The objective of this study was to describe the epidemiology, clinical characteristics, microbiology and outcomes of patients of all ages with Streptococcus pneumoniae meningitis between 2000 and 2004; two years pre- and postintroduction of an S pneumoniae 7-valent conjugate vaccine program in Alberta in children younger than two years of age. The high mortality rate associated with S pneumoniae meningitis, despite appropriate therapy, suggests that prevention of S pneumoniae meningitis is critical. Despite implementation of a PCV-7 program in Alberta, rates of S pneumoniae meningitis in children younger than two years of age is still high. Thus, continued research into safe and efficacious vaccines covering a broader range of S pneumoniae serotypes is necessary.
To describe the epidemiology, clinical characteristics, microbiology and outcomes of patients of all ages with Streptococcus pneumoniae meningitis two years pre- and postintroduction of a S pneumoniae 7-valent conjugate vaccine program in Alberta in children <2 years of age.
Between 2000 and 2004, all cases of invasive pneumococcal disease in Alberta were identified. From this cohort, patients with S pneumoniae meningitis were identified by chart review. Clinical data, laboratory data and in-hospital outcomes were collected.
Of the 1768 cases of invasive pneumococcal disease identified between 2000 and 2004, 110 (6.2%) had S pneumoniae meningitis. The overall incidence was 0.7 per 100,000 persons and remained unchanged over the study period. The rate in children <2 years of age appeared to fall over time, from 10.5 per 100,000 persons in 2000 to five per 100,000 persons in 2004, although there was insufficient evidence of a statistically significant time trend within any age group. Overall, the mean age was 30 years and 47% were male. In-hospital mortality was 20%, ranging from 6% in those ≤2 years of age to 31% for those ≥18 years of age, despite appropriate antimicrobial therapy.
The high mortality rate associated with S pneumoniae meningitis suggests that prevention by vaccination is critical. In children <2 years of age, there was a downward trend in the rate of S pneumoniae meningitis after implementation of the S pneumoniae 7-valent conjugate vaccine program, but rates were still high.
Conjugate; Meningitis; Streptococcus pneumoniae; Vaccine
Pneumococcal peritonitis is uncommon and poorly understood.
As part of a five-year study (2000 to 2004) of invasive pneumococcal disease (IPD) in Alberta, all cases of peritonitis due to Streptococcus pneumoniae were reviewed and compared with all other cases of IPD.
Twenty-three of 1768 (1.3%) IPD patients were found to have peritonitis. Patients with peritonitis were more likely to have cirrhosis, hepatitis C, alcoholism and HIV/AIDS, than the remainder of the patients with IPD. The all-cause mortality did not differ between the two groups. Peritonitis was classified as primary in nine (39%) patients, secondary in 12 (52%) patients, and genitourinary in females, specifically, in two (9%) patients. Pneumococcal serotypes causing peritonitis were under-represented in current vaccines – 17% among peritonitis patients versus 53% for the remainder of IPD patients for the 7-valent pneumococcal conjugate vaccine, and 56% versus 86% for the 23-valent pneumococcal polysaccharide vaccine.
Peritonitis represents a small subset of patients with IPD, but one that is likely to grow in importance given the increase in the number of patients with hepatitis C and HIV, and the reduced coverage of peritonitis serotypes in currently available vaccines.
Mortality; Peritonitis; Pneumococcal; Serotypes; Vaccine
The vast majority of research in the area of community-acquired pneumonia (CAP) has been based on patients admitted to hospital. And yet, the majority of patients with CAP are treated on an ambulatory basis as outpatients, either by primary care physicians or in Emergency Departments. Few studies have been conducted in outpatients with pneumonia, and there is a paucity of data on short and long term morbidity or mortality and associated clinical correlates in this group of patients.
From 2000–2002, all CAP patients presenting to 7 Emergency Departments in Edmonton, Alberta, Canada were prospectively enrolled in a population-based registry. Clinical data, including pneumonia severity index (PSI) were collected at time of presentation. Patients discharged to the community were then followed for up to 5 years through linkage to the provincial administrative databases. The current report provides the rationale and design for the cohort, as well as describes baseline characteristics and 30-day morbidity and mortality.
