Prognostic clinical decision support for pneumonia in the emergency department: A randomized trial

BACKGROUND

Hospitalization rates for childhood pneumonia vary widely. Risk-based clinical decision support (CDS) interventions may reduce unwarranted variation.

METHODS

We conducted a pragmatic randomized trial in two US pediatric emergency departments (EDs) comparing electronic health record (EHR)-integrated prognostic CDS versus usual care for promoting appropriate ED disposition in children (<18 years) with pneumonia. Encounters were randomized 1:1 to usual care versus custom CDS featuring a validated pneumonia severity score predicting risk for severe in-hospital outcomes. Clinicians retained full decision-making authority. The primary outcome was inappropriate ED disposition, defined as early transition to lower- or higher-level care. Safety and implementation outcomes were also evaluated.

RESULTS

The study enrolled 536 encounters (269 usual care and 267 CDS). Baseline characteristics were similar across arms. Inappropriate disposition occurred in 3% of usual care encounters and 2% of CDS encounters (adjusted odds ratio: 0.99, 95% confidence interval: [0.32, 2.95]). Length of stay was also similar and adverse safety outcomes were uncommon in both arms. The tool's custom user interface and content were viewed as strengths by surveyed clinicians (>70% satisfied). Implementation barriers include intrinsic (e.g., reaching the right person at the right time) and extrinsic factors (i.e., global pandemic).

CONCLUSIONS

EHR-based prognostic CDS did not improve ED disposition decisions for children with pneumonia. Although the intervention's content was favorably received, low subject accrual and workflow integration problems likely limited effectiveness. Clinical Trials Registration: NCT06033079.

Validation of Childhood Pneumonia Prognostic Models for Use in Emergency Care Settings

BACKGROUND

Unwarranted variation in disposition decisions exist among children with pneumonia. We validated three prognostic models for predicting pneumonia severity among children in the emergency department (ED) and hospital.

METHODS

We performed a two-center, prospective study of children 6 months to <18 years presenting to the ED with pneumonia from January 2014 to May 2019. We evaluated three previously developed disease-specific prognostic models which use demographic, clinical, and diagnostic predictor variables, with each model estimating risk for Very Severe (mechanical ventilation or shock), Severe (ICU without very severe features), and Moderate/Mild (Hospitalization without severe features or ED discharge) pneumonia. Predictive accuracy was measured using discrimination (concordance or c-statistic) and re-calibration.

RESULTS

There were 1088 children included in one or more of the three models. Median age was 3.6 years and the majority of children were male (53.7%) and identified as non-Hispanic White (63.7%). The distribution for the ordinal severity outcome was mild or moderate (79.1%), severe (15.9%), and very severe (4.9%). The three models each demonstrated excellent discrimination (C-statistic range across models [0.786-0.803]) with no appreciable degradation in predictive accuracy from the derivation cohort.

CONCLUSIONS

All three prognostic models accurately identified risk for three clinically meaningful levels of pneumonia severity and demonstrated very good predictive performance. Physiologic variables contributed the most to model prediction. Application of these objective tools may help standardize and improve disposition and other management decisions for children with pneumonia.

Prognostic value of serial neutrophil-to-lymphocyte ratio measurements in hospitalized community-acquired pneumonia

Introduction

Several serum inflammatory markers are associated with poor clinical outcomes in community-acquired pneumonia (CAP). However, the prognosis and early treatment response in hospitalized CAP patients based on serial neutrophil-to-lymphocyte ratio (NLR) measurement has never been investigated.

Methods

We performed a retrospective observational study for 175 consecutive patients hospitalized with CAP between February 2016 and February 2018. NLR, C-reactive protein (CRP) and procalcitonin levels were measured on admission day (D1) and on hospital day 4 (D4). The Pneumonia Severity Index (PSI) was also assessed on admission. The primary endpoint was all-cause death within 30 days after admission. The secondary endpoint was early treatment response such as intensive care unit (ICU) admission during hospitalization and clinical unstability on day 4.

