Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. American Thoracic Society. Medical Section of the American Lung Association

Definition, Epidemiology, and Pathogenesis of Severe Community-Acquired Pneumonia

The clinical presentation of community-acquired pneumonia (CAP) can vary widely among patients. While many individuals with mild symptoms can be managed as outpatients with excellent outcomes, there is a distinct subgroup of patients who present with severe CAP. In these cases, the mortality rate can reach approximately 25% within 30 days and even up to 50% within a year. It is crucial to focus attention on these patients who are at higher risk. Among the various definitions of severe CAP found in the literature, one commonly used criterion is the requirement for admission to intensive care unit. Notable epidemiological characteristics of these patients include the impact of acute cardiovascular diseases on clinical outcomes and the enduring, independent effect of pneumonia on long-term outcomes. Factors such as pathogen virulence, the presence of comorbidities, and the host response are important contributors to the pathogenesis of severe CAP. In these patients, the host response may be dysregulated and compartmentalized. Gaining a better understanding of the epidemiology and pathogenesis of severe CAP will provide a foundation for the development of new therapies for this condition. This manuscript aims to review the definition, epidemiology, and pathogenesis of severe CAP, shedding light on important aspects that can aid in the improvement of patient care and outcomes.

Analysis of Risk Factors for Pneumonia Death in ICU Environment Based on Logistic Regression

Objective

To explore the risk and protect factors for death of pneumonia patients in intensive care unit (ICU), we conducted this logistic regression research.

Methods

We collected demographic and nursing care data for 80 patients form Wuhan fourth hospital, in which 40 patients were dead and the other 40 patients were alive. Difference analysis, Pearson's correlation matrix, and logistic regression were conducted to explore the risk and protective factors for living status of pneumonia patients in ICU.

Results

A total of 40 individuals were dead from pneumonia in ICU. The demographic and nursing information had no difference between death and living groups except age. After that, correlation analysis showed that there were correlations between living status, age, and marriage. Logistic regression showed that age (odds ratio (OR) = 0.94, P < 0.05) and no education (OR = 0.21, P < 0.05) may be harmful for pneumonia patients living status while high-quality nursing (OR = 2.72, P < 0.05) may be helpful for pneumonia patients living status.

Conclusion

High-quality care plays an important role in protecting the survival of patients with pneumonia, and old age and uneducated may be the risk factors for the death of patients with pneumonia.

Acute but not chronic heart failure is associated with higher mortality among patients hospitalized with pneumonia: An analysis of a nationwide database

Background:

Among patients admitted for pneumonia, heart failure (HF) is associated with worse outcomes. It is unclear whether this association is due to acute HF exacerbations, complex medical management, or chronic co-morbid conditions.

Methods:

This is a retrospective cohort study of patients admitted between July 2010 and June 2015 at 651 US hospitals with a principal diagnosis of either pneumonia or secondary diagnosis of pneumonia with a primary diagnosis of respiratory failure or sepsis. Comorbidities were identified by ICD-9 codes and medical management by daily charge codes. Patients were categorized according to the presence and acuity of admission diagnosis of HF. In-hospital mortality was the primary outcome. Secondary outcomes included length of stay, hospital cost, ICU admission, use of mechanical ventilation, vasopressors and inotropes. Logistic regression was used to study the association of outcomes with presence and acuity of HF.

Results:

Of 783,702 patients who met inclusion criteria, 212,203 (27%) had a diagnosis of HF. Of these, 56,306 (26.5%) had acute while 48,188 (22.7%) had chronic HF on admission; 51% had a diagnosis of unspecified HF. In multivariable-adjusted models, having any HF was associated with increased mortality (OR 1.35 [1.33 – 1.38]) compared to those without HF; increased mortality was associated with acute HF (OR 1.19 [1.15 – 1.22]) but not chronic HF (OR 0.92 [0.89 – 0.96]).

Conclusion:

The worse outcomes for pneumonia patients with HF appear due to acute HF exacerbations. Adjustment for HF without accounting for chronicity could lead to biased prognostic and billing estimates.

Respiratory MUC5B disproportion is involved in severe community-acquired pneumonia

BACKGROUND

Mucus production is a process involved in the pathogenesis of Community-acquired pneumonia (CAP). The study is to determine Mucin 5B (MUC5B) protein concentration and its proportion in the bronchoalveolar lavage fluid (BALF) of CAP patients and evaluate its value to help assess disease severity.

METHODS

A total of 118 patients were enrolled in this cross-sectional study, including 45 with severe CAP (SCAP) and 73 with non-severe CAP (NSCAP). MUC5B concentration in BALF were determined by immunoblotting analysis. Total protein concentration of BALF was detected by Pierce BCA kit. Cytokines IL6, IL10, IFNγ, IL13, and IL17 in BALF were measured using commercial enzyme-linked immunosorbent assay (ELISA). Spearman's correlation analysis was applied to evaluate the relationships between MUC5B concentration or MUC5B/total protein ratio and the CURB-65 score, as well as cytokines. Logistic regression analysis was used to identify the independent factors associated with severe CAP. Receiver operating characteristic (ROC) curve was used to evaluate the assessment value of MUC5B/total protein ratio and other indexes for CAP severity.

RESULTS

MUC5B concentration in the BALF of NSCAP group was higher than that in SCAP group [NSCAP 13.56 µg/ml (IQR 5.92-25.79) vs. SCAP 8.20 µg/ml (IQR 4.97-14.03), p = 0.011]. The total protein concentration in the BALF of NSCAP group was lower than that in SCAP group [NSCAP 0.38 mg/ml (IQR 0.15-1.10) vs. SCAP 0.68 mg/ml (IQR 0.46-1.69), p = 0.002]. The MUC5B/total protein ratio was remarkably higher in NSCAP group than that in SCAP groups [NSCAP 3.66% (IQR 1.50-5.56%) vs. SCAP 1.38% (IQR 0.73-1.76%), p < 0.001]. MUC5B/total protein ratio was negatively correlated with total protein concentration (r_s = - 0.576, p < 0.001), IL6 (r_s = - 0.312, p = 0.001), IL10 (r_s = - 0.228, p = 0.013), IL13 (r_s = - 0.183, p = 0.048), IL17 (r_s = - 0.282, p = 0.002) and CURB-65 score (r_s = - 0.239, p = 0.009). Logistic regression identified that MUC5B/total protein ratio, IL6 level and CURB-65 score as independent variables related to CAP severity. ROC curve demonstrated best assessment value of MUC5B/total protein ratio for SCAP (AUC 0.803, p < 0.001), with a sensitivity of 88.9% and a specificity of 64.4%.

CONCLUSIONS

Respiratory MUC5B disproportion is related to CAP severity. MUC5B/total protein ratio may serve as an assessment marker and a potential therapeutic target for severe CAP.

