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Bacteremic pneumococcal pneumonia: clinical outcomes and preliminary results of inflammatory response

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Abstract

Purpose

Further examination of clinical outcomes and inflammatory response of bacteremic pneumococcal community-acquired pneumonia (CAP) is of great interest to enhance the care of patients with pneumococcal CAP.

Methods

This is a secondary analysis of the Community Acquired Pneumonia Organization (CAPO) to compare the time to clinical stability (TCS), length of hospital stay (LOS), and in-hospital mortality of hospitalized pneumococcal CAP patients with and without bacteremia. To measure the effect of bacteremia in pneumococcal CAP patients on outcomes, we modeled all-cause in-hospital mortality using a Poisson regression model, and TCS and LOS using Cox proportional hazards models. Adjusted multivariate regression models were also used to predict the probability of occurrence of each of the study outcomes. To investigate the inflammatory response, we measured the plasma levels of pro- and anti-inflammatory cytokines [tumor necrosis factor (TNF)-α, interleukin (IL)-1rα, IL-6, IL-8, IL-10], inflammatory biomarkers [C-reactive protein (CRP), pro-calcitonin (PCT), and B-type natriuretic peptide (BNP)], and peripheral blood neutrophil responses in 10 patients, 4 bacteremic and 6 non-bacteremic pneumococcal CAP, upon admission and every other day during the first 6 days of hospitalization. Functional data were presented as median and standard error of the median (SEM); due to small number of samples no statistical comparisons were performed between groups.

Results

From 833 pneumococcal CAP patients, 394 patients (47 %) were bacteremic. Bacteremic pneumococcal CAP were less likely to reach TCS with an adjusted hazard ratio (AHR) of 0.82 (95 % CI 0.69–0.97; p = 0.02) and had higher in-hospital mortality with an AHR of 1.63 (95 % CI 1.06–2.50, p = 0.026). Bacteremic pneumococcal CAP patients had a longer LOS than non-bacteremic pneumococcal CAP (p < 0.003). Higher plasma levels of CRP, PCT, and BNP were found in bacteremic than in non-bacteremic patients. The bacteremic group had consistently higher plasma levels of both pro- and anti-inflammatory cytokines. The blood neutrophil functional responses were similar in both groups of patients.

Conclusions

Bacteremic pneumococcal CAP patients were significantly associated with higher in-hospital mortality, lower TCS, and longer LOS. HIV-infected patients showed a greater mortality which was not statistically significant. Bacteremic pneumococcal CAP patients had higher levels of biomarkers and systemic cytokines.

