Bacterial profile, antimicrobial susceptibility patterns, and associated factors of community-acquired pneumonia among adult patients in Gondar, Northwest Ethiopia: A cross-sectional study

Introduction

Community-acquired pneumonia is associated with higher morbidity, hospitalization, and mortality in adults. Likewise, antimicrobial resistance has increased in recent decades in Ethiopia. Therefore, this study was aimed to determine the bacterial isolates, their antimicrobial susceptibility patterns, and factors associated with community-acquired pneumonia among adult patients in Gondar, Northwest Ethiopia.

Materials and methods

This institutional-based cross-sectional study was conducted from April to June 2021. Sociodemographic, clinical, and other relevant data were collected using a pre-tested questionnaire. A total of 312 sputum specimens were collected using sputum cups and inoculated into blood agar, chocolate agar, mannitol salt agar, and MacConkey agar plates, which were then incubated at 37°C for 24 hours. The bacterial isolates were identified based on Gram staining, colony characteristics, and biochemical tests. Antimicrobial susceptibility testing was performed using the Kirby-Bauer disk diffusion method. Inducible clindamycin resistance among the S. aureus isolates was detected by the D-test. Data were entered using EPI data version 4.6 and analyzed using SPSS version 20. P-value ≤ 0.05 at 95% CI was considered statistically significant.

Results

Of 312 cases, 39.4% (n = 123; 95% CI: 34.1%–44.9%) were found to have culture-confirmed pneumonia. The most common isolates were K. pneumoniae (31.0%, n = 39), S. pneumoniae (26.2%, n = 33), and S. aureus (20.6%, n = 26). The gram-positive bacteria were susceptible to chloramphenicol (100%) and clindamycin (96.6%). Gram-negative bacteria were susceptible to gentamicin (87.5%), azithromycin (87.1%), ciprofloxacin (86.6%), and ceftriaxone (79.0%) but highly resistant to ampicillin (100%), followed by tetracycline (87.1%), doxycycline (86.4%), co-trimoxazole (80.6%), and amoxicillin-clavulanic acid (79.0%). Overall, 72.2% of the isolates were multi-drug resistant to K. pneumoniae (94.9%, n = 37), E. coli (93.8%, n = 15), and S. pneumoniae (72.7%, n = 24). Only, 7.7% of S. aureus isolates showed inducible clindamycin resistance. Aging (AOR: 3.248, 95% CI: 1.001–10.545, p = 0.050), a history of pneumonia (AOR: 7.004, 95% CI: 3.591–13.658, p = 0.001), alcohol use (AOR: 6.614, 95% CI: 3.399–12.872, p < 0.001), and overcrowded living conditions (AOR: 4.348, 95% CI: 1.964–9.624, p = 0.001) were significantly associated with culture-positive sputum.

Conclusion and recommendations

This study found a high prevalence of bacteria-caused community-acquired pneumonia among adults and low susceptibility to ampicillin, tetracyclines, and amoxicillin-clavulanic acid. Therefore, culture-based bacterial identification and local antibiotic susceptibility testing should be performed regularly. Additionally, new insights into vaccine coverage against highly multi-drug resistant bacteria, particularly K. pneumoniae, are necessary.

Genetic Regulation of Cytokine Response in Patients with Acute Community-Acquired Pneumonia

Background: Community-acquired pneumonia (CAP) is an acute disease condition with a high risk of rapid deteriorations. We analysed the influence of genetics on cytokine regulation to obtain a better understanding of patient’s heterogeneity. Methods: For up to N = 389 genotyped participants of the PROGRESS study of hospitalised CAP patients, we performed a genome-wide association study of ten cytokines IL-1β, IL-6, IL-8, IL-10, IL-12, MCP-1 (MCAF), MIP-1α (CCL3), VEGF, VCAM-1, and ICAM-1. Consecutive secondary analyses were performed to identify independent hits and corresponding causal variants. Results: 102 SNPs from 14 loci showed genome-wide significant associations with five of the cytokines. The most interesting associations were found at 6p21.1 for VEGF (p = 1.58 × 10⁻²⁰), at 17q21.32 (p = 1.51 × 10⁻⁹) and at 10p12.1 (p = 2.76 × 10⁻⁹) for IL-1β, at 10p13 for MIP-1α (CCL3) (p = 2.28 × 10⁻⁹), and at 9q34.12 for IL-10 (p = 4.52 × 10⁻⁸). Functionally plausible genes could be assigned to the majority of loci including genes involved in cytokine secretion, granulocyte function, and cilial kinetics. Conclusion: This is the first context-specific genetic association study of blood cytokine concentrations in CAP patients revealing numerous biologically plausible candidate genes. Two of the loci were also associated with atherosclerosis with probable common or consecutive pathomechanisms.

Activation and Functional Alteration of Mucosal-Associated Invariant T Cells in Adult Patients With Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) remains the significant infectious cause of morbidity and mortality worldwide. Although mucosal-associated invariant T cells (MAIT) play roles in the pathogenesis of children CAP and ICU-associated pneumonia, their roles in adult CAP are largely unexplored. In this study, we investigated the frequency, phenotype, and function of MAIT cells in peripheral blood and bronchoalveolar lavage fluid (BALF) of adult CAP patients. Our data indicate that MAIT-cell frequency is profoundly lower in the peripheral blood of CAP patients compared to that in healthy individuals. Furthermore, the circulatory MAIT cells express higher levels of CD69 and PD-1 compared to those in healthy individuals. In BALF of CAP patients, MAIT-cell frequency is higher and MAIT cells express higher levels of CD69 and PD-1 compared to their matched blood counterparts. Levels of IL-17A and IFN-γ are increased in BALF of CAP patients compared to those in BALF of patients with pulmonary small nodules. The IL-17A/IFN-γ ratio is significantly positively correlated with MAIT frequency in BALF of CAP patients, suggesting a pathogenic role of MAIT-17 cells in CAP. Of note, blood MAIT-cell frequency in CAP patients is strongly negatively correlated with high-sensitivity C-reactive protein (hsCRP) and neutrophil count percentage in blood. The ability of circulating MAIT cells in CAP patients to produce IFN-γ is significantly impaired compared to those in healthy individuals. In summary, our findings suggest the possible involvement of MAIT cells in the immunopathogenesis of adult CAP.

Krueppel-Like Factor 4 Expression in Phagocytes Regulates Early Inflammatory Response and Disease Severity in Pneumococcal Pneumonia

The transcription factor Krueppel-like factor (KLF) 4 fosters the pro-inflammatory immune response in macrophages and polymorphonuclear neutrophils (PMNs) when stimulated with Streptococcus pneumoniae, the main causative pathogen of community-acquired pneumonia (CAP). Here, we investigated the impact of KLF4 expression in myeloid cells such as macrophages and PMNs on inflammatory response and disease severity in a pneumococcal pneumonia mouse model and in patients admitted to hospital with CAP. We found that mice with a myeloid-specific knockout of KLF4 mount an insufficient early immune response with reduced levels of pro-inflammatory cytokines and increased levels of the anti-inflammatory cytokine interleukin (IL) 10 in bronchoalveolar lavage fluid and plasma and an impaired bacterial clearance from the lungs 24 hours after infection with S. pneumoniae. This results in higher rates of bacteremia, increased lung tissue damage, more severe symptoms of infection and reduced survival. Higher KLF4 gene expression levels in the peripheral blood of patients with CAP at hospital admission correlate with a favourable clinical presentation (lower sequential organ failure assessment (SOFA) score), lower serum levels of IL-10 at admission, shorter hospital stay and lower mortality or requirement of intensive care unit treatment within 28 days after admission. Thus, KLF4 in myeloid cells such as macrophages and PMNs is an important regulator of the early pro-inflammatory immune response and, therefore, a potentially interesting target for therapeutic interventions in pneumococcal pneumonia.

One year after ICU admission for severe community-acquired pneumonia of bacterial, viral or unidentified etiology. What are the outcomes?

INTRODUCTION

Multiplex polymerase chain reaction (mPCR) for respiratory virus testing is increasingly used in community-acquired pneumonia (CAP), however data on one-year outcome in intensive care unit (ICU) patients with reference to the causative pathogen are scarce.

MATERIALS AND METHODS

We performed a single-center retrospective study in 123 ICU patients who had undergone respiratory virus testing for CAP by mPCR and with known one-year survival status. Functional status including dyspnea (mMRC score), autonomy (ADL Katz score) and need for new home-care ventilatory support was assessed at a one-year post-ICU follow-up. Mortality rates and functional status were compared in patients with CAP of a bacterial, viral or unidentified etiology one year after ICU admission.

