Prognostic factors and prediction models for hospitalisation and all-cause mortality in adults presenting to primary care with a lower respiratory tract infection: a systematic review

OBJECTIVE

To identify and synthesise relevant existing prognostic factors (PF) and prediction models (PM) for hospitalisation and all-cause mortality within 90 days in primary care patients with acute lower respiratory tract infections (LRTI).

DESIGN

Systematic review.

METHODS

Systematic searches of MEDLINE, Embase and the Cochrane Library were performed. All PF and PM studies on the risk of hospitalisation or all-cause mortality within 90 days in adult primary care LRTI patients were included. The risk of bias was assessed using the Quality in Prognostic Studies tool and Prediction Model Risk Of Bias Assessment Tool tools for PF and PM studies, respectively. The results of included PF and PM studies were descriptively summarised.

RESULTS

Of 2799 unique records identified, 16 were included: 9 PF studies, 6 PM studies and 1 combination of both. The risk of bias was judged high for all studies, mainly due to limitations in the analysis domain. Based on reported multivariable associations in PF studies, increasing age, sex, current smoking, diabetes, a history of stroke, cancer or heart failure, previous hospitalisation, influenza vaccination (negative association), current use of systemic corticosteroids, recent antibiotic use, respiratory rate ≥25/min and diagnosis of pneumonia were identified as most promising candidate predictors. One newly developed PM was externally validated (c statistic 0.74, 95% CI 0.71 to 0.78) whereas the previously hospital-derived CRB-65 was externally validated in primary care in five studies (c statistic ranging from 0.72 (95% CI 0.63 to 0.81) to 0.79 (95% CI 0.65 to 0.92)). None of the PM studies reported measures of model calibration.

CONCLUSIONS

Implementation of existing models for individualised risk prediction of 90-day hospitalisation or mortality in primary care LRTI patients in everyday practice is hampered by incomplete assessment of model performance. The identified candidate predictors provide useful information for clinicians and warrant consideration when developing or updating PMs using state-of-the-art development and validation techniques.

PROSPERO REGISTRATION NUMBER

CRD42022341233.

Primary Care Antibiotic Prescribing and Infection-Related Hospitalisation

Inappropriate prescribing of antibiotics has been widely recognised as a leading cause of antimicrobial resistance, which in turn has become one of the most significant threats to global health. Given that most antibiotic prescriptions are issued in primary care settings, investigating the associations between primary care prescribing of antibiotics and subsequent infection-related hospitalisations affords a valuable opportunity to understand the long-term health implications of primary care antibiotic intervention. A narrative review of the scientific literature studying associations between primary care antibiotic prescribing and subsequent infection-related hospitalisation was conducted. The Web of Science database was used to retrieve 252 potentially relevant studies, with 23 of these studies included in this review (stratified by patient age and infection type). The majority of studies (n = 18) were published in the United Kingdom, while the remainder were conducted in Germany, Spain, Denmark, New Zealand, and the United States. While some of the reviewed studies demonstrated that appropriate and timely antibiotic prescribing in primary care could help reduce the need for hospitalisation, excessive antibiotic prescribing can lead to antimicrobial resistance, subsequently increasing the risk of infection-related hospitalisation. Few studies reported no association between primary care antibiotic prescriptions and subsequent infection-related hospitalisation. Overall, the disparate results in the extant literature attest to the conflicting factors influencing the decision-making regarding antibiotic prescribing and highlight the necessity of adopting a more patient-focussed perspective in stewardship programmes and the need for increased use of rapid diagnostic testing in primary care.

Short-Term Readmission Following Community-Acquired Pneumonia: A Cross-Sectional Study

Background:Community-acquired pneumonia continues to be a major cause of morbidity and mortality. Hospital readmissions following community-acquired pneumonia are linked to significant cost of care and medical burdens. This study aimed to determine the incidence and reasons for readmission as well as to assess factors associated with short-term hospital readmission among community-acquired pneumonia patients. Methods:A retrospective, cross-sectional study was conducted on 582 medical records of community-acquired pneumonia inpatients from December 2018 to December 2019 at an 800-bed tertiary hospital in Ho Chi Minh City, Vietnam. We collected data on patient characteristics, pneumonia severity at hospital admission, microbiology and antibiotic resistance, appropriateness of empiric antibiotic therapies, and the readmissions information. Multivariable logistic regression analyses were performed to identify factors associated with 30-day hospital readmission. Results: Of the 582 hospitalized community-acquired pneumonia patients, 11.9% were readmitted to the hospital within 30 days. About half of the cases (43.5%) were due to pneumonia. Multidrug-resistant bacteria accounted for 43.2% of the pathogen isolates. A high Charlson comorbidity index (aOR, 1.40; CI 95%, 1.08-1.82) and multidrug-resistant infection (aOR, 2.63; CI 95%, 1.05-6.56) were associated with higher odds of all-cause readmission. Conclusions:Hospital readmissions within 30 days occurred frequently among community-acquired pneumonia inpatients, and the most common reason for readmission recorded was pneumonia-related. Monitoring closely patients with multimorbidity or multidrug-resistant infections may improve treatment outcomes.

