Initial management of pneumonia and sepsis: factors associated with improved outcome.

Processes of care and adherence to guidelines have been associated with improved survival in community-acquired pneumonia (CAP). In sepsis, bundles of processes of care have also increased survival. We aimed to audit compliance with guideline-recommended processes of care and its impact on outcome in hospitalised CAP patients with sepsis. We prospectively studied 4,137 patients hospitalised with CAP in 13 hospitals. The processes of care evaluated were adherence to antibiotic prescription guidelines, first dose within 6 h and oxygen assessment. Outcome measures were mortality and length of stay (LOS). Oxygen assessment was measured in 3,745 (90.5%) patients; 3,024 (73.1%) patients received antibiotics according to guidelines and 3,053 (73.8%) received antibiotics within 6 h. In CAP patients with sepsis, the strongest independent factor for survival was antibiotic adherence (OR 0.4). In severe sepsis, only compliance to antibiotic adherence plus first dose within 6 h was associated with lower mortality (OR 0.60), adjusted for fine prognostic scale and hospital. Antibiotic adherence was related to shorter hospital stay. In sepsis, antibiotic adherence is the strongest protective factor of care associated with survival and LOS. In severe sepsis, combined antibiotic adherence and first dose within 6 h may reduce mortality.

[Detection of latent tuberculosis infection in peritoneal dialysis patients: new methods]. / Detección de la infección tuberculosa latente en pacientes en diálisis peritoneal: Nuevos métodos.

OBJECTIVE: The risk for tuberculosis (TB) is increased in patients with chronic renal failure and dialysis. Tuberculin skin test (TST) is the classical diagnostic method for screening despite its low sensitivity. New methods based on interferon-gamma have been developed. The aim of this study was to evaluate if Quantiferon® TB-gold In Tube (QFT-GIT) could be useful in the diagnosis of TB infection in patients on peritoneal dialysis (PD). PATIENTS AND METHODS: Fifty-four patients on PD were included in the study. They were evaluated for latent tuberculosis with QFT-GIT, TST and an assessment by an expert pulmonologist using patient's medical history and x-rays. Agreement between test results was determined. RESULTS: The prevalence of a positive TST was 29.6% for the first test and 31.5% for the second (booster effect). A positive chest x-ray increased the rate of detection of patients with latent TB infection up to 42.6% and the expert physician's evaluation to 44.4%. The correlation between QFT-GIT and TST was fair (k=0.36; P=.006), as it was between TST and expert physician's evaluation (k=0.257; P=.06). CONCLUSIONS: According to our experience QFT-GIT represents an important advantage in the diagnosis of latent TB infection in chronic renal failure patients on PD. It may complement but not replace TST.

Bacteraemic pneumococcal pneumonia in COPD patients: better outcomes than expected.

The purpose of the study was to compare the clinical characteristics and outcomes of bacteraemic pneumococcal pneumonia (BPP) in chronic obstructive pulmonary disease (COPD) and non-COPD patients. A case-control study was conducted. Cases were any adult with BPP and forced expiratory volume in 1 second (FEV(1)) <80% and FEV(1)/forced expiratory vital capacity (FVC) <70%. Controls were patients with BPP without clinical diagnosis of COPD matched 1:2 by age, gender and date of isolation. Variables included co-morbidities, serotypes, pneumonia severity index (PSI), treatment and mortality. There were 45 cases and 90 controls. No significant differences were found in Charlson scores, antibiotic treatment, serotype distribution and severity. Malignancy, shock and mechanical ventilation were less frequent in COPD patients. One patient died vs 14 controls (p = 0.02). In univariate analysis, shock, multilobar involvement, Charlson score, heart failure and absence of COPD were associated with mortality. After adjustment for the presence of shock there were no differences in mortality. BPP presents less frequently with shock and has a lower mortality rate in COPD patients than in non-COPD patients.

Community-acquired pneumonia in patients with and without chronic obstructive pulmonary disease.

