Non-severe Community-acquired Pneumonia Research Articles

COMPERISON OF “OLD” AND “NEW” ACUTE PHASE REACTANTS IN PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA AND DIABETS MELLITUS 2 TYPE AS INFLAMMATORY CHANGES MARKERS

The aim of the study was to evaluate “old” (WBC count) and “new” inflammatory biomarkers in hospitalized patients with non-severe community-acquired pneumonia in patients with\without Diabetes Mellitus 2 type. Materials and methods. At inclusion, clinical and laboratory parameters of pneumonia were recorded and the CRB-65 was evaluated. A total of 131 adult patients hospitalized with non-severe CAP were included in this prospective study. Levels of pro-inflammatory (IL-1β, IL-8, TNF-α), anti-inflammatory (IL-10) cytokines and markers of inflammation (CRP, complete blood count) were determined at the beginning of the disease (day O) and in 48-72 hours. Results. The level of leukocytes in CBC was significantly higher in the main group at the beginning of the disease, as well after 10 ± 2 days from day 0 the number of episodes of leukocytosis > 10 · 109 / l was higher (8.5% vs. 2%, respectively, p <0,05). There was no statistically significant difference between the studied inflammatory biomarkers levels in the both groups of patients with and without concomitant diabetes. There was a tendency to a higher number of cases of "recovery" after CAP in the group with CRP levels during hospitalization ≥ 21.8 pg / ml (22% vs. 48%, p <0.1). Conclusion. It can be assumed that such a low dynamics of inflammatory markers is associated with involutive changes in the immune system due to older age of the patients included in the study and the influence of DM on the immune system reactivity in the CAP with concomitant DM 2 type with immune response suppression can also explain absence of significant difference in inflammatory biomarkers concentration in the groups compered in this study.

Rs1840680 single nucleotide polymorphism in Pentraxin 3: a potential protective biomarker of severe community-acquired pneumonia.

ObjectiveSingle nucleotide polymorphisms (SNPs) of pentraxin 3 (PTX3) are associated with various outcomes of lung infections. This study aimed to analyze the relationship between PTX3 polymorphisms and the severity of community-acquired pneumonia (CAP).MethodsThis is a retrospective case-control study comprising 43 patients with severe CAP (SCAP) and 97 patients with non-severe CAP. Three SNPs in the PTX3 gene (rs2305619, rs3816527, and rs1840680) from peripheral blood samples were genotyped by real-time polymerase chain reaction. The association between each SNP and the CAP severity was analyzed by logistic regression analysis.ResultsWe found that the rs1840680 polymorphism was significantly associated with CAP clinical severity. However, no such association was observed for the genotypes and allele frequencies of rs2305619 or rs3816527. The PTX3 rs1840680 AG genotype was an independent factor for a lower risk of SCAP after multivariate logistic regression analysis. Male sex and coronary heart disease were associated with an increased risk of SCAP.ConclusionsThe PTX3 rs1840680 AG genotype was found to be associated with a lower risk of SCAP, and may serve as a potential protective biomarker to help clinical judgment and management.

Admission lysophosphatidylethanolamine acyltransferase level predicts the severity and prognosis of community-acquired pneumonia.

Early diagnosis and prognosis of patients with community-acquired pneumonia (CAP) are still difficult clinical challenges. This study aimed to investigate the role of lysophosphatidylethanolamine acyltransferase (LPEAT) in CAP and to evaluate the effectiveness of this enzyme as an indicator of disease severity and risk of death in CAP. This retrospective, multi-center study was conducted in 2017. A total of 267 patients with CAP were included. Of these 267 patients, 175 patients had non-severe CAP (non-SCAP) and 92 patients had severe CAP (SCAP). In addition, we recruited 15 healthy volunteers and 42 hospitalized disease controls in our study. The demographic and clinical characteristics were recorded for all participants. Admission levels of LPEAT were determined by quantitative enzyme-linked immunosorbent assay. Admission levels of LPEAT in patients with SCAP were significantly higher, particularly in non-survivors and were not affected by the causative etiology. Furthermore, when the patients were stratified according to PSI and CURB-65 scores, the patients with high severity scores had higher LPEAT levels upon admission than patients with low severity scores. LPEAT also performed well in predicting SCAP in patients with CAP. Moreover, LPEAT could predict the 30-day mortality rate of patients with CAP, and combining LPEAT with the clinical severity score further improved the accuracy of mortality prediction. Elevated LPEAT levels can reliably predict the severity of illness in patients with CAP at the time of admission. Adding LPEAT to clinical scoring methods could improve prognostic accuracy. Trial registration ClinicalTrials.gov, NCT03093220. Registered on March 28th, 2017.