Results

The 30-day mortality rate was 9.7%. In multivariate analysis, NLR D4 (OR: 1.11; 95% CI: 1.04–1.18; P = 0.003) and its incremental change (NLR D4/D1 >1) (OR: 7.10; 95% CI: 2.19–23.06; P = 0.001) were significant predictors of 30-day mortality. NLR D4 and its incremental change were significant predictors of ICU admission and clinical unstability on day 4 in multivariate analyses. Adding of incremental NLR change significantly improved the prognostic ability of the PSI. The additive value of incremental NLR change for the prognostic ability of the PSI was larger than that of incremental CRP change.

Conclusion

Serial NLR measurement represents useful laboratory tool to predict the prognosis and early treatment response of hospitalized CAP patients.

Identifying patients with symptoms suspicious for COVID-19 at elevated risk of adverse events: The COVAS score

Objective

Develop and validate a risk score using variables available during an Emergency Department (ED) encounter to predict adverse events among patients with suspected COVID-19.

Methods

A retrospective cohort study of adult visits for suspected COVID-19 between March 1 – April 30, 2020 at 15 EDs in Southern California. The primary outcomes were death or respiratory decompensation within 7-days. We used least absolute shrinkage and selection operator (LASSO) models and logistic regression to derive a risk score. We report metrics for derivation and validation cohorts, and subgroups with pneumonia or COVID-19 diagnoses.

Results

26,600 ED encounters were included and 1079 experienced an adverse event. Five categories (comorbidities, obesity/BMI ≥ 40, vital signs, age and sex) were included in the final score. The area under the curve (AUC) in the derivation cohort was 0.891 (95% CI, 0.880–0.901); similar performance was observed in the validation cohort (AUC = 0.895, 95% CI, 0.874–0.916). Sensitivity ranging from 100% (Score 0) to 41.7% (Score of ≥15) and specificity from 13.9% (score 0) to 96.8% (score ≥ 15). In the subgroups with pneumonia (n = 3252) the AUCs were 0.780 (derivation, 95% CI 0.759–0.801) and 0.832 (validation, 95% CI 0.794–0.870), while for COVID-19 diagnoses (n = 2059) the AUCs were 0.867 (95% CI 0.843–0.892) and 0.837 (95% CI 0.774–0.899) respectively.

Conclusion

Physicians evaluating ED patients with pneumonia, COVID-19, or symptoms suspicious for COVID-19 can apply the COVAS score to assist with decisions to hospitalize or discharge patients during the SARS CoV-2 pandemic.

Value of Blood Cultures in the Management of Children Hospitalized with Community-Acquired Pneumonia

Background and objectives

Current guidelines for the management of community-acquired pneumonia (CAP) in children recommend obtaining a blood culture for children with moderate to severe pneumonia; yet, there is no guidance to assess the severity of the disease. Thus, a blood culture is obtained for the majority of children admitted with CAP, regardless of the severity of their symptoms. The study was designed to investigate and identify the prevalence of bacteremia in pediatric patients hospitalized with CAP and to evaluate the clinical and laboratory variables associated with bacteremia.

Methods

We conducted a medical record review of children aged from two months to 18 years diagnosed with CAP between January 1, 2013, and December 31, 2017, at our two urban tertiary centers. We used binary logistic regression analysis and chi-square tests to look at factors associated with blood culture positivity.

Results

A total of 464 patients were admitted with CAP. Blood cultures were obtained in 357 (76.9%) patients; 23 patients had repeated cultures. Fifteen patients had positive cultures: 5/380 (1.3%) were considered true positive results and 10/380 (2.6%) were considered contaminants. Intensive care unit (ICU) admission (OR 5.6 with 95% CI (1- 31), p<0.03), toxic appearance (OR 12.8 with 95% CI (1.3-125), p<0.01), and significantly elevated C-reactive protein (CRP) (>300 mg/L (p<0.01) were associated with bacteremia.

