Outcome Of Severe Community-acquired Pneumonia Research Articles

Assessment of the prognosis of the outcome of severe community-acquired pneumonia caused by <i>Klebsiella pneumoniae</i>

Introduction. The problem of an adequate assessment of the prognosis of the outcome of severe community-acquired pneumonia (CAP) is particularly difficult if it is caused by an unusual pathogen for it, in particular Klebsiella pneumoniae.The objective was to develop the approach for predicting the survival of a heterogeneous population of patients with CAP caused by Klebsiella pneumoniae using statistical approaches based on artificial neural networks.Materials and methods. The design is a retrospective, multicenter, controlled, non-randomized study. Inclusion criteria: clinical, laboratory and radiological diagnosis of CAP associated with Klebsiella pneumoniae with a SOFA score of 2 or more points. The development included 100 patients. 50 died. The prognostic significance of the SOFA, APACHE II, PSI/PORT, Glasgow and Charlson comorbidity index, procalciotonin, C-reactive protein scales was evaluated. The data obtained were evaluated in the StatPlus 7 and Pycharm GPT programs.Results. None of the stated scales has shown its significance. There were no statistically significant differences between the surviving and deceased patients in terms of the level of biomarkers studied. In this regard, we have compiled a logistic regression equation for assessing the prognosis based on a combination of the SOFA score, the Charlson index and the procalcitonin level.Conclusion. In assessing the prognosis of outcome in patients with CAP caused by Klebsiella pneumoniae, it is advisable to use a combination of data from the SOFA score, Charlson comorbidity index and procalciotonin levels. Threshold critical values are SOFA score of more than 4 points, Charlson comorbidity index of more than 7 points, procalciotonin level of more than 2 ng/ml.

Prognostic factors of severe community-acquired staphylococcal pneumonia in France.

PurposeStaphylococcus aureus causes severe forms of community-acquired pneumonia (CAP), namely staphylococcal pleuropneumonia in young children and staphylococcal necrotising pneumonia in older patients. Methicillin resistance and the Panton–Valentine leukocidin (PVL) toxin, as well as less specific factors, have been associated with poor outcome in severe CAP, but their roles are unclear.MethodsA prospective multicentre cohort study of severe staphylococcal CAP was conducted in 77 paediatric and adult intensive care units in France between January 2011 and December 2016. After age-clustering, risk factors for mortality, including pre-existing conditions, clinical presentation, laboratory features, strain genetic lineage, PVL, other virulence factors and methicillin resistance were assessed using univariate and multivariable Cox and LASSO (least absolute shrinkage and selection operator) regressions.ResultsOut of 163 included patients, aged 1 month to 87 years, 85 (52.1%) had PVL-positive CAP; there were 20 (12.3%) patients aged <3 years (hereafter “toddlers”), among whom 19 (95%) had PVL-positive CAP. The features of PVL-positive CAP in toddlers matched with the historical description of staphylococcal pleuropneumonia, with a lower mortality (three (15%) out of 19) compared to PVL-positive CAP in older patients (31 (47%) out of 66). Mortality in older patients was predicted by PVL-positivity (hazard ratio (HR) 1.81, 95% CI 1.03–3.17) and methicillin resistance (HR 2.37, 95% CI 1.29–4.34) independently from S. aureus lineages and the presence of other determinants of virulence.ConclusionPVL was associated with staphylococcal pleuropneumonia in toddlers and was a risk factor for mortality in older patients with severe CAP, independently of methicillin resistance, S. aureus genetic background and other virulence factors.

Should COVID-19 take advice from rheumatologists?

Should COVID-19 take advice from rheumatologists?

Sphingosine-1-phosphate as an indicator for deciding the use of adjuvant corticosteroids therapy in community-acquired pneumonia (sphingosine-1-phosphate and pneumonia trial): Study protocol for a randomized, placebo-controlled trial.