Pharmacoeconomic analysis of first-choice antimicrobial drugs prescribed for outpatient treatment of non-severe community-acquired pneumonia

The study aimed to perform a pharmacoeconomic analysis of antimicrobial drugs (AMDs) prescribed for the treatment of community-acquired pneumonia (CAP) in outpatient conditions. Materials and methods . 650 medical histories of patients aged 18 to 65 years old with a diagnosis of CAP who received outpatient treatment in a larg Moscow municipal polyclinic in 2018-2019 were selected for pharmacoeconomic analysis. A model of antimicrobial drug consumption was built based on actual Algorithms of Patients’ Management endorsed by the Moscow Department of Healthcare (MDH) in 2018. The analysis of the used AMPs costs in real medical practice and the simulated situation was carried out. To process the obtained results, "Statistica 13.0" software was used Results . The studied sampling of 650 medical histories included 386 (59.4%) women and 264 (40.6%) men with an average age of 39.8±16.8 years The average real clinical course cost of antimicrobial treatment calculated with a reference to the price and the percentage of total AMDs administered was worth 617.50 rubles. A comparison of the calculated average actual and simulated average AMDs course costs revealed that outpatient treatmen of CAP patients with adherence to the current MDH Algorithms would cost 394.13 rubles what would be 1.6 times more cost-effective than in the current practice. Conclusions. A course of outpatient treatment of CAP with aminopenicillins and macrolides in accordance with the actual MDH Algorithms regarding the preferences of doctors when choosing antimicrobial drugs within groups would cost on average 394.13 rubles which makes it more cost-effective as compared to real practice expenses.

Predictive and Prognostic Utility of the Serum Level of Resistin-Like Molecule Beta for Risk Stratification in Patients with Community-Acquired Pneumonia.

Despite progress in intensive care, the morbidity and mortality of patients with community-acquired pneumonia (CAP) remains high. Furthermore, the predictive and prognostic utility of resistin-like molecule beta (RELM-β) in patients with CAP is uncertain. This study investigated the role of RELM-β in patients with CAP and evaluated its correlation with disease severity and the risk of death. A prospective, multicenter study was conducted in 2017, and admission serum levels of RELM-β were detected using quantitative enzyme-linked immunosorbent assay. A total of 114 and 112 patients with severe CAP (SCAP) and non-severe CAP (NSCAP) were enrolled, respectively, with 15 healthy controls. Patients with SCAP, especially non-survivors, had significantly higher levels of serum RELM-β than patients with NSCAP. RELM-β levels positively correlated with severity scores and consistently predicted SCAP in patients with CAP (area under the curve = 0.794). Increased levels of RELM-β were closely related to the severity and prognosis of patients with CAP. The accuracy of 30-day mortality predictions of CURB-65 (confusion, urea, respiratory rate, blood pressure, and age ≥ 65 years) can be significantly improved when combined with RELM-β levels. The level of RELM-β can assist clinicians in risk stratification of patients with CAP in early stages.

