社区获得性肺炎( CAP) 是严重威胁人类健康的常见疾病之一, 但在其诊断和治疗仍存在相当大的差异。临床路径( clinical pathway, CP) 是一种新的临床诊疗规范管理方式,近年来开始应用于CAP 的临床诊治, 陆续有协会组织开始制定关于CAP 的临床路径, 并应用于临床。
ObjiectiveTo obtain reliable evidence of diagnosis and treatment through evaluating the validity of pneumonia severity index (PSI), CURB-65 and acute physiology and chronic health evaluationⅡ(APACHEⅡ) scores in predicting risk stratification, severity evaluation and prognosis in elderly community-acquired pneumonia (CAP) patients.MethodsClinical and demographic data were collected and retrospectively analyzed in 125 in-hospital patients with CAP admitted in Shanghai Dahua Hospital from January 2012 to April 2015. The severity of pneumonia was calculated with PSI, CURB-65 and APACHEⅡgroups during 1 to 3 days after admission. Mortality and intensive care unit (ICU) admission rates were evaluated among patients in each scores and was categorized into three classes, namely mild, moderate and severe groups during 1 to 3 days after admission. Mortality and ICU admission rates were evaluated among patients in each severity level. Through evaluating the sensitivity, specificity, the predicting values and the area under receiver operating characteristic (ROC) curve (AUC) among PSI, CURB-65 and APACHEⅡ, the validity and consistency of these three scoring systems were assessed.ResultsUsing PSI, CURB-65 and APACHEⅡ scoring systems, the patients were categorized into mild severity (48.8%, 64.0% and 52.8%, respectively), moderate severity (37.6%, 23.2% and 32.0%, respectively) and severe severity (13.6%, 12.8% and 15.2%, respectively). In PSI, CURB-65 and APACHEⅡ systems, the mortality in high risk groups was 41.3%, 62.5% and 47.4%, respectively; The ICU-admission rate in high risk groups was 88.3%, 100.0% and 94.7%, respectively. The sensitivity of PSI, CURB-65 and APACHEⅡ was 50.0%, 71.4% and 64.3% in predicting mortality, and was 46.8%, 50.0% and 59.3% in predicting ICU-admission, respectively. PSI, CURB-65 and APACHEⅡ showed similar specificity (approximately 90%) in predicting mortality and ICU admission. ROC was conducted to evaluate the sensitivity of PSI, APACHEⅡ and CURB-65 in predicting mortality and ICU admission. The AUC had no significant difference among these three scoring systems. The AUC of PSI, CURB-65 and APACHEⅡwas 0.893, 0.871, 0.880, respectively for predicting mortality, and was 0.949, 0.837, 0.949, respectively for predicting ICU admission. There was no significant difference among these three scoring in predicting mortality and ICU admission (all P>0.05).ConclusionsPSI, CURB-65 and APACHEⅡ performed similarly and achieved high predictive values in elderly patients with CAP. The three scoring systems are consistent in predicting mortality risk in elderly CAP patients. The CURB-65 is more sensitive in predicting the risk of death, and more early in identifing patients with high risk of death. The APACHEⅡ is more sensitive in predicting the risk of ICU admission, and has good value in identifying severe patients and choosing the right treatment sites.
Objective To explore clinical characteristics and risk factors for mortality of community-acquired pneumonia due to Enterobacteriaceae (EnCAP) . Methods This was a single-center, retrospective study. Baseline demographic, clinic, radiologic characteristcs, treatment and outcomes were compared between patients hospilized with EnCAP and community-acquired pneumonia due to Streptoccocus pneumoniae (SpCAP) during January 1, 2010 to December 31, 2015. A univariate and multivariate logistic regression analysis was performed to determine factors independently associated with 30-day mortality for EnCAP. Results In comparison with SpCAP, cerebrovascular disease, chronic hepatopathy, chronic renal disease, aspiration risk, confusion, pleural effusion and higher PSI risk class/CURB-65 score, lower leukocyte, hemoglobin, albumin, longer length of stay in hospital were associated with EnCAP. Multivariate logistic regression analysis demonstrated sepsis shock (OR 1.700, P=0.018, 95%CI 0.781 to 38.326), hemoglobin (OR 0.087, P=0.011, 95%CI 0.857 to 0.981) and appropriate empirical antimicrobial therapy (OR 0.108, P=0.002, 95%CI 0.011 to 0.151) were risk factor for 30-day mortality of EnCAP. Conclusions The clinical characteristics of EnCAP are different with SpCAP. Clinic physicians should pay much attention to the risk factors for 30-day mortality of EnCAP.