Impact of the Programa Mais médicos (more doctors Programme) on primary care doctor supply and amenable mortality: quasi-experimental study of 5565 Brazilian municipalities

BACKGROUND

Investing in human resources for health (HRH) is vital for achieving universal health care and the Sustainable Development Goals. The Programa Mais Médicos (PMM) (More Doctors Programme) provided 17,000 doctors, predominantly from Cuba, to work in Brazilian primary care. This study assesses whether PMM doctor allocation to municipalities was consistent with programme criteria and associated impacts on amenable mortality.

METHODS

Difference-in-differences regression analysis, exploiting variation in PMM introduction across 5565 municipalities over the period 2008-2017, was employed to examine programme impacts on doctor density and mortality amenable to healthcare. Heterogeneity in effects was explored with respect to doctor allocation criteria and municipal doctor density prior to PMM introduction.

RESULTS

After starting in 2013, PMM was associated with an increase in PMM-contracted primary care doctors of 15.1 per 100,000 population. However, largescale substitution of existing primary care doctors resulting in a net increase of only 5.7 per 100,000. Increases in both PMM and total primary care doctors were lower in priority municipalities due to lower allocation of PMM doctors and greater substitution effects. The PMM led to amenable mortality reductions of - 1.06 per 100,000 (95%CI: - 1.78 to - 0.34) annually - with greater benefits in municipalities prioritised for doctor allocation and where doctor density was low before programme implementation.

CONCLUSIONS

PMM potential health benefits were undermined due to widespread allocation of doctors to non-priority areas and local substitution effects. Policies seeking to strengthen HRH should develop and implement needs-based criteria for resource allocation.

PANDEMIC INFLUENZA A (H1N1) 2009 PRESENTING AS A MILD DISEASE IN CHILDREN IN A CROATIAN CLINICAL CENTRE

Pandemic influenza A virus (H1N1) 2009 causes a disease that is epidemiologically and clinically not significantly different from seasonal influenza, but there are differences. The aim of the study was to display and compare epidemiological and clinical characteristics of pandemic influenza in children. At Dr. Fran Mihaljević University Hospital for Infectious Diseases in Zagreb, in the first two seasons, the incidence of pandemic influenza virus A (H1N1) in particular was exhaustively analyzed only in patients with laboratory-confirmed pandemic influenza A virus (H1N1) 2009. In hospitalized children with documented influenza pandemic, moderate form of the disease predominated, which ultimately meant shorter hospital stay and fewer complications. Otitis media was the rarest complication in children in both seasons. In conclusion, children younger than 5 years, especially boys, were vulnerable groups for pandemic influenza, presenting as a mild disease with low mortality and few complications. Most of the affected children with influenza did not have important risk factors such as asthma and obesity, highlighted by other authors as significant risk factors.

Biomarkers and clinical scoring systems in community-acquired pneumonia

Community-acquired pneumonia (CAP) is the third most common cause of death globally. Due to the complexity of CAP, it is widely accepted that, currently, clinical prognosis and diagnosis is inadequate for the assessment of the severity of the disease. With the aim to determining the initial treatment and the appropriate level of intervention, several clinical scores of severity and biomarkers have been developed. Both biomarkers and clinical scoring systems are expected to determine the different aspects of the host factor and the response to therapy, in order for physicians to be able to make an accurate benefit/risk assessment that will lead to proper diagnosis and correct prescription of antibiotics. This review aims to highlight the prognostic and diagnostic accuracy of various laboratory and clinical parameters in CAP and discuss the perspectives for the reduction of CAP mortality.

Funding and policy incentives to encourage implementation of point-of-care C-reactive protein testing for lower respiratory tract infection in NHS primary care: a mixed-methods evaluation

OBJECTIVES

Utilisation of point-of-care C-reactive protein testing for lower respiratory tract infection has been limited in UK primary care, with costs and funding suggested as important barriers. We aimed to use existing National Health Service funding and policy mechanisms to alleviate these barriers and engage with clinicians and healthcare commissioners to encourage implementation.