1363. Assessment and Quantification of Nasopharyngeal Streptococcus pneumoniae Colonization Does Not Discriminate Between Children with Viral and Bacterial Respiratory Infection

BackgroundPediatric uncomplicated pneumonia can be caused by viruses, bacteria, and atypical pathogens. Unfortunately, readily-available diagnostics do not reliably identify which cases of uncomplicated pneumonia have a bacterial etiology. It has been suggested that measuring pneumococcal nasopharyngeal carriage can discriminate between viral and bacterial disease. The objective of this study was to determine if nasopharyngeal pneumococcal carriage differed between children with definite viral disease, definite bacterial disease, and respiratory disease of indeterminate etiology.MethodsThree cohorts were recruited. Cohort 1 consisted of children with acute respiratory illness admitted to the pediatric intensive care unit; Cohort 2 consisted of previously healthy children with acute respiratory illness admitted to the general pediatric ward; and Cohort 3 consisted of previously healthy children diagnosed with non-severe community-acquired pneumonia in the emergency department. Children were categorized into the following disease categories: a) viral infection syndrome, b) pneumonia complicated by effusion/empyema, or c) ‘indeterminate’ pneumonia. Study subjects’ nasopharyngeal swabs (NPS) underwent quantitative PCR testing for S. pneumoniae.ResultsThere were 206 children in Cohort 1, 122 children in Cohort 2, and 179 children in Cohort 3. The median subject age was 2.5 y (25-75%ile 1.3-4.9 y). Only a minority (227/507, 45%) had pneumococcal carriage detected; in those participants, there was no association of quantitative genomic load with age, cohort, or disease category. In multivariate logistic regression, NPS pneumococcal carriage (positivity >3 log copies/mL) was associated with younger age and cohort of recruitment, but not with disease category (all those with indeterminate non-severe pneumonia were from Cohort 3).Table 1. Comparison of subjects in different cohorts Table 2. Comparison of subjects in different disease categories Table 3. Associations with nasopharyngeal pneumococcal colonization >3 log copies/mL. ConclusionThe nasopharyngeal S. pneumoniae carriage patterns of subjects with definite viral infection were very similar to those with definite bacterial infection and to those with indeterminate pneumonia. It would therefore appear that assessment and quantification of nasopharyngeal pneumococcal colonization is not useful to discriminate between acute viral and bacterial respiratory disease in children in North America.Disclosures All Authors: No reported disclosures

Results of respiratory muscle strength study in young persons with community-acquired pneumonia

Aim. To evaluate the strength of the respiratory muscles (RM) in young people with community-acquired pneumonia (CAP) of varying severity and the completeness of its recovery during convalescence. Materials and methods. The study involved 104 men aged 18-23 years who were in hospital with a diagnosis of CAP. Non-severe CAP was diagnosed in 78 (75%) patients and severe CAP in 26 (25%). The strength indices of expiratory and inspiratory RM were recorded on a MicrоRPM device (CareFusion, Great Britain) at the height of the disease and during the period of convalescence. Anthropometric indicators were measured, the mass of skeletal muscles (MSM) was calculated according to the formula of J.Mateika, the ratio of MSM to total body mass (TBM), expressed as a percentage, is determined. The degree of fatigue of RM was studied by means of loading tests on incentive spirometer with adjustable expiratory and inspiratory resistance TheraPEP and Coach 2 (Smiths Medical, Great Britain). The fatigue index (FI) of expiratory and inspiratory RM was calculated as the ratio of the difference in the strength of the RM before and after the load to the initial value, expressed as a percentage. Results. At the height of the disease, the average values of the power characteristics of RM in patients with severe CAP compared to non-severe CAP shifted toward lower values. Moreover, the severity of the dysfunction of expiratory RM was more noticeable in comparison with inspiratory ones. The direct dependence of RM strength indicators on MSM was established. In convalescents, with an increase in MSM, a decrease in the FI was recorded, which demonstrated a greater resistance of RM to resistive breathing in this category of patients. Conclusion. The functional status of RM depends on the severity of CAP, but also on MSM, which indicates the important role of the muscle component in providing pulmonary ventilation. The use of adjustable expiratory and inspiratory resistance tests is a useful tool for assessing the completeness of the strength recovery of the RM after having CAP.

