Elena Prina

Community-acquired pneumonia

Summary Community-acquired pneumonia causes great mortality and morbidity and high costs worldwide. Empirical selection of antibiotic treatment is the cornerstone of management of patients with pneumonia. To reduce the misuse of antibiotics, antibiotic resistance, and side-effects, an empirical, effective, and individualised antibiotic treatment is needed. Follow-up after the start of antibiotic treatment is also important, and management should include early shifts to oral antibiotics, stewardship according to the microbiological results, and short-duration antibiotic treatment that accounts for the clinical stability criteria. New approaches for fast clinical (lung ultrasound) and microbiological (molecular biology) diagnoses are promising. Community-acquired pneumonia is associated with early and late mortality and increased rates of cardiovascular events. Studies are needed that focus on the long-term management of pneumonia.

Thrombocytosis Is a Marker of Poor Outcome in Community-Acquired Pneumonia

BACKGROUND Thrombocytosis, often considered a marker of normal inflammatory reaction of infections, has been recently associated with increased mortality in hospitalized patients with community-acquired pneumonia (CAP). We assessed the characteristics and outcomes of patients with CAP and thrombocytosis (platelet count ≥ 4 × 105/mm3) compared with thrombocytopenia (platelet count < 105/mm3) and normal platelet count. METHODS We prospectively analyzed 2,423 consecutive, hospitalized patients with CAP. We excluded patients with immunosuppression, neoplasm, active TB, or hematologic disease. RESULTS Fifty-three patients (2%) presented with thrombocytopenia, 204 (8%) with thrombocytosis, and 2,166 (90%) had normal platelet counts. Patients with thrombocytosis were younger (P < .001); those with thrombocytopenia more frequently had chronic heart and liver disease (P < .001 for both). Patients with thrombocytosis presented more frequently with respiratory complications, such as complicated pleural effusion and empyema (P < .001), whereas those with thrombocytopenia presented more often with severe sepsis (P < .001), septic shock (P = .009), need for invasive mechanical ventilation (P < .001), and ICU admission (P = .011). Patients with thrombocytosis and patients with thrombocytopenia had longer hospital stays (P = .004), and higher 30-day mortality (P = .001) and readmission rates (P = .011) than those with normal platelet counts. Multivariate analysis confirmed a significant association between thrombocytosis and 30-day mortality (OR, 2.720; 95% CI, 1.589-4.657; P < .001). Adding thrombocytosis to the confusion, respiratory rate, and BP plus age ≥65 years score slightly improved the accuracy to predict mortality (area under the receiver operating characteristic curve increased from 0.634 to 0.654, P = .049). CONCLUSIONS Thrombocytosis in patients with CAP is associated with poor outcome, complicated pleural effusion, and empyema. The presence of thrombocytosis in CAP should encourage ruling out respiratory complication and could be considered for severity evaluation.

New Sepsis Definition (Sepsis-3) and Community-acquired Pneumonia Mortality. A Validation and Clinical Decision-Making Study

Rationale: The Sepsis‐3 Task Force updated the clinical criteria for sepsis, excluding the need for systemic inflammatory response syndrome (SIRS) criteria. The clinical implications of the proposed flowchart including the quick Sequential (Sepsis‐related) Organ Failure Assessment (qSOFA) and SOFA scores are unknown. Objectives: To perform a clinical decision‐making analysis of Sepsis‐3 in patients with community‐acquired pneumonia. Methods: This was a cohort study including adult patients with community‐acquired pneumonia from two Spanish university hospitals. SIRS, qSOFA, the Confusion, Respiratory Rate and Blood Pressure (CRB) score, modified SOFA (mSOFA), the Confusion, Urea, Respiratory Rate, Blood Pressure and Age (CURB‐65) score, and Pneumonia Severity Index (PSI) were calculated with data from the emergency department. We used decision‐curve analysis to evaluate the clinical usefulness of each score and the primary outcome was in‐hospital mortality. Measurements and Main Results: Of 6,874 patients, 442 (6.4%) died in‐hospital. SIRS presented the worst discrimination, followed by qSOFA, CRB, mSOFA, CURB‐65, and PSI. Overall, overestimation of in‐hospital mortality and miscalibration was more evident for qSOFA and mSOFA. SIRS had lower net benefit than qSOFA and CRB, significantly increasing the risk of over‐treatment and being comparable with the “treat‐all” strategy. PSI had higher net benefit than mSOFA and CURB‐65 for mortality, whereas mSOFA seemed more applicable when considering mortality/intensive care unit admission. Sepsis‐3 flowchart resulted in better identification of patients at high risk of mortality. Conclusions: qSOFA and CRB outperformed SIRS and presented better clinical usefulness as prompt tools for patients with community‐acquired pneumonia in the emergency department. Among the tools for a comprehensive patient assessment, PSI had the best decision‐aid tool profile.

