The study was conducted in a 670-bed tertiary teaching hospital in Paris, France. We retrospectively reviewed medical records of all consecutive adult patients who required ICU admission between January 2007 and March 2014 for acute respiratory failure. Pneumonia was diagnosed with the following criteria: a new alveo- lar, interstitial or alveolo-interstitial opacity on chest radiography, associated with at least two of the following: cough, sputum production, temperature above 38 °C or below 35 °C, and auscultatory findings consistent with pneumonia or dyspnoea. To be considered a community- acquiredpneumonia, symptoms had to develop in the community or within the first 48 h after hospital admis- sion [ 11 – 13 ]. Patients were admitted to the ICU from the emergency department or directly from the pre-hospital emergency medical team. The institutional review board of our institution approved the study.
Materials and Methods
We performed a post hoc analysis of the original data from the Emergency Department Community-AcquiredPneumonia (EDCAP) and Pneumocom-1 studies. The methods used for both studies are reported elsewhere [10, 18]. Briefly, the EDCAP study was a cluster randomized trial involving 32 hospitals in Connecticut and western Pennsylvania, while the Pneumcom-1 study was a multicenter prospective observational cohort study conducted in 16 hospitals in France. Each study protocol received the approval from the institutional review boards at the participating institutions.
ESCAPED was a multicenter, prospective, interventional study, entitled “Early Thoracic CT-Scan for Community- AcquiredPneumonia at the Emergency Department (ESCAPED)” , conducted from November 2011 to January 2013, in four emergency departments (EDs) of four tertiary teaching hospitals in Paris, France, designed to measure the impact of thoracic CT scan on clinical decision. The study was sponsored and monitored by the Paris public health hospitals, and funded by the French Ministry of Health. The French health authorities (Agence nationale de sécurité des medicaments et produits de santé, ANSM) and the institutional review board for the protection of human subjects approved the study protocol and patient informed consent procedures. All enrolled patients provided written informed consent for inclusion. The protocol was regis- tered in the clinicaltrial.gov website under the PACSCAN acronym, the French translation of the English ESCAPED acronym (NCT01574066). The Ethics Committee of Ile de France (Comité de Protection des Personnes. Paris N° 2011-oct-12749) approved the study protocol.
Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, 75015 Paris, France
* Correspondence: firstname.lastname@example.org; Tel.: +331-560-162-63
Received: 2 April 2019; Accepted: 27 May 2019; Published: 3 June 2019
Abstract: Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to alleviate symptoms during community-acquiredpneumonia (CAP), while neither clinical data nor guidelines encourage this use. Experimental data suggest that NSAIDs impair neutrophil intrinsic functions, their recruitment to the inflammatory site, and the resolution of inflammatory processes after acute pulmonary bacterial challenge. During CAP, numerous observational data collected in hospitalized children, hospitalized adults, and adults admitted to intensive care units (ICUs) support a strong association between pre-hospital NSAID exposure and a delayed hospital referral, a delayed administration of antibiotic therapy, and the occurrence of pleuropulmonary complications, even in the only study that has accounted for a protopathic bias. Other endpoints have been described including a longer duration of antibiotic therapy and a greater hospital length of stay. In all adult series, patients exposed to NSAIDs were younger and had fewer comorbidities. The mechanisms by which NSAID use would entail a complicated course in pneumonia still remain uncertain. The temporal hypothesis and the immunological hypothesis are the two main emerging hypotheses. Current data strongly support an association between NSAID intake during the outpatient treatment of CAP and a complicated course. This should encourage experts and scientific societies to strongly advise against the use of NSAIDs in the management of lower respiratory tract infections.
