Decrease in Mortality in Severe Community-Acquired Pneumococcal Pneumonia: Impact of Improving Antibiotic Strategies (2000-2013)

doi:10.1378/chest.13-1531

Chest

Volume 146, Issue 1, July 2014, Pages 22-31

https://doi.org/10.1378/chest.13-1531 Get rights and content

OBJECTIVE

The objective of the present study was to compare antibiotic prescribing practices and survival in the ICU for patients with pneumococcal severe community-acquired pneumonia (SCAP) between 2000 and 2013.

METHODS

This was a matched case-control study of two prospectively recorded cohorts in Europe. Eighty patients from the Community-Acquired Pneumonia en la Unidad de Cuidados Intensivos (CAPUCI) II study (case group) were matched with 80 patients from CAPUCI I (control group) based on the following: shock at admission, need of mechanical ventilation, COPD, immunosuppression, and age.

RESULTS

Demographic data were comparable in the two groups. Combined antibiotic therapy increased from 66.2% to 87.5% (P < .01), and the percentage of patients receiving the first dose of antibiotic within 3 h increased from 27.5% to 70.0% (P < .01). ICU mortality was significantly lower (OR, 0.82; 95% CI, 0.68-0.98) in cases, both in the whole population and in the subgroups of patients with shock (OR, 0.67; 95% CI, 0.50-0.89) or receiving mechanical ventilation (OR, 0.73; 95% CI, 0.55-0.96). In the multivariate analysis, ICU mortality increased in patients requiring mechanical ventilation (OR, 5.23; 95% CI, 1.60-17.17) and decreased in patients receiving early antibiotic treatment (OR, 0.36; 95% CI, 0.15-0.87) and combined therapy (OR, 0.19; 95% CI, 0.07-0.51).

CONCLUSIONS

In pneumococcal SCAP, early antibiotic prescription and use of combination therapy increased. Both were associated with improved survival.

Section snippets

Materials and Methods

This was a matched case-control study of two cohorts of patients prospectively recorded in Europe (the Community-Acquired Pneumonia en la Unidad de Cuidados Intensivos [CAPUCI] studies). CAPUCI I and II are two European, prospective, multicenter studies conducted in patients admitted to the ICU for CAP. The CAPUCI I study recorded data from 33 hospitals from 2000 to 2002. Data from this cohort have been reported elsewhere.¹¹ The CAPUCI II study was a follow-up project endorsed by the European

Results

One hundred and sixty patients were enrolled: 80 patients from the 2008 to 2013 cohort (case group) paired with 80 from the 2000 to 2002 cohort (control group). Figure 1 shows the algorithm for the selection of the patients and the ICU mortality for each subgroup; incidence of severe pneumococcal pneumonia increased significantly (43.9% vs 27.0%; OR, 1.30; 95% CI, 1.15-1.48). Table 1 shows the variables used to match patients. The groups presented identical prevalence of the items evaluated:

Discussion

The main finding of this study was a 15% decrease in ICU mortality due to SCAP caused by S pneumoniae during the study period. Several changes in antibiotic prescription practices were detected, and an association between improved survival and both earlier antibiotic administration and increased combined antibiotic therapy was identified.

The World Health Organization's annual reports stress the minimal decrease in worldwide mortality secondary to lower respiratory infection: from 4.1 million

Conclusions

In summary, incidence, mortality, and management of severe pneumococcal pneumonia has significantly changed in the last decade. Improved ICU survival was associated with earlier antibiotic prescription and increased use of combined antibiotic therapy.

Acknowledgments

Author contributions: S. G. served as principal author, had full access to all of the data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis. S. G. and J. R. contributed to the study concept and design; B. B., J. S.-V., J. V., L. V., R. Z., and A. T. contributed to data interpretation; S. G. and J. R. contributed to drafting of the manuscript; B. B., J. S.-V., J. V., L. V., R. Z., and A. T. contributed to critical revision of the

References (51)