Applying machine learning algorithms to electronic health records predicted pneumonia after respiratory tract infection

OBJECTIVES

To predict community acquired pneumonia (CAP) after respiratory tract infection (RTI) consultations in primary care by applying machine learning to electronic health records (EHRs).

STUDY DESIGN AND SETTING

A population-based cohort study was conducted using primary care electronic health records between 2002 to 2017. 16,289 patients who consulted with RTIs then subsequently diagnosed with pneumonia within 30 days were compared with a random sample of eligible RTI patients. Variable selection compared logistic regression, random forest and penalized regression models. Prediction models were developed using classification and regression trees (CART) and logistic regression. Model performance was assessed through internal and temporal validations.

RESULTS

Older age, comorbidity and initial presentation with lower respiratory tract infection (LRTIs) were identified as the main predictors of pneumonia diagnosis. Developed models achieved good discrimination accuracy with AUROC for the logistic regression model being 0.81 (0.80, 0.84) and 0.70 (0.69, 0.71) for CART during internal validation, and 0.80 (0.79, 0.81) vs 0.68 (0.67, 0.69) for temporal validation.

CONCLUSION

From a large number of candidate variables, a small number of predictors of pneumonia were consistently identified through machine learning variable selection procedures. Logistic regression generally provided better model performance than CART models.

Intersections between pneumonia, lowered oxygen saturation percentage and immune activation mediate depression, anxiety, and chronic fatigue syndrome-like symptoms due to COVID-19: A nomothetic network approach

BACKGROUND

COVID-19 is associated with neuropsychiatric symptoms including increased depressive, anxiety and chronic fatigue-syndrome (CFS)-like and physiosomatic symptoms.

AIMS

To delineate the associations between affective and CFS-like symptoms in COVID-19 and chest computed tomography scan anomalies (CCTAs), oxygen saturation (SpO₂), interleukin (IL)-6, IL-10, C-Reactive Protein (CRP), albumin, calcium, magnesium, soluble angiotensin converting enzyme (ACE2) and soluble advanced glycation products (sRAGEs).

METHOD

The above biomarkers were assessed in 60 COVID-19 patients and 30 healthy controls who had measurements of the Hamilton Depression (HDRS) and Anxiety (HAM-A) and the Fibromyalgia and Chronic Fatigue (FF) Rating Scales.

RESULTS

Partial Least Squares-SEM analysis showed that reliable latent vectors could be extracted from a) key depressive and anxiety and physiosomatic symptoms (the physio-affective or PA-core), b) IL-6, IL-10, CRP, albumin, calcium, and sRAGEs (the immune response core); and c) different CCTAs (including ground glass opacities, consolidation, and crazy paving) and lowered SpO₂% (lung lesions). PLS showed that 70.0% of the variance in the PA-core was explained by the regression on the immune response and lung lesions latent vectors. One common "infection-immune-inflammatory (III) core" underpins pneumonia-associated CCTAs, lowered SpO₂ and immune activation, and this III core explains 70% of the variance in the PA core, and a relevant part of the variance in melancholia, insomnia, and neurocognitive symptoms.

DISCUSSION

Acute SARS-CoV-2 infection is accompanied by lung lesions and lowered SpO₂ which may cause activated immune-inflammatory pathways, which mediate the effects of the former on the PA-core and other neuropsychiatric symptoms due to SARS-CoV-2 infection.

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.

Radiologic aspects of COVID-19 pneumonia: outcomes and thoracic complications

Outcomes vary widely in patients with COVID-19. Whereas some patients have only mild symptoms of short duration, others develop severe disease that leads to acute respiratory distress syndrome requiring prolonged stays in intensive care units. Radiologically, the initial stage is characterized by viral pneumonia with mild expression. In some patients, however, the onset of the immune response results in acute lung damage with organizing pneumonia and diffuse alveolar damage. Moderate-severe disease is associated with a high incidence of pulmonary embolisms, generally peripherally distributed and associated with endothelial damage, prolonged stays in bed, and coagulopathy. Other relatively common complications are spontaneous pneumothorax and pneumomediastinum due to the rupture of alveolar walls and barotrauma in mechanically ventilated patients. Superinfection, generally bacterial and less commonly fungal, is more common in patients with severe disease.

Radiologic aspects of COVID-19 pneumonia: Outcomes and thoracic complications

Outcomes vary widely in patients with COVID-19. Whereas some patients have only mild symptoms of short duration, others develop severe disease that leads to acute respiratory distress syndrome requiring prolonged stays in intensive care units. Radiologically, the initial stage is characterized by viral pneumonia with mild expression. In some patients, however, the onset of the immune response results in acute lung damage with organizing pneumonia and diffuse alveolar damage.

Moderate-severe disease is associated with a high incidence of pulmonary embolisms, generally peripherally distributed and associated with endothelial damage, prolonged stays in bed, and coagulopathy. Other relatively common complications are spontaneous pneumothorax and pneumomediastinum due to the rupture of alveolar walls and barotrauma in mechanically ventilated patients. Superinfection, generally bacterial and less commonly fungal, is more common in patients with severe disease.

Advances in community-acquired pneumonia

Community-acquired pneumonia is one of the commonest and deadliest of the infectious diseases, yet our understanding of it remains relatively poor. The recently published American Thoracic Society and Infectious Diseases Society of America Community-acquired pneumonia guidelines acknowledged that most of what we accept as standard of care is supported only by low quality evidence, highlighting persistent uncertainty and deficiencies in our knowledge. However, progress in diagnostics, translational research, and epidemiology has changed our concept of pneumonia, contributing to a gradual improvement in prevention, diagnosis, treatment, and outcomes for our patients. The emergence of considerable evidence about adverse long-term health outcomes in pneumonia survivors has also challenged our concept of pneumonia as an acute disease and what treatment end points are important. This review focuses on advances in the research and care of community-acquired pneumonia in the past two decades. We summarize the evidence around our understanding of pathogenesis and diagnosis, discuss key contentious management issues including the role of procalcitonin and the use or non-use of corticosteroids, and explore the relationships between pneumonia and long-term outcomes including cardiovascular and cognitive health.

Predicting 30-day mortality of patients with pneumonia in an emergency department setting using machine-learning models

OBJECTIVE

This study aimed to confirm the accuracy of a machine-learning-based model in predicting the 30-day mortality of patients with pneumonia and evaluating whether they were required to be admitted to the intensive care unit (ICU).

METHODS

The study conducted a retrospective analysis of pneumonia patients at an emergency department (ED) in Seoul, Korea, from January 1, 2016 to December 31, 2017. Patients aged 18 years or older with a pneumonia registry designation on their electronic medical record were enrolled. We collected their demographic information, mental status, and laboratory findings. Three models were used: the pre-existing CURB-65 model, and the CURB-RF and Extensive CURB-RF models, which were machine-learning models that used a random forest algorithm. The primary outcomes were ICU admission from the ED or 30-day mortality. Receiver operating characteristic curves were constructed for the models, and the areas under these curves were compared.

