A national confidential enquiry into community acquired pneumonia deaths in young adults in England and Wales. British Thoracic Society Research Committee and Public Health Laboratory Service

Use of chest X-ray in the assessment of community acquired pneumonia in primary care - an intervention study

OBJECTIVES

The aim of this study was to explore if consequent use of chest X-ray (CXR), when the physician is not sure of the diagnosis of pneumonia after clinical examination and CRP-testing, favors a more restrictive prescribing of antibiotics.

DESIGN

This was an intervention study conducted between September 2015 and December 2017.

SETTING

Two intervention primary health care centers (PHCCs) and three control PHCCs in the southeast of Sweden.

INTERVENTION

All patients were referred for CXR when the physician´s suspicion of pneumonia was 'unsure', or 'quite sure' after CRP-testing. Control units managed patients according to their usual routine after clinical examination and CRP-testing.

SUBJECTS

A total of 104 patients were included in the intervention group and 81 patients in the control group. The inclusion criteria of the study were clinically suspected pneumonia in patients ≥18 years, with respiratory symptoms for more than 24 h. Main outcome measure: Antibiotic prescribing rate.

RESULTS

In the intervention group, 85% were referred for CXR and 69% were prescribed antibiotics, as compared to 26% and 77% in the control group. The difference in antibiotic prescribing rate was not statistically significant, unadjusted OR 0.68 [0.35-1.3] and adjusted OR 1.1 [CI 0.43-3.0]. A total of 24% of patients with negative CXR were prescribed antibiotics.

CONCLUSION

This study could not prove that use of CXR when the physician was not sure of the diagnosis of pneumonia results in lowered antibiotic prescribing rate in primary care. In cases of negative findings on CXR the physicians do not seem to rely on the outcome when it comes to antibiotic prescribing. Key Points Routine use of chest X-ray when the clinical diagnosis of pneumonia is uncertain has not been proven to result in lowered antibiotic prescribing rate. Physicians do not fully rely on chest X-ray outcome and to some extent prescribe antibiotics even if negative, when community-acquired pneumonia is suspected. Chest X-ray is already used in one out of four cases in routine primary care of pneumonia patients in Sweden.

In-Hospital Deaths Among Adults With Community-Acquired Pneumonia

BACKGROUND

Adults hospitalized with community-acquired pneumonia (CAP) are at high risk for short-term mortality. However, it is unclear whether improvements in in-hospital pneumonia care could substantially lower this risk. We extensively reviewed all in-hospital deaths in a large prospective CAP study to assess the cause of each death and assess the extent of potentially preventable mortality.

METHODS

We enrolled adults hospitalized with CAP at five tertiary-care hospitals in the United States. Five physician investigators reviewed the medical record and study database for each patient who died to identify the cause of death, the contribution of CAP to death, and any preventable factors potentially contributing to death.

RESULTS

Among 2,320 enrolled patients, 52 (2.2%) died during initial hospitalization. Among these 52 patients, 33 (63.4%) were ≥ 65 years old, and 32 (61.5%) had ≥ two chronic comorbidities. CAP was judged to be the direct cause of death in 27 patients (51.9%). Ten patients (19.2%) had do-not-resuscitate orders prior to admission. Four patients were identified in whom a lapse in quality of care potentially contributed to death; preexisting end-of-life limitations were present in two of these patients. Two patients seeking full medical care experienced a lapse in in-hospital quality of pneumonia care that potentially contributed to death.

CONCLUSIONS

In this study of adults with CAP at tertiary-care hospitals with a low mortality rate, most in-hospital deaths did not appear to be preventable with improvements in in-hospital pneumonia care. Preexisting end-of-life limitations in care, advanced age, and high comorbidity burden were common among those who died.

Determining best outcomes from community-acquired pneumonia and how to achieve them

Community-acquired pneumonia (CAP) is a common acute medical illness with a standard, effective treatment that was introduced before the evidenced-based medicine era. Mortality rates have improved in recent decades but improvements have been minimal when compared to other conditions such as acute coronary syndromes. The standardized approach to treatment makes CAP a target for comparative performance and outcome measures. While easy to collect, simplistic outcomes such as mortality, readmission and length of stay are difficult to interpret as they can be affected by subjective choices and health care resources. Proposed clinical- and patient-reported outcomes are discussed below and include measures such as the time to clinical stability (TTCS) and patient satisfaction, which can be compared between health institutions. Strategies to improve these outcomes include use of a risk stratification tool, local antimicrobial guidelines with antibiotic stewardship and care bundles to include early administration of antibiotics and early mobilization.