Safety and Pharmacokinetics of Recombinant Human Plasma Gelsolin in Patients Hospitalized for Nonsevere Community-Acquired Pneumonia

There remains an unmet need to address the substantial morbidity and mortality associated with severe community-acquired pneumonia (sCAP). Recombinant human plasma gelsolin (rhu-pGSN) improves disease outcomes in diverse animal models of infectious and noninfectious inflammation. This blinded dose-escalation safety study involved non-intensive care unit (ICU) patients admitted for mild CAP and randomized 3:1 to receive adjunctive rhu-pGSN or placebo intravenously. Thirty-three subjects were treated: 8 in the single-dose phase and 25 in the multidose phase. For the single-dose phase, rhu-pGSN at 6 mg/kg of body weight was administered once. For the multidose phase, a daily rhu-pGSN dose of 6, 12, or 24 mg/kg was given on 3 consecutive days. Adverse events (AEs) were generally mild in both treatment groups irrespective of dose. The only serious AE (SAE) in the single-dose phase was a non-drug-related pneumonia in a rhu-pGSN recipient who died after institution of comfort care. One single-dose placebo recipient had a drug-related AE (maculo-papular rash). In the multidose phase, there were 2 SAEs in 1 placebo recipient, including a fatal pulmonary embolism. In the 18 rhu-pGSN recipients in the multidose phase, there were no serious or drug-related AEs, and nausea and increased blood pressure were each reported in 2 patients. The median rhu-pGSN half-life exceeded 17 h with all dosing regimens, and supraphysiologic levels were maintained throughout the 24-h dosing interval in the 2 highest dosing arms. Rhu-pGSN was well tolerated overall in CAP patients admitted to non-ICU beds, justifying a larger proof-of-concept trial in an ICU population admitted with sCAP. (This study has been registered at ClinicalTrials.gov under identifier NCT03466073.).

Cold-inducible RNA-binding protein might determine the severity and the presences of major/minor criteria for severe community-acquired pneumonia and best predicted mortality

BackgroundSeverity of community-acquired pneumonia (CAP) depends on microbial pathogenicity, load and virulence, and immune responses. The Infectious Disease Society of America and the American Thoracic Society (IDSA/ATS) minor criteria responsible for clinical triage of patients with CAP are of unequal weight in predicting mortality. It is unclear whether the IDSA/ATS major/minor criteria might be strongly and positively associated with the immune responses. It is warranted to explore this intriguing hypothesis.MethodsA prospective cohort study of 404 CAP patients was performed. Cold-inducible RNA-binding protein (CIRP) levels were measured using a sandwich-based enzyme-linked immunosorbent assay. The receiver operating characteristic curves were created and the areas under the curves were calculated to illustrate and compare the accuracy of the indices.ResultsSevere CAP patients meeting the major criteria had the highest plasma concentrations of CIRP. The more the number of most predictive minor criteria strongly associated to mortality, i.e. arterial oxygen pressure/fraction inspired oxygen ≤ 250 mmHg, confusion, and uremia, present, the higher the CIRP level. Interestingly, the patients with non-severe CAP meeting the most predictive minor criteria demonstrated unexpectedly higher CIRP level compared with the patients with severe CAP not fulfilling the criteria. Procalcitonin (PCT), interleukin-6 (IL-6), C-reactive protein (CRP), sequential organ failure assessment (SOFA) and pneumonia severity index (PSI) scores, and mortality confirmed similar intriguing patterns. CIRP was strongly linked to PCT, IL-6, CRP, minor criteria, SOFA and PSI scores, and mortality (increased odds ratio 3.433). The pattern of sensitivity, specificity, positive predictive value, and Youden’s index of CIRP ≥ 3.50 ng/mL for predicting mortality was the optimal. The area under the receiver operating characteristic curve of CIRP was the highest among the indices.ConclusionsCIRP levels were strongly correlated with the IDSA/ATS major/minor criteria. CIRP might determine the severity and the presences of major/minor criteria and best predicted mortality, and a CIRP of ≥ 3.50 ng/mL might be more valuable cut-off value for severe CAP, suggesting that CIRP might be a novel and intriguing biomarker for pneumonia to monitor host response and predict mortality, which might have implications for more accurate clinical triage decisions.

