CHEST Original Research

COMMUNITY-ACQUIRED PNEUMONIA

Severity of Pneumococcal Pneumonia

Associated With Genomic Bacterial
Load
Jordi Rello, MD, PhD; Thiago Lisboa, MD; Manel Lujan, MD;
Miguel Gallego, MD; Cordelia Kee, PhD; Ian Kay, BSc, MBSc;
Diego Lopez, MD; and Grant W. Waterer, MBBS, PhD, FCCP; for the
DNA-Neumococo Study Group*

Background: There is a clinical need for more objective methods of identifying patients at risk for
septic shock and poorer outcomes among those with community-acquired pneumonia (CAP). As
viral load is useful in viral infections, we hypothesized that bacterial load may be associated with
outcomes in patients with pneumococcal pneumonia.
Methods: Quantification of Streptococcus pneumoniae DNA level by real-time polymerase chain
reaction (rt-PCR) was prospectively conducted on whole-blood samples from a cohort of 353
patients who were displaying CAP symptoms upon their admission to the ED.
Results: CAP caused by S pneumoniae was documented in 93 patients (36.5% with positive blood
culture findings). A positive S pneumoniae rt-PCR assay finding was associated with a statistically
significant higher mortality (odds ratio [OR], 7.08), risk for shock (OR, 6.29), and the need for
mechanical ventilation (MV) [OR, 7.96]. Logistic regression, adjusted for age, sex, comorbidities,
and pneumonia severity index class, revealed bacterial load as independently associated with
septic shock (adjusted odds ratio [aOR], 2.42; 95% CI, 1.10 to 5.80) and the need for MV (aOR,
2.71; 95% CI, 1.17 to 6.27). An S pneumoniae bacterial load of > 103 copies per milliliter occurred
in 29.0% of patients (27 of 93 patients; 95% CI, 20.8 to 38.9%) being associated with a statistically
significant higher risk for septic shock (OR, 8.00), the need for MV (OR, 10.50), and hospital
mortality (OR, 5.43).
Conclusion: In patients with pneumococcal pneumonia, bacterial load is associated with the
likelihood of death, the risk of septic shock, and the need for MV. High genomic bacterial load
for S pneumoniae may be a useful tool for severity assessment.
(CHEST 2009; 136:832 840)
Abbreviations: AKI acute kidney injury; AUROC area under the receiver operating characteristic curve;
CAP community-acquired pneumonia; IQR interquartile range; lytA autolysin-A; MV mechanical ventilation;
OR odds ratio; PCR polymerase chain reaction; PSI pneumonia severity index; rt-PCR real-time PCR

S treptococcus pneumoniae is the leading cause of

community-acquired pneumonia (CAP) world-
wide.1,2 Currently available microbiological tests (eg,
sputum and blood cultures) have limited clinical utility
due to both low sensitivity and the delay for culture
results to be available.3 6 Although urinary antigen
testing for S pneumoniae is quicker, this test has
significant limitations including a significant rate of
false-positive results.7,8 Non-culture-based diagnostic
polymerase chain reaction (PCR) techniques allowed
the accurate and rapid quantification of bacterial load
(consisting of both viable and nonviable bacteria).9
The major challenges associated with CAP include
identifying patients at risk of septic shock and death,
and identifying those patients who could benefit
more from intensive care or adjuvant therapy. Pa-
tients are commonly stratified into risk groups by
using scoring systems (eg, pneumonia severity index
[PSI])10 or confusion, urea 7 mmol/L, respiratory
rate 30 breaths/min, BP 90 mm Hg systolic or
60 mm Hg diastolic, age 65 years (or CURB-
65)11 scores. While these scoring systems perform
reasonably well when studied in large cohorts, they
should not be used for clinical decisions at an