Prognostic factors for mortality due to pneumonia among adults from different age groups in Singapore and mortality predictions based on PSI and CURB-65

INTRODUCTION

Pneumonia is associated with considerable mortality. However, there is limited information on age-specific prognostic factors for death from pneumonia.

METHODS

Patients hospitalised with a diagnosis of pneumonia through the emergency department were stratified into three age groups: 18-64 years, 65-84 years and ≥ 85 years. Multivariate logistic regression and receiver operating characteristic curve analyses were conducted to evaluate prognostic factors for mortality and the performance of pneumonia severity scoring tools for mortality prediction.

RESULTS

A total of 1,902 patients were enrolled (18-64 years: 614 [32.3%]; 65-84 years: 944 [49.6%]; ≥ 85 years: 344 [18.1%]). Mortality rates increased with age (18-64 years: 7.3%; 65-84 years: 16.1%; ≥ 85 years: 29.7%; p < 0.001). Malignancy and tachycardia were prognostic of mortality among patients aged 18-64 years. Male gender, malignancy, congestive heart failure and eight other parameters reflecting acute disease severity were associated with mortality among patients aged 65-84 years. For patients aged ≥ 85 years, altered mental status, tachycardia, blood urea nitrogen, hypoxaemia, arterial pH and pleural effusion were significantly predictive of mortality. The Pneumonia Severity Index (PSI) was more sensitive than CURB-65 (confusion, uraemia, respiratory rate ≥ 30 per minute, low blood pressure, age ≥ 65 years) for mortality prediction across all age groups.

CONCLUSION

The predictive effect of prognostic factors for mortality varied among patients with pneumonia from the different age groups. PSI performed significantly better than CURB-65 for mortality prediction, but its discriminative power decreased with advancing age.

A mortality prediction rule for non-elderly patients with community-acquired pneumonia

BACKGROUND

No mortality prediction rule is suited for non-elderly patients with community-acquired pneumonia. Therefore, we tried to create a mortality prediction rule that is simple and suitable for non-elderly patients with community-acquired pneumonia.

METHODS

Because of low mortality at young age, we used information from an administrative database that included A-DROP data. We analysed the rate and risk factors for in-hospital community-acquired pneumonia-associated death among non-elderly patients and created a mortality prediction rule based on those risk factors.

RESULTS

We examined 49,370 hospitalisations for patients aged 18-64 years with community-acquired pneumonia. The 30-day fatality rate was 1.5%. Using regression analysis, five risk factors were selected: patient requires help for feeding, the existence of malignancy, confusion, low blood pressure, and age 40-64 years. Each risk factor of our proposed mortality risk scoring system received one point. A total point score for each patient was obtained by summing the points. The negative likelihood ratio for the score 0 group was 0.01, and the positive likelihood ratio for the score ≥4 group was 19.9. The area under the curve of the risk score for non-elderly (0.86, 95% confidence interval: 0.84-0.87) was higher than that of the A-DROP score (0.72, 95% confidence interval: 0.70-0.74) (P < 0.0001).

CONCLUSIONS

Our newly proposed mortality risk scoring system may be appropriate for predicting mortality in non-elderly patients with community-acquired pneumonia. It showed a possibility of a better prediction value than the A-DROP and is easy to use in various clinical settings.

Community-acquired pneumonia in primary care: clinical assessment and the usability of chest radiography

OBJECTIVES

To investigate the diagnostic value of different clinical and laboratory findings in pneumonia and to explore the association between the doctor's degree of suspicion and chest X-ray (CXR) result and to evaluate whether or not CXR should be used routinely in primary care, when available.

DESIGN

A three-year prospective study was conducted between September 2011 and December 2014.

SETTING

Two primary care settings in Linköping, Sweden.

SUBJECTS

A total of 103 adult patients with suspected pneumonia in primary care.

MAIN OUTCOME MEASURES

The physicians recorded results of a standardized medical physical examination, including laboratory results, and rated their suspicion into three degrees. The outcome of the diagnostic variables and the degree of suspicion was compared with the result of CXR.

RESULTS

Radiographic pneumonia was reported in 45% of patients. When the physicians were sure of the diagnosis radiographic pneumonia was found in 88% of cases (p < 0.001), when quite sure the frequency of positive CXR was 45%, and when not sure 28%. Elevated levels of C-reactive protein (CRP) ≥ 50mg/L were associated with the presence of radiographic pneumonia when the diagnosis was suspected (p < 0.001).

CONCLUSION

This study indicates that CXR can be useful if the physician is not sure of the diagnosis, but when sure one can rely on one's judgement without ordering CXR.

