Pneumonia Patient Outcomes Research Team Research Articles

Application of metagenomic next-generation sequencing in the diagnosis and resistome analysis of community-acquired pneumonia pathogens from bronchoalveolar lavage samples.

To perform a prospective diagnostic study exploring the clinical utility of metagenomic next-generation sequencing (mNGS) in diagnosing community-acquired pneumonia (CAP), and revealing resistome differences in bronchoalveolar lavage fluid (BALF) from CAP patients with varying severity of admission base on Pneumonia Patient Outcomes Research Team (PORT) risk classes. We compared the diagnostic performances of mNGS and conventional testing for the detection of pathogens in BALF from 59 CAP patients, and performed resistome differences analysis of metagenomic data from 59 BALF samples, namely, 25 from CAP patients with PORT score I (I group), 14 from CAP patients with PORT score II (II group), 12 from CAP patients with PORT score III (III group), and 8 from CAP patients with PORT score IV (IV group). The diagnostic sensitivities of mNGS and conventional testing for the detection of pathogens in BALF in patients with CAP were 96.6% (57/59) and 30.5% (18/59), respectively. There was a significant difference in the overall relative abundance of resistance genes between the four groups (P=0.014). The results of principal coordinate analysis based on Bray-Curtis dissimilarities showed that there were significant differences in the composition of resistance genes among the I, II, III, and IV groups (P=0.007). A large number of antibiotic resistance genes, such as those affiliated with multidrug, tetracycline, aminoglycoside, and fosfomycin resistance, were enriched in the IV group. In conclusion, mNGS has a high diagnostic value in CAP. There were significant differences present in microbiota resistance to antibiotics in BALF from CAP patients in different PORT risk classes, which should attract enough attention.

Omadacycline vs moxifloxacin in adults with community-acquired bacterial pneumonia

ObjectiveCommunity-acquired bacterial pneumonia (CABP) is a major clinical burden worldwide. In the phase III OPTIC study (NCT02531438) in CABP, omadacycline was found to be non-inferior to moxifloxacin for investigator-assessed clinical response (IACR) at post-treatment evaluation (PTE, 5–10 days after last dose). This article reports the efficacy findings, as specified in the European Medicines Agency (EMA) guidance. MethodsPatients were randomized 1:1 to omadacycline 100 mg intravenously (every 12 h for two doses, then every 24 h) with optional transition to 300 mg orally after 3 days, or moxifloxacin 400 mg intravenously (every 24 h) with optional transition to 400 mg orally after 3 days. The total treatment duration was 7−14 days. The primary endpoint for EMA efficacy analysis was IACR at PTE in patients with Pneumonia Patient Outcomes Research Team (PORT) risk class III and IV. ResultsIn total, 660 patients were randomized as PORT risk class III and IV. Omadacycline was non-inferior to moxifloxacin at PTE. The clinical success rates were 88.4% and 85.2%, respectively [intent-to-treat population; difference 3.3; 97.5% confidence interval (CI) −2.7 to 9.3], and 92.5% and 90.5%, respectively (clinically evaluable population; difference 2.0; 97.5% CI 3.2–7.4). Clinical success rates with omadacycline and moxifloxacin were similar against identified pathogens and across key subgroups. ConclusionsOmadacycline was non-inferior to moxifloxacin for IACR at PTE, with high clinical success across pathogen types and patient subgroups.

Prognostic influence of toll-like receptor 4 gene polymorphism into community-acquired pneumonia course among young patients with cytomegalovirus persistence.

