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Community-acquired pneumonia and nursing home-acquired pneumonia in the very elderly patients
Abstract
The rapid increase in the elderly population is leading to a corresponding increase in the number of people requiring medical care. To date no comparative study between community-acquired pneumonia (CAP) and nursing home-acquired pneumonia (NHAP) has been reported in the very elderly non-intubated patients. The present study was undertaken to compare the clinical characteristics and microbial etiology between CAP and NHAP in elderly patients >/=85-years old. There were 54 patients with NHAP and 47 with CAP. Performance status was significantly worse in the NHAP than in the CAP group. Among all patients, the most frequent pathogens were Chlamydophilia pneumoniae followed by Streptococcus pneumoniae, Mycoplasma pneumoniae influenza virus and Staphylococcus aureus. The frequency of S. peumoniae was significantly higher in NHAP patients than in CAP patients after adjusting for age and sex. Physical activity, nutrition status and dehydration were significant prognostic factors of pneumonia among all patients. In-hospital mortality was significantly higher in NHAP than in CAP after adjusting for age and sex. This study demonstrated that the etiology and clinical outcome differ between CAP and NHAP patients in the very elderly non-intubated population.
... Atypical organisms such as C pneumoniae and M pneumoniae as an etiology of NHAP were rare in 2 studies, 21,22 but common in 2 Japanese studies done by the same group of investigators. 19,20 Methods to detect viruses were used in 4 studies and 3 detected viruses 19,20,22 ; influenza virus and respiratory syncytial virus were the most common viruses identified. ...
... Atypical organisms such as C pneumoniae and M pneumoniae as an etiology of NHAP were rare in 2 studies, 21,22 but common in 2 Japanese studies done by the same group of investigators. 19,20 Methods to detect viruses were used in 4 studies and 3 detected viruses 19,20,22 ; influenza virus and respiratory syncytial virus were the most common viruses identified. ...
... 27 Because of the adverse effects of hospitalization there have been increasing demands on nursing homes to reduce hospitalizations, 28 which has resulted in studies to define "potentially avoidable hospitalizations" of nursing home residents. 27À30 Pneumonia is one of the common diagnoses associated 19 Maruyama et al 20 Pulverino et al 21 Ma et al 22 Ewig et al 23 Putot et al 24 with potentially avoidable hospitalizations of nursing home residents. 31 Multiple factors have been identified that result in hospitalization of residents with suspected NHAP: elevated respiratory rate, afterhours evaluation, for-profit facility ownership, severity of illness, radiographic pneumonia, oxygen saturation <90%, and facility resources. ...
This is the second of 2 parts of a narrative review of nursing home-associated pneumonia (NHAP) that deals with etiology and treatment in the nursing home. In the 1980s and 1990s, the etiology of NHAP was considered to be similar to community-acquired pneumonia (CAP). This belief was reflected in CAP guidelines until 2005 when the designation healthcare-associated pneumonia or HCAP was introduced and nursing home residents were included in the HCAP category. Patients in the HCAP group were thought to be at high risk for pneumonia because of multidrug resistant organisms and required empiric broad-spectrum antibiotic therapy much like people with hospital-acquired infection. Subsequent studies of the etiology of NHAP using sophisticated diagnostic testing found limited evidence of resistant organisms such as methicillin-resistant Staphylococcus aureus or resistant gram-negative organisms or atypical organisms. In terms of management of NHAP in the nursing home there are several considerations that are discussed: hospitalization decision, initial oral or parenteral therapy, timing of switch to an oral regimen if parenteral therapy is initially prescribed, duration of therapy with an emphasis on shorter courses, and follow-up during therapy including the use of the "antibiotic time out" protocol. The oral and parenteral antibiotic regimens recommended for treatment of NHAP in this report are based on limited information because there are no randomized controlled trials to define the optimum regimen. In conclusion, most residents with pneumonia can be treated successfully in the nursing home. However, there is an urgent need for a specific NHAP diagnosis and treatment guideline that will give providers guidance in the management of this infection in the nursing home.
... При сравнительном анализе 2 когорт больных ВП (n = 50) пожилого возраста с двусторонними ин фильтративными изменениями в легких кардиоген ного (n = 60) и некардиогенного (40 (80 %)) генеза Y.J.Lee et al. не выявлено статистически значимых различий по данному показателю гемограммы [84]. У лиц старше 80 лет синдром системного воспали тельного ответа может вообще не регистрироваться: в исследовании T.Maruyama et al. у больных ВП (n = 47; средний возраст -88,7 ± 2,7 года) уровень лейкоцитов периферической крови составил 10,59 ± 5,48 × 10 9 / л [101]. ...
... Динамика уровня сывороточного СРБ при разви тии бактериальной ИНДП у лиц старших возраст ных групп с коморбидной патологией не ассоцииро вана с какими либо специфическими особенностями в сравнении с остальной популяцией. В многочис ленных исследованиях зарегистрированы различные средние показатели концентрации в крови данного воспалительного маркера у пожилых лиц с ВП: [100][101][102]106]. Таким образом, уровень СРБ сыворотки крови при ВП у изучаемой группы больных характеризует ся высокой вариабельностью, однако не достигает критически высоких значений, за исключением случаев выявления A.Lacoma et al. бактериемии (87,94 (28,78-141,8) мг / л у пациентов без бактерие мии vs 349, 35 (233,67-536,35) мг / л у пациентов с бактериемией (n = 75; средний возраст -67,0 ± 17,9 года) [103]. ...
... Именно этот по казатель используется в ряде исследований, посвя щенных эффективности антимикробной терапии при бактериальных ИНДП, в т. ч. в субпопуляции больных старших возрастных групп с различной сопутствующей патологией. Так, T.Maruyama et al. у пациентов с ВП (n = 47) старше 84 лет зарегистри рован положительный ранний клинический ответ при эмпирической АБТ 1 АБП в 60 %, при на значении комбинации из 2 препаратов -в 65,5 %, из 3 препаратов -в 100 % случаев соответственно [101]. При сравнении эффективности 4 режимов АМТ у больных (n = 204; возраст -70-94 года), госпитали зированных с тяжелой ВП, показано, что применение меропенема, имипенема / циластатина, комбинации кларитромицина с амикацином сопровождалось со поставимым клиническим ответом (86,5; 86,3; 85,7 % соответственно), который был несколько ниже при использовании комбинации кларитромицина с цеф триаксоном (69 %). ...
... The 2 studies demonstrating the largest role of atypical bacteria in NHAP were published by Japanese investigators, Maruyama et al, in 2008 and 2010 as shown in Table 1. [20][21][22] In their 2008 prospective, comparative study of patients hospitalized with NHAP or late-onset HAP between June 2004 and May 2005, C. pneumoniae was found to be the most common bacterial pathogen in patients with NHAP, occurring in 48% of patients with confirmed microbial etiologies. 20 In 2010, Maruyama et al published a similar prospective study comparing the bacterial etiology among patients 85 years of age and older with CAP and NHAP admitted to the same hospital and during the same study period as their previously published study. ...
... 20 In 2010, Maruyama et al published a similar prospective study comparing the bacterial etiology among patients 85 years of age and older with CAP and NHAP admitted to the same hospital and during the same study period as their previously published study. 22 Similar to the 2008 study, just over a 100 patients were enrolled, and again C. pneumoniae was found to be the most frequent pathogen among NHAP patients. The frequency of C. pneumoniae and M. pneumoniae among all NHAP patients was not found to be statistically different than the frequency observed in the comparator CAP cohort (p = .3162, ...
... respectively). 22 In another prospective study, Lim et al 23 Maruyama et al [20][21] confirmed microbial etiologies, and M. pneumoniae was the most common pathogen (n = 78) followed by C. pneumoniae (n = 55), Coxiella burnetii (n = 2), and L. pneumophila (n = 1). Although the frequency of atypical bacteria in NHAP patients alone was not provided, the majority of atypical pathogens were detected in patients over the age of 65 years (63.4%), with more than 16% of these patients being nursing home residents. ...
Background: Nursing home-acquired pneumonia (NHAP) has been identified as one of the leading causes of mortality and hospitalization for long-term care residents. However, current and previous pneumonia guidelines differ on the appropriate management of NHAP in hospitalized patients, specifically in regard to the role of atypical bacteria such as Chlamydiae pneumonia, Mycoplasma pneumoniae, and Legionella.
Objectives: The purpose of this review is to evaluate clinical trials conducted in hospitalized patients with NHAP to determine the prevalence of atypical bacteria and thus the role for empiric antibiotic coverage of these pathogens in NHAP.
Methods: Comprehensive MEDLINE (1966-April 2016) and Embase (1980-April 2016) searches were performed using the terms “atypical bacteria”, “atypical pneumonia”, “nursing-home acquired pneumonia”, “pneumonia”, “elderly”, “nursing homes”, and “long term care”. Additional articles were retrieved from the review of references cited in the collected studies. Thirteen published clinical trials were identified.
Results: In the majority of studies, atypical bacteria were infrequently identified in patients hospitalized with NHAP. However, when an active community-acquired pneumonia (CAP) cohort was available, the rate of atypical bacteria between NHAP and CAP study arms was similar. Only 3 studies in this review adhered to recommended strategies for investigating atypical bacteria; in 2 of these studies, C. pneumoniae was the most common pathogen identified in NHAP cohorts.
Conclusion: Although atypical bacteria were uncommon in most NHAP studies in this review, suboptimal microbial investigations were commonly performed. To accurately describe the role of atypical bacteria in NHAP, more studies using validated diagnostic tests are needed.
... Many of them have to enter a nursing home [2], and pneumonia is one of the most common infections identified in nursing home residents [3]. Pneumonia occurring in nursing homes (Nursing home-acquired pneumonia, NHAP) has been considered to be distinct from community-acquired pneumonia (CAP) with unique epidemiological features and poor outcomes [4][5][6][7][8][9][10][11] since its proposal in 1978 [12]. The mortality of NHAP ranges from 6.5 to 40% [4,6], and it is as high as 18.1% in Japan [13]. ...
... NHAP patients are known to show a higher mortality rate than CAP patients [4][5][6][7][8][9][10][11], but useful prognostic predictors for NHAP are lacking. Moreover, the prognostic predictors for CAP such as albumin or C-reactive protein [44,45] were not predictors for NHAP (Table 3). ...
Introduction:
Despite the poor prognosis for nursing home acquired pneumonia (NHAP), a useful prognostic factor is lacking. We evaluated protein C (PC) activity as a predictor of in-hospital death in patients with NHAP and community-acquired pneumonia (CAP).
Methods:
This prospective, observational study included all patients hospitalized with pneumonia between July 2007 and December 2012 in a single hospital. We measured PC activity at admission and investigated whether it was different between survivors and non-survivors. We also examined whether PC activity < 55% was a predictor for in-hospital death of pneumonia by logistic regression analysis with CURB-65 items (confusion, blood urea >20 mg/dL, respiratory rate >30/min, and blood pressure <90/60 mmHg, age >65). When it was a useful prognostic factor for pneumonia, we combined PC activity with the existing prognostic scores, the pneumonia severity index (PSI) and CURB-65, and analyzed its additional effect by comparing the areas under the receiver operating characteristic curves (AUCs) of the modified and original scores.
Results:
Participants comprised 75 NHAP and 315 CAP patients. PC activity was lower among non-survivors than among survivors in NHAP and all-pneumonia (CAP+NHAP). PC activity <55% was a useful prognostic predictor for NHAP (Odds ratio 7.39 (95% CI; 1.59-34.38), and when PSI or CURB-65 was combined with PC activity, the AUC improved (from 0.712 to 0.820 for PSI, and 0.657 to 0.734 for CURB-65).
Conclusions:
PC activity was useful for predicting in-hospital death of pneumonia, especially in NHAP, and became more useful when combined with the PSI or CURB-65.
... Compared with younger age groups, the elderly have significant differences in terms of their demographics, risk factors, clinical presentations, and disease etiologies (5). Although there is no information about the microbial etiology of CAP in the current clinical guidelines, Streptococcus pneumonia, Staphylococcus aureus and Enterobacteriaceae are considered the main causes of pneumonia in the elderly; some previous studies also found that Chlamydophila pneumoniae and viruses can cause pneumonia in the elderly (6). Due to special conditions pertaining to elderly individuals, elderly patients with CAP always have poor prognoses, with a high mortality rate of approximately 5-15% (7); this high mortality rate remains a challenge in the clinical setting. ...
