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Clinical Illness and Outcomes in Patients with Severe Community-Acquired Pneumonia: A Prospective Study

Vijay Kumar Mittapally1* and Divya Lanka2

1Department of Biotechnology, Periyar University, Salem, Tamil nadu

2Department of Pharmaceutics, Gland Institute of Pharmaceutical Sciences, Kothapet, Medak dist.

Corresponding Author:
Vijay Kumar Mittapally
Master of Sciences
Department of Biotechnology
Periyar University
Salem, Tamilnadu, India
Tel: 91-9949985675

Received: 04/01/2015; Revised: 25/01/2015; Accepted: 02/02/2015

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Purpose of review
Pneumonia is considered as the main lung infectious diseases cause for death and also the seventh leading cause for death overall within the United States. There is important interest in understanding the connection between community-acquired pneumonia (CAP) and mortality.

Recent findings
Pneumonia is that the seventh leading explanation for death in US. It’s calculable that there are four million cases of community-acquired pneumonia (CAP)/yr within the US that ends in close to ten million medico visits, one million hospitalizations, and 45,000 deaths. There are not any massive studies from Asian nation on incidence of CAP; but, mortality knowledge on total variety of deaths square measure obtainable associated with lower respiratory tract infection (LRTI). Variety of deaths owing to LRTI was 35.1/100,000 population in 2008 compared to 35.8/100,000 population for TB & deaths associated with gastro enteral infections & parasitic diseases was 194.9/100,000 population. As per the WHO knowledge overall mortality because of LRTI is around 20% in our country.

This review focuses on the latest literature assessing the importance and also the frequency of long associated outcomes in patients with CAP, the risk factors, and conceivable ramifications for future methods. Numerous danger elements that incorporate age, sex, comorbid conditions, kind of pneumonia, and seriousness of illness are connected with higher long-term mortality.


Community-acquired pneumonia, Streptococcus pneumonia, outcome, Mycobacterium tuberculosis, Chronic obstructive pulmonary disease (COPD), Pneumonia


Community-acquired pneumonia (CAP) can be characterized both on clinical and radiographic discoveries. Without midsection radiograph, CAP is characterized as: (a) side effects of an intense lower respiratory tract illness for fewer than one week; (b) a minimum of one general feature (temperature >37.7°C, chills, and rigors, and/or severe malaise); and (c) new focal chest signs on examination (bronchial breath sounds and/or crackles); with (d) no alternative clarification for the illness [1].

Community-acquired pneumonia (CAP) is an essential issue with significant morbidity, mortality, and expense. Top records for 3–5 cases for each 1000 person-years, particularly in the elderly with a 10-fold increased incidence rate. Moreover, the frequency of CAP has not decreased in the course of recent decades, notwithstanding advances in supportive care. CAP remains a frequent drawback in clinical practice, especially for those patients who need hospitalization and ICU admission. Approximately 100 patients admitted to clinic with a determination of CAP oblige ICU care. The mortality connected with CAP significantly relies on upon the clinical setting where it is dealt with. This mortality is only just under 3% in the outpatient setting, around 5–10% in inpatients not obliging ICU care, as high as 25% in intubated patients, and almost 50% in ICU patients obliging vasopressors. Hence, the in-clinic case causality rate for patients with serious illness remains intolerably high [2-5].

Pneumonia is the seventh leading explanation for death overall, and accounted for 59 000 deaths within the year 2008 within the USA. Additionally, in 2008, flu and pneumonia along was the seventh reason for death for those aged 1–24 years and for those aged sixty five years or older. aggregate expense of pneumonia was some $20 billion, as well as $14 billion in care expenditures and $6 billion in lost productivity. Patients with pneumonia are in danger for developing complications like requiring mechanical ventilation [6] for hypoxemic respiratory failure, requirement for vasopressors for hemodynamic instability, and multiorgan system failure [7-11].