Objectives:The aim of this study was to determine the predictive role of TLR4 polymorphism in CAP course among young cytomegalovirus-positive patients.Subjects and Methods:One hundred and five patients with pneumonia (age range: 18–44 years) and 61 healthy respondents were observed clinically and specifically (by cytomegalovirus markers and TLR4 + 3725 G/C polymorphism).Results:Among CAP patients, there were 51 male (48.6%) and 54 female (51.4%), with average age 34.1 ± 0.8 years, and there were 19 (18.1%) patients with Pneumonia Patient Outcomes Research Team (PORT) I, 46 (43.8%) patients with PORT II, 31 (29.5%) patients with PORT III, and 9 (8.6%) patients with PORT IV. Cytomegalovirus persistence was detected in 80 (48.2%) patients and 34 (20.5%) healthy respondents (P = 0.003). G/G genotype of TLR4 signaling was found in 78 (74%) patients with pneumonia, G/C in 24 (23%) patients, and C/C in 3 (3%) patients. Among G/C patients, there were 16.2% cytomegalovirus-positive patients versus 6.7% negative patients (P < 0.05), as well as among G/G patients, and there were 59% versus 15,2%, accordingly (P < 0.01). The patients of the main group with G/G genotype were characterized by mostly mild (PORT I – 15 [14.3%]) and moderate pneumonia severity (PORT II – 32 [30.5%] and PORT III – 26 [24.8%] patients). The patients with G/C genotype were characterized by mostly PORT II (11 [10.5%] patients). All C/C genotype patients have PORT II (P < 0.05).Conclusions:Cytomegalovirus persistence worsens the pneumonia course. G/G and G/C TLR4 genotypes are associated with mild pneumonia severity.

Year in review 2014: Lung cancer, pleural diseases, respiratory infections and tuberculosis, bronchoscopic intervention and imaging.

Year in review 2014: Lung cancer, pleural diseases, respiratory infections and tuberculosis, bronchoscopic intervention and imaging.

Ceftobiprole medocaril: a review of its use in patients with hospital- or community-acquired pneumonia.

Ceftobiprole, the active metabolite of the prodrug ceftobiprole medocaril (Zevtera(®)), is a new generation broad-spectrum intravenous cephalosporin with activity against methicillin-resistant Staphylococcus aureus. Ceftobiprole exhibits potent in vitro activity against a number of Gram-positive and Gram-negative pathogens associated with hospital-acquired pneumonia (HAP) and community-acquired pneumonia (CAP). It is the first cephalosporin monotherapy approved in the EU for the treatment of both HAP (excluding ventilator associated-pneumonia [VAP]) and CAP. In phase III trials, ceftobiprole medocaril was noninferior, in terms of clinical cure rates at the test-of-cure visit, to ceftazidime plus linezolid in patients with HAP and to ceftriaxone±linezolid in patients with CAP severe enough to require hospitalization. In patients with HAP, noninferiority of ceftobiprole medocaril to ceftazidime plus linezolid was not demonstrated in a subset of patients with VAP. In patients with CAP, ceftobiprole medocaril was effective in those at risk for poor outcomes (pneumonia severity index ≥91, Pneumonia Patient Outcomes Research Team score IV-V or bacteraemic pneumonia). In the phase III trials, ceftobiprole medocaril was generally well tolerated, with ≈10% of patients discontinuing the treatment because of adverse events. The most common treatment-related adverse events occurring in ceftobiprole recipients in the trials in patients with HAP or CAP included nausea, diarrhoea, infusion site reactions, vomiting, hepatic enzyme elevations and hyponatraemia. Therefore, ceftobiprole medocaril monotherapy offers a simplified option for the initial empirical treatment of patients with HAP (excluding VAP) and in those with CAP requiring hospitalization.

Predictors of the pathogenicity of methicillin-resistant Staphylococcus aureus nosocomial pneumonia.

The clinical characteristics of patients with nosocomial pneumonia (NP) associated with methicillin-resistant Staphylococcus aureus (MRSA) infection are not well characterized. Three hundred and thirty-seven consecutive patients with MRSA isolation from respiratory specimens who attended our hospital between April 2007 and March 2011 were enrolled. Patients characteristics diagnosed with 'true' MRSA-NP were described with regards to clinical, microbiological features, radiological features and genetic characteristics of the isolates. The diagnosis of 'true' MRSA-NP was confirmed by anti-MRSA treatment effects, Gram-staining or bronchoalveolar lavage fluid culture. Thirty-six patients were diagnosed with 'true' MRSA-NP, whereas 34 were diagnosed with NP with MRSA colonization. Patients with a MRSA-NP had a Pneumonia Patient Outcomes Research Team score of 5 (58.3% vs 23.5%), single cultivation of MRSA (83.3% vs 38.2%), MRSA quantitative cultivation yielding more than 10(6) CFU/mL (80.6% vs 47.1%), radiological findings other than lobar pneumonia (66.7% vs 26.5%), and a history of head, neck, oesophageal or stomach surgery (30.6% vs 11.8%). These factors were shown to be independent predictors of the pathogenicity of 'true' MRSA-NP by multivariate analysis (P < 0.05). 'True' MRSA-NP shows distinct clinical and radiological features from NP with MRSA colonization.

