Primary Diagnosis Of Community-acquired Pneumonia Research Articles

Impact of inhaled corticosteroid use on outcome in COPD patients admitted with pneumonia

The aim of this study was to investigate whether inhaled corticosteroid (ICS) use affects outcome in patients with chronic obstructive pulmonary disease (COPD) admitted with community-acquired pneumonia (CAP). This was a prospective, observational study of patients with spirometry-confirmed COPD presenting with a primary diagnosis of CAP in Lothian, UK. Outcome measures were compared between ICS users and non-ICS users. Of 490 patients included in the study, 76.7% were classified as ICS users. ICS users had higher Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage compared with non-ICS users (mean ± sd 3.2 ± 0.8 versus 2.6 ± 0.9; p<0.0001). There were no significant differences in pneumonia severity (mean ± sd Pneumonia Severity Index (PSI) 4.2 ± 0.8 versus 4.3 ± 0.8 (p = 0.3); mean ± sd CURB-65 score 2.1 ± 1.3 versus 2.3 ± 1.3 (p = 0.07)) or markers of systemic inflammation (median C-reactive protein 148 (interquartile range 58-268) mg·L(-1) versus 183 (IQR 85-302) mg·L(-1); p = 0.08) between ICS users and non-ICS users. On multivariable analysis, after adjustment for COPD severity and PSI, ICS use was not independently associated with 30-day mortality (OR 1.71, 95% CI 0.75-3.90; p = 0.2), 6-month mortality (OR 1.62, 95% CI 0.82-3.16; p = 0.2), requirement for mechanical ventilation and/or inotropic support (OR 0.73, 95% CI 0.33-1.62; p = 0.4) or development of complicated pneumonia (OR 0.71, 95% CI 0.25-1.99; p = 0.5). Prior ICS use had no impact on outcome in patients with COPD admitted with CAP.

Human rhinovirus C infections mirror those of human rhinovirus A in children with community-acquired pneumonia

Background Human rhinoviruses (HRVs) are among the most common causes of community-acquired pneumonia (CAP) in children. However, the differential roles of the three HRV species HRV-A, HRV-B, and HRV-C in pediatric CAP are not fully understood. Objective To determine the distribution of HRV species and their roles in children hospitalized with CAP in Beijing, China. Study design Nasopharyngeal aspirates were collected between April 2007 and March 2008 from 554 children with a primary diagnosis of CAP. HRVs in the clinical samples were detected by RT-PCR and by sequencing. Infections with other respiratory viruses were identified by PCR. Results HRVs were detected in 99 patients (17.87%). Among these patients, 51.52% tested positive for HRV-A, 38.38% for HRV-C, and 10.10% for HRV-B. HRVs were detected throughout the study period. The monthly distribution of HRV infections varied with HRV species. Median age, gender, symptoms, severity, and duration of hospitalization for single HRV-C infections were similar to those observed for single HRV-A infections. Co-infections with other respiratory viruses were detected in 57.58% of the HRV-positive children. HRV/RSV dual infections were correlated with a higher frequency of shortness of breath (HRV-A group, P 2tail = 0.01; HRV-C group, P 2tail = 0.015) and lower median ages (HRV-A group, P 2tail = 0.049; HRV-C group, P 2tail = 0.009). Conclusion Our study shows that HRV-C strains circulate at a prevalence intermediate between HRV-A and HRV-B. The severity of clinical manifestations for HRV-C is comparable to that for HRV-A in children with CAP. These findings point to an important role of both HRV-A and HRV-C in pediatric CAP.

Admission hypoglycaemia is associated with adverse outcome in community-acquired pneumonia

The aim of our study was to investigate if hypoglycaemia correlates with outcome in community-acquired pneumonia (CAP). We performed a prospective, observational study of consecutive patients presenting with a primary diagnosis of CAP in Lothian (UK). Admission plasma glucose was measured and, on this basis, patients were divided into two groups, hypoglycaemic (<4.4 mmol x L(-1) or <79.0 mg x dL(-1)) and nonhypoglycaemic (> or = 4.4 mmol x L(-1) or > or = 79.0 mg x dL(-1)). Outcomes of interest were 30-day mortality, need for mechanical ventilation and inotropic support. Multivariable logistic regression was used to compare these outcomes in hypoglycaemic patients to nonhypoglycaemic patients, adjusting for diabetes mellitus, prior statin use and Pneumonia Severity Index. In total, 1,050 patients were included in the study with 5.4% classified as hypoglycaemic. Increased rates of 30-day mortality (28.1% versus 7.5%, p<0.0001), need for mechanical ventilation (29.8% versus 6.5%, p<0.0001) and need for inotropic support (21.1% versus 4.8%, p<0.0001) were observed in hypoglycaemic patients compared with nonhypoglycaemic patients. On multivariable analysis, hypoglycaemia was independently associated with increased 30-day mortality (OR 2.25, 95% CI 1.1-4.7; p = 0.03), need for mechanical ventilation (OR 3.8, 95% CI 1.9-7.5; p = 0.0002) and need for inotropic support (OR, 2.9, 95% CI 1.4-6.3; p = 0.0006). Admission hypoglycaemia is associated with increased 30-day mortality, need for mechanical ventilation and inotropic support in patients presenting with CAP.

