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  • Pneumon 2011, 24(4):361-367
    SUMMARY. Objective: Multiple international studies have shown that the adherence of chest physicians to guidelines is variable. In Greece there is lack of information on this subject. An epidemiological study was conducted to evaluate the temporal trends of the adherence to guidelines of Greek chest physicians. Retrospective assessment was made of their degree of adherence to international guidelines for the management of patients hospitalized for community acquired pneumonia (CAP) and the patient-related factors that influence this. Methods: The medical records were studied of 80 randomly selected patients admitted to the Chest Diseases Hospital of Athens in the first 6 months of 2000 with a presumptive diagnosis of CAP. Epidemiological and clinical data and information on admission criteria, diagnostic procedures and antibiotic treatment were collected from those fulfilling the diagnostic criteria for CAP. The appropriateness of the recorded procedures and treatment was evaluated in comparison to the CAP guidelines that were in use during the study period. Odds ratios (OR) for associated factors were calculated (the lower the OR value the lower the degree of adherence). Results: During the study period 67 eligible patients, with a mean age of 58.8 years, were identified. The rate of diagnostic procedures ranged from 100% for chest X-ray to 12% for blood culture. About 71% of patients had received appropriate antibiotic treatment on admission. An age of above than 70 years, altered mental status, aspiration, respiratory failure and multilobar pneumonia were found to be significant predictors of inappropriate therapy with ORs of 0.2 (95% CI: 0.1- 0.6, p=0.004), 0.04 (95% CI: 0-0.4, p=0.004), 0.04 (95% CI: 0-0.3, p=0.002), 0.3 (95% CI: 0-0.87, p=0.02), and 0.1 (95% CI:0.04-0.50, p=0.001) respectively. Aspiration was the most important factor for non-adherence on multivariate analysis adjusted for age (OR:0.05, 95% CI: 0.005-0.45, p=0.008). Conclusions: The adherence to CAP management guidelines was not grossly unsatisfactory but room for improvement was revealed. Pneumon 2011, 24(4):361-367.
     
  • Pneumon 2011, 24(4):379-391
    SUMMARY. As resistance to Streptococcus pneumoniae has escalated dramatically over the past decades, the efficacy of the three major classes of antibiotics most commonly used for the empirical treatment of community-acquired pneumonia (CAP), (i.e., β-lactams, macrolides and respiratory quinolones) is under investigation. According to recently published international data 21.8% of strains of S. pneumoniae are penicillin non-susceptible and 36.3% are resistant to azithromycin. Rates of quinolone resistance remain low, but clonal spread of resistant strains has been reported in closed communities. The precise clinical impact of antimicrobial resistance is difficult to assess, but treatment failures due to antibiotic-resistant S. pneumoniae have been documented. Comparison of the relatively small number of failures with the magnitude of confirmed resistance reveals a paradox that has not been clarified and possibly involves both pharmacokinetic and pharmacodynamic parameters. It is evident that the final outcome of CAP depends not only on the therapeutic regime but also on a variety of factors including the genetic characteristics of the bacterial strain and the background of the patient. Knowledge of the mechanisms of the emergence and spread of resistance is necessary for the rational selection of appropriate antibiotics. Current data suggest that the possibility of penicillin resistance should not be a leading factor for the choice of the therapeutic regime in CAP. In Greece, monotherapy of CAP with a macrolide poses clinical risks, while quinolones should be used with caution. In the setting of increasing resistance the administration of the appropriate antimicrobial therapy is essential for the prevention of emerging infections due to resistant S. pneumoniae strains, which apart from the increased cost of treatment may lead to an unfavourable outcome. Pneumon 2011, 24(4):379-391.
     
