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Concept: Community-acquired pneumonia

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BACKGROUND AND OBJECTIVE: Aspiration pneumonia is one of the common presentations of community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP). However, its significance has not yet been fully evaluated due to the difficulties associated with diagnosis of this condition. This study aimed to evaluate the impact of objectively-defined aspiration pneumonia on the patients' prognosis with CAP and HCAP. METHODS: This is a multicenter retrospective cohort study consisting of 417 CAP and 220 HCAP patients. We defined aspiration pneumonia as: having both risk factors for aspiration (dysphagia due to a neurological disorder, or disturbance of consciousness) and evidence of gravity-dependent opacity on chest CT. The prognostic factors for 30-day mortality were analyzed. RESULTS: One hundred and sixteen (18%) patients met the definition of aspiration pneumonia, 72 (11%) patients had risks for aspiration alone, 129 (20%) patients had CT findings consistent with aspiration alone, and 320 (50%) patients had neither. Patients diagnosed with aspiration pneumonia had a significantly worse survival than those with risk factors alone (p=0.001), CT findings of aspiration alone (p=0.009), and neither (p<0.001). A multivariate analysis indicated that aspiration pneumonia was independently associated with increased 30-day mortality (adjusted hazard ratio 5.690, p<0.001) after adjusting for other variables, including the category of pneumonia, performance status, the severity score (CURB-65), and treatment failure due to resistant pathogens. CONCLUSIONS: Aspiration pneumonia may be a significant predictor of mortality among CAP and HCAP patients. Therefore, the concept of aspiration pneumonia should be considered in the guidelines for these types of pneumonia.

Concepts: Cohort study, Epidemiology, Pneumonia, Risk, Relative risk, Aspiration pneumonia, Community-acquired pneumonia, Healthcare-associated pneumonia

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The aim of the present study is to evaluate the usefulness of two biomarkers-procalcitonin (PCT) and C-reactive protein (CRP)-in addition to the CURB-65 score for assessing the site of care and the etiology of non-severe community-acquired pneumonia (CAP). We conducted a prospective observational study from April 1, 2006, to June 30, 2007, in a single teaching hospital in northern Spain among patients with non-severe CAP. In addition to collecting data needed to determine the CURB-65 score, microbial cultures were taken and levels of PCT and CRP were measured. We compared the prognostic accuracy of these biomarkers with the CURB-65 score to predict hospitalization and microbial etiology using receiver operating characteristic (ROC) curves. A total of 344 patients with non-severe CAP were enrolled; 73 were admitted to the hospital and 271 were treated on an outpatient basis. An etiologic diagnostic was made for 44 %, with atypical pathogens predominating. Levels of PCT and CRP increased with increasing CURB-65 scores. Patients admitted to the hospital had higher PCT and CRP levels than outpatients (p < 0.001). For predicting hospitalization, PCT had a better area under the ROC curve (AUC) (0.81) than the CURB-65 score alone (0.77). For PCT plus the CURB-65 score, the AUC increased significantly from 0.77 to 0.83. In patients with bacterial CAP, the biomarker levels were significantly higher than among patients with atypical or viral etiology (p < 0.001). PCT with a cut-off point of 0.15 ng/mL was the best predictor for bacterial etiology and for select patients eligible for outpatient care. In conclusion, levels of PCT and CRP positively correlate with increasing severity of CAP and may have a role in predicting both patients who can safely receive outpatient care and the microbial etiology in patients with low CURB-65 scores.

Concepts: Scientific method, Bacteria, Pneumonia, Hospital, Observational study, C-reactive protein, Receiver operating characteristic, Community-acquired pneumonia

