Community-acquired Pneumonia In Intensive Care Unit Research Articles

Severe community-acquired pneumonia in general medical wards: outcomes and impact of initial antibiotic selection

BackgroundMost international guidelines recommend empirical therapy for community-acquired pneumonia (CAP) to be based on site of care. Some patients with severe CAP are managed in general wards because of limited intensive care unit (ICU) bed or because of unrecognition of the pneumonia severity. Appropriate initial antibiotic treatment for severe CAP outside ICU has not yet been established. This study aimed to determine the prevalence and the impact of initial antibiotic selection on the outcomes of patients with severe CAP who were admitted and managing in general wards.MethodsThis prospective observational study included consecutive patients hospitalized for presumed CAP in general wards over a 1-year period. Severe CAP was identified using the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) criteria. Initial antibiotic treatment in the first 24 h were collected. The primary outcome was the rate of unfavorable outcome (composite outcome of treatment failure and in-hospital death). The secondary outcome was the number of hospital-free days assessed 30 days after enrollment into the study.ResultsThere were 94 patients hospitalized with CAP of which 50 (53.2%) patients were compatible with severe CAP. An etiologic diagnosis was found in 43 (45.8%) patients. The most common pathogens identified in patients with severe CAP were Staphylococcus aureus (28.6%) and Klebsiella pneumoniae (28.6%), followed by Pseudomonas aeruginosa (17.9%). Patients with severe CAP had significantly more positive blood culture than patients with non-severe CAP (24% VS 4.5%; p = .008). Initial antibiotic treatment were discordant with the IDSA/ATS guidelines in 42% of all patients hospitalized with CAP, and 52% of patients with severe CAP. Multivariate analysis revealed that age (OR 1.1, 95% CI 1.01–1.1) and initial antibiotic treatment discordant to guidelines for severe CAP in ICU (OR 4.6, 95% CI 1.3–17.1) were independent risk factors of the unfavorable outcome of patients with severe CAP. Patients with unfavorable outcome had lower number of hospital-free days than patients with favorable outcome (5.2 ± 8 days VS 18 ± 7.1 days; p < .001).ConclusionsPatients with severe CAP outside ICU should be recognized for appropriate initial antibiotic selection to improve outcomes.

Management of pneumonia in intensive care

Pneumonia, an inflammatory infiltrate of the alveolar airspace, is commonly triggered by bacterial infection of the lungs, or less commonly by viral or fungal infection. It remains the commonest infective reason for admission to intensive care as well as being the most common secondary infection acquired whilst in the intensive care unit (ICU). It presents a significant global burden of disease and is especially prevalent in low- and middle-income countries. The major categories of pneumonia encountered by the Intensive Care clinician are community-acquired, ventilator-acquired, non-ventilator hospital-acquired and pneumonia in the immunocompromised patient. An appreciation of the type of pneumonia a patient has developed is critical to its effective treatment. Pneumonia is the commonest precipitant of acute respiratory distress syndrome (ARDS) and clinicians should be mindful that the evidence-base surrounding ARDS will, in large part, apply to severe pneumonia. The causative organisms which lead to pneumonia vary depending on the site of acquisition (community or hospital-acquired), the immune status of the patient and the presence of intercurrent medications including antibiotics. Current standard microbiological testing is seldom able to give a rapid answer as to which microorganisms is present and causing infection. Therefore, empirical therapy guided by knowledge of local microbial flora and resistance patterns is the recommended course of action. This approach risks the over-treatment of pneumonia with unnecessarily broad-spectrum agents which bring with them the problems of antibiotic-associated harm. Novel rapid diagnostic tests aimed at both the pathogen and the host response hold promise in the rationalisation and appropriate targeting of antimicrobial therapy. At present neither scoring systems nor diagnostic tests are able to accurately risk stratify a patient’s need for intensive care admission. Beyond antibiotic therapy, a number of adjuvant therapies have been trialled in pneumonia although none have yet made it into widespread clinical use. Corticosteroids are recommended in some cases of community-acquired pneumonia (CAP), but their role in the patient with severe CAP in ICU remains uncertain whilst they are a risk factor for the development of hospital and ventilator-acquired pneumonia. Immuno-stimulation has not yet translated from small scale clinical trials into clinical use. Supportive management includes lung protective ventilation, and those interventions proven to improve outcomes in ARDS. This review will give an overview of the epidemiology of severe pneumonia, the microbiological causes and diagnostic strategies. It will then turn to management, including antimicrobial therapy, role of adjuvant therapies, respiratory support and prevention of complications.

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

To determine predictors of intensive care unit (ICU) mortality in patients with community-acquired pneumonia (CAP), to develop a pneumonia-specific prognostic index, and to evaluate this index prospectively. Combined retrospective and prospective clinical study over two periods: January 1987-December 1992 and January 1993-December 1994. Four medical ICUs in the north of France. Derivation cohort: 335 patients admitted to one ICU were retrospectively studied to determine prognosis factors and to develop a pneumonia-specific prognostic index. Validation cohort: 125 consecutive patients, admitted to four ICUs, were prospectively enrolled to evaluate this index. In the derivation cohort, 16 predictors of mortality were identified and assigned a value directly proportional to their magnitude in the mortality model: aspiration pneumonia (-0.37), grading of sepsis > or = 11 (-0.2), antimicrobial combination (-0.01), Glasgow score > 12+mechanical ventilation (MV) (+0.09), serum creatinine > or = 15 mg/l (+0.22), chest involvement shown by X-ray > or = 3 lobes (+0.28), shock (+0.29), bacteremia (+0.29), initial MV (+0.29), underlying ultimately or rapidly fatal illness (+0.31), Simplified Acute Physiology Score > or = 12 (+0.49), neutrophil count < or = 3500/ mm3 (+0.52), acute organ system failure score > or = 2 (+0.64), delayed MV (+0.67), immunosuppression (+1.38), and ineffective initial antimicrobial therapy (+1.5). An index was obtained by adding each patient's points. According to a receiver operating characteristic curve, the cut-off value of this index was 2.5. In the validation cohort, an index of > or = 2.5 could predict death with a positive predictive value of 0.92, sensitivity 0.61, and specificity 0.98. This index, which performs well in classifying patients at high-risk of death, may help physicians in initial patient care (appropriateness of the initial antimicrobial therapy) and guide future clinical research (analysis and design of therapeutic trials).