Mortality In Severe Community-acquired Pneumonia Research Articles

Low thoracic skeletal muscle is a risk factor for 6-month mortality of severe community-acquired pneumonia in older men in intensive care unit

BackgroundPatients with severe community-acquired pneumonia (sCAP) admitted to the intensive care unit (ICU) often exhibit muscle catabolism, muscle weakness, and/or atrophy, all related to an increased morbidity and mortality. However, the relationship between thoracic skeletal muscle mass and sCAP-related mortality has not been well-studied. Early recognition of sarcopenia in ICU patients with sCAP would benefit their prognosis.MethodsA retrospective study was conducted in Taizhou Hospital of Zhejiang Province, involving 101 patients with sCAP admitted in the ICU between December 2022 and February 2023. We measured the cross-sectional aera of the pectoralis, intercostal, paraspinal, serratus, and latissimus muscles at the T4 vertebral level (T4CSA) using chest computed tomography. Discriminatory thresholds were established by performing receiver operating characteristic curve analysis, with a designated cutoff value of 96.75 cm2 for male patients. This cohort was classified into mortality and survival groups based on a 6-month post-admission outcome. Univariate and multifactorial logistic regression analyses were performed to validate the correlation between low thoracic skeletal muscle area and prognostic outcomes.ResultsThe mean age of the patients was 75.39 ± 12.09 years, with an overall 6-month mortality of 73.27%. T4CSA of the 6-month survival group was significantly larger than that in the mortality group for overall cohort. The T4CSA in the survival group was significantly larger than that in the mortality group (104.29 ± 23.98cm2 vs. 87.44 ± 23.0cm2, p = 0.008). T4CSA predicted the 6-month mortality from sCAP in males with an AUC of 0.722 (95% confidence interval (CI), 0.582–0.861). The specificity and sensitivity were 71.4% and 71.1%, respectively, (p < 0.05). No significant difference was observed between the two groups in terms of T4CSA.ConclusionsThis study revealed that low thoracic skeletal muscle mass increased the risk of all-cause 6-month mortality in ICU patients with sCAP, particularly among male patients.

Infectious diseases: what's new in 2023

The year 2023 saw the publication of several studies in various areas of infectious diseases. The administration of corticosteroids decreased mortality in severe community-acquired pneumonia. Administration of doxycycline post-exposure prophylaxis reduced the risk of bacterial sexually transmitted infections at the risk of resistance selection. An herbal preparation decreased mortality in sepsis. A meta-analysis concludes that oseltamivir does not significantly reduce the risk of hospitalisation for influenza. Discontinuation of antibiotic prophylaxis during dental procedures in Sweden did not increase the incidence of viridans group Streptococcus endocarditis. Several studies have led to the introduction of RSV (Respiratory Syncytial Virus (RSV) vaccination. 2023 also saw the resurgence of invasive Group A Streptococcal infections, of which clinicians must be wary.

Corticosteroids in ARDS.

Acute respiratory distress syndrome (ARDS) is frequently associated with sepsis. ARDS and sepsis exhibit a common pathobiology, namely excessive inflammation. Corticosteroids are powerful anti-inflammatory agents that are routinely used in septic shock and in oxygen-dependent SARS-CoV-2 related acute respiratory failure. Recently, corticosteroids were found to reduce mortality in severe community-acquired pneumonia. Corticosteroids may therefore also have a role to play in the treatment of ARDS. This narrative review was undertaken following a PubMed search for English language reports published before January 2023 using the terms acute respiratory distress syndrome, sepsis and steroids. Additional reports were identified by examining the reference lists of selected articles and based on personnel knowledge of the authors of the field. High-quality research is needed to fully understand the role of corticosteroids in the treatment of ARDS and to determine the optimal timing, dosing and duration of treatment.