Aspiration Risk Factors, Microbiology, and Empiric Antibiotics for Patients Hospitalized With Community-Acquired Pneumonia

Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role. What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP? This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups. We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0%vs1.03%vs1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3%vs44.3%vs33.3%, P= .021) and lower rates of total gram-positive bacteria (7.1%vs38.1%vs50.0%, P< .001) when compared with patients with severe CAP/AspRF+ and severe CAP/AspRF-, respectively. Most patients (>50%in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics. Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage.

Effect of 23S rRNA gene mutations in Mycoplasma pneumoniae on severity of community-­acquired pneumonia in young adult patients treated at the Smolensk military hospital

Objective. To evaluate effect of 23S rRNA gene mutations in Mycoplasma pneumoniae on severity of community-acquired pneumonia (CAP) in young adult patients. Materials and Methods. A total of 42 case histories of young adult patients with CAP treated at the Smolensk military hospital over the period of 25 October 2017 to 25 December 2019 were reviewed. «AmpliSens® Mycoplasma pneumoniae/Chlamydophila pneumoniae-FL» real-time PCR kit was used to detect M. pneumoniae from nasopharyngeal swabs collected prior to antimicrobial therapy. Testing for 23S rRNA gene mutations conferring macrolide resistance was performed by real-time PCR melt curve analysis (patent no. 2646123) and confirmed by DNA sequencing. Results. All patients had a clinical picture of non-severe CAP on hospital admission. All patients were treated with standard doses of azithromycin or clarithromycin. No respiratory failure or any other complications were observed. Macrolide-resistant genotype of M. pneumoniae was detected in 4 (9.5%) patients. Clinical, laboratory and radiological resolution of pneumonia in all cases occurred on day 10– 16, regardless of the presence of macrolide-resistant genotype. Conclusions. There were no differences in clinical course of severity between CAP caused by M. pneumoniae with 23S rRNA gene mutation and CAP caused by wild-type M. pneumoniae The presence of mutations in the 23S rRNA gene of M. pneumoniae did not worsen the clinical course of CAP.

About Management of Cough in Patients with Community-acquired Pneumonia: the Results of MUCASTAT PLUS Trial

The objective: to study an effectiveness and tolerability of free prescription by physicians of erdostein and ambroxol for management of cough in hospitalized patients with non-severe community-acquired pneumonia on the background of standard antibacterial treatment after completion of MUCASTAT trial.Materials and methods. 245 patients (110 men and 135 women) aged 21–82 years were included in an open prospective non-randomized study. All the patients received standard antibacterial treatment for 7–10 days and mucoactive drugs of erdosteine (Mucitus) or ambroxol in standard dosages for no less then 6 days. CAP-Sym-12 and Scale of Estimation of CAP (SECAP) questionnaires were used to estimate pneumonia-related symptoms.Results. In 2–3 days from the beginning of therapy the patients from erdosteine group began to estimate their well-being (condition) and cough intensity (according to CAP-Sym-12 questionnaire) better, than patients from ambroxol group. In subsequent observation periods (in 7±1 and 12±2 days from the beginning of treatment) superiority of erdosteine was documented by objective (lesser quantity of patients suffering from cough and sputum expectoration) and subjective methods (CAP-Sym-12 and SECAP questionnaires).Conclusion. An effectiveness, good tolerability and superiority of erdosteine over ambroxol for management of cough and sputum expectoration in hospitalized patients with community acquired pneumonia on the background of standard antibacterial treatment were confirmed in MUCASTAT PLUS study.

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.

Community-acquired pneumonia in elderly patients: the effectiveness of antimicrobial therapy regimens.

