Comparative analysis of clinical features between severe coronavirus disease 2019 and severe community acquired pneumonia / 中华危重病急救医学

Objective:To compare and analyze the clinical features of patients with severe coronavirus disease 2019 (sCOVID-19) and severe community acquired pneumonia (sCAP) who meet the diagnostic criteria for severe pneumonia of the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS).Methods:A retrospective comparative analysis of the clinical records of 116 patients with sCOVID-19 admitted to the department of critical care medicine of Wuhan Third Hospital from January 1, 2020 to March 31, 2020 and 135 patients with sCAP admitted to the department of critical care medicine of Shanghai First People's Hospital from January 1, 2010 to December 31, 2017 was conducted. The basic information, diagnosis and comorbidities, laboratory data, etiology and imaging results, treatment, prognosis and outcome of the patients were collected. The differences in clinical data between sCOVID-19 and sCAP patients were compared, and the risk factors of death were analyzed.Results:The 28-day mortality of sCOVID-19 and sCAP patients were 50.9% (59/116) and 37.0% (50/135), respectively. The proportion of arterial partial pressure of oxygen/fraction of inspired oxygen (PaO 2/FiO 2)≤250 mmHg (1 mmHg ≈ 0.133 kPa) in sCOVID-19 patients was significantly higher than that of sCAP [62.1% (72/116) vs. 34.8% (47/135), P < 0.01]. The possible reason was that the proportion of multiple lung lobe infiltration in sCOVID-19 was significantly higher than that caused by sCAP [94.0% (109/116) vs. 40.0% (54/135), P < 0.01], but the proportion of sCOVID-19 patients requiring mechanical ventilation was significantly lower than that of sCAP [45.7% (53/116) vs. 60.0% (81/135), P < 0.05]. Further analysis of clinical indicators related to patient death found that for sCOVID-19 patients PaO 2/FiO 2, white blood cell count (WBC), neutrophils (NEU), neutrophil percentage (NEU%), neutrophil/lymphocyte ratio (NLR), total bilirubin (TBil), blood urea nitrogen (BUN), albumin (ALB), Ca 2+, prothrombin time (PT), D-dimer, C-reactive protein (CRP) and other indicators were significantly different between the death group and the survival group, in addition, the proportion of receiving mechanical ventilation, gamma globulin, steroid hormones and fluid resuscitation in death group were higher than survival group. Logistic regression analysis showed that the need for mechanical ventilation, NLR > 10, TBil > 10 μmol/L, lactate dehydrogenase (LDH) > 250 U/L were risk factors for death at 28 days. For sCAP patients, there were significant differences in age, BUN, ALB, blood glucose (GLU), Ca 2+ and D-dimer between the death group and the survival group, but there was no significant difference in treatment. Logistic regression analysis showed that BUN > 7.14 mmol/L and ALB < 30 g/L were risk factors for 28-day death of sCAP patients. Conclusions:The sCOVID-19 patients in this cohort have worse oxygen condition and symptoms than sCAP patients, which may be due to the high proportion of lesions involving the lungs. The indicators of the difference between the death group and the survival group were similar in sCOVID-19 and sCAP patients. It is suggested that the two diseases have similar effects on renal function, nutritional status and coagulation function. But there were still differences in risk factors affecting survival. It may be that sCOVID-19 has a greater impact on lung oxygenation function, inflammatory cascade response, and liver function, while sCAP has a greater impact on renal function and nutritional status.

Clinical factors associated with composition of lung microbiota and important taxa predicting clinical prognosis in patients with severe community-acquired pneumonia / 医学前沿

Few studies have described the key features and prognostic roles of lung microbiota in patients with severe community-acquired pneumonia (SCAP). We prospectively enrolled consecutive SCAP patients admitted to ICU. Bronchoscopy was performed at bedside within 48 h of ICU admission, and 16S rRNA gene sequencing was applied to the collected bronchoalveolar lavage fluid. The primary outcome was clinical improvements defined as a decrease of 2 categories and above on a 7-category ordinal scale within 14 days following bronchoscopy. Sixty-seven patients were included. Multivariable permutational multivariate analysis of variance found that positive bacteria lab test results had the strongest independent association with lung microbiota (R2 = 0.033; P = 0.018), followed by acute kidney injury (AKI; R2 = 0.032; P = 0.011) and plasma MIP-1β level (R2 = 0.027; P = 0.044). Random forest identified that the families Prevotellaceae, Moraxellaceae, and Staphylococcaceae were the biomarkers related to the positive bacteria lab test results. Multivariable Cox regression showed that the increase in α-diversity and the abundance of the families Prevotellaceae and Actinomycetaceae were associated with clinical improvements. The positive bacteria lab test results, AKI, and plasma MIP-1β level were associated with patients' lung microbiota composition on ICU admission. The families Prevotellaceae and Actinomycetaceae on admission predicted clinical improvements.

