The cost of treating community-acquired pneumonia

Medical resource utilization among community-acquired pneumonia patients initially treated with levofloxacin 750 mg daily versus ceftriaxone 1000 mg plus azithromycin 500 mg daily: a US-based study

OBJECTIVE

The 2007 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines recommend that community-acquired pneumonia (CAP) patients admitted to hospital wards initially receive respiratory fluoroquinolone monotherapy or beta-lactam plus macrolide combination therapy. There is little evidence as to which regimen is preferred, or if differences in medical resource utilization exist between therapies. Thus, the authors compared length of hospital stay (LOS) and length of intravenous antibiotic therapy (LOIV) for patients who received initial levofloxacin 750 mg daily versus ceftriaxone 1000 mg plus azithromycin 500 mg daily ('combination therapy').

RESEARCH DESIGN AND METHODS

Adult hospital CAP cases from January 2005 to December 2007 were identified by principal discharge diagnosis code. Patients with a chest infiltrate and medical notes indicative of CAP were included. Direct intensive care unit admits and healthcare-associated cases were excluded. A propensity score technique was used to balance characteristics associated with initial antimicrobial therapy using multivariable regression to derive the scores. Propensity score categories, defined as propensity score quintiles, rather than propensity scores themselves, were used in the least squares regression model to assess the impact of LOS and LOIV.

RESULTS

A total of 495 patients from six hospitals met study criteria. Of these, 313 (63%) received levofloxacin and 182 (37%) received combination therapy. Groups were similar with respect to age, sex, most comorbidities, presenting signs and symptoms, and Pneumonia Severity Index (PSI) risk class. Patients on combination therapy were more likely to have heart failure and receive pre-admission antibiotics. Adjusted least squares mean (+/-SE) LOS and LOIV were shorter with levofloxacin versus combination therapy: LOS, 4.6 +/- 0.17 vs. 5.4 +/- 0.22 days, p < 0.01; and LOIV, 3.6 +/- 0.17 vs. 4.8 +/- 0.21 days, p < 0.01. Results for PSI risk class III or IV patients were: LOS, 5.0 +/- 0.30 vs. 5.9 +/- 0.37 days, p = 0.07; and LOIV, 3.7 +/- 0.33 vs. 5.2 +/- 0.39 days, p < 0.01. Due to the retrospective study design, limited sample size, and scope (single health-network), the authors encourage replication of this study in other data sources.

CONCLUSIONS

Given the LOS and LOIV reductions of 0.8 and 1.2 days, respectively, utilization of levofloxacin 750 mg daily for CAP patients admitted to the medical floor has the potential to result in substantial cost savings for US hospitals.

Early switch to oral treatment in patients with moderate to severe community-acquired pneumonia: a meta-analysis

BACKGROUND

Early switch to oral antibacterials is recommended for the treatment of hospitalized patients with community-acquired pneumonia (CAP). However, its efficacy and safety in patients with more severe forms of CAP have not been well established.

OBJECTIVE

To evaluate early switch to oral treatment in hospitalized patients with moderate to severe CAP.

METHODS

Two reviewers independently extracted data from relevant randomized controlled trials (RCTs) with the same total duration of antibacterial treatment in the compared groups (early switch from intravenous to oral and conventional intravenous treatment for the whole duration of therapy).

RESULTS

Six RCTs including 1219 patients fulfilled the criteria for inclusion in the meta-analysis. Treatment success was not different between early switch to oral treatment and intravenous only treatment groups in both intention to treat (odds ratio [OR] 0.76; 95% CI 0.36, 1.59) and clinically evaluable patients (OR 0.92; 95% CI 0.61, 1.39). Mortality and recurrence of CAP were not different (OR 0.81; 95% CI 0.49, 1.33 and OR 1.81; 95% CI 0.70, 4.72, respectively), while duration of hospitalization was shorter (weight mean difference -3.34; 95% CI -4.42, -2.25) and drug-related adverse events were fewer in the early switch group (OR 0.65; 95% CI 0.48, 0.89). Findings were similar in patients with severe CAP.

CONCLUSIONS

Early conversion to oral antibacterials seems to be as effective as continuous intravenous treatment in patients with moderate to severe CAP and results in substantial reduction in duration of hospitalization.

Association between proton pump inhibitors and respiratory infections: a systematic review and meta-analysis of clinical trials

BACKGROUND

Proton pump inhibitors (PPIs) have become the mainstay of treatment for and prevention of many serious gastrointestinal diseases. Laboratory and clinical evidence suggests that the increase in gastric pH caused by PPIs may be linked to increased bacterial colonization of the stomach and may predispose patients to an increased risk for respiratory infections.

OBJECTIVE

To examine the association between PPI treatment and respiratory infections.

METHODS

A literature search was conducted using PubMed, MEDLINE and Cochrane databases of randomized, placebo-controlled trials evaluating the efficacy of PPIs. Studies that listed and quantified the specific adverse events of 'respiratory infection' or 'upper respiratory infection' (or equivalent), and compared their rates between PPIs and placebo were included. The chi(2) analysis was used to calculate the significance of association in individual studies and a meta-analysis of the selected studies was performed.

RESULTS

Of 7457 studies initially identified and 70 relevant randomized, controlled trials (RCTs) selected, seven studies met the inclusion criteria. A total of 16 comparisons for chi(2) analysis were possible given the multiple dosage arms used in several studies. PPIs included in the studies were esomeprazole, rabeprazole, pantoprazole and omeprazole. More than one-half of the studies showed a trend toward an association between PPI use and respiratory infections, although the majority of the studies failed to show a significant correlation. A single study using high-dose esomeprazole (40 mg) showed a significant association -4.3% rate of respiratory infections in the active group compared with 0% in the placebo group (P<0.05). Meta-analysis showed a trend toward an association between PPIs and respiratory infections, although it failed to reach significance (OR 1.42, 95% CI 0.86 to 2.35; P=0.17).

CONCLUSION

Although a trend was evident in both a chi(2) analysis of individual studies and a meta-analysis, the present review and meta-analysis failed to show a conclusive association between PPIs and respiratory infections. Very few RCTs actively sought out respiratory infections, which excluded the majority of RCTs identified. A well-structured, placebo-controlled prospective study would be needed to determine whether a true association between PPIs and respiratory infections exists.

Potential for cost-savings in the care of hospitalized low-risk community-acquired pneumonia patients in China

BACKGROUND

The cost of treating community-acquired pneumonia (CAP) in China is a heavy economic burden for the society.

OBJECTIVE

To investigate the costs of hospitalization of low-risk CAP patients and how hospitalization costs can be reduced through proper usage of hospital resources.

METHODS

Two hundred thirty-six patients with low-risk CAP who were hospitalized between January 2000 and December 2005 in a 1161-bed tertiary care teaching hospital were included in a retrospective cohort study. Their hospitalization costs and antibiotic therapy were analyzed. General linear model was utilized to determine correlative variables associated with total hospital costs.

