[Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. / Behandlung von erwachsenen Patienten mit ambulant erworbener Pneumonie ­ Update 2021.

The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.

[Large Pneumothorax in a Sleep Apnea Patient with CPAP without Previously Known Lung and Thoracic Diseases - a Case Report]. / Großer Pneumothorax unter CPAP-Therapie beim Schlafapnoepatienten ohne vorbekannte Lungen- und Thoraxerkrankungen ­ ein Fallbericht.

CPAP is the most common treatment for obstructive sleep apnea.Serious complications from this treatment are very rare. Pneumothorax following lung barotrauma under CPAP therapy has been described in case reports only in patients with pre-existing lung and thoracic diseases.A 68-year-old sleep apnea patient without pre-existing lung or thoracic diseases and with established CPAP therapy since many years was admitted to the hospital after a severe thoracic pain event with persistent shortness of breath. Chest radiograph and computed tomography showed an extensive right-sided pneumothorax with basal bullous emphysema. After surgical treatment of the secondary spontaneous pneumothorax, on the third postoperative day CPAP with reduced pressure was re-introduced with satisfactory sleep apnea findings and without pneumothorax recurrence.As possible cause of pneumothorax in the patient, alveolar inflammatory changes due to over-distention and increased pressure in the alveoli was assumed, which can occur after years of CPAP treatment with gradual pressure increase.In summary, in sleep apnea patients treated with CPAP for years, after sudden onset of thoracic pain and shortness of breath possible spontaneous pneumothorax should be considered.

[Complications after Indwelling Pleural Catheter Implant for Symptomatic Recurrent Benign and Malignant Pleural Effusions]. / Komplikationen nach pleuralem getunnelten Dauerkatheter bei symptomatischen rezidivierenden benignen und malignen Pleuraergüssen.

BACKGROUND: Implant of indwelling pleural catheters (IPC) represents an established therapy method in addition to pleurodesis for symptomatic recurrent benign and malignant pleural effusions (BPE and MPE).There are only few studies on IPC safety during follow-up, especially with regard to infection and pneumothorax rates.The aim of our investigation was to determine the complication frequency after IPC implant and its predictive factors in patients with BPE vs. MPE. METHODS: Retrospective analysis of all IPC implantations in the pneumology department at the University Hospital Dresden during 2015 - 2018. RESULTS: An IPC was implanted in 86 patients (43 m/f each; age 66.9 ±â€Š13.3 years) with symptomatic BPE and MPE. BPE and MPE was present in 12.8 % (11/86) and 87.2 % (75/86) of the patients, respectively.A predominantly small and asymptomatic pneumothorax was detectable as an immediate complication in 43/86 (50 %) of patients; 34/43 (79 %) of patients did not require any specific therapy. For 9/43 patients, IPC suction was required for a median period of three days; 8/43 patients had a large pneumothorax with partial or complete regression after a median period of two days.Catheter infection developed in 15.1 % (13/86) of the total group and 36.4 % (4/11) of the BPE vs. 12 % (9/75) of the MPE after a median period of 87 (BPE/MPE 116/87) days. This was more common in BPE (p = 0.035), large pneumothorax (4/8 patients; p = 0.015) and longer catheter dwell times (124 ±â€Š112 vs. 71 ±â€Š112 days; p = 0.07). CONCLUSION: Small pneumothoraxes are frequent after IPC implantation, but usually do not require specific therapy. IPC infection was detected in 15.1 % of all patients after a median period of 87 days. This was more common in patients with BPE, longer catheter dwell times and large pneumothorax.

[Chronic Granulomatous Disease: A Rare Differential Diagnosis in Recurrent Pulmonary Infections in Adults]. / Septische Granulomatose als seltene Differenzialdiagnose rezidivierender pulmonaler Infektionen bei Erwachsenen.