The total sample included 3874 patients. After excluding patients who were hospitalized, died or returned to the Emergency Department the same day they were initially discharged (n = 451; 12 %), and patients who could not be linked to provincial administrative databases (n = 237; 6 %), the final cohort included 3186 patients treated according to a validated clinical management pathway and discharged back to the community. Mean age was 51 (SD = 20) years, 53 % male; 4 % resided in a nursing home, 95 % were independently mobile, and 88 % had mild (PSI class I-III) pneumonia. Within 30-days, return to Emergency Department was common (25 %) as was hospitalization (8 %) and 1 % of patients had died.
To our knowledge, this represents the largest clinically-detailed outpatient CAP cohort assembled to date and will add to our understanding of the determinants and outcomes in this under-researched patient population. The rich clinical data along with the long term health care utilization and mortality will allow for the identification of novel prognostic indicators. Given how under studied this population is, the findings should aid clinicians in the routine care of their outpatients with pneumonia and help define the next generation of research questions.
A single clone of Streptococcus pneumoniae serotype 5 caused this epidemic.
In Canada before 2005, large outbreaks of pneumococcal disease, including invasive pneumococcal disease caused by serotype 5, were rare. Since then, an epidemic of serotype 5 invasive pneumococcal disease was reported: 52 cases during 2005, 393 during 2006, 457 during 2007, 104 during 2008, and 42 during in 2009. Of these 1,048 cases, 1,043 (99.5%) occurred in the western provinces of Canada. Median patient age was 41 years, and most (659 [59.3%]) patients were male. Most frequently representing serotype 5 cases (compared with a subset of persons with non–serotype 5 cases) were persons who were of First Nations heritage or homeless. Restriction fragment-length polymorphism typing indicated that the epidemic was caused by a single clone, which multilocus sequence typing identified as sequence type 289. Large pneumococcal epidemics might go unrecognized without surveillance programs to document fluctuations in serotype prevalence.
Streptococcus pneumoniae; serotype 5; epidemic; invasive pneumococcal disease; bacteria; Canada; IPD; surveillance
Background. Swine outbreaks of pandemic influenza A (pH1N1) suggest human introduction of the virus into herds. This study investigates a pH1N1 outbreak occurring on a swine research farm with 37 humans and 1300 swine in Alberta, Canada, from 12 June through 4 July 2009.
Methods. The staff was surveyed about symptoms, vaccinations, and livestock exposures. Clinical findings were recorded, and viral testing and molecular characterization of isolates from humans and swine were performed. Human serological testing and performance of the human influenza-like illness (ILI) case definition were also studied.
Results. Humans were infected before swine. Seven of 37 humans developed ILI, and 2 (including the index case) were positive for pH1N1 by reverse-transcriptase polymerase chain reaction (RT-PCR). Swine were positive for pH1N1 by RT-PCR 6 days after contact with the human index case and developed symptoms within 24 h of their positive viral test results. Molecular characterization of the entire viral genomes from both species showed minor nucleotide heterogeneity, with 1 amino acid change each in the hemagglutinin and nucleoprotein genes. Sixty-seven percent of humans with positive serological test results and 94% of swine with positive swab specimens had few or no symptoms. Compared with serological testing, the human ILI case definition had a specificity of 100% and sensitivity of 33.3%. The only factor associated with seropositivity was working in the swine nursery.
Conclusions. Epidemiologic data support human-to-swine transmission, and molecular characterization confirms that virtually identical viruses infected humans and swine in this outbreak. Both species had mild illness and recovered without sequelae.
Chronic obstructive pulmonary disease (COPD) is a complex, multisystem disorder that often results in exacerbations requiring emergency department (ED) management. Following an exacerbation and discharge from the ED, reassessment and management adjustment with a health care provider are recommended to re-establish control of the disease.
To describe outcomes of all COPD presentations to EDs made by adults in Alberta including the time spent in the ED and the physician visits following the ED visit.
Provincial administrative databases were used to obtain all ED encounters for COPD during six fiscal years (1999 to 2005). The information extracted included demographics, ED visit timing, and acute and subacute outcomes (physician visits up to 365 days after discharge for all 7302 discharged individuals during a one-year period). Data analysis included descriptive summaries and survival curves.
