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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Clinical presentations and outcome of severe community-acquired pneumonia</title><author><name sortKey="Elshamly, Mousa" sort="Elshamly, Mousa" uniqKey="Elshamly M" first="Mousa" last="Elshamly">Mousa Elshamly</name><affiliation><nlm:aff id="af005">Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Egypt</nlm:aff></affiliation></author><author><name sortKey="Nour, Mohamed O" sort="Nour, Mohamed O" uniqKey="Nour M" first="Mohamed O." last="Nour">Mohamed O. Nour</name><affiliation><nlm:aff id="af010">Department of Community & Occupational Medicine, Faculty of Medicine, Al-Azhar University (Damietta Branch), Egypt</nlm:aff></affiliation></author><author><name sortKey="Omar, Abdelmaaboud M M" sort="Omar, Abdelmaaboud M M" uniqKey="Omar A" first="Abdelmaaboud M. M." last="Omar">Abdelmaaboud M. M. Omar</name><affiliation><nlm:aff id="af015">Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University, Egypt</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmc">7125902</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7125902</idno><idno type="RBID">PMC:7125902</idno><idno type="doi">10.1016/j.ejcdt.2016.06.002</idno><idno type="pmid">NONE</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000C11</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000C11</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Clinical presentations and outcome of severe community-acquired pneumonia</title><author><name sortKey="Elshamly, Mousa" sort="Elshamly, Mousa" uniqKey="Elshamly M" first="Mousa" last="Elshamly">Mousa Elshamly</name><affiliation><nlm:aff id="af005">Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Egypt</nlm:aff></affiliation></author><author><name sortKey="Nour, Mohamed O" sort="Nour, Mohamed O" uniqKey="Nour M" first="Mohamed O." last="Nour">Mohamed O. Nour</name><affiliation><nlm:aff id="af010">Department of Community & Occupational Medicine, Faculty of Medicine, Al-Azhar University (Damietta Branch), Egypt</nlm:aff></affiliation></author><author><name sortKey="Omar, Abdelmaaboud M M" sort="Omar, Abdelmaaboud M M" uniqKey="Omar A" first="Abdelmaaboud M. M." last="Omar">Abdelmaaboud M. M. Omar</name><affiliation><nlm:aff id="af015">Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University, Egypt</nlm:aff></affiliation></author></analytic><series><title level="j">The Egyptian Journal of Chest Diseases and Tuberculosis</title><idno type="ISSN">0422-7638</idno><idno type="eISSN">2090-9950</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Severe community-acquired pneumonia (SCAP) represents a frequent and potentially life-threatening condition. About 10% of all hospitalized patients with CAP require admission to the intensive care unit (ICU), and the mortality of these patients reaches 20–50%.</p></sec><sec><title>Objective</title><p>To evaluate the clinical presentation, bacteriological profile and outcome of severe community-acquired pneumonia (SCAP).</p></sec><sec><title>Patients and methods</title><p>54 patients presented by symptoms and sign of severe community acquired pneumonia who were admitted to respiratory care unit of Alhussein, Al-Azhar University Hospital from August 2015 to March 2016 were subjected to full clinical examination, chest X ray, complete blood picture, sputum and blood culture, PCR for suspected cases of Influenza H1N1 and MERS-COV, treatment, follow up, data collections and statistical analysis.</p></sec><sec><title>Results</title><p>The present study included 54 patients 26 males and 28 females with SCAP who were admitted to respiratory care unit of Alhussein, Al-Azhar University Hospital. The most common comorbidities were diabetes mellitus and hypertension. The most common presentations were fever, cough, dyspnea and hypoxemia. Two patients developed renal failure and 4 patients developed septic shock. The most common isolated organism was <italic>Streptococcus pneumoniae</italic>, Influenza H1N1, and <italic>Staphylococcus aureus</italic>. Mortality was 24% and it was common in patients with comorbidity than in patients without comorbidities.</p></sec><sec><title>Conclusion</title><p>SCAP occurs more frequently in those with comorbidities. The most frequent isolated causative organism of SCAP is <italic>S. pneumoniae</italic>, Influenza H1N1 and <italic>S. aureus</italic>. SCAP is associated with significant mortality, early recognition and prompt treatment may improve outcome.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Marik, P E" uniqKey="Marik P">P.E. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Egypt J Chest Dis Tuberc</journal-id><journal-id journal-id-type="iso-abbrev">Egypt J Chest Dis Tuberc</journal-id><journal-title-group><journal-title>The Egyptian Journal of Chest Diseases and Tuberculosis</journal-title></journal-title-group><issn pub-type="ppub">0422-7638</issn><issn pub-type="epub">2090-9950</issn><publisher><publisher-name>The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmc">7125902</article-id><article-id pub-id-type="publisher-id">S0422-7638(16)30036-X</article-id><article-id pub-id-type="doi">10.1016/j.ejcdt.2016.06.002</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Clinical presentations and outcome of severe community-acquired pneumonia</article-title></title-group><contrib-group><contrib contrib-type="author" id="au005"><name><surname>Elshamly</surname><given-names>Mousa</given-names></name><email>dr-mousa_elshamly@hotmail.com</email><xref rid="af005" ref-type="aff">a</xref><xref rid="cor1" ref-type="corresp">⁎</xref></contrib><contrib contrib-type="author" id="au010"><name><surname>Nour</surname><given-names>Mohamed O.</given-names></name><email>drmun78@yahoo.com</email><xref rid="af010" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="au015"><name><surname>Omar</surname><given-names>Abdelmaaboud M.M.