Medline ® Abstracts for References 88,89

of 'Treatment of community-acquired pneumonia in adults who require hospitalization'

88
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Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications.
AU
Arancibia F, Ewig S, Martinez JA, Ruiz M, Bauer T, Marcos MA, Mensa J, Torres A
SO
Am J Respir Crit Care Med. 2000;162(1):154.
 
The aim of the study was to determine the causes and prognostic implications of antimicrobial treatment failures in patients with nonresponding and progressive life-threatening, community-acquired pneumonia. Forty-nine patients hospitalized with a presumptive diagnosis of community-acquired pneumonia during a 16-mo period, failure to respond to antimicrobial treatment, and documented repeated microbial investigation>/= 72 h after initiation of in-hospital antimicrobial treatment were recorded. A definite etiology of treatment failure could be established in 32 of 49 (65%) patients, and nine additional patients (18%) had a probable etiology. Treatment failures were mainly infectious in origin and included primary, persistent, and nosocomial infections (n = 10 [19%], 13 [24%], and 11 [20%]of causes, respectively). Definite but not probable persistent infections were mostly due to microbial resistance to the administered initial empiric antimicrobial treatment. Nosocomial infections were particularly frequent in patients with progressive pneumonia. Definite persistent infections and nosocomial infections had the highest associated mortality rates (75 and 88%, respectively). Nosocomial pneumonia was the only cause of treatment failure independently associated with death in multivariate analysis (RR, 16.7; 95% CI, 1.4 to 194.9; p = 0.03). We conclude that the detection of microbial resistance and the diagnosis of nosocomial pneumonia are the two major challenges in hospitalized patients with community-acquired pneumonia who do not respond to initial antimicrobial treatment. In order to establish these potentially life-threatening etiologies, a regular microbial reinvestigation seems mandatory for all patients presenting with antimicrobial treatment failures.
AD
Servei de Pneumologia i Al.lergia Respiratoria, Servei de Malalties Infeccioces, Servei de Microbiologia, Hospital Clinic i Provincial, Universitat de Barcelona, Spain.
PMID
89
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Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome.
AU
Menéndez R, Torres A, Zalacaín R, Aspa J, Martín Villasclaras JJ, Borderías L, Benítez Moya JM, Ruiz-Manzano J, Rodríguez de Castro F, Blanquer J, Pérez D, Puzo C, Sánchez Gascón F, Gallardo J, Alvarez C, Molinos L, Neumofail Group
SO
Thorax. 2004;59(11):960.
 
BACKGROUND: An inadequate response to initial empirical treatment of community acquired pneumonia (CAP) represents a challenge for clinicians and requires early identification and intervention. A study was undertaken to quantify the incidence of failure of empirical treatment in CAP, to identify risk factors for treatment failure, and to determine the implications of treatment failure on the outcome.
METHODS: A prospective multicentre cohort study was performed in 1424 hospitalised patients from 15 hospitals. Early treatment failure (<72 hours), late treatment failure, and in-hospital mortality were recorded.
RESULTS: Treatment failure occurred in 215 patients (15.1%): 134 early failure (62.3%) and 81 late failure (37.7%). The causes were infectious in 86 patients (40%), non-infectious in 34 (15.8%), and undetermined in 95. The independent risk factors associated with treatment failure in a stepwise logistic regression analysis were liver disease, pneumonia risk class, leucopenia, multilobar CAP, pleural effusion, and radiological signs of cavitation. Independent factors associated with a lower risk of treatment failure were influenza vaccination, initial treatment with fluoroquinolones, and chronic obstructive pulmonary disease (COPD). Mortality was significantly higher in patients with treatment failure (25% v 2%). Failure of empirical treatment increased the mortality of CAP 11-fold after adjustment for risk class.
CONCLUSIONS: Although these findings need to be confirmed by randomised studies, they suggest possible interventions to decrease mortality due to CAP.
AD
Servicio de Neumología, Hospital Universitario La Fe, Valencia, Spain. rmenend@separ.es
PMID