. However, this recommendation has not been tested prospectively. We evaluated the yield of microbiological studies in 259 patients with parapneumonic pleural effusion. Microbiological studies were positive on the pleural fluid of 50 patients (19.3%). In 48 of the 50 patients with positive microbiological results (96%), the need for pleural drainage was correctly predicted by pleural fluid parameters. There were no differences in hospital stay (9.5+/-2.5 days versus 9.9+/-3.2 days, P=0.68) or in mortality (2 deaths in each group, P=0.58) between the group of patients in which antibiotic treatment was changed according to microbiological results and the group of patients in which it is not. In conclusion, this study demonstrates that, at least in our institution, routine microbial investigation of pleural fluid adds very little to the standard management of parapneumonic effusions.

Severe community-acquired pneumonia: an Australian perspective

BACKGROUND

Severe community-acquired pneumonia (CAP) is a common disease with a relatively high mortality. The initial treatment is empirical, based on a broad range of potential pathogens. There are minimal published data describing microbiological causes of pneumonia in Australia.

AIMS

To describe the aetiology and characteristics of severe CAP in patients requiring intensive care unit (ICU) admission, to identify factors predicting mortality and to audit current practices of investigation and antibiotic management of these patients from an Australian perspective.

METHODS

A retrospective analysis of patient case notes was performed for 96 consecutive patients admitted to two ICU with severe CAP. Data recorded included patient demographics, comorbidities, antimicrobial treatment, investigations and outcome (mortality, length of stay).

RESULTS

Overall, mortality was 32%. A microbiological diagnosis was made in 46% of patients. The most frequent causative organisms were Streptococcus pneumoniae (13 cases), influenza A (9), Haemophilus influenzae (5) and Staphylococcus aureus (4); aerobic Gram-negative bacilli collectively accounted for five cases. Blood cultures were positive in 20% of patients. Seventy patients (73%) required mechanical ventilation and 61 patients (63%) required inotropic support. Laboratory abnormalities including acute renal failure, metabolic acidosis and coagulopathy were frequent. Factors associated with mortality on multivariate analysis were age, antibiotic administration prior to hospital presentation, delay in hospital antibiotic administration of more than 4 h, and presence of multilobar or bilateral consolidation on chest X-ray.

CONCLUSIONS

Severe CAP requiring ICU admission was associated with a mortality rate of 32%, despite appropriate antimicrobial therapy including a beta-lactam and a macrolide antibiotic in most cases. Causative organisms identified were similar to those found in previous studies. High rates of viral causes (28% of identified pathogens) were noted. Low rates of legionellosis and other atypical causes were found, most probably due to a lack of systematic testing for these agents.

Swedish guidelines for the management of community-acquired pneumonia in immunocompetent adults

This document presents the evidence-based guidelines of the Swedish Society of Infectious Diseases for the management of adult immunocompetent patients with community-acquired pneumonia (CAP), who are assessed at hospital. The prognostic score 'CURB-65' is recommended for all CAP patients in the emergency room. The score provides an assessment tool for the decision regarding outpatient treatment or level of hospital supervision, the choice of microbiological investigations, and empirical antibiotic treatment. In patients with non-severe CAP (CURB-65 score 0-2) we recommend initial narrow-spectrum antibiotic treatment, orally or intravenously, primarily directed at Streptococcus pneumoniae. In those with CURB-65 score 3, penicillin G or a cephalosporin intravenously is recommended. For CURB-65 score 0-3 atypical pathogens should be covered only when they are suspected on clinical or epidemiological grounds. In patients with CURB-65 score 4-5 intravenous combination therapy with either cephalosporin/macrolide or penicillin G/fluoroquinolone is recommended. Efforts should be made to identify the CAP aetiology in order to support the ongoing antibiotic treatment or to suggest treatment alterations. Recommended measures for prevention of CAP include influenza -- and pneumococcal -- vaccination to risk groups and efforts for smoking cessation.

Prognosis factors and outcome of community-acquired pneumonia needing mechanical ventilation

PURPOSE

To evaluate the variables associated with mortality of patients with community-acquired pneumonia who require mechanical ventilation and to determine the attributable morbidity and intensive care unit (ICU) mortality of community-acquired pneumonia.

MATERIAL AND METHODS

Retrospective cohort study carried out in 361 ICUs from 20 countries including 124 patients who required mechanical ventilation on the first day of admission to the hospital due to acute respiratory failure secondary to severe community-acquired pneumonia. To assess the factors associated with outcome, a forward stepwise logistic regression analysis was performed, and to determine the attributable mortality of community-acquired pneumonia, a matched study design was used.

RESULTS

We found 3 independent variables significantly associated with death in patients with community-acquired pneumonia requiring mechanical ventilation: simplified acute physiological score greater than 45 (odds ratio, 5.5 [95% confidence interval, 1.7-12.3]), shock (odds ratio, 5.7 [95% confidence interval, 1.7-10.1]), and acute renal failure (odds ratio, 3.0 [95% confidence interval, 1.1-4.0]). There was no statistically significant difference in ICU mortality among patients with or without community-acquired pneumonia (32% vs 35%; P=.59).

