RESUMO
INTRODUCTION: Aspiration pneumonia is increasingly recognised as a common condition. While antibiotics covering anaerobes are thought to be necessary based on old studies reporting anaerobes as causative organisms, recent studies suggest that it may not necessarily benefit prognosis, or even be harmful. Clinical practice should be based on current data reflecting the shift in causative bacteria. The aim of this review was to investigate whether anaerobic coverage is recommended in the treatment of aspiration pneumonia. METHODS: A systematic review and meta-analysis of studies comparing antibiotics with and without anaerobic coverage in the treatment of aspiration pneumonia was performed. The main outcome studied was mortality. Additional outcomes were resolution of pneumonia, development of resistant bacteria, length of stay, recurrence, and adverse effects. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: From an initial 2523 publications, one randomised control trial and two observational studies were selected. The studies did not show a clear benefit of anaerobic coverage. Upon meta-analysis, there was no benefit of anaerobic coverage in improving mortality (Odds ratio 1.23, 95% CI 0.67-2.25). Studies reporting resolution of pneumonia, length of hospital stay, recurrence of pneumonia, and adverse effects showed no benefit of anaerobic coverage. The development of resistant bacteria was not discussed in these studies. CONCLUSION: In the current review, there are insufficient data to assess the necessity of anaerobic coverage in the antibiotic treatment of aspiration pneumonia. Further studies are needed to determine which cases require anaerobic coverage, if any.
Assuntos
Doença Pulmonar Obstrutiva Crônica , Administração por Inalação , Corticosteroides/uso terapêutico , Agonistas de Receptores Adrenérgicos beta 2/efeitos adversos , Broncodilatadores/efeitos adversos , Quimioterapia Combinada , Humanos , Antagonistas Muscarínicos/uso terapêutico , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Índice TerapêuticoRESUMO
INTRODUCTION: Nursing and healthcare-associated pneumonia (NHCAP) was proposed by the Japanese Respiratory Society in 2011. However, the clinical characteristics of NHCAP are still unclear. Thus, this study aimed to clarify its clinical characteristics. METHODS: This multicenter prospective observational study included 596 patients with NHCAP from 73 centers in Japan between May 2014 and February 2016. RESULTS: Patient background was characterized by an older age (81.5 ± 10.1 years), most patients had complications (94.1%), and many patients had a high probability of aspiration pneumonia (68.6%). Among the isolates, Streptococcus pneumoniae was the most common (12.7%), while Pseudomonas aeruginosa was also isolated at 10.8%. The overall 30-day mortality rate for patients was 11.9%, and the factors affecting mortality were non-ambulatory status, high blood urea nitrogen level, impaired consciousness, and low albumin level. Sulbactam/ampicillin was the most commonly administered antibiotic, including in groups with high severity of illness and high risk of multidrug-resistant (MDR) pathogens. Both the A-DROP and I-ROAD scores were useful in predicting the prognosis of NHCAP. Confirmation of intention to provide do not attempt resuscitation (DNAR) instructions was given to 333 patients (55.9%), and 313 patients agreed to DNAR instructions. CONCLUSIONS: NHCAP tends to occur in elderly patients with underlying diseases. The risk of MDR pathogens and the mortality rate are intermediate for community-acquired pneumonia and hospital-acquired pneumonia. As NHCAP is considered an important concept in an aging society, such as in Japan, establishing a treatment strategy that considers not only prognosis but also quality of life would be beneficial.
