Sepsis pp 22-40 | Cite as

Community-Acquired Pneumonia (International Vision)

  • Alejandro Rodríguez
  • Jordi Rello

Abstract

Community-acquired pneumonia (CAP) is generally regarded as pneumonia requiring a specific clinical approach in the intensive care unit (ICU). Between 10% and 36% of patients with CAP who are hospitalized need ICU treatment, and mortality ranges from 20% to 50%. The ICU admission and management should be customized in each patient.

The spectrum of causative agents of severe CAP (SCAP) is similar to that found in hospitalized patients or outpatients with CAP. Streptococcus pneumoniae and Legionella species (spp.) account for 50% of cases with etiologic diagnosis. However, Legionella spp. are rarely reported in South America, where S. pneumoniae, Haemophilus influenzae, and Staphylococcus aureus are the most frequent findings. Interestingly, ICU admission for tuberculosis can reach 10% of total cases in some countries.

The usefulness of diagnostic testing in the management of SCAP is a subject of controversy. However, knowledge of the causative agents is useful, given the possibility of adjusting antibiotic treatment, and improves the outcome. Blood culture, Gram stain, and urinary detection of antigens should be done.

Shock and refractory hypoxemia management do not differ for the general population with septic shock. The goal of resuscitation in shock is the restoration of tissue perfusion. Normalization of cellular metabolism and noninvasive forms of ventilation or a protective ventilatory strategy using low tidal volumes are recommended.

The guidelines for initial antibiotic management should be customized to each country or to each institution and patient. We believe that cefotaxime/ceftriaxone should be the cornerstone of therapy in combination with macrolide, but antibiotic coverage for Legionella spp. and Pseudomonas aeruginosa might be necessary in intubated critically ill patients when SCAP etiology is unknown.

