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Original Research: PNEUMONIA |

Incidence, Etiology, Timing, and Risk Factors for Clinical Failure in Hospitalized Patients With Community-Acquired Pneumonia

Stefano Aliberti, MD; Asad Amir, MD; Paula Peyrani, MD; Mehdi Mirsaeidi, MD, MPH; Marty Allen, MD; Brian K. Moffett, MD; John Myers, PhD; Fidaa Shaib, MD; Maria Cirino, MD; Jose Bordon, MD; Francesco Blasi, MD, PhD; Julio A. Ramirez, MD
Author and Funding Information

*From the Institute of Respiratory Diseases (Drs. Aliberti and Blasi), University of Milan, Milan, Italy; the Department of Medicine (Drs. Amir, Peyrani, Mirsaeidi, Allen, and Ramirez), Division of Infectious Diseases, the Department of Internal Medicine (Dr. Moffett), the Department of Bioinformatics and Biostatistics (Dr. Myers), School of Public Health and Information Sciences, and the Department of Medicine (Drs. Shaib and Cirino), Division of Pulmonary and Critical Care Medicine, University of Louisville, Louisville, KY; and the Section of Infectious Diseases (Dr. Bordon), Department of Medicine, Providence Hospital, Washington, DC.

Correspondence to: Julio A. Ramirez, MD, University of Louisville, Division of Infectious Diseases, 512 South Hancock St, Louisville, KY 40206; e-mail: j.ramirez@louisville.edu


The work was performed in the Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY.

This work was accepted as oral communication at the European Respiratory Society Annual Congress 2007.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2008;134(5):955-962. doi:10.1378/chest.08-0334
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Background:  The etiology of clinical failure in hospitalized patients with community-acquired pneumonia (CAP) may be related or unrelated to pulmonary infection. The objective of this study was to define the incidence, etiology, timing, and risk factors associated with clinical failures related to CAP vs those unrelated to CAP.

Methods:  Observational retrospective study of consecutive CAP patients. All patients who experienced clinical failure were identified. Cases were presented to a review committee that defined, by consensus, etiology, timing, and risk factors for clinical failures related to CAP.

Results:  Among 500 patients who were enrolled in the study, clinical failure was identified in 67 (13%). Clinical failure was related to CAP in 54 patients (81%). The most common etiologies for clinical failure related to CAP were severe sepsis (33%), acute myocardial infarction (28%), and progressive pneumonia (19%). All cases of severe sepsis occurred in the first 72 h of hospitalization. The most common etiology for clinical failure unrelated to CAP was the development of hospital-acquired pneumonia (45%). At the time of hospital admission, factors associated with clinical failure related to CAP were advanced age, congestive heart failure, hypotension, abnormal gas exchange, acidosis, hypothermia, thrombocytopenia, and pleural effusion.

Conclusions:  The development of severe sepsis early during hospitalization is the primary etiology for clinical failure related to CAP. To achieve early treatment intervention, physicians should maintain a high index of suspicion for severe sepsis in hospitalized patients with CAP. To decrease the number of clinical failures unrelated to CAP, interventions need to be developed at the local level to improve the processes of care for patients with pneumonia.

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