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Antibiothérapie courte au cours de la pneumonie aiguë communautaire : revue de la littérature et perspectives. Rev Mal Respir 2020; 37:26-33. [DOI: 10.1016/j.rmr.2019.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 12/05/2018] [Indexed: 11/18/2022]
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Ebell MH, Walsh ME, Fahey T, Kearney M, Marchello C. Meta-analysis of Calibration, Discrimination, and Stratum-Specific Likelihood Ratios for the CRB-65 Score. J Gen Intern Med 2019; 34:1304-1313. [PMID: 30993633 PMCID: PMC6614215 DOI: 10.1007/s11606-019-04869-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/19/2018] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients. OBJECTIVE To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios. DESIGN Meta-analysis of accuracy, discrimination, and calibration. METHODS We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported. KEY RESULTS Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95% CI 0.71-0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95% CI 0.91-1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70-0.81) and 0.88 (0.69-1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients. CONCLUSIONS The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4% overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5%.
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Affiliation(s)
- Mark H Ebell
- Department of Epidemiology and Biostatistics, College of Public Health , University of Georgia, Athens, GA, USA.
| | - Mary E Walsh
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Maggie Kearney
- Department of Epidemiology and Biostatistics, College of Public Health , University of Georgia, Athens, GA, USA
| | - Christian Marchello
- Department of Epidemiology and Biostatistics, College of Public Health , University of Georgia, Athens, GA, USA
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Voiriot G, Philippot Q, Elabbadi A, Elbim C, Chalumeau M, Fartoukh M. Risks Related to the Use of Non-Steroidal Anti-Inflammatory Drugs in Community-Acquired Pneumonia in Adult and Pediatric Patients. J Clin Med 2019; 8:jcm8060786. [PMID: 31163625 PMCID: PMC6617416 DOI: 10.3390/jcm8060786] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/22/2019] [Accepted: 05/27/2019] [Indexed: 12/22/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to alleviate symptoms during community-acquired pneumonia (CAP), while neither clinical data nor guidelines encourage this use. Experimental data suggest that NSAIDs impair neutrophil intrinsic functions, their recruitment to the inflammatory site, and the resolution of inflammatory processes after acute pulmonary bacterial challenge. During CAP, numerous observational data collected in hospitalized children, hospitalized adults, and adults admitted to intensive care units (ICUs) support a strong association between pre-hospital NSAID exposure and a delayed hospital referral, a delayed administration of antibiotic therapy, and the occurrence of pleuropulmonary complications, even in the only study that has accounted for a protopathic bias. Other endpoints have been described including a longer duration of antibiotic therapy and a greater hospital length of stay. In all adult series, patients exposed to NSAIDs were younger and had fewer comorbidities. The mechanisms by which NSAID use would entail a complicated course in pneumonia still remain uncertain. The temporal hypothesis and the immunological hypothesis are the two main emerging hypotheses. Current data strongly support an association between NSAID intake during the outpatient treatment of CAP and a complicated course. This should encourage experts and scientific societies to strongly advise against the use of NSAIDs in the management of lower respiratory tract infections.
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Affiliation(s)
- Guillaume Voiriot
- Assistance Publique-Hôpitaux de Paris, Service de Réanimation médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, 75020 Paris, France.
- Sorbonne Université, UFR Médecine, 75006 Paris, France.
- Faculté de Médecine, GRC CARMAS, Université Paris Est, 94000 Créteil, France.
| | - Quentin Philippot
- Assistance Publique-Hôpitaux de Paris, Service de Réanimation médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, 75020 Paris, France.
| | - Alexandre Elabbadi
- Assistance Publique-Hôpitaux de Paris, Service de Réanimation médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, 75020 Paris, France.
| | - Carole Elbim
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, Team "Immune System, Neuroinflammation and Neurodegenerative Diseases", Hôpital Saint-Antoine, 75012 Paris, France.
| | - Martin Chalumeau
- UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris Descartes University, 75014 Paris, France.
- Department of General Pediatrics and Pediatric Infectious Diseases, Necker hospital for Sick Children, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, 75015 Paris, France.
| | - Muriel Fartoukh
- Assistance Publique-Hôpitaux de Paris, Service de Réanimation médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, 75020 Paris, France.
- Sorbonne Université, UFR Médecine, 75006 Paris, France.
- Faculté de Médecine, GRC CARMAS, Université Paris Est, 94000 Créteil, France.
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Partouche H, Lepoutre A, Vaure CBD, Poisson T, Toubiana L, Gilberg S. Incidence of all-cause adult community-acquired pneumonia in primary care settings in France. Med Mal Infect 2018; 48:389-395. [DOI: 10.1016/j.medmal.2018.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/18/2017] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
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Voiriot G, Chalumeau M, Messika J, Basille D, Philippe B, Ricard JD, Andrejak C, Jounieaux V, Sanchez O, Fartoukh M. [Risks associated with the use of non-steroidal anti-inflammatory drugs during pneumonia]. Rev Mal Respir 2018; 35:430-440. [PMID: 29754841 DOI: 10.1016/j.rmr.2017.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 12/10/2017] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Outpatient treatment of community-acquired pneumonia (CAP) patients with non-steroidal anti-inflammatory drugs (NSAIDs) is frequent, although this is not based on clinical recommendations and there is no scientific evidence supporting better symptom relief in comparison to acetaminophen. STATE OF THE ART Experimental data suggest that NSAIDs alter the intrinsic functions of neutrophils, limit their locoregional recruitment, alter bacterial clearance and delay the resolution of inflammatory processes during acute bacterial pulmonary challenge. In hospitalized children and adults with CAP, observational data suggest a strong and independent association between the outpatient exposure to NSAIDs and the occurrence of pleuropulmonary complications (pleural empyema, excavation, and abscess). In the only study taking into account possible protopathic bias, the association still persists. Other markers of morbidity have been described, including delay in hospital management, prolonged antibiotic therapy, and higher transfer rate to an intensive care unit. PERSPECTIVES Data describing the role of self-medication and the biological mechanisms involved are needed. CONCLUSIONS Intake of NSAIDs during outpatient treatment of CAP is probably the second modifiable factor of morbidity after inadequate antibiotic therapy. In light of existing data in children and adults, health authorities should urgently reassess the risk-benefit ratio of NSAIDS in CAP.