Keywords

Intensive Care Unit Admission Mean Arterial Pressure Respir Crit Pneumonia Severity Index International Vision 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Barlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis 2000; 31: 347–82.CrossRefGoogle Scholar
  2. 2.
    Hirani NA, Macfarlane JT. Impact of management guidelines on the outcome of severe community acquired pneumonia. Thorax 1997; 52: 17–21.PubMedCrossRefGoogle Scholar
  3. 3.
    Almirall J, Bolibar I, Vidal J, et al. Epidemiology of community-acquired pneumonia in adults: a population-based study. Eur Respir J 2000; 15: 757–63.PubMedCrossRefGoogle Scholar
  4. 4.
    Jokinen C, Heiskanen L, Juvonen H, et al. Incidence of community-acquired pneumonia in the population of four municipalities in Eastern Finland. Am J Epidemiol 1993; 137: 977–88.PubMedGoogle Scholar
  5. 5.
    Lave JR, Lin CJ, Fine MJ, et al. The cost of treating patients with community-acquired pneumonia. Semin Respir Crit Care Med 1999; 20: 189–97.CrossRefGoogle Scholar
  6. 6.
    Gallego M, Rello J. Severe community-acquired pneumonia. In: Rello J, Vallés J, and Kollef M, eds. Critical care infectious diseases textbook. Dordrecht: Kluwer Academic Publishers, 2001: 37: 611–23.CrossRefGoogle Scholar
  7. 7.
    American Thoracic Society. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity and initial antimicrobial therapy. Am Rev Respir Dis 1993; 148: 1418–26.Google Scholar
  8. 8.
    European Study on Community-Acquired Pneumonia (ESOCAP) Committee. Guidelines for management of adult community-acquired lower respiratory tract infections. Eur Respir J 1998, 11: 986–98.CrossRefGoogle Scholar
  9. 9.
    BTS guidelines for the management of community-acquired pneumonia in adults. Thorax 2001;56[Suppl 4]S1–S64.Google Scholar
  10. 10.
    Ewing S, Ruiz M, Mensa J, et al. Severe community-acquired pneumonia: assessment of severity criteria. Am J Respir Crit Care Med 1998, 158: 1102–8.Google Scholar
  11. 11.
    Research Committee of British Thoracic Society and the Health Laboratory Service. Community-acquired pneumonia in adults in British hospitals in 1982–83: a survey of aetiology, mortality, prognostic factors and outcome. Q J Med 1987, 62: 195–201.Google Scholar
  12. 12.
    Arnold FW, Ramirez JA, McDonald LC, et al. Hospitalization for community-acquired pneumonia. Chest 2003; 124: 121–4.PubMedCrossRefGoogle Scholar
  13. 13.
    Fine MJ, Auble TE, Yealy DM, et al. A predictive rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336: 243–50.PubMedCrossRefGoogle Scholar
  14. 14.
    Rosón B, Carratald J, Dorca J, et al. Etiology, reasons for hospitalization, risk classes, and outcome of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria. Clin Infect Dis 2001; 33: 158–65.PubMedCrossRefGoogle Scholar
  15. 15.
    Marras TK, Gutierrez C, Chan C. Applying a prediction rule to identify low-risk patients with community-acquired pneumonia. Chest 2000; 118: 1339–43.PubMedCrossRefGoogle Scholar
  16. 16.
    Zalacain R, Torres A, Celis R, et al. Community-acquired pneumonia in the elderly: Spanish multicentre study. Eur Respir J 2003; 21: 294–302.PubMedCrossRefGoogle Scholar
  17. 17.
    EI-Ebiary M, Sarmiento X, Tones A, et al. Prognostic factors of severe Legionella pneumonia requiring admission to ICU. Am J Respir Crit Care Med 1997; 156: 146–772.Google Scholar
  18. 18.
    Roig J, Rello J. Legionnaires’ disease: a rational approach to therapy. J Antimicrob Chemother 2003; 51: 1119–29.PubMedCrossRefGoogle Scholar
  19. 19.
    Roig J, Sabria M, Pedro-Botet ML. Legionella spp: community acquired and nosocomial infections. Cun Opin Infect Dis 2003; 16: 145–51.CrossRefGoogle Scholar
  20. 20.
    Lopardo G, Sturba E, Martinez ML, et al. Detection of acute infection due to Legionella pneumophila in patients with community acquired pneumonia in Buenos Aires city. Medicine (B. Aires) 2002; 62: 145–8.Google Scholar