832 Original Research

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2009 American College of Chest Physicians
individual patient level. Currently, no microbiologi-
cal information is helpful for severity assessment.
ICU admission decisions are still based mainly on
the clinical judgment of attending physicians and are
exposed to important variability. The American Tho-
racic Society/Infectious Diseases Society of America
guidelines1 suggest the following two major criteria
for ICU admission: septic shock and the need of
mechanical ventilation (MV). Liapikou et al12 re-
ported that invasive MV was the main determinant
for ICU admission, followed by septic shock. In the
absence of these two major criteria, ICU admission
was not related to survival. Identifying patients at
higher risk for septic shock and the need for invasive
MV could be a useful surrogate for ICU admission.13
Although diagnosis may benefit from quantitative
real-time PCR (rt-PCR) for S pneumoniae in whole-
blood samples,14,15 the relationship between pneu-
mococcal bacterial load and clinical outcomes has
not been investigated. In this study, we analyzed the
quantitative bacterial load of S pneumoniae in a
cohort of patients admitted to the hospital with CAP.
These data were correlated with clinical data and
outcomes of disease to determine the following:
(1) the relationship between bacterial load and the
development of septic shock, and the need for MV;
and (2) whether mortality and secondary outcomes,
such as acute kidney injury (AKI) and ARDS, were
associated with higher bacterial loads.
Manuscript received January 31, 2009; revision accepted March
24, 2009.
Affiliations: From the Critical Care Department (Drs. Rello and
Lisboa), Hospital Universitari Joan XXIII, Tarragona, Spain;
University Rovira i Virgili (Drs. Rello and Lisboa), IISPV,
Tarragona, Spain; Centro de Investigacon Biomedica en Red
Enfermedades Respiratorias (CIBERes) [Drs. Rello, Lisboa,
Lujan, Gallego, and Lopez], Tarragona, Spain; Hospital de
Sabadell (Drs. Lujan and Gallego), Sabadell, Spain; School of
Medicine and Pharmacology (Drs. Kee and Waterer), University
of Western Australia, Perth, WA, Australia; the Department of
Microbiology and Infectious Diseases (Mr. Kay), Royal Perth
Hospital, Perth, WA, Australia; and Fundacion Jimenez Diaz
(Dr. Lopez), Madrid, Spain.
*A complete list of members of the DNA-Neumococo Study
Group is located in the Appendix.
Presented in part at the 2008 American Thoracic Society Con-
ference, Toronto, ON, Canada.
Funding/Support: This study was funded by FIS 04/1500,
Fondo de Investigaciones Sanitarias, CIBER Enfermedades Res-
piratorias (CIBERes 06/06/0036), and AGAUR (2005/SGR/920).
Dr. Waterer is supported by the National Health and Medical
Research Council of Australia.
2009 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians (www.chestjournal.org/site/
misc/reprints.xhtml).
Correspondence to: Jordi Rello, MD, PhD, Critical Care Depart-
ment, Joan XXIII University Hospital, Carrer Dr. Mallafre Guasch
4, 43007 Tarragona, Spain; e-mail: jrello.hj23.ics@gencat.cat
DOI: 10.1378/chest.09-0258
www.chestjournal.org
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2009 American College of Chest Physicians
Materials and Methods
Study Design
This was a prospective study of adult patients hospitalized with
CAP. Data and blood samples were collected in the ED. Data
were entered into an electronic database for analysis. Patients
were observed for the development of the predefined end points
of septic shock development and the need for MV from the time
they were admitted to the ED until they were discharged from
the hospital. Secondary outcomes were the development of AKI
and ARDS, and in-hospital mortality.
Study Population
Adult patients admitted to the ED with a diagnosis of CAP
were included in the study. CAP was defined as the presence of
a new pulmonary infiltrate on the chest radiograph at the time of
hospitalization, plus either a new or increased cough with or
without sputum production, or an abnormal temperature
( 35.6C or 37.8C), or an abnormal serum leukocyte count
(ie, leukocytosis, left shift, or leukopenia) as defined by local
laboratory standards. Two sets of blood cultures and 4 mL of an
ethylenediaminetetraacetic acid-treated blood sample for rt-PCR
were obtained in the ED at the time the patients were hospital-
ized, before starting antibiotic treatment. Patients receiving
outpatient antimicrobial therapy prior to admission to the hospi-
tal were not included in the study. The study was approved by the
Joan XXIII University hospital ethics board, and all patients or
next of kin signed an informed consent.
Study Variables
The variables considered in each patient included in the study
were as follows: demographics (ie, age and sex); underlying
comorbidities (ie, chronic heart disease, neoplasia, liver disease,
diabetes mellitus, COPD, HIV infection, alcoholism, cortico-
therapy, and obesity); results of laboratory cultures (ie, blood
culture, respiratory sample culture, and urinary antigen); severity
of CAP (ie, risk class according to the PSI, the need for MV, the
development of septic shock, AKI, and ARDS); and in-hospital
mortality.
Definitions
A diagnosis of CAP due to S pneumoniae was considered to be
definite when this microorganism was isolated from an uncon-
taminated sample (pleural fluid or blood culture) or significant
growth in a respiratory fluid sample obtained by endotracheal
aspiration ( 105 colony-forming units per milliliter) or BAL
( 104 colony-forming units per milliliter). It was considered to
be probable when a positive sputum sample culture, positive
urinary antigen test, or positive rt-PCR findings were obtained.
Underlying comorbidity was defined as the presence of one of
the following chronic conditions: immuncompromise, defined as
primary immunodeficiency or immunodeficiency secondary to
splenectomy, hematologic malignancy, autoimmune disorder,
radiation treatment, use of cytotoxic drugs, or cancer chemother-
apy within 4 weeks before the episode; chronic heart disease,
which was considered in patients admitted to the hospital with
New York Heart Association class III and IV symptoms of heart
failure; liver disease, which was considered in patients with
