What Are The Economic Consequences Of Cap
A prevalence-based burden of illness study estimated that CAP in the UK incurred a direct healthcare cost of Â£441 million annually at 1992â3 prices. The average cost for managing pneumonia in the community was estimated at Â£100 per episode compared with Â£1700â5100 when the patient required admission to hospital. Hospitalisation accounted for 87% of the total annual cost.
A similar exercise conducted in 1997 in the USA calculated that annual costs of CAP amounted to $8.4 billion, 52% of the costs being for the inpatient care for 1.1 million patients and the remaining costs for the 4.4 million outpatient consultations. The average hospital length of stay varied between 5.8 days for those under 65 years of age and 7.8 days for older patients. A prospective study of costs and outcome of CAP from five hospitals in North America concluded that costs of antibiotic therapy varied widely but had no effect on outcome or mortality. Patients treated in the hospitals with the lowest costs did not have worse medical outcomes.
The direct costs associated with CAP are high and mostly associated with inpatient care costs.
Substantial costs savings could likely be made by strategies to prevent CAP, to reduce the requirement for hospital admission and to shorten the length of hospital stay.
What Are The Optimum Antibiotic Choices When Specific Pathogens Have Been Identified
In routine clinical practice, only about one-third to one-quarter of patients with CAP admitted to hospital will be defined microbiologically. Of these, some such as mycoplasma, chlamydophila and C burnetii infection will be diagnosed late in the illness on the basis of seroconversion, reducing the opportunity for early targeted therapy. Among patients managed in the community, very few will be microbiologically defined.
When a pathogen has been identified, specific therapy as summarised in is proposed. In transferring patients from empirical to pathogen-targeted therapy, the regimen and route of administration will be determined by the continued need for parenteral therapy and known drug intolerance. Hence, provides preferred and alternative regimens for intravenous or oral administration. However, it should be remembered that approximately 10% of infections will be of mixed aetiology, although many such co-pathogens will be viral and hence not influenced by antibiotic choice. These recommendations are again based on a synthesis of information which includes in vitro activity of the drugs, appropriate pharmacokinetics and clinical evidence of efficacy gleaned from a variety of studies. The choice of agent may be modified following the availability of sensitivity testing or following consultation with a specialist in microbiology, infectious disease or respiratory medicine.
Cost Of Antimicrobial Therapy
Economic pressures have accentuated the focus on reducing health care costs and utilizing resources while maintaining or improving quality of care.31 These pressures are exacerbated by the growing resistance of S. pneumoniae to penicillin.31,32 This pattern of resistance increases the cost of treatment because of prolonged hospitalization, relapses, and the use of more expensive antibacterial agents.3337
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When Should The Chest Radiograph Be Repeated During Recovery And What Action Should Be Taken If The Radiograph Has Not Returned To Normal
Repeat chest radiographs are probably often ordered unnecessarily following CAP. Although it has become usual practice to repeat the chest radiograph on hospital discharge and again at âroutineâ hospital clinic follow-up at around 6 weeks later, there is no evidence on which to base a recommendation regarding the value of this practice in patients who have otherwise recovered satisfactorily.
The practice of performing bronchoscopy in patients admitted to hospital with CAP prior to hospital discharge has been investigated. In patients aged > 50 years or who were current or ex-smokers, 14% were found to have an abnormality at bronchoscopy .
The chest radiograph need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery from CAP.
A chest radiograph should be arranged after about 6 weeks for all those patients who have persistence of symptoms or physical signs or who are at higher risk of underlying malignancy whether or not they have been admitted to hospital.
Further investigations which may include bronchoscopy should be considered in patients with persisting signs, symptoms and radiological abnormalities at around 6 weeks after completing treatment.
It is the responsibility of the hospital team to arrange the follow-up plan with the patient and the general practitioner for those patients admitted to hospital .
What Is The Mortality Of Cap
The reported mortality of adults with CAP managed in the community is low and less than 1%. Deaths in the community due to CAP are rare in the UK. In one study only seven cases were identified by coronersâ post mortems over 1 year in Nottingham, a large urban city of three quarters of a million, giving an incidence of 1 per 100â000.
