No abstract

The diagnosis of community-acquired pneumonia (CAP) with chronic heart failure (CHF) is associated with objective difficulties. Our case–control study aims to establish whether established serum inflammatory biomarkers are relevant to the diagnosis of CAP in patients with CHF. Seventy inpatients with previously diagnosed CHF and suspected non-severe CAP were recruited and then stratified into two subgroups with confirmed and rejected diagnosis of CAP. С-reactive protein (CRP), procalcitonin (PCT), tumor necrosis factor α (TNFα), interleukin-6 (IL-6) and brain natriuretic peptide (BNP) were measured. The value of biomarkers was determined using logistic regression, and their discriminatory efficacy was assessed by analyzing receiver operating characteristic (ROC) curves. Significantly higher levels of CRP 50.0 (35.5–98.5) mg/L, PCT 0.10 (0.05–0.54) ng/mL and IL-6 46.1(21.4–150.3) pg/mL in cases were identified as compared to the control group—15.0 (9.5–25.0) mg/L, 0.05 (0.05–0.05) ng/mL and 13.6 (9.5; 25.0) pg/mL, respectively. The Area Under the ROC Curve (95% CI) was the highest for CRP—0.91 (0.83–0.98), followed by PCT—0.81 (0.72–0.90) and IL-6—0.81 (0.71–0.91). A CRP value of >28.5 mg/L had an optimal sensitivity and specificity ratio (85.7/91.4%). In conclusion, the measurement of serum CRP, PCT and IL-6 levels can be useful for the diagnosis of CAP in patients with CHF. CRP showed optimal diagnostic utility in this population.

Chronic heart failure (CHF) is one of the most common comorbidities in elderly patients with community-acquired pneumonia (CAP).The aim of this study was to investigate etiology of CAP in patients with concomitant CHF.Methods. This prospective observational study involved adult hospitalized patients with CAP and concomitant CHF. CAP was confirmed by chest X-ray. Sputum samples or oropharyngeal swabs, blood and urine samples were collected in all eligible patients before starting the therapy with systemic antibiotics. Sputum was cultured for «typical» bacterial pathogens, such as Streptococcus pneumoniae, Staphylococcus aureus, Enterobacterales, etc., in accordance with standard methods and procedures. Mycoplasma pneumoniae, Chlamydophila pneumoniae and respiratory viruses in sputum or oropharyngeal swabs were identified using the real-time polymerase chain reaction (PCR). Urine samples were used to determine serogroup 1 Legionella pneumophila and S. pneumoniae soluble antigens using bedside immunochromatography.Results. Fifty patients were enrolled in the study. The mean age was 72.2 ± 9.5 years, 27 (54%) were females. The etiology of CAP was identified in 23 cases (46%). S. pneumoniae was the most common pathogen (16/23; 69.7%) followed by respiratory viruses (3/23; 13.1%), such as type 3 parainfluenza virus, coronavirus, human metapneumovirus; Haemophilus influenzae (1/23; 4.3%), S. aureus (1/23; 4.3%), and Klebsiella pneumoniae (1/23; 4.3%). S. pneumoniae and parainfluenza virus co-infection was diagnosed in one of 23 patients (4.3%).Conclusion. S. pneumoniae and respiratory viruses were predominant causative pathogens of CAP in hospitalized adults with concomitant CHF. Therefore, bedside tests for urine pneumococcal antigens should be used more widely considering difficult sputum expectoration in elderly. Atypical bacterial pathogens (M. pneumoniae, C. pneumoniae, L. pneumophila) were not identified in this study, so the routine PCR-test and urine tests for L. pneumophila antigens are thought to be not useful.

