Moderate Community-acquired Pneumonia Research Articles

Switching from intravenous to oral antibiotics in hospitalized patients with community-acquired pneumonia: A real-world analysis 2010–2018

The Japanese Respiratory Society 2017 guidelines strongly recommend switching from intravenous (IV) to oral antibiotics in patients with community-acquired pneumonia (CAP), following improvement in clinical symptoms and laboratory findings. Here, we retrospectively investigated the real-world, nationwide treatment and switching patterns for hospitalized patients with CAP in Japan using administrative data from 372 Japanese Diagnosis Procedure Combination hospitals from April 2010 to December 2018. Hospitalizations for CAP (patient age ≥20 years) with an A-DROP classification for CAP severity and IV antibiotics initiated on the admission date were included. Overall, 210,314 hospitalizations (moderate CAP: 61.7%) in 183,607 patients were analyzed. The median (interquartile range [IQR]) age at admission was 79 (70–86) years. Penicillin (51.9%) and cephalosporin (38.9%) were the most common IV antibiotic classes used and the median (IQR) duration of IV use was 8 (6–11) days. Switching to oral antibiotics during a hospitalization occurred in 30.1% (n = 63,311) of patients after a median (IQR) of 7 (5–10) days of IV treatment. The most frequently used oral antibiotic classes after a switch were fluoroquinolone (45.9%) and penicillin (24.8%). The switch rate was higher among hospitalizations with milder CAP, in respiratory medicine ward and in larger hospitals. The overall switch rates did not change over the study period. The findings from this analysis suggest that early switch from IV to oral antibiotics was not widely implemented during the 8 years of the study period. Further observation will be needed to see the potential impact of the guidelines update in 2017 in Japan.

Medical evacuation of patients (injured) in the Arctic zone by non-staff units of the Disaster Medicine Service of the Northern Fleet of Russia

Relevance.The development of the Arctic territories of Russia determines the need to protect civilian and military facilities and improve the provision of emergency specialized medical care to servicemen in remote garrisons.Intention. To study the organization of medical evacuation of military personnel with community-acquired pneumonia from remote garrisons in the Arctic zone of Russia for 2013–2017.Methodology.We conducted a retrospective analysis of all cases of medical evacuations of military personnel from remote Arctic garrisons. In addition, we studied data from 87 case histories, medical evacuation cards for military personnel with moderate and severe community-acquired pneumonia transferred to the 1469th Naval Clinical Hospital of Severomorsk and the central military medical organizations from 2008 to 2010 and from 2013 to 2017.Results and Discussion. In 20% and 20–30% of cases, medical evacuation was performed, respectively, due to injuries and community-acquired pneumonia. A structural-functional model of the provision of emergency specialized medical care to servicemen with community-acquired pneumonia in remote Arctic garrisons has been formed using the forces and means of emergency forces of the Disaster Medicine Service of the Northern Fleet of Russia. The results of optimization of the organization of medical evacuation of patients with severe community-acquired pneumonia are presented.Conclusion.To improve the effectiveness of emergency medical care in patients with community-acquired pneumonia, it is advisable to include in the system of special training of medical staff and nursing staff a training course on the organization of medical evacuation in the Arctic zone of Russia.

Cosyntropin testing does not predict response to glucocorticoids in community-acquired pneumonia in a randomized controlled trial.

Glucocorticoids have been shown to improve outcome in community-acquired pneumonia (CAP). However, glucocorticoids have potential side-effects, and treatment response may vary. It is thus crucial to select patients with high likelihood to respond favourably. In critical illness, cosyntropin testing is recommended to identify patients in need for glucocorticoids. We investigated whether cosyntropin testing predicts treatment response to glucocorticoids in CAP. Predefined secondary analysis of a randomized controlled trial. Hospitalized patients with CAP. We performed 1µg cosyntropin tests in a randomized trial comparing prednisone 50mg for 7days to placebo. We investigated whether subgroups based on baseline and stimulated cortisol levels responded differently to glucocorticoids with regard to time to clinical stability (TTCS) and other outcomes by inclusion of interaction terms into statistical models. A total of 326 patients in the prednisone and 309 patients in the placebo group were evaluated. Neither basal cortisol nor a Δcortisol <250nmol/L after stimulation nor the combination of basal cortisol and Δcortisol predicted treatment response as measured by TTCS (all P for interaction >0.05). Similarly, we found no effect modification with respect to mortality, rehospitalization, antibiotic treatment duration or CAP-related complications (all P for interaction >0.05). However, glucocorticoids had a stronger effect on shortening length of hospital stay in patients with a baseline cortisol of ≥938nmol/L (P for interaction=0.015). Neither baseline nor stimulated cortisol after low-dose cosyntropin testing at a dose of 1µg predicted glucocorticoid responsiveness in mild to moderate CAP. A treatment decision for or against adjunct glucocorticoids in CAP should not be made depending on cortisol values or cosyntropin testing results.