PURPOSE: The purpose of this study was to analyse the possible differences, especially those regarding mortality, between patients hospitalized for community-acquired pneumonia (CAP) with and without chronic obstructive pulmonary disease (COPD), and the risk factors related to mortality in the COPD group. METHODS: 710 patients with CAP were included in a prospective multicenter observational study. 244 of the patients had COPD confirmed by spirometry. RESULTS: COPD was associated with mortality in patients with CAP (OR=2.62 CI: 1.08-6.39). Patients with COPD and CAP had a significantly higher 30-day mortality rate as compared to patients without COPD. Multivariate analysis showed that PaO(2)< or =60 mmHg (OR=7.95; 95% CI: 3.40-27.5), PaCO(2)> or =45 mmHg (OR=4.6; CI: 2.3-15.1); respiratory rate > or =30/min (OR=12.25; CI: 3.45-35.57), pleural effusion (OR=8.6; 95% CI: 2.01-24.7), septic shock (OR=12.6; 95% CI: 3.4-45.66) and renal failure (OR=13.4; 95% CI: 3.2-37.8) were significantly related to mortality. Purulent sputum and fever were considered as protective factors. CONCLUSIONS: COPD was an independent risk factor for mortality in patients with CAP. Hypoxemia and hypercapnia are associated with mortality in patients with CAP with and without COPD. Chronic obstructive pulmonary disease and PaCO(2) value could be useful prognostic factors and should be incorporated in risk stratification in patients with CAP.

Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome.

BACKGROUND: An inadequate response to initial empirical treatment of community acquired pneumonia (CAP) represents a challenge for clinicians and requires early identification and intervention. A study was undertaken to quantify the incidence of failure of empirical treatment in CAP, to identify risk factors for treatment failure, and to determine the implications of treatment failure on the outcome. METHODS: A prospective multicentre cohort study was performed in 1424 hospitalised patients from 15 hospitals. Early treatment failure (<72 hours), late treatment failure, and in-hospital mortality were recorded. RESULTS: Treatment failure occurred in 215 patients (15.1%): 134 early failure (62.3%) and 81 late failure (37.7%). The causes were infectious in 86 patients (40%), non-infectious in 34 (15.8%), and undetermined in 95. The independent risk factors associated with treatment failure in a stepwise logistic regression analysis were liver disease, pneumonia risk class, leucopenia, multilobar CAP, pleural effusion, and radiological signs of cavitation. Independent factors associated with a lower risk of treatment failure were influenza vaccination, initial treatment with fluoroquinolones, and chronic obstructive pulmonary disease (COPD). Mortality was significantly higher in patients with treatment failure (25% v 2%). Failure of empirical treatment increased the mortality of CAP 11-fold after adjustment for risk class. CONCLUSIONS: Although these findings need to be confirmed by randomised studies, they suggest possible interventions to decrease mortality due to CAP.

Clinical characteristics and response to newer quinolones in Legionella pneumonia: a report of 28 cases.

Twenty-eight (11.6%) out of 241 Spanish patients enrolled in an international phase III clinical trial of mild to moderate community-acquired pneumonia (CAP) comparing gemifloxacin vs. trovafloxacin were diagnosed of Legionnaires' disease. A definite diagnosis was established by seroconversion in 13 patients of whom only 2 had a positive Legionella urinary antigen. The remaining 15 patients were possible Legionella infections based on a single elevated IgG titer (> or = 1:512). All patients had a radiologically confirmed diagnosis of pneumonia, 5 (19%) patients were older than 65, comorbidity was present in 9 (33%), and 10 (36%) had to be hospitalized. Fifteen patients were treated with oral gemifloxacin (320 mg/day) and 13 with oral trovafloxacin (200 mg/day). Overall, clinical success occurred in 25 (89.3%) patients after 7 days of treatment and only 1 patient needed a 14-day treatment. There were only one adverse event withdrawal and one clinical failure, and no patients died. In light of the favorable clinical outcome, the use of newer fluoroquinolones seems adequate for the treatment of suspected or proven Legionella pneumonia.

[Community-acquired pneumonia (CAP) with hospital treatment. The value of the clinical picture and complementary exams in predicting its etiology]. / Neumonía adquirida en la comunidad (NAC) con tratamiento hospitalario. Interés de la clínica y exámenes complementarios en la predicción de la etiología.