Risk Stratification for Cardiac Complications in Patients Hospitalized for Community-Acquired Pneumonia

To derive and validate a clinical rule that stratifies the risk of cardiac complications in patients hospitalized for community-acquired pneumonia (CAP) and compare its performance to the pneumonia severity index (PSI) score. Two cohorts of patients hospitalized for CAP were selected for the study. We used regression techniques in the derivation cohort (1343 patients enrolled in the Pneumonia Patient Outcomes Research Team study between October 1991 and March 1994) to generate a prediction rule that we validated in the validation cohort (608 patients enrolled in the Dissemination of Guidelines for Length of Stay study between February 1998 and March 1999). Discrimination and reclassification analyses compared its performance against the PSI score. A prediction model for cardiac complications in the derivation cohort included age, 3 preexisting conditions, 2 vital signs, and 7 common laboratory or radiographic parameters. Discrimination (C statistic, 0.81; 95% CI, 0.78-0.84) and calibration (Hosmer-Lemeshow goodness-of-fit test, χ(2)=13.0; P=.11) were good. We derived a point score system from this model that when applied to the validation cohort also had good discrimination (C statistic, 0.78; 95% CI, 0.74-0.83) and calibration (Hosmer-Lemeshow, χ(2)=9.0; P=.34). On the basis of this score, we defined 4 categories of incremental risk of cardiac complications. The incidence of cardiac complications across risk categories increased linearly (from lowest to highest) in both the derivation (3.0%, 17.8%, 35.2%, and 72.2%) and validation (5.0%, 8.2%, 28.3%, and 48.9%) cohorts (Cochran-Armitage linear trend test, P<.01). The new score outperformed the PSI score in predicting cardiac complications in the validation cohort (C statistic, 0.78 vs 0.74; P=.03; proportion of patients correctly reclassified by the new score, 44%). We derived and validated a clinical rule that accurately stratifies the risk of cardiac complications in patients hospitalized for CAP.

The Impact of Statin and Macrolide Use on Early Survival in Patients With Pneumococcal Pneumonia

BackgroundMortality in pneumococcal pneumonia remains high despite early antibiotic eradication of bacteria. Most deaths occur within the first week, the time of peak inflammatory responses. Statins and macrolides have broad immunosuppressive activity; their impact, separately and together, on survival in patients with pneumococcal pneumonia was evaluated. MethodsAll patients with pneumococcal pneumonia seen at a single medical center from 2000 through 2010 were included in this retrospective cohort study. A multivariate-adjusted Cox proportional hazard model was used to evaluate survival. ResultsOf 347 patients with pneumococcal pneumonia, 90 (26%) were taking a statin at presentation and 126 (36%) were started on treatment with a macrolide. Thirty-two (9%) statin users were treated with a macrolide. Statin users were older than non-statin users, with a higher prevalence of diabetes, coronary artery disease and chronic kidney disease and a lower prevalence of alcohol consumption and liver disease. Statin users had higher mean Pneumonia Patient Outcomes Research Team scores. Patients treated with a macrolide were not different from those who received other antibiotics. The risk of mortality among statin users was reduced at 7, 14, 20 and 30 days after admission. Mortality was not reduced in patients treated with a macrolide or with a macrolide plus a statin compared with those who did not receive a macrolide. ConclusionsPatients who are receiving statins at the time of admission for pneumococcal pneumonia have better clinical outcomes than those who are not. Treatment with a macrolide does not appear to confer a survival benefit.