Conclusion

The prevalence of bacteremia among children admitted for CAP is low. The use of routine blood cultures should be reserved for children with moderate to severe pneumonia. Further studies are required to better risk-stratify children with CAP.

Severity scoring systems for pneumonia: current understanding and next steps

PURPOSE OF REVIEW

To describe the current understanding and clinical applicability of severity scoring systems in pneumonia management.

RECENT FINDINGS

Severity scores in community-acquired pneumonia are strong markers of mortality, but are not necessarily clinical decision-aid tools. The use of severity scores to support outpatient care in low-risk patients has moderate-to-strong evidence available in the literature, mainly for the pneumonia severity index, and must be applied together with clinical judgment. It is not clear that severity scores are helpful to guide empiric antibiotic treatment. The inclusion of biomarkers and performance status might improve the predictive performance of the well known severity scores in community-acquired pneumonia. We should improve our methods for score evaluation and move toward the development of decision-aid tools.

SUMMARY

The application of the available evidence favors the use of severity scoring systems to improve the delivery of care for pneumonia patients. The incorporation of new methodologies and the formulation of different questions other than mortality prediction might help the further development of severity scoring systems, and enhance their support to the clinical decision-making process for the pneumonia-management cascade.

Factors Associated With Pneumonia Severity in Children: A Systematic Review

Community-acquired pneumonia in children is associated with significant morbidity and mortality; however, data are limited in predicting which children will have negative outcomes, including clinical deterioration, severe disease, or development of complications. The Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) pediatric pneumonia guideline includes criteria that were modified from adult criteria and define pneumonia severity to assist with resource allocation and site-of-care decision-making. However, the PIDS/IDSA criteria have not been formally developed or validated in children. Definitions for mild, moderate, and severe pneumonia also vary across the literature, further complicating the development of standardized severity criteria. This systematic review summarizes (1) the current state of the evidence for defining and predicting pneumonia severity in children as well as (2) emerging evidence focused on risk stratification of children with pneumonia.

Rebounds after discharge from the emergency department for community-acquired pneumonia: focus on the usefulness of severity scoring systems

Background:

Community-acquired pneumonia (CAP) is common cause of hospital admission and leading cause of morbidity and mortality. Severity scoring systems are used to predict risk profile, outcome and mortality, and to help decisions about management strategies.

Aim of the work and Methods:

To critically analyze pneumonia “rebound” cases, once discharged from the emergency department (ED) and afterwards admitted. We conducted an observational clinical study in the acute setting of a university teaching hospital, prospectively analyzing, in a 1 year period, demographic, medical, clinical and laboratory data, and the outcome.

Results:

249 patients were discharged home with diagnosis of CAP; 80 cases (32.1%) resulted in the high-intermediate risk class according to CURB-65 or CRB-65. Twelve patients (4.8%) presented to the ED twice and were then admitted. At their first visit 5 were in the high-intermediate risk group; just 4 of them were in the non-low risk group at the time of their admission. The rebound cohort showed some peculiar abnormalities in laboratory parameters (coagulation and renal function) and severe chest X-rays characteristics. None died in 30 days.

Conclusions:

The power of CURB-65 to correctly predict mortality for CAP patients discharged home from the ED is not confirmed by our results; careful clinical judgement seems to be irreplaceable in the management process. Many patients with a high-intermediate risk according to CURB-65 can be safely treated as outpatients, according to adequate welfare conditions; we identified a subgroup of cases that should worth a special attention and, therefore, a brief observation period in the ED before the final decision to safely discharge or admit. (www.actabiomedica.it)

Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases

Introduction

In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute.

Materials and methods

A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development.

Conclusion

The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

Predicting Severe Pneumonia Outcomes in Children

BACKGROUND

Substantial morbidity and excessive care variation are seen with pediatric pneumonia. Accurate risk-stratification tools to guide clinical decision-making are needed.