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Acknowledgments

The authors gratefully acknowledge the work of the CAPO investigators in building and maintaining the CAPO dataset. The CAPO investigators and affiliations are: Region I—United States of America: Drs. Julio Ramirez, Forest Arnold and Paula Peyrani, University of Louisville Hospital, Louisville, KY; Dr. Raul Nakamatsu, Veterans Affairs Medical Center, Louisville, KY; Dr. Stephen Blatt, Good Samaritan Hospital, Cincinnati; Dr. Jose Bordon, Providence Hospital, Washington, D.C.; Dr. Steven Burdette, Greene Memorial Hospital, Dayton; Dr. Thomas File, Jr., Northeastern Ohio Universities, Summa Health System, Akron, OH, and Orlando Regional Medical Center, Orlando, FL; Dr. Peter Gross, Hackensack University Medical Center, Hackensack, NJ; Daniel Musher, Michael E. DeBakey Veterans Affairs Medical Center, Houston; Belinda Ostrowsky, Montefiore Medical Center, Weiler Hospital, New York, NY; Dr. Marcos Restrepo, University of Texas Health Sciences Center Hospital, San Antonio; Canada: Dr. Thomas Marrie, University of Alberta Hospital, Sturgeon Community Hospital, Grey Nuns Hospital, and Royal Alexandra Hospital, Edmonton, Alberta; Dr. Karl Weiss, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal; Region II—Andorra: Dr. Jorge Roig, Hospital Nostra Senyora de Meritxell, Escaldes; Germany: Dr. Harmut Lode, City Hosp. E.v.Behring/Lungenklinik Heckeshorn, Berlin; Tobias Welte, Medizinische Hochschule Hannover, Hannover; Italy: Drs. Francesco Blasi, Stephano Aliberti, Paolo Tarsia, and Roberto Cosentini, Department of Pathophysiology and Transplantation, University of Milan, and Emergency Medicine department, IRCCS Fondazione Ca` Granda Ospedale Maggiore, Milan, Italy; Dr. Giulia, Policlinico di Modena, Modena; Dr. Delfino Legnani, Ospedale L. Sacco, Milan; Dr. Paolo Rossi, S. Maria della Misericordia, Udine; Dr. Vincenzo Valenti, Policlinico San Donato Milanese, Milan; Dr. Antonio Voza, IRCCS Istituto Clinico Humanitas, Milan; Scotland: Dr. James Chalmers, Royal Infirmary of Edinburgh, Western General Hospital, Edinburgh; Dr. Tom Fardon, Ninewells Hospital, Dundee; Spain: Dr. Antoni Torres, Instituto de Neumonologia y Cirugia Toracica, Ciber de Enfermedades Respiratorias (CIBER), Barcelona; Dr. Maria Bodi, Hospital Universitario Joan XXIII, Tarragona, Spain; Dr. Jose Porras, Hospital Sant Pau i Santa Tecla, Tarragona; Dr. Jordi Rello, Critical Care Department, Joan XXIII University Hospital, CIBER Enfermedades Respiratorias, University Rovira & Virgili, Tarragona; Dr. Rosario Menendez, Pneumology Service, Hospital Universitario La Fe; CIBER Enfermedades Respiratorias, Valencia; Dr. Daniel Portela Ojales, Hospital Xeral-Cies, Vigo; Dr. Benito Rodriguez, Hospital IVSS Dr. Domingo Guzman Lander, Barcelona;  Switzerland: Dr. Daiana Stolz, Universitatsspital Basel, Basel; Region III—Argentina: Dr. Guillermo Benchetrit, IDIM A. Lanari, Buenos Aires; Dr. Jorge Corral, Hospital Dr Oscar Alende, Mar del Plata; Dr. Martin Gnoni, Sanatorio Central Emprendimientos Medicos Hospitalarios Sociedad Anonima, Mar del Plata; Dr. Jose Gonzalez, Hospital Enrique Tornu, Buenos Aires; Dr. Gustavo Lopardo, Professor Bernardo Houssay Hospital, Buenos Aires; Dr. Horatio Lopez, Centro de Infectologia, Buenos Aires; Dr. Carlos Luna, Hospital de Clinicas, Buenos Aires; Dr. Saavedra Federico, Sanatorio Otamendi Miroli, Bueno Aires; Dr. Carlos Victorio, Clinica Uruguay, Entre Rios; Dr. Jorge Martinez, Instituto Medico Platense, La Plata; Dr. Lucia Marzoratti, Sanatorio 9 de Julio, Tucuman; Dr. Eduardo Rodriguez, Hospital Espanol de La Plata, La Plata; Dr. Maria Rodriguez, Hospital Rodolfo Rossi, La Plata; Dr. Alejandro Videla, Hospital Universitario Austral, Buenos Aires; Dr. Lautaro de Vedia, Hospital Francisco J. Muniz, Buenos Aires; Chile: Dr. Manuel Barros, C van Buren, Valprasio; Dr. Alejandro Diaz, Pontificia Univesidad Católica de Chile, Santiago; Patricia Fernandez, Instituto Nacional del Torax, Santiago; Dr. Patricio Jimenez, Hospital Clinico Regional, Valdivia; Dr. Maria Parada, Clinica las Condes, Santiago; Dr. Raul Riquelme, Hospital de Puerto Montt, Puerto Montt; Guatemala: Dr. Juan Manuel Luna, Hospital Nacional Roosevelt, Guatemala City; Panama: Ivan Toala, Complejo Hospitalario Dr. Arnulfo Arias Madrid, Panama City; Paraguay: Guillermo Arbo, Clinica San Roque y Centro Médico La Costa, Asuncion; Puerto Rico: Dr. Ricardo Fernandez, Hospital Municipal de San Juan, San Juan; Uruguay: Dr. Aiello Gonzalo, Hospital Marciel, Montevideo; Venezuela: Dr. Federico Arteta, Hospital Luis Gomez Lopez- Ascardio, Barquisimeto; Dr. Jose Delgado, Hospital Central Dr. Urquinaona, Maracaibo; Dr. Gur Levy, Hospital Universitario de Caracas, Caracas; Dr. Mario Perez Mirabel, Hospital Universitario de Los Andes, Merida; Dr. Ludwig Rivero, Hospital Central University Antonio M. Pineda, Barquisimeto.

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Authors and Affiliations

  1. Section of Infectious Diseases, Providence Hospital, Washington, DC, 20017, USA

    J. M. Bordon, S. Fazeli, A. Mathur & M. Rahmani

  2. Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY, USA

    R. Fernandez-Botran

  3. Division of Infectious Diseases, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA

    T. L. Wiemken, P. Peyrani, F. W. Arnold, L. Rodriquez-Hernandez, R. R. Kelley, L. E. Binford, S. Uppatla, R. Cavallazzi & J. Ramirez

  4. Division of Nephrology, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA

    S. M. Uriarte & M. J. Rane

  5. Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Ca` Granda Ospedale Maggiore, Milan, Italy

    F. Blasi

  6. Respiratory Unit, Department of Health Science, University of Milan Bicocca, AO San Gerardo, Monza, Italy

    S. Aliberti

  7. Department of Pulmonary Diseases, South Texas Veterans Health Care System and University of Texas at San Antonio, San Antonio, TX, USA

    M. I. Restrepo

  8. Veterans Administration Medical Center, Louisville, KY, USA

    J. Ramirez

  9. Department of Internal Medicine, Orlando Health, Florida, USA

    K. Ayesu

Authors
  1. J. M. Bordon
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  2. R. Fernandez-Botran
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  3. T. L. Wiemken
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  8. M. J. Rane
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  9. R. R. Kelley
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  10. L. E. Binford
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  12. R. Cavallazzi
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  13. F. Blasi
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  14. S. Aliberti
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  15. M. I. Restrepo
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  16. S. Fazeli
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  17. A. Mathur
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  18. M. Rahmani
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  19. K. Ayesu
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  20. J. Ramirez
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Corresponding author

Correspondence to J. M. Bordon.

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The authors do not have any conflicts of interest to disclose.

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This study was not funded. No author received compensation for this manuscript.

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Bordon, J.M., Fernandez-Botran, R., Wiemken, T.L. et al. Bacteremic pneumococcal pneumonia: clinical outcomes and preliminary results of inflammatory response. Infection 43, 729–738 (2015). https://doi.org/10.1007/s15010-015-0837-z

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  • DOI: https://doi.org/10.1007/s15010-015-0837-z

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