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BACKGROUND: Aspiration pneumonia is a common syndrome, although less well characterized than other pneumonia syndromes. We describe a large population of patients with aspiration pneumonia. METHODS: In this retrospective population study, we queried the electronic medical records at a tertiary-care, university-affiliated hospital from 1996 to 2006. Patients were initially identified by International Classification of Diseases, 9th Revision code 507.x; subsequent physician chart review excluded patients with aspiration pneumonitis and those without a confirmatory radiograph. Patients with community-acquired aspiration pneumonia were compared to a contemporaneous population of community-acquired pneumonia (CAP) patients. We compared CURB-65 (a clinical prediction rule based on Confusion, Uremia, Respiratory rate, Blood Pressure, and age)-predicted mortality with actual 30-day mortality. RESULTS: We identified 628 patients with aspiration pneumonia, of which 510 were community-acquired. Median age was 77 years, with 30-day mortality of 21%. Compared to CAP patients, patients with community-acquired aspiration pneumonia had more frequent inpatient admission (99% vs 58%) and intensive care unit admission (38% vs 14%), higher Charlson comorbidity index (3 vs 1), and higher prevalence of do not resuscitate/intubate orders (24% vs 11%). CURB-65 predicted mortality poorly in aspiration pneumonia patients (area under the curve, 0.66). CONCLUSIONS: Patients with community-acquired aspiration pneumonia are older, have more comorbidities, and demonstrate higher mortality than CAP patients, even after adjustment for age and comorbidities. CURB-65 poorly predicts mortality in this population. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine.

Concepts: Medicine, Disease, Pneumonia, Comorbidity, Aspiration pneumonia, Clinical prediction rule, CURB-65, Community-acquired pneumonia

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Background. There are limited data on the performance of the pneumonia severity index (PSI) and CURB-65, which were originally developed for community-acquired pneumonia (CAP), for patients with healthcare-associated pneumonia (HCAP).Methods. The performances of PSI and CURB-65 were retrospectively evaluated in patients with HCAP compared to patients with CAP using prospectively collected data between January 2008 and December 2010.Results. In total, 938 patients hospitalized with pneumonia were eligible for this study, consisting of 519 (55%) with CAP and 419 (45%) with HCAP. The PSI and CURB-65 scores had similar trends of increasing mortality with worsening risk class in both HCAP and CAP groups. In the HCAP group, however, the low-risk patients identified using CURB-65 had a higher aggregate 30-day mortality compared with the low-risk patients identified using PSI. Although the performances of PSI and CURB-65 in the HCAP group showed similar trends to those observed in the CAP group, the estimated areas under receiver operating characteristic curve of PSI (0.679, 95% CI 0.619 - 0.739) and CURB-65 (0.599, 95% CI 0.522 - 0.675) in the HCAP group were significantly lower than those in the CAP group (0.835, 95% CI 0.768 for PSI; 0.759, 95% CI 0.686 - 0.832 for CURB-65).Conclusions. The performances of PSI and CURB-65 for predicting 30-day mortality in patients with HCAP were comparable to those in patients with CAP. However, the discriminatory powers of PSI and CURB-65 for 30-day mortality were significantly lower in the HACP group than those in the CAP group.

Concepts: Pneumonia, Hospital, Receiver operating characteristic, CURB-65, Community-acquired pneumonia, Healthcare-associated pneumonia, Pneumonia severity index

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The role of neutrophil and lymphocyte counts in blood as prognosis predictors in Community Acquired Pneumonia (CAP) has not been adequately studied. This was a derivation-validation retrospective study in hospitalized patients with CAP and no prior immunosuppression. We evaluated by multivariate analysis the association between neutrophil and lymphocyte counts and mortality risk at 30-days post hospital admission in these patients. The derivation cohort (n=1550 patients) was recruited in a multi-site study. The validation cohort (n=2846 patients) was recruited in a single-site study. In the derivation cohort, a sub-group of lymphopenic patients, those with <724lymphocytes/mm(3), showed a 1.93-fold increment in the risk of mortality, independently of the CURB-65 score, critical illness, and receiving an appropriate antibiotic treatment. In the validation cohort, patients with <724lymphocytes/mm(3) showed a 1.86-fold increment in the risk of mortality. The addition of 1 point to the CURB-65 score in those patients with <724lymphocytes/mm(3) improved the performance of this score to identify non-survivors in both cohorts. In conclusion, lymphopenic CAP constitutes a particular immunological phenotype of the disease which is associated with an increased risk of mortality. Assessing lymphocyte counts could contribute to personalized clinical management in CAP.