Assuntos
Infecções Comunitárias Adquiridas , Infecção Hospitalar , Pneumonia Associada a Assistência à Saúde , Pneumonia , Idoso , Antibacterianos/uso terapêutico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/epidemiologia , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/epidemiologia , Pneumonia Associada a Assistência à Saúde/tratamento farmacológico , Pneumonia Associada a Assistência à Saúde/epidemiologia , Humanos , Japão/epidemiologia , Pneumonia/tratamento farmacológico , Estudos Prospectivos , Qualidade de VidaRESUMO
In the 21st century, aspiration pneumonia (ASP) is very common in older patients, and has a high mortality rate. ASP is diagnosed following confirmation of inflammatory findings in the lungs and overt aspiration or the existence of dysphagia. It is dominant in hospitalized community-acquired pneumonia (CAP), nursing and healthcare-associated pneumonia (NHCAP), and hospital-acquired pneumonia (HAP). The incidence of ASP is increasing every year. The human and experimental animal data revealed that micro-aspiration due to dysphagia during the night is the central mechanism of ASP. Therefore, the precise assessment of swallowing function is the key to diagnose ASP. From a therapeutic point of view, an appropriate administration of antibiotics, as well as a comprehensive approach for dysphagia plays a pivotal role in the prognosis and recovery from ASP. The non-pharmacologic approach, including swallowing rehabilitation and oral care, and a pharmacologic approach including ACE inhibitors and bronchodilators, are essential modalities for treatment and prevention of ASP. The clinical data of NHCAP provides us with a promising treatment strategy for ASP.
Assuntos
Infecções Comunitárias Adquiridas , Transtornos de Deglutição , Pneumonia Associada a Assistência à Saúde , Pneumonia Aspirativa , Pneumonia , Idoso , Animais , Transtornos de Deglutição/epidemiologia , Transtornos de Deglutição/etiologia , Humanos , Modelos Animais , Pneumonia/tratamento farmacológico , Pneumonia/epidemiologia , Pneumonia Aspirativa/tratamento farmacológico , Pneumonia Aspirativa/epidemiologia , Pneumonia Aspirativa/etiologiaRESUMO
Objective In patients demonstrating dementia with Lewy bodies (DLB), pneumonia is a common complication. However, the prognostic factors for the survival time in DLB with pneumonia have not been investigated by autopsy in patients with neuropathologically confirmed DLB. Methods We conducted a retrospective study of the medical and autopsy reports of 42 patients admitted to a Japanese hospital between 2005 and 2014. The patients were neuropathologically diagnosed as having DLB by post-mortem examinations. We analyzed the effects of various factors on the time from DLB onset to death. Results Thirty-nine of the 42 patients with DLB (92.9%) developed pneumonia during hospitalization. The median age at DLB onset was 78 years and the median time from DLB onset to death was 8 years. The Cox proportional hazard model demonstrated cerebral infarction [Hazard Ratio (HR), 2.36 (95% CI 1.12-4.96), p=0.023], muscle weakness [HR, 2.04 (0.95-4.39), p=0.067], male sex [HR, 2.84 (1.24-6.50), p=0.014], and age at onset (≥78 years.) [HR, 4.71 (1.82-12.18), p=0.001] to be prognostic factors for a shorter time from DLB onset to death. Conclusion Careful treatment of cerebral infarction and muscle weakness of the lower extremities is crucial for DLB patients with pneumonia, especially for those over 78 years of age, in order to maximize the patients' life expectancies.
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Doença por Corpos de Lewy/complicações , Pneumonia/complicações , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Autopsia , Infarto Cerebral/complicações , Feminino , Humanos , Doença por Corpos de Lewy/diagnóstico , Masculino , Debilidade Muscular/complicações , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores Sexuais , Análise de SobrevidaRESUMO
Many respiratory diseases including COPD are systemic disorders as well as pulmonary disorders. The diseases predominantly occurred in older peoples in advanced countries. Comprehensive therapeutic strategy including bronchodilators and systemic rehabilitation is necessary for maintenance of stable condition of pulmonary diseases. Importantly, physical activity is a key factor for the prognosis in the diseases, in this point, bone function and muscle function should be improved by the appropriate treatment. The regular assessment of bone density and muscle function are necessary for better prognosis of COPD patients.