documented biopsy-proven cirrhosis, documented portal hyper-
tension, episodes of past upper GI bleeding attributed to portal
hypertension, or previous episodes of hepatic encephalopathy;
corticosteroid therapy, which was defined as using daily doses of
CHEST / 136 / 3 / SEPTEMBER, 2009 833
 20 mg of prednisolone (or equivalent) for 2 weeks; COPD,
which was defined as a disease state characterized by the
presence of airflow limitation due to chronic bronchitis or
emphysema; obesity, which was considered in patients with a
body mass index 30 kg/m2; septic shock, which was defined as
systolic BP 90 mm Hg despite fluid resuscitation of 20 mL/kg
and the need for vasopressor agents; ARDS, which was diagnosed
according to the criteria of the American-European Consensus
Conference Committee16; and AKI, which was defined as an
urine output of 20 mL/h or a total urine output of 80 mL in
4 h. Rapid radiologic spread was defined by an increase in the
size of the opacities by 50% at 48 h after presentation. Blood
cultures were processed using a standard system (Versa TREK
Instrument System 220/240; TREK Diagnostic Systems; Cleve-
land, OH). Bacterial identification and susceptibility testing were
performed using standard methods.
Quantification of the Pneumococcal Load
Quantification of the S pneumoniae bacterial load was per-
formed in frozen samples at the University of Western Australia
laboratory (Perth, WA, Australia), as previously described else-
where.14,15 The assay targets the autolysin-A (lytA) gene, which
has been shown to be specific for S pneumoniae, and provides an
accurate reproducibility of 95% in whole blood samples if the
bacterial load is more than eight copies per milliliter.15 Because
lytA is a single-copy gene, the number of copies measured is
equivalent to the bacterial load number.
Statistical Analysis
Statistical analysis was performed using statistical software
package (SPSS, version 11.0 for Windows; SPSS, Inc; Chicago,
IL). Categorical data were analyzed by using the 2 test or Fisher
exact test and were described as proportions. Continuous vari-
ables were compared by using the t test or the Mann-Whitney U
test and were described as the mean (SD) or median (interquar-
tile range [IQR]) according to the presence of normal distribu-
tion. The number of copies of the lytA gene (and therefore the
quantity of S pneumoniae DNA in copies per milliliter) was
analyzed after logarithmic transformation. The area under the
receiver operating characteristic curve (AUROC) was considered
to be an index of discrimination. Logistic regression models were
used to identify factors associated with the primary outcomes.
Potential risk factors included age, sex, the presence of comor-
bidities, the severity of pneumonia episode (PSI class), and
bacterial load measurements. The results are expressed as odds
ratios (ORs) with 95% CIs. Statistical significance was defined as
a two-tailed p value 0.05.
Results
Study Population
A total of 353 white patients with CAP were
included in the study, of whom 93 were documented
as a having a diagnosis of definite CAP (n 44) or
probable CAP (n 49) caused by S pneumoniae,
and 260 patients had no evidence of S pneumoniae
and a negative rt-PCR result. A description of the
techniques used to detect S pneumoniae is shown in
Table A1 (in the online supplemental material).
Clinical characteristics of the 260 patients with neg-
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2009 American College of Chest Physicians
ative bacterial load and no evidence of S pneumoniae
are described in Table A2 (in the online supplemen-
tal material). Further analysis is restricted to 93
patients with documented pneumococcal CAP.
Among the 93 pneumococcal CAP patients, the
mean ( SD) age was 63.0 18.6 years. Comorbidi-
ties were present in 86.0% of patients, and the most
frequent were tobacco use, heart disease, diabetes
mellitus, and COPD. The baseline characteristics of
these patients are detailed in Table 1. There were no
patients presenting with splenectomy, functional
asplenia, or hypogammaglobulinemia.
Qualitative rt-PCR Analysis
No difference was found in the clinical character-
istics or the prevalence of comorbidities between
patients with positive and negative bacterial loads
(Table 1). Patients with positive rt-PCR results were
more likely to have positive blood culture findings
(OR, 5.87; 95% CI, 1.90 to 17.91). The documenta-
tion of bacterial load was associated with AKI (OR,
4.40; 95% CI, 1.42 to 13.50), septic shock devel-
opment (OR, 6.29; 95% CI, 1.49 to 26.06), the
need for MV (OR, 7.96; 95% CI, 1.24 to 49.66),
and higher in-hospital mortality (OR, 7.08; 95%
CI, 1.10 to 44.45).
The S pneumoniae rt-PCR assay was compared
with blood cultures (Table A3 in the online supple-
mental material). rt-PCR detected S pneumoniae
DNA in 85.3% of patients with positive blood culture
findings, whereas blood culture findings were posi-
tive in only 50% of the patients with detectable
S pneumoniae DNA. All of the five patients with a
positive blood culture but no DNA detectable by
using rt-PCR survived and did not have nonfatal
complications of sepsis (ie, septic shock or the need
for MV). In all patients with a positive S pneumoniae
rt-PCR assay result but no other test positive for
S pneumoniae, no other pathogen was detected on
sputum or blood cultures.
Bacterial Genomic Load and Clinical Outcomes
In patients with documented bacterial load, the
number of copies of S pneumoniae DNA per milli-
liter in whole blood samples (or S pneumoniae
bacterial load) was significantly associated with
worse clinical outcomes. S pneumoniae bacterial load
ranged from 10 to 1,474,000 copies per milliliter
(median, 1,075 copies per milliliter; IQR, 25 to 75%
or 410 to 10,715 copies per milliliter). The distribu-
tion of patients according to the logarithm of the
number of copies of S pneumoniae DNA is shown in
Table 2. Median S pneumoniae bacterial load values
were significantly higher in patients in whom septic
shock developed (13,520 copies per milliliter [IQR,
Original Research
 Table 1Clinical Characteristics of 93 Patients With Pneumococcal Pneumonia According to PCR Results
Overall PCR-Positive Results PCR-Negative Results
Variables (n 93) (n 58) (n 35) p Value

