Author information
Abstract
BACKGROUND:
Community-acquired pneumonia (CAP) is the third-leading infectious cause of death worldwide. The standard treatment of CAP has not changed for the past fifty years and its mortality and morbidity remain high despite adequate antimicrobial treatment. Systemic corticosteroids have anti-inflammatory effects and are therefore discussed as adjunct treatment for CAP. Available studies show controversial results, and the question about benefits and harms of adjunct corticosteroid therapy has not been conclusively resolved, particularly in the non-critical care setting.
METHODS/DESIGN:
This randomized multicenter study compares a treatment with 7 days of prednisone 50 mg with placebo in adult patients hospitalized with CAP independent of severity. Patients are screened and enrolled within the first 36 hours of presentation after written informed consent is obtained. The primary endpoint will be time to clinical stability, which is assessed every 12 hours during hospitalization. Secondary endpoints will be, among others, all-cause mortality within 30 and 180 days, ICU stay, duration of antibiotic treatment, disease activity scores, side effects and complications, value of adrenal function testing and prognostic hormonal and inflammatory biomarkers to predict outcome and treatmentresponse to corticosteroids. Eight hundred included patients will provide an 85% power for the intention-to-treat analysis of the primary endpoint.
DISCUSSION:
This largest to date double-blind placebo-controlled multicenter trial investigates the effect of adjunct glucocorticoids in 800 patients with CAP requiring hospitalization. It aims to give conclusive answers about benefits and risks of corticosteroid treatment in CAP. The inclusion of less severe CAP patients will be expected to lead to a relatively low mortality rate and survival benefit might not be shown. However, our study has adequate power for the clinically relevant endpoint of clinical stability. Due to discontinuing glucocorticoids without tapering after seven days, we limit duration of glucocorticoid exposition, which may reduce possible side effects.
2.
Integrated community case management of malaria and pneumonia increases prompt and appropriate treatmentfor pneumonia symptoms in children under five years in Eastern Uganda.
Kalyango JN1, Alfven T, Peterson S, Mugenyi K, Karamagi C, Rutebemberwa E.
Author information
BACKGROUND:
Efforts to improve access to treatment for common illnesses in children less than five years initially targeted malaria alone under the home management of malaria strategy. However under this strategy, children with other illnesses were often wrongly treated with anti-malarials. Integrated community case management of common childhood illnesses is now recommended but its effect on promptness of appropriatepneumonia treatment is unclear.
OBJECTIVES:
To determine the effect of integrated malaria and pneumonia management on receiving prompt and appropriate antibiotics forpneumonia symptoms and treatment outcomes as well as determine associated factors.
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METHODS:
A follow-up study was nested within a cluster-randomized trial that compared under-five mortality in areas where community health workers (CHWs) treated children with malaria and pneumonia (intervention areas) and where they treated children with malaria only (control areas). Children treated by CHWs were enrolled on the day of seeking treatment from CHWs (609 intervention, 667 control) and demographic, illness, andtreatment seeking information was collected. Further information on illness and treatment outcomes was collected on day four. The primary outcome was prompt and appropriate antibiotics for pneumonia symptoms and the secondary outcome was treatment outcomes on day four.
RESULTS:
Children in the intervention areas were more likely to receive prompt and appropriate antibiotics for pneumonia symptoms compared to children in the control areas (RR = 3.51, 95%CI = 1.75-7.03). Children in the intervention areas were also less likely to have temperature ≥37.5C on day four (RR = 0.29, 95%CI = 0.11-0.78). The decrease in fast breathing between day one and four was greater in the intervention (9.2%) compared to the control areas (4.2%, p-value = 0.01).
CONCLUSIONS:
Integrated community management of malaria and pneumonia increases prompt and appropriate treatment for pneumoniasymptoms and improves treatment outcomes.
3.
Procalcitonin for diagnosis of bacterial pneumonia in critically ill patients during 2009 H1N1 influenza pandemic: a prospective cohort study, systematic review and individual patient data meta-analysis.
Pfister R, Kochanek M, Leygeber T, Brun-Buisson C, Cuquemelle E, Machado MB, Piacentini E, Hammond NE, Ingram PR, Michels G.
Abstract
INTRODUCTION:
Procalcitonin (PCT) is helpful for diagnosing bacterial infections. The diagnostic utility of PCT has not been examined thoroughly in critically ill patients with suspected H1N1 influenza.
METHODS:
Clinical characteristics and PCT were prospectively assessed in 46 patients with pneumonia admitted to medical ICUs during the 2009 and 2010 influenza seasons. An individual patient data meta-analysis was performed by combining our data with data from five other studies on the diagnostic utility of PCT in ICU patients with suspected 2009 pandemic influenza A(H1N1) virus infection identified by performing a systematic literature search.