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Affiliation(s)
- G Voiriot
- Service de réanimation médico-chirurgicale, hôpital Tenon, hôpitaux universitaires de l'Est-Parisien, Assistance publique-hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France.
| | - M Chalumeau
- Service de pédiatrie générale et maladies infectieuses, hôpital universitaire Necker-Enfants-Malades, Assistance publique-hôpitaux de Paris, 75015 Paris, France; Faculté de médecine, université Paris-Descartes-Paris-V, 75006 Paris, France
| | - J Messika
- Service de réanimation médico-chirurgicale, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord-Val-de-Seine, Assistance publique-hôpitaux de Paris, 92700 Colombes, France
| | - D Basille
- Service de pneumologie et réanimation respiratoire, centre hospitalier universitaire Amiens-Picardie, 80080 Amiens, France
| | - B Philippe
- Service de pneumologie, centre hospitalier René-Dubos, 95300 Pontoise, France
| | - J-D Ricard
- Service de réanimation médico-chirurgicale, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord-Val-de-Seine, Assistance publique-hôpitaux de Paris, 92700 Colombes, France; Faculté de médecine, université Paris-Diderot-Paris-VII, 75013 Paris, France
| | - C Andrejak
- Service de pneumologie et réanimation respiratoire, centre hospitalier universitaire Amiens-Picardie, 80080 Amiens, France; Faculté de médecine, université de Picardie-Jules-Verne, 80025 Amiens, France
| | - V Jounieaux
- Service de pneumologie et réanimation respiratoire, centre hospitalier universitaire Amiens-Picardie, 80080 Amiens, France; Faculté de médecine, université de Picardie-Jules-Verne, 80025 Amiens, France
| | - O Sanchez
- Faculté de médecine, université Paris-Descartes-Paris-V, 75006 Paris, France; Service de pneumologie, soins intensifs et endoscopies bronchiques, hôpital européen Georges-Pompidou, hôpitaux universitaires Paris-Ouest, Assistance Publique-hôpitaux de Paris, 75015 Paris, France
| | - M Fartoukh
- Service de réanimation médico-chirurgicale, hôpital Tenon, hôpitaux universitaires de l'Est-Parisien, Assistance publique-hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France; Faculté de médecine, Sorbonne université Paris, 75013 Paris, France
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Personne V, Chevalier J, Buffel du Vaure C, Partouche H, Gilberg S, de Pouvourville G. CAPECO: Cost evaluation of community acquired pneumonia managed in primary care. Vaccine 2016; 34:2275-80. [PMID: 26979138 DOI: 10.1016/j.vaccine.2016.03.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 02/05/2016] [Accepted: 03/04/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Estimating the economic burden of community acquired pneumonia (CAP) managed in ambulatory setting is needed in France since no data are available. METHOD A retrospective study (CAPECO) was conducted based on a prospective French study describing patients with suspected CAP managed in primary care (CAPA). The aim of the CAPECO study was to estimate and explain medical costs of a disease episode in CAP patients only followed in ambulatory care and in hospitalised patients. Primary endpoints were the direct medical costs, impact on productivity and costs of incident CAP over one year. Secondary endpoint was to describe predictive factors of costs, hospital admission and stay length. RESULTS In this cohort of 886 patients, resulting in an incidence of CAP of 400 per 100,000 inhabitants per year, the mean direct medical cost of a disease episode of CAP was € 118.8 for strictly ambulatory patients with an equal weight for medical time, drugs, diagnostic procedures and tests. This direct cost was € 102.1 before admission for patients who were finally hospitalised. The mean cost of hospital admissions was € 3522.9. Main predictive factors of hospital admission and stay length were respectively a history of chronic respiratory disease and older age. Factors of direct medical cost were prescribing X-ray examination and having a positive X-ray. The impact of a disease episode on productivity was € 1980 (sd 1400) per ambulatory episode and € 5425 (sd 4760) per episode leading to hospital admission. CONCLUSION Costs per ambulatory episode were modest but increased substantially in hospitalised patients, who were more numerous when chronic respiratory disorders were present and in the elderly. Indirect costs were significant. Deciders should thus consider both direct and indirect costs when assessing preventive interventions in the context of this disease.
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Affiliation(s)
- V Personne
- Département de médecine générale, Faculté de médecine, Sorbonne Paris Cité, Université Paris Descartes, Paris, France.
| | - J Chevalier
- Health Systems, ESSEC Business School, Avenue Bernard Hirsch, BP 50105, 95021 Cergy-Pontoise Cedex, France
| | - C Buffel du Vaure
- Département de médecine générale, Faculté de médecine, Sorbonne Paris Cité, Université Paris Descartes, Paris, France
| | - H Partouche
- Département de médecine générale, Faculté de médecine, Sorbonne Paris Cité, Université Paris Descartes, Paris, France
| | - S Gilberg
- Département de médecine générale, Faculté de médecine, Sorbonne Paris Cité, Université Paris Descartes, Paris, France
| | - G de Pouvourville
- Health Systems, ESSEC Business School, Avenue Bernard Hirsch, BP 50105, 95021 Cergy-Pontoise Cedex, France
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