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Lee J, Zhu Y, Williams DJ, Self WH, Arnold SR, McCullers JA, Ampofo K, Pavia AT, Anderson EJ, Jain S, Edwards KM, Grijalva CG. Red Blood Cell Distribution Width and Pediatric Community-Acquired Pneumonia Disease Severity. Hosp Pediatr 2022; 12:798-805. [PMID: 35922590 PMCID: PMC10753971 DOI: 10.1542/hpeds.2022-006539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES No standardized risk assessment tool exists for community-acquired pneumonia (CAP) in children. This study aims to investigate the association between red blood cell distribution width (RDW) and pediatric CAP. METHODS Data prospectively collected by the Etiology of Pneumonia in the Community study (2010-2012) was used. Study population was pediatric patients admitted to tertiary care hospitals in Nashville and Memphis, Tennessee with clinically and radiographically confirmed CAP. The earliest measured RDW value on admission was used, in quintiles and also as a continuous variable. Outcomes analyzed were: severe CAP (requiring ICU, mechanical ventilation, vasopressor support, or death) or moderate CAP (hospital admission only). Analysis used multivariable logistic regression and restricted cubic splines modeling. RESULTS In 1459 eligible children, the median age was 29 months (interquartile range: 12-73), median RDW was 13.3% (interquartile range: 12.5-14.3), and 289 patients (19.8%) developed severe disease. In comparison with the lowest RDW quintile (Q1), the adjusted odds ratio (95% CI) for severe CAP in subsequent quintiles were, Q2: 1.20 (0.72-1.99); Q3: 1.28 (0.76-2.14); Q4: 1.69 (1.01-2.82); Q5: 1.25 (0.73-2.13). Consistently, RDW restricted cubic splines demonstrated an independent, nonlinear, positive association with CAP severity (P = .027), with rapid increases in the risk of severe CAP with RDW values up to 15%. CONCLUSIONS Higher presenting RDW was associated with an increased risk of severe CAP in hospitalized children. Widely available and inexpensive, RDW can serve as an objective data point to help with clinical assessments.
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Affiliation(s)
- Jaclyn Lee
- Vanderbilt University School of Medicine, Nashville, TN
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Derek J. Williams
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Jonathan A. McCullers
- University of Tennessee Health Sciences Center, Memphis, TN
- St. Jude Children’s Research Hospital, Memphis, TN
| | - Krow Ampofo
- University of Utah Health Sciences Center, Salt Lake City, UT
| | - Andrew T. Pavia
- University of Utah Health Sciences Center, Salt Lake City, UT
| | - Evan J. Anderson
- Departments of Pediatrics and Medicine, Emory University School of Medicine, Atlanta, GA
| | - Seema Jain
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Kathryn M. Edwards
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Carlos G. Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
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Computerized Mortality Prediction for Community-acquired Pneumonia at 117 Veterans Affairs Medical Centers. Ann Am Thorac Soc 2021; 18:1175-1184. [PMID: 33635750 DOI: 10.1513/annalsats.202011-1372oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Computerized severity assessment for community-acquired pneumonia could improve consistency and reduce clinician burden. Objectives: To develop and compare 30-day mortality-prediction models using electronic health record data, including a computerized score with all variables from the original Pneumonia Severity Index (PSI) except confusion and pleural effusion ("ePSI score") versus models with additional variables. Methods: Among adults with community-acquired pneumonia presenting to emergency departments at 117 Veterans Affairs Medical Centers between January 1, 2006, and December 31, 2016, we compared an ePSI score with 10 novel models employing logistic regression, spline, and machine learning methods using PSI variables, age, sex and 26 physiologic variables as well as all 69 PSI variables. Models were trained using encounters before January 1, 2015; tested on encounters during and after January 1, 2015; and compared using the areas under the receiver operating characteristic curve, confidence intervals, and patient event rates at a threshold PSI score of 970. Results: Among 297,498 encounters, 7% resulted in death within 30 days. When compared using the ePSI score (confidence interval [CI] for the area under the receiver operating characteristic curve, 0.77-0.78), performance increased with model complexity (CI for the logistic regression PSI model, 0.79-0.80; CI for the boosted decision-tree algorithm machine learning PSI model using the Extreme Gradient Boosting algorithm [mlPSI] with the 19 original PSI factors, 0.83-0.85) and the number of variables (CI for the logistic regression PSI model using all 69 variables, 0.84-085; CI for the mlPSI with all 69 variables, 0.86-0.87). Models limited to age, sex, and physiologic variables also demonstrated high performance (CI for the mlPSI with age, sex, and 26 physiologic factors, 0.84-0.85). At an ePSI score of 970 and a mortality-risk cutoff of <2.7%, the ePSI score identified 31% of all patients as being at "low risk"; the mlPSI with age, sex, and 26 physiologic factors identified 53% of all patients as being at low risk; and the mlPSI with all 69 variables identified 56% of all patients as being at low risk, with similar rates of mortality, hospitalization, and 7-day secondary hospitalization being determined. Conclusions: Computerized versions of the PSI accurately identified patients with pneumonia who were at low risk of death. More complex models classified more patients as being at low risk of death and as having similar adverse outcomes.