DESIGN

A mixed-methods study design was adopted, including a qualitative survey to identify clinicians' and commissioners' perceived benefits, barriers and enablers post-implementation, and quantitative analysis of results from a real-world implementation study.

INTERVENTIONS

We developed a funding specification to underpin local reimbursement of general practices for test delivery based on an item of service payment. We also created training and administrative materials to facilitate implementation by reducing organisational burden. The implementation study provided intervention sites with a testing device and supplies, training and practical assistance.

RESULTS

Despite engagement with several groups, implementation and uptake of our funding specification were limited. Survey respondents confirmed costs and funding as important barriers in addition to physical and operational constraints and cited training and the value of a local champion as enablers.

CONCLUSIONS

Although survey respondents highlighted the clinical benefits, funding remains a barrier to implementation in UK primary care and appears not to be alleviated by the existing financial incentives available to commissioners. The potential to meet incentive targets using lower cost methods, a lack of policy consistency or competing financial pressures and commissioning programmes may be important determinants of local priorities. An implementation champion could help to catalyse support and overcome operational barriers at the local level, but widespread implementation is likely to require national policy change. Successful implementation may reproduce antibiotic prescribing reductions observed in research studies.

Incidence, aetiology and outcome of pleural empyema and parapneumonic effusion from 1998 to 2012 in a population of New Zealand children

AIM

To document rising incidence rates of childhood empyema and parapneumonic effusion (PPE) in South Auckland, New Zealand between 1998 and 2012; to compare epidemiology, pathogens and outcomes of children with empyema and PPE; and to ascertain whether primary care antibiotic prescribing, delayed presentation, or bacterial epidemiology might account for the rising incident rates.

METHODS

Children aged 0 to14 years hospitalised with pleural empyema or PPE were retrospectively identified. Empyema was defined by ultrasound and pleural tap criteria. PPE was defined as the presence of pleural fluid on chest xray not fulfilling empyema criteria. Epidemiology, clinical features, microbiology and outcomes of empyema and PPE were compared and incidence rates analysed.

RESULTS

Of 184 cases identified, 104 met the criteria for empyema. Empyema incidence increased from 1 per 100 000 children aged 0 to 14 years in 1998 to 10 per 100 000 in 2012, with a peak incidence of 13 per 100 000 in 2009. Staphylococcus aureus was most frequently detected (n=38), followed by Streptococcus pneumoniae (n=31). Cases of S. aureus empyema increased 4 fold over the 15 years. Dominant S. pneumoniae serotypes were 1 and 14. Thirty-five percent of empyema and 53% of PPE cases received pre-hospital antibiotics. Children who received pre-hospital antibiotics were more than 40% less likely to require surgical intervention than those not pre-treated.

CONCLUSIONS

Childhood empyema incidence has increased markedly in South Auckland. Paediatric S. aureus empyema is becoming increasingly common in South Auckland. Pre-hospital antibiotic prescribing may mitigate the need for surgical intervention in our population.

Risk factors for hospital admission in the 28 days following a community-acquired pneumonia diagnosis in older adults, and their contribution to increasing hospitalisation rates over time: a cohort study

OBJECTIVES

To determine factors associated with hospitalisation after community-acquired pneumonia (CAP) among older adults in England, and to investigate how these factors have contributed to increasing hospitalisations over time.

DESIGN

Cohort study.

SETTING

Primary and secondary care in England.

POPULATION

39,211 individuals from the Clinical Practice Research Datalink, who were eligible for linkage to Hospital Episode Statistics and mortality data, were aged ≥ 65 and had at least 1 CAP episode between April 1998 and March 2011.

MAIN OUTCOME MEASURES

The association between hospitalisation within 28 days of CAP diagnosis (a 'post-CAP' hospitalisation) and a wide range of comorbidities, frailty factors, medications and vaccinations. We examined the role of these factors in post-CAP hospitalisation trends. We also looked at trends in post-CAP mortality and length of hospitalisation over the study period.

RESULTS

14 comorbidities, 5 frailty factors and 4 medications/vaccinations were associated with hospitalisation (of 18, 12 and 7 considered, respectively). Factors such as chronic lung disease, severe renal disease and diabetes were associated with increased likelihood of hospitalisation, whereas factors such as recent influenza vaccination and a recent antibiotic prescription decreased the odds of hospitalisation. Despite adjusting for these and other factors, the average predicted probability of hospitalisation after CAP rose markedly from 57% (1998-2000) to 86% (2009-2010). Duration of hospitalisation and 28-day mortality decreased over the study period.