Introduction:Pneumonia is one of the leading causes of death worldwide, represents a potentially life-threatening condition. In recent studies, adjuvant corticosteroids therapy has been shown to improve outcome in severe community-acquired pneumonia (CAP); however, the treatment response to corticosteroids vary. It is important to select patients likely to benefit from the treatment. Currently, the optimal patient selection of corticosteroids treatment is not yet clearly defined.Methods:Sphingosine-1-phosphate and pneumonia (SOPN) trial is a double-blinded, randomized, placebo-controlled trial that will investigate if sphingosine-1-phosphate (S1P) can be an indicator for initiating adjuvant corticosteroids therapy in patients with severe CAP. Participants will be recruited from the emergency department and randomized to receive 20 mg of methylprednisolone twice daily or placebo for 5 days. The primary outcome will be “in-hospital mortality.” Secondary outcomes will include intensive care unit (ICU) admission, length of ICU stay, length of hospital stay, and clinical outcomes at Day 7 and Day 14.Conclusion:SOPN trial is the first randomized placebo-controlled trial to investigate whether S1P can be a predictive biomarker for adjuvant corticosteroids therapy in patients with severe CAP. The trial will add additional data for the appropriate use of adjuvant corticosteroids therapy in patients with severe CAP. Results from this clinical trial will provide foundational information supporting that if the S1P is appropriate for guiding the patient selection for corticosteroids adjuvant therapy.

Interleukin 1 receptor antagonist (IL1RA) gene polymorphism and levels associated with adverse outcome in severe community-acquired pneumonia in children: A hospital-based study in India.

High morbidity and mortality due to community-acquired pneumonia (CAP) is seen in children under 5 years of age in India. Besides identified risk factors for CAP, there may be a phenotype-genotype association with cytokines, resulting in enhanced inflammatory response resulting in the adverse outcome (AO), namely complications and death. To assess the association of IL1RA gene polymorphism on serum levels of IL1RA and with AO in children under 5 years of age hospitalized with WHO-defined severe CAP. A prospective cohort study with nested case-control design conducted in a tertiary care teaching hospital after obtaining institutional ethical approval. Included were children between 2 and 59 months of age hospitalized with WHO-defined severe CAP with consistent radiological abnormalities. Excluded were those with suspected or proven cystic fibrosis, pulmonary tuberculosis, malignancy, immunodeficiency, and congenital heart disease. Polymerase chain reaction (PCR) was used to analyze the Variable Number of Tandem Repeats (VNTRs) of IL1RA gene polymorphism and ELISA test to detect serum levels of IL1RA. From 2014 to 2016, of 420 screened cases, 350 were eligible and included, of which 132 (37.7%) had no complication and 218 (62.3%) had AO, which included complications like empyema, pyopneumothorax, acute respiratory distress syndrome (ARDS), and septic shock of these 24 (6.9%) expired. Higher risk of AO was seen in A2A2 genotype (OR 11.18, p 0.0001) and lower in A1A1 genotype (OR 0.18, P < 0.0001). Serum IL1RA (ng/mL) was statistically significantly elevated in CAP with AO (2.55 ± 1.44) versus uncomplicated (0.87 ± 0.52) (P < 0.0001). In IL1RA gene, A1A1 genotype was associated with lower risk and A2A2 genotype with increased the risk of AO. Higher serum levels of IL1RA were found in A2A2 genotype indicating possibly enhanced inflammatory response resulting in AO of CAP.

Abstract P-175: RISK FACTORS FOR MORTALITY IN CHILDREN WITH SEVERE COMMUNITY-ACQUIRED PNEUMONIA ADMITTED TO AN PEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: To determine the clinical characteristics and outcome of severe community-acquired pneumonia (S-CAP) in children admitted to PICU of one referral center and to identify risk factors for poor outcomes. Methods Retrospective study that included children admitted to PICU of the Institute of Tropical Medicine of Asuncion, from 2004 to 2016 with a diagnosis of S-CAP. Clinical, microbiological and outcome were obtained from patient records, with emphasis in the analysis of duration of mechanical ventilation (MV), duration of stay in the PICU, and survival or death. Associations of variables with mortality were tested using standard statistical tools. Results During the study period, 222 children with S-CAP was admited to PICU, with a mean age of 38,1 + 47,8 months, and a male/female ratio of 1.7:1. Eighty-nine patients (40%) required VM. Bacteremia was observed in 42 patiens (19%). Staphyloccus aureus (27 patients, 12%) and Streptococcus pneumoniae (12 patients, 5%) were the most frequent organims isolated. The mean duration of stay in the PICU was 12,7 ± 11,6 days and the mortality was 18.9% (42 patients). Risk factors associated with mortality were leukopenia (WBC< 4500/mm3) [p<0,0009 RR 2.34 (1.3-4,2)], presence of bacteremia [p<0,00001 RR 2,88 (1,7-4,8)], staphyloccocal etiology [p=0.01 RR2,23 (1,2-4)], and mechanical ventilation requirement [p <0,000001 RR 60,35 (8,5 - 430.8)] Conclusions Severe pediatric pneumonia accounts for a significant number of PICU admissions in our country and is associated with significant mortality (18,9%),. The presence of leukopenia, bacteremia and mechanical ventilatory requirement were identified as early prognostic variables independently associated with poor clinical outcome.

