Management Of Community-acquired Pneumonia Research Articles

Incidence of drug-resistant pathogens in community-acquired pneumonia at a safety net hospital.

The 2019 Infectious Diseases Society of America guideline for the management of community-acquired pneumonia (CAP) emphasizes the need for clinician to understand local epidemiological data to guide selection of appropriate treatment. Currently, the local distribution of causative pathogens and their associated resistance patterns in CAP is unknown. A retrospective observational study was performed of patients admitted to an 870-bed safety net hospital between March 2016 and March 2021 who received a diagnosis of CAP or healthcare-associated pneumonia within the first 48 hours of admission. The primary outcome was the incidence of CAP caused by methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa (PsA) as determined by comparing the number of satisfactory sputum cultures or blood cultures with these drug-resistant organisms to the total number of reviewed patients. Secondary outcomes studied included risk factors associated with CAP caused by drug-resistant organisms, utilization of broad-spectrum antibiotics, appropriate antibiotic de-escalation within 72 hours, and treatment duration. In this 220-patient cohort, MRSA or PsA was isolated from three sputum cultures and no blood cultures. The local incidence of drug-resistant pathogens among the analyzed sample of CAP patients was 1.4% (n = 3/220). The overall incidence of CAP caused by MRSA or PsA among admitted patients is low at our safety-net county hospital. Future research is needed to identify local risk factors associated with the development of CAP caused by drug-resistant pathogens.IMPORTANCEThis study investigates the incidence of drug-resistant pathogens including methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa among community-acquired pneumonia (CAP) patients at a safety net hospital. Understanding local bacteria resistance patterns when treating CAP is essential and supported by evidence-based guidelines. Our findings empower other clinicians to investigate resistance patterns at their own institutions and identify methods to improve antibiotic use. This has the potential to reduce the unnecessary use of broad-spectrum antibiotic agents and combat the development of antibiotic resistance.

A Study on the Etiology and Clinical Manifestations of Community-Acquired Pneumonia in Adults in Western India.

Community-acquired pneumonia (CAP) is an acute lung infection affecting the alveoli in individuals who have not had recent exposure to healthcare settings. It is characterized by newly detected pulmonary infiltration on a chest X-ray or computed tomography scan, accompanied by at least two of the following symptoms: a new or worsening cough, shortness of breath, increased sputum production, fever or hypothermia, pleuritic chest pain, hypoxia, confusion, or an abnormal WBC count (either leukopenia or leukocytosis). It is a major contributor to global mortality and morbidity, especially in elderly populations. This study aims to investigate the etiology of CAP in our region and analyze the clinical characteristics of patients diagnosed with CAP. This prospective, hospital-based study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, a 2,011-bed multispecialty hospital. The study included 100 patients over 18 years old, diagnosed with CAP, and hospitalized between January 2023 and January 2024. All patients underwent a thorough clinical assessment, and sputum cultures were collected on the day of admission. Patients under 18 years old, those who had been hospitalized within the preceding two weeks, individuals with pneumonia caused by tuberculosis oraspiration pneumonia, patients with compromised immune systems, and pregnant women were excluded. The study included 100 patients with a mean age of 53.13 years (±18.31). The most common age group was 59-68 years, which included 25 (25%) cases, followed by the 69-78 yearage group with 18 (18%) cases and the 18-28 yearage group with 15 (15%) cases. The majority were male, with 61 (61%) cases. Common symptoms included fever in 78 cases (78%), chest pain in 69 cases (69%), dyspnea in 65 cases (65%), and cough in 51 cases (51%). Sputum cultures showed growth in 65 cases (65%), with Klebsiella pneumoniae being the most prevalent pathogen in 28cases (43%), followed by Streptococcus pneumoniae in 18 cases (28%). Together, these two pathogens accounted for 46 out of 65 positive samples (70%). This study highlights the clinical profile and rising etiology of K. pneumoniae in CAPin adults in Western India, particularly in the elderly. These findings underscore the need for periodic updates on CAP etiology to inform empirical treatment strategies effectively. Future research should use advanced diagnostics and diverse samples to refine CAP management, with continuous monitoring to update treatment protocols.

Controversies in the management of community-acquired pneumonia in adults.