KEY POINTS

There are different guidelines but no consensus on how to manage community-acquired pneumonia in primary care. When the physician is sure of the diagnosis the judgement is reliable without chest X-ray and antibiotics can be safely prescribed. Chest X-ray can be useful in the assessment of pneumonia in primary care, when the physician is not sure of the diagnosis.

An internet-delivered handwashing intervention to modify influenza-like illness and respiratory infection transmission (PRIMIT): a primary care randomised trial

BACKGROUND

Handwashing to prevent transmission of respiratory tract infections (RTIs) has been widely advocated, especially during the H1N1 pandemic. However, the role of handwashing is debated, and no good randomised evidence exists among adults in non-deprived settings. We aimed to assess whether an internet-delivered intervention to modify handwashing would reduce the number of RTIs among adults and their household members.

METHODS

We recruited individuals sharing a household by mailed invitation through general practices in England. After consent, participants were randomised online by an automated computer-generated random number programme to receive either no access or access to a bespoke automated web-based intervention that maximised handwashing intention, monitored handwashing behaviour, provided tailored feedback, reinforced helpful attitudes and norms, and addressed negative beliefs. We enrolled participants into an additional cohort (randomised to receive intervention or no intervention) to assess whether the baseline questionnaire on handwashing would affect handwashing behaviour. Participants were not masked to intervention allocation, but statistical analysis commands were constructed masked to group. The primary outcome was number of episodes of RTIs in index participants in a modified intention-to-treat population of randomly assigned participants who completed follow-up at 16 weeks. This trial is registered with the ISRCTN registry, number ISRCTN75058295.

FINDINGS

Across three winters between Jan 17, 2011, and March 31, 2013, we enrolled 20,066 participants and randomly assigned them to receive intervention (n=10,040) or no intervention (n=10,026). 16,908 (84%) participants were followed up with the 16 week questionnaire (8241 index participants in intervention group and 8667 in control group). After 16 weeks, 4242 individuals (51%) in the intervention group reported one or more episodes of RTI compared with 5135 (59%) in the control group (multivariate risk ratio 0·86, 95% CI 0·83-0·89; p<0·0001). The intervention reduced transmission of RTIs (reported within 1 week of another household member) both to and from the index person. We noted a slight increase in minor self-reported skin irritation (231 [4%] of 5429 in intervention group vs 79 [1%] of 6087 in control group) and no reported serious adverse events.

INTERPRETATION

In non-pandemic years, an effective internet intervention designed to increase handwashing could have an important effect in reduction of infection transmission. In view of the heightened concern during a pandemic and the likely role of the internet in access to advice, the intervention also has potential for effective implementation during a pandemic.

FUNDING

Medical Research Council.

Improving outcomes from community-acquired pneumonia

PURPOSE OF REVIEW

We are entering into a new era of healthcare wherein patient outcomes are increasingly being publicly reported, not just by institution, but by individual clinicians. This review focuses on the issue of quality of care of patients with community-acquired pneumonia (CAP), in particular the choice of outcome, quality of data needed and recommendations of the current bundle of care suggested by the available literature as delivering the best chance of favourable outcomes for patients.

RECENT FINDINGS

There is increasing evidence that pneumonia outcomes have improved over the past decade, particularly mortality. However, we have been oversimplistic in setting quality targets and that a bundle of care is required to deliver best outcomes, such as has been shown with the surviving sepsis campaign. Equally, the quality of data available to compare outcomes needs to be significantly improved on what is currently available.

SUMMARY

To achieve best outcomes for their patients, physicians must be actively comparing their outcomes against other institutions and not rely on historical data. A bundle of care that includes rapid administration of antibiotics, use of combination antibiotic therapy including a macrolide and early mobilization is a good starting point.

Association between hospital case volume and mortality in non-elderly pneumonia patients stratified by severity: a retrospective cohort study

Background

The characteristics and aetiology of pneumonia in the non-elderly population is distinct from that in the elderly population. While a few studies have reported an inverse association between hospital case volume and clinical outcome in elderly pneumonia patients, the evidence is lacking in a younger population. In addition, the relationship between volume and outcome may be different in severe pneumonia cases than in mild cases. In this context, we tested two hypotheses: 1) non-elderly pneumonia patients treated at hospitals with larger case volume have better clinical outcome compared with those treated at lower case volume hospitals; 2) the volume-outcome relationship differs by the severity of the pneumonia.