There were 85,330 ED visits for acute COPD, of which 67% were discharged from the ED. Median ED length of stay was longer in large urban areas (Calgary: 5 h 9 min; Edmonton: 4 h 58 min) than in other regions of Alberta (1 h 17 min). Admissions resulted from 32% of visits and varied among regions; however, few were admitted to the intensive care unit (1%) or died (0.1%). Following discharge, the median time to first follow-up with a physician was 13 days; however, only 40% of patients had follow-up visits in the first seven days. Repeat ED visits within seven days occurred in 5.7% of discharged patients, while 25.6% of discharged patients had repeat ED visits within 365 days of discharge.
More than 30% of COPD ED visits resulted in admission; regional variation was significant. Moreover, discharged patients experienced delayed follow-up and often required repeat ED visits. Interventions to improve reassessment and reduce COPD-related repeat ED visits should be explored.
Chronic obstructive pulmonary disease; Databases; Emergency medicine; Epidemiology; Respiratory diseases
To assess knowledge of pandemic influenza, we administered a questionnaire to all medical students at the University of Alberta; 354 (69%) of 510 students responded. Data from questionnaires such as this could help determine the role of medical students during a public health emergency.
Pandemic influenza; medical students; knowledge; volunteering; attitudes; penalties; dispatch
To determine factors associated with the length of stay (LOS) for patients with suspected community-acquired pneumonia (CAP) who required hospitalization for treatment.
The authors studied a population-based prospective cohort of 2757 adults with suspected CAP who were admitted over a two-year period. Logistic regression, multiple linear regression, and classification and regression trees were used to determine the factors associated with LOS.
The study was conducted in two community and tertiary care hospitals, two community and secondary care hospitals, and two community hospitals in the Capital Health Region of Edmonton, Alberta.
Symptoms such as sweats, shaking chills and wheezing were associated with an LOS of seven days or shorter, whereas weight loss, functional impairment, heart, renal or neoplastic diseases and time to first dose of antibiotic were predictive of an LOS greater than seven days. Regression tree analysis indicated that rapid achievement of physiological stability was associated with a shorter LOS. The use of an indwelling urinary catheter was found to be an important determinant of LOS.
The present study found several new associations with increased LOS in patients with CAP, including functional status, time to receipt of first dose of antibiotic therapy, use of certain antibiotics, presence of a urinary catheter and the importance of time to physiological stability. An intervention targeting avoidance of urinary catheters may be associated with a shorter LOS.
Community-acquired; Length of stay; Pneumonia
Most patients with community-acquired pneumonia (CAP) are treated on an ambulatory basis.
To evaluate the reasons for presentation to hospital after treatment for CAP on an ambulatory basis.
The study, conducted in five hospitals in the Capital Health Region (Edmonton, Alberta), enrolled adult patients aged 17 years or older who presented with a history of having been diagnosed and treated for pneumonia within the previous month. A current diagnosis of pneumonia was based on two or more symptoms or signs of CAP, plus radiographic evidence of pneumonia.
Seventy-five (77.3%) of the 97 patients who met the inclusion criteria had CAP, and 22 (22.7%) patients presented with a noninfectious illness. Of the patients with CAP, 25 (33.3%) met the study criteria for worsening of a comorbid illness, 23 (30.7%) had clinical failure, 16 (21.3%) had microbiological failure, six (8.0%) were noncompliant, four (5.3%) had failure of expectations and one (1.3%) had adverse effects of antimicrobial therapy.
Underlying diseases, exacerbations of comorbidities and complications of CAP, as well as confounders such as unusual infections and noninfectious conditions that mimic CAP, are all reasons for presenting to hospital after treatment for CAP in an ambulatory setting.
Community-acquired pneumonia; Reasons for consulting hospital
To determine the factors that predict whether or not ambulatory patients with community-acquired pneumonia (CAP) treated in an emergency room (ER) setting will have blood cultures drawn and the factors that predict a positive blood culture.
Prospective observational study of all patients with a diagnosis of CAP, as made by an ER physician, who presented to any of seven Edmonton-area ERs over a two-year period.