RESULTS:
PCT levels, measured within 24 hours of ICU admission, were significantly elevated in patients with bacterial pneumonia (isolated or coinfection with H1N1; n = 77) (median = 6.2 μg/L, interquartile range (IQR) = 0.9 to 20) than in patients with isolated H1N1 influenza pneumonia (n = 84; median = 0.56 μg/L, IQR = 0.18 to 3.33). The area under the curve of the receiver operating characteristic curve of PCT was 0.72 (95% confidence interval (CI) = 0.64 to 0.80; P < 0.0001) for diagnosis of bacterial pneumonia, but increased to 0.76 (95% CI = 0.68 to 0.85; P < 0.0001) when patients with hospital-acquired pneumonia and immune-compromising disorders were excluded. PCT at a cut-off of 0.5 μg/L had a sensitivity (95% CI) and a negative predictive value of 80.5% (69.9 to 88.7) and 73.2% (59.7 to 84.2) for diagnosis of bacterial pneumonia, respectively, which increased to 85.5% (73.3 to 93.5) and 82.2% (68.0 to 92.0) in patients without hospital acquired pneumonia or immune-compromising disorder.
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CONCLUSIONS:
In critically ill patients with pneumonia during the influenza season, PCT is a reasonably accurate marker for detection of bacterialpneumonia, particularly in patients with community-acquired disease and without immune-compromising disorders, but it might not be sufficient as a stand-alone marker for withholding antibiotic treatment.
4.
The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review.
Goldberg LS1, Altman KW2.
Author information
Abstract
PURPOSE:
Over 4.5 million people in North America had a diagnosis of dementia in the year 2000, and more than half had advanced disease with potential aspiration risk. There is much controversy regarding the use and timing of enteral feeding support in these patients with dysphagia. The management of dysphagia is far more complex when considering quality of life, "comfort care" hand feeding, the use of percutaneous endoscopic gastrostomy tube (PEG), and associated mortality rates. This study seeks to critically review the literature that evaluates PEG placement in this population.
METHODS:
A systematic literature review of PubMed, from 1995-2012, was conducted to identify studies relating to PEG placement in dementia patients with dysphagia. The principal outcomes and related survival rates for this population were compared.
RESULTS:
In total, 100 articles were identified in the search. Of these, ten met the search criteria and were analyzed. There was one study with a 2b level of evidence, one with 3b, and the remainder had level 4. All studies discussed long-term survival in the PEG versus non-PEG populations. No studies showed definitive evidence to suggest long-term survival rates improved in patients who underwent PEG placement as compared to those who did not. Two studies documented median survival worse in patients over age 80 with dementia and PEG placement.
CONCLUSION:
There is presently no evidence to suggest long-term survival rates improved in patients with advanced dementia who underwent PEG placement for dysphagia. Relevance to quality of life, need for nutrition and hydration, and ethical considerations in the decision process are discussed.
5.
Simvastatin to modify neutrophil function in older patients with septic pneumonia (SNOOPI): study protocol for a randomised placebo-controlled trial.
Greenwood H, Patel J, Mahida R, Wang Q, Parekh D, Dancer RC, Khiroya H, Sapey E, Thickett DR1.
Author information
Abstract
BACKGROUND:
Community-acquired pneumonia (CAP) is considered the leading cause of death from infectious disease in developed countries, while complications of CAP - sepsis being the most common and challenging - increase the risk of mortality. During the progression of sepsis, a state of neutrophil 'paralysis' develops resulting in the impairment of neutrophil anti-microbial functions including: chemotaxis, production of reactive oxygen species, and formation of neutrophil extracellular traps (NETs). Mechanisms underlying defective neutrophil function remain elusive although NET formation has been implicated in the immunosuppression and increased rates of sepsis observed in neonates. There is, however, increasing evidence that statins are able to modulate neutrophil function in sepsis as several systematic reviews have concluded that statins have a role in improving infection-related outcomes and mortality while, in vitro, statins have also been shown to boost NET formation in healthy individuals.
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METHODS/DESIGN:
The 'SNOOPI' trial is a phase 4, randomised placebo-controlled trial. The aim of this study is to determine whether oraltreatment with simvastatin compared to placebo optimises neutrophil anti-microbial functions in elderly patients with septic pneumonia improving patient outcomes in the elderly. The primary outcome will be NET production within 72 to 96 hours of treatment with simvastatin or placebo measured in response to a number of inflammatory mediators, including IL8, f-Met-Leu-Phe and lipopolysaccharide. Secondary outcomes include neutrophil migratory capacity; reactive oxygen species production; neutrophil phagocytic capacity; safety and tolerability of simvastatin administration within this patient group; biological markers of neutrophil activation, the inflammatory response, alveolar epithelial and endothelial injury; systemic endothelial function biomarkers and pulmonary extracellular matrix degradation. This study aims to recruit 60 patients admitted into Queen Elizabeth Hospital Birmingham NHS-Foundation Trust.
DISCUSSION:
This study will investigate the ability of in vivo simvastatin therapy to modulate neutrophil anti-microbial functions in CAP-associated sepsis.
TRIAL REGISTRATION:
EudraCT number: 2012-003343-29 (Trial Registered: 26 November 2012).
6.
Early jejunal feeding by bedside placement of a nasointestinal tube significantly improves nutritional status and reduces complications in critically ill patients versus enteral nutrition by a nasogastric tube.
Wan B1, Fu H2, Yin J3.