CI Kang et al.
Risk factors and pathogenic significance of bacteremic pneumonia in adult patients with community-acquired pneumococcal pneumonia
J Infect
(2013)
R Menéndez et al.
Cytokine activation patterns and biomarkers are influenced by microorganisms in community-acquired pneumonia
Chest
(2012)
E Crisafulli et al.
Systemic inflammatory pattern of patients with community-acquired pneumonia with and without COPD
Chest
(2013)
F Froes
Community-acquired pneumonia in adults in mainland Portugal: incidence and mortality in hospital inpatients between 1998 and 2000 [in Portugese]
Rev Port Pneumol
(2003)
G Kumar et al.
Nationwide trends of severe sepsis in the 21st century (2000-2007)
Chest
(2011)
J Rello et al.
A three-year study of severe community-acquired pneumonia with emphasis on outcome
Chest
(1993)
JM Sirvent et al.
Predictive factors of mortality in severe community-acquired pneumonia: a model with data on the first 24h of ICU admission
Med Intensiva
(2013)
RR Yates
New intervention strategies for reducing antibiotic resistance
Chest
(1999)
M Ferrer et al.
The impact of guidelines on the outcomes of community-acquired and ventilator-associated pneumonia
Clin Chest Med
(2011)
GW Waterer et al.
Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia
Chest
(2006)

Cited by (77)

Macrolides in community-acquired pneumonia
2024, The Lancet Respiratory Medicine
Steroids in severe community-acquired pneumonia: dangerous, worthless, or miracle cure? The roller coaster of clinical trials
2023, Anaesthesia Critical Care and Pain Medicine
Bacteraemic pneumococcal pneumonia and SARS-CoV-2 pneumonia: differences and similarities
2022, International Journal of Infectious Diseases
Citation Excerpt :
The present study found that patients with B-PCAP had worse clinical presentation and laboratory findings, but in-hospital mortality was much higher in patients with SARS-CoV-2 pneumonia. The prognosis of B-PCAP has improved in recent years due to new vaccines (Whitney et al., 2003), early diagnosis and improvements in treatment (Gattarello et al., 2014). In contrast, SARS-CoV-2 pneumonia is a new illness and there is currently no specific antiviral treatment.
To analyse differences in clinical presentation and outcome between bacteraemic pneumococcal community-acquired pneumonia (B-PCAP) and sSvere Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pneumonia.
This observational multi-centre study was conducted on patients hospitalized with B-PCAP between 2000 and 2020 and SARS-CoV-2 pneumonia in 2020. Thirty-day survival, predictors of mortality, and intensive care unit (ICU) admission were compared.
In total, 663 patients with B-PCAP and 1561 patients with SARS-CoV-2 pneumonia were included in this study. Patients with B-PCAP had more severe disease, a higher ICU admission rate and more complications. Patients with SARS-CoV-2 pneumonia had higher in-hospital mortality (10.8% vs 6.8%; P=0.004). Among patients admitted to the ICU, the need for invasive mechanical ventilation (69.7% vs 36.2%; P<0.001) and mortality were higher in patients with SARS-CoV-2 pneumonia. In patients with B-PCAP, the predictive model found associations between mortality and systemic complications (hyponatraemia, septic shock and neurological complications), lower respiratory reserve and tachypnoea; chest pain and purulent sputum were protective factors in these patients. In patients with SARS-CoV-2 pneumonia, mortality was associated with previous liver and cardiac disease, advanced age, altered mental status, tachypnoea, hypoxaemia, bilateral involvement, pleural effusion, septic shock, neutrophilia and high blood urea nitrogen; in contrast, ≥7 days of symptoms was a protective factor in these patients. In-hospital mortality occurred earlier in patients with B-PCAP.
Although B-PCAP was associated with more severe disease and a higher ICU admission rate, the mortality rate was higher for SARS-CoV-2 pneumonia and deaths occurred later. New prognostic scales and more effective treatments are needed for patients with SARS-CoV-2 pneumonia.
Sepsis presentation and pathophysiology
2022, Viral, Parasitic, Bacterial, and Fungal Infections: Antimicrobial, Host Defense, and Therapeutic Strategies
As a disease process sepsis represents an interplay between pathogen and host immune response. This interaction results in characteristic physical exam findings that can differ based on pathology. Early recognition and proper understanding of the underlying disease pathology is imperative to effective treatment and prevention of long-term complications. This chapter reviews disease presentation, pathophysiology, and current standard of care treatment for patients with sepsis, including those with COVID-19 pneumonia. Utilizing the most up-to-date guideline recommendations, this overview covers both medical and surgical causes of sepsis along with their treatments, while providing a molecular and cellular understanding for the disease process.
Impact of time to antibiotic therapy on clinical outcome in patients with bacterial infections in the emergency department: implications for antimicrobial stewardship
2021, Clinical Microbiology and Infection
Rapid initiation of antibiotic treatment is considered crucial in patients with severe infections such as septic shock and bacterial meningitis, but may not be as important for other infectious syndromes. A better understanding of which patients can tolerate a delay in start of therapy is important for antibiotic stewardship purposes.
To explore the existing evidence on the impact of time to antibiotics on clinical outcomes in patients presenting to the emergency department (ED) with bacterial infections of different severity of illness and source of infection.
A literature search was performed in the PubMed/MEDLINE database using combined search terms for various infectious syndromes (sepsis/septic shock, bacterial meningitis, lower respiratory tract infections, urinary tract infections, intra-abdominal infections and skin and soft tissue infections), time to antibiotic treatment, and clinical outcome.
The literature search generated 8828 hits. After screening titles and abstracts and assessing potentially relevant full-text papers, 60 original articles (four randomized controlled trials, 43 observational studies) were included. Most articles addressed sepsis/septic shock, while few studies evaluated early initiation of therapy in mild to moderate disease. The lack of randomized trials and the risk of confounding factors and biases in observational studies warrant caution in the interpretation of results. We conclude that the literature supports prompt administration of effective antibiotics for septic shock and bacterial meningitis, but there is no clear evidence showing that a delayed start of therapy is associated with worse outcome for less severe infectious syndromes.
For patients presenting with suspected bacterial infections, withholding antibiotic therapy until diagnostic results are available and a diagnosis has been established (e.g. by 4–8 h) seems acceptable in most cases unless septic shock or bacterial meningitis are suspected. This approach promotes the use of ecologically favourable antibiotics in the ED, reducing the risks of side effects and selection of resistance.
Community-Acquired Pneumonia
2021, Encyclopedia of Respiratory Medicine, Second Edition
Community-acquired pneumonia (CAP) remains one of the most frequent causes of death worldwide, and the most common infection requiring hospitalization. Worldwide CAP is the leading infectious disease cause of death and the fourth leading cause of death overall and the leading cause of death in children. While most of the literature on CAP is on patients who become ill enough to require admission to hospital, less severe disease that is treated in the outpatient setting is also exceptionally common.

