Predicting Treatment Failure in Community Acquired Pneumonia
Predicting Treatment Failure in Community Acquired Pneumonia
Introduction: Treatment failure in community-acquired-pneumonia (CAP) patients is associated with a high mortality rate, and therefore are a matter of great concern in clinical management. Those patients have increased mortality and are a target population for randomized clinical trials.
Methods: A case–control study was performed in patients with CAP (non-failure cases vs. failure cases, discriminating by late and early failure). CRP, PCT, interleukin 1, 6, 8 and 10 and TNF were determined at days 1 and 3 of hospitalization.
Results: A total of 253 patients were included in this study where 83 patients presented treatment failure. Of these, 40 (48.2%) had early failure. A discriminative effect was found for a higher CURB-65 score among late failure patients (p = 0.004). A significant increase on day 1 of hospitalization in CRP (p < 0.001), PCT (p = 0.004), IL-6 (p < 0.001) and IL-8 (p = 0.02), and a decrease in IL-1 (p = 0.06) in patients with failure was observed compared with patients without failure. On day 3, only the increase in CRP (p < 0.001), PCT (p = 0.007) and IL-6 (p < 0.001) remained significant. Independent predictors for early failure were higher IL-6 levels on day 1 (OR = 1.78, IC = 1.2-2.6) and pleural effusion (OR = 2.25, IC = 1.0–5.3), and for late failure, higher PCT levels on day 3 (OR = 1.60, IC = 1.0–2.5), CURB-65 score ≥ 3 (OR = 1.43, IC = 1.0–2.0), and multilobar involvement (OR = 4.50, IC = 2.1–9.9).
Conclusions: There was a good correlation of IL-6 levels and CAP failure and IL-6 & PCT with late CAP failure. Pleural effusion and multilobar involvement were simple clinical predictors of early and late failure, respectively.
Community-acquired pneumonia (CAP) is a major health problem worldwide. Clinically, CAP exhibits enormous variety in the severity of presentation, from septic shock at one end of the spectrum to almost asymptomatic disease at the other. Treatment failure is a matter of great concern in the management of CAP. The reported incidence of treatment failure among hospitalized patients with CAP ranges from 2.4% to 31% for early failure and from 3.9% to 11% for late failure.
It has been recognized that an excessive systemic proinflammatory response in patients with sepsis and severe CAP is associated with deleterious effects and a worse prognosis. Conversely, an exaggerated anti-inflammatory response conducted by some grade of impaired immune response may have a negative effect on clinical resolution. Among the cytokines involved in the inflammatory response, we can include interleukin 10 (IL-10) as a critical anti-inflammatory cytokine that attenuates inflammatory responses in macrophages and T cells, tumor necrosis factor (TNF-α), interleukin 1 (IL-1), interleukin 6 (IL-6) and interleukin 8 (IL-8). Some inflammation markers, such as C-reactive protein (CRP) and procalcitonin (PCT), have been recognized for some time in clinical management,. Therefore, besides clinical factors, cytokine levels can predict CAP-failure and should be included to determine those patients with CAP who are most at risk of developing treatment failure. Early prediction of CAP-failure is a critical step toward better management and improvement of survival. In this study, we aimed to determine clinical and cytokine-level predictors of CAP-failure, including the different types of failure (early and late). The aim of this research is to ascertain the parameters, including cytokine levels, for predicting CAP failure in general, and more specifically, late and early failure.
Abstract and Introduction
Abstract
Introduction: Treatment failure in community-acquired-pneumonia (CAP) patients is associated with a high mortality rate, and therefore are a matter of great concern in clinical management. Those patients have increased mortality and are a target population for randomized clinical trials.
Methods: A case–control study was performed in patients with CAP (non-failure cases vs. failure cases, discriminating by late and early failure). CRP, PCT, interleukin 1, 6, 8 and 10 and TNF were determined at days 1 and 3 of hospitalization.
Results: A total of 253 patients were included in this study where 83 patients presented treatment failure. Of these, 40 (48.2%) had early failure. A discriminative effect was found for a higher CURB-65 score among late failure patients (p = 0.004). A significant increase on day 1 of hospitalization in CRP (p < 0.001), PCT (p = 0.004), IL-6 (p < 0.001) and IL-8 (p = 0.02), and a decrease in IL-1 (p = 0.06) in patients with failure was observed compared with patients without failure. On day 3, only the increase in CRP (p < 0.001), PCT (p = 0.007) and IL-6 (p < 0.001) remained significant. Independent predictors for early failure were higher IL-6 levels on day 1 (OR = 1.78, IC = 1.2-2.6) and pleural effusion (OR = 2.25, IC = 1.0–5.3), and for late failure, higher PCT levels on day 3 (OR = 1.60, IC = 1.0–2.5), CURB-65 score ≥ 3 (OR = 1.43, IC = 1.0–2.0), and multilobar involvement (OR = 4.50, IC = 2.1–9.9).
Conclusions: There was a good correlation of IL-6 levels and CAP failure and IL-6 & PCT with late CAP failure. Pleural effusion and multilobar involvement were simple clinical predictors of early and late failure, respectively.
Introduction
Community-acquired pneumonia (CAP) is a major health problem worldwide. Clinically, CAP exhibits enormous variety in the severity of presentation, from septic shock at one end of the spectrum to almost asymptomatic disease at the other. Treatment failure is a matter of great concern in the management of CAP. The reported incidence of treatment failure among hospitalized patients with CAP ranges from 2.4% to 31% for early failure and from 3.9% to 11% for late failure.
It has been recognized that an excessive systemic proinflammatory response in patients with sepsis and severe CAP is associated with deleterious effects and a worse prognosis. Conversely, an exaggerated anti-inflammatory response conducted by some grade of impaired immune response may have a negative effect on clinical resolution. Among the cytokines involved in the inflammatory response, we can include interleukin 10 (IL-10) as a critical anti-inflammatory cytokine that attenuates inflammatory responses in macrophages and T cells, tumor necrosis factor (TNF-α), interleukin 1 (IL-1), interleukin 6 (IL-6) and interleukin 8 (IL-8). Some inflammation markers, such as C-reactive protein (CRP) and procalcitonin (PCT), have been recognized for some time in clinical management,. Therefore, besides clinical factors, cytokine levels can predict CAP-failure and should be included to determine those patients with CAP who are most at risk of developing treatment failure. Early prediction of CAP-failure is a critical step toward better management and improvement of survival. In this study, we aimed to determine clinical and cytokine-level predictors of CAP-failure, including the different types of failure (early and late). The aim of this research is to ascertain the parameters, including cytokine levels, for predicting CAP failure in general, and more specifically, late and early failure.