Community-acquired pneumonia (CAP) is a curable disease. Both the European and American clinical practice guidelines provide algorithms how to manage patients with CAP. However, as populations worldwide are ageing and bacteria are becoming multidrug resistant, it is necessary to address the major factors that put patients at risk of poor outcome.

These may include age, comorbidities, the settings where pneumonia was acquired or treated, the need for hospitalisation or ICU admission, likely causative pathogen (bacteria or virus) in a certain region and their local susceptibility pattern. One complicating fact is the lack of definite causative pathogen in approximately 50% of patients making it difficult to choose the most appropriate antibiotic treatment. When risk factors are present simultaneously in patients, fewer treatment options could be rather challenging for physicians. For example, the presence of comorbidities (renal, cardiac, hepatic) may exclude certain antibiotics due to potential adverse events. Assessing the severity of the disease and monitoring biomarkers, however, could help physicians to estimate patient prognosis once diagnosis is confirmed and treatment has been initiated.

This review article addresses the most important risk factors of poor outcome in CAP patients.

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Several studies have reported a positive relationship between lung function impairment and the metabolic syndrome. This is most usually explained by abdominal adiposity. We hypothesized that the main determinant of the association between lung function impairment and abdominal obesity is the presence of visceral fat.

Methods The present study is a cross-sectional analysis of 98 non-diabetic men aged between 50 and 70 years with the metabolic syndrome. The amount of visceral and subcutaneous adipose tissue was determined by an MRI scan. The association between visceral fat and measures of lung function (FEV1, FVC, exhaled and NO) was assessed using linear regression.

Results 98 participants were included in this analysis. There was a linear inverse association between visceral fat and both FEV1 and FVC. None of the other different fat-related measurements (subcutaneous fat, waist circumference and BMI) or features of the metabolic syndrome were found to be associated with these lung function measurements.

Conclusion In non-diabetic subjects with the metabolic syndrome and a lung function that is within the normal range, visceral fat is negatively correlated with FEV1 and FVC.

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Systemic glucocorticosteroids are side-effect prone but often necessary for the treatment of severe asthma (SA). Our goal was to assess the usefulness of medical history, physiological variables and biomarkers as predictors of response to oral steroids.

Methods After 4 weeks of treatment optimization, 84 patients with SA and 62 with mild-to-moderate asthma (MA) underwent a 2 week double-blind placebo-controlled oral prednisolone intervention (0.5mg/kg BW daily) (NCT00555607).

Results Responders had a lower FEV1% (73.7 vs 88.0), lower FEV1/FVC ratio (0.65 vs 0.73), lower quality of life (SGRQ score 39.1 vs 31.4), lower total sputum cell number (1.0 vs 4.5×10⁶) and higher number of sputum eosinophils (16.8% vs 6.3%) (p <0.05). For all asthmatics, the degree of improvement in FEV1 correlated with sputum eosinophils, level of asthma control, FeNO, quality of life, age of asthma onset and blood eosinophils. In SA, sputum eosinophils≥3% (OR 9.91), FEV1 ≤60% (OR 3.7), and SGRQ>42.2 (OR 3.25) were associated with a good response to oral prednisolone. The highest sensitivity and specificity to predict more than 12% increase in FEV1 in SA after oral prednisolone was found for sputum eosinophils≥3% and FeNO>45ppb.

Conclusions Sputum eosinophils and FeNO were the best predictors of favorable response to oral prednisolone in severe asthmatics. A guided approach to glucocorticosteroid treatment should be recommended as it favors better control of the disease and presumably a lower rate of adverse events. The study has been registered at the site: clinicaltrials.gov with number: NCT00555607.

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GOLD proposed a COPD assessment framework focussed on symptoms measured by the COPD Assessment Test™ (CAT) or the mMRC and on exacerbation risk based on poor lung function (FEV1 <50%) or a history of ≥2 exacerbations in the previous year. This analysis examined the characteristics of COPD patients recruited from routine clinical settings and classified using the GOLD framework.

1041 European COPD patients (38.5% from primary care) from the Adelphi Respiratory Disease Specific Programme with information on CAT, mMRC, spirometry and exacerbation history in the previous year were analysed.

Their mean age was 64.9 ± 9.9 years and mean FEV1 was 62.5 ± 17.8% predicted; 80% were in GOLD 2 spirometric grade or milder. CAT and mMRC cut points identified different groups of patients; using CAT, the composition was: Group A 9.3%, Group B 48.5%, Group C 0.7% and Group D 41.5%. 80% were classified as high risk based on exacerbation history and 25% of patients in a low risk category (GOLD A and B) had 1 exacerbation in the previous year. The incidence of diabetes, hypertension and hyperlipidaemia rose with worsening GOLD group (all p < 0.0001); diabetes GOLD A 4%, GOLD B 16%, GOLD D 29%; hypertension GOLD A 38%, GOLD B 55%, GOLD D 65%; hyperlipidaemia GOLD A 13%, GOLD B 30%, GOLD D 37%.

In patients seen in routine clinical settings, 25% of GOLD low risk patients had one exacerbation per year and the incidence of cardio-vascular and metabolic diseases increases with worsening GOLD group.

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