Lionel A. Mandell, Richard G. Wunderink, Antonio Anzueto, John G. Bartlett, G. Douglas Campbell, Nathan C. Dean, Scott F. Dowell, Thomas M. File, Jr. Daniel M. Musher, Michael S. Niederman, Antonio Torres, and Cynthia G. Whitney McMaster University Medical School, Hamilton, Ontario, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, and Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas; Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; Division of Pulmonary and Critical Care Medicine, LDS Hospital, and University of Utah, Salt Lake City, Utah; Centers for Disease Control and Prevention, Atlanta, Georgia; Northeastern Ohio Universities College of Medicine, Rootstown, and Summa Health System, Akron, Ohio; State University of New York at Stony Brook, Stony Brook, and Department of Medicine, Winthrop University Hospital, Mineola, New York; and Cap de Servei de Pneumologia i Allergia Respiratoria, Institut Clinic del Torax, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biomediques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain.

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Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults

Infectious Diseases Society of America.

Background: In the assessment of severity in community acquired pneumonia (CAP), the modified British Thoracic Society (mBTS) rule identifies patients with severe pneumonia but not patients who might be suitable for home management. A multicentre study was conducted to derive and validate a practical severity assessment model for stratifying adults hospitalised with CAP into different management groups. Methods: Data from three prospective studies of CAP conducted in the UK, New Zealand, and the Netherlands were combined. A derivation cohort comprising 80% of the data was used to develop the model. Prognostic variables were identified using multiple logistic regression with 30 day mortality as the outcome measure. The final model was tested against the validation cohort. Results: 1068 patients were studied (mean age 64 years, 51.5% male, 30 day mortality 9%). Age ⩾65 years (OR 3.5, 95% CI 1.6 to 8.0) and albumin C onfusion, U rea >7 mmol/l, R espiratory rate ⩾30/min, low systolic( B lood pressure), age ⩾65 years (CURB-65 score) based on information available at initial hospital assessment, enabled patients to be stratified according to increasing risk of mortality: score 0, 0.7%; score 1, 3.2%; score 2, 3%; score 3, 17%; score 4, 41.5% and score 5, 57%. The validation cohort confirmed a similar pattern. Conclusions: A simple six point score based on confusion, urea, respiratory rate, blood pressure, and age can be used to stratify patients with CAP into different management groups.

https://thorax.bmj.com/content/thoraxjnl/58/5/377.full.pdf

Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study

Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention.

Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia.Methods: A multidisciplinary panel conducted pra...

/pdf/diagnosis-and-treatment-of-adults-with-community-acquired-4u8h6pikis.pdf

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America

BACKGROUND: Community acquired pneumonia remains an important cause of hospital admission and carries an appreciable mortality. Criteria for the assessment of severity during admission have been developed by the British Thoracic Society (BTS). A study was performed to determine the sensitivity and specificity of a severity rule based on a modification of the BTS prognostic rules applied on admission, to compare severity as assessed by medical staff with the modified rule, and to determine the microbiological cause of community acquired pneumonia in Christchurch. METHODS: A 12 month study of all adults admitted to Christchurch Hospital with community acquired pneumonia was undertaken. Three hundred and sixteen consecutive patients with suspected community acquired pneumonia were screened for inclusion. Variables obtained from the history, examination, investigations, and initial treatment were examined for association with mortality. RESULTS: Two hundred and fifty five patients met the inclusion criteria. Their mean age was 58 years (range 18-97). A microbiological diagnosis was made in 181 cases (71%), Streptococcus pneumonia (39%), Mycoplasma pneumoniae (16%), Legionella species (11%), and Haemophilus influenzae (11%) being the most commonly identified organisms. Patients had a 36-fold increased risk of death if any two of the following were present on admission: respiratory rate > or = 30/min, diastolic BP 7 mmol/l, or confusion. The severity rule identified 19 of the 20 patients who died and six of eight patients admitted to the intensive care unit as having life threatening community acquired pneumonia. The sensitivity of the modified rule for predicting death was 0.95 and the specificity 0.71. In 47 cases (21%) the clinical team appeared to underestimate the severity of the illness. CONCLUSIONS: The organisms responsible for community acquired pneumonia in Christchurch are similar to those reported from other centres except for Legionella species which were more common than in most studies. The modification of the BTS prognostic rules applied as a severity indicator at admission performed well and could be incorporated into management guidelines.

https://thorax.bmj.com/content/thoraxjnl/51/10/1010.full.pdf

Community acquired pneumonia: aetiology and usefulness of severity criteria on admission.

