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CLINICAL REVIEW: Hannah J Durrington and Charlotte Summers Recent changes in the management of community acquired pneumonia in adults BMJ 2008; 336: 1429-1433 [Full text]

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What about viral community-acquired pneumonias?

G Y Shin   (25 June 2008)

Practical Guide for the Management of Community Acquired Pneumonia

Moises A. Santos Peña MD MSc, Rocha Hernández Juan F. MD MSc, de Pazos Carrazana Juan L MD, Fragoso Marchante MC MD, Hernández Fernández Juana MSc, Solano López Edita MSc, Jiménez Estrada G MD   (27 June 2008)

Viruses are an important cause of community acquired pneumonia

Anant Mohan, New Delhi-110029, India.   (12 July 2008)

Should we modify the CURB65 score to read NEW urea >7

Mobin Mohteshamzadeh   (6 August 2008)

What about viral community-acquired pneumonias? 25 June 2008
G Y Shin, Locum consultant virologist Infection & Immunity, 5/F North Wing, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH Send response to journal: Re: What about viral community-acquired pneumonias?	Sir, As an erstwhile Microbiologist, I read the recent review of community acquired pneumonia (CAP) by Durrington and Summers with interest[1]. As a Virologist, I was somewhat disappointed by it. The authors appear to have virtually disregarded respiratory viruses in their review. Yet the authors' have conceded that viruses are a cause of CAP, as they list "Respiratory viruses" as a cause of CAP in outpatients and inpatients. I was intrigued by the absence of “Respiratory viruses” as a cause of CAP in the Intensive Care Unit setting. Are the authors implying that respiratory viruses do not cause CAP of a severity that requires intensive care unit admission? I suspect many readers would beg to differ. A quick PubMed review of the literature (limited to articles in English, papers on adult patients, in the last 3 years) confirms that viruses are an important cause of CAP. The frequency of viral aetiologies in a sample of studies of CAP published in this period were 15%, 29%, 32%, 23% and 56% respectively[2-6]. Durrington and Summers are not alone in neglecting respiratory viruses during a discussion of CAP. I note that in the most recent update to the British Thoracic Society guidelines on CAP, the word “virus” appears only once in the entire 19-page document[7]. I believe that there is a common misconception that the term community acquired pneumonia refers only to bacterial infections. Perhaps this is historical. However, as diagnostic techniques improve, in particular with the increasing availability of nucleic acid amplification tests, it is time to challenge this convention. This misconception has potentially deleterious clinical consequences. If clinicians do not even think of a viral aetiology in-patients with CAP, it is unlikely they will consider investigations to diagnose respiratory viruses. The costs of not recognising the possibility of viral aetiologies in CAP are clear: inappropriate use of antibiotics for a viral infection, missing the opportunity to consider antiviral therapy in cases of influenza infection and a failure to institute appropriate infection control measures when CAP is viral in origin. I suggest that in retrospect, the authors should have specified that the scope of their review was limited to bacterial CAP. References 1. Durrington HJ, Summers C. Recent changes in the management of community acquired pneumonia in adults. BMJ 2008;336:1429-33 2. Charles PG, Whitby M, Fuller AJ et al. The etiology of community- acquired pneumonia in Australia: why penicillin plus doxycycline or macrolide is the most appropriate therapy. Clin Infect Dis. 2008;46(10):1513-21 3. Jennings LC, Anderson TP, Beynon KA et al. Incidence and characteristics of viral community-acquired pneumonia in adults. Thorax 2008;63(1):42-8 4. Diaz A, Barria P, Niederman M et al. Etiology of community-acquired pneumonia in hospitalized patients in Chile: the increasing prevalence of respiratory viruses among classic pathogens. Chest 2007; 131(3):779-87 5. Angeles Marcos M, Camps M, Pumarola T et al. The role of viruses in the aetiology of community-acquired pneumonia in adults. Antivir Ther 2006;11(3):351-9 6. Templeton KE, Scheltinga SA, van den Eeden WC et al. Improved diagnosis of the etiology of community-acquired pneumonia with real-time polymerase chain reaction. Clin Infect Dis. 2005;41(3):345-51 7. British Thoracic Society Guidelines on the management of community acquired pneumonia in adults – 2004 update. Available at http://www.brit- thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/MACAPrevisedApr04.pdf (accessed 25/6/08) Competing interests: None declared
