Cases Of Severe Community-acquired Pneumonia Research Articles

A dead case of severe community-acquired pneumonia caused by highly pathogenic Klebsiella pneumoniae

A dead case of severe community-acquired pneumonia caused by highly pathogenic Klebsiella pneumoniae

Impact of the pneumococcal 10-valent vaccine on reducing hospitalization for community-acquired pneumonia in children

ObjectiveTo describe and analyze the occurrence of hospitalizations for community-acquired pneumonia in children before and after the pneumococcal 10-valent conjugate vaccine implementation into the National Immunization Program. MethodsThis is an ecological study that includes records of children younger than one year old, vaccinated and not vaccinated with the pneumococcal 10-valent conjugate vaccine in the periods pre- and post-inclusion of the vaccine in the National Immunization Program in the area covered by the Regional Health Superintendence of Alfenas, state of Minas Gerais, Brazil. Vaccination was considered as the exposure factor and hospitalization for community-acquired pneumonia as the endpoint, using secondary annual data by municipality. The prevalence ratio and its 95% confidence interval (95%CI) were used to verify the association between variables. The Z test was used to calculate the difference between proportions. ResultsConsidering the 26 municipalities of the Regional Health Superintendence of Alfenas, there was a significant reduction in hospitalizations for community-acquired pneumonia in children younger than one year of age, with prevalence ratio (PR)=0.81 (95%CI: 0.74–0.89; p<0.05), indicating a 19% lower prevalence of hospitalization for community-acquired pneumonia in the post-vaccination period. ConclusionsThe results suggest the effectiveness of the pneumococcal 10-valent conjugate vaccine in preventing severe cases of community-acquired pneumonia in children younger than one year of age.

Community-acquired pneumonia related to intracellular pathogens.

Community-acquired pneumonia (CAP) is associated with high rates of morbidity and mortality worldwide; the annual incidence of CAP among adults in Europe has ranged from 1.5 to 1.7 per 1000 population. Intracellular bacteria are common causes of CAP. However, there is considerable variation in the reported incidence between countries and change over time. The intracellular pathogens that are well established as causes of pneumonia are Legionella pneumophila, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Chlamydophila psittaci, and Coxiella burnetii. Since it is known that antibiotic treatment for severe CAP is empiric and includes coverage of typical and atypical pathogens, microbiological diagnosis bears an important relationship to prognosis of pneumonia. Factors such as adequacy of initial antibiotic or early de-escalation of therapy are important variables associated with outcomes, especially in severe cases. Intracellular pathogens sometimes appear to cause more severe disease with respiratory failure and multisystem dysfunction associated with fatal outcomes. The clinical relevance of intracellular pathogens in severe CAP has not been specifically investigated. We review the prevalence, general characteristics, and outcomes of severe CAP cases caused by intracellular pathogens.

Adjunctive Corticosteroid Therapy Improves Lung Immunopathology and Survival During Severe Secondary Pneumococcal Pneumonia in Mice

Secondary bacterial pneumonia is a significant cause of morbidity and mortality during influenza, despite routine use of standard antibiotics. Antibiotic-induced immunopathology associated with bacterial cell wall lysis has been suggested to contribute to these poor outcomes. Using Streptococcus pneumoniae in a well-established murine model of secondary bacterial pneumonia (SBP) following influenza, we stratified disease severity based on pneumococcal load in the lungs via in vivo bioluminescence imaging. Ampicillin treatment cured mice with mild pneumonia but was ineffective against severely pneumonic mice, despite effective bacterial killing. Adjunctive dexamethasone therapy improved ampicillin-induced immunopathology and improved outcomes in mice with severe SBP. However, early dexamethasone therapy during primary influenza infection impaired lung adaptive immunity as manifest by increased viral titers, with an associated loss of its protective functions in SBP. These data support adjunctive clinical use of corticosteroids in severe cases of community-acquired pneumonia.

