Candent issues in pneumonia. Reflections from the Fifth Annual Meeting of Spanish Experts 2023

Abstract

Pneumonia is a multifaceted illness with a wide range of clinical manifestations, degree of severity and multiple potential causing microorganisms. Despite the intensive research of recent decades, community-acquired pneumonia remains the third-highest cause of mortality in developed countries and the first due to infections; and hospital-acquired pneumonia is the main cause of death from nosocomial infection in critically ill patients. Guidelines for management of this disease are available world wide, but there are questions which generate controversy, and the latest advances make it difficult to stay them up to date. A multidisciplinary approach can overcome these limitations and can also aid to improve clinical results. Spanish medical societies involved in diagnosis and treatment of pneumonia have made a collaborative effort to actualize and integrate last expertise about this infection. The aim of this paper is to reflect this knowledge, communicated in Fifth Pneumonia Day in Spain. It reviews the most important questions about this disorder, such as microbiological diagnosis, advances in antibiotic and sequential therapy, management of beta-lactam allergic patient, preventive measures, management of unusual or multi-resistant microorganisms and adjuvant or advanced therapies in Intensive Care Unit.

Keywords: Community-acquired pneumonia; aetiology; diagnosis stewardship; epidemiology; healthcare-associated pneumonia; management; nosocomial pneumonia; prevention; therapeutic failure.

Figure 1

Modified PANNUCI algorithm from empirical to targeted treatment on nosocomial pneumonia in ICUs in European countries (both immunocompetent and immunosuppressed). Adapted from Candel et al. [18] AT: antimicrobial therapy; vHAP: ventilated hospital-acquired pneumonia; VAP: ventilator-associated pneumonia; MDR: multidrug resistant; PCR: polymerase chain reaction; CFT/TAZ: ceftolozane/tazobactam; CAZ/AVI: ceftazidime/avibactam; PIP/TAZ: piperacillin/tazobactam; AMG: aminoglycoside; AZT: Aztreonam; EAT: empirical antimicrobial treatment; TAT: targeted treatment; OXA-48: OXA-48 Carbapenemase; KPC: Klebsiella pneumoniae Carbapenemase; MER-VAR: meropenem-vaborbactam; IMI-REL: imipenem-relebactam; ESBL-E: extended spectrum beta-lactamase-producing enterobacteria; PJ: Pneumocystis jirovecii. * If Oxa-48 susceptible to CAZ/AVI.

Figure 2

Beta-lactam structure Solid arrow: beta-lactam ring. Dashed arrow: group ring. R, R1, R2: lateral chains.

Figure 3

Algorithm of hemodynamic management. MAP: mean arterial pressure, cvSO₂: central venous oxygen saturation, P(v-a)CO₂: partial pression veno-arterial of CO₂, Tv: tidal volume, PPV: pulse pression variation, SVV: systolic volume variation, IVT: integral of velocity with respect to left ventricular outflow tract flow, DIVC: inferior vein cava diameter, MFC: mini-fluid challenge, PLE: passive leg elevation, EEO: end-expiratory occlusion, SV: systolic volume, CW: cardiac waste, LVEF: left ventricle ejection fraction, CI: cardiac index, CFI: cardiac function index, ELWI: extravascular lung water index, GEDI: global end-diastolic global volume index, PAFI: relationship between oxygen arterial partial pression and oxygen inspired fraction, e/e’: echocardiogram e/e’ index.

Figure 4

Unified approach to treat ARDS. ECCO2R: extracorporeal carbon dioxide removal. ECMO: extracorporeal membrane oxygenation. PEEP: positive end-expiratory pressure.