Early switch therapy from intravenous sulbactam/ampicillin to oral garenoxacin in patients with community-acquired pneumonia: a multicenter, randomized study in Japan

The switch from intravenous to oral antibiotic therapy is recommended for treating hospitalized patients with community-acquired pneumonia (CAP). We performed a multicenter, randomized study to assess the benefit of switching from intravenous sulbactam/ampicillin (SBT/ABPC) to oral garenoxacin (GRNX) in patients with CAP. Among adult CAP patients who must be hospitalized for intravenous antibiotic treatment, those with Pneumonia Patient Outcomes Research Team (PORT) scores of II-IV (mild to moderate) were initially treated with intravenous SBT/ABPC (6 g/day) for 3 days. A total of 108 patients who fulfilled the inclusion criteria (improved respiratory symptoms, CRP < 15 mg/dl, adequately improved oral intake, fever ≤ 38 °C for ≥ 12 h), were divided into two groups based on the antibiotic administered, the GRNX (switch to GRNX 400 mg/day) and SBT/ABPC groups (continuous administration of SBT/ABPC), for 4 days. Improvement in clinical symptoms, chest radiographic findings, and clinical effectiveness were evaluated by a central review board. Improvement in clinical symptoms was 96.3 and 90.2% in the GRNX and SBT/ABPC groups, respectively. Improvement in chest radiographic findings was 94.4 and 90.2% and clinical effectiveness was 94.4 and 90.2% in the GRNX and SBT/ABPC groups, respectively. Microbiological efficacy was 90.9 and 69.2% in the GRNX and SBT/ABPC groups, respectively. There were no significant differences between the groups. Converting to GRNX was as effective as continuous SBT/ABPC treatment in mild to moderate CAP patients in whom initial intravenous antibiotic treatment was successful.

A multicenter analysis of the ED diagnosis of pneumonia

Objectives The objective of this study was to describe the prevalence of pneumonia-like signs and symptoms in patients admitted from the emergency department (ED) with a diagnosis of community acquired pneumonia (CAP) but subsequently discharged from the hospital with a nonpneumonia diagnosis. Methods A retrospective, structured, chart review of ED patients with CAP at 3 academic hospitals was performed by trained extractors on all adult patients admitted for CAP. Demographic data, Pneumonia Patient Outcomes Research Team scores, and discharge diagnosis data ( International Classification of Diseases, Ninth Revision [ ICD-9] codes) were extracted using a predetermined case report form. Results A total of 800 patients were admitted from the ED with a diagnosis of CAP from the 3 hospitals, and 219 (27.3%; 95% confidence interval [CI], 24-31) ultimately had a nonpneumonia diagnosis upon discharge. Characteristics of this group included a mean age of 62.6 years, 50% female, and a history of congestive heart failure (CHF) (14%) or cancer (12%). After excluding patients with missing data, 123 patients (65%) had an abnormal chest x-ray, and 13% had abnormal oxygen saturation. Cough, sputum production, fever, tachypnea, or leukocytosis were present in 91.5% of this cohort, and 63.8% had at least 2 of these findings. Twenty alternate ICD-9s were identified, including non-CAP pulmonary disease (18%; 95% CI, 13-24), renal disease (16%; 95% CI, 13-19), other infections (9%; 95% CI, 7-11), cardiovascular diseases (3%; 95% CI, 2-4), and other miscellaneous diagnosis (28%; 95% CI, 25-31). Conclusions Our data suggest that the ED diagnosis of CAP frequently differs from the discharge diagnosis. This may be due to the fact that a diagnosis of CAP relies on a combination of potentially nonspecific clinical and radiographic features. New diagnostic approaches and tools with better specificity are needed to improve ED diagnosis of CAP.

Overview of Recent Studies of Community‐Acquired Pneumonia

All recent studies of antibacterial drugs for the indication of community-acquired pneumonia submitted to the US Food and Drug Administration have been designed as noninferiority studies. We provide a summary of results of 7 recent clinical studies of oral antibacterial drugs for treatment of community-acquired pneumonia. In these 7 studies, the majority of patients enrolled had Pneumonia Patient Outcomes Research Team scores of I or II. The percentage of randomized subjects with pathogens identified at baseline ranged from 47% to 76%, and the percentage of subjects with Streptoccocus pneumoniae isolated at baseline ranged from approximately 6% to 20%. The primary end point in these studies was clinical cure, assessed 7-21 days after completion of therapy. Clinical cure rates were >80% in the intent-to-treat populations and >90% in the per-protocol populations. We also briefly summarize the results from several recently submitted clinical studies of intravenously administered antibacterial drugs for treatment of community-acquired pneumonia, in which we found similar results.