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Envelhecimento/fisiologia , Doenças Musculares/terapia , Osteoporose/diagnóstico , Osteoporose/terapia , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/terapia , Densidade Óssea/fisiologia , Humanos , Doenças Musculares/complicações , Doenças Musculares/diagnóstico , Osteoporose/complicações , Prognóstico , Doença Pulmonar Obstrutiva Crônica/complicaçõesRESUMO
A genetic contribution to develop chronic obstructive pulmonary disease(COPD) is estimated. However, candidate gene studies on COPD and related phenotypes have not been well replicated. Research on the genetic pathologic background of COPD using genome-wide association studies (GWASs) has progressed in recent years. The novel candidate genes including CHRNA3/5 (cholinergic nicotine receptor alpha 3/5), IREB2 (iron regulatory binding protein 2), HHIP (hedgehog-interacting protein), and FAM13A (family with sequence similarity 13, member A) are identified in multiple populations. However, their pathological roles remain poorly understood. The nicotine dependency, pulmonary development, and pulmonary/systemic inflammatory diathesis may be involved in genetic background of COPD.
Assuntos
Estudo de Associação Genômica Ampla , Proteínas do Tecido Nervoso/genética , Doença Pulmonar Obstrutiva Crônica/genética , Receptores Nicotínicos/genética , Proteínas de Transporte/genética , Progressão da Doença , Proteínas Ativadoras de GTPase/genética , Predisposição Genética para Doença/genética , Humanos , Proteína 2 Reguladora do Ferro/genética , Glicoproteínas de Membrana/genética , Polimorfismo Genético , Doença Pulmonar Obstrutiva Crônica/etiologia , Fumar/efeitos adversos , Fumar/genética , TabagismoRESUMO
BACKGROUND: Pneumonia is a major, complicated disease in patients with dementia. However, the influence of pneumonia on the prognosis of patients with varying types of dementia has not been fully evaluated. METHODS: We retrospectively analyzed the data from medical and autopsy reports. All study patients had been hospitalized and underwent brain autopsy in a hospital in Toyohashi, Japan, between 2005 and 2014. The patients with subtypes of dementia, specifically Alzheimer's disease (AD), dementia with Lewy bodies (DLB), or vascular dementia (VaD), were neuropathologically diagnosed and examined. Pneumonia incidence, cause of death, and the clinical time-course of dementia were compared among the dementia subtypes. The time to death from dementia onset (survival time) was compared by the Kaplan-Meier method among subtypes of dementia with or without pneumonia. Risk factors for survival time on all study patients were analyzed with the Cox proportional hazard model. RESULTS: Of the 157 eligible patients, 63 (40.1%) had AD, 42 (26.8%) had DLB, and 52 (33.1%) had VaD. Pneumonia complication was observed with high incidence in each subtype of dementia, especially in DLB (90.5%). The median total duration from dementia onset to death was 8 years in AD and DLB, and 5 years in VaD. The VaD subtype had more male patients than AD or DLB (P = 0.010), and age of death in this group was the youngest among the three groups (P = 0.018). A significant difference was observed in the survival time by the Kaplan-Meier method among the three groups (P < 0.001) and among the groups with pneumonia (P = 0.002). The factors associated with shorter survival time were male gender, pneumonia complications, diabetes mellitus, age of dementia onset ≥ 75 years, and VaD. CONCLUSIONS: Pneumonia complications shortened the survival time of patients with AD, DLB, and VaD.