Clinical presentations and outcome of severe community-acquired pneumonia

BackgroundSevere community-acquired pneumonia (SCAP) represents a frequent and potentially life-threatening condition. About 10% of all hospitalized patients with CAP require admission to the intensive care unit (ICU), and the mortality of these patients reaches 20–50%. ObjectiveTo evaluate the clinical presentation, bacteriological profile and outcome of severe community-acquired pneumonia (SCAP). Patients and methods54 patients presented by symptoms and sign of severe community acquired pneumonia who were admitted to respiratory care unit of Alhussein, Al-Azhar University Hospital from August 2015 to March 2016 were subjected to full clinical examination, chest X ray, complete blood picture, sputum and blood culture, PCR for suspected cases of Influenza H1N1 and MERS-COV, treatment, follow up, data collections and statistical analysis. ResultsThe present study included 54 patients 26 males and 28 females with SCAP who were admitted to respiratory care unit of Alhussein, Al-Azhar University Hospital. The most common comorbidities were diabetes mellitus and hypertension. The most common presentations were fever, cough, dyspnea and hypoxemia. Two patients developed renal failure and 4 patients developed septic shock. The most common isolated organism was Streptococcus pneumoniae, Influenza H1N1, and Staphylococcus aureus. Mortality was 24% and it was common in patients with comorbidity than in patients without comorbidities. ConclusionSCAP occurs more frequently in those with comorbidities. The most frequent isolated causative organism of SCAP is S. pneumoniae, Influenza H1N1 and S. aureus. SCAP is associated with significant mortality, early recognition and prompt treatment may improve outcome.

Outcomes in patients with community-acquired pneumonia admitted to the intensive care unit

Severe community-acquired pneumonia (CAP) portends a serious prognosis. The temporal trend in outcome of severe CAP is not well established. We evaluated the temporal trends in the outcomes of severe CAP. This is a secondary analysis of 800 patients with severe CAP enrolled in the Community-Acquired Pneumonia Organization International Cohort. Severe CAP was defined as CAP requiring admission to the intensive care unit. Only patients admitted to the ICU upon hospital admission were included in this study. We assessed the trend in outcomes of these patients during three time periods: Period I (June 2001 to April 2004), Period II (May 2004 to January 31 2008), and Period III (February 2008 to February 2013). After adjustment for other variables, mortality was higher for patients admitted during Period II compared with Period I (RR: 1.46; 95% CI: 1.002 to 2.14; P value=0.049), and for Period III compared with Period I (RR: 1.70; 95% CI: 1.15 to 2.50; P value=0.008). No significant difference in length of stay or time to clinical stability was found among the three periods. The mortality of patients with severe CAP increased over time in our study population. This finding has important health policy implications if confirmed by other studies.

Outcome of severe community-acquired pneumonia: the impact of comorbidities

Several comorbidities have been independently associated with both predisposition to community-acquired pneumonia and a worse outcome. The goal of this study was to evaluate the impact of comorbidities on the outcome of patients with severe community-acquired pneumonia (SCAP).

Severe sepsis in community-acquired pneumonia — Early recognition and treatment

Despite remarkable advances in its management, community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality leading to significant consumption of health, social and economic resources.The assessment of CAP severity is a cornerstone in its management, facilitating selection of the most appropriate site of care and empirical antibiotic therapy. Several clinical scoring systems based on 30-day mortality have been developed to identify those patients with the highest risk of death. Although well validated in appropriate patient groups, each system has its own limitations and each exhibits different sensitivity and specificity values. These problems have increased interest in the use of biomarkers to predict CAP severity. Although so far no ideal solution has been identified, recent advances in bacterial genomic load quantification have made this tool very attractive.Early antibiotic therapy is essential to the reduction of CAP mortality and the selection of antibiotic treatment according to clinical guidelines is also associated with an improved outcome. In addition, the addition of a macrolide to standard empirical therapy seems to improve outcome in severe CAP although the mechanism of this is unclear. Finally, the role of adjuvant therapy has not yet been satisfactorily established.In this review we will present our opinion on current best practice in the assessment of severity and treatment of severe CAP.