RESULTS

Out of the 1,974 pneumonia patients, 1,732 patients were eligible to be included in the study; from these, 473 patients died within 30 days or were initially admitted to the ICU from the ED. The area under receiver operating characteristic curves of CURB-65, CURB-RF, and extensive-CURB-RF were 0.615 (0.614-0.616), 0.701 (0.700-0.702), and 0.844 (0.843-0.845), respectively.

CONCLUSION

The proposed machine-learning models could predict the mortality of patients with pneumonia more accurately than the pre-existing CURB-65 model and can help decide whether the patient should be admitted to the ICU.

Development and validation a nomogram for predicting the risk of severe COVID-19: A multi-center study in Sichuan, China

BACKGROUND

Since December 2019, coronavirus disease 2019 (COVID-19) emerged in Wuhan and spread across the globe. The objective of this study is to build and validate a practical nomogram for estimating the risk of severe COVID-19.

METHODS

A cohort of 366 patients with laboratory-confirmed COVID-19 was used to develop a prediction model using data collected from 47 locations in Sichuan province from January 2020 to February 2020. The primary outcome was the development of severe COVID-19 during hospitalization. The least absolute shrinkage and selection operator (LASSO) regression model was used to reduce data size and select relevant features. Multivariable logistic regression analysis was applied to build a prediction model incorporating the selected features. The performance of the nomogram regarding the C-index, calibration, discrimination, and clinical usefulness was assessed. Internal validation was assessed by bootstrapping.

RESULTS

The median age of the cohort was 43 years. Severe patients were older than mild patients by a median of 6 years. Fever, cough, and dyspnea were more common in severe patients. The individualized prediction nomogram included seven predictors: body temperature at admission, cough, dyspnea, hypertension, cardiovascular disease, chronic liver disease, and chronic kidney disease. The model had good discrimination with an area under the curve of 0.862, C-index of 0.863 (95% confidence interval, 0.801-0.925), and good calibration. A high C-index value of 0.839 was reached in the interval validation. Decision curve analysis showed that the prediction nomogram was clinically useful.

CONCLUSION

We established an early warning model incorporating clinical characteristics that could be quickly obtained on admission. This model can be used to help predict severe COVID-19 and identify patients at risk of developing severe disease.

Evidence supporting recommendations from international guidelines on treatment, diagnosis, and prevention of HAP and VAP in adults

Clinical practice guidelines (CPGs) are intended to support clinical decisions and should be based on high-quality evidence. The objective of the study was to evaluate the quality of evidence supporting the recommendations issued in CPGs for therapy, diagnosis, and prevention of hospital-acquired and ventilator-associated pneumonia (HAP/VAP). CPGs released by international scientific societies after year 2000, using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology, were analyzed. Number and strength of recommendations and quality of evidence (high, moderate, low, and very low) were extracted and indexed in the aforementioned sections. High-quality evidence was based on randomized control trials (RCT) without important limitations and exceptionally on rigorous observational studies. Eighty recommendations were assessed, with 7 (8.7%), 24 (30.0%), 29 (36.3%), and 20 (25.0%) being supported by high, moderate, low, and very low-quality evidence, respectively. Highest evidence degree was reported for 26 prevention recommendations, with 7 (26.9%) supported by high-quality evidence and no recommendation based on very low-quality evidence. In contrast, among 9 recommendations for diagnosis and 45 for therapy, none was supported by high-quality evidence, in spite of being recommended as strong in 33.3% and 46.7%, respectively. Among HAP/VAP diagnosis recommendations, the majority of evidence was rated as low or very low-quality (55.6% and 22.2%, respectively) whereas among HAP/VAP therapy recommendations, 4/5 were rated as low and very low-quality (40% each). In conclusion, among HAP/VAP international guidelines, most recommendations, particularly in therapy, remain supported by observational studies, case reports, and expert opinion. Well-designed RCTs are urgently needed.

Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort Study

BACKGROUND

Randomized trials demonstrate no benefit from antibiotic treatment exceeding the shortest effective duration.

OBJECTIVE

To examine predictors and outcomes associated with excess duration of antibiotic treatment.

DESIGN

Retrospective cohort study.

SETTING

43 hospitals in the Michigan Hospital Medicine Safety Consortium.

PATIENTS

6481 general care medical patients with pneumonia.

MEASUREMENTS

The primary outcome was the rate of excess antibiotic treatment duration (excess days per 30-day period). Excess days were calculated by subtracting each patient's shortest effective (expected) treatment duration (based on time to clinical stability, pathogen, and pneumonia classification [community-acquired vs. health care-associated]) from the actual duration. Negative binomial generalized estimating equations (GEEs) were used to calculate rate ratios to assess predictors of 30-day rates of excess duration. Patient outcomes, assessed at 30 days via the medical record and telephone calls, were evaluated using logit GEEs that adjusted for patient characteristics and probability of treatment.

RESULTS

Two thirds (67.8% [4391 of 6481]) of patients received excess antibiotic therapy. Antibiotics prescribed at discharge accounted for 93.2% of excess duration. Patients who had respiratory cultures or nonculture diagnostic testing, had a longer stay, received a high-risk antibiotic in the prior 90 days, had community-acquired pneumonia, or did not have a total antibiotic treatment duration documented at discharge were more likely to receive excess treatment. Excess treatment was not associated with lower rates of any adverse outcomes, including death, readmission, emergency department visit, or Clostridioides difficile infection. Each excess day of treatment was associated with a 5% increase in the odds of antibiotic-associated adverse events reported by patients after discharge.

LIMITATION

Retrospective design; not all patients could be contacted to report 30-day outcomes.

CONCLUSION

Patients hospitalized with pneumonia often receive excess antibiotic therapy. Excess antibiotic treatment was associated with patient-reported adverse events. Future interventions should focus on whether reducing excess treatment and improving documentation at discharge improves outcomes.

PRIMARY FUNDING SOURCE

Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program.

Impact of Cefotaxime Non-susceptibility on the Clinical Outcomes of Bacteremic Pneumococcal Pneumonia

Background: We aimed to analyze the impact of cefotaxime non-susceptibility on the 30-day mortality rate in patients receiving a third-generation cephalosporin for pneumococcal bacteremic pneumonia. Methods: We conducted a retrospective observational study of prospectively collected data from the Hospital Clinic of Barcelona. All adult patients with monomicrobial bacteremic pneumonia due to Streptococcus pneumoniae and treated with a third-generation cephalosporin from January 1991 to December 2016 were included. Risk factors associated with 30-day mortality were evaluated by univariate and multivariate analyses. Results: During the study period, 721 eligible episodes were identified, and data on the susceptibility to cefotaxime was obtainable for 690 episodes. Sixty six (10%) cases were due to a cefotaxime non-susceptible strain with a 30-day mortality rate of 8%. Variables associated with 30-day mortality were age, chronic liver disease, septic shock, and the McCabe score. Infection by a cefotaxime non-susceptible S. pneumoniae did not increase the mortality rate. Conclusion: Despite the prevalence of cefotaxime, non-susceptible S. pneumoniae has increased in recent years. We found no evidence to suggest that patients hospitalized with bacteremic pneumonia due to these strains had worse clinical outcomes than patients with susceptible strains.

