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Wakabayashi T, Hamaguchi S, Morimoto K. Clinically defined aspiration pneumonia is an independent risk factor associated with long-term hospital stay: a prospective cohort study. BMC Pulm Med 2023; 23:351. [PMID: 37718411 PMCID: PMC10506309 DOI: 10.1186/s12890-023-02641-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 09/07/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Long-term hospital stay is associated with functional decline in patients with pneumonia, especially in the elderly. Among elderly patients with pneumonia, aspiration pneumonia is a major category. Clinical definition is usually used because it can occur without apparent aspiration episodes. It is still not clear whether a long-term hospital stay is due to aspiration pneumonia itself caused by underlying oropharyngeal dysfunction or simply due to functional decline in elderly patients with multiple comorbidities during acute infection. The aim of this study is to identify whether clinically defined aspiration pneumonia itself was associated with a long-term hospital stay. METHODS A prospective observational study on community-acquired (CAP) or healthcare-associated pneumonia (HCAP) was conducted from January 2012 through January 2014. Aspiration pneumonia was clinically defined as pneumonia not only occurring in patients after documented aspiration episodes, but also occurring in those with underlying oropharyngeal dysfunction: chronic disturbances of consciousness and/or chronic neuromuscular diseases. We defined thirty-day hospital stay as a long-term hospital stay and compared it with logistic regression analysis. Potential confounders included age, sex, HCAP, body mass index (BMI), long-term bed-ridden state, heart failure, cerebrovascular disorders, dementia, antipsychotics use, hypnotics use, and CURB score which is a clinical prediction tool used to assess the severity, standing for; C (presence of Confusion), U (high blood Urea nitrogen level), R (high Respiratory rate), and B (low Blood pressure). In a sub-analysis, we also explored factors associated with long-term hospital stay in patients with aspiration pneumonia. RESULTS Of 2,795 patients, 878 (31.4%) had aspiration pneumonia. After adjusting potential confounders, the aspiration pneumonia itself was significantly associated with long-term hospital stay (adjusted odds ratio 1.44; 95% confidence interval 1.09-1.89, p < 0.01), as were higher age, male sex, high CURB score, HCAP, low BMI, heart failure, cerebrovascular disease, and antipsychotics use. Sub-analysis revealed factors associated with long-term hospital stay in the aspiration pneumonia, which included male sex, and multi-lobar chest X-ray involvement. CONCLUSIONS Clinically defined aspiration pneumonia itself was independently associated with long-term hospital stay. This result could potentially lead to specific rehabilitation strategies for pneumonia patients with underlying oropharyngeal dysfunction.
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Affiliation(s)
- Takao Wakabayashi
- Department of General and Emergency Medicine, Japan Community Healthcare Organization Sapporo Hokushin Hospital, 2-1,2-Jo,6-Chome, Atsubetsu-Cho, Atsubetsu-Ku, Sapporo, 004-8618, Japan
- Department of General Internal Medicine, Ebetsu City Hospital, Hokkaido, Japan
| | - Sugihiro Hamaguchi
- Department of General Internal Medicine, Ebetsu City Hospital, Hokkaido, Japan.
- Department of General Internal Medicine, Fukushima Medical University, 1, Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Konosuke Morimoto
- Department of Respiratory Infections, Institute of Tropical Medicine, Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
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In-hospital mortality for aspiration pneumonia in a tertiary teaching hospital: A retrospective cohort review from 2008 to 2018. J Otolaryngol Head Neck Surg 2023; 52:23. [PMID: 36879258 PMCID: PMC9990357 DOI: 10.1186/s40463-022-00617-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 12/23/2022] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Aspiration pneumonia is a preventable condition that has higher rates of recurrence and mortality compared to non-aspiration pneumonia. The primary objective of the study was to examine independent patient factors that are associated with mortality in those requiring acute admission for aspiration pneumonia at a tertiary institution. Secondary goals of the study were to review whether factors such as mechanical ventilation and speech language pathology intervention can impact patient mortality, length of stay (LOS), and costs relating to hospitalization. METHODS Patients older than 18 years of age who were admitted with a primary diagnosis of aspiration pneumonia from January 1, 2008 to December 31, 2018 at Unity Health Toronto-St. Michael's hospital in Toronto, Canada, were included in the study. Descriptive analyses were performed on patient characteristics using age as a continuous variable as well as a dichotomous variable with age 65 as a cut-off. Multivariable logistic regression was used to identify independent factors that contributed to in-hospital mortality and Cox proportional-hazard regression was used to identify independent factors that affected LOS. RESULTS A total of 634 patients were included in this study. 134 (21.1%) patients died during hospitalization with an average age of 80.3 ± 13.4. The in-hospital mortality did not change significantly over the ten-year period (p = 0.718). Patients who died had longer LOS with a median length of 10.5 days (p = 0.012). Age [Odds Ratio (OR) 1.72, 95% Confidence Interval (95% CI) 1.47-2.02, p < 0.05] and invasive mechanical ventilation (OR 2.57, 95% CI 1.54-4.31, p < 0.05) were independent predictors of mortality while female gender was found to be a protective factor (OR 0.60, 95% CI 0.38-0.92, p = 0.02). Elderly patients had five times higher risk of dying during their hospital course when compared to younger patients [Hazard Ratio (HR) 5.25, 95% CI 2.99-9.23, p < 0.05). CONCLUSION Elderly patients are a high-risk population for developing aspiration pneumonia and are at higher risk of death when hospitalized for this condition. This warrants improved preventative strategies in the community. Further studies involving other institutions and creating a Canada-wide database are required.
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Oh TK, Kim HG, Song IA. Epidemiologic Study of Intensive Care Unit Admission in South Korea: A Nationwide Population-Based Cohort Study from 2010 to 2019. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:81. [PMID: 36612396 PMCID: PMC9819529 DOI: 10.3390/ijerph20010081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 06/17/2023]
Abstract
We aimed to investigate the trends of intensive care unit (ICU) admissions in South Korea from 2010 to 2019. We included all adult patients (≥20 years old) who were admitted to the ICU during hospitalization from 2010 to 2019 in South Korea. There were 3,517,423 ICU admissions of 2,461,848 adult patients. Of the ICU admission cases, 66.8% (2,347,976/3,517,423) were surgery-associated admissions, and the rate of in-hospital mortality after ICU admission was 12.0% (422,155 patients). The most common diagnoses were diseases of the circulatory system (36.8%) and pneumonia (4%). The 30-day, 90-day, and 1-year mortality rates were 16.0%, 23.6%, and 33.3% in 2010, and these values slightly decreased by 2019 to 14.7%, 22.1%, and 31.7%, respectively. The proportions of continuous renal replacement therapy (CRRT) use and extracorporeal membrane oxygenation (ECMO) support were 2.0% and 0.3% in 2010, and these values gradually increased by 2019 to 4.7% and 0.8%, respectively. Although the age and cost of hospitalization among critically ill patients who were admitted to the ICU increased from 2010 to 2019, the mortality rate decreased slightly. Moreover, the proportions of ECMO support and CRRT use had increased in our South Korean cohort.
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Affiliation(s)
- Tak-Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul 04551, Republic of Korea
| | - Hyeong-Geun Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul 04551, Republic of Korea
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Impact on antimicrobial consumption of procalcitonin-guided antibiotic therapy for pneumonia/pneumonitis associated with aspiration in comatose mechanically ventilated patients: a multicenter, randomized controlled study. Ann Intensive Care 2021; 11:145. [PMID: 34636974 PMCID: PMC8505789 DOI: 10.1186/s13613-021-00931-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 09/21/2021] [Indexed: 12/24/2022] Open
Abstract
Background In comatose patients receiving oro-tracheal intubation for mechanical ventilation (MV), the risk of aspiration is increased. Aspiration can lead to chemical pneumonitis (inflammatory reaction to the gastric contents), or aspiration pneumonia (infection caused by inhalation of microorganisms). Distinguishing between the two types is challenging. We tested the interest of using a decisional algorithm based on procalcitonin (PCT) values to guide initiation and discontinuation of antibiotic therapies in intubated patients. Methods The PROPASPI (PROcalcitonin Pneumonia/pneumonitis Associated with ASPIration) trial is a multicenter, prospective, randomized, controlled, single-blind, superiority study comparing two strategies: (1) an intervention group where threshold PCT values were used to guide initiation and discontinuation of antibiotics (PCT group); and (2) a control group, where antibiotic therapy was managed at the physician’s discretion. Patients aged 18 years or over, intubated for coma (Glasgow score ≤ 8), with MV initiated within 48 h after admission, were eligible. The primary endpoint was the duration of antibiotic treatment during the first 15 days after admission to the ICU. Results From 24/2/2015 to 28/8/2019, 1712 patients were intubated for coma in the 5 participating centers, of whom 166 were included in the study. Data from 159 were available for intention-to-treat analysis: 81 in the PCT group, and 78 in the control group. Overall, 67 patients (43%) received antibiotics in the intensive care unit (ICU); there was no significant difference between groups (37 (46%) vs 30 (40%) for PCT vs control, p = 0.432). The mean duration of antibiotic treatment during the first 15 days in the ICU was 2.7 ± 3.8 days; there was no significant difference between groups (3.0 ± 4.1 days vs 2.3 ± 3.4 days for PCT vs control, p = 0.311). The mean number of days under MV was significantly higher in the PCT group (3.7 ± 3.6 days) than in controls (2.7 ± 2.5 days, p = 0.033). The duration of ICU stay was also significantly longer in the PCT group: 6.4 ± 6.5 days vs 4.6 ± 3.5 days in the control group (p = 0.043). After adjustment for SAPS II score, the difference in length of stay and duration of mechanical ventilation between groups was no longer significant. Conclusion The use of PCT values to guide therapy, in comparison to the use of clinical, biological (apart from PCT) and radiological criteria, does not modify exposure to antibiotics in patients intubated for coma. Trial registration Clinicaltrials.gov Identifier NCT02862314. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00931-4.
