Aetiology and outcome of severe community-acquired pneumonia

Department of Microbiology and Public Health Laboratory Service Laboratory, Queen's Medical Centre, Nottingham, UK
Journal of Infection (Impact Factor: 4.44). 06/1985; 10(3):204-10. DOI: 10.1016/S0163-4453(85)92463-6
Source: PubMed


Between January 1972 and December 1981, 50 patients with severe community-acquired pneumonia were admitted to the intensive care unit of a district general hospital. A causal pathogen was identified in 41 cases (82%). Streptococcus pneumoniae (16 cases), Legionella pneumophila (15 cases) and Staphylococcus aureus (5 cases) were the commonest. Assisted ventilation was required in 44 patients, of whom 25 died (57%). All 5 patients with staphylococcal pneumonia and 12(75%) with pneumococcal pneumonia died. Only 5 (33%) with Legionnaires' disease died. Mortality was significantly associated with age. Recommendations for the management of severe pneumonia are made.

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    • "Nearly all patients who die as a consequence of severe CAP develop severe sepsis or septic shock. ICU-based studies in the UK and Spain report mortality rates of 20% to 50% in severe CAP patients, depending on admission criteria [11-13]. "
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    ABSTRACT: Mortality in patients with community-acquired pneumonia (CAP) who require intubation or support with inotropes in an intensive care unit setting remains extremely high (up to 50%). Systematic use of objective severity-of-illness criteria, such as the Pneumonia Severity Index (PSI), British Thoracic Society CURB-65 (an acronym meaning Confusion, Urea, Respiratory rate, Blood pressure, age >/=65 years), or criteria developed by the Infectious Diseases Society of America/American Thoracic Society, to aid site-of-care decisions for pneumonia patients is emerging as a step forward in patient management. Experience with the Predisposition, Infection, Response, and Organ dysfunction (PIRO) score, which incorporates key signs and symptoms of sepsis and important CAP risk factors, may represent an improvement in staging severe CAP. In addition, it has been suggested that implementing a simple care bundle in the emergency department will improve management of CAP, using five evidence-based variables, with immediate pulse oxymetry and oxygen assessment as the cornerstone and initial step of treatment.
    Critical care (London, England) 11/2008; 12 Suppl 6(Suppl 6):S2. DOI:10.1186/cc7025 · 4.48 Impact Factor
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    • "The overall ICU mortality of 35% is lower than the figures of 48%, 57% and 58% reported in previous UK studies [3-6], and is more similar to reports from New Zealand and other European countries, where seven studies have reported mortalities of 40% or less [10-16]. This apparent improvement in outcome may be due to improved clinical practice (supported perhaps by the fall in admissions only after CPR, which were 7, 13 and 25% in earlier studies [3,5,6]), but may also be due to differing admission policies and also the potential for bias in the previous UK studies. These studies were all small (maximum 62 cases) and two were based in single centres and may, therefore, not be representative of the UK as a whole. "
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    ABSTRACT: This paper describes the case mix, outcome and activity for admissions to intensive care units (ICUs) with community-acquired pneumonia (CAP). We conducted a secondary analysis of a high quality clinical database, the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database, of 301,871 admissions to 172 adult ICUs across England, Wales and Northern Ireland, 1995 to 2004. Cases of CAP were identified from pneumonia admissions excluding nosocomial pneumonias and the immuno-compromised. It was not possible to review data from the time of hospital admission; therefore, some patients who developed hospital-acquired/nosocomial pneumonia may have been included. We identified 17,869 cases of CAP (5.9% of all ICU admissions). There was a 128% increase in admissions for CAP from 12.8 per unit to 29.2 per unit during the study period compared to only a 24% rise in total ICU admissions (p < 0.001). Eighty-five percent of admissions were from within the same hospital. Fifty-nine percent of cases were admitted to the ICU < 2 days, 21.5% between 2 and 7 days, and 19.5% > 7 days after hospital admission. Between 1995 and 1999 and 2000 and 2004 there was a rise in admissions from accident and emergency (14.8% to 16.8%; p < 0.001) and high dependency units (6.9% to 11.9%; p < 0.001) within the same hospital, those aged > 74 (18.5 to 26.1%; p < 0.001), and mean APACHE II score (6.83 to 6.91; p < 0.001). There was a fall in past history of severe respiratory problems (8.7% to 6.4%; p < 0.001), renal replacement therapy (1.6% to 1.2%; p < 0.01), steroid treatment (3.4% to 2.8%; p < 0.05), sedation/paralysis (50.2% to 40.4%; p < 0.001), cardiopulmonary resuscitation prior to admission (7.5% to 5.5%; p < 0.001), and septic shock (7.3% to 6.6%; p < 0.001). ICU mortality was 34.9% and ultimate hospital mortality 49.4%. Mortality was 46.3% in those admitted to the ICU within 2 days of hospital admission rising to 50.4% in those admitted at 2 to 7 days and 57.6% in those admitted after 7 days following hospital admission. CAP makes up a small, but important and rising, proportion of adult ICU admissions. Survival of over half of all cases vindicates the use of ICU facilities in CAP management. Nevertheless, overall mortality remains high, especially in those admitted later in their hospital stay.
    Critical care (London, England) 02/2006; 10 Suppl 2(Suppl 2):S1. DOI:10.1186/cc4927 · 4.48 Impact Factor
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    ABSTRACT: The guidelines of the American Thoracic Society (ATS) for the initial management of adults with community-acquired pneumonia (CAP) include the recommendation to cover Pseudomonas aeruginosa in the initial empiric antimicrobial regimen of patients with CAP and suspected structural lung disease (e.g. bronchiectasis) and in those with severe CAP (1). This view might be challenged by concerns whether the incidence of Pseudomonas aeruginosa in patients with severe CAP really justifies such an antimicrobial treatment approach. In the following, we will review the evidence that exists about a significant role of Pseudomonas aeruginosa in patients with severe CAP, describe the clinical characteristics of severe pseudomonal CAP, and discuss potential consequences for initial empiric antibiotic choices.
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