Association of admission lactate with mortality in adult patients with severe community-acquired pneumonia

PurposeThe present study was conducted to investigate the association of admission lactate with mortality in severe community-acquired pneumonia (SCAP). MethodsWe performed a retrospective, observational, cohort study on adult SCAP patients admitted to intensive care unit (ICU) in West China Hospital of Sichuan University between December 2011 and December 2018. The primary outcome was hospital mortality. Univariate and then multivariate analysis were performed to identify independent risk factors for hospital mortality. The association of admission lactate categories with hospital mortality was examined in three logistic regression models and Kaplan–Meier plots. We also applied restricted cubic splines to estimate the potential non-linear associations. ResultsIn total, 2275 SCAP patients were included. Admission lactate remained a significant factor for mortality after multivariate regression (OR: 1.085; 95% CI: 1.033,1.141; by continuous variable). After lactate was categorized into quartiles and the confounders were fully adjusted, compared with the quartile 1, ORs (95% CIs) of hospital mortality for quartile 2, quartile 3 and quartile 4 were 1.001 (0.759–1.321), 1.153 (0.877–1.516) and 1.593 (1.202–2.109), respectively (P for trend =0.001). Survival curves indicated that elevated lactate was associated with poor prognosis (P < 0.001). Moreover, this association was non-linear, indicating that increased lactate has the most notable impact on mortality within the range of 1.5 to 4 mmol/L (P non-linear: 0.029 for hospital mortality; 0.004 for ICU mortality). ConclusionElevated admission lactate has a significant, independent, and potentially non-linear association with increased mortality in SCAP patients.

Development and Validation of a Nomogram for Predicting 28-Day Mortality on Admission in Elderly Patients with Severe Community-Acquired Pneumonia.

IntroductionThere were few studies on the mortality of severe community-acquired pneumonia (SCAP) in elderly people. Early prediction of 28-day mortality of hospitalized patients will help in the clinical management of elderly patients (age ≥65 years) with SCAP, but a prediction model that is reliable and valid is still lacking.MethodsThe 292 elderly patients with SCAP met the criteria defined by the American Thoracic Society from 33 hospitals in China. Clinical parameters were analyzed by the use of univariable and multivariable logistic regression analysis. A nomogram to predict the 28-day mortality in elderly patients with SCAP was constructed and evaluated using the area under the receiver operating characteristic curve (AUC) and internally verified using the Bootstrap method.ResultsA total of 292 elderly patients (227 surviving and 65 died within 28 days) were included in the analysis. Age, Glasgow score, blood platelet, and blood urea nitrogen values were found to be significantly associated with 28-day mortality in elderly patients with SCAP. The AUC of the nomogram was 0.713 and the calibration curve for 28-day mortality also showed high coherence between the predicted and actual probability of mortality.ConclusionThis study provides a nomogram containing age, Glasgow score, blood platelet, and blood urea nitrogen values that can be conveniently used to predict 28-day mortality in elderly patients with SCAP. This model has the potential to assist clinicians in evaluating prognosis of patients with SCAP.

Serum levels of SIRT3 and other inflammatory factors are associated with clinical outcomes and prognosis in severe community-acquired pneumonia in adults: A prospective study.

The aim of this study was to investigate clinical significance of SIRT3 in severe community-acquired pneumonia (CAP) patients.This prospective observational research enrolled a total of 114 severe CAP patients who went to our hospital during January 2018 to December 2019. Serum SIRT3 and IL-1β, IL-6, and tumor necrosis factor (TNF)-α levels were determined using the enzyme-linked immunosorbent assay (ELISA) method. Demographic data, including age, sex, and body mass index (BMI), as well as clinical symptoms, SOFA and SMART-COP scores were collected. The routine blood test was conducted for all patients and white blood cell (WBC) amount, as well as serum levels of C-reactive protein (CRP), D-Dimer, and procalcitonin (PCT).Among all patients, 55 cases died during the study period. The serum levels of CRP, PCT, IL-1β, and IL-6, as well as SOFA and SMART-COP scores were markedly higher in deceased patients than in the survival patients. The expression of SIRT3 was significantly decreased in severe CAP patients compared with the healthy, especially in the deceased patients. SIRT3 levels were negatively correlated with levels of CRP, PCT, IL-1β, and IL-6. Patients with SIRT3 low expression showed remarkably higher expression of CRP, PCT, IL-1β, and IL-6, as well as high SMART-COP scores, higher 1-month mortality rate, and shorter survival. Only SIRT3 and IL-1β were independent risk factors for 1-month mortality in severe CAP patients.Lower serum SIRT3 level predicts poor clinical outcomes and prognosis in severe CAP patients.