RESULTS

The bacterial, viral and unidentified groups included 19 (15.4%), 37 (30.1%), and 67 (54.5%) patients, respectively. In multivariate analysis, one-year mortality in the bacterial group was higher compared to the viral group (HR 2.92, 95% CI 1.71-7.28, p = 0.02) and tended to be higher compared to the unidentified etiology group (p = 0.06); but no difference was found between the viral and the unidentified etiology group (p = 0.43). In 64/83 one-year survivors with a post-ICU follow-up consultation, there were no differences in mMRC score, ADL Katz score and new home-care ventilatory support between the groups (p = 0.52, p = 0.37, p = 0.24, respectively). Severe dyspnea (mMRC score = 4 or death), severe autonomy deficiencies (ADL Katz score ≤ 2 or death), and major adverse respiratory events (new home-care ventilatory support or death) were observed in 52/104 (50.0%), 47/104 (45.2%), and 65/104 (62.5%) patients, respectively; with no difference between the bacterial, viral and unidentified group: p = 0.58, p = 0.06, p = 0.61, respectively.

CONCLUSIONS

CAP of bacterial origin had a poorer outcome than CAP of viral or unidentified origin. At one-year, impairment of functional status was frequently observed, with no difference according to the etiology.

Antibiotic treatment with one single dose of gentamicin at admittance in addition to a β-lactam antibiotic in the treatment of community-acquired bloodstream infection with sepsis

Background

Combination therapy in the treatment of sepsis, especially the value of combining a β-Lactam antibiotic with an aminoglycoside, has been discussed. This retrospective cohort study including patients with sepsis or septic shock aimed to investigate whether one single dose of gentamicin at admittance (SGA) added to β-Lactam antibiotic could result in a lower risk of mortality than β-Lactam monotherapy, without exposing the patient to the risk of nephrotoxicity.

Methods and findings

All patients with positive blood cultures were evaluated for participation (n = 1318). After retrospective medical chart review, a group of patients with community-acquired sepsis with positive blood cultures who received β-Lactam antibiotic with or without the addition of SGA (n = 399) were included for the analysis. Mean age was 74.6 yrs. (range 19–98) with 216 (54%) males. Sequential Organ Failure Assessment score (SOFA score) median was 3 (interquartile range [IQR] 2–5) and the median Charlson Comorbidity Index for the whole group was 2 (IQR 1–3). Sixty-seven (67) patients (17%) had septic shock. The 28-day mortality in the combination therapy group was 10% (20 of 197) and in the monotherapy group 22% (45 of 202), adjusted HR 3.5 (95% CI (1.9–6.2), p = < 0.001. No significant difference in incidence of acute kidney injury (AKI) was detected.

Conclusion

This retrospective observational study including patients with community-acquired sepsis or septic shock and positive blood cultures, who meet Sepsis-3 criteria, shows that the addition of one single dose of gentamicin to β-lactam treatment at admittance was associated with a decreased risk of mortality and was not associated with AKI. This antibiotic regime may be an alternative to broad-spectrum antibiotic treatment of community-acquired sepsis. Further prospective studies are warranted to confirm these results.

COVID-19 Is Distinct From SARS-CoV-2-Negative Community-Acquired Pneumonia

Background: Corona virus disease (COVID-19) is an infectious respiratory disease that has spread rapidly across the world. Many studies have already evaluated the clinical features of COVID-19, but how it compares with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-negative community-acquired pneumonia (SN-CAP) is still unclear. Moreover, COVID-19 mortality is correlated with disease severity, but indicators for severity grading have not been specified. We aimed to analyze the clinical characteristics of COVID-19 in comparison with SN-CAP and find indicators for disease severity in COVID-19. Methods: Patients diagnosed with COVID-19 and SN-CAP were enrolled. Clinical, radiological, and laboratory data were analyzed. Results: The numbers of COVID-19 and SN-CAP patients enrolled were 304 and 138, respectively. The age of the patients was not significantly different between the groups. Compared with SN-CAP, COVID-19 patients had more symptoms of fever and dyspnea; and showed significant difference in blood count results. Computed tomography (CT) imaging of COVID-19 patients showed patchy ground-glass opacities that correlated with disease severity, whereas the CT imaging of SN-CAP patients showed patchy high-density shadows. COVID-19 patients were classified into moderate, severe, and critically severe groups. The severe and critically severe groups had elevated levels of white blood cells (WBC), neutrophils, platelets, C-reaction protein (CRP), lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), troponin-I, creatinine, and blood urea nitrogen (BUN). However, they had decreased levels of lymphocytes, lymphocyte ratio, and albumin. Compared with the younger patients, the older COVID-19 individuals had more chronic diseases and significantly elevated levels of WBC, neutrophil, and CRP levels. Conclusion: SN-CAP showed more inflammatory reaction than COVID-19. Old people with chronic diseases are more susceptible to COVID-19 and have a high likelihood of developing severe and critically severe infection. Levels of WBC, lymphocytes, neutrophils, CRP, NLR, PLR, troponin-I, creatinine, and BUN are important indicators for severity grading in COVID-19.

Public health might be endangered by possible prolonged discharge of SARS-CoV-2 in stool

•The published data, which showed the COVID-19 patients with low digestive. •manifestation, might be misleading. Case with negative URT test showed positive in. •rectal scarab which challenge the isolation protocol. •As fomite transmission caused clusters of infection of SARS, adequate disinfection. •operations should be adopted in SARS-CoV-2 outbreak.

Mucosal-associated invariant T cells and Vδ2+ γδ T cells in community acquired pneumonia: association of abundance in sputum with clinical severity and outcome

Mucosal-associated invariant T (MAIT) cells and Vδ2+ γδ T cells are anti-bacterial innate-like lymphocytes (ILLs) that are enriched in blood and mucosa. ILLs have been implicated in control of infection. However, the role of ILLs in community-acquired pneumonia (CAP) is unknown. Using sputum samples from a well-characterized CAP cohort, MAIT cell and Vδ2+ T cell abundance was determined by quantitative polymerase chain reaction (qPCR). Cytokine and chemokine concentrations in sputum were measured. The capacity of bacteria in sputum to produce activating ligands for MAIT cells and Vδ2+ T cells was inferred by 16S rRNA sequencing. MAIT cell abundance in sputum was higher in patients with less severe pneumonia; duration of hospital admission was inversely correlated with both MAIT and Vδ2+ T cell abundance. The abundance of both ILLs was higher in patients with a confirmed bacterial aetiology; however, there was no correlation with total bacterial load or the predicted capacity of bacteria to produce activating ligands. Sputum MAIT cell abundance was associated with interferon (IFN)-α, IFN-γ, and sputum neutrophil abundance, while Vδ2+ T cell abundance was associated with CXCL11 and IFN-γ. Therefore, MAIT and Vδ2+ T cells can be detected in sputum in CAP, where they may contribute to improved clinical outcome.

Community-acquired bacterial meningitis in adults: in-hospital prognosis, long-term disability and determinants of outcome in a multicentre prospective cohort

OBJECTIVES

To identify factors associated with unfavourable in-hospital outcome (death or disability) in adults with community-acquired bacterial meningitis (CABM).

METHODS

In a prospective multicentre cohort study (COMBAT; February 2013 to July 2015), all consecutive cases of CABM in the 69 participating centres in France were enrolled and followed up for 12 months. Factors associated with unfavourable outcome were identified by logistic regression and long-term disability was analysed.

RESULTS

Among the 533 individuals enrolled, (Streptococcus pneumoniae 53.8% (280/520 isolates identified), Neisseria meningitidis 21.3% (111/520), others 24.9% (129/520)), case fatality rate was 16.9% (90/533) and unfavourable outcome occurred in 45.0% (225/500). Factors independently associated with unfavourable outcome were: age >70 years (adjusted odds ratio (aOR) 4.64; 95% CI 1.93-11.15), male gender (aOR 2.11; 95% CI 1.25-3.57), chronic renal failure (aOR 6.65; 95% CI 1.57-28.12), purpura fulminans (aOR 4.37; 95% CI 1.38-13.81), localized neurological signs (aOR 3.72; 95% CI 2.29-6.05), disseminated intravascular coagulation (aOR 3.19; 95% CI 1.16-8.79), cerebrospinal fluid (CSF) white-cell count <1500 cells/μL (aOR 2.40; 95% CI 1.42-4.03), CSF glucose concentration (0.1-2.5 g/L: aOR 1.92; 95% CI 1.01-3.67; <0.1 g/L: aOR 2.24; 95% CI 1.01-4.97), elevated CSF protein concentration (aOR 1.09; 95% CI 1.03-1.17), time interval between hospitalization and lumbar puncture >1 day (aOR 2.94; 95% CI 1.32-6.54), and S. pneumoniae meningitis (aOR 4.99; 95% CI 1.98-12.56), or meningitis other than N. meningitidis (aOR 4.54; 95% CI 1.68-12.27). At 12 months, 26.7% (74/277) had hearing loss, 32.8% (87/265) depressive symptoms, 31.0% (86/277) persistent headache, and 53.4% had a physical health-related quality of life (142/266) <25th centile of the distribution of the score in the general French population (p < 0.0001).

CONCLUSIONS

The burden of CABM (death, disability, depression, impaired quality of life and hearing loss) is high. Identification of cases from the first symptoms may improve prognosis.

CLINICALTRIAL

Gov identification number: NCT01730690.