Assuntos
Doença de Alzheimer/complicações , Autopsia , Transtornos Cognitivos/etiologia , Demência Vascular/complicações , Doença por Corpos de Lewy/complicações , Pneumonia/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/mortalidade , Doença de Alzheimer/psicologia , Demência Vascular/mortalidade , Demência Vascular/psicologia , Feminino , Humanos , Incidência , Japão/epidemiologia , Doença por Corpos de Lewy/mortalidade , Doença por Corpos de Lewy/psicologia , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de SobrevidaRESUMO
A 68-year-old man was diagnosed with non small cell lung cancer in May 2013. Although the patient was negative for EGFR mutation, he wished to undergo treatment with gefitinib and erlotinib as first-line therapy. However, one year later, he was admitted to our hospital because of cardiac tamponade due to malignant pericarditis. He received pericardial drainage, after which his condition was stabilized. He was diagnosed with lung adenocarcinoma by cytology of pericardial effusion and treated with pemetrexed plus cisplatin as second-line therapy. Thereafter, the malignant effusion was decreased and the primary lesion was regressed. He received six courses of chemotherapy, however, brain metastases and bone metastases appeared. The brain metastases were controlled with gamma knife radiosurgery and he received carboptatin-paclitaxel plus bevacizumab as third-line therapy. The patient is currently receiving chemotherapy without any recurrence of malignant pericarditis or cardiac tamponade.
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Adenocarcinoma/complicações , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Tamponamento Cardíaco/etiologia , Neoplasias Pulmonares/complicações , Pericardite/etiologia , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma de Pulmão , Idoso , Tamponamento Cardíaco/diagnóstico por imagem , Cisplatino/administração & dosagem , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Masculino , Imagem Multimodal , Pemetrexede/administração & dosagem , Derrame Pericárdico/diagnóstico por imagem , Derrame Pericárdico/etiologia , Pericardite/diagnóstico por imagem , Tomografia por Emissão de Pósitrons , Tomografia Computadorizada por Raios XRESUMO
BACKGROUNDS: Aspiration pneumonia is a dominant form of community-acquired and healthcare-associated pneumonia, and a leading cause of death among ageing populations. However, the risk factors for developing aspiration pneumonia in older adults have not been fully evaluated. The purpose of the present study was to determine the risk factors for aspiration pneumonia among the elderly. METHODOLOGY AND PRINCIPAL FINDINGS: We conducted an observational study using data from a nationwide survey of geriatric medical and nursing center in Japan. The study subjects included 9930 patients (median age: 86 years, women: 76%) who were divided into two groups: those who had experienced an episode of aspiration pneumonia in the previous 3 months and those who had not. Data on demographics, clinical status, activities of daily living (ADL), and major illnesses were compared between subjects with and without aspiration pneumonia. Two hundred and fifty-nine subjects (2.6% of the total sample) were in the aspiration pneumonia group. In the univariate analysis, older age was not found to be a risk factor for aspiration pneumonia, but the following were: sputum suctioning (odds ratio [OR] = 17.25, 95% confidence interval [CI]: 13.16-22.62, p < 0.001), daily oxygen therapy (OR = 8.29, 95% CI: 4.39-15.65), feeding support dependency (OR = 8.10, 95% CI: 6.27-10.48, p < 0.001), and urinary catheterization (OR = 4.08, 95% CI: 2.81-5.91, p < 0.001). In the multiple logistic regression analysis, the risk factors associated with aspiration pneumonia after propensity-adjustment (258 subjects each) were sputum suctioning (OR = 3.276, 95% CI: 1.910-5.619), deterioration of swallowing function in the past 3 months (OR = 3.584, 95% CI: 1.948-6.952), dehydration (OR = 8.019, 95% CI: 2.720-23.643), and dementia (OR = 1.618, 95% CI: 1.031-2.539). CONCLUSION: The risk factors for aspiration pneumonia were sputum suctioning, deterioration of swallowing function, dehydration, and dementia. These results could help improve clinical management for preventing repetitive aspiration pneumonia.