CONCLUSIONS

The risk factors we describe enable identification of patients at increased likelihood of post-CAP hospitalisation and thus in need of proactive case management. Our analyses also provide evidence that while comorbidities and frailty factors contributed to increasing post-CAP hospitalisations in recent years, the trend appears to be largely driven by changes in service provision and patient behaviour.

Pneumococcal lower respiratory tract infections in adults: an observational case-control study in primary care in Belgium

Background

Serious lower respiratory tract infections (SLRTIs), especially Streptococcus pneumoniae (SP)-related pneumonia cause considerable morbidity and mortality. Chest imaging, sputum and blood culture are not routinely obtained by general practitioners (GPs). Antibiotic therapy is usually started empirically. The BinaxNOW® and Urine Antigen Detection (UAD) assays have been developed respectively to detect a common antigen from all pneumococcal strains and the 13 pneumococcal serotypes present in the vaccine Prevenar 13® (PCV13).

Methods

OPUS-B was a multicentre, prospective, case-control, observational study of patients with SLRTI in primary care in Belgium, conducted during two winter seasons (2011–2013). A urine sample was collected at baseline for the urine assays. GPs were blinded to the results. All patients with a positive BinaxNOW® test and twice as much randomly selected BinaxNOW® negative patients were followed up. Recorded data included: socio-demographics, medical history, vaccination history, clinical symptoms, CRB-65 score, treatments, hospitalization, blood cultures, healthcare use, EQ-5D score. The objectives were to evaluate the percentage of SP SLRTI within the total number of SLRTIs, to assess the percentage of SP serotypes and to compare the burden of disease between pneumococcal and non-pneumococcal SLRTIs.

Results

There were 26 patients with a BinaxNOW® positive test and 518 patients with a BinaxNOW® negative test. The proportion of pneumococcal SLRTI was 4.8 % (95 % CI: 3.1 %–7.2 %). Sixty-eight percent of positive cases showed serotypes represented in PCV13. In the BinaxNOW-positive patients, women were more numerous, there was less exposure to young children, seasonal influenza vaccination was less frequent, COPD was more frequent, the body temperature and the number of breaths per minute were higher, the systolic blood pressure was lower, the frequency of sputum, infiltrate, chest pain, muscle ache, confusion/disorientation, diarrhoea, pneumonia and exacerbations of COPD was more frequent, EQ-5D index and VAS scale were lower, the number of visits to the GP, of working days lost and of days patients needed assistance were higher.

Conclusions

SP was responsible for approximately 5 % of SLRTIs observed in primary care in Belgium. Pneumococcal infection was associated with a significant increase in morbidity. Sixty-eight percent of serotypes causing SLRTI were potentially preventable by PCV13.

Illness perception and related behaviour in lower respiratory tract infections—a European study

BACKGROUND

Lower respiratory tract infection (LRTI) is a common presentation in primary care, but little is known about associated patients' illness perception and related behaviour.

OBJECTIVE

To describe illness perceptions and related behaviour in patients with LRTI visiting their general practitioner (GP) and identify differences between European regions and types of health care system.

METHODS

Adult patients presenting with acute cough were included. GPs recorded co morbidities and clinical findings. Patients filled out a diary for up to 4 weeks on their symptoms, illness perception and related behaviour. The chi-square test was used to compare proportions between groups and the Mann-Whitney U or Kruskal Wallis tests were used to compare means.

RESULTS

Three thousand one hundred six patients from 12 European countries were included. Eighty-one per cent (n = 2530) of the patients completed the diary. Patients were feeling unwell for a mean of 9 (SD 8) days prior to consulting. More than half experienced impairment of normal or social activities for at least 1 week and were absent from work/school for a mean of 4 (SD 5) days. On average patients felt recovered 2 weeks after visiting their GP, but 21% (n = 539) of the patients did not feel recovered after 4 weeks. Twenty-seven per cent (n = 691) reported feeling anxious or depressed, and 28% (n = 702) re-consulted their GP at some point during the illness episode. Reported illness duration and days absent from work/school differed between countries and regions (North-West versus South-East), but there was little difference in reported illness course and related behaviour between health care systems (direct access versus gate-keeping).

CONCLUSION

Illness course, perception and related behaviour in LRTI differ considerably between countries. These finding should be taken into account when developing International guidelines for LRTI and interventions for setting realistic expectations about illness course.