Construction of early warning index for critical condition of severe community-acquired pneumonia in emergency department / 中国实用护理杂志

Objective:Based on the clinical indicators of severe community-acquired pneumonia in emergency department, the early warning indicators of critical condition were constructed.Methods:The general information, vital signs before entering ICU, laboratory indexes and the survival rate in 30 days of 118 patients with community-acquired pneumonia were retrospectively collected in the emergency care unit of Peking Union Medical College Hospital from January to December 2018. The indexes of death patients (24 cases) and alive patients (98 cases) underwent comparative analysis, using ROC curve to predict the clinical outcome and reliable parameters of emergency patients with community-acquired pneumonia. The best cutoff value was determined according to Youden index and then undergoing multiple factors Logistic stepwise regression analysis. Then early warning model of critical degree was finally built.Results:Eleven indicators were used to predict the criticality of patients with acute community-acquired pneumonia, including AVPU (alert, voice, pain, unresponsive) score, Glasgow Coma Scale(GCS), heart rate, pulse oxygen saturation (SpO 2), fraction of inspiration O 2, oxygenation index,potential of hydrogen, blood potassium (K +), bilirubin, urea nitrogen, and C reactive protein, the optimal cutoff values were 2 points, 8 points, 91 times per minute, 0.94, 41%, 81.20%, 7.38, 4.0 mmol/L, 10.90 μmol/L, 2.23 mmol/L, and 41.5 mg/L. Multiple Logistic stepwise regression showed that the independent factors for predicting death were GCS score, SpO 2 and urea nitrogen, and the predictive ability of the early-warning model was 83.7%. Conclusions:GCS score, SpO 2 and urea nitrogen are effective early warning indicators for the severity of severe community-acquired pneumonia in emergency department, which are conducive to the rapid and efficient early identification and treatment of critically ill patients. Therefore, they are worthy of promotion and application in clinical practice.

Predictive research of 5-hydroxytryptamine in severity of severe community-acquired pneumonia / 基础医学与临床

Objective To search for potential prognostic markers for severe community-acquired pneumonia（SCAP）using non-targeted metabolomics. Methods Testing plasma samples from 30 healthy people and 68 SCAP patients (all collected from January 2015 to June 2019 at Peking Union Medical College Hospital) by liquid chromatography mass spectrometry(LC-MS ).According to clinical prognosis，patients were divided into survive group (n=49)and non-survive group(n=19).OPLS-DA(multivariate statistical analysis)and Kruskal Wallis Test (single variable statistical analysis) were used to identify differential metabolites. Correlation analysis of clinical indicators and prognostic analysis were also used for differential metabolites. Results Totally 3463 metabolites were detected in healthy people and SCAP patients by LC-MS. Among them, 126 metabolites were screened out by OPLS-DA andKruskal Wallis Test analysis methods. Prognostic analysis showed that the quantity of 5-hydroxytryptamine(5-HT) was significantly different between survive group and non-survive group(P<0.05，AUC>0.75).Correlation analysis of clinical indicators showed that 5-HT was positively correlated with oxygenation index (OI) and negatively cor-related with acute physiology and chronic health evaluation(APACHE II)score. Conclusions The 5-HT as a potential prognostic marker for SCAP，may predict the prognosis of SCAP patients.

Xuebijing injection versus placebo for critically ill patients with severe community-acquired pneumonia: a randomized controlled trial: research results and clinical value / 中华危重病急救医学

This article is based on the research paper named Xuebijing injection versus placebo for critically ill patients with severe community-acquired pneumonia: a randomized controlled trial which was published in Critical Care Medicine (CCM), introducing its study results and relevant clinical value. Moreover, we attached two peer experts' comments on this study for the readers' reference.

Xuebijing injection versus placebo for critically ill patients with severe community-acquired pneumonia:a randomized controlled trial: research results and clinical value / 中华危重病急救医学

This article is based on the research paper named Xuebijing injection versus placebo for critically ill patients with severe community-acquired pneumonia: a randomized controlled trial which was published in Critical Care Medicine (CCM), introducing its study results and relevant clinical value. Moreover, we attached two peer experts' comments on this study for the readers' reference.

Xuebijing injection versus placebo for critically ill patients with severe community-acquired pneumonia:a randomized controlled trial: research results and clinical value / 中华危重病急救医学

This article is based on the research paper named Xuebijing injection versus placebo for critically ill patients with severe community-acquired pneumonia: a randomized controlled trial which was published in Critical Care Medicine (CCM), introducing its study results and relevant clinical value. Moreover, we attached two peer experts' comments on this study for the readers' reference.

Analysis of prognostic related risk factors in elderly patients with severe community acquired pneumonia / 中国中西医结合急救杂志

