Nose-Picking Can Spread Pneumonia

MedicalResearch.com Interview with:
"still picking her nose" by quinn norton is licensed under CC BY 2.0Dr Victoria Connor 

Clinical Research Fellow
Liverpool School of Tropical Medicine and Royal Liverpool Hospital 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Pneumococcus is a bacteria which is very common and causes lots of different infections (pneumococcal disease). Infections can be non-invasive or invasive. Non-invasive diseases include middle ear infections, sinusitis and bronchitis. Invasive infections including chest infection (pneumonia), infections of brain and spinal cord (meningitis) and blood infections (sepsis).

Invasive pneumococcal infections is a major cause of death around the world and in the UK, is estimated that is responsible for 1.3 million deaths in children under 5 annually. Pneumococcal disease causes more deaths in low and middle income countries where approximately 90% of pneumonia deaths occur.

Pneumococcus also is commonly carried (colonises) the nose/throat of children and adults. This colonisation is important to understand as it is the main source of the bacterial transmission and is also the first step in pneumococcal infections.

The understanding of transmission of pneumococcus is currently poor. It is generally thought that transmission occurs through breathing in the respiratory sections of someone carrying pneumococcus in their nose which are infected with pneumococcus.

However more recently studies especially in mice have shown that there may be a role of hands or other objects as vehicles for the transmission of pneumococcus.

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Pneumonia Patients on Ventilators May Benefit from New Ceftolozane/Tazobactam Antibiotics

MedicalResearch.com Interview with:

Dr. Elizabeth Rhee MD Director, Infectious Disease Clinical Research at Merck

Dr. Rhee

Dr. Elizabeth Rhee MD
Director, Infectious Disease Clinical Research Merck

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: High-risk patients, such as the critically ill, with suspected bacterial infections require prompt treatment with appropriate empiric therapy to improve survival. Given the high prevalence of multidrug-resistant (MDR) Pseudomonas aeruginosa in the ICU setting, new safe and broadly effective treatment options are needed for critically ill patients requiring antipseudomonal agents.

Ceftolozane/tazobactam (C/T) is an antipseudomonal cephalosporin/beta-lactamase inhibitor combination with broad in vitro activity against Gram-negative pathogens, including MDR P. aeruginosa and many extended-spectrum beta-lactamase (ESBL) producers. It is FDA approved for complicated intra-abdominal and urinary tract infections in adults at 1.5g (1g/0.5g) q8h. C/T is currently being studied at 3g (2g/1g) q8h, for the treatment of ventilated nosocomial pneumonia, in the ASPECT-NP Phase 3 trial.

This Phase 1 pharmacokinetic (PK) study investigated the penetration of a 3g dose of C/T in the epithelial lining fluid (ELF) of ventilated patients with proven or suspected pneumonia. This is the dose and patient population being evaluated in ASPECT-NP. ELF lines the alveoli, and investigators took samples in a group of 26 patients to see what amount of C/T was in the lung and what was circulating in the plasma during the dosing intervals.

In mechanically ventilated critically ill patients, the 3g dose of C/T achieved ≥50% lung penetration (relative to free plasma) and sustained levels in ELF above the target concentrations for the entire dosing interval. These findings support the 3g dose that is included in the ASPECT-NP Phase 3 trial.  Continue reading

Opioids For Pain Can Exacerbate Pneumococcal Infections

MedicalResearch.com Interview with:

Andrew Wiese, PhD Postdoctoral Research Fellow, Department of Health Policy Vanderbilt University Medical Center

Dr. Wiese

Andrew Wiese, PhD
Postdoctoral Research Fellow
Department of Health Policy
Vanderbilt University Medical Center

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: As opioid use has increased in the U.S., the safety of prescription opioids has come under further scrutiny.

In animal studies, use of certain opioids has been associated with increased susceptibility to bacterial infections, including infectious due to Streptococcus pneumoniae, the pathogen that causes invasive pneumococcal disease. Invasive pneumococcal disease includes bacteremia, meningitis, and invasive pneumonia, all of which are associated with high mortality. Although those associations have been well established in animal experiments, it is important to understand the risk of serious infections among humans taking prescription opioid analgesics.

We found that prescription opioid use is associated with a significantly increased risk for laboratory-confirmed invasive pneumococcal diseases, and that this association was strongest for opioids used at high doses, those classified as high potency and long-acting formulations.