... In the present study, a retrospective analysis was conducted with 909 of the 1013 patients older than 55 years with CAP who presented at Wuhan People's Hospital of Dongxihu District, China, from January 2010 to June 2015. The diagnostic criteria for CAP were as follows: 1) fever (438 o C), cough, purulent sputum or change in the characteristics of the respiratory secretions; 2) a radiographic infiltrate compatible with pneumonia; and 3) laboratory data, such as leucopenia, leukocytosis, and increased arterial-alveolar gradient (6). Patients with immunosuppression, organ transplantation, active thoracic malignancy, hospital-acquired pneumonia, pulmonary embolism, chemotherapy, or corticosteroid therapy were excluded. ...
Objective:
The present study aimed to investigate the relationship between obesity and mortality in patients with community-acquired pneumonia (CAP) in China.
Methods:
In total, 909 patients with CAP were recruited for this study from January 2010 to June 2015. All patients were selected and divided into 4 groups according to their body mass index (BMI) values. All patients' clinical information was recorded. The associations among mortality; BMI; the 30-day, 6-month and 1-year survival rates for different BMI classes; the etiology of pneumonia in each BMI group; and the risk factors for 1-year mortality in CAP patients were analyzed.
Result:
With the exception of the level of C-reactive protein (CRP), no other clinical indexes showed significant differences among the different BMI groups. No significant differences were observed among all groups in terms of the 30-d and 6-month mortality rates (p>0.05). There was a significantly lower risk of 1-year mortality in the obese group than in the nonobese group, (p<0.05). Logistic regression analysis showed that there were seven independent risk factors for 1-year mortality in CAP patients, namely, age, cardiovascular disease, cerebrovascular disease, obesity, APACHE II score, level of CRP and CAP severity.
Conclusion:
Compared with nonobese patients with CAP, obese CAP patients may have a lower mortality rate, especially with regard to 1-year mortality, and CRP may be associated with the lower mortality rate in obese individuals than in nonobese individuals.
... 20 Among patients who reside in LTCFs, pneumonia-related signs and symptoms were demonstrated to be subtler than in CAP patients from the same age group. 80 As many as 73% of these LTCF cases present with confusion. Fever and respiratory symptoms were less common than in other CAP patients. ...
... 104 In another study, low serum albumin levels and lymphocytes (both of which represent poor nutritional status) were associated with mortality. 80 ...
The incidence of pneumonia increases with age, and is particularly high in patients who reside in long-term care facilities (LTCFs). Mortality rates for pneumonia in older adults are high and have not decreased in the last decade. Atypical symptoms and exacerbation of underlying illnesses should trigger clinical suspicion of pneumonia. Risk factors for multidrug-resistant organisms are more common in older adults, particularly among LTCF residents, and should be considered when making empiric treatment decisions. Monitoring of clinical stability and underlying comorbid conditions, potential drug-drug interactions, and drug-related adverse events are important factors in managing elderly patients with pneumonia.
... Our results support those of a previous study in which functional status was the main determinant of outcome in elderly patients with pneumonia (7). Additionally, previous reports have indicated that performance status (PS) evaluation is useful for predicting the outcome of patients with pneumonia (19,20). Therefore, PS is one of the criteria of nursing and healthcare-associated pneumonia (NHCAP), which was newly categorized in the 2011 Japanese Respiratory Society guidelines (6,21). ...
... Previous studies reported that serum albumin was an independent prognostic factor in CAP, NHAP, and HAP patients (19,20). In the present study, the low serum albumin levels observed in the diminished ADL group could be indicative of malnutrition, which is probably related to the high frequency of tube feeding in these patients. ...
Objective:
In Japan, the number of elderly people who have difficulties performing the activities of daily living (ADLs) is increasing. The objective of this study was to assess the relationship between ADL and the clinical characteristics of pneumonia.
Methods:
We conducted a retrospective study of 219 adult patients hospitalized due to pneumonia [151 patients with community-acquired pneumonia (CAP) and 68 patients with healthcare-associated pneumonia (HCAP)]. CAP, HCAP, and all the patients were stratified into two groups using a modified version of the Katz index of five ADLs as follows: independent in all ADLs or dependent in one to three ADLs (CAP-A, HCAP-A, and All-A groups) and dependent in four or five ADLs (CAP-B, HCAP-B, and All-B groups). Disease severity, microbiological findings, and mortality were compared between the groups.
Results:
As the ability to perform ADLs declined, A-DROP scores (the CAP severity measurement index) increased significantly in CAP (CAP-A: 1.1±1.1, CAP-B: 2.6±1.1), HCAP (HCAP-A: 2.0±1.0, HCAP-B: 2.8±1.0), and all patients (All-A: 1.3±1.1, All-B: 2.8±1.0). Thirty-day mortality was higher in the CAP-B (23.1%) and All-B (19.2%) groups than in the CAP-A (0.7%) and All-A (1.8%) groups, respectively. A multivariate Cox proportional hazards analysis showed an ADL score ≥ four to be a significant predictor of 30-day mortality in CAP patients [hazard ratio (HR), 19.057; 95% confidence interval (CI), 1.930-188.130] and in all patients (HR, 8.180; 95% CI, 1.998-33.494).
Conclusion:
A functional assessment using a modified version of the Katz index is useful for the management of CAP and HCAP patients.
... Some studies, mainly from the United States, reported a higher frequency of drug-resistant pathogens and mortality in HCAP than in CAP [4,5], whereas several European studies found a lower frequency of drug-resistant pathogens and demonstrated the efficacy of narrow-spectrum therapy [6][7][8]. Nursing home-acquired pneumonia (one type of HCAP) in Japan and Spain has a mortality rate and etiology more similar to CAP than to hospital-acquired pneumonia (HAP) [9][10][11]. It is desirable not to use aggressive empiric combination therapy for HCAP patients if it is not necessary, as it may possibly lead to drug toxicity, as well as promoting future antimicrobial resistance [12]. ...
... Four hundred fifteen patients (93.3%) received recommended therapy. One hundred sixteen CAP patients (93.5%) received CAP therapy and 299 HCAP patients (93.1%) were treated in accordance with the algorithm [11]. The remaining 30 patients were treated with other regimens and survived, and were included in the statistical analyses. ...
Background. Optimal empiric therapy for hospitalized patients with healthcare-associated pneumonia (HCAP) is uncertain.
Methods. We prospectively applied a therapeutic algorithm, based on the presence of risk factors for multidrug-resistant (MDR) pathogens in a multicenter cohort study of 445 pneumonia patients, including both community-acquired pneumonia (CAP; n = 124) and HCAP (n = 321).
Results. MDR pathogens were more common (15.3% vs 0.8%, P < .001) in HCAP patients than in CAP patients, including Staphylococcus aureus (11.5% vs 0.8%, P < .001); methicillin-resistant S. aureus (6.9% vs 0%, P = .003); Enterobacteriaceae (7.8% vs 2.4%, P = .037); and Pseudomonas aeruginosa (6.9% vs 0.8%, P = .01). Using the proposed algorithm, HCAP patients with ≥2 MDR risk factors, one of which was severity of illness (n = 170), vs HCAP patients with 0–1 risk factor (n = 151) had a significantly higher frequency of MDR pathogens (27.1% vs 2%, P < .001). In total, 93.1% of HCAP patients were treated according to the therapy algorithm, with only 53% receiving broad-spectrum empiric therapy, yet 92.9% received appropriate therapy for the identified pathogen. Thirty-day mortality was significantly higher for HCAP than for CAP (13.7% vs 5.6%, P = .017), but among HCAP patients with 0–1 MDR risk factor, mortality was lower than with ≥2 MDR risk factors (8.6% vs 18.2%, P = .012). In multivariate analysis, initial treatment failure, but not inappropriate empiric antibiotic therapy, was a mortality risk factor (odds ratio, 72.0).
Conclusions. Basing empiric HCAP therapy on its severity and the presence of risk factors for MDR pathogens is a potentially useful approach that achieves good outcomes without excessive use of broad-spectrum antibiotic therapy.
Clinical Trials Registration. Japan Medical Association Center for Clinical Trials, JMA-IIA00054.
... There are three reports from Japan related to patients who meet the third requirement in the definition of NHCAP (NHCAP patients with poor ADL): ''Elderly or disabled and requiring nursing care'', and all three reports state that the pathogens listed in Table 3, including pneumococci and other streptococci, MRSA, Klebsiella, Pseudomonas aeruginosa, and methicillin-susceptible Staphylococcus aureus (MSSA), are the pathogens that are most often isolated in patients with poor ADL, the same as in HCAP and NHAP [29][30][31] (Level IVa). In addition, there is a report of a study in which atypical pathogens (Chlamydophila and Mycoplasma pneumoniae) were isolated from a high proportion of patients with poor ADL, 44.7% [30] (Level IVa). ...
... There are three reports from Japan related to patients who meet the third requirement in the definition of NHCAP (NHCAP patients with poor ADL): ''Elderly or disabled and requiring nursing care'', and all three reports state that the pathogens listed in Table 3, including pneumococci and other streptococci, MRSA, Klebsiella, Pseudomonas aeruginosa, and methicillin-susceptible Staphylococcus aureus (MSSA), are the pathogens that are most often isolated in patients with poor ADL, the same as in HCAP and NHAP [29][30][31] (Level IVa). In addition, there is a report of a study in which atypical pathogens (Chlamydophila and Mycoplasma pneumoniae) were isolated from a high proportion of patients with poor ADL, 44.7% [30] (Level IVa). ...
... Several new scoring systems, such as CORB75 (confusion, oxygen saturation, respiratory rate, systolic blood pressure, age ≥ 75 years) and UBMo index (the urea multiplied by the N-terminal-pro-brain natriuretic peptide plasmatic rate, divided by the monocyte count) have been devised to improve the performance of prognostic prediction for CAP in the older population 15,16 . However, a useful prognostic prediction model for these patients based on a prospective and well-validated cohort has not yet been established 12,14,[17][18][19] . ...
The discriminative power of CURB-65 for mortality in community-acquired pneumonia (CAP) is suspected to decrease with age. However, a useful prognostic prediction model for older patients with CAP has not been established. This study aimed to develop and validate a new scoring system for predicting mortality in older patients with CAP. We recruited two prospective cohorts including patients aged ≥ 65 years and hospitalized with CAP. In the derivation (n = 872) and validation cohorts (n = 1,158), the average age was 82.0 and 80.6 years and the 30-day mortality rate was 7.6% (n = 66) and 7.4% (n = 86), respectively. A new scoring system was developed based on factors associated with 30-day mortality, identified by multivariate analysis in the derivation cohort. This scoring system named CHUBA comprised five variables: confusion, hypoxemia (SpO 2 ≤ 90% or PaO 2 ≤ 60 mmHg), blood urea nitrogen ≥ 30 mg/dL, bedridden state, and serum albumin level ≤ 3.0 g/dL. With regard to 30-day mortality, the area under the receiver operating characteristic curve for CURB-65 and CHUBA was 0.672 (95% confidence interval, 0.607–0.732) and 0.809 (95% confidence interval, 0.751–0.856; P < 0.001), respectively. The effectiveness of CHUBA was statistically confirmed in the external validation cohort. In conclusion, a simpler novel scoring system, CHUBA, was established for predicting mortality in older patients with CAP.
... Poor nutritional status damages respiratory function, thus impairing immune function and increasing pneumonia (26,27). Adequate nutrition can enhance respiratory muscle function and immune defense (28,29). Therefore, nutritional intervention can control disease progression and improve respiratory function, thus reducing morbidity and mortality (30), hospitalization costs, and re-hospitalizations (31,32). ...
Background: Malnutrition and comorbidity are two common geriatric syndromes. The pathology of pneumonia is multifactorial, making its diagnosis and management a great challenge. Hospital-acquired pneumonia (HAP) and community-acquired pneumonia (CAP) are two main types of pneumonia. However, the effect of geriatric syndromes on pneumonia and its prognosis have not been clearly explored.
Methods: We collected the relevant electronic data of inpatients aged over 65 years and diagnosed with pneumonia in the Geriatrics Department Building of the First Affiliated Hospital with Nanjing Medical University between December 2018 and December 2019, and further divided them into HAP group and CAP group. The correlations of age, age-adjusted Charlson Comorbidity Index (aCCI), basic diseases and nutritional indexes (i.e., albumin, electrolyte, hemoglobin) with pneumonia and prognosis were analyzed. We analyzed the associations between infection prognosis/infection level and age, nutritional status, aCCI and underlying diseases, using linear regression model. The box plot was applied to present infection outcome, and the nomogram was built for predicting infection outcomes. We utilized the heat map to show the associations between nutritional status and infection level/outcome in all infected patients, HAP, and CAP.