Baseline characteristics
Age, yr* 66.0 (45.077.0) 64.0 (44.076.0) 69.0 (45.081.0) 0.26
Age 50 yr 26 (27.9) 17 (29.3) 9 (25.7) 0.89
Male sex 66 (71.0) 45 (77.6) 21 (60.0) 0.09
PSI class I 9 (9.7) 5 (8.6) 4 (11.4) 0.72
PSI class II 13 (14.0) 7 (12.1) 6 (17.1) 0.54
PSI class III 14 (15.1) 6 (10.3) 8 (22.8) 0.18
PSI class IV 45 (48.4) 28 (48.3) 17 (48.6) 0.85
PSI class V 12 (12.9) 12 (20.7) 0 0.003
Presence of comorbidity 80 (86.0) 49 (84.5) 31 (88.6) 0.76
Alcohol 14 (15.1) 8 (13.8) 6 (17.1) 0.77
Tobacco smoking 32 (34.4) 21 (36.2) 11 (31.4) 0.66
Diabetes mellitus 21 (22.6) 13 (22.4) 8 (22.9) 0.99
Obesity 7 (7.5) 3 (5.2) 4 (11.4) 0.42
Liver disease 8 (8.6) 5 (8.6) 3 (8.6) 0.99
Heart disease 23 (24.7) 15 (25.9) 8 (22.9) 0.81
Neurologic condition 9 (9.7) 5 (8.6) 4 (11.4) 0.72
Cancer 8 (8.6) 5 (8.6) 3 (8.6) 0.99
HIV 6 (6.5) 3 (5.2) 3 (8.6) 0.67
Corticosteroid therapy 6 (6.5) 4 (6.9) 2 (5.7) 0.99
COPD 20 (21.5) 13 (22.4) 7 (20.0) 0.99
Clinical outcomes
Rapid RX spread 8 (8.6) 8 (13.8) 0 0.02
Bacteremia 34 (36.6) 29 (50.0) 5 (14.3) 0.001
AKI 25 (26.9) 21 (36.2) 4 (11.4) 0.01
ARDS 6 (6.5) 5 (8.6) 1 (2.9) 0.40
Septic shock 18 (19.4) 16 (27.6) 2 (5.7) 0.01
Need for MV 12 (12.9) 11 (19.0) 1 (2.9) 0.02
Mortality 11 (11.8) 10 (17.2) 1 (2.9) 0.048
Data are presented as No. (%) unless otherwise stated. RX radiologic.
*Values are given as the median (IQR).