The data also showed that opioids previously described as immunosuppressive in prior experimental studies conducted in animals had the strongest association with invasive pneumococcal diseases in humans. Continue reading

Teaching Deep Breathing Before Abdominal Surgery Reduced Post-Op Pneumonia

MedicalResearch.com Interview with:
Ianthe Boden

Titled Cardiorespiratory APAM, PhD Candidate, MSc, BAppSc
Manager Abdominal Surgery Research Group
Clinical Lead – Cardiorespiratory Physiotherapy, Physiotherapy Department
Allied Health Services
Tasmanian Health Services – North |
Launceston General Hospital
Launceston TA 

MedicalResearch.com: What is the background for this study?

Response: Major upper abdominal surgery involves opening up the abdomen – mainly to remove cancer or damaged bowel, liver, stomach, pancreas, or kidney.  It is, by far, the most common major surgical procedure performed in developed countries with millions of procedures performed per annum. Unfortunately a respiratory complication following these operations occurs relatively frequently with between 1 in 10 to almost a half of all patients getting some type of respiratory complication after surgery. Respiratory complications included problems such as pneumonia, lung collapse, respiratory failure, and an acute asthma attack. These complications, especially pneumonia and respiratory failure, are strongly associated with significant morbidity, mortality, increased antibiotic usage and longer hospital stay.

These breathing problems occur quite quickly after surgery, becoming evident usually within the first two to three days after surgery. In an effort to ameliorate these complications in developed countries it is common for physiotherapists/respiratory therapists to see a patient for the first time on the day after surgery and start patients doing breathing exercises. However as respiratory dysfunction starts occurring immediately following surgery it is debated that these breathing exercises are being provided too late. Initiating prophylactic treatment more than 24 hours after the end of surgery may not be as effective as starting prophylaxis immediately. Unfortunately, immediately after surgery patients are either very sleepy, in pain, feeling sick, or delirious. It may not be possible to effectively teach patients at this point on the importance of breathing exercises and get good performance.

One method to overcome this would be to meet patients before the operation to educate them about their risk of a postoperative chest infection and to motivate and train them to perform breathing exercises to do immediately on waking from surgery. Previous trials have indicated that this may help prevent postoperative respiratory complications, although evidence is inconclusive and weak.

We set out to robustly and conclusively see if respiratory complications could be prevented after major upper abdominal surgery if patients were taught breathing exercises to do as soon as they woke up after the operation. We ran this trial in two countries (Australia and New Zealand) and three different types of hospitals.  All patients were met by a physiotherapist at our hospitals’ scheduled pre-admission clinic appointment and either provided with an information booklet (control) or provided with an additional 30 minute education and training session with the physiotherapist. At this preoperative session the patient was educated about respiratory complications, their risk, and how to prevent them with breathing exercises. These exercises were then taught and practiced for just three repetitions. Patients were instructed to do these breathing exercises for 20 repetitions as soon as they woke from surgery and then 20 times every hour after surgery until they were up and out of bed frequently.

Following surgery each patient had a standardised rehabilitation program and no respiratory therapy of any type was provided to the patients after surgery.

For the first two weeks after surgery patients were assessed daily for a respiratory complication by research assistants unaware of what treatment the patient had received before surgery.

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Pneumococcal Vaccine Rates Still Too Low Among Adults With Work-Related Asthma

MedicalResearch.com Interview with:

Katelynn Dodd MPH Respiratory Health Division National Institute for Occupational Safety and Health Centers for Disease Control and Prevention Morgantown WV 26505

Katelynn Dodd

Katelynn Dodd MPH
Respiratory Health Division
National Institute for Occupational Safety and Health
Centers for Disease Control and Prevention
Morgantown WV 26505

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Adults with asthma are at increased risk for pneumococcal infection. Adults with asthma who get pneumococcal pneumonia are at risk for additional complications including asthma exacerbation and invasive pneumococcal disease. Our results indicated that adults with work-related asthma were more likely to have received a pneumococcal vaccine than adults with non-work-related asthma—54 percent compared to 35 percent respectively; however, pneumococcal vaccination coverage among all adults with asthma, work-related or not, who have ever been employed in this study falls short of achieving the coverage public health experts recommend. Among adults with work-related asthma, pneumococcal vaccine coverage was lowest among Hispanics (36 percent), those without health insurance (39 percent), and adults aged 18 to 44 years (42 percent).