Differences between Community - and Hospital - acquired urinary tract infections in a tertiary care hospital

The aim of this retrospective study was to highlight the differences in antibiotic resistance between Hospital-acquired and Community-acquired urinary tract infections (UTIs). Antimicrobial UTIs resistance data were collected from March 2011 to March 2018. Uropathogens were identified from 41,715 patients using routine laboratory methods. Differences in antibiotic resistance between Hospital and Community (non-hospitalized) patients were statistically validated. Odds ratio (OR) and p-values was used to determine whether a particular exposure (hospitalization) was a risk factor for a particular outcome (higher antibiotic resistance). We reported a general increase of unnecessary urine cultures in both community and hospital patients. The most representative microorganism isolated from Community (58.2%) and Hospital (47.6%) was E. coli. UTIs causative bacteria in hospitalized patients was more than twice as resistant to Trimetoprim/sulphamethoxazole (OR 2.26) and Imipenem (OR 2.56), for Gram-positive and Gram-negative, respectively, than in Community patients. Nitrofurantoin was the only agent without differences in resistance rate between community and hospital UTIs. Therefore, physicians could use it as a definitive therapy for uncomplicated cystitis and as a prophylactic agent for recurrent uncomplicated cystitis. With this work we provided a general protocol applicable by physicians to select the most suitable, if necessary, UTIs empiric treatment.

Serum Exosomal MicroRNAs Predict Acute Respiratory Distress Syndrome Events in Patients with Severe Community-Acquired Pneumonia

BACKGROUND

Severe community-acquired pneumonia (SCAP) requiring intensive care unit (ICU) treatment commonly causes acute respiratory distress syndrome (ARDS) with high mortality. This study was aimed at evaluating whether microRNAs (miRNAs) in circulating exosomes have the predictive values for patients at risk of developing ARDS due to SCAP.

METHODS

ARDS/ALI-relevant miRNAs were obtained by literature search. Exosomes in serum were isolated by ultracentrifugation method and identified by Transmission Electron Microscopy. Then the miR profiling in the exosomes using real-time PCR was analyzed in SCAP patients with or without ARDS. Moreover, multivariate Cox proportional regression analysis was performed to estimate the odds ratio of miRNA for the occurrence of ARDS and prognosis. The receiver operating characteristics (ROC) curves were calculated to discriminate ARDS cases. Finally, the Kaplan-Meier curve using log-rank method was performed to test the equality for survival distributions with different miRNA classifiers.

RESULTS

A total of 53 SCAP patients were finally recruited. Ten miRNAs were picked out. Further, a subset of exosomal miRNAs, including the miR-146a, miR-27a, miR-126, and miR-155 in ARDS group exhibited significantly elevated levels than those in non-ARDS group. The combined expression of miR-126, miR-27a, miR-146a, and miR-155 predicted ARDS with an area under the curve of 0.909 (95 % CI 0.815 -1). Only miR-126 was selected to have potential to predict the 28-day mortality (OR=1.002, P=0.024) with its median value classifier.

CONCLUSIONS

The altered levels of circulating exosomal microRNAs may be useful biologic confirmation of ARDS in patients with SCAP.

Guidelines to Manage Community-Acquired Pneumonia

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

Circulating sphingosine-1-phosphate as a prognostic biomarker for community-acquired pneumonia

Early determination of the severity of Community-Acquired Pneumonia (CAP) is essential for better disease prognosis. Current predictors are suboptimal, and their clinical utility remains to be defined, highlighting the need for developing biomarkers with efficacious prognostic value. Sphingosine-1-phosphate (S1P) is a bioactive sphingolipid with a documented regulatory role in immune defense and maintenance of endothelial barrier integrity. For early diagnose of CAP and recognition of severe CAP patients, we conduct this pilot study to access the potential utility of the circulating S1P in an Emergency department setting. In the prospective study, plasma S1P levels were quantified in healthy controls and patients with CAP. Also, their discriminating power was assessed by receiver operating characteristic analysis. The association between S1P levels and disease severity indices was assessed by Spearman correlation and logistic regression tests. Patients with CAP had significantly higher plasma S1P levels than healthy individuals (CAP: 27.54 ng/ml, IQR = 14.37–49.99 ng/ml; Controls: 10.58 ng/ml, IQR = 4.781–18.91 ng/ml; p < 0.0001). S1P levels were inversely correlated with disease severity in patients with CAP. Based on multivariate logistic regression analysis, the plasma S1P concentrations showed significant predicting power for mortality (OR: 0.909; CI: 0.801–0.985; p < 0.05), intensive care unit admission (OR: 0.89; CI: 0.812–0.953; p < 0.005) and long hospital stay (OR: 0.978; CI: 0.961–0.992; p < 0.005). Interestingly, significantly elevated levels of S1P were noted in patients who received methylprednisolone treatment during hospitalization. These results suggest that S1P may be associated with the pathogenesis of CAP and may have prognostic utility in CAP and its therapy, especially in the Emergency Department setting.

Acute Community-Acquired Bacterial Meningitis: Update on Clinical Presentation and Prognostic factors

The epidemiology of community-acquired bacterial meningitis (CABM) in adults has changed significantly in the past several years. Despite substantial improvement in patient care, CABM remains a major cause of morbidity and mortality. Thus, new prognostic factors could help improve patient stratification. We conducted a multicenter retrospective study to determine the clinical pattern of CABM in an urban area of Western Europe and to identify potential predictors of unfavorable prognosis and complicated course. Over a period of 6-8 years, 79 adult CABM cases were treated at three tertiary hospitals. A Glasgow Outcome Scale (GOS) score of ≤4 was defined as unfavorable outcome. Predictors of unfavorable prognosis or complicated course were identified through logistic-regression analysis. S. pneumoniae was the most frequent pathogen (34%). 82% of patients exhibited at least two of five signs, including fever, neck stiffness, altered mental status, headache and nausea. Almost 50% presented focal neurological deficits; the overall mortality rate was 15%. In the multivariate analysis, risk factors for an unfavorable outcome included a GCS score of ≤13, female sex, and etiology by L. monocytogenes and gram-negative bacilli. However, risk factors for systemic complications were a GCS score of ≤13 and reduced platelet count, whereas C-Reactive Protein (CRP) increase was associated with a higher rate of neurological complications. Patients with non-pneumococcal CABM were more prone to an unfavorable outcome, probably because of underutilization of empiric ampicillin in patients at risk of listeriosis and because the suspicion of pneumococcal infection was facilitated by the existence of otitis and the higher yield of Gram's stain. Patients presenting a GCS of ≤13, thrombocytopenia and/or increased CRP, may benefit from more aggressive care to avoid in-hospital complications and neurological sequelae.

The impact of glycemic variability on length of stay and mortality in diabetic patients admitted with community-acquired pneumonia or chronic obstructive pulmonary disease

AIM

To investigate the influence of glycemic variability (GV) on length of stay and in-hospital mortality in non-critical diabetic patients.

METHODS

A observation retrospective study was performed. Diabetic patients admitted between January and June 2016 with the diagnosis of community-acquire pneumonia (CAP) and/or acute exacerbation of chronic obstructive pulmonary disease (COPD) were enrolled and glycemic control (persistent hyperglycemia, hypoglycemia, mean glucose level (MGL) and respective standard deviation (SD) and coefficient of variation (CV)) were evaluated. Primary outcomes were length of stay and in-hospital mortality.

RESULTS

Data from 242 patients were analyzed. Fifty-eight percent of the patients were male, with a median age of 77 years (min-max, 29-98). Patients had on average 2.1 glucose readings-day and the MGL was 193.3 mg/dl (min-max, 84.3-436.6). Hypoglycemia was documented in 13.4% of the patients and 55.4% had persistent hyperglycemia. The median length of hospital stay was 10 days (min-max, 1-66) and in-hospital mortality was 7.4%. We found a significant higher in-hospital mortality in older patients, with history of cancer and with nosocomial infections. We did not find any correlation between MGL, SD, CV, hypoglycemia or persist hyperglycemia and in-hospital mortality. A longer length of stay was observed in patients with heavy alcohol consumption and nosocomial infections. The length of stay was negatively correlated with the mean glucose level (r²-0.147; p < 0.05) and positively correlated with the coefficient of variation (p 0.162; p < 0.05).

CONCLUSION

This study confirmed the negative impact of the glycemic variability in the outcomes of diabetic patients admitted with CAP or acute exacerbation of COPD.

[Clinical features of community-acquired pneumonia associated with acute kidney injury in elderly patients.]

The aim of the study was to determin the incidence, severity and prognostic significance of acute kidney injury (AKI) in elderly patients with community-acquired pneumonia (CAP). 122 older patients (≥60 years) with community-acquired pneumonia were examined. Acute kidney injury was diagnosed in 49 (40,2%) patients including 47 (95,9%) patients with AKI occurring prehospital. In patients with community-acquired pneumonia associated with acute kidney injury the clinical picture of AKI was harder. Also disturbance of consciousness, dyspnea, leg swelling, tachycardia, abnormal liver function tests such as hyperbilirubinemia and hypertransaminasemia were diagnosed more frequently in this group of patients. With the development of AKI increased in-hospital mortality: odds ratio of death among patients with CAP associated with AKI was 8,3 (95% CI 2,75-25,28). So, the development of AKI in elderly patients with CAP is an actual health problem requiring the development of preventive measures and drug therapy in patients with CAP and also mandatory monitoring of patients who have had acute kidney injury.