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Aliberti S, Dela Cruz CS, Amati F, Sotgiu G, Restrepo MI. Community-acquired pneumonia. Lancet 2021; 398:906-919. [PMID: 34481570 DOI: 10.1016/s0140-6736(21)00630-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/22/2021] [Accepted: 03/05/2021] [Indexed: 02/06/2023]
Abstract
Community-acquired pneumonia is not usually considered a high-priority problem by the public, although it is responsible for substantial mortality, with a third of patients dying within 1 year after being discharged from hospital for pneumoniae. Although up to 18% of patients with community-acquired pneumonia who were hospitalised (admitted to hospital and treated there) have at least one risk factor for immunosuppression worldwide, strong evidence on community-acquired pneumonia management in this population is scarce. Several features of clinical management for community-acquired pneumonia should be addressed to reduce mortality, morbidity, and complications related to community-acquired pneumonia in patients who are immunocompetent and patients who are immunocompromised. These features include rapid diagnosis, microbiological investigation, prevention and management of complications (eg, respiratory failure, sepsis, and multiorgan failure), empirical antibiotic therapy in accordance with patient's risk factors and local microbiological epidemiology, individualised antibiotic therapy according to microbiological data, appropriate outcomes for therapeutic switch from parenteral to oral antibiotics, discharge planning, and long-term follow-up. This Seminar offers an updated view on community-acquired pneumonia in adults, with suggestions for clinical and translational research.
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Affiliation(s)
- Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy.
| | - Charles S Dela Cruz
- Department of Internal Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale School of Medicine, New Haven, CT, USA
| | - Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy
| | - Giovanni Sotgiu
- Department of Medical, Surgical and Experimental Sciences, Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | - Marcos I Restrepo
- Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
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LoVecchio F, Schranz J, Alexander E, Mariano D, Meads A, Sandrock C, Moran GJ, Giordano PA. Oral 5-Day Lefamulin for Outpatient Management of Community-Acquired Bacterial Pneumonia: Post-hoc Analysis of the Lefamulin Evaluation Against Pneumonia (LEAP) 2 Trial. J Emerg Med 2021; 60:781-792. [PMID: 33731270 DOI: 10.1016/j.jemermed.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/29/2020] [Accepted: 02/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Safe and effective oral antibiotics are needed for outpatient management of moderate to severe community-acquired bacterial pneumonia (CABP). OBJECTIVE We describe a post-hoc analysis of adults with CABP managed as outpatients from the Lefamulin Evaluation Against Pneumonia (LEAP) 2 double-blind, noninferiority, phase 3 clinical trial. METHODS LEAP 2 compared the efficacy and safety of oral lefamulin 600 mg every 12 h (5 days) vs. oral moxifloxacin 400 mg every 24 h (7 days) in adults (inpatients and outpatients) with Pneumonia Outcomes Research Team (PORT) risk classes II‒IV. RESULTS Overall, 41% (151 of 368) of patients receiving lefamulin and 43% (159 of 368) of patients receiving moxifloxacin started treatment as outpatients-44% and 40%, respectively, were PORT risk class III/IV, and 21% in both groups had CURB-65 scores of 2‒3. Early clinical response (at 96 ± 24 h) and investigator assessment of clinical response success rates at test of cure (5‒10 days after last study drug dose) were high and similar in both groups among all (lefamulin, 91% vs. moxifloxacin, 89‒90%), PORT risk class III/IV (89‒91% vs. 88‒91%), and CURB-65 score 2‒3 (87‒90% vs. 82‒88%) outpatients. Few outpatients (lefamulin, 2.6%; moxifloxacin, 2.5%) discontinued the study drug because of treatment-emergent adverse events (TEAEs). No outpatient in the lefamulin group was hospitalized for a TEAE, compared with 5 patients (3%), including two deaths, in the moxifloxacin group. CONCLUSIONS These data suggest that 5 days of oral lefamulin can be given in lieu of fluoroquinolones for outpatient treatment of adults with CABP and PORT risk class III/IV or CURB-65 scores of 2‒3.