Macrolides for the therapy of nosocomial infections

Nosocomial infections are an emerging threat. Available solutions are limited due to the multidrug-resistance pattern of the pathogens. Macrolides modulate the immune function of the host and may be active in this setting. Findings of in-vitro and experimental animal studies are presented. Clinical studies of community-acquired pneumonia (CAP) and ventilator-associated pneumonia (VAP) are described. Macrolides decrease production of proinflammatory cytokines by circulating monocytes and by alveolar macrophages and decrease apoptosis of circulating lymphocytes in animal models of acute infections. They also inhibit gene expression of proteins participating in quorum sensing of Pseudomonas aeruginosa. Retrospective cohort studies indicate that addition of a macrolide significantly improves outcome in severe CAP. One randomized, double-blind, clinical study is available. This involves patients with VAP allocated to placebo or intravenous clarithromycin 1 g once daily for 3 days. Clarithromycin treatment significantly decreased time to resolution of VAP and time until weaning from mechanical ventilation. The described findings are promising for the use of macrolides in nosocomial infections.

The impact of coagulation parameters on the outcomes of patients with severe community-acquired pneumonia requiring intensive care unit admission

IntroductionCoagulation abnormalities are frequent in patients with severe infections. However, the predictive value of d-dimer and of the presence of associated coagulation derangements in severe community-acquired pneumonia (CAP) remains to be thoroughly evaluated. The aim of this study was to investigate the predictive value of coagulation parameters in patients with severe CAP admitted to the intensive care unit. Methodsd-Dimer, antithrombin, International Society of Thrombosis and Hemostasis score, clinical variables, Sequential Organ Failure Assessment (SOFA), The Acute Physiology and Chronic Health Evaluation II (APACHE II) and the CURB-65 score were measured in the first 24 hours. Results are shown as median (25%-75% interquartile range). The main outcome measure was hospital mortality. ResultsNinety patients with severe CAP admitted to the intensive care unit were evaluated. Overall hospital mortality was 15.5%. d-Dimer levels in nonsurvivors were higher than those in survivors. In the univariate analysis, d-dimer, SOFA, and APACHE II scores were predictors of death. The discriminative ability of d-dimer (area under receiver operating curve = 0.75 [95% confidence interval, 0.64-0.83]; best cutoff for d-dimer was 1798 ng/mL) for in-hospital mortality was comparable with APACHE II and SOFA and better than C-reactive protein. Moreover, the addition of d-dimer to APACHE II or SOFA score increased the discriminative ability of both scores (area under the receiver operating curve = 0.82 [0.72-0.89] and 0.84 [0.75-0.91], respectively). Conclusionsd-Dimer levels are good predictors of outcome in severe CAP and may augment the predictive ability of scoring systems as APACHE II and SOFA.

Adrenal Response in Severe Community-Acquired Pneumonia: Impact on Outcomes and Disease Severity

High cortisol levels are frequent in patients with severe infections. However, the predictive value of total cortisol and of the presence of critical illness-related corticosteroid insufficiency (CIRCI) in severe community-acquired pneumonia (CAP) remains to be thoroughly evaluated. The aim of this study was to investigate the predictive value of adrenal response in patients with severe CAP admitted to the ICU. Baseline and postcorticotropin cortisol levels C-reactive protein (CRP), d-dimer, clinical variables, sequential organ failure assessment (SOFA), APACHE (acute physiology and chronic health evaluation) II, and CURB-65 (confusion, urea nitrogen, respiratory rate, BP, age > or = 65 years) scores were measured in the first 24 h. Results are shown as median (interquartile range [IQR]). The major outcome measure was hospital mortality. Seventy-two patients with severe CAP admitted to the ICU were evaluated. Baseline cortisol levels were 18.1 microg/dL (IQR, 14.4 to 26.7 microg/dL), and the difference between baseline and postcorticotropin cortisol after 250 microg of corticotropin was 19 microg/dL (IQR, 12.8 to 27 microg/dL). Baseline cortisol levels presented positive correlations with scores of disease severity, including CURB-65, APACHE II, and SOFA (p < 0.05). Cortisol levels in nonsurvivors were higher than in survivors. CIRCI was diagnosed in 29 patients (40.8%). In univariate analysis, baseline cortisol, CURB-65, and APACHE II were predictors of death. The discriminative ability of baseline cortisol (area under receiver operating characteristic curve, 0.77; 95% confidence interval, 0.65 to 0.90; best cutoff for cortisol, 25.7 microg/dL) for in-hospital mortality was better than APACHE II, CURB-65, SOFA, d-dimer, or CRP. Baseline cortisol levels are better predictors of severity and outcome in severe CAP than postcorticotropin cortisol or routinely measured laboratory parameters or scores as APACHE II, SOFA, and CURB-65.