Community-acquired pneumonia (CAP) is a common infectious syndrome in Australia and a leading global cause of morbidity and mortality. It drives a significant amount of antimicrobial prescribing in Australia. Accurate assessment and stratification of CAP severity is important. However, adequate evaluation is challenging and controversy remains about the optimal method. Streptococcus pneumoniae is the most commonly identified bacterial pathogen causing CAP. As such, oral amoxicillin monotherapy is the mainstay of empirical therapy for low-severity CAP. The need to start empirical therapy for pathogens such as Mycoplasma pneumoniae and Legionella species in low-severity CAP remains controversial; evaluating the causative pathogen on clinical grounds alone is difficult. Oral antibiotics recommended for CAP (e.g. amoxicillin, doxycycline) have excellent bioavailability and may be used instead of intravenous therapy in some hospitalised patients. A duration of 5 days of antibiotic therapy is recommended in clinical practice guidelines for patients with uncomplicated CAP who meet stability criteria at follow-up.

Role of biomarkers in community-acquired pneumonia management

Role of biomarkers in community-acquired pneumonia management

Efficacy and safety of vitamin C supplementation in the treatment of community-acquired pneumonia: a systematic review and meta-analysis with trial sequential analysis

Community-acquired pneumonia (CAP) poses a significant global health challenge, prompting exploration of innovative treatments. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of vitamin C supplementation in adults undergoing treatment for CAP. A comprehensive search of the MEDLINE, Embase, CINAHL, the Cochrane Central Register of Controlled Trials, and Clinical Trials.gov databases from inception to 17 November 2023 identified six randomized-controlled-trials (RCTs) meeting inclusion criteria. The primary outcome analysis revealed a non-significant trend towards reduced overall mortality in the vitamin C group compared to controls (RR 0.51; 95% CI 0.24 to 1.09; p = 0.052; I2 = 0; p = 0.65). Sensitivity analysis, excluding corona-virus-disease 2019 (COVID-19) studies and considering the route of vitamin C administration, confirmed this trend. Secondary outcomes, including hospital length-of-stay (LOS), intensive-care-unit (ICU) LOS, and mechanical ventilation, exhibited mixed results. Notably, heterogeneity and publication bias were observed in hospital LOS analysis, necessitating cautious interpretation. Adverse effects were minimal, with isolated incidents of nausea, vomiting, hypotension, and tachycardia reported. This meta-analysis suggests potential benefits of vitamin C supplementation in CAP treatment. However, inconclusive findings and methodological limitations warrants cautious interpretation, emphasising the urgency for high-quality trials to elucidate the true impact of vitamin C supplementation in CAP management.

Adverse outcomes in patients hospitalized with pneumonia at age 60 or more: A prospective multi-centric hospital-based study in India.

Limited data exists regarding risk factors for adverse outcomes in older adults hospitalized with Community-Acquired Pneumonia (CAP) in low- and middle-income countries such as India. This multisite study aimed to assess outcomes and associated risk factors among adults aged ≥60 years hospitalized with pneumonia. Between December 2018 and March 2020, we enrolled ≥60-year-old adults admitted within 48 hours for CAP treatment across 16 public and private facilities in four sites. Clinical data and nasal/oropharyngeal specimens were collected by trained nurses and tested for influenza, respiratory syncytial virus (RSV), and other respiratory viruses (ORV) using the qPCR. Participants were evaluated regularly until discharge, as well as on the 7th and 30th days post-discharge. Outcomes included ICU admission and in-hospital or 30-day post-discharge mortality. A hierarchical framework for multivariable logistic regression and Cox proportional hazard models identified risk factors (e.g., demographics, clinical features, etiologic agents) associated with critical care or death. Of 1,090 CAP patients, the median age was 69 years; 38.4% were female. Influenza viruses were detected in 12.3%, RSV in 2.2%, and ORV in 6.3% of participants. Critical care was required for 39.4%, with 9.9% in-hospital mortality and 5% 30-day post-discharge mortality. Only 41% of influenza CAP patients received antiviral treatment. Admission factors independently associated with ICU admission included respiratory rate >30/min, blood urea nitrogen>19mg/dl, altered sensorium, anemia, oxygen saturation <90%, prior cardiovascular diseases, chronic respiratory diseases, and private hospital admission. Diabetes, anemia, low oxygen saturation at admission, ICU admission, and mechanical ventilation were associated with 30-day mortality. High ICU admission and 30-day mortality rates were observed among older adults with pneumonia, with a significant proportion linked to influenza and RSV infections. Comprehensive guidelines for CAP prevention and management in older adults are needed, especially with the co-circulation of SARS-CoV-2.