Prognostic value of clinical scoring systems and coagulation parameters in severe community aquired pneumonia

Introduction Predicting ICU outcome in community-acquired pneumonia (CAP) is important for effective clinical decision making. CAP is associated with coagulation abnormalities even in patients with nonsevere illness, and these parameters may improve the ability of simple clinical scores to expect mortality in severe CAP. Patients and methods A prospective study was conducted on 100 patients with a primary diagnosis of CAP and who needed admission to ICU Minia University Hospital between the period of September 2018 and October 2019. The study aimed to evaluate the value of clinical scoring systems and coagulation parameters to predict prognosis of severe CAP. Results The overall ICU mortality was 41%. Following multivariable regression, male sex, Simplified Acute Physiological Score II score, diagnosis of cancer, and prothrombin time (PT) were significantly associated with ICU mortality. Apart from Acute Physiologic Assessment and Chronic Health Evaluation III score, all other severity scores, including the CURB-65 score, can differentiate between ICU survivors and nonsurvivors when calculated at the time of admission to ICU (P&lt;0.0001). Allocating an extra point for PT more than 17 s to the CURB-65 score improved its sensitivity. Conclusion Mortality from severe CAP remains high. The ability of the CURB-65 score to differentiate between survivors and nonsurvivors of severe CAP is comparable to other more complex scores. Addition of PT may further improve its discriminatory ability.

Usefulness of β-lactam and macrolide combination therapy for treating community-acquired pneumonia patients hospitalized in the intensive care unit: Propensity score analysis of a prospective cohort study

IntroductionWhether β-lactam and macrolide combination therapy reduces mortality in severe community-acquired pneumonia (SCAP) patients hospitalized in the intensive care unit (ICU) is controversial. The aim of the present study was to evaluate the usefulness of β-lactam and macrolide combination therapy for SCAP patients hospitalized in the ICU. MethodsA prospective, observational, cohort study of hospitalized pneumonia patients was performed. Hospitalized SCAP patients admitted to the ICU within 24 h between October 2010 and October 2017 were included for analysis. The primary outcome was 30-day mortality, and secondary outcomes were 14-day mortality and ICU mortality. Inverse probability of treatment weighting (IPTW) analysis as a propensity score analysis was used to reduce biases, including six covariates: age, sex, C-reactive protein, albumin, Pneumonia Severity Index score, and APACHE II score. ResultsA total of 78 patients were included, with 48 patients in the non-macrolide-containing β-lactam therapy group and 30 patients in the macrolide combination therapy group. β-lactam and macrolide combination therapy significantly decreased 30-day mortality (16.7% vs. 43.8%; P = 0.015) and 14-day mortality (6.7% vs. 31.3%; P = 0.020), but not ICU mortality (10% vs 27.1%, P = 0.08) compared with non-macrolide-containing β-lactam therapy. After adjusting by IPTW, macrolide combination therapy also decreased 30-day mortality (odds ratio, 0.29; 95%CI, 0.09–0.96; P = 0.04) and 14-day mortality (odds ratio, 0.19; 95%CI, 0.04–0.92; P = 0.04), but not ICU mortality (odds ratio, 0.34; 95%CI, 0.08–1.36; P = 0.13). ConclusionsCombination therapy with β-lactam and macrolides significantly improved the prognosis of SCAP patients hospitalized in the ICU compared with a non-macrolide-containing β-lactam regimen.