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  • Pneumon 2011, 24(4):394
    LETTER FROM THE EDITORIAL BOARD
     
  • Pneumon 2011, 24(4):405-416
    SUMMARY. Most forms of asthma can be controlled by inhaled corticosteroids (ICS), but a substantial number of patients still experience symptoms and limitations in their personal and social life despite being on appropriate maintenance therapy. These patients with severe asthma account for almost half of the cost of the disease and most of its morbidity and mortality. To date, the use of ICS and long acting bronchodilators (LABAs) is the basis of severe asthma treatment, but the optimal use and dosage of these drugs should be determined based on the available evidence. Anti-immunoglobulin E (anti-IgE) has been recently established for the treatment of patients with severe allergic asthma whose symptoms are inadequately controlled with ICS/LABA. The use of long-acting anticholinergics (LAMA) as add-on therapy is currently under investigation in clinical trials. Alternative forms of treatment, such as macrolide therapy, have produced conflicting results, while an approach based on anti-tumour necrosis factor-α (anti-TNFα) has proven ineffective. The targeted inhibition of interleukin (IL) 2, IL 4, IL 5, IL-9 and IL 13 is currently being investigated. A nondrug treatment, bronchial thermoplasty (BT), has been reported to provide some benefits to patients with severe asthma, but the long-term benefit/risk ratio for BT is unknown at present. In view of the heterogeneity of severe asthma, the present challenge is to determine the appropriate phenotype for current and innovative forms of treatment. Pneumon 2011, 24(4):405-416.
     
  • Pneumon 2011, 24(4):430-444
    SUMMARY. Many non invasive measurements are available that can help in the diagnosis, assessment and treatment of severe asthma. The fraction of exhaled nitric oxide (FeNO) helps in identification of severe asthma phenotypes, assessment of asthma control and detection of types of asthma that will benefit from treatment with corticosteroids or that will need tailored therapy with new drugs. Induced sputum examination is used mainly for distinguishing between the eosinophilic and other phenotypes, and for the monitoring of treatment. High resolution computed tomography (HRCT) of the chest helps to confirm the diagnosis of severe asthma and to detect underlying diseases, and is useful for monitoring airways remodelling. Questionnaires are used in the assessment of asthma control. Other methods, such as the electronic nose (e-nose) and exhaled breath condensate show promise of being useful. These non-invasive methods are very important in the assessment and management of severe asthma, taking into account that although asthma is generally a benign disease, severe asthma is very difficult to treat and requires constant monitoring. Invasive methods have limited utility for severe asthma monitoring since they are not suitable for repeated sampling. Pneumon 2011, 24(4):430-444.
     
  • Pneumon 2011, 24(4):453-460
    SUMMARY. The correct diagnosis of asthma is usually made easily and most patients respond to treatment. Approximately 5 to 10% of patients, however, have severe refractory asthma that continues to be poorly controlled despite maximal inhaled therapy. Severe asthma is not a single disease, but a collection of different phenotypes, the identification of which is crucial since this can lead to better disease management and optimal response to appropriate treatment. Additionally, specific diagnostic problems characterize asthma in the elderly and obscure the differentiation of asthma from chronic obstructive pulmonary disease (COPD). In elderly patients with longterm asthma, reversibility of airway obstruction is diminished, and a disease pattern similar to that of COPD may develop. In addition, smoking and ageing both increase bronchial hyperresponsiveness (BHR) and neutrophil numbers, resulting in asthma with a COPD phenotype. On the other hand, a subgroup of patients with COPD shows reversibility of airway obstruction associated with increased exhaled nitric oxide (NO) and sputum eosinophilia. COPD is often accompanied by BHR, and both smoking and ageing appear to be risk factors for increasing BHR, while smoking cessation improves BHR, both in patients with asthma and those with COPD. Rigid diagnostic criteria, using a combination of tests of lung function, BHR and atopy status, high resolution computed tomography (HRCT) chest scan and the newly developed biological techniques for the assessment of biomarker profiles, can facilitate the correct diagnosis and the distinction between the severe asthma phenotypes. Pneumon 2011, 24(4):453-460.
     
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