RESULTS

The median length of hospital stay was 12 days and the median duration of intravenous (IV) antibiotic therapy was 10 days, they were correlated significantly (P = 0.000, r = 0.81). The median total hospital cost was $556.50 (mean $705.60), of which 48.9% was for drugs, 21.9% for laboratory tests, 8.6% for radiology, 6.5% for medical staff, 6.3% for hospital beds, and 5.3% for examination. General linear model analysis determined that duration of IV antibiotic therapy, Pneumonia Severity Index class, age, and initial empirical antibiotic therapy failure were correlative factors of total hospital costs. Pathogens were identified in 106 patients (44.9%), Mycoplasma pneumoniae was the most common pathogen (19.9%), followed by Streptococcus pneumoniae (8.5%), and Haemophilus influenza (5.5%). The majority of patients accepted initial empirical beta-lactam (37.3%) or fluoroquinolone (30.9%) monotherapy, the empirical treatment failure rates were 20.5% and 5.5%, respectively.

CONCLUSIONS

Efforts to reduce duration of IV antibiotic therapy will have the most profound effect on reducing total hospital costs of low-risk CAP. The atypical pathogens should be considered for initial empirical antibiotics in low-risk CAP therapy in China.

Treatment of oral and pharyngeal dysphagia

Research on treatment of oropharyngeal dysphagia has supported several treatment approaches. Treatment can include postural changes, heightening preswallow sensory input, voluntary swallow maneuvers, and exercises. Evidence to support the efficacy of these procedures is variable. An instrumental study of a patient's oropharyngeal swallow forms the basis for treatment selection.

Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials

BACKGROUND

We investigated whether the use of respiratory fluoroquinolones was associated with better clinical outcomes compared with the use of macrolides and beta- lactams among adults with pneumonia.

METHODS

We searched PubMed, Current Contents, Scopus, EMBASE, ClinicalTrials.gov and Cochrane with no language restrictions. Two reviewers independently extracted data from published trials that compared fluoroquinolones (levofloxacin, moxifloxacin, gemifloxacin) with macrolides or beta-lactams or both. A meta-analysis was performed with the clinical outcomes of mortality, treatment success and adverse outcomes.

RESULTS

We included 23 trials in our meta-analysis. There was no difference in mortality among patients who received fluoroquinolones or the comparator antibiotics (OR 0.85, 95% CI 0.65-1.12). Pneumonia resolved in more patients who received fluoroquinolones compared with the comparator antibiotics for the included outcomes in the intention-to-treat population (OR 1.17, 95% CI 1.00-1.36), clinically evaluable population (OR 1.26, 95% CI 1.06-1.50) and the microbiologically assessed population (OR 1.67, 95% CI 1.28-2.20). Fluoroquinolones were more effective than a combination of beta-lactam and macrolide (OR 1.39, 95% CI 1.02-1.90). They were also more effective for patients with severe pneumonia (OR 1.84, 95% CI 1.02-3.29), those who required admission to hospital (OR = 1.30, 95% CI 1.04-1.61) and those who required intravenous therapy (OR = 1.44, 15% CI 1.13-1.85). Fluoroquinolones were more effective than beta-lactam and macrolide in open-label trials (OR = 1.35, 95% CI 1.08-1.69) but not in blinded randomized controlled trials (OR = 1.13, 95% CI 0.85-1.50).

INTERPRETATION

Fluoroquinolones were associated with higher success of treatment for severe forms of pneumonia; however, a benefit in mortality was not evident. A randomized controlled trial that includes patients with severe pneumonia with or without bacteremia is needed.

Benefit-risk assessment of telithromycin in the treatment of community-acquired pneumonia

The purpose of this review is to assess the benefits and risks associated with the use of the ketolide antibacterial telithromycin, currently licensed for the treatment of adults with mild to moderate community-acquired pneumonia (CAP). Telithromycin is active against both the major (Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis) and atypical/intracellular (Chlamydophila pneumoniae, Legionella pneumophila and Mycoplasma pneumoniae) CAP pathogens. It is associated with a low potential to select for resistance and has maintained its in vitro activity against isolates of respiratory pathogens in countries where it has been in clinical use for several years. In randomized clinical trials, telithromycin has demonstrated efficacy comparable to the established antibacterial classes (macrolides, fluoroquinolones and beta-lactams) in the treatment of CAP.The safety profile of telithromycin is broadly similar to that of other antibacterials used to treat CAP. The most common adverse events are gastrointestinal adverse effects and headache; these are generally mild to moderate in severity and reversible. Telithromycin appears to be well tolerated by adult patients in all age groups, including those with co-morbid conditions. In common with other antibacterials, telithromycin has the potential to affect the corrected QT interval; the concomitant use of cisapride or pimozide with telithromycin is contraindicated, while telithromycin should be avoided in patients receiving Class IA or Class III antiarrhythmic drugs. Visual disturbances (usually transient) have occurred in a small proportion of patients treated with telithromycin; it is recommended that activities such as driving are minimized during treatment. Telithromycin is contraindicated in patients with myasthenia gravis. Hepatic dysfunction may occur in some patients taking telithromycin; rare cases of acute hepatic failure and severe liver injury, including deaths, have been reported. As telithromycin is an inhibitor of the cytochrome P450 (CYP) 3A4 system, coadministration of telithromycin with drugs metabolized by this pathway may require dose adjustments (e.g. with benzodiazepines) or a temporary hiatus in the use of the coadministered drug (e.g. HMG-CoA reductase inhibitors) metabolized by CYP3A4. Telithromycin may potentiate the effects of oral anticoagulants; careful monitoring is recommended in patients receiving telithromycin and oral anticoagulants simultaneously.Although serious and sometimes fatal events have occurred in patients receiving telithromycin therapy, current data indicate that telithromycin offers an acceptable benefit risk ratio in the treatment of mild to moderate CAP.

Review: Novel targets in the management of pneumonia

Community-acquired pneumonia (CAP) is the leading cause of death from infectious diseases in the US. It accounts each year for 500,000 hospitalizations and 45,000 deaths and represents one of the most common causes of intensive care unit (ICU) admission. The mortality rate due to severe CAP has shown little improvement in the past three decades, remaining between 21% and 58% in patients admitted to the intensive care unit. Antimicrobial agents are the cornerstone of therapy against CAP, but there are some novel antibiotic and nonantibiotic therapies that have been recently tested that may potentially impact outcomes of patients with severe CAP. We will review the most recent data regarding novel therapies in patients with the highest risk of death such as those with severe CAP.