Marked Reduction in 28-day Mortality Among Elderly Patients with Severe Community-acquired Pneumonia: Post Hoc Analysis of a Large Randomized Controlled Trial.

BackgroundThere were few studies on the case mortality of severe community-acquired pneumonia (CAP) in elderly people. Improved outcomes with XueBiJing (XBJ) injection vs placebo have been shown in overall trial populations. We investigated the efficacy and safety of XBJ vs placebo in subjects with severe CAP stratified by age (<65 and ≥65 years).MethodsThis post hoc analysis of a large randomized trial compared data from elderly and nonelderly patients with XBJ, 100 mL, q 12 h, or a visually indistinguishable placebo for five-to-seven days.ResultsAmong subjects ≥65 years (n=291), 23 (16.0%) XBJ recipients and 41 (27.9%) placebo recipients (P=0.014) died within 28 days. Among subjects <65 years (n=360), XBJ still had lower mortality (XBJ 15.6% vs placebo 22.8%; P=0.082), without significantly statistical difference. Total duration of ICU stay and the time of mechanical ventilation were similar in both groups (P>0.05). XBJ also had a favorable safety profile, with no clinically relevant differences between the two groups. The overall incidence of adverse events was similar in both groups.ConclusionXBJ was safe and effective for reduction in 28-day mortality among elderly patients with severe CAP. Additional confirmatory trials involving elderly patients are needed to further confirm the present results.Trial Registrationhttp://www.chictr.org.cn/index.aspx. ChiCTR-TRC-13003534.

Admission IL-32 concentration predicts severity and mortality of severe community-acquired pneumonia independently of etiology

BackgroundSevere community-acquired pneumonia (SCAP) is a critical disorder with high morbidity and mortality, usually manifested as acute respiratory failure and septic shock generally caused by exaggerated systemic inflammation. Interleukin-32 (IL-32), a pro-inflammatory cytokine, has been reported involved in various infectious diseases. We investigated the efficacy of the plasma IL-32 as a biomarker for evaluating the severity and clinical outcomes in SCAP patients. MethodsA total of 124 adult immunocompetent SCAP patients and 87 healthy controls were enrolled in this observational, prospective cohort study. ResultsWe found that PBMCs IL-32 mRNA and plasma IL-32 concentrations on admission of SCAP patients were significantly higher than healthy controls. Plasma IL-32 concentrations closely correlated with increasing severity scores, the need for vasopressor support or invasive mechanical ventilation but not with the etiology. The area under the curve (AUC) for predicting 30-day mortality using IL-32 was 0.812, is superior to WBCs and CRP. Incorporation of IL-32 with the severity scores were shown to improve the prognostic accuracy considerably. Furthermore, the 30-day cumulative survival rate in high IL-32 concentration group was significantly lower than that in the low concentration group. In a multivariate Cox regression analysis, higher IL-32 concentration and higher PSI score were recognized as the independent risk factors for survival, and the relative risks were 2.568 and 3.362, respectively. ConclusionsAdmission IL-32 concentration closely related to the severity and mortality of SCAP, and it may be served as a potential biomarker to help clinical judgment and management.

