Medline ® Abstracts for References 77,78,83
of 'Treatment of community-acquired pneumonia in adults who require hospitalization'
Patterns of resolution of chest radiograph abnormalities in adults hospitalized with severe community-acquired pneumonia.
Bruns AH, Oosterheert JJ, Prokop M, Lammers JW, Hak E, Hoepelman AI
Clin Infect Dis. 2007;45(8):983.
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.
Division of Medicine, Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands.
Radiographic resolution of community-acquired pneumonia.
Mittl RL Jr, Schwab RJ, Duchin JS, Goin JE, Albeida SM, Miller WT
Am J Respir Crit Care Med. 1994;149(3 Pt 1):630.
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)
Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia.
Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial.
Oosterheert JJ, Bonten MJ, Schneider MM, Buskens E, Lammers JW, Hustinx WM, Kramer MH, Prins JM, Slee PH, Kaasjager K, Hoepelman AI
OBJECTIVES: To compare the effectiveness of an early switch to oral antibiotics with the standard 7 day course of intravenous antibiotics in severe community acquired pneumonia.
DESIGN: Multicentre randomised controlled trial.
SETTING: Five teaching hospitals and 2 university medical centres in the Netherlands.
PARTICIPANTS: 302 patients in non-intensive care wards with severe community acquired pneumonia. 265 patients fulfilled the study requirements.
INTERVENTION: Three days of treatment with intravenous antibiotics followed, when clinically stable, by oral antibiotics or by 7 days of intravenous antibiotics.
MAIN OUTCOME MEASURES: Clinical cure and length of hospital stay.
RESULTS: 302 patients were randomised (mean age 69.5 (standard deviation 14.0), mean pneumonia severity score 112.7 (26.0)). 37 patients were excluded from analysis because of early dropout before day 3, leaving 265 patients for intention to treat analysis. Mortality at day 28 was 4% in the intervention group and 6% in the control group (mean difference 2%, 95% confidence interval -3% to 8%). Clinical cure was 83% in the intervention group and 85% in the control group (2%, -7% to 10%). Duration of intravenous treatment and length of hospital stay were reduced in the intervention group, with mean differences of 3.4 days (3.6 (1.5) v 7.0 (2.0) days; 2.8 to 3.9) and 1.9 days (9.6 (5.0) v 11.5 (4.9) days; 0.6 to 3.2), respectively.
CONCLUSIONS: Early switch from intravenous to oral antibiotics in patients with severe community acquired pneumonia is safe and decreases length of hospital stay by 2 days.
TRIAL REGISTRATION: Clinical Trials NCT00273676 [ClinicalTrials.gov].
Department of Internal Medicine and Infectious Diseases, University Medical Centre, PO Box 85500, 3508 GA Utrecht, Netherlands.