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Affiliation(s)
- Frank LoVecchio
- ASU, U of AZ, Creighton, Valleywise Medical Center, University of Arizona, Phoenix, Arizona
| | | | | | - David Mariano
- Nabriva Therapeutics US, Inc., King of Prussia, Pennsylvania
| | - Andrew Meads
- Nabriva Therapeutics US, Inc., King of Prussia, Pennsylvania
| | | | | | - Philip A Giordano
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
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Jones BE, Collingridge DS, Vines CG, Post H, Holmen J, Allen TL, Haug P, Weir CR, Dean NC. CDS in a Learning Health Care System: Identifying Physicians' Reasons for Rejection of Best-Practice Recommendations in Pneumonia through Computerized Clinical Decision Support. Appl Clin Inform 2019; 10:1-9. [PMID: 30602195 PMCID: PMC6327742 DOI: 10.1055/s-0038-1676587] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/09/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Local implementation of guidelines for pneumonia care is strongly recommended, but the context of care that affects implementation is poorly understood. In a learning health care system, computerized clinical decision support (CDS) provides an opportunity to both improve and track practice, providing insights into the implementation process. OBJECTIVES This article examines physician interactions with a CDS to identify reasons for rejection of guideline recommendations. METHODS We implemented a multicenter bedside CDS for the emergency department management of pneumonia that integrated patient data with guideline-based recommendations. We examined the frequency of adoption versus rejection of recommendations for site-of-care and antibiotic selection. We analyzed free-text responses provided by physicians explaining their clinical reasoning for rejection, using concept mapping and thematic analysis. RESULTS Among 1,722 patient episodes, physicians rejected recommendations to send a patient home in 24%, leaving text in 53%; reasons for rejection of the recommendations included additional or alternative diagnoses beyond pneumonia, and comorbidities or signs of physiologic derangement contributing to risk of outpatient failure that were not processed by the CDS. Physicians rejected broad-spectrum antibiotic recommendations in 10%, leaving text in 76%; differences in pathogen risk assessment, additional patient information, concern about antibiotic properties, and admitting physician preferences were given as reasons for rejection. CONCLUSION While adoption of CDS recommendations for pneumonia was high, physicians rejecting recommendations frequently provided feedback, reporting alternative diagnoses, additional individual patient characteristics, and provider preferences as major reasons for rejection. CDS that collects user feedback is feasible and can contribute to a learning health system.