Seven hundred ninety-three (19.2%) of 4124 patients with CAP had blood cultures drawn. The site-specific blood culture rates ranged from 7.8% to 25% (P<0.001); 41 of 793 (5.1%) were positive. Streptococcus pneumoniae accounted for 58.5% of the isolates while Staphylococcus aureus and Escherichia coli each accounted for 14.6%, or six patients each. Only two of the 24 patients with S pneumoniae bacteremia were subsequently admitted to hospital while all six of the patients with S aureus were admitted. Only one of the six patients with E coli bacteremia was treated at home. No factors were predictive of positive blood cultures on multivariate analysis.
Physicians are selective in ordering blood cultures on patients with ambulatory pneumonia who present to an ER, and the positivity rate of 5.1% is quite high. No factors are predictive of positive blood cultures on multivariate analysis, thus clinical judgment has to prevail in the decision to perform blood cultures. Breakthrough bacteremia can occur with microorganisms susceptible to the antibiotics that the patient is receiving.
Ambulatory; Blood cultures; Community-acquired pneumonia; Streptococcus pneumoniae
There has never been a cross-Canada surveillance project to determine the rate of Legionella species as a cause of community-acquired pneumonia requiring hospitalization and to determine whether there are any regional differences in the rates of Legionnaires' disease in Canada. Anecdotally, Legionnaires' disease is thought to be uncommon in Western Canada.
From January, 1996 through to October 31, 1997, a prospective study of the etiology of community acquired pneumonia requiring admission to 15 tertiary care hospitals in eight Canadian provinces was conducted. A urine sample from each patient was tested for Legionella pneumophila serogroup 1 antigen using a commercially available ELISA assay. A culture of sputum or other respiratory specimens for Legionellaceae was carried out at the discretion of the attending physician. Two hundred thirty-four patients had acute and 6-week convalescent serum samples tested for antibodies to L pneumophila serogroups 1 through 6 using an ELISA method.
28 of the 850 patients (3.2%) had Legionnaires' disease; 18 of 823 (2.1%) were positive for L pneumophila serogroup 1 by urinary antigen testing. The rate of Legionnaires' disease, based on urinary antigen, at the Halifax site was higher than that at the other sites (seven of 163 patients versus 11 of 660 [P=0.04]). Of the 28 cases of Legionnaires' disease identified using all methods, 11 of 277 patients (3.9%) were enrolled from Western provinces versus 17 of 573 patients (2.9%) from Eastern provinces (P=nonsignificant).
Legionnaires' disease is just as common in Western as in Eastern Canada. L pneumophila serogroup 1 may be more common in Halifax than at the other sites studied.
Acquired pneumonia; Canada; Legionella; Legionella urine antigen; Legionnaires' disease
The objective of the present paper is to describe the clinical and computed tomography features of 'explosive pleuritis', an entity first named by Braman and Donat in 1986, and to propose a case definition. A case report of a previously healthy, 45-year-old man admitted to hospital with acute onset pleuritic chest pain is presented. The patient arrived at the emergency room at 15:00 in mild respiratory distress; the initial chest x-ray revealed a small right lower lobe effusion. The subsequent clinical course in hospital was dramatic. Within 18 h of admission, he developed severe respiratory distress with oxygen desaturation to 83% on room air and dullness of the right lung field. A repeat chest x-ray, taken the morning after admission, revealed complete opacification of the right hemithorax. A computed tomography scan of the thorax demonstrated a massive pleural effusion with compression of pulmonary tissue and mediastinal shift. Pleural fluid biochemical analysis revealed the following concentrations: glucose 3.5 mmol/L, lactate dehydrogenase 1550 U/L, protein 56.98 g/L, amylase 68 U/L and white blood cell count 600 cells/mL. The pleural fluid cultures demonstrated light growth of coagulase-negative staphylococcus and viridans streptococcus, and very light growth of Candida albicans. Cytology was negative for malignant cells. Thoracotomy was performed, which demonstrated a loculated parapneumonic effusion that required decortication. The patient responded favourably to the empirical administration of intravenous levofloxacin and ceftriaxone, and conservative surgical methods in the management of the empyema. This report also discusses the patient's rapidly progressing pleural effusion and offers a potential case definition for explosive pleuritis. Explosive pleuritis is a medical emergency defined by the rapid development of a pleural effusion involving more than 90% of the hemithorax over 24 h, which causes compression of pulmonary tissue and mediastinal shift to the contralateral side.