METHODS

We developed risk models to predict severe pneumonia outcomes in children (<18 years) by using data from the Etiology of Pneumonia in the Community Study, a prospective study of community-acquired pneumonia hospitalizations conducted in 3 US cities from January 2010 to June 2012. In-hospital outcomes were organized into an ordinal severity scale encompassing severe (mechanical ventilation, shock, or death), moderate (intensive care admission only), and mild (non-intensive care hospitalization) outcomes. Twenty predictors, including patient, laboratory, and radiographic characteristics at presentation, were evaluated in 3 models: a full model included all 20 predictors, a reduced model included 10 predictors based on expert consensus, and an electronic health record (EHR) model included 9 predictors typically available as structured data within comprehensive EHRs. Ordinal regression was used for model development. Predictive accuracy was estimated by using discrimination (concordance index).

RESULTS

Among the 2319 included children, 21% had a moderate or severe outcome (14% moderate, 7% severe). Each of the models accurately identified risk for moderate or severe pneumonia (concordance index across models 0.78-0.81). Age, vital signs, chest indrawing, and radiologic infiltrate pattern were the strongest predictors of severity. The reduced and EHR models retained most of the strongest predictors and performed as well as the full model.

CONCLUSIONS

We created 3 risk models that accurately estimate risk for severe pneumonia in children. Their use holds the potential to improve care and outcomes.

Risk factors for Clostridium difficile infection in hospitalized patients with community-acquired pneumonia

OBJECTIVES

Clostridium difficile infection (CDI) is strongly associated with anti-biotic treatment, and community-acquired pneumonia (CAP) is the leading indication for anti-biotic prescription in hospitals. This study assessed the incidence of and risk factors for CDI in a cohort of patients hospitalized with CAP.

METHODS

We analysed data from a prospective, observational cohort of patients with CAP in Edinburgh, UK. Patients with diarrhoea were systematically screened for CDI, and risk factors were determined through time-dependent survival analysis.

RESULTS

Overall, 1883 patients with CAP were included, 365 developed diarrhoea and 61 had laboratory-confirmed CDI. The risk factors for CDI were: age (hazard ratio [HR], 1.06 per year; 95% confidence interval [CI], 1.03-1.08), total number of antibiotic classes received (HR, 3.01 per class; 95% CI, 2.32-3.91), duration of antibiotic therapy (HR, 1.09 per day; 95% CI, 1.00-1.19 and hospitalization status (HR, 13.1; 95% CI, 6.0-28.7). Antibiotic class was not an independent predictor of CDI when adjusted for these risk factors (P > 0.05 by interaction testing).

CONCLUSIONS

These data suggest that reducing the overall antibiotic burden, duration of antibiotic treatment and duration of hospital stay may reduce the incidence of CDI in patients with CAP.

Clinical Application of High-Resolution Computed Tomographic Imaging Features of Community-Acquired Pneumonia

Background

This article discusses the value of high-resolution computed tomography (HRCT) in the diagnosis and treatment of pulmonary infections. Lung infection caused by pathogens is an important cause of death. Traditional methods to treat lung infection involved empirical antibiotic therapy. Thin-slice CT scanning is widely used in the clinical setting, and HRCT scan can very clearly show alveolar and bronchiolar involvement of infection.

Material/Methods

In total, 178 patients with community-acquired pneumonia (CAP) were enrolled. All the patients underwent CT scan, qualified sputum, and blood samples for culture or immunological biochemical tests. CT imaging features, pathogenic bacteria, and treatment results were used for statistical analysis.

Results

In 77 patients with lobar consolidation, the rate of detection was 43.26% (77/178), and in 101 patients with lobular pneumonia it was 56.74% (101/178). In 51 patients, pathogenic bacteria were detected (28.65%, 51/178). Sixteen of 33 patients detected with bacteria had cavities (48.5%, 16/33) and 35 of 145 patients detected with bacteria had no cavities (24.1%, 35/145). The difference between the 2 groups was statistically significant (χ²=7.795, P=0.005). According to the pathogenic bacteria, 38 patients were cured (74.51%, 38/51), and according to the CT imaging features 81 patients were cured (71.05%, 81/114). No statistically significant difference was found between them (χ²=0.209, P=0.647).