Mortality indicators in community-acquired pneumonia requiring intensive care in Turkey

Severe community-acquired pneumonia (SCAP) is a fatal disease. This study was conducted to describe an outcome analysis of the intensive care units (ICUs) of Turkey. This study evaluated SCAP cases hospitalized in the ICUs of 19 different hospitals between October 2008 and January 2011. The cases of 413 patients admitted to the ICUs were retrospectively analyzed. Overall 413 patients were included in the study and 129 (31.2%) died. It was found that bilateral pulmonary involvement (odds ratio (OR) 2.5, 95% confidence interval (CI) 1.1-5.7) and CAP PIRO score (OR 2, 95% CI 1.3-2.9) were independent risk factors for a higher in-ICU mortality, while arterial hypertension (OR 0.3, 95% CI 0.1-0.9) and the application of non-invasive ventilation (OR 0.2, 95% CI 0.1-0.5) decreased mortality. No culture of any kind was obtained for 90 (22%) patients during the entire course of the hospitalization. Blood, bronchoalveolar lavage, and non-bronchoscopic lavage cultures yielded enteric Gram-negatives (n=12), followed by Staphylococcus aureus (n=10), pneumococci (n=6), and Pseudomonas aeruginosa (n=6). For 22% of the patients, none of the culture methods were applied. SCAP requiring ICU admission is associated with considerable mortality for ICU patients. Increased awareness appears essential for the microbiological diagnosis of this disease.

Guidelines and management of hospitalized patients with community-acquired pneumonia: the Italian experience of the FASTCAP study

BACKGROUND Nowadays few data are available addressing the validation of guidelines concerning diagnosis and treatment of Community-Acquired Pneumonia (CAP) in clinical practice. AIM OF THE STUDY To evaluate the impact of compliance to the recommendations issued by the Italian Federation of Internal Medicine (FADOI) in 2002 on the management of hospitalised CAP. METHODS National, multicentre, interventional, “before-after” survey, performed in 31 hospitals in Italy. All patients with CAP of Fine class IV or V (excluding those who were directly admitted to intensive care units) were included. The study was composed of three consecutive periods: 1) a retrospective phase (RP); 2) guideline implementation; 3) a prospective phase (PP). Results were expressed as Odds Ratios (OR) with 95% confidence intervals (95% CI) adjusted for risk factors and corrected for multiple comparisons in subgroups. RESULTS A significant increase in use of combinations was observed in the PP (p = 0.006). Moreover, a shift of prescription from β-lactams to fluoroquinolones as initial monotherapy was recorded. Therapies adherent to FADOI recommendations increased by 10.9% in the PP (p &lt; 0.001). Therapeutic success improved after implementation of recommendations (73.9 vs 71.5%; OR = 0.83; 95% CI = 0.69-1.00; p = 0.049). The difference was particularly evident in Fine class V (58.0 vs 52.5%; OR = 0.71; 95% CI = 0.51-0.98; p = 0.036), where a trend towards a lower mortality occurred (23.1 vs 26.3%; OR = 0.71; 95% CI = 0.48-1.05; p = 0.090). Therapies compliant with FADOI recommendations showed a higher success rate in both study phases (76.6% vs 70.3%; OR = 0.74; 95% CI = 0.60-0.90; p = 0.004). Levofloxacin was the most clinically effective first-cycle therapy with 79.1% of success, the least effective being an antipneumococcal cephalosporin alone with 68.6% (OR = 0.72; 95% CI = 0.51-1.01; p = 0.053). Etiologic diagnosis was obtained in less than 12% of patients in both study phases. Mean lengths of hospital stay were 12.2 and 11.9 days in the RP and PP, respectively. CONCLUSIONS Implementation of FADOI therapeutic recommendations led to a significantly better outcome in terms of clinical success, especially in more severe cases of CAP. Possibly, more “aggressive” approaches towards implementation may result in further improvement in the overall management of CAP.

Etiology and Factors Contributing to the Severity and Mortality of Community-acquired Pneumonia

Community-acquired pneumonia (CAP) remains a major cause of death. No studies have reported the use of rapid influenza diagnostic tests (RIDT) for the etiological diagnosis, and the factors contributing to severity and mortality have not yet been fully investigated. The aim of this study was to review the etiologies of CAP using RIDT and to identify risk factors related to the severity and mortality of the disease. This retrospective study assessed these factors in hospitalized patients, with special emphasis on microbial etiology. A total of 1,032 patients aged 63.9±18.3 years were studied, 66.2% of whom were men. Microbial identification was obtained in 57.0% of the cases. The most frequent causative microbial agents were Streptococcus pneumoniae, Mycoplasma pneumoniae and the influenza virus, and the second most frequent pathogens in the patients with severe CAP and the non-survivors were S. pneumoniae and the influenza virus. Age (≥65 years), chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, dementia and Legionella spp. infection and polymicrobial infection were each found to be independent factors related to severity in the multivariate analysis, whereas "unidentified pathogen" was found to be an independent factor for non-severe CAP. Age (≥65 years), chronic pulmonary aspergillosis, post-lung cancer surgery and severe CAP were found to be independent factors for non-survival according to a multivariate analysis. In addition to S. pneumoniae, the influenza virus was a frequent cause of CAP overall and a frequent causative pathogen in both severe cases of CAP and non-survivors. Legionella spp. infection and polymicrobial infection were found to be an independent factor for the severity of CAP along with advanced age and certain comorbidities. An advanced age, certain respiratory comorbidities and severe CAP were found to be important independent factors for the mortality of CAP.