View all citing articles on Scopus

*The investigators in the Community-Acquired Pneumonia en la Unidad de Cuidados Intensivos (CAPUCI) II study group are listed in e-Appendix 1.

FUNDING/SUPPORT: This study received support from the following: 2001/SGR414, Red Respira Instituto de Salud Carlos III [RTIC 03/11], fondo de investigación sanitaria [PI 04/1500], and Centro de Investigación en Red de Enfermedades Respiratorias (proyecto corporativo de investigación Pneumonia).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

View full text

Chest

Original ResearchChest InfectionsFeaturedDecrease in Mortality in Severe Community-Acquired Pneumococcal Pneumonia: Impact of Improving Antibiotic Strategies (2000-2013)

OBJECTIVE

METHODS

RESULTS

CONCLUSIONS

Section snippets

Materials and Methods

Results

Discussion

Conclusions

Acknowledgments

J Infect

Chest

Chest

Rev Port Pneumol

Chest

Chest

Med Intensiva

Chest

Clin Chest Med

Chest

Int J Infect Dis

Chest

Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults

Clin Infect Dis

Clinical and economic burden of community-acquired pneumonia among adults in Europe

Thorax

Severe community-acquired pneumonia: use of intensive care services and evaluation of American and British Thoracic Society Diagnostic criteria

Am J Respir Crit Care Med

Hospitalized community-acquired pneumonia in the elderly: age- and sex-related patterns of care and outcome in the United States

Am J Respir Crit Care Med

The impact of prior outpatient ACE inhibitor use on 30-day mortality for patients hospitalized with community-acquired pneumonia

BMC Pulm Med

Comparison between pathogen directed antibiotic treatment and empirical broad spectrum antibiotic treatment in patients with community acquired pneumonia: a prospective randomised study

Thorax

Empirical atypical coverage for inpatients with community-acquired pneumonia: systematic review of randomized controlled trials

Arch Intern Med

Antibiotic prescription for community-acquired pneumonia in the intensive care unit: impact of adherence to Infectious Diseases Society of America guidelines on survival

Clin Infect Dis

Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults

Clin Infect Dis

Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis

JAMA

Microbial etiology of community-acquired pneumonia in the adult population of 4 municipalities in eastern Finland

Clin Infect Dis

Incidence of community-acquired pneumonia in the population of four municipalities in eastern Finland

Am J Epidemiol

Increasing hospital admissions for pneumonia, England

Emerg Infect Dis

Original Research
Chest Infections
Featured
Decrease in Mortality in Severe Community-Acquired Pneumococcal Pneumonia: Impact of Improving Antibiotic Strategies (2000-2013)