Explosive pleuritis; Pleurisy; Pleuritis; Pneumonia
Chlamydia pneumoniae is a recently recognized respiratory tract pathogen. It accounts for 6 to 10% of all cases of community acquired pneumonia requiring admission to hospital. Two patients hospitalized with C pneumoniae pneumonia are presented to illustrate its range of severity and the extrapulmonary manifestations.
Chlamydia pneumoniae; Community acquired pneumonia
While Staphylococcus aureus is an uncommon but serious cause of traditional community-acquired pneumonia (CAP), it is a predominant cause of nosocomial pneumonia in addition to the unique clinical entity of health care-associated pneumonia (HCAP). A cohort of bacteremic S aureus pneumonia cases was reviewed to determine the role of HCAP among the cohort, and to assess for differences between CAP and HCAP.
PATIENTS AND METHODS
Bacteremic S aureus pneumonia cases were identified from a prospective study of all patients diagnosed with CAP who presented to hospitals in Edmonton, Alberta, between November 2000 and November 2002. These cases were subsequently reviewed retrospectively. Demographic, clinical and microbiological data were obtained, and patients were classified as having CAP or HCAP. Relatedness of isolates was determined by pulsed-field gel electrophoresis analysis in conjunction with epidemiological information.
There were 28 cases of bacteremic S aureus pneumonia identified. Fifty-seven per cent were reclassified as having HCAP, and 43% remained classified as having CAP. The CAP cohort was significantly younger than the HCAP cohort (mean age 49.0±23.7 years versus 67.8±18.6 years; P=0.035) with higher rates of intravenous drug use (50% versus 0%; P=0.002). Long-term care facility residence (44%) was common in the HCAP cohort. The HCAP cohort presented with more severe illness, having a higher mean pneumonia severity index score (143.1±41.1 versus 98.2±54.6; P=0.028), and despite fewer embolic complications, there was a trend toward a significantly higher mortality rate (31% versus 0%; P=0.052). Two community-acquired isolates cultured in the setting of intravenous drug use were methicillin-resistant, and no isolates were positive for Panton-Valentine leukocidin. There was evidence of relatedness involving 44% of the HCAP isolates by pulsed-field gel electrophoresis analysis.
HCAP accounts for a significant number of cases that, when using traditional definitions, would be classified as CAP. Severity of illness and mortality was excessive within the HCAP group. There was evidence of relatedness and spread of common strains in the HCAP cohort. The present study supports recommendations for treatment guidelines directed toward the entity of HCAP and the empirical coverage of S aureus among certain high-risk groups.
Community-acquired pneumonia; Health care-associated pneumonia; Staphylococcus aureus
Since the 1990s, reports of Q fever in Nova Scotia, Canada, have declined. Passive surveillance for Q fever in Nova Scotia and its neighboring provinces in eastern Canada indicates that the clinical manifestation of Q fever in the Maritime provinces is pneumonia and that incidence of the disease may fluctuate.
Q fever; Coxiella burnetii; pneumonia; Nova Scotia; New Brunswick; Prince Edward Island; Canada; dispatch
To determine whether statins reduce mortality or need for admission to intensive care in patients admitted to hospital with community acquired pneumonia; and to assess whether previously reported improvements in sepsis related outcomes were a result of the healthy user effect.
Population based prospective cohort study.
Six hospitals in Capital Health, Edmonton, Alberta, Canada.
Adults admitted to hospital with pneumonia and categorised according to use of statins for at least one week before admission and during hospital stay.
Main outcome measures
Composite of in-hospital mortality or admission to an intensive care unit.
Of 3415 patients with pneumonia admitted to hospital, 624 (18%) died or were admitted to an intensive care unit. Statin users were less likely to die or be admitted to an intensive care unit than non-users (50/325 (15%) v 574/3090 (19%), odds ratio 0.80, P=0.15). After more complete adjustment for confounding, however, the odds ratios changed from potential benefit (0.78, adjusted for age and sex) to potential harm (1.10, fully adjusted including propensity scores, 95% confidence interval 0.76 to1.60).
