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Páginas: 16 (3752 palabras) Publicado: 23 de septiembre de 2012
For the full versions of these articles see bmj.com

CLINICAL REVIEW

Recent changes in the management of community acquired pneumonia in adults
Hannah J Durrington, Charlotte Summers
Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge CB2 2QQ Correspondence to: C Summers cs493@medschl.cam.ac.uk
BMJ 2008;336:1429-33doi:10.1136/bmj.a285

In 1901 William Osler described pneumonia as the “captain of the men of death.”1 Mortality has altered little since penicillin became routinely available, and community acquired pneumonia remains a leading cause of mortality worldwide.2 Here, we review studies published in the past two years and focus on changes in the aetiology, stratification of severity, and antimicrobial management ofcommunity acquired pneumonia in adults.
What is community acquired pneumonia and how is it diagnosed? The British Thoracic Society (BTS) defines community acquired pneumonia as the presence of symptoms and signs consistent with acute lower respiratory tract infection, in association with new radiographic shadowing (figure) for which there is no alternative explanation, which is managed aspneumonia and is the main reason for seeking healthcare advice. 3 This definition may not be useful, however, when radiology is not easily accessible. A review of studies that used clinical definitions based on symptoms and signs found these alternative definitions to be inferior to radiography in detecting pneumonia. 3 How common is community acquired pneumonia? The annual incidence of communityacquired pneumonia in the United Kingdom is 5-11 cases per 1000 adult population.4 Incidence data cannot be extrapolated to other populations because health care varies greatly worldwide. The incidence of the disease varies

with age, being higher in very young children and elderly people.5
What organisms cause community acquired pneumonia? Data from a prospective observational study in a UK teachinghospital show that a microbiological diagnosis can be made in 75% of cases.6 In real life practice, outside clinical trials, the rate of microbiological diagnosis is much lower, around 10-20%. The most common causative organism worldwide is Streptococcus pneumoniae. The incidence of less common organisms is variable and depends upon geography, healthcare setting, and the availability of suitablediagnostic tests. Box 1 shows the most common organisms in order of incidence and this subject has been extensively reviewed elsewhere.7 Atypical pneumonia refers to pneumonia caused by organisms such as Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella spp. A recent retrospective observational study based on data obtained as part of drug trials from 4337 patients in 21 countries foundthat the organism was an atypical one in 22% of cases of community acquired pneumonia where an organism was identified, which suggests that these organisms may be more common than previously thought.8 How has the aetiology of community acquired pneumonia changed? Although no evidence of major changes in the aetiology of community acquired pneumonia has been seen worldwide, new strains of previouslyidentified organisms have emerged that may, in future, have global implications. Pneumococcal vaccination In 2000, a heptavalent conjugate pneumococcus vaccine was licensed in the United States. The vaccine was recommended for all children under 2 years and some older children with “high risk” conditions. Takeup of the vaccine in the US by 2004 was around 73%.9
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Sources and selectioncriteria We searched Medline with the phrase “((community acquired pneumonia [title]) not (infant* or neonat* or child*))” and restricted the search to articles published in English in the previous two years. We identified 149 articles, the titles of which we reviewed to identify major themes. Where necessary we made additional searches based on the themes highlighted by the initial search. We then...
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