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Semin Respir Crit Care Med 2009; 30(2): 154-160
DOI: 10.1055/s-0029-1202934
© Thieme Medical Publishers

Early and Late Treatment Failure in Community-Acquired Pneumonia

Carolina Garcia-Vidal1 , Jordi Carratalà1
  • 1Infectious Disease Service, Hospital Universitari de Bellvitge. Institut d'investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
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Publikationsdatum:
18. März 2009 (online)

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ABSTRACT

Treatment failure is a matter of great concern in the management of community-acquired pneumonia (CAP). Defined generally as lack of response or clinical deterioration, failure is considered early when it occurs within the first 72 hours and late when it occurs after 72 hours. The reported incidence of treatment failure among hospitalized patients with CAP ranges from 2.4 to 31% for early failure and from 3.9 to 11% for late failure. Most cases of early failure occur because of inadequate host–pathogen responses. Factors associated with treatment failure include high-risk pneumonia, liver disease, multilobar infiltrates, Legionella pneumonia, gram-negative pneumonia, pleural effusion, cavitation, leucopenia, and discordant antimicrobial therapy. Conversely, influenza vaccination, initial treatment with fluoroquinolones, and chronic obstructive pulmonary disease have been linked with a lower risk of failure. Treatment failure is associated with high morbidity and mortality rates. Its detection and management require careful clinical assessment. Certain serum biological markers may be helpful to identify patients with a higher risk of deterioration and poor prognosis. Because inadequate host–pathogen responses are responsible for a significant number of failures, strategies aimed at modulating the inflammatory response should be investigated. Discordant therapy can be prevented by rational application of the current antibiotic guidelines.

KEYWORDS

Early failure - late failure - community-acquired pneumonia - inflammatory response - biomarkers