Results: The final study comprised samples of 669 pneumonia patients divided into HAP group ( n = 517) and CAP group ( n = 152). In all patients, the infection outcome was negatively correlated with age ( P = 0.013). The level of albumin was negatively correlated with infection prognosis in all patients ( P = 0.03), and negatively correlated with neutrophil count and CRP ( P = 0.008, P < 0.001). ACCI was positively correlated with CRP ( P = 0.003). The prognosis was negatively associated with age and albumin level. In the patients with basic dementia/Alzheimer's disease and chronic obstructive pulmonary disease/asthma, the prognosis was worse.
Conclusion: There was a correlation between poor nutritional status-related indexes and inflammatory indexes. A poor nutritional status might predict a high risk of pneumonia in elderly adults. Advanced age and comorbidities were risk factors for the occurrence and poor prognosis of pneumonia. Therefore, comorbidities should be well-treated in the elderly with pneumonia.
... Pain is a common symptom of ECMO treatment. Severe pneumonia is in critical condition, and negative emotions caused by the disease and treatment often occur [27]. The patients in the OG were treated with analgesic and sedative drugs combined with psychological intervention. ...
Objective:
To study the application value of prone nursing combined with extracorporeal membrane oxygenation (ECMO) in patients with severe pneumonia.
Methods:
Altogether 96 patients with severe pneumonia from December 2016 to June 2018 were selected as the research participants, and 48 patients were included in the observation group (OG) to receive prone nursing with ECMO, while the other 48 patients were included in the control group (CG) to receive routine nursing with ECMO. Complications, cardiopulmonary function, VAS, SAS, SDS, MMAS-8 scores and nursing satisfaction were compared.
Results:
After nursing, the incidence of complications in the OG was lower than that in the CG, LVEDD and LVESD in OG were lower than those in CG, while LVEF, FEV1 and FVC were higher than those in CG. The scores of VAS, SAS and SDS in OG were lower than those in CG. The MMAS-8 score in the OG was higher than that in the CG. The total nursing satisfaction of the OG was higher than that of the CG (All P<0.05).
Conclusion:
Prone nursing combined with ECMO can reduce the incidence of complications of severe pneumonia and improve the cardiopulmonary function of patients, which is worthy of clinical promotion.
... Nutritional status, which is commonly estimated by body mass index (BMI), is a representative host factor affecting CAP mortality. Low BMI, indicating poor nutritional status, is associated with the presence of chronic disease, impairment of immune function, and respiratory muscle dysfunction, which ultimately weaken host defense mechanisms against CAP [5,6]. Meanwhile, overweight and obesity, expressed as high BMI, are related to an increased risk of CAP and alterations of inflammatory response in the lungs [7], and thus high BMI has been widely presumed to adversely affect the clinical course of CAP. ...
Background
The relationship between body mass index (BMI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) has not been fully investigated in patients with community-acquired pneumonia (CAP).
Methods
This prospective observational study examined 510 consecutive patients hospitalized for CAP. NT-proBNP, BMI, and the pneumonia severity index (PSI) were determined for all participants. The moderating effects of BMI on the relationship between NT-proBNP and CAP mortality were examined using interaction terms in a multivariable regression model. The ability of NT-proBNP to predict mortality was evaluated using the area under the curve (AUC).
Results
A significant inverse relationship was observed between BMI and NT-proBNP. After multivariable adjustment including BMI, NT-proBNP remained a significant predictor of CAP mortality. The AUC of the fully adjusted (including BMI) NT-proBNP model was significantly higher than that excluding BMI (p = 0.021) and that of PSI (p = 0.038), respectively. The predictive performance of NT-proBNP for mortality significantly differed by BMI group, with the NT-proBNP of the overweight and obesity group having a significantly higher AUC than that of the underweight and normal-weight group. The AUC of NT-proBNP was significantly higher and tended to be higher than that of PSI in the overweight group (p = 0.013) and the obesity group (p = 0.113), respectively.
Conclusions
BMI significantly strengthens the prognostic performance of NT-proBNP in CAP patients. The BMI–NT-proBNP interaction is significantly associated with CAP mortality, but as a prognostic determinant for CAP, NT-proBNP seems to be more useful for overweight and obese patients than for underweight and normal-weight patients.
... MC-CAP was more common in the elderly and more likely to complicate underlying pulmonary diseases in the present study, a result that is consistent with previous studies [19,20]. Elderly patients' propensity to develop MC-CAP might be explained by the asymptomatic [19]. ...
Abstract Background Although Moraxella catarrhalis (M. catarrhalis) is a common cause of community-acquired pneumonia (CAP), studies investigating clinical manifestations of CAP due to M. catarrhalis (MC-CAP) in adults are limited. Since S. pneumoniae is the leading cause of CAP globally, it is important to distinguish between MC-CAP and CAP due to S. pneumoniae (SP-CAP) in clinical practice. However, no past study compared clinical characteristics of MC-CAP and SP-CAP by statistical analysis. We aimed to clarify the clinical characteristics of MC-CAP by comparing those of SP-CAP, as well as the utility of sputum Gram staining. Methods This retrospective study screened CAP patients aged over 20 years visiting or admitted to Okinawa Miyako Hospital between May 2013 and April 2018. Among these, we included patients whom either M. catarrhalis alone or S. pneumoniae alone was isolated from their sputum by bacterial cultures. Results We identified 134 MC-CAP and 130 SP-CAP patients. Although seasonality was not observed in SP-CAP, almost half of MC-CAP patients were admitted in the winter. Compared to those with SP-CAP, MC-CAP patients were older (p
... Malnutrition leads to the development of pneumonia and weakens the physical activity and immune system [5]. Therefore, adequate nutrition directly aids respiratory muscle function and immune defense mechanisms and provides high immunity against environmental pathogens in the lungs to reduce potential disease progression [6,7]. ...
Pneumonia leads to changes in body composition and weakness due to the malnourished condition. In addition, patient family caregivers always have a lack of nutritional information, and they do not know how to manage patients’ nutritional intake during hospitalization and after discharge. Most intervention studies aim to provide nutritional support for older patients. However, whether long-term nutritional intervention by dietitians and caregivers from patients’ families exert clinical effects—particularly in malnourished pneumonia—on nutritional status and readmission rate at each interventional phase, from hospitalization to postdischarge, remains unclear. To investigate the effects of an individualized nutritional intervention program (iNIP) on nutritional status and readmission rate in older adults with pneumonia during hospitalization and three and six months after discharge. Eighty-two malnourished older adults with a primary diagnosis of pneumonia participated. Patients were randomly allocated to either a nutrition intervention (NI) group or a standard care (SC) group. Participants in the NI group received an iNIP according to energy and protein intake requirements in addition to dietary advice based on face-to-face interviews with their family caregivers during hospitalization. After discharge, phone calls were adopted for prescribing iNIPs. Anthropometry (i.e., body mass index, limb circumference, and subcutaneous fat thickness), blood parameters (i.e., albumin and total lymphocyte count), hospital stay, Mini-Nutritional Assessment-Short Form (MNA-SF) score, target daily calorie intake, total calorie intake adherence rate, and three-major-nutrient intakes were assessed during hospitalization and three and six months after discharge. Both groups received regular follow-up through phone calls. Furthermore, the rate of readmission resulting from pneumonia was recorded after discharge. During hospital stay, the NI group showed significant increases in daily calorie intake, total calorie intake adherence rate, and protein intake compared with the SC group (p < 0.05); however, no significant difference was found in anthropometry, blood biochemical values, MNA-SF scores, and hospital stay. At three and six months after discharge, the NI group showed significantly higher daily calorie intake and MNA-SF scores (8.2 vs. 6.5 scores at three months; 9.3 vs. 7.6 scores at six months) than did the SC group (p < 0.05). After adjusting for sex, the readmission rate for pneumonia significantly decreased by 77% in the NI group compared with that in the SC group (p = 0.03, OR: 0.228, 95% CI: 0.06–0.87). A six-month iNIP under dietitian and patient family nutritional support for malnourished older adults with pneumonia can significantly improve their nutritional status and reduce the readmission rate.
... MC-CAP was more common in the elderly and more likely to complicate underlying pulmonary diseases in the present study, a result that is consistent with previous studies [19,20]. Elderly patients' propensity to develop MC-CAP might be explained by the asymptomatic carriage rate of M. catarrhalis. ...
... The main consequences of immunosenescence in patients with CAP include the high risk of misdiagnosis of pneumonia because some specific symptoms of lower respiratory tract infection such as cough, chest pain or fever do not reflect the real state of elderly patients with pneumonia [31]. ...
Community-acquired pneumonia (CAP) can occur at any time of life, but its incidence and risk of death are linked to increasing age. CAP in the elderly is a major health problem associated with high rates of readmission, morbidity, and mortality. Since the clinical presentation of pneumonia in the elderly may be atypical, clinicians should suspect pneumonia in older patients presenting symptoms such as falls and altered mental status, fatigue, lethargy, delirium, anorexia, in order to avoid the complications associated with delayed diagnosis and therapy. Streptococcus pneumoniae remains the most frequently reported pathogen in this population. However, particular attention should be paid to patients with risk factors for multidrug resistant pathogens, because a large proportion of elderly persons present multimorbidity. Vaccination is one of the most important preventive approaches for CAP in the elderly. In addition, lifestyle-tailored interventions for different modifiable risk factors will help to reduce the risk of pneumonia in elderly persons. Surveillance of etiological pathogens may improve vaccination policies in this population.
... Glycopeptides or linezolid are the primary choice for CA-MRSA pneumonia (1, 299) (III B). The clinical manifestations of elderly CAP can be atypical (302,303). The manifestations may only include poor appetite, urinary incontinence, tiredness and altered mental state, etc. (2,301). ...
Community-acquired pneumonia (CAP) in adults is an infectious disease with high morbidity in China and the rest of the world. With the changing pattern in the etiological profile of CAP and advances in medical techniques in diagnosis and treatment over time, Chinese Thoracic Society of Chinese Medical Association updated its CAP guideline in 2016 to address the standard management of CAP in Chinese adults. Extensive and comprehensive literature search was made to collect the data and evidence for experts to review and evaluate the level of evidence. Corresponding recommendations are provided appropriately based on the level of evidence. This updated guideline covers comprehensive topics on CAP, including etiology, antimicrobial resistance profile, diagnosis, empirical and targeted treatments, adjunctive and supportive therapies, as well as prophylaxis. The recommendations may help clinicians manage CAP patients more effectively and efficiently. CAP in pediatric patients and immunocompromised adults is beyond the scope of this guideline. This guideline is only applicable for the immunocompetent CAP patients aged 18 years and older. The recommendations on selection of antimicrobial agents and the dosing regimens are not mandatory. The clinicians are recommended to prescribe and adjust antimicrobial therapies primarily based on their local etiological profile and results of susceptibility testing, with reference to this guideline. This article is protected by copyright. All rights reserved.
... These earlier findings suggested the potential role of dyspnea as a predictor of mortality. Next, the ECOG performance status was a significant predictor of the prognosis, corresponding to previous studies in which the ECOG performance status was shown to be an important predictor of mortality in patients with pneumonia, especially among elderly patients or those with healthcare-associated pneumonia (20)(21)(22)(23). Although comorbidity and the functional status can be important factors when assessing the severity and prognosis of pneumonia (21,24), we found that the use of CCI as a scoring system for comorbidity was not a significant predictor of 30day mortality, even on the univariate analysis. ...
Objective:
The optimal prognostic model for community-acquired pneumonia (CAP) remains unclear. In this study, we sought to identify independent predictors of 30-day mortality in patients with CAP and to determine whether adding specific prognostic factors to each of the two clinical prediction scores could improve the prognostic yield.
Methods:
This retrospective study involved 797 CAP patients who had been hospitalized at a tertiary referral center. The patients were categorized into two groups: those who survived and those who had died on or before 30 days after admission. Select clinical parameters were then compared between the two groups.