Combination antibiotic therapy improves survival in patients with community-acquired pneumonia and shock*

To assess whether combination antibiotic therapy improves outcome of severe community-acquired pneumonia in the subset of patients with shock. Secondary analysis of a prospective observational, cohort study. Thirty-three intensive care units (ICUs) in Spain. Patients were 529 adults with community-acquired pneumonia requiring ICU admission. None. Two hundred and seventy (51%) patients required vasoactive drugs and were categorized as having shock. The effects of combination antibiotic therapy and monotherapy on survival were compared using univariate analysis and a Cox regression model. The adjusted 28-day in-ICU mortality was similar (p = .99) for combination antibiotic therapy and monotherapy in the absence of shock. However, in patients with shock, combination antibiotic therapy was associated with significantly higher adjusted 28-day in-ICU survival (hazard ratio, 1.69; 95% confidence interval, 1.09-2.60; p = .01) in a Cox hazard regression model. Even when monotherapy was appropriate, it achieved a lower 28-day in-ICU survival than an adequate antibiotic combination (hazard ratio, 1.64; 95% confidence interval, 1.01-2.64). Combination antibiotic therapy does not seem to increase ICU survival in all patients with severe community-acquired pneumonia. However, in the subset of patients with shock, combination antibiotic therapy improves survival rates.

Age Is Not a Risk Factor for Mortality in Severe Community-acquired Pneumoni

PURPOSE: Medical literature frequently identifies advanced age as a poor prognostic factor in community-acquired pneumonia(CAP). The aim of this study was to evaluate the impact of age on the outcome of severe CAP.

Prognostic factors in severe community-acquired pneumonia in patients without co-morbid illness.

We wished to determine the prognostic factors and the impact of initial empirical antibiotic therapy on the outcome of severe community-acquired pneumonia in patients without underlying co-morbid illness. This is a retrospective record review of consecutive patients with severe community-acquired pneumonia who were divided into those with and without underlying co-morbid illness. There were 182 patients including 112 primary (no co-morbid illness) and 70 secondary (underlying co-morbid illness) pneumonias. The overall mortality was 41.8% and there were no differences in APACHE II score or mortality when comparing cases with primary (37.5%) and secondary infections (48.6%). The mortality was significantly higher in patients with negative microbiology. Univariate analysis identified a number of parameters and various antibiotic regimens, which appeared to be associated with a significantly poorer outcome. On multivariate analysis multilobar pulmonary consolidation, need for mechanical ventilation, inotropes and dialysis were documented to be independent predictors of mortality. Only in their absence could different antibiotic regimens be shown to have an apparent impact on outcome and further analysis suggested that the reason for these differences related predominantly to differences in the severity of the infection. Markers of disease severity appear to be the most important predictors of outcome in patients with severe community-acquired pneumonia.

Aetiology and outcome of severe community-acquired pneumonia in Singapore.