Objective To analyze the related risk factors affecting the prognosis of elderly patients with severe community acquired pneumonia (SCAP). Methods A retrospective study method was conducted; the elderly (≥ 75 years old) patients with SCAP treated in the First Affiliated Hospital of Hainan Medical College from January 2015 to January 2019 were enrolled. The general data of patients were collected, including sex, age, oxygenation index (PaO2/FiO2), involved organs, presence or absence of following diseases or treatment: damage in multiple lung lobes, septic shock, basic diseases (cardiovascular disease, chronic lung disease, diabetes, hypertension, and cerebrovascular disease), invasive mechanical ventilation, ventilator-associated pneumonia (VAP), misinhalation event, hyponatremia, respiratory acidosis, hypoproteinemia, intubation times, total mechanical ventilation time, etc. According to the prognosis, the patients were divided into a death group and a survival group. The general data were compared between the two groups with different prognoses. Single factor analysis was carried out by selecting variables. The indicators with statistical significant differences in the results of univariate analysis were introduced into the multivariate Logistic regression analysis to analyze the related risk factors affecting the prognosis of elderly patients with SCAP. The receiver operating characteristic (ROC) curve was drawn to analyze the predictive values of risk factors in the patients with SCAP. Results A total of 112 patients were included, 33 died, and the mortality rate was 29.46%. Univariate analysis showed that the following factors were higher in the death group than those in the survival group: organ involvement >2 [69.70% (23/33) vs. 35.44% (28/79)], lung lobe damage ≥ 3 [75.76% (25/33) vs. 51.90% (41/79)], invasive mechanical ventilation [72.73% (24/33) vs. 32.91% (26/79)], diabetes [30.30% (10/33) vs. 12.66% (10/79)], intubation times ≥2 [57.58% (19/33) vs. 48.10% (38/79)], hypoproteinemia [75.76% (25/33) vs. 41.77% (33/79)], hyponatremia [72.73% (24/33) vs. 48.10% (38/79)], respiratory acidosis [66.67% (22/33) vs. 44.30 %(35/79)] and total mechanical ventilation time ≥ 15 days [69.70% (23/33) vs. 40.51 (32/79)]; the factors in the death group lower than those in the survival group were: septic shock [3.03% (1/33) vs. 17.72% (14/79)], chronic lung disease [6.06% (2/33) vs. 25.32% (20/79)] and PaO2/FiO2 [mmHg (1 mmHg = 0.133 kPa): 102.89±14.78 vs. 109.56±14.08],the differences were statistically significant (all P < 0.05); there were no significant differences in gender, age, cardiovascular disease, hypertension, VAP, misinhalation events and cerebrovascular disease between the two groups (all P > 0.05). Multivariate Logistic regression analysis showed that diabetes mellitus [odds ratio (OR) = 1.074, 95% confidence interval (95%CI) = 1.017-1.287, P =0.045], septic shock (OR = 2.765, 95%CI = 1.083-3.411, P = 0.047), hyponatremia (OR = 1.792, 95%CI = 1.128-1.417, P = 0.006), hypoalbuminemia (OR = 2.187, 95%CI = 1.872-5.462, P = 0.046), invasive mechanical ventilation (OR = 5.870, 95%CI = 2.324-23.796, P = 0.001), respiratory acid poisoning (OR = 2.934, 95%CI = 2.454-7.275, P = 0.043), time of mechanical ventilation (OR= 1.986, 95%CI = 2.467-3.483, P = 0.034), number of intubation (OR = 6.760, 95%CI = 2.116-24.696, P = 0.001), PaO2/FiO2 (OR = 1.981, 95%CI = 1.006-1.417, P = 0.007), organ involvement > 2 (OR = 2.924, 95%CI = 2.534-6.285, P = 0.048), chronic lung disease (OR = 2.887, 95%CI = 1.487-3.483, P = 0.039), and lung lobe damage≥3 (OR = 2.754, 95%CI = 1.131-1.798, P = 0.045) were independent risk factors affecting the prognosis of elderly patients with SCAP. ROC analysis showed that hyponatremia, hypoalbuminemia, invasive mechanical ventilation, total mechanical ventilation time, PaO2/FiO2, organ involvement > 2, damage of lung lobes ≥ 3, had predictive values for the prognosis of SCAP [the areas under ROC curve (AUC) were 0.377, 0.267, 0.301, 0.646, 0.650, 0.329, and 0.381, respectively, all P < 0.05]. Conclusions Underlying disease, invasive mechanical ventilation, respiratory acidosis, total mechanical ventilation time, PaO2/FiO2, intubation times ≥ 2, chronic lung disease and lung damage≥ 3 lobes are the independent risk factors for the prognosis of elderly patients with severe community acquired pneumonia. Clinical treatment should focus on the above aspects to minimize the mortality of patients.

Impact of systemic corticosteroids on the clinical outcomes in patients with severe community-acquired pneumonia: a multi-center retrospective study / 中华危重病急救医学