</given-names></name><email>abdelmaaboudm@yahoo.com</email><xref rid="af015" ref-type="aff">c</xref></contrib></contrib-group><aff id="af005"><label>a</label>Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Egypt</aff><aff id="af010"><label>b</label>Department of Community & Occupational Medicine, Faculty of Medicine, Al-Azhar University (Damietta Branch), Egypt</aff><aff id="af015"><label>c</label>Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University, Egypt</aff><author-notes><corresp id="cor1"><label>⁎</label>Corresponding author. <email>dr-mousa_elshamly@hotmail.com</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>18</day><month>6</month><year>2016</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="ppub"><month>10</month><year>2016</year></pub-date><pub-date pub-type="epub"><day>18</day><month>6</month><year>2016</year></pub-date><volume>65</volume><issue>4</issue><fpage>831</fpage><lpage>839</lpage><history><date date-type="received"><day>17</day><month>3</month><year>2016</year></date><date date-type="accepted"><day>2</day><month>6</month><year>2016</year></date></history><permissions><copyright-statement>© 2016 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.</copyright-statement><copyright-year>2016</copyright-year><copyright-holder>The Egyptian Society of Chest Diseases and Tuberculosis</copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="ab005"><sec><title>Background</title><p>Severe community-acquired pneumonia (SCAP) represents a frequent and potentially life-threatening condition. About 10% of all hospitalized patients with CAP require admission to the intensive care unit (ICU), and the mortality of these patients reaches 20–50%.</p></sec><sec><title>Objective</title><p>To evaluate the clinical presentation, bacteriological profile and outcome of severe community-acquired pneumonia (SCAP).</p></sec><sec><title>Patients and methods</title><p>54 patients presented by symptoms and sign of severe community acquired pneumonia who were admitted to respiratory care unit of Alhussein, Al-Azhar University Hospital from August 2015 to March 2016 were subjected to full clinical examination, chest X ray, complete blood picture, sputum and blood culture, PCR for suspected cases of Influenza H1N1 and MERS-COV, treatment, follow up, data collections and statistical analysis.</p></sec><sec><title>Results</title><p>The present study included 54 patients 26 males and 28 females with SCAP who were admitted to respiratory care unit of Alhussein, Al-Azhar University Hospital. The most common comorbidities were diabetes mellitus and hypertension. The most common presentations were fever, cough, dyspnea and hypoxemia. Two patients developed renal failure and 4 patients developed septic shock. The most common isolated organism was <italic>Streptococcus pneumoniae</italic>, Influenza H1N1, and <italic>Staphylococcus aureus</italic>. Mortality was 24% and it was common in patients with comorbidity than in patients without comorbidities.</p></sec><sec><title>Conclusion</title><p>SCAP occurs more frequently in those with comorbidities. The most frequent isolated causative organism of SCAP is <italic>S. pneumoniae</italic>, Influenza H1N1 and <italic>S. aureus</italic>. SCAP is associated with significant mortality, early recognition and prompt treatment may improve outcome.</p></sec></abstract><kwd-group id="kg005"><title>Keywords</title><kwd>Presentation</kwd><kwd>Outcome</kwd><kwd>Severe community acquired pneumonia</kwd></kwd-group></article-meta></front><body><sec id="s0005"><title>Introduction</title><p id="p0005">Community-acquired pneumonia (CAP) is defined as an infection of the lung parenchyma that is not acquired in a hospital, long-term care facility, or other contact with the health care system <xref rid="b0005" ref-type="bibr">[1]</xref>. CAP continues to be a major cause of morbidity and mortality. Despite the availability of adequate anti biological agents to treat this illness, it has remained the fourth most common cause of death in Japan since 1975 <xref rid="b0010" ref-type="bibr">[2]</xref>. Common causative agents of pneumonia in ambulatory patients are <italic>Streptococcus pneumoniae</italic>, <italic>Mycoplasma pneumoniae</italic>, <italic>Haemophilus influenzae</italic>, <italic>Chlamydia pneumoniae</italic> and respiratory viruses (influenza A and B, adenovirus, respiratory syncytial virus and parainfluenza) <xref rid="b0015" ref-type="bibr">[3]</xref>, <xref rid="b0020" ref-type="bibr">[4]</xref>. Mortality was the highest for <italic>Staphylococcus aureus</italic> (50%), and the lowest for <italic>Chlamydia pneumoniae</italic> (4.5%). Mortality was not seen with <italic>M. pneumoniae</italic>. Pneumonia due to aerobic Gram negative organisms was uncommon, even though empirical therapy with a combination of broad-spectrum antibiotics was often used in this subgroup <xref rid="b0025" ref-type="bibr">[5]</xref>. Severe community-acquired pneumonia (SCAP) represents a frequent and potentially life-threatening condition. About 10% of all hospitalized patients with CAP require admission to the intensive care unit (ICU), and the mortality of these patients reaches 20–50% <xref rid="b0030" ref-type="bibr">[6]</xref>. Severe CAP has been defined as those cases that require admission to the ICU. Direct admission to an ICU is required for patients with septic shock or acute respiratory failure requiring invasive mechanical ventilation, which are defined as major severity criteria in the modified score of the American Thoracic Society (ATS) guidelines that are used to define severe CAP <xref rid="b0035" ref-type="bibr">[7]</xref>.</p><sec id="s0010"><title>Aim of the work</title><p id="p0010">To evaluate the clinical presentation, bacteriological profile and outcome of severe community acquired pneumonia.</p></sec><sec id="s0015"><title>Study design</title><p id="p0015">Prospective study.</p></sec></sec><sec id="s0020"><title>Patients and methods</title><p id="p0020">After the approval of local ethics committee 54 patients (26 males and 28 females) presented by symptoms and sign of severe community acquired pneumonia who were admitted to respiratory care unit of Alhussein, Al-Azhar University Hospital from August 2015 to March 2016 were subjected to the following:<list list-type="simple" id="l0005"><list-item id="o0005"><label>(1)</label><p id="p0025"><bold>History taking:</bold> Fever, cough, pleuritic chest pain, dyspnea, mental confusion and comorbidities.</p></list-item><list-item id="o0010"><label>(2)</label><p id="p0030"><bold>Clinical examination:</bold> Both general and local examination of the chest.</p></list-item><list-item id="o0015"><label>(3)</label><p id="p0035"><bold>Plain chest X-ray (CXR):</bold> A chest radiograph was done for all patients who were likely to have pneumonia to establish the diagnosis, and follow up when needed.</p></list-item><list-item id="o0020"><label>(4)</label><p id="p0040"><bold>Chest computed tomography (CT)</bold> was done when indicated.