Recent Advances in Community-Acquired Pneumonia: Inpatient and Outpatient

doi:10.1378/chest.06-1994

Chest

Volume 131, Issue 4, April 2007, Pages 1205-1215

https://doi.org/10.1378/chest.06-1994 Get rights and content

Community-acquired pneumonia (CAP) is a common illness, with the majority of patients treated out of the hospital, yet the greatest burden of the cost of care comes from inpatient management. In the past several years, the management of these patients has advanced, with new information about the natural history and prognosis of illness, the utility of serum markers to guide management, the use of appropriate clinical tools to guide the site-of-care decision, and the finding that guidelines can be developed in a way that improves patient outcome. The challenges to patient management include the emergence of new pathogens and the progression of antibiotic resistance in some of the common pathogens such as Streptococcus pneumoniae. Few new antimicrobial treatment options are available, and the utility of some new therapies has been limited by drug-related toxicity. Ancillary care for severe pneumonia with activated protein C and corticosteroids is being studied, but recently, inpatient care has been most affected by the development of evidence-based “core measures” for management that have been promoted by the Centers for Medicare and Medicaid Services, which form the basis for the public reporting of hospital performance in CAP care.

Section snippets

Understanding the Natural History and Prognosis of CAP

Most of the studies of CAP have examined the short-term outcomes of the illness, focusing on either 30-day or inpatient mortality. Kaplan and colleagues¹ used a Medicare database to perform a matched case-control study to evaluate the long-term impact (ie, 1-year mortality rate) of older patients with CAP. The authors compared 158,960 CAP patients to 794,333 hospitalized control subjects (5 for each patient) matching for age, sex, and race. While the in-hospital mortality rate for CAP patients

Drug-Resistant Pneumococcus

While the clinical relevance of DRSP continues to be debated, recent data¹⁴ have suggested that the frequency of some forms of drug resistance may be stabilizing or declining, while concerns still remain for other classes of antibiotics. Using data from 2002 to 2003, Doern et al¹⁴ studied 1,817 pneumococcal respiratory isolates from 44 US centers and observed that while penicillin resistance was present (34.2%), it was not occurring with an increased frequency. They found that 15.7% of isolates

New Approaches to Therapy

Guidelines for CAP have stressed the approach of empiric therapy, recognizing the difficulty of obtaining pathogen-specific data that allow the early focusing of initial therapy choices. One recent study²⁴ found that when therapy was given according to guidelines, it led to patients becoming clinically stable sooner than if other therapy had been used. However, the value of empiric therapy was evaluated directly in a study from the Netherlands²⁵ that used a prospective, randomized, open study

Core Measures for Inpatient Care

Since 1998, the CMS, in conjunction with the Joint Commission on the Accreditation of Healthcare Organizations, has promoted standards of care for CAP patients that have been shown to improve outcomes, with the expectation that hospitals will meet these standards whenever possible (Table 1). The pressure to achieve a high compliance rate with these measures has increased with the move to collect data on compliance and to publicly report the information. The evidence that supports these core

Conclusion

While the studies of CAP in the past several years have tackled a large number of important topics, the general direction of new developments, which have been discussed in this review, has been to describe ways to improve patient management and patient outcomes. Many of the findings have been incorporated into performance measures related to disease management, and the evidence base to support these recommendations is strong and continues to expand.

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Cited by (71)