Results:
During the 30-day period, there were 72 deaths (9%). We constructed two models for a multivariate analysis: one was based on a high CURB-65 score (3-5) and the other on a high pneumonia severity index (PSI) class (V). In both models, a high CURB-65 score or a high PSI class, along with the presence of dyspnea, high Eastern Cooperative Oncology Group (ECOG) performance status (3-4), and a low serum albumin level, were independent predictors of 30-day mortality. In both the CURB-65-based and PSI-based models, the addition of dyspnea, high ECOG performance status, and hypoalbuminemia (<3 g/dL) enhanced the prognostic assessment, and subsequently, the c-statistics calculated with the use of three- or four- predictor combinations exceeded 0.8.
Conclusion:
In addition to the CURB-65 or PSI, the clinical factors of dyspnea, the ECOG performance status, and serum albumin level may be independent predictors of 30-day mortality in CAP patients. When combined with the CURB-65 or PSI, these parameters provide additional evidence for predicting poor prognoses.
... These finding suggest that malnutrition may be an important risk factor for CAP. Another study revealed that physical activity, nutritional status, and dehydration were significant prognostic factors in very old patients with pneumonia [11]. Moreover, in patients with CAP, a low serum albumin level (≤3.0 g/dL) and a low BMI during hospitalization were associated with death from pneumonia during a follow-up period after discharge [12]. ...
Background:
Pneumococcal pneumonia is the most common form of community-acquired pneumonia (CAP). Although a pneumococcal conjugate vaccine has contributed to a reduction in the incidence of pneumococcal pneumonia among older children and adults, no significant decrease in the incidence has been observed among persons aged ≥65 years. A low body mass index and hypoalbuminemia are common in Japanese patients with CAP, but the association of other nutritional parameters with the severity of pneumonia or length of hospital stay in patients with pneumococcal pneumonia is unclear.
Methods:
Fifty-seven previously healthy inpatients who presented with pneumococcal pneumonia were divided into two groups: those aged ≥65 years (n = 36) and those aged <65 years (n = 21). Patients' characteristics (the Confusion, Urea, Respiratory rate, Blood pressure, age >65 years (CURB-65) score), the pneumonia severity index (PSI), and inflammatory and metabolic nutritional parameters were compared between the two groups.
Results:
The older group showed significantly lower serum albumin and cholinesterase (ChE) levels. Multivariate linear regression analysis revealed that the PSI was positively correlated with age in both groups. In the younger age group, both the CURB-65 score and PSI showed significant negative correlations with the serum ChE level, and there was a significant negative correlation between the length of stay and serum total cholesterol (T-cho) level. In the older group, the fasting period, lymphocyte count, and age showed significant positive correlations with the length of stay. There was a significant negative correlation between the length of stay and serum albumin level, but no correlation with the serum ChE or T-cho levels, in the older patients.
Conclusions:
Our findings suggest that in patients aged <65 years, age and serum ChE and T-cho levels were associated with both the severity of pneumococcal pneumonia and length of stay. In contrast, the length of stay in older patients was associated with multiple factors that differed from those in younger patients. These differences may reflect age-related immunosenescence in older patients and a greater effect of serum ChE and T-cho levels on immunity in younger patients.
... To show the involvement of QTc interval prolongation as a prognostic factor in elderly pneumonia, further prospective studies to evaluate the relevance of factors known to influence QTc intervals and factors potentially contributing to mortality in pneumonia will be necessary. Furthermore, since the present analysis did not distinguish between CAP and NHCAP cases, one can't rule out the possibility that there were differences in risk factors between CAP and NHCAP cases [31]. In the present study, since the number of subjects was too small, such a comparison was not made and further studies will be necessary. ...
Acute pneumonia is a serious problem in the elderly and various risk factors have already been reported, but the involvement of QTc interval prolongation remains uncertain. The aim of this study was to elucidate the prognostic factors for the development of pneumonia in elderly patients and to study the possible involvement of QTc interval prolongation.
The subjects were 249 hospitalized pneumonia patients more than 65 years old in Aki-Ohta Hospital from January 2010 to December 2013. Community-acquired pneumonia patients and nursing care and healthcare-associated pneumonia patients were included in the study. The pneumonia severity index, vital signs, blood chemistry data and ECG findings were retrospectively compared using multiple logistic regression analysis.
39 patients died within 30 days from onset. The clinical features related to poor prognosis were: advanced age, past history of cerebral vascular disease and/or diabetes mellitus, decreased serum albumin level, higher CURB-65 or PORT index scores and QTc interval prolongation. Patients showing a prolonged QTc interval had a higher mortality than those with a normal QTc interval. A prolonged QTc interval was not related to serum calcium concentration and/or treatment with QTc prolongation drug, clarithromycin or azithromycin, but related to age, lower albumin concentration and past history of diabetes mellitus.
These findings suggest potential prognostic factors for pneumonia in elderly patients, including a prolonged QTc interval (> 0.44 seconds).
... Advances in modern medicine have led to a rapid increase in the aging population with a subsequent increase in the number of elderly population requiring medical care [16]. An increase in the annual incidence of NHAP of up to 1.9 million cases is expected over the next 3 decades [14]. ...
Background
Pneumonia is among the foremost causes of hospitalization and mortality in patients residing in extended care facilities. Despite its prevalence, there is currently little literature focusing on the course and management of nursing home-acquired pneumonia (NHAP) in the emergency department (ED). Our objective was to investigate the ED presentation, course, management and outcomes in patients admitted through the ED with NHAP.
Methods
A retrospective chart review of nursing home patients with a presumptive or final diagnosis of pneumonia admitted through the ED was performed at two large hospitals in Detroit, Michigan.
Results
A total of 296 patients were included in the study from 2002 to 2007 with a mean age of 81.1 years (SD ± 10.95) and 55.4% females. Blood cultures were performed on 90.8% of patients in the ED; 17.8% of these revealed growths, but half of these were considered contaminants. Initial chest x-ray in the ED was read as possible pneumonia in 18.2% of patients; 73.9% were started on antibiotics (ABX) in the ED. Mean hospital length of stay (LOS) was 10.75 days (SD ± 9.35) and in-hospital mortality was 16.2%. Time until first ABX in univariate analysis was nearly significant (p = 0.053) for mortality prediction, and the appropriate versus inappropriate ABX (per the Infectious Diseases Society of America and American Thoracic Society guidelines) did not affect mortality. Patients treated with a single ABX had significantly increased LOS (p = 0.0089). There was poor correlation between LOS and time until first ABX as well as LOS and time until appropriate ABX with a correlation coefficient of -0.048 (p = 0.42) and -0.08 (p = 0.43), respectively.
Conclusions
In this data set of NHAP patients admitted through the ED, we found a surprisingly low prevalence of true-positive blood cultures, high incidence of antibiotic pre-treatment at nursing homes prior to admission, high hospital mortality and low immunization rates. There was a wide spectrum of pathogens grown in blood culture. Only two thirds of the patients had dyspnea at presentation, and less than half had either cough or fever. On physical examination, about one fourth had no clinical findings consistent with pneumonia. Further, less than one fifth of chest x-rays were interpreted as possible pneumonia.
... In other words, we estimated a larger fraction of lower respiratory infection deaths in children younger than 5 years due to Hib than did Watt and colleagues. The main reason for this diff erence is that Watt and colleagues assumed that Hib in individuals older than 2 years does not cause death; the available obser vational data, [81][82][83][84] however, show Hib mortality at all ages. For example, results from the study in Japan 84 showed severe cases of hospitalacquired and community-acquired pneumonia related to Hib, the diff erences in these assessments for all the respir atory pathogens is even more striking. ...
Background: Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex.
Methods: We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions.
Findings: In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted.
Conclusions: Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis.
Funding: Bill & Melinda Gates Foundation.
Objective
Epidemiological information is essential in providing appropriate empiric antimicrobial therapy for pneumonia. This study aimed to clarify the epidemiology of community-acquired pneumonia (CAP) by conducting a systematic review of published studies in Japan.
Design
Systematic review.
Data source
PubMed and Ichushi web database (January 1970 to October 2022).
Eligibility criteria
Clinical studies describing pathogenic micro-organisms in CAP written in English or Japanese, excluding studies on pneumonia other than adult CAP, investigations limited to specific pathogens and case reports.
Data extraction and synthesis
Patient setting (inpatient vs outpatient), number of patients, concordance with the CAP guidelines, diagnostic criteria and methods for diagnosing pneumonia pathogens as well as the numbers of each isolate. A meta-analysis of various situations was performed to measure the frequency of each aetiological agent.
Results
Fifty-six studies were included and 17 095 cases of CAP were identified. Pathogens were undetectable in 44.1% (95% CI 39.7% to 48.5%). Streptococcus pneumoniae was the most common cause of CAP requiring hospitalisation or outpatient care (20.0% (95% CI 17.2% to 22.8%)), followed by Haemophilus influenzae (10.8% (95% CI 7.3% to 14.3%)) and Mycoplasma pneumoniae (7.5% (95% CI 4.6% to 10.4%)). However, when limited to CAP requiring hospitalisation, Staphylococcus aureus was the third most common at 4.9% (95% CI 3.9% to 5.8%). Pseudomonas aeruginosa was more frequent in hospitalised cases, while atypical pathogens were less common. Methicillin-resistant S. aureus accounted for 40.7% (95% CI 29.0% to 52.4%) of S. aureus cases. In studies that used PCR testing for pan-respiratory viral pathogens, human enterovirus/human rhinovirus (9.4% (95% CI 0% to 20.5%)) and several other respiratory pathogenic viruses were detected. The epidemiology varied depending on the methodology and situation.
Conclusion
The epidemiology of CAP varies depending on the situation, such as in the hospital versus outpatient setting. Viruses are more frequently detected by exhaustive genetic searches, resulting in a significant variation in epidemiology.
Background:
To look at the differences and similarities in albumin and lipid metabolism in non-severe COVID-19 infection, non-severe community-acquired pneumonia, and severe community pneumonia with underlying diseases, as well as the relationship between albumin and lipid metabolism and inflammatory mediators.
Methods:
This retrospective analysis comprised 253 individuals with bacterial pneumonia and COVID-19 infection (1 May 2021-1 May 2022). Routine blood examination, blood lipid levels, albumin level, C-reactive protein (CRP) levels, coagulation function, cardiac enzymes, liver function, renal function, immunological function, and bacterial culture were also collected. Correlation analysis was performed using Spearman's test for lipid parameter and Inflammatory factors in the blood. Furthermore, the multiple linear regression (MLR) analysis was employed to analyze the multicollinearity in lipidomics data. The statistical analysis was performed using SPSS statistic version 19.0.
Results:
There were 63 (24.90%) non-severe community-acquired pneumonia patients (NSCAP), 48 (18.97%) severe community-acquired pneumonia patients (SCAP), 112 (44.27%) non-severe COVID-19 infection patients (NSCOV), and 30 (11.86%) healthy volunteers (HV). In all, 45.59% (116/253) of the patients had underlying diseases. Patients with community-acquired pneumonia had lower albumin and cholesterol levels than those with non-severe COVID-19 infection and healthy controls (t = -3.81, -2.09, P = 0.00, 0.04). Albumin, triglyceride, cholesterol, and LDL-C levels in peripheral blood were considerably lower in the SCAP group than in the NSCAP group. Albumin, cholesterol, HDL-C, LDL-C, and aop-A were all inversely connected with CRP in the SCAP with underlying illness group, but cholesterol level was favorably correlated with lymphocyte count (R = 0.36, P = 0.01). Hypoproteinemia, hypotriglyceridemia, and an elevated neutrophil-to-lymphocyte count ratio are all risk factors for severe community-acquired pneumonia.
Conclusion:
Hypoalbuminemia and abnormal lipid metabolism are important indicators of bacterial infection, especially severe bacterial pneumonia.
Background
Influenza and respiratory syncytial virus (RSV) contribute significantly to the burden of acute lower respiratory infection (ALRI) inpatient care, but heterogeneous coding practices and availability of inpatient data make it difficult to estimate global hospital utilization for either disease based on coded diagnoses alone.
Methods
This study estimates rates of influenza and RSV hospitalization by calculating the proportion of ALRI due to influenza and RSV and applying this proportion to inpatient admissions with ALRI coded as primary diagnosis. Proportions of ALRI attributed to influenza and RSV were extracted from a meta-analysis of 360 total sources describing inpatient hospital admissions which were input to a Bayesian mixed effects model over age with random effects over location. Results of this model were applied to inpatient admission datasets for 44 countries to produce rates of hospital utilization for influenza and RSV respectively, and rates were compared to raw coded admissions for each disease.