The role of biomarkers in community-acquired pneumonia: predicting mortality and response to adjunctive therapy

Patients with community-acquired pneumonia (CAP) in the hospital setting exhibit markedly abnormal levels of various biomarkers of infection, inflammation and coagulation. CAP is a well characterized disease, relatively homogeneous and amenable to management according to defined protocols. Hence, this group of patients represents an opportunity to investigate further these biomarkers as a means of determining disease severity and identifying candidates for new therapies. Changes in biomarker levels during the course of disease may enable physicians to identify those patients who are most at risk for deterioration and progression toward severe CAP and who are in greatest need of early intervention. Subgroup analysis of the placebo-controlled OPTIMIST trial of tifacogin in severe sepsis revealed a trend toward benefit in patients with procalcitonin levels of 2 ng/ml or greater and in those with high baseline markers of activated coagulation. Biomarker studies are being undertaken as part of the ongoing CAPTIVATE study. This study includes patients with severe CAP and will compare the efficacy and safety of recombinant tissue factor pathway inhibitor (tifacogin) versus placebo. In the future it may also be possible to use genomic markers to identify patients at greatest risk for deterioration or complications.

Hyponatremia and hospital outcomes among patients with pneumonia: a retrospective cohort study

Background

Community-acquired (CAP) and nosocomial pneumonias contribute substantially to morbidity and hospital resource utilization. Hyponatremia, occurring in >1/4 of patients with CAP, is associated with greater disease severity and worsened outcomes.

Methods

To explore how hyponatremia is associated with outcomes in hospitalized patients with pneumonia, we analyzed a large administrative database with laboratory component from January 2004 to December 2005. Hyponatremia was defined as at least two [Na⁺] < 135 mEq/L within 24 hours of admission value.

Results

Of 7,965 patients with pneumonia, 649 (8.1%) with hyponatremia were older (72.4 ± 15.7 vs. 68.0 ± 22.0, p < 0.01), had a higher mean Deyo-Charlson Comorbidity Index Score (1.7 ± 1.7 vs. 1.6 ± 1.6, p = 0.02), and higher rates of ICU (10.0% vs. 6.3%, p < 0.001) and MV (3.9% vs. 2.3%, p = 0.01) in the first 48 hours of hospitalization than patients with normal sodium. Hyponatremia was associated with an increased ICU (6.3 ± 5.6 vs. 5.3 ± 5.1 days, p = 0.07) and hospital lengths of stay (LOS, 7.6 ± 5.3 vs. 7.0 ± 5.2 days, p < 0.001) and a trend toward increased hospital mortality (5.4% vs. 4.0%, p = 0.1). After adjusting for confounders, hyponatremia was associated with an increased risk of ICU (OR 1.58, 95% CI 1.20–2.08), MV (OR 1.75 95% CI 1.13–2.69), and hospital death (OR 1.3, 95% CI 0.90–1.87) and with increases of 0.8 day to ICU and 0.3 day to hospital LOS, and over $1,300 to total hospital costs.

Conclusion

Hyponatremia is common among hospitalized patients with pneumonia and is associated with worsened clinical and economic outcomes. Studies in this large population are needed to explore whether prompt correction of [Na⁺] may impact these outcomes.

SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia

BACKGROUND

Existing severity assessment tools, such as the pneumonia severity index (PSI) and CURB-65 (tool based on confusion, urea level, respiratory rate, blood pressure, and age >or=65 years), predict 30-day mortality in community-acquired pneumonia (CAP) and have limited ability to predict which patients will require intensive respiratory or vasopressor support (IRVS).

METHODS

The Australian CAP Study (ACAPS) was a prospective study of 882 episodes in which each patient had a detailed assessment of severity features, etiology, and treatment outcomes. Multivariate logistic regression was performed to identify features at initial assessment that were associated with receipt of IRVS. These results were converted into a simple points-based severity tool that was validated in 5 external databases, totaling 7464 patients.

RESULTS

In ACAPS, 10.3% of patients received IRVS, and the 30-day mortality rate was 5.7%. The features statistically significantly associated with receipt of IRVS were low systolic blood pressure (2 points), multilobar chest radiography involvement (1 point), low albumin level (1 point), high respiratory rate (1 point), tachycardia (1 point), confusion (1 point), poor oxygenation (2 points), and low arterial pH (2 points): SMART-COP. A SMART-COP score of >or=3 points identified 92% of patients who received IRVS, including 84% of patients who did not need immediate admission to the intensive care unit. Accuracy was also high in the 5 validation databases. Sensitivities of PSI and CURB-65 for identifying the need for IRVS were 74% and 39%, respectively.

CONCLUSIONS

SMART-COP is a simple, practical clinical tool for accurately predicting the need for IRVS that is likely to assist clinicians in determining CAP severity.

Measuring acceptable treatment failure rates for community-acquired pneumonia: potential for reducing duration of treatment and antimicrobial resistance

OBJECTIVE

This study was designed to establish the rates of treatment failure for community-acquired pneumonia that are acceptable to knowledgeable and experienced physicians, in order to facilitate the interpretation of existing studies and the design of new studies aimed at optimizing the duration of antibiotic therapy. Reducing the duration of antibiotic therapy is one strategy for reducing antibiotic exposure and thereby minimizing the potential for the emergence of antimicrobial resistance.

DESIGN

Survey soliciting the acceptable failure rate for treatment given to an adult patient with uncomplicated community-acquired pneumonia treated with standard-of-care therapy in the outpatient setting. Analysis was performed using a modification of established methods of contingent valuation analysis.

PARTICIPANTS

Six hundred eighty infectious diseases physicians in North America who were also members of the Emerging Infections Network of the Infectious Diseases Society of America.

RESULTS

Three hundred seventy-five (55.1%) of 680 physicians responded to the survey. The median acceptable failure rate for treatment was 13.5%. Five hundred ten respondents (75.0%) found a failure rate of 7.3% acceptable, and 170 respondents (25.0%) found a failure rate of 19.8% acceptable.

CONCLUSIONS

This study identified the failure rates for treatment of community-acquired pneumonia that were acceptable to infectious disease physicians. This range of acceptable treatment failure rates may facilitate the design of studies aimed at optimizing the duration of antimicrobial therapy for community-acquired pneumonia.

Overview of Results From the Largest Clinical Trial for Dysphagia Treatment Efficacy

Information presented herein provides an overview of the largest randomized clinical trial ever completed in dysphagia. The two-part sequential randomized clinical trial studied the effect of two common dysphagia interventions (chin tuck and thickened liquids) for immediate prevention of aspiration during videofluorographic assessment and also for the incidence of pneumonia at 3-months for patients with Parkinson's disease and/or dementia. Results indicated that thickened liquids (nectar-thick or honey-thick) prevented aspiration during the radiographic study more frequently than chin-down posture; however, both interventions were equally successful at preventing pneumonia. Adverse events such as urinary tract infection and dehydration were more common with thickened liquids. Median length of hospital stay due to pneumonia was three times longer for patients drinking honey-thick liquids compared to nectar-thick and chin-tuck arms of the study. Several important secondary outcomes are discussed as well as implications for clinical practice. The reader is encouraged to refer to other published works for detailed information that is highlighted in this overview.

Epidemiology, clinical and economic outcomes of admission hyponatremia among hospitalized patients

BACKGROUND

Hyponatremia, the most frequent electrolyte derangement identified among hospitalized patients, is associated with worsened outcomes in patients with pneumonia, heart failure and other disorders.