LUNG VESSELS THROMBOSIS IN HOSPITALIZED PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA: ROLE OF ENDOTHELIAL FUNCTION, HEMOSTASIS, FIBRINOLYSIS AND INFLAMMATION ON DIFFERENT PHASES OF TREATMENT

There are limited data on the relationship between the severity of community-acquired pneumonia (CAP), biomarkers of inflammation and coagulation as well. The aim was to evaluate the association between the severity of CAP and risk of thrombosis in patients with moderate and severe CAP. To estimate the role of parameters of systemic inflammation, endothelial dysfunction, hemostasis, coagulation on different phases of treatment. The main group was 75 patients CAP. We divided the main group according severity: subgroup 1 – 41 patients with moderate CAP, subgroup 2 – 34 patients with severe CAP. Blood coagulation test, determination of biomarkers was performed at admission before starting of antibacterial treatment and after clinical stability on 7–10 day after hospitalization. We found that in both subgroup 1 and subgroup 2 the mean levels of CRP and fibrinogen were higher than in control group. Moreover, the mean level of D-dimer was significantly higher and protein C (PC) was significantly lower in both subgroups in comparison with control group. Normalization of PC is coming after 7–10 days of antibacterial treatment, vice versa ET-1, which reflects prolong endothelial dysfunction in patients with severe CAP. Patients with severe CAP have the high risk of thrombosis which can be associated with endothelial dysfunction; definition of such parameters as ET-1 and PC can be useful for establishment of different coagulant disorders in patient with mild and moderate CAP, and their dynamic changes could be the initial point of prescribing or cancelling of anticoagulant treatment.

Antimicrobial Therapy in Community-Acquired Pneumonia in Children.

Empirical antibiotic therapy remains the cornerstone of treatment in community-acquired pneumonia (CAP). However, the best option for empirical antibiotics for treatment on an ambulatory basis, as well as in those requiring hospitalization, is still unclear. This review tries to answer the question regarding the most appropriate antibiotics in different settings in children with CAP as well as duration of therapy. Recent studies have provided insights regarding use of oral antibiotics in children with mild to moderate CAP, and severe CAP with lower chest retractions but no hypoxia. In view of rapidly emerging resistance among various causative pathogens, several new drugs have been currently approved, or are under trial for CAP in children. Current knowledge suggests that the choice of antibiotics for ambulatory treatment of CAP is oral amoxicillin with a duration of 3-5days. Children with CAP with lower chest retractions but no hypoxia can be treated with oral amoxicillin. Severe pneumonia can be treated with intravenous antibiotics consisting of penicillin/ampicillin with or without an aminoglycoside. Several new drugs have been developed and approved for use in CAP caused by multidrug-resistant organisms, but these should be used judiciously to avoid emergence of further resistance. Future research is needed regarding the safety and efficacy of newer drugs in children.

Moving Past the Routine Use of Macrolides-Reviewing the Role of Combination Therapy in Community-Acquired Pneumonia.