The clinical efficacy of using «protected» aminopenicillins (amoxicillin/clavulanate, amoxicillin/sulbactam) and the 3rd generation cephalosporins in the treatment of mild community-acquired pneumonia in patients older than 60 years in hospital has been evaluated. Analyzed 71 case histories. The assessment was carried out on the basis of a comprehensive analysis of clinical, laboratory and radiological data. A comparative analysis of the clinical efficacy and safety of the antibiotic regimens under study demonstrated the obvious advantage of using «protected» aminopenicillins over the existing practice of treating non-severe community-acquired pneumonia in patients of older age groups.

High incidence of rhinovirus infection in children with community-acquired pneumonia from a city in the Brazilian pre-Amazon region.

Community‐acquired pneumonia (CAP) is the leading cause of child death worldwide. Viruses are the most common pathogens associated with CAP in children, but their incidence varies greatly. This study investigated the presence of respiratory syncytial virus (RSV), adenovirus, human rhinovirus (HRV), human metapneumovirus (HMPV), human coronavirus (HCoV‐OC43 and HCoV‐NL63), and influenza A virus (FluA) in children with CAP and the contributing risk factors. Here, children with acute respiratory infections were screened by pediatrics; and a total of 150 radiographically‐confirmed CAP patients (aged 3 months to 10 years) from two clinical centers in Sao Luis, Brazil were recruited. Patient's clinical and epidemiological data were recorded. Nasopharyngeal swab and tracheal aspirate samples were collected to extract viral nucleic acid. RSV, adenovirus, rhinovirus, FluA, HMPV, HCoV‐OC43, and HCoV‐NL63 were detected by real‐time polymerase chain reaction. The severe CAP was associated with ages between 3 and 12 months. Viruses were detected in 43% of CAP patients. Rhinovirus infections were the most frequently identified (68%). RSV, adenovirus, FluA, and coinfections were identified in 14%, 14%, 5%, and 15% of children with viral infection, respectively. Rhinovirus was associated with nonsevere CAP (P = .014); RSV, FluA, and coinfections were associated with severe CAP (P < .05). New strategies for prevention and treatment of viral respiratory infections, mainly rhinovirus and RSV infections, are necessary.

Utility of Blood Cultures in Pneumonia

IntroductionBlood cultures are of limited utility in nonsevere community-acquired pneumonia, though routinely recommended for severe community-acquired pneumonia or health care-associated pneumonia due to perceived greater bacteremia risk, particularly with multidrug-resistant organisms. The utility of this practice is unknown. MethodsIn this observational cohort study, we abstracted data from medical records for consecutive hospitalizations for pneumonia by adults to an academic medical center from 2014-2015. The primary outcomes included bacteremia, multidrug-resistant organism bacteremia, and appropriate management changes attributed to culture results, stratified by pneumonia classification (nonsevere community-acquired pneumonia, severe community-acquired pneumonia, or health care-associated pneumonia) and likelihood the bacteremia was due to pneumonia vs another infection. We assessed the diagnostic test performance of one or more guideline-defined risk factors for bacteremia in nonsevere community-acquired pneumonia, for whom cultures are routinely recommended. ResultsOf 456 pneumonia hospitalizations, 30 (6.6%) had bacteremia, with a greater incidence in severe community-acquired pneumonia (14.7%) than nonsevere community-acquired pneumonia (7.8%) and health care-associated pneumonia (6.6%; P = .12). Seventeen bacteremia cases were likely due to pneumonia (3.7%). Only 2 (0.4%) had multidrug-resistant organisms (both health care-associated pneumonia), one of whom was due to pneumonia. Appropriate management changes occurred in 8 cases (1.8%; 7 de-escalation and 1 escalation of antibiotics); only 1 with bacteremia likely due to pneumonia (de-escalation). The one case of appropriate antibiotic escalation occurred in a patient with vancomycin-resistant Enterococcus unrelated to pneumonia. Having one or more guideline-defined risk factors did not identify bacteremia in nonsevere community-acquired pneumonia (positive likelihood ratio, 1.10; 95% confidence interval, 0.61-1.99). ConclusionRoutine blood cultures in pneumonia have extremely low yield and utility irrespective of severity and risk.