RESEARCH DESIGN AND METHODS

We performed a retrospective cohort study of hospitalized patients to quantify the attributable influence of admission hyponatremia on hospital costs and outcomes. Data were derived from a large administrative database with laboratory components, representing 198,281 discharges from 39 US hospitals from January 2004 to December 2005. Hyponatremia was defined as admission serum [Na(+)]<135 mEq/L.

RESULTS

The incidence of hyponatremia at admission was 5.5% (n=10,899). Patients with hyponatremia were older (65.7+/-19.6 vs. 61.5+/-21.8, p<0.001) and had a higher Deyo-Charlson Comorbidity Index score (1.8+/-2.1 vs. 1.3+/-1.8, p<0.001) than those with normal [Na(+)]. A higher proportion of hyponatremic patients required intensive care unit (ICU) (17.3% vs. 10.9%, p<0.001) and mechanical ventilation (MV) (5.0% vs. 2.8%, p<0.001) within 48 hours of hospitalization. Hospital mortality (5.9% vs. 3.0%, p<0.001), mean length of stay (HLOS, 8.6+/-8.0 vs. 7.2+/-8.2 days, p<0.001) and costs ($16,502+/-$28,984 vs. $13,558+/-$24,640, p<0.001) were significantly greater among patients with hyponatremia than those without. After adjusting for confounders, hyponatremia was independently associated with an increased need for ICU (OR 1.64, 95% CI 1.56-1.73) and MV (OR 1.68, 95% CI 1.53-1.84), and higher hospital mortality (OR 1.55, 95% CI 1.42-1.69). Hyponatremia also contributed an increase in HLOS of 1.0 day and total hospital costs of $2,289.

CONCLUSIONS

Hyponatremia is common at admission among hospitalized patients and is independently associated with a 55% increase in the risk of death, substantial hospital resource utilization and costs. Potential for bias inherent in the retrospective cohort design is the main limitation of our study. Studies are warranted to explore how prompt normalization of [Na(+)] may impact these outcomes.

A cost-minimisation analysis comparing moxifloxacin with levofloxacin plus ceftriaxone for the treatment of patients with community-acquired pneumonia in Germany: results from the MOTIV trial

OBJECTIVE

This study presents a cost-minimisation analysis of moxifloxacin compared to combination treatment with levofloxacin and ceftriaxone in patients hospitalised with community-acquired pneumonia (CAP) in Germany.

RESEARCH DESIGN AND METHODS

In the MOTIV study, 738 adult patients with CAP requiring hospitalisation and initial parenteral antibiotic therapy were randomised to sequential IV/oral therapy with either moxifloxacin (n = 368), or levofloxacin and ceftriaxone (n = 365). The primary effectiveness endpoint was the proportion of patients demonstrating clinical improvement 5-7 days after the completion of study treatment. Subgroup analysis considered patients with severe CAP according to pneumonia severity index (PSI) risk class IV and V, microbiologically proven infection, a history of chronic obstructive pulmonary disease, and a history of cardiovascular disease. The analysis included the cost of study medication, hospital stay, readmission and inpatient procedures and diagnostics. Event frequency in the study was multiplied by German unit costs to estimate per-patient expenditure. The analysis was conducted from a hospital perspective. Sensitivity analysis investigated the effect of costing from an insurer perspective.

RESULTS

No significant difference was found in the percentage of successfully treated patients. Average per patient cost was euro 2190 for the moxifloxacin group, and euro 2619 for the levofloxacin + ceftriaxone group (difference -euro 430, 95% CI: -euro 138, -euro 740; p < 0.05). Variability in total costs was wide, with some patients accruing up to euro 18,000. Medication cost was significantly lower with moxifloxacin than levofloxacin + ceftriaxone (-euro 470, 95% CI: -euro 522, -euro 421), and accounted for between 15 and 30% of total costs.

CONCLUSIONS

In this analysis of patients hospitalised with CAP in Germany, treatment with moxifloxacin was significantly less costly than treatment with levofloxacin and ceftriaxone.

Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial

BACKGROUND

Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions.

OBJECTIVE

To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease.

DESIGN

Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005.

SETTING

47 hospitals and 79 subacute care facilities.

PATIENTS

515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months.

INTERVENTION

Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position.

MEASUREMENTS

The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators.

RESULTS

52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%).

LIMITATIONS

A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs.

CONCLUSION

No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.

Risk prediction with procalcitonin and clinical rules in community-acquired pneumonia

STUDY OBJECTIVE

The Pneumonia Severity Index and CURB-65 predict outcomes in community-acquired pneumonia but have limitations. Procalcitonin, a biomarker of bacterial infection, may provide prognostic information in community-acquired pneumonia. Our objective is to describe the pattern of procalcitonin in community-acquired pneumonia and determine whether procalcitonin provides prognostic information beyond the Pneumonia Severity Index and CURB-65.

METHODS

We conducted a multicenter prospective cohort study in 28 community and teaching emergency departments. Patients presenting with a clinical and radiographic diagnosis of community-acquired pneumonia were enrolled. We stratified procalcitonin levels a priori into 4 tiers: I: less than 0.1; II: greater than 0.1 to less than 0.25; III: greater than 0.25 to less than 0.5; and IV: greater than 0.5 ng/mL. Primary outcome was 30-day mortality.

RESULTS

One thousand six hundred fifty-one patients formed the study cohort. Procalcitonin levels were broadly spread across tiers: 32.8% (I), 21.6% (II), 10.2% (III), and 35.4% (IV). Used alone, procalcitonin had modest test characteristics: specificity (35%), sensitivity (92%), positive likelihood ratio (1.41), and negative likelihood ratio (0.22). Adding procalcitonin to the Pneumonia Severity Index in all subjects minimally improved performance. Adding procalcitonin to low-risk Pneumonia Severity Index subjects (classes I to III) provided no additional information. However, subjects in procalcitonin tier I had low 30-day mortality, regardless of clinical risk, including those in higher risk classes (1.5% versus 1.6% for those in Pneumonia Severity Index classes I to III versus classes IV/V). Among high-risk Pneumonia Severity Index subjects (classes IV/V), one quarter (126/546) were in procalcitonin tier I, and the negative likelihood ratio of procalcitonin tier I was 0.09. Procalcitonin tier I was also associated with lower burden of other adverse outcomes. Similar results were observed with CURB-65 stratification.

CONCLUSION

Selective use of procalcitonin as an adjunct to existing rules may offer additional prognostic information in high-risk patients.

C-reactive protein is an independent predictor of severity in community-acquired pneumonia

BACKGROUND

C-reactive protein (CRP) is an acute phase protein synthesized by the liver primarily in response to interleukin-6. Initial studies have suggested that inflammatory markers may have a role in predicting severity. We investigated whether admission and day 4 CRP could predict severity in community-acquired pneumonia.