The reported mortality of adults hospitalised with CAP has varied widely. The BTS multicentre study reported a mortality of 5.7%, but did not study patients over the age of 74 years. Other UK studies have reported mortalities of 8%, 12% and 14%. Countries with similar healthcare systems have reported hospital mortality rates of 4%, 7%, 8% and 10%.
The longer term mortality of CAP is high, reflecting the frailty of many patients who develop CAP in the first instance. In a US study the 90-day all-cause mortality was 8.7% and mortality at 5.9 years was 39.1%. Age, level of education, male sex and nursing home residence were independently associated with long-term mortality. Other studies found long-term mortality to be 20.8% at 1 year, 34.1% at a mean of 901 days and 35.8% at 5 years.
What Is The Target End User Audience
We want these guidelines to be of value to:
Hospital-based medical and other staff involved with managing adult patients with CAP.
Those teaching about the subject at both undergraduate and postgraduate level.
The guidelines have been developed to apply to the UK healthcare system and population, but they might also be of value to other countries which operate similar healthcare services, with appropriate modification to take into account differences in licensing and availability of antimicrobial agents.
What Microbiological Investigations Should Be Performed In Patients Admitted To Hospital With Cap
The investigations that are recommended for patients admitted to hospital are summarised in . More extensive microbiological investigations are recommended only for patients with moderate or high severity CAP, unless there are particular clinical or epidemiological features that warrant further microbiological studies. Comments and recommendations regarding specific investigations are given below.
5.11.1 Blood cultures
Microbial causes of CAP that can be associated with bacteraemia include S pneumoniae, H influenzae, S aureus and K pneumoniae. Isolation of these bacteria from blood cultures in patients with CAP is highly specific in determining the microbial aetiology. Bacteraemia is also a marker of illness severity. However, many patients with CAP do not have an associated bacteraemia. Even in pneumococcal pneumonia the sensitivity of blood cultures is at most only 25%, and is even lower for patients given antibiotic treatment before admission. Several predominantly retrospective North American studies and reviews have questioned the utility of routine blood cultures in patients hospitalised with CAP on grounds of low sensitivity, cost and negligible impact on antimicrobial management. However, despite these limitations, most continue to recommend blood cultures in high severity CAP.
5.11.2 Sputum cultures
5.11.3 Sputum Gram stain
5.11.4 Other tests for Streptococcuspneumoniae
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Pneumonia In The Elderly
Elderly patients with pneumonia may not exhibit typical symptoms or physical examination findings seen in younger adults, such as pleuritic chest pain, cough, fever, and leukocytosis. Signs and symptoms more frequently seen in older adults include falls, decreased appetite, or functional impairment. A change in mental status should prompt evaluation for an infectious cause., As with any adult, risk factors for atypical or drug-resistant pathogens should guide treatment. Elderly patients with history of stroke or known dysphagia are at an increased risk for aspiration pneumonia. Residents of nursing homes or long-term care facilities are at an increased risk for methicillin-resistant Staphylococcus aureus or multidrug-resistant pathogens.
Formulations Of These Recommendations
The recommendations for treatment have been made on the basis of assessing a matrix of laboratory, clinical, pharmacokinetic and safety data, interpreted in an informed manner. While this remains an unsatisfactory basis for making robust evidence-based recommendations, it highlights the need for appropriate, prospective, randomised controlled studies designed to address the many key questions that will enable the management of CAP to be placed on a sounder basis. The responsibility for this presents a challenge to medical practitioners, healthcare systems, grant-giving bodies and industry. We have also only considered antibiotics licensed and available in the UK at the time we prepared these guidelines.
Currently, within the UK, control of hospital-acquired infection by C difficile, MRSA and pathogens with extended Î²-lactamase activity is a priority of local and strategic health authorities. In line with the principles of prudent use of antibiotics, the current guidelines have been modified to discourage unnecessary use of broad-spectrum antibiotics, especially cephalosporins and fluoroquinolones. The development of refined techniques for severity stratification have enabled a strategy of targeted antibiotic escalation, which should restrict the use of empirical potent broad-spectrum therapy to those cases in which it is necessary.