Concepts: Immune system, Epidemiology, Medical terms, Hospital, Actuarial science, Arthralgia, Community-acquired pneumonia, Pneumonia severity index

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Aim of this study was to develop a new simpler and more effective severity score for community-acquired pneumonia (CAP) patients. A total of 1640 consecutive hospitalized CAP patients in Second Affiliated Hospital of Zhejiang University were included. The effectiveness of different pneumonia severity scores to predict mortality was compared, and the performance of the new score was validated on an external cohort of 1164 patients with pneumonia admitted to a teaching hospital in Italy. Using age ≥ 65 years, LDH > 230 u/L, albumin < 3.5 g/dL, platelet count < 100 × 10(9)/L, confusion, urea > 7 mmol/L, respiratory rate ≥ 30/min, low blood pressure, we assembled a new severity score named as expanded-CURB-65. The 30-day mortality and length of stay were increased along with increased risk score. The AUCs in the prediction of 30-day mortality in the main cohort were 0.826 (95% CI, 0.807-0.844), 0.801 (95% CI, 0.781-0.820), 0.756 (95% CI, 0.735-0.777), 0.793 (95% CI, 0.773-0.813) and 0.759 (95% CI, 0.737-0.779) for the expanded-CURB-65, PSI, CURB-65, SMART-COP and A-DROP, respectively. The performance of this bedside score was confirmed in CAP patients of the validation cohort although calibration was not successful in patients with health care-associated pneumonia (HCAP). The expanded CURB-65 is objective, simpler and more accurate scoring system for evaluation of CAP severity, and the predictive efficiency was better than other score systems.

Concepts: Blood, Hospital, Prediction, Futurology, Scores, Community-acquired pneumonia, Healthcare-associated pneumonia, Pneumonia severity index

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Solithromycin, a new macrolide, and the first fluoroketolide in clinical development, with activity against macrolide-resistant bacteria, was tested in 132 patients with moderate to moderately severe community-acquired bacterial pneumonia (CABP) in a multi-center, double-blind, randomized Phase 2 study. Patients were enrolled and randomized (1:1) to either solithromycin 800 mg orally (PO) on Day 1 followed by 400 mg PO daily on Days 2 to 5 or levofloxacin 750 mg PO daily on Days 1 to 5. Efficacy outcome rates of clinical success at the test-of-cure visit 4 to 11 days after the last dose of study drug were comparable in the Intent-to-Treat (ITT) (84.6% for solithromycin vs. 86.6% for levofloxacin) and microbiological Intent-to-Treat (mITT) (77.8% for solithromycin vs. 71.4% for levofloxacin) populations. Early response success at Day 3, defined as improvement in at least two cardinal symptoms of pneumonia, was also comparable (72.3% for solithromycin vs. 71.6% for levofloxacin). More patients treated with levofloxacin than solithromycin experienced treatment-emergent adverse events (TEAEs) during the study (45.6% vs. 29.7%). The majority of TEAEs were mild or moderate gastrointestinal symptoms, and included nausea (1.6% solithromycin; 10.3% levofloxacin), diarrhea (7.8% solithromycin; 5.9% levofloxacin), and vomiting (0% solithromycin; 4.4% levofloxacin). Six patients, all of whom received levofloxacin, discontinued study drug due to an AE. Solithromycin demonstrated comparable efficacy and favorable safety relative to levofloxacin. These findings support a Phase 3 study of solithromycin for the treatment of CABP.

Concepts: Pharmacology, Clinical trial, Bacteria, Microbiology, Pneumonia, Randomized controlled trial, Community-acquired pneumonia, Bacterial pneumonia

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 Fluoroquinolones have equivalent oral and intravenous bioavailability, but hospitalized patients with community-acquired pneumonia (CAP) generally are treated intravenously. Our objectives were to compare outcomes of hospitalized CAP patients initially receiving intravenous versus oral respiratory fluoroquinolones.

Concepts: Pneumonia, Community-acquired pneumonia, Levofloxacin, Healthcare-associated pneumonia

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Italian pediatric antimicrobial prescription rates are among the highest in Europe. As a first step in an Antimicrobial Stewardship Program, we implemented a Clinical Pathway (CP) for Community Acquired Pneumonia with the aim of decreasing overall prescription of antibiotics, especially broad-spectrum.

Concepts: Medicine, Bacteria, Pneumonia, Community-acquired pneumonia, Levofloxacin, Antibiotics, Healthcare-associated pneumonia