25 to 75%/1,093 to 30,500 copies per milliliter] vs
690 copies per milliliter [IQR, 25 to 75%/366 to
6,550 copies/mL], respectively; p 0.05).
Effect of Bacterial Load on Septic Shock and the
Need for MV
Figure 1 shows the predicted probability of septic
shock, and Figure 2 shows the predicted probability
of the need for MV as a function of S pneumoniae
bacterial load. Each log increase in the bacterial load
was associated with an increase of 2.5 times in the
probability of septic shock and a two times higher
risk for needing MV.
Table 2Distribution of S pneumoniae Bacterial Loads in
Patients With S pneumoniae CAP as Detected by rt-PCR
Logarithm Scale
2.00
2.002.99
3.003.99
4.004.99
5.00
A logistic regression model adjusted for age, sex,
the presence of comorbidities, and severity index
(PSI class I to III or IV to V) identified that the
S pneumoniae bacterial load was independently as-
sociated with septic shock (adjusted OR, 2.42; 95%
CI, 1.10 to 5.80; [Hosmer-Lemeshow goodness of fit
p value 0.43]) and the need for MV (adjusted OR,
2.71; 95% CI, 1.17 to 6.27; [Hosmer-Lemeshow
goodness of fit p value 0.25]).
Discrimination Assessment: AUROC Analysis
The discriminative ability of bacterial load to
assess clinical outcomes in patients with pneumococ-
cal pneumonia was evaluated with AUROC analysis.
rt-PCR performance was acceptable for septic shock
(AUROC, 0.79; 95% CI, 0.67 to 0.92; p 0.05) and
the need for MV (AUROC, 0.77; 95% CI, 0.64 to
No. (%) 0.91; p 0.05).
44 (47.3) Effect of Bacterial Load on Clinical Outcomes
22 (23.6)
13 (14.0) High S pneumoniae bacterial load, using a break-
12 (12.9) point of 103 copies per milliliter, was associated
2 (2.2)
with a specificity of around 80% for septic shock