Conclusions

Treatment effect of CAP based on HRCT findings is not inferior to treatment effect guided by microbial characterization.

Risk stratification by abbMEDS and CURB-65 in relation to treatment and clinical disposition of the septic patient at the emergency department: a cohort study

Background

Sepsis leads to high mortality, therefore risk stratification is important. The abbMEDS (abbreviated Mortality Emergency Department Sepsis) score assesses sepsis severity and predicts mortality. In community-acquired pneumonia, the CURB-65 (Confusion, Urea, Respiration, Blood pressure, Age) also provides support in clinical decisions regarding antibiotic treatment and clinical disposition.

We investigated the predictive value and feasibility of the abbMEDS and CURB-65 in sepsis patients at the ED and the relationship between the scores and antibiotic treatment and clinical disposition (i.e. admission and type of ward).

Methods

In this retrospective cohort study, we included 725 sepsis patients at the ED. We investigated the value in predicting 28-day mortality and feasibility of both scores. We calibrated the abbMEDS. We further assessed the relationship between the three risk categories per score and antibiotic treatment (i.e. oral and intravenous narrow or broad-spectrum) and clinical disposition.

Results

Both abbMEDS and CURB-65 were good predictors of 28-day mortality (13.0 %) (AUC 0.77 [95 % CI 0.72 – 0.83] and 0.73 [95 % CI 0.67 - 0.78], respectively) and feasible (complete score 92.7 and 93.9 %, respectively). In the high risk category of the abbMEDS, all patients were admitted and treated with intravenous broad-spectrum antibiotics. In the high risk category of the CURB-65, 2.5 % were not admitted and 4.4 % received no antibiotics.

Conclusion

Both abbMEDS and CURB-65 are good predictors of 28-day mortality in septic ED patients. The abbMEDS is well calibrated and matches current clinical decisions concerning antibiotic treatment and clinical disposition, while this is less so for the CURB-65. In the future, use of the abbMEDS at the ED may improve sepsis care when its value as a decision support tool can be confirmed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-015-0056-z) contains supplementary material, which is available to authorized users.

Prognostic utility of serum CRP levels in combination with CURB-65 in patients with clinically suspected sepsis: a decision curve analysis

OBJECTIVES

The prognostic utility of serum C reactive protein (CRP) alone in sepsis is controversial. We used decision curve analysis (DCA) to evaluate the clinical usefulness of combining serum CRP levels with the CUBR-65 score in patients with suspected sepsis.

DESIGN

Retrospective cohort study.

SETTING

Emergency department (ED) of an urban teaching hospital in Japan.

PARTICIPANTS

Consecutive ED patients over 15 years of age who were admitted to the hospital after having a blood culture taken in the ED between 1 January 2010 and 31 December 2012.

MAIN OUTCOME MEASURES

30-day in-hospital mortality.

RESULTS

Data from 1262 patients were analysed for score evaluation. The 30-day in-hospital mortality was 8.4%. Multivariable analysis showed that serum CRP ≥150 mg/L was an independent predictor of death (adjusted OR 2.0; 95% CI 1.3 to 3.1). We compared the predictive performance of CURB-65 with the performance of a modified CURB-65 with that included CRP (≥150 mg/L) to quantify the clinical usefulness of combining serum CRP with CURB-65. The areas under the receiver operating characteristics curves of CURB-65 and a modified CURB-65 were 0.76 (95% CI 0.72 to 0.80) and 0.77 (95% CI 0.72 to 0.81), respectively. Both models had good calibration for mortality and were useful among threshold probabilities from 0% to 30%. However, while incorporating CRP into CURB-65 yielded a significant category-free net reclassification improvement of 0.387 (95% CI 0.193 to 0.582) and integrated discrimination improvement of 0.015 (95% CI 0.004 to 0.027), DCA showed that CURB-65 and the modified CURB-65 score had comparable net benefits for prediction of mortality.

CONCLUSIONS

Measurement of serum CRP added limited clinical usefulness to CURB-65 in predicting mortality in patients with clinically suspected sepsis, regardless of the source.