Statins are not associated with reduced mortality or need for admission to an intensive care unit in patients with pneumonia; reports of benefit in the setting of sepsis may be a result of confounding.
Multispacer sequence typing is the first reliable method for typing Coxiella burnetii isolates.
Coxiella burnetii is a strict intracellular bacterium with potential as a bioterrorism agent. To characterize different isolates of C. burnetii at the molecular level, we performed multispacer sequence typing (MST). MST is based on intergenic region sequencing. These regions are potentially variable since they are subject to lower selection pressure than the adjacent genes. We screened 68 spacers in 14 isolates and selected the 10 that exhibited the most variation. These spacers were then tested in 159 additional isolates obtained from different geographic areas or different hosts or were implicated in different manifestations of human disease caused by C. burnetii. The sequence analysis yielded 30 different allelic combinations. Phylogenic analysis showed 3 major clusters. MST allows easy comparison and exchange of results obtained in different laboratories and could be a useful tool for identifying bacterial strains.
Keywords: Coxiella burnetii; Q fever; Phylogeny; Bacterial typing; DNA sequence analysis
To determine the extent of intravenous (IV) antibiotic use for community-acquired pneumonia (CAP) in emergency departments, the practice patterns in seven emergency departments serving the adult residents of one Canadian city were observed.
An observational study of nonhospitalized adults diagnosed with CAP in seven emergency departments was conducted between November 15, 2000, and November 19, 2002. Data related to antibiotic treatment of CAP administered in the emergency department and patient-specific characteristics potentially predictive of IV treatment were collected.
A total of 3512 subjects were identified, of which 4.9% received treatment with IV antibiotics. Cefuroxime and levofloxacin were the most commonly used IV agents, while orally-treated subjects primarily received a macrolide or levofloxacin. The proportion of subjects receiving IV antibiotics differed significantly among the seven sites: 1.4%–10.6% (p > 0.0001). Logistic regression identified a number of independent predictors of receipt of IV antibiotics including risk class, temperature, respiratory rate, study year, presence of vomiting, prior antibiotic treatment, and personal care home residence. However, these predictors did not explain intersite differences.
Only a small proportion of patients (4.9%) presenting to the emergency department with CAP received IV antibiotics. While patient demographics and severity indicators influenced the likelihood of receipt of IV antibiotics, considerable intersite variation existed, despite adjustment for such factors.
pneumonia; ambulatory care; antiinfective agents; infections; intravenous
Most cases of echinococcal disease (ED) acquired in Canada are thought to be due to the sylvatic form of Echinococcus granulosus, which may be more benign than ED due to either Echinococcus multilocularis or the pastoral form of E. granulosus. There are limited descriptions of the clinical course and outcome of Canadian patients with ED in the modern era.
A retrospective chart review was performed of patients hospitalized with echinococcal disease (ED) from 1991 to 2001 in Edmonton, Alberta.
Forty-two cases of ED were identified of which 19 were definite, 3 probable, and 20 possible. Further analysis was limited to the 22 definite and probable cases, of which 77% were female and 41% aboriginal, with an age range of 5 to 87 years. Nine patients (40%) had pulmonary involvement and 11 (50%) hepatic involvement. One patient had an intracardiac mass presenting as a cerebrovascular event and one had a splenic cyst. Seven of the 22 patients had combined surgical resection and medical treatment, six had surgical resection of the cyst alone, four had cyst aspiration, one had medical treatment alone and four had no specific treatment. There was no mortality attributable to ED but three patients died of unrelated illnesses.
Echinococcal disease in northern Alberta has a marked diversity of clinical presentations, and generally has a good prognosis despite a wide variety of therapeutic interventions.