Phenotyping community-acquired pneumonia according to the presence of acute respiratory failure and severe sepsis

BackgroundAcute respiratory failure (ARF) and severe sepsis (SS) are possible complications in patients with community-acquired pneumonia (CAP). The aim of the study was to evaluate prevalence, characteristics, risk factors and impact on mortality of hospitalized patients with CAP according to the presence of ARF and SS on admission.MethodsThis was a multicenter, observational, prospective study of consecutive CAP patients admitted to three hospitals in Italy, Spain, and Scotland between 2008 and 2010. Three groups of patients were identified: those with neither ARF nor SS (Group A), those with only ARF (Group B) and those with both ARF and SS (Group C) on admission.ResultsAmong the 2,145 patients enrolled, 45% belonged to Group A, 36% to Group B and 20% to Group C. Patients in Group C were more severe than patients in Group B. Isolated ARF was correlated with age (p < 0.001), COPD (p < 0.001) and multilobar infiltrates (p < 0.001). The contemporary occurrence of ARF and SS was associated with age (p = 0.002), residency in nursing home (p = 0.007), COPD (p < 0.001), multilobar involvement (p < 0.001) and renal disease (p < 0.001). 4.2% of patients in Group A died, 9.3% in Group B and 26% in Group C, p < 0.001. After adjustment, the presence of only ARF had an OR for in-hospital mortality of 1.85 (p = 0.011) and the presence of both ARF and SS had an OR of 6.32 (p < 0.001).ConclusionsThe identification of ARF and SS on hospital admission can help physicians in classifying CAP patients into three different clinical phenotypes.

New aspects in the management of pneumonia

Despite improvements in the management of community-acquired pneumonia (CAP), morbidity and mortality are still high, especially in patients with more severe disease. Early and appropriate antibiotics remain the cornerstone in the treatment of CAP. However, two aspects seem to contribute to a worse outcome: an uncontrolled inflammatory reaction and an inadequate immune response. Adjuvant treatments, such as corticosteroids and intravenous immunoglobulins, have been proposed to counterbalance these effects. The use of corticosteroids in patients with severe CAP and a strong inflammatory reaction can reduce the time to clinical stability, the risk of treatment failure, and the risk of progression to acute respiratory distress syndrome. The administration of intravenous immunoglobulins seems to reinforce the immune response to the infection in particular in patients with inadequate levels of antibodies and when an enriched IgM preparation has been used; however, more studies are needed to determinate their impact on outcome and to define the population that will receive more benefit.

Lung ultrasound in the evaluation of pleural effusion

In recent years, there has been an increasing interest in the use of ultrasound for the evaluation of chest diseases, especially for the study of bedridden, critically ill patients. In fact, the ultrasound method presents various advantages: it uses no radiation; it is inexpensive; it can be used at the bedside; it is noninvasive; and it can be repeated as necessary. In addition, ultrasound is starting to be a method used by professionals, other than radiologists, who have specific clinical questions,

Invasive Disease vs Urinary Antigen-Confirmed Pneumococcal Community-Acquired Pneumonia