Outpatient management of community-acquired pneumonia

PURPOSE OF REVIEW

The first guidelines on community-acquired pneumonia (CAP) were published in 1993, but since then many of the challenges regarding the outpatient management of CAP persist. These include the difficulty in establishing the initial clinical diagnosis, its risk stratification, which will dictate the place of treatment, the empirical choice of antibiotics, the relative scarcity of novel antibiotics and the importance of knowing local microbiological susceptibility patterns.

RECENT FINDINGS

New molecular biology methods have changed the etiologic perspective of CAP, especially the contribution of virus. Lung ultrasound and biomarkers might aid diagnosis and severity stratification in the outpatient setting. Antibiotic resistance is a growing problem that reinforces the importance of novel antibiotics. And finally, prevention and the use of anti-pneumococcal vaccine are instrumental in reducing the burden of disease.

SUMMARY

Most of CAP cases are managed in the community; however, most research comes from hospitalized severe patients. New and awaited advances might contribute to aid diagnosis, cause and assessment of patients with CAP in the community. This knowledge might prove decisive in the execution of stewardship programmes that maintain current antibiotics, safeguard future ones and reinforce prevention.

Predicting the need for ICU admission in community-acquired pneumonia

BACKGROUND

Multiple criteria have been proposed to define community-acquired pneumonia (CAP) severity and predict ICU admission. Validity studies have found differing results. We tested four models to assess severe CAP built upon the criteria included in the 2007 IDSA/ATS guidelines, hypothesizing that a model providing different weights for each individual criterion may be of better predictability.

METHODS

Retrospective analysis of a prospective cohort study of adult hospitalizations for CAP at nine hospitals in Louisville, KY from June 2014 to May 2016. Four models were tested. Model 1: original 2007 IDSA/ATS criteria. Model 2: modified IDSA/ATS criteria by removing multilobar infiltrates and changing BUN threshold to ≥30 mg/dL; adding lactate level >2 mmol/L and requirement of non-invasive mechanical ventilation (NIMV). CAP was severe with 1 major criterion or 3 minor criteria. Model 3: same criteria as model 2, CAP was severe with 1 major criterion or 4 minor criteria. Model 4: multiple regression analysis including the modified criteria as described in models 2 and 3 with a score assigned to each variable according to the magnitude of association between variable and need for ICU.

RESULTS

8284 CAP hospitalizations were included. 1458 (18%) required ICU. Model 4 showed highest prediction of need for ICU with an area under the curve of 0.91, highest accuracy, specificity, positive predictive value, and agreement among models.

CONCLUSION

Assigning differential weights to clinical predictive variables generated a score with accuracy that outperformed the original 2007 IDSA/ATS criteria for severe CAP and ICU admission.

Health Care-Associated Pneumonia: Is It Still a Useful Concept?

"Health care-associated pneumonia (HCAP) was introduced into guidelines because of concerns about the increasing prevalence of drug-resistant pathogens (DRPs) not covered by standard empirical therapy. We now know that DRPs are very localized phenomena with low rates in most sites. Although HCAP risk factors are associated with a higher mortality, this is driven by comorbidities rather than the pathogens. Empirical coverage of DRPs has generally not resulted in better patient outcomes. A far more nuanced approach must be taken for patients with risk factors for DRPs taking into account the local cause and severity of disease.

Guidelines to Manage Community-Acquired Pneumonia

Few guidelines have greater acceptance than that for management of community-acquired pneumonia (CAP). Despite this, areas remain controversial, and new challenges continue to emerge. Current guidelines differ from those of northern European countries predominantly in need for macrolide combination with β-lactams for hospitalized, non-intensive care unit patients. A preponderance of evidence favors combination therapy. Challenges for current and future CAP guidelines include new antibiotic classes, emergence of viruses as major causes for CAP, new diagnostic modalities, alternative risk stratification for pathogens resistant to usual CAP antibiotics, and evidence-based management of severe CAP, including immunomodulatory therapy such as corticosteroids.

[Impact of the ERA and GES health programs on mortality from community-acquired pneumonia in persons aged ≥65 years in ChileImpacto do programa de saúde ERA e do GES na mortalidade por pneumonia adquirida na comunidade em indivíduos com idade acima de 65 anos no Chile]

Objetivo.

Evaluar el impacto del Programa de Enfermedades Respiratorias del Adulto (ERA) y el Régimen General de Garantías Explícitas en Salud (GES) en la mortalidad por neumonía adquirida en la comunidad (NAC) en personas de 65 años o más en Chile.

Métodos.

En este estudio ecológico se calcularon las tasas anuales y trimestrales de mortalidad por NAC en personas de 65 a 79 años y de 80 años o más entre 1990 y 2014. Las fuentes de información fueron las bases de datos del Departamento de Estadística e Información de Salud y del Instituto Nacional de Estadística de Chile. Como intervenciones se evaluó el Programa ERA (puesto en marcha en el 2001) y la inclusión de la NAC en el GES (a partir del 2005). Los datos se analizaron mediante el método de series de tiempo interrumpidas, según el modelo de Prais-Winsten. Se consideró un nivel de significación del 5%.

Resultados.

El análisis mostró que después del inicio del programa ERA se observaron disminuciones significativas de la tasa de mortalidad por NAC en los dos grupos de edad estudiados, mientras que a partir de la incorporación de la NAC al programa GES no se encontraron cambios estadísticamente significativos en esas tasas.

Conclusiones.

La implementación del programa ERA contribuyó a reducir las tasas de mortalidad por NAC en personas de 65 años o más en Chile, no así la incorporación de la NAC al GES.

Why is the rate of pneumococcal pneumonia declining?

PURPOSE OF REVIEW

As Streptococcus pneumoniae was considered the etiological agent of nearly all the cases of pneumonia at the beginning of the 20th century, and today is identified in fewer than 10-15% of cases, we analyze the possible causes of such a decline.

RECENT FINDINGS

Extensive use of early empiric antimicrobial therapy, discovery of previously unrecognized pathogens, availability to newer diagnostic methods for the recognition of the pneumonia pathogens (PCR, urinary antigens, monoclonal antibodies etc.) and of improved preventive measures, including vaccines, are some of possible explanations of the declining role of S. pneumoniae in the cause of pneumonia.