</p></list-item><list-item id="o0025"><label>(5)</label><p id="p0045"><bold>Laboratory Investigations:</bold> It was done in clinical pathology department of Alhussien University Hospital, Central laboratories of ministry of health and private laboratories.<list list-type="simple" id="l0010"><list-item id="o0030"><label>–</label><p id="p0050"><bold>Complete blood picture:</bold> Total leukocyte count, (TLC), hemoglobin concentration. Blood film to demonstrate differential white blood cell count (WBCs) and morphology of red blood cells (RBCs), erythrocyte sedimentation rate (ESR) using Western Green method. Liver function test (alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP)-total and direct bilirubin-total proteins, and albumin. Kidney function test (creatinine and urea) Fasting blood sugar, and Post prandial (2 h) blood sugar.</p><p id="p0055">The diagnosis of severe community acquired pneumonia (SCAP) was done according to the Infectious Diseases Society of America/American Thoracic Society.</p></list-item></list></p></list-item><list-item id="o0035"><label>(6)</label><p id="p0060"><bold>Microbiological evaluation:</bold> Sputum, blood culture (2 samples from 2 different sites after complete aseptic condition to avoid contamination), pleural fluid, transthoracic needle aspiration, tracheobronchial aspirate, and bronchoalveolar lavage (BAL) fluid in selected cases (BALF). Samples were plated on the following media: blood agar, MacConkey agar, chocolate agar and Sabouraud agar. Staining of selected samples was done by gram stain. Urine was tested for the presence of <italic>S. pneumoniae</italic> and Legionella antigen. Identification of microorganisms and susceptibility testing was performed according to standard methods <xref rid="b0040" ref-type="bibr">[8]</xref>.</p></list-item></list></p><sec id="s0025"><title>Quantitative sputum culture (QSC)</title><p id="p0065">Sputum obtained from adults having clinically and/or radiologically diagnosed CAP. All of the samples contained >=25 polymorphonuclear leukocytes (PNL), and <10 epithelial cells per low-power field (LPF) under light microscopy. Quantitative cultures were performed. Blood and chocolate and MacConkey agar plates were used for culture and standard microbiological methods were used for bacterial identification. 24 and 48 h later both direct plates and quantitative cultures were observed. Cut off point >=10<sup>5</sup> CFU/ml was determined to be positive for the QSC <xref rid="b0045" ref-type="bibr">[9]</xref>.</p><p id="p0070">Quantitative cultures of bronchoalveolar lavage (BAL) fluid, a colony count of ⩾10<sup>4</sup> CFU/ml represents a bacterial load which is indicative of bacterial pneumonia. A BAL fluid colony count below the 10<sup>4</sup> CFU/ml threshold points to oropharyngeal contamination. Quantitative cultures of transthoracic needle aspiration, tracheobronchial aspirate, a colony count of ⩾10<sup>3</sup> CFU/ml represents a bacterial load which is indicative of bacterial pneumonia. A BAL fluid colony count below the 10<sup>3</sup> CFU/ml threshold points to contamination <xref rid="b0050" ref-type="bibr">[10]</xref>.</p></sec><sec id="s0030"><title>Quantitative culture of the blood</title><p id="p0075">A single bacterial count >100 CFU/ml in the quantitative culture of the blood specimen in the presence of a positive qualitative peripheral blood culture of the same organism is an indication of sepsis <xref rid="b0055" ref-type="bibr">[11]</xref>.</p><p id="p0080"><italic>Ziehl Neelsen stain</italic>: Direct smear stained with Gram stain and Ziehl Neelsen stain (to detect acid fast bacilli).</p><p id="p0085"><italic>Polymerase chain reaction</italic>: PCR to detect nucleic acids of Influenza H1N1 and Corona virus.<table-wrap position="float" id="t0045"><table frame="hsides" rules="groups"><tbody><tr><td><bold>Table [A]:</bold> Definition of severe community-acquired pneumonia according to the 2007 Infectious Disease Society of America/American Thoracic Society community-acquired pneumonia guidelines <xref rid="b0040" ref-type="bibr">[8]</xref>.</td></tr><tr><td><bold>Minor criteria:</bold> three or more of</td></tr><tr><td> Respiratory rate >30 breaths/min.</td></tr><tr><td> PaO<sub>2</sub>/FiO<sub>2</sub> ratio <250.</td></tr><tr><td> Multilobar infiltrates.</td></tr><tr><td> Confusion/disorientation.</td></tr><tr><td> Uremia (BUN level >20 mg/dL).</td></tr><tr><td> Leukopenia (WBC count <4000 cells/mm<sup>3</sup>).</td></tr><tr><td> Thrombocytopenia (platelet count <100,000 cells/mm<sup>3</sup>).</td></tr><tr><td> Hypothermia (core temperature <36 °C).</td></tr><tr><td> Hypotension requiring aggressive fluid resuscitation.</td></tr><tr><td><bold>Major criteria:</bold> one or more of</td></tr><tr><td> Invasive mechanical ventilation.</td></tr><tr><td> Septic shock with the need for vasopressors</td></tr><tr><td><bold>Abbreviations:</bold> PaO<sub>2</sub> = arterial oxygen tension; FiO<sub>2</sub> = inspiratory oxygen fraction; BUN = blood urea nitrogen; WBC = white blood cell.</td></tr></tbody></table></table-wrap></p><sec id="s0035"><title>Inpatient, ICU treatment <xref rid="b0040" ref-type="bibr">[8]</xref></title><p id="p0090"><list list-type="simple" id="l0015"><list-item id="o0040"><label>(1)</label><p id="p0095">A beta-lactam (cefotaxime, ceftriaxone, or ampicillin–sulbactam) plus either azithromycin (level II evidence) or a fluoroquinolone (level I evidence) (strong recommendation) (For penicillin-allergic patients, respiratory fluoroquinolone and aztreonam are recommended.)</p></list-item><list-item id="o0045"><label>(2)</label><p id="p0100">For Pseudomonas infection, use an antipneumococcal, antipseudomonal beta-lactam (piperacillin–tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750-mg dose) or the above beta-lactam plus an aminoglycoside and azithromycin or the above beta-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for the above beta-lactam). (Moderate recommendation; level III evidence.)</p></list-item><list-item id="o0050"><label>(3)</label><p id="p0105">For community-acquired methicillin-resistant <italic>S. aureus</italic> infection, add vancomycin or linezolid. (Moderate recommendation; level III evidence).</p></list-item></list></p></sec></sec><sec id="s0040"><title>Statistical analysis of data</title><p id="p0110">Statistical analysis was carried out using the SPSS computer package version 17.0 (SPSS Inc., Chicago, IL, USA). The collected data were statistically managed as follows:<list list-type="simple" id="l0020"><list-item id="o0055"><label>–</label><p id="p0115">For descriptive statistics: mean ± SD were used for quantitative variables while the number and percentage were used for qualitative variables.