Prognostic performance of MR-pro-adrenomedullin in patients with community acquired pneumonia in the Emergency Department compared to clinical severity scores PSI and CURB

AIM

(i) evaluate the performance of MR-pro-ADM in reflecting the outcome and risk for CAP patients in the emergency department, and (ii) compare the prognostic performance of MR-pro-ADM with that of clinical scores PSI and CURB65.

METHODS

Observational prospective, single-center study in patients with suspected community acquired pneumonia (CAP). Eighty one patients underwent full clinical and laboratory assessment as by protocol, and were followed up a 28 days. Primary endpoints measured were: death, death at 14 days, non-invasive mechanical ventilation (NIMV), endotracheal intubation (EI), ICU admission, overall hospital stay >10 days, emergency department stay >4 days. The discriminative performance of MR-pro-ADM and clinical scores was assessed by AUROC analysis.

RESULTS

The distribution for MR-pro-ADM followed an upward trend, increasing with the increase of both PSI (p<0.001) and CURB65 (p<0.001) classes. However, the difference between MRproADM values and score classes was significant only in the case of CURB65 classes 0 and 1 (p = 0.046), 2 (p = 0.013), and 3 (p = 0.011); and with PSI classes 5, 3 (p = 0.044), and 1 (p = 0.020). As to the differences among variables for the six end-points, MR-pro-ADM values in the two groups selected for each considered end-point differed in a statistically significant manner for all endpoints. Both PSI and CURB65 differed significantly for all end-points, except for stay in the ED longer than 4 days and the hospital stay longer than 10 days and endotracheal intubation (only PSI classes differed with statistical significance). ROC analyses evidenced that MR-pro-ADM values gave the greatest AUC for the prediction of death, endotracheal intubation, hospital stay >10 days and DE stay >4 days, compared to the PSI and CURB (though difference not statistically significant). For each endpoint measured, the best thresholds values for Mr-pro-ADM were: 1.6 (specificity 76.5%; sensitivity 77.8%) for death; 2.5 (specificity 88.9%; sensitivity 80.0%) for death at 14 days; 1.5 (specificity 77.0%; sensitivity 87.5%) for NIMV; 2.4 (specificity 88.7%; sensitivity 83.3%) for endotracheal intubation; 0.9 (specificity 53.5%; sensitivity 70.6%) for DE stay greater than 4 days; 1.9 (specificity 82.1%; sensitivity 55.3%) for hospital stay greater than 10 days. The AUC for the combination of MR-pro-ADM and PSI was 81.29% [63.41%-99.17%], but not in a statistically significant manner compared to the AUCs of the single predictors. Conversely, the AUC for the combination of MR-pro-ADM and CURB65 was 87.58% [75.54%-99.62%], which was significantly greater than the AUC of CURB65 (p = 0.047) or PSI (p = 0.017) alone.

CONCLUSIONS

The present study confirms that assessment of MR-pro-ADM levels in CAP patients in addition to CURB scores increases the prognostic accuracy of CURB alone and may help rule out discrepancies arising from flawed clinical severity classification. With particular reference to patients scoring in the upper classes of CURB and PSI, MR-pro-ADM values provided additional information towards a better risk stratification of those patients. In particular, our results pointed towards two MR-pro-ADM threshold values that appear to predict with a good degree of accuracy the patient's need for non-invasive mechanical ventilation, endotracheal intubation, or intensive care. This aspect, however, deserves further investigation.

Proteomic study revealed cellular assembly and lipid metabolism dysregulation in sepsis secondary to community-acquired pneumonia

Sepsis is a life-threatening disorder characterized by organ dysfunction and a major cause of mortality worldwide. The major challenge in studying sepsis is its diversity in such factors as age, source of infection and etiology. Recently, genomic and proteomic approaches have improved our understanding of its complex pathogenesis. In the present study, we use quantitative proteomics to evaluate the host proteome response in septic patients secondary to community-acquired pneumonia (CAP). Samples obtained at admission and after 7 days of follow-up were analyzed according to the outcomes of septic patients. The patients' proteome profiles were compared with age- and gender-matched healthy volunteers. Bioinformatic analyses of differentially expressed proteins showed alteration in the cytoskeleton, cellular assembly, movement, lipid metabolism and immune responses in septic patients. Actin and gelsolin changes were assessed in mononuclear cells using immunofluorescence, and a higher expression of gelsolin and depletion of actin were observed in survivor patients. Regarding lipid metabolism, changes in cholesterol, HDL and apolipoproteins were confirmed using enzymatic colorimetric methods in plasma. Transcriptomic studies revealed a massive change in gene expression in sepsis. Our proteomic results stressed important changes in cellular structure and metabolism, which are possible targets for future interventions of sepsis.

A novel biochemical marker for community-acquired pneumonia: Ischemia-modified albumin

INTRODUCTION

Community-acquired pneumonia (CAP) is a frequent cause of hospitalization and a leading cause of mortality worldwide. Early diagnosis and the initiation of appropriate antibiotic therapy are essential to reduce pneumonia-related morbidity and mortality. CRP is a well-established biomarker in many clinical settings, but has been traditionally considered not specific enough to be a useful guide in the diagnostic process of pneumonia. There is still a need for more specific and practical markers in CAP for diagnosis. The aim of this study was to investigate the diagnostic value of ischemia-modified albumin (IMA) levels in the diagnosis of CAP in the Emergency Department.

METHODS

The study included 81 patients admitted with CAP and 81 control patients. Initial hour levels of IMA and CRP were measured. The IMA mean levels were compared between the study and control group. Correlation analyses were performed to investigate the association of serum IMA levels with CRP.

RESULTS

Mean levels of IMA were 0.532±0.117IU/ml in the study group and 0.345±0.082IU/ml in the control group. IMA levels were significantly higher in the study group compared to the control group. The IMA level of 0.442IU/ml had sensitivity of 75.3% and specificity of 91.3% and was positively correlated with CRP levels (r=0.506; p<0.05).

CONCLUSION

Blood IMA levels significantly increase in adult patients presenting with CAP. IMA may be considered as a novel biomarker in the diagnosis of CAP.

The Clinical Significance of FilmArray Respiratory Panel in Diagnosing Community-Acquired Pneumonia

AIM

FilmArray Respiratory Panel (FilmArray RP) test is an emerging diagnostic method in fast detecting multiple respiratory pathogens; the methodology and clinical significance of FilmArray RP in community-acquired pneumonia (CAP) diagnosis were evaluated in this study.

METHODS

Specimens from 74 patients with CAP were analyzed and compared using FilmArray RP, traditional multiple PCR assay, bacterial (or fungal) culture, and serological detection.

RESULTS

FilmArray RP and multiplex PCR showed 100% coincidence rate in detecting coronaviruses 229E, OC43, HKU1, and NL63, human metapneumovirus, influenza A and B, and parainfluenza viruses (PIV1, PIV2, and PIV4). There were 15 viral specimens tested as disagreement positive results. FilmArray RP had higher detection rate in detecting dual viral and Mycoplasma pneumoniae infection. The positive bacteria (or fungi) were found in 25 specimens.

CONCLUSIONS

This study demonstrated the capability of FilmArray RP for simultaneous detection of broad-spectrum respiratory pathogens and potential use in facilitating better patient care.

Efficacy and Safety of Adjunctive Corticosteroids Therapy for Severe Community-Acquired Pneumonia in Adults: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Adjunctive corticosteroids therapy is an attractive option for community-acquired pneumonia (CAP) treatment. However, the effectiveness of adjunctive corticosteroids on mortality of CAP remains inconsistent, especially in severe CAP. We performed a meta-analysis to evaluate the efficacy and safety of adjunctive corticosteroids in severe CAP patients.

METHODS

Three databases of PubMed, EMBASE and Cochrane Library were searched for related studies published in English up to December, 2015. Randomized controlled trials (RCTs) of corticosteroids in hospitalized adults with severe CAP were included. Meta-analysis was performed by a random-effect model with STATA 11.0 software. We estimated the summary risk ratios (RRs) or effect size (ES) with its corresponding 95% confidence interval (95%CI) to assess the outcomes.

RESULTS

We included 8 RCTs enrolling 528 severe CAP patients. Adjunctive corticosteroids significantly reduced all-cause mortality (RR = 0.46, 95%CI: 0.28 to 0.77, p = 0.003), risk of adult respiratory distress syndrome (ARDS) (RR = 0.23, 95%CI: 0.07 to 0.80, p = 0.02) and need for mechanical ventilation (RR = 0.50, 95%CI: 0.27 to 0.92, p = 0.026). Adjunctive corticosteroids did not increase frequency of hyperglycemia requiring treatment (RR = 1.03, 95%CI: 0.61 to 1.72, p = 0.91) or gastrointestinal hemorrhage (RR = 0.66, 95%CI: 0.19 to 2.31, p = 0.52). In subgroup analysis by duration of corticosteroids, we found that prolonged corticosteroids therapy significantly reduced all-cause mortality (RR = 0.41, 95%CI: 0.20 to 0.83, p = 0.01) and length of hospital stay (-4.76 days, 95% CI:-8.13 to -1.40, p = 0.006).