Objective To assess the impact of short-term, low-dose systemic glucorticosteroids treatment on the clinical outcomes in patients with severe community-acquired pneumonia (SCAP). Methods A multi-center retrospective study was conducted. Data of patients hospitalized with SCAP in five teaching hospitals from Beijing, Shandong and Yunnan Provinces from January 1st, 2013 to December 31st, 2015 were reviewed. Patients were divided into steroids group and non-steroids group according to whether treated with glucorticosteroids during the disease course or not. Data of patients were reviewed, including gender, age, underlying disease, blood routine, biochemical examination and radiology findings (the worst value was recorded if there were more than one value), supportive treatment, complications (hyperglycemia needing insulin treatment and gastrointestinal bleeding) and clinical outcomes [early (0-3 days) treatment failure, late (4-14 days) treatment failure and 30-day mortality, treatment failure was defined as one of the followings: needing noninvasive or invasive ventilation, needing vasopressor use or death]. Univariate and multivariate Logistic regression was performed to evaluate the impact of short-term, low-dose systemic glucorticosteroids on the clinical outcomes in SCAP patients. Results Overall, 3 561 immunocompetent adult and adolescent patients with community-acquired pneumonia (CAP) were screened, 132 SCAP patients were entered into final analysis, including 24 patients in steroids group and 108 patients in non-steroids group. The patients in steroids group were prescribed with methylprednisolone (0.6±0.1) mg·kg-1·d-1 for (4.0±1.7) days. Compared with patients in non-steroids group, patients in steroids group showed younger age [years old: 70.5 (59.0, 75.0) vs. 80.0 (76.0, 85.0)], less frequency of male [41.7% (10/24) vs. 72.2% (78/108)], less comorbidities with cardiovascular [16.7% (4/24) vs. 42.6% (46/108)] and cerebrovascular disease [0% (0/24) vs. 40.7% (44/108)], less confusion [16.7% (4/24) vs. 40.7% (44/108)]; more frequency of chronic obstructive pulmonary disease [COPD, 41.7% (10/24) vs. 13.0% (14/108)], asthma [25.0% (6/24) vs. 1.9% (2/108)], chronic hepatic disease [8.3% (2/24) vs. 0% (0/108)] and respiratory rate≥30 times/min [33.3% (8/24) vs. 9.3% (10/108)] with significant differences (all P < 0.05), the proportion of guideline-based empirical antimicrobial therapy, early needing noninvasive ventilation, late gastrointestinal bleeding, early and late hyperglycemia needing insulin treatment were higher in steroids group than non-steroids group [50.0% (12/24) vs. 21.3% (23/108), 33.3% (8/24) vs. 7.4% (8/108), 20.8% (5/24) vs. 4.6% (5/108), 20.8% (5/24) vs. 1.9% (2/108), 37.5% (9/24) vs. 2.8% (3/108), all P < 0.05]. Adjusted by gender, age, comorbidities and empirical antimicrobial therapy, Logistic regression confirmed short-term, low-dose systemic glucorticosteroids was associated with higher risk for vasopressor usage [odds ratio (OR) = 3.369, 95% confidence interval (95%CI) = 1.369-6.133, P = 0.035], hyperglycaemia needing insulin treatment (OR = 4.738, 95%CI = 1.890-8.652, P = 0.017) in late stage and 30-day mortality (OR = 2.187, 95%CI = 1.265-4.743, P = 0.002). Conclusion Adjunctive treatment with short-term, low-dose systemic glucorticosteroids worsen the clinical outcomes and should not be used to SCAP patients routinely.

Interpretation of design ideas and implementation process of randomized controlled trial of Xuebijing injection in the treatment of severe community-acquired pneumonia / 中华危重病急救医学

A multicenter blinded randomized controlled trial (RCT) was conducted in accordance with international clinical trial standards to evaluate the efficacy and safety of Xuebijing injection in the treatment of severe community-acquired pneumonia (SCAP) under strict quality control condition. This article aims to illustrate key contents of the design ideas and implementation process of the RCT of Xuebijing injection in the treatment of SCAP, including the selection of research objects, design, implementation, and insights, etc., share experience with researchers of the respiratory and critical care, and provide reference for future studies in critical care.

Current status and prospect of treatment for severe community acquired pneumonia / 中华危重病急救医学

Severe community acquired pneumonia (SCAP) has raised substantial concern due to high morbidity and mortality. SCAP is usually associated with multiple organ dysfunction syndrome (MODS) and sepsis. It is suggested that organ function and coagulation/fibrinolysis improvement, organ injury reduction and organ repair facilitation are highly required besides microbiology detection and optimization of antibiotics strategy on treatment of SCAP. Neutralization antibody, steroid, immunmodulatory therapy, and Chinese medicine etc. contribute to organ function improvement from different perspective. The unique profile of multiple target and personalized therapy of Chinese medicine may become a promising new option for SCAP and MODS. The combination of Western and Chinese Medicine shed new light on SCAP treatment.

Survey on the use of glucocorticoids in severe community-acquired pneumonia in intensive care unit of forty-five hospitals in Zhejiang Province / 中华危重病急救医学

Objective To investigate the use of glucocorticoids in patients with severe community-acquired pneumonia (SCAP) in the intensive care unit (ICU) of Hospitals in Zhejiang Province and to provide a reference for guiding clinical use of SCAP patients. Methods To draw up a questionnaire with reference to the Chinese and international guidelines, and to investigate the knowledge of community-acquired pneumonia (CAP) related guidelines and the use of glucocorticoids in patients with SCAP by doctors in hospitals above secondary level in Zhejiang Province by Email. Then the valid questionnaire was analyzed. Results In June 2016, 340 questionnaires were distributed, and all were returned after 2 months, with 333 of valid; 333 doctors from 45 ICUs in Zhejiang Province participated in the survey. ① The knowledge of CAP-related guidelines in ICU doctors: 79.58% (265/333) of the doctors had read the CAP guidelines, and those who work over 10 years had a higher reading rate than those with 1-5 years and 6-10 years [93.07% (94/101) vs. 74.00% (111/150), 73.17% (60/82), both P < 0.05]. Post-graduates and above had higher reading rates than undergraduates [85.35% (134/157) vs. 74.43% (131/176), P < 0.05]. Senior doctors had higher reading rates than the junior and intermediate doctors [93.07% (94/101) vs. 71.43% (80/112), 75.83% (91/120), both P < 0.05]. The rate of understanding the clinical application of glucocorticoids was 13.81% (46/333). The doctors who work over 10 years and the seniorshad a relatively high awareness rate, 23.76% (24/101) and 20.79% (21/101) respectively. However, there was no significant difference in the awareness rate between doctors with different degrees and different levels of hospitals. ② For the use of glucocorticoids in different causes of pneumonia, 44.74% (149/333) of doctors routinely used glucocorticoids in severe viral pneumonia. The proportion of glucocorticoids used in severe bacterial pneumonia, severe fungal pneumonia, severe pneumocystis pneumonia, chronic obstructive pulmonary disease (COPD) and severe pneumonia were 22.82% (76/333), 9.31% (31/333), 22.52% (75/333) and 18.32% (61/333), respectively. ③ The way of glucocorticoid usage: 79.58% (265/333) of doctors chose methylprednisolone, 4.20% (14/333) chose hydrocortisone, 1.20% (4/333) chose dexamethasone, and 15.02% (50/333) had not use glucocorticoids. The proportion of physicians who chose to use glucocorticoids within 24 hours of admission and 1-7 days after admission were 52.65% (149/283) and 47.35% (134/283), respectively. Glucocorticoids were used more in doctors with lower academic qualifications and hospitals within 24 hours. The undergraduate degree was 61.39% (97/158), and the second-grade class hospital was 67.50% (27/40). Among the doctors who chose methylprednisolone, 60.75% (161/265) prescribe the dose ≤80 mg/d;79.15% (224/283) chose the course of ≤7 days. The number of years of work, education, professional title and hospital grade had no significant effect on the choice of methylprednisolone and the course of treatment. Conclusions ICU doctors of 45 hospitals in Zhejiang Province have a high degree of heterogeneity in the understanding of the use and guidelines of glucocorticoids in SCAP. It is necessary to strengthen the ICU doctor's study of clinical guidelines at home and abroad and to develop a glucocorticoid use plan according to the specific conditions of patients, so that SCAP patients can benefit more.