Simple criteria to assess mortality in patients with community-acquired pneumonia

The Pneumonia Patient Outcomes Research Team (PORT) developed a prediction rule to identify patients with community-acquired pneumonia (CAP) who are at risk for death and other adverse outcomes. Simpler criteria are needed to evaluate risk of mortality in CAP. Observational study of patients with CAP admitted to a tertiary care university hospital. Epidemiological, clinical, radiological and laboratory data associated with mortality were analysed. A cohort of 211 patients with CAP was studied. Severity distribution according to PORT score was 12.3%, 15.6%, 19%, 35.5% and 17.5% in groups I, II, III, IV and V, respectively; mean age was 63 years (range, 13 to 100 years); in 43.6% age was < 65 years; 61.5% patients had > or = 1 underlying disease (congestive heart failure in 33.6% and chronic lung disease in 29.9%). Mortality rate was 0% in groups I-II, 2.5% in group III, 5.3% in group IV and 27% in group V. All variables considered in PORT-score were included in a mortality predicting model; factors significantly associated with death were: altered mental status, respiratory rate > or = 30/min, pH < 7.35, glucose > or = 250 mg/dl and age > 65 years; 99% of patients who had none of these abnormalities survived. Simpler criteria to assess mortality in CAP were identified. Non-existence of altered mental status, respiratory rate > or = 30/min, pH < 7.35, glucose > or = 250 mg/dl and age > 65 years predicted a non-fatal outcome in 99% of patients. These clinical or laboratory findings should be considered as mortality predictors, can be used as severity adjustment measure and may help physicians make more rational decisions about hospitalization in CAP.

Severe Sepsis in Community-Acquired Pneumonia: When Does It Happen, and Do Systemic Inflammatory Response Syndrome Criteria Help Predict Course?

<h3>Study objectives</h3> Most natural history studies of severe sepsis are limited to ICU populations. We describe the onset and timing of severe sepsis during the hospital course for patients hospitalized with community-acquired pneumonia (CAP). We also determine the ability of the systemic inflammatory response syndrome (SIRS) and other proposed risk stratification scores measured at emergency department (ED) presentation to predict progression to severe sepsis, septic shock, or death. <h3>Design</h3> Retrospective analysis of a prospective observational outcome study from the Pneumonia Patient Outcomes Research Team (PORT). <h3>Setting</h3> Four academic medical centers in the United States and Canada between October 1991 and March 1994. <h3>Participants</h3> The 1,339 patients hospitalized for CAP in the PORT study cohort, and a random subset of 686 patients for whom we had information for SIRS criteria. <h3>Interventions</h3> None. <h3>Measurements and results</h3> All subjects had infection (CAP). Severe sepsis was defined as new-onset acute organ dysfunction in this cohort, using consensus criteria. Severe sepsis developed in one half of the patients (n = 639, 48%), nonpulmonary organ dysfunction developed in 520 patients (39%), and septic shock developed in 61 subjects (4.5%). Severe sepsis and septic shock were present at ED presentation in 457 patients (71% of severe sepsis cases) and 27 patients (44% of septic shock cases), respectively. While SIRS was common at presentation (82% of the subset of 686 had two SIRS criteria), it was not associated with increased odds for progression to severe sepsis (odds ratios [ORs], 0.65 and 0.89 for two or more SIRS criteria and three or more SIRS criteria, respectively), septic shock (ORs, 0.80 and 0.55), or death (ORs, 0.65 and 0.39), with poor discrimination (all receiver operating characteristic [ROC] areas under the curve < 0.5). The pneumonia severity index was associated with severe sepsis (p < 0.001) with moderate discrimination (ROC, 0.63). <h3>Conclusions</h3> Severe sepsis is common in hospitalized CAP patients, occurring early in the hospital course. SIRS criteria do not appear to be useful predictors for progression to severe sepsis in CAP.

Do fluoroquinolones actually increase mortality in community-acquired pneumonia?

