Rosanel Amaro

Influence of Previous Use of Inhaled Corticoids on the Development of Pleural Effusion in Community-acquired Pneumonia

RATIONALE Previous use of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease has been associated with increased risk of community-acquired pneumonia. However, ICS have been associated with fewer pneumonia complications and decreased risk of pneumonia-related mortality. OBJECTIVES The objective of the study was to assess the influence of previous use of ICS on the incidence of parapneumonic effusion in patients with different baseline respiratory disorders. METHODS We conducted a single-center cohort study of 3,612 consecutively collected patients diagnosed with community-acquired pneumonia. We assessed clinical, radiographic, and pleural-fluid chemistry and microbiologic variables. Patients were classified according to whether or not they received prior ICS treatment. MEASUREMENTS AND MAIN RESULTS A total of 633 patients (17%) were treated with corticosteroids before the diagnosis of pneumonia (chronic obstructive pulmonary disease, 54%; asthma, 13%). Incidence of parapneumonic effusion was lower in patients with ICS use compared with non-ICS patients (5% vs. 12%; P < 0.001). After matching according to propensity scores (n = 640), prior treatment with corticosteroids was still significantly associated with a lower incidence of parapneumonic effusion (odds ratio, 0.40; 95% confidence interval, 0.23-0.69; P = 0.001) compared with patients without ICS treatment. Prior ICS treatment was associated with higher levels of glucose (P = 0.003) and pH (P = 0.02), and lower levels of protein (P = 0.01) and lactic acid dehydrogenase (P = 0.007) in the pleural fluid. CONCLUSIONS Prior treatment with ICS in a population of patients with different respiratory chronic disorders who develop pneumonia is associated with lower incidence of parapneumonic effusion.

Community-acquired lung respiratory infections in HIV-infected patients: microbial aetiology and outcome

We describe the aetiology of community-acquired pneumonia (CAP) in HIV-infected patients, risk factors for bacterial or Pneumocystis jirovecii CAP and prognostic factors of 30-day mortality. This was a prospective observational study of 331 consecutive adult CAP cases in HIV-infected patients (January 2007 to July 2012). 128 (39%) patients had CD4+ cell counts <200 per mm3 and 99 (43%) ha HIV RNA levels <200 copies per mL on antiretroviral therapy. Streptococcus pneumoniae was the most frequent microorganism in the group with CD4+ cell counts ≥200 per mm3; P. jirovecii was the most frequent microorganism in the group with CD4+ cell counts <200 per mm3 and in patients with HIV RNA ≥200 copies per mL. Predictors of bacterial CAP were: time with symptoms ≤5 days (OR 2.6, 95% CI 1.5–4.4), C-reactive protein level ≥22 mg·dL−1 (OR 4.3, 95% CI 2.3–8.2) and hepatitis C virus co-infection (OR 2.3, 95% CI 1.4–3.9). White blood cell count ≤4×1012 per L (OR 3.7, 95% CI 1.2–11.5), lactate dehydrogenase (LDH) level ≥598 U·L−1 (OR 12.9, 95% CI 4.2–39.7) and multilobar infiltration (OR 5.8, 95% CI 1.9–19.5) were predictors of P. jirovecii. Overall 30-day mortality was 7%. Appropriate antibiotic treatment (OR 0.1, 95% CI 0.03–0.4), LDH ≥598 U·L−1 (OR 6.2, 95% CI 1.8–21.8) and mechanical ventilation (OR 22.0, 95% CI 6.2–78.6) were the variables independently associated with 30-day mortality. The described predictors may help clinicians to distinguish between bacterial and P. jirovecii pneumonia in patients with suspected or confirmed HIV infection. Clinical risk factors in HIV patients to distinguish between bacterial and Pneumocystis jirovecii pneumonia http://ow.ly/sV2hf

Predictive and prognostic factors in patients with blood-culture-positive community-acquired pneumococcal pneumonia