</p></list-item><list-item id="o0060"><label>–</label><p id="p0120">For analytic statistics: chi-square test was used to assess the differences in frequency of qualitative variables, while Fischer’s exact test (FET) was applied if any expected cell values in a 2́2 table was <5.</p></list-item><list-item id="o0065"><label>–</label><p id="p0125">In order to assess the differences in means of quantitative variables between both groups, independent sample <italic>t</italic>-test was applied.</p></list-item><list-item id="o0070"><label>–</label><p id="p0130">The statistical methods were verified, assuming a significant level of <italic>P</italic> < 0.05 and a highly significant level of <italic>P</italic> < 0.001.</p></list-item></list></p></sec></sec><sec id="s0045"><title>Results</title><p id="p0135">The present study included 54 patients 26 males and 28 females with SCAP. From 54 there were 28 patients 15 males and 13 females with comorbidities and 26 patients 11 males and 15 females without comorbidities. The most common comorbidities was diabetes mellitus and hypertension (13%), chronic bronchitis (11.1%) and bronchial asthma (7.4%) (<xref rid="t0005" ref-type="table">Table 1</xref>).<table-wrap position="float" id="t0005"><label>Table 1</label><caption><p>Demographic data & distribution of comorbidity among the studied sample.</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Characteristics</th><th>No (%) (total no = 54)</th></tr></thead><tbody><tr><td>Age in years (Mean ± SD)</td><td>44.4 ± 5.8</td></tr><tr><td colspan="2">
</td></tr><tr><td><italic>Gender</italic></td><td></td></tr><tr><td> Male</td><td>26 (48.1%)</td></tr><tr><td> Female</td><td>28 (51.9%)</td></tr><tr><td colspan="2">
</td></tr><tr><td><italic>Comorbidities</italic></td><td>28 (51.9%)</td></tr><tr><td> Male</td><td>15 (27.8%)</td></tr><tr><td> Female</td><td>13 (24.1%)</td></tr><tr><td colspan="2">
</td></tr><tr><td><italic>No comorbidities</italic></td><td>26 (48.1%)</td></tr><tr><td> Males</td><td>11 (20.3%)</td></tr><tr><td> Females</td><td>15 (27.8%)</td></tr><tr><td colspan="2">
</td></tr><tr><td colspan="2"><italic>Comorbidities</italic></td></tr><tr><td>1-Bronchial asthma</td><td>4 (7.4%)</td></tr><tr><td>2-Chronic bronchitis</td><td>6 (11.1%)</td></tr><tr><td>3-Hypertension + DM</td><td>7 (13.0%)</td></tr><tr><td>4-Cardiomyopathy</td><td>1 (1.9%)</td></tr><tr><td>5-Mitral stenosis</td><td>2 (3.7%)</td></tr><tr><td>6-Systemic lupus erythematosus</td><td>2 (3.7%)</td></tr><tr><td>7-Liver cirrhosis</td><td>1 (1.9%)</td></tr><tr><td>8-Pulmonary fibrosis</td><td>1 (1.9%)</td></tr><tr><td>9-Hypogammaglobulinemia</td><td>1 (1.9%)</td></tr><tr><td>10-Wagner<bold><sup>,</sup></bold>s granulomatosis</td><td>1 (1.9%)</td></tr><tr><td>11-Septic emboli</td><td>1 (1.9%)</td></tr><tr><td>12-Hodgkin’s lymphoma</td><td>1 (1.9%)</td></tr></tbody></table></table-wrap></p><p id="p0140">As regards clinical presentation, fever was present in 85.7% of patients with comorbidities compared to 100% in patients without comorbidities, cough 100%, shortness of breath 92.5%, hypoxemia was 82.1% in patients with comorbidities compared to 76.9% in patients without comorbidities, expectoration was 78.6% in patients with comorbidities compared to 73.1% in patient without comorbidities, confusion was 25% in patients with comorbidities compared to 7.7% in patients without comorbidities. Low systolic blood pressure (BP) was 39.3% in patients with comorbidities compared to 11.5% in patients without comorbidities, low diastolic BP was 35.7% in patients with comorbidities compared to 7.7% in patients without comorbidities, differences were statistically significant. Complication in form of renal failure occurred in 7.1% and septic shock in 14.3% in patients with comorbidities compared to septic shock in 7.7% in patients without comorbidities, the difference was statistically non significant (see <xref rid="t0010" ref-type="table">Table 2</xref>).<table-wrap position="float" id="t0010"><label>Table 2</label><caption><p>Comparison between patients with and without comorbidities regarding clinical presentation.</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Clinical presentation</th><th>Patients with comorbidities no = 28 (%)</th><th>Patients without comorbidities no = 26 (%)</th><th><italic>P</italic>-value</th></tr></thead><tbody><tr><td>Fever > 38.5</td><td>24 (85.7)</td><td>26 (100.0)</td><td>0.112</td></tr><tr><td>Cough</td><td>28 (100.0)</td><td>26 (100.0)</td><td>–</td></tr><tr><td>Shortness of breath</td><td>26 (92.9)</td><td>24 (92.3)</td><td>1.000</td></tr><tr><td>Expectoration</td><td>22 (78.6)</td><td>19 (73.1)</td><td>0.754</td></tr><tr><td>Confusion</td><td>7 (25.0)</td><td>2 (7.7)</td><td>0.144</td></tr><tr><td>PaO<sub>2</sub>/FiO<sub>2</sub> <250</td><td>23 (82.1)</td><td>20 (76.9)</td><td>0.741</td></tr><tr><td>Systolic blood pressure <90 mmHg</td><td>11 (39.3)</td><td>3 (11.5)</td><td><bold>0.030</bold><xref rid="tblfn2" ref-type="table-fn">⁎</xref></td></tr><tr><td>Diastolic blood pressure <60 mmHg</td><td>10 (35.7)</td><td>2 (7.7)</td><td><bold>0.021</bold><xref rid="tblfn2" ref-type="table-fn">⁎</xref></td></tr><tr><td colspan="4">
</td></tr><tr><td colspan="4">Complications</td></tr><tr><td> Renal failure</td><td>2 (7.1)</td><td>0 (0.0)</td><td rowspan="3">0.261<xref rid="tblfn1" ref-type="table-fn">1</xref></td></tr><tr><td> Septic shock</td><td>4 (14.3)</td><td>2 (7.7)</td></tr><tr><td>No complications</td><td>22 (78.6)</td><td>24 (92.3)</td></tr></tbody></table><table-wrap-foot><fn><p>Values analyzed by Fisher’s exact test.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tblfn1"><label>1</label><p id="np005">Values analyzed by Chi-square test.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tblfn2"><label>⁎</label><p id="np010">Significant.</p></fn></table-wrap-foot></table-wrap></p><p id="p0145"><xref rid="t0015" ref-type="table">Table 3</xref>showed initial laboratory investigation, complete blood picture, blood urea nitrogen, serum creatinine, serum sodium, serum potassium and blood gas analyses. The difference between both groups was statistically significant as regards hemoglobin which was low in patients with comorbidities, high neutrophils count, high blood urea and serum creatinine in patients with comorbidities, compared to patients without comorbidities. Low PH and PaO<sub>2</sub> with high PaCo<sub>2</sub> in patients with comorbidities compared to patients without comorbidities the differences was statistically significant.