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Pneumonia Aspirativa/epidemiologia , Atividades Cotidianas , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Humanos , Japão/epidemiologia , Modelos Logísticos , Razão de Chances , Fatores de RiscoRESUMO
Pneumonia in the elderly results in the highest mortality among cases of community-acquired pneumonia (CAP). The pathophysiology of pneumonia in the elderly is primarily due to aspiration pneumonia (ASP). ASP comprises two pathological conditions: airspace infiltration with bacterial pathogens and dysphagia-associated miss-swallowing. The first-line therapy for the treatment of bacterial pneumonia in the elderly is a narrow spectrum of antibiotics, including sulbactam/ampicillin, which are effective against major lower respiratory infection pathogens and anaerobes. The bacterial pathogens of ASP cases of pneumonia in the elderly are similar to those associated with adult CAP. In addition to an appropriate course of antibiotics, pharmacologic and non-pharmacologic approaches for dysphagia and upper airway management are necessary for the treatment and prevention of pneumonia. Swallowing rehabilitation, oral health care, pneumococcal vaccination, gastroesophageal reflux management, and a head-up position during the night are necessary for the treatment and prevention of repeated episodes of pneumonia in elderly patients. In addition, tuberculosis should always be considered for the differential diagnosis of pneumonia in this patient population.
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Infecções Respiratórias , Manuseio das Vias Aéreas , Antibacterianos/uso terapêutico , Deglutição , Transtornos de Deglutição/complicações , Transtornos de Deglutição/fisiopatologia , Transtornos de Deglutição/reabilitação , Diagnóstico Diferencial , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/terapia , Humanos , Masculino , Vacinas Pneumocócicas , Postura , Recidiva , Infecções Respiratórias/complicações , Infecções Respiratórias/microbiologiaRESUMO
We report a case of acute respiratory failure in a 77-year-old male with chronic obstructive pulmonary disease (COPD) who showed marked eosinophilia (61.5% of the peripheral total white blood cells [WBCs]; 13,200/mm(3)). The patient was an ex-smoker, but he had started smoking again one month previously, His forced expiratory volume in one second (FEV1) was low and dyspnea symptom was observed. Although rhonchi were detected, wheezing chest sounds were not detected. Chest X-radiography and computed tomography of the lung revealed diffuse bilateral pulmonary infiltrates and emphysematous changes. He was given intravenous methyl prednisolone (1,000 mg) for 3 consecutive days. The abnormal shadows on the chest X-ray film improved remarkably and the eosinophils in his peripheral blood were reduced. Furthermore, it was no longer necessary to administer oxygen to treat his hypoxemia. The symptomatic and clinical course mimicked to a case of acute eosinophilic pneumonia (AEP). However, transbronchial lung biopsy specimens did not reveal eosinophilic infiltration in the alveolar septa. The fraction of eosinophils in the patient's bronchoalveolar lavage was 4.4% and not greater than 25%. After hospitalization, 5-15 mg of prednisolone administered orally in combination with bronchodilators to better manage his clinical symptoms. This case was thus determined to correspond to elderly asthma-COPD overlap syndrome (ACOS).
Assuntos
Asma/complicações , Doença Pulmonar Obstrutiva Crônica/complicações , Idoso , Asma/diagnóstico , Diagnóstico Diferencial , Eosinofilia/diagnóstico , Humanos , Masculino , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Eosinofilia Pulmonar/diagnóstico , Insuficiência Respiratória/complicaçõesRESUMO
A 90-year-old man with a previous history of brain infarction and diabetes mellitus presented with a gait disturbance. Although brain computed tomography (CT) showed no abnormalities, except for the old infarction, the patient experienced recurrent epileptic seizures. He was therefore admitted to our hospital for a further examination of the seizures. However, upon admission, he also presented with a fever and elevated C-reactive protein levels, indicating systemic inflammation. Based on the presence of bilateral infiltration visible on a chest X-radiograph, the patient was diagnosed with aspiration pneumonia. The administration of 4.5 g of sulbactam and ampicillin did not reduce the inflammation or resolve the abnormal lung findings. Therefore, he was intubated and placed on a ventilator. With the patient under ventilator management, we subsequently performed bronchoscopic alveolar lavage. Elevated neutrophil and lymphocyte counts were noted in the alveolar lavage fluid; therefore, we administered pulse steroid therapy with 500 mg of methylprednisolone. The sputum and alveolar lavage fluid samples collected 13 and 14 days, respectively, after admission were negative for Mycobacterium according to a smear test. In contrast, the cultured sputum samples collected on day 13 were positive for Mycobacterium tuberculosis; polymerase chain reaction testing confirmed the sputum culture results. A postmortem pathological examination of the lungs revealed neutrophilic exudative pneumonia as well as acute fibrinous and organizing pneumonia. Although Ziehl-Neelsen staining demonstrated a large number of positive bacteria, no epithelioid-cell granulomas were observed. M. tuberculosis lesions were also found in the liver, spleen, bones, and adrenal glands, suggesting hematogenous dissemination. Aspiration pneumonia is very common in elderly patients with a history of stroke, and these patients are also at risk of other pulmonary disorders and infections including M. tuberculosis. Prior to administering treatment for aspiration pneumonia, clinicians should consider the potential for other pulmonary infiltration disorders in the differential diagnosis, particularly in elderly post-stroke patients.
