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Open Access 01-10-2011 | Research

Community-acquired polymicrobial pneumonia in the intensive care unit: aetiology and prognosis

Authors: Catia Cillóniz, Santiago Ewig, Miquel Ferrer, Eva Polverino, Albert Gabarrús, Jorge Puig de la Bellacasa, Josep Mensa, Antoni Torres

Published in: Critical Care | Issue 5/2011

Abstract

Introduction

The frequency and clinical significance of polymicrobial aetiology in community-acquired pneumonia (CAP) patients admitted to the ICU have been poorly studied. The aim of the present study was to describe the prevalence, clinical characteristics and outcomes of severe CAP of polymicrobial aetiology in patients admitted to the ICU.

Methods

The prospective observational study included 362 consecutive adult patients with CAP admitted to the ICU within 24 hours of presentation; 196 (54%) patients had an established aetiology.

Results

Polymicrobial infection was present in 39 (11%) cases (20% of those with defined aetiology): 33 cases with two pathogens, and six cases with three pathogens. The most frequently identified pathogens in polymicrobial infections were Streptococcus pneumoniae (n = 28, 72%), respiratory viruses (n = 15, 39%) and Pseudomonas aeruginosa (n = 8, 21%). Chronic respiratory disease and acute respiratory distress syndrome criteria were independent predictors of polymicrobial aetiology. Inappropriate initial antimicrobial treatment was more frequent in the polymicrobial aetiology group compared with the monomicrobial aetiology group (39% vs. 10%, P < 0.001), and was an independent predictor of hospital mortality (adjusted odds ratio = 10.79, 95% confidence interval = 3.97 to 29.30; P < 0.001). The trend for higher hospital mortality of the polymicrobial aetiology group compared with the monomicrobial aetiology group (n = 8, 21% versus n = 17, 11%), however, was not significantly different (P = 0.10).

Conclusions

Polymicrobial pneumonia occurs frequently in patients admitted to the ICU. This is a risk factor for inappropriate initial antimicrobial treatment, which in turn independently predicts hospital mortality.

Ewig S, Woodhead M, Torres A: Towards a sensible comprehension of severe community-acquired pneumonia. Intensive Care Med 2011, 37: 214-223. 10.1007/s00134-010-2077-0CrossRefPubMed

Gutierrez F, Masia M, Rodriguez JC, Mirete C, Soldan B, Padilla S, Hernandez I, Royo G, Martin-Hidalgo A: Community-acquired pneumonia of mixed etiology: prevalence, clinical characteristics, and outcome. Eur J Clin Microbiol Infect Dis 2005, 24: 377-383. 10.1007/s10096-005-1346-2CrossRefPubMed

de Roux A, Ewig S, Garcia E, Marcos MA, Mensa J, Lode H, Torres A: Mixed community-acquired pneumonia in hospitalised patients. Eur Respir J 2006, 27: 795-800. 10.1183/09031936.06.00058605CrossRefPubMed

Lieberman D, Schlaeffer F, Boldur I, Horowitz S, Friedma MG, Leiononen M, Horovitz O, Manor E, Porath A: Multiple pathogens in adult patients admitted with community-acquired pneumonia: a one year prospective study of 346 consecutive patients. Thorax 1996, 51: 179-184. 10.1136/thx.51.2.179PubMedCentralCrossRefPubMed

Lim WS, Macfarlane JT, Boswell TC, Harrison TG, Rose D, Leinonen M, Saikku P: Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax 2001, 56: 296-301. 10.1136/thorax.56.4.296PubMedCentralCrossRefPubMed

Cilloniz C, Ewig S, Polverino E, Marcos MA, Esquinas C, Gabarrus A, Mensa J, Torres A: Microbial aetiology of community-acquired pneumonia and its relation to severity. Thorax 2011, 66: 340-346. 10.1136/thx.2010.143982CrossRefPubMed

Menendez R, Cordoba J, de la Cuadra P, Cremades MJ, Lopez-Hontagas JL, Salavert M, Gobernado M: Value of the polymerase chain reaction assay in noninvasive respiratory samples for diagnosis of community-acquired pneumonia. Am J Respir Crit Care Med 1999, 159: 1868-1873.CrossRefPubMed

Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN: A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997, 336: 243-250. 10.1056/NEJM199701233360402CrossRefPubMed

Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG: 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.CrossRefPubMed

10.

European Committee on Antimicrobial Susceptibility Testing[http://www.eucast.org/clinical_breakpoints/]

11.

Hosmer D, Lemeshow S: Applied Logistic Regression. New York: Wiley; 1989.

12.

Liapikou A, Ferrer M, Polverino E, Balasso V, Esperatti M, Piner R, Mensa J, Luque N, Ewig S, Menendez R, Niederman MS, Torres A: Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission. Clin Infect Dis 2009, 48: 377-385. 10.1086/596307CrossRefPubMed

13.

von Baum H, Schweiger B, Welte T, Marre R, Suttorp N, Pletz MW, Ewig S: How deadly is seasonal influenza associated pneumonia? The German Competence Network for Community-acquired pneumonia (CAPNETZ). Eur Respir J 2010, 37: 1151-1157.CrossRefPubMed

14.

