The clinical features of severe community-acquired pneumonia presenting as septic shock

doi:10.1053/jcrc.2000.16460

Journal of Critical Care

Volume 15, Issue 3, September 2000, Pages 85-90

The results of this study were presented, in part, at the American College of Chest Physicians Annual Symposium, Toronto, Canada, November, 1998 (abstract No 261).

https://doi.org/10.1053/jcrc.2000.16460 Get rights and content

Abstract

Purpose: The purpose of this article was to determine the outcome, clinical and prognostic features, and microbiology of a large group of patients with community-acquired pneumonia (CAP) presenting in septic shock. Materials and Methods: The placebo limb of the Norasept II database was examined. Data were collected on patients in septic shock with a diagnosis of CAP who presented to a participating site from home. Results: One hundred and forty-eight patients met the study criteria. The 28-day survival was 53%. One hundred and four pathogens were isolated from 77 (52%) patients with 24 (16%) patients having polymicrobial infections. The most common pathogen was Streptococcus pneumoniae (19%), followed by Staphylococcus aureus (18%), Haemophilus influenzae (14%), Klebsiella pneumoniae (11%), and Pseudomonas aeruginosa (7%). Infection with P. aeruginosa or Acinetobacter species carried a very high mortality (82%). The only clinical variables recorded in the database that could identify patients with pseudomonas or acinetobacter infection was a history of alcohol abuse. Comorbidities were present in 74% of patients, involving predominantly the cardiorespiratory system. Logistic regression analysis demonstrated APACHE II score and serum interleukin 6 (IL-6) concentration to be significant independent predictors of mortality. Patients with pseudomonas or acinetobacter infection had significantly higher IL-6 levels and significantly lower tumor necrosis factor alpha levels when compared with the rest of the cohort of patients. Conclusion: A diverse spectrum of both gram-positive and gram-negative pathogens were implicated in patients with CAP presenting in septic shock, necessitating broad spectrum empiric antimicrobial coverage. This coverage should include antipseudomonal activity, particularly in alcoholic patients. Severity of illness (APACHE II score) and IL-6 levels were important prognostic factors. Infection with P. aeruginosa and Acinetobacter species carried a very high mortality. Copyright © 2000 by W.B. Saunders Company

Section snippets

Materials and methods

The placebo limb of the Norasept II database was analyzed. The details of the Norasept II study have been previously published.¹⁴ In summary, adults older than 18 years admitted to hospital with septic shock and who met all the following criteria were eligible for enrollment if the following criteria were met: (1) duration of shock < 12 hours, (2) clinical evidence of acute infection, (3) hyperthermia/hypothermia, (4) tachycardia, (5) need for mechanical ventilation or tachypnea, and (6)

Results

One hundred and forty-eight patients met the study criteria. The 28-day survival was 53%. Logistic regression using forward variable selection demonstrated the APACHE II score and IL-6 levels to be significant independent predictors of mortality. Although the IL-6 levels were significantly higher in the nonsurvivors compared with the survivors, we did not find any cutoff value that reliably predicted the outcome for individual patients. The baseline (day 1) clinical features of the survivors

Discussion

In this study, we have demonstrated that CAP presenting in septic shock carries a high mortality, is associated with a wide spectrum of pathogens, and occurs predominantly in patients with premorbid medical conditions. The high mortality is in keeping with other studies where the mortality of patients with CAP admitted to the ICU has varied from 22% to 53%, being as high as 60% in patients who develop septic shock.8, 15, 16, 17 As in other studies, patients with CAP requiring treatment in the

Acknowledgements

The author expresses his gratitude to Mr. Thomas E. Mansfield III, Senior Clinical Programmer Analyst, Bayer Corporation, for his invaluable help in preparing the data for analysis and the Bayer Corporation for providing access to the data.

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PCT is widely used as rule out test for sepsis and it is frequently requested by primary care doctors facilitating clinician decision. Several studies have shown that the prognosis depends on the rapidity of specific treatment, which should ideally be initiated within four hours and no later than eight hours after diagnosis [6–7]. The original reference was the method BRAHMS PCT Kryptor© assay.
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The intra and inter assay imprecision of Lumipulse®G BRAHMS PCT was between 2 and 5%. The LoD in our condition was 0.0029 ng/mL in accordance with the LoD provided by the manufacturer (0.0048 ng/mL). The linear equation of linearity was y = 1,001 × − 0,052 with r² = 0.99, with a mean recovery (SD) percentage of 1.8% (8%). Correlation studies showed a good correlation (r = 0.99) between plasma on Kryptor and Lumipulse, with a bias of 0.02 in the range from 0.12 to 1 ng/mL.
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Alcohol use, and misuse, has been a part of human culture for thousands of years. In the modern medical era, a great deal of attention has been justifiably focused on elucidating the mechanisms underlying the psychological and biological addiction to alcohol. However, a significant percentage, if not the majority, of alcohol-related morbidity and mortality occurs in individuals who do not meet the formal diagnostic criteria for alcohol use disorders. For example, many serious medical consequences of chronic alcohol ingestion can occur in individuals who do not have signs or symptoms of alcohol dependence. There is now clear evidence that even in otherwise healthy-appearing individuals who chronically consume excessive amounts of alcohol, alveolar macrophage immune capacity is impaired and, as a consequence, these individuals are at significantly increased risk of pneumonia. This brief review summarizes some of the key mechanisms underlying this phenomenon and proposes a hypothetical scheme by which alcohol interferes with zinc bioavailability within the alveolar space and thereby dampens macrophage function.
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^*: Address reprint requests to Paul E. Marik, MD, Department of Internal Medicine, Rm 2A-68, Washington Hospital Center, 110 Irving St, NW, Washington, DC 20010-2975.

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Original InvestigationsThe clinical features of severe community-acquired pneumonia presenting as septic shock*

Abstract

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Chest

Lancet

Chest

Clin Chest Med

Chest

Crit Care Clin

Am J Med

Blood

Cytokine

Am J Med

Chest

Chest

National Center for Health Statistics. Mortality Patterns-United States, 1990

Monthly Vital Stat Rep

Annual summary of births, marriages, divorces and deaths. United States, 1993

Monthly Vital Statistics Report

Community-acquired pneumonia

N Engl J Med

Community-acquired pneumonia requiring hospitalization: 5-year prospective study

Rev Infect Dis

Prognosis and outcomes of patients with community acquired pneumonia: A meta-analysis

JAMA

Severe community-acquired pneumonia in ICUs: Prospective validation of a prognostic score

Intensive Care Med

A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit

Intensive Care Med

Severe community-acquired pneumococcal pneumonia. The French Study Group of Community-Acquired Pneumonia in ICU

Scand J Infect Dis

Severe community-acquired pneumonia: Etiology, prognosis, and treatment

Am Rev Respir Dis

The intensive care management, mortality and prognostic indicators in severe community-acquired pneumococcal pneumonia

Intensive Care Med

Guidelines for the initial management of adults with community-acquired pneumonia: Diagnosis, assessment of severity and initial antimicrobial therapy

Am Rev Respir Dis

Original Investigations
The clinical features of severe community-acquired pneumonia presenting as septic shock*