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ERS International congress 2014 Hot topics in pneumonia: a clinician‘s point of view Gernot G.U. Rohde, MD, PhD Associate Professor for Respiratory Medicine

Overview 1.Risk factors for CAP 2.Risk factors for severe outcomes of CAP 3.Microbiology of CAP

Overview 1.Risk factors for CAP 2.Risk factors for severe outcomes of CAP 3.Microbiology of CAP

Almirall J et al., Eur Respir J 2013; 41: 923–928

Hyoid movement: time of maximal hyoid vertical extension Almirall J et al., Eur Respir J 2013; 41: 923–928

CHARACTERISTICS OF ALL PARTICIPANTS ON ENTRY STRATIFIED BY OCCURRENCE OF PNEUMONIA Ali Shah et al., AJRCCM Vol 188, Iss. 5, pp 586–592

Risk of subsequent development of dementia Ali Shah et al., AJRCCM Vol 188, Iss. 5, pp 586–592

Overview 1.Risk factors for CAP 2.Risk factors for severe outcomes of CAP 3.Microbiology of CAP

Overview 1.Risk factors for CAP 2.Risk factors for severe outcomes of CAP 3.Microbiology of CAP

Mortality assessment of COPD disease patients hospitalised with CAP according to prior cv status Sibila O et al., Eur Respir J 2014; 43: 36–42

Survival in COPD patients with CAP stratified by cv status Sibila O et al., Eur Respir J 2014; 43: 36–42

Singanayagam et al., Eur Respir J 2013; 42: 180–187 Cox proportional hazards regression analysis showing the relationship between BMI and 30-day mortality Obese = BMI > 30

King P et al., Eur Respir J 2013; 41: 929–934 Multilevel regression analyses of clinical outcomes by body mass index (BMI) classification

Arnold FW et al., Eur Respir J 2013; 41: 1135–1140 Clinical outcomes by sex for 6718 patients with CAP

Burgos J et al., Eur Respir J 2014; 43: 545–553 Serotypes causing invasive pneumococcal pneumonia in patients presenting with or without respiratory failure

Burgos J et al., Eur Respir J 2014; 43: 545–553 Multivariate analysis: variables associated with respiratory failure

90 days mortality stratified by serum glucose levels on admission overall (n=6016) Lepper et al., BMJ 2012

90 days mortality stratified by serum glucose levels on admission without diabetes (n=5141) Lepper et al., BMJ 2012

90 day mortality stratified by diabetes Lepper et al., BMJ 2012

90 day mortality stratified by diabetes and Glc levels Lepper et al., BMJ 2012

Crude and adjusted analyses of cohorts with the highest mortality Lepper et al., BMJ 2012

Cortisol levels by 30-day mortality (a), critical pneumonia (b) Kolditz et al., BMC Infectious Diseases 2012

Cortisol levels by severity of CAP according to CRB-65 score Kolditz et al., BMC Infectious Diseases 2012

ROC Analyses Kolditz et al., BMC Infectious Diseases 2012

Overview 1.Risk factors for CAP 2.Risk factors for severe outcomes of CAP 3.Microbiology of CAP

Overview 1.Risk factors for CAP 2.Risk factors for severe outcomes of CAP 3.Microbiology of CAP

Patient flow Shindo Y et al., AJRCCM Vol 188, Iss. 8, pp 985–995,

SYMP-ARI Study

Pathogens in CAP in adults (SYMPARI) n = (14%) pos.

Pathogens in CAP in children (SYMPARI) n = (69,4%) pos.

Summary Relevant new risk factors for the development of CAP have been identified, such as dysphagia and cognitive function Determinants of adverse outcomes continue to be „hot“ such as cardio-vascular disease, obesity, gender, pneumococcal serotypes, glucose or cortisol Research into microbiology progresses towards more intensive but also extensive assessments which can be linked to clinical outcome

The future of pneumonia research is bright Picture from

Community-acquired pneumonia in the younger is an entity of its own. 7,803 patients were studied (aged <65 yrs) was 52.3% (18 to <30 yrs 6.4%; <40 yrs 17.1%; <50 yrs 29.4%). Comorbidity was present in only half of the younger patients (46.6% versus 88.2%). Fever and chest pain were more common. Most younger patients presented with mild CAP (74.0% had a CRB-65 [corrected] score of 0 (confusion of new onset, [corrected] respiratory rate of ≥ 30 breaths · min(-1), blood pressure <90 mmHg or diastolic blood pressure ≤ 60 mmHg, age ≥ 65 yrs)). Overall, Streptococcus pneumoniae and Mycoplasma pneumoniae were the most frequent pathogens in the younger patients. Short-term mortality was very low (1.7% versus 8.2%) and even lower in patients without comorbidity (0.3% versus 2.4%). Long-term mortality was 3.2% versus 15.9%, also lower in patients without comorbidity (0.8% versus 6.1%). Klapdor B et al., Eur Respir J May;39(5):

Presentation, etiology and outcome of pneumonia in younger nursing home residents Around 16% of patients with NHAP (n=100) were aged /= 65 years (n=518). Comorbidity was present in most patients with NHAP but the pattern of comorbidity differed significantly. The rate of potential MDR pathogens was low among both age groups (together around 5%). According to the CRB-65 score, NHAP presented less severe in the younger. Short and long-term mortality was twice as low in the younger with rates of 12.9% vs 26.6%, and 24.3% vs 43.8%, p and 0.002), respectively. Whereas the rate of mechanical ventilation was more than twofold higher (12% vs 5%) (p=0.008) Klapdor B et al., J Infect Jul;65(1):32-38

Nursing-home-acquired pneumonia in Germany: an 8-year prospective multicentre study. Patients with NHAP presented with more severe pneumonia as assessed by CRB-65 score than patients with CAP but received the same frequency of mechanical ventilation and less antimicrobial combination treatment. There were no clinically relevant differences in aetiology, multidrug- resistant pathogens were very rare (<5%). Short-term and long-term mortality in the NHAP group was higher than in the CAP group for patients aged ≥65 years (26.6% vs 7.2% and 43.8% vs 14.6%, respectively). However, there was no association between excess mortality and potential multidrug-resistant pathogens. Ewig S et al., Thorax Feb;67(2):132-8.