Evaluating the utility of procalcitonin and a clinical decision support tool to determine duration of antimicrobial therapy for respiratory tract infections.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Procalcitonin (PCT) levels may play a role in decreasing the duration of antimicrobial therapy in institutions that have long durations of therapy for management of community-acquired pneumonia. We assessed the impact of the combination of pharmacist stewardship interventions assisted by a clinical decision support (CDS) tool and PCT assessment on the antimicrobial days of therapy (DOT) prescribed for respiratory tract infections (RTIs). We conducted a quasi-experimental study in which patients in the preintervention group were admitted between April and June 2021 and patients in the intervention group were admitted between April and June 2022. In the intervention phase, a CDS tool was utilized to alert clinical pharmacists when patients met specific criteria. This alert was programmed to activate for individual patients when a reported PCT level was less than 0.25ng/mL and on antimicrobials prescribed for an RTI as indicated by providers in the electronic health record. Stewardship interventions were made by pharmacists via prospective audit and feedback. The primary endpoint was inpatient antimicrobial DOT for RTIs. There were 90 patients in the preintervention group and 104 patients in the intervention group. Although baseline characteristics were not well matched between the groups, favoring the preintervention group, the median DOT was lower in the intervention group at 3 days (interquartile range [IQR], 2-4 days), compared to 4 days (IQR, 2.8-5 days) in the preintervention group (P = 0.001). The results of our study demonstrate the utility of pharmacist interventions coupled with CDS and PCT in reducing antimicrobial DOT prescribed for RTIs. Antimicrobial stewardship programs may benefit from implementing a PCT bundle.

Biomarkers: Are They Useful in Severe Community-Acquired Pneumonia?

Community acquired pneumonia (CAP) is a prevalent infectious disease often requiring hospitalization, although its diagnosis remains challenging as there is no gold standard test. In severe CAP, clinical and radiologic criteria have poor sensitivity and specificity, and microbiologic documentation is usually delayed and obtained in less than half of sCAP patients. Biomarkers could be an alternative for diagnosis, treatment monitoring and establish resolution. Beyond the existing evidence about biomarkers as an adjunct diagnostic tool, most evidence comes from studies including CAP patients in primary care or emergency departments, and not only sCAP patients. Ideally, biomarkers used in combination with signs, symptoms, and radiological findings can improve clinical judgment to confirm or rule out CAP diagnosis, and may be valuable adjunctive tools for risk stratification, differentiate viral pneumonia and monitoring the course of CAP. While no single biomarker has emerged as an ideal one, CRP and PCT have gathered the most evidence. Overall, biomarkers offer valuable information and can enhance clinical decision-making in the management of CAP, but further research and validation are needed to establish their optimal use and clinical utility.

Comparison Effects of Postural Drainage and Positive Expiratory Pressure Technique in Community Acquired Pneumonia

Background: Community-acquired pneumonia (CAP) is a major health concern worldwide, leading to substantial hospitalization and morbidity. Physiotherapy interventions like postural drainage and positive expiratory pressure (PEP) are commonly used in managing CAP, but their relative effectiveness in improving respiratory parameters is not fully understood. Objective: The study aimed to compare the effects of postural drainage and PEP techniques on respiratory parameters, specifically pH values and alveolar-arterial oxygen tension, in patients with CAP. Methods: In this randomized clinical trial, 46 patients with mild to moderate CAP were divided into two groups: postural drainage (n=23) and PEP technique (n=23). Data collection occurred pre- and post-intervention in each session, with analysis conducted using SPSS version 23. The Shapiro-Wilk test determined data normality, leading to the use of the Mann-Whitney U test for non-parametric data. Results: Improvements in oxygen saturation were observed in both groups. However, other arterial blood gas parameters, including pH and alveolar-arterial oxygen tension, showed no significant changes post-intervention. Specifically, pH values for the postural drainage group had mean ranks of 21.13, 22.04, 24.74, and 20.70 across sessions, while the PEP technique group showed mean ranks of 25.87, 24.96, 22.26, and 26.30, with p-values ranging from 0.152 to 0.525. Similarly, alveolar-arterial oxygen tension comparisons yielded p-values between 0.056 and 0.231. Conclusion: Both postural drainage and PEP techniques effectively improved oxygen saturation in CAP patients, but they did not significantly impact other respiratory parameters. This suggests their utility in specific areas of respiratory management in CAP, with limitations in broader pulmonary function improvement.

