Data Collection And Variables
We registered data into the CAPNETZ database and into a local database in EpiData entry 3.1 . Data collection was performed from September 2014 until January 2015. All data stem from electronic patient files as well as laboratory, microbiological and radiological databases.
For each patient, we recorded demographics, comorbidities, symptoms, clinical values including CURB-65 , and biochemical test results on admission. Patients were divided in to risk groups according to CURB-65 score . The number of co-morbidities was assessed by categorizing patients into three groups based on the sum of conditions . In addition, we recorded microbiological test results, complications and the length of the hospital admission . We registered the total duration of antibiotic treatment and duration of intravenous antibiotic treatment . Only the therapeutic agents given initially were recorded. We followed patients for 6 months after admission, to register deaths. Variables not mentioned in the patient file were noted as missing, except for co-morbidities which were recorded as absent if not mentioned.
Outpatient Vs Inpatient Treatment
Choosing between outpatient and inpatient treatment is a crucial decision because of the possible risk of death.9,15,16 This decision not only influences diagnostic testing and medication choices, it can have a psychological impact on patients and their families. On average, the estimated cost for inpatient care of patients with CAP is $7,500. Outpatient care can cost as little as $150 to $350.1719 Hospitalization of a patient should depend on patient age, comorbidities, and the severity of the presenting disease.9,20
Physicians tend to overestimate a patients risk of death14 therefore, many low-risk patients who could be safely treated as out-patients are admitted for more costly inpatient care. The Pneumonia Severity Index was developed to assist physicians in identifying patients at a higher risk of complications and who are more likely to benefit from hospitalization.9,15,16 Investigators developed a risk model based on a prospective cohort study16 of 2,287 patients with CAP in Pittsburgh, Boston, and Halifax, Nova Scotia. By using the model, the authors found that 26 to 31 percent of the hospitalized patients were good outpatient candidates, and an additional 13 to 19 percent only needed brief hospital observation. They validated this model using data17 from more than 50,000 patients with CAP in 275 U.S. and Canadian hospitals.1517,21,22
Information from reference 15.
C Studies Of Diagnosis
â¡ Was the finding or result compared with a 24 carat gold standard for diagnosis?
â¡ Was the finding or result determined blind to the gold standard?
â¡ Was the gold standard determined blind to the finding or test result?
â¡ Was the gold standard determined in all cases, not just those with an abnormal result?
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.
Children Between 60 Days And 18 Years Of Age
Diagnosis. History taking and a complete physical exam are critical to diagnose CAP in children. History of the patient should include the age of the child, type of symptoms and date of onset, immunization status , possibility of aspiration, and recent exposure to tuberculosis. The complete physical exam, including vital signs, can often help determine the severity of pneumonia. Severely ill children should be evaluated for signs of parapneumonic effusion or empyema, including dyspnea, dry cough, pleuritic chest pain, frictional rub on auscultation, or diminished breath sounds. In less acutely ill children, the following combinations of clinical findings are the most predictive of severe CAP :
- In infants less than 12 months of age: nasal flaring and oxygen saturation less than 96 percent on room air and respiratory rate above 50 and intercostal retractions.
- In children 1 to 5 years of age: SpO2 less than 96 percent and respiratory rate above 40.
- In children greater than 5 years of age: SpO2 less than 96 percent and respiratory rate above 30.
In the outpatient setting, high-dose amoxicillin has been demonstrated to be a reasonable option for CAP, since Streptococcus pneumoniae is a common pathogen among children. According to the Te xas Childrens Hospital clinical guideline, outpatient treatment differs by age group:
In an inpatient, non-ICU setting, recommended therapy according to age groups is:
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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.
How Does The Aetiology Differ In Certain Geographical Areas
Specific studies suggest a higher frequency of certain pathogens in some geographical areas as described in the 2001 BTS guidelines . A global study found a frequency of atypical pathogens of 20â28% of cases in different regions of the world. A similar figure of 23.5% was found in a multicentre South Asian study.
Pathogens which are more common as a cause of community acquired pneumonia in certain geographical regions
Studies from Chile and Nicaragua report a similar pathogen spectrum to previous European studies.
Evidence of legionella infection was found in 31.7% of non-consecutive pneumonia cases in Trinidad and 5.1% of 645 consecutive cases in Brazil. An incidence of 5.2% for C pneumoniae was found by the same group, with a frequency of 8.1% being found in a Canadian study. In 62% of these cases an additional pathogen was also found.
An outpatient study in Arizona found evidence of coccidioidomycosis in 29% of 55 cases.
