Category Archives: Community-acquired pneumonia

Inpatient care of community-acquired pneumonia: DISCUSSION (5)

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Limitations of the PSI may be related to either intrinsically poor accuracy or inadequate transportability. Given the excellent performance of the model in the validation set of Fine et al , we suspect that the PSI is not intrinsically inaccurate, but rather that it is not readily transportable. In other words, one may not necessarily expect it to perform as well in other geographic or temporal settings, or in samples with different case ascertainment methods. Suboptimal transportability was observed by Flanders et al , who recommended recalibration of the PSI for its application in other settings. Poor transportability may occur due to the presence of a different spectrum of disease severity in a new population or underfitting (the omission of an important prognostic variable that is distributed differently in the new setting than in the original setting) . One example is the clinical impression of macroaspiration discussed above, which is a strong independent predictor not included in the PSI. In addition, difficult to quantify yet clinically important prognostic factors, such as a clinician’s overall impression of illness severity, may also be relevant. Prospective study may be helpful in further elucidating unmeasured important confounders.

Inpatient care of community-acquired pneumonia: DISCUSSION (4)

The association that we observed between certain antibiotic combinations and mortality may relate to effects of the antimicrobials themselves (inferior antibacterial effect or increased toxicity) or the presence of an unknown confounder, a particular problem in any study that is nonrandomized. Given the higher illness severity, as measured by the PSI, in patients receiving the ‘high risk’ antibiotic combinations, it is likely that other confounding factors are the cause. In the case of treatment with antianaerobe agents, the clinical suspicion of aspiration pneumonia is likely a powerful risk factor for mortality in CAP and should be considered in CAP mortality risk stratification. buy asthma inhalers

Inpatient care of community-acquired pneumonia: DISCUSSION (3)

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There are several noteworthy observations regarding the use of specific antibiotics — buy ampicillin. The choice of antibiotic therapy was associated with illness severity. There was progressively increasing severity, measured by the PSI, in cases treated with macrolide monotherapy, cephalosporin or levofloxacin monotherapy, cephalosporin plus a macrolide and antianaerobe agents. Empirical treatment with antianaerobe agents or cephalosporin plus a macrolide was associated with higher mortality (odds ratio 2.7 for both), despite controlling for PSI score.

Inpatient care of community-acquired pneumonia: DISCUSSION (2)

We were unable to detect an association between guideline adherence and mortality or LOS. The apparent lack of association could be due to a true lack of benefit from guideline adherence, inadequate power to detect a difference or a systematic difference between guideline-adherent and guideline-discordant cases not accounted for in the multivariable analysis. In the case of mortality, inadequate power is particularly likely given the relatively small number of patients reaching the end point and the relatively small number of cases not treated according to guidelines. buy asthma inhaler

Inpatient care of community-acquired pneumonia: DISCUSSION (1)

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We consider our experience with the inpatient treatment of CAP to be generalizable to similar contemporary populations in other Canadian centres. The cohort was composed of elderly patients (mean age 78 years) with a high risk of mortality (mean PSI score 116, class 4), reflecting the aging patient population and high illness acuity seen in patients admitted urgently to acute care hospitals. Our broad definition of CAP allows for the results to be generalizable by taking into account the diagnostic uncertainty in patients with high rates of cardiopulmonary disease presenting with acute chest symptoms. The finding of only 61% male patients in our cohort could reflect a bias in case ascertainment; however, a similar male predominance has been reported in other Canadian studies. flovent inhaler

Inpatient care of community-acquired pneumonia: RESULTS (2)

Analysis by empirical antibiotic regimen

The most commonly-selected antibiotic regimens are shown in Figure 2. Quinolone monotherapy (levofloxacin in 98%) and cephalosporin monotherapy (cefuroxime in over 90%) were the two most common regimens in the recent and early cohorts, respectively. Baseline clinical characteristics and univariate outcome analyses classified by empirical antibiotics are presented in Tables 3 and 4. On average, patients receiving empirical cephalosporin plus a macrolide or anaerobic coverage had higher PSI scores, while patients treated with empirical macrolide monotherapy had lower PSI scores (Table 3). Univariate analyses of clinical outcomes were consistent with the differences in PSI scores. Patients receiving empirical cephalosporin plus a macrolide or anaerobic coverage had longer LOSs and higher mortality, while patients treated with empirical macrolide monotherapy had shorter LOSs and lower mortality (Table 4).

Inpatient care of community-acquired pneumonia: RESULTS (1)

patients

Of the 2324 potentially eligible cases, approximately 70% from each era were reviewed (Figure 1). Of the 1682 (72%) potentially eligible cases reviewed, 698 eligible cases were identified and reviewed in full. Of the 984 ineligible cases, 416 (42%) were due to recent hospital discharge, 342 (35%) were due to coexisting infection, 108 (11%) did not meet either symptomatic or radiographic criteria for CAP and 118 (12%) were immune suppressed. Baseline and outcome data classified by secular period and guideline adherence are presented in Tables 1 and 2, respectively. Overall, the patients were elderly (median age 78 years) and had high illness severity (mean PSI score 116, risk class 4). Fifty-five patients (8%) were admitted to the intensive care unit at some time during hospitalization, while 40 patients (6%) were admitted to the intensive care unit within the first 24 h after admission. Median LOS was seven days, and in-hospital mortality was 9.2%.

Inpatient care of community-acquired pneumonia: PATIENTS AND METHODS (3)

Statistical analysis

Baseline characteristics and outcomes are described as one large group and divided by era and guideline adherence. Continuous data are expressed as mean (± SD) for normal distributions or median (plus quartiles) and compared with t tests or Mann-Whitney U tests. Baseline categorical data were compared with X2 tests (Yates corrected for 2×2 tables). Differences between empirical antimicrobial regimens were analyzed using %2 tests for categorical data and analyses of variance or Kruskall-Wallis tests for continuous data. Multivariable analyses consisted of linear and logistical regression for continuous and binary outcomes, respectively. Non-normally distributed explanatory variables were transformed with the natural logarithm.

Inpatient care of community-acquired pneumonia: PATIENTS AND METHODS (2)

antibiotic

All three sites have general internal medicine (GIM) clinical teaching units into which patients with CAP are generally admitted and managed. The source of referrals is almost exclusively from the emergency department (ED), to which patients either self-refer or are sent by primary care practitioners. If the ED physician decides that the patient requires admission or to see a specialist, a consultation from the GIM service is obtained. The GIM team makes the admission decision and all inpatient care decisions.

Inpatient care of community-acquired pneumonia: PATIENTS AND METHODS (1)

Patients and study site

Charts of potential cases were identified retrospectively by International Coding of Diagnosis (Ninth Revision) classification, including codes for pneumonia and potentially overlapping diagnostic codes, including chronic bronchitis, emphysema and asthma — buy flovent inhaler. A stratified, random sample of potential cases, admitted to our institutions between November 1997 and June 2000, was reviewed. Based on resource limitations, our review was limited to 70% of cases admitted during each study era (defined below).

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