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Epilepsia/complicações , Pneumonia Aspirativa/terapia , Acidente Vascular Cerebral/terapia , Tuberculose/diagnóstico , Idoso de 80 Anos ou mais , Autopsia , Humanos , Masculino , Pneumonia Aspirativa/etiologia , Acidente Vascular Cerebral/complicações , Falha de TratamentoRESUMO
We encountered 2 patients with pulmonary Mycobacterium avium complex disease in whom resistance to clarithromycin (CAM) was confirmed after treatment with rifampicin, ethambutol, and CAM. We evaluated the disease course in both patients. The deterioration of radiological findings was preceded by the acquisition of resistance to CAM in both cases. When symptoms of pulmonary MAC disease exacerbate, and radiological findings deteriorate, we should reconsider the type of treatment after determination of the minimal inhibitory concentration (MIC) of CAM for culture positive MAC strains.
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Claritromicina/farmacologia , Complexo Mycobacterium avium/efeitos dos fármacos , Idoso , Idoso de 80 Anos ou mais , Farmacorresistência Bacteriana , Feminino , Humanos , Masculino , Tuberculose Pulmonar/microbiologiaRESUMO
BACKGROUND: While pulmonary aspiration syndrome (PAS) is primarily clinically diagnosed, atypical PAS cases can be misdiagnosed clinically and are more accurately diagnosed histologically. To elucidate clinicopathological features of these rare cases, we examined PAS cases determined by histological examination of transbronchial lung biopsy (TBLB) specimens. METHODS: Of 6105 TBLB cases investigated from 1990 to 2007, 11 were diagnosed as PAS based on histology. Of these, we examined 9 records in detail, as the medical records for 2 cases were unavailable. RESULTS: Histopathological findings indicated 8 patients with aspiration pneumonia and 1 with diffuse aspiration bronchiolitis. However, the pre-bronchoscopy diagnoses included lung cancer, mycobacteriosis, organizing pneumonia, repetitive pneumonia, fungal infection, and interstitial pneumonia. PAS was not considered before TBLB. Only 4 of the 9 patients developed subjective symptoms including fever and cough with sputum production. Laboratory findings demonstrated elevation of white blood cell (WBC) count in only 1 patient and elevation of C reactive protein (CRP) level in 4 patients. Radiographic examination revealed abnormal findings in the dorsal right lower lobes, which was the most vulnerable site for aspiration pneumonia, and also in the upper and ventral portions of the lung. Although the characteristic findings of PAS were scarce, all patients had conditions predisposing to aspiration; i.e., gastrectomy, excessive alcohol drinking, post-cerebral infarction, and sinobronchial syndrome. CONCLUSIONS: We diagnosed 9 PAS patients on the basis of histological findings that were distinct from clinical findings. Despite presenting with variable symptoms and laboratory and radiographic findings, they all exhibited predisposing factors to aspiration.