  21. 21.
    Cabello H, Cortes C, Ruiz M, et al. Community acquired pneumonia. Report of 8 cases of severe pneumonia by serogroup 1 Legionella pneumophila in Chile. Rev Med Chil 2002; 130: 309–13.PubMedGoogle Scholar
  22. 22.
    Woodhead M. Community-acquired pneumonia in Europe: causative pathogens and resistance patterns. Eur Respir J 2002; 20 [Suppl 36]: 20S - 27S.CrossRefGoogle Scholar
  23. 23.
    Pachón J, Prado MD, Capote F, et al. Severe community acquired pneumonia: etiology, prognosis and treatment. Am Rev Respir Dis 1990; 142: 369–73.PubMedGoogle Scholar
  24. 24.
    Rello J, Quintana E, Ausina V, et al. A three-year study of severe community acquired pneumonia with emphasis in outcome. Chest 1993; 103: 232–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Moine P, Vercken JB, Chevret S, et al. Severe community-acquired pneumonia: etiology, epidemiology, and prognosis factors. Chest 1994; 105: 1487–95.PubMedCrossRefGoogle Scholar
  26. 26.
    Leroy O, Santré C, Beuscart C, et al. A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit. Intensive Care Med 1995; 21: 24–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Rello J, Rodriguez R, Jubert P, et al. Severe community-acquired pneumonia in the elderly: epidemiology and prognosis. Clin Infect Dis 1996; 23: 723–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Wattanathum A, Chaoprasong C, Nunthapisud P, et al. Community-acquired pneumonia in Southeast Asia. The microbial differences between ambulatory and hospitalized patients. Chest 2003; 123: 1512–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Rello J, Bodi M, Mariscal D, et al. Microbiological testing and outcome of patients with severe community-acquired pneumonia. Chest 2003; 123: 174–80.PubMedCrossRefGoogle Scholar
  30. 30.
    Jasovich A, Soutric J, Morera G, et al. Efficacy of amoxicillin-sulbactam, given twice a day for the treatment of community-acquired pneumonia. A clinical trial based on a pharmacodynamic model. J Chemother 2002; 14: 591–6.PubMedGoogle Scholar
  31. 31.
    Soca A, Bazet C, Battistesa S, et al. Severe community-acquired pneumonia. Pac Crit 1999; 12: 96–107.Google Scholar
  32. 32.
    Bantar C, Bavestrello L, Crucio D, et al. Acute community-acquired pneumonia in adults. Guidelines for initial antimicrobial therapy based on local evidence from a South American Working Group (Conesur). J Chemother 2002; 14 [Suppl 4]: S1 - S22.Google Scholar
  33. 33.
    Marrie Ti, Peeling RW, Reid T, et al. Chlamydia species as a cause of community-acquired pneumonia in Canada. Eur Respir J 2003; 21: 779–84.CrossRefGoogle Scholar
  34. 34.
    Menéndez R, Córdoba J, de la Cuadra P, et al. Value of the polymerase chain reaction assay in noninvasive respiratory samples for diagnosis of community-acquired pneumonia. Am J Respir Crit Care Med 1999; 159: 1868–3.PubMedGoogle Scholar
  35. 35.
    Rello J, PaivaA, Dias CS. Current dilemmas in the management of adults with severe community-acquired pneumonia. In: Vincent JL, ed. Yearbook of intensive care and emergency medicine. New York: Springer-Verlag, 2003: 162–74.Google Scholar
  36. 36.
    Ewing S, Bauer T, Hasper E, et al. Value of routine microbial investigation in community-acquired pneumonia treated in a tertiary care centre. Respiration 1991; 63: 164–9.Google Scholar
  37. 37.
    Waterer GW, Wunderink RG. The influence of the severity of community-acquired pneumonia on the usefulness of blood cultures. Respir Med 2001; 95: 78–82.PubMedCrossRefGoogle Scholar
  38. 38.
    Leeper KV, Torres A. Community-acquired pneumonia in the intensive care unit. Clin Chest Med 1995; 16: 155–71.PubMedGoogle Scholar
  39. 39.
    Rosón B, Guidol F. Utility of Gram stain and sputum culture in the management of community-acquired pneumonia. Clin Pulm Med 2003; 10: 1–5.CrossRefGoogle Scholar
  40. 40.
    Ewing S, Torres A. Severe community-acquired pneumonia. Clin Chest Med 1999; 20: 575–80.CrossRefGoogle Scholar