Results
For most age groups, these methods estimated a higher national admission rate than the rate of directly coded influenza or RSV admissions in the same inpatient sources. In many inpatient sources, International Classification of Disease (ICD) coding detail was insufficient to estimate RSV burden directly. The influenza inpatient burden estimates in older adults appear to be substantially underestimated using this method on primary diagnoses alone. Application of the mixed effects model reduced heterogeneity between countries in influenza and RSV which was biased by coding practices and between-country variation.
Conclusions
This new method presents the opportunity of estimating hospital utilization rates for influenza and RSV using a wide range of clinical databases. Estimates generally seem promising for influenza and RSV associated hospitalization, but influenza estimates from primary diagnosis seem highly underestimated among older adults. Considerable heterogeneity remains between countries in ALRI coding (i.e., primary vs non-primary cause), and in the age profile of proportion positive for influenza and RSV across studies. While this analysis is interesting because of its wide data utilization and applicability in locations without laboratory-confirmed admission data, understanding the sources of variability and data quality will be essential in future applications of these methods.
The aims of this study were to evaluate clinical course of community-acquired pneumonia (CAP) in patients with chronic heart failure (CHF) and to assess the time course of serum biomarkers, such as C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), tumor necrosis factor α (TNF-α), and brain natriuretic peptide (BNP), at baseline and after treatment in patients with CAP and CHF. Methods. This was a prospective observational study. Adult patients with CHF admitted to a hospital due to suspected CAP were recruited in the study. The diagnosis of CAP was confirmed by chest computed tomography (CT). Subsequently, patients were assigned to the group 1 (with confirmed CAP) or the group 2 (with respiratory infections other than CAP). Echocardiography was performed in all patients at baseline and in follow-up visits. In addition to the routine clinical examination and laboratory tests, serum biomarkers were measured in all patients at admission (Visit 1), at days 10 to 14 (Visit 2), and at days 28 to 42 (Visit 3). Standard statistical methods were used for data analysis. Results. Seventy patients who met the inclusion criteria were enrolled in this study; of them, 35 patients had confirmed CAP and 35 patients had respiratory infections other than CAP. Both groups were similar for demographic and clinical characteristics, as well as for laboratory, echocardiographic and radiological findings. CAP did not affect the clinical course of CHF and echocardiographic parameters did not differ significantly between the groups. Clinical signs of both diseases improved after the treatment in majority of patients. Echocardiographic parameters also improved in both groups that indicates the improvement in cardiac dysfunction under the treatment. During the follow-up, the most prominent changes were seen in CRP level which was significantly higher at baseline in CAP patients compared to patients with other respiratory infections. CRP level decreased at Visit 2 in both groups and in Visit 3 in CAP group. CRP levels differed significantly between the groups both at Visits 1 and 2. Other biomarkers, such as PCT, IL-6, and BNP, were significantly higher at Visit 1 compares to Visit 2. TNF-α level did not change significantly neither in any group during the study nor between the groups at any study time. Conclusion. CAP did not affect the clinical course of CHF. Inflammatory biomarkers, such as CRP, PCT, and IL-6, could be used additionally to the routine diagnostic procedures to differentiate between CAP and other respiratory infections in patients with CHF. CRP is the most promising biomarker. Serum levels of the biomarkers decreased significantly under the standard hospital treatment of CAP and CHF; this could be considered to evaluate treatment success and prognosis.
The 23-valent pneumococcal polysaccharide vaccine (PPSV23) for elderly people has been included in the National Immunization Program (NIP) of Japan since October 2014. Targets for PPSV23 were restricted to persons ≧65 years of age and persons 60 to 64 years of age with an underlying severe physical disability (expressed as 1st grade in Japan). In this study, the clinical courses of non-target persons ＜65 years of age were compared between those with non-severe underlying diseases (A group) and those without underlying diseases (B group), and the need to expand the targets for PPSV23 within the NIP was investigated. Persons with pneumococcal pneumonia who were diagnosed based on a positive sputum or blood culture result were enrolled between January 2004 and April 2014. As a result, the number of subjects in A group was 2.6 times larger than that in B group, and this difference was especially pronounced (4.2 times) among subjects between the age of 60 to 64 years. These findings suggest that persons with underlying disease without a 1st grade physical disability might also be susceptible to pneumococcal pneumonia. No significant differences in the severity of pneumonia, the length of treatment, or the rates of admission were seen between A group and B group. The severity of pneumonia and the rates of admission among targets of the NIP were significantly higher than those of A group. In conclusion, our study suggests that A group should also be included among the targets of the NIP and that all targets eligible to receive the pneumococcal vaccine within NIP should be inoculated.
Mycoplasma pneumoniae expresses β-glycolipids (β-GGLs) in cytoplasmic membranes, which possess a unique β(1 → 6)-linked disaccharide epitope, which has high potential in biochemical and medicinal applications. In the present study, a series of β-GGLs homologues with different acyl chains (C12, C14, C16, and C18) were prepared from a common precursor. An ELISA assay using an anti-(β-GGLs) monoclonal antibody indicated that the synthetic homologues with long acyl chains had greater diagnostic potential in the order C18 > C16 > C14 > C12. Toward a simultaneous detection of natural glycolipids by mass spectrometry (MS), a deuterium-labeled C16 homologue (β-GGL-C16-d 3) was prepared and applied as an internal standard for a high-resolution electrospray ionization MS (ESI-MS) analysis. The ESI-MS analysis was used to identify and quantify acyl homologues (C16/C16, C16/C18, and C18/C18) of β-GGL-C16 in cultured M. pneumoniae. A β-GGLs homologue with a 1,2-diacetyl group (C2) was also prepared as a "water soluble" glycolipid homologue and characterized by ¹H NMR spectroscopy. We envisage that each of these chemosynthetic homologues will provide promising approaches to solve medical and biological problems associated with mycoplasma infectious diseases (MIDs).
During the period from February 2013 to April 2014, 74 (12.3%) isolates of Streptococcus pneumoniae were isolated from 600 patients (359 males and 241 females) with clinical symptoms of Lower respiratory tract infections (LRTI) (pneumonia and COPD) obtained from Najaf/Iraq Hospitals. Patients in the age groups 51-60 years had a high percentage of S. pneumoniae isolates (19.7%) compared with other age groups with a significant variation (P0.05). Smokers have been shown to have increased risk to LRTI than non-smokers (P>0.05), and there was no significant variation between Urban and Rural (56.8:43.2%) patients. S. pneumoniae showed different susceptibilities towards antibiotics used in this study. The highest rate of resistance was against erythromycin (100%), azithromycin (83.8%), clindamycin (83.8%) and trimethoprim/sulfamethaxzol (81.1%) and moderate resistance to ceftriaxone (67.6%), cefotaxime (64.9%), chloramphenicol (64.9%), tetracycline (59.5%) and benzylpenicillin (45.9%) whereas there was a relatively lower resistance towards others. The results of this study showed that S. pneumoniae isolates were found to be remarkable sensitive to Vancomycin (100%) and Imipenem (100%). In this study, sixteen antibiotics were tested for (MIC) against 37 S. pneumoniae isolates by using Vitek-2 antibiotic susceptibility testing (AST) cards (41497) AST-GP74. 100% and 83.8% of S. pneumoniae isolates were resistant to erythromycin and SXT with MIC ≥1 mg/ml and 4/76 mg/ml of these antibiotic respectively, and moderately resistant to cefotaxime 64.9%, ceftriaxone 64.9% and chloramphenicol 64.9% with MIC 4 mg/ml for CTX and CRO each one, and MIC 8 mg/ml for C only. All isolates showed 100% sensitivity for each of Vancomycin and Erythromycin with MIC mg/ml and ≤1 mg/ml and ≤2 mg/ml, respectively. S. pneumoniae isolates showed a high rate of sensitivity to Ertapenem 97.3% with MIC ≤1 mg/ml, Telithromycin 89.2% with MIC ≤1, Meropenem 86.5% with MIC ≤0.25 mg/ml.
To clarify the functional changes after hospitalization due to pneumonia in elderly Japanese patients, we investigated the changes in physical functioning, nutritional routes, and diet that occurred after hospitalization in patients with nursing and healthcare-associated pneumonia (NHCAP). We analyzed 405 patients with NHCAP and compared findings with 448 patients with community-acquired pneumonia (CAP). Among the NHCAP patients, 140 (34%) patients showed a decline in activities of daily living function between baseline and discharge. After hospital discharge, 149 (37%) NHCAP patients did not return to the same residence location compared with where they were living prior to hospital admission. The frequency of this outcome was significantly higher in NHCAP patients than in CAP patients (p < 0.0001). After 6 months' follow-up, of the patients who transferred to different hospitals, 41 (73%) patients with CAP had returned to their own home, but only 16 (20%) patients with NHCAP could return home (p < 0.0001). Rates of alteration of nutritional route and type of diet from oral nutrition were significantly higher in NHCAP patients compared with CAP patients (22% vs 4%, p < 0.0001). Our results demonstrated that approximately one-third of hospitalized patients with NHCAP showed a decline in physical function. In addition, approximately one-fifth of NHCAP patients had changed their route of nutrition and type of diet. Our results indicated that physicians should attach greater importance to preventative measures against NHCAP rather than relying on antibiotic therapy post-infection in the management of pneumonia in elderly patients in order to extend their healthy life expectancy.
The most common causes of airway inflammation are Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Staphylococcus aureus and Pseudomonas aeruginosa infection. It is important that atypical pathogens such as Mycoplasma pneumoniae, Chlamydophilla pneumoniae and Legionella pneumophila are responsible for severe infecftions. Bacterial pneumonia among the most dangerous and carries the highest risk of death are nosocomial infection.
During recent decades, specific phenotypes of patients with community-acquired pneumonia (CAP) have been described, exerting distinctive clinical features, severity, aetiology and outcome. Today, CAP in the elderly (≥65 years) clearly forms the core group within the concept of CAP. Clinical presentation may be oligosymptomatic, and comorbid conditions are present in a high proportion of patients. In contrast, CAP in younger patients (<65 years) has a more typical clinical presentation. Mortality is low and Mycoplasma pneumoniae is the second most common pathogen. The main feature of nursing home-acquired pneumonia is a very high mortality, which is mainly driven by poor functional status. Clinical presentation of patients with CAP and chronic obstructive pulmonary disease (COPD) is typically more severe, despite a similar mortality compared to patients without COPD. In addition, Pseudomonas aeruginosa has to be taken into account in patients with severe COPD.Aspirationasacauseof pneumonia is underdiagnosed. Patients suffering from dysphagia, for example, are at risk of recurrent pneumonia.
Lower respiratory tract infections are frequent in patients living in nursing homes. It is very important to distinguish the pneumonia from the bronchitis in order to give the most appropriate treatment and to increase the rational use of antibiotics. We propose herein a decision tree to help the therapeutic challenge.
Use of the pneumococcal conjugate vaccines among children in the U.S. since 2000 has dramatically reduced pneumococcal disease burden among adults. Significant vaccine-preventable morbidity and mortality from pneumococcal infections still remains, especially among older adults. The U.S. Advisory Committee on Immunization Practices (ACIP) has recently recommended the routine use of both pneumococcal conjugate (PCV13) and polysaccharide vaccines (PPSV23) for adults >= 65 years. These recommendations were based on the remaining burden of illness among adults and the importance of non-bacteremic pneumonia prevention in light of new evidence confirming the efficacy of PCV13 to prevent pneumococcal pneumonia among older adults. This paper reviews the evidence that led ACIP to make recommendations for PCV13 and PPSV23 use among adults, and highlights potential gaps to be addressed by future studies to inform adult vaccination policy. The changing epidemiology of invasive pneumococcal disease and pneumonia should be closely monitored to evaluate the effectiveness and continued utility of the current vaccination strategy, and to identify future directions for pneumococcal disease prevention among older adults.
The population worldwide continues to age, with those over the age of 80 years constituting the fastest-growing sector of the population. As one ages, infectious complications become more frequent, leading to higher rates of hospitalization. This is also true for the lung, where pneumonia is one of the most frequent causes for hospitalization in the elderly and is the number 3 cause of death in the United States. Several unique changes occur with aging, both in the structure and the function of the respiratory system itself and in the immune system, which increase the predisposition and the potential severity of pneumonia as one ages. In this review, we will highlight the risk factors that are associated with the increased incidence of pneumonia in the elderly and will explore the changes that occur with aging, with focus on the innate and the adaptive immune systems that increase their predisposition to infections.