SUMMARY

The 14-valent and the 23-valent capsular polysaccharide pneumococcal vaccines were licensed in 1977 and 1983, respectively. The seven-valent protein-conjugated capsular polysaccharide vaccine, approved for routine use in children starting at 2 months of age, was highly effective in preventing invasive pneumococcal disease in children but also in adults because of the herd effect. In 2010, the 13-valent protein-conjugated capsular polysaccharide vaccine replaced seven-valent protein-conjugated capsular polysaccharide vaccine. With the use of conjugated vaccines, a decrease of the vaccine-type invasive pneumococcal disease for all age groups was observed. Both the direct effect of the vaccine and the so-called herd immunity are considered responsible for much of the decline.

Disease Risk and Mortality Prediction in Intensive Care Patients with Pneumonia. Australian and New Zealand Practice in Intensive Care (ANZPIC II)

This study of ventilated patients investigated pneumonia risk factors and outcome predictors in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units within Australia and New Zealand. For community acquired pneumonia, mortality increased with immunosuppression (OR 5.32, CI 95% 1.58–17.99, P<0.01), clinical signs of consolidation (OR 2.43, CI 95% 1.09–5.44, P=0.03) and Sepsis-Related Organ Failure Assessment (SOFA) scores (OR 1.19, CI 95% 1.08–1.30, P<0.001) but improved if appropriate antibiotic changes were made within three days of intensive care unit admission (OR 0.42, CI 95% 0.20–0.86, P=0.02). For hospital-acquired pneumonia, immunosuppression (OR 6.98, CI 95% 1.16–42.2, P=0.03) and non-metastatic cancer (OR 3.78, CI 95% 1.20–11.93, P=0.02) were the principal mortality predictors. Alcoholism (OR 7.80, CI 95% 1.20–17.50, P<0.001), high SOFA scores (OR 1.44, CI 95% 1.20–1.75, P=0.001) and the isolation of “high risk” organisms including Pseudomonas aeruginosa, Acinetobacter spp, Stenotrophomonas spp and methicillin resistant Staphylococcus aureus (OR 4.79, CI 95% 1.43–16.03, P=0.01), were associated with increased mortality in ventilator-associated pneumonia. The use of non-invasive ventilation was independently protective against mortality for patients with community-acquired and hospital-acquired pneumonia (OR 0.35, CI 95% 0.18–0.68, P=0.002). Mortality was similar for patients requiring both invasive and non-invasive ventilation and non-invasive ventilation alone (21% compared with 20% respectively, P=0.56).

Pneumonia risks and mortality predictors in Australian and New Zealand ICUs vary with pneumonia type. A history of alcoholism is a major risk factor for mortality in ventilator-associated pneumonia, greater in magnitude than the mortality effect of immunosuppression in hospital-acquired pneumonia or community-acquired pneumonia. Non-invasive ventilation is associated with reduced ICU mortality. Clinical signs of consolidation worsen, while rationalising antibiotic therapy within three days of ICU admission improves mortality for community-acquired pneumonia patients.

Community-Acquired Pneumonia

Community-acquired pneumonia is one of the most common infections seen in emergency department patients. There is a wide spectrum of disease severity and viral pathogens are common. After a careful history and physical examination, chest radiographs may be the only diagnostic test required. The first step in management is risk stratification, using a validated clinical decision rule and serum lactate, followed by early antibiotics and fluid resuscitation when indicated. Antibiotics should be selected with attention to risk factors for multidrug-resistant respiratory pathogens. Broad use of pneumococcal vaccine in adults and children can prevent severe community-acquired pneumonia.

Validity of SMART-COP score in prognosis and severity of community acquired pneumonia in the emergency department

BACKGROUND

Determining prognosis in community acquired pneumonia (CAP), is very important. Many scores are introduced up to now for prediction of pneumonia prognosis like SMART-COP.

OBJECTIVE

To evaluate validity of SMART-COP score in prognosis and severity of CAP in emergency department (ED).

METHODS

All patients older than 18 years old with clinical suspicion of CAP (meeting the inclusion criteria), were enrolled in our study. In this prospective study, patients were admitted to the ED of a tertiary referral center. Hospital length of stay, rate of intensive care unit (ICU) admission, mortality rate, number of intensive respiratory or vasopressor support (IRVS) use, patients' SMART-COP scores and all demographic data were recorded. Validity of SMART-COP in the prediction of IRVS rate and its correlation with other variables were determined.

RESULTS

In this study, 47.6% and 52.4% of patients were females and males respectively. The mean age of patients was 68.13 ± 16.60 years old. The mean hospital length of stay was 13.49 ± 5.62 days. Of all patients entered in our study, 55 cases (38.5%) needed ICU admission, 29 cases (20.3%) were expired within 1 month and 44 cases (30.8%) needed IRVS during their treatment. SMART-COP ≥5 (high risk CAP) accurately predicted the rate of ICU admission, one-month mortality and IRVS need (p-value = 0.001).

CONCLUSIONS

SMART-COP≥5 had a high sensitivity and specificity in the prediction of patients' prognosis with severe CAP in the ED.

Twenty-year trend in mortality among hospitalized patients with pneumococcal community-acquired pneumonia

BACKGROUND

There is only limited information on mortality over extended periods in hospitalized patients with pneumococcal community-acquired pneumonia (CAP). We aimed to evaluate the 30-day mortality and whether is changed over a 20-year period among immunocompetent adults hospitalized with pneumococcal CAP.

METHODS

We conducted a retrospective observational study of data that were prospectively collected at the Hospital Clinic of Barcelona of all adult patients hospitalized with diagnosis of pneumococcal CAP over a 20-year period. To aid analysis, results were divided into four periods of 5 years each (1997-2001, 2002-2006, 2007-2011, 2012-2016). The primary outcome was 30-day mortality, but secondary outcomes included intensive care unit (ICU) admission, lengths of hospital and ICU-stays, ICU-mortality, and need of mechanical ventilation.

RESULTS

From a cohort of 6,403 patients with CAP, we analyzed the data for 1,120 (17%) adults with a diagnosis of pneumococcal CAP. Over time, we observed decreases in the rates of alcohol consumption, smoking, influenza vaccination, and older patients (age ≥65 years), but increases in admissions to ICU and the need for non-invasive mechanical ventilation. The overall 30-day mortality rate was 8% (95% confidence interval, 6%-9%; 84 of 1,120 patients) and did not change significantly between periods (p = 0.33). Although, we observed a decrease in ICU-mortality comparing the first period (26%) to the second one (10%), statistical differences disappeared with adjustment (p0.38).

CONCLUSION

Over time, 30-day mortality of hospitalized pneumococcal CAP did not change significantly. Nor did it change in the propensity-adjusted multivariable analysis. Since mortality in pneumococcal pneumonia has remained unaltered for many years despite the availability of antimicrobial agents with proven in vitro activity, other non-antibiotic strategies should be investigated.