Admission chest radiographs predict illness severity for children hospitalized with pneumonia

OBJECTIVE

To assess whether radiographic findings predict outcomes among children hospitalized with pneumonia.

METHODS

This retrospective study included children <18 years of age from 4 children's hospitals admitted in 2010 with clinical and radiographic evidence of pneumonia. Admission radiographs were categorized as single lobar, unilateral or bilateral multilobar, or interstitial. Pleural effusions were classified as absent, small, or moderate/large. Propensity scoring was used to adjust for potential confounders, including need for supplemental oxygen, intensive care, and mechanical ventilation, as well as hospital length of stay and duration of supplemental oxygen.

RESULTS

There were 406 children (median age, 3 years). Infiltrate patterns included: single lobar, 61%; multilobar unilateral, 13%; multilobar bilateral, 16%; and interstitial, 10%. Pleural effusion was present in 21%. Overall, 63% required supplemental oxygen (median duration, 31.5 hours), 8% required intensive care, and 3% required mechanical ventilation. Median length of stay was 51.5 hours. Compared with single lobar infiltrate, all other infiltrate patterns were associated with need for intensive care; only bilateral multilobar infiltrate was associated with need for mechanical ventilation (adjusted odds ratio [aOR]: 3.0, 95% confidence interval [CI]: 1.2-7.9). Presence of effusion was associated with increased length of stay and duration of supplemental oxygen; only moderate/large effusion was associated with need for intensive care (aOR: 3.2, 95% CI: 1.1-8.9) and mechanical ventilation (aOR: 14.8, 95% CI: 9.8-22.4).

CONCLUSIONS

Admission radiographic findings are associated with important hospital outcomes and care processes and may help predict disease severity.

Predictors of mortality in hospitalized adults with acute exacerbation of chronic obstructive pulmonary disease

RATIONALE

There is a need to identify clinically meaningful predictors of mortality following hospitalized COPD exacerbation.

OBJECTIVES

The aim of this study was to systematically review the literature to identify clinically important factors that predict mortality after hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

Eligible studies considered adults admitted to hospital with COPD exacerbation. Two authors independently abstracted data. Odds ratios were then calculated by comparing the prevalence of each predictor in survivors versus nonsurvivors. For continuous variables, mean differences were pooled by the inverse of their variance, using a random effects model.

MEASUREMENTS AND MAIN RESULTS

There were 37 studies included (189,772 study subjects) with risk of death ranging from 3.6% for studies considering short-term mortality, 31.0% for long-term mortality (up to 2 yr after hospitalization), and 29.0% for studies that considered solely intensive care unit (ICU)-admitted study subjects. Twelve prognostic factors (age, male sex, low body mass index, cardiac failure, chronic renal failure, confusion, long-term oxygen therapy, lower limb edema, Global Initiative for Chronic Lung Disease criteria stage 4, cor pulmonale, acidemia, and elevated plasma troponin level) were significantly associated with increased short-term mortality. Nine prognostic factors (age, low body mass index, cardiac failure, diabetes mellitus, ischemic heart disease, malignancy, FEV1, long-term oxygen therapy, and PaO2 on admission) were significantly associated with long-term mortality. Three factors (age, low Glasgow Coma Scale score, and pH) were significantly associated with increased risk of mortality in ICU-admitted study subjects.

CONCLUSION

Different factors correlate with mortality from COPD exacerbation in the short term, long term, and after ICU admission. These parameters may be useful to develop tools for prediction of outcome in clinical practice.

Major advances in managing community-acquired pneumonia

This article is a non-systematic review of selected recent publications in community-acquired pneumonia, including a comparison of various guidelines. Risk stratification of patients has recently been advanced by the addition of several useful biomarkers. The issue of single versus dual antibiotic treatment remains controversial and awaits a conclusive randomized controlled trial. However, in the meantime, there is a working consensus that more severe patients should receive dual therapy.