Pneumonia in older adults residing in nursing homes can be challenging to diagnose and treat. Pneumococcal and influenza immunizations decrease the risk of pneumonia and are recommended for all nursing home patients. Older adults with pneumonia may not display classic signs and symptoms of infection, although most have at least one respiratory symptom. Suspicion of pneumonia is heightened if pulse oximetry measurements are low. The diagnosis of pneumonia is confirmed by chest radiography. To determine whether treatment is necessary and where treatment should occur, the patient's overall prognosis should be considered. If treatment is to occur, antibiotics should be administered as soon as possible for a duration of five to eight days; however, treatment may be extended in the absence of clinical resolution or in the presence of Pseudomonas aeruginosa. Oral antibiotics may be administered in the nursing home, whereas hospitalized patients should initially receive intravenous antibiotics and transition to oral antibiotics after clinical improvement. Antibiotic regimens for patients treated in the nursing home include a respiratory fluoroquinolone, or a beta-lactam antibiotic with a macrolide. Hospitalized patients may receive the same regimens, although several other oral and intravenous options are acceptable. Patients' prognosis can be accurately estimated using the SOAR score (which uses systolic blood pressure, oxygenation, age, and respiratory rate).
In 2026, the elderly population (age≥65 years) in Korea is projected to be 20.8% of the total population. Along with this rise will be the rise in need for medical care in geriatric hospitals. Geriatric inpatients are vulnerable to infections because of functional disabilities and comorbidities. We investigated the clinical features of pneumonia in the elderly at these facilities.
Pneumonia is a serious medical pathology frequent in elderly people. The physiological changes of the respiratory system linked with age reduce postural drainage capacities and increase the risk of acute respiratory failure. Associated with other comorbidities, chronic inhalation is a major risk factor of pneumonia in elderly people. Prevention is based on vaccination, nutrition, dental care and an adapted diet.
Copyright © 2012. Published by Elsevier Masson SAS.
Use of the pneumococcal conjugate vaccines among children in the US since 2000 has dramatically reduced pneumococcal disease burden among adults. Significant vaccine-preventable morbidity and mortality from pneumococcal infections still remains, especially among older adults. The US Advisory Committee on Immunization Practices (ACIP) has recently recommended the routine use of both pneumococcal conjugate (PCV13) and polysaccharide vaccines (PPSV23) for adults ≥65 years. These recommendations were based on the remaining burden of illness among adults and the importance of non-bacteremic pneumonia prevention in light of new evidence confirming the efficacy of PCV13 to prevent pneumococcal pneumonia among older adults. This paper reviews the evidence that led the ACIP to make recommendations for PCV13 and PPSV23 use among adults, and highlights potential gaps to be addressed by future studies to inform adult vaccination policy. The changing epidemiology of invasive pneumococcal disease and pneumonia should be closely monitored to evaluate the effectiveness and continued utility of the current vaccination strategy, and to identify future directions for pneumococcal disease prevention among older adults.
Published by Elsevier Ltd.
These revised recommendations of the Advisory Committee on Immunization Practices update recommendations published in MMWR in 1994 and include updated information on the two currently available vaccines and on vaccine safety. They also include an update on the epidemiology of enteric fever in the United States, focusing on increasing drug resistance in Salmonella enterica serotype Typhi, the cause of typhoid fever, as well as the emergence of Salmonella serotype Paratyphi A, a cause of paratyphoid fever, against which typhoid vaccines offer little or no protection.
On June 20, 2014, a Nebraska long-term care facility notified the East Central District Health Department (ECDHD) and Nebraska Department of Health and Human Services (NDHHS) of an outbreak of respiratory illness characterized by cough and fever in 22 residents and resulting in four deaths during the preceding 2 weeks. To determine the etiologic agent, identify additional cases, and implement control measures, Nebraska and CDC investigators evaluated the facility's infection prevention measures and collected nasopharyngeal (NP) and oropharyngeal (OP) swabs or autopsy specimens from patients for real-time polymerase chain reaction (PCR) testing at CDC. The facility was closed to new admissions until 1 month after the last case, droplet precautions were implemented, ill residents were isolated, and group activities were canceled. During the outbreak, a total of 55 persons experienced illnesses that met the case definition; 12 were hospitalized, and seven died. PCR detected Mycoplasma pneumoniae DNA in 40% of specimens. M. pneumoniae should be considered a possible cause of respiratory illness outbreaks in long-term care facilities. Morbidity and mortality from respiratory disease outbreaks at long-term care facilities might be minimized if facilities monitor for respiratory disease clusters, report outbreaks promptly, prioritize diagnostic testing in outbreak situations, and implement timely and strict infection control measures to halt transmission.
During its February 2015 meeting, the Advisory Committee on Immunization Practices (ACIP) recommended 9-valent human papillomavirus (HPV) vaccine (9vHPV) (Gardasil 9, Merck and Co., Inc.) as one of three HPV vaccines that can be used for routine vaccination. HPV vaccine is recommended for routine vaccination at age 11 or 12 years. ACIP also recommends vaccination for females aged 13 through 26 years and males aged 13 through 21 years not vaccinated previously. Vaccination is also recommended through age 26 years for men who have sex with men and for immunocompromised persons (including those with HIV infection) if not vaccinated previously. 9vHPV is a noninfectious, virus-like particle (VLP) vaccine. Similar to quadrivalent HPV vaccine (4vHPV), 9vHPV contains HPV 6, 11, 16, and 18 VLPs. In addition, 9vHPV contains HPV 31, 33, 45, 52, and 58 VLPs. 9vHPV was approved by the Food and Drug Administration (FDA) on December 10, 2014, for use in females aged 9 through 26 years and males aged 9 through 15 years. For these recommendations, ACIP reviewed additional data on 9vHPV in males aged 16 through 26 years. 9vHPV and 4vHPV are licensed for use in females and males. Bivalent HPV vaccine (2vHPV), which contains HPV 16, 18 VLPs, is licensed for use in females. This report summarizes evidence considered by ACIP in recommending 9vHPV as one of three HPV vaccines that can be used for vaccination and provides recommendations for vaccine use.
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.
Pneumonia is a major cause of morbidity and mortality leading to a high rate of hospitalization especially in theelderly. It is often a sign of frailty and is associated with a poor prognosis. However, taking into account the geriatric specificities (risk factors, atypical clinical presentations with "geriatric syndromes", ethical debate) using an interdisciplinary and a comprehensive geriatric approach remains an important responsibility of the general practitionner. This article summarizes these specificities and offers interventions targeted on the characteristics of elderly patients.
Nursing and healthcare-associated pneumonia (NHCAP) is a relatively new condition that was recently defined by the Japanese Respiratory Society. Previous reports and guidelines have not thoroughly investigated the adverse prognostic factors and validity of the selection criteria for NHCAP. The purpose of this research was to clarify the adverse prognostic factors of NHCAP and investigate the validity of the selection criteria with respect to patient deaths.
We retrospectively analyzed 418 patients with pneumonia who were admitted to our hospital between January 2009 and December 2011.
We analyzed 215 (51.4%) cases of community-acquired pneumonia (CAP) and 203 (48.6%) cases of NHCAP. NHCAP patients were generally older and had poorer performance status (PS), more complications, and higher levels of mortality than CAP patients. In both groups, the most common causative pathogen was Streptococcus pneumoniae. A multivariate analysis of NHCAP revealed that age≥80 years, oxygen saturation (SpO2)≤90%, and methicillin-resistant Staphylococcus aureus (MRSA) infection to be independent factors associated with mortality. Of the NHCAP selection criteria, a PS≥3 and a hospitalization history within the past 90 days were adverse prognostic factors in the broad community-acquired pneumonia category (CAP+NHCAP), according to a multivariate analysis. Univariate analysis revealed that admission to an extended care facility or nursing home was associated with death.
Our results demonstrated that age≥80 years, SpO2≤90%, and MRSA infection were adverse prognostic factors for NHCAP patients. Furthermore, we confirmed the validity of the NHCAP selection criteria.
Background
Cytomegalovirus (CMV) frequently is observed in immunocompromised hosts. The aim of this study was to report cases of ventilator-associated CMV pneumonia diagnosed by pathologic examination in intensive care patients without acquired immunodeficiency syndrome or hematologic malignancy or who were not receiving immunosuppressive agents.
Methods
From June 1, 1989, to May 31, 1994, 2,785 patients were hospitalized. During the study period, 60 autopsies and 26 open-lung biopsies were performed in nonimmunocompromised patients who were seen with acute respiratory failure and/or symptoms suggestive of ventilator-associated pneumonia. Cytomegalovirus pneumonia was diagnosed using pulmonary samples by the identification of large cells with large nuclei containing a basophilic or eosinophilic inclusion surrounded by a light halo. These typical findings always were associated with a diffuse interstitial pneumonitis.
Results
Cytomegalovirus pneumonia was diagnosed after histologic examination in 25 patients. The reason for admission to the intensive care unit was major surgery in 13 patients and medical problems in 12 patients. Ventilator-associated CMV pneumonia was diagnosed by histologic examination 22.4 +/- 8.8 days after admission to the intensive care unit (median 18 days; range 10-40 days). The clinical description was similar with the 25 patients who were seen with ventilator associated CMV pneumonia and the 61 patients without ventilator-associated CMV pneumonia. However, there was a more severe hypoxemia 72 +/- 16 vs. 95 +/- 41 mmHg, P < 0.05) and a higher Weinberg's radiologic score (9.2 +/- 1.9 vs. 7.4. +/- 2.7, P < 0.05) in the ventilator-associated CMV pneumonia group. Diagnosis of ventilator-associated CMV pneumonia was made for 9 of 17 patients when shell-vial culture technique using fluorescein-labelled antibody E 13 was performed on bronchoalveolar lavage products. Four of the eight patients treated by ganciclovir therapy died of multiple organ dysfunction syndrome.
Conclusions
The diagnosis of ventilator-associated CMV pneumonia should not be excluded in intensive care patients, even those without acquired immunodeficiency syndrome, hematologic malignancy, or immunosuppressive agents on admission.
Cytomegalovirus (CMV) frequently is observed in immunocompromised hosts. The aim of this study was to report cases of ventilator-associated CMV pneumonia diagnosed by pathologic examination in intensive care patients without acquired immunodeficiency syndrome or hematologic malignancy or who were not receiving immunosuppressive agents.
From June 1, 1989, to May 31, 1994, 2,785 patients were hospitalized. During the study period, 60 autopsies and 26 open-lung biopsies were performed in nonimmunocompromised patients who were seen with acute respiratory failure and/or symptoms suggestive of ventilator-associated pneumonia. Cytomegalovirus pneumonia was diagnosed using pulmonary samples by the identification of large cells with large nuclei containing a basophilic or eosinophilic inclusion surrounded by a light halo. These typical findings always were associated with a diffuse interstitial pneumonitis.
Cytomegalovirus pneumonia was diagnosed after histologic examination in 25 patients. The reason for admission to the intensive care unit was major surgery in 13 patients and medical problems in 12 patients. Ventilator-associated CMV pneumonia was diagnosed by histologic examination 22.4 +/- 8.8 days after admission to the intensive care unit (median 18 days; range 10-40 days). The clinical description was similar with the 25 patients who were seen with ventilator associated CMV pneumonia and the 61 patients without ventilator-associated CMV pneumonia. However, there was a more severe hypoxemia 72 +/- 16 vs. 95 +/- 41 mmHg, P < 0.05) and a higher Weinberg's radiologic score (9.2 +/- 1.9 vs. 7.4. +/- 2.7, P < 0.05) in the ventilator-associated CMV pneumonia group. Diagnosis of ventilator-associated CMV pneumonia was made for 9 of 17 patients when shell-vial culture technique using fluorescein-labelled antibody E 13 was performed on bronchoalveolar lavage products. Four of the eight patients treated by ganciclovir therapy died of multiple organ dysfunction syndrome.
The diagnosis of ventilator-associated CMV pneumonia should not be excluded in intensive care patients, even those without acquired immunodeficiency syndrome, hematologic malignancy, or immunosuppressive agents on admission.