Centres for Disease Control and Prevention: Bacterial coinfections in lung tissue specimens from fatal cases of 2009 pandemic influenza A (H1N1)-United States, May-August 2009. MMWR Morb Mortal Wkly Rep 2009, 58: 1071-1074.

15.

Martin-Loeches I, Sanchez-Corral A, Diaz E, Granada RM, Zaragoza R, Villavicencio C, Albaya A, Cerda E, Catalan RM, Luque P, Paredes A, Navarrete I, Rello J, Rodriguez A: Community-acquired respiratory coinfection in critically ill patients with pandemic 2009 influenza A(H1N1) virus. Chest 2011, 139: 555-562. 10.1378/chest.10-1396CrossRefPubMed

16.

Riquelme R, Torres A, Rioseco ML, Ewig S, Cilloniz C, Riquelme M, Inzunza C, Polverino E, Gomez Y, Marcos MA, Contreras C, Gabarrus A, Fasce R: Influenza pneumonia: a comparison between seasonal influenza virus and the H1N1 pandemic. Eur Respir J 2011, 38: 106-111. 10.1183/09031936.00125910CrossRefPubMed

17.

McCullers JA: Insights into the interaction between influenza virus and pneumococcus. Clin Microbiol Rev 2006, 19: 571-582. 10.1128/CMR.00058-05PubMedCentralCrossRefPubMed

18.

Carratala J, Mykietiuk A, Fernandez-Sabe N, Suarez C, Dorca J, Verdaguer R, Manresa F, Gudiol F: Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med 2007, 167: 1393-1399. 10.1001/archinte.167.13.1393CrossRefPubMed

19.

Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Le J, Macfarlane JT, Read RC, Roberts HJ, Levy ML, Wani M, Woodhead MA: BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009,64(Suppl 3):iii1-iii55. 10.1136/thx.2009.121434CrossRefPubMed

20.

Dallas J, Skrupky L, Abebe N, Boyle WA, Kollef MH: Ventilator-associated tracheobronchitis in a mixed surgical and medical ICU population. Chest 2011, 139: 513-518. 10.1378/chest.10-1336CrossRefPubMed

21.

Torres A, Dorca J, Zalacaín R, Bello S, El-Ebiary M, Molinos L, Arevalo M, Blanquer J, Celis R, Iriberri M, Prats E, Fernandez R, Irigaray R, Serra J: Community-acquired pneumonia in chronic obstructive pulmonary disease. Spanish Multicenter Study. Am J Respir Crit Care Med 1996, 154: 1456-1461.CrossRefPubMed

22.

Murphy TF: Pseudomonas aeruginosa in adults with chronic obstructive pulmonary disease. Curr Opin Pulm Med 2009, 15: 138-142. 10.1097/MCP.0b013e328321861aCrossRefPubMed

23.

Sethi S, Maloney J, Grove L, Wrona C, Berenson CS: Airway inflammation and bronchial bacterial colonization in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2006, 173: 991-998. 10.1164/rccm.200509-1525OCPubMedCentralCrossRefPubMed

24.

Bauer TT, Ewig S, Rodloff AC, Muller EE: Acute respiratory distress syndrome and pneumonia: a comprehensive review of clinical data. Clin Infect Dis 2006, 43: 748-756. 10.1086/506430CrossRefPubMed

25.

Kumar A, Ellis P, Arabi Y, Roberts D, Light B, Parrillo JE, Dodek P, Wood G, Kumar A, Simon D, Peters C, Ahsan M, Chateau D: Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest 2009, 136: 1237-1248. 10.1378/chest.09-0087PubMed

26.

Niederman MS: Appropriate use of antimicrobial agents: challenges and strategies for improvement. Crit Care Med 2003, 31: 608-616. 10.1097/01.CCM.0000050464.70382.D6CrossRefPubMed

27.

Palacios G, Hornig M, Cisterna D, Savji N, Bussetti AV, Kapoor V, Hui J, Tokarz R, Briese T, Baumeister E, Lipkin WI: Streptococcus pneumoniae coinfection is correlated with the severity of H1N1 pandemic influenza. PLoS One 2009, 4: e8540. 10.1371/journal.pone.0008540PubMedCentralCrossRefPubMed

Title: Community-acquired polymicrobial pneumonia in the intensive care unit: aetiology and prognosis
Authors: Catia Cillóniz
Santiago Ewig
Miquel Ferrer
Eva Polverino
Albert Gabarrús
Jorge Puig de la Bellacasa
Josep Mensa
Antoni Torres
Publication date: 01-10-2011
Publisher: BioMed Central
Published in: Critical Care / Issue 5/2011
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/cc10444

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Community-acquired polymicrobial pneumonia in the intensive care unit: aetiology and prognosis

Abstract

Introduction

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

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