<table-wrap position="float" id="t0015"><label>Table 3</label><caption><p>Comparison between patients with and without comorbidities regarding initial laboratory investigations.</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Laboratory investigations</th><th>Patients with comorbidity no = 28</th><th>Patients without comorbidity no = 26</th><th><italic>P</italic>-value</th></tr></thead><tbody><tr><td>Hemoglobin (g/dL)</td><td align="char">10.5 ± 2.3</td><td align="char">14.8 ± 2.1</td><td align="char"><0.001<xref rid="tblfn3" ref-type="table-fn">⁎</xref></td></tr><tr><td>Total leukocyte count (×10<sup>9</sup>/L)</td><td align="char">16.3 ± 5.1</td><td align="char">15.4 ± 5.0</td><td align="char">0.529</td></tr><tr><td>Neutrophils (%)</td><td align="char">84.4 ± 8.3</td><td align="char">78.3 ± 7.9</td><td align="char"><bold>0.007</bold><xref rid="tblfn3" ref-type="table-fn">⁎</xref></td></tr><tr><td>Lymphocytes (%)</td><td align="char">28.2 ± 7.6</td><td align="char">31.1 ± 6.2</td><td align="char">0.142</td></tr><tr><td>Platelets (×10<sup>9</sup>/L)</td><td align="char">223.0 ± 55.0</td><td align="char">243.0 ± 68.4</td><td align="char">0.242</td></tr><tr><td>Serum BUN (mg/dL)</td><td align="char">45.6 ± 6.1</td><td align="char">35.6 ± 4.8</td><td align="char"><bold><0.001</bold><xref rid="tblfn3" ref-type="table-fn">⁎</xref></td></tr><tr><td>Serum creatinine (mg/dL)</td><td align="char">2.2 ± 0.8</td><td align="char">1.1 ± 0.6</td><td align="char"><bold><0.001</bold><xref rid="tblfn3" ref-type="table-fn">⁎</xref></td></tr><tr><td>Serum sodium (mmol/L)</td><td align="char">139.1 ± 5.0</td><td align="char">135.0 ± 3.4</td><td align="char"><bold>0.001</bold><xref rid="tblfn3" ref-type="table-fn">⁎</xref></td></tr><tr><td>Serum potassium (mmol/L)</td><td align="char">3.6 ± 1.4</td><td align="char">4.2 ± 0.7</td><td align="char">0.056</td></tr><tr><td colspan="4">
</td></tr><tr><td>ABG</td><td align="char"></td><td align="char"></td><td></td></tr><tr><td> PH</td><td align="char">7.26 ± 0.09</td><td align="char">7.36 ± 0.08</td><td align="char"><bold><0.001</bold><xref rid="tblfn3" ref-type="table-fn">⁎</xref></td></tr><tr><td> PaCo<sub>2</sub> (mmHg)</td><td align="char">48.1 ± 8.7</td><td align="char">33.0 ± 4.6</td><td align="char"><bold><0.001</bold><xref rid="tblfn3" ref-type="table-fn">⁎</xref></td></tr><tr><td> PaO<sub>2</sub> (mmHg)</td><td align="char">41.1 ± 7.5</td><td align="char">49.1 ± 7.9</td><td align="char"><bold><0.001</bold><xref rid="tblfn3" ref-type="table-fn">⁎</xref></td></tr></tbody></table><table-wrap-foot><fn><p>Values present as mean ± SD and analyzed by independent samples <italic>t</italic>-test.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tblfn3"><label>⁎</label><p id="np015">Significant.</p></fn></table-wrap-foot></table-wrap></p><p id="p0150"><xref rid="t0020" ref-type="table">Table 4</xref>showed chest X-ray finding. Bilateral patchy infiltrate in 35.1%, bilateral patchy infiltrate with cavitations in 3.7%, bilateral lower lobes infiltrate in 16.6%, bilateral lower lobes consolidation with pleural effusion in 3.7%, right lower lobe consolidation in 14.8%, left lower lobe consolidation in 11.1%, right upper lobe consolidation with cavitations in 3.7% and right lower lobe consolidation with cavitations in 3.7% and right lower lobe consolidation and pleural effusion in 7.4%.<table-wrap position="float" id="t0020"><label>Table 4</label><caption><p>Chest X-ray finding.</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Chest X-ray finding</th><th>Causative organism</th><th>No</th><th>No = 54 (%)</th></tr></thead><tbody><tr><td rowspan="4">1-Bilateral patchy infiltrate</td><td>– Influenza H1N1</td><td align="char">7</td><td rowspan="4">19 (35.1%)</td></tr><tr><td>– <italic>Staphylococcus aureus</italic></td><td align="char">5</td></tr><tr><td>– <italic>Hemophilus influenza</italic></td><td align="char">4</td></tr><tr><td>– <italic>Streptococcus pneumonia</italic></td><td align="char">3</td></tr><tr><td rowspan="2">2-Bilateral patchy infiltrate with cavitations</td><td>– <italic>Pseudomonas aeruginosa</italic></td><td align="char">1</td><td rowspan="2">2 (3.7%)</td></tr><tr><td>– <italic>Staphylococcus aureus</italic></td><td align="char">1</td></tr><tr><td rowspan="3">3-Bilateral lower lobes infiltrates</td><td>– <italic>Streptococcus pneumonia</italic></td><td align="char">5</td><td rowspan="3">9 (16.6%)</td></tr><tr><td>– <italic>Moraxella catarrhalis</italic></td><td align="char">3</td></tr><tr><td>– <italic>Klebsiella pneumonia</italic></td><td align="char">1</td></tr><tr><td rowspan="2">4-Bilateral lower lobes consolidation with pleural effusion</td><td>– <italic>Acinetobacter baumannii</italic></td><td align="char">1</td><td rowspan="2">2 (3.7%)</td></tr><tr><td>– <italic>Streptococcus pneumonia</italic></td><td align="char">1</td></tr><tr><td rowspan="3">5-Right lower lobe consolidation</td><td>– <italic>E. coli</italic></td><td align="char">4</td><td rowspan="3">8 (14.8%)</td></tr><tr><td>– <italic>Pseudomonas aeruginosa</italic></td><td align="char">3</td></tr><tr><td>– <italic>Streptococcus pneumonia</italic></td><td align="char">1</td></tr><tr><td rowspan="4">6-Left lower lobe consolidation</td><td>– <italic>Streptococcus pneumonia</italic></td><td align="char">2</td><td rowspan="4">6 (11.1%)</td></tr><tr><td>– <italic>Klebsiella pneumonia</italic></td><td align="char">2</td></tr><tr><td>– <italic>Hemophilus influenza</italic></td><td align="char">1</td></tr><tr><td>– <italic>Acinetobacter baumannii</italic></td><td align="char">1</td></tr><tr><td rowspan="2">7-Right upper lobe consolidation and cavitations</td><td>– <italic>Mycobacterium tuberculosis</italic></td><td align="char">1</td><td rowspan="2">2 (3.7%)</td></tr><tr><td>– <italic>Klebsiella pneumonia</italic></td><td align="char">1</td></tr><tr><td rowspan="2">8-Right lower lobe consolidation and cavitations</td><td>– <italic>Acinetobacter baumannii</italic></td><td align="char">1</td><td rowspan="2">2 (3.7%)</td></tr><tr><td>– <italic>Klebsiella pneumonia</italic></td><td align="char">1</td></tr><tr><td rowspan="4">9-Right lower lobe consolidation and pleural effusion</td><td>– <italic>Acinetobacter baumannii</italic></td><td align="char">1</td><td rowspan="4">4 (7.4%)</td></tr><tr><td>– <italic>Klebsiella pneumonia</italic></td><td align="char">1</td></tr><tr><td>– <italic>Legionella species</italic></td><td align="char">1</td></tr><tr><td>– <italic>Hemophilus influenza</italic></td><td align="char">1</td></tr></tbody></table></table-wrap></p><p id="p0155"><xref rid="t0025" ref-type="table">Table 5</xref>showed sputum culture results, <italic>S. pneumoniae</italic> was the most common organism, it occurred in 18.5%, <italic>S. aureus</italic> in 11.1%, Influenza H1N1 in 12.9%, <italic>Klebsiella pneumonia</italic> in 7.4%, <italic>H. influenzae</italic> in 9.2%, <italic>Moraxella catarrhalis</italic> in 3.7%, Legionella species in 1.8%, <italic>Pseudomonas aeruginosa</italic> in 5.5%, <italic>Acinetobacter baumannii</italic> in 3.7%, and <italic>Mycobacterial tuberculosis</italic> in 1.8%. No bacterial growth occurred in 24%.