Purpose of ReviewDespite advances in diagnostic microbiology and sepsis management, community-acquired pneumonia (CAP) remains a significant cause of morbidity and mortality. Current recommendations regarding the use of beta-lactams in combination with macrolides published in clinical practice guidelines are variable and based on low-quality evidence that is frequently retrospective, observational, and heterogeneous in nature. While population-based studies have historically suggested improved clinical outcomes with the routine use of macrolide combination therapy in hospitalized patients with CAP, emerging evidence from recent randomized controlled trials has challenged this practice. In this article, we discuss the historical rationale and current evidence for combination macrolide therapy in the management of CAP.Recent FindingsRecent randomized controlled trials have assessed the non-inferiority of beta-lactam monotherapy compared to beta-lactam/macrolide combination therapy in adult patients hospitalized with CAP. Beta-lactam monotherapy was associated with equivalent clinical outcomes in patients with mild to moderate CAP. Patients with severe CAP managed with beta-lactam monotherapy have demonstrated worse clinical outcomes when compared to patients treated with combination therapy. In addition, previous beta-lactam exposure prior to hospitalization has not been shown to negatively impact outcomes in patients managed with beta-lactam monotherapy in the hospital.SummaryCurrent evidence supports the use of beta-lactam monotherapy in adult patients hospitalized with mild to moderate CAP. While existing evidence supports the use of combination therapy in patients with severe pneumonia, further large-scale randomized controlled trials are urgently needed to clarify the role of combination therapy in this population.

Antimicrobial therapy of community-acquired pneumonia in a hospital setting (clinical and economic aspects)

The aim is to study the clinical and economic components of antimicrobial therapy (AMT) of community-acquired pneumonia (CAP) in a hospital ptactice. Materials and methods. Case reports of 48 patients with CAP hospitalized in FBU PMLC FMBA in the city of Nizhny Novgorod during 2016 were studied. All patients with CAP hospitalized during that period were included in the study. A retrospective analysis of AMT was carried out based on the data from inpatient CAP cases. Results. We compared the real number of prescriptions of antimicrobial agents for CAP in this hospital with the number of prescriptions required by the approved standards. We found that the real numbers exceeded the recommended standards in the cases of severe CAP as follows: 2.1- fold for 3d generation cephalosporins, 1.3-fold for fluoroquinolones, and 1.3-fold for carbapenems. Also notable was the use of ceftaroline fosamil – the 5th generation cephalosporin, which was not part of the standard therapy. Macrolides were not given to patients with severe CAP. In the treatment of CAP of moderate severity, fluoroquinolones were used 1.2 times more often than that recommended by the standard protocol, 3d generation cephalosporins – 1.5 times more often; macrolides – 5 times less often, as well as carbapenems (not part of the standard) and 5th generation cephalosporins (not part of the standard). The average duration and cost of monotherapy of moderate CAP were: 10.5 days and 731.65 rubles for ceftriaxone; 9.1 days and 1353.00 rubles – for levofloxacin; 4 days and 11035.36 rubles – for ceftaroline fosamyl; 9 days and 16,153.35 rubles – for ertapenem. Positive clinical outcomes were noted in 85% of cases. In 15% of cases, additional AMT was required. As a starting therapy for severe CAP, antimicrobial monotherapy was prescribed in 89.3% of cases. Its efficacy was 0.920. The treatment regimen was changed in two cases. Conclusion. The present findings, namely the discrepancy between the real number of AMT prescriptions and the standard recommendations might be due to an ineffective previous outpatient treatment and prolonged duration of the disease. It is important to note that the treatment standard was adopted in 2012. Since then, a number of novel effective AMT agents have been approved for clinical use: for example, ceftaroline fosamil – cephalos (cephalosporin of the 5th generation) is approved for the treatment of CAP, incl. in children from 2 months of age. There is also a change in the structure of the CAP pathogens that involves bacterial associations and the emergence of AMT resistant bacteria. The widespread use of macrolides inevitably leads to the development of new resistant strains. According to the published reports, the following species play an increasing role in the etiology of CAP: Streptococcus pneumoniae, Haemophilus influenzae, and also the associations S. pneumoniae-H. Influenzae and S. pneumoniae-M. pneumoniae. Associations of pathogens are observed in more than 60% of patients with CAP.

A survey of the antibiotic prescribing practices of doctors in an Australian Emergency Department.

