Community-acquired pneumonia (CAP) is an infectious illness that frequently motivates hospital admission when comorbid conditions are present. However, the epidemiology of CAP in relation to the underlying disease of the patients is not well known. We performed a prospective multicenter study with the aim of assessing the clinical characteristics, etiology, and outcome of chronic obstructive pulmonary disease (COPD) patients with CAP. Between October 1992 and December 1994 we studied 124 COPD patients (mean FEV1 40 +/- 11% of predicted, mean FVC/FEV1 49 +/- 10) admitted because of CAP to one of the participating centers. An attempt to obtain an etiologic diagnosis was performed by means of blood cultures (n = 123), sputum cultures (n = 97), pleural fluid cultures (n = 17), protected specimen brush samples (n = 41), percutaneous transthoracic needle aspiration (n = 41), and serology (n = 106). Etiologic diagnosis was achieved in 80 (64%) of cases, however, diagnosis based upon valid techniques was only possible in 73 (59%) cases. The main causal microorganisms were the following: Streptococcus pneumoniae in 32 (43%), Chlamydia pneumoniae in 9 (12%), Hemophilus influenzae in 7 (9%), Legionella pneumophila in 7 (9%), Streptococcus viridans in 3 (4%), Coxiella burnetii in 3 (4%), Mycoplasma pneumoniae in 2 (3%), Nocordia asteroides 2, Aspergillus ssp. 1, and others 10. In three of these cases the etiology was polymicrobial. Bacteremia was present in 19 (15%) cases; S. pneumoniae was the most frequent isolate (13 cases). Antibiotic treatment was modified in 22 cases due to etiologic findings, and in 9 due to therapeutic failure. Ten patients died (8%), and 22 needed mechanical ventilation, the mortality rate in the latter population being 23%. Total or partial resistance of S. pneumoniae to penicillin was observed in 10 of 32 (31%) isolations, and to erythromycin in 2 (6%). The results of this study are important for the standardization of empiric antibiotic strategies in COPD patients with pneumonia.

Biomarkers are useful in community-acquired pneumonia (CAP). Recently, midregional (MR) proadrenomedullin (proADM) has been shown to be of potential prognostic use. We sought to determine whether this prognostic role depends on the cause of CAP.We conducted a prospective cohort study of immunocompetent patients with CAP. Pneumonia Severity Index (PSI) and CURB-65 score (confusion (abbreviated mental test score of f8), urea o7 mol?L -1 , respiratory rate o30 breaths?min -1 , blood pressure ,90 mmHg systolic or ,60 mmHg diastolic, and age o65 yrs), blood C-reactive protein, procalcitonin, MR-proADM, and microbiological studies were systematically performed. Patients were grouped as bacterial, viral/atypical and mixed CAP, and were followed up at 30, 90 and 180 days, and 1 yr. We recruited 228 CAP patients. Identification of at least one pathogen was achieved in 155 (68%) patients. MR-proADM levels closely correlated with increasing severity scores, and showed an important predictive power for complications and short-and long-term mortality (1 yr). Its addition to PSI and CURB-65 significantly improved their prognostic accuracy. A MR-proADM cutoff of 0.646 nmol?L -1 identified 92% of patients scored as PSI classes IV and V as high risk. MRproADM outcome prediction power was not affected by different aetiologies. MR-proADM has high short-and long-term prognostic accuracy, and increases the accuracy of clinical scores. The prognostic value of MR-proADM is not modified by different possible CAP aetiologies.

Chronic obstructive pulmonary disease (COPD) is a frequent comorbidity in patients with community-acquired pneumonia (CAP). We investigated the impact of COPD on outcomes of CAP patients.We prospectively studied the clinical presentation of 1,379 patients admitted with CAP during a 4-yr period. A comparative analysis of disease severity and course was performed between 212 patients with COPD, as confirmed by spirometry, and 1,167 non-COPD patients.COPD patients (mean forced expiratory volume in 1 s 47.7¡16.3% predicted) were older and more likely to have previously received antibiotics (37.1% versus 28.3%; p,0.01) than those without COPD. They presented with more severe respiratory failure (arterial oxygen tension/ inspiratory oxygen fraction 270.4 versus 287.8; p,0.01) and more severe pneumonia (pneumonia severity index 118.3 versus 108.5; p,0.001) compared with non-COPD patients. However, COPD patients had less multilobar infiltration (44 (21%) versus 349 (30%); p,0.01) and fewer pulmonary complications (24 (14%) versus 241 (24%); p,0.01). A total of 89 (6.5%) patients died within 30 days. COPD patients had no significant difference in their 30-day mortality rate compared with non-COPD patients (nine (4.2%) patients versus 81 (7%); p50.14).Despite worse clinical presentation, COPD patients had a similar mortality rate compared to non-COPD patients. Previous antibiotic treatment and the decreased incidence of pulmonary complications in COPD may account for these findings.

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BackgroundSevere sepsis, may be present on hospital arrival in approximately one-third of patients with community-acquired pneumonia (CAP).ObjectiveTo determine the host characteristics and micro-organisms associated with severe sepsis in patients hospitalized with CAP.ResultsWe performed a prospective multicenter cohort study in 13 Spanish hospital, on 4070 hospitalized CAP patients, 1529 of whom (37.6%) presented with severe sepsis. Severe sepsis CAP was independently associated with older age (>65 years), alcohol abuse (OR, 1.31; 95% CI, 1.07–1.61), chronic obstructive pulmonary disease (COPD) (OR, 1.75; 95% CI, 1.50–2.04) and renal disease (OR, 1.57; 95% CI, 1.21–2.03), whereas prior antibiotic treatment was a protective factor (OR, 0.62; 95% CI, 0.52–0.73). Bacteremia (OR, 1.37; 95% CI, 1.05–1.79), S pneumoniae (OR, 1.59; 95% CI, 1.31–1.95) and mixed microbial etiology (OR, 1.65; 95% CI, 1.10–2.49) were associated with severe sepsis CAP.ConclusionsCAP patients with COPD, renal disease and alcohol abuse, as well as those with CAP due to S pneumonia or mixed micro-organisms are more likely to present to the hospital with severe sepsis.

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We found no evidence suggesting that patients hospitalized for macrolide-resistant S. pneumoniae pneumonia were more severely ill on presentation or had worse clinical outcomes if they were treated with guideline-compliant versus noncompliant regimens.