<table-wrap position="float" id="t0025"><label>Table 5</label><caption><p>Comparison between patients with and without comorbidities regarding sputum culture.</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Sputum culture</th><th>Patients with comorbidities no = 28 (%)</th><th>Patients without comorbidities no = 26 (%)</th><th>Total</th><th><italic>P</italic>-value</th></tr></thead><tbody><tr><td>1-<italic>Streptococcus pneumonia</italic></td><td>5 (17.9)</td><td>5 (19.2)</td><td>10 (18.5%)</td><td align="char">1.000</td></tr><tr><td>2-Hemophilus influenza</td><td>3 (10.7)</td><td>2 (7.7)</td><td>5 (9.2%)</td><td align="char">1.000</td></tr><tr><td>3-<italic>Moraxella catarrhalis</italic></td><td>1 (3.6)</td><td>1 (3.8)</td><td>2 (3.7%)</td><td align="char">1.000</td></tr><tr><td>4-<italic>Staphylococcus aureus</italic></td><td>3 (10.7)</td><td>3 (11.5)</td><td>6 (11.1%)</td><td align="char">1.000</td></tr><tr><td>5-Legionella species</td><td>1 (3.6)</td><td>0 (0.0)</td><td>1 (1.8%)</td><td align="char">1.000</td></tr><tr><td>6-Klebsiella pneumonia</td><td>4 (14.3)</td><td>0 (0.0)</td><td>4 (7.4%)</td><td align="char">0.112</td></tr><tr><td>7-<italic>Pseudomonas aeruginosa</italic></td><td>3 (10.7)</td><td>0 (0.0)</td><td>3 (5.5%)</td><td align="char">0.237</td></tr><tr><td>8-<italic>Acinetobacter baumannii</italic></td><td>2 (7.1)</td><td>0 (0.0)</td><td>2 (3.7%)</td><td align="char">0.491</td></tr><tr><td>9-Influenza H1N1</td><td>4 (14.3)</td><td>3 (11.5)</td><td>7 (12.9%)</td><td align="char">1.000</td></tr><tr><td>10-Mycobacterium tuberculosis</td><td>1 (3.6)</td><td>0 (0.0)</td><td>1 (1.8%)</td><td align="char">1.000</td></tr><tr><td>11-Negative</td><td>0 (0.0)</td><td>13 (50.0)</td><td>13 (24%)</td><td align="char"><bold><0.001</bold><xref rid="tblfn4" ref-type="table-fn">⁎</xref></td></tr></tbody></table><table-wrap-foot><fn><p>Values analyzed by Fisher’s exact test.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tblfn4"><label>⁎</label><p id="np020">Significant.</p></fn></table-wrap-foot></table-wrap></p><p id="p0160"><xref rid="t0030" ref-type="table">Table 6</xref>showed blood culture result of both groups, organism isolated only in (31.5%), the organisms isolated were <italic>Escherichia coli</italic> in 7.4%, <italic>S. pneumoniae</italic> in 5.5%, <italic>S. aureus</italic> in 5.5%, <italic>K. pneumonia</italic> in 5.5%, <italic>P. aeruginosa</italic> in 1.8%, and <italic>A. baumannii</italic> in 3.7%.<table-wrap position="float" id="t0030"><label>Table 6</label><caption><p>Comparison between patients with and without comorbidity regarding blood culture.</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Blood culture</th><th>Patients with comorbidity no = 28 (%)</th><th>Patients without comorbidity no = 26 (%)</th><th>Total no = 54(%)</th><th><italic>P</italic>-value</th></tr></thead><tbody><tr><td>1-<italic>Streptococcus pneumonia</italic></td><td>2 (7.1)</td><td>1 (3.8)</td><td>3 (5.5)</td><td align="char">1.000</td></tr><tr><td>2-<italic>Hemophilus influenza</italic></td><td>1 (3.6)</td><td>0 (0.0)</td><td>1 (1.8)</td><td align="char">1.000</td></tr><tr><td>3-<italic>Staphylococcus aureus</italic></td><td>2 (7.1)</td><td>1 (3.8)</td><td>3 (5.5)</td><td align="char">1.000</td></tr><tr><td>6-<italic>Klebsiella pneumoniae</italic></td><td>3 (10.7)</td><td>0 (0.0)</td><td>3 (5.5)</td><td align="char">0.237</td></tr><tr><td>7-<italic>Pseudomonas aeruginosa</italic></td><td>1 (3.6)</td><td>0 (0.0)</td><td>1 (1.8)</td><td align="char">1.000</td></tr><tr><td>8-<italic>Acinetobacter baumannii</italic></td><td>2 (7.1)</td><td>0 (0.0)</td><td>2 (3.7)</td><td align="char">0.491</td></tr><tr><td>7-<italic>E. coli</italic></td><td>3 (10.7)</td><td>1 (3.8)</td><td>4 (7.4)</td><td align="char">0.612</td></tr><tr><td>8-No growth</td><td>14 (50.0)</td><td>23 (88.5)</td><td><bold>37 (68.5)</bold></td><td align="char"><bold>0.003</bold><xref rid="tblfn5" ref-type="table-fn">⁎</xref></td></tr></tbody></table><table-wrap-foot><fn><p>Values analyzed by Fisher’s exact test.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tblfn5"><label>⁎</label><p id="np025">Significant.</p></fn></table-wrap-foot></table-wrap></p><p id="p0165"><xref rid="t0035" ref-type="table">Table 7</xref>showed that 42.9% from patients with comorbidities needed invasive mechanical ventilation compared to 23.1% for patient without comorbidities, and 21.4% from patients with comorbidities needed non invasive mechanical ventilation compared to 19.2% for patients without comorbidity. Inotropic support needed in 21.4% of patients with comorbidities compared to 7.7% in patients without comorbidities. ICU stay was 7 ± 1.2 days for patients with comorbidities compared to 4 ± 0.9 days for patients without comorbidities. Hospital stay was 13 ± 1.5 days for patients with comorbidities compared to 8 ± 1.6 days for patients without comorbidities. Mortality was 32.1% for patients with comorbidities compared to 15.3% for patients without comorbidities, the total mortality was 24%.<table-wrap position="float" id="t0035"><label>Table 7</label><caption><p>Comparison between patients with and without comorbidities regarding the need for mechanical ventilation (MV), hospital stay & mortality.