REFERENCES

  • 1 Mandell L A, Wunderink R G, Anzueto A et al.. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.  Clin Infect Dis. 2007;  44(Suppl 2) S27-S72
    CrossrefPubMedSuche in Google Scholar
  • 2 Menéndez R, Torres A. Treatment failure in community-acquired pneumonia.  Chest. 2007;  132 1348-1355
    CrossrefPubMedSuche in Google Scholar
  • 3 Arancibia F, Ewig S, Martinez J A et al.. Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications.  Am J Respir Crit Care Med. 2000;  162 154-160
    CrossrefPubMedSuche in Google Scholar
  • 4 Rosón B, Carratalà J, Fernández-Sabé N, Tubau F, Manresa F, Gudiol F. Causes and factors associated with early failure in hospitalized patients with community-acquired pneumonia.  Arch Intern Med. 2004;  164 502-508
    CrossrefPubMedSuche in Google Scholar
  • 5 Menéndez R, Torres A, Zalacaín R et al.. Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome.  Thorax. 2004;  59 960-965
    CrossrefPubMedSuche in Google Scholar
  • 6 Menéndez R, Cavalcanti M, Reyes S et al.. Markers of treatment failure in hospitalised community acquired pneumonia.  Thorax. 2008;  63 447-452
    CrossrefPubMedSuche in Google Scholar
  • 7 Hoogewerf M, Oosterheert J J, Hak E, Hoepelman I M, Bonten M JM. Prognostic factors for early clinical failure in patients with severe community-acquired pneumonia.  Clin Microbiol Infect. 2006;  12 1097-1104
    CrossrefPubMedSuche in Google Scholar
  • 8 Montravers P, Fagon J Y, Chastre J et al.. Follow-up protected specimen brushes to assess treatment in nosocomial pneumonia.  Am Rev Respir Dis. 1993;  147 38-44
    PubMedSuche in Google Scholar
  • 9 Örtqvist A, Kalin M, Lejdeborn L, Lundberg B. Diagnostic fiberoptic bronchoscopy and protected brush culture in patients with community-acquired pneumonia.  Chest. 1990;  97 576-582
    CrossrefPubMedSuche in Google Scholar
  • 10 Oosterheert J J, Bonten M J, Schneider M M et al.. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomized trial.  BMJ. 2006;  333 1193-1197
    CrossrefPubMedSuche in Google Scholar
  • 11 Kelley M A, Weber D J, Gilligan P, Cohen M S. Breakthrough pneumococcal bacteremia in patients being treated with azithromycin and clarithromycin.  Clin Infect Dis. 2000;  31 1008-1011
    CrossrefPubMedSuche in Google Scholar
  • 12 Musher D M, Dowell M E, Shortridge V D et al.. Emergence of macrolide resistance during treatment of pneumococcal pneumonia.  N Engl J Med. 2002;  346 630-631
    CrossrefPubMedSuche in Google Scholar
  • 13 Davidson R, Cavalcante R, Brunton J L et al.. Resistance to levofloxacin and failure of treatment of pneumococcal pneumonia.  N Engl J Med. 2002;  346 747-750
    CrossrefPubMedSuche in Google Scholar
  • 14 Low D E. Quinolone resistance among pneumococci: therapeutic and diagnostic implications.  Clin Infect Dis. 2004;  38(Suppl 4) S357-S362
    CrossrefPubMedSuche in Google Scholar
  • 15 Garcia-Vidal C, Fernández-Sabé N, Carratalà J et al.. Early mortality in patients with community-acquired pneumonia: causes, and risk factors.  Eur Respir J. 2008;  32 733-739
    CrossrefPubMedSuche in Google Scholar
  • 16 Monton C, Torres A, El-Ebiary M et al.. Cytokine expression in severe pneumonia: a bronchoalveolar lavage study.  Crit Care Med. 1999;  27 1745-1753
    PubMedSuche in Google Scholar
  • 17 Confalonieri M, Urbino R, Potena A et al.. Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study.  Am J Respir Crit Care Med. 2005;  171 242-248
    CrossrefPubMedSuche in Google Scholar
  • 18 Garcia-Vidal C, Calbo E, Pascual V, Ferrer C, Quintana S, Garau J. Effects of systemic steroids in patients with severe community-acquired pneumonia.  Eur Respir J. 2007;  30 951-956
    CrossrefPubMedSuche in Google Scholar
  • 19 Sibila O, Agustí C, Torres A. Corticosteroids in severe pneumonia.  Eur Respir J. 2008;  32 259-264
    CrossrefPubMedSuche in Google Scholar
  • 20 Carratalà J, Martín-Herrero J E, Mykietiuk A, García-Rey C. Clinical experience in the management of community-acquired pneumonia: lessons from the use of fluoroquinolones.  Clin Microbiol Infect. 2006;  12(Suppl 3) 2-11
    PubMedSuche in Google Scholar
  • 21 Marrie T J, Lau C Y, Wheeler S L, Wong C J, Vandervoort M K, Feagan B G. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin.  JAMA. 2000;  283 749-755
    CrossrefPubMedSuche in Google Scholar
  • 22 Carratalà J, Fernández-Sabé N, Ortega L et al.. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients.  Ann Intern Med. 2005;  142 165-172
    CrossrefPubMedSuche in Google Scholar
  • 23 File Jr T M, Segreti J, Dunbar L et al.. A multicenter, randomized study comparing the efficacy and safety of intravenous and/or oral levofloxacin versus ceftriaxone and/or cefuroxime axetil in treatment of adults with community-acquired pneumonia.  Antimicrob Agents Chemother. 1997;  41 1965-1972
    PubMedSuche in Google Scholar
  • 24 Welte T, Petermann W, Schürmann D, Bauer T T, Reimnitz P. Moxirapid Study Group . Treatment with sequential intravenous or oral moxifloxacin was associated with faster clinical improvement than was standard therapy for hospitalized patients with community-acquired pneumonia who received initial parenteral therapy.  Clin Infect Dis. 2005;  41 1697-1705
    CrossrefPubMedSuche in Google Scholar
  • 25 Mykietiuk A, Carratalà J, Fernández-Sabé N et al.. Clinical outcomes for hospitalized patients with Legionella pneumonia in the antigenuria era: the influence of levofloxacin therapy.  Clin Infect Dis. 2005;  40 794-799
    CrossrefPubMedSuche in Google Scholar
  • 26 Dalhoff A, Shalit I. Immunomodulatory effect of quinolones.  Lancet Infect Dis. 2003;  3 359-371
    CrossrefPubMedSuche in Google Scholar
  • 27 Calbo E, Alsina M, Rodríguez-Carballeira M, Lite J, Garau J. Systemic expression of cytokine production in patients with severe pneumococcal pneumonia: effects of treatment with a beta-lactam versus a fluoroquinolone.  Antimicrob Agents Chemother. 2008;  52 2395-2402
    CrossrefPubMedSuche in Google Scholar
  • 28 Gross P A, Hermogenes A W, Sacks H S et al.. the efficacy of influenza vaccine in elderly persons: a meta-analysis and review of the literature.  Ann Intern Med. 1995;  123 518-527
    PubMedSuche in Google Scholar
  • 29 Spaude K A, Brutyn E, Kirchner C, Kim A, Daley J, Fisman D N. Influenza vaccination and risk of mortality among adults hospitalized with community-acquired pneumonia.  Arch Intern Med. 2007;  167 53-59
    CrossrefPubMedSuche in Google Scholar
  • 30 Nelson S. Novel nonantibiotic therapies for pneumonia: cytokines and host defense.  Chest. 2001;  119(Suppl 2) 419S-425S
    CrossrefPubMedSuche in Google Scholar
  • 31 Skerrett S J, Park D R. Anti-inflammatory treatment of acute and chronic pneumonia.  Semin Respir Infect. 2001;  16 76-84
    PubMedSuche in Google Scholar
  • 32 Fernández-Serrano S, Dorca J, Coromines M, Carratalà J, Gudiol F, Manresa F. Molecular inflammatory responses measured in blood of patients with severe community-acquired pneumonia.  Clin Diagn Lab Immunol. 2003;  10 813-820
    CrossrefPubMedSuche in Google Scholar
  • 33 Póvoa P. Serum markers in community-acquired pneumonia and ventilator-associated pneumonia.  Curr Opin Infect Dis. 2008;  21 157-162
    CrossrefPubMedSuche in Google Scholar
  • 34 Smith R P, Lipworth B J, Cree I A, Spiers E M, Winter J H. C-reactive protein: a clinical marker in community-acquired pneumonia.  Chest. 1995;  108 1288-1291
    CrossrefPubMedSuche in Google Scholar
  • 35 Coelho L, Póvoa P, Almeida E et al.. Usefulness of C-reactive protein in monitoring the severe community-acquired pneumonia clinical course.  Crit Care. 2007;  11 R92
    CrossrefPubMedSuche in Google Scholar
  • 36 Chalmers J D, Singanayagam A, Hill A T. C-reactive protein is an independent predictor of severity in community-acquired pneumonia.  Am J Med. 2008;  121 219-225
    CrossrefPubMedSuche in Google Scholar
  • 37 Bruns A HW, Oosterheert J J, Hak E, Hoepelman A IM. Usefulness of consecutive C-reactive protein measurements in follow-up of severe community-acquired pneumonia.  Eur Respir J. 2008;  32 726-732
    CrossrefPubMedSuche in Google Scholar

Jordi CarratalàM.D. Ph.D. 

Infectious Disease Service, Hospital Universitari de Bellvitge, Feixa Llarga s/n

08907 L'Hospitalet de Llobregat, Barcelona, Spain

eMail: jcarratala@ub.edu