Value of glucocorticoid steroids in the treatment of patients with severe community-acquired pneumonia complicated with septic shock / 中华危重病急救医学

Objective To discuss the value of glucocorticoid steroids (GCs) in the treatment of patients with severe community-acquired pneumonia (SCAP) complicated with septic shock.Methods A prospectively controlled randomized trial was conducted.Fifty-eight SCAP patients complicated with septic shock admitted to emergency intensive care unit (ICU) of China-Japan Friendship Hospital from May 2014 to February 2016 were enrolled.The patients were randomly divided into conventional treatment group (n =29) and GCs group (n =29).Fluid resuscitation,vasopressors,mechanical ventilation if needed,antibiotics and other general treatment including symptomatic treatment and eliminating phlegm were given to patients in both groups.Beside the treatment mentioned above,80 mg methylprednisolone once a day for 7 days was added to patients in GCs group.The changes in oxygenation index (PaO2/FiO2) and C-reactive protein (CRP) at 1,4,8 days after treatment as well as the imaging improvement in both groups were observed.Discharge or death was set as a cut-off point,the average time of temperature controlling,duration of mechanical ventilation,time of vasopressors usage and 28-day mortality were observed.The incidence of hyperglycemia,infection and hemorrhage of digestive tract were observed.Results There were no statistically differences in gender,age and body mass between the two groups,indicating that baseline data for the two groups were balanced.PaO2/FiO2 after treatment in the two groups was gradually increased,and it was significantly higher at 8 days after treatment in GCs group than that of conventional treatment group [mmHg (1 mmHg =0.133 kPa):426.46 ± 86.97 vs.363.00 ± 83.96,P ＜ 0.05].CRP after treatment in the two groups was gradually decreased,and it was significantly lower at 4 days and 8 days after treatment in GCs group than that of conventional treatment group (mg/L:95.78 ± 47.38 vs.124.72 ± 51.01,57.60 ± 47.44 vs.88.85 ± 48.18,both P ＜ 0.05).Radiographic imaging improved rate at 4 days and 8 days after treatment in GCs group was significantly higher than that of conventional treatment group (55.2％ vs.27.6％,75.9％ vs.51.7％,both P ＜ 0.05),and average time of temperature controlling (days:3.94 ± 2.39 vs.7.22 ± 3.11),time of vasopressors usage (hours:13.64 ± 6.47 vs.28.34 ± 12.56),and the average hospitalization days (days:28.50 ± 8.61 vs.36.21 ± 15.26)in GCs group were significantly shorter than those of conventional treatment group (all P ＜ 0.01).There was no significant difference in duration of mechanical ventilation between GCs group and conventional treatment group (days:13.39 ± 2.62 vs.16.16 ± 5.85,P ＞ 0.05).28-day mortality of the two groups was 10.3％ equally (P ＞ 0.05).No significant differences in the incidences of hyperglycemia (10.3％ vs.6.9％),infection (51.7％ vs.55.2％) and gastrointestinal bleeding (3.4％ vs.0) were found between GCs group and conventional treatment group (all P ＞ 0.05),indicating that glucocorticoid steroids could not increase the common side effects.Conclusion GCs is an important adjuvant treatment of patients with SCAP complicated with septic shock.