We studied 162 patients with community-acquired pneumonia admitted for hospital treatment, in order to determine the utility of clinical and ancillary examinations for predicting etiology and guiding the most appropriate empirical treatment. Acute first appearance of symptoms, purulent expectoration, chest sounds indicating lung condensation, pleuritic chest pain and leukocytosis over 12,500/ml were statistically significant in differentiating typical pneumonias from those with atypical behavior patterns. The last two features were the most relevant according to multivariate analysis. We conclude that careful taking of case histories and basic blood testing continue to be relevant and must not be considered anachronistic for the differential diagnosis of community-acquired pneumonias.

Adenosine deaminase activity in the aetiological diagnosis of community-acquired pneumonia.

A prospective study was undertaken to assess the usefulness of serum adenosine deaminase (ADA) activity in the aetiological diagnosis of 75 patients (mean age 58 years) with community-acquired pneumonia who required hospitalization. Measurements of ADA were also carried out in 35 healthy subjects (mean age 52 years). The serum ADA activity in patients with typical bacterial pneumonia (TBP) was 21 +/- 7 IU/l and in controls 22 +/- 9 IU/l. In 43 patients with atypical pneumonia (AP), ADA levels (43 +/- 23 IU/l) were significantly higher than in the previously related groups (p < 0.001). Analysis within the group of atypical pneumonia showed significant differences for infections caused by Coxiella burnetii (61 +/- 19 IU/l, p < 0.001), Mycoplasma pneumoniae (44 +/- 26 IU/l, p < 0.001) and Legionella pneumophila (39 +/- 15 IU/l, p < 0.05), as compared with patients with bacterial pneumonia and normal control subjects. We conclude that serum ADA in patients with community-acquired pneumonia requiring hospitalization may provide useful additional diagnostic information on the aetiology of pulmonary infection.

Community-acquired pneumonia in chronic obstructive pulmonary disease: a Spanish multicenter study.

Community-acquired pneumonia (CAP) is an infectious illness that frequently motivates hospital admission when comorbid conditions are present. However, the epidemiology of CAP in relation to the underlying disease of the patients is not well known. We performed a prospective multicenter study with the aim of assessing the clinical characteristics, etiology, and outcome of chronic obstructive pulmonary disease (COPD) patients with CAP. Between October 1992 and December 1994 we studied 124 COPD patients (mean FEV1 40 +/- 11% of predicted, mean FVC/FEV1 49 +/- 10) admitted because of CAP to one of the participating centers. An attempt to obtain an etiologic diagnosis was performed by means of blood cultures (n = 123), sputum cultures (n = 97), pleural fluid cultures (n = 17), protected specimen brush samples (n = 41), percutaneous transthoracic needle aspiration (n = 41), and serology (n = 106). Etiologic diagnosis was achieved in 80 (64%) of cases, however, diagnosis based upon valid techniques was only possible in 73 (59%) cases. The main causal microorganisms were the following: Streptococcus pneumoniae in 32 (43%), Chlamydia pneumoniae in 9 (12%), Hemophilus influenzae in 7 (9%), Legionella pneumophila in 7 (9%), Streptococcus viridans in 3 (4%), Coxiella burnetii in 3 (4%), Mycoplasma pneumoniae in 2 (3%), Nocordia asteroides 2, Aspergillus ssp. 1, and others 10. In three of these cases the etiology was polymicrobial. Bacteremia was present in 19 (15%) cases; S. pneumoniae was the most frequent isolate (13 cases). Antibiotic treatment was modified in 22 cases due to etiologic findings, and in 9 due to therapeutic failure. Ten patients died (8%), and 22 needed mechanical ventilation, the mortality rate in the latter population being 23%. Total or partial resistance of S. pneumoniae to penicillin was observed in 10 of 32 (31%) isolations, and to erythromycin in 2 (6%). The results of this study are important for the standardization of empiric antibiotic strategies in COPD patients with pneumonia.

Endobronchial lipomas.

We report 2 cases of endobronchial lipomas diagnosed by biopsy through a fiberoptic bronchoscope. Its endoscopic differences with bronchial adenomas are analyzed. Computerized tomography contribution to differential diagnosis with other pulmonary tumors is reported. Early diagnosis is advised and the endoscopic removal, before pulmonary complications are observed, is thought preferable to surgery.