To assess the risk and prognostic factors of community-acquired pneumonia occurring in the elderly (over age 65 yr) requiring hospitalization, two studies, case-control and cohort, were performed over an 8-mo period in a 1,000-bed university teaching hospital. We studied 101 patients with pneumonia (cases), age 78.5 +/- 7.9 yr (mean +/- SD). Each case was matched for sex, age (+/- 5 yr), and date of admission (+/- 2 d) with a control subject, without pneumonia during the preceding 3 yr, arriving at the emergency room. Etiologic diagnosis was obtained in 43 of 101 (42%) cases. The main microbial agents causing pneumonia were: Streptococcus pneumoniae (19 of 43, 44%), and Chlamydia pneumoniae (9 of 43, 21%). Gram-negative bacilli were uncommon (2 of 43, 5%). The multivariate analysis demonstrated that large-volume aspiration, and low serum albumin (< 30 mg/dl) were independent risk factors associated with the development of pneumonia. Crude mortality rate was 26% (26 of 101), while pneumonia-related mortality was 20% (20 of 101). The attributable mortality was 23% (odds ratio [OR]: 11.3; 95% confidence interval [CI]: 3.25 to 60.23; p < 0.0001). The multivariate analysis showed that patients had a worse prognosis if they were previously bedridden, had prior swallowing disorders, body temperature on admission was less than 37 degrees C, respiratory frequency was greater than 30/min or had three or more affected lobes on chest radiograph. Age by itself was not a significant factor related to prognosis. Among the significant risk factors, only nutritional status is probably amenable to medical intervention. The prognostic factors found in this study may help to identify, upon admission, those subjects at higher risk and who may require special observation.
Chlamydia pneumoniae has been associated with atherosclerosis and several other chronic diseases, but reports from different laboratories are
highly variable and “gold standards” are lacking, which has led to calls for more standardized approaches to diagnostic testing.
Using leading researchers in the field, we reviewed the available approaches to serological testing, culture, DNA amplification,
and tissue diagnostics to make specific recommendations. With regard to serological testing, only use of microimmunofluorescence
is recommended, standardized definitions for “acute infection” and “past exposure” are proposed, and the use of single immunoglobulin
(Ig) G titers for determining acute infection and IgA for determining chronic infection are discouraged. Confirmation of a
positive culture result requires propagation of the isolate or confirmation by use of polymerase chain reaction (PCR). Four
of 18 PCR assays described in published reports met the proposed validation criteria. More consistent use of control antibodies
and tissues and improvement in skill at identifying staining artifacts are necessary to avoid false-positive results of immunohistochemical
staining. These standards should be applied in future investigations and periodically modified as indicated.
Community-acquired pneumonia (CAP) in the elderly has increased as a consequence of an overall increase of the elderly population. A controversy about the aetiology and outcome of CAP in this population still exists and more epidemiological studies are needed. A prospective, 12-month, multicentre study was carried out to assess the clinical characteristics, aetiology, evolution and prognostic factors of elderly patients (> or = 65 yrs) admitted to hospital for CAP. The study included 503 patients (age 76 +/- 7 yrs). The clinical picture lasted < or = 5 days in 318 (63%) and the main clinical features were cough (n = 407, 81%) and fever (n = 380, 76%). Aetiological diagnosis was achieved in 199 (40%) cases, with a definite diagnosis obtained in 164 (33%). Of the 223 microorganisms isolated the main agents found were Streptococcus pneumoniae in 98 (49%) and Haemophilus influenzae in 27 (14%). A total of 53 patients died (11%) and the multivariate analysis showed the following factors of bad prognosis: previous bed confinement, alteration in mental status, absence of chills, plasma creatinine > or = 1.4 mg x dL(-1), oxygen tension in arterial blood/inspiratorv oxygen fraction ratio < 200 at the time of admission, and shock and renal failure during the evolution. The results of this study may aid in the management of empiric antibiotic treatment in elderly patients with community-acquired pneumonia and the patients who have a greater probability of bad evolution may be identified based on the risk factors.
Streptococcus pneumoniae is suspected to cause an important proportion of community-acquired pneumonia (CAP) whose aetiology cannot be detected with conventional tests. In this study, the authors evaluated the diagnostic yield of a new immunochromatographic membrane test (ICT) for the detection of the S. pneumoniae antigen in the urine of patients admitted with diagnosed CAP. ICT was performed in unconcentrated and concentrated urine from all the patients. ICT was repeated 1 month after discharge in a group initially testing positive. The authors also studied the ICT in clinically stable human immunodeficiency virus type 1 (HIV1)-infected patients. S. pneumoniae antigen was detected in all of the 68 (100%) patients tested with definitive pneumococcal pneumonia. In five of these cases ICT was only positive when it had been performed on the patients. The S. pneumoniae antigen was also detected in 36 (69.2%) of 52 patients with probable pneumococcal pneumonia and in 50 of 277 (18%) patients without pneumococcal pneumonia. ICT remained positive in 16 (69.5%) of 23 patients, 1 month after hospital discharge. Nasopharyngeal colonisation with S. pneumoniae was detected in 8 (12%) of 68 clinically stable HIV1 infected patients, but none tested ICT positive. The Binax NOW it immunochromatographic membrane test is a rapid, sensitive and specific test for detecting pneumococcal community-acquired pneumonia in adults. The test may remain positive for several weeks after pneumococcal pneumonia.
OBJECTIVE: To determine the extent and severity of illness and mode of transmission of Chlamydia pneumoniae infection in 3 nursing home outbreaks. DESIGN & SETTING: Retrospective cohort study in 3 nursing homes in Ontario from September to November 1994. SUBJECTS: A total of 549 residents and 65 staff members. MAIN OUTCOME MEASURES: Morbidity and mortality were determined by a review of disease surveillance forms, residents' charts, and a self-administered questionnaire to staff. Single and paired serum samples for C. pneumoniae serological testing and nasopharyngeal swabs for C. pneumoniae culture were collected, and direct fluorescent antibody assays were performed to confirm C. pneumoniae infection. RESULTS: The attack rates for confirmed and suspected cases combined were 68%, 46%, and 44% among residents in nursing homes A, B, and C, respectively, and 34% among nursing home C staff. A total of 16 cases of pneumonia confirmed by chest x-ray and 6 deaths were identified. The spectrum of illness among nursing home C residents included a new cough in 58 (100%), fever in 37 (64%), sore throat in 14 (24%), and hoarseness in 8 (14%). Staff members at nursing home C were more likely to report hoarseness (p < 0.001) and sore throat (p < 0.001). Residents who smoked had onset of illness earlier than nonsmokers (p = 0.007), which perhaps is related to airborne transmission in a designated smoking room. CONCLUSIONS: Chlamydia pneumoniae caused serious morbidity and mortality among residents and morbidity among staff; C. pneumoniae is an important cause of respiratory disease outbreaks in nursing homes, and diagnostic tests must be readily available for early recognition of C. pneumoniae infections.
Chlamydia pneumoniae has been found to be associated with cerebrovascular and cardiovascular diseases in seroepidemiologic studies. The aim of this study was to investigate whether this organism is associated with increased intima media thickness (IMT) of carotid arteries in asymptomatic individuals. Serum titer of antibodies to C pneumoniae antibodies IgA and IgG in 100 asymptomatic individuals older than 40 years was measured by microimmunofluorescence. These subjects also had their IMT measured by B-mode ultrasound in the common carotid artery on both sides. Comparison of baseline characteristics between the group with abnormal IMT (>0.08 cm) and group having normal IMT (<or=0.08 cm) showed significant association of C pneumoniae antibodies and hypertension with the former (i.e., abnormal IMT group). Multiple logistic regression (stepwise method) established C pneumoniae as an independent risk factor for increased IMT. To conclude, this study demonstrated that C pneumoniae infection is associated with an increase of IMT in the common carotid artery.
Pneumonia is a leading killer of children in developing countries and results in significant morbidity worldwide. This article reviews the management of pneumonia and its complications from the perspective of both developed and resource-poor settings. In addition, evidence-based management of other respiratory infections, including tuberculosis, is discussed. Finally, the management of common complications of pneumonia is reviewed.
To determine the extent and severity of illness and mode of transmission of Chlamydia pneumoniae infection in 3 nursing home outbreaks.
Retrospective cohort study in 3 nursing homes in Ontario from September to November 1994.
A total of 549 residents and 65 staff members.
Morbidity and mortality were determined by a review of disease surveillance forms, residents' charts, and a self-administered questionnaire to staff. Single and paired serum samples for C pneumoniae serological testing and nasopharyngeal swabs for C pneumoniae culture were collected, and direct fluorescent antibody assays were performed to confirm C pneumoniae infection.
The attack rates for confirmed and suspected cases combined were 68%, 46%, and 44% among residents in nursing homes A, B, and C, respectively, and 34% among nursing home C staff. A total of 16 cases of pneumonia confirmed by chest x-ray and 6 deaths were identified. The spectrum of illness among nursing home C residents included a new cough in 58 (100%), fever in 37 (64%), sore throat in 14 (24%), and hoarseness in 8 (14%). Staff members at nursing home C were more likely to report hoarseness (P<.001) and sore throat (P<.001). Residents who smoked had onset of illness earlier than nonsmokers (P=.007), which perhaps is related to airborne transmission in a designated smoking room.
Chlamydia pneumoniae caused serious morbidity and mortality among residents and morbidity among staff; C pneumoniae is an important cause of respiratory disease outbreaks in nursing homes, and diagnostic tests must be readily available for early recognition of C pneumoniae infections.
The etiology of severe pneumonia requiring mechanical ventilation in the very elderly has been imprecise because of lack of comprehensive studies and low yield of diagnostic approach. Overall, 104 patients 75 yr of age and older with severe pneumonia were studied prospectively at two university-affiliated hospitals. Microbial investigation included blood culture, serology, pleural fluid, and bronchoalveolar secretions. Streptococcus pneumoniae (14%), gram-negative enteric bacilli (14%), Legionella sp. (9%), Hemophilus influenzae (7%), and Staphylococcus aureus (7%) were the predominant pathogens in community-acquired pneumonia (CAP). Staphylococcus aureus (29%), gram-negative enteric bacilli (15%), Streptococcus pneumoniae (9%), and Pseudomonas aeruginosa (4%) accounted for most isolates of nursing home-acquired pneumonia (NHAP). The case fatality rate was 55% (53% for CAP and 57% for NHAP; p > 0.5). Activity of Daily Living (ADL) Index, pulmonary, endocrine and central nervous system (CNS) comorbidities were associated with distinct microbial etiology. By multivariate analysis, hospital mortality was associated independently with 24-h urine output (odds ratio [OR], 5.6; 95% confidence interval [CI], 2.5 to 7.9; p < 0.001), septic shock (OR, 4.3; 95% CI, 1.9 to 8.9; p = 0.0059), radiographic multilobar involvement (OR, 3.7; 95% CI, 1.8 to 15.6; p = 0.02), and inadequate antimicrobial therapy (OR, 2.6; 95% CI, 1.4 to 23.9; p = 0.034). Further studies should focus on identifying effective antimicrobial regimens in randomized trials.
Nursing home acquired pneumonia (NHAP) is thought to be clinically distinct from community acquired pneumonia (CAP). This observation, based on studies conducted mainly in North America, may not be relevant in countries with a different healthcare system.
The authors describe an 18-month prospective cohort study of 437 patients admitted to hospital with CAP, 40 (9%) of whom came from nursing homes. Detailed microbiological tests were performed in a subset of patients over 12 months.
Patients with NHAP were less likely to have a productive cough (odds ratio (OR) 0.4, p=0.02) or pleuritic pain (OR 0.1, p=0.03), but they were more likely to be confused (OR 2.6, p<0.001). They had poorer functional status (p<0.001) and more severe disease (p=0.03). Mortality was higher compared to CAP (53% versus 13%), but this was mainly explained by prior functional status (OR 0.5, after adjustment for functional status). Pathogens were identified in 68% of 22 NHAP and 80% of 44 matched CAP patients. Streptococcus pneumoniae was the most common (55% NHAP, 43% CAP). Atypical pathogens, enteric Gram negative bacilli and Staphylococcus aureus were uncommon.
In conclusion, differences in functional status accounted for the increased mortality in nursing home acquired pneumonia compared to community acquired pneumonia. The pathogens implicated were similar. No grounds for a difference in choice of empirical antibiotics were apparent.
To examine the epidemiology of invasive pneumococcal disease in older adults hospitalized for invasive pneumococcal disease who are living in the community and in long-term care facilities (LTCFs) in the United States.