Methods

We conducted the study using the Japanese Diagnosis Procedure Combination database. Patients aged 18–64 years discharged from the participating hospitals between July to December 2010 were included. The hospitals were categorized into four groups (very-low, low, medium, high) based on volume quartiles. The association between hospital case volume and in-hospital mortality was evaluated using multivariate logistic regression with generalized estimating equations adjusting for pneumonia severity, patient demographics and comorbidity score, and hospital academic status. We further analyzed the relationship by modified A-DROP pneumonia severity score calculated using the four severity indices: dehydration, low oxygen saturation, orientation disturbance, and decreased systolic blood pressure.

Results

We identified 8,293 cases of pneumonia at 896 hospitals across Japan, with 273 in-hospital deaths (3.3%). In the overall population, no significant association between hospital volume and in-hospital mortality was observed. However, when stratified by pneumonia severity score, higher hospital volume was associated with lower in-hospital mortality at the intermediate severity level (modified A-DROP score = 2) (odds ratio (OR) of very low vs. high: 2.70; 95% confidence interval (CI): 1.12–6.55, OR of low vs. high: 2.40; 95% CI:0.99–5.83). No significant association was observed for other severity strata.

Conclusions

Hospital case volume was inversely associated with in-hospital mortality in non-elderly pneumonia patients with intermediate pneumonia severity. Our result suggests room for potential improvement in the quality of care in hospitals with lower volume, to improve treatment outcomes particularly in patients admitted with intermediate pneumonia severity.

Clinical characteristics of severe community-acquired pneumonia among younger patients: an analysis of 18 years at a community hospital

Unlike elderly patients with community-acquired pneumonia whose outcomes are markedly affected by their background characteristics, it appears that the severity of the infection itself contributes to outcomes in younger patients with community-acquired pneumonia. In order to identify clinical characteristics of severe community-acquired pneumonia in younger patients under 60 years old, among such cases prospectively collected at our hospital over a period of 18 years, those meeting the criteria for severe community-acquired pneumonia, as defined in the Infectious Diseases Society of America/American Thoracic Society Guidelines for community-acquired pneumonia, were retrospectively examined and compared to elderly patients with severe community-acquired pneumonia. Younger patients with severe pneumonia accounted for 12.9% of younger hospitalized patients. Although the incidence of severe pneumonia in younger patients was lower than that in elderly patients, its severity may be underestimated by severity assessment based on the conventional guidelines. Thus, attention is required. While Streptococcus pneumoniae and Legionella species were important causative pathogens, atypical pathogens and viruses were also frequently detected. There were only 11 deaths over a period of 18 years. Based on multivariate analysis, the risk factors for aggravation of community-acquired pneumonia among younger patients were age 50 years or older, diabetes mellitus, chronic liver disease, and Legionella pneumonia. Although the mortality rate from community-acquired pneumonia is extremely low in previously healthy younger patients, outcomes might be poor for patients with underlying diseases and those with rapid progression. Multimodal treatments including respiratory management may be appropriate.

Risks of nonsteroidal antiinflammatory drugs in undiagnosed intensive care unit pneumococcal pneumonia: younger and more severely affected patients

PURPOSE

The purpose of this study is to investigate whether exposure to nonsteroidal antiinflammatory drugs (NSAIDs) at the early stage of severe pneumococcal community-acquired pneumonia (CAP) requiring intensive care unit (ICU) admission may affect its presentation and outcome.

MATERIAL AND METHODS

Medical records of ICU adult patients (12-year period) with a pneumococcal CAP diagnosis were retrospectively analyzed according to previous NSAID exposure.

RESULTS

One hundred six confirmed pneumococcal CAP were identified, 20 received NSAIDs within 4 (2-6) days before admission. Nonsteroidal antiinflammatory drug-exposed patients were younger (43.3 vs 62.2 years; P < .0001), had less frequently at least one chronic comorbid condition (40% vs 75%; P = .003), had more often complicated pleural effusions (20% vs 2.3%; P = .01), and more frequent pleuropulmonary complications (odds ratio: 5.75 [1.97-16.76]). Nonsteroidal antiinflammatory drug patients required more often noninvasive ventilatory support (25% vs 4.6%; P = .003). Intensive care unit length of stay and mortality were similar.

CONCLUSIONS

We report as severe pneumococcal pneumonia in young and healthy patients exposed to NSAIDs as in older, more comorbid, and nonexposed ones. Nonsteroidal antiinflammatory drug use may mask initial symptoms and delay antimicrobial therapy, thus predisposing to worse outcomes.

Why do nonsurvivors from community-acquired pneumonia not receive ventilatory support?