Value Addition on Trend of Pneumonia Disease in India- The Current Update

Pneumonia continues to be the leading infectious cause of death among children under the age of five worldwide. Diagnosis of this disease is primarily dependent on physical examination, clinical history, and radiographic studies. Microbiological studies of the lower respiratory tract secretions have proven to be futile, however, sputum gram staining and culturing methods often aid in the diagnosis and management of these infections. Aspiration pneumonia often occurs in a community setting and primarily involves anaerobes like Staphylococcus aureus or gram-negative rods such as Klebsiella pneumonia, and other Enterobacteriaceae and Pseudomonas species. The total number of cases taken in the study of acute pneumonia was 22 (15 male subjects and 7 female subjects). Biochemical tests were conducted for identifying different organisms present in the samples collected from patients suffering from acute pneumonia. Distribution of bacteria in the case of acute pneumonia was as follows: Staphylococcus aureus was recorded to be the highest (36.36%) followed by Streptococcus pneumonia (18.18%) and Klebsiella pneumonia (18.18%), Pseudomonas pneumonia (13.63%), Haemophilus influenza (9.09%) and lastly Chlamydia pneumonia (4.45%). A maximum number of laboratories proven acute pneumonia cases (36.36%) belonged to 61-70 years. The distribution of cases was marginally more in urban areas (63.63%). By occupation largest group (36.36%) was of others in case of acute pneumonia were as farmers, housewives and others were the largest groups (22.73%) each. The microbial etiology derived from the present study found that Klebsiella pneumonia was an independent risk factor for mortality in severe community-acquired pneumonia. Moreover, two important findings were drawn from this study. K. pneumonia was identified as the causative pathogen in 22% of cases, second to S. pneumonia.

Advances in severe community-acquired pneumonia.

Community-acquired pneumonia (CAP) is a common respiratory disease and is considered to be the leading cause of mortality among various infectious diseases.[1,2] A large population-based study showed that among hospitalized patients diagnosed with pneumonia, 21% of them required the intensive care unit (ICU) admission, 6% required invasive mechanical ventilation, and 2% died.[3] Although therapeutic strategies have been significantly improved over recent years, the morbidity and mortality of CAP, especially severe CAP (SCAP), remain high. Mortality of SCAP has been reported to range from 17% to 49% by different multi-center cohort studies.[4] The Infectious Diseases Society of America (IDSA), American Thoracic Society (ATS) and the Infectious Disease Assembly, Chinese Thoracic Society, have published consensus guidelines for CAP (IDSA/ATS 2007, CTS 2016), which clearly defined SCAP criteria.[5] According to IDSA/ATS SCAP criteria, patients with SCAP requiring ICU admission should have at least one major criteria (invasive mechanical ventilation or septic shock with the need for vasopressors) or at least three minor criteria (respiratory rate ≥30 breaths/min, oxygenation index (PaO2/FiO2) ratio ≤250, multi-lobe infiltrates, hypothermia (core temperature <36°C), leukopenia (white blood cell count <4000 cells/mm3), thrombocytopenia (platelet count <100,000 cells/mm3), hypotension requiring aggressive fluid resuscitation, confusion/disorientation, and uremia (blood urea nitrogen (BUN) ≥20 mg/dL).[5] To date, confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater (CURB-65) and pneumonia severity index (PSI), the two primary clinical assessment tools utilized, have been widely used to evaluate the mortality risk of CAP patients in clinical practice.[6,7] Several risk factors associated with high mortality in SCAP have been identified, including anti-microbial resistance, increased age, septic shock, and acute respiratory failure.[8] It is thus greatly beneficial to distinguish high-risk patients with SCAP and formulate personalized treatment strategies. Optimal ICU management and rational application of antibiotics were reported to be two key factors determining outcomes of patients with SCAP.[1] Recently, several advances in SCAP have been made and here we summarized the updated knowledge of diagnostic and therapeutic strategies for SCAP.

Factors associated with mortality in severe community-acquired pneumonia: A multicenter cohort study

ObjectiveDescribe characteristics and outcomes of CAP admitted to public ICUs in Brazil. MethodsRetrospective cohort study in 4 Tertiary Public Hospitals in Rio de Janeiro, Brazil during 2016. Patients admitted to ICUs with a diagnosis of community-acquired pneumonia were included. Clinical and outcomes data were collected from Epimed Monitor System. ResultsFrom 7902 admissions, 802 patients (10, 1%) were included and analyzed. Main source of admission was the emergency department (78, 3%). Median age was 66 (IQR 54–77) years, SAPS3 71(IQR 58–83) and SOFA D1 9(IQR 5–12) points. 67% of patients needed invasive mechanical ventilation, 12% hemodialysis. 47% required vasopressors. ICU and hospital mortality were 55.9% and 66.5% respectively. In a multivariate analysis, malnutrition [OR 2.28(1.21–4.3)], septic shock at admission [OR 1.95(1.39–2.75)], AIDS [3.04(1.16–7.93]), invasive mechanical ventilation [5.07(5.54–7.27)], age > 65 years [2.07(1.48–2.90)] and LOS >1 day before ICU admission [1.90(1.34–2.71)] were associated with increased mortality. ConclusionCAP is associated with high mortality in patients admitted to public ICUs in Brazil. The current findings may help improve resource allocation and should aim at improving access to ICU care since delayed admission was associated with increased hospital mortality.