Membership Of The Bts Community Acquired Pneumonia Guidelines Committee And Affiliations
Wei Shen Lim , Consultant Respiratory Physician, Nottingham University Hospitals Simon Baudouin, Senior Lecturer in Critical Care Medicine, Royal Victoria Infirmary and Intensive Care Society Robert George, Director Respiratory and Systemic Infections Department, Health Protection Agency Centre for Infections, Colindale Adam Hill, Consultant Respiratory Physician, Edinburgh Royal Infirmary Conor Jamieson, Principal Pharmacist â Anti-infectives, Heart of England NHS Trust and British Society of Antimicrobial Chemotherapy Ivan Le Jeune, Consultant in Acute Medicine, Nottingham University Hospitals and Society for Acute Medicine John Macfarlane, Professor of Respiratory Medicine, University of Nottingham and Consultant Respiratory Physician, Nottingham University Hospitals Robert Read, Professor in Infectious Diseases, University of Sheffield and British Infection Society Helen Roberts, Specialist Registrar in Respiratory Medicine, Mid-Trent rotation, Nottingham University Hospitals Mark Levy, General Practitioner, Royal College of General Practitioners and General Practice Airways Group Mushtaq Wani, Health Care of the Elderly Consultant, Swansea NHS Trust and British Geriatrics Society Mark Woodhead, Consultant Respiratory Physician, Manchester Royal Infirmary.
Length And Route Of Treatment
We are not aware of any controlled trials that have specifically addressed the question of how long pneumonia should be treated. This decision is usually based on the pathogen, response to treatment, comorbid illness, and complications. Until further data are forthcoming, it seems reasonable to treat pneumonia caused by S. pneumoniae until the patient has been afebrile for 72 h . Pneumoniae caused by bacteria that can necrose pulmonary parenchyma should probably be treated for 2 weeks. Pneumonia caused by M. pneumoniae or C. pneumoniae should probably be treated for at least 2 weeks, as should legionnaires’ disease in immunocompetent individuals . Azithromycin may be used for shorter courses of treatment because of its very long half-life in tissues .
As cost considerations and pressure to treat patients with pneumonia outside the hospital increase, there is rising interest in the use of oral therapy. For many drugs that are well absorbed from the gut, there is no clear advantage of parenteral therapy. Nevertheless, for most patients admitted to the hospital, common practice is at least to begin therapy with iv drugs. Although no studies verify a superior outcome, this practice is justified by concern for absorption in acutely ill patients.
Patients who fail to respond. When patients fail to respond or their conditions deteriorate after initiation of empirical therapy, a number of possibilities should be considered .
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General: Is The Study Relevant To Our Question
â¡ Were the patients studied similar to target patients?
â¡ Were the outcome measures of interest to us and our patients?
â¡ Was the clinical setting similar to our setting?
â¡ Was the study carried out in a healthcare system similar to ours?
â¡ Is the study design recognisable and appropriate, with clear methods described?
â¡ Is the study recent enough to take account of any important advances?
â¡ If negative, was this study large enough to provide useful information?
Using Oral Rather Than Parenteral Antibiotics
Major advantages of oral over the intravenous route are the absence of cannula-related infections or thrombophlebitis, a lower drug cost, and a reduction in hidden costs such as the need for a health professional and equipment to administer intravenous antibiotics. Oral therapy may potentially enable an early discharge from the hospital, or directly from the emergency department. For example, a single dose of intravenous antibiotic for paediatric uncomplicated urinary tract infections did not reduce the rate of representation or readmission. This suggests most children with a urinary tract infection can be managed with oral antibiotics alone.
A key consideration is the bioavailability of oral antibiotics. This varies in comparison to intravenous formulations . Some oral antibiotics have equivalent bioavailability to the intravenous drug. They could be substituted, depending on the condition being treated and the required site of drug penetration.