OBJECTIVE

We investigated rates and predictors of ventilatory support during hospitalization in seemingly not severely compromised nonsurvivors of community-acquired pneumonia (CAP).

METHODS

We used the database from the German nationwide mandatory quality assurance program including all hospitalized patients with CAP from 2007 to 2011. We selected a population not residing in nursing homes, not bedridden, and not referred from another hospital. Predictors of ventilatory support were identified using a multivariate analysis.

RESULTS

Overall, 563,901 patients (62.3% of the whole population) were included. Mean age was 69.4 ± 16.6 years; 329,107 (58.4%) were male. Mortality was 39,895 (7.1%). A total of 28,410 (5.0%) received ventilatory support during the hospital course, and 76.3% of nonsurvivors did not receive ventilatory support (62.6% of those aged <65 years and 78% of those aged ≥65 years). Higher age (relative risk (RR) 0.48, 95% confidence interval (CI) 0.44-0.51), failure to assess gas exchange (RR 0.18, 95% CI 0.14-0.25) and to administer antibiotics within 8 h of hospitalization (RR 0.48, 95% CI 0.39-0.59) were predictors of not receiving ventilatory support during hospitalization. Death from CAP occurred significantly earlier in the nonventilated group (8.2 ± 8.9 vs. 13.1 ± 14.1 days; p < 0.0001).

CONCLUSIONS

The number of nonsurvivors without obvious reasons for withholding ventilatory support is disturbingly high, particularly in younger patients. Both performance predictors for not being ventilated remain ambiguous, because they may reflect either treatment restrictions or deficient clinical performance. Elucidating this ambiguity will be part of the forthcoming update of the quality assurance program.

Viral pneumonia

About 200 million cases of viral community-acquired pneumonia occur every year-100 million in children and 100 million in adults. Molecular diagnostic tests have greatly increased our understanding of the role of viruses in pneumonia, and findings indicate that the incidence of viral pneumonia has been underestimated. In children, respiratory syncytial virus, rhinovirus, human metapneumovirus, human bocavirus, and parainfluenza viruses are the agents identified most frequently in both developed and developing countries. Dual viral infections are common, and a third of children have evidence of viral-bacterial co-infection. In adults, viruses are the putative causative agents in a third of cases of community-acquired pneumonia, in particular influenza viruses, rhinoviruses, and coronaviruses. Bacteria continue to have a predominant role in adults with pneumonia. Presence of viral epidemics in the community, patient's age, speed of onset of illness, symptoms, biomarkers, radiographic changes, and response to treatment can help differentiate viral from bacterial pneumonia. However, no clinical algorithm exists that will distinguish clearly the cause of pneumonia. No clear consensus has been reached about whether patients with obvious viral community-acquired pneumonia need to be treated with antibiotics. Apart from neuraminidase inhibitors for pneumonia caused by influenza viruses, there is no clear role for use of specific antivirals to treat viral community-acquired pneumonia. Influenza vaccines are the only available specific preventive measures. Further studies are needed to better understand the cause and pathogenesis of community-acquired pneumonia. Furthermore, regional differences in cause of pneumonia should be investigated, in particular to obtain more data from developing countries.

Respiratory infections: a current and future threat

Despite all the medical progress in the last 50 years pulmonary infections continue to exact and extremely high human and economic cost. This review will focus on the human, pathogen and environmental factors that contribute to the continued global burden or respiratory diseases with a particular focus on areas where we might hope to see some progress in the coming decades.

C-reactive protein and community-acquired pneumonia in ambulatory care: systematic review of diagnostic accuracy studies

BACKGROUND

There is uncertainty regarding the diagnostic value of C-reactive protein (CRP) in patients presenting with symptoms suggestive of community-acquired pneumonia (CAP) in community or ambulatory settings.

OBJECTIVE

We assessed the diagnostic value of CRP in primary care and accident and emergency departments in terms of ruling in or ruling out CAP.

METHODS

Diagnostic accuracy systematic review, we searched PubMed from January 1966 to September 2008 and EMBASE from January 1980 to September 2008 using a diagnostic accuracy search filter. We included cross-sectional or cohort studies that assess the diagnostic utility of CRP at different cut-points against a reference standard of chest X-ray. We calculated pooled positive and negative likelihood ratios (LRs) and assessed heterogeneity using the I(2) index.

RESULTS

Eight studies incorporating 2194 patients were included. The median prevalence of CAP was 14.6% (range 5%-89%). At a CRP cut-point of < or =20 mg/l, the pooled positive LR+ was 2.1 [95% confidence interval (CI) 1.8-2.4] and the pooled negative LR- was 0.33 (95% CI 0.25-0.43). At the two other CRP cut-points (< or =50, >100 mg/l), the results were heterogeneous, so the pooled results should be interpreted with caution.