Impact of microbial Aetiology on mortality in severe community-acquired pneumonia

BackgroundThe impact of different classes of microbial pathogens on mortality in severe community-acquired pneumonia is not well elucidated. Previous studies have shown significant variation in the incidence of viral, bacterial and mixed infections, with conflicting risk associations for mortality. We aimed to determine the risk association of microbial aetiologies with hospital mortality in severe CAP, utilising a diagnostic strategy incorporating molecular testing. Our primary hypothesis was that respiratory viruses were important causative pathogens in severe CAP and was associated with increased mortality when present with bacterial pathogens in mixed viral-bacterial co-infections.MethodsA retrospective cohort study from January 2014 to July 2015 was conducted in a tertiary hospital medical intensive care unit in eastern Singapore, which has a tropical climate. All patients diagnosed with severe community-acquired pneumonia were included.ResultsA total of 117 patients were in the study. Microbial pathogens were identified in 84 (71.8%) patients. Mixed viral-bacterial co-infections occurred in 18 (15.4%) of patients. Isolated viral infections were present in 32 patients (27.4%); isolated bacterial infections were detected in 34 patients (29.1%). Hospital mortality occurred in 16 (13.7%) patients. The most common bacteria isolated was Streptococcus pneumoniae and the most common virus isolated was Influenza A. Univariate and multivariate logistic regression showed that serum procalcitonin, APACHE II severity score and mixed viral-bacterial infection were associated with increased risk of hospital mortality. Mixed viral-bacterial co-infections were associated with an adjusted odds ratio of 13.99 (95% CI 1.30–151.05, p = 0.03) for hospital mortality.ConclusionsRespiratory viruses are common organisms isolated in severe community-acquired pneumonia. Mixed viral-bacterial infections may be associated with an increased risk of mortality.

Abstract 145: Glucocorticoid Treatment is Associated With Lower Incidence of Myocardial Infarction in Patients Hospitalized for Community-acquired Pneumonia

Background: Previous reports suggest that patients hospitalized for community-acquired pneumonia (CAP) have an enhanced risk of myocardial infarction (MI). Glucocorticoids have been proposed for the treatment of CAP. Although a recent meta-analysis showed that glucocorticoids can reduce morbidity and mortality in severe CAP, their role in the treatment of pneumonia remains unclear. Experiments in vitro and in vivo demonstrated that glucocorticoids inhibit platelet aggregation and platelet-related arterial thrombosis. Since enhanced platelet activation seems to play a role in the occurrence of MI in CAP patients, aim of the study was to assess the impact of glucocorticoids on MI occurrence in a cohort of patients hospitalized for CAP. Methods and Results: Consecutive patients admitted to the University-Hospital Policlinico Umberto I (Rome, Italy) with CAP were recruited and prospectively followed-up until discharge. The primary outcome of the study was the occurrence of an MI during hospitalization. Seven-hundred fifty-eight patients (493 males, 265 females; age: 71.7 ± 14.4 years) were included in the study: 241 (32%) were treated with systemic glucocorticoids (methylprednisolone, betamethasone or prednisone) during in-hospital follow-up, whereas 517 patients were not treated with systemic glucocorticoids. During the follow-up, 62 patients (8.2%) had an MI. Compared to the nonglucocorticoid group, patients treated with glucocorticoids showed a lower incidence of MI (9.5% vs. 5.4%; p=0.011). A Cox regression analysis showed that age, a history of coronary heart disease, and a major degree of respiratory impairment (pO2&lt;60mmHg and pH&lt;7.35) was positively associated to MI incidence, whereas glucocorticoid therapy was negatively associated. Compared to patients not receiving glucocorticoids, the propensity score adjusted analysis confirmed that patients taking glucocorticoids had a lower incidence of MI (HR: 0.458; 95% CI: 0.235 - 0.893, p=0.022). Conclusion: This study shows that in-hospital glucocorticoids treatment is associated with a lower incidence of MI within hospital-stay in a large cohort of patients with pneumonia.