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Antibiotic Failure in Community Acquired Pneumonia Surprisingly Common

MedicalResearch.com Interview with:

Dr. James A. McKinnell, MD LA BioMed Assistant Professor of Medicine David Geffen School of Medicine at UCLA

Dr. McKinnell

Dr. James A. McKinnell, MD
LA BioMed
Assistant Professor of Medicine
David Geffen School of Medicine at UCLA

MedicalResearch.com: What is the background for this study?

Response: Pneumonia is the leading cause of death from infectious disease in the United States. We conducted this study because current community-acquired pneumonia guidelines from the American Thoracic Society and the Infectious Disease Society America, published in 2007, provide some direction about prescribing antibiotics for community-acquired pneumonia. But large-scale, real-world data are needed to better understand and optimize antibiotic choices and to better define clinical risk factors that may be associated with treatment failure. Antibiotic failure for community-acquired pneumonia is associated with substantial morbidity and mortality and results in significant medical expenditures.

We examined databases containing records for 251,947 adult patients who were treated between 2011 and 2015 with a single class of antibiotics (beta-lactam, macrolide, tetracycline, or fluoroquinolone) following a visit to their physician for treatment for community-acquired pneumonia. We defined treatment failure as either the need to refill antibiotic prescriptions, antibiotic switch, ER visit or hospitalization within 30 days of receipt of the initial antibiotic prescription.

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Regular Dental Check Ups Linked To Lower Risk of Pneumonia

MedicalResearch.com Interview with:
Michelle E. Doll, M.D., M.P.H.

Assistant Professor
Associate Hospital Epidemiologist
Department of Internal Medicine
Division of Infectious Diseases
North Hospital
Richmond, VA 23298-0019

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: There are many studies that show that poor oral health is associated with systemic conditions including bacterial pneumonias. Many find this link surprising, but considering that the airways are a direct conduit between the oral cavity and the lungs, saliva containing oral bacteria is able to track down into the lungs via aspiration. Previous studies have found that good oral health seems to prevent pneumonias in people susceptible to lung infections, possibly because the types and quantities of bacteria residing in the mouth are different in people with healthy versus unhealthy teeth.

In my infectious disease clinical practice, I am often frustrated by my inability to assist patients with dental problems. Many of my patients are immunosuppressed, and when they have tooth decay for which they are unable to get timely dental care, I worry about consequences of untreated dental disease; lack of access to dental care is common in the United States. For these reasons, we decided to use data from the Medical Expenditure Panel Survey (MEPS) to determine whether dental care is preventive for bacterial pneumonia. The MEPS database is a large, nationwide survey administered by the Agency for Healthcare Research and Quality (AHRQ), with comprehensive insurance data including dental insurance and access. We found that those who never see the dentist were 86% more likely to get pneumonia in a year, compared to those who visit the dentist for routine check-ups twice a year or more. Furthermore, even those who visit the dentist less than once yearly were at smaller but still significantly increased risk of pneumonia compared to those who see the dentist more frequently.

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Five Risk Factors for 30-day Mortality in Patients With Pneumonia

Yuichiro Shindo, M.D., Ph.D. Visiting Researcher Department of Anesthesiology Washington University School of Medicine St. Louis, MO Assistant Professor Institute for Advanced Research, Nagoya University, Department of Respiratory Medicine, Nagoya University Graduate School of Medicine Showa-ku, Nagoya Japan

Dr. Yuichiro Shindo

MedicalResearch.com Interview with:
Yuichiro Shindo, M.D., Ph.D.
Assistant Professor
Institute for Advanced Research, Nagoya University,
Department of Respiratory Medicine, Nagoya University Graduate School of Medicine
Showa-ku, Nagoya Japan

Medical Research: What is the background for this study? What are the main findings?

Dr. Shindo: Appropriate initial antibiotic treatment is essential for the treatment of pneumonia.  However, many patients may develop adverse outcomes, even if they receive appropriate initial antibiotics.  To our knowledge, there have been no studies that clearly demonstrated the risk factors in patients who receive appropriate antibiotic treatment.  If these factors are clarified, we can identify those patients with pneumonia for whom adjunctive therapy other than antibiotic treatment can prove beneficial in terms of improved outcomes.  This study aimed to clarify the risk factors for 30-day mortality in patients who received appropriate initial antibiotic treatment and elucidate potential candidates for adjunctive therapy.