METHODS

A prospective study was carried out over a 2-year period in a large teaching hospital. CRP was measured on admission and on day 4. The outcomes of interest were: 30-day mortality; need for mechanical ventilation and/or inotropic support; development of complicated pneumonia (lung abscess, empyema, or complicated parapneumonic effusion); the value of predictive tests were assessed using multivariate logistic regression.

RESULTS

There were 570 patients included in the study; 30-day mortality was 9.6%. Low CRP levels showed a high negative predictive value for excluding 30-day mortality (CRP <10 mg/L=100%, CRP <50=99.1%, CRP <100=98.9%, CRP <200=94.9%). Low admission CRP levels <100 mg/L were independently associated with reduced 30-day mortality (odds ratio [OR] 0.18; 0.04-0.85), P=.03; need for mechanical ventilation and/or inotropic support (OR 0.21; 0.14-0.4), P=.002; and complicated pneumonia (OR 0.05; 0.01-0.35), P=.003. A CRP that fails to fall by 50% or more within 4 days of admission is independently associated with increased 30 day mortality (OR 24.5; 6.4-93.4), P <.0001; need for mechanical ventilation and/or inotropic support (OR 7.1; 2.8-17.8), P <.0001 and complicated pneumonia (OR 15.4; 6.32-37.6), P <.0001.

CONCLUSIONS

Admission CRP <100 mg/L has reduced risk for 30-day mortality, need for mechanical ventilation and/or inotropic support, and complicated pneumonia. Failure of CRP to fall by 50% or more at day 4 leads to an increased risk for 30-day mortality, need for mechanical ventilation and/or inotropic support, and complicated pneumonia. C-reactive protein is an independent marker of severity in community-acquired pneumonia.

A comparison of levofloxacin and moxifloxacin use in hospitalized community-acquired pneumonia (CAP) patients in the US: focus on length of stay

OBJECTIVE

Length of stay (LOS) and hospitalization costs were compared among patients admitted for community-acquired pneumonia (CAP) and initially treated with either levofloxacin 750 mg intravenous (IV) or with moxifloxacin 400 mg IV. Hospital-related complications and relationship of LOS and comorbidities were descriptively examined.

METHODS

A retrospective database study was conducted of adult patients admitted for CAP and given levofloxacin 750 mg IV or moxifloxacin 400 mg IV through the first 3 days of hospitalization, using the Premier Perspective comparative database. Cohorts were matched 1:1 by hospital geographic location, by coarse caliper propensity scores using all baseline covariates, and by Mahalanobis metric matching based on age and severity (All Patient Refined-Diagnosis-related Groups Severity of Illness (APR-DRG SOI) index). Comparisons between groups were further adjusted for characteristics that remained imbalanced after matching using generalized estimating equation methodology.

RESULTS

The initial sample of 3868 patients (levofloxacin = 827; moxifloxacin = 3041) was reduced to 1594 (797 patients per treatment group) after matching. Analyses of matched cohorts showed that the mean hospital LOS was significantly shorter for patients treated with levofloxacin 750 mg IV than for those patients treated with moxifloxacin 400 mg IV (5.8 vs. 6.4 days, respectively; least squares mean difference = 0.54 days; p = 0.020). Hospitalization costs were also lower for the levofloxacin 750 mg IV-treated patients (least squares mean difference = US$129; p = 0.753). There were no significant differences in the percentage of patients experiencing complications.

LIMITATIONS

Although claims databases provide large sample sizes and reflect routine care, they do have several inherent limitations. Since randomization of subjects is not possible, adequate statistical techniques must be used to ensure treatment groups are balanced with respect to patient and clinical characteristics. In addition, data may be missing or miscoded.

CONCLUSIONS

This retrospective study suggests that among patients hospitalized with CAP, initial treatment with levofloxacin 750 mg IV is associated with a significantly shorter mean hospital LOS compared with treatment with moxifloxacin 400 mg IV. The clinical implications of a shorter hospital LOS include improved patient and economic outcomes.

A cost-effectiveness analysis of antimicrobial treatment of community-acquired pneumonia taking into account resistance in Belgium

OBJECTIVE

This article assesses the cost-effectiveness of outpatient antimicrobial treatment of community-acquired pneumonia (CAP) taking into account resistance in Belgium.

RESEARCH DESIGN AND METHODS

Our decision analytic model focused on mild to moderate CAP, but did not consider severe CAP. Treatment pathways reflected empirical treatment initiated in the absence of data on CAP aetiology. First-line treatment consisted of moxifloxacin, co-amoxiclav, cefuroxime or clarithromycin. If first-line treatment was unsuccessful, patients were either hospitalised or second-line treatment with a different antimicrobial was initiated. Clinical failure rates were obtained from the published literature or expert opinion. Costs were calculated using published sources from the third-party payer perspective.

MAIN OUTCOME MEASURES

Effectiveness measures included first-line clinical failure avoided, second-line treatment avoided, hospitalisation avoided and death avoided. Healthcare costs were included, but costs of productivity loss were not considered.

RESULTS

Costs of treating a CAP episode amounted to 144E with moxifloxacin/co-amoxiclav; 222E with co-amoxiclav/clarithromycin; 211E with cefuroxime/moxifloxacin; and 193E with clarithromycin/moxifloxacin. The rate of first-line failure was 5%, 16%, 19% and 18% for these four treatment strategies, respectively. The rate of second-line treatment amounted to 4%, 13%, 16% and 15%, respectively. The hospitalisation rate was 1%, 4%, 4% and 4%, respectively. The death rate was 0.01%, 0.04%, 0.03% and 0.03%, respectively. Sensitivity analyses supported the dominance of moxifloxacin/co-amoxiclav in nearly all scenarios.

CONCLUSIONS

First-line treatment of CAP patients with moxifloxacin followed by co-amoxiclav or hospitalisation if required was more effective and less costly as compared with first-line treatment with co-amoxiclav, cefuroxime or clarithromycin.

Pneumonia in the older patient

This article examines the bacteriology, clinical features, therapy for, and prevention of pneumonia in older patients. The discussion focuses on patients who develop pneumonia out of the hospital, including individuals with community-acquired pneumonia and health care-associated pneumonia. Health care-associated pneumonia incorporates patients who live in nursing homes when they develop pneumonia and in many instances requires management similar to nosocomial pneumonia. We have chosen not to discuss nosocomial pneumonia in older patients because it does not have distinctive features or a different management approach than when this illness arises in younger patients.