I read with interest the report by Mortensen and coworkers [1], who found the use of initial empiric antimicrobial therapy with a β-lactam and a fluoroquinolone to be associated with increased short-term mortality in patients with severe community-acquired pneumonia (CAP) compared with other guideline-concordant antimicrobial regimens. However, the study has a number of limitations other than those stated by the authors. First and foremost, almost 51% of the patients had a PORT (Pneumonia Patient Outcomes Research Team) score of 1–4 and did not meet the inclusion criteria as specified by the authors. Second, almost 9% of the patients received antibiotics after 8 hours, which alone is known to influence outcomes in patients with pneumonia. Two large studies showed that antibiotic administration within 4 hours [2] and 8 hours [3] of arrival in the hospital was associated with decreased mortality and length of stay. It is possible that this group of patients who received treatment after 8 hours was composed entirely of those who received fluoroquinolones, thus accounting for the adverse outcomes with this treatment. Another important point pertains to the choice of antibiotic; almost 25% of the patients in the study received piperacillin–tazobactam for CAP. This treatment should be reserved for serious hospital-acquired infections, and routinely is not necessary for management of CAP except in situations where Pseudomonas aeruginosa infection is suspected [4]. Using inappropriate antibiotics in such situations has increased the incidence of expanded-spectrum β-lactamases, which are resistant to multiple classes of antibiotics [5].

Epidemiology of community-acquired pneumonia in adult patients at the dawn of the 21st century: a prospective study on the Mediterranean coast of Spain

This study presents data from a prospective study of adult patients with community‐acquired pneumonia (CAP). Of 493 patients included in the study, 223 (45.2%) were aged ≥ 65 years, and 265 (53.7%) had one or more underlying diseases, mostly chronic obstructive pulmonary disease, diabetes mellitus or dementia. In total, 281 microorganisms were identified in 250 (50.7%) patients, with two or more pathogens detected in 28 (5.7%) cases. Microbial diagnosis varied according to age, severity, co‐morbidity and site‐of‐care, but there was much overlap among groups. Streptococcus pneumoniae was the single most prevalent organism in outpatients, patients admitted to hospital, and patients who died, either as a single pathogen or combined with another organism. Infections caused by ‘atypical’ pathogens were seen across all groups, including the elderly and patients with co‐morbidities. Mortality varied according to the pneumonia severity index (PSI) of the pneumonia patient outcomes research team. Shock (OR 34.48), an age of > 65 years (OR 25) and altered mental status (OR 9.92) were factors associated independently with 30‐day mortality. Key findings from this study were the advanced age of the population with CAP, and the high prevalence of dementia as an underlying disease. The study also revealed that microbiological diagnosis of CAP remains problematic. Although certain epidemiological features may help to predict the microbial aetiology, the overlap among groups reduces the usefulness of this information in guiding therapeutic decisions. Greater effort should be made to improve identification methods for microbial pathogens causing CAP.

Early Administration of Antibiotics Does Not Shorten Time to Clinical Stability in Patients With Moderate-to-Severe Community-Acquired Pneumonia

To determine if there is a statistically significant difference in the time to clinical stability (TCS) between those patients with moderate-to-severe (MTS) community-acquired pneumonia (CAP) who received their antibiotics within 4 h and those who received their antibiotics after 4 h. Prospective observational study. A large metropolitan teaching institution with 62,000 annual emergency department visits from May 1999 through January 2001. Patients were > or = 21 year with MTS CAP as defined by the Pneumonia Patient Outcomes Research Team (PORT). Triage-to-needle time (group 1, 0 to 240 min; group 2, 241 to 480 min; and group 3, > 480 min) was the independent variable, and TCS was the dependent variable. Our hypothesis was that door-to-needle time < 4 h would result in TCS reduction of 0.5 days. Statistical analysis was performed using the two-tailed Student t test, analysis of variance, and multiple linear regression; p < 0.05 was considered significant. Four hundred nine patients with MTS CAP achieved clinical stability during their hospital stay. Fifty-four percent of patients received antibiotics within 4 h. The mean time to receiving antibiotics was 131.46 min (2.19 h) in group 1, 335.52 min (5.59 h) in group 2, and 783.98 min (13.07 h) in group 3. Mean TCS was 3.19 days in group 1, 3.16 days in group 2, and 3.29 days in group 3. There were no statistically significant differences in TCS between the study groups. The administration of antibiotics within 4 h does not reduce the TCS in adult patients with MTS-CAP, as defined by the PORT group. Future studies using other physiologic parameters should be explored.

