Dataset Information

Survival with optimal medical management in a cohort of severe necrotizing bacterial lung infections.

ABSTRACT:

Background

Necrotizing pneumonia and lung gangrene represent a continuum of severe lung infection. Traditionally, severe cases have been referred for surgical debridement. However, this has been linked to high mortality. Some groups have published encouraging results using a conservative medical approach. Unfortunately, lack of a standardized definition of necrotizing pneumonia has precluded meaningful comparison between medical and surgical approach in severe cases. Our objective was to describe the outcome of a cohort of severe necrotizing pneumonia treated with optimal medical management.

Methods

We conducted an observational retrospective study by reviewing charts and radiology records of patients hospitalized between 2006-2019 in a tertiary center. We included all patients with severe necrotizing infection, defined as a necrotizing cavity involving at least 50% of a lobe, or smaller multilobar cavities. We made no distinction between necrotizing pneumonia and gangrene as there are no standardized criteria.

Results

A total of 50 consecutive patients were included. On imaging, 42% had multilobar cavities and mean diameter of the largest cavity in each case was 5.9 cm. 50% required mechanical ventilation (median duration 12 days) and 44% needed vasopressors. Four patients (8%) had decortication surgery, while none underwent lung resection. Four patients (8%) died. The extent of infiltrates and number of cavities were not associated with mortality but the extent of infiltrates was associated with risk of intubation (P=0.004).

Conclusions

We presented one of the largest series of medically-treated severe necrotizing lung infections in the pre-coronavirus disease-2019 (COVID-19) era. The overwhelming majority of patients recovered with optimal medical management alone. Our results strongly support avoiding pulmonary resection in patients with severe necrotizing bacterial lung infections.

SUBMITTER: Larose JC

PROVIDER: S-EPMC10407478 | biostudies-literature | 2023 Jul

REPOSITORIES: biostudies-literature

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Publications

Survival with optimal medical management in a cohort of severe necrotizing bacterial lung infections.

Larose Jean-Christophe JC Wang Han Ting HT Rakovich George G

Journal of thoracic disease 20230720 7

<h4>Background</h4>Necrotizing pneumonia and lung gangrene represent a continuum of severe lung infection. Traditionally, severe cases have been referred for surgical debridement. However, this has been linked to high mortality. Some groups have published encouraging results using a conservative medical approach. Unfortunately, lack of a standardized definition of necrotizing pneumonia has precluded meaningful comparison between medical and surgical approach in severe cases. Our objective was to ...[more]

PMID: 37559659

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Project description:BackgroundChronic lung infections are the primary cause of morbidity and mortality in Cystic Fibrosis (CF) patients. Recent molecular biological based studies have identified a surprisingly wide range of hitherto unreported bacterial species in the lungs of CF patients. The aim of this study was to determine whether the species present were active and, as such, worthy of further investigation as potential pathogens.MethodsTerminal Restriction Fragment Length Polymorphism (T-RFLP) profiles were generated from PCR products amplified from 16S rDNA and Reverse Transcription Terminal Restriction Fragment Length Polymorphism (RT-T-RFLP) profiles, a marker of metabolic activity, were generated from PCR products amplified from 16S rRNA, both extracted from the same CF sputum sample. To test the level of activity of these bacteria, T-RFLP profiles were compared to RT-T-RFLP profiles.ResultsSamples from 17 individuals were studied. Parallel analyses identified a total of 706 individual T-RF and RT-T-RF bands in this sample set. 323 bands were detected by T-RFLP and 383 bands were detected by RT-T-RFLP (statistically significant; P < or = 0.001). For the group as a whole, 145 bands were detected in a T-RFLP profile alone, suggesting metabolically inactive bacteria. 205 bands were detected in an RT-T-RFLP profile alone and 178 bands were detected in both, suggesting a significant degree of metabolic activity. Although Pseudomonas aeruginosa was present and active in many patients, a low occurrence of other species traditionally considered to be key CF pathogens was detected. T-RFLP profiles obtained for induced sputum samples provided by healthy individuals without CF formed a separate cluster indicating a low level of similarity to those from CF patients.ConclusionThese results indicate that a high proportion of the bacterial species detected in the sputum from all of the CF patients in the study are active. The widespread activity of bacterial species in these samples emphasizes the potential importance of these previously unrecognized species within the CF lung.

Project description:ImportanceAssessment of the quality of initial care is necessary to target priority actions that can reduce the still high morbidity and mortality due to community-onset severe bacterial infections (COSBIs) among children.ObjectiveTo study the prevalence, characteristics, and determinants of suboptimal care in the initial management of COSBIs.Design, setting, and participantsThis prospective, population-based, cohort study and confidential enquiry was conducted between August 2009 and January 2014 in western France, a region accounting for 15% of the French pediatric population (1 968 474 children aged 1 month to 16 years) and including 6 pediatric intensive care units (PICUs) and 35 emergency departments. Participants included all children aged 1 month to 16 years who died before PICU admission or were admitted to a PICU with a COSBI (ie, bacterial sepsis, including meningitis, purpura fulminans, and pulmonary, osteoarticular, intra-abdominal, cardiac, and soft-tissue severe infections). Data were analyzed from March to June 2020.ExposuresSuboptimal care determined according to evaluation of 8 types of care: (1) the delay in seeking care by family, (2) the physician's evaluation of severity, (3) the patient's referral at the first consultation with signs of severity, (4) the timing and (5) dosage of antibiotic treatment, (6) the timing and (7) volume of fluid bolus administration, and (8) the clinical reassessment after fluid bolus.Main outcomes and measuresTwo experts assessed the quality of care before death or PICU admission as optimal, possibly suboptimal, or certainly suboptimal. The consequences and determinants of certainly suboptimal care were identified with multinomial logistic regression and generalized linear mixed models.ResultsOf the 259 children included (median [IQR] age, 24 [6-66] months; 143 boys [55.2%]), 27 (10.4%) died, and 25 (9.6%) had severe sequelae at PICU discharge. The quality of care was certainly suboptimal in 89 cases (34.4%). Suboptimal care was more frequent in children with sequelae (adjusted odds ratio [aOR], 5.61; 95% CI, 1.19-26.36) and less frequent in children who died (aOR, 0.16; 95% CI, 0.04-0.65) vs those surviving without sequelae. Factors independently associated with suboptimal care were age younger than 5 years (aOR, 3.15; 95% CI, 1.25-7.90), diagnosis of sepsis with no source (aOR, 5.77; 95% CI, 1.64-20.30) or meningitis (aOR, 3.39; 95% CI, 1.15-9.96) vs other severe infections, and care by a primary care physician (aOR, 3.22; 95% CI, 1.17-8.88) vs a pediatric hospital service.Conclusions and relevanceThis study found that suboptimal care is frequent in the initial management of COSBI and is associated with severe sequelae. The paradoxical association with reduced risk of death may be explained by an insufficient adjustment on bacterial or host intrinsic factors. Management could be optimized by improving the quality of primary care, especially for young children.

Dataset Information

Survival with optimal medical management in a cohort of severe necrotizing bacterial lung infections.

Background

Methods

Results

Conclusions

Publications

Survival with optimal medical management in a cohort of severe necrotizing bacterial lung infections.

Similar Datasets

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