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Ewig S, Kolditz M, Pletz M, Altiner A, Albrich W, Drömann D, Flick H, Gatermann S, Krüger S, Nehls W, Panning M, Rademacher J, Rohde G, Rupp J, Schaaf B, Heppner HJ, Krause R, Ott S, Welte T, Witzenrath M. [Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. Pneumologie 2021; 75:665-729. [PMID: 34198346 DOI: 10.1055/a-1497-0693] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta-Kranken-Anstalt Bochum
| | - M Kolditz
- Universitätsklinikum Carl-Gustav Carus, Klinik für Innere Medizin 1, Bereich Pneumologie, Dresden
| | - M Pletz
- Universitätsklinikum Jena, Institut für Infektionsmedizin und Krankenhaushygiene, Jena
| | - A Altiner
- Universitätsmedizin Rostock, Institut für Allgemeinmedizin, Rostock
| | - W Albrich
- Kantonsspital St. Gallen, Klinik für Infektiologie/Spitalhygiene
| | - D Drömann
- Universitätsklinikum Schleswig-Holstein, Medizinische Klinik III - Pulmologie, Lübeck
| | - H Flick
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Lungenkrankheiten, Graz
| | - S Gatermann
- Ruhr Universität Bochum, Abteilung für Medizinische Mikrobiologie, Bochum
| | - S Krüger
- Kaiserswerther Diakonie, Florence Nightingale Krankenhaus, Klinik für Pneumologie, Kardiologie und internistische Intensivmedizin, Düsseldorf
| | - W Nehls
- Helios Klinikum Erich von Behring, Klinik für Palliativmedizin und Geriatrie, Berlin
| | - M Panning
- Universitätsklinikum Freiburg, Department für Medizinische Mikrobiologie und Hygiene, Freiburg
| | - J Rademacher
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - G Rohde
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Pneumologie und Allergologie, Frankfurt/Main
| | - J Rupp
- Universitätsklinikum Schleswig-Holstein, Klinik für Infektiologie und Mikrobiologie, Lübeck
| | - B Schaaf
- Klinikum Dortmund, Klinik für Pneumologie, Infektiologie und internistische Intensivmedizin, Dortmund
| | - H-J Heppner
- Lehrstuhl Geriatrie Universität Witten/Herdecke, Helios Klinikum Schwelm, Klinik für Geriatrie, Schwelm
| | - R Krause
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Infektiologie, Graz
| | - S Ott
- St. Claraspital Basel, Pneumologie, Basel, und Universitätsklinik für Pneumologie, Universitätsspital Bern (Inselspital) und Universität Bern
| | - T Welte
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - M Witzenrath
- Charité, Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie, Berlin
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Marin-Corral J, Pascual-Guardia S, Amati F, Aliberti S, Masclans JR, Soni N, Rodriguez A, Sibila O, Sanz F, Sotgiu G, Anzueto A, Dimakou K, Petrino R, van de Garde E, Restrepo MI. Aspiration Risk Factors, Microbiology, and Empiric Antibiotics for Patients Hospitalized With Community-Acquired Pneumonia. Chest 2020; 159:58-72. [PMID: 32687909 DOI: 10.1016/j.chest.2020.06.079] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role. RESEARCH QUESTION What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP? STUDY DESIGN AND METHODS This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups. RESULTS We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P = .021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P < .001) when compared with patients with severe CAP/AspRF+ and severe CAP/AspRF-, respectively. Most patients (>50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics. INTERPRETATION Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage.
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Affiliation(s)
- Judith Marin-Corral
- Critical Care Department, Hospital del Mar, Barcelona, Spain, and the Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX
| | - Sergi Pascual-Guardia
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX; Respiratory Department, Hospital del Mar, IMIM, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Francesco Amati
- Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, and University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Stefano Aliberti
- Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, and University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Joan R Masclans
- Critical Care Department, Hospital del Mar, Barcelona, Spain, and the Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Nilam Soni
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX; Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX
| | - Alejandro Rodriguez
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain; Critical Care Medicine, Hospital Universitari Joan XXIII and Rovira & Virgili University, Tarragona, Spain
| | - Oriol Sibila
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain; Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and University of Barcelona, Barcelona, Spain
| | - Francisco Sanz
- Pulmonology Department, Consorci Hospital General Universitari de Valencia, Valencia, Spain
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Antonio Anzueto
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX; Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX
| | - Katerina Dimakou
- 5th Department of Pulmonary Medicine, Sotiria Chest Diseases Hospital, Athens, Greece
| | | | - Ewoudt van de Garde
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marcos I Restrepo
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX; Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX.
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Manabe T, Kotani K, Teraura H, Minami K, Kohro T, Matsumura M. Characteristic Factors of Aspiration Pneumonia to Distinguish from Community-Acquired Pneumonia among Oldest-Old Patients in Primary-Care Settings of Japan. Geriatrics (Basel) 2020; 5:E42. [PMID: 32645839 PMCID: PMC7555817 DOI: 10.3390/geriatrics5030042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Aspiration pneumonia (AsP), a phenotype of community-acquired pneumonia (CAP), is a common and problematic disease with symptomless recurrence and fatality in old adults. Characteristic factors for distinguishing AsP from CAP need to be determined to manage AsP. No such factorial markers in oldest-old adults, who are often seen in the primary-care settings, have yet been established. Methods: From the database of our Primary Care and General Practice Study, including the general backgrounds, clinical conditions and laboratory findings collected by primary care physicians and general practitioners, the records of 130 patients diagnosed with either AsP (n = 72) or CAP (n = 58) were extracted. Characteristic factors associated with the diagnosis of AsP were statistically compared between AsP and CAP. Results: The patients were older in the AsP group (median 90 years old) than in the CAP group (86 years old). The body temperature, heart rate, and diastolic blood pressure were lower in the patients with AsP than in those with CAP. Witnessed meal dysphagia by families and caregivers was reported only in AsP. Living in a nursing home, comorbidities of cerebral infarction and dementia (as positive factors) and hypertension (as a negative factor) were considered predictive to diagnose AsP in a stepwise logistic regression analysis. Conclusions: Among oldest-old adults in primary-care settings, living in a nursing home and the dysphagia risks are suggested to be characteristic factors for diagnosing AsP. Age and some relevant clinical information may help manage AsP and also be useful for families and caregivers.
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Affiliation(s)
- Toshie Manabe
- Division of Community and Family Medicine, Center of Community Medicine, Jichi Medical University, Shimotsuke-City, Tochigi 329-0498, Japan; (T.M.); (H.T.)
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Center of Community Medicine, Jichi Medical University, Shimotsuke-City, Tochigi 329-0498, Japan; (T.M.); (H.T.)
| | - Hiroyuki Teraura
- Division of Community and Family Medicine, Center of Community Medicine, Jichi Medical University, Shimotsuke-City, Tochigi 329-0498, Japan; (T.M.); (H.T.)
| | - Kensuke Minami
- Division of Infectious Diseases, Jichi Medical University Hospital, Shimotsuke-City, Tochigi 329-0498, Japan;
| | - Takahide Kohro
- Data Science Center, Jichi Medical University, Shimotsuke-City, Tochigi 329-0498, Japan;
| | - Masami Matsumura
- Division of General Medicine, Center of Community Medicine, Jichi Medical University, Shimotsuke-City, Tochigi 329-0498, Japan;
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Legriel S, Grigoresco B, Martel P, Henry-Lagarrigue M, Lvovschi V, Troché G, Amara M, Jacq G, Bruneel F, Bernard M, Marinier A, Bedos JP. Diagnostic Accuracy of Procalcitonin for Early Aspiration Pneumonia in Critically Ill Patients with Coma: A Prospective Study. Neurocrit Care 2020; 30:440-448. [PMID: 30267280 DOI: 10.1007/s12028-018-0623-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Early diagnostic orientation for differentiating pneumonia from pneumonitis at the early stage after aspiration would be valuable to avoid unnecessary antibiotic therapy. We assessed the accuracy of procalcitonin (PCT) in diagnosing aspiration pneumonia (AP) in intensive care unit (ICU) patients requiring mechanical ventilation after out-of-hospital coma. METHODS Prospective observational 2-year cohort study in a medical-surgical ICU. PCT, C-reactive protein (CRP) and white blood cell count (WBC) were measured at admission (H0) and 6 h (H), H12, H24, H48, H96, and H120 after inclusion. Lower respiratory tract microbiological investigations performed routinely in patients with aspiration syndrome were the reference standard for diagnosing AP. Performance of PCT, CRP, and WBC up to H48 in diagnosing AP was compared based on the areas under the ROC curves (AUC) and likelihood ratios (LR+ and LR-) computed for the best cutoff values. RESULTS Of 103 patients with coma, 45 (44%) had AP. Repeated PCT assays demonstrated a significant increase in patients with AP versus without AP from H0 to H120. Among the three biomarkers, PCT showed the earliest change. ROC-AUC values were poor for all three biomarkers. Best ROC-AUC values for diagnosing AP were for CRP at H24 [0.73 (95%CI 0.61-0.84)] and PCT at H48 [0.73 (95%CI 0.61-0.84)]. LR+ was best for PCT at H24 (3.5) and LR- for CRP and WBC at H24 (0.4 and 0.4, respectively). CONCLUSIONS Early and repeated assays of PCT, CRP, and WBC demonstrated significant increases in all three biomarkers in patients with versus without AP. All three biomarkers had poor diagnostic performance for ruling out AP. Whereas PCT had the fastest kinetics, PCT assays within 48 h after ICU admission do not help to diagnose AP in ICU patients with coma.