The use of 30-day outcomes in clinical studies might belittle the morbidity and mortality and will result in inaccurate inferences. Therefore, the understanding of long haul mortality (arbitrary >3 months) factors, frequency, forecast, and suggestions on patient consideration are essential issues that require further assessment in patients with CAP. Different studies have self-addressed the relationship of pneumonia and pneumonia-related factors with long haul mortality [12-15].

A restricted range of studies have surveyed the association of various kinds of pneumonia and long-term outcomes in patients with CAP. Cecere et al. [15] contemplated more youthful grown-ups and patients with health-care-associated pneumonia (HCAP) compared with CAP patients. The authors inferred that admission to the hospital for HCAP, and to a lesser degree CAP, was related to long-term mortality even in young patients. Comparative results were reported by Hsu et al. [16] World Health Organization showed that 1-year HCAP mortality was nearly double that of CAP, which HCAP was a freelance predictor of one-year mortality [odds quantitative relation (OR) 1.99, 95% confidence interval (CI) 1.87–2.11]. Furthermore, HCAP patients incurred considerably higher prices throughout the initial hospital stay and in the accompanying 12 months. Mortensen et al. [17] conjointly showed that patients obliged nursing home living arrangement were more prone to have long-term mortality (hazard quantitative relation 1.5, 95% CI 1.1–2.1). Nursing home habitation is a standout amongst the most widely recognized common risk factors for HCAP diagnosis [18-23].

Identifying the etiology of pneumonia

Recognizable proof of the pathogens in charge of pneumonia is trying because of challenges getting direct lung tests and in addition the oropharyngeal sullying of expectorant. Deciphering the consequences of pneumonia etiology studies obliges a comprehension of the impediments consequently forced [24-28].

Taking samples specifically from the lung through transthoracic needle aspiration represents to a theoretic perfect indicative strategy, with high rates of positive results. Comparable high-quality results can be gotten through some bronchoscopic strategies [29-34]. These methods are regularly considered excessively intrusive, with expenses and dangers exceeding saw advantage. Blood culture is a typical system in clinical practice, and bacterial development from blood is more likely than not critical, however the rate of positive culture is regularly <10%. Pleural effusions can be tapped securely, when they are available; be that as it may, the affectability of pleural liquid culture is poor [35].

A higher rate of positive culture is acquired from sputum, despite the fact that contamination by microscopic organisms colonizing the oropharynx makes deciphering the hugeness of sputum isolate difficult [36-39]. Microscopic examination of sputum for the vicinity of white platelets and epithelial cells can build the dependability of sputum culture. The affectability of every microbiological diagnostics depending on culture of living microorganisms is hampered by anti-microbial utilization before examining.

Contamination by "atypical" bacteria (Mycoplasma, Chlamydophila and Legionella spp.) can be reflectively evaluated through serology; Legionella spp. can likewise be cultured. On the other hand, PCR of respiratory examples is progressively utilized. Translation of serology is hampered by an absence of standardised techniques and trouble in recognizing current disease and past contamination without intense and recuperating samples. Elucidation of PCR is entangled by oropharyngeal contamination and accidental carriage [40-44]. Urine antigen testing is broadly utilized for two living beings: S. pneumoniae, where the test performs well in grown-ups; and L. pneumophila, where the test is particular and much faster than culture however needs affectability, particularly in less extreme cases.

Review investigations of CAP face issues identified with vulnerability about case definition, inadequate recording of clinical data and deficient or low quality microbiological examination. Frequently these studies have an emphasis on a specific gathering of pathogens and infrequently utilize a wide, efficient methodology. Progressively it is perceived that a control gathering is useful where upper airways samples are being taken and colonization, instead of contamination, is a probability.