Early identification of patients at risk for acute respiratory distress syndrome among severe pneumonia: a retrospective cohort study

Background

Severe pneumonia is the predominant cause for acute respiratory distress syndrome (ARDS). Identification of ARDS from patients with severe pneumonia remains a significant clinical problem due to the overlap of clinical presentations and symptoms. Early recognition of risks for ARDS from severe pneumonia is of great clinical value.

Methods

From April 2014 to December 2015, patients with severe pneumonia at admission were retrieved from the hospital database, of which ARDS developed within 7 days were further identified. We compared the demographic and clinical characteristics at admission between severe pneumonia patients with and without ARDS development, followed by analysis of potential predictors for ARDS development and mortality. Multivariate logistic regression and receiver operating characteristic (ROC) curves were performed to screen independent risk factors and identify their sensitivity in predicting ARDS development and prognosis.

Results

Compared with severe pneumonia without ARDS development, patients with ARDS development had shorter disease duration before admission, higher lung injury score (LIS), serum fibrinogen (FiB), and positive end-expiratory pressure (PEEP), lower Marshall score, sequential organ failure assessment score and proportion of cardiovascular and gastrointestinal diseases, but similar mortality. Serum FiB >5.15 g/L [adjusted odds ratio (OR) 1.893, 95% confidence interval (CI): 1.141-3.142, P=0.014] and PEEP >6.5 cmH₂O (adjusted OR 1.651, 95% CI: 1.218-2.237, P=0.001) were independent predictors for ARDS development with a sensitivity of 58.3% and 87.5%, respectively, and pH <7.35 (adjusted OR 0.832, 95% CI: 0.702-0.985, P=0.033) was an independent risk factor for ARDS mortality with a sensitivity of 95.2%.

Conclusions

ARDS development risk could be early recognized by PEEP >6.5 cmH₂O and serum FiB >5.15 g/L in severe pneumonia patients, and pH <7.35 is a reliable prognostic factor in predicting ARDS mortality risk.

Diagnostic value of bronchoalveolar lavage in children with nonresponding community-acquired pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality in hospitalized children. In CAP, causative agents are seldom identified using noninvasive diagnostic procedures. For those children not responding to empiric antibiotic therapy, it is vital to identify the causative pathogens for further management.

METHODS

We aimed to determine the usefulness of identifying the causative agents by bronchoalveolar lavage (BAL) in hospitalized children with nonresponding CAP. Ninety children hospitalized for CAP and treated with empiric antibiotics but having persistent fever ≥48 hours were enrolled, and their BAL data were retrospectively reviewed.

RESULTS

Aerobic bacteria were isolated from 38 (42%) of 90 cultures, and anaerobic bacteria were isolated from eight (24%) of 33 cultures. The bacteria isolated most frequently were Streptococcus viridians (26.3%), Pseudomonas aeruginosa (23.7%), and Staphylococcus aureus (15.8%). Streptococcus pneumoniae was isolated from the BALs of only two children, and Haemophilus influenzae from none. For positive aerobic culture results, BAL results guided modifications of antibiotic regimens in 21 episodes (21 of 38, 55.3%).

CONCLUSION

BAL results guided a change of antimicrobials in 55% of children with positive aerobic cultures (29% of all children in the study) and contributed to a high rate of successful therapy.

Patterns of C-reactive protein ratio predicts outcomes in healthcare-associated pneumonia in critically ill patients with cancer

PURPOSE

Describe the patterns of C-reactive protein relative changes in response to antibiotic therapy in critically ill cancer patients with healthcare-associated pneumonia (HCAP) and its ability to predict outcome.

METHODS

Secondary analysis of a prospective cohort of critically ill cancer patients with HCAP. CRP was sampled every other day from D0 to D6 of antibiotic therapy. Patients were classified according to an individual pattern of CRP-ratio response: fast - CRP at D4 of therapy was <0.4 of D0 CRP; slow - a continuous but slow decrease of CRP; non - CRP remained ≥0.8 of D0 CRP; biphasic - initial CRP decrease to levels <0.8 of the D0 CRP followed by a secondary rise ≥0.8.

RESULTS

129 patients were included and septic shock was present in 74% and invasive mechanical ventilation was used in 73%. Intensive care unit (ICU) and hospital mortality rates were 47% and 64%, respectively. By D4, both CRP and CRP-ratio of survivors were significantly lower than in nonsurvivors (p<0.001 and p=0.004, respectively). Both time-dependent analysis of CRP-ratio of the four previously defined patterns (p<0.001) as ICU mortality were consistently different [fast 12.9%, slow 43.2%, biphasic 66.7% and non 71.8% (p<0.001)].

CONCLUSION

CRP-ratio was useful in the early prediction of poor outcomes in cancer patients with HCAP.

Disease burden of community acquired pneumonia among children under 5 y old in China: A population based survey

BACKGROUND

To obtain the baseline data on the incidence and cost of community acquired pneumonia among under-5 children for future studies, and provide evidence for shaping China's strategies regarding pneumococcal conjugate vaccine (PCV).

METHODS

Three townships from Heilongjiang, Hebei and Gansu Province and one community in Shanghai were selected as study areas. A questionnaire survey was conducted to collect data on incidence and cost of pneumonia among children under 5 y old in 2012.

RESULTS

The overall incidence of clinically diagnosed pneumonia in children under 5 y old was 2.55%. The incidence in urban area was 7.97%, higher than that in rural areas (1.68%). However, no difference was found in the incidences of chest X-ray confirmed pneumonia between urban and rural areas (1.67% vs 1.23%). X-ray confirmed cases in rural and urban areas respectively accounted for 73.45% and 20.93% of all clinically diagnosed pneumonia. The hospitalization rate of all cases was 1.40%. Incidence and hospitalization rate of pneumonia decreased with age, with the highest rates found among children younger than one year and the lowest among children aged 4 (incidence: 4.25% vs 0.83%; hospitalization: 2.75% vs 0.36%). The incidence was slightly higher among boys (2.92% vs 2.08%). The total cost due to pneumonia for the participants was 1138 733 CNY. The average cost and median cost was 5722 CNY and 3540 CNY separately. Multivariate analysis showed that the only factor related to higher cost was hospitalization.

CONCLUSIONS

The disease burden was high for children under 5 y old, especially the infant. PCV has not been widely used among children, and thus further health economics evaluation on introducing PCV into National Immunization Program should be conducted.

Emergency Physician to Admitting Physician Handovers: An Exploratory Study

Current emphasis on the number of deaths due to medical errors has pushed the patient safety issue to the forefront at many medical institutions. The Institute of Medicine's recommendation for improved coordination and collaboration between physicians, as well as the paucity of related literature, has led the authors to explore the nature of the handover between emergency department and admitting physicians.