Chronic granulomatous disease (CGD) should be considered as a differential diagnosis in children and adolescents with frequent infections, especially when caused by certain specific pathogens.This case report describes a 64-year-old female with multiple recurrent and complicated bronchopulmonary infections, caused by common, but also rare pathogens, autoimmune phenomena, malignancies and recurrent organizing pneumonia (OP) with granulomas. Finally, the patient was diagnosed with p47phox-deficient chronic granulomatous disease (CGD).Individuals with a primary immunodeficiency may survive multiple complications and may be diagnosed at an advanced age especially if the affected structure shows residual activity. When confronted with patients with recurrent bronchopulmonary infections, especially with certain specific rare pathogens, in combination with organizing pulmonary granulomas as well as autoimmune phenomena, CGD should be considered even in elderly patients. Delayed diagnosis significantly increases mortality and morbidity in such cases.

[Biomarkers in Diagnosis, Treatment and Prognosis of Infectious Lung Diseases]. / Biomarker in der Diagnostik, Therapie und Prognose infektiöser Lungenerkrankungen.

Biomarkers play an important role in the management of infectious pulmonary diseases, even though there is only limited evidence that biomarker-guided therapies are superior to clinical strategies.Well-established indications for the use of biomarkers are the guidance of the duration of antibiotic therapy in community-acquired pneumonia (CAP) by PCT, the decision against the use of antibiotics by CRP or PCT in ambulatory settings, and the evaluation of CAP treatment by CRP or PCT kinetics.In the prognostic assessment of CAP, the standard biomarkers of acute organ dysfunction should be given priority, e. g. leukocyte and platelet counts, creatinine/urea and lactate, in combination with clinical signs and symptoms.MR-pro-ADM could enrich diagnostics in the future. Genetic transcriptome analysis is a completely new and promising concept.

[Epidemiology, Diagnosis and Treatment of Adult Patients with Nosocomial Pneumonia - Update 2017 - S3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy, the German Radiological Society and the Society for Virology]. / Epidemiologie, Diagnostik und Therapie erwachsener Patienten mit nosokomialer Pneumonie ­ Update 2017.

Nosocomial pneumonia (HAP) is a frequent complication of hospital care. Most data are available on ventilator-associated pneumonia. However, infections on general wards are increasing. A central issue are infections with multidrug resistant (MDR) pathogens which are difficult to treat in the empirical setting potentially leading to inappropriate use of antimicrobial therapy.This guideline update was compiled by an interdisciplinary group on the basis of a systematic literature review. Recommendations are made according to GRADE giving guidance for the diagnosis and treatment of HAP on the basis of quality of evidence and benefit/risk ratio.This guideline has two parts. First an update on epidemiology, spectrum of pathogens and antimicrobials is provided. In the second part recommendations for the management of diagnosis and treatment are given. New recommendations with respect to imaging, diagnosis of nosocomial viral pneumonia and prolonged infusion of antibacterial drugs have been added. The statements to risk factors for infections with MDR pathogens and recommendations for monotherapy vs combination therapy have been actualised. The importance of structured deescalation concepts and limitation of treatment duration is emphasized.

Clinical Relevance of Computed Tomography Pulmonary Venography.

BACKGROUND: In clinical routine, the pulmonary contrast-enhanced chest computer tomography (CT) is usually focussed on the pulmonary arteries. The purpose of this pictorial essay is to raise the clinicians' awareness for the clinical relevance of CT pulmonary venography. CASE PRESENTATION: A pictorial case series illustrates the clinical consequences of different pulmonary venous pathologies on systemic, pulmonary and bronchial circulation. CONCLUSION: Computed tomography pulmonary venography must be considered before atrial septal defect (ASD) closure and pulmonary lobectomy. Computed tomography pulmonary venography should be considered for patients with right ventricular overload and pulmonary hypertension, as well as for patients with unclear recurrent pulmonary infections, progressive dyspnoea, pleural effusions, haemoptysis, and for patients with respiratory distress after lung-transplantation.

[Management of Adult Community-acquired Pneumonia and Prevention - Update 2016]. / Behandlung von erwachsenen Patienten mit ambulant erworbener Pneumonie und Prävention - Update 2016.

The present guideline provides a new and updated concept of treatment and prevention of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2009.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment as well as primary and secondary prevention.

Assessment of oxygenation and comorbidities improves outcome prediction in patients with community-acquired pneumonia with a low CRB-65 score.