In this study, the 30-day mortality in 579 pneumonia patients who received appropriate initial antibiotics was 10.5%.  The independent risk factors included albumin < 3.0 mg/dL, nonambulatory status, pH < 7.35, respiration rate ≥ 30/min, and blood urea nitrogen ≥ 20 mg/dL.  The 30-day mortality for the number of risk factors was 0.8% (0), 1.2% (1), 16.8% (2), 22.5% (3), and 43.8% (4–5).

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Men At Higher Risk of Severe Pneumonia

Annabelle de St. Maurice MD, MPH Pediatric Infectious Disease Fellow Vanderbilt Children's HospitaMedicalResearch.com Interview with:
Annabelle de St. Maurice MD, MPH
Pediatric Infectious Disease Fellow
Vanderbilt Children’s Hospital

 Medical Research: What is the background for this study? What are the main findings?

Dr. de St. Maurice: Susceptibility to certain infectious diseases appears to vary by gender. For example, males may be at increased risk of certain infections in childhood, including lower respiratory tract infections such as RSV, however females may have more severe infections, such as influenza, during pregnancy. Some early studies have suggested that males may be at increased risk of pneumococcal infections but this has not been confirmed. Furthermore, whether those potential gender differences remain after introduction of pneumococcal conjugate vaccines is unknown.

Invasive pneumococcal disease, which includes meningitis, bacteremic pneumonia and bacteremia/septicemia, is a significant cause of morbidity and mortality in the United States in children and adults. The 7-valent pneumococcal conjugate vaccine (PCV7) and the 13-valent pneumococcal conjugate vaccine (PCV13) led to declines in invasive pneumococcal disease rates as well as eliminated racial disparities in regards to invasive pneumococcal disease rates. Our study sought to identify potential gender differences in the incidence of invasive pneumococcal disease, and to determine the impact of vaccines on gender differences in the susceptibility to these diseases.

We conducted a large study that used data from a population-based surveillance system of invasive pneumococcal diseases in Tennessee. This is part of a large CDC funded network of surveillance sites for these diseases. For our study, we identified patients with laboratory-confirmed invasive pneumococcal disease, and calculated the incidence of invasive pneumococcal diseases from 1998-2013 by gender. We also stratified the calculations by age groups and race, both well-known factors that affect the occurrence of invasive pneumococcal disease.

Our study found that males had generally higher rates of invasive pneumococcal disease than females across age groups, regardless of race. Although introduction of the pneumococcal conjugate vaccines led to a significant decrease in invasive pneumococcal disease rates, males continued to have higher rates than females in several age groups.

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ICU Treatment For Pneumonia May Decrease Readmissions and Costs

Thomas Valley, MD Fellow, Division of Pulmonary and Critical Care University of Michigan Ann Arbor, MIMedicalResearch.com Interview with:
Thomas Valley, MD
Fellow, Division of Pulmonary and Critical Care
University of Michigan
Ann Arbor, MI

Medical Research: What is the background for this study? What are the main findings?

Dr. Valley: There has been dramatic growth in intensive care unit (ICU) use over the past 30 years. As the reasons for this growth are not entirely clear, some have suggested that the ICU is a meaningful source of low-value care. The value of the ICU, however, depends on the net benefit that ICUs provide patients. Prior observational studies assessing the effectiveness of the ICU were limited because patients admitted to the ICU are inherently sicker and more likely to die than patients admitted to the general ward. Given the substantial number of patients with pneumonia who are admitted to an ICU, it is vital to understand whether admission to the ICU is beneficial.

In our study of 1.1 million Medicare beneficiaries with pneumonia between 2010 and 2012, we used an instrumental variable, a statistical technique to pseudo-randomize patients based on their proximity to a hospital that uses the ICU frequently for pneumonia, in order to determine whether ICU admission saved lives and at what financial cost. An estimated 13 percent of patients were admitted to the ICU solely because they lived closest to a hospital that used the ICU frequently for pneumonia. Among these patients, ICU admission was associated with a nearly six percent reduction in 30-day mortality compared to general ward admission. In addition, there were no significant differences in hospital costs or Medicare reimbursement between patients admitted to the ICU and to the general ward.

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Steroids May Improve Outcomes For Community-Acquired Pneumonia

Reed A.C. Siemieniuk, MD Department of Clinical Epidemiology & Biostatistics Ontario CanadaMedicalResearch.com Interview with:
Reed A.C. Siemieniuk, MD
Department of Clinical Epidemiology & Biostatistics
Ontario Canada

Medical Research: What is the background for this study? What are the main findings?