Studies from south and east Asia found high frequencies of S pneumonia,C pneumonia and Gram-negative bacteria and Haemophilus influenzae in Thailand. In China, H influenzae was the predominant pathogen in one study, but S pneumoniae and M pneumoniae in another.S pneumoniae followed by H influenzae predominated in Japan, and S pneumoniae followed by M pneumoniae in Taiwan.
S pneumoniae and Klebsiella pneumoniae were found to be the most frequent causes of CAP in the ICU on an Indian Ocean island.
Which Oral Antibiotics Are Recommended On Completion Of Intravenous Therapy
The selection of agents for oral administration following initial intravenous therapy is based on antimicrobial spectrum, efficacy, safety and cost considerations. Although it may appear logical to select the oral formulation of a parenteral agent, this is not essential and such oral agents may not meet the criteria for selection. For macrolides, oral clarithromycin is better tolerated than oral erythromycin. A clinical judgement can be made whether to change to oral monotherapy in those who have responded favourably to parenteral combination therapy or where there is microbiological documentation of the nature of the infection, in which case the recommendations in should be adopted.
The antibiotic choices for the switch from intravenous to oral are straightforward where there are effective and equivalent oral and parenteral formulations.
In the case of parenteral cephalosporins, the oral switch to co-amoxiclav 625 mg three times daily is recommended rather than to oral cephalosporins.
For those treated with benzylpenicillin + levofloxacin, oral levofloxacin with or without oral amoxicillin 500 mgâ1.0 g three times daily is recommended.
B Empiric Therapy For Patients Who Require Inpatient Management
- Obtain urine culture to confirm susceptibility
- First-line empiric therapy*:
- Ceftriaxone 1g IV Q24H +/- Ampicillin 2 g IV Q6H
- Step down to appropriate oral antibiotics when patient is afebrile and hemodynamically stable, based on culture and susceptibility results
- Usual duration of therapy is 7 days for uncomplicated pyelonephritis complicated infections require 10-14 days of therapy and occasionally longer, in consultation with Urology and Infectious Diseases
*Suggest coverage for extended-spectrum beta-lactamase producing organisms in the following circumstances:
- Known ESBL colonization
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Recommended Diagnostic Evaluation In Community
Guidelines for microbiologic testing for diagnosis of CAP in individuals without HIV generally also apply to persons with HIV.57
Gram stain and culture of sputum is recommended in all hospitalized patients meeting the criteria stated above and is optional in individuals with HIV and CAP not meeting these criteria. In general, Gram stain and culture of expectorated sputum should be performed only if a good-quality specimen can be obtained prior to initiation of antibiotics, and quality performance measures for collection, transport, and processing of samples can be met. Sputum cultures in patients with HIV have been shown to identify a bacterial etiology in up to 30% to 40% of good quality specimens47,59 although yield is less in other studies.14,28 Correlation of sputum culture with Gram stain can help in interpretation of sputum culture data. For intubated patients, an endotracheal aspirate sample should be obtained promptly after intubation, or bronchoscopy may be indicated.
Blood cultures are more likely to be positive in individuals with HIV than in those without HIV. Patients with HIV, particularly those with lower CD4 counts, are at increased risk of invasive infection with S. pneumoniae. Given concerns for drug-resistant S. pneumoniae,60,61 as well as S. aureus and/or other drug-resistant pathogens, blood cultures are recommended for patients with HIV who meet the criteria as noted above, and are optional for those who do not meet the criteria listed.
Reviewing Severity Status After Initial Assessment In Hospital
Regular and structured clinical review and reassessment of disease severity facilitates the stepping down and stepping up of antibiotic management.
Regular assessment of disease severity is recommended for all patients following hospital admission. The âpost takeâ round by a senior doctor and the medical team provides one early opportunity for this review.
All patients deemed at high risk of death on admission to hospital should be reviewed medically at least 12-hourly until shown to be improving.
