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* From the Louisiana State University Health Sciences Center, Shreveport, LA.
Correspondence to: G. Douglas Campbell, Jr., MD, FCCP, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Louisiana State University Health Sciences Center—Shreveport, 1501 Kings Hwy, Shreveport, LA 71103; e-mail: dcamp{at}lsumc.sh.edu
Key Words: BAL • community-acquired pneumonia • ventilator-associated pneumonia
Severity of Illness
1. Atlas SJ, Benzer TI, Borowsky LH, et al. Safely increasing the proportion of patients with community-acquired pneumonia treated as outpatients: an interventional trial. Arch Intern Med 1998; 158:1350–1356
The pneumonia severity index of Fine et al1 was evaluated prospectively in 166 patients and was compared to 147 consecutive retrospective control subjects with low-risk community-acquired pneumonia. Using this index, hospital admissions were significantly reduced to 42% from 57% for control subjects, but 9% of patients were later admitted to the hospital compared to 0% for control subjects. Patient satisfaction was also significantly lower (patients, 71%; control subjects, 90%). While initial hospitalization rates did decrease, a 9% late admission rate using the pneumonia severity index raises concerns that the use of such an index might underestimate the severity of pneumonia.
2. Ewig S, Ruiz M, Mensa J, et al. Severe community-acquired pneumonia: assessment of severity criteria. Am J Respir Crit Care Med 1998; 158:1102–1108.
This study attempted to validate the 10 American Thoracic Society criteria used to identify cases of severe community-acquired pneumonia and to optimize the severity criteria according to a new prediction rule.2 Three hundred ninety-four patients with community-acquired pneumonia who required hospitalization (64 patients were admitted to an ICU) were prospectively enrolled. American Thoracic So ciety criteria were found to be very sensitive but not specific. Multivariate logistic regression analysis identified three minor criteria (systolic BP < 90 mm Hg, multilobar involvement, and PaO2/fraction of inspired oxygen ratio < 250) and two major criteria (requirement for mechanical ventilation and the presence of septic shock). The presence of two minor criteria or one major criterion had a sensitivity of 78%, a specificity of 94%, a positive predictive value of 75%, and a negative predictive value of 95%.
Treatment
3. Gleason PP, Meehan TP, Fine JM, et al. Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia. Arch Intern Med 1999; 159:2562–2572
This was a large study using a Medicare database of
12,945 inpatients (
65 years old) assessing the relationship between
initial antimicrobial therapy and outcome. The primary physician
selected antimicrobial therapy. Outcomes for different antimicrobial
therapies were compared, and mortality was significantly lower
when a macrolide plus a second-generation cephalosporin, a
nonpseudomonal third-generation cephalosporin, or a fluoroquinolone
alone was selected as the initial therapy. Mortality was significantly
higher among patients receiving therapy with a ß-lactam/ß-lactamase
inhibitor plus a macrolide.
IV to Oral Switch
4. Ramirez JA, Vargas S, Ritter GW, et al. Early switch from IV to oral antibiotics and early hospital discharge: a prospective observational study of 200 consecutive patients with community-acquired pneumonia. Arch Intern Med 1999; 159:2449–2454
In a prospective study of 200 consecutive hospitalized patients with community-acquired pneumonia, the switch from IV to oral antibiotic therapy was attempted when the following specific criteria were met: cough and shortness of breath improved; temperature was < 37.8°C for at least 8 h; the WBC count was normalizing; and oral intake and GI absorption were adequate. An early switch within the first 3 days was accomplished in 133 patients, with only 1 patient not responding. Early discharge occurred in 88 patients. Patient satisfaction was 95%.