In order to help judging readiness for discharge for hospitalized patients with community- acquiredpneumonia (CAP), Halm et al. 9 proposed criteria to define clinical stability and assessed the association of unfulfilled criteria with bad outcomes. In their definition, a stable patient associated, during a 24 hours period, temperature ≤37.8°C, heart rate ≤100 beats/min, respiratory rate ≤24 breaths/min, systolic blood pressure ≥90mmHg, arterial oxygen saturation ≥90% or PO 2 ≥60mmHg on room air, ability to maintain oral intake and normal
Mots clés Pneumonie aiguë communautaire grave · Détresse respiratoire · Bactérie atypique · Légionellose · Pneumonie virale
Abstract Usually, intensivists do not focus on atypical bac- teria and viruses in severe community-acquiredpneumonia (CAP). Only Legionella pneumophila and influenza virus, following the recent H1N1 influenza pandemic, are routinely suggested as responsible agents. However, CAP due to aty- pical bacteria may represent up to 44% of all CAP. Viral CAP is considered less severe than the usual bacterial ones, although 25% of them warrant hospitalization and 15% result in severe sepsis. Even though L. pneumophila is the most frequently atypical pathogen involved in severe cases, Mycoplasma pneumoniae may be responsible for multi- organ failure. To date, tools including detection of Legio- nella antigen in urine and Mycoplasma using polymerase chain reaction (PCR) allow rapid and accurate diagnosis. The treatment is based on macrolides and fluoroquinolones that can be associated in severe Legionnaire diseases. The presence of virus in CAP, either alone or in association with bacteria, has been demonstrated using molecular biology tests. These techniques also allowed the identification of several new viruses in CAP. However, the exact role of these detected viruses in CAP as well as the efficiency of antiviral therapy still represent major unsolved concerns.
ger DE, Coley CM, Marrie TJ, Kapoor WN, (1997) A prediction rule to identify low-risk patients with community-acquired pneu- monia. N Engl J Med 336: 243 –250
11. Lim WS, Van Der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, Lewis SA, Macfarlane JT, (2003) Defining commu- nity acquiredpneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58: 377 –382 12. Wunderink RG, Laterre PF, Francois B, Perrotin D, Artigas A, Vidal LO, Lobo SM, Juan JS, Hwang SC, Dugernier T, LaRosa S, Wittebole X, Dhainaut JF, Doig C, Mendelson MH, Zwingels- tein C, Su G, Opal S, CAPTIVATE Trial Group, (2011) Recom- binant Tissue Factor Pathway Inhibitor in severe community- acquiredpneumonia: a randomized trial. Am J Respir Crit Care Med 183: 1561–1568
Pneumonia was defined by signs and symptoms of lower respiratory tract infection (e.g., cough, expectoration, and chest pain) and pulmonary infiltrates on chest X Ray reviewed by a radiologist, that were not attributable to other causes, but coinciding with S. aureus isolation by at least 1 of the following procedures: (1) pleural effu- sion or lung abscess; (2) broncho-alveolar lavage fluid culture (10 4 CFU/mL), Wimberley brushing (10 3 CFU/ mL), or protected tracheal aspiration (10 3 CFU/mL); and (3) blood culture revealing S. aureus as the sole potential pathogen. Cases with respiratory symptoms starting at least 48 h after hospitalization were classified as nosoco- mial and were excluded from the study. Leukopenia was defined as severe if median leukocyte count was < 3,000
recommending the use of amoxicillin, prescription rates of amoxicillin for CAP increased from 2 to 44 % .
We observed that younger ages were associated with a higher risk of non-compliance in period 1, whereas, by contrast, the aOR for non-compliance was 1.2 for each year of age in period 2. This could be attributed to the increased likelihood that during the first period, young chil- dren were more likely to receive amoxicillin-clavulanate than in the second period. The use of amoxicillin- clavulanate could be explained by the fear of invasive Haemophilus influenzae type b. We also observed that children with risk factors for invasive pneumococcal infec- tion were more likely to be subject to non-compliant pre- scriptions, particularly during period 2. We hypothesize that doctors might fear, in an irrational manner, encoun- tering resistant pneumococci in these children. Indeed, since the more widespread use of the pneumococcal vac- cine, resistance to penicillin has decreased, as described in a previous Palestinian–Israeli study . This decrease in the resistance to penicillin was also observed in France, with 82 % of the 1858 strains analysed by the national reference centre being susceptible to amoxicillin in 2009 vs. 92 % of the 957 analysed strains in 2012 (p < 0.001) [14, 15]. The use of broad spectrum antibiotics was therefore needed less often. It has also been shown that antibiotic guidelines for upper respiratory tract infec- tions, published on November 2011 in France, had a major impact on antibiotic prescriptions, resulting in increased amoxicillin use . These recommenda- tions could have also impacted the antibiotic prescrip- tions for pneumonia in our study by sensitizing prescribers to the need to use narrow-spectrum anti- biotics in order to limit the risk of resistant bacteria.