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Affiliation(s)
- Stéphane Legriel
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France.
- Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France.
- INSERM U970, Paris Cardiovascular Research Center, Paris, France.
| | - Benedicte Grigoresco
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Patricia Martel
- Public Health Department, Centre Hospitalier Universitaire Ambroise Paré, Boulogne, France
| | - Matthieu Henry-Lagarrigue
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Virginie Lvovschi
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Gilles Troché
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Marlène Amara
- Microbiology Department, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Gwenaelle Jacq
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Fabrice Bruneel
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Maguy Bernard
- Department of Metabolic Biochemistry, Pitié Salpêtrière-Charles Foix University Hospital (AP-HP), Paris, France
- Department of Oncology and Endocrine Biochemistry, Pitié Salpêtrière-Charles Foix University Hospital (AP-HP), Paris, France
| | - Anne Marinier
- Biochemistry Department, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - Jean-Pierre Bedos
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
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9
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Affiliation(s)
- Jonathan D Dear
- Department of Medicine and Epidemiology, University of California, Davis, One Shields Avenue, Davis, CA 95616, USA. https://twitter.com/jddear
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10
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Akata K, Noguchi S, Kawanami T, Hata R, Naito K, Mukae H, Yatera K. [Microbiology of Aspiration Pneumonia]. J UOEH 2019; 41:185-192. [PMID: 31292363 DOI: 10.7888/juoeh.41.185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The number of patients with pneumonia has been increasing as the population ages, and most fatal pneumonia cases are the elderly with aspiration pneumonia. Although aspiration pneumonia leads to poor short- and long-term prognosis, there have been no practical ways to diagnose it precisely. Persistent subclinical aspiration without any subjective symptoms is problematic in clinical practice in patients with aspiration pneumonia, and physicians can only use aspiration risks such as brain infarction to diagnose aspiration pneumonia. Anaerobes have been believed to be major causative pathogens in aspiration pneumonia, based on data from the 1970's. In relation to these data, Marik insisted that there is a possible overestimation of anaerobes because 1) the sampling of microbiologic specimens was in the late phase in the course of the illness, especially frequently after developing complications such as abscesses, necrotizing pneumonia, or empyema thoracis; 2) the organisms recovered by percutaneous transtracheal aspiration (PTA) sampling could have been contaminated by the aspiration of oropharyngeal flora during the PTA procedure or colonized in the trachea; and 3) many of the patients had chronic alcoholism or were under general anesthesia. In addition, 4) oral care was not common in the 1970s, and 5) the patients in these reports were relatively young. Molecular biological approaches using the 16S ribosomal RNA (rRNA) gene have recently been used, and have enabled us to detect more exact pathogens compared to conventional bacterial culture. Using the method with the detection of the 16S rRNA gene, we evaluated the bacterial phylotypes in bronchoalveolar lavage fluid in patients with aspiration pneumonia and found that oral streptococci were the most detected phylotypes (31.0%), while anaerobes were only 6.0%. Our results suggest that oral streptococci are important, and anaerobes may have been overestimated as causative pathogens in patients with aspiration pneumonia.
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Affiliation(s)
- Kentaro Akata
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Shingo Noguchi
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Toshinori Kawanami
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Ryosuke Hata
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Keisuke Naito
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Hiroshi Mukae
- Second Department of Internal Medicine, Nagasaki University School of Medicine
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
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11
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Karasahin O, Tasar PT, Timur O, Binici DN, Yilmaz TK, Aslan A, Sahin S. High C-Reactive Protein and Low Albumin Levels Predict High 30-Day Mortality in Patients Undergoing Percutaneous Endoscopic Gastrotomy. Gastroenterology Res 2017; 10:172-176. [PMID: 28725304 PMCID: PMC5505282 DOI: 10.14740/gr862w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 05/31/2017] [Indexed: 01/16/2023] Open
Abstract
Background Percutaneous endoscopic gastrotomy (PEG) enables long-term enteral feeding. The aim of this study was to identify biomarkers that may guide the decision of whether to perform the elective procedure of PEG. Methods The medical records of all patients who underwent PEG in our hospital from 2010 to 2016 were screened retrospectively. Patients with mortality within a 30-day follow-up period and those without were compared using the Chi-square test, and continuous variables were compared with the Kruskal-Wallis and Mann-Whitney U tests. Receiver operating characteristic (ROC) curve analysis was used to demonstrate the ability of biomarkers to predict mortality; a cut-off point was determined and its sensitivity, specificity, and positive and negative predictive values were calculated. The Youden index was used to determine the cut-off point. Kaplan-Meier analysis was used to identify PEG-related mortality risk factors and a Cox regression model was applied for risk characterization. Results A total of 120 patients who underwent PEG were evaluated in the study. The mean age was 67.00 ± 18.00 years. The most common indication for PEG was cerebrovascular disease, in 69 (57.5%) of the patients. Infection of the PEG site was most common within 14 days after PEG tube placement, occurring in 13 patients (10.3%). The mortality rate among patients with post-PEG infection was 68.2%, significantly higher than in patients without infection (P = 0.012). Thirty-four patients (28.3%) died within 30 days of undergoing PEG. CRP values ≥ 78.31 mg/L increased mortality by 8.756-fold, and albumin levels < 2.71 g/dL increased mortality by 2.255-fold. Conclusion Our results indicate that the presence of both high CRP level and low albumin level were associated with significantly higher rate of mortality (73.1%) in patients who underwent PEG.
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Affiliation(s)
- Omer Karasahin
- Infectious Diseases Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Pinar Tosun Tasar
- Geriatrics Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Ozge Timur
- Internal Medicine Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Dogan Nasir Binici
- Internal Medicine Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Tugba Kiper Yilmaz
- Internal Medicine Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Adem Aslan
- General Surgery Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Sevnaz Sahin
- Department of Internal Medicine, Department of Geriatrics, Ege University School of Medicine, Izmir, Turkey
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12
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Boyles TH, Brink A, Calligaro GL, Cohen C, Dheda K, Maartens G, Richards GA, van Zyl Smit R, Smith C, Wasserman S, Whitelaw AC, Feldman C. South African guideline for the management of community-acquired pneumonia in adults. J Thorac Dis 2017; 9:1469-1502. [PMID: 28740661 DOI: 10.21037/jtd.2017.05.31] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Tom H Boyles
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adrian Brink
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa
| | - Greg L Calligaro
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Cheryl Cohen
- Centre for Respiratory Disease and Meningitis, National Institute for Communicable Diseases, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Guy A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard van Zyl Smit
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | | | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew C Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Charles Feldman
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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13
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Komiya K, Rubin BK, Kadota JI, Mukae H, Akaba T, Moro H, Aoki N, Tsukada H, Noguchi S, Shime N, Takahashi O, Kohno S. Prognostic implications of aspiration pneumonia in patients with community acquired pneumonia: A systematic review with meta-analysis. Sci Rep 2016; 6:38097. [PMID: 27924871 PMCID: PMC5141412 DOI: 10.1038/srep38097] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 11/04/2016] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Kosaku Komiya
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, 1217 East Marshall Street: KMSB, Room 215 Richmond, Virginia 23298, USA.,Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan.,Clinical Research Center of Respiratory Medicine, Tenshindo Hetsugi Hospital, 5956 Nihongi, Nakahetsugi, Oita, 879-7761, Japan
| | - Bruce K Rubin
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, 1217 East Marshall Street: KMSB, Room 215 Richmond, Virginia 23298, USA
| | - Jun-Ichi Kadota
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Hiroshi Mukae
- Second Department of Internal Medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tomohiro Akaba
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, 1217 East Marshall Street: KMSB, Room 215 Richmond, Virginia 23298, USA
| | - Hiroshi Moro
- Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, 757 Asahi-machi, Chuo-ku, Niigata, 951-8510, Japan
| | - Nobumasa Aoki
- Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, 757 Asahi-machi, Chuo-ku, Niigata, 951-8510, Japan
| | - Hiroki Tsukada
- Department of Respiratory Medicine/Infectious Disease, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, 950-1197, Japan
| | - Shingo Noguchi
- Department of Respiratory Medicine, University of Occupational and Environmental Health, 1-1 Idaigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Institute of Biomedical &Health Sciences, Hiroshima University Advanced Emergency and Critical Care Center, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan
| | - Osamu Takahashi
- Center for Clinical Epidemiology, St. Luke's Life Science Institute, 10-1 Akashicho, Chuo-ku, Tokyo, 104-0044, Japan
| | - Shigeru Kohno
- Second Department of Internal Medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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14
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Cukic V, Hadzic A. The Most Common Detected Bacteria in Sputum of Patients with Community Acquired Pneumonia (CAP) Treated In Hospital. Med Arch 2016; 70:354-358. [PMID: 27994296 PMCID: PMC5136428 DOI: 10.5455/medarh.2016.70.354-358] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 10/11/2016] [Indexed: 12/02/2022] Open
Abstract
Introduction: Community acquired pneumonia (CAP) is the most common infective pulmonary disease. Objective: To show the most common detected bacteria in bacterial culture of sputum in patients with CAP hospitalized in Clinic for Pulmonary Diseases and TB “Podhrastovi” in four-year period: from 2012 to 2015. Material and methods: This is the retrospective analysis. Each patient gave sputum 3 days in a row when admitted to hospital. Sputum has been examined: bacterial culture with antibiotics sensitivity, Gram stain, Mycobacterium tuberculosis; in cases with high temperature blood cultures were done; when we were suspicious about bronchial carcinoma bronchoscopy with BAL (bronchoalveolar lavage) was done. We show analyzed patients according to age, sex, whether they had pneumonia or bronchopneumonia, bacteria isolated in sputum and in BAL. Results: 360 patients with CAP were treated in four-year period (247 males and 113 females). 167 or 43, 39 % had pneumonia (119 males and 48 females). Number of males was significantly bigger (χ2 = 30,186; p<0,001). 193 or 53, 61 % had bronchopneumonia (128 males and 65 females). Number of males was significantly bigger (χ2 = 20,556; p<0,001). Number of patients with negative bacterial culture of sputum (131–78, 44%) was significantly bigger than number of patients with positive culture (36–21, 56%) (χ2 = 50,042; p<0,001) in pneumonia. Number of patients with negative bacterial culture of sputum (154- 79, 79%) was significantly bigger than number of patients with positive culture (39- 20, 21%) (χ2 = 68,523; p<0,001) in bronchopneumonia. Streptococcus pneumoniae was significantly most common detected bacterium compared with the number of other isolated bacteria; in pneumonia (χ2 =33,222; p<0,001) and in bronchopneumonia (χ2 =51,231; p<0,001). Conclusion: It is very important to detect the bacterial cause of CAP to administrate the targeted antibiotic therapy.