Appropriate antibiotic prescribing is important for good patient care and reducing the development of resistance. There has been limited research into doctors' prescribing practices. The aim of this study is to evaluate antibiotic prescribing practices in an Australian emergency department compared with the Therapeutic Guidelines. A case vignette survey was sent to emergency department doctors at The Townsville Hospital between February and May 2016. Antibiotic choices were assessed for appropriateness using the National Antimicrobial Prescribing Survey guidelines. Factors associated with antibiotic choice were assessed according to case, clinician experience and rationale. Data was analysed using a non-parametric Kruskal-Wallis test. Post-hoc analysis of variance was performed using Dunn test with Bonferroni correction for multiple simultaneous comparisons, with p<0.05 considered significant. 197 of 274 antibiotic choices (72%) were appropriate with 149 (54%) optimal. Antibiotic choice was more likely to be appropriate for a urinary tract infection (UTI) compared with severe pyelonephritis (p<0.01), severe cellulitis (p<0.01), moderate community-acquired pneumonia (CAP) (p<0.01) and sepsis (p<0.01), and was more likely to be appropriate for cellulitis than CAP (p=0.03) and sepsis (p=0.02). Antibiotic choices were more likely to be appropriate when doctors reported basing antibiotic choice on the Therapeutic Guidelines compared with current hospital practice (p=0.02). No significant difference was found in antibiotic appropriateness in relation to grade of doctor (p=0.34). This study demonstrates generally poor antibiotic prescribing compliance withthe Therapeutic Guidelines across all grades of clinician. Antibiotic prescribing was more likely to be appropriate if based on the Therapeutic Guidelines and in less severe infection.

ТИРЕОЇДНИЙ СТАТУС У ДІТЕЙ, ХВОРИХ НА ПОЗАЛІКАРНЯНУ ПНЕВМОНІЮ

Позалікарняна пневмонія дитячого віку є однією з актуальних проблем педіатрії. Попри те, що в останні десятиліття були досягнуті вражаючі результати в розумінні патогенезу пневмонії, відбувається збільшення числа хворих на пневмонію з тяжкою формою, що вимагає тривалої госпіталізації і значних фінансових витрат. Усе це обґрунтовує доцільність пошуку нових маркерів тяжкої форми пневмонії у дітей.Мета дослідження – вивчити зміни функціонального стану щитоподібної залози залежно від тяжкості запального процесу при позалікарняній пневмонії у дітей шкільного віку.Матеріали і методи. Було обстежено 50 дітей у віці 6–14 років із позалікарняною пневмонією. Усім пацієнтам проводили клініко-лабораторне та інструментальне обстеження відповідно до критеріїв діагностики пневмонії і оцінки тяжкості стану. Окремо досліджували стан щитоподібної залози шляхом проведення ультразвукового обстеження. Функціональну активність тиреоїдної системи оцінювали за допомогою визначення в крові рівнів вільного тироксину (вT4), вільного трийодтироніну (вT3) і тиреотропного гормону (ТТГ).Результати досліджень та їх обговорення. У статті наведено лабораторні показники стану тиреоїдного статусу дітей із позалікарняною пневмонією середнього ступеня тяжкості й тяжкого ступеня при госпіталізації у стаціонар і в динаміці на 21 добу від початку захворювання. Усі дані зіставляли з результатами обстежень групи контролю. Отримані результати дають можливість стверджувати, що при тяжкому ступені позалікарняної пневмонії у дітей відбувається транзиторна зміна гормонального статусу тиреоїдної системи, таким, як зниження рівня вТ3 і підвищення концентрації ТТГ в крові, без структурних змін самої щитоподібної залози. Це, у свою чергу, призводить до формування синдрому еутиреоїдної патології. У динаміці, на 21 добу від початку захворювання спостерігалася нормалізація спочатку змінених рівнів вT3 і ТТГ в крові. Під впливом лікування пневмонії відзначалася стабілізація стану хворих дітей і нормалізація тиреоїдного статусу. Концентрація вТ3 менше 3,41 пмоль/л є додатковим маркером тяжкості пневмонії у дітей.Висновки. У пацієнтів із позалікарняною пневмонією тяжкого ступеня транзиторно розвивався синдром псевдодисфункції щитоподібної залози (тип 1, тип 5); одними з перспективних маркерів тяжкого ступеня позалікарняної пневмонії є гормони щитоподібної залози; тяжкий ступінь позалікарняної пневмонії (ПП) у дітей шкільного віку призводить до гормонального дисбалансу тиреоїдної системи, але без структурних змін самої залози.