P15 How important are blood cultures in the management of patients suspected to have Community Acquired Pneumonia?

BackgroundIt is acknowledged in the BTS guidelines that the routine use of blood cultures in community acquired pneumonia (CAP) has been questioned on the grounds of cost, low sensitivity and...

The Medical Educators' Contribution to Curtailing Antimicrobial Resistance

The European Commission has stated that antimicrobial resistance now takes the lives of approximately 25 000 patients each year throughout the European Union.1 While investing in research will ultimately lead to the discovery of new antimicrobial agents, basic educational groundwork is likely to be just as important. Prescribing antibiotics inappropriately is the major cause of antibiotic resistance.2 Two years ago, in a 1000-bed North East General Hospital, I audited, with Hospital approval, the application of diagnostic criteria for community-acquired pneumonia (CAP) and acute exacerbation of chronic obstructive pulmonary disease and subsequent compliance with Hospital antimicrobial policy. While 92% of diagnoses complied with Hospital guidelines, inappropriate antimicrobial prescribing totalled 50%. The main sources of this deficit were two-fold: poor application of scores from CURB-65 (a simple system that assigns up to 5 points for clinical features of pneumonia: Confusion, Urea [serum] level, Respiratory rate, Blood pressure, Age over 65)3 in differentiating among mild, moderate, and severe cases of CAP, and reliance on anecdotal “evidence” and therefore ignoring Hospital antimicrobial policy. Simple measures such as the availability of a CURB-65 assessment tool and focused education that targets antimicrobial reasoning could help reduce this deficit and thus reduce the emergence of antimicrobial resistance. While it is impossible to use this reasoning to explain antimicrobial resistance alone, it serves as an indicator that fundamentally, we should do better with what we have while seeking new antimicrobials. An audit demonstrated that educating junior doctors (residents) and using a restricted group of antibiotics resulted in a reduced incidence of multidrug-resistant microbes.4 In its recent document “Tomorrows Doctors,” the United Kingdom's General Medical Council defined standards and outcomes of undergraduate teaching.5 Although general principles are addressed, complexities and practicalities of antimicrobial prescribing are not. As a newly qualified junior doctor, I feel my undergraduate training prepared me well with regard to the knowledge and skills I now use. However, I feel more time could have been devoted to discussing the basics of practicing, particularly the intricacies of prescribing common drugs such as antibiotics. The European Commission has assigned approximately €600 million ($735 million US) to research tackling antibiotic resistance.1 If a small fraction of this amount were now invested in educating junior doctors about antimicrobial prescribing, we would have already laid the foundations for safeguarding the future of newly discovered antimicrobials against pathogen resistance, thus beginning to reverse the escalating problem of antimicrobial resistance.

Community-acquired Legionella Pneumonia in the intensive care unit: Impact on survival of combined antibiotic therapy

ObjectivesTo compare intensive care unit (ICU) mortality in patients with severe community-acquired pneumonia (SCAP) caused by Legionella pneumophila receiving combined therapy or monotherapy. MethodsA prospective multicenter study was made, including all patients with sporadic, community-acquired Legionnaires’ disease (LD) admitted to the ICU. Admission data and information on the course of the disease were recorded. Antibiotic prescriptions were left to the discretion of the attending physician and were not standardized. ResultsTwenty-five cases of SCAP due to L. pneumophila were included, and 7 patients (28%) out of 25 died after a median of 7 days of mechanical ventilation. Fifteen patients (60%) presented shock. Levofloxacin and clarithromycin were the antibiotics most commonly used in monotherapy, while the most frequent combination was rifampicin plus clarithromycin. Patients subjected to combination therapy presented a lower mortality rate versus patients subjected to monotherapy (odds ratio for death [OR] 0.15; 95%CI 0.02–1.04; p=0.08). In patients with shock, this association was stronger and proved statistically significant (OR for death 0.06; 95%CI 0.004–0.86; p=0.04). ConclusionsCombined antibiotic therapy decreases mortality in patients with SCAP and shock caused by L. pneumophila.