CONCLUSIONS

CRP may be of value in ruling out a diagnosis of CAP in situations where the probability of CAP >10%, typically accident and emergency departments. In primary care, additional diagnostic testing with CRP is unlikely to alter the probability of CAP sufficiently to change subsequent management decisions such as antibiotic prescribing or referral to hospital.

Predicting the need for mechanical ventilation and/or inotropic support for young adults admitted to the hospital with community-acquired pneumonia

The UK Department of Health has published concerns that pneumonia severity scores determined at hospital admission may underestimate the severity of pneumonia in young adults. SMART-COP (systolic blood pressure, multilobar chest radiography involvement, albumin level, respiratory rate, tachycardia, confusion, oxygenation, and arterial pH) was superior to both the CURB65 (confusion, urea, respiratory rate, systolic or diastolic blood pressure, and age >or=65 years) score and the Pneumonia Severity Index in predicting the need for mechanical ventilation and/or inotropic support, but SMART-COP would still incorrectly stratify 15% of patients.

Severity scores for community-acquired pneumonia

An assessment of the severity of illness of a patient is one of the most important components of their early management. It guides decisions regarding the most appropriate site of care and the selection of empiric antibiotic therapy. In recent years, prediction tools, known as severity scores, have been promoted to assist early assessments of the severity of illness for patients with community-acquired pneumonia. Several different severity scores now exist and these have been modified over time. Each tool has particular strengths and weaknesses. This article reviews the evolution of severity scores for patients with community-acquired pneumonia and compares their performance in different patient cohorts for different outcomes of interest, as described in the published literature to date. It also discusses how these tools could be evaluated more comprehensively so that their place in patient management can be better appreciated.

Antibiotic Prescribing in Critical Care: Specific Indications

This article outlines recommendations for the treatment of specific infections occurring in the setting of critical care. In the interests of brevity, a limited number of infections are discussed and recommendations are largely confined to empirical therapy. Basic principles of diagnosis and treatment apply in all cases, including appropriate de-escalation when an organism is identified. These aspects of treatment have been dealt with in part one of this article – ‘Antibiotic prescribing in critical care: general principles' published in the winter 2007 edition of JICS.

The role of evidence in the decline of antibiotic use for common respiratory infections in primary care

Antibiotic prescribing in primary care for common respiratory infections increased steadily until the mid 1990s, when the trend reversed noticeably. During the subsequent decade, antibiotic prescribing reduced by up to one-third in some countries. Explanations for this reduction have focused on a decline in the incidence and severity of common respiratory infections, and on the resulting decrease in the number of patients seeking consultation. We argue that evidence from primary-care research had a central role in changing the practice of antibiotic prescribing, and discuss the concern that has arisen among some physicians around this issue. Targeted reductions in antibiotic prescribing constitute a balancing act between individual and societal concerns, pitting the expected gains in preserving the usefulness of an antibiotic against any given reduction in use. There may be unintended consequences for decreasing antibiotic use beyond a certain point without adequate supporting evidence. A new approach to antibiotic prescribing requires comprehensive research to answer why change is necessary, and how that change can be safely implemented. Future policies must move beyond a "one size fits all" mindset if public and provider behaviours are expected to become more congruent with the growing research evidence.

Rapid diagnosis of pneumococcal pneumonia among HIV-infected adults with urine antigen detection

OBJECTIVES

Streptococcus pneumoniae is the leading cause of bacterial pneumonia and associated bacteremia during HIV infection. Rapid diagnostic assays may limit inappropriate therapy.

METHODS

Clinical signs and symptoms and sera and urine were collected prospectively from 70 adults with pneumococcal pneumonia, including 47 with HIV co-infection. Pneumococcal C-polysaccharide antigen was detected in urine using the Binax immunochromatographic test (ICT). A systematic review of 24 published studies was conducted.

RESULTS

Clinical symptoms, signs, and laboratory parameters except leukocytosis, were similar in HIV-infected and HIV-seronegative pneumonia. The performance of the urine antigen ICT was independent of HIV-status (sensitivity 81%, specificity 98%, positive (PPV) and negative predictive values (NPV) 98%, and 82%, respectively). The sensitivity of sputum Gram's stain was 58% (34/59) with sputum unable to be provided by 16%. The CRP response was identical in HIV-infected (mean+/-SD) 133+/-88 vs. seronegative 135+/-104 mg/L (p=0.9). In the systematic review, the ICT performance revealed 74% sensitivity (95% CI 72-77%) and 94% specificity (95% CI 93-95%). Urine antigen testing increases etiologic diagnosis by 23% (range: 10-59%) when testing adults with community acquired pneumonia of unknown etiology.