In patients with pneumococcal community-acquired pneumonia (CAP), the risk factors for bacteraemia and its impact on outcomes are not fully elucidated. We aimed to compare characteristics of patients with blood-culture-positive versus blood-culture-negative pneumococcal CAP, and to characterise bacteraemic serotypes. We describe a prospective, observational study on nonimmunocompromised patients with pneumococcal CAP, from 1996 to 2013. We define severe pneumonia according to American Thoracic Society/Infectious Diseases Society of America guidelines. Of a total of 917 patients with pneumococcal CAP, 362 had blood-culture-positive pneumococcal pneumonia (BCPPP; 39%). High C-reactive protein (CRP) (≥20 mg·dL−1) (odds ratio (OR) 2.36, 95% CI 1.45–3.85), pleural effusion (OR 2.03, 95% CI 1.13–3.65) and multilobar involvement (OR 1.69, 95% CI 1.02–2.79) were independently associated with bacteraemic CAP, while nursing home resident (OR 0.12, 95% CI 0.01–1.00) was found as a protective factor. Despite the clinical differences, BCPPP showed similar outcomes to blood-culture-negative pneumococcal pneumonia (BCNPP). 14% of the serotypes (period 2006–2013) causing bacteraemia are included in pneumococcal conjugate vaccine PVC7, 74% in pneumococcal conjugate vaccine PVC13 and 83% in pneumococcal polysaccharide vaccine PPSV23. Pleural effusion, a high level of CRP and multilobar involvement predicted an increased risk of BCPPP. Although BCPPP patients were more severely ill at admission, mortality was not significantly greater than in BCNPP patients. Pleural effusion, multilobar involvement and CRP ≥20 mg·dL–1 indicate high risk of bacteraemic pneumococcal pneumonia http://ow.ly/4mJk2Z

The impact of guidelines on the outcomes of community-acquired and ventilator-associated pneumonia.

The correct implementation of the current guidelines for the management of community-acquired pneumonia is associated with less mortality, faster clinical stabilization, and lower costs in these patients. By contrast, implementing the current guidelines for the management of hospital-acquired pneumonia has been followed by an increase in initially adequate antibiotic treatment but has not been accompanied by a consistently improved outcome in patients.

Does health care associated pneumonia really exist

The most recent ATS guidelines for nosocomial pneumonia of 2005 describe a new clinical category of patients, Health Care-Associated Pneumonia which includes a number of very heterogeneous conditions possibly associated with a high risk of multi-drug resistant (MDR) infections and of mortality. This paper aims at reviewing the current literature on HCAP and examines the controversial issues of HCAP etiology and outcomes, underlining the need of a profound revision of the HCAP concept in the face of the poor and contrasting scientific evidence supporting its basis.

Severity and outcomes of community acquired pneumonia in asthmatic patients

BACKGROUND Limited information is available about clinical outcomes and microbiology of community-acquired pneumonia in asthma. METHODS We prospectively studied 4079 CAP patients over a 12-years period and found 139 (3.4%) asthmatic patients. RESULTS Asthmatics showed younger age (57 ± 19 vs. 66 ± 19 years), less males (32% vs. 68%) and less active smokers (15% vs. 25%). Moreover, they had used more frequently inhaled corticosteroids (ICs, 53% vs. 17%, p < 0.001) and antibiotics (32% vs. 24%, p = 0.041). In comparison with non asthma-CAP, asthmatics showed at admission more pleuritic pain and dyspnoea but less severe pneumonia (PSI, CURB-65, PaO(2)/FIO(2) ratio; p < 0.05). No differences were observed in CAP microbiology, being Streptococcus pneumoniae the most frequent isolate. Clinical outcomes in asthmatic patients were similar to the general population (mortality, mechanical ventilation, etc.) but with a shorter median length of stay (6 [3; 9] vs. 7 [4; 10] days, p = 0.023). The chronic use of ICs did not influence clinical presentation and outcomes among asthmatic patients. CONCLUSIONS Asthmatics were younger and showed similar clinical presentation. Consistently with PSI, asthmatics showed similar outcomes than the general population. The microbial aetiology of CAP in asthma did not differ from the general population and antibiotic therapy should follow current guidelines.