Research was conducted at two Ohio hospitals to document the phases and issues found in emergency department (ED) handovers. The phases for ED handovers were similar to those found in shift changes in other types of industries (e.g., paper mill, air traffic control) with minor variations in the order of the phases. Three areas were identified where potential errors could occur including the spoken communication between physicians, selection of diagnostic tests based on the specific admitting physician, and the use of surrogates by the admitting physician. Physicians identified the level of trust in ED resident physicians, incomplete handovers between ED physicians at their shift change, differences in exams and treatment plans based on admitting physician, and notification of possible admission prior to receiving results for exams as potential problem areas.

The findings of this research illustrate the need for future research into physician communication. These studies have tremendous opportunity to enable the Institute of Medicine's goal of improving communication between physicians for better patient care and outcomes.

Shoot, Ready, Aim: Pneumonia Care Quality and Costs in a Community Hospital

Mandatory community-acquired pneumonia (CAP) protocol usage was proposed in our community-based teaching hospital because of senior medical staff perceptions that excessive variation in CAP care was adversely affecting clinical outcomes and costs. The purpose of our study was to examine CAP process of care variation, outcomes, and costs to ascertain whether the mandatory CAP protocol could be justified. The study consisted of an analysis of administrative and sampled chart data. We looked at pneumonia severity, orders for blood cultures or sputum staining, antibiotic usage, symptom resolution, length of stay, discharge status, readmission risk by follow-up time, and financial data. We found that process of care variation was low, clinical outcomes were generally good, and CAP care was profitable. Our data suggested that the proposed mandatory CAP protocol was not necessary. Our experience supports the management principle that fact finding should usually precede decision making, not the reverse.

Overcoming Barriers to Pneumococcal Vaccination in Patients With Pneumonia

Inpatient pneumococcal vaccination remains underutilized, and little data exist to guide hospital personnel in improving their performance. The authors report their experience with a stepwise program to improve vaccination assessment rates for hospitalized patients with community-acquired pneumonia. They assessed barriers to vaccination and applied a stepwise educational and intranet-based decision support implementation program for hospitalized patients with community-acquired pneumonia. Preintervention vaccination rates were 0%. Primary nursing and physician barriers were assessed. An educational intervention increased vaccination assessment rates to 35%, a nursing decision-support tool to 42%, and approval of a standing order policy to 96%. For patients older than 65 years, vaccination assessment rates increased 33%, 67%, and 100%, respectively. An educational program combined with a decision support tool and a standing order policy can improve vaccination assessment rates to high levels. This study suggests that a multidimensional intervention is required to improve compliance with inpatient vaccination best clinical practices.

Severe community-acquired pneumonia: timely management measures in the first 24 hours

Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.

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.

Pneumonia after Major Cancer Surgery: Temporal Trends and Patterns of Care

Rationale. Pneumonia is a leading cause of postoperative complication. Objective. To examine trends, factors, and mortality of postoperative pneumonia following major cancer surgery (MCS). Methods. From 1999 to 2009, patients undergoing major forms of MCS were identified using the Nationwide Inpatient Sample (NIS), a Healthcare Cost and Utilization Project (HCUP) subset, resulting in weighted 2,508,916 patients. Measurements. Determinants were examined using logistic regression analysis adjusted for clustering using generalized estimating equations. Results. From 1999 to 2009, 87,867 patients experienced pneumonia following MCS and prevalence increased by 29.7%. The estimated annual percent change (EAPC) of mortality after MCS was −2.4% (95% CI: −2.9 to −2.0, P < 0.001); the EAPC of mortality associated with pneumonia after MCS was −2.2% (95% CI: −3.6 to 0.9, P = 0.01). Characteristics associated with higher odds of pneumonia included older age, male, comorbidities, nonprivate insurance, lower income, hospital volume, urban, Northeast region, and nonteaching status. Pneumonia conferred a 6.3-fold higher odd of mortality. Conclusions. Increasing prevalence of pneumonia after MCS, associated with stable mortality rates, may result from either increased diagnosis or more stringent coding. We identified characteristics associated with pneumonia after MCS which could help identify at-risk patients in order to reduce pneumonia after MCS, as it greatly increases the odds of mortality.

Dysphagia, dystussia, and aspiration pneumonia in elderly people

Despite the development and wide distribution of guidelines for pneumonia, death from pneumonia is increasing due to population aging. Conventionally, aspiration pneumonia was mainly thought to be one of the infectious diseases. However, we have proven that chronic repeated aspiration of a small amount of sterile material can cause the usual type of aspiration pneumonia in mouse lung. Moreover, chronic repeated aspiration of small amounts induced chronic inflammation in both frail elderly people and mouse lung. These observations suggest the need for a paradigm shift of the treatment for pneumonia in the elderly. Since aspiration pneumonia is fundamentally based on dysphagia, we should shift the therapy for aspiration pneumonia from pathogen-oriented therapy to function-oriented therapy. Function-oriented therapy in aspiration pneumonia means therapy focusing on slowing or reversing the functional decline that occurs as part of the aging process, such as "dementia → dysphagia → dystussia → atussia → silent aspiration". Atussia is ultimate dysfunction of cough physiology, and aspiration with atussia is called silent aspiration, which leads to the development of life-threatening aspiration pneumonia. Research pursuing effective strategies to restore function in the elderly is warranted in order to decrease pneumonia deaths in elderly people.

Age-dependent differences in microglial responses to systemic inflammation are evident as early as middle age

Whereas age increases microglial inflammatory activities and impairs their ability to effectively regulate their immune response, it is unclear at what age these exaggerated responses begin. We tested the hypotheses that augmented microglial responses to inflammatory challenge are present as early as middle age and that repeated stimulation of primed microglia in vivo would reveal microglial senescence. Microglial gene expression was investigated in a mouse model of repeated systemic inflammation induced by intraperitoneal injection of bacterial lipopolysaccharide (LPS). Following LPS, microglia from middle-aged mice (9-10 mo) displayed larger increases in Tnfα, Il-6, and Il-1β gene expression compared with young adults (2 mo). Similar results were observed in the spleens of middle-aged mice, indicating that exaggeration of both central and peripheral immune responses are already evident at early middle age. Interestingly, despite greater proinflammatory responses to the first LPS challenge in the aged mice, there were no age-dependent differences in either microglia or spleen following a subsequent LPS dose, suggesting that animals at this age retain the ability to effectively control their immune response following repeated challenge. The exacerbated microglial immune response to systemic inflammation at early middle age suggests that the CNS may be vulnerable to age-dependent alterations earlier than previously appreciated.

Sustainability of professionals' adherence to clinical practice guidelines in medical care: a systematic review

OBJECTIVES

To evaluate (1) the state of the art in sustainability research and (2) the outcomes of professionals' adherence to guideline recommendations in medical practice.

DESIGN

Systematic review.