Community-Acquired Pneumonia in Children.

Community-acquired pneumonia (CAP) is the most common cause of childhood mortality globally. In the United States, CAP is a leading cause of pediatric hospitalization and antibiotic use and is associated with substantial morbidity. There has been a dramatic shift in microbiological etiologies for CAP in children over time as pneumococcal pneumonia has become less common and viral etiologies have become predominant. There is no commonly agreed on approach to the diagnosis of CAP in children. When indicated, antimicrobial treatment should consist of narrow-spectrum antibiotics. In this article, we will describe the current understanding of the microbiological etiologies, clinical presentation, diagnostic approach, risk factors, treatment, and future directions in the diagnosis and management of pediatric CAP.

39 Mind the CURB! Improving adherence to guidelines for management of community-acquired pneumonia

39 Mind the CURB! Improving adherence to guidelines for management of community-acquired pneumonia

Клинико-лабораторные предикторы тяжелой внебольничной пневмонии у детей до четырех лет

Community-acquired pneumonia (CAP) is a major cause of pediatric morbidity and mortality. Currently, there is no common approach to determination of CAP severity in children, which hampers early diagnosis and treatment of the disease. The study was aimed to determine clinical and laboratory predictors of severe CAP in children under 4 years of age. Analysis of clinical data, parameters of complete blood count (CBC), C-reactive protein (CRP) using nonparametric methods for hypothesis testing, univariate correlation analysis, cross-tabulation (Statistica 10.0), logistic regression, and ROC analysis (SPSS Statistics 20.0) was performed in 72 children aged 1 month to 3 years 11 months admitted to hospital due to CAP. Severe CAP was diagnosed in 16.7% of children. Causes of severe CAP included respiratory distress (moderate — 58.3%, severe — 16.7% of cases) and sepsis (25%). We identified significant clinical predictors of severe CAP: vomiting (OR 4.2), tachypnea (OR 28.3), chest wall retractions (OR 6), wheezing (OR 4), and the absence of rhinitis (OR 0.21). Isolated assessment of the CBC and CRP did not allow to predict CAP severity. We have developed a prediction model predicting severe CAP in children under 4 years of age based on the presence of rhinitis, tachypnea, as well as leukocyte count (sensitivity and specificity 91.7%). Thus, currently the main cause of severe CAP in children under 4 years of age is respiratory distress, in which wheezing predominates. Physical examination with an emphasis on detection of rhinitis and respiratory distress is essential for diagnosing severe CAP. The use of a pneumonia severity prediction model may contribute to improvement of management of CAP in patients under 4 years of age.

Diagnosis, treatment, and prevention of community-acquired pneumonia in children: an evidence-based clinical practice guideline adapted for the use in Egypt using ‘Adapted ADAPTE’

BackgroundWe recently adapted a guideline for Community-Acquired Pneumonia (CAP) in children to the Egyptian health system. Adaptation of evidence-based clinical practice guidelines to the local healthcare context is a valid alternative to de novo development that can upgrade their application without enforcing a major burden on resources. The objective of this manuscript is to elucidate diagnosis, treatment, and prevention of CAP as well as methods used for the adaptation process to produce the 1st National Guideline for Community-Acquired Pneumonia in children in Egypt using Adapted ADAPTE method. The full process was described extensively with all three phases of set up, adaptation, and finalization. An adaptation group and an external review including clinical content experts and methodologists conducted the process.ResultsThe authors adapted 10 principal categories of recommendations from three source Clinical Practice Guidelines. Recommendations incorporate; common clinical manifestations, indications for hospitalization and intensive care unit admission, indications for laboratory investigations and radiology in diagnosis, choice of empiric antibiotic therapy in the outpatient and hospitalized children with non-complicated CAP and the duration of therapy, the role of influenza antiviral therapy, follow-up anticipated response to therapy, management of non-responding pneumonia, criteria of safe discharge, and prevention of CAP. Many tools were gathered and established to improve implement ability containing two clinical algorithms for management of non-complicated CAP and for non-responding pneumonia in children, pathway for assessment of severity of CAP in primary care facilities, medication tables, simplified Arabic patient information, PowerPoint slide presentation lecture for management of CAP, and online resources.ConclusionThe final clinical guideline supports pediatricians and related healthcare workers with evidence-based applicable guidance for managing community-acquired pneumonia in Egypt. This work demonstrated the efficiency of Adapted ADAPTE and highlighted the importance of a cooperative clinical and methodological professional group for adaptation of national guidelines.

