Seminars in respiratory and critical care medicine
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Community-acquired pneumonia (CAP) is a global disease responsible for a large proportion of deaths and having significant economic cost. As diagnostic tools have increased in sensitivity, our understanding of the etiology of CAP has begun to change with a significant increase in confirmed viral infections and the recognition that multiple pathogens are frequently present. Empiric therapy remains the standard of care and guidelines are mostly based on published data from the United States or Europe. ⋯ New pathogens are emerging more frequently, as evidenced by severe acute respiratory syndrome, Middle East respiratory syndrome, influenza A H1N1 09, and avian influenza, all of which have global ramifications and good clinicians need to stay informed of evolving threats. There are clearly differences in outcomes from CAP across the globe, but accurately comparing them is difficult given the vast differences in age, comorbidities, and access to healthcare. Improved quality of outcome databases will be a key driver of quality improvement in coming years.
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Semin Respir Crit Care Med · Dec 2016
ReviewThe Modern Diagnostic Approach to Community-Acquired Pneumonia in Adults.
Respiratory tract infections, the majority of which are community acquired, are among the leading causes of death worldwide and a leading indication for hospital admission. The burden of disease demonstrates a "U"-shaped distribution, primarily affecting young children as the immune system matures, and older adults as the process of immunosenescence and accumulation of comorbidities leads to increased susceptibility to infection. Diagnosis of community-acquired pneumonia (CAP) is traditionally based on demonstration of a new infiltrate on a chest radiograph in a patient presenting with an acute respiratory illness or sepsis. ⋯ Urinary antigen tests, polymerase chain reaction assays, and even next-generation sequencing technologies have become available and are increasing the rates of positive diagnosis. In an era of increasing antimicrobial resistance, the accurate diagnosis of CAP and determining the causative pathogen are ever more important. Getting these both right is key in reducing both morbidity and mortality from CAP, and appropriate antimicrobial stewardship which is now an international healthcare priority.
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Semin Respir Crit Care Med · Dec 2016
ReviewAntibiotic Resistance in Community-Acquired Pneumonia Pathogens.
The overwhelming majority of cases of community-acquired pneumonia (CAP) can be treated with the standard antibiotic regimens of a macrolide and cephalosporin or a fluoroquinolone. Despite high rates, current levels of β-lactam resistance generally do not result in treatment failure for patients with CAP when appropriate agents and doses are used. Following the introduction of the pneumococcal conjugate vaccines, the incidence of invasive pneumococcal disease declined drastically, coinciding with a decrease in penicillin resistance. ⋯ The inability to routinely culture H. influenzae suggests that macrolide and β-lactam resistance, while present, is not a big issue. Unless risk factors for a hospital-associated strain are present, the most common Enterobacteriaceae to cause CAP, including Escherichia coli and Klebsiella, are generally susceptible to usual CAP antibiotics. Given the limited role of antibiotic resistance in CAP, a strong rationale is needed for use of antibiotics other than the standard β-lactam/macrolide or fluoroquinolone regimens.
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Community-acquired pneumonia (CAP) in sub-Saharan Africa is a common cause of adult hospitalization and is associated with significant mortality. Human immunodeficiency virus (HIV) prevalence in the region leads to differences in CAP epidemiology compared with most high-income settings: patients are younger, and coinfection with tuberculosis and opportunistic infections is common and difficult to diagnose. Resource limitations affect the availability of medical expertise as well as radiological and laboratory diagnostic services. ⋯ This review summarizes recent data from sub-Saharan Africa describing the burden, etiology, risk factors, and outcome of CAP. We describe the rational and context-appropriate approach to CAP diagnosis and management, including supportive therapy. Priorities for future research to inform strategies for CAP prevention and initial management are suggested.