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2009 American College of Chest Physicians
 Figure 1. Predicted probability of septic shock as a function of S pneumoniae bacterial load detected
by quantitative rt-PCR.
development and the need for MV. Sensitivities and
specificities for septic shock and the need for MV for
different breakpoints of S pneumoniae bacterial load
are also detailed in Table A4 (in the online supple-
mental material). When comparing patients with a
high S pneumoniae bacterial load ( 103 copies per
milliliter) and low S pneumoniae bacterial load
( 103 copies per milliliter or undetectable) [Table
A5 in the online supplemental material, Table 3 in
the article, a significant difference was found in
relevant clinical outcomes such as bacteremia (OR,
6.25; 95% CI, 2.38 to 16.40), rapid radiologic spread
(OR, 22.75; 95% CI, 3.36 to 148.37), AKI (OR, 7.00;
95% CI, 2.57 to 19.07), ARDS (OR, 14.77; 95% CI,
2.12 to 99.49), the need for MV (OR, 10.50; 95% CI,
2.74 to 39.63), and septic shock (OR, 8.00; 95%
CI, 2.65 to 24.12) [Fig 3]. The documentation of a
bacterial load 1,000 copies per milliliter was asso-
ciated with a higher risk for hospital mortality (OR,
5.43; 95% CI, 1.52 to 19.24) [Fig 4].
Discussion
This study confirms the association between a high
quantitative bacterial genomic load of S pneumoniae
in blood samples and increased mortality. It also
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2009 American College of Chest Physicians
reveals an association between bacterial load and the
development of septic shock or the need for MV.
The implication of these findings is that a sample
obtained for bacterial load measurement will provide
valuable prognostic information. Our observations
also reveal some insight into the mechanisms that
underlie the risk factors associated with death and
shock in patients with pneumococcal pneumonia.
Our data demonstrate that patients with CAP with
103 copies per milliliter S pneumoniae DNA in
their blood at the time of ED presentation are an
easily and specifically defined high-risk group for
septic shock, the need for MV,12,13 and death. More-
over, the detection of bacterial load is nearly twice as
sensitive as blood cultures for the detection of
pneumococcal bacteremia. This new assay has the
potential to greatly increase our ability to accurately
stratify the severity of pneumonia in patients in the
ED, and may be of interest for the stratification of
patients enrolling in clinical trials for adjuvant ther-
apies, as well as increasing our understanding of the
biology of sepsis.
This study documents that a S pneumoniae quan-
titative rt-PCR assay of whole blood exceeds the
sensitivity of blood cultures.17 With improved DNA
extraction techniques and other assay refinements,
Original Research
 Figure 2. Predicted probability of the need for MV as a function of S pneumoniae bacterial load
detected by quantitative rt-PCR.
the assay used in this study compared very favorably
with blood cultures. In addition, the quantitative
rt-PCR assay can deliver a result within a few hours
(4 to 6 h), unlike blood cultures, with the potential to
have an impact on the critical phase of early clinical
care.
While the rt-PCR assay did not detect S pneu-
moniae DNA in five patients with positive blood
culture findings, all of these patients had a very
benign clinical course. It is quite possible that these
patients had very low levels of bacteremia, beyond
the current sensitivity of the rt-PCR assay but de-
tectable after several days of growth in cultures.
Further refinements in DNA extraction and in the
rt-PCR assay may further improve the sensitivity of
this test. A further advantage of the lytA assay is that,
unlike urinary antigen tests, positive results have not
been seen in healthy control subjects.7,8,18
The strong correlation we observed between clin-
ical outcomes and S pneumoniae bacterial load might
modify the current paradigm of management for
patients with pneumococcal CAP. Invasive pneumo-
coccal disease is associated with a high mortality
despite antimicrobial therapy,19 and our findings are
consistent with those of a smaller study20 in children
with invasive pneumococcal disease. Currently, hos-
pital admission and site-of-care decisions are largely
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2009 American College of Chest Physicians
based on scoring systems that assign weights to
different predictive variables such as age, sex, comor-
bid diseases, and features of physiologic compro-
mise. While these predictive scoring systems per-
form relatively well in large cohorts, at an individual
patient level they are only crude predictors of out-
come. Adding bacterial load to the predictive algo-
rithms may allow a much more accurate determina-
tion of clinical outcome in individual patients.
ICU admission criteria are quite variable in differ-
ent institutions and depend largely on the availability
of resources. There is no gold standard with which
to decide the need for ICU admission. Despite the
use of severity scores, ICU admission decisions are
still based mainly on the clinical judgment of attend-
ing physicians. In 2007, Valencia et al21 reported that
most patients with CAP who were in PSI class V
were treated on a hospital ward. In that study,21 69%
of the patients admitted to the ICU required intu-
bation and MV, and/or presented with shock. Bacte-
rial load identified patients who were at higher risk
for septic shock and the need for MV, the major
criteria for ICU admission of the American Thoracic
Society/Infectious Diseases Society of America
guidelines,1 as separate outcomes. Bacterial load
could be useful as a stratification tool for identifying
patients at higher risk for ICU admission.
CHEST / 136 / 3 / SEPTEMBER, 2009 837
 Table 3Characteristics of Patients With
Pneumococcal Pneumonia According to Quantitative
S pneumoniae rt-PCR Results

