Clinical Stability versus Clinical Failure in Patients with Community-Acquired Pneumonia

Abstract

Once antibiotics have been started in patients with community-acquired pneumonia (CAP), the evaluation of clinical outcomes represents one of the essential steps in patient care. Among CAP patients who improve, recognition of clinical stability should be based on both subjective and objective parameters that are locally available in the everyday clinical practice. Different steps in the management of the pneumonia depend on this early outcome, including the switch from intravenous to oral antibiotics, patients' discharge from the hospital, and outcomes after hospitalization. When deterioration occurs in CAP patients, a “treatment failure” or a “clinical failure” should be identified. It is crucial to understand the etiology of failure so as to develop different measures at both international and local levels to prevent adverse outcomes. Finally, several efforts should be made to define incidence, timing, and risk factors for nonresolving pneumonia that, to date, remains one of the most indeterminate clinical outcomes in patients with CAP.

Keywords

community-acquired pneumonia - outcomes - failure - nonresolving pneumonia - stability

• References

• 1 Ramirez JA. Community-Acquired Pneumonia: A Plan for Implementing National Guidelines at the Local Hospital Level. Philadelphia, PA: Lippincott Williams & Wilkins; 2003
• 2 Ramirez JA, Vargas S, Ritter GW , et al. Early switch from intravenous to oral antibiotics and early hospital discharge: a prospective observational study of 200 consecutive patients with community-acquired pneumonia. Arch Intern Med 1999; 159 (20) 2449-2454
• 3 Halm EA, Fine MJ, Marrie TJ , et al. Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines. JAMA 1998; 279 (18) 1452-1457
• 4 Niederman MS, Mandell LA, Anzueto A , et al; American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001; 163 (7) 1730-1754
• 5 Mandell LA, Wunderink RG, Anzueto A , et al; Infectious Diseases Society of America; American Thoracic Society. 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. 02) S27-S72
• 6 Woodhead M, Blasi F, Ewig S , et al; European Respiratory Society; European Society of Clinical Microbiology and Infectious Diseases. Guidelines for the management of adult lower respiratory tract infections. Eur Respir J 2006; 27 (2) 439
• 7 Lim WS, Baudouin SV, George RC , et al; Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009; 64 (Suppl. 03) iii1-iii55
• 8 Menéndez R, Martinez R, Reyes S , et al. Stability in community-acquired pneumonia: one step forward with markers?. Thorax 2009; 64 (11) 987-992
• 9 Menéndez R, Torres A, Rodríguez de Castro F , et al; Neumofail Group. Reaching stability in community-acquired pneumonia: the effects of the severity of disease, treatment, and the characteristics of patients. Clin Infect Dis 2004; 39 (12) 1783-1790
• 10 Viale P, Scudeller L, Petrosillo N , et al. Clinical stability in human immunodeficiency virus-infected patients with community-acquired pneumonia. Clin Infect Dis 2004; 38 (2) 271-279
• 11 Christensen D, Feldman C, Rossi P , et al; Community-Acquired Pneumonia Organization Investigators. HIV infection does not influence clinical outcomes in hospitalized patients with bacterial community-acquired pneumonia: results from the CAPO international cohort study. Clin Infect Dis 2005; 41 (4) 554-556
• 12 Arnold FW, Brock GN, Peyrani P , et al; CAPO authors. Predictive accuracy of the pneumonia severity index vs CRB-65 for time to clinical stability: results from the Community-Acquired Pneumonia Organization (CAPO) International Cohort Study. Respir Med 2010; 104 (11) 1736-1743
• 13 Ramirez JA, Bordon J. Early switch from intravenous to oral antibiotics in hospitalized patients with bacteremic community-acquired Streptococcus pneumoniae pneumonia. Arch Intern Med 2001; 161 (6) 848-850
• 14 Athanassa Z, Makris G, Dimopoulos G, Falagas ME. Early switch to oral treatment in patients with moderate to severe community-acquired pneumonia: a meta-analysis. Drugs 2008; 68 (17) 2469-2481