Considerations about antibiotic management for community-acquired pneumonia: unmet needs and future perspectives.

Considerations about antibiotic management for community-acquired pneumonia: unmet needs and future perspectives.

Severe community-acquired pneumonia: principles of diagnostics and intensive therapy

BACKGROUND. Pneumonia is an important medical and social problem due to its high prevalence, high rates of disability and mortality, and significant economic losses due to this disease. In Ukraine in 2017, the incidence of pneumonia among adults was 384.0 cases per 100,000 population, and the mortality rate was 11.7 per 100,000 population, i. e. more than 3 % of those who had pneumonia died. Community-acquired pneumonia (CAP) is the leading cause of morbidity and mortality from pneumonia among all age groups worldwide: 3-4 million people suffer from CAP with high morbidity and mortality.&#x0D; OBJECTIVE. To analyze the pathogenesis, diagnosis, and treatment of severe CAP from the modern literature data to optimize the treatment of this group of patients.&#x0D; MATERIALS AND METHODS. Bibliosemantic, comparative, and system analysis methods were used. The proposed recommendations are based on the analysis of modern literature, the results of randomized studies, and meta-analyses devoted to the investigation of the problem of diagnosis and management of severe CAP.&#x0D; RESULTS AND DISCUSSION. The problems of pathogenesis, diagnosis, and treatment of severe CAP were analyzed using modern literature data to optimize the treatment of this group of patients. CAP can be caused by various pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae, atypical bacteria (eg, Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella species), and viruses. It is quite difficult to establish the etiology of pneumonia even with the use of modern microbiological technologies, therefore, in many countries of the world, a classification is used that takes into account the conditions of the occurrence of the disease, the features of the infection of the lung tissue, as well as the immune reactivity of the patient’s organism. This classification makes it possible to predict the probable causative agent of the disease with a fairly high degree of probability. The diagnosis of CAP is considered established in the presence of radiologically confirmed focal infiltration of lung tissue and at least two of the following clinical signs: acute onset of the disease with a body temperature &gt;38 °C, cough with sputum, physical signs (muffled or dull percussion sound, weakened and/or harsh bronchial breathing, a focus of sonorous small vesicular rales and/or crepitations), leukocytosis (&gt;10×109 /L), and/or shift to rod nuclear cells (&gt;10 % of them). The severity of CAP is assessed clinically, as well as using the criteria given in the scales to determine the need for the patient to be hospitalized or admitted to the intensive care unit (ICU). Patients with CAP requiring mechanical ventilation or with septic shock should be admitted to the ICU.&#x0D; CONCLUSIONS. Severe CAP is associated with high morbidity and mortality, and although there are European and non-European guidelines for CAP, there are no specific guidelines for severe CAP. These international guidelines from ERS, ESICM, ESCMID, and ALAT present evidence-based clinical recommendations for the diagnosis, empiric treatment, and antibiotic therapy of severe CAP according to the GRADE approach. In addition, existing knowledge gaps were identified and recommendations for future research were provided.

The prognostic value of rapid risk scores among patients with community-acquired pneumonia : Aretrospective cohort study.

Community-acquired pneumonia (CAP) is afrequent reason for emergency department (ED) presentations. Various risk scores have been validated in the management of CAP and are recommended for daily practice. The aim of the study was to evaluate the performance of the rapid risk scores (the rapid acute physiology score (RAPS), the rapid emergency medicine score (REMS), the Worthing physiological scoring system (WPS), CURB-65 and CRB-65) among patients with CAP. This retrospective cohort study was conducted in the ED of atertiary hospital between 1 January 2019 and 31 December 2019. Patients aged ≥ 18years and diagnosed with CAP were included. Patients who were transferred from another center or with missing records were excluded. Demographic information, vital signs, level of consciousness, laboratory results, and outcomes were recorded. Atotal of 2057 patients were included in the final analysis. The 30-day mortality of the patients was 15.2% (n = 312). The WPS achieved the most successful results for all three outcomes, 30-day mortality, intensive care unit (ICU) admission and mechanical ventilation (MV) needs (area under the curve, AUC 0.810, 0.918, and 0.910, respectively; p < 0.001). In the prediction of mortality, RAPS, REMS, CURB-65, and CRB-65 had a moderate overall performance (AUC 0.648, 0.752, 0.778, and 0.739, respectively). In the prediction of ICU admission and MV needs, RAPS, REMS, CURB-65, and CRB-65 had moderate to good overall performance (AUC at ICU admission 0.793, 0.873, 0.829, and 0.810; AUC for MV needs 0.759, 0.892, 0.754, and 0.738, respectively). Advanced age, lower levels of mean arterial pressure and peripheral oxygen saturation, presence of active malignancy and cerebrovascular disease, and ICU admission were associated with mortality (p < 0.05). The WPS outperformed other risk scores in patients with CAP and can be used safely. The CRB-65 can be used to discriminate critically ill patients with CAP due to its high specificity. The overall performances of the scores were satisfactory for all three outcomes.