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Affiliation(s)
- Vesna Cukic
- Clinic for Pulmonary Diseases and TB "Podhrastovi", Clinical Center of Sarajevo University, Sarajevo, Bosnia and Herzegovina
| | - Armin Hadzic
- Department for Pulmonary Diseases, Cantonal hospital Zenica, Zenica, Bosnia and Herzegovina
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15
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Akata K, Yatera K, Yamasaki K, Kawanami T, Naito K, Noguchi S, Fukuda K, Ishimoto H, Taniguchi H, Mukae H. The significance of oral streptococci in patients with pneumonia with risk factors for aspiration: the bacterial floral analysis of 16S ribosomal RNA gene using bronchoalveolar lavage fluid. BMC Pulm Med 2016; 16:79. [PMID: 27169775 PMCID: PMC4864928 DOI: 10.1186/s12890-016-0235-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 05/01/2016] [Indexed: 11/10/2022] Open
Abstract
Background Aspiration pneumonia has been a growing interest in an aging population. Anaerobes are important pathogens, however, the etiology of aspiration pneumonia is not fully understood. In addition, the relationship between the patient clinical characteristics and the causative pathogens in pneumonia patients with aspiration risk factors are unclear. To evaluate the relationship between the patient clinical characteristics with risk factors for aspiration and bacterial flora in bronchoalveolar lavage fluid (BALF) in pneumonia patients, the bacterial floral analysis of 16S ribosomal RNA gene was applied in addition to cultivation methods in BALF samples. Methods From April 2010 to February 2014, BALF samples were obtained from the affected lesions of pneumonia via bronchoscopy, and were evaluated by the bacterial floral analysis of 16S rRNA gene in addition to cultivation methods in patients with community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP). Factors associated with aspiration risks in these patients were analyzed. Results A total of 177 (CAP 83, HCAP 94) patients were enrolled. According to the results of the bacterial floral analysis, detection rate of oral streptococci as the most detected bacterial phylotypes in BALF was significantly higher in patients with aspiration risks (31.0 %) than in patients without aspiration risks (14.7 %) (P = 0.009). In addition, the percentages of oral streptococci in each BALF sample were significantly higher in patients with aspiration risks (26.6 ± 32.0 %) than in patients without aspiration risks (13.8 ± 25.3 %) (P = 0.002). A multiple linear regression analysis showed that an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of ≥3, the presence of comorbidities, and a history of pneumonia within a previous year were significantly associated with a detection of oral streptococci in BALF. Conclusions The bacterial floral analysis of 16S rRNA gene revealed that oral streptococci were mostly detected as the most detected bacterial phylotypes in BALF samples in CAP and HCAP patients with aspiration risks, especially in those with a poor ECOG-PS or a history of pneumonia.
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Affiliation(s)
- Kentaro Akata
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu city, Fukuoka, 807-8555, Japan
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu city, Fukuoka, 807-8555, Japan
| | - Kei Yamasaki
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu city, Fukuoka, 807-8555, Japan
| | - Toshinori Kawanami
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu city, Fukuoka, 807-8555, Japan
| | - Keisuke Naito
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu city, Fukuoka, 807-8555, Japan
| | - Shingo Noguchi
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu city, Fukuoka, 807-8555, Japan
| | - Kazumasa Fukuda
- Department of Microbiology, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu city, Fukuoka, 807-8555, Japan
| | - Hiroshi Ishimoto
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu city, Fukuoka, 807-8555, Japan.,Second Department of Internal Medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hatsumi Taniguchi
- Department of Microbiology, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu city, Fukuoka, 807-8555, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu city, Fukuoka, 807-8555, Japan. .,Second Department of Internal Medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
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16
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Les pneumonies d’inhalation. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1155-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Higuchi S, Kabeya Y, Matsushita K, Taguchi H, Ishiguro H, Kohshoh H, Yoshino H. Barthel Index as a Predictor of 1-Year Mortality in Very Elderly Patients Who Underwent Percutaneous Coronary Intervention for Acute Coronary Syndrome: Better Activities of Daily Living, Longer Life. Clin Cardiol 2015; 39:83-9. [PMID: 26720494 DOI: 10.1002/clc.22497] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/01/2015] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is safe and effective in very elderly patients, defined as those who are age ≥85 years, with acute coronary syndrome (ACS). However, the prognostic factors remain unknown. The association between activities of daily living (ADL) and the prognosis after PCI has not yet been investigated. HYPOTHESIS Better ADL is associated with better 1-year prognosis. METHODS This retrospective study included 91 consecutive very elderly patients with ACS. We calculated the Barthel Index (BI) as an indicator for ADL. Patients were classified into 2 groups according to BI: high BI (≥85) and low BI (<85). The BI was assessed both on admission (pre-BI) and at discharge (post-BI). RESULTS In the 91 patients (mean age, 88.2 ± 3.0 years, 52% male), 1-year mortality was 33%. The Cox regression model demonstrated that low pre-BI was not a risk factor for 1-year mortality (hazard ratio: 0.73, 95% confidence interval [CI]: 0.30-1.78, P = 0.490). However, post-BI was significantly associated with 1-year mortality (hazard ratio: 0.25, 95% CI: 0.11-0.57, P = 0.001). The 1-year mortality of the high and the low post-BI group was estimated as 21% (95% CI: 12%-35%) and 62% (95% CI: 42%-82%), respectively. A 5-unit decrease in post-BI was related to a 1.10-fold increased risk for 1-year mortality (95% CI: 1.05-1.15, P < 0.001). CONCLUSIONS Activities of daily living at discharge, although not before admission, may be a useful predictor for 1-year mortality in very elderly patients undergoing PCI for ACS.
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Affiliation(s)
- Satoshi Higuchi
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan
| | - Yusuke Kabeya
- Division of General Internal Medicine, Department of Internal Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Kenichi Matsushita
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan
| | - Hiroki Taguchi
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan
| | - Haruhisa Ishiguro
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan
| | - Hideyasu Kohshoh
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan
| | - Hideaki Yoshino
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan
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18
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Abstract
Backgrounds Aspiration pneumonia is a dominant form of community-acquired and healthcare-associated pneumonia, and a leading cause of death among ageing populations. However, the risk factors for developing aspiration pneumonia in older adults have not been fully evaluated. The purpose of the present study was to determine the risk factors for aspiration pneumonia among the elderly. Methodology and Principal Findings We conducted an observational study using data from a nationwide survey of geriatric medical and nursing center in Japan. The study subjects included 9930 patients (median age: 86 years, women: 76%) who were divided into two groups: those who had experienced an episode of aspiration pneumonia in the previous 3 months and those who had not. Data on demographics, clinical status, activities of daily living (ADL), and major illnesses were compared between subjects with and without aspiration pneumonia. Two hundred and fifty-nine subjects (2.6% of the total sample) were in the aspiration pneumonia group. In the univariate analysis, older age was not found to be a risk factor for aspiration pneumonia, but the following were: sputum suctioning (odds ratio [OR] = 17.25, 95% confidence interval [CI]: 13.16–22.62, p < 0.001), daily oxygen therapy (OR = 8.29, 95% CI: 4.39–15.65), feeding support dependency (OR = 8.10, 95% CI: 6.27–10.48, p < 0.001), and urinary catheterization (OR = 4.08, 95% CI: 2.81–5.91, p < 0.001). In the multiple logistic regression analysis, the risk factors associated with aspiration pneumonia after propensity-adjustment (258 subjects each) were sputum suctioning (OR = 3.276, 95% CI: 1.910–5.619), deterioration of swallowing function in the past 3 months (OR = 3.584, 95% CI: 1.948–6.952), dehydration (OR = 8.019, 95% CI: 2.720–23.643), and dementia (OR = 1.618, 95% CI: 1.031–2.539). Conclusion The risk factors for aspiration pneumonia were sputum suctioning, deterioration of swallowing function, dehydration, and dementia. These results could help improve clinical management for preventing repetitive aspiration pneumonia.
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19
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Kakavas S, Mongardon N, Cariou A, Gulati A, Xanthos T. Early-onset pneumonia after out-of-hospital cardiac arrest. J Infect 2015; 70:553-62. [PMID: 25644317 DOI: 10.1016/j.jinf.2015.01.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/09/2015] [Accepted: 01/24/2015] [Indexed: 12/20/2022]
Abstract
Early-onset pneumonia (EOP) is a common complication after successful cardiopulmonary resuscitation. Currently, EOP diagnosis is difficult because usual diagnostic tools are blunted by the features of post-cardiac arrest syndrome and therapeutic hypothermia itself. When the diagnosis of EOP is suspected, empiric antimicrobial therapy should be considered following bronchopulmonary sampling. The onset of EOP increases the length of mechanical ventilation duration and intensive care unit stay, but its influence on survival and neurological outcome seems marginal. Therapeutic hypothermia has been recognized as an independent risk factor for this infectious complication. All together, these observations underline the need for future prospective clinical trials to better delineate pathogens and risk factors associated with EOP. In addition, there is a need for diagnostic approaches serving the accurate diagnosis of EOP.