CONCLUSIONS

Community-acquired pneumonia needing mechanical ventilation is not a disease associated with higher mortality. The main determinants of patient outcome were initial severity of illness and the development of shock and/or acute renal failure.

Severe community-acquired pneumonia in an intensive care unit: risk factors for mortality

OBJECTIVE

To evaluate severe community-acquired pneumonia (SCAP) patients in an intensive care unit (ICU) with regard to risk factors for mortality and to compare ICU patients with matched non-ICU patients to evaluate whether our judgement for ICU admission was appropriate or not.

MATERIALS AND METHODS

During a 7-year period, all patients with CAP who were admitted to the ICU were examined. They underwent clinical and radiographic evaluations, and two commonly used severity of illness scores were also calculated using the Simplified Acute Physiological Score (SAPS) and the Acute Physiology and Chronic Health Evaluation (APACHE) II methods. To detect risk factors for ICU admission using existing guidelines, each study patient was matched with two patients hospitalized in a general medical ward.

RESULTS

Seventy-two patients were identified during the study period. Their mean age was 72.9 years, and 35 patients (48.6%) subsequently died. For the univariate analysis, there were significant differences with the pulse rate > or = 130/min, blood urea nitrogen > or = 30 mg/dl, multilobar shadow, SAPS > or = 13, APACHE II > or = 23, and the occurrence of septic shock between the survivors and those who died. For the multivariate analysis, septic shock (p = 0.0005, odds ratio of 26.6) and blood urea nitrogen > or = 30 mg/dl (p = 0.037, odds ratio of 5.38) were associated with mortality. Regarding the characteristics of different clinical predictions for ICU admission, the revised American Thoracic Society criteria might have been the most accurate.

CONCLUSION

Septic shock was associated with high mortality, which is a more accurate and higher predictor of mortality than was physical examination, laboratory or radiographic findings.

The impact of mechanical ventilation on the moxifloxacin treatment of experimental pneumonia caused by Streptococcus pneumoniae

OBJECTIVE

Streptococcus pneumoniae is a leading cause of community-acquired pneumonia and is responsible for early-onset ventilator-associated pneumonia as well. In intensive care units, community-acquired pneumonia is still associated with a mortality rate of up to 30%, especially when mechanical ventilation is required. Our objective was to study to what extent MV could influence the efficacy of moxifloxacin in a rabbit model of pneumonia.

DESIGN

Prospective experimental study.

SETTING

University hospital laboratory.

SUBJECTS

Male New Zealand White rabbits (n = 75).

INTERVENTIONS

S. pneumoniae (16089 strain; minimal inhibitory concentration for moxifloxacin = 0.125 mg/L) was instilled intrabronchially. Four hours later, a human-like moxifloxacin treatment was initiated in spontaneously breathing (SB) and mechanically ventilated (MV) animals. Untreated rabbits were used as controls. Survivors were killed 48 hrs later. Pneumonia was assessed and moxifloxacin pharmacokinetics were analyzed.

MEASUREMENTS AND MAIN RESULTS

Moxifloxacin treatment was associated with an improvement in survival in the SB animals (13 of 13 [100%] vs. eight of 37 [21.6%] controls). The survival rate was less influenced by treatment in MV rabbits (seven of 15 [46.1%] vs. one of eight [12.5%] controls). The lung bacterial burden was greater in MV compared with SB rabbits (5.1 +/- 2.4 vs. 1.6 +/- 1.4 log10 colony-forming units/g, respectively). Nearly all the untreated animals presented bacteremia as reflected by a positive spleen culture. No bacteremia was found in SB animals treated with moxifloxacin. In contrast, three of 13 (23.1%) moxifloxacin-treated and MV animals had positive spleen cultures. The apparent volume of distribution of moxifloxacin was lower in MV compared with SB rabbits.

CONCLUSIONS

In our model of moxifloxacin-treated S. pneumoniae pneumonia, mechanical ventilation was associated with a higher mortality rate and seemed to promote bacterial growth as well as systemic spread of the infection. In addition, the volume of distribution of moxifloxacin was reduced in the presence of mechanical ventilation. Although the roles of factors such as anesthesia, paralysis, and endotracheal tube insertion could not be established, these results suggest that mechanical ventilation may impair host lung defense, rendering antibiotic therapy less effective.

[Guidelines for the management of community pneumonia in adult who needs hospitalization]

Community acquired pneumonia is still an important health problem. In Spain the year incidence is 162 cases per 100,000 inhabitants with 53,000 hospital admission costing 115 millions of euros per year. In the last years there have been significant advances in the knowledge of: aetiology, diagnostic tools, treatment alternatives and antibiotic resistance. The Spanish Societies of Intensive and Critical Care (SEMICYUC), Infectious Diseases and Clinical Microbiology (SEIMC) and Pulmonology and Thoracic Surgery (SEPAR) have produced these evidence-based Guidelines for the management of community acquired pneumonia in Adults. The main objective is to help physicians to make decisions about this disease. The different points that have been developed are: aetiology, diagnosis, treatment and prevention.