1 -ФГАОУ ВО «Российский университет дружбы народов»: 117198, Москва, ул. Миклухо Маклая, 6; 2 -ГБОУ ВПО «Смоленский государственный медицинский университет» Минздрава России: 214019, Смоленск, ул. Крупской, 28; 3 -НИИ антимикробной химиотерапии ГБОУ ВПО «Смоленский государственный медицинский университет» Минздрава России: 214019, Смоленск, ул. Кирова, 46а; 4 -Межрегиональная ассоциация по клинической микробиологии и антимикробной химиотерапии: 214019, Смоленск, ул. Кирова, 46а; 5 -ГБОУ ВПО «Воронежский государственный медицинский университет имени Н.Н.Бурденко» Минздрава России: 394036, Воронеж, ул. Студенческая, 10; 6 -ГОБУЗ «Мурманская областная клиническая больница имени П.А.Баяндина»:183047, Мурманск, ул. Павлова, 6; 7 -ГБОУ ВПО «Владивостокский государственный медицинский университет» Минздрава России: 690002, Владивосток, Проспект Острякова, 2; 8 -НУЗ «Дорожная клиническая больница на ст. Новосибирск Главный ОАО "РЖД"»: 630003, Новосибирск, Владимирский спуск, 2а; 9 -ФГАОУ ВО «Северо Восточный федеральный университет имени М.К.Аммосова»: 677000, Якутск, ул. П.Алексеева, 83а Резюме Внебольничная пневмония (ВП) является распространенным заболеванием у взрослых. При определении места лечения больного и объема терапии большое значение имеет точная оценка степени тяжести ВП. Цель. Исследование критериев, используемых врачами в клинической практике для определения тяжести ВП. Материалы и методы. При анкетировании врачей (n = 165) многопрофильных стационаров в 6 городах России установлено, что важным маркером тяжелой ВП считаются данные рентгенографии органов грудной клетки (80 % респондентов). В качестве критериев тяжести ВП 78,8; 66,1; 55,8 и 23,6 % опрошенных отмечены клинические особеннос ти, наличие сопутствующих заболеваний, лабораторные изменения и данные анамнеза соответственно. Среди клинических критериев тяжести наиболее часто упоминались одышка / тахипноэ (78,8 %) и нарушение сознания (78,8 %), среди рентгенологических -наличие очагов деструкции (80,6 %), лабораторных -гиперлейкоцитоз или лейкопения (89,7 %). Прогностические шкалы у пациентов с ВП в ру тинной клинической практике используют 10,3 % респондентов, при этом только в единичных случаях указывались рекомендованные национальными клиническими руководствами шкалы PORT и CURB / CRB 65. Результаты. По результатам опроса установлено, что в целом врачи информированы о ключевых критериях оценки тяжести ВП и факторах риска неблагоприятного прогноза. Заключение. Для более эффективного внедрения в клиническую практику валидизированных шкал, позволяющих объективизировать оценку степе ни тяжести и / или прогноза ВП у взрослых, следует предпринять дополнительные усилия. Ключевые слова: тяжелая внебольничная пневмония, критерии тяжелой внебольничной пневмонии, шкалы оценки степени тяжести и прогноза. SummaryWe aimed to assess the criteria used by physicians in routine clinical practice to assess severity of community acquired pneumonia (CAP) in adults. Methods. A survey of 165 physicians from multi profile hospitals was performed at six Russian cities. Resu...

Aim.To prove that diagnostic algorithm based on additional measurement of serum C-reactive protein (CRP) for administration of systemic antibacterial therapy (ABT) to patients with suspected community-acquired pneumonia (CAP) and concomitant chronic heart failure (CHF) does not influence outcomes of disease.Materials and methods.This open, single-center, randomized, prospective, noninferiority study included 160 adult patients with documented functional class II–IV CHF who had been admitted with a preliminary diagnosis of non-severe CAP. Patients were randomized at 1:1 to two groups; group 1 – with additional measurement of CRP (n=80) and group 2 – with the use of routine diagnostic methods (n=80). In group 1, systemic ABT was administered only when serum CRP was >28.5 mg / l (threshold level of the biomarker calculated at the previous stage of the study); group 2 received a standard treatment. Noninferiority test result for both algorithms was evaluated by the number of patients with clinical success on days 12–14 (primary endpoint). Non-inferiority margin was δ=–13.5 %. In addition secondary endpoints (early clinical response on days 3–5; early in-hospital adverse events (development of complications; admission to intensive care unit (ICU); death), death, recurrent CAP or CHF worsening with readmission at 28 day; mortality at 90 and 180 days) were estimated. Standard statistical tools were used for all intergroup comparisons.Results:76 patients of each group reached the primary endpoint. Systemic ABT was administered to 51 (67.1 %) patients in group 1 and 76 (100 %) patients in group 2 (p<0.05). Both groups were comparable (p>0.05) regarding all endpoints: clinical success, 70 (92.1 %) vs. 69 (90.8 %), Δ=1.3 % (one-sided 97.5 % CI: – 8.25 % for non-inferiority margin δ=–13.5 %); early clinical response, 66 (86.8 %) vs. 68 (89.5 %); admission to ICU, 1 (1.3 %) vs. 1 (1.3 %); development of complications, 20 (26.3 %) vs. 22 (28.9 %); readmission, 5 (6.6 %) vs. 6 (7.9 %); in-hospital mortality, 2 (2.6 %) vs. 1 (1.3 %), mortality at 28 day, 3 (3.9 %) vs. 2 (2.6 %), at 90 day, 5 (6.6 %) vs. 4 (5.3 %), at 180 day, 8 (10.5 %) vs. 9 (11.8 %) cases, respectively.Conclusion:additional measurement of serum CRP in patients with CHF and suspected non-severe CAP was able to reduce rate of systemic ABT administration without outcomes and prognosis worsening.