Dr. Siemieniuk: Local and cytokine-mediated systematic inflammatory responses help clear bacterial pathogens in community-acquired pneumonia (CAP), but often they can also cause harm. Pneumonia is the most common cause of the acute respiratory distress syndrome (ARDS), an often fatal inflammatory complication. Two randomized trials were published earlier this year, each of which suggested the possibility of  benefit from adjunctive corticosteroid therapy. We decided to perform a systematic review and meta-analysis, taking all available data into consideration.

Corticosteroids may be effective for reducing the incidence of ARDS by 6%, the need for mechanical ventilation by 5%, and mortality by 3% (all moderate confidence). They also reduce time to clinical stability and time to discharge by approximately 1 day (high confidence).

For an interactive summary of findings table that shows the study’s findings, please see: http://isof2.epistemonikos.org/#/finding/550bc6acf30d0c43083e63a0.

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Community-Acquired Pneumonia Requiring Hospitalization Remains Significant Burden Especially For Elderly

MedicalResearch.com Interview with:
Seema Jain, MD Medical Epidemiologist Epidemiology and Prevention Branch, Influenza Division Centers for Disease Control and Prevention Atlanta, GA 30329Seema Jain, MD
Medical Epidemiologist
Epidemiology and Prevention Branch, Influenza Division
Centers for Disease Control and Prevention
Atlanta, GA 30329

Medical Research: What is the background for this study? What are the main findings?

Dr. Jain: Community-acquired pneumonia is a leading infectious cause of hospitalization and death among U.S. adults. The last population-based study of community-acquired pneumonia was conducted in the 1990s before the pneumococcal conjugate vaccine and improved diagnostics (molecular detection and urine antigen tests) were available.  Thus, this was an opportune time to examine this question again.  The CDC Etiology of Pneumonia in the Community (EPIC) study attempts to fill in gaps in knowledge about pneumonia in adults, including older adults, by providing estimates of the incidence of community-acquired pneumonia hospitalizations in U.S. adults, as well as its viral and bacterial causes.

The main findings were that the burden of community-acquired pneumonia requiring hospitalization in adults was substantial, with the greatest burden found in adults 80 years of age and older. Human rhinovirus (HRV), influenza and Streptococcus pneumoniae were the most commonly detected pathogens.  However, no pathogen was detected in the majority of adults hospitalized with community-acquired pneumonia.

Medical Research: What should clinicians and patients take away from your report?

Dr. Jain:

  • Increasing coverage of recommended influenza and pneumococcal vaccines and developing effective vaccines and treatments for human metapneumovirus (HMPV), respiratory syncytial virus (RSV) and parainfluenza viruses (PIV) could reduce the pneumonia burden among adults.
  • It’s crucial for adults, especially older adults and adults with certain medical conditions, to receive recommended influenza and pneumococcal vaccines to prevent pneumonia.
  • A yearly flu vaccine is recommended for everyone age 6 months and older.
  • Pneumococcal vaccines are recommended for all adults age 65 and older and for adults younger than 65 years who have certain medical conditions or who smoke cigarettes.
  • In the majority (62%) of patients, no pathogen was detected, highlighting the need for development of new, more sensitive rapid diagnostic tests and methods to accurately identify pneumonia pathogens and target appropriate treatment.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Jain: We need future research to help the development of better diagnostic tests for determining microbiological causes of pneumonia, including tests that can distinguish between bacteria, viruses, and other pathogens.  In addition, for the respiratory pathogens we do know contribute to pneumonia but for which we do not have any prevention methods, such as HMPV and RSV, we need to develop prevention methods that could reduce the burden of disease, this includes vaccines.  We also need to determine factors associated with use of vaccines that we have at hand- both for influenza and pneumococcus- to increase uptake in the adult population.

Citation:

Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults

Seema Jain, M.D., Wesley H. Self, M.D., M.P.H., Richard G. Wunderink, M.D., Sherene Fakhran, M.D., M.P.H., Robert Balk, M.D., Anna M. Bramley, M.P.H., Carrie Reed, Ph.D., Carlos G. Grijalva, M.D., M.P.H., Evan J. Anderson, M.D., D. Mark Courtney, M.D., James D. Chappell, M.D., Ph.D., Chao Qi, Ph.D., Eric M. Hart, M.D., Frank Carroll, M.D., Christopher Trabue, M.D., Helen K. Donnelly, R.N., B.S.N., Derek J. Williams, M.D., M.P.H., Yuwei Zhu, M.D., Sandra R. Arnold, M.D., Krow Ampofo, M.D., Grant W. Waterer, M.B., B.S., Ph.D., Min Levine, Ph.D., Stephen Lindstrom, Ph.D., Jonas M. Winchell, Ph.D., Jacqueline M. Katz, Ph.D., Dean Erdman, Dr.P.H., Eileen Schneider, M.D., M.P.H., Lauri A. Hicks, D.O., Jonathan A. McCullers, M.D., Andrew T. Pavia, M.D., Kathryn M. Edwards, M.D., and Lyn Finelli, Dr.P.H. for the CDC EPIC Study Team

July 14, 2015DOI: 10.1056/NEJMoa1500245

Seema Jain, MD (2015). Community-Acquired Pneumonia Requiring Hospitalization Remains Significant Burden Especially For Elderly 

Pneumonia As Hospital Quality Indicator May Lead To Overly Aggressive Care

Mihaela S Stefan, MD FACP Research Scientist, Center for Quality of Care Research Director of Outpatient Perioperative Clinic and Medical Consultation Program Academic Hospitalist Baystate Medical Center Assistant Professor of Medicine, Tufts University School of Medicine Springfield MA 01199MedicalResearch.com Interview with:
Mihaela S Stefan, MD FACP
Research Scientist, Center for Quality of Care Research
Director of Outpatient Perioperative Clinic and
Medical Consultation Program
Academic Hospitalist Baystate Medical Center
Assistant Professor of Medicine, Tufts University School of Medicine
Springfield MA 01199

MedicalResearch: What is the background for this study?

Dr. Stefan : Mortality rates for patients with pneumonia are publicly reported and are used to evaluate hospital performance. The rates are calculated using Medicare administrative claims data which provide limited insight into severity of illness and comorbidities that may be associated with death. The mortality measure does not take into consideration advance directives or changes in goals of care preferences during hospitalization.

MedicalResearch: What are the main findings?

Dr. Stefan : In this retrospective chart review of 202 adults who died with a principal diagnosis of pneumonia between January 2008 and December 2012 in 3 hospitals in MA, we assessed the proportion of patients for whom pneumonia was determined to play a major or a minor role in the patient death. Pneumonia was considered a minor cause if the patient had advanced life threatening illnesses and this was found in 82% of the deaths. More than half of the patients were DNR at admission to the hospital. The majority of patients who died were frail elderly with life-threatening conditions who decided to forgo aggressive care at some point during their admission. Only a small fraction of deaths in the pneumonia mortality measure were the direct result of pneumonia.
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NEJM Research Discusses Right Antibiotic Strategy For Community-Acquired Pneumonia in Adults

Henri van Werkhoven PhD student | Julius Center for Health Sciences and Primary Care University Medical Center Utrecht, Utrecht, The NetherlandsMedicalResearch.com Interview with:
Henri van Werkhoven
PhD student and

Douwe-PostmaDouwe Postma
PhD student
Julius Center for Health Sciences and Primary Care
University Medical Center Utrecht, Utrecht, The Netherlands

Medical Research: What is the background for this study? What are the main findings?

Response: Community-acquired pneumonia is an important cause of hospitalization and death worldwide. Recommendations for antibiotic treatment in patients hospitalized to a non-ICU ward vary widely between guidelines, because the optimal antibiotic strategy is unknown. Interpretation of the available evidence from clinical studies is complicated by the heterogeneity in designs and findings. In our study, we hypothesized that the most conservative strategy, beta-lactam monotherapy, would be non-inferior to strategies with a broader range of antibiotic coverage. The latter strategies are potentially related to increased antibiotic resistance.

For this purpose, we randomized hospitals to follow three different strategies of preferred antibiotic treatment in consecutive periods of four months. Physicians were allowed to deviate from the preferred antibiotic treatment for medical reasons. We found that a strategy with beta-lactam monotherapy (e.g. amoxicillin) as the preferred treatment was non-inferior to the strategies with beta-lactam/macrolide combination therapy or fluoroquinolone monotherapy for 30 and 90-day all-cause mortality. Also there was no difference in length of hospitalization and rate of complications.