103 copies/mL 103 copies/mL

Variables (n 66) (n 27) p Value

Age 50 yr 19 (28.8) 7 (25.9) 0.99

Male sex 45 (68.2) 21 (77.8) 0.45
PSI class IIII 30 (45.5) 6 (22.2) 0.06
PSI class IVV 36 (54.5) 21 (77.8)
Presence of 57 (86.4) 23 (85.2) 0.99
comorbidity
Alcohol 9 (13.6) 5 (18.5) 0.54
Tobacco 23 (34.8) 9 (33.3) 0.99
Diabetes mellitus 15 (22.7) 6 (22.2) 0.99
Obesity 5 (7.6) 2 (7.4) 0.99
Liver disease 4 (6.1) 4 (14.8) 0.22
Heart disease 15 (22.7) 8 (29.6) 0.60
Neurologic 5 (7.6) 4 (14.8) 0.44
condition Figure 3. Septic shock development according to quantitative
Cancer 6 (9.1) 2 (7.4) 0.99 rt-PCR results in patients with pneumococcal pneumonia.
HIV 5 (7.6) 1 (3.7) 0.67
Corticosteroid 3 (4.5) 3 (11.1) 0.35
therapy
COPD 14 (21.2) 6 (22.2) 0.99 large proportion of patients with CAP with negative
Clinical culture findings actually have S pneumoniae. An-
outcomes other potential limitation is the absence of informa-
Rapid RX 1 (1.5) 7 (25.9) 0.001
tion regarding the time elapsed from the onset of
spread
Bacteremia 16 (24.2) 18 (66.6) 0.001 infection to diagnosis. Although samples were trans-
AKI 10 (15.1) 15 (55.5) 0.001 ported to a central laboratory, it is unlikely that the
ARDS 1 (1.5) 5 (18.5) 0.007 transport caused significant DNA degradation. Pre-
Septic shock 6 (9.1) 12 (44.4) 0.001 vious studies have reported a relatively long persis-
Need for MV 3 (4.5) 9 (33.3) 0.001
tence of DNA in ethylenediaminetetraacetic acid-
Mortality 4 (6.1) 7 (25.9) 0.012
treated whole-blood samples. Moreover, studies with
Data are presented as No. (%), unless otherwise stated. See Table 1
meningococcal disease24,25 have documented that
for abbreviation not used in the text.
bacterial load measurements are unaffected by the
delay in sample submission or by the administration
of antibiotics before hospital admission. The impli-
Aside from the significant implications for therapy in cation of these findings is that a sample obtained for
patients with pneumococcal CAP, our findings open up bacterial load measurement will provide valuable
new insights into the biology of sepsis. The prevailing prognostic information.
sepsis paradigm suggests that the primary driver is an In conclusion, the intensity of bacteremia in pa-
excessive host inflammatory response to bacterial tients with pneumococcal pneumonia is associated
pathogens.22 Our data demonstrate that, at least in
patients with pneumococcal pneumonia, a major deter-
mining factor for shock and organ failures was bacterial
load in the bloodstream. The correlation of bacterial
load, with age, proinflammatory genotypes, and specific
serotypes should be evaluated in further studies.
Our study has some limitations. While the number
of patients is relatively large for pneumonia cohort
studies, the total number of important outcomes (eg,
shock) is not large. Wide CIs are due to the small
sample size. Another limitation is that this assay is
valid only for pneumococcal pneumonia. In addition,
this assay cannot be used to exclude S pneumoniae,
because negative results may occur with pneumococ-
cal disease with a low degree of systemic invasion.
However, S pneumoniae is the major pathogen in Figure 4. Mortality according to quantitative rt-PCR results in
CAP,1,2 and prior reports23 have suggested that a patients with pneumococcal pneumonia.