  41. 41.
    Mandell LA, Marrie TJ, Grossman RF, et al. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by Canadian Infectious Diseases Society and Canadian Thoracic Society. Clin Infect Dis 2000; 31: 383–421.PubMedCrossRefGoogle Scholar
  42. 42.
    Sanyal S, Smith PR, Saha AC, et al. Initial microbiologic studies did not affect outcome in adults hospitalized with community-acquired pneumonia. Am J Respir Crit Care Med 1999, 160: 346–8.PubMedGoogle Scholar
  43. 43.
    Campbell SG, Marrie TJ, Anstey R, et al. The contribution of blood cultures to the clinical management of adult patients admitted to the hospital with community-acquired pneumonia. A prospective observational study. Chest 2003; 123: 1142–50.PubMedCrossRefGoogle Scholar
  44. 44.
    Vallés J, Rello J, Ochagavía A, et al. Community-acquired bloodstream infection in critically ill adult patients. Impact of shock and inappropriate antibiotic therapy on survival. Chest 2003; 123: 1615–24.PubMedCrossRefGoogle Scholar
  45. 45.
    Rello J, Gallego M, Mariscal D, et al. The value of routine microbial investigation in ventilator-associated pneumonia. Am J Respir Crit Care Med 1997; 156: 196–200.PubMedGoogle Scholar
  46. 46.
    American Thoracic Society. ATS guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity. Antimicrobial therapy and prevention. Am J Respir Crit Care Med 2001; 163: 1730–54.Google Scholar
  47. 47.
    Feinsilver SH, Fein AM, Niederman NS, et al. Utility of fiberoptic bronchoscopy in non-resolving pneumonia. Chest 1990; 98: 1322–6.PubMedCrossRefGoogle Scholar
  48. 48.
    Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community acquired pneumonia: a meta-analysis. JAMA 1996; 276: 134–41.CrossRefGoogle Scholar
  49. 49.
    Marrie TJ. Epidemiology of community acquired pneumonia in the elderly. Semin Respir Infect 1990; 5: 260–8.PubMedGoogle Scholar
  50. 50.
    Riquelme R, Torres A, EI-Ebiary M, et al. Community acquired pneumonia in the elderly. A multivariate analysis of risks and prognostic factors. Am J Respir Crit Care Med 1996; 154: 1450–5.PubMedGoogle Scholar
  51. 51.
    Fernandez-Sabé N, Carratalà J, Rost% B, et al. Community-acquired pneumonia in very elderly patients: causative organisms, clinical characteristics and outcomes. Medicine (Baltimore) 2003; 82: 159–69.Google Scholar
  52. 52.
    Lim WS, van der Eerden MM, Laing R, et al. Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58: 377–82.PubMedCrossRefGoogle Scholar
  53. 53.
    Torres A, Dorca J, Zalacaín R, et al. Community-acquired pneumonia in chronic obstructive pulmonary disease. A Spanish multicenter study. Am J Respir Crit Care Med 1996; 154: 1456–61.PubMedGoogle Scholar
  54. 54.
    Seneff MG, Wagner DP, Wagner RD, et al. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA 1995; 274: 1852–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Torres A, Serra-Batlles J, Ferrer A, et al. Severe community acquired pneumonia: epidemiology and prognostic factors. Am Rev Respir Dis 1991; 114: 312–5.CrossRefGoogle Scholar
  56. 56.
    Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process, and outcome in elderly patients with pneumonia. JAMA 1997; 278: 2080–4.PubMedCrossRefGoogle Scholar
  57. 57.
    Saldías Penafiel F, O’Brien Solar A, Gederlini Gollerino A, et al. Community-acquired pneumonia requiring hospitalization in immunocompetent elderly patients: clinical features, prognostic factors and treatment. Arch Bronconeumol 2003; 39: 333–40.CrossRefGoogle Scholar
  58. 58.
    Bantar C, Bavestrello L, Curcio D, et al. Acute community-acquired pneumonia in adults: guidelines for initial antimicrobial therapy based on local evidence from a South American Working Group (ConsenSur). J Chemother 2002; 14: 1–22.PubMedGoogle Scholar
  59. 59.
    Rello J, Catalan M, Díaz E, et al. Associations between empirical antimicrobial therapy at the hospital and mortality in patients with severe community-acquired pneumonia. Intensive Care Med 2002; 28: 1030–5.PubMedCrossRefGoogle Scholar