Evaluation of severity score-guided approaches to macrolide use in community-acquired pneumonia.

International guidelines including those in the UK, Japan, Australia and South Africa recommend the avoidance of macrolides in patients with low-severity community-acquired pneumonia (CAP). We hypothesised that severity scores are poor predictors of atypical pneumonia and response to macrolide therapy, and thus, inadequate tools for guiding antibiotic prescriptions.Secondary analysis of four independent prospective CAP datasets was conducted. The predictive values of the CURB-65 and pneumonia severity index (PSI) for clinically important groups of causative pathogens were evaluated. The effect of macrolide use according to risk class was assessed by multivariable analysis.Patients (3297) were evaluated, and the predictive values of CURB-65 and PSI for atypical pathogens were poor (AUC values of 0.37 and 0.42, respectively). No significant differences were noted among the effects of macrolide use on mortality in patients with mild, moderate and severe CAP, according to either CURB-65 (interaction testing severe versus mild disease OR=0.74 (0.29-1.89)) or PSI (severe versus mild disease OR=3.4 (0.055-2.10)), indicating that severity scores were not significant modifiers of response to macrolide therapy.Severity scores did not accurately predict response to macrolide therapy in CAP, suggesting that current guidance to use these tools for empirical antibiotic choices might not be justified.

A randomized, open, multicenter clinical study on the short course of intravenous infusion of 750 mg of levofloxacin and the sequential standard course of intravenous infusion/oral administration of 500 mg of levofloxacin for treatment of community-acquired pneumonia.

To compare 5-day regimen of levofloxacin 750 mg IV daily with 7-14-day conventional regimen of levofloxacin 500 mg intravenous to oral (IV/PO) daily for treatment of community-acquired pneumonia (CAP) in Chinese population. This was a non-inferiority study to assess the difference of clinical efficacy at the end of treatment (EOT) between two regimens. Adult CAP patients with CURB-65 score 0-2 were enrolled from 17 hospitals in China from November 2012 to July 2014. The subjects were randomized into levofloxacin 750 or 500 mg group and the clinical data were collected. Sputum and blood specimens were sent for bacterial culture. The urinary antigen of Streptococcus pneumoniae (S. pneumoniae) was detected as well. At EOT, the clinical efficacy (primary endpoint), microbiological efficacy and safety were evaluated. A total of 457 patients were enrolled. Intent-to-treat (ITT) for primary endpoint analysis and per-protocol set (PPS) populations were 448 and 427 patients respectively. The therapeutic durations were 4.86 and 10.35 days and the mean drug exposure was 3,641.4 and 5,169.6 mg in 750 and 500 mg groups respectively. The clinical efficacy rate was 91.40% (202/221) in 750 mg group and 94.27% (214/227) in 500 mg group (ITT, P=0.2449). The difference in clinical efficacy rate was -2.87 (95% CI: -7.64, 1.90) between the two groups. The non-inferiority hypothesis of two groups was tenable (Δ=10%). The bacterial eradication rate was 100.00% in both groups. The most common drug-related clinical adverse events were injection site and gastrointestinal reactions. The most common drug-related laboratory abnormalities were WBC decrease and ALT/AST elevation. No statistical difference was found between two groups (P>0.05). The 5-day regimen of levofloxacin 750 mg daily is non-inferior to 7-14-day conventional regimen of 500 mg daily in clinical efficacy for treatment of mild to moderate Chinese CAP population. The short course regimen allows the reduction of antimicrobial drug exposure and is well tolerated.

Lack of Chlamydia-related bacteria among patients with community-acquired pneumonia.