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Affiliation(s)
- S Kakavas
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece; Pulmonary Department, Evangelismos, General Hospital of Athens, Greece.
| | - N Mongardon
- Université Paris Est, Faculté de Médecine, Service d'Anesthésie et des Réanimations Chirurgicales, Hôpitaux Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, Créteil, France; Service d'Anesthésie et des Réanimations Chirurgicales, Hôpitaux Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris Est, Faculté de Médecine, INSERM U955, Equipe 3, physiopathologie et pharmacologie des insuffisances coronaires et cardiaques, Créteil, France.
| | - A Cariou
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Service de Réanimation Médicale, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France; Service de Réanimation Médicale, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine; INSERM U970, Paris Cardiovascular Research Centre (PARCC), European Georges Pompidou Hospital, Paris, France.
| | - A Gulati
- Midwestern University, Downers Grove, IL, USA.
| | - T Xanthos
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece; Midwestern University, Downers Grove, IL, USA.
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20
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Affiliation(s)
- Jonathan D Dear
- William R. Pritchard Veterinary Medical Teaching Hospital, University of California-Davis, One Shields Avenue, Davis, CA 95616, USA.
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Taylor JK, Fleming GB, Singanayagam A, Hill AT, Chalmers JD. Risk factors for aspiration in community-acquired pneumonia: analysis of a hospitalized UK cohort. Am J Med 2013; 126:995-1001. [PMID: 24054176 DOI: 10.1016/j.amjmed.2013.07.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 04/23/2013] [Accepted: 07/12/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is a move toward finding clinically useful "phenotypes" in community-acquired pneumonia: groups of patients displaying distinct clinical characteristics, microbiology, and prognosis. Aspiration pneumonia is an intuitive clinical phenotype; however, to date there are no recognized diagnostic criteria, and data regarding outcomes in suspected aspiration are limited. METHODS An observational study of 1348 patients hospitalized with community-acquired pneumonia in the United Kingdom examined both short- and long-term outcomes for patients at risk of aspiration pneumonia. Patients were defined as "at risk" in the presence of chronic neurologic disorders, esophageal disorders and dysphagia, impaired conscious level, vomiting, or witnessed aspiration. The primary outcome was 30-day mortality. Secondary outcomes included 1-year mortality, readmissions, and recurrent pneumonia within 1 year. RESULTS Some 13.8% of the cohort were classified as "at risk of aspiration." These patients were older (median age, 74 years [interquartile range, 60-84] vs 66 years [interquartile range, 49-77]; P < .0001) and more likely to have comorbidities (chronic liver disease 11.3% vs 3.7%, P < .0001; congestive heart failure 28% vs 17.1%, P = .0004; and stroke 26.9% vs 9.5%, P < .0001). Patients at risk of aspiration pneumonia had a poorer short-term outcome (30-day mortality 17.2% vs 7.7%, P < .0001), but after adjusting for their greater severity of illness and comorbidities this difference was not significant (odds ratio 1.05; 95% confidence interval [CI], 0.63-1.76; P = .8). However, patients with aspiration risk factors were at greater risk of poor long-term outcomes with increased 1-year mortality (hazard ratio [HR], 1.73; 95% CI, 1.15-2.58), increased risk of rehospitalization (HR, 1.52; 95% CI, 1.21-1.91), and a strong association with recurrent admissions with pneumonia (HR, 3.13; 95% CI, 2.05-4.78) after multivariable adjustment. CONCLUSIONS Using risk factors to identify patients at risk of aspiration pneumonia identifies a distinct clinically useful phenotype of patients with greater severity of disease and poorer long-term outcomes.
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Microbiology and prognostic factors of hospital- and community-acquired aspiration pneumonia in respiratory intensive care unit. Am J Infect Control 2013; 41:880-4. [PMID: 23523524 DOI: 10.1016/j.ajic.2013.01.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 12/19/2012] [Accepted: 01/03/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Incidence of aspiration pneumonia in hospital-acquired pneumonia and community-acquired pneumonia is high; however, many features of this disease remain imprecise. Our objective was to characterize the microbial etiology and their antibiotic resistance and to determine the prognostic factors in aspiration pneumonia among patients admitted to a respiratory intensive care unit (RICU). METHODS A prospective survey was conducted in 112 patients exhibiting hospital-or community-acquired aspiration pneumonia in the RICU of a provincial general hospital from 2010-2012. Bronchoalveolar lavage sampling was collected, and then followed by standard culture and drug-sensitive test. Risk factors were analyzed by multivariate logistic analysis. RESULTS One hundred twenty-eight strains were isolated in 94 patients, gram-negative bacilli (57.8%) was the predominant cultured microorganism, followed by fungus (28.9%) and gram-positive cocci (13.3%). The 5 main isolated bacteria demonstrated high and multiantibiotic resistance. The crude overall mortality was 43.8%, 50%, and 40%, respectively, in hospital- and community-acquired aspiration pneumonia group. Multivariate logistic analysis identified age older than 65 years, use of inotropic support, and ineffective initial therapy as independent risk factors of poor outcome. CONCLUSIONS The predominant pathogenic bacteria of aspiration pneumonia in patients admitted to an RICU were antibiotic-resistant bacteria, and effective initial supportive management secured better prognosis.
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Waybright RA, Coolidge W, Johnson TJ. Treatment of clinical aspiration: A reappraisal. Am J Health Syst Pharm 2013; 70:1291-300. [DOI: 10.2146/ajhp120319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ryan A. Waybright
- Avera McKennan Hospital and University Health Center (AMHUHC), Sioux Falls, SD; at the time of writing he was Postgraduate Year 2 (PGY2) Critical Care Pharmacy Resident, AMHUHC
| | - William Coolidge
- AMHUHC; at the time of writing he was PGY2 Critical Care Pharmacy Resident, AMHUHC
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Recomendaciones para el diagnóstico, tratamiento y prevención de la neumonía adquirida en la comunidad en adultos inmunocompetentes. INFECTIO 2013. [DOI: 10.1016/s0123-9392(13)70019-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Bosch X, Formiga F, Cuerpo S, Torres B, Rosón B, López-Soto A. Aspiration pneumonia in old patients with dementia. Prognostic factors of mortality. Eur J Intern Med 2012; 23:720-6. [PMID: 22964260 DOI: 10.1016/j.ejim.2012.08.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/09/2012] [Accepted: 08/19/2012] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
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Heppner HJ, Sehlhoff B, Niklaus D, Pientka L, Thiem U. [Pneumonia Severity Index (PSI), CURB-65, and mortality in hospitalized elderly patients with aspiration pneumonia]. Z Gerontol Geriatr 2012; 44:229-34. [PMID: 21769515 DOI: 10.1007/s00391-011-0184-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Aspiration pneumonia is associated with a high morbidity and mortality in elderly patients. In order to provide risk-adapted medical care, it is necessary to establish valid prognostic tools for these patients. OBJECTIVE The value of two well-established scores to assess prognosis in community-acquired pneumonia (CAP), i.e., CURB-65 and the Pneumonia Severity Index (PSI), was evaluated in elderly patients hospitalized for aspiration pneumonia. MATERIAL AND METHODS A total of 209 patients hospitalized with aspiration pneumonia between 2001 and 2005 in a single center were evaluated using PSI and CURB-65. For comparison of morbidity and mortality, an equally large group of inpatients with CAP was analyzed. RESULTS The mean age of patients with aspiration pneumonia was 76.7 ± 13.4 years, and 104 (49.8 %) were female. Patients with aspiration pneumonia more frequently showed a history of cancer, hypotension, and hyponatriemia on admission. Mortality was clearly higher in comparison to patients with CAP (39.2% vs. 16.3%). The Odds Ratio (OR) for mortality was 1.03 (95% CI 0.59; 1.79) for a CURB-65 score of 3-5 points compared to 0-2 points. In cases of CAP, OR showed a statistically significant increase of risk (OR 2.50; 95% CI 1.04; 6.06), for CURB-65 scores of 3-5 points vs. 0-2 points). In aspiration pneumonia, the PSI showed a trend towards increasing mortality within higher risk class. CONCLUSIONS In geriatric patients hospitalized with aspiration pneumonia, CURB-65 and PSI have no prognostic value.
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Affiliation(s)
- H J Heppner
- Klinik für Notfall- und internistische Intensivmedizin, Klinikum Nürnberg, Nürnberg, Deutschland
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Early administration of sivelestat, the neutrophil elastase inhibitor, in adults for acute lung injury following gastric aspiration. Shock 2012; 36:223-7. [PMID: 21617577 DOI: 10.1097/shk.0b013e318225acc3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Gastric aspiration is the major cause of acute lung injury (ALI) and acute respiratory distress syndrome. Aspiration-induced ALI is believed to be, at least in part, facilitated by neutrophil-derived mediators and toxic molecules. We conducted a prospective cohort study based on the hypothesis that sivelestat, a specific neutrophil elastase inhibitor, is effective for treating ALI following gastric aspiration. Forty-four ALI patients who showed evidence of aspiration were observed within 12 h before intensive care unit admission and who had been mechanically ventilated within 12 h after admission were included in this study. Lung injury score (LIS) and PAO2/FiO2 (P/F) ratio on day 7 were defined as the primary outcomes of the study. Twenty-three patients were assigned to the sivelestat group and 21 to the control group. In univariate analyses, the proportions of patients with LIS lower than 1.0 on day 7 and a P/F greater than 300 on day 7 were significantly higher in the sivelestat group than in the control group (60.9% vs. 26.3%, P = 0.03; 87.0% vs. 36.8%, P = 0.001). In the logistic regression model, the use of sivelestat was an independent predictor for LIS lower than 1.0 on day 7 (relative risk, 7.4; 95% confidence interval [CI], 1.51-36.48) and for a P/F ratio higher than 300 on day 7 (relative risk, 18.5; 95% CI, 2.72-126.46). In the Cox proportional hazards model, the use of sivelestat was associated with a lower cumulative proportion of patients who received mechanical ventilation during the initial 14 days (hazard ratio, 2.6; 95% CI, 1.17-5.55).