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Current Status Of Scoring Systems For The Assessment Of Cap Severity At Admission And Scoring Systems For Early Identification Of Risk For The Need Ventilatory And/or Vasopressor Support To Prevent The Development Of Severe Sepsis Or Treatment Failure What Are The Recommendations
Patients with a diagnosis of CAP should always be assessed for disease severity, a precaution that has a direct positive impact on mortality.- Currently available prognostic scoring systems measure severity and help predict prognosis in CAP, informing the decision regarding site of care , the need for etiologic investigation, and the choice of antibiotics and their route of administration.,
Validated instruments include the Pneumonia Severity Index mental Confusion, Urea, Respiratory rate, Blood pressure, and age 65 years CRB-65 the 2007 American Thoracic Society/Infectious Diseases Society of America guidelines Systolic blood pressure, Multilobar involvement, Albumin, Respiratory rate, Tachycardia, Confusion, Oxygenation, and pH and Severe Community-Acquired Pneumonia -the last three being related to severe pneumonia and ICU admission.-
It is important to stress that disease severity as determined by scoring systems is a major factor in the decision regarding hospital admission however, other factors, such as the possibility of using oral drugs, comorbidities, psychosocial factors and socioeconomic characteristics that indicate vulnerability of the individual, should be taken into account.,, Ideally, SpO2 should always be monitored: SpO2 values below 92% should be an indication for hospital admission.,
A Comparative Cost Analysis Of Antibiotic Treatment For Community Acquired Pneumonia In Adult Inpatients At Piggs Peak Government Hospital In Swaziland
- Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
Background: Of the different types of pneumonia, community acquired pneumonia , has been identified as the leading cause of infectious morbidity and mortality in the western and developing countries. To eradicate the bacterial cause of CAP, medical doctors) often tend to prescribe a differing cocktail of medicine which may be costly for the health care system.
Aim: To analyze the cost of oral and/or intravenous antibiotic medicine use in different treatment approaches for treating CAP in adult inpatients from the health care system perspective.
Settings: This study was undertaken at Piggs Peak Government Hospital, a 220 bed tertiary hospital located in the rural northern Hhohho region of Swaziland.
Method: Seventy-one medical records of adult patients, hospitalized and diagnosed with CAP at Piggs Peak Government Hospital from July 2014 to June 2015, were retrieved and entered into the database once confirmed as having met the selection criteria. Only direct antibiotic medicine costs were considered. The total cost per treatment option was calculated by multipling the unit cost of the medicine by the administration frequency and the length of hospital stay. The Kruskal-Wallis test was used to compare the cost difference between more than two treatment options.
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How Your Doctor Chooses
Your doctor will select the right antibiotic for you based on multiple factors, including:
- Your age: People 65 and older have a greater risk of serious complications from pneumonia infections.
- Your health history: A history of smoking, lung diseases, or other conditions may influence a person’s ability to fight off infections.
- The exact infection you have: Your doctor may take a sample and test it for bacteria. They can then pick an antibiotic based on your specific infection.
- Your previous experiences with antibiotics: Make sure to tell your doctor if you are allergic to any medications, had bad reactions to antibiotics in the past, or have developed an antibacterial-resistant infection.
- The antibiotic sensitivity of the bacteria: The lab will test the bacteria causing your pneumonia to determine which antibiotics it is sensitive or resistant to.
Doctors typically choose your antibiotics prescription based on what medicines they think will be most effective and cause the fewest side effects.
Question : Should A Clinical Prediction Rule For Prognosis Plus Clinical Judgment Versus Clinical Judgment Alone Be Used To Determine Inpatient General Medical Versus Higher Levels Of Inpatient Treatment Intensity For Adults With Cap
We recommend direct admission to an ICU for patients with hypotension requiring vasopressors or respiratory failure requiring mechanical ventilation .
For patients not requiring vasopressors or mechanical ventilator support, we suggest using the IDSA/ATS 2007 minor severity criteria together with clinical judgment to guide the need for higher levels of treatment intensity .
Summary of the evidence
The PSI and CURB-65 were not designed to help select the level of care needed by a patient who is hospitalized for CAP. Several prognostic models have been designed to predict the need for higher levels of inpatient treatment intensity using severity-of-illness parameters based on patient outcomes . Studies of prognostic models have used different end points, including inpatient mortality , ICU admission , receipt of intensive respiratory or vasopressor support , or ICU admission plus receipt of a critical therapy . In comparative studies, these prognostic models yield higher overall accuracy than the PSI or CURB-65 when using illness outcomes other than mortality .
Rationale for the recommendation
Research needed in this area
Controlled studies are needed to study the effectiveness and safety of using illness severity tools as decision aids to guide the intensity of treatment in adults hospitalized for pneumonia.
How Long Youll Take Them
A course of antibiotics for uncomplicated pneumonia treatment is usually for five to seven days. One course will usually be enough to cure your pneumonia. In some cases, you may need more than one course of antibiotics if your infection doesnt start improving or it seems like its not responding to the medications.
Stay in touch with your doctor to ensure your infection is clearing up. Youll likely start to feel better and have some symptom relief one to three days after you start your pneumonia treatment, but it may take a week or more for your symptoms to go away completely.
Taking your medication as prescribed, especially for antibiotics, is incredibly important. Even if youre feeling better, you need to take the entire course.
Do not stop taking antibiotics early, even if your symptoms improve, as the infection would not be fully treated and could become antibiotic-resistant. This will make treatment more complicated. If youre experiencing side effects, talk to your doctor. Only stop your medication if your doctor tells you its OK to do so.