Practical Guide for the Management of Community Acquired Pneumonia 27 June 2008
Moises A. Santos Peña MD MSc, Epidemiology Department Gustavo Aldereguia Lima University Hospital. Cienfuegos. Cuba, Rocha Hernández Juan F. MD MSc, de Pazos Carrazana Juan L MD, Fragoso Marchante MC MD, Hernández Fernández Juana MSc, Solano López Edita MSc, Jiménez Estrada G MD Send response to journal: Re: Practical Guide for the Management of Community Acquired Pneumonia	Due to the challenging discussion developed at our department in regard to the Clinical Review entitled Recent Changes in the Management of Community Acquired Pneumonia in Adults, published in the BMJ last June 21st by Hannah J Durrington and Charlotte Summers, we would like to share some considerations about this important health problem in our institution. Pneumonia has been considered a health problem for ages. Sir William Osler’s phrases have become famous since the early times of modern medicine when he referred in the first books about Internal Medicine how this entity had been affecting human beings. Later on, after the introduction of antibiotics in the medical practice, there was a dramatical change, however, this pathology is still the most important cause of morbidity and mortality due to infectious diseases nowadays. In countries such as US and UK it is considered the sixth cause of death and about 99% of deaths due to infectious diseases are caused by Community Acquired Pneumonia. Although its incidence differs from one country to the other and changes according to seasons it has been calculated in about 2-15 per 1000 yearly, increasing its importance economically since it is considered the leading cause of absence to jobs, incapacity and activity restriction in western countries. Cuba is not an exception. Pneumonia has been includend between the main fourth causes of death since the year 2001, together with influenza due to the number of death it causeshence becoming the principal cause of death due to infection. In our hospital which gives medical assistance to around 400 000 inhabitants Community Acquired Pneumonia (CAP) is a frequent cause of hospital admission. In a research which was started in the year 2006, 1477 patients were admitted because of this disease and 32 % of them died due to severely ill stages of the disease and complications. In order to decrease this risk in our hospital, physicians began to use Clinical Practical Guidelines for the management of this entity. This guide stratifies patients into five groups according to the severity of the disease, its clinical presentation, prognosis and associated pathologies amongst some important factors, which determine the place of the patient’s admission (open wards or ICUs) as well as the therapeutic management. After achieving a correct diagnosis, the second step is to define if the patient will receive outpatient treatment or hospitalization. Hospital admission is one of the most important clues in the treatment of a patient who suffers from CAP. Admission decision is a complex and difficult fact that depends on the severity of the patient’s illness and on some specific circumstances such as social conditions, home support, patient or relatives’ preferences which may become determinant factors in decision taking. In general there is no rule for exact categorizing patients in risk groups and probably this situation won’t change in the future so at present hospital admission depends on the physician’s clinical reasoning, whose interpretation of the problem is related to the physician’s knowledge, experience, environment, and comprehension of the dynamics of the medical services. The consequences of using the clinical reasoning can lead to a great variety in the management of CAP in different countries worldwide. Therefore, achieving a balance between the clinical thinking and sistematizing Clinical Guidelines is a need We recognize the way in which British Society of Diseases of the Thorax (BTS) has recently updated its Clinical Guidelines with more operative statements that allow the right identification of severely ill Penumonias. All the Clinical Guidelines agree in the fact that the clinical syndromes are not specific and that the diagnostic tests are too slow or insufficiently fiable to help physicians select an initial treatment. An adequate empirical approach lies on a