A new method to predict hospital mortality in severe community acquired pneumonia

Background & aimsThe aim of this study is to develop a new method that is able to accurately predict the 28day hospital mortality in patients with severe community acquired pneumonia (SCAP) at an early stage. MethodsWe selected 37,348 SCAP patients in ICU from 173 hospitals during 2011.1–2013.12. The predictive factors for 28day hospital mortality were evaluated retrospectively. All cases underwent intensive care, blood routine, blood biochemical tests and arterial blood gas analysis. Under the Classification and Regression Tree (CART) analysis, a new clinical scoring system was developed for early prediction in SCAP patients. The receiver-operating characteristic (ROC) curve was plotted to calculate the area under the receiver operating characteristic curve (AUC). ResultsA novel clinical model named CLCGH scoring system, including Serum creatinine (Cr) >259.5μmol/L, leukocyte (WBC)>17.35×109/L, C-reactive protein (CRP)>189.4μg/mL, GCS≤9 and serum HCO3−≤17.65mmol/L, was carried out and each index was an independent factor for hospital mortality in SCAP. In validation cohort, the AUC of the new scoring system was 0.889 for prediction of hospital mortality, which was similar to SOFA score 0.877, APACHEII score 0.864, and was better than the PSI score 0.761 and CURB-65 score 0.767. ConclusionsThe new scoring system CLCGH is an efficient, accurate and objective method to predicate the early hospital mortality among SCAP patients.

The Use of Polymerase Chain Reaction Amplification for the Detection of Viruses and Bacteria in Severe Community-Acquired Pneumonia

Background: Pathogens are often not identified in severe community-acquired pneumonia (CAP), and the few studies using polymerase chain reaction (PCR) techniques for virus detection are from temperate countries. Objective: This study assesses if PCR amplification improves virus and bacteria detection, and if viral infection contributes to mortality in severe CAP in a tropical setting, where respiratory pathogens have less well-defined seasonality. Methods: In this cohort study of patients with severe CAP in an intensive care unit, endotracheal aspirates for intubated patients and nasopharyngeal swabs for non-intubated patients were sent for PCR amplification for respiratory viruses. Blood, endotracheal aspirates for intubated patients, and sputum for non-intubated patients were analysed using a multiplex PCR system for bacteria. Results: Out of 100 patients, using predominantly cultures, bacteria were identified in 42 patients; PCR amplification increased this number to 55 patients. PCR amplification identified viruses in 32 patients. In total, only bacteria, only viruses, and both bacteria and viruses were found in 37, 14, and 18 patients, respectively. The commonest viruses were influenza A H1N1/2009 and rhinovirus; the commonest bacterium was Streptococcus pneumoniae. Hospital mortality rates for patients with no pathogens, bacterial infection, viral infection, and bacterial-viral co-infection were 16.1, 24.3, 0, and 5.6%, respectively (p = 0.10). On multivariable analysis, virus detection was associated with lower mortality (adjusted odds ratio 0.12, 95% confidence interval 0.2-0.99; p = 0.049). Conclusions: Viruses and bacteria were detected in 7 of 10 patients with severe CAP with the aid of PCR amplification. Viral infection appears to be independently associated with lower mortality.