C-reactive protein evaluation in communityacquired pneumonia with comorbid chronic heart failure as criterion of antibiotic prescription

To prove that diagnostic algorithm based on additional measurement of serum C-reactive protein (CRP) for administration of systemic antibacterial therapy (ABT) to patients with suspected community-acquired pneumonia (CAP) and concomitant chronic heart failure (CHF) does not influence outcomes of disease. This open, single-center, randomized, prospective, noninferiority study included 160 adult patients with documented functional class II-IV CHF who had been admitted with a preliminary diagnosis of non-severe CAP. Patients were randomized at 1:1 to two groups; group 1 - with additional measurement of CRP (n=80) and group 2 - with the use of routine diagnostic methods (n=80). In group 1, systemic ABT was administered only when serum CRP was &gt;28.5 mg / l (threshold level of the biomarker calculated at the previous stage of the study); group 2 received a standard treatment. Noninferiority test result for both algorithms was evaluated by the number of patients with clinical success on days 12-14 (primary endpoint). Non-inferiority margin was δ=-13.5 %. In addition secondary endpoints (early clinical response on days 3-5; early in-hospital adverse events (development of complications; admission to intensive care unit (ICU); death), death, recurrent CAP or CHF worsening with readmission at 28 day; mortality at 90 and 180 days) were estimated. Standard statistical tools were used for all intergroup comparisons. 76 patients of each group reached the primary endpoint. Systemic ABT was administered to 51 (67.1 %) patients in group 1 and 76 (100 %) patients in group 2 (p&lt;0.05). Both groups were comparable (p&gt;0.05) regarding all endpoints: clinical success, 70 (92.1 %) vs. 69 (90.8 %), Δ=1.3 % (one-sided 97.5 % CI: - 8.25 % for non-inferiority margin δ=-13.5 %); early clinical response, 66 (86.8 %) vs. 68 (89.5 %); admission to ICU, 1 (1.3 %) vs. 1 (1.3 %); development of complications, 20 (26.3 %) vs. 22 (28.9 %); readmission, 5 (6.6 %) vs. 6 (7.9 %); in-hospital mortality, 2 (2.6 %) vs. 1 (1.3 %), mortality at 28 day, 3 (3.9 %) vs. 2 (2.6 %), at 90 day, 5 (6.6 %) vs. 4 (5.3 %), at 180 day, 8 (10.5 %) vs. 9 (11.8 %) cases, respectively. additional measurement of serum CRP in patients with CHF and suspected non-severe CAP was able to reduce rate of systemic ABT administration without outcomes and prognosis worsening.

The usefulness of serum procalcitonin, C-reactive protein, soluble triggering receptor expressed on myeloid cells 1 and Clinical Pulmonary Infection Score for evaluation of severity and prognosis of community-acquired pneumonia in elderly patients

AimsTo comparatively analyze the usefulness of serum procalcitonin (PCT), C-reactive protein (CRP), soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) and Clinical Pulmonary Infection Score (CPIS) for assessing the severity and prognosis of community-acquired pneumonia (CAP) in the elderly. MethodsA total of 214 elderly patients with CAP and 106 healthy persons were enrolled in this prospective study. On the admission day, serum inflammatory markers, including CRP, PCT, sTREM-1, and CPIS were analyzed. By severity, the CAP patients were subdivided into non-severe CAP group and severe CAP group. By outcome, the patients were classified into survival group and death group. The efficiency of three inflammatory markers and CPIS on predicting prognosis of pneumonia patients was then analyzed. ResultsThe serum inflammatory markers and CPIS were significantly higher in CAP patients than in healthy controls. These biomarkers and CPIS were significantly higher in patients with severe CAP than in patients with non-severe CAP. Compared with patients who would survive, these markers and CPIS were significantly higher in patients who would die. Receiver operating characteristic curve analysis showed that the area under the curve and sensitivity were higher for serum sTREM-1 than for other indicators, while the specificity of serum PCT was the highest. ConclusionsSerum CRP, PCT, and sTREM-1 and CPIS determined on the admission day are effective indicators to evaluate the severity and prognosis of CAP in the elderly. The prognostic value of PCT and sTREM-1 is better than that of CRP and CPIS.