The signs and symptoms of pneumonia differ from mild to severe, depending on factors such as the type of germ causing the infection and your age and general wellbeing [45-49]. The most common symptoms of Pneumonia are:

1. Cough

2. Fever

3. Chills/sweats

4. Restlessness

5. Irritability

6. Loss of appetite

7. Abnormally sleepy

8. Wheezing

9. Shortness of breath

10. Fast breathing

11. Flaring of nostrils

12. Refusal to drink

13. Lower chest indrawing

14. Chest pain

15. Difficulty in breathing

16. Vomiting

17. Grunting

18. Blue coloration of skin

19. Coughing up blood

20. Convulsions

Risk factors in patients with community-acquired pneumonia

Early identification proof of patients at danger for extreme CAP can help patient management. In spite of the fact that age is a vital risk factor for advancement of CAP, co-morbidities additionally have essential influence in deciding the danger for pneumonia and illness seriousness. Doctors ought to accordingly consider any history of chronic obstructive pulmonary disease (COPD) [50-52], renal deficiency/dialysis, chronic heart failure, coronary artery disease, diabetes mellitus, unending neurologic sickness, and endless liver malady/liquor misuse when they focus understanding administration. In patients older than 60 years, risk is further expanded in the vicinity of asthma, liquor addiction, or immunosuppression, and in organized patients [53-55].

Different factors that have been involved in expanding mortality in serious CAP patients incorporate male sex, and the advancement of acute respiratory failure, extreme sepsis/septic stun, and bacteremia. Some particular pathogens likewise convey an expanded risk for extreme CAP. The most well-known organisms observed in patients admitted to the ICU are Streptococcus pneumoniae, Legionella pneumophila, and Haemophilus influenzae. The most well-known lethal pathogens are S. pneumoniae, Pseudomonas aeruginosa, and L. pneumophila, and the recent two pathogens are as often as possible connected with a requirement for mechanical ventilation. The most pervasive pathogen connected with extreme CAP, to be specific S. pneumoniae, is in charge of 66% of CAP-related passings. In spite of the fact that the most noticeably bad result is connected with contamination with Gram-negative organisms, such contaminations are moderately rare [56-58].

Indications of illness movement during the initial 72 hours after hospital admission are additionally connected with expanded danger for death. For patients without co-morbidities, vicinity of multilobar solidification and requirement for mechanical ventilation or inotropic backing are connected with more noteworthy sickness seriousness and higher death rates [59-62].

Rising proof recommends that discriminatingly critically ill patients with severe CAP and COPD are more prone to need mechanical ventilation and convey expanded danger for mortality. In an auxiliary investigation of an imminent study in which 428 immunocompetent patients admitted to the ICU for extreme CAP were assessed, all patients were stratified as indicated by the vicinity or nonappearance of COPD. Altogether, 176 COPD patients were contrasted and 252 non-COPD patients, and COPD ended up being an essential risk factor for mortality [63-65]. In COPD patients, both mechanical ventilation (odds ratio = 2.78, 95% certainty interim [CI] = 1.63 to 4.74) and ICU mortality (chances proportion = 1.58, 95% CI = 1.01 to 1.43) rates were higher than in non-COPD patients. The ICU death rate was 39% in COPD patients at first intubated and 50% in the individuals who did not react to noninvasive ventilation. Patients with a background marked by COPD are liable to have more extreme signs at presentation: septic stun; tachypnea; lower pH, incomplete oxygen strain, and oxygen immersion; and more prominent halfway carbon dioxide pressure. COPD is more basic with expanding age, in male patients, and in patients with diabetes or chronic heart failure [67].

Recently reanalysis of the Community-Acquired Pneumonia Intensive Care Unit (CAPUCI) study, in which patients with serious CAP obliging ICU confirmation were evaluated, has proposed that radiologic movement of pulmonary infiltrates is a critical unfriendly prognostic element. Conversely, bacteremia levels showed up not to influence patient outcomes.

Mycobacterium tuberculosis

Numerous studies found that TB was normal among patients presenting with CAP, which is additionally the case among high-pervasiveness populaces in Africa, the Middle East and the USA [68]. However, as a result of the conflicting way to deal with TB analysis the information are fragmented, making correlations between nations troublesome. In spite of these instabilities, these information demonstrate that M. tuberculosis is an essential reason for lower respiratory contamination in numerous parts of Asia. Choices about the decision of routine examinations performed for CAP and the decision of exact treatment ought to mirror this. Specifically, care ought to be brought with the observational utilization of anti-microbials with antituberculous movement, for example, quinolones, which may prompt a halfway reaction, cover analysis and at last advance the improvement of drug-resistant TB [69-72].

