Seminars in respiratory and critical care medicine
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Despite potent antibiotics, community-acquired pneumonia (CAP) remains the most common cause of death from infection and the seventh overall leading cause of death in the United States. For this reason, interest has been redirected into non-antibiotic therapeutic measures. Despite theoretical benefits, the existing literature does not suggest a clear benefit for corticosteroid treatment, but large prospective randomized trials are needed. ⋯ Exogenous surfactant replacement is being explored as adjunctive therapy for acute lung injury due to CAP. Statin use before CAP diagnosis is associated with improved outcome but requires further research to determine if initiation at the time of diagnosis will affect outcome. Other therapies have theoretical benefit but are not yet in the stage of clinical trials.
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Semin Respir Crit Care Med · Apr 2009
ReviewStreptococcus pneumoniae: does antimicrobial resistance matter?
Over the past 3 decades, antimicrobial resistance among Streptococcus pneumoniae, the most common cause of community-acquired pneumonia (CAP), has escalated dramatically worldwide. In the late 1970s, strains of pneumococci displaying resistance to penicillin were described in South Africa and Spain. By the early 1990s, penicillin-resistant clones of S. pneumoniae spread rapidly across Europe and globally. ⋯ Given these confounding factors, dissecting out the impact of antimicrobial resistance on clinical outcomes is difficult, if not impossible. Prospective, randomized trials designed to assess the clinical significance of antimicrobial resistance among pneumococci are lacking, and for logistical reasons, will never be done. Does in vitro resistance translate into clinical failures? Should changing resistance patterns modify our choice of therapy for CAP or for suspected pneumococcal pneumonia? In this review, we discuss several facets, including mechanisms of antimicrobial resistance among specific antibiotic classes, epidemiology and spread of antimicrobial resistance determinants regionally and worldwide, risk factors for acquisition and dissemination of resistance, the impact of key international clones displaying multidrug resistance, the clinical impact of antimicrobial resistance, and strategies to limit or curtail antimicrobial resistance among this key respiratory tract pathogen.
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Community-acquired pneumonia (CAP) is a common and serious problem in the United States, and the sixth leading cause of death in those over age 65. Not only has short-term mortality been evaluated, but 1-year mortality may be as high as 40% in Medicare patients who have been admitted to the hospital with CAP. In the United States, guidelines for CAP management have been available since 1993, with the most recent version published in 2007 as a joint effort of the Infectious Diseases Society of America and the American Thoracic Society. ⋯ S. approach to CAP compared with elsewhere include not only a unique set of bacteriologic considerations and therapy recommendations that follow these concerns but also a different approach to assessing severity of illness and recommended diagnostic testing, as well as the inclusion of performance measures to optimize disease management. Compared with European and British guidelines, the U. S. therapy of CAP has a greater emphasis on the role of atypical pathogens, a more defined role for fluoroquinolones as first-line therapy, less reliance on oral therapy for hospitalized patients, and less regard for the value of certain beta-lactam agents.