Assessment of physicians’ and senior medical students’ knowledge in treatment of patients with community-acquired pneumonia: Current results of the KNOCAP project

Introduction. Community-acquired pneumonia (CAP) remains one of the most acute problems of bronchopulmonary pathology being the 4th in the mortality structure (after cardiovascular, cerebrovascular diseases and malignant neoplasms) and the 1st among all fatalities from infectious diseases. Thanks to the scientific progress achieved in the antibiotic therapy and vaccine prophylaxis, the death toll has decreased four times compared to its rate during the “pre-antibiotic era“. However, nowadays there is a steadily increasing trend in the pneumonia mortality rate in Russia. The only possible way to increase efficacy of CAP treatment is timely initiated rational antibiotic therapy, considering the possible etiologies, risk factors and the severity of the patient’s condition.&#x0D; Materials and methods. The article represents the results of anonymous prospective surveys within the framework of the KNOCAP multi-centered research project aimed at accessing the knowledge on the fundamental issues in diagnosis and treatment of community-acquired pneumonia. The survey involved 222 students in their fifth- and sixth years in medical institute from Belgorod, Dnepr (Dnipro), Voronezh, Kiev (Kyiv) and Saratov and 110 physicians from Krasnodar, Saratov, Belgorod and Dnepr.&#x0D; Results and discussion. According to the results of the survey, such levels of correct answers were given by doctors and students, respectively: the inadmissibility of antimicrobial therapy (AMT) delay in CAP - 82% and 59%; the main criterion for withholding AMT - 56% and 37%; “sequential therapy” - 61% and 59%. At the same time, only 24% of the students and 23% of the physicians surveyed correctly reported typical mistakes in the treatment of a non-severe CAP with 50% or more accuracy; and in case of initial treatment, the number of correct responses was less than 28% for students and 45% for doctors.&#x0D; Conclusion. The survey showed that both senior medical students majoring in Medical Care and general practitioners had a low level of knowledge in CAP treatment. Hence, curricula need to be adjusted both in medical universities and in health institutions for practitioners in order to inform them and, thus, improve the quality of their knowledge in this field.

Priority for Treatment and Intensive Care of Patients With Non-Severe Community-Acquired Pneumonia

BackgroundThe Infectious Disease Society of America/the American Thoracic Society (IDSA/ATS) minor criteria for severe community-acquired pneumonia (CAP) are of unequal weight in predicting mortality. It is unclear whether the patients with non-severe CAP meeting the minor criteria most strongly associated to mortality should have the priority for treatment and intensive care. It is warranted to explore this intriguing hypothesis. MethodsA retrospective cohort study of 1230 patients with CAP was performed. This was tested against a prospective 2-center cohort of 1749 adults with CAP. ResultsThe patients with CAP fulfilling the predictive findings most strongly associated to mortality, i.e. PaO2/FiO2 ≤ 250 mm Hg, confusion, and uremia, showed higher mortality rates than those not fulfilling the predictive findings in subgroup analyses of the retrospective cohort. The more the number of predictive findings present, the higher the mortality rates. The prospective cohort confirmed a similar pattern. Interestingly, the patients with non-severe CAP meeting the predictive findings demonstrated unexpectedly higher mortality rates compared with the patients with severe CAP not meeting the predictive findings in the prospective cohort (P = 0.003), although there only existed death of an uptrend in the retrospective cohort. Two similar and intriguing paradigms about sequential organ failure assessment (SOFA) scores and pneumonia severity index (PSI) scores were confirmed in the 2 cohorts. ConclusionsThe patients with non-severe CAP fulfilling the predictive findings most strongly associated to mortality demonstrated higher SOFA and PSI scores and mortality rates, and might have the priority for treatment and intensive care.