Severity of illness

A large portion of the seriousness hazard evaluations concentrate on transient mortality by measuring the variables included in organ dysfunction in patients with CAP. Admission to the doctor's facility or the improvement of moderate to extreme pneumonia may impact the danger of long-term mortality. In a study by Karhu et al., [73] serious CAP (ICU-conceded patients with pneumonia) contrasted with healing center obtained and ventilator-related pneumonia had the most reduced 1-year mortality. However, seriousness of illness was measured by ICU affirmation and not by any of the approved pneumonia severity of illness scores. The two most generally utilized and approved strategies incorporate the pneumonia severity index score (PSI) and the CURB-65. The PSI is a 20-point score utilized at the season of clinical presentation that arranges patients into five risk classifications. It utilizes three demographic parameters, five comorbid conditions, five physical examination discoveries, and seven research center/imaging discoveries to ascertain the final score. The quantity of focuses for every variable are included and after that stratified into the danger classifications in light of their rate danger to anticipate 30-day mortality. PSI is vigorously affected by age, and the expansive number of variables assessed makes it complex to utilize. Conversely are the CURB-65, CURB, and CRB (more straightforward instrument that does not oblige blood urea nitrogen). Check 65 is a less unpredictable score got from the first CURB with the expansion of age as another variable. This score is additionally in view of the 30-day mortality chance and is made out of just five variables (representing one point every): confusion, urea, respiratory rate, pulse, and age over 65 years old (CURB-65). Notwithstanding the effortlessness, the capacity of this instrument to foresee long haul mortality is not embraced in clinical practice. Sligl et al. [74] demonstrated that, among a few danger components, high PSI score (changed for age) was connected with higher 1-year mortality. On the other hand, the greater part of the studies tending to seriousness of ailment have included incendiary or disease parameters to survey results, with specific confinements. This is the reason critical hobby has risen in cardiovascular biomarkers as imperative prescient apparatuses.

Good practices to be followed in the ICU

Stress ulcer prophylaxis

Stress ulcer prophylaxis ought to for the most part be kept away from with a specific end goal to protect gastric capacity. At whatever point stress ulcer prophylaxis is demonstrated, sucralfate should be favored keeping in mind the end goal to lessen the danger of VAP. The two noteworthy danger elements for clinically vital gastrointestinal draining because of anxiety ulceration incorporate mechanical ventilation for >48 h and coagulopathy. Proton pump inhibitors (PPI) are better than H2 receptor foes (H2RA), while H2RA are better than acid neutralizers or sucralfate. Prophylactic operators that increment gastric pH (e.g. PPIs, H2RA, and stomach settling agents) may build the danger of nosocomial pneumonia contrasted with operators that don't change gastric pH (sucralfate). In those with high danger of anxiety ulcer dying, H2RA and PPIs ought to be utilized, with sucralfate held in patients with low to direct risk of gastrointestinal bleeding [75-77].

Early enteral feeding

Enteral feeding is better than parenteral nutrition and ought to be utilized at whatever point endured and as a part of those with no contraindications to enteral sustaining. Enteral nutrition is connected with a lower occurrence of disease, yet not mortality [78].

Deep venous thrombosis prophylaxis

Pneumonic embolism remains the most widely recognized preventable reason for doctor's facility passing. DVT prophylaxis with unfractionated heparin (5000 U thrice a day) or a low-sub-atomic weight heparin ought to be routinely utilized as a part of all ICU patients with no contraindications to prophylactic anticoagulation [79-83].