CONCLUSIONS

Results from this meta-analysis suggested that adjunctive corticosteroids therapy was safe and beneficial for severe CAP. In addition, prolonged corticosteroids therapy was more effective. These results should be confirmed by adequately powered studies in the future.

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

Background

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

Objective

To describe the predictors and the outcomes of early clinical stability

Methods

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

Results

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

Conclusions

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

[A Patient with a Wedge-shaped Pulmonary Lesion Associated with Streptococcus parasanguinis]

An 84-year-old man was admitted to our hospital with bloody sputum. He was found to have a right lower lobe wedge-shaped nodular lesion with chest X-ray and computed tomography of the chest. Ceftriaxone and minocycline were started empirically based on a working diagnosis of community-acquired pneumonia. Streptococcus parasanguinis was isolated with sputum cultures obtained on three consecutive days and was identified based on its biochemical properties. S. parasanguinis is a member of the sanguinis group of viridans Streptococci. It is known as a causative pathogen for endocarditis. There are very few reports of S. parasanguinis associated with pulmonary infections. The present report describes the association of S. parasanguinis with a wedge-shaped nodular lesion in the lungs.

Severe Community-Acquired Pneumonia Caused by Human Adenovirus in Immunocompetent Adults: A Multicenter Case Series

Background

Severe community-acquired pneumonia (CAP) caused by human adenovirus (HAdV), especially HAdV type 55 (HAdV-55) in immunocompetent adults has raised increasing concerns. Clinical knowledge of severe CAP and acute respiratory distress syndrome induced by HAdV-55 is still limited, though the pathogen has been fully characterized by whole-genome sequencing.

Methods

We conducted a multicentre retrospective review of all consecutive patients with severe CAP caused by HAdV in immunocompetent adults admitted to the Emergency Department Intensive Care Unit of two hospitals in Northern China between February 2012 and April 2014. Clinical, laboratory, radiological characteristics, treatments and outcomes of these patients were collected and analyzed.

Results

A total of 15 consecutive severe CAP patients with laboratory-confirmed adenovirus infections were included. The median age was 30 years and all cases were identified during the winter and spring seasons. HAdV-55 was the most frequently (11/15) detected HAdV type. Persistent high fever, cough and rapid progression of dyspnea were typically reported in these patients. Significantly increased pneumonia severity index (PSI), respiratory rate, and lower PaO₂/FiO₂, hypersensitive CRP were reported in non-survivors compared to survivors (P = 0.013, 0.022, 0.019 and 0.026, respectively). The rapid development of bilateral consolidations within 10 days after illness onset were the most common radiographic finding, usually accompanied by adjacent ground glass opacities and pleural effusions. Total mortality was 26.7% in this study. Corticosteroids were prescribed to 14 patients in this report, but the utilization rate between survivors and non-survivors was not significant.

Conclusions

HAdV and the HAdV-55 sub-type play an important role among viral pneumonia pathogens in hospitalized immunocompetent adults in Northern China. HAdV should be tested in severe CAP patients with negative bacterial cultures and a lack of response to antibiotic treatment, even if radiologic imaging and clinical presentation initially suggest bacterial pneumonia.

Community-acquired Haemophilus influenzae pneumonia--New insights from the CAPNETZ study

OBJECTIVES

We aimed to identify clinical characteristics and to assess effectiveness of different initial antibiotic regimens in adult patients with community-acquired pneumonia (CAP) caused by Haemophilus influenzae.

METHODS

Characteristics were compared between patients with H. influenzae monoinfection versus CAP of other and unknown aetiology enrolled by the German prospective cohort study CAPNETZ. Impact of initial antibiotic treatment on "early clinical response" according to FDA criteria and overall clinical cure were analysed.

RESULTS

H. influenzae was found in 176 out of 2790 patients with pathogen detection (6.3%). Characteristics significantly associated with a H. influenzae CAP (p < 0.017) included purulent sputum, prior pneumococcal vaccination and respiratory co-morbidities. Early clinical response rates on day 4 did not differ between patients receiving any mono- versus combination therapy (85.9% versus 88%), but were numerically higher for regimens including any fluoroquinolone (96.7%) and lower under macrolide monotherapy (70%). Initial CURB-65 score and chronic liver disease were identified as negative predictors for "early clinical response". At day 14, overall clinical cure was 91.9%.

CONCLUSIONS

H. influenzae was a common CAP pathogen, particularly in patients with previous pneumococcal vaccination and respiratory co-morbidities. Severity of illness and chronic liver disease were associated with a lower rate of "early clinical response".

Plasma Monocyte Chemoattractant Protein-1 Level as a Predictor of the Severity of Community-Acquired Pneumonia

Monocyte chemoattractant protein (MCP)-1 increases in the serum of immunocompetent patients with community-acquired pneumonia (CAP). However, the correlation between the circulating level of MCP-1 and severity of CAP remains unclear. This study investigated differential changes in the plasma MCP-1 levels of patients with CAP before and after an antibiotic treatment and further analyzes the association between the CAP severity and MCP-1 levels. We measured the plasma MCP-1 levels of 137 patients with CAP and 74 healthy controls by using a commercial enzyme-linked immunosorbent assay. Upon initial hospitalization, Acute Physiology and Chronic Health Evaluation II (APACHE II); confusion, urea level, respiratory rate, blood pressure, and age of >64 years (CURB-65); and pneumonia severity index (PSI) scores were determined for assessing the CAP severity in these patients. The antibiotic treatment reduced the number of white blood cells (WBCs) and neutrophils as well as the level of C-reactive protein (CRP) and MCP-1. The plasma MCP-1 level, but not the CRP level or WBC count, correlated with the CAP severity according to the PSI (r = 0.509, p < 0.001), CURB-65 (r = 0.468, p < 0.001), and APACHE II (r = 0.360, p < 0.001) scores. We concluded that MCP-1 levels act in the development of CAP and are involved in the severity of CAP.

Biomarkers for predicting short-term mortality in community-acquired pneumonia: A systematic review and meta-analysis

OBJECTIVES

The pneumonia severity index and CURB-65 are risk assessment tools widely used in community-acquired pneumonia (CAP). However, limitations in these prognostic scores have led to increasing interest in finding biomarkers that might provide additional information. To date, the role of these biomarkers has not been fully elucidated.

METHODS

We systematically searched the Medline, Web of Knowledge, Science Direct, and LILACS databases. We included studies that assessed the accuracy of biomarkers for the prediction of in-hospital or ≤30-day mortality, in hospitalized adults with CAP. Two independent investigators extracted patient and study characteristics, which were thereafter pooled using a random effects model. Relationships between sensitivity and specificity of biomarkers and prognostic scores were plotter using the area under the receiver operator characteristic curve (AUC).

RESULTS

We included 24 articles and 2 databases from 1069 reviewed abstracts, which provided 10,319 patients for analysis. Reported mortality rates varied from 2.4% to 34.6%. The highest AUC values for predicting mortality were associated with pro-adrenomedullin (0.80) and prohormone forms of atrial natriuretic peptide (0.79), followed by cortisol (0.78), procalcitonin (0.75), copeptin (0.71), and C-reactive protein (0.62). There were no statistically significant differences between the AUCs of the studied biomarkers, other than for copeptin and C-reactive protein, which performed comparatively poorly. When compared with the CAP-specific scores, the AUCs were not significantly different from those of most biomarkers.

CONCLUSIONS

The identified biomarkers are able to predict mortality with moderate to good accuracy in CAP. However, biomarkers have no clear advantage over CAP-specific scores for predicting mortality.

The natural history of community-acquired common colds symptoms assessed over 4-years

BACKGROUND

The common cold is the most frequently experienced infection among humans, but limited data exist to characterize the onset, duration, severity and intersection of symptoms in community-acquired colds. A more complete understanding of the symptom frequency and burden in naturally occurring colds is needed.

METHODOLOGY

We characterized common cold symptoms from 226 cold episodes experienced by 104 male or female subjects. Subjects were enrolled in the work environment in an attempt to start symptom evaluation (frequency and severity) at the earliest sign of their cold. We also assessed the symptom that had the greatest impact on the subject by asking them to identify their single most bothersome symptom.

RESULTS

Symptom reporting started within 24 hours of cold onset for most subjects. Sore throat was a harbinger of the illness but was accompanied by multiple symptoms, including nasal congestion, runny nose and headache. Cough was not usually the most frequent symptom, but was present throughout the cold, becoming most bothersome later in the cold. Nasal congestion, pain (eg, sore throat, headache, muscle pains) or feverishness and secretory symptoms (eg, runny nose, sneezing), and even cough, were simultaneously experienced with high incidence over the first 4 days of illness. The single most bothersome symptom was sore throat on day 1, followed by nasal congestion on days 2-5 and cough on days 6 and 7.