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Affiliation(s)
- Barbara E. Jones
- VA Salt Lake City IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah, United States
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, Utah, United States
| | | | | | - Herman Post
- Homer Warner Center for Informatics, Intermountain Healthcare, Murray, Utah, United States
| | - John Holmen
- Homer Warner Center for Informatics, Intermountain Healthcare, Murray, Utah, United States
| | - Todd L. Allen
- Department of Emergency Medicine, Intermountain Healthcare, Murray, Utah, United States
| | - Peter Haug
- Homer Warner Center for Informatics, Intermountain Healthcare, Murray, Utah, United States
| | - Charlene R. Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
| | - Nathan C. Dean
- Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare and University of Utah, Murray, Utah, United States
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Faverio P, Aliberti S, Bellelli G, Suigo G, Lonni S, Pesci A, Restrepo MI. The management of community-acquired pneumonia in the elderly. Eur J Intern Med 2014; 25:312-9. [PMID: 24360244 PMCID: PMC4102338 DOI: 10.1016/j.ejim.2013.12.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 12/01/2013] [Accepted: 12/02/2013] [Indexed: 12/27/2022]
Abstract
Pneumonia is one of the main causes of morbidity and mortality in the elderly. The elderly population has exponentially increased in the last decades and the current epidemiological trends indicate that it is expected to further increase. Therefore, recognizing the special needs of older people is of paramount importance. In this review we address the main differences between elderly and adult patients with pneumonia. We focus on several aspects, including the atypical clinical presentation of pneumonia in the elderly, the methods to assess severity of illness, the appropriate setting of care, and the management of comorbidities. We also discuss how to approach the common complications of severe pneumonia, including acute respiratory failure and severe sepsis. Moreover, we debate whether or not elderly patients are at higher risk of infection due to multi-drug resistant pathogens and which risk factors should be considered when choosing the antibiotic therapy. We highlight the differences in the definition of clinical stability and treatment failure between adults and elderly patients. Finally, we review the main outcomes, preventive and supportive measures to be considered in elderly patients with pneumonia.
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Affiliation(s)
- Paola Faverio
- Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy; University of Texas Health Science Center at San Antonio, TX, USA
| | - Stefano Aliberti
- Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy.
| | - Giuseppe Bellelli
- Department of Health Science, University of Milan Bicocca, Geriatric Clinic, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Giulia Suigo
- Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Sara Lonni
- Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Alberto Pesci
- Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Marcos I Restrepo
- University of Texas Health Science Center at San Antonio, TX, USA; South Texas Veterans Healthcare System Audie L. Murphy Division, San Antonio, TX, USA; Veterans Evidence Based Research Dissemination and Implementation Center (VERDICT), San Antonio, TX, USA
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Aliberti S, Brambilla AM, Chalmers JD, Cilloniz C, Ramirez J, Bignamini A, Prina E, Polverino E, Tarsia P, Pesci A, Torres A, Blasi F, Cosentini R. Phenotyping community-acquired pneumonia according to the presence of acute respiratory failure and severe sepsis. Respir Res 2014; 15:27. [PMID: 24593040 PMCID: PMC4015148 DOI: 10.1186/1465-9921-15-27] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 02/20/2014] [Indexed: 01/16/2023] Open
Abstract
Background Acute respiratory failure (ARF) and severe sepsis (SS) are possible complications in patients with community-acquired pneumonia (CAP). The aim of the study was to evaluate prevalence, characteristics, risk factors and impact on mortality of hospitalized patients with CAP according to the presence of ARF and SS on admission. Methods This was a multicenter, observational, prospective study of consecutive CAP patients admitted to three hospitals in Italy, Spain, and Scotland between 2008 and 2010. Three groups of patients were identified: those with neither ARF nor SS (Group A), those with only ARF (Group B) and those with both ARF and SS (Group C) on admission. Results Among the 2,145 patients enrolled, 45% belonged to Group A, 36% to Group B and 20% to Group C. Patients in Group C were more severe than patients in Group B. Isolated ARF was correlated with age (p < 0.001), COPD (p < 0.001) and multilobar infiltrates (p < 0.001). The contemporary occurrence of ARF and SS was associated with age (p = 0.002), residency in nursing home (p = 0.007), COPD (p < 0.001), multilobar involvement (p < 0.001) and renal disease (p < 0.001). 4.2% of patients in Group A died, 9.3% in Group B and 26% in Group C, p < 0.001. After adjustment, the presence of only ARF had an OR for in-hospital mortality of 1.85 (p = 0.011) and the presence of both ARF and SS had an OR of 6.32 (p < 0.001). Conclusions The identification of ARF and SS on hospital admission can help physicians in classifying CAP patients into three different clinical phenotypes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Francesco Blasi
- Department of Pathophysiology and Transplantation, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via F, Sforza 35, Milan, Italy.
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