Improving outcomes of elderly patients with community-acquired pneumonia

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in elderly patients. Therefore, efforts to optimize the healthcare process for patients with CAP are warranted. An organized approach to management is likely to improve clinical results. Assessing the severity of CAP is crucial to predicting outcome, deciding the site of care, and selecting appropriate empirical therapy. Unfortunately, current prognostic scoring systems for CAP such as CURB-65 (confusion, uraemia, respiratory rate, low blood pressure and 65 years of age) or the Pneumonia Severity Index have not been validated specifically in older adults, in whom assessment of mortality risk alone might not be adequate for predicting outcomes. Obtaining a microbial diagnosis remains problematic and may be particularly challenging in frail elderly persons, who may have greater difficulties producing sputum. Effective empirical treatment involves selection of a regimen with a spectrum of activity that includes the causative pathogen. Although most cases of CAP are probably caused by a single pathogen, dual and multiple infections are increasingly being reported. Streptococcus pneumoniae remains the overriding aetiological agent, particularly in very elderly people. However, respiratory viruses and 'atypical' organisms such as Chlamydia pneumoniae are being described with increasing frequency in old patients, and aspiration pneumonia should also be taken into consideration, particularly in very elderly subjects and those with dementia. Age >65 years is a well established risk factor for infection with drug-resistant S. pneumoniae. Clinicians should be aware of additional risk factors for acquiring less common pathogens or antibacterial-resistant organisms that may suggest that additions or modifications to the basic empirical regimen are warranted. In addition to administration of antibacterials, appropriate supportive therapy, covering management of severe sepsis and septic shock, respiratory failure, as well as management of any decompensated underlying disease, may be critical to improving outcomes in elderly patients with CAP. Immunization with pneumococcal and influenza vaccines has also been demonstrated to be beneficial in numerous large studies. There is good evidence that implementation of guidelines leads to improvement in clinical outcomes in elderly patients with CAP, including a reduction in mortality. Protocols should address a comprehensive set of elements in the process of care and should periodically be evaluated to measure their effects on clinically relevant outcomes. Assessment of functional clinical outcome variables, in addition to survival, is strongly recommended for this population.

Short- versus long-course antibacterial therapy for community-acquired pneumonia : a meta-analysis

BACKGROUND

The evidence for traditionally recommended 7- to 14-day duration of antibacterial therapy for community-acquired pneumonia (CAP) is not well established.

OBJECTIVES

We endeavoured to assess the effectiveness and safety of shorter than traditionally recommended antibacterial therapy for CAP.

METHODS

We performed a meta-analysis of randomized controlled trials (RCTs) comparing short- (< or = 7 days) versus long- (> or = 2 days difference) course therapy for CAP with the same antibacterial regimens, in the same daily dosages.

RESULTS

Five RCTs involving adults (including outpatients and inpatients who did not require intensive care) and two RCTs involving children (aged 2-59 months, residing in developing countries) were included. All RCTs were double-blind and assessed patients with CAP of mild to moderate severity. No differences were found between short- (adults 3-7 days; children 3 days) and long- (adults 7-10 days; children 5 days) course regimens (adults - amoxicillin, cefuroxime, ceftriaxone, telithromycin and gemifloxacin; children - amoxicillin) regarding clinical success at end-of-therapy (six RCTs; 5107 patients [1095 adults, 4012 children]; fixed-effect model [FEM]; odds ratio [OR] = 0.89; 95% CI 0.74, 1.07), clinical success at late follow-up, microbiological success, relapses, mortality (seven RCTs; 5438 patients; FEM; OR = 0.57; 95% CI 0.23, 1.43), adverse events (five RCTs; 3214 patients; FEM; OR = 0. 90; 95% CI 0.72, 1.13) or withdrawals as a result of adverse events. No differences were found in subset analyses of adults or children, and of patients treated with no more than 5-day short-course regimens versus at least 7-day long-course regimens.

CONCLUSION

No difference was found in the effectiveness and safety of short- versus long-course antimicrobial treatment of adult and paediatric patients with CAP of mild to moderate severity.

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

BACKGROUND AND OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Cost-effectiveness of oral gemifloxacin versus intravenous ceftriaxone followed by oral cefuroxime with/without a macrolide for the treatment of hospitalized patients with community-acquired pneumonia

We studied the cost-effectiveness of oral gemifloxacin with intravenous ceftriaxone followed by oral cefuroxime with or without a macrolide to treat patients hospitalized with community-acquired pneumonia. Data were prospectively collected as part of a randomized multicenter study. The costs evaluated included antimicrobial acquisition (1st level); plus preparation, dispensing, and administration costs, and treatment of antimicrobial-related adverse events and clinical failures (2nd level); plus per diem costs for hospital stay related to study drug administration (3rd level). At follow-up, clinical success was similar between gemifloxacin (76.9%)- and ceftriaxone (79.1%)-treated patients. The median 1st-level costs for gemifloxacin and ceftriaxone were $136 and $470 (P<0.001), respectively. For the 2nd level, these costs were $158 and $542 (P<0.001), and for the 3rd level, these were $5052 and $5789 (P=0.025), respectively. The median cost per expected success was $6568 for gemifloxacin and $7321 for ceftriaxone (P=0.29). Oral gemifloxacin is clinically effective and has an economic advantage over ceftriaxone, followed by oral cefuroxime with or without a macrolide.

Objective Computer-Based Assessment of Valleculae Residue – Is It Useful?

There have been questions about the reliability of subjective rating scales used to assess valleculae residue from fluoroscopic images. The aim of this study was to assess interrater agreement on one such scale, and compare it with agreement using a new objective measurement scale. Five speech and language therapists rated 100 valleculae residue still images from 20 consecutive patients using standard clinical practice (i.e., subjective visual grading of the videofluoroscopy still and rating as none, mild, moderate, or severe). The images were rerated by the same clinicians using Picture Archiving Communication System measurement tools. The valleculae residue ratio relates the residue size to the size of an individual's valleculae. A valleculae residue ratio scale was devised using a linear classifier, which defines the cutoff between grades of valleculae residue (none, mild, moderate, and severe). The new method proved at least as reliable as the traditional method; for interrater reliability, kappa = 0.73 vs. 0.73; for intrarater reliability, kappa = 0.87 vs. 0.85. The valleculae residue ratio is proposed as a new quick reliable method of quantifying residue where the Picture Archiving Communication System is available. We now wish to test the impact of this method where poor inter- and intrarater reliability exists.

How long should we treat community-acquired pneumonia?

PURPOSE OF REVIEW

The studies reviewed in this article suggest that a shorter duration of antibiotic therapy is comparable to standard therapy in the treatment of community-acquired pneumonia and promotes reduction of adverse events, microbial resistance, cost, and improved patient compliance.

RECENT FINDINGS

Community-acquired pneumonia has traditionally been treated with a 7-14-day course of antimicrobial therapy. Since there have been few well controlled trials regarding the optimal duration of therapy, however, there has been no consensus on length of therapy among different organizational guidelines. Several recent studies have demonstrated that shorter course antibiotic regimens are effective in the treatment of community-acquired pneumonia.

SUMMARY

Short-course antibiotic therapy is equivalent to standard length of therapy for clinical cure and bacterial eradication. Minimization of drug exposure, however, reduces selection pressure for resistant strains, strengthens patient compliance, and potentially reduces adverse events such as Clostridium difficile infections.

Gemifloxacin once daily for 5 days versus 7 days for the treatment of community-acquired pneumonia: a randomized, multicentre, double-blind study

OBJECTIVES

Short-course therapy has been advocated for the treatment of community-acquired pneumonia (CAP). We compared the efficacy and safety of 5 and 7 day courses of gemifloxacin for outpatient treatment of mild-moderate CAP.