Author information
Abstract
in English, Chinese
BACKGROUND AND OBJECTIVE:
Unguided nasojejunal feeding tube insertion success rates are low. Controversy persists about how to safely and efficiently perform enteral nutrition (EN) in critically ill patients. This study explores an innovative blind nasointestinal tube (NIT) insertion method and compares nasogastric and nasointestinal feeding.
METHODS:
Seventy critically ill patients admitted to the intensive care unit (ICU) were divided randomly into a nasogastric tube group (NGT; n=35) and an NIT group (NIT; n=35). After bedside NGT and blind-type NIT insertion, tube position was assessed and EN was started on day 1. Patients' nutritional status parameters, mechanical ventilation duration, average ICU stay, nutritional support costs, and feeding complications were compared.
RESULTS:
Pre-albumin and transferrin levels on days 7 and 14 were significantly higher in the NIT group than in the NGT group (p<0.01, p<0.05). Bloating, diarrhea, upper gastrointestinal bleeding, and liver damage did not differ significantly between groups (p>0.05). Interleukin-6 and tumor necrosis factor-α levels and APACHE II score were significantly lower in the NIT group than in the NGT group (p<0.01, p<0.05). Reflux andpneumonia incidences, mechanical ventilation duration, average ICU stay length, and nutritional support costs were significantly lower in the NIT group than in the NGT group (p<0.01).
CONCLUSION:
Blind bedside NIT insertion is convenient and its use can effectively improve nutritional status, reduce feeding complications, and decrease nutritional support costs of critically ill patients.
7.
Pre-analytic factors and initial biomarker levels in community-acquired pneumonia patients.
Kutz A1, Grolimund E1, Christ-Crain M2, Thomann R3, Falconnier C4, Hoess C5, Henzen C6, Zimmerli W4, Mueller B1, Schuetz P1; ProHOSP Study Group.
Collaborators (35)
Author information
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Abstract
BACKGROUND:
Blood biomarkers are increasingly used to diagnose, guide therapy in, and risk-stratify community-acquired pneumonia (CAP) patients in emergency departments (EDs). How pre-analytic factors affect these markers' initial levels in this population is unknown.
METHODS:
In this secondary analysis of consecutive ED patients with CAP from a large multicentre antibiotic stewardship trial, we used adjusted multivariate regression models to determine the magnitude and statistical significance of differences in mean baseline concentrations of five biomarkers (procalcitonin [PCT], C-reactive protein [CRP], white blood cells count [WBC], proadrenomedullin [ProADM], copeptin) associated with six pre-analytic factors (antibiotic or corticosteroid pretreatment, age, gender, chronic renal failure or chronic liver insufficiency).
RESULTS:
Of 925 CAP patients (median age 73 years, 58.8% male), 25.5% had antibiotic pretreatment, 2.4%, corticosteroid pretreatment, 22.3%, chronic renal failure, 2.4% chronic liver insufficiency. Differences associated with pre-analytic factors averaged 6.1% 4.6%; the three largest statistically significant changes (95% confidence interval) were: PCT, +14.2% (+2.1% to +26.4%, p = 0.02) with liver insufficiency; ProADM, +13.2% (+10.2% to +16.1%, p < 0.01) with age above median; CRP, -12.8% (-25.4% to -0.2%, p = 0.05) with steroid pretreatment. In post hoc sensitivity analyses, reclassification statistics showed that these factors did not result in significant changes of biomarker levels across clinically used cut-off ranges.
CONCLUSIONS:
Despite statistically significant associations of some pre-analytic factors and biomarker levels, a clinically relevant influence seems unlikely. Our observations reinforce the concept of using biomarkers in algorithms with widely-separated cut-offs and overruling criteria considering the entire clinical picture.
TRIAL REGISTRATION:
Identifier ISRCTN95122877.
KEYWORDS:
Blood biomarkers; C-reactive protein; Community-acquired pneumonia; Copeptin; Pre-analytic factors; Pretreatment; Proadrenomedullin; Procalcitonin; White blood cells count
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7. . . .., ....,2004.
8. . . 2. 49 .: , 2007. 1376 .
Қ:
1. , . . , ., ., 2003.
2. . . ., 2002.
3. .., ... - . - .2002.
4. .., .. . , 2004.
5. .., .., .., ... 2 ., .-.: , 2002. 1248 . .
6. .., .. . .: , 2006 303 .
7. .. . .: , 2006. 192 .
қ: ұқ ұ(ққ ғ ұқ).
Қ ң ғғ ғ :
ѳ қ ү қ ң? ұғғ қ ү ң, қ ү ң, қ ә қ ң ә ғ ң? Қ қ қ ң?
қғ ә ғ қ ?
ү ң ә ң ң әң . ұ ә ү ө қ ө.
: ө ү ң әң ғwww.pubmed.com Clinical Queries қ , 3 ә ү ң (ү).
қ
ғ
(David Sackett) ғ ң
ғ ү ә қ ?
ғ қ қ ?
қ қ ө ү ү ү қ қ ?
ү қ ?
қ қ ү қ ?
ә ү қ қ?