correct knowledge of the most frequent local pathogen agents and on the fact that a small amount of antibiotics (or a simple agent) would usually be effective. This approach has the advantage that it avoids a long time to start treatment meanwhile lab tests are at disposal. The assessment of the severity of the patient who suffer from pneumonia allow to predict the follow up of the disease, to orient treatment, microbiological studies and empirical antimicrobial treatment. We suggest to stratify patients according to different risk types, by using the best method according to the context. Clinical reasoning and medical experience should be over the predictive models which are not infallibles. References: 1. Durrington HJ, Summers Ch. Recent changes in the management of community acquired pneumonia in adults. BMJ 2008; 336: 1429-33 2. Mills GD, Oehley , Arrol B. Effectiveness of âlactam antibiotics compared with antibiotics active against atypical pathogens in non-severe community acquired pneumonia: meta-analysis. BMJ 2205; 330: 456. 3. File TM, Tan JS. International guidelines for the treatment of community- acquired pneumonia in adults: the role of macrolides. Drugs 2003; 63: 181-205. 4. Oosterheert JJ, Bonten MJM, Schneider MME, Buskens E, Lammers JWJ, Hustinx WMN, Kramer MHH, Prins JM, Slee PH, Kaasjager K, Hoepelman AIM. Efefectiveness of early switch from intravenous to oral antibiotics severe community acquired pneumonia: multicentre randomised trial. BMJ 2006; 333: 1193. 5. Diaz A, Barria P, Niedermen M et al. Etiology of community- acquired pneumonia in hospitalized patients in Chile: the increasing prevalence of respiratory viruses among classic pathogen. Chest 2007; 131 (3): 779-87. Competing interests: None declared
Viruses are an important cause of community acquired pneumonia 12 July 2008
Anant Mohan, Assistant Professor of Medicine All India Institute of Medical Sciences,, New Delhi-110029, India. Send response to journal: Re: Viruses are an important cause of community acquired pneumonia	In response to the article by Durrington and Summers (1), we would like to underline the fact that viruses are an important cause of community acquired pneumonia, a fact not emphasised enough in the above article. Respiratory viruses, such as Influenza, Rhinovirus, Respiratory syncitial virus, and Adenovirus, are especially common causes of pneumonia causing acute exacerbation of chronic obstructive pulmonary disease(AECOPD). Upto 50% of AECOPD are postulated to be viral in etiology and are associated with greater morbidity and higher recurrence rate.(2,3) This is significant since these patients are unlikely to respond to antibiotic therapy. In addition, a high index of suspicion is essential in order to collect respiratory samples at the earliest to achieve a definitive diagnosis. References: 1.Hannah J Durrington and Charlotte Summers.Recent changes in the management of community acquired pneumonia in adults.BMJ 2008; 336: 1429- 1433. 2.Rohde G, Wiethege A, Borg I, Kauth M, T Bauer T, Gillissen A, Bufe A, Schultze-Werninghaus G. Respiratory viruses in exacerbations of chronic obstructive pulmonary disease requiring hospitalization: a case-control study. Thorax 2003; 58:37-42. 3.Greenberg SB, Allen M, Wilson J, et al. Respiratory viral infections in adults with and without chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000; 162:167–73. Competing interests: None declared
Should we modify the CURB65 score to read NEW urea >7 6 August 2008
Mobin Mohteshamzadeh, Consultant Nephrologist and Physician Royal Berkshire NHS Foundation Trust, London Road, Reading, RG1 5PN Send response to journal: Re: Should we modify the CURB65 score to read NEW urea >7	As a Nephrologist and Physician I still occasionally take part in the general medical take and so read this article with much interest as we have just changed our hospital antibiotic protocol. The incorporation of the CURB65 score into hospital policies often means that admission or discharge may hang on this score and in-deed the route and type of antibiotic given may be very different depending on the CURB65 score. Patients with chronic kidney disease or on dialysis often present to our establishment and this can leave junior doctors in some what of a dilemma as to how to treat these patients and in the past I have suggested that they use the CRB65 score and to ignore the urea. I feel we ought to be clear on this point and add the word "NEW" before Urea > 7, to avoid confusion amongst Physicians. Competing interests: None declared