BACKGROUND: Addition of assessment of comorbid diseases ('D') and oxygen saturation ('S') to the CRB-65 score has been recommended to improve its accuracy for risk stratification in community-acquired pneumonia (CAP). The aim of this study was to validate the resulting DS-CRB-65 score in a large cohort of patients with CAP. METHODS: A total of 4432 patients prospectively enrolled in the CAPNETZ cohort were included in this study. Predefined end points were 28-day mortality, requirement for mechanical ventilation or vasopressors (MV/VS) and requirement for MV/VS or intensive care unit admission (MV/VS/ICU). Receiver operating characteristic curve analysis was used to determine the accuracy of the CRB-65 score and the addition of D (extra-pulmonary comorbidities) and S (oxygen saturation <90% or partial pressure of oxygen <8 kPa). Binary logistic regression and the method of Hanley and McNeil were used to compare the criteria. RESULTS: The mortality rate was 4.0%, and 4.2% of patients required MV/VS and 6.6% required MV/VS/ICU. After multivariate analysis, D and S independently were added to the CRB-65 criteria for mortality prediction, but only S improved prediction of MV/VS and MV/VS/ICU (P < 0.001 for all). The area under the curve of the CRB-65 score was significantly improved by adding D and S for all end points (P < 0.02). Amongst patients who died or required MV/VS despite a CRB-65 score of 0, 64-80% would have been identified by the DS-CRB-65 score. CONCLUSIONS: The addition of assessment of oxygenation and comorbidities significantly improved the prognostic accuracy of the CRB-65 score. Consequently, the DS-CRB-65 score may have a useful role in risk stratification algorithms for CAP.

Ambrisentan improves exercise capacity and symptoms in patients with portopulmonary hypertension.

INTRODUCTION: Ambrisentan, a selective endothelin receptor antagonist has been approved in several countries for pulmonary arterial hypertension. No data have been published on the efficacy of ambrisentan on improvement of exercise capacity in patients with portopulmonary hypertension (PoPH). PATIENTS AND METHODS: We retrospectively analyzed the safety and efficacy of ambrisentan in patients with PoPH in four German university hospitals. RESULTS: 14 patients with moderate to severe PoPH were included. The median follow-up was 16 months (IQR, 12 - 21). 6 minute walk tests after 6 and 12 months improved from 376 meters (IQR, 207 - 440) at baseline to 415 meters (IQR, 393 - 475; p = 0.011) and 413 meters (IQR, 362 - 473, p = 0.005), respectively. WHO- functional class after 1 year of therapy with ambrisentan also improved significantly (p = 0.014). No significant changes in blood gas analysis and liver function tests (aspartate aminotransferase, alanine aminotransferase, total bilirubin, and international normalized ratio) during therapy with ambrisentan were detectable. CONCLUSIONS: The present study demonstrates significant improvement of exercise capacity and clinical symptoms without relevant safety concerns during ambrisentan treatment in patients with PoPH.

Adrenal function is related to prognosis in moderate community-acquired pneumonia.

The aim of our study was to prospectively examine adrenal function, including cosyntropin stimulation, and its prognostic value in patients with moderate community-acquired pneumonia (CAP). 59 consecutive adult patients hospitalised on normal wards because of CAP were enrolled. A cosyntropin stimulation test was performed and serum concentrations of C-reactive protein, procalcitonin, interleukin-6, tumour necrosis factor-α, ACTH, cortisol, dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulfate (DHEAS) were measured. Predefined outcome parameters were clinical instability after 72 h, mortality and combined intensive care unit (ICU) admission or mortality. Critical illness-related corticosteroid insufficiency (CIRCI) occurred in six patients (10.3%). Cortisol, age-corrected DHEA, ACTH and the DHEA/DHEAS ratio were elevated in patients remaining unstable after 72 h. In multivariate analysis, cortisol (p = 0.03), ACTH (p = 0.04) and the pneumonia severity index (PSI) score (p = 0.005) independently predicted clinical instability after 72 h, and only cortisol predicted mortality (p = 0.04) and combined ICU-admission or mortality (p = 0.006). The predictive value of serum cortisol after receiver operating characteristic curve analysis equalled that of the PSI score. Patients with serum cortisol >734 nmol·L(-1) had a high probability for mortality (OR 38.3; p = 0.002). CIRCI is rare in patients with moderate CAP. Adrenal function is related to the prognosis of CAP. The diagnostic accuracy of serum cortisol equals that of the PSI score. Serum cortisol should be evaluated within clinical prediction scores on larger studies.