PATIENTS AND METHODS

In a multicentre, double-blind, parallel group study, patients were randomized to receive 320 mg of oral gemifloxacin once daily for 5 or 7 days. Over 95% of all patients in each cohort had a Fine score of <or=III. The primary efficacy endpoint was clinical cure at follow-up (days 24-30). Secondary outcomes were clinical and bacteriological responses at the end of therapy (days 7-9) and bacteriological and radiological responses at follow-up. Adverse events (AEs) were also monitored.

RESULTS

In a total of 469 per protocol (PP) patients, clinical resolution at follow-up was 95% and 92% for 5 and 7 day treatments, respectively [95% confidence interval (CI) -1.48, 7.42], indicating non-inferiority of 5 day treatment. Clinical resolution at the end of therapy was 96% for both regimens (95% CI -3.85, 3.42). Bacteriological response rates in PP patients at the end of therapy were 94% and 96% for 5 and 7 day groups, respectively (95% CI -8.27, 3.25) and 91% for both groups at follow-up (95% CI -6.89, 7.93). Radiological success in PP patients at follow-up was 98% and 93% in 5 and 7 day groups, respectively (95% CI 0.35, 7.91). Pre-therapy pathogens were identified in 242 (47.3%) patients, most commonly Streptococcus pneumoniae. Frequency of treatment-related AEs was 21% in both cohorts with discontinuation rates of 1.2% and 2% in the 5 and 7 day groups, respectively. A lower incidence of rash was observed in the 5 day cohort (0.4%) versus the 7 day cohort (2.8%) (P=0.04).

CONCLUSIONS

Gemifloxacin once daily for 5 days is not inferior to 7 days in the PP population with respect to clinical, bacteriological and radiological efficacy. Further work is needed, however, to explore whether fewer treatment days would improve patient compliance and reduce the incidence of AEs.

Use of population pharmacokinetic modeling and Monte Carlo simulation to describe the pharmacodynamic profile of cefditoren in plasma and epithelial lining fluid

Cefditoren is a broad-spectrum, oral cephalosporin that is highly active against clinically relevant respiratory tract pathogens, including multidrug-resistant Streptococcus pneumoniae. This study described its pharmacodynamic profile in plasma and epithelial lining fluid (ELF). Plasma and ELF pharmacokinetic data were obtained from 24 patients under fasting conditions. Cefditoren and urea concentrations were determined in plasma and bronchoalveolar lavage fluid by liquid chromatography-tandem mass spectrometry. Concentration-time profiles in plasma and ELF were modeled using a model with three disposition compartments and first-order absorption, elimination, and transfer. Pharmacokinetic parameters were identified in a population pharmacokinetic analysis (big nonparametric adaptive grid with adaptive gamma). Monte Carlo simulation (9,999 subjects) was performed with the ADAPT II program to estimate the probability of target attainment at which the free-cefditoren plasma concentrations (88%) protein binding and total ELF concentrations exceeded the MIC for 33% of the dosing interval for 400 mg cefditoren given orally every 12 h. After the Bayesian step, the overall fits of the model to the data were good, and plots of predicted versus observed concentrations for plasma and ELF showed slopes and intercepts very close to the ideal values of 1.0 and 0.0, respectively. In the plasma probability of target attainment analysis, the probability of achieving a time for which free, or unbound, plasma concentration exceeds the MIC of the organism for 33% of the dosing interval was <80% for a MIC of >0.06 mg/liter. Similar to plasma, the probability of achieving a time above the MIC of 33% was <80% for MIC of >0.06 mg/liter in ELF. Cefditoren was found to have a low probability of achieving a bacteriostatic effect against MICs of >0.06 mg/liter, which includes most S. pneumoniae isolates with intermediate susceptibility to penicillin, when given in the fasting state in both plasma and ELF.

Recent advances in community-acquired pneumonia: inpatient and outpatient

Community-acquired pneumonia (CAP) is a common illness, with the majority of patients treated out of the hospital, yet the greatest burden of the cost of care comes from inpatient management. In the past several years, the management of these patients has advanced, with new information about the natural history and prognosis of illness, the utility of serum markers to guide management, the use of appropriate clinical tools to guide the site-of-care decision, and the finding that guidelines can be developed in a way that improves patient outcome. The challenges to patient management include the emergence of new pathogens and the progression of antibiotic resistance in some of the common pathogens such as Streptococcus pneumoniae. Few new antimicrobial treatment options are available, and the utility of some new therapies has been limited by drug-related toxicity. Ancillary care for severe pneumonia with activated protein C and corticosteroids is being studied, but recently, inpatient care has been most affected by the development of evidence-based "core measures" for management that have been promoted by the Centers for Medicare and Medicaid Services, which form the basis for the public reporting of hospital performance in CAP care.

Cost-effectiveness of empirical prescribing of antimicrobials in community-acquired pneumonia in three countries in the presence of resistance

OBJECTIVES

To assess the cost-effectiveness of empirical outpatient treatment options for community-acquired pneumonia (CAP) in France, the USA and Germany, representing high, moderate and low antimicrobial resistance prevalence, respectively.

METHODS

A decision analytic model was developed for mild-to-moderate CAP outpatient treatment. Treatment algorithms incorporated follow-up after treatment failure due to resistance or other reasons. First-line treatment included moxifloxacin, beta-lactams, macrolides or doxycycline; second-line treatment used a different antimicrobial class. Country-specific resistance and co-resistance prevalences to first- and second-line therapy for the major CAP pathogens were derived from surveillance studies. Clinical failure rates due to antimicrobial-susceptible and -resistant pathogens were obtained from the literature or estimated. Total costs were estimated using standard sources and a third-party payer perspective. Outcome measures included first-line clinical failures avoided, second-line treatments avoided and hospitalizations avoided. Incremental cost-effectiveness ratios (ICERs) were calculated.

RESULTS

First-line moxifloxacin treatment followed by co-amoxiclav dominated all other treatments in France, the USA and in Germany for all outcome measures. Sensitivity analyses maintained moxifloxacin dominance in France and the USA but affected ICERs in some cases in Germany.

CONCLUSIONS

Antimicrobial resistance/spectrum have a significant impact on outcomes and costs in empirical outpatient CAP treatment. Despite low acquisition costs for generic antibiotics, first-line treatment effective against the major CAP pathogens, including strains resistant to other antimicrobials, resulted in better clinical outcomes in all countries and lower treatment costs for all.

Hyponatremia in community-acquired pneumonia

BACKGROUND/AIM

Community-acquired pneumonia (CAP) is a frequent cause for hospitalization and may result in a number of different renal and electrolyte complications. The purpose of this study was to describe the incidence of hyponatremia in CAP and to analyze risk factors for its occurrence.

METHODS

Records were reviewed for all 342 subjects who participated in the Community-Acquired Pneumonia Standardized Order Set study, a 2-year trial of supplemental treatment tools in hospital pneumonia treatment.