CONCLUSIONS

Urinary antigen detection provides a credible rapid diagnostic test for pneumococcal pneumonia regardless of HIV-status. CRP response to acute infection is similar in HIV co-infection and increases diagnostic certainty.

Pneumonia during pregnancy

BACKGROUND

We determined the incidence, clinical course, risk factors, and outcomes of community-acquired pneumonia complicating pregnancy.

METHODS

A prospective study was performed of pregnant and nonpregnant patients in the same age range who presented to any of 6 hospitals in Edmonton, Alberta, with signs and symptoms of pneumonia together with an acute infiltrate evident on chest radiography compatible with pneumonia.

RESULTS

There were 28 patients with pneumonia during pregnancy, for an incidence of 1.1 per 1000 deliveries, whereas there were 333 nonpregnant females in the 20- to 40-year age group with pneumonia, for an incidence of 1.3 per 1000. No significant differences in signs and symptoms were present between the two groups. Asthma requiring treatment was present in 46.4% of the pregnant patients, compared with 17.1% of the nonpregnant patients. No maternal or fetal deaths were noted except an abortion at 10 weeks of gestation. No anomaly was detected among newborns. Two patients had preterm deliveries.

CONCLUSIONS

Pneumonia is well tolerated during pregnancy. Asthma may be a predisposing factor for pneumonia in this group of patients.

Reducing door-to-antibiotic time in community-acquired pneumonia: Controlled before-and-after evaluation and cost-effectiveness analysis

BACKGROUND

Practice guidelines suggest that all patients hospitalised with community-acquired pneumonia (CAP) should receive antibiotics within 4 h of admission. An audit at our hospital during 1999-2000 showed that this target was achieved in less than two thirds of patients with severe CAP.

METHODS

An experienced multidisciplinary steering group designed a management pathway to improve the early delivery of appropriate antibiotics to patients with CAP. This was implemented using a multifaceted strategy. The effect of implementation was evaluated using a controlled before-and-after study design over two winter seasons (November-April 2001-2 and 2002-3). Cost-effectiveness analyses were performed from the hospital's perspective.

RESULTS

The proportion of patients receiving appropriate antibiotics within 4 h of admission to hospital increased from 33% to 56% at the intervention site, and from 32% to 36% at the control site (absolute change adjusted for differences in severity of illness 17%, p = 0.035). The cost per additional patient receiving appropriate antibiotics within 4 h was 132 pound with no post-implementation evaluation, and 456 pound for a limited post-implementation evaluation. Simple modelling from the results of a large observational study suggests that the cost per death prevented could be 3003 pound with no post-implementation evaluation, or 16,632 pound with a limited post-implementation evaluation.

CONCLUSIONS

The intervention markedly improved door-to-antibiotic time, albeit at considerable cost. It might still be a cost-effective strategy, however, to reduce mortality in CAP. Uncertainty about the cost effectiveness of such interventions is likely to be resolved only by a well-designed, cluster randomised trial.

Monotherapy versus combination antimicrobial therapy for pneumococcal pneumonia

PURPOSE OF REVIEW

In the past 5 years a number of studies have suggested that combination antibiotic therapy may be superior to monotherapy for pneumococcal pneumonia. This review outlines the major findings for and against combination therapy.

RECENT FINDINGS

The evidence for a benefit of multiple antibiotics is strongest in patients with severe, bacteremic pneumococcal disease. All of these studies have limitations due to their retrospective or uncontrolled design. Unfortunately prospective, randomized, double-blind, controlled studies have not been performed in an appropriately severe disease cohort and are therefore urgently needed. Several viable mechanisms for a benefit of combination therapy have been proposed, especially related to non-antibiotic effects of macrolides. There is also some evidence that third-generation cephalosporins may be superior to penicillins as the non-macrolide component of combination therapy.

SUMMARY

Although based on retrospective and observational data, there is substantial evidence to support combination antibiotic therapy, at least in patients with severe bacteremic pneumococcal pneumonia. What evidence is available supports a cephalosporin/macrolide combination as being associated with the highest survival, but proper prospective studies in patients with severe pneumonia are urgently required to clarify this issue.