Clinical and bacteriological profile of community acquired pneumonia in hospitalized children

Community-acquired pneumonia (CAP) is the leading cause of mortality and morbidity with important clinical impact across the World. India accounts for 23 per cent of global pneumonia burden with case fatality rates between 14 and 30 per cent. Pneumonia is basically classified into typical and atypical pneumonia. Emerging evidence indicates that dual typical and atypical bacterial infections function synergistically in many cases and together likely enhance the severity of CAP. However, the optimal management of CAP in children is still not well defined and the diagnosis is challenging when based solely on clinical observations since the common symptoms of CAP, especially at an early stage, are similar to those of ordinary respiratory tract infections. So RT-PCR is a rapid and precise molecular technique is used for rapid detection of bacteria causing community acquired pneumonia. A total of 268 samples were tested for the respective bacterial pathogens, among the tested the most common pathogen was Haemophilus influenzae (18.3%, 49/268) followed by S. pneumoniae (14.6%,39/268), M. catarhallis (9.3%,25/268),M. pneumoniae (9%, 24/268), B. parapertusis (3.4%,9/268), B. pertusis (1.5%, 4/268), C. pneumoniae (1.5%, 4/268), C. burnetti (1.1%, 3/268)and L. pneumophila (0.74%, 2/268). H. influenza and S. pneumoniae were the most commonly detected organisms among the community acquired pneumonia patients.

P24 Auditing antibiotic course lengths for the management of community-acquired pneumonia and hospital-acquired pneumonia against current NICE guidance

Abstract Background Protracted antibiotic course lengths for the treatment of community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP) contribute to increased risk of antibiotic resistance.1 Optimizing antibiotic course length in line with the current national guidance improves patient safety and overall cost savings.1 NICE guidelines state that antibiotic treatment should be stopped at day 5 if patients were afebrile for &amp;lt;48 hours with one or no sign of clinical instability, defined as systolic blood pressure &amp;lt; 90 mmHg, heart rate &amp;gt; 100/minute, respiratory rate &amp;gt; 24/minute, arterial oxygen saturation &amp;lt; 90% or oxygen partial pressure &amp;gt; 60 mmHg in room air.2 Objectives To assess the current prescribing practice for antibiotic course lengths of CAP and HAP across medical specialties at RCHT. Methods A list of patients discharged from medical specialities (respiratory, cardiology, nephrology, gastroenterology, endocrinology and geriatrics) between 1 August and 1 September 2022 with the coded indication of CAP or HAP was requested from the RCHT Informatics Team. Inclusion criteria were any hospitalized patient aged ≥18 years, with a CAP/HAP diagnosis with pulmonary infiltrate on chest X-ray plus at least one symptom including cough, fever, dyspnoea and chest pain. Patients were excluded if having chronic immunosuppression; HIV positive; living in a nursing/care home, onsite subacute care unit or intensive therapy unit (ITU) or palliative care unit within last 14 days; having taken antibiotics 30 days before admission; requiring a longer duration of therapy because of an uncommon cause; requiring a chest tube or having had a condition complicated by extrapulmonary infection.1 For each patient, the patient’s vital signs at day 5 of antibiotic course and the total antibiotic course lengths were recorded. Results A total of 27 patients were assessed for eligibility; of these, 22 patients (81%) met the inclusion criteria, and 5 patients were excluded. Among those excluded, two recently stepped down from ITU, two lived in a nursing/care home and one had taken antibiotics 30 days before admission. Of the 22 patients, 10 patients (45%) received 5 or 6 days of antibiotics for CAP/HAP. The remaining 12 patients (55%) received courses between 7 to 10 days despite meeting the criteria for stopping antibiotics at 5 days. The mean and median of antibiotic course length including all specialities were 6.5 and 6.3 days, respectively. Conclusions This audit demonstrates that almost half of patients with CAP /HAP are being managed with antibiotic courses of fewer than 7 days. Further prescriber and pharmacy team education sessions on appropriate course lengths are needed. There is consideration for an alert notification on EPMA which reminds prescribers to check patient’s vital signs on day 5 when prescribed an antibiotic for the treatment of CAP and HAP. Recommendation would be to reaudit with a longer data collection timeframe and larger sample size.