Admission IL-32 concentration predicts severity and mortality of severe community-acquired pneumonia independently of etiology
2020, Clinica Chimica Acta
Citation Excerpt :
The CURB-65 [18], developed by the British Thoracic Society, including five items, which is simpler to calculate than PSI. However, CURB-65 does not account for comorbidities, thus, this approach easy to underestimate the mortality in elderly patients who may decompensate significantly even with mild pneumonia [22]. Since false-positive or -negative results could not be avoided in both scoring systems, adding easily accessible and objective biomarkers may help quickly assess the severity of disease, improve the accuracy of the two scoring systems, guide for clinical decision-making and rational use of intensive care resources, and is conducive to reducing mortality.
Severe community-acquired pneumonia (SCAP) is a critical disorder with high morbidity and mortality, usually manifested as acute respiratory failure and septic shock generally caused by exaggerated systemic inflammation. Interleukin-32 (IL-32), a pro-inflammatory cytokine, has been reported involved in various infectious diseases. We investigated the efficacy of the plasma IL-32 as a biomarker for evaluating the severity and clinical outcomes in SCAP patients.
A total of 124 adult immunocompetent SCAP patients and 87 healthy controls were enrolled in this observational, prospective cohort study.
We found that PBMCs IL-32 mRNA and plasma IL-32 concentrations on admission of SCAP patients were significantly higher than healthy controls. Plasma IL-32 concentrations closely correlated with increasing severity scores, the need for vasopressor support or invasive mechanical ventilation but not with the etiology. The area under the curve (AUC) for predicting 30-day mortality using IL-32 was 0.812, is superior to WBCs and CRP. Incorporation of IL-32 with the severity scores were shown to improve the prognostic accuracy considerably. Furthermore, the 30-day cumulative survival rate in high IL-32 concentration group was significantly lower than that in the low concentration group. In a multivariate Cox regression analysis, higher IL-32 concentration and higher PSI score were recognized as the independent risk factors for survival, and the relative risks were 2.568 and 3.362, respectively.
Admission IL-32 concentration closely related to the severity and mortality of SCAP, and it may be served as a potential biomarker to help clinical judgment and management.
Usefulness of plasma neutrophil gelatinase-associated lipocalin concentration for predicting the severity and mortality of patients with community-acquired pneumonia
2016, Clinica Chimica Acta
Citation Excerpt :
Although the PSI and CURB-65 score are widely used to assess disease severity and to predict hospital mortality, they fall short of expectations. The PSI occasionally underestimates the severity of illness in young adults, whereas the CURB-65 criteria do not generally account for comorbid conditions [9]. Jeong et al. demonstrated that the performance of the Acute Physiology and Chronic Health Evaluation II (APACHE II) is significantly superior for predicting mortality compared with the PSI and CURB-65 score [10].
The usefulness of plasma neutrophil gelatinase-associated lipocalin (NGAL) concentration for predicting the outcome of community-acquired pneumonia (CAP) is unclear. We evaluated the prognostic value of plasma NGAL concentration for predicting disease severity in comparison with other widely used biological markers of inflammation in patients with CAP.
NGAL, procalcitonin, and C-reactive protein concentrations were measured in 362 patients with CAP, who were followed for up to 30 days. The Pneumonia Severity Index (PSI) and CURB-65 score were obtained for all patients.
The median plasma NGAL concentration increased with CAP severity classified according to the PSI. Plasma NGAL concentration was higher in nonsurvivors than in survivors. The AUC for predicting mortality was highest for NGAL concentration (0.871), followed by that for PSI (0.865) and procalcitonin concentration (0.744). Multivariable logistic regression analysis showed that plasma NGAL concentration was an independent predictor of hospital mortality in CAP patients. Plasma NGAL concentration correlated positively with C-reactive protein and procalcitonin concentrations, CURB-65 score, and PSI.
Plasma NGAL concentration is a valuable biological marker in the assessment of the severity and prediction of the prognosis of patients with CAP in the emergency department.
Management of severe community-acquired pneumonia: A survey on the attitudes of 468 physicians in Iberia and South America
2014, Journal of Critical Care
The purpose of this study is to characterize the practices of pulmonary, internal medicine, and critical care physicians toward the management of patients with severe community-acquired pneumonia (CAP).
A cross-sectional international anonymous survey was conducted among a convenience sample of critical care, pulmonary, emergency, and internal medicine physicians from Portugal, Spain, and South America between October and December 2008. The electronic survey evaluated physicians’ attitudes toward diagnosis, risk assessment, and therapeutic interventions for patients with severe CAP.
Four hundred sixty-eight physicians responded being 84.6% from 4 countries (Brazil, Portugal, Spain, and Argentina) whom 66.9% had more than 10 years experience. Risk assessment of severe CAP was very heterogeneous being clinical evaluation the most frequent. Although blood cultures were recognized as presenting a poor diagnostic performance, they were performed by 77.1%. In opposition, the presence of urinary pneumococcal and Legionella antigen was asked by less than one-third of physicians. The great majority (95%) prescribes antibiotics according to a guideline being the combination of β-lactam plus macrolide the most frequent choice.
Despite the recent advances of knowledge reflected in the present study in the management of severe CAP, several of them are still incompletely translated into clinical practice. Significant variation in practice is observed among physicians and represents a potential target for future research and educational interventions.
Severe Community-Acquired Pneumonia
2013, Critical Care Clinics
Citation Excerpt :
The CURB-65 appears to be more discriminatory compared with the PSI among patients requiring hospital admission; with a score of greater than or equal to 3 denoting severe disease, which may warrant ICU admission. In contrast, the lack of comorbid disease burden in CURB-65 makes it easy to underestimate the mortality risk in elderly, frail patients who may decompensate significantly even with mild pneumonia.142 Current IDSA/ATS guidelines propose their own set of criteria, suggesting that patients be admitted to the ICU if they have 1 major or 3 minor criteria (see Box 1).27
The association between serum complement C3a and severity in patients with community-acquired pneumonia
2023, Frontiers in Immunology
Clinical muscle mass-related biomarkers that predict mortality in older patients with community-acquired pneumonia
2022, BMC Geriatrics

View all citing articles on Scopus

: Dr. Niederman has been a speaker, consultant, or researcher for Schering, Johnson and Johnson, Aventis, Pfizer, Bayer, Merck, Elan, and Wyeth.

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Recent Advances in Chest MedicineRecent Advances in Community-Acquired Pneumonia: Inpatient and Outpatient

Section snippets

Understanding the Natural History and Prognosis of CAP

Drug-Resistant Pneumococcus

New Approaches to Therapy

Core Measures for Inpatient Care

Conclusion

Clin Ther

Am J Med

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Int J Antimicrob Agents

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Pneumonia: still the old man’s friend?

Arch Intern Med

Prognosis after community-acquired pneumonia in the elderly: a population-based 12 year follow-up study

Am J Med

Combining information from prognostic scoring tools for CAP: an American view on how to get the best of all worlds

Eur Respir J

Severe community-acquired pneumonia as a cause of severe sepsis: data from the PROWESS study

Crit Care Med

Validation of a predictive rule for the management of community-acquired pneumonia

Eur Respir J

Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial

Am J Respir Crit Care Med

Diagnostic and prognostic values of admission procalcitonin levels in community-acquired pneumonia in an intensive care unit

Infection

Procalcitonin kinetics in the prognosis of severe community-acquired pneumonia

Intensive Care Med

Recent Advances in Chest Medicine
Recent Advances in Community-Acquired Pneumonia: Inpatient and Outpatient