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Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--summary. Clin Microbiol Infect 2012; 17 Suppl 6:1-24. [PMID: 21951384 DOI: 10.1111/j.1469-0691.2011.03602.x] [Citation(s) in RCA: 192] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.
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Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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Perbet S, Mongardon N, Dumas F, Bruel C, Lemiale V, Mourvillier B, Carli P, Varenne O, Mira JP, Wolff M, Cariou A. Early-Onset Pneumonia after Cardiac Arrest. Am J Respir Crit Care Med 2011; 184:1048-54. [DOI: 10.1164/rccm.201102-0331oc] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--full version. Clin Microbiol Infect 2011; 17 Suppl 6:E1-59. [PMID: 21951385 PMCID: PMC7128977 DOI: 10.1111/j.1469-0691.2011.03672.x] [Citation(s) in RCA: 581] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.
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Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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Noveanu M, Breidthardt T, Reichlin T, Gayat E, Potocki M, Pargger H, Heise A, Meissner J, Twerenbold R, Muravitskaya N, Mebazaa A, Mueller C. Effect of oral β-blocker on short and long-term mortality in patients with acute respiratory failure: results from the BASEL-II-ICU study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R198. [PMID: 21047406 PMCID: PMC3219994 DOI: 10.1186/cc9317] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Revised: 07/14/2010] [Accepted: 11/03/2010] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Acute respiratory failure (ARF) is responsible for about one-third of intensive care unit (ICU) admissions and is associated with adverse outcomes. Predictors of short- and long-term outcomes in unselected ICU-patients with ARF are ill-defined. The purpose of this analysis was to determine predictors of in-hospital and one-year mortality and assess the effects of oral beta-blockers in unselected ICU patients with ARF included in the BASEL-II-ICU study. METHODS The BASEL II-ICU study was a prospective, multicenter, randomized, single-blinded, controlled trial of 314 (mean age 70 (62 to 79) years) ICU patients with ARF evaluating impact of a B-type natriuretic peptide- (BNP) guided management strategy on short-term outcomes. RESULTS In-hospital mortality was 16% (51 patients) and one-year mortality 41% (128 patients). Multivariate analysis assessed that oral beta-blockers at admission were associated with a lower risk of both in-hospital (HR 0.33 (0.14 to 0.74) P = 0.007) and one-year mortality (HR 0.29 (0.16 to 0.51) P = 0.0003). Kaplan-Meier analysis confirmed the lower mortality in ARF patients when admitted with oral beta-blocker and further shows that the beneficial effect of oral beta-blockers at admission holds true in the two subgroups of patients with ARF related to cardiac or non-cardiac causes. Kaplan-Meier analysis also shows that administration of oral beta-blockers before hospital discharge gives striking additional beneficial effects on one-year mortality. CONCLUSIONS Established beta-blocker therapy appears to be associated with a reduced mortality in ICU patients with acute respiratory failure. Cessation of established therapy appears to be hazardous. Initiation of therapy prior to discharge appears to confer benefit. This finding was seen regardless of the cardiac or non-cardiac etiology of respiratory failure. TRIAL REGISTRATION clinicalTrials.gov Identifier: NCT00130559.
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Affiliation(s)
- Markus Noveanu
- Department of Internal Medicine, University Hospital Basel, Petersgraben 4, 4053 Basel, Switzerland
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Volakli E, Spies C, Michalopoulos A, Groeneveld ABJ, Sakr Y, Vincent JL. Infections of respiratory or abdominal origin in ICU patients: what are the differences? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R32. [PMID: 20230620 PMCID: PMC2887138 DOI: 10.1186/cc8909] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 02/26/2010] [Accepted: 03/15/2010] [Indexed: 12/29/2022]
Abstract
INTRODUCTION There are few data related to the effects of different sources of infection on outcome. We used the Sepsis Occurrence in Acutely ill Patients (SOAP) database to investigate differences in the impact of respiratory tract and abdominal sites of infection on organ failure and survival. METHODS The SOAP study was a cohort, multicenter, observational study which included data from all adult patients admitted to one of 198 participating intensive care units (ICUs) from 24 European countries during the study period. In this substudy, patients were divided into two groups depending on whether, on admission, they had abdominal infection but no respiratory infection or respiratory infection but no abdominal infection. The two groups were compared with respect to patient and infection-related characteristics, organ failure patterns, and outcomes. RESULTS Of the 3,147 patients in the SOAP database, 777 (25%) patients had sepsis on ICU admission; 162 (21%) had abdominal infection without concurrent respiratory infection and 380 (49%) had respiratory infection without concurrent abdominal infection. Age, sex, and severity scores were similar in the two groups. On admission, septic shock was more common in patients with abdominal infection (40.1% vs. 29.5%, P = 0.016) who were also more likely to have early coagulation failure (17.3% vs. 9.5%, P = 0.01) and acute renal failure (38.3% vs. 29.5%, P = 0.045). In contrast, patients with respiratory infection were more likely to have early neurological failure (30.5% vs. 9.9%, P < 0.001). The median length of ICU stay was the same in the two groups, but the median length of hospital stay was longer in patients with abdominal than in those with respiratory infection (27 vs. 20 days, P = 0.02). ICU (29%) and hospital (38%) mortality rates were identical in the two groups. CONCLUSIONS There are important differences in patient profiles related to the site of infection; however, mortality rates in these two groups of patients are identical.
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Affiliation(s)
- Elena Volakli
- Dept of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de lennik 808, Brussels, Belgium
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Eizadi-Mood N, Saghaei M, Alfred S, Zargarzadeh AH, Huynh C, Gheshlaghi F, Yaraghi A, Saad YS. Comparative evaluation of Glasgow Coma Score and gag reflex in predicting aspiration pneumonitis in acute poisoning. J Crit Care 2009; 24:470.e9-15. [PMID: 19327309 DOI: 10.1016/j.jcrc.2008.08.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2007] [Revised: 05/08/2008] [Accepted: 08/25/2008] [Indexed: 02/08/2023]
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Falguera M, Carratalà J, Ruiz-Gonzalez A, Garcia-Vidal C, Gazquez I, Dorca J, Gudiol F, Porcel JM. Risk factors and outcome of community-acquired pneumonia due to Gram-negative bacilli. Respirology 2009; 14:105-11. [PMID: 18699803 DOI: 10.1111/j.1440-1843.2008.01371.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Several sets of guidelines have advocated initial antibiotic treatment for community-acquired pneumonia due to Gram-negative bacilli in patients with specific risk factors. However, evidence to support this recommendation is scarce. We sought to identify risk factors for community-acquired pneumonia due to Gram-negative bacilli, including Pseudomonas aeruginosa, and to assess outcomes. METHODS An observational analysis was carried out on prospectively collected data for immunocompetent adults hospitalized for community-acquired pneumonia in two acute-care hospitals. Cases of pneumonia due to Gram-negative bacilli were compared with those of non-Gram-negative bacilli causes. RESULTS Sixty-one (2%) of 3272 episodes of community-acquired pneumonia were due to Gram-negative bacilli. COPD (odds ratio (OR) 2.4, 95% confidence interval (CI): 1.2-5.1), current use of corticosteroids (OR 2.8, 95% CI: 1.2-6.3), prior antibiotic therapy (OR 2.6, 95% CI: 1.4-4.8), tachypnoea >or=30 cycles/min (OR 2.1, 95% CI: 1.1-4.2) and septic shock at presentation (OR 6.1, 95% CI: 2.5-14.6) were independently associated with Gram-negative bacilli pneumonia. Initial antibiotic therapy in patients with pneumonia due to Gram-negative bacilli was often inappropriate. These patients were also more likely to require admission to the intensive care unit, had longer hospital stays, and higher early (<48 h) (21% vs 2%; P < 0.001) and overall mortality (36% vs 7%; P < 0.001). CONCLUSIONS These results suggest that community-acquired pneumonia due to Gram-negative bacilli is uncommon, but is associated with a poor outcome. The risk factors identified in this study should be considered when selecting initial antibiotic therapy for patients with community-acquired pneumonia.
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Affiliation(s)
- Miquel Falguera
- Internal Medicine Service, Institut de Recerca Biomèdica de Lleida (IRBLLEIDA), Hospital Universitari Arnau de Vilanova, University of Lleida, Lleida, Spain.
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Leroy O, Mikolajczyk D, Devos P, Chiche A, Grunderbeeck NV, Boussekey N, Alfandari S, Georges H. Validation of a prediction rule for prognosis of severe community-acquired pneumonia. Open Respir Med J 2008; 2:67-71. [PMID: 19365534 PMCID: PMC2606649 DOI: 10.2174/1874306400802010067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 07/11/2008] [Accepted: 07/24/2008] [Indexed: 01/30/2023] Open
Abstract
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.
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Affiliation(s)
- Olivier Leroy
- Service de Réanimation et Maladies Infectieuses. Hôpital Chatiliez. Tourcoing 59, France; Département de Bio Statistiques. CHRU Lille 59, France.