Objective To investigate the relationship between the red blood cell distribution width (RDW) and the severity of community-acquired pneumonia (CAP). Methods The clinical data of 285 adult patients with CAP admitted from November 2014 to August of 2017 were analyzed retrospectively. The severity of CAP was evaluated by pneumonia severity index (PSI) score. Meanwhile, 60 cases with qualified medical examination were collected as a healthy control group. The distributions of PSI score, RDW, procalcitonin (PCT), C-reactive protein (CRP) and neutrophil percentage (NEU%) were described in the patients with different risk degree. The correlation analysis of various indicators were analyzed by Spearman correlation. The threshold of RDW(%) was calculated through the construction of the general linear regression equation. The risk factors of PSI score were analyzed with multiple linear regression. Results The higher the risk stratification, the higher the distribution of PSI scores, RDW, PCT, CRP and NEU% were. RDW was positively correlated with PCT, CRP, and NEU% (r values were 0.417, 0.252, 0.318, respectively, P<0.05). PSI score was positively correlated with RDW, PCT, CRP, and NEU% (r values were 0.537,0.598, 0.557, 0.482, respectively, P<0.05). RDW was positively correlated with PSI score (r=0.537, P<0.05). The thresholds of RDW(%) were 14.514 and 19.041. Multiple linear regression showed that RDW, PCT, CRP and NEU% were all influential factors of PSI scores and explained 46.9% of the total mutation rate. Conclusion RDW is correlated with the severity of CAP, and can predict the severity of CAP.
Objective To investigate the clinical characteristics and death risk factors of patients with community acquired pneumonia and sepsis. Methods Data of 350 patients with community-acquired pneumonia and sepsis admitted to the Intensive Care Unit of Third Xiangya Hospital of Central South University from January 2015 to October 2021 were retrospectively analyzed, and their basic characteristics, laboratory results and treatment were analyzed. Results The absolute value of white blood cell, neutrophil ratio, absolute value of neutrophil, inflammatory index, liver and kidney function, coagulation function, cardiac enzymology, lactic acid and sequential organ failure evaluation score of patients with community acquired pneumonia sepsis in the non-survival group were higher than those in the survival group. Logistic regression analysis showed that respiratory rate, heart rate, mean arterial pressure, blood oxygen saturation, C-reactive protein, D-dimer, lactic acid, creatinine and lymphocyte ratio may be independent risk factors for 28-day death in patients with community-acquired pneumonia and sepsis.The receiver operating characteristic curve shows that the combination of the above indicators to predict the risk of death of patients has the best sensitivity, specificity and maximum area under the curve, which is superior to the prediction value of individual variables. Conclusions Patients in the non-survivor group of community-acquired pneumonia sepsis had more severe inflammatory response and organ function impairment. Respiratory rate, heart rate, mean arterial pressure, blood oxygen saturation, C-reactive protein, D-dimer, lactic acid, creatinine, lymphocyte ratio and other indicators are independent risk factors for death of patients with community-acquired pneumonia and sepsis, which have better prognostic value when combined.