Methicillin-Resistant Staphylococcus aureus and Community-Acquired Pneumonia: An Evolving Relationship

Methicillin-Resistant Staphylococcus aureus and Community-Acquired Pneumonia: An Evolving Relationship

Community-acquired pneumonia due to Panton–Valentine leukocidin-producing Staphylococcus aureus in an HIV-2-infected patient

Pneumonia caused by Panton-Valentine leukocidin-producing Staphylococcus aureus is associated with a high fatality rate. There have been few reported cases in HIV-1-co-infected patients. Here we report a fatal case of severe community-acquired pneumonia caused by Panton-Valentine leukocidin-producing S. aureus in a 45-year-old woman with HIV-2 infection.

Severe Pneumonia Due to Chlamydophila pneumoniae in a Patient With Rheumatoid Arthritis Following Treatment With Infliximab

We report a case of severe community-acquired pneumonia due to Chlamydophila pneumoniae in a 46-year-old woman with rheumatoid arthritis treated with methtotrexate and infliximab. Pneumonia due to C. pneumoniae, an intracellular pathogen, should be added to the growing list of infectious complications following treatment with tumor necrosis factor alpha (TNF-a) antagonists.

Panton-Valentine Leukocidin–positiveStaphylococcus aureus, Singapore

Panton-Valentine Leukocidin–positive<i>Staphylococcus aureus</i>, Singapore

Detección de Legionella Pneumophila como agente etiológico de neumonía grave adquirida en la comunidad

Los microorganismos aislados con mayor frecuencia en pacientes con neumonía grave adquirida en la comunidad (NAC) son: Streptococcus pneumoniae, Legionella pneumophila y gérmenes Gram negativos. En Colombia no se han reportado casos de neumonía por Legionella ya que se requiere un medio de cultivo especial para su aislamiento. Con el fin de determinar el papel de este microorganismo como agente etiológico de la neumonía grave adquirida en la comunidad, se hizo un estudio descriptivo, sobre una población de 187 enfermos, quienes constituyen la totalidad de los casos de NAC que ingresaron al Hospital de San José, en la ciudad de Bogotá, Colombia, entre octubre de 1999 a junio de 2001 y de los cuales 20 representan los casos de NAC grave. En este estudio, la Legionella pneumophila no se aisló como agente etiológico de NAC grave, por lo tanto la indicación terapéutica de los macrólidos en nuestro medio, sospechando esta patología, debe ser reevaluada.

Surgical Drainage of Lung Abscess Complicating Acute Community-Acquired Pneumonia

Two cases of severe community-acquired pneumonia requiring IPPV and complicated by the development of lung abscess were successfully treated with early surgical drainage. This procedure may be a life-saving measure in certain instances.

Severe Community-acquired Pneumonia: Etiology, Prognosis, and Treatment

The frequency of community-acquired pneumonia coupled with its mortality rate of 10 to 25% is of growing concern to clinicians. A prospective study of 67 patients with severe community-acquired pneumonia was carried out to determine the causative agents, the impact fore-knowledge of the etiology has on the outcome, the value of clinical and radiologic criteria in predicting the evolution, and the efficacy of empirical therapy. The study group included 45 men and 22 women (mean age: 56.8 +/- 16.6 yr), and 46.2% suffered from a concurrent debilitating disease. The cause of pneumonia was diagnosed in 32 cases, and the most common pathogens were Streptococcus pneumoniae (37.5%), Legionella pneumophila (21.8%), and gram-negative bacilli (25.0%). The fact that fungal infections were present in three patients and Pneumocystis carinii in one are worthy of note. The overall death rate was 20.8%. A fatal outcome was related to the age of the patient (p less than 0.05), the presence of debilitating disease (p = 0.026), and septic shock (p = 0.0009). Diagnosis of the causative agents did not aid in increasing the survival rate, but it did allow for better patient management. Most of the patients (85.1%) initiated on treatment with erythromycin plus tobramycin recovered, but only 68.4% of the subjects commenced on treatment with other therapeutics survived. Furthermore, it was necessary to modify the therapy of a greater percentage of the latter group (p less than 0.025). Gram-negative bacillary pneumonia was a frequent finding among the patients who did not recover, making empirical treatment with erythromycin plus third generation cephalosporins most advisable for severe cases of community-acquired pneumonia.