The aetiology of community-acquired pneumonia is only determined in approximately 50% of cases [1]. Chlamydia and Chlamydia-related bacteria may be the agents of some pneumonia of unknown etiology. Indeed, C. psittaci and C. pneumoniae are well-established agents of pneumonia [2], whereas Parachlamydia acanthamoebae and Simkania negevensis are considered to be emerging agents of lung infections [3], [4]. However, routine cultures fail to detect these strict intracellular Chlamydiales, and broad-range eubacterial 16S rRNA PCRs (applied to lung biopsy or pleural fluid samples) also fail to detect Chlamydiales [5]. Moreover, several additional bacteria belonging to the Chlamydiales order might possibly be involved in lung infections, including Rhabdochlamydia spp. and Waddlia spp., as well as new lineages. To fully investigate the role of all members of the Chlamydiales in lung infections, we thus investigated by a pan-Chlamydiales PCR oropharyngeal samples taken from a total of 564 patients with moderately severe community-acquired pneumonia included in a prospective study [6]. Briefly, DNA was extracted using the QIAamp DNA Mini Kit (Qiagen, Hilden, Germany). Then we performed in duplicate a homemade pan-Chlamydiales real-time PCR, as described elsewhere [7]. The results of all tests but one were negative. The positive sample, taken from a 79-year-old Swiss man, showed the presence of C. psittaci DNA. The patient was hospitalized for fever and cough. He complained of acute-onset cough, dyspnea on minimal exertion and fever. His medical history was notable for cerebrovascular disease, coronary artery disease and diabetes mellitus. There was no recent travel or documented exposure to animals. At admission the patient was disoriented, hypoxemic and febrile (38.3°C), with mild tachypnea and tachycardia. Chest examination revealed dullness on percussion and crackles at the left pulmonary base. He exhibited mild leukocytosis and elevated urea. Consolidation of the left lower lobe and a small pleural effusion were documented by chest X-ray. Intravenous cefuroxime and oral clarithromycin were administered. His condition rapidly improved, and the patient was transferred on the tenth day after admission to a rehabilitation facility. Two pairs of blood cultures, obtained before the administration of any antibiotics, remained sterile. Urine was negative for the presence of Legionella pneumophila and Streptococcus pneumoniae antigens. Normal oropharyngeal flora was recovered by culture from a sputum sample. Testing for the presence of C. pneumoniae and Mycoplasma pneumoniae by PCR on the oropharyngeal swab was also negative. Contrarily to what we expected, no Chlamydia-related bacteria have been detected by the pan-Chlamydiales PCR in the largest cohort published to date. This contrasts with previous work by Marrie et al. [8], who identified two seroconversions among 255 patients with community-acquired pneumonia requiring hospitalization (0.8%), and with the study by Casson et al. [9] documenting DNA of Parachlamydia acanthamoebae in 15% of nasopharyngeal swabs taken from children with a bronchiolitis. The difference may be due to the different study populations. Here, only adults with mild and moderate community-acquired pneumonia were enrolled and immunocompromised patients were excluded, whereas in previous studies P. acanthamoebae was mainly documented among immunosuppressed patients [8], [10] and children [7], [9]. The absence of S. negevensis DNA argues against a pathogenic role of Simkania, a still-controversial question [2], [3]. On the other hand, the documented C. psittaci infection underlines the importance of a complete diagnostic assessment, including C. psittaci, even in absence of history of exposure to birds. These data, taken together with the findings of our study, demonstrate that outside specific local conditions that may lead to cases clusters or outbreaks, different members of the Chlamydiales order, including C. pneumoniae, are not common agents of community-acquired pneumonia [11].

