Medline ® Abstracts for References 2,76,81
of 'Treatment of community-acquired pneumonia in adults who require hospitalization'
Epidemiology and predictors of multidrug-resistant community-acquired and health care-associated pneumonia.
Gross AE, Van Schooneveld TC, Olsen KM, Rupp ME, Bui TH, Forsung E, Kalil AC
Antimicrob Agents Chemother. 2014 Sep;58(9):5262-8. Epub 2014 Jun 23.
There are limited U.S. data describing the risk factors for multidrug-resistant organism (MDRO) isolation in community-acquired pneumonia (CAP) and health care-associated pneumonia (HCAP). However, concern for the presence of these pathogens drives the prescribing of empiric broad-spectrum antibiotics for CAP and HCAP. A retrospective study of all adults hospitalized with community-onset pneumonia (CAP and HCAP) at a large U.S. medical center from January 2010 to December 2011 was conducted. The objective was to ascertain the rate of pneumonia caused by MDROs and to evaluate whether HCAP is a risk factor for MDRO pneumonia. Univariate and propensity score-adjusted multivariate analyses were performed. A total of 521 patients (50.5% CAP and 49.5% HCAP) were included. The most common etiologies of pneumonia were primary viral and Streptococcus pneumoniae. MDROs were isolated in 20 (3.8%) patients overall, and MDROs occurred in 5.9% and 1.9% of HCAP and CAP patients, respectively. The presence of an MDRO was not associated with HCAP classification (odds ratio [OR]=1.95; 95% confidence interval [95% CI], 0.66 to 5.80; P=0.23) or with most of its individual components (hemodialysis, home infusion, home wound care, and≥48-h hospitalization in the last 90 days). Independent predictors of MDRO included the following: Pseudomonas aeruginosa colonization/infection in the previous year (OR=7.43; 95% CI, 2.24 to 24.61; P<0.001), antimicrobial use in the previous 90 days (OR=2.90; 95% CI, 1.13 to 7.45; P=0.027), admission from a nursing home (OR=4.19; 95% CI, 1.55 to 11.31; P=0.005), and duration of hospitalization in the previous 90 or 180 days (P=0.013 and P=0.002, respectively). MDROs were uncommon in HCAP and CAP. HCAP did not predict MDRO isolation. Local etiology of community onset pneumonia and specific MDRO risk factors should be integrated into therapeutic decisions to prevent empirical overprescribing of antibiotics for methicillin-resistant Staphylococcus aureus (MRSA) and P. aeruginosa.
University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois, USA University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA University of Nebraska Medical Center, College of Pharmacy, Omaha, Nebraska, USA University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska, USA firstname.lastname@example.org.
Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia.
Waterer GW, Kessler LA, Wunderink RG
OBJECTIVES: The time to the first antibiotic dose (TFAD) has been adopted as a measure of quality of care in patients with community-acquired pneumonia (CAP) based on two retrospective studies of large Medicare databases. The mechanism by which a difference of a few hours in receiving antibiotics can be deleterious is difficult to understand given the historical data regarding how long it takes for antibiotics to influence outcome. We investigated the factors that predict a prolonged TFAD and their association with mortality.
DESIGN: Prospective cohort study.
SETTING: A large tertiary hospital.
PATIENTS: Immunocompetent adults admitted to the hospital with CAP.
RESULTS: A total of 451 patients with CAP were studied. A TFAD of>4 h was associated with increased mortality (p = 0.017).Altered mental state (p = 0.001), absence of fever (p = 0.02), absence of hypoxia (p = 0.025), and increasing age (p = 0.038) were significant predictors of a TFAD of>4 h. After adjusting for these factors, the association between TFAD and mortality was not statistically significant (p = 0.131). Similar findings were observed in patients who were>or = 65 years.
CONCLUSIONS: A delay in administering antibiotics in patients with CAP is more common in patients who present with an altered mental state or minimal signs of sepsis. TFAD is likely to be a marker of comorbidities driving both an atypical presentation and mortality rather than directly contributing to outcome. Using TFAD as an indicator of quality of care in patients with CAP without significant additional clinical information is potentially misleading as the relationships among TFAD, comorbidities, and outcome are complex.
University of Western Australia, School of Medicine and Pharmacology, 4th Floor MRF Building, Royal Perth Hospital, GPO Box X2213, Perth, WA, Australia 6847. email@example.com
Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study.
Fine MJ, Stone RA, Singer DE, Coley CM, Marrie TJ, Lave JR, Hough LJ, Obrosky DS, Schulz R, Ricci EM, Rogers JC, Kapoor WN
Arch Intern Med. 1999;159(9):970.
BACKGROUND: Although understanding the processes of care and medical outcomes for patients with community-acquired pneumonia is instrumental to improving the quality and cost-effectiveness of care for this illness, limited information is available on how physicians manage patients with this illness or on medical outcomes other than short-term mortality.
OBJECTIVES: To describe the processes of care and to assess a broad range of medical outcomes for ambulatory and hospitalized patients with community-acquired pneumonia.
METHODS: This prospective, observational study was conducted at 4 hospitals and 1 health maintenance organization in Pittsburgh, Pa, Boston, Mass, and Halifax, Nova Scotia. Data were collected via patient interviews and reviews of medical records for 944 outpatients and 1343 inpatients with clinical and radiographic evidence of community-acquired pneumonia. Processes of care and medical outcomes were assessed 30 days after presentation.
RESULTS: Only 29.7% of outpatients had 1 or more microbiologic tests performed, and only 5.7% had an assigned microbiologic cause. Although 95.7% of inpatients had 1 or more microbiologic tests performed, a cause was established in only 29.6%. Six outpatients (0.6%) died, and 3 of these deaths were pneumonia related. Of surviving outpatients, 8.0% had 1 or more medical complications. At 30 days, 88.9% (nonemployed) to 95.6% (employed) of the surviving outpatients had returned to usual activities, yet 76.0% of outpatients had 1 or more persisting pneumonia-related symptoms. Overall, 107 inpatients (8.0%) died, and 81 of these deaths were pneumonia related. Most surviving inpatients (69.0%) had 1 or more medical complications. At 30 days, 57.3% (non-employed) to 82.0% (employed) of surviving inpatients had returned to usual activities, and 86.1% had 1 or more persisting pneumonia-related symptoms.
CONCLUSIONS: In this study, conducted primarily at hospital sites with affiliated medical education training programs, virtually all outpatients and most inpatients had pneumonia of unknown cause. Although outpatients had an excellent prognosis, pneumonia-related symptoms often persisted at 30 days. Inpatients had substantial mortality, morbidity, and pneumonia-related symptoms at 30 days.
Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, PA, USA. firstname.lastname@example.org