Mimivirus, the largest virus known to date, is an amebal pathogen like Legionella spp. When mimivirus was used as an antigen in a migration inhibition factor assay, seroconversion was found in patients with both community- and hospital-acquired pneumonia. Mimivirus DNA was found in respiratory samples of patients with hospital-acquired pneumonia.
pneumonia; mimivirus; dispatch
The present study tested acute and convalescent serum samples from 788 patients hospitalized for community-acquired pneumonia in seven Canadian provinces for antibodies to Coxiella burnetii. One hundred nine patients (13.8%) had antibodies to this microorganism, and seven patients had acute Q fever. Serological evidence of infection with C burnetii was present in patients from all seven provinces. Three of the seven cases of acute Q fever were from Manitoba, suggesting that there may be unrecognized cases of Q fever in this province. In addition, a case of acute Q fever in Newfoundland, where there had previously been no reported cases, was noted, although subsequently, an outbreak of Q fever on goat farms has been reported.
Canada; Coxiella burnetti; Fever; Seroepidemiology
To identify the factors associated with the use of arterial blood gas (ABG) and pulse oximetry (PO) in the initial management of patients with community-acquired pneumonia (CAP) and arterial hypoxemia at presentation.
A total of 944 outpatients and 1,332 inpatients with clinical and radiographic evidence of CAP prospectively enrolled from 5 study sites in the United States and Canada.
Separate multivariate logistic regression analyses were used to 1) compare measurement of ABG and PO within 48 hours of presentation across sites while controlling for patient differences, and 2) identify factors associated with arterial hypoxemia (PaO2<60 mm Hg or SaO2<90% for non–African Americans and <92% for African Americans) while breathing room air.
Range of ABG use by site was from 0% to 6.4% (P = .06) for outpatients and from 49.2% to 77.3% for inpatients (P < .001), while PO use ranged from 9.4% to 57.8% for outpatients (P < .001) and from 47.9% to 85.1% for inpatients (P < .001). Differences among sites remained after controlling for patient demographic characteristics, comorbidity, and illness severity. In patients with 1 or more measurements of oxygenation at presentation, hypoxemia was independently associated with 6 risk factors: age >30 years (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.7 to 5.9), chronic obstructive pulmonary disease (OR, 1.9; 95% CI, 1.4 to 2.6), congestive heart failure (OR, 1.5; 95% CI, 1.0 to 2.1), respiratory rate >24 per minute (OR, 2.3; 95% CI, 1.8 to 3.0), altered mental status (OR, 1.6; 95% CI, 1.1 to 2.3), and chest radiographic infiltrate involving >1 lobe (OR, 2.2; 95% CI, 1.7 to 2.9). The prevalence of hypoxemia among those tested ranged from 13% for inpatients with no risk factors to 54.6% for inpatients with ≥3 risk factors. Of the 210 outpatients who had ≥2 of these risk factors, only 64 (30.5%) had either an ABG or PO performed. In the 48 outpatients tested without supplemental O2with ≥2 risk factors 8.3% were hypoxemic.
In the initial management of CAP, use of ABG and PO varied widely across sites. Increasing the assessment of arterial oxygenation among patients with CAP is likely to increase the detection of arterial hypoxemia, particularly among outpatients.
community-acquired pneumonia; hypoxemia; blood gas analysis; oximetry
The seroprevalence of Coxiella burnetii among cattle, sheep, and goats in Newfoundland was determined by microimmunofluorescence. Seropositivity to phase II antigen increased in sheep from 3.1% in 1997 to 23.5% in 1999–2000 (P < 0.001). Cows (24%) had antibodies to phase I antigen; goats (15.6%) had antibodies to phase II antigen. Seroprevalence of C. burnetii is increasing among sheep.
Community-acquired pneumonia (CAP) is a serious illness with a significant impact on individual patients and society as a whole. Over the past several years, there have been significant advances in the knowledge and understanding of the etiology of the disease, and an appreciation of problems such as mixed infections and increasing antimicrobial resistance. The development of additional fluoroquinolone agents with enhanced activity against Streptococcus pneumoniae has been important as well.
It was decided that the time had come to update and modify the previous CAP guidelines, which were published in 1993. The current guidelines represent a joint effort by the Canadian Infectious Diseases Society and the Canadian Thoracic Society, and they address the etiology, diagnosis and initial management of CAP. The diagnostic section is based on the site of care, and the treatment section is organized according to whether one is dealing with outpatients, inpatients or nursing home patients.
Canada; Community-acquired pneumonia; Guidelines