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Respiratory Viral Infections Leading to Pediatric Pneumonia

Seema Jain, MD Medical Epidemiologist Epidemiology and Prevention Branch, Influenza Division Centers for Disease Control and Prevention Atlanta, GA 30329MedicalResearch.com Interview with:
Seema Jain, MD

Medical Epidemiologist
Epidemiology and Prevention Branch, Influenza Division
Centers for Disease Control and Prevention
Atlanta, GA 30329

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Jain: Pneumonia is the leading cause of hospitalization among children in the United States with medical costs estimated at almost $1 billion in 2009.  The Centers for Disease Control and Prevention’s Etiology of Pneumonia in the Community (EPIC) study was a multi-center, active population-based surveillance study that aimed to estimate the incidence and etiology of community-acquired pneumonia requiring hospitalization in U.S. children.  Children in the study were enrolled from January 2010 to June 2012 in three U.S. children’s hospitals in Memphis, Nashville, and Salt Lake City. Study staff tested children using a range of laboratory tests for viral and bacterial respiratory pathogen detection.

During the study period, the EPIC study team enrolled 2,638 children, of which 2,358 (89 percent) had radiographically-confirmed pneumonia. The median age of children in the study was 2 years old. Intensive care was required for 497 (21 percent) of the children, and three children died.  Among 2,222 children with radiographic pneumonia and specimens available for both bacterial and viral testing, a pathogen was detected in 1802 (81%).  One or more viruses were detected in 1,472 (66%) of these children.  Bacteria were detected in 175 (8%), and bacterial and viral co-detection occurred in 155 (7%).  The study estimated that annual pneumonia incidence was 15.7/10,000 children during the study period.  The highest incidence was among children younger than 2 years old (62.2/10,000).  Respiratory syncytial virus (RSV) was the most common pathogen detected (28%), and it was associated with the highest incidence among children younger than 2 years old with pneumonia.  Human rhinovirus was detected in 22 percent of cases, but it was also identified in 17 percent of asymptomatic controls who were enrolled, by convenience sample, at the same site during the same time period; thus, making it challenging to interpret the meaning of human rhinovirus detection in children hospitalized with pneumonia.  Other detected pathogens were human metapneumovirus (13%), adenovirus (11%), Mycoplasma pneumoniae (8%), parainfluenza viruses (7%), influenza (7%), coronaviruses (5%), Streptococcus pneumoniae (4%), Staphylococcus aureus (1%), and Streptococcus pyogenes (<1%).  The low prevalence of bacterial detections likely reflects both the effectiveness of bacterial conjugate vaccines and suboptimal sensitivity of bacterial diagnostic tests. Continue reading

PCV13 Vaccine Markedly Protects Elderly Against Community Acquired Pneumonia

Dr. Susanne Huijts – Pulmonary resident UMC Utrecht | Research physician UMCU Julius Center for Health Sciences and Primary Care NetherlandsMedicalResearch.com Interview with: 
Dr. Susanne Huijts
Research Physician at UMCU Julius Center for Health Sciences Pulmonary resident, UMC Utrecht Center
Utrecht, Netherlands

 

Medical Research: What are the main findings of the study?

Dr. Huijts: The CAPiTA trial evaluated the efficacy of the 13-valent pneumococcal conjugate vaccine (PCV13) in adults of 65 years and older. In the per protocol analysis vaccine efficacy of 45.6% was demonstrated for the first episode vaccine type (VT) pneumococcal community acquired pneumonia (CAP); 45.0% for the first episode of non-bacteremic/ non-invasive (NB/NI) VT-CAP, and 75.0% for the first episode of VT-invasive pneumococcal disease.

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Community Acquired Pneumonia May Require Two Antibiotics

MedicalResearch.com Interview with:
Dr. Nicolas Garin MD
Division of General Internal Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
Division of Internal Medicine, Hôpital Riviera-Chablais, Monthey, Switzerland

Medical Research: What are the main findings of the study?

Dr. Garin: Empiric treatment with a betalactam drug (monotherapy) was not equivalent to the combination of a betalactam and a macrolide in patients hospitalized for moderate severity pneumonia (proportion of patients not having reached clinical stability at day 7 was 41.2 % in the monotherapy vs. 33.6 % in the combination therapy arm, between arm difference 7.6 %). This occurred despite systematic search for Legionella infection in the monotherapy arm. There was no difference in early or late mortality, but patients in the monotherapy arm were more frequently readmitted. Patients with higher severity of disease (in PSI category IV, or with a CURB-65 score higher than 1) seemed to benefit from combination therapy (HR 0.81 for the primary outcome of clinical instability at day 7), although it was statistically not significant. There was no difference in the primary outcome for patients in PSI category I to III.