CONCLUSION

There is substantial overlap in the appearance of common cold symptoms over the first several days of the common cold. Nasal congestion, secretory and pain symptoms frequently occur together, with cough being somewhat less prominent, but quite bothersome when present. These data establish the typical symptomatology of a common cold and provide a foundation for the rational treatment of cold symptoms typically experienced by cold sufferers.

Individualizing risk of multidrug-resistant pathogens in community-onset pneumonia

Introduction

The diffusion of multidrug-resistant (MDR) bacteria has created the need to identify risk factors for acquiring resistant pathogens in patients living in the community.

Objective

To analyze clinical features of patients with community-onset pneumonia due to MDR pathogens, to evaluate performance of existing scoring tools and to develop a bedside risk score for an early identification of these patients in the Emergency Department.

Patients and Methods

This was an open, observational, prospective study of consecutive patients with pneumonia, coming from the community, from January 2011 to January 2013. The new score was validated on an external cohort of 929 patients with pneumonia admitted in internal medicine departments participating at a multicenter prospective study in Spain.

Results

A total of 900 patients were included in the study. The final logistic regression model consisted of four variables: 1) one risk factor for HCAP, 2) bilateral pulmonary infiltration, 3) the presence of pleural effusion, and 4) the severity of respiratory impairment calculated by use of PaO2/FiO2 ratio. A new risk score, the ARUC score, was developed; compared to Aliberti, Shorr, and Shindo scores, this point score system has a good discrimination performance (AUC 0.76, 95% CI 0.71-0.82) and calibration (Hosmer-Lemeshow, χ2 = 7.64; p = 0.469). The new score outperformed HCAP definition in predicting etiology due to MDR organism. The performance of this bedside score was confirmed in the validation cohort (AUC 0.68, 95% CI 0.60-0.77).

Conclusion

Physicians working in ED should adopt simple risk scores, like ARUC score, to select the most appropriate antibiotic regimens. This individualized approach may help clinicians to identify those patients who need an empirical broad-spectrum antibiotic therapy.

Rapidly Progressive Seeding of a Community Acquired Pathogen in an Immune-competent Host--End Organ Damage from Head to Bone

This report describes a 64-years-old male patient that presented to our hospital with a chief complaint of acute worsening of his usual chronic lower back pain, progressive weakness in lower extremities and subjective fevers at home. Spine CT failed to demonstrate any infectious foci but showed partially visualized lung cavitary lesion and renal pole abnormalities. Blood cultures grew methicillin-sensitive Staphylococcus Aureus (MSSA). Transthoracic echocardiogram (TTE) showed no signs of infective endocarditis (IE). Later, the patient experienced an acute deterioration on clinical status and examination showed development of a new murmur. He also developed new hemiparesis with up-going babinski reflex. A head MRI showed multiple infarcts. MRI spine displayed osteomyelitis at T12-L1. Cerebro-spinal fluid was positive for meningitis. A transesophageal echocardiogram (TEE) was performed demonstrating new severe mitral and mild tricuspid regurgitations with a definitive 1.5 cm mobile vegetation on posterior mitral leaflet. We present is a very interesting case of a rapidly progressive MSSA infection. MSSA meningitis is a rare disease; there are only few reported cases in the literature to date. We describe a case of MSSA bacteremia, of questionable source, that resulted in MSSA endocarditis affecting right and left heart in a patient who did not have a history of intravenous drug use (IVDU) or immunosuppression. The case was complicated by septic emboli to systemic circulation involving the kidneys, vertebral spine (osteomyelitis), lungs and brain with consequent meningitis and stroke. Even when MSSA infections are well known, to our knowledge there are no previous case reports describing such an acute-simultaneous-manifestation of multi-end-organ failure, including meningitis and stroke. These latter are rarely reported, even individually.

[Coagulopathy correlates with outcomes in patients with community- acquired pneumonia]

OBJECTIVE

To explore and evaluate the predictive value of coagulopathy in patients with community-acquired pneumonia (CAP) METHODS: A retrospective study was performed by investigating the prothrombin time (PT), activated partial thromboplastin time (APTT), plasma fibrinogen (FIB), thrombin time (TT), platelets (PLT), and D-dimer in 385 patients with CAP, who were admitted to the Respiratory Medical Department of the First Affiliated Hospital of Xiamen University from June, 2010 to May, 2011. The differences of the aforementioned results in patients with different prognostic risks were compared and analyzed. The Pneumonia Severity Index (PSI) was calculated to assess the severity.

RESULTS

The serum levels of PT, TT and D-dimer in high-risk patients with CAP were (15.1 ± 1.4) s, (16.0 ± 1.8) s, (7.5 ± 8.3) mg/L, respectively. They were all increased compared with those in the low-risk group (14.5 ± 0.9) s, (15.4 ± 1.2) s, (1.6 ± 2.0) mg/L]; the differences being statistically significant (P < 0.001), while PLT, APTT, and FIB were not statistically different (P > 0.05). The difference of the abnormal rate of PLT, PT, and D-dimer in high-risk group and the low-risk group were 30% (45/148) and 20% (47/237), 18% (26/148) and 5% (13/237), 99% (146/148) and 85% (202/237), respectively, the differences being statistically significant (χ² value were 5.602, 14.609, 23.442, respectively, P < 0.05), while TT, APTT, FIB were not (P > 0.05). Rank correlation existed between D-dimer and PSI (r = 0.798, P < 0.001), while there was no correlation between PLT and PSI (χ² = 6.040, P > 0.05). D-dimer in patients with respiratory failure was (10.0 ± 9.9) mg/L, which was significantly increased compared with that in patients without respiratory failure (2.4 ± 3.6) mg/L, P < 0.001, and there was no significant difference in PLT (χ² = 3.457, P > 0.05). D-dimer was significantly higher in patients who died of pneumonia as compared to those who survived [(14.0 ± 8.8) mg/L, (2.8 ± 4.6) mg/L, P < 0.001], and there was a significant difference in PLT (χ² = 4.909, P < 0.05). The area under the receiver operator characteristic curve (ROC) of D-dimer, PSI and PLT were 0.962, 0.906, 0.583, respectively. Concerning the predictive value of mortality, both D-dimer and PSI showed ideal predictive accuracy (P < 0.001). The sensitivity of D-dimer was superior to its specificity. PLT showed poor predictive value for mortality.

CONCLUSIONS

D-dimer was significantly higher in patients with CAP. D-dimer level was positively correlated with severity and mortality. D-dimer could be a good biomarker to assess the severity and mortality of patients with CAP.

Osteopathic manipulative treatment as a useful adjunctive tool for pneumonia

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 2007 (1) and resulted in the hospitalization of 1.1 million patients (2). With an average length of in-patient hospital stay of five days (2), pneumonia and influenza comprise significant financial burden costing the United States $40.2 billion in 2005 (3). Under the current Infectious Disease Society of America/American Thoracic Society guidelines, standard-of-care recommendations include the rapid administration of an appropriate antibiotic regiment, fluid replacement, and ventilation (if necessary). Non-standard therapies include the use of corticosteroids and statins; however, these therapies lack conclusive supporting evidence (4). (Figure 1) Osteopathic Manipulative Treatment (OMT) is a cost-effective adjunctive treatment of pneumonia that has been shown to reduce patients' length of hospital stay, duration of intravenous antibiotics, and incidence of respiratory failure or death when compared to subjects who received conventional care alone (5). The use of manual manipulation techniques for pneumonia was first recorded as early as the Spanish influenza pandemic of 1918, when patients treated with standard medical care had an estimated mortality rate of 33%, compared to a 10% mortality rate in patients treated by osteopathic physicians (6). When applied to the management of pneumonia, manual manipulation techniques bolster lymphatic flow, respiratory function, and immunological defense by targeting anatomical structures involved in the these systems(7,8, 9, 10). The objective of this review video-article is three-fold: a) summarize the findings of randomized controlled studies on the efficacy of OMT in adult patients with diagnosed pneumonia, b) demonstrate established protocols utilized by osteopathic physicians treating pneumonia, c) elucidate the physiological mechanisms behind manual manipulation of the respiratory and lymphatic systems. Specifically, we will discuss and demonstrate four routine techniques that address autonomics, lymph drainage, and rib cage mobility: (1) Rib Raising, (2) Thoracic Pump, (3) Doming of the Thoracic Diaphragm, and (4) Muscle Energy for Rib 1.

Hospital-onset influenza hospitalizations--United States, 2010-2011

BACKGROUND

Seasonal influenza is responsible for more than 200,000 hospitalizations each year in the United States. Although hospital-onset (HO) influenza contributes to morbidity and mortality among these patients, little is known about its overall epidemiology.

OBJECTIVE

We describe patients with HO influenza in the United States during the 2010-2011 influenza season and compare them with community-onset (CO) cases to better understand factors associated with illness.

