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A review article published in 2011 [ 7] showed that many studies supporting initial dual therapy in the most severe CAP requiring hospital admission were often retrospective, used a broad range of antibiotic regimens with some leading to conflicting results.
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The most severe: cow's milk.
We suspect that only the most severe cases of CAP caused by PVL-secreting MSSA are reported and that many cases are not detected, making it difficult to describe the full spectrum of clinical illness and to form meaningful conclusions based on the case reports.
Dual therapy might be expected to improve outcomes of patients with the most severe forms of CAP.
In this setting, Salluh et al.[ 24]reported that most patients with severe CAP admitted to the ICU had adrenal insufficiency caused by a disregulation of the hypothalamic-pituitaryadrenal axis.
The survival benefit was most pronounced in severe CAP patients with Streptococcus pneumoniae infection and in CAP patients at high risk for death, as indicated by an APACHE II score above 25, Pneumonia Severity Index score above 4, or CURB-65 score above 3.
What are the most relevant criteria for severe CAP? Basically, there are two possibilities: admission to ICU or respiratory/circulatory support requirement [ 1].
The most frequent etiologies in severe CAP in the present cohort were Staphylococcus aureus followed by Legionella pneumophila and Haemophilus influenzae.
The most prevalent pathogen associated with severe CAP, namely S. pneumoniae, is responsible for two-thirds of CAP-related deaths.
Furthermore, it appears that patients in whom a tifacogin benefit is most likely are those with severe CAP with a documented infection.
Pneumonia is the most common cause of severe sepsis, and severe CAP should be seized in the overall context of sepsis from pulmonary infection with organ dysfunction(s) potentially requiring intensive care [ 5, 21].
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