A recent meta-analysis of corticosteroids in pneumonia found that hydrocortisone was not useful in this context, and only prednisone or methyl prednisolone was beneficial [ 37 ]. However, this meta-analysis considered community- acquiredpneumonia (CAP) rather than HAP or ventilator- acquiredpneumonia (VAP). The micro-organisms involved in each entity are different; in CAP, they are frequently virulent and transmitted by inhaled aerosols. Moreover, re- spiratory physiology and immunity is severely impaired in patients suffering from HAP or VAP and admitted in ICU. Indeed, mechanical ventilation promotes a specific histo- logical pattern of pneumonia [ 38 , 39 ]. Furthermore, comparative analysis of the host response to CAP and to HAP in patients with critical illness has revealed distinct transcriptional and plasma protein responses [ 40 ] showing the functional alterations of the immune response in patients admitted to hospital.
Our results showed that Streptococcus infections were not fre- quent in the community setting, in opposite to previous studies [23,24] that showed that this germ was the most common eti- ological pathogen isolated. This might be due to the fact that currently, S. pyogenes is considered a rare cause of communityacquiredpneumonia, being a clinical entity seen only sporadically after an inﬂuenza infection  . Furthermore, the proportion of CAP attributed to S. pneumoniae showed great variation between countries, with average rates of 24% in Japan, 14% in South Korea and Taiwan, 12% in The Philippines, 8–9% in Thailand, China and India and 4–5% in Malaysia and Singapore  . A lack of rigorous microbiological standards, for example, specimen collection fol- lowing antibiotic use, delays in specimen transport, or culture of specimens with inadequate microscopic screening for white blood
Conflicts of interest
Authors declare no conflict of interest.
1. Song JH, Thamlikitkul V, Hsueh PR. Clinical and economic burden of community-acquiredpneumonia amongst adults in the Asia-Pacific region. Int J Antimicrob Agents 2011; 38: 108e17 .
Community-acquired Pseudomonas aeruginosa (P. aerugi- nosa) infections are rare. Most cases involve patients either with underlying immunosuppression or structural chronic lung diseases, such bronchiectasis. The virulence factors play an important role that may lead to acute lung injury, bacteremia, sepsis and invasion of tissues. P. aeruginosa possesses a virulence mechanism known as the type III secretion system. The type III secretory toxin, ExoU is a major virulence factor associated with poor clinical outcome. We report here an atypical case of a community- acquired invasive infection due to a hypervirulent ExoU- producing strain, in an immunocompetent patient.
Keywords Virus · Cytomegalovirus · Herpes simplex virus · Pneumonia · Mechanical Ventilation · Intensive care unit
En dehors du contexte de l ’immunodépression (transplanta- tion, sida), la recherche de virus n ’est pas souvent effectuée chez le patient de réanimation sous ventilation mécanique (VM). Pourtant, les progrès effectués dans la détection de ces pathogènes ont permis de mieux évaluer l ’impact des virus chez ces patients . Certes, les virus peuvent être res- ponsables de tableaux infectieux sévères accompagnés d ’un syndrome de détresse respiratoire aigu (SDRA) conduisant le patient en réanimation ; il s ’agit alors d’infections virales « communautaires » comme celles causées par le virus de la grippe . Mais certains virus peuvent également se mani- fester chez le patient déjà admis en réanimation et sous VM ; on parlera alors d ’infections virales « nosocomiales », essen- tiellement respiratoires (Tableau 1).
A new classification algorithm for eosinophilic pneu- monia in children is also proposed (Figure 3), including two main differential diagnoses to ICEP: hypereosinophilic asthma and idiopathic interstitial pneumonia. The overall impression is that idiopathic chronic eosinophilic pneu- monia is part of the clinical spectrum of a wider group of lung diseases, with some potential overlap between them, making a clear distinction sometimes difficult. Molecular analysis should likely help in the clarification of this aspect and better circumvent underlying biological processes.