Duration of Antibiotic Treatment in Community-Acquired Pneumonia

The optimal duration of antibiotic treatment in communityacquired pneumonia (CAP) has not been completely established, and there are discrepancies even between various clinical guidelines published to date. The British Thoracic Society1 recommends 7 days of antibiotic treatment in patients with uncomplicated mild to moderate CAP. In 2011, the ERS2 published guidelines recommending that treatment should not exceed 8 days in responding patients defined by clinical stability criteria. However, as far back as 2007, the IDSA/ATS3 recommended a minimum treatment of 5 days, providing that the patient remained a febrile for 48–72 h, with no more than 1 sign of clinical instability. Efforts to cut back on widespread antibiotic use have been associated with multiple benefits, such as a decrease in microbial resistance, fewer adverse effects, and improved treatment adherence. The use of low-dose and long-duration (>5 days) betalactamics is associated with an increase in pharyngeal carriage of penicillin-resistant Streptococcus pneumoniae.4 Despite this, reducing the duration of antibiotic treatment in CAP can be complicated in routine clinical practice. In this respect, Moussaoui et al.5 conducted a clinical trial in 186 patients with CAP and a pneumonia severity score (PSI) of less than 110 points, who were given amoxicillin. In patients who presented an initial improvement after 72 h, 3 days of amoxicillin was equivalent to continuing the treatment for 8 days. Clinical cure was achieved after 10 days in 93% of cases in both groups. In view of the concentration-dependent bactericide activity and prolonged post-antibiotic effect of quinolones, it is logical to presume that by increasing the dose, and therefore the peak concentration and area under the curve, the duration of antibiotic treatment can be reduced without affecting efficacy. Dunbar et al.6 compared a 5-day course of levofloxacin 750 mg versus a 10-day course of 500 mg of the same antibiotic in patients with CAP PSI I–IV. He found that both were at least equally effective, and that fever was resolved earlier in the first group. Macrolides are known to have a long half-life and excellent lung penetration, which undoubtedly facilitates their use in short

British Thoracic Society community acquired pneumonia guideline and the NICE pneumonia guideline: how they fit together

The British Thoracic Society (BTS) guideline for the management of adults with community acquired pneumonia (CAP) published in 2009 was compared with the 2014 National Institute for Health and Care...

British Thoracic Society community acquired pneumonia guideline and the NICE pneumonia guideline: how they fit together

The British Thoracic Society (BTS) guideline for the management of adults with community acquired pneumonia (CAP) published in 2009 was compared with the 2014 National Institute for Health and Care...

Revisiting community case management of childhood pneumonia: perceptions of caregivers and grass root health providers in Uttar Pradesh and Bihar, northern India.

BackgroundCommunity-acquired pneumonia (CAP) is the leading cause of under-five mortality globally with almost one-quarter of deaths occurring in India.ObjectivesTo identify predisposing, enabling and service-related factors influencing treatment delay for CAP in rural communities of two states in India. Factors investigated included recognition of danger signs of CAP, health care decision making, self-medication, treatment and referral by local practitioners, and perceptions about quality of care.MethodsQualitative research employing case studies (CS) of care-seeking, key informant interviews (KII), semi-structured interviews (SSI) and focus group discussions (FGD) with both video presentations of CAP signs, and case scenarios. Interviews and FGDs were conducted with parents of under-five children who had suffered CAP, community health workers (CHW), and rural medical practitioners (RMP).ResultsFrom September 2013 to January 2014, 30 CS, 43 KIIs, 42 SSIs, and 42 FGDs were conducted. Recognition of danger signs of CAP among caregivers was poor. Fast breathing, an early sign of CAP, was not commonly recognized. Chest in-drawing was recognized as a sign of serious illness, but not commonly monitored by removing a child’s clothing. Most cases of mild to moderate CAP were brought to RMP, and more severe cases taken to private clinics in towns. Mothers consulted local RMP directly, but decisions to visit doctors outside the village required consultation with husband or mother-in-law. By the time most cases reached a public tertiary-care hospital, children had been ill for a week and treated by 2-3 providers. Quality of care at government facilities was deemed poor by caregivers.ConclusionTo reduce CAP-associated mortality, recognition of its danger signs and the consequences of treatment delay needed to be better recognized by caregivers, and confidence in government facilities increased. The involvement of RMP in community based CAP programs needs to be investigated further given their widespread popularity.

Relationship between chemiluminescent and enzymatic activity of blood neutrophils interactions in patients with community6 acquired pneumonia

The aim of the study was to investigate enzymatic and chemiluminescent activity in blood neutrophils of patients with moderate and severe communityacquired pneumonia (CAP). Methods. The study involved 48 patients with moderate CAP and 40 patients with severe CAP; they were examined on admission. Synthesis of primary and secondary reactive oxygen species (ROS) was evaluated using the chemiluminescence assay. Neutrophil NAD(P)dependent dehydrogenase activity was assessed using the bioluminescent method. Results. The «respiratory burst» was found in neutrophils of CAP patients. Terminal reactions of the anaerobic glycolysis and the tricarbonic acid cycle were intensified in patients with severe CAP only. Increased lipid anabolism activity and substrate outflow from the tricarbonic acid cycle via NADHdependent glutamate dehydrogenase were shown regardless of CAP severity. The canonical analysis showed abnormalities of metabolic mechanisms of the «respiratory burst» in blood neutrophils in CAP. Conclusion. The metabolic disorders and «respiratory burst» intensity in CAP arize the need for pathogenic correction. High NADHdepend ent dehydrogenase activity and lower chemiluminescent activity in blood neutrophils could be used as additional markers of severe course of CAP.

