Medline ® Abstracts for References 60-63

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.

BACKGROUND: Timing of follow-up chest radiographs for patients with severe community-acquired pneumonia (CAP) is difficult, because little is known about the time to resolution of chest radiograph abnormalities and its correlation with clinical findings. To provide recommendations for short-term, in-hospital chest radiograph follow-up, we studied the rate of resolution of chest radiograph abnormalities in relation to clinical cure, evaluated predictors for delayed resolution, and determined the influence of deterioration of radiographic findings during follow-up on prognosis.

METHODS: A total of 288 patients who were hospitalized because of severe CAP were followed up for 28 days in a prospective multicenter study. Clinical data and scores for clinical improvement at day 7 and clinical cure at day 28 were obtained. Chest radiographs were obtained at hospital admission and at days 7 and 28. Resolution and deterioration of chest radiograph findings were determined.

RESULTS: At day 7, 57 (25%) of the patients had resolution of chest radiographabnormalities, whereas 127 (56%) had clinical improvement (mean difference, 31%; 95% confidence interval, 25%-37%). At day 28, 103 (53%) of the patients had resolution of chest radiograph abnormalities, and 152 (78%) had clinical cure (mean difference, 25%; 95% confidence interval, 19%-31%). Delayed resolution of radiograph abnormalities was independently associated with multilobar disease (odds ratio, 2.87; P<or = .01); dullness to percussion at physical examination (odds ratio, 6.94; P<or = .01); high C-reactive protein level, defined as>200 mg/L (odds ratio, 4.24; P<or = .001); and high respiratory rate at admission, defined as>25 breaths/min (odds ratio, 2.42; P<or = .03). There were no significant differences in outcome at day 28 between patients with and patients without deterioration of chest radiograph findings during the follow-up period (P>.09).

CONCLUSIONS: Routine short-term follow-up chest radiographs (obtained<28 days after hospital admission) of hospitalized patients with severe CAP seem to provide no additional clinical value.

Clinicians are frequently faced with patients in whom the radiographic resolution of community-acquired pneumonia seems delayed. Previous studies of radiographic resolution of the disease have yielded conflicting results. We prospectively assessed the radiographic resolution of pneumonia in 81 non-immuno-compromised patients, presenting to the emergency room and ambulatory clinics of a large university hospital, who met clinical and radiographic criteria for pneumonia. Serial chest radiographs were obtained every 2 wk for an initial period of 8 wk, and then every 4 wk until 24 wk had passed, or until all radiographic abnormalities had cleared. Forty-one of the 81 patients (50.6%) demonstrated complete clearance after 2 wk. Fifty of the 75 patients (66.7%) followed to 4 wk demonstrated complete clearance. The rate of clearance was inversely correlated with age (p<0.001) and involvement of single versus multiple lobes (p<0.0001) (log-rank test). Clearance was faster in those patients treated as outpatients (3.8 wk versus 9.1 wk, p = 0.03) and in patients who were nonsmokers (4.5 wk versus 8.4 wk, p = 0.05) (log-rank test). Multivariate regression analysis demonstrated that only age (relative risk for clearance, +0.79 per decade) and single versus multiple lobes involved (relative risk for clearance, 0.55 for more than one lobe) had independent predictive value (Cox proportional hazards regression model).The radiographic resolution of pneumonia occurs more rapidly in younger patients and in those with only a single lobe involved.(ABSTRACT TRUNCATED AT 250 WORDS)

OBJECTIVES: To investigate the radiographic clearance of proven community-acquired nontuberculous bacterial pneumonia in nonimmunocompromised older patients to provide working estimates of the rate of radiographic resolution as a function of the patient cumulative comorbidities, extent of initial radiographic involvement, functional status, and causative pathogens.

DESIGN: A prospective study.

PARTICIPANTS: Seventy-four patients aged 70 and older, consecutively admitted to a hospital for community-acquired bacterial pneumonia.

SETTING: A university-affiliated teaching hospital.

MEASUREMENTS: Chest radiographs were performed every 3 weeks from the date of admission for a total period of 12 weeks or until all radiographic abnormalities had resolved or returned to baseline.

RESULTS: Sixty-four patients (86%) completed the study. The rate of radiographic clearance was estimated at 35.1% within 3 weeks, 60.2% within 6 weeks, and 84.2% within 12 weeks. Radiographic resolution was significantly slower for those with high comorbidity index, bacteremia, multilobar involvement, and enteric gram-negative bacilli pneumonias. Multivariate regression analysis demonstrated that the comorbidity index (relative risk for clearance=0.67 per class index, P<.001) and multilobar disease (relative risk for clearance=0.24 for more than one lobe, P<.001) had independent predictive value (Cox proportional hazards regression model) on the rate of resolution.

CONCLUSION: The radiographic resolution of nontuberculous bacterial pneumonia in the elderly should take into account the extent of lobar disease and the burden of underlying illnesses. A waiting period of 12 to 14 weeks is recommended for slowly resolving pneumonia to be considered nonresolving.