</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>Patients with comorbidities no = 28 (%)</th><th>Patients without comorbidities no = 26 (%)</th><th>Total no = 54 (%)</th><th><italic>P</italic>-value</th></tr></thead><tbody><tr><td>Needed invasive MV</td><td>12 (42.9)</td><td>6 (23.1)</td><td>18 (33.3)</td><td align="char">0.155</td></tr><tr><td>Needed non invasive MV</td><td>6 (21.4)</td><td>5 (19.2)</td><td>11 (20.4)</td><td align="char">1.000</td></tr><tr><td>Inotropic support</td><td>6 (21.4)</td><td>2 (7.7)</td><td>8 (14.8)</td><td align="char">0.253</td></tr><tr><td>ICU stay in days<xref rid="tblfn6" ref-type="table-fn">1</xref></td><td>7.0 ± 1.2</td><td>4.1 ± 0.9</td><td>5.6 ± 1.8</td><td align="char"><bold><0.001</bold><xref rid="tblfn7" ref-type="table-fn">⁎</xref></td></tr><tr><td>Hospital stay in days<xref rid="tblfn6" ref-type="table-fn">1</xref></td><td>13.0 ± 1.5</td><td>8.0 ± 1.6</td><td>10.6 ± 2.9</td><td align="char"><bold><0.001</bold><xref rid="tblfn7" ref-type="table-fn">⁎</xref></td></tr><tr><td>Mortality</td><td>9 (32.1)</td><td>4 (15.3)</td><td>13 (24)</td><td align="char">0.207</td></tr></tbody></table><table-wrap-foot><fn><p>Values analyzed by Fisher’s exact test.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tblfn6"><label>1</label><p id="np030">Values present as mean ± SD & analyzed by independent samples <italic>t</italic>-test.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tblfn7"><label>⁎</label><p id="np035">Significant.</p></fn></table-wrap-foot></table-wrap></p><p id="p0170">Mortality was 100% in patients with <italic>A. baumannii</italic> multidrug resistant (MDR) pneumonia, (66.6%) in patients with <italic>P. aeruginosa</italic> pneumonia, 50% in patients with <italic>K. pneumonia</italic>, 33.3% in patients with <italic>S. aureus</italic> pneumonia, 28.5% in patients with Influenza H1N1 pneumonia, and 33% in patients with <italic>S. pneumoniae</italic> (see <xref rid="t0040" ref-type="table">Table 8</xref>, <xref rid="f0005" ref-type="fig">Figure 1</xref>, <xref rid="f0010" ref-type="fig">Figure 2</xref>, <xref rid="f0015" ref-type="fig">Figure 3</xref>, <xref rid="f0020" ref-type="fig">Figure 4</xref>).<table-wrap position="float" id="t0040"><label>Table 8</label><caption><p>Percentage of mortality according to causative organism.</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Causative organism</th><th>Percentage of mortality no = percentage (%)</th></tr></thead><tbody><tr><td>Influenza H1N1</td><td>2/7 (28.57%)</td></tr><tr><td><italic>Staphylococcus aureus</italic></td><td>2/6 (33.3%)</td></tr><tr><td><italic>Acinetobacter baumannii</italic> MDR</td><td>2/2 (100%)</td></tr><tr><td><italic>Klebsiella pneumoniae</italic></td><td>2/4 (50%)</td></tr><tr><td><italic>Pseudomonas aeruginosa</italic></td><td>2/3 (66.6%)</td></tr><tr><td><italic>Streptococcus pneumonia</italic></td><td>3/10 (33%)</td></tr></tbody></table></table-wrap><fig id="f0005"><label>Figure 1</label><caption><p>Chest X ray of 40 year old female with severe CAP.</p></caption><graphic xlink:href="gr1"></graphic></fig><fig id="f0010"><label>Figure 2</label><caption><p>Chest X ray of 35 year old male with severe CAP.</p></caption><graphic xlink:href="gr2"></graphic></fig><fig id="f0015"><label>Figure 3</label><caption><p>Chest X ray of 38 year female with severe CAP.</p></caption><graphic xlink:href="gr3"></graphic></fig><fig id="f0020"><label>Figure 4</label><caption><p>CT chest of 53 year male patient with severe CAP.</p></caption><graphic xlink:href="gr4"></graphic></fig></p></sec><sec id="s0050"><title>Discussion</title><p id="p0175">Severe community acquired pneumonia (SCAP) occurs in approximately 18–36% <xref rid="b0060" ref-type="bibr">[12]</xref> of all CAP. The mortality rate for CAP is <5% for outpatient cases, it rises to 10% in admitted ward patients and can exceed 30% in patients admitted to intensive care unit (ICU) <xref rid="b0065" ref-type="bibr">[13]</xref>. In our study 28 out of 54 patients (51.85%) admitted with SCAP had comorbidities. The most common comorbidities were diabetes mellitus and hypertension (13%), chronic bronchitis (11.1%) and bronchial asthma (7.4%). There were 2 patients diagnosed as Systemic lupus erythematosus, 1 patient diagnosed as Hodgkin’s lymphoma, 2 patients diagnosed as severe mitral stenosis, 1 patient diagnosed as Wagner<sup>’</sup>s granulomatosis, 1 patient diagnosed as Hypogammaglobulinemia and 1 patient diagnosed as Septic pulmonary emboli, and all these 8 patients were diagnosed for the first time.</p><p id="p0180">In this study the most common clinical presentations were fever, cough, dyspnea and hypoxemia. 2 patients developed acute renal failure and 6 patients developed septic shock. In study done by Aya et al. <xref rid="b0070" ref-type="bibr">[14]</xref>, they found that (72.2%) was complaining of fever, (89.9%) was complaining of cough, sputum production was present in (66.66%), dyspnea was present in (66.6%), pleuritic chest pain was present in (35.11%), and non respiratory complaints in the form of nausea, vomiting, myalgia and headache were found in (38.69%).</p><p id="p0185">In our study there was a low hemoglobin level, high neutrophil count, elevated blood urea and serum creatinine with low PH, high PaCo<sub>2</sub> and low PaO<sub>2</sub> in patients with comorbidities compared to patients without comorbidities, the differences were statistically significant. This indicates more severe diseases and multiple organ dysfunction in patients with comorbidities.</p><p id="p0190">In this study chest X-ray showed Bilateral patchy infiltrate in 35.1% which is common with Influenza A H1N1, <italic>S. aureus</italic>, <italic>Haemophilus influenza</italic>, and <italic>S. pneumoniae</italic>; bilateral patchy infiltrate with cavitations in 3.7%, and it was common with <italic>S. aureus</italic>, and <italic>P. aeruginosa</italic>; bilateral lower lobes infiltrate in 16.6% which occurred with <italic>S. pneumoniae</italic>, <italic>M. catarrhalis</italic>, and <italic>Klebsiella pneumonia</italic>; bilateral lower lobe consolidation with pleural effusion in 3.7%; right lower lobe consolidation in 14.8%; left lower lobe consolidation in 11.1%; right upper lobe consolidation in 3.7% and right lower lobe consolidation with cavitations in 3.7% and right lower lobe consolidation and pleural effusion in 7.4%. In the study done by Kantor <xref rid="b0075" ref-type="bibr">[15]</xref> he found the patterns of lobar pneumonia and bronchopneumonia were equally frequent in pneumococcal pneumonia. The radiographic findings of Legionella consist of segmental peripheral consolidations, there may also be lobar involvement, and bilateral disease is seen in more than half of the patients <xref rid="b0080" ref-type="bibr">[16]</xref>. Viral pneumonia has a radiologic pattern consisting of poorly defined air-space nodules of 4–10 mm, patchy areas of peribronchial ground glass opacity, and air-space consolidation. Hyperinflation is also commonly present because of the associated bronchiolitis. Pneumonia could progress as seen by the rapid confluence of consolidation leading to diffuse alveolar damage, which consists of homogenous or patchy unilateral or bilateral air-space consolidation and ground-glass opacity or poorly defined centrilobular nodules <xref rid="b0085" ref-type="bibr">[17]</xref>. The predominant radiographic patterns in H1N1 pneumonia are bilateral ground glass opacity and alveolar consolidation <xref rid="b0090" ref-type="bibr">[18]</xref>. Striking characteristic of <italic>S. pneumonia</italic> is its tendency to involve the pleura, parapneumonic effusions are common in <italic>Pneumococcal pneumonia</italic><xref rid="b0095" ref-type="bibr">[19]</xref>. In the study conducted by Ali Khawaja et al. <xref rid="b0100" ref-type="bibr">[20]</xref> they found that the most common chest X ray finding in patient with CAP was lobar consolidation in (63%) followed by pleural effusion in (37%) and interstitial infiltrates in (28%). In another study by Seksan et al. <xref rid="b0105" ref-type="bibr">[21]</xref> they found that the most common pulmonary infiltration pattern of X-ray in patients with CAP was patchy infiltrates in (69.3%), followed by interstitial infiltrations in (22.2%), diffuse alveolar infiltrations in (5.0%) and multilobar infiltrations in (3.5%).</p><p id="p0195">In this study, sputum culture showed that <italic>S. pneumoniae</italic> was the most common isolated organism, it occurred in 18.5%, <italic>S. aureus</italic> in 11.1%, Influenza H1N1 in 12.9%, <italic>K. pneumonia</italic> in 7.4%, <italic>H. influenzae</italic> in 9.2%, <italic>M. catarrhalis</italic> in 3.7%, Legionella species in 1.8%, <italic>P. aeruginosa</italic> in 5.5%, <italic>A. baumannii</italic> multidrug resistant (MDR) in 3.7%, and <italic>M. tuberculosis</italic> in 1.8%. No bacterial growth occurred in 24%. <italic>P. aeruginosa</italic>, <italic>K. pneumonia</italic>, <italic>E. coli</italic> and <italic>A. baumannii</italic> were predominantly present in patients with comorbidities, which can be explained by airway colonization by these organisms, also Influenza H1N1 is considered high because our study was done mainly during winter season. In the study done by Boixeda et al. <xref rid="b0110" ref-type="bibr">[22]</xref>, they found that the most frequently isolated microorganism in patients with comorbidities and COPD was <italic>P. aeruginosa</italic> in 27 (30.7%), followed by <italic>S. pneumoniae</italic> in 23 (26.1%), Enterobacteriaceae in 18 (20.4%), <italic>H. influenza</italic> in 14 cases (15.9%), and finally <italic>M. catarrhalis</italic> in 6 (6.8%). In another study done File <xref rid="b0020" ref-type="bibr">[4]</xref> he found that the most common causes of severe pneumonia are <italic>S. pneumoniae</italic>, <italic>S. aureus</italic>, Legionella spp. Gram-negative bacilli and <italic>H. influenza</italic>.</p><p id="p0200">In our study blood culture showed that organism isolated only in 50 % of patients with comorbidities compared to 11.5% in patients without comorbidities, the difference was statistically significant, the organisms isolated were <italic>E. coli</italic> in 7.4%, <italic>S. pneumoniae</italic> in 5.5%, <italic>S. aureus</italic> in 5.5%, <italic>K. pneumonia</italic> in 5.5%, <italic>P. aeruginosa</italic> in 1.8%, <italic>A. baumannii</italic> in 3.7%. Khawaja et al. <xref rid="b0100" ref-type="bibr">[20]</xref> found that blood cultures were positive in 15 patients (13.3%) with severe CAP and in 9 patients (6.1%) with non-severe CAP, there were significantly more patients with positive blood cultures among those with severe CAP than non severe CAP.</p><p id="p0205">In our study 42.9% from patients with comorbidities needed invasive mechanical ventilation compared to 23.1% for patient without comorbidities, and 21.4% from patients with comorbidities needed non invasive mechanical ventilation compared to 19.2% for patient without comorbidities. Inotropic support was needed in 21.4% of patients with comorbidities compared to 7.7% in patients without comorbidities, ICU stay was 7 ± 1.2 days for patients with comorbidities compared to 4 ± 0.9 days for patients without comorbidities. Hospital stay was 13 ± 1.5 days for patients with comorbidities compared to 8 ± 1.6 days for patients without comorbidities. Previous studies by Sreekanth A and Praveen Kumar Reddy. <xref rid="b0115" ref-type="bibr">[23]</xref> they found that the hospital stay was longer for patients with comorbidities compared to patients without comorbidities, the most frequent complication recorded was sepsis in 38 cases (31%) in patients with comorbidity and 19% in patients without comorbidity, and sepsis was the cause of death in 57% cases. Previous studies by Yoshimoto et al. <xref rid="b0120" ref-type="bibr">[24]</xref> admit that septic shock was associated with higher mortality and is a frequent complication.</p><p id="p0210">In our study mortality was 32.1% for patients with comorbidities compared to 15.3% for patients without comorbidities, the total mortality was 24%. In our study the infection with <italic>P. aeruginosa</italic> was associated with worst outcome as 3 out of 3 patients infected with this pathogens died. Internationally the reported mortality of patients with severe CAP is between 35.8% and 39.1% at 5 years <xref rid="b0125" ref-type="bibr">[25]</xref>. Mortality in patients infected with <italic>P. aeruginosa</italic> was 66.6%, the lowest mortality was with streptococcal pneumonia 22.2% <xref rid="b0125" ref-type="bibr">[25]</xref>. In the study done by Yoshimoto et al. <xref rid="b0120" ref-type="bibr">[24]</xref>, the mortality rate for SCAP requiring ICU admission was 48.6%.</p><p id="p0215">The major limitation of our study was the lack of availability of serological tests for the diagnosis of viral and atypical pathogens.</p></sec><sec id="s0055"><title>Conclusion</title><p id="p0220">SCAP occurs more frequently in those with comorbidities. The most frequent causative organism of SCAP isolated is <italic>S. pneumoniae</italic>, Influenza H1N1and <italic>S. aureus</italic>. 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