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Brogly N, Devos P, Boussekey N, Georges H, Chiche A, Leroy O. Impact of thrombocytopenia on outcome of patients admitted to ICU for severe community-acquired pneumonia. J Infect 2007; 55:136-40. [PMID: 17350105 DOI: 10.1016/j.jinf.2007.01.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Revised: 01/14/2007] [Accepted: 01/24/2007] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate the prevalence and the prognostic value of thrombocytopenia in patients admitted to ICU for severe community-acquired pneumonia. METHODS Multicentre observational study was conducted in 7 ICUs in the north of France over a 19-year period (1987-2005). The primary outcome measure was the ICU mortality. RESULTS Eight hundred and twenty-two patients were studied. A platelet count < 150x10(9)/L was observed at ICU admission in 202 (25%) patients. Admission platelet count was between 101 and 149x10(9)/L, 51 and 100x10(9)/L, 21 and 50x10(9)/L, and < or = 20x10(9)/L in 100, 61, 32 and 9 patients, respectively. ICU mortality rate was 35.4%. Classifying patients into 3 categories with the following cut-offs of platelet count, > or = 150x10(9)/L, 51-149x10(9)/L, and < or = 50x10(9)/L, we observed a significant increase in ICU mortality rates which were 30.8% in the first group, 44.1% in the second group and 70.7% in the last one (p<0.0001). In multivariate analysis, thrombocytopenia < or = 50x10(9)/L appeared as an independent predictor of mortality (AOR=4.386). CONCLUSIONS In patients admitted to ICU for severe community-acquired pneumonia, thrombocytopenia has a high prevalence and influences the outcome.
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Affiliation(s)
- Nicolas Brogly
- Service de Réanimation Médicale et Maladies Infectieuses, Université de Lille, Hôpital G. Chatiliez, 135 rue du Président Coty, 59208 Tourcoing, France
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Abstract
In this review, we aim to lead the readers through the historical highlights of pathophysiological concepts and treatment of pneumonia. Understanding the aetiology, the risk factors and the pathophysiology influenced our management approaches to pneumonia. Pneumonia is still associated with significant morbidity and mortality, presents in a variety of healthcare settings and imposes a considerable cost to healthcare services. Guidelines have been issued by international and national scientific societies in order to spread the scientific knowledge on this important disease and to improve its management.
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Affiliation(s)
- Francesco Blasi
- Istituto di Tisiologia e Malattie dell'Apparato Respiratorio, University of Milan, Ospedale Maggiore Fondazione IRCCS Policlinico, Mangiagalli e Regina Elena, Via F. Sforza 35, Milan 20122, Italy.
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Reza Shariatzadeh M, Huang JQ, Marrie TJ. Differences in the Features of Aspiration Pneumonia According to Site of Acquisition: Community or Continuing Care Facility. J Am Geriatr Soc 2006; 54:296-302. [PMID: 16460382 DOI: 10.1111/j.1532-5415.2005.00608.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the prevalence of aspiration pneumonia and to compare the features and risk factors for this entity in patients from continuing care facilities (CCFs) and the community who were admitted to the hospital with pneumonia. DESIGN Prospective population-based study. SETTING Six hospitals in Capital Health Region (Edmonton), Alberta, Canada. PARTICIPANTS One thousand nine hundred forty-six adults admitted with pneumonia. Patients were stratified by their residence as community or CCF. MEASUREMENTS Aspiration pneumonia prevalence; risk factors; and outcomes such as mortality, length of stay, and intensive care unit admission rates. RESULTS Ten percent of those with community-acquired pneumonia (CAP) had aspirated, compared with 30% of those with CCF-acquired pneumonia. Those with community-acquired aspiration pneumonia (CAAP) and those with CCF-acquired aspiration pneumonia (CCF-AP) were younger, more likely to go to ICU, and more likely to require mechanical ventilation and had a longer length of stay and a higher mortality rate than nonaspirators. The risk factors for aspiration differed; for those with CAAP, impaired consciousness due to alcohol, drugs, or hepatic failure predominated, whereas 72% of those with CCF-AP had neurological disease that resulted in dysphagia. Eighty percent were treated with antibiotics effective against anaerobic bacteria. CONCLUSION Aspiration pneumonia is common in patients with both CAP and CCF-acquired pneumonia. The risk factors differ, and there is a high mortality rate. Neurological disease dominates as the predisposing factor toward aspiration pneumonia in people in CCFs.
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Álvarez-Rocha L, Alós J, Blanquer J, Álvarez-Lerma F, Garau J, Guerrero A, Torres A, Cobo J, Jordá R, Menéndez R, Olaechea P, Rodríguez de castro F. [Guidelines for the management of community pneumonia in adult who needs hospitalization]. Med Intensiva 2005; 29:21-62. [PMID: 38620135 PMCID: PMC7131443 DOI: 10.1016/s0210-5691(05)74199-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2004] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- L. Álvarez-Rocha
- Grupo de Trabajo de Enfermedades Infecciosas. Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (GTEI de la SEMICYUC)
| | - J.I. Alós
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - J. Blanquer
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
| | - F. Álvarez-Lerma
- Grupo de Estudio de la Infección en el Paciente Crítico. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIPC de la SEIMC)
| | - J. Garau
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - A. Guerrero
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - A. Torres
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
| | - J. Cobo
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - R. Jordá
- Grupo de Trabajo de Enfermedades Infecciosas. Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (GTEI de la SEMICYUC)
| | - R. Menéndez
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
| | - P. Olaechea
- Grupo de Trabajo de Enfermedades Infecciosas. Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (GTEI de la SEMICYUC)
| | - F. Rodríguez de castro
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
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Isbister GK, Downes F, Sibbritt D, Dawson AH, Whyte IM. Aspiration pneumonitis in an overdose population: frequency, predictors, and outcomes. Crit Care Med 2004; 32:88-93. [PMID: 14707564 DOI: 10.1097/01.ccm.0000104207.42729.e4] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize the frequency of aspiration pneumonitis in an unselected population of overdose patients and, further, to identify factors that predispose to aspiration pneumonitis and the outcomes of patients with aspiration pneumonitis compared with those without. DESIGN Retrospective cohort study. SETTING Toxicology unit of a tertiary referral hospital. PATIENTS All poisoning admissions. MEASUREMENTS AND MAIN RESULTS A total of 71 of 4,562 poisoning admissions to the Hunter Area Toxicology Service between January 1997 and October 2002 had definite aspiration pneumonitis (1.6%; 95% confidence interval, 1.2-2.0). Older age, Glasgow Coma Score of <15, spontaneous emesis, seizures, delayed presentation to hospital, and ingestion of tricyclic antidepressants were associated with an increased risk of aspiration pneumonitis. Paracetamol poisoning and female sex were associated with a decreased risk of aspiration pneumonitis with univariate analysis. Ingestion of alcohol, benzodiazepines, antipsychotics, and administration of activated charcoal were not associated with aspiration pneumonitis. A logistic regression model for predicting aspiration pneumonitis contained seven predictors: age, sex, Glasgow Coma Score of <15 (odds ratio, 3.14; 95% confidence interval, 1.87-5.27), emesis (odds ratio, 4.17; 95% confidence interval, 2.44-7.13), seizure, tricyclic antidepressant ingestion, and time from ingestion to presentation (delay of >24 hrs [odds ratio, 4.42; 95% confidence interval, 2.42-8.10]). The mortality for patients with aspiration pneumonitis was 8.5% compared with 0.4% for those without (odds ratio, 23; 95% confidence interval, 9-60; p <.0001), and they had a significantly higher intensive care unit admission rate. The median length of stay of patients with aspiration pneumonitis was 126 hrs (interquartile range, 62-210 hrs) compared with 14.7 hrs (interquartile range, 7-23 hrs) in patients without (p <.0001). CONCLUSIONS Our study has shown a number of risk factors in overdose patients that are associated with aspiration pneumonitis that may allow the early identification of these patients for appropriate observation and management. Patients with aspiration pneumonitis have a significantly increased mortality and length of stay in the hospital.
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Recomendações de abordagem diagnóstica e terapêutica da pneumonia da comunidade em adultos imunocompetentes. REVISTA PORTUGUESA DE PNEUMOLOGIA 2003; 9:435-61. [PMID: 15188068 DOI: 10.1016/s0873-2159(15)30691-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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El-Solh AA, Pietrantoni C, Bhat A, Aquilina AT, Okada M, Grover V, Gifford N. Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med 2003; 167:1650-4. [PMID: 12689848 DOI: 10.1164/rccm.200212-1543oc] [Citation(s) in RCA: 188] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
We sought to investigate prospectively the microbial etiology and prognostic indicators of 95 institutionalized elders with severe aspiration pneumonia, and to investigate its relation to oral hygiene in using quantitative bronchial sampling. Data collection included demographic information, Activity of Daily Living, Plaque Index, antimicrobial therapy, and outcome. Out of the 67 pathogens identified, Gram-negative enteric bacilli were the predominant organisms isolated (49%), followed by anaerobic bacteria (16%), and Staphylococcus aureus (12%). The most commonly encountered anaerobes were Prevotella and Fusobacterium species. Aerobic Gram-negative bacilli were recovered in conjunction with 55% of anaerobic isolates. The Plaque Index did not differ significantly between the aerobic (2.2 +/- 0.4) and the anaerobic group (2.3 +/- 0.3). Functional status was the only determinant of the presence of anaerobic bacteria. Although seven cases with anaerobic isolates received initially inadequate antimicrobial therapy, six had effective clinical response. The crude mortality was 33% for the aerobic and 36% for the anaerobic group (p = 0.9). Stepwise multivariate analysis identified hypoalbuminemia (p < 0.001) and the burden of comorbid diseases (p < 0.001) as independent risk factors of poor outcome. In view of the rising resistance to antimicrobial agents, the importance of adding anaerobic coverage for aspiration pneumonia in institutionalized elders needs to be reexamined.