  60. 60.
    Luna C, Famiglietti A, Absi R, et al. Community-acquired pneumonia: etiology, epidemiology and outcome at a teaching hospital in Argentina. Chest 2000; 118: 1344–54.PubMedCrossRefGoogle Scholar
  61. 61.
    Lujan M, Gallego M, Fontanals D, et al. Association of discordant antibiotic therapy and mortality in adults with bacteremic pneumococcal community-acquired pneumonia. Crit Care Med 2004; 32 (3): 625–31.PubMedCrossRefGoogle Scholar
  62. 62.
    Yu VL, Chiou CCC, Feldman C, et al. An international prospective study of pneumococcal bacteremia: correlation with in vitro resistance, antibiotic administered and clinical outcome. Clin Infect Dis 2003; 37: 230–37.PubMedCrossRefGoogle Scholar
  63. 63.
    Orranti AR, Silva H, Pontani D, et al. El grupo de estudio Artemis para America Latina: el proyecto Artemis, un estudio sobre la actividad de algunos ATB de use comtín para el tratamiento de las infecciones en diez países de Latinoamerica. Rev Panam Infectolog 1998; 2: 68–75.Google Scholar
  64. 64.
    Guzmdn-Blanco M, Casellas JM, Sader HS, et al. Bacterial resistance to antimicrobial agents in Latin America. The giant is awakening. Infect Dis Clin North Am 2000; 14: 6781.Google Scholar
  65. 65.
    Vidaur L, Rodriguez A, Rello J. ATB therapy for sepsis, severe sepsis and septic shock.:A patient-based approach inspired on “The Tarragona Strategy.” In: Yearbook of intensive care and emergency medicine. New York: Springer-Verlag, (in press).Google Scholar
  66. 66.
    Vincent JL. Hemodynamic support in septic shock. Intensive Care Med 2001; 27: S80 - S92.PubMedCrossRefGoogle Scholar
  67. 67.
    Neviere R, Mathieu D, Chagnon JL, et al. The contrasting effects of dobutamine and dopamine on gastric mucosal perfusion in septic patients. Am J Respir Crit Care Med 1996; 154: 1684–8.PubMedGoogle Scholar
  68. 68.
    Marik PE, Mohedin J. The contrasting effects of dopamine and norepinephrine on systemic and splanchnic oxygen utilization in hyperdynamic sepsis. JAMA 1994; 272: 1354–7.PubMedCrossRefGoogle Scholar
  69. 69.
    Ronco JJ, Fenwick JC, Tweeddale MG, et al. Identification of the critical oxygen delivery for anaerobic metabolism in critically ill septic and nonseptic humans. JAMA 1993; 270: 1724–30.PubMedCrossRefGoogle Scholar
  70. 70.
    Kellum JA, Kramer DJ, Lee K, et al. Release of lactate by lung in acute lung injury. Chest 1997; 111: 1301–5.PubMedCrossRefGoogle Scholar
  71. 71.
    Gutierrez G, Palizas F, Doglio GR, et al. Gastric intramucosal pH as a therapeutic index of tissue oxygenation in critically ill patients. Lancet 1992; 339: 195–9.PubMedCrossRefGoogle Scholar
  72. 72.
    Girou E. Prevention of nosocomial infections in acute respiratory failure patients. Eur Respir J 2003; 42 [Supp1]: 72–6.CrossRefGoogle Scholar
  73. 73.
    Domenighetti G, Gayer R, Gentilini R Noninvasive pressure support ventilation in non-COPD patients with acute cardiogenic pulmonary edema and severe community-acquired pneumonia: acute effects and outcome. Intensive Care Med 2002; 28: 1226–32.PubMedCrossRefGoogle Scholar
  74. 74.
    Confalonieri M, Potena A, Carbone G, et al. Acute respiratory failure in patients with severe community-acquired pneumonia: a prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med 1999; 160: 1585–91.PubMedGoogle Scholar
  75. 75.
    Jolliet P, Abajo B, Pasquina P, et al. Non-invasive pressure support ventilation in severe community-acquired pneumonia. Intensive Care Med 2001; 27: 812–21.PubMedCrossRefGoogle Scholar
  76. 76.
    The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342: 1301.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2004

Authors and Affiliations

  • Alejandro Rodríguez
  • Jordi Rello

There are no affiliations available

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