A multidisciplinary intervention to reduce antibiotic duration in lower respiratory tract infections

OBJECTIVES

Prolonged antibiotic courses are common in patients with lower respiratory tract infections (LRTIs) and contribute to antibiotic resistance and side effects. This study describes a multidisciplinary intervention to reduce antibiotic duration in LRTI patients.

METHODS

This was a prospective before-and-after intervention study conducted from November 2011 to December 2012. Antibiotic duration was recorded for 6 months for all LRTI admissions (pneumonia, exacerbation of chronic obstructive pulmonary disease, exacerbation of asthma, and other LRTIs), followed by the introduction of an intervention intended to reduce the duration of antibiotic treatment. The intervention incorporated an antibiotic duration based on the CURB65 score, automatic stop dates and pharmacist feedback to prescribers.

RESULTS

Two hundred and eighty-one patients were included in the pre-intervention group and 221 in the post-intervention group. The intervention resulted in a reduction in the duration of antibiotic treatment from 8.3 to 6.8 days (P < 0.001, 18.1% relative reduction). The rate of antibiotic-related adverse effects reduced from 31% to 19% (P = 0.03, 39.3% relative reduction). There was no increase in mortality or length of stay

CONCLUSIONS

A simple intervention can significantly reduce antibiotic duration and antibiotic-related side effects.

Community-acquired pneumonia

Community-acquired pneumonia (CAP) is one of the most common acute infections requiring admission to hospital. The main causative pathogens of CAP are Streptococcus pneumoniae, influenza A, Mycoplasma pneumoniae and Chlamydophila pneumoniae, and the dominant risk factors are age, smoking and comorbidities. The incidence of CAP and its common complications, such as the requirement for intensive care and complicated parapneumonic effusions, are increasing, making it essential for all physicians to have a good understanding of the management of CAP. Although the diagnosis and treatment of CAP is straightforward in most cases, it can be more complex, and recent data indicate that the mortality of CAP in the UK is surprisingly high. In the future, routine use of biomarkers to improve risk stratification and tailor management to individual patients could improve outcomes, and there is some evidence that modulation of CAP-associated inflammation could also be beneficial. Both research into host-microbial interactions in the lung and clinical trials of different management and preventative treatments are urgently needed to combat the increasing morbidity and mortality associated with CAP.

Community-Acquired Pneumonia in the Conjugate Vaccine Era

Community-acquired pneumonia (CAP) remains one of the most common serious infections encountered among children worldwide. In this review, we highlight important literature and recent scientific discoveries that have contributed to our current understanding of pediatric CAP. We review the current epidemiology of childhood CAP in the developed world, appraise the state of diagnostic testing for etiology and prognosis, and discuss disease management and areas for future research in the context of recent national guidelines.

Can we use severity assessment tools to increase outpatient management of community-acquired pneumonia?

Outpatient management of community-acquired pneumonia (CAP) has several potential advantages, including significant cost-savings, a reduction in hospital-acquired infections and increased patient satisfaction. Despite the benefits, it is often difficult to identify which patients may be managed in the community without compromising patient safety. CAP severity scores, such as the pneumonia severity index (PSI) and the British Thoracic Society CURB65/CRB65 scores are designed to identify groups of patients at low risk of mortality who may be suitable for outpatient care. This review discusses the strengths and weaknesses of severity scores for use in determining site of care for patients with pneumonia. Use of the PSI in emergency departments has been shown to increase the proportion of patients treated in the community without increasing patient mortality or hospital readmissions. The CURB65 and CRB65 scores are less complex alternatives to the PSI that have been shown to perform similarly for prediction of 30-day mortality. All 3 scores identify populations at low risk of mortality who may be eligible for outpatient care. Nevertheless, a number of factors not included in severity scores may prevent discharge of these patients, including social factors, co-morbidities and severity markers not captured by severity scores. The limitations of severity scores are discussed along with recent attempts to improve predictive tools, with the development of new biomarkers and alternative scoring systems.