Recomendações de abordagem diagnóstica e terapêutica da pneumonia da comunidade em adultos imunocompetentes

The Portuguese Respiratory Society makes a series of recommendations as to the state of the art of the diagnostic, therapeutic and preventive approach to community-acquired pneumonia in immunocompetent adults in Portugal. These proposals should be regarded as general guidelines and are not intended to replace the clinical sense used in resolving each individual case. Our main goal is to stratify the patients according to the risk of morbidity and mortality in order to justify the following decisions more rationally: the choice of place of treatment (outpatient or inpatient), diagnostic tests and antimicrobial therapy. We also make a set of recommendations for the prevention of CAP. We plan to conduct multi-centre prospective studies, preferably in collaboration with other scientific societies, in order to be able to characterise the situation in Portugal more accurately and regularly update this document.

Life-threatening hemoptysis in adults with community-acquired pneumonia due to Panton-Valentine leukocidin-secreting Staphylococcus aureus

Three new consecutive cases of life-threatening hemoptysis in adults with community-acquired pneumonia due to Panton-Valentine leukocidin-secreting Staphylococcus aureus are presented, focusing on the particular clinical presentation of this new entity. Between December 1999 and March 2001, three adults aged from 23 to 67 years were admitted to our respiratory intensive care unit for massive hemoptysis and septic shock associated with community-acquired Staphylococcus aureus pneumonia. Isolates were sent to the Centre National de Référence des Toxémies Staphylococciques in Lyon, France, where they were found to secrete Panton-Valentive leukocidin. The clinical course was similar in the three patients, with massive hemoptysis and septic shock necessitating mechanical ventilation. Two patients died rapidly; necropsy showed pulmonary vascular necrosis in one of them. The third patient recovered after appropriate antibiotic therapy. Leukocidin/neutrophil interactions in the pulmonary vasculature may cause severe hemoptysis in patients with community-acquired Staphylococcus aureus pneumonia secreting Panton-Valentine leukocidin. Adult patients with massive hemoptysis and suspected community-acquired pneumonia should receive antibiotic regimens covering Staphylococcus aureus.

[Prognostic factors associated with community-acquired aspiration pneumonia]

BACKGROUND

Aspiration pneumonia (AP) represents about 5-24% of community-acquired pneumonias. This condition mainly affects elderly patients and causes a high mortality. Our objective was to quantify the AP mortality rate and to identify prognostic factors upon patients admission.

PATIENTS AND METHOD

We underwent a retrospective observational study of a cohort of AP patients admitted to a tertiary care hospital during a 29 months period. The in-hospital mortality rate was calculated. To identify prognostic factors, basal characteristics of patients as well as their clinical presentation and complementary tests performed on admission were studied and analyzed by univariate and multivariate techniques. Odds ratios and 95% confidence intervals were estimated.

RESULTS

Thirty six out of 105 admitted patients with AP died (cumulative mortality incidence rate 34%, 95% CI 25-44%). In the univariate analysis, demographic, clinical and complementary test variables were associated with mortality. Final logistic model revealed the following independent variables: living in a nursing home (OR = 3.4; 95% CI 1.1-10.9), high degree of dependence (OR = 0.3; 95% CI, 0.1-0.9), body temperature (OR = 0.5 per Celsius degree; 95% CI, 0.3-1.0), serum creatinine levels (OR = 2.2 per mg/100 ml; 95% CI, 1.2-4.1) and LDH serum concentrations (OR = 1.5 per 100 IU/L; 95% CI, 1.1-2.0).

CONCLUSIONS

The mortality of community-acquired AP is very high. In addition to clinical and biological parameters on admission such as body temperature and LDH and creatinine serum concentrations, living in a nursing home and having a high degree of dependence for the basic daily activities were identified as independent prognostic factors. An in-depth knowledge of prognostic factors related to pre-admission care and assistance is needed to decrease the mortality in these patients.

Clinical perspectives on new antimicrobials: focus on fluoroquinolones

Respiratory tract infections are the most common infectious presentation in the community and hospital settings and are a major cause of morbidity and mortality worldwide. Recently, newer fluoroquinolones have been recommended for the treatment of these infections. Among them, moxifloxacin shows improved activity against gram-positive pathogens, has maintained potency against gram-negative organisms, and shows activity against atypical pathogens and anaerobes. Moxifloxacin also has excellent in vitro activity against strains resistant to penicillin, erythromycin, and other fluoroquinolones, such as levofloxacin. Moxifloxacin has demonstrated clinical efficacy rates of 90%-95% in clinical trials in community-acquired pneumonia, acute exacerbations of chronic bronchitis, and acute sinusitis. In these trials, moxifloxacin demonstrated no serious or unexpected adverse effects. Development of resistance appears to be slower for moxifloxacin than for several other fluoroquinolones, making moxifloxacin a good treatment choice. The pharmacodynamics of moxifloxacin support once-daily oral therapy of short duration, providing convenience, compliance, and safety advantages.