Etiology
5. Ruiz-Gonzalez A. Falguera M, Nogues A, et al. Is Streptococcus pneumoniae the leading cause of pneumonia of unknown etiology? A microbiologic study of lung aspirates in consecutive patients with community-acquired pneumonia. Am J Med 1999; 106:385–390
This is a prospective study of 109 consecutive patients who underwent transthoracic needle aspiration along with routine diagnostic studies to identify the etiology of their community-acquired pneumonia. Routine diagnostic studies identified an etiology in 54 patients (50%). Transthoracic needle aspiration identified a second pathogen in 4 of these 54 patients, and in the remaining 55 patients who did not receive a diagnosis, a pathogen was identified in 36 patients. S pneumoniae was the most common pathogen found, accounting for 25% of all cases
6. Rello J, Sa-Borges M, Correa H, et al. Variations in etiology of ventilator-associated pneumonia across four treatment sites: implications for antimicrobial prescribing practices. Am J Respir Crit Care Med 1999; 160:608–613
This is a retrospective study from three different
geographic locations comparing the pathogens recovered from patients
with ventilator-associated pneumonia (VAP), using either a
protected-specimen brush or BAL, to the results reported by Trouillet
et al.3
Patients were separated into four groups that were
based on length of stay before the onset of pneumonia (< 7 days or
7 days) and prior use of antibiotics. Results from the four
institutions showed wide variations in the incidence of pathogens
between hospitals, suggesting that antimicrobial therapy needs to be
tailored for each institution based on up-to-date information.
Diagnosis
7. Grossman RF, Baughman R, Campbell GD, et al. Evidence-based assessment of diagnostic tests for ventilator-associated pneumonia: report of the Clinical Practice Guideline Panel. Chest 2000; 117:177S–218S
This is an exhaustive evidence-based review of the literature evaluating diagnostic testing in patients who have clinical evidence of VAP. Available studies are presented and graded, and recommendations are made for assessing patients suspected of having VAP.
Risk Factors
8. Feikin DR, Schuchat A, Kolczak M, et al. Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, from 1995 to 1997. Am J Public Health 2000; 90:223–229
Epidemiologic factors affecting mortality were determined from
a geographically diverse population in 5,837 cases of
community-acquired pneumococcal pneumonia that were diagnosed by
positive culture results from a sterile site. Although advanced age,
the presence of underlying disease, and Asian race were factors that
affected mortality, it also was increased among patients infected with
penicillin-resistant pneumococci (mean inhibitory concentration, 4
µg/mL) or cefotaxime-resistant pneumococci (mean inhibitory
concentration, 2.0 µg/mL) after 4 days of hospitalization.
9. Luna CM, Videla A, Mattera J, et al. Blood cultures have limited value in predicting severity of illness and as a diagnostic tool in ventilator-associated pneumonia. Chest 1999; 116:1075–1084
This is a prospective study to determine the usefulness of blood cultures for confirming the etiology and severity of VAP. BAL was performed on 162 patients meeting the clinical criteria for VAP, and in these patients two sets of blood cultures also were collected. BAL specimens were positive for pneumonia in 90 patients, and blood culture findings were positive in 27 patients. In 22 patients, both the BAL specimens and blood culture findings were positive, but in 6 patients an extrapulmonary source was found. Blood cultures had a low sensitivity for identifying an etiology and were unable to predict severity of illness.
10. Markowicz P, Wolff M, Djedaini K, et al. Multicenter prospective study of ventilator-associated pneumonia during ARDS: incidence, prognosis, and risk factors. ARDS Study Group. Am J Respir Crit Care Med 2000; 161:1942–1948
The incidence of VAP in 134 patients with ARDS was compared to the incidence in 744 non-ARDS patients. The incidence of VAP was significantly higher among ARDS patients than non-ARDS patients (36.5% vs 23%, respectively; p < 0.002). While VAP was noted to significantly prolong the time of mechanical ventilation, its occurrence did not affect outcome. The use and duration of sucralfate were both risk factors for VAP.
Footnotes
Abbreviation: VAP = ventilator-associated pneumonia
Received for publication October 9, 2000. Accepted for publication November 9, 2000.
References
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