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Closing in On Effective Treatment for RSV Virus Infections

John DeVincenzo, M.D. Professor of Pediatrics Division of Infectious Diseases Professor of Microbiology, Immunology and Biochemistry University of Tennessee School of Medicine. University of Tennessee. Medical Director, Molecular Diagnostics and Virology Laboratories Le Bonheur Children's Hospital Memphis, TennesseeMedicalResearch.com Interview with:
John DeVincenzo, M.D.
Professor of Pediatrics
Division of Infectious Diseases
Professor of Microbiology, Immunology and Biochemistry
University of Tennessee School of Medicine.
Le Bonheur Children’s Hospital Memphis, Tennessee

Medical Research: What are the main findings of the study?

Dr. DeVincenzo: The main findings are

  • a) This is the first time that anyone has shown that the infection caused by the RSV virus can be effectively reduced in a human after the infection has already started.
  •  b) We also show for the first time that once we reduce the amount of virus in the patient, that very quickly, they start to feel better. This clinical improvement was not expected to occur so rapidly.
  • c) The antiviral appeared safe and it was easy to give.

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Hospitalized Pneumonia Patients May Benefit from Azithromycin

Dr. Eric M. Mortensen, M.D., M.Sc. VA North Texas Health Care System and University of Texas Southwestern Medical Center, DallasMedicalResearch.com Interview with:
Dr. Eric M. Mortensen, M.D., M.Sc.
VA North Texas Health Care System and
University of Texas Southwestern Medical Center, Dallas

 

MedicalResearch: What are the main findings of the study?

Dr. Mortensen: The main findings of our study was that for older patients hospitalized with pneumonia that with the use of azithromycin although there is a small increase in the number of non-fatal heart attacks there was a much lower decrease in mortality.   In addition there were no other significant increases in cardiac events.  So the overall risk:benefit ratio was that for each non-fatal heart attack there were 7 deaths that were prevented.
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Pneumonia Risk Increased From Sleep Apnea

Dr. Vincent Yi-Fong Su Department of Chest Medicine Taipei Veterans General Hospital Taipei, TaiwanMedicalResearch.com Interview with:
Dr. Vincent Yi-Fong Su
Department of Chest Medicine
Taipei Veterans General Hospital
Taipei, Taiwan


MedicalResearch.com: What are the main findings of the study?

Answer: We found interestingly that patients with sleep apnea experienced a 1.20-fold (95% CI, 1.10-1.31; p <0.001) increase in incident pneumonia compared to patients without sleep apnea. We also demonstrated an “exposure-response relationship,” in that the patients with more severe sleep apnea might have a higher risk for pneumonia than did those of milder severity.
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Obstructive Sleep Apnea: Outcomes in Hospitalized Pneumonia Patients

Dr. Peter Lindenauer MD MS Director, Center for Quality of Care Research Baystate Medical Center, Springfield, MA, USMedicalResearch.com Interview Invitation with:
Dr. Peter Lindenauer MD MS
Director, Center for Quality of Care Research
Baystate Medical Center, Springfield, MA, US

MedicalResearch.com: What are the main findings of the study?

Answer: Among a cohort of 250,000 patients hospitalized for pneumonia at 347 US hospitals, those with a diagnosis of obstructive sleep apnea were twice as likely to be intubated at the time of hospital admission than patients without sleep apnea.  In addition, patients with sleep apnea had approximately 50% higher risk of needing to be transferred to the ICU after initial admission to a regular bed, and a 70% increased risk of requiring intubation later in the hospital stay.  Patients with sleep apnea stayed longer in the hospital and incurred higher costs than those without sleep apnea.

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Pneumonia: Improved Antibiotic Strategies and Decreased Mortality

MedicalResearch.com Interview with:
Dr Simone Gattarello
Vall d’Hebron Hospital, Critical Care Department
Universitat Autonoma de Barcelona and Medicine Department, Spain

MedicalResearch.com: What are the main findings of the study?

Dr. Gattarello: The main findings from the present study are a 15% decrease in ICU mortality due to severe community-acquired pneumonia caused by Streptococcus pneumoniae in the last decade; moreover, several changes in antibiotic prescription practices were detected and an association between improved survival and both earlier antibiotic administration and increased combined antibiotic therapy were identified. In summary, in severe pneumococcal pneumonia combined antibiotic therapy and early antibiotic administration are associated with lower mortality.
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