The aim of this study was to determine the aetiology and outcome of severe community-acquired pneumonia, and to assess whether the existing guidelines for initial antimicrobial therapy are being applied. The records of 57 consecutive nonimmunocompromised patients admitted to the medical intensive care unit (ICU) between January 1989 and May 1993 with this diagnosis were reviewed. The microbiological data, chest radiographic changes and outcome were analysed. Nine (16%) of the 57 patients had pulmonary tuberculosis. When these patients were excluded from further analysis, a microbiological diagnosis was made in 41 (72%) cases. The most commonest pathogens were Burkholderia pseudomallei (n=10), Klebsiella spp. (n=5) and Staphylococcus aureus (n=5), Mycoplasma pneumoniae (n=4) and Streptococcus pneumoniae (n=2) were less common. This microbiological spectrum was quite different from that in the West, where the incidence of S. pneumoniae was higher. Also, when pulmonary tuberculosis was excluded, the mortality (67%) was much higher than that in other series. This was attributed to the high incidence of unrecognized B. pseudomallei infection, which is associated with a very high mortality in the region under study. In addition to applying published guidelines on severe community-acquired pneumonia, the endemicity of certain organisms such as Mycobacterium tuberculosis and Burkholderia pseudomallei in different geographical regions needs to be considered when choosing initial empirical antimicrobial therapy.

The aetiology, management and outcome of severe community-acquired pneumonia on the intensive care unit

In a retrospective study of adults with severe community-acquired pneumonia (SCAP) admitted to the intensive care unit, 60 patients were identified from 25 hospitals within the 12-month study period. Thirty-two percent were aged less than 44 years and 65% less than 65. One-third were previously fit. Two or more of the following three features, respiratory rate greater than or equal to 30 min-1, diastolic blood pressure less than or equal to 60 mmHg and blood urea greater than 7 mmol l-1, were present in 72%. A pathogen was identified in 58% and five pathogens, Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumophila, Mycoplasma pneumoniae and Staphylococcus aureus accounted for 86% of these. Gram-negative enterobacteria were identified only once. Forty-eight percent reached the intensive care unit within 24 h of hospital admission, with respiratory failure or progressive exhaustion being the main reason for transfer. However, eight patients were only transferred following a cardio-respiratory arrest on the general ward. Eighty-eight percent received assisted ventilation which was given for a median of 8 days. A median of 4 (range 1-11) different antibiotics were given to each patient, with erythromycin and the penicillins prescribed most frequently. Aminoglycosides were given to 43% of patients, although Gram-negative enterobacteria were rarely found. Forty-eight percent died during the acute illness and a further 5% died shortly afterwards. Multi-organ failure was common with respiratory failure alone accounting for a minority of deaths. Forty-eight percent of deaths occurred within 1 week of hospital admission, but of 18 patients still receiving assisted ventilation at 14 days, 67% survived.(ABSTRACT TRUNCATED AT 250 WORDS)

A new diagnostic approach to the patient with severe pneumonia.

36 patients with severe community-acquired pneumonia, treated in an intensive care unit (ICU), were examined in a prospective study using a comprehensive diagnostic program to establish an early etiological diagnosis. The resulting prompt and adequate antimicrobial therapy may have decreased the number of fatal cases. Special emphasis was placed on the use of a method incorporating fiberoptic bronchoscopy, together with protected brush sampling and bronchial lavage. An etiological diagnosis was established in 81% (29/36) of the cases. This etiological diagnosis was established within 48-72 h in 53% (19/36) of the patients, S. pneumoniae being the most frequent agent found (12 patients). This information, however, was poorly utilized since in only 11/19 of these patients was the antimicrobial therapy changed from a broad-spectrum antibiotic to a more specific narrow spectrum agent. The overall mortality rate was 22% (8/36). 7/8 patients who died had compromising factors. Most deaths in community-acquired pneumonia are still associated with pneumococcal infection. We conclude that fiberoptic bronchoscopy with brush samples via a plugged double lumen catheter provides the least misleading information concerning the etiological agent in pneumonia; sampling should be done as soon as possible after admission to the hospital, ideally before the need for ICU treatment; factors other than prompt antimicrobial therapy may influence the outcome of severe community-acquired pneumonia.

Aetiology and outcome of severe community-acquired pneumonia

Between January 1972 and December 1981, 50 patients with severe community-acquired pneumonia were admitted to the intensive care unit of a district general hospital. A causal pathogen was identified in 41 cases (82%). Streptococcus pneumoniae (16 cases), Legionella pneumophila (15 cases) and Staphylococcus aureus (5 cases) were the commonest. Assisted ventilation was required in 44 patients, of whom 25 died (57%). All 5 patients with staphylococcal pneumonia and 12(75%) with pneumococcal pneumonia died. Only 5 (33%) with Legionnaires' disease died. Mortality was significantly associated with age. Recommendations for the management of severe pneumonia are made.