Objective To establish a model for prognosis analysis of severe community-acquired pneumonia in order to find the independent risk factors for mortality. Methods The data of 88 patients with severe community-acquired pneumonia enrolled from 533 community-acquired pneumonia patients in Fujian Provincial Hospital from April 2012 to December 2015 were analyzed, they were divided into a survival group and a death group according to prognosis. The clinical materials of basic data of the population, clinical manifestation, treatment and prognosis and pulmonary severity indexes were collected. Then univariate analysis was used to screen risk factors of death before logistic multivaritae regression was applied to explore independent risk factors. Results The different pathogen groups including viral, bacterial, mixed infection, negative and other groups were compared and no differences were found in mortality (all P>0.05). Univariate analysis revealed antibiotics treatment before admission, higher APACHEⅡ score, higher Chalison's score, septicopyemia, and higher level of procalcitonin, blood urea nitrogen (BUN), blood glucose, lactate could increase death risk for the patients. While antiviral treatment and no invasive mechanical ventilation were determined as protective factors. Logistic multivaritae regression showed three factors including higher lactate and higher serum BUN and higher heart rates were independent death risk factors [OR values were 4.704 (95%CI 0.966-22.907), 1.264 (95%CI 0.994-1.606), and 1.081 (95%CI 1.003-1.165), respectively]. Whereas no invasive mechanical ventilation was protective factor (OR=0.033, 95%CI 0.001-0.764). Conclusion The patients with higher lactate and BUN, higher heart rate and accepting invasive mechanical ventilation have poor prognosis.
Community-acquired pneumonia (CAP) is still a common disease that seriously affects people’s health. It is of great clinical significance for proper anti-infective therapy to identify the characteristics and changes of the pathogens. Along with the accelerated process of aging population, increased use of immunosuppression agents, and increased morbidity of malignant tumor and underlying diseases, the pathogenic spectrum of patients with CAP varies as well. This article reviews the important pathogenic changes of CAP in recent years.
Community-acquired pneumonia refers to infectious pulmonary parenchyma inflammation that occurs outside the hospital, including pneumonia that occurs during the incubation period after admission of pathogens with a clear incubation period. Community-acquired pneumonia has a high incidence and mortality rate, imposing a heavy medical burden and posing a serious threat to social public health. In the diagnosis and treatment of community-acquired pneumonia, traditional Chinese medicine and Western medicine each have their own advantages. In order to strengthen the diagnosis and treatment of community-acquired pneumonia through the integration of traditional Chinese and Western medicine, and improve the prevention and treatment level of community-acquired lung disease, this guideline was developed by the Internal Medicine Professional Committee of the World Federation of Chinese Medicine Societies, led by Henan University of Chinese Medicine and the First Affiliated Hospital of Henan University of Chinese Medicine. This guideline refers to the development methods and processes of international clinical practice guidelines, based on the best existing evidence, combined with the characteristics of integrated traditional Chinese and Western medicine in the treatment of community-acquired pneumonia, weighing the pros and cons of intervention measures, and finally forming six recommended opinions, in order to provide references for the clinical practice of integrated traditional Chinese and Western medicine in the treatment of community-acquired pneumonia.
ObjectiveTo investigate the etiologic feature and prognosis of adult patients with severe community-acquired pneumonia (SCAP). MethodsAccording to the guideline on the diagnosis and treatment of community-acquired pneumonia in 2006, 105 patients with SCAP were included in the study. The proportion of pathogens (including multiple resistant bacteria) and mortality rate were recorded. Appropriate statistical methods were selected and all data were analyzed by using SPSS Version 18.0 computerized program. ResultsThe predominant pathogen with SCAP was Pseudomonas aeruginosa, followed by Klebsiella pneumoniae, Staphylococcus aureus, and Legionella pneumophila. In death cases, Klebsiella pneumoniae was the most common pathogen, followed by Staphylococcus aureus. It was showed in the drug sensitivity test that most pathogens were drug-sensitive strains. The patients with tumor had higher risks to get infected with Gram-negative bacillus. ConclusionsThe etiology of patients with SCAP in our emergency department is given priority to Gram-negative bacillus and sensitive strains, of which Pseudomonas aeruginosa and Klebsiella pneumoniae are predominant. As for the Gram-positive cocci, Staphylococcus aureus is the most common pathogen. Legionella pneumophila is the most common pathogen in atypical pathogens, which only account for a small proportion of the aetiology of SCAP. Patients with Klebsiella pneumoniae and Staphylococcus aureus infections are associated with poor prognosis.