Treatment failure rates and health care utilization and costs among patients with community-acquired pneumonia treated with levofloxacin or macrolides in an outpatient setting: A retrospective claims database analysis

Background: Macrolide antibiotics and fluoroquinolones are extensively used in the treatment of community-acquired pneumonia (CAP).Objective: This analysis was conducted to compare treatment failure rates and health care utilization and cost outcomes among patients with CAP treated with levo-floxacin (500 or 750 mg) or macrolides (azithromycin, clarithromycin, or erythromycin) in an outpatient setting.Methods: This was a retrospective analysis of claims data from a large US health plan. Patients were aged ≥18 years and had a primary diagnosis of CAP that was treated with oral levofloxacin or a macrolide in an outpatient setting (including physicians' offices, outpatient clinics, urgent care centers, and large ambulatory health centers). Patients were followed for 30 days after the index drug date to measure study outcomes. Multivariate regression analysis and a propensity score technique were used to compare rates of treatment failure and CAP-related health care utilization and costs. Two post hoc subgroup analyses were conducted in patients aged ≥50 and ≥65 years.Results: Of the 7526 patients meeting the inclusion criteria, 2968 (39.4%) were treated with levofloxacin and 4558 (60.6%) with a macrolide. Unadjusted rates of treatment failure were 21.1% and 22.7% in the levofloxacin and macrolide cohorts, respectively. After adjustment for demographic characteristics, baseline comorbidities, and severity of illness, levofloxacin recipients were significantly less likely to experience treatment failure than macrolide recipients (odds ratio [OR] = 0.84; 95% CI, 0.75-0.94, P = 0.003). The likelihood of treatment failure was significantly lower in levofloxacin recipients aged ≥50 years (OR = 0.79; 95% CI, 0.66–0.94; P = 0.007) and ≥65 years (OR = 0.65; 95% CI, 0.43–1.00; P = 0.049) compared with the corresponding subgroups of macrolide recipients. The magnitude of this difference was greatest in the subgroup aged ≥65 years, which had a 35% reduced risk of treatment failure compared with the corresponding group of macrolide-treated patients. The rate of CAP-related emergency department visits was significantly lower among patients receiving levofloxa-cin (OR = 0.68; 95% CI, 0.51–0.91; P = 0.009); there were no differences in CAP-related hospitalizations or total CAP-related health care costs between levofloxa-cin and macrolide recipients.Conclusions: Multivariate-adjusted rates of treatment failure in outpatients with CAP were significantly lower in those treated with levofloxacin relative to those treated with a macrolide. The lower rates of treatment failure with levofloxacin were consistently observed across all patients and in the subgroups aged ≥50 and ≥65 years. Rates of emergency department visits were also significantly lower among levofloxacin-treated patients, whereas overall CAP-related hospitali-zations and costs did not differ significantly between the 2 treatment groups.

A teaching hospital's experience applying the Pneumonia Severity Index and antibiotic guidelines in the management of community‐acquired pneumonia

The Pneumonia Severity Index (PSI) was developed to predict mortality in community-acquired pneumonia (CAP). It has been prospectively validated to identify patients who are at low risk of death and thereby aid in the selection of patients for outpatient management. This study assessed the compliance of medical staff at a university teaching hospital with the use of the PSI and the PSI-based local antibiotic guidelines in admitted patients. This was a retrospective study of 137 consecutive adults admitted with a primary diagnosis of CAP between July and December 2003. Implementation of the PSI and local antibiotic guidelines occurred 4 months prior to the study period. The data collected included patient demographics, PSI parameters, patient outcomes, adherence and compliance with the PSI scoring process and local antibiotic guidelines. Forty per cent of all CAP admissions were patients in PSI Class I to III. The compliance with scoring the PSI was low (45 out of 137 patients; 33%), as was the accuracy of the PSI scoring (26 out of 45 patients; 58%). Compliance with the local antibiotic guidelines was 87% in patients in whom the PSI was performed. In admitted patients, non-adherence with the PSI admission guidelines was common. Compliance with scoring the PSI and its scoring accuracy was low. This may be due to a lack of awareness and its relative complexity. Further studies to identify potential barriers to compliance are warranted.

Characterizing and developing strategies for the treatment of community-acquired pneumonia at a community hospital.