Updating cut-off values of severity scoring systems for community-acquired pneumonia to orchestrate more predictive accuracy

Background: The assessment of severity is crucial in the management of community-acquired pneumonia (CAP). It remains unknown whether updating cut-off values of severity scoring systems orchestrate improvement in predictive accuracy. Methods: 3,212 patients with CAP were recruited to two observational prospective cohort studies. Three bettered scoring systems were derived from the corresponding well-established and extensively used pneumonia-specific severity scoring systems, i.e. pneumonia severity index, minor criteria and CURB-65 (confusion, urea >7 mmol/L, respiratory rate ≥30/min, low blood pressure, and age ≥65 years) score, with the updating cut-off values for tachypnea and low blood pressure. Cronbach α was employed to determine construct validity. Discrimination was valued by calculating the area under the receiver operating characteristic curve (AUROC) and net reclassification improvement (NRI). Results: Respiratory rate ≥22/min and systolic blood pressure ≤100 mm Hg were performed better than respiratory rate ≥30/min and hypotension for predicting mortality in the derivation cohort, respectively (AUROC, 0.823 vs 0.519, 0.688 vs 0.622; NRI, 0.61, 0.13). Bettered scoring systems orchestrated higher convergences, indicated by greater Cronbach α and more decrease in Cronbach α if the updating cut-off values were deleted. The six scoring systems agreed well with one another. Bettered- pneumonia severity index, minor criteria and CURB-65 score showed higher associations with severity and mortality rates and demonstrated greater predictive accuracies for mortality compared with the corresponding original systems (AUROC, 0.939 vs 0.883, 0.909 vs 0.871, 0.913 vs 0.859; NRI, 0.113, 0.076, 0.108; respectively). The validation cohort confirmed a similar pattern. Conclusions: Updating cut-off values of severity scoring systems for CAP orchestrate improvement in predictive accuracy, suggesting that it may facilitate the rationalization of clinical triage decision-making and further reduce mortality. The current studies provide the first known prospective evidence of potential benefit of the updating cut-off values of severity scoring systems for CAP in predictive accuracy. Key messages Updating cut-off values were performed better for predicting mortality. Bettered scoring systems orchestrated higher convergences. Bettered scoring systems demonstrated greater predictive accuracies for mortality.

Does etiological investigation have an impact on the outcomes of community-acquired pneumonia? – A prospective cohort study

IntroductionThere is lack of evidence that etiological investigation influences outcomes in community-acquired pneumonia (CAP). Guidelines recommend diverse approaches to this matter. Our aim was to find if etiological investigation has an impact on CAP management and outcomes. MethodsProspective cohort study, conducted over a two years’ period, in a community-based hospital, including all adult patients with CAP. Univariate and multivariate logistic regression modeling were performed to understand the association of etiological identification with CAP outcomes, particularly hospital mortality. ResultsA total of 660 cases of CAP were included, with a mean±sd age of 74±15 years and 58.9% of males. Etiology was documented in 33% of cases. Antibiotic (ATB) was modified in 148 patients, in 51 (34%) motivated by microbiological results. There was no significant impact on hospital mortality of microbiological documentation (35.5% vs 31.2%, p=0.352), or the fact that ATB was modified due to microbiological findings (27.0% vs 36.9%, p=0.272). When stratified by 3 subgroups of risk for drug-resistant pathogens (zero, one or two risk factors: being bed-ridden and/or ATB use within 90 days), etiology identification still did not influence mortality. When adjusted for CURB-65, Charlson's index, being bed-ridden, having had ATB or hospitalization within 90 days or coming from long-term care facilities, microbial identification was not associated with lower mortality. ConclusionEtiological investigation of patients with CAP does not have an association with hospital mortality, irrespective of the risk for drug-resistant pathogens.