Improved survival among ICU-hospitalized patients with community-acquired pneumonia by unidentified organisms: a multicenter case-control study.

A retrospective analysis from prospectively collected data was conducted in intensive care units (ICUs) at 33 hospitals in Europe comparing the trend in ICU survival among adults with severe community-acquired pneumonia (CAP) due to unknown organisms from 2000 to 2015. The secondary objective was to establish whether changes in antibiotic policies were associated with different outcomes. ICU mortality decreased (p = 0.02) from 26.9% in the first study period (2000-2002) to 15.7% in the second period (2008-2015). Demographic data and clinical severity at admission were comparable between groups, except for age over 65 years and incidence of cardiomyopathy. Over time, patients received higher rates of combination therapy (94.3 vs. 77.2%; p < 0.01) and early (<3h) antibiotic delivery (72.9 vs. 50.3%; p < 0.01); likewise, the 2008-2015 group was more likely to receive adequate antibiotic prescription [as defined by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines] than the 2000-2002 group (70.7 vs. 48.2%; p < 0.01). Multivariate analysis showed an independent association between decreased ICU mortality and early (<3h) antibiotic administration [odds ratio (OR) 3.48 [1.70-7.15], p < 0.01] or adequate antibiotic prescription according to guidelines (OR 2.22 [1.11-4.43], p = 0.02). In conclusion, our findings suggest that ICU mortality in severe CAP due to unidentified organisms has decreased in the last 15years. Several changes in management and better compliance with guidelines over time were associated with increased survival.

Mortality predictors in patients with severe community-acquired pneumonia requiring ICU admission

Community-acquired pneumonia (CAP) is a major cause of mortality. This prospective study was conducted to describe patient’s characteristics, mortality rate, and etiological pathogens in patients with severe CAP who required ICU admission and to determine the predictors of mortality. This was a multicenter prospective observational study of 57 consecutive patients who were admitted to the ICU with diagnosis of severe CAP from October 2012 to August 2015. Overall 57 patients were included in the study and the overall ICU mortality rate was 49.1%. Heart disease and chronic obstructive pulmonary disease were the most common comorbidities associated with severe CAP. Comparison between survivors and nonsurvivors revealed that mortality was associated with old age (P=0.01), low diastolic blood pressure (P=0.04), low PaO2/FiO2 (P=0.04), high acute physiology and chronic health evaluation II (APACHE II) score (P=0.001), (CURB-65) score (P=0.005), low hemoglobin (P=0.008), and high urea (P=0.04). The univariate analysis demonstrated that the following were the predictors of mortality: age older than 65 years (P=0.03); APACHE II score greater than 20 (P=0.007); CURB-65 of 3 or greater (0.03); total leukocyte count less than 4 or greater than 11×109/(P=0.04); PaO2/FiO2 less than 250 (P=0.03); serum urea greater than 30 mg/dl (P=0.04); presence of septic shock (P=0.003); mechanical ventilation requirement (P=0.02); and bilateral or multilobar infiltrate on chest radiograph (P=0.03). Multiple regression analysis identified high APACHE II score (>20) and septic shock as significant independent predictors of mortality in severe CAP. Microbiological identification was obtained in 52.6% of cases, with positive blood culture in 17.5%. The most frequently isolated pathogens were Streptococcus pneumonia (S. pneumonia) (19.3%) and Staphylococcus aureus (S. aureus) (15.8%). Mortality rate in patients with severe CAP was high as reported by most of the other studies. The presence of septic shock and high APACHE II were independent predictors of mortality. Heart disease and chronic obstructive pulmonary disease were the most common comorbidities. Microbiological identification was obtained in 52.6% of cases, and S. pneumonia and S. aureus were the most frequently isolated pathogens.

Macrolides and Mortality in Severe Community-Acquired Pneumonia*

Tayside Respiratory Research Group, University of Dundee and Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom * See also p. 420. The author has disclosed that he does not have any potential conflicts of interest.