Retrospective Analysis on Implement Effect of Traditional Chinese Medicine Clinical Pathway for Wind-warm Lung-heat Disease (Non-severe Community-acquired Pneumonia) / 世界科学技术-中医药现代化

This study was aimed to evaluate the feasibility of wind-warm lung-heat disease (non-severe community-acquired pneumonia, CAP) from the clinical curative effect, hospitalization days, medical expenses and other aspects. This study selected 198 wind-warm lung-heat disease (non-severe CAP) inpatients from January, 2012 to December, 2012 with the conventional therapy in the Respiratory Department, Wuhan Integrated Traditional Chinese Medicine (TCM) & Western Medicine Hospital as the control group. And another 179 wind-warm lung-heat disease (non-severe CAP) inpatients were selected from January, 2013 to December, 2013 with the TCM clinical pathway treatment in the Respiratory Department of the same hospital as the treatment group. Retrospective analysis was used to compare the clinical curative effects, hospitalization days, and medical cost differences. The results showed that TCM clinical pathway for wind-warm lung-heat disease (non-severe CAP) can shorten the hospitalization days and reduce patients’ medical costs, and ensure the clinical curative effects. It was concluded that the standardized TCM clinical pathway had positive effect on wind-warm lung-heat disease (non-severe CAP). Therefore, the formulation and implementation of TCM clinical pathway was of great significance in the treatment of wind-warm lung-heat disease (non-severe CAP).

Cost-effectiveness Analysis of Levofloxacin and Cefoxitin in the Treatment of Adult Non-severe Communi-ty-acquired Pneumonia / 中国药房

OBJECTIVE:To evaluate and compare cost-effectiveness of levofloxacin and cefoxitin in the treatment of adult non-severe community-acquired pneumonia(CAP). METHODS:71 cases of adult non-severe CAP were selected and divided into levofloxacin group (group A,33 cases) and cefoxitin group (group B,38 cases). Gronp A received Mesylate levofloxacin injec-tien 200 ml inotraveously,once a day;group B received Cefoxitin for injection 2.0 g intravenously,3 times a day,for 8 days. Clinical efficacy,excellence time and ADR of 2 groups were observed,and cost-effectiveness analysis was conducted. RESULTS:The total effective rate of group A and group B were 87.88% and 65.79%,and excellence time(5.53±2.56)d and(3.87±3.03)d, with statistical significance(P0.05). The total costs were 6 748.93 yuan and 8 110.34 yuan;the cost-effectiveness ratios were 76.80 and 123.28;incremental cost-effectiveness ratio was -61.63%. Results of sensitivity analysis matched results of cost-effectiveness analysis. CONCLU-SIONS:Levofloxacin save more and is economical in the treatment of adult non-severe CAP.

Evolución clínico-radiológica de la neumonía grave adquirida en la comunidad / Clinical and radiological evolution of severe community-acquired pneumonia

Introducción: la neumonía es una de las causas más importantes de mortalidad entre la población menor de 5 años en los países en desarrollo. Objetivo: analizar la expresión clínico-radiológica y la evolución de los pacientes en un quinquenio. Métodos: se realizó un trabajo prospectivo descriptivo de corte transversal, con los pacientes que ingresaron con neumonía grave adquirida en la comunidad en el Servicio de Enfermedades Respiratorias, en un quinquenio (2003-2007), que fueron seguidos por consulta externa al egreso, hasta su alta médica. Se practicó un análisis de las variables clínico-radiológicas. Se procesaron los datos utilizando la prueba de chi cuadrado. Resultados: de los 217 pacientes analizados, 149 (68,6 por ciento) tenían de 1 a 4 años, y el 53 por ciento era del sexo masculino. La fiebre, la polipnea y el tiraje estuvo presente en todos los pacientes. Las complicaciones más frecuentes fueron: el derrame pleural y el absceso pulmonar en 60,7 y 27,6 por ciento respectivamente. El pulmón derecho resultó el más afectado, pero el que más se complicó fue el izquierdo. Conclusiones: todos los pacientes tuvieron una evolución favorable, a pesar de que más de la mitad se complicaron. Se encontró que los pacientes con afectación en un solo pulmón, tienen más posibilidades de complicarse que cuando la afectación es bilateral

Introduction: pneumonia is one of the most important causes of mortality in the population under 5 years of age in the developing countries. Objective: to analyze the clinical and radiological expression and the progression of patients in a five-year period. Methods: a prospective, descriptive and cross-sectional study was performed on patients who had suffered severe community-acquired pneumonia and had been admitted to the respiratory disease center in the 2003 through 2007 period. They had been followed up at the outpatient service up to their discharge from hospital. The clinical and radiological variables were analyzed. Data were processed with the Chi-square test. Results: of 217 analyzed patients, 149 (68.6 percent) were one to 4 years-old and 53 percent were males. Fever, polypnea, and tirage were observed in patients. The most frequent complications comprised pleural effusion and pulmonary abscess in 60.7 and 27.6 percent of cases, respectively. The right lung was the most affected but complications were more common in the left lung. Conclusions: all the patients had favorable progression, although more than a half suffered complications. It was found that those patients with only one lung affected, were more likely to get complicated than those with both lungs affected by the disease

Neumonía grave del adulto adquirida en la comunidad manejada en sala de cuidados generales en un hospital público / Severe community-acquired pneumonia in adult patients managed in a general ward at a public hospital

Introducción: la neumonía grave del adulto adquirida en la comunidad (NAC grave) se caracteriza por requerir manejo en la unidad de cuidados intensivos (UCI), dado su mayor mortalidad y riesgo de complicaciones, por lo cual se han diseñado distintas escalas de predicción de gravedad. Objetivo: identificar apacientes adultos con NAC grave manejados en la sala de cuidados generales. Pacientes y Métodos: estudio clínico descriptivo retrospectivo, se revisaron las fichas clínicas de 131 pacientes adultos egresados del servicio de medicina del hospital de Quilpué con el diagnóstico de NAC entre el 1 de enero y 31 de diciembre del 2010. Se examinaron los criterios de NAC grave de la Sociedad de Tórax Americana (ATS) y se midió el CURB-65 de 89 pacientes que consignaban esta información. Resultados: en 16 pacientes (18 por ciento) se obtuvo una puntuación del CURB-65 > 3 y en 8 pacientes (9 por ciento) se identificaron > 3 criterios menores de la ATSy en 2 de ellos un criterio mayor. Conclusión: se identificaron pacientes con NAC grave manejados en la sala de cuidados generales de un hospital publico.