Community-acquired pneumonia: why aren't national antibiotic guidelines followed?

Adherence to guidelines for the management of community-acquired pneumonia (CAP) has been shown to improve patients' clinical outcomes. This study aimed to assess adherence to the Australian Therapeutic Guidelines (TG14) for the empirical management of CAP, and explore the potential barriers affecting adherence to these guidelines. Medical records were reviewed for all patients who were diagnosed with CAP within 24h of presentation at the Royal Hobart Hospital, the main teaching hospital in Tasmania, Australia, between July 2010 and March 2011. A survey of emergency department and medical team prescribers was also undertaken to identify potential barriers to adhere with the guidelines. χ(2) and Fisher's exact tests were used to test the significance between categorical data. To compare categorical and scale data, the Mann-Whitney U-test was used. A total of 193 patient records were assessed. The overall adherence to TG14 for the empirical antibiotic management of CAP was 16.1% (3.1%, 20.7% and 25.4% for patients with mild, moderate and severe CAP, respectively). Ceftriaxone was prescribed to 34.4%, 26.8% and 57.4% of patients with mild, moderate and severe CAP, respectively. The response rate to the barrier survey was 43.1%; of those who responded, 46.4% thought the influence of senior doctors on junior doctors could be a factor affecting adherence to the guidelines. Other barriers noted were a lack of guideline awareness (39.3%), the requirement to calculate the severity of CAP (35.7%), and the existence of other guidelines that conflict with TG14 (28.6%). Adherence to CAP treatment guidelines was poor, especially in patients with mild disease. Prescribing was mainly influenced by senior doctors. Efforts to improve compliance with CAP treatment guidelines should consider the potential barriers that hinder adherence.

FEATURES OF NEUTROPHILIC GRANULOCYTE CHEMILUMINESCENT ACTIVITY IN PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA

Aim. The aim of the study was to investigate luminol-dependent and lucigenin-dependent neutrophil granulocyte chemiluminescence in patients with community-acquired pneumonia (CAP). Methods. Forty-eight patients with moderate CAP and 40 patients with severe CAP were examined during two-week treatment. Primary and secondary reactive oxygen species (ROS) production was investigated using the chemiluminescence assay. Results. Patients with moderate CAP maintained a high-level ROS production for 2 weeks of the treatment; a trend towards improving neutrophil functional activity was seen after 7 days of the treatment. In patients with severe CAP superoxide radical production improved to the end of the study, whereas secondary ROS synthesis remained elevated during the entire treatment period with slowing secondary ROS accumulation rate to the end of the study which adversely affected neutrophilic granulocyte reactivity. Conclusion. Thus, neutrophil granulocyte chemiluminescence disorders as well as clinical risk factors could be considered as predictors of severe CAP.

Etiological agerelated description of communityacquired pneumonia in children

Aim. The study was aimed at investigation of etiology of communityacquired pneumonia (CAP) in children in relation to age. Methods. Chlamydophila pneumoniae, Mycoplasma pneumoniaе, respiratory viruses, Epstein–Barr virus, cytomegalovirus and human herpes virus type 6 were searched using bacteriological, serological and molecular methods. Results . We examined 145 hospitalized children aged 1 month to 17 years with respiratory infection complicated by moderate CAP. Viruses were detected in 62 % of children under 4 years old, in 43 % of children of 4 to 7 years old and in 17 % of schoolage children. A rate of mixed viralbacterial CAP decreased with aging and was found in 30 % of children under 4 years old and in 4 % of schoolage children. Conclusion . Viral infection, mainly respiratory syncytial virus and cytomegalovirus, prevailed in the etiology of CAP in children under 4 years; C. pneumoniae and M. pneumoniae prevailed in schoolage children.