Patients admitted to Lions Gate Hospital, North Vancouver, British Columbia, with a primary diagnosis of community-acquired pneumonia (CAP) have a mean length of stay (LOS) of 9.1 days compared with 7.9 days for peer group hospitals. This difference of 1.2 days results in an annual potential savings of 406 bed days and warranted an investigation into the management of CAP. To characterize and provide recommendations for the management of CAP. A retrospective chart review of patients admitted with a primary diagnosis of CAP between May 1, 2000 and August 31, 2000. Fifty-one patients were included in the study, with a mean LOS of 9.9 days and a median LOS of five days. Based on pneumonia severity index scores calculated for each patient, eight patients (16%) were admitted inappropriately. Initial empirical antibiotic choices were consistent with the Canadian CAP guidelines in 27 patients (53%), with inconsistencies arising mainly because cephalosporin or azithromycin monotherapy regimens were prescribed. Step-down from intravenous to oral antibiotics occurred in approximately 20 patients (39%). An additional 12 patients (24%) could have undergone step-down, and step-down was not applicable in 19 patients (37%). The potential annual cost avoidance from implementing admission criteria based on a pneumonia severity index score, applying step-down criteria and promoting early discharge criteria was estimated to be $220,000. Considerable variability exists in the treatment of CAP. A CAP preprinted order sheet was developed to address the issues identified in the present study and provide consistency in the management of CAP at Lions Gate Hospital.

CONTINUOUS VS. INTERMITTENT INFUSION OF CEFUROXIME FOR THE TREATMENT OF COMMUNITY-ACQUIRED PNEUMONIA

There is increasing interest in the clinical utility and pharmacoeconomic benefits of continuous infusion (CI) therapy with β-lactam antibiotics because this form of therapy may be as efficacious as and less costly than intermittenl infusion (II) therapy. We investigated the efficacy, pharmacokinetics, and pharmacocconomics of CI cefuroxime therapy in adult patients with a primary diagnosis of community-acquired pneumonia (CAP) who were admitted to a 800-bed community teaching hospital. Twenty-five patients with CAP who received 750 or l500 mg of cefuroxime per day by CI were compared with 25 patients given 750 mg of cefuroxime three times daily by II. Clinical cure or improvement at the end of the course of intravenous therapy and 30 clays later occurred in 23/24 and 21/22 evaluable patients in the II and CI groups, respectively. Steady-slate serum cefuroxime concentrations in CI patients were 13.25 ± 6.29 μg/mL. These concentrations are more; than two to lour limes the MIC90 values of the bacterial pathogens typically associated with CAP. The mean (± SD) total amount of intravenous drug used (II group, 8021 ± 3444 mg; CI group, 5953 ± 3210 mg; P = .04) and cost of the drug, labor, and supplies (II group, $83.85 ± $34.82; CI group, $63.64 ± $30.95; P = .04) were less in the CI group. Duration of inpalienl antimicrobial therapy and length of hospital stay tended to be shorter in the CI group, by 14.7 and 11.6 hours, respectively (P = not significant). The duration of outpatient oral therapy was longer in the CI group (P = .05). Consequently, there was a tendency toward shorter duration of inpalienl therapy and longer duration of outpatient therapy in the CI group. These data support CI celuroxime therapy as a pharmacody-namically sound and pharmacoeconomically beneficial alternative to II therapy in the treatment of CAP. However, randomized controlled trials may be warranted to verify the equivalence of efficacy between treatment regimens.

The cost of treating community-acquired pneumonia

Community-acquired pneumonia (CAP) is responsible for an average of 4.5 million visits annually to physicians' offices, emergency departments, and outpatient clinics. However, there have been few studies using national data on the costs of treating CAP. Without such data, it is difficult to assess whether new therapies and treatment strategies are needed to improve patient outcomes. We conducted a retrospective analysis based on national incidence data and paid claims data for patients treated for CAP to assess the frequency of services rendered and costs to the health-care system. Records were selected for the study based on a primary diagnosis of CAP according to the International Classification of Diseases, 9th Revision. Incidence data were derived from the National Health and Nutrition Examination Survey III. Medicare was the primary source of data for patients aged ≥65 years. Data from the National Healthcare Cost and Utilization Project, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey were used to determine the cost of treating patients aged <65 years. We arrived at a total cost of $4.8 billion for treating patients aged ≥65 years and $3.6 billion for treating patients aged <65 years. These calculations were based on the following: 1.1 million hospital discharges resulting in inpatient costs of $4.4 billion (52.4% of the $8.4 billion) for the 0.6 million patients aged ≥65 years and $3.1 billion (36.9% of the $8.4 billion) for the 0.5 million patients aged <65 years. The average hospital length of stay was 7.8 days with an average cost of $7166 for patients aged ≥65 years and 5.8 days with an average cost of $6042 for younger patients. Room and board represented the largest percentage of the average hospital bill for patients with CAP. Inpatient physician service costs were $305 million and $192 million for the ≥65 and <65 groups, respectively. Based on 1.1 million outpatient office visits for those aged ≥65 years and 3.3 million visits for those aged <65, total outpatient costs were $119 million and $266 million, respectively. Given the overwhelming cost burden for CAP in the hospital setting, any new therapy that allows patients to be treated in the outpatient setting could result in significant savings, especially for patients aged ≥65 years.