Validation of the Infectious Diseases Society of America/American Thoratic Society minor criteria for intensive care unit admission in community-acquired pneumonia patients without major criteria or contraindications to intensive care unit care

BACKGROUND

The 2007 Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) guidelines for community-acquired pneumonia (CAP) recommended new criteria to guide admission to the intensive care unit (ICU) for patients with this condition. Although the major criteria (requirement for mechanical ventilation or septic shock requiring vasopressor support) are well established, the value of the minor criteria alone have not been fully validated.

METHODS

We performed a prospective observational study of consecutive adult patients with CAP admitted to NHS Lothian (Scotland, United Kingdom). Patients meeting the IDSA/ATS major criteria on admission were excluded, along with patients not suitable for ICU care owing to advanced directives or major comorbid illnesses. Performance characteristics for the IDSA/ATS minor criteria were calculated and compared with those for alternative scoring systems identified in the literature. Two definitions of severe CAP were used as primary end points: ICU admission, and subsequent requirement for mechanical ventilation or vasopressor support (MV/VS); 30-day mortality was a secondary outcome.

RESULTS

The study included 1062 patients with CAP potentially eligible for ICU admission. Each of the 9 minor criteria was associated with increased risk of MV/VS and 30-day mortality in univariate analysis. Two hundred seven patients had ≥ 3 minor criteria (19.5%). The IDSA/ATS 2007 criteria had an area under the receiver operating characteristic curve of 0.85 (0.82-0.88) for prediction of MV/VS, 0.85 (0.82-0.88) for prediction of ICU admission, and 0.78 (0.74-0.82) for prediction of 30-day mortality. The IDSA/ATS 2007 criteria were at least equivalent to more established scoring systems for prediction of MV/VS and ICU admission and equivalent to alternative scoring systems for predicting 30-day mortality in this patient population.

CONCLUSIONS

In a population of patients with CAP without contraindications to ICU care, the IDSA/ATS minor criteria predict subsequent requirement for MV/VS, ICU admission, and 30-day mortality.

Predicting mortality with severity assessment tools in out-patients with community-acquired pneumonia

INTRODUCTION

In community-acquired pneumonia, severity assessment tools, such as CRB65, CURB65 and Pneumonia Severity Index (PSI), have been promoted to increase the proportion of patients treated in the community. The prognostic accuracy of these scores is established in hospitalized patients, but less is known about their use in out-patients. We aimed to study the accuracy of these severity tools to predict mortality in patients managed as out-patients.

METHODS

We performed a systematic review and meta-analysis according to MOOSE guidelines. From 1980 to 2010, we identified 13 studies reporting prognostic information for the CRB65, CURB65 and PSI severity scores in out-patients (either exclusively managed in the community or discharged from an emergency department <24 h after admission). Two reviewers independently collected data and assessed study quality. Performance characteristics across the studies were pooled using a random-effects model. Relationships between sensitivity and specificity were plotted using summary receiver operator characteristic curves (sROC).

RESULTS

Out-patient mortality ranged from 0% to 3.5%. Four studies were identified for CRB65, 2 for CURB65 and 10 for PSI. Mortality was low for out-patients in the low-risk CRB65 classes [CRB65 0 or 1: mortality occurred in 3 of 1494 patients (0.2%)] but higher in CRB65 Groups 2-4 [mortality 13 of 154 patients (8.4%)]. Similarly, mortality was low in PSI Classes I-III [mortality 8 of 3655 patients (0.2%)] managed as out-patients but higher in Classes IV and V [mortality 32 of 317 patients (10.1%)]. CRB65 showed pooled sensitivity of 81% (54-96%), pooled specificity of 91% (90-93%) and the area under the sROC was 0.91 [standard error (SE) 0.05]. For PSI, pooled sensitivity was 92% (64-100%), pooled specificity was 90% (89-91%) and area under the sROC was 0.92 (SE 0.03). There were insufficient studies to analyse CURB65.

CONCLUSION

The limited data available suggest that CRB65 and PSI can identify groups of patients at low risk of mortality that can be safely managed in the community.