Glucose control

We suggest a plasma glucose focus of 140–180 mg/dL in many patients with pneumonia, as opposed to a more stringent focus on (80–110 mg/dL) or a more liberal focus on (180–200 mg/dL). This glucose extent maintains a strategic distance from hyperglycemia, while minimizing the risk of both hypoglycemia and different harms connected with a lower blood glucose target [84,85].

Blood products

Red platelets should be transfused at a hemoglobin edge of <7 g/dL with the exception of in those with myocardial ischemia and pregnancy. Platelet transfusion is shown in patients with platelet number <10,000/μL, or <20,000/μL if there is active bleeding [86-89]. Fresh frozen plasma is demonstrated just if there is an archived variation from the norm in the coagulation tests and there is active bleeding or if a method is arranged.

Inoculation remains the essential preventive methodology for CAP in the elderly. Rules suggest vaccination against both influenza virus and S. pneumoniae in patients over the age of 65. In any case, both inoculations are generously underused in this powerless population.

Antibiotic treatment in patients with CAP

Current ERS/ESCMID guidelines (2011 version) for the treatment of CAP suggest one of the accompanying for the treatment of CAP in hospitalized patients:

• Aminopenicillin ± macrolide

• Aminopenicillin beta-lactamase inhibitor ± macrolide

• Non-antipseudomonal cephalosporin III

• Cefotaxime or ceftriaxone ± macrolide

• Levofloxacin

• Moxifloxacin

• Penicillin G ± macrolide

Vaccination to elderly patients in order to prevent CAP

Recent meta-analyses provide evidence supporting the recommendation of pneumococcal polysaccharide vaccine (PPV) to prevent invasive pneumococcal disease in adults, but, with regard to adults with chronic illness, do not find compelling evidence to support the routine use of PPV to prevent all-cause pneumonia or mortality. However, the 23-valent vaccine prevented pneumococcal pneumonia and reduced mortality due to pneumococcal pneumonia in nursing-home residents in a randomized trial [90]. Moreover, in a matched case–control study in patients aged ≥65 years and hospitalized with CAP, Domínguez and colleagues found an effectiveness of 23.6% for the PPV for preventing hospitalizations due to pneumonia [91].

Recently, randomized trials have demonstrated that 13-valent pneumococcal conjugate immunization (PCV13) actuates a more noteworthy useful safe reaction than PPSV23 for the larger part of serotypes secured by PCV13 in grown-ups. Hence, the United States Food and Drug Administration affirmed the utilization of the PCV13 in this populace. Then again, studies assessing the clinical viability of PCV vaccination in grown-ups are inadequate [92]. Thus, recently it was proposed that there is no epidemiological motivation to inoculate more seasoned grown-ups with PCV because of the way that PCV inoculation of children’s has additionally decreased the rate of conjugate immunization serotype infection in established adults [93-95].

As to effect of flu inoculation on CAP, a Cochrane meta-examination did not discover any impact on clinic affirmations, frequency of pneumonia, or complication rates in the middle of immunized and unvaccinated patients. Then again, in the elderly, immunizations against flu and pneumococcus are connected with diminished danger of hospitalization for coronary illness and intense cardiovascular occasions. These discoveries highlight the advantages of vaccination and bolster endeavors to expand vaccination rates among the elderly [96-98].


Appropriate selection of diagnostic tests and experimental treatment for CAP is critical and depends both on information of the regular pathogens recognized in etiology studies and on the consequences of helpful trials. The accessible etiology information from Asia are constrained however recommend that utilization of exact rules in view of western information may be wrong because of the higher extent of CAP connected with GNB and TB [99-103]. Community-acquired pneumonia is an important issue with critical morbidity, mortality, and expense. There is noteworthy enthusiasm for understanding the relationship in the middle of CAP and mortality for patients who survive the starting intense occasion. A superior comprehension of long-term mortality (arbitrary >3 months) factors, frequency, forecast, and suggestions on patient consideration are essential issues that require further assessment in patients with CAP. Early identification proof of nonresponse and convenient utilization of nonresponse and helpful systems can help to enhance the outcomes of these patients.