Management of patients with community-acquired pneumonia in a primary care hospital: a critical evaluation

Abstract

The aim of the study was to evaluate routine management of patients with community-acquired pneumonia (CAP) with regard to severity patterns, diagnostic approaches and results, as well as initial empiric antimicrobial treatment and its impact on outcome.Two hundred and thirty-two consecutive patients with CAP admitted to a primary care hospital were studied prospectively. Patients were classified according to Fine's severity score. Severe pneumonia was defined as admission at the ICU. Diagnostic approaches and initial antimicrobial treatment were judged according to the guidelines of the European Respiratory Society (ERS).Fifty-five patients (24%) had mild, 156 (67%) moderate, and 21 (9%) severe CAP. At least one microbial examination was performed in 124 patients (54%). There was no association between microbial investigation and severity of CAP. Inadequate initial antimicrobial treatment was significantly more frequent in severe (18/21, 86%), than in mild (5/55, 9%) and moderate CAP (39/156, 25%, P< 0·0001). Conversely, antimicrobial overtreatment occurred significantly more often in mild (30/55, 55%) and moderate (77/156, 49%) than in severe CAP (0/21, 0%, P<0·0001). Inadequate initial antimicrobial treatment was more frequent in non-responders [18/62 (29%) vs. 31/170, (18%), RR 1·6 95% CI 0·9–2·6, P=0·07] and was associated with a longer duration of hospitalization (17±11 vs. 14±8 days, P=0·03). Mortality was not affected by inadequate initial antimicrobial treatment [5/62 (8%) vs. 10/170 (6%), RR 1·4 95% CI 0·5–3·9, P=0·55].Principal conceptual weaknesses which might be subject to intervention were (1) the hospitalization of patients with mild pneumonia at low risk of mortality; (2) the lack of association between microbial investigation and severity of CAP; (3) antimicrobial overtreatment of patients with non-severe CAP; and (4) inadequate antimicrobial treatment with increased number of primary treatment failures and duration of hospitalization.