The effect of spontaneous breathing on systemic interleukin-6 during ventilator weaning

During the weaning process, spontaneous breathing trials (SBTs) involve cardiopulmonary stress for ventilated patients. As interleukin (IL)-6 is a major modulator of the stress response, we hypothesised that systemic IL-6 increases during a SBT and that this increase is more evident in SBT failure. 49 SBTs of 30-min duration were performed on different mechanically ventilated patients, and classified as SBT failure or success. Blood samples were drawn before and at the end of the SBT. An additional sample was drawn 24 h later in a subset of patients (n=39). Serum IL-6 levels and other inflammatory mediators commonly associated with stress were determined. IL-6 levels increased from mechanical ventilation to spontaneous breathing in all patients (p=0.02) and in the chronic obstructive pulmonary disease (COPD) population (p=0.05) with SBT failure compared with success, but not in non-COPD patients (p=0.12). After 24 h of SBT stress, IL-6 levels decreased in patients with SBT failure (under mechanical ventilation at that point) (p=0.02) and those with weaning success (p=0.04). No changes were observed in the remaining inflammatory mediators. Systemic IL-6 increases during a 30-min, failed SBT, especially in COPD patients. Future studies may corroborate the different IL-6 responses among different populations who initiate weaning, together with the potential clinical implications.

Invasive Pneumococcal Disease Today: Epidemiology, Treatment, and Prevention

Invasive pneumococcal disease (IPD) refers to pneumonia, meningitis, bacteremia, and infections of other normally sterile sites with Streptococcus pneumoniae. Among infectious diseases, IPD is a leading cause of morbidity and mortality in children and adults. The incidence, severity, and mortality of IPD vary widely depending on several factors, some host-related, and others organism-related. After vaccine introduction, rates of IPD because of vaccine serotypes have dramatically decreased among children in the vaccine target and among nonvaccine children and adults. However, rates of IPD because of new emerging nonvaccine serotypes have increased. Continuous monitoring and surveillance studies focused on the clinical and molecular epidemiology of IPD will be required to understand the impact of the new vaccines and any possible modifications in the pattern of disease presentation.

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.

Initial Inflammatory Profile in Community-acquired Pneumonia Depends on Time since Onset of Symptoms

&NA; Rationale: Assessment of the inflammatory response can help the decision‐making process when diagnosing community‐acquired pneumonia (CAP), but there is a lack of information about the influence of time since onset of symptoms. Objectives: We studied the impact of the number of days since onset of symptoms on inflammatory cytokines and biomarker concentrations at CAP diagnosis in hospitalized patients. Methods: We performed a secondary analysis in two prospective cohorts including 541 patients in the derivation cohort and 422 in the validation cohort. The time since onset of symptoms was self‐reported, and patients were classified as early presenters (<3 d) and nonearly presenters. Biomarkers (C‐reactive protein [CRP] and procalcitonin [PCT] in both cohorts) and cytokines in the derivation cohort (IL‐1, ‐ 6, ‐8, ‐10, and tumor necrosis factor‐&agr;) were measured within 24 hours of hospital admission. Measurements and Main Results: In early presenters, CRP was significantly lower, whereas PCT, IL‐6, and IL‐8 were higher. Nonearly presenters showed significantly lower PCT, IL‐6, and IL‐8 levels. In the validation cohort, CRP and PCT exhibited identical patterns: CRP levels were 36.4% greater in patients with 3 or more days since onset of symptoms than in those with less than 3 days since symptom onset in the derivation cohort and 38.2% in the validation cohort. PCT levels were 40% lower in patients with 3 or more days since onset of symptoms in the derivation cohort and 56% in the validation cohort. Conclusions: Time since symptom onset modifies the systemic inflammatory profile at CAP diagnosis. This information has relevant clinical implications for management, and it should be taken into account in the design of future clinical trials.