Analysis of 2402 cases of invasive pneumococcal disease requiring hospitalization in 2000 and 2001 that the Centers for Disease Control and Prevention's Active Bacterial Core Surveillance collected in nine states.
Hospital.
Hospitalized LTCF residents and community-living older adults in the United States.
Age- and residence-specific pneumococcal disease incidence rates per 100000 persons, case-fatality rates, and trends in antimicrobial resistance.
Nationally, the rate of invasive pneumococcal disease in LTCF residents was 194.2 cases per 100000 persons aged 65 and older and 44.6 for community-living older adults (relative risk=4.4, 95% confidence interval (CI)=4.2-4.5). Compared with community-living older adults, case-fatality rates were 1.9 times higher (30.8% vs 16.0%, 95% CI=1.5-2.5). Pneumococcal strains from LTCF residents were significantly more likely to be nonsusceptible to levofloxacin than strains from community- living older adults (5.7% vs 0.4%, P<.001).
Older adults living in LTCFs are at a higher risk for invasive pneumococcal disease and death than are community-living older adults. Additionally, fluoroquinolone resistance is significantly higher in older adults living in LTCFs and may provide clues to emerging antimicrobial resistance in the general population.
Pneumonia is a major medical problem in the very old. The increased frequency and severity of pneumonia in the elderly is largely explained by the ageing of organ systems (in particular the respiratory tract, immune system, and digestive tract) and the presence of comorbidities due to age-associated diseases. The most striking characteristic of pneumonia in the very old is its clinical presentation: falls and confusion are frequently encountered, while classic symptoms of pneumonia are often absent. Community-acquired pneumonia (CAP) and nursing-home acquired pneumonia (NHAP) have to be distinguished. Although there are no fundamental differences in pathophysiology and microbiology of the two entities, NHAP tends to be much more severe, because milder cases are not referred to the hospital, and residents of nursing homes often suffer from dementia, multiple comorbidities, and decreased functional status. The immune response decays with age, yet pneumococcal and influenza vaccines have their place for the prevention of pneumonia in the very old. Pneumonia in older individuals without terminal disease has to be distinguished from end-of-life pneumonia. In the latter setting, the attributable mortality of pneumonia is low and antibiotics have little effect on life expectancy and should be used only if they provide the best means to alleviate suffering. In this review, we focus on recent publications relative to CAP and NHAP in the very old, and discuss predisposing factors, microorganisms, diagnostic procedures, specific aspects of treatment, prevention, and ethical issues concerning end-of-life pneumonia.
To evaluate the efficacy of a rapid immunochromatographic membrane test (ICT) for the detection of Streptococcus pneumoniae urinary antigen for diagnosing S. pneumoniae pneumonia, ICT was performed with urine samples using the Binax NOW Streptococcus pneumoniae kit at the time of admission. The results were compared with those from conventional microbiological studies. Three hundred and forty-nine adult patients with CAP who were admitted to the hospital were studied prospectively between February 2001 and January 2004. The ICT test was positive in 115 (33.0%) of 349 patients enrolled into the study and in 63 (75.9%) of 83 patients with pneumococcal pneumonia confirmed by conventional methods. The test revealed a sensitivity of 75.9% and a specificity of 94.0% with conventional microbiological criteria used as the reference standard. The positive predictive value was 91.3%, and the negative predictive value was 82.6%. The clinical features of 53 patients in whom ICT was positive and no pathogen was identified showed no significant difference from those of 83 patients who had pneumococcal pneumonia identified by conventional methods. The diagnostic yield of pneumococcal pneumonia was increased up to 38.9% using ICT combined with conventional methods. The Binax NOW ICT to detect S. pneumoniae urinary antigen is therefore a rapid and useful method for diagnosing pneumococcal pneumonia. Induction of ICT will prove the predominance of S. pneumoniae in the etiology of CAP.
Multiple studies have suggested an association between Chlamydia pneumoniae and Mycoplasma pneumoniae infection and cardiovascular disease. We investigated whether the risk of cerebrovascular disease is associated with Legionella pneumophila infection and the aggregate number/infectious burden of these atypical respiratory pathogens.
One hundred patients aged >65 years admitted with acute stroke or transient ischemic attack (TIA) and 87 control patients admitted concurrently with acute noncardiopulmonary, noninfective conditions were recruited prospectively. Using enzyme-linked immunosorbent assay (ELISA) kits, we previously reported the seroprevalences of C pneumoniae and M pneumoniae in these patients. We have now determined the seroprevalences of L pneumophila IgG and IgM in this cohort of patients using ELISA.
The seroprevalences of L pneumophila IgG and IgM were 29% (n=91) and 12% (n=81) in the stroke/TIA group and 22% (n=86) and 10% (n=72) in the controls, respectively. Using logistic regression to adjust for age, sex, hypertension, smoking, diabetes, ischemic heart disease, and ischemic ECG, the odds ratios for stroke/TIA in relation to L pneumophila IgG and IgM were 1.52 (95% CI, 0.70 to 3.28; P=0.29) and 1.49 (95% CI, 0.45 to 4.90; P=0.51), respectively. The odds ratios in relation to IgG seropositivity for 1, 2, or 3 atypical respiratory pathogens after adjustment were 3.89 (95% CI, 1.13 to 13.33), 2.00 (95% CI, 0.64 to 6.21), and 6.67 (95% CI, 1.22 to 37.04), respectively (P=0.06).
L pneumophila seropositivity is not significantly associated with stroke/TIA. However, the risk of stroke/TIA appears to be associated with the aggregate number of chronic infectious burden of atypical respiratory pathogens such as C pneumoniae, M pneumoniae, and L pneumophila.
Review of recent studies (2003 and 2004) concerning pneumonia in the very old.
Hospitalisation for community-acquired pneumonia (CAP) in the elderly is associated with a high mortality and with a high rate of readmission within the following year. Functional status, altered mental status, number of comorbidities, aspiration pneumonia, renal failure, and nutritional status are all indicators of adverse prognosis. Although Streptococcus pneumoniae, Haemophilus influenzae, Enterobacteriacae, and Staphylococcus aureus are the most frequently identified causative microorganisms, viruses account for up to 26% of hospital admissions for CAP. Chlamydia pneumoniae is also implicated in CAP and in nursing-home-acquired pneumonia (NHAP), with recent reports of outbreaks in nursing homes. Aspiration pneumonia is frequent in the elderly and occurs with increased frequency in patients with nasogastric tubes or percutaneous enterogastric tubes. In severe aspiration pneumonia, 20% of organisms implicated are anaerobic and 80% aerobic, most of which are gram-negative Enterobacteriaceae. Poor oral hygiene increases subsequent risk of pneumonia: dental plaque may act as a reservoir for pathogenic organisms implicated in CAP or NHAP. Prevention of CAP and NHAP relies on the combined use of influenza and pneumococcal vaccination, which decreases hospital admissions and in-hospital mortality for CAP.
Recent studies stress the importance of aspiration as a frequent mechanism of CAP, provide new insights as to causative organisms in this setting, and underline the contribution of combined vaccination in reducing morbidity and mortality.
Pneumonia represents the leading cause of infection-related death and the fifth cause of overall mortality, in the elderly. Several risk factors for acquiring pneumonia in older age have been reported, such as alcoholism, lung and heart diseases, nursing home residence and swallowing disorders. The clinical characteristics of pneumonia in the elderly differ substantially compared with younger patients, and the severity of the disease is strongly associated with increased age and age-related comorbidities. Streptococcus pneumoniae is the leading pathogen responsible for pneumonia in elderly; enteric Gram-negative rods should be considered in nursing-home-acquired pneumonia, as well anaerobes in patients with aspiration pneumonia. Antimicrobial therapy should take into account the most recent guidelines, which are briefly presented in this review. A special consideration should be given to the preventive measures, including vaccination, oral care and nutrition.
The lack of specific tests for the diagnosis of chronic Chlamydia pneumoniae infection has led to the use of enzyme immunoassay (EIA) instead of the gold standard, that is, microimmunofluorescence (MIF), in the measurement of C. pneumoniae antibodies. We assessed the predictive values of C. pneumoniae antibody levels and seroconversions measured by MIF and EIA for coronary events in the prospective Helsinki Heart Study. Sera from 239 cases with coronary events and 239 controls were available at the baseline and data from 210 cases and 211 controls before and after the event. The agreement between MIF and EIA antibody levels was best in high antibody titers. In conditional logistic regression analysis, only high IgA MIF titers (>/=40) at the baseline predicted future coronary events, and the participants with MIF seroconversion between consecutive sera had a higher (nonsignificant) risk for coronary events than the controls. The difference in the kinetics of EIA and MIF antibodies demonstrated that MIF should remain the gold standard.
There are no prospective comparison of the etiology and clinical outcome between hospital-acquired pneumonia (HAP) and nursing home-acquired pneumonia (NHAP) in non-intubated elderly. This study prospectively evaluated the etiology of HAP and NHAP in non-intubated elderly. A prospective cohort study was carried out in a rural region of Japan where the population over 65 years of age represents 30% of the population. A total of 108 patients were enrolled. There were 33 patients with HAP and 75 with NHAP. Etiologic diagnosis was established in 78.8% of HAP and in 72% of NHAP patients. The most frequent pathogens were Chlamydophila pneumoniae followed by Streptococcus pneumoniae, Staphylococcus aureus and Influenza virus. The frequency of Streptococcus pneumoniae and Influenza virus was significantly higher, whereas the frequency of Staphylococcus aureus and Enterobacteriaceae was significantly lower in NHAP compared to HAP. Performance and nutritional status were significantly worse in patients with HAP than in those with NHAP. Hospital mortality was significantly lower in patients with NHAP compared to those with HAP. This study demonstrated that C. pneumoniae, Streptococcus pneumoniae, Staphylococcus aureus and Influenza virus are frequent causative agents of pneumonia in non-intubated elderly and that the responsible pathogens and clinical outcome differ between NHAP and HAP.
Binax NOW Streptococcus pneumoniae kit, Binax Inc, USA) and Legionella pneumophila
- Positive
- S Antigen
- Pneumoniae
positive urinary antigen for S. pneumoniae (Binax NOW Streptococcus pneumoniae kit, Binax Inc, USA) and Legionella pneumophila (Legionella Urine Antigen EIA, Biotest AG, Germany);
Pneumonia in the elderly working group, area de tuberculosis e infecciones respira-torias. Community-acquired pneumonia in the elderly: spanish multicentre study
- Torres R A Zalacain
- Celis R J Blanquer
- Esteban J L Aspa
- R Mené
- R Blanquer
- Borderí
Zalacain R, Torres A, Celis R, Blanquer J, Aspa J, Esteban L, Mené R, Blanquer R, Borderí L. Pneumonia in the elderly working group, area de tuberculosis e infecciones respira-torias. Community-acquired pneumonia in the elderly: spanish multicentre study. Eur Respir J 2003;21:294e302.
Etiology of severre pneumonia in the very elderly ATS and IDSAGuidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associ-ated pneumonia
- El-Solh Aa
- Ramadan P F Sikka
- Davies
El-Solh AA, Sikka P, Ramadan F, Davies J. Etiology of severre pneumonia in the very elderly. Am J Respir Crit Care Med 2001; 163:645e51. 8. ATS and IDSAGuidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associ-ated pneumonia. Am J Respir Crit Care Med 2005;171:388e416.
Standardizing Chla-mydia pneumoniae assays: recommendtions from the centers for disease control and prevention (USA) and the laboratory center for disease control (Canada)
- Dowell
- Sf
- Peeling Rw
- J Boman
Dowell SF, Peeling RW, Boman J, et al. Standardizing Chla-mydia pneumoniae assays: recommendtions from the centers for disease control and prevention (USA) and the laboratory center for disease control (Canada). Clin Infect Dis 2001;33: 492e502.
ATS and IDSAGuidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia
ATS and IDSAGuidelines for the management of adults with
hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388e416.
Cytomegalovirus. An unexpected cause of ventilator-associated pneumonia
- Papazian
Guidelines for the management of community acquired pneumonia in adults, revised edition
- Committee for The Japanese Respiratory Society guidelines for the management of respiratory infections
Pneumonia in the elderly
- R Jordi
- G Miquel
Pneumonia in the elderly working group, area de tuberculosis e infecciones respiratorias. Community-acquired pneumonia in the elderly: spanish multicentre study
- Zalacain