METHODS

We identified laboratory-confirmed, influenza-related hospitalizations using the Influenza Hospitalization Surveillance Network (FluSurv-NET), a network that conducts population-based surveillance in 16 states. CO cases had laboratory confirmation ≤ 3 days after hospital admission; HO cases had laboratory confirmation > 3 days after admission.

RESULTS

We identified 172 (2.8%) HO cases among a total of 6,171 influenza-positive hospitalizations. HO and CO cases did not differ by age (P = .22), sex (P = .29), or race (P = .25). Chronic medical conditions were more common in HO cases (89%) compared with CO cases (78%) (P < .01), and a greater proportion of HO cases (42%) than CO cases (17%) were admitted to the intensive care unit (P < .01). The median length of stay after influenza diagnosis of HO cases (7.5 days) was greater than that of CO cases (3 days) (P < .01).

CONCLUSION

HO cases had greater length of stay and were more likely to be admitted to the intensive care unit or die compared with CO cases. HO influenza may play a role in the clinical outcome of hospitalized patients, particularly among those with chronic medical conditions.

Usefulness of plasma YKL-40 in management of community-acquired pneumonia severity in patients

Plasma YKL-40 level has been reported as playing a significant role in community-acquired pneumonia (CAP). However, the correlation between plasma level of YKL-40 and the severity of CAP has not been reported. This study identifies the relationship between plasma level changes of the YKL-40 gene in adult patients hospitalized with CAP. The ELISA was used to measure the plasma YKL-40 level from 61 adult CAP patients before and after antibiotic treatment and from 60 healthy controls. The plasma YKL-40 levels were significantly increased in patients with CAP compared to normal controls. Moreover, the plasma concentration of YKL-40 correlated with the severity of CAP based on the pneumonia severity index (PSI) score (r = 0.630, p < 0.001), the CURB-65 (confusion, uremia, respiratory rate, BP, age 65 years) score (r = 0.640, p < 0.001), the Acute Physiology And Chronic Health Evaluation II (APACHE II) score (r = 0.539, p < 0.001) and length of hospital stay (r = 0.321, p = 0.011), respectively. In conclusion, plasma YKL-40 may play a role in the diagnosis and clinical assessment of CAP severity, which could potentially guide the development of treatment strategies.

Influenza C virus–associated community-acquired pneumonia in children

To evaluate the impact of influenza C (ICV) infection in children with community-acquired pneumonia (CAP), all of the children consecutively seen during 4 influenza seasons with respiratory symptoms and radiographically confirmed CAP were prospectively evaluated. ICV was identified in the respiratory secretions of five of 391 patients (1·3%). In children with ICV-associated CAP, clinical data were similar to those observed in children with IAV-associated CAP and worse than those observed in children with IBV-associated. The phylogenetic tree showed that the sequenced strains clustered in two of the six ICV lineages. These findings highlight that ICV can be a cause of CAP of children and that this can be severe enough to require hospitalization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IgM levels in plasma predict outcome in severe pandemic influenza

BACKGROUND

Little is known on the participation of immunoglobulin isotypes and subclasses in the pathogenesis of the severe disease caused by the pandemic influenza virus (influenza A(H1N1)pdm09).

OBJECTIVES

(1) To evaluate the association between plasma levels of IgG1, IgG2, IgG3, IgG4, IgA, IgM, IgE and outcome in patients with severe pandemic influenza. (2) To evaluate the association between immunoglobulin and cytokine levels in these patients.

STUDY DESIGN

40 critically ill patients with community acquired pneumonia and influenza A(H1N1)pdm09 infection were recruited from November 2010 to February 2011. Plasma samples were collected during the first 24h following admission to the ICU. Immunoglobulins and 17 major cytokines were profiled in plasma.

RESULTS

15 patients died (37.5%). When the association between clinical variables and prognosis was assessed, prior immunosuppression, APACHE II score, levels of IgG2 and levels of IgM were associated with outcome in a univariate Cox regression analysis. Kaplan Meier analysis showed that patients with levels of IgG2 and IgM < 59 and<58 mg/dl respectively died earlier. Multivariate Cox regression analysis showed that APACHE II score and levels of IgM were the best predictors of outcome, being levels of IgM a protective factor against mortality. IgM was the immunoglobulin showing the largest number of negative correlations with cytokine levels.

CONCLUSIONS

Our results support a central role of IgM in preventing uncontrolled inflammatory response and mortality in severe pandemic influenza. Early assessment of IgM could contribute to guide clinical decisions in these patients.

[Clinical analysis of 22 cases community-acquired Pseudomonas aeruginosa urinary tract infection]

OBJECTIVE

To study the characteristics of community-acquired urinary tract infections (CAUTIs) in children, analyze the risk factors and the susceptibility of antibiotics, thus to provide references to the diagnosis and medication of Pseudomonas aeruginosa (PA)-CAUTIs. Mothod Totally 22 cases of PA-CAUTIs were selected in one hospital from Jan, 2006 to Jan, 2012, their clinical information, laboratory results and radiological images were collected, and were compared with the CAUTIs cased by E. coli of those randomly selected over the same period.

RESULT

In those 22 cases with PA-CAUTIs, the mean value of protein level was (32.25 ± 13.81) mg/ml, 19 of them were hospitalized, 6 had urinary operation history, 7 of them had long-term usage of glucocorticoids or immunosuppressive agents, and 20 had underlying diseases. A total of 22 children with 26 PA-CAUTIs episodes were compared to E. coli-CAUTIs. Compared with E. coli-CAUTIs patients, children with PA-CAUTIs more often presented with a lower albumin (P = 0.017), a history of urinary operation(P = 0.03), more cases had a history of urinary operation (P = 0.03), a long-term usage of glucocorticoids or immunosuppressive medication (P = 0.044). Through multivariate logistic regression of variables that were significant in univariate analysis (with hospitalizations, long-term usage of glucocorticoids or immunosuppressive, albumin, underlying disease and urinary operation histories), and it turned out that underlying diseases (odds ratio 8.500, 95% CI 1.513 - 47.761, P = 0.037) and with urinary operation histories (odds ratio 6.196, 95% CI 1.120 - 34.273, P = 0.037) were proved as the independent risk factors for PA-CAUTIs. Those PA bacterial strains had a 36.36% resistance rate to piperacillin, aztreonam and gentamicin, a 31.82% resistance rate to cefepime and ceftazidime, while the resistance rate (4.55%) to carbapenem antibiotics was relatively low, only to bacillosporin all the strains were sensitive.

CONCLUSION

Underlying diseases and the urinary operation histories are the independent risk factors of the occurrence of PA-CAUTIs, carbapenem antibiotics and bacillosporin can be considered as the drugs of choice for its treatment.

[Meningitis due to Listeria monocytogenes in adults]

INTRODUCTION

Listeria monocytogenes is the third most common cause of community-acquired bacterial meningitis in adults.

AIMS

To describe the characteristics of meningitis caused by Listeria (LM) in adults and to compare them with those of meningitis due to other causations (nLM).

PATIENTS AND METHODS

A retrospective analysis of a series of hospital cases was conducted, including patients aged between ≥ 14 years diagnosed with LM in a referral hospital between 1982 and 2011.

RESULTS

The study involves 16 cases of LM, 12.1% of the cases of community-acquired meningitis with an identified aetiology. Predisposing factors were age (mean of 65 versus 52 years; p = 0.019) and immunosuppression/comorbidity (62.5% versus 3.4%; p < 0.001), treatment with corticoids (37.5%) and chronic liver disease (25%) being the most frequent. The classical triads of acute bacterial meningitis, clinical features and analysis of the cerebrospinal fluid (CSF) were observed in 50 and 75% of the cases, respectively. Patients with LM presented lower leukocyte counts in CSF, a lower percentage of neutrophils, a greater frequency of lymphocytic pleocytosis and a lower frequency of Gram stain positive than those with nLM. The mortality rate was 12.5%, similar to that of patients with nLM.

CONCLUSIONS

LM mainly affects patients who are immunosuppressed or with comorbidity, as well as elderly patients, although it may occur in the absence of risk factors. Clinically it does not differ from other causes of meningitis, but the initial CSF study may suggest it. Its mortality rate is similar to that of meningitis due to other aetiologies.

Clinical characteristics and outcome of patients with community-onset Klebsiella pneumoniae bacteremia requiring intensive care

BACKGROUND

Klebsiella pneumoniae (K. pneumoniae) is the major pathogen of community-acquired pyogenic infections in Taiwan and can lead to poor prognosis in critically ill patients complicated with bacteremia. This study investigated the characteristics and outcome of patients with community-onset K. pneumoniae bacteremia who required intensive care.

METHOD

Adult patients with community-onset K. pneumoniae bacteremia requiring intensive care were retrospectively analyzed, compared with those treated in ordinary wards, and determined for risk factors for infection-related mortality and long-term mortality at a medical center in Taiwan over a 3-year period.