BACKGROUND: The burden of pneumococcal disease is measured only through patients with invasive pneumococcal disease. The urinary antigen test (UAT) for pneumococcus has exhibited high sensitivity and specificity. We aimed to compare the pneumococcal pneumonias diagnosed as invasive disease with pneumococcal pneumonias defined by UAT results. METHODS: A prospective observational study of consecutive nonimmunosuppressed patients with community‐acquired pneumonia was performed from January 2000 to December 2014. Patients were stratified into two groups: invasive pneumococcal pneumonia (IPP) defined as a positive blood culture or pleural fluid culture result and noninvasive pneumococcal pneumonia (NIPP) defined as a positive UAT result with negative blood or pleural fluid culture result. RESULTS: We analyzed 779 patients (15%) of 5,132, where 361 (46%) had IPP and 418 (54%) had NIPP. Compared with the patients with IPP, those with NIPP presented more frequent chronic pulmonary disease and received previous antibiotics more frequently. Patients with IPP presented more severe community‐acquired pneumonia, higher levels of inflammatory markers, and worse oxygenation at admission; more pulmonary complications; greater extrapulmonary complications; longer time to clinical stability; and longer length of hospital stay compared with the NIPP group. Age, chronic liver disease, mechanical ventilation, and acute renal failure were independent risk factors for 30‐day crude mortality. Neither IPP nor NIPP was an independent risk factor for 30‐day mortality. CONCLUSIONS: A high percentage of confirmed pneumococcal pneumonia is diagnosed by UAT. Despite differences in clinical characteristics and outcomes, IPP is not an independent risk factor for 30‐day mortality compared with NIPP, reinforcing the importance of NIPP for pneumococcal pneumonia.

Nosocomial pneumonia in the intensive care unit: how should treatment failure be predicted?

ICUAP includes pneumonia acquired during ICU stays of patients under mechanical ventilation (ventilator-associated pneumonia, or VAP), as well as of non-ventilated patients (NV-ICUAP). Although the current literature contains few studies examining NV-ICUAP, it has been suggested that both diagnoses present with similar pathogens and, depending on case-mix, similar outcomes.

Dyspnea of Unknown Cause. Think about Diaphragm

A patient with 2 weeks of breathlessness during daily activities and intense pain in the right shoulder was referred for physiological evaluation. A chest radiograph showed new right hemidiaphragm elevation, pulmonary function tests demonstrated reduced lung volumes, and maximum inspiratory pressure was markedly reduced. Additional testing based on an understanding of the structure, function, and innervation of the diaphragm confirmed the diagnosis.

The PES (Pseudomonas, Enterobacteriaceae ESBL, Methicillin-resistant Staphylococcus aureus) Concept in Community-acquired Pneumonia

One of the main concerns about the management of community-acquired pneumonia (CAP) is to choose an adequate empirical antibiotic treatment. Patients with CAP usually respond to the standard antibiotics suggested by CAP guidelines; however, a small percentage of patients need a different and more aggressive treatment because of the presence of resistant pathogens. The critical point is to identify this small subgroup of CAP patients and to avoid the overtreatment of the remaining CAP patients. Therefore, it is important to create a tool to stratify patients at risk for resistant pathogens. The definition of health care–associated pneumonia has not proven to be effective. Moreover, recent studies proposed new scores on the basis of specific factors to screen the population at risk. However, they presented limitations: there was a lack of strong external validation, they included immunosuppressed patients, and they used different definitions of multidrug-resistant pathogens. In this review, we underline the limitations of the current approach to guide empirical antibiotic therapy in CAP. We propose to avoid the term multidrug resistant in favor of a novel definition called “PES concept,” which includes the 3 most frequent resistant pathogens in CAP that are not susceptible to the antibiotics suggested by the guidelines: Pseudomonas aeruginosa, Enterobacteriaceae ESBL positive, and methicillin-resistant Staphylococcus aureus. This new concept is treatment oriented and classifies pathogens according to their response to a specific class of antibiotics. Thus, we present a conceptual framework to guide the empirical antibiotic selection considering 3 groups of patients: immunosuppressed patients with CAP, patients with CAP without risk factors for PES, and patients with CAP with high risk for PES pathogens.