Introduction: severe community-acquired pneumonia (severe CAP) is characterized by intensive care unit (ICU) requirement, given its higher mortality and complications rate. Different prediction scales have been designed to assess severity. Objective: identify adult patients with severe CAP managed in the general ward of a public hospital. Patients and Methods: retrospective descriptive study, including all adult patients dischargedfrom hospital with CAP diagnosis, from january 1st to december 31st, 2010, with a total of 131 medical records reviewed. The American Thoracic Society criteria (ATS) of severe CAP and CURB-65 scores from 89 medical records were calculated. Results: 16 patients (18 percent) had CURB-65 score > 3, 8 patients (9 percent) had > 3 minor ATS criteria, and 2 of those patients had a major criterion. Conclusion: a significant number of patients with severe CAP were managed on the general ward of a public hospital.

Neumonía aguda grave de la comunidad en menores de 65 años sin comorbilidades conocidas previamente: estudio multicéntrico retrospectivo / Severe community acquired pneumonia in healthy adults: a multicenter retrospective study

Objetivo: analizar las características epidemiológicas, clínicas y de estudios complementarios en pacientes jóvenes y sanos con neumonía aguda grave de la comunidad (NACG). Material y Método: evaluación retrospectiva de historias clínicas de adultos menores de 65 años, sin comorbilidades, internados con NACG entre 1998 y 2008. Resultados: se identificaron 40 pacientes (M/F = 0.48), edad promedio 37.8 ± 14.1años (16-61). El 42.5% requirió ventilación mecánica y el 57.5% inotrópicos. La PaO2/FiO2 inicial fue 203.6 ± 91.4 mmHg (50-366.7) y las anomalías de laboratorio más frecuentesincluyeron anemia, leucocitosis, hipoalbuminemia y urea y creatinina elevadas. El tratamiento antibiótico empírico consistió en ceftriaxona o ß-lactámico/inhibidor de ß-lactamasas (BL) + macrólido en el 70% de los casos. La etiología se reveló en el 50%,los patógenos y su frecuencia fueron: Streptococcus Pneumoniae, 35%; Leptospira, 15%; Hantavirus y Mycoplasma pneumoniae, 10% y Legionella pneumophila, Pneumocystisjirovecii, Histoplasma capsulatum, Klebsiella pneumoniae, Haemophilus influenzae BL (-) y Staphylococcus aureus sensible a meticilina, 5%. El 77.5% de los pacientes presentócomplicaciones, las más frecuentes fueron shock, insuficiencia respiratoria, insuficiencia renal aguda y derrame pleural. Ocho pacientes presentaron comorbilidades desconocidas,incluyendo HIV positivo, diabetes mellitus, asma, insuficiencia cardíaca e hipotiroidismo. La mortalidad fue 12.5%. Hipotensión arterial diastólica, taquicardia, requerimiento dehemodiálisis y tratamiento inadecuado se asociaron independientemente a mortalidad. Conclusiones: el 20% de los menores de 65 años con NACG, presumiblemente sanos, tenían comorbilidades. El patógeno más frecuente fue neumococo y la mortalidad se asoció a la gravedad de la sepsis e inadecuación del tratamiento.

Aims: to analyze epidemiologic, clinical and other abnormalities in healthy young adults with severe community acquired pneumonia (SCAP). Methods: retrospective analysis of clinical records of adults younger than 65 years, with SCAP and without previously known comorbidities, admitted from 1998 to 2008. Results: forty patients were included (M/F = 0.48), age 37.8 ± 14.1 years (range 16 - 61). Mechanical ventilation was used in 42.5% and vasopressors in 57.5% of patients. Initial PaO2/FIO2 ratio was 203.6 ± 91.4 mmHg (50 - 366.7); frequent laboratory abnormalities included: anemia, leukocytosis, hypoalbuminemia and high urea and creatinine levels.The empiric antimicrobial therapy was ceftriaxone or ß-lactam/ß - lactamases (BL) inhibitor plus macrolide in 70% of cases. The etiology was established in 50%; the specific pathogens were: Streptococcus pneumoniae, 35%; Leptospira, 15%; Hantavirus and Mycoplasma pneumoniae, 10%; and Legionella pneumophila, Pneumocystisjirovecii, Histoplasma capsulatum, Klebsiella pneumoniae, Haemophilus influenzae BL (-) and methicillin susceptible Staphylococcus aureus, 5%. Complications were present in 77.5% including shock, respiratory failure, acute renal failure and pleural effusion.Eight patients presented previously unknown comorbidities including HIV infection, diabetes mellitus, asthma, congestive cardiac failure and hypothyroidism. Mortality was 12.5 %. Diastolic arterial hypotension, taquichycardia, requirement of hemodialysis and inadequate therapy were significantly associated to mortality. Conclusions: 20% of young and presumably healthy adults with SCAP had comorbidities. S. pneumoniae was the commonest pathogen; mortality was associated with severity of sepsis and inadequate therapy.

