Medline ® Abstracts for References 88,89

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

88
TI
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
89
TI
Causes and factors associated with early failure in hospitalized patients with community-acquired pneumonia.
AU
Rosón B, CarratalàJ, Fernández-SabéN, Tubau F, Manresa F, Gudiol F
SO
Arch Intern Med. 2004;164(5):502.
 
BACKGROUND: Early failure is a matter of great concern in the treatment of community-acquired pneumonia. However, information on its causes and risk factors is lacking.
METHODS: Observational analysis of a prospective series of 1383 nonimmunosuppressed hospitalized adults with community-acquired pneumonia. Early failure was defined as lack of response or worsening of clinical or radiologic status at 48 to 72 hours requiring changes in antibiotic therapy or invasive procedures. Concordance of antimicrobial therapy was examined for cases with an etiologic diagnosis.
RESULTS: At 48 to 72 hours, 238 patients (18%) remained febrile, but most of them responded without further changes in antibiotic therapy. Eighty-one patients (6%) had early failure. The main causes of early failure were progressive pneumonia (n = 54), pleural empyema (n = 18), lack of response (n = 13), and uncontrolled sepsis (n = 9). Independent factors associated with early failure were older age (>65 years) (odds ratio [OR], 0.35), multilobar pneumonia (OR, 1.81), Pneumonia SeverityIndex score greater than 90 (OR, 2.75), Legionella pneumonia (OR, 2.71), gram-negative pneumonia (OR, 4.34), and discordant antimicrobial therapy (OR, 2.51). Compared with treatment responders, early failures had significantly higher rates of complications (58% vs 24%) and overall mortality (27% vs 4%) (P<.001 for both).
CONCLUSIONS: Early failure is infrequent but is associated with high morbidity and mortality rates. Its detection and management require careful clinical assessment. Most cases occur because of inadequate host-pathogen responses. Discordant therapy is a less frequent cause of failure, which may be preventable by rational application of the current antibiotic guidelines.
AD
Infectious Disease Service, Hospital Universitari de Bellvitge, University of Barcelona, L'Hospitalet, Barcelona, Spain.
PMID