[Retrospective analysis of tuberculosis caused by Mycobacterium bovis 2004 - 2008]. / Retrospektive Analyse von Tuberkuloseerkrankungen durch Mycobacterium bovis 2004 - 2008.

BACKGROUND: mycobacterium bovis is a rare cause of tuberculosis in Germany. Epidemiological data are sparse. METHODS: we have carried out a retrospective analysis of all patients diagnosed with tuberculosis caused by M. BOVIS in a pneumological referral centre between 2004 and 2008. RESULTS: M. bovis was isolated in 8 out of 203 (3,9  %) patients with a new diagnosis of tuberculosis. The median age of these patients was 69 years, and 7 out of 8 showed risk factors for reactivation of a latent tuberculosis infection. In 4 patients (50  %) an extrapulmonary manifestation was present. All isolates of M. bovis were resistant to pyrazinamide, one isolate had an additional resistance to isoniazide. In 6 out of 8 patients prolonged tuberculostatic treatment of 8 - 12 months was recommended. CONCLUSIONS: the proportion of tuberculosis caused by M. bovis was higher than that reported for Germany (3.9 vs. 1,5 %). Predominantly elderly patients with risk factors for reactivation of a latent tuberculosis infection were affected. In accordance with the literature a high rate of extrapulmonary manifestations was detected. Because of the genetic resistance of M. bovis to pyrazinamide prolonged antimycobacterial treatment is recommended.

[Current concepts for the microbiological detection of airway pathogens]. / Aktuelle Konzepte zum mikrobiologischen Nachweis von Atemwegserregern.

The frequency and range of bacterial pathogens in respiratory tract infections depends on a variety of variables. The aetiology is influenced by the type of respiratory tract infection (acute bronchitis, acute exacerbation of chronic bronchitis, community-acquired pneumonia, nosocomial pneumonia), geographic and seasonal factors, and by the diagnostic methods implemented to identify the pathogens. Furthermore, there exists a considerable uncertainty concerning the clinical relevance of positive bacteriological findings in respiratory secretions because they are retrieved from non-sterile or contaminated environments. To differentiate infection from contamination, both microbiological and clinical findings have to be assessed, which might be difficult in the setting of systemic or local immunosuppression.

Healthcare-associated pneumonia: is there any reason to continue to utilize this label in 2019?

BACKGROUND: There is an ongoing controversy on the role of the healthcare-associated pneumonia (HCAP) label in the treatment of patients with pneumonia. OBJECTIVE: To provide an update of the literature on patients meeting criteria for HCAP between 2014 and 2018. SOURCES: The review is based on a systematic literature search using PubMed-Central full-text archive of biomedical and life sciences literature at the U.S. National Institutes of Health's National Library of Medicine (NIH/NLM). CONTENT: Studies compared clinical characteristics of patients with HCAP and community-acquired pneumonia (CAP). HCAP patients were older and had a higher comorbidity. Mortality rates in HCAP varied from 5% to 33%, but seemed lower than those cited in the initial reports. Criteria behind the HCAP classification differed considerably within populations. Microbial patterns differed in that there was a higher incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, and, to a lesser extent, enterobacteriaceae. Definitions and rates of multidrug-resistant (MDR) pneumonia also varied considerably. Broad-spectrum guideline-concordant treatment did not reduce mortality in four observational studies. The HCAP criteria performed poorly as a predictive tool to identify MDR pneumonia or pathogens not covered by treatment for CAP. A new score (Drug Resistance in Pneumonia, DRIP) outperformed HCAP in the prediction of MDR pathogens. Comorbidity and functional status, but not different microbial patterns, seem to account for increased mortality. IMPLICATIONS: HCAP should no longer be used to identify patients at risk of MDR pathogens. The use of validated predictive scores along with implementation of de-escalation strategies and careful individual assessment of comorbidity and functional status seem superior strategies for clinical management.