Factores asociados a mortalidad en neumonía grave adquirida en la comunidad, periodo 2005-2010 / Predictor factors of mortality in severe community acquired pneumonia between 2005-2010

La neumonía grave adquirida en la comunidad (NAC) representa 10 por ciento-30 por ciento del total de esta patología. La morbilidad y la mortalidad son elevadas. Objetivo: Dilucidar factores predictores de mortalidad en NAC. A través de sus historias clínicas, se obtuvieron antecedentes de 121 pacientes (100 por ciento) que ingresaron con este diagnóstico, durante 2005-2010. Resultados: Media de edad de 59,2 +/- 19,1 años, 61,1 por ciento sexo masculino y 79,3 por ciento con comorbilidad; 74,3 por ciento con CURB-65 entre 3 y 5 y 64,4 por ciento con al menos 2 criterios mayores ATS modificados. Media de puntaje de APACHE II de ingreso de 20,3 +/- 7,7 puntos y media de puntaje SOFA de8,5 +/- 3,9 puntos. Mortalidad global del grupo de 31,1 por ciento. Pacientes no fallecidos versus fallecidos con puntaje CURB-65 mayor a 3 en 66,6 por ciento versus 89,4 por ciento, respectivamente (p=0,08), puntaje APACHE II de 18,1 +/- 6,7 versus 25 +/- 7,8 puntos, respectivamente (p<0,0001) y puntaje SOFA de 7,7+/- 4 versus 10 +/- 3,1 puntos, respectivamente (p= 0,003). Mortalidad en relación al ingreso precoz a UCI (antes de 24 horas de evolución) 24,6 por ciento versus 42,2 por ciento cuando fue tardío (p= 0,035). Se observó tendencia a menor mortalidad (26,9 por ciento) en quienes tuvieron cobertura para gérmenes atípicos versus 35,5 por ciento sin cobertura (p= 0,09). El score SOFA y APACHE II en general tienen una buena correlación en relación a mortalidad, sin embargo, la mayor influencia en este punto lo tienen el ingreso precoz a una Unidad de Cuidados Intensivos, los protocolos de reanimación precoz y la cobertura para gérmenes atípicos.

Severe community acquired pneumonia represents 10 –30 percent of this disease. High morbidity and mortality. In this review, we pretend found some predictor factors of mortality in this type of pneumonia. We realize a retrospective study of 121 adult patients admitted at ICU with diagnosis of severe community acquired pneumonia, between 2005-2010. Results: The patients was an average of age of 59,2 +/- 19,1 years, 61,1 percent were male and 79,3 percent with comorbidity; 74,3 percent with CURB – 65 score between 3 – 5 and 64,4 percent with at least 2 major criteria ATS modified. At admission: average of APACHE II score of 20,3 +/- 7,7 points and average of SOFA socre of 8,5 +/- 3,9 points. Global mortality of 31,1 percent. Survivor patients versus patients who died because of the disease, with CURB-65 score up to 3 points in 66,6 percent versus 89,4 percent, respectively (p=0,08), APACHEII score of 18,1 +/- 6,7 versus 25 +/- 7,8 points, respectively (p<0,0001) and SOFA score of 7,7 +/- 4 versus 10 +/- 3,1 points, respectively (p=0,003); 24,6 percent versus 42,2 percent of mortality in early admission to ICU (before 24 hours of evolution) and delayed admission, respectively (p=0,035). Tendence to minor mortality in patients who recived atypical bacteria treatment (26,9 percent versus 35,5 percent, p=0,09). The SOFA and APACHE II score with good correlation with mortality, however, the most important point is the early admission to ICU, early reanimation protocols and atypical bacteria treatment.

Association study of TLR4 polymorphisms with severe community-acquired pneumonia susceptibility and outcome / 中华急诊医学杂志

Objective To investigate the possible association of TLR4 polymorphisms with susceptibility and prognosis of SCAP.Method A total of 360 CAP patients hospitalized in emergency department of Zhongshan hospital from May 2005 to April 2008 were enrolled in this case-control study.Patients were excluded if they had metastatic tumors,autoimmune diseases,AIDS or received immunosuppressive drugs.This study was approved by the ethical committee of Zhongshan hospital,Fudan University.Patients were divided into SCAP group(n = 180)and NSCAP group(n = 180)according to the illness severity,and were divided into survival group(n = 300)and death group(n = 60)according to the 30-day mortality.Hapmap database of Han Chinese population was used to select the Tag SNPs.Primer 3 software was used to design the PCR and sequencing primers.Genomic DNA was extracted from peripheral blood mononuclear cells.Genotyping was performed by sequencing the PCR products.We used X2 analysis to evaluate the significance of differences in genotype and allele frequencies between different groups.Results The distributions of three TagSNPs(rs2149356,rs11536879,rs1927907)were consistent with Hardy-Weinberg equilibrium.The allele and genotype frequencies of three TagSNPs in the SCAP group did not differ from the NSCAP group.Also,no significant difference was found between survivor group and non-survivor group.The haplotype frequencies of CA,TA and TG were not significantly different between SCAP group and NSCAP group.And no significant difference of haplotype frequency was existed between survivor group and nonsurvivor group.Conclusions This study suggested that TLR4 gene polymorphisms were not significantly associated with the susceptibility and prognosis of SCAP.