DATA SOURCES

Searches were conducted until August 2015 in MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and the Guidelines International Network (GIN) library. A snowball strategy, in which reference sections of other reviews and of included papers were searched, was used to identify additional papers.

ELIGIBILITY CRITERIA

Studies needed to be focused on sustainability and on professionals' adherence to clinical practice guidelines in medical care. Studies had to include at least 2 measurements: 1 before (PRE) or immediately after implementation (EARLY POST) and 1 measurement longer than 1 year after active implementation (LATE POST).

RESULTS

The search retrieved 4219 items, of which 14 studies met the inclusion criteria, involving 18 sustainability evaluations. The mean timeframe between the end of active implementation and the sustainability evaluation was 2.6 years (minimum 1.5-maximum 7.0). The studies were heterogeneous with respect to their methodology. Sustainability was considered to be successful if performance in terms of professionals' adherence was fully maintained in the late postimplementation phase. Long-term sustainability of professionals' adherence was reported in 7 out of 18 evaluations, adherence was not sustained in 6 evaluations, 4 evaluations showed mixed sustainability results and in 1 evaluation it was unclear whether the professional adherence was sustained.

CONCLUSIONS

(2) Professionals' adherence to a clinical practice guideline in medical care decreased after more than 1 year after implementation in about half of the cases. (1) Owing to the limited number of studies, the absence of a uniform definition, the high risk of bias, and the mixed results of studies, no firm conclusion about the sustainability of professionals' adherence to guidelines in medical practice can be drawn.

Management of community-acquired pneumonia in an Australian regional hospital

OBJECTIVE

Current management of hospitalised patients with community-acquired pneumonia (CAP) in an Australian regional hospital in accordance with the recommended guidelines is unknown. The prescription rate of inappropriate antibiotic therapy was measured and analysed.

DESIGN

A retrospective audit, December 2012 to November 2013.

SETTING

Regional Australian hospital in North East Victoria.

INTERVENTIONS

Interventions were the average of inpatient and intensive care unit length of stay, time to first antibiotic and to first chest X-ray, days of intravenous antibiotics, and extra intravenous therapy; proportion of intensive care unit admissions, average time to first antibiotic administration, patients with failed outpatient management of CAP, initial microbiological investigations, positive investigations, predominant microbiology, antibiotic choice, and concordance with guidelines; proportion of justifiable deviation from guidelines, ratio of patients switched to oral therapy appropriately, complications during therapy, clinical failure, inpatient mortality, mortality at 30 days, mortality at 6 months, and readmission with CAP in 30 days and in 3 months.

MAIN OUTCOME MEASURES

To improve the rates of concordance with guidelines by following a specified method to rate severity of CAP, to clearly document reasons for non-concordance with guidelines, and to rationalise investigations.

RESULTS

To improve antibiotic stewardship in the management of CAP.

CONCLUSION

In an Australian regional hospital, ceftriaxone and azithromycin were the predominant combination used at 56%, demonstrating that mild CAP was frequently overtreated. Mild CAP was eight times more likely to be treated as severe CAP (odds ratio = 8.2 (95% confidence interval, 1.7-40.3) P < 0.009). There is a need for a simple yet effective strategy to be introduced to rationalise treatment and investigation of CAP in this setting.

No Resistance to Penicillin, Cefuroxime, Cefotaxime, or Vancomycin in Pneumococcal Pneumonia

OBJECTIVES

Group B Streptococcus is a primary source of pneumonia, which is a leading cause of death worldwide. During the last few decades, there has been news of growing antibiotic resistance in group B streptococci to penicillin and different antibiotic agents. This clinical study retrospectively analyzes antimicrobial resistance in inpatients who were diagnosed with group B streptococcal pneumonia.

METHODS

All of the required information from inpatients who were identified to have group B streptococcal pneumonia was sourced from the database at the Department of Internal Medicine of HELIOS Clinic Wuppertal, Witten/Herdecke University, in Germany, from 2004-2014. Antimicrobial susceptibility testing was performed for the different antimicrobial agents that were regularly administered to these inpatients.

RESULTS

Sixty-six inpatients with a mean age of 63.3 ± 16.1 years (45 males [68.2%, 95% CI 60.0%-79.4%] and 21 females [31.8%, 95% CI 20.6%-43.0%]) were detected to have group B streptococcal pneumonia within the study period from January 1, 2004, to August 12, 2014. Group B Streptococcus had a high resistance rate to gentamicin (12.1%), erythromycin (12.1%), clindamycin (9.1%), and co-trimoxazole (3.0%), but it was not resistant to penicillin, cefuroxime, cefotaxime, or vancomycin (P < 0.0001).

CONCLUSION

No resistance to penicillin, cefuroxime, cefotaxime, or vancomycin was detected among inpatients with pneumonia caused by group B streptococci.

Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis

BACKGROUND

Community-acquired pneumonia (CAP) is common and often severe.

PURPOSE

To examine the effect of adjunctive corticosteroid therapy on mortality, morbidity, and duration of hospitalization in patients with CAP.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through 24 May 2015.

STUDY SELECTION

Randomized trials of systemic corticosteroids in hospitalized adults with CAP.

DATA EXTRACTION

Two reviewers independently extracted study data and assessed risk of bias. Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation system by consensus among the authors.

DATA SYNTHESIS

The median age was typically in the 60s, and approximately 60% of patients were male. Adjunctive corticosteroids were associated with possible reductions in all-cause mortality (12 trials; 1974 patients; risk ratio [RR], 0.67 [95% CI, 0.45 to 1.01]; risk difference [RD], 2.8%; moderate certainty), need for mechanical ventilation (5 trials; 1060 patients; RR, 0.45 [CI, 0.26 to 0.79]; RD, 5.0%; moderate certainty), and the acute respiratory distress syndrome (4 trials; 945 patients; RR, 0.24 [CI, 0.10 to 0.56]; RD, 6.2%; moderate certainty). They also decreased time to clinical stability (5 trials; 1180 patients; mean difference, -1.22 days [CI, -2.08 to -0.35 days]; high certainty) and duration of hospitalization (6 trials; 1499 patients; mean difference, -1.00 day [CI, -1.79 to -0.21 days]; high certainty). Adjunctive corticosteroids increased frequency of hyperglycemia requiring treatment (6 trials; 1534 patients; RR, 1.49 [CI, 1.01 to 2.19]; RD, 3.5%; high certainty) but did not increase frequency of gastrointestinal hemorrhage.

LIMITATIONS

There were few events and trials for many outcomes. Trials often excluded patients at high risk for adverse events.

CONCLUSION

For hospitalized adults with CAP, systemic corticosteroid therapy may reduce mortality by approximately 3%, need for mechanical ventilation by approximately 5%, and hospital stay by approximately 1 day.

PRIMARY FUNDING SOURCE

None.