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2009 American College of Chest Physicians
with poor outcome. In addition, this assay has a
greater sensitivity than the current methods used to
identify S pneumoniae in patients with CAP who
have been admitted to the ED. In patients with
pneumococcal pneumonia, high bacterial load has
the potential to be an early and objective marker of
prognosis to identify candidates for ICU admission
or adjuvant therapy in randomized clinical trials.
Acknowledgments
Author contributions: Drs. Rello and Lisboa were responsible
for analysis of data and writing the first draft of the article; all
remaining authors contributed scientifically to the final ver-
sion of the article. Drs. Rello, Gallego, Lujan, Lopez, and
Lisboa enrolled patients, recorded variables, conducted the
follow-up, and collected samples. Drs. Waterer and Kee, and Mr.
Kay were responsible for performing the quantitative reverse
transcription PCR assay.
Financial/nonfinancial disclosures: The authors have re-
ported to the ACCP that no significant conflicts of interest exist
with any companies/organizations whose products or services
may be discussed in this article.
Appendix
The DNA-Neumococo Study Group
Jordi Rello, Thiago Lisboa, Frederic Gomez, Guillermo
Canardo, Monica Magret, and Alejandro Rodriguez (Microbi-
ology, Critical Care and Emergency Departments, Hospital
Universitari Joan XXIII, Tarragona, Spain); Miguel Gallego,
Manel Lujan, Dionisia Fontanals, and Dolors Mariscal (Pneu-
mology and Microbiology Departments, Corporacio Parc Tauli,
Sabadell, Spain); Grant Waterer and Cordelia Kee (School of
Medicine and Pharmacology, University of Western Australia,
Perth, Australia); Todd M. Pryce, Silvano Palladino, Ian Kay, and
Ronan Murray (Department of Microbiology and Infectious
Diseases, Royal Perth Hospital, Perth, Australia); Diego Lopez
(Critical Care Department, Fundacion Jimenez Diaz, Madrid,
Spain); Diego Guerrero (Emergency Department, Hospital Dr
Negrin, Las Palmas de Gran Canarias, Spain); Jose Valles and
Rosario Menendez (Respiratory Department Hospital La Fe,
Valencia, Spain).
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