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Types Of Antibiotics For Pneumonia
There are multiple types of antibiotics that work in slightly different ways. Some are more commonly used to treat pneumonia than others based on things like:
- The bacteria causing infection
- The severity of the infection
- If youre in a patient group at greatest risk from pneumonia
The types of antibiotics that your doctor might typically prescribe for pneumonia include the following:
Antibiotics prescribed for children with pneumonia include the following:
- Infants, preschoolers, and school-aged children with suspected bacterial pneumonia may be treated with amoxicillin.
- Children with suspected atypical pneumonia can be treated with macrolides.
- Children allergic to penicillin will be treated with other antibiotics as needed for the specific pathogen.
- Hospitalized, immunized children can be treated with ampicillin or penicillin G.
- Hospitalized children and infants who are not fully vaccinated may be treated with a cephalosporin.
- Hospitalized children with suspected M. pneumoniae or C. pneumoniae infection may be treated with combination therapy of a macrolide and a beta-lactam antibiotic .
- Hospitalized children with suspected S. aureus infections might be treated with a combination of Vancocin or clindamycin and a beta-lactam.
Scope Of These Guidelines
These guidelines refer to the management of adults with community acquired pneumonia of all ages in the community or in hospital. They have been developed to apply to the UK healthcare system and population. They might equally be applicable to any other countries which operate similar healthcare services .
They are NOT aimed at patients with known predisposing conditions such as cancer or immunosuppression admitted with pneumonia to specialist units such as oncology, haematology, palliative care, infectious diseases units or AIDS units.
They do NOT apply to the much larger group of adults with non-pneumonic lower respiratory tract infection, including illnesses labelled as acute bronchitis, acute exacerbations of chronic obstructive pulmonary disease or âchest infectionsâ.
Synopsis of the management of adult patients seen in hospital with suspected community acquired pneumonia, with cross reference to relevant sections in the document text.
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What Is The Role Of Ct Lung Scans In Cap
There are few data on the role of high-resolution CT lung scans in CAP. A small study has reported that high-resolution CT scans may improve the accuracy of diagnosing CAP compared with chest radiography alone. Similarly, CT lung scans have improved sensitivity compared with standard chest radiographs in patients with mycoplasma pneumonia. CT lung scans may be useful in subjects where the diagnosis is in doubt but, in general, there is little role for CT scanning in the usual investigation of CAP.
With regard to aetiology, one study has reported a difference in CT appearances in 18 patients with CAP due to bacterial infections compared with 14 patients with atypical pathogens.
CT scanning currently has no routine role in the investigation of CAP.
Severity Assessment Of Cap In Patients Seen In Hospital
The severity assessment of CAP in patients seen in hospital is shown in .
For all patients, the CURB65 score should be interpreted in conjunction with clinical judgement.
Patients who have a CURB65 score of 3 or more are at high risk of death. These patients should be reviewed by a senior physician at the earliest opportunity to refine disease severity assessment and should usually be managed as having high severity pneumonia. Patients with CURB65 scores of 4 and 5 should be assessed with specific consideration to the need for transfer to a critical care unit .
Patients who have a CURB65 score of 2 are at moderate risk of death. They should be considered for short-stay inpatient treatment or hospital-supervised outpatient treatment.
Patients who have a CURB65 score of 0 or 1 are at low risk of death. These patients may be suitable for treatment at home.
When deciding on home treatment, the patientâs social circumstances and wishes must be taken into account in all instances.
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What Microbiological Investigations Should Be Performed In Patients With Suspected Cap In The Community
For patients managed in the community, microbiological investigations are not recommended routinely.
Examination of sputum should be considered for patients who do not respond to empirical antibiotic therapy.
Examination of sputum for Mycobacterium tuberculosis should be considered for patients with a persistent productive cough, especially if malaise, weight loss or night sweats, or risk factors for tuberculosis are present.
Urine antigen investigations, PCR of upper or lower respiratory tract samples or serological investigations may be considered during outbreaks or epidemic mycoplasma years, or when there is a particular clinical or epidemiological reason.