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Affiliation(s)
- Ali A El-Solh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University at Buffalo School of Medicine, NY, USA.
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Ramos A, Asensio A, Caballos D, Mariño MJ. [Prognostic factors associated with community-acquired aspiration pneumonia]. Med Clin (Barc) 2002; 119:81-4. [PMID: 12106534 DOI: 10.1016/s0025-7753(02)73326-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Antonio Ramos
- Medicina Interna III, Hospital Universitario Puerta de Hierro, Madrid, Spain.
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Leroy O, Sanders V, Girardie P, Devos P, Yazdanpanah Y, Georges H, Beaucaire G. Mortality due to ventilator-associated pneumonia: impact of medical versus surgical ICU admittance status. J Crit Care 2001; 16:90-7. [PMID: 11689764 DOI: 10.1053/jcrc.2001.28192] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare the prognosis of medical versus surgical patients developing ventilator-associated pneumonia (VAP). MATERIALS AND METHODS An observational cohort study included 125 consecutive patients exhibiting VAP. Incidence of death occurred at two different times: during intensive care unit (ICU) stay and during hospital stay. RESULTS Eighty-seven patients were included in the medical group and 38 in the surgical group. On ICU admission and at the time of VAP onset, most collected data, such as demographic parameters, severity of underlying diseases, and current illness, risk factors forVAP development andVAP characteristics were similar in the two groups. Mortality rates during ICU and hospital stays were not significantly different in medical (49%, 56%) and surgical (55%, 61%) groups. In multivariate logistic regression model adjusting for main factors of VAP mortality, surgical admittance status demonstrated no significant impact on mortality assessed during ICU stay (AOR = 1.6; 0.6 - 4.3 CI) and during hospital stay (AOR = 1.6; 0.6 - 4.2 CI). CONCLUSIONS In this series, after adjustment for mortality confounding factors, medical versus surgical admittance status was not a significant determinant of VAP mortality.
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Affiliation(s)
- O Leroy
- Service de Réanimation Médicale et Maladies Infectieuses, Université de Lille, Centre Hospitalier, Tourcoing 59208, France
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Kudoh I, Miyazaki H, Ohara M, Fukushima J, Tazawa T, Yamada H. Activation of alveolar macrophages in acid-injured lung in rats: different effects of pentoxifylline on tumor necrosis factor-alpha and nitric oxide production. Crit Care Med 2001; 29:1621-5. [PMID: 11505142 DOI: 10.1097/00003246-200108000-00020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether acid instillation augments tumor necrosis factor-alpha and nitric oxide production by alveolar macrophages in rats, and to study the effects of treatment with pentoxifylline before acid instillation on the production of these inflammatory mediators. DESIGN Controlled laboratory investigation on tumor necrosis factor-alpha and nitric oxide production by alveolar macrophages of rats that had acid-induced lung injury. SETTING University research laboratory. SUBJECT Alveolar macrophages of rats. INTERVENTIONS Alveolar macrophages were recovered by bronchoalveolar lavage at 4, 10, 16, 24, and 72 hrs after unilateral hydrochloric acid (pH, 1.0; volume, 0.1 mL) instillation into the lungs of rats. Alveolar macrophages then were cultured with or without lipopolysaccharide. One group of rats was pretreated with pentoxifylline before acid instillation. MEASUREMENTS AND MAIN RESULTS Alveolar macrophages from both acid-instilled and contralateral lungs, which had recovered 24 hrs after acid instillation, produced significantly greater tumor necrosis factor-alpha and nitric oxide. Subsequent exposure to lipopolysaccharide, as a surrogate for bacterial infection, further promoted tumor necrosis factor-alpha and nitric oxide release. Alveolar macrophages from rats pretreated with pentoxifylline before acid instillation produced significantly less tumor necrosis factor-alpha and did not overproduce tumor necrosis factor-alpha when exposed to lipopolysaccharide. In contrast, pretreatment with pentoxifylline had no effect on nitric oxide production by alveolar macrophages. CONCLUSIONS Acid instillation stimulates alveolar macrophages to produce tumor necrosis factor-alpha and nitric oxide. Pentoxifylline preserved innate production of tumor necrosis factor-alpha to lipopolysaccharide and did not inhibit the production of bactericidal nitric oxide. This may partly explain why pentoxifylline reduces acid aspiration-induced lung injury while maintaining the host's ability to combat bacterial infection after acid aspiration.
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Affiliation(s)
- I Kudoh
- Department of Anesthesiology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
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Defouilloy C, Gérard A, Berche P, Jambou P, Choutet P. Évaluation d'une stratégie thérapeutique utilisant l'association amoxicilline–acide clavulanique par voie veineuse avec relais oral dans les pneumopathies précoces du patient sous ventilation artificielle. Med Mal Infect 2001. [DOI: 10.1016/s0399-077x(01)00163-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Arancibia F, Ewig S, Martinez JA, Ruiz M, Bauer T, Marcos MA, Mensa J, Torres A. Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications. Am J Respir Crit Care Med 2000; 162:154-60. [PMID: 10903235 DOI: 10.1164/ajrccm.162.1.9907023] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of the study was to determine the causes and prognostic implications of antimicrobial treatment failures in patients with nonresponding and progressive life-threatening, community-acquired pneumonia. Forty-nine patients hospitalized with a presumptive diagnosis of community-acquired pneumonia during a 16-mo period, failure to respond to antimicrobial treatment, and documented repeated microbial investigation >/= 72 h after initiation of in-hospital antimicrobial treatment were recorded. A definite etiology of treatment failure could be established in 32 of 49 (65%) patients, and nine additional patients (18%) had a probable etiology. Treatment failures were mainly infectious in origin and included primary, persistent, and nosocomial infections (n = 10 [19%], 13 [24%], and 11 [20%] of causes, respectively). Definite but not probable persistent infections were mostly due to microbial resistance to the administered initial empiric antimicrobial treatment. Nosocomial infections were particularly frequent in patients with progressive pneumonia. Definite persistent infections and nosocomial infections had the highest associated mortality rates (75 and 88%, respectively). Nosocomial pneumonia was the only cause of treatment failure independently associated with death in multivariate analysis (RR, 16.7; 95% CI, 1.4 to 194.9; p = 0.03). We conclude that the detection of microbial resistance and the diagnosis of nosocomial pneumonia are the two major challenges in hospitalized patients with community-acquired pneumonia who do not respond to initial antimicrobial treatment. In order to establish these potentially life-threatening etiologies, a regular microbial reinvestigation seems mandatory for all patients presenting with antimicrobial treatment failures.
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Affiliation(s)
- F Arancibia
- Servei de Pneumologia i Al.lergia Respiratoria, Servei de Malalties Infeccioces, Servei de Microbiologia, Hospital Clinic i Provincial, Universitat de Barcelona, Spain
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Corne P, Bourdin A, Hernandez M, Landreau L, Jonquet O. [Aspiration pneumonia from Pasteurella multocida]. Rev Med Interne 1999; 20:951-2. [PMID: 10573736 DOI: 10.1016/s0248-8663(00)80105-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ruiz M, Ewig S, Marcos MA, Martinez JA, Arancibia F, Mensa J, Torres A. Etiology of community-acquired pneumonia: impact of age, comorbidity, and severity. Am J Respir Crit Care Med 1999; 160:397-405. [PMID: 10430704 DOI: 10.1164/ajrccm.160.2.9808045] [Citation(s) in RCA: 421] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to determine the etiology of community-acquired pneumonia (CAP) and the impact of age, comorbidity, and severity on microbial etiologies of such pneumonia. Overall, 395 consecutive patients with CAP were studied prospectively during a 15-mo period. Regular microbial investigation included examination of sputum, blood culture, and serology. Sampling of pleural fluid, transthoracic puncture, tracheobronchial aspiration, and protected specimen brush (PSB) sampling were performed in selected patients. The microbial etiology was determined in 182 of 395 (46%) cases, and 227 pathogens were detected. The five most frequent pathogens were Streptococcus pneumoniae (65 patients [29%]), Haemophilus influenzae (25 patients [11%]), Influenza virus A and B (23 patients [10%]), Legionella sp. (17 patients [8%]), and Chlamydia pneumoniae (15 patients [7%]). Gram-negative enteric bacilli (GNEB) accounted for 13 cases (6%) and Pseudomonas aeruginosa for 12 cases of pneumonia (5%). Patients aged < 60 yr were at risk for an "atypical" bacterial etiology (odds ratio [OR]: 2.3; 95% confidence interval [CI]: 1.2 to 4.5), especially Mycoplasma pneumoniae (OR: 5.3; 95% CI: 1.7 to 16.8). Comorbid pulmonary, hepatic, and central nervous illnesses, as well as current cigarette smoking and alcohol abuse, were all associated with distinct etiologic patterns. Pneumonia requiring admission to the intensive care unit was independently associated with the pathogens S. pneumoniae (OR: 2.5; 95% CI: 1.3 to 4.7), gram-negative enteric bacilli, and P. aeruginosa (OR: 2.5; 95% CI: 0.99 to 6.5). Clinical and radiographic features of "typical" pneumonia were neither sensitive nor specific for the differentiation of pneumococcal and nonpneumococcal etiologies. These results support a management approach based on the associations between etiology and age, comorbidity, and severity, instead of the traditional syndromic approach to CAP.
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Affiliation(s)
- M Ruiz
- Department of Medicine, University of Barcelona, Barcelona, Spain
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