• 15 Aliberti S, Peyrani P, Filardo G , et al. Association between time to clinical stability and outcomes after discharge in hospitalized patients with community-acquired pneumonia. Chest 2011; 140 (2) 482-488
• 16 Aliberti S, Blasi F, Zanaboni AM , et al. Duration of antibiotic therapy in hospitalised patients with community-acquired pneumonia. Eur Respir J 2010; 36 (1) 128-134
• 17 Genné D, Kaiser L, Kinge TN, Lew D. Community-acquired pneumonia: causes of treatment failure in patients enrolled in clinical trials. Clin Microbiol Infect 2003; 9 (9) 949-954
• 18 Arancibia F, Ewig S, Martinez JA , et al. Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications. Am J Respir Crit Care Med 2000; 162 (1) 154-160
• 19 Genné D, Sommer R, Kaiser L , et al. Analysis of factors that contribute to treatment failure in patients with community-acquired pneumonia. Eur J Clin Microbiol Infect Dis 2006; 25 (3) 159-166
• 20 Hoogewerf M, Oosterheert JJ, Hak E, Hoepelman IM, Bonten MJ. Prognostic factors for early clinical failure in patients with severe community-acquired pneumonia. Clin Microbiol Infect 2006; 12 (11) 1097-1104
• 21 Aliberti S, Amir A, Peyrani P , et al. Incidence, etiology, timing, and risk factors for clinical failure in hospitalized patients with community-acquired pneumonia. Chest 2008; 134 (5) 955-962
• 22 Ott SR, Hauptmeier BM, Ernen C , et al. Treatment failure in pneumonia: impact of antibiotic treatment and cost analysis. Eur Respir J 2012; 39 (3) 611-618
• 23 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 (5) 502-508
• 24 Menéndez R, Cavalcanti M, Reyes S , et al. Markers of treatment failure in hospitalised community acquired pneumonia. Thorax 2008; 63 (5) 447-452
• 25 Hess G, Hill JW, Raut MK , et al. Comparative antibiotic failure rates in the treatment of community-acquired pneumonia: results from a claims analysis. Adv Ther 2010; 27 (10) 743-755
• 26 Kaye KS, Harris AD, McDonald JR, Strausbaugh LJ, Perencevich E ; Infectious Diseases Society of America Emerging Infections Network. Measuring acceptable treatment failure rates for community-acquired pneumonia: potential for reducing duration of treatment and antimicrobial resistance. Infect Control Hosp Epidemiol 2008; 29 (2) 137-142
• 27 Ye X, Sikirica V, Schein JR , et al. Treatment failure rates and health care utilization and costs among patients with community-acquired pneumonia treated with levofloxacin or macrolides in an outpatient setting: a retrospective claims database analysis. Clin Ther 2008; 30 (2) 358-371
• 28 Menéndez R, Torres A, Zalacaín R , et al; Neumofail Group. Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome. Thorax 2004; 59 (11) 960-965
• 29 Mortensen EM, Coley CM, Singer DE , et al. Causes of death for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med 2002; 162 (9) 1059-1064
• 30 Ramirez J, Aliberti S, Mirsaeidi M , et al. Acute myocardial infarction in hospitalized patients with community-acquired pneumonia. Clin Infect Dis 2008; 47 (2) 182-187
• 31 Singanayagam A, Singanayagam A, Elder DH, Chalmers JD. Is community-acquired pneumonia an independent risk factor for cardiovascular disease?. Eur Respir J 2012; 39 (1) 187-196
• 32 Corrales-Medina VF, Suh KN, Rose G , et al. Cardiac complications in patients with community-acquired pneumonia: a systematic review and meta-analysis of observational studies. PLoS Med 2011; 8 (6) e1001048
• 33 Garcia-Vidal C, Carratalà J. Early and late treatment failure in community-acquired pneumonia. Semin Respir Crit Care Med 2009; 30 (2) 154-160
• 34 Menéndez R, Torres A, Zalacaín R , et al; NEUMOFAIL Group. Guidelines for the treatment of community-acquired pneumonia: predictors of adherence and outcome. Am J Respir Crit Care Med 2005; 172 (6) 757-762
• 35 Low DE, Mazzulli T, Marrie T. Progressive and nonresolving pneumonia. Curr Opin Pulm Med 2005; 11 (3) 247-252
• 36 Kyprianou A, Hall CS, Shah R, Fein AM. The challenge of nonresolving pneumonia: knowing the norms of radiographic resolution is key. Postgrad Med 2003; 113 (1) 79-82 , 85–88, 91–92
• 37 Salomoni G, Aliberti S, Travierso C , et al. Incidence, risk factors and outcomes of nonresolving pneumonia. Paper presented at: European Respiratory Society Annual Congress; September 18–22, 2010; Barcelona, Spain