Community-acquired Pneumonia (CAP) Decision Guidelines: Are the Pneumonia Patient Outcomes Research Team (PORT) Guidelines a Reliable Tool for Predicting Morbidity in the Immunosuppressed (IS) Population?

Community-acquired Pneumonia (CAP) Decision Guidelines: Are the Pneumonia Patient Outcomes Research Team (PORT) Guidelines a Reliable Tool for Predicting Morbidity in the Immunosuppressed (IS) Population?

Factors Influencing the Hospital Admission Decision of Low-Risk Patients with Community Acquired Pneumonia: Evaluating the Usefulness of a Prediction Rule

Introduction The Pneumonia Patient Outcomes Research Team (PORT) derived and validated a Prediction Rule to identify low-risk patients with community-acquired pneumonia (CAP).1 This prediction rule was implemented in the Accident &amp; Emergency (A&amp;E) Department of Prince of Wales Hospital to help select patients suitable for outpatient treatment. Materials &amp; Methods A retrospective study of all cases of CAP admitted from A&amp;E, age above 14, over a six-month period (the period of implementation of the Prediction Rule) was performed. Patients belonging to the low-risk categories were identified after review of the records. Factors likely to influence the admission decision were noted. Descriptive statistics was generated. Results Eighty-five patients were identified, 61 (71.8%) females and 24 (28.2%) males. The mean age was 59.1 years (±17.3 years, SD). Fifty-three (62.3%) patients had at least one significant comordid condition (e.g. chronic lung disease, diabetes). Of the remaining patients, 20 (23.5%) had at least one identifiable factor (e.g. haemoptysis, multilobar infiltrates in chest radiograph) influencing the hospitalisation decision; and only 12 (14.1%) had no reason, identifiable retrospectively, to justify hospitalised care. Conclusions A substantial number of low-risk patients with CAP (classified according to the Prediction Rule) were admitted. Most of these patients had identifiable comorbid conditions and prognostic factors that had not been accounted for by the Prediction Rule guidelines. Further evaluation of the significance of these additional variables is required in order to give the guidelines a better predictive value.

Community-Acquired Pneumonia

We initiated a prospective study with a group of practitioners to assess the etiology, clinical presentation, and outcome of community-acquired pneumonia in patients diagnosed in the outpatient setting. All patients with signs and symptoms suggestive of pneumonia and an infiltrate on chest X-ray underwent an extensive standard workup and were followed over 4 weeks. Over a 4-year period, 184 patients were eligible, of whom 170 (age range, 15-96 yr; median, 43 yr) were included and analyzed. In 78 (46%), no etiologic agent could be demonstrated. In the remaining 92 patients, 107 etiologic agents were implicated: 43 were due to "pyogenic" bacteria (39 Streptococcus pneumoniae, 3 Haemophilus spp., 1 Streptococcus spp.), 39 were due to "atypical" bacteria (24 Mycoplasma pneumoniae, 9 Chlamydia pneumoniae, 4 Coxiella burnetii, 2 Legionella spp.), and 25 were due to viruses (20 influenza viruses and 5 other respiratory viruses). There were only a few statistically significant clinical differences between the different etiologic categories (higher age and comorbidities in viral or in episodes of undetermined etiology, higher neutrophil counts in "pyogenic" episodes, more frequent bilateral and interstitial infiltrates in viral episodes). There were 2 deaths, both in patients with advanced age (83 and 86 years old), and several comorbidities. Only 14 patients (8.2%) required hospitalization. In 6 patients (3.4%), the pneumonia episode uncovered a local neoplasia. This study shows that most cases of community-acquired pneumonia have a favorable outcome and can be successfully managed in an outpatient setting. Moreover, in the absence of rapid and reliable clinical or laboratory tests to establish a definite etiologic diagnosis at presentation, the spectrum of the etiologic agents suggest that initial antibiotic therapy should cover both S. pneumoniae and atypical bacteria, as well as possible influenza viruses during the epidemic season.

Community-Acquired Pneumonia

Community-Acquired Pneumonia