Genetic Susceptibility to Pneumonia

The persistent mortality from community-acquired pneumonia may be explained by genetic predisposition. Specific mutations or polymorphisms in host response genes that are associated with adverse outcomes from infection can be grouped into four categories: antigen recognition, proinflammatory responses, anti-inflammatory responses, and effector mechanisms. Mannose-binding lectin polymorphisms have a more dominant role in pneumonia when compared with other pattern recognition molecules such as the toll-like receptors. The roles of TNF and lymphotoxin alpha polymorphisms remain unclear despite extensive study. IL-10 and IL-1 receptor antagonist polymorphisms have an important role in the anti-inflammatory response. Specific organ dysfunction, such as ARDS or DIC, may be related to polymorphisms in specific effector genes.

Community-acquired pneumonia: pathophysiology and host factors with focus on possible new approaches to management of lower respiratory tract infections

The present understanding of the pathophysiology of community-acquired pneumonia (CAP) explains the mechanism for many specific manifestations, but does not address adequately why only some patients experience complications. Recent advances in under-standing the genetics of complex illnesses offer hope for a more complete insight into the pathogenesis of CAP. This article reviews genetic variation in the molecules involved in the known patho-genic mechanisms of CAP, including cough, bacterial recognition, inflammation and the compensatory anti-inflammatory response,and organ dysfunction.

Evaluation of advanced neonatal nurse practitioners: confidential enquiry into the management of sentinel cases

OBJECTIVE

To evaluate the quality of the neonatal care delivered by an advanced neonatal nurse practitioner led service at Ashington Hospital, Northumberland.

SETTING

Maternity service with no resident paediatric medical input.

DESIGN

Comparison of quality measures on sentinel cases with five comparator hospitals using modified confidential enquiry.

RESULTS

On six out of seven dimensions, the neonatal nurse practitioner service performed better than the average of the five comparator hospitals, and overall ranked second.

CONCLUSION

Good quality neonatal care can be delivered by advanced neonatal nurse practitioners alone, without the support of resident junior paediatricians.

Treatment of community-acquired lower respiratory tract infections during pregnancy

The incidence of lower respiratory tract infection (LRTI) in women of child-bearing age is approximately 64 per 1000 population. The spectrum of illness ranges from acute bronchitis, which is very common, through influenza virus infection and exacerbations of underlying lung disease, to pneumonia, which, fortunately is uncommon (<1.5% LRTI), but can be severe.

Acute bronchitis is generally mild, self-limiting and usually does not require antibacterial therapy. Influenza virus infection in pregnant women has been recently related to increased hospitalization for acute cardiorespiratory conditions. At present, the safety of the newer neuraminidase inhibitors for the treatment of influenza virus infection has not been established in pregnancy and they are not routinely recommended. In influenza virus infection complicated by pneumonia, antibacterial agents active against Staphylococcus aureus and Streptococcus pneumoniae superinfection should be used.

There are few data on infective complications of asthma or COPD in pregnancy. The latter is rare, as patients with COPD are usually male and aged over 45 years. Management is the same as for nonpregnant patients.

The incidence and mortality of pneumonia in pregnancy is similar to that in nonpregnant patients. Infants born to pregnant patients with pneumonia have been found to be born earlier and weigh less than controls. Risk factors for the development of pneumonia include anemia, asthma and use of antepartum corticosteroids and tocolytic agents. Based on the few available studies, the main pathogens causing pneumonia are S. pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae and viruses. β-Lactam and macrolide antibiotics therefore remain the antibiotics of choice in terms of both pathogen coverage and safety in pregnancy. In HIV-infected pregnant patients, recurrent bacterial pneumonia, but not Pneumocystis carinii pneumonia (PCP), is more common than in nonpregnant patients. Trimethoprim/sulfamethoxazole (cotrimoxazole) has not definitely been associated with adverse clinical outcomes despite theoretical risks. Currently it is still the treatment of choice in PCP, where mortality remains high.

In conclusion, there are few data specifically related to pregnant women with different types of LRTI. Where data are available, no significant differences compared with nonpregnant patients have been identified. In considering the use of any therapeutic agent or investigation in pregnant patients with LRTI, safety aspects must be carefully weighed against potential benefit. Otherwise, management strategies should not differ from those for nonpregnant patients. Further research in this area is warranted.

Severe community-acquired pneumococcal pneumonia (CAP) - a potentially fatal illness

Two cases of severe community-acquired pneumococcal pneumonia (CAP) admitted to our hospital within 24 h are described, both in young males. These two cases illustrate the usefulness of the British Thoracic Society severity criteria and serve to emphasize the importance of early recognition of adverse physiology in critically ill patients. We should not lose sight of the continued impact of pneumonia in this climate of widespread fear about severe acute respiratory syndrome (SARS).