RESULTS

Among the 309 patients with community-onset K. pneumoniae bacteremia, 58 patients (18.8%) required intensive care. Respiratory tract infection [Odds ratio (OR) = 3.67, 95% confidence interval (CI) = 1.79-7.50, p < 0.001] was the independent risk factor for ICU admission. Infection-related mortality was 34.5%. Higher APACHE II score (OR = 1.43; 95% CI = 1.02-2.01; p = 0.041) and underlying malignant neoplasm (OR = 35.48; 95% CI = 2.54-495.57; p = 0.008) were independent predictors of infection-related mortality on multivariate logistic regression. One-year overall mortality was 58.6% and malignant neoplasm was the predisposing factor for poor long-term outcome.

CONCLUSION

Nearly one fifth of patients with community-onset K. pneumoniae bacteremia required intensive care and this was associated with high mortality and poor long-term prognosis. Physicians should recognize the distinct characteristics and risk factors for mortality among these patients.

CURB-65 score predicted mortality in community-acquired pneumonia better than IDSA/ATS minor criteria in a low-mortality-rate setting

The CURB-65 scoring system performs well at identifying patients with pneumonia who have a low risk of death. Whether it predicts mortality in community-acquired pneumonia (CAP) better than the 2007 Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) minor criteria in low-mortality-rate settings is not clear. The purpose of this study was to determine the hypothesis.A total of 1,230 adult inpatients admitted to our hospital from 2005 to 2009 for CAP were reviewed retrospectively.The hospital mortality was 1.3 %. Percentage mortality increased significantly with CURB-65 score and the increasing number of IDSA/ATS minor criteria present. The number of CURB-65 criteria or IDSA/ATS minor criteria present had significant increased odds ratios for mortality of 7.547 and 2.711, respectively. The sensitivities of a CURB-65 score of ≥ 3 and the presence of ≥ 3 minor criteria in predicting mortality was 25 % and 37.5 %, which increased to 75 % and 62.5 %, while the cut-off values reduced to ≥ 2 criteria, respectively. The area under the receiver operating characteristic curve for CURB-65 was greater than the corresponding area for IDSA/ATS minor criteria in predicting hospital mortality (0.915 vs. 0.805, p = 0.0091).CURB-65 score predicted hospital mortality better than IDSA/ATS minor criteria, and a CURB-65 score of ≥ 2 or the presence of ≥ 2 minor criteria might be more valuable cut-off values for "severe" CAP in a low-mortality-rate setting.

Pneumonia part 1: Pathology, presentation and prevention

Pneumonia is a significant cause of morbidity and mortality and can affect all age groups although it is the very young and the very old who are most at risk. Pneumonia can be caused by many different organisms and can present as a primary condition or as a complication of other diseases or acute health problems. This article will give an overview of the disease, its symptoms and treatment and will focus primarily on community-acquired pneumonia. Two further articles will look at specific causative organisms, i.e. Streptococcus Pneumoniae and influenza, as well as the preventive strategies for these.

SWAB/NVALT (Dutch Working Party on Antibiotic Policy and Dutch Association of Chest Physicians) guidelines on the management of community-acquired pneumonia in adults

The Dutch Working Party on Antibiotic Policy (SWAB) and the Dutch Association of Chest Physicians (NVALT) convened a joint committee to develop evidence-based guidelines on the diagnosis and treatment of community acquired pneumonia (CAP). The guidelines are intended for adult patients with CAP who present at the hospital and are treated as outpatients as well as for hospitalised patients up to 72 hours after admission. Areas covered include current patterns of epidemiology and antibiotic resistance of causative agents of CAP in the Netherlands, the possibility to predict the causative agent of CAP on the basis of clinical data at first presentation, risk factors associated with specific pathogens, the importance of the severity of disease upon presentation for choice of initial treatment, the role of rapid diagnostic tests in treatment decisions, the optimal initial empiric treatment and treatment when a specific pathogen has been identified, the timeframe in which the first dose of antibiotics should be given, optimal duration of antibiotic treatment and antibiotic switch from the intravenous to the oral route. Additional recommendations are made on the role of radiological investigations in the diagnostic work-up of patients with a clinical suspicion of CAP, on the potential benefit of adjunctive immunotherapy, and on the policy for patients with parapneumonic effusions.

The role of procalcitonin in adult patients with community-acquired pneumonia--a systematic review

INTRODUCTION

Promising results in relation to severity assessment and treatment of patients with community-acquired pneumonia (CAP) have recently been presented from the study of procalcitonin (PCT) levels in these patients.

METHODS

A systematic search in PubMed and the Cochrane Library was conducted. Articles in English, German and Swedish were searched to investigate the role of PCT in adults with CAP.

RESULTS

The most thoroughly studied topic is the prediction of complications and death during hospital stay. PCT has predictive properties comparable to those of the Pneumonia Severity Index and the CURB65 scoring systems, and it may represent an addition to these indices. Furthermore, PCT levels may indicate aetiology as patients with typical bacterial infection have higher PCT levels than patients with atypical and viral aetiologies. The literature also indicates that PCT can distinguish CAP from asthma and acute exacerbation of chronic obstructive pulmonary disease. Several studies and a meta-analysis have shown that administration of antibiotics according to a PCT algorithm in a hospital setting reduced the use of antibiotics with no evidence of an increased risk.

CONCLUSION

PCT should only be an adjunct to the clinical examination and should be regarded a prognostic rather than diagnostic factor. PCT may help to safely reduce anti-biotic use, but more research is required. Limitations of the present study include the heterogeneity of the literature with regard to setup and quality, differences in biochemical methods and diagnostic criteria of CAP and, finally, the risk of publication bias.

Efficacy and significance of various scores for pneumonia severity in the management of patients with community-acquired pneumonia in China

BACKGROUND

Community-acquired pneumonia (CAP) remains one of the leading causes of death from infectious diseases around the world. Most severe CAP patients are admitted to the intensive care unit (ICU), and receive intense treatment. The present study aimed to evaluate the role of the pneumonia severity index (PSI), CURB-65, and sepsis score in the management of hospitalized CAP patients and explore the effect of ICU treatment on prognosis of severe cases.

METHODS

A total of 675 CAP patients hospitalized in the Second Affiliated Hospital of Zhejiang University School of Medicine were retrospectively investigated. The ability of different pneumonia severity scores to predict mortality was compared for effectiveness, while the risk factors associated with 30-day mortality rates and hospital length of stay (LOS) were evaluated. The effect of ICU treatment on the outcomes of severe CAP patients was also investigated.

RESULTS

All three scoring systems revealed that the mortality associated with the low-risk or intermediate-risk group was significantly lower than with the high-risk group. As the risk level increased, the frequency of ICU admission rose in tandem and LOS in the hospital was prolonged. The areas under the receiver operating characteristic curve in the prediction of mortality were 0.94, 0.91 and 0.89 for the PSI, CURB-65 and sepsis score, respectively. Compared with the corresponding control groups, the mortality was markedly increased in patients with a history of smoking, prior admission to ICU, respiratory failure, or co-morbidity of heart disease. The differences were also identified in LOS between control groups and patients with ICU treatment, heart, or cerebrovascular disease. Logistic regression analysis showed that age over 65 years, a history of smoking, and respiratory failure were closely related to mortality in the overall CAP cohort, whereas age, ICU admission, respiratory failure, and LOS at home between disease attack and hospital admission were identified as independent risk factors for mortality in the high-risk CAP sub-group. The 30-day mortality of patients who underwent ICU treatment on admission was also higher than for non-ICU treatment, but much lower than for those patients who took ICU treatment subsequent to the failure of non-ICU treatment.

CONCLUSIONS

Each severity score system, CURB-65, sepsis severity score and especially PSI, was capable of effectively predicting CAP mortality. Delayed ICU admission was related to higher mortality rates in severe CAP patients.

Serum activity of indoleamine 2,3-dioxygenase predicts prognosis of community-acquired pneumonia

OBJECTIVES

Indoleamine 2,3-dioxygenase (IDO) catalyzes the rate-limiting step of tryptophan (Trp) degradation in the kynurenine (Kyn) pathway. By depleting Trp, IDO plays a critical role in inducing immune suppression and tolerance. The aim of present study was to investigate serum IDO activity, determined by Kyn-to-Trp ratio (Kyn/Trp ratio), in community-acquired pneumonia (CAP) and to examine its clinical significance.

METHODS

This study subjects consisted of 129 consecutive patients with CAP and 64 healthy controls. The concentrations of Kyn and Trp were measured simultaneously by liquid chromatography/electrospray ionization tandem mass spectrometry.

RESULTS

The CAP patients had significantly higher Kyn concentrations and significant lower Trp concentrations than the controls (p < 0.0001 and p < 0.0001, respectively). Accordingly, IDO activity was significantly higher (2.4-fold) in the patients than in the controls (p < 0.0001). IDO activity correlated well with PSI (Pneumonia Severity Index) and CURB65 (p = 0.0005 and p < 0.0001, respectively). Moreover, the IDO activity and Kyn concentration were significantly higher in the nonsurvivors and were found to predict mortality in multivariate analysis.

CONCLUSIONS

IDO activity was increased in CAP, and this activity was associated with the severity and outcome of this disease. These results suggest that IDO activity can predict prognosis of CAP.