Legionella pneumonia can be difficult to diagnose. Existing laboratory tests for detecting Legionella species lack sensitivity or provide only a retrospective diagnosis. We used the polymerase chain reaction (PCR) with primers that amplify a 104-base pair segment of the coding region of the 5S tRNA gene to detect Legionella DNA in urine and serum samples from patients with pneumonia. Stored urine and serum samples from patients enrolled in two prospective studies of pneumonia were tested. Legionella DNA was detected in urine and/or serum samples from 18 (64%) of 28 patients with legionella pneumonia diagnosed by conventional tests, but it was not detected in urine or serum samples from 24 patients with pneumonia due to other organisms. The sensitivity of PCR improved to 73% if testing was restricted to samples taken within 4 days of the onset of symptoms. Detection of Legionella DNA in urine and serum promises to be a valuable tool for the rapid diagnosis of legionella pneumonia.

Use of the polymerase chain reaction to detect Legionella DNA in urine and serum samples from patients with pneumonia.

BACKGROUND: A study was undertaken to investigate the relationship between air pollution levels and respiratory symptoms and peak expiratory flow rate (PEFR) in subjects with chronic obstructive pulmonary disease (COPD) living in Christchurch, New Zealand. METHODS: Forty subjects aged over 55 years with COPD completed twice daily diaries for three months during the winter of 1994. Subjects recorded respiratory symptoms, PEFR, outdoor activity, visits to doctor or hospital, and medication use. All were resident within a 5 km radius of the regional council's air pollution monitoring site. Daily and hourly mean pollutant levels (particulates (PM10, nitrogen dioxide (NO2), sulphur dioxide (SO2) and carbon monoxide (CO)) were measured at the monitoring site. RESULTS: Pollution levels were generally low relative to those recorded in previous years. The New Zealand Ministry for the Environment guidelines for PM10 were exceeded on five occasions, and for CO six times. No association was found between PEFR and any of the pollution variables. A rise in the PM10 concentration equivalent to the interquartile range was associated with an increase in night time chest symptoms (relative risk 1.38, 95% CI 1.07 to 1.78). A rise in NO2 concentrations equivalent to the interquartile range was associated with increased reliever inhaler use (relative risk 1.42, 95% CI 1.13 to 1.79) and for 24 hour lag analysis with increased nebuliser use (relative risk 2.81, 95% CI 1.81 to 4.39). There was no increase in the relative risk of other symptoms in relation to pollution levels. CONCLUSIONS: These effects, demonstrated in a small susceptible group of subjects with COPD, indicate that adverse outcomes can be measured in response to pollution levels that are within current guidelines.

https://thorax.bmj.com/content/thoraxjnl/52/12/1040.full.pdf

Respiratory effects of air pollution in chronic obstructive pulmonary disease: a three month prospective study.

BACKGROUND: There is evidence to suggest that changes in weather and airborne fungal spore and pollen counts may affect asthma symptoms. METHODS: The relationship between climate, airborne fungal spore, and pollen counts and peak expiratory flow rate (PEFR) and asthma symptoms was prospectively investigated in a population of mild to moderate asthmatic subjects in Blenheim, New Zealand. Subjects recorded twice daily PEFR measurements and asthma symptom scores for up to one year. Spore and pollen counts were measured two hourly and meteorological data were measured hourly. Individual, within person, multiple linear regression analyses were conducted, adjusting for auto-correlation. A random effects model was assumed for the individual regression co-efficients and weighted estimates of the mean of these coefficients were obtained by the method of maximum likelihood. RESULTS: One hundred and thirty nine asthmatic patients (60% atopic) aged 17-80 years completed the study. Of the weather variables, only temperature showed a small but consistent association with PEFR. The mean rise in PEFR for an 8.8 degrees C (2 SD) change in temperature was 0.78% (95% CI 0.44% to 1.11%), approximately 3.0 l/min. There was a weak association between days of high basidiospore counts and increased nocturnal wakening and reliever medication use. Pollen counts showed no consistent association with either PEFR or asthma symptoms. CONCLUSIONS: The results of this study suggest that the effects of weather and aeroallergens on PEFR and asthma symptoms in this population are small, and that other causes need to be sought to account for variations in asthma severity and exacerbations.

https://thorax.bmj.com/content/thoraxjnl/52/6/528.full.pdf

G. I. Town

Papers

Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study

Community acquired pneumonia: aetiology and usefulness of severity criteria on admission.

Use of the polymerase chain reaction to detect Legionella DNA in urine and serum samples from patients with pneumonia.

Respiratory effects of air pollution in chronic obstructive pulmonary disease: a three month prospective study.

Climate and aeroallergen levels in asthma : a 12 month prospective study