RESULTS

Hyponatremia (serum sodium concentration <136 mg/dl) was present at hospital admission in 27.9% of patients. The magnitude was generally mild, only 4.1% of patients had serum sodium <130 mEq/l. Patients with hyponatremia had greater initial heart rate (100.2 vs. 93.2 beats/min, p = 0.03), white blood cell count (15,100 vs. 12,100/mul, p < 0.0001) and pneumonia severity index class 4 or 5 (35.7 vs. 25.1% of patients, p = 0.05). Hyponatremia at admission was associated with greater risk for death and increased length of hospital stay. Hyponatremia developed during the hospitalization in 10.5% of subjects, with most cases being mild, only 2.6% of all patients having serum sodium decrease to <130 mEq/l. Patients developing hyponatremia were more likely to have end-stage renal disease and to have had initial intravenous fluids other than isotonic saline, but had similar severity of illness on admission to those without acquired hyponatremia.

CONCLUSION

Hyponatremia is a common complication present at the time of admission for CAP. It is associated with more severe illness, increased mortality risk and extended hospital stays. Hyponatremia develops less frequently during the hospitalization and is unrelated to severity of illness on admission, but is an iatrogenic complication and thus initial treatment with isotonic saline may reduce the risk of this complication.

Early switch to oral antibiotics and early discharge guidelines in the management of community-acquired pneumonia

BACKGROUND AND OBJECTIVE

The major cost of managing community-acquired pneumonia (CAP) relates to the duration i.v. antibiotic use and length of hospital stay (LOS). Guidelines on early switch to oral antibiotics and early discharge from hospital may help to achieve a unified approach to managing CAP. The aim of this study was to assess the benefits and safety of these guidelines in an Australian respiratory medicine unit.

METHODS

This prospective study included consecutive patients admitted with a diagnosis of CAP over a 6-month period. Early switch to oral antibiotics and early discharge guidelines were implemented one month prior to the evaluation period. Comparison was made to a retrospective control group admitted before the guidelines were implemented. Data collection included patient demographics, clinical and outcome parameters, duration of i.v. antibiotics and LOS. Thirty-day outcomes on patient safety and satisfaction were collected from the prospective group.

RESULTS

One hundred and twenty-five patients in the prospective group were compared to 100 patients in the controls. Baseline characteristics were similar between the comparison groups. Both the mean duration of i.v. antibiotics used (3.38 +/- 0.22 vs. 3.99 +/- 0.28 days, P = 0.03) and LOS (7.62 +/- 0.60 vs. 8.36 +/- 0.55 days, P = 0.04) were significantly shorter in the prospective group. Thirty-day readmission rate was 6% and patient self-reported overall satisfaction was 93.9% in those who were followed up.

CONCLUSIONS

The use of early switch and early discharge guidelines for CAP reduced the duration of i.v. antibiotics and LOS while maintaining high levels of safety and patient satisfaction.

Clinical implications of macrolide resistance in community-acquired respiratory tract infections

Laboratory surveillance data suggest that macrolide resistance among Streptococcus pneumoniae has increased dramatically over the past 15 years. This review examines the specifics of macrolide resistance and the clinical relevance of in vitro susceptibility testing in light of the pharmacokinetics and pharmacodynamics of azithromycin and clarithromycin. These drugs concentrate extensively within respiratory tissue and have other positive characteristics not reflected by in vitro susceptibility testing. In general, clarithromycin is the most potent macrolide and the one most likely to maintain clinical efficacy against the low-level resistance associated with most macrolide-resistant pneumococci in the USA. These findings suggest that susceptibility data may underestimate clinical utility and that clarithromycin still has a place in the empiric treatment of respiratory infections.

Community-Acquired Respiratory Complications in the Intensive Care Unit: Pneumonia and Acute Exacerbations of COPD

This chapter will review the two most common lower respiratory tract infections in the intensive care unit (ICU), community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In addition we will provide an overview of the topics including recommendations for the diagnosis and treatment.

Levofloxacin 750-mg for 5 days for the treatment of hospitalized Fine Risk Class III/IV community-acquired pneumonia patients

BACKGROUND

The efficacy and safety of 750-mg, 5-day levofloxacin was recently shown to be comparable to 500-mg, 10-day levofloxacin in a randomized, double-blind, multicentre clinical trial for mild-to-severe community-acquired pneumonia (CAP). This subgroup analysis attempted to compare the safety and efficacy of a short-course levofloxacin regimen with traditional levofloxacin dosing for PSI Class III/IV patients.

METHODS

This retrospective, subgroup analysis focused on Pneumonia Severity Index Class III and IV patients enrolled in the study. Measurements included clinical and microbiological success rates, adverse events, and symptom resolution by day 3 of therapy.

RESULTS

Of the 528 patients in the ITT population, 219 (41.5%) were categorized as PSI Class III/IV and included in this analysis. Among the clinically evaluable patients, 90.8% (69/76) of patients treated with the 750-mg regimen achieved clinical success, compared with 85.5% (71/83) treated with 500-mg levofloxacin (95% CI,-15.9 to 5.4). Eradication rates in the microbiologically evaluable population were comparable for the 750- and 500-mg regimens (88.9% vs 87.5%, respectively; 95% CI,-18.3 to 15.6). Both regimens were well tolerated and had comparable safety profiles. A greater proportion of patients in the 750-mg treatment group experienced resolution of fever (48.4% vs 34.0%; P=.046) and purulent sputum (48.4% vs 27.5%; P=.007) by day 3 of therapy.

CONCLUSIONS

The 750-mg, 5-day levofloxacin course achieved comparable clinical and microbiologic efficacy to the 500-mg, 10-day regimen. By day 3 of therapy, a greater proportion of patients in the 750-mg group had objective and subjective resolution of fever. Further research is needed to determine the economic significance of short-course levofloxacin therapy.

The role of new therapies for severe community-acquired pneumonia

PURPOSE OF REVIEW

Community-acquired pneumonia (CAP) is associated with significant morbidity and mortality and is the most common cause of death from infectious diseases. CAP patients requiring intensive care unit (ICU) admission carry the highest mortality rates. This paper aims to review the current literature regarding epidemiology, risk factors, severity criteria and reasons for admitting the hospitalized patient to the ICU, and the empiric and specific antibiotic therapeutic regimens employed.

RECENT FINDINGS

Multiple sets of clinical practice guidelines have been published in the past few years addressing the treatment of CAP. The guidelines all agree that CAP patients admitted to the hospital represent a major concern, and appropriate empiric therapy should be instituted to improve clinical outcomes.

SUMMARY

The cost, morbidity and mortality of CAP patients requiring ICU admission remain unacceptably high. These are heterogeneous groups of patients, so it is important to use risk-stratification based on clinical parameters and prediction tools. Appropriate antibiotic therapy is an important component in the management of both groups of patients. In particular, it is essential to administer an appropriate antimicrobial agent from the initiation of therapy, so that the risks of treatment failure and the morbidity of CAP may be minimized.