Does prolonged onset of symptoms have a prognostic significance in community-acquired pneumonia?

BACKGROUND AND OBJECTIVE

Severity assessment is made at the time of the initial clinical presentation in patients with community-acquired pneumonia (CAP). It is unclear how the gap between time of presentation and duration of symptoms onset may impact clinical outcomes. Here we evaluate the association of prolonged onset of symptoms (POS) and the impact on clinical outcomes among hospitalized patients with CAP.

METHODS

This was a prospective, multicentre study of CAP in Spain. The primary outcomes were the clinical factors associated with POS defined as days from symptoms onset to pneumonia diagnosis >7 days. The secondary outcomes were intensive care unit (ICU) admission, the presence of suppurative complications, septic shock and 30-day mortality.

RESULTS

We enrolled 1038 patients diagnosed of CAP: 152 (14.6%) patients had a POS. In multivariate analysis, the presence of prior corticosteroid therapy, alcohol abuse, prior antibiotic therapy, and confusion, urea, respiratory rate, blood pressure and age 65 years or older score 0-1 was independently associated with POS. Patients with POS had a higher incidence of suppurative complications, but not of 30-day mortality when compared with a shorter onset of symptoms.

CONCLUSIONS

Approximately 15% of patients diagnosed with CAP had POS. Risk factors associated with POS were previous corticosteroids and antibiotic therapy, alcoholism and less severe pneumonia. POS was associated with a higher rate of suppurative complications and less need for ICU admission.

Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort

BACKGROUND

Patterns of health-care use and comorbidities present in patients in the period before diagnosis of chronic obstructive pulmonary disease (COPD) are unknown. We investigated these factors to inform future case-finding strategies.

METHODS

We did a retrospective analysis of a clinical cohort in the UK with data from Jan 1, 1990 to Dec 31, 2009 (General Practice Research Database and Optimum Patient Care Research Database). We assessed patients aged 40 years or older who had an electronically coded diagnosis of COPD in their primary care records and had a minimum of 3 years of continuous practice data for COPD (2 years before diagnosis up to a maximum of 20 years, and 1 year after diagnosis) and at least two prescriptions for COPD since diagnosis. We identified missed opportunites to diagnose COPD from routinely collected patient data by reviewing patterns of health-care use and comorbidities present before diagnosis. We assessed patterns of health-care use in terms of lower respiratory consultations (infective and non-infective), lower respiratory consultations with a course of antibiotics or oral steroids, and chest radiography. If these events did not lead to a diagnosis of COPD, they were deemed to be missed opportunities. This study is registered with ClinicalTrials.gov, number NCT01655667.

FINDINGS

We assessed data for 38,859 patients. Opportunities for diagnosis were missed in 32,900 (85%) of 38,859 patients in the 5 years immediately preceding diagnosis of COPD; in 12,856 (58%) of 22,286 in the 6-10 years before diagnosis, in 3943 (42%) of 9351 in the 11-15 years before diagnosis; and in 95 (8%) of 1167 in the 16-20 years before diagnosis. Between 1990 and 2009, we noted decreases in the age at diagnosis (0·05 years of age per year, 95% CI 0·03-0·07) and yearly frequency of lower respiratory prescribing consultations (rate ratio 0·982 opportunities per year, 95% CI 0·979-0·985). Prevalence of all comorbidities present at COPD diagnosis increased except for asthma and bronchiectasis, which decreased between 1990 and 2007, from 281 (33·4%) of 842 patients to 451 of 1465 (30·8%) for asthma, and from 53 of 842 (6·3%) to 53 of 1465 (3·6%) for bronchiectasis. In the 2 years before diagnosis, of 6897 patients who had had a chest radiography, only 2296 (33%) also had spirometry.

INTERPRETATION

Opportunities to diagnose COPD at an earlier stage are being missed, and could be improved by case-finding in patients with lower respiratory tract symptoms and concordant long-term comorbidities.

FUNDING

UK Department of Health, Research in Real Life.

Frequency of metabolic syndrome and 25-hydroxyvitamin D3 levels in patients with non-alcoholic fatty liver disease

AIM

It is known that insulin resistance has an important role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD) and that serum 25-hidroksivitamin D3 [25-(OH)D] levels are found low in the presence of insulin resistance. Metabolic syndrome (MetS) is characterized by insulin resistance. The purpose of the present study was to determine the levels of 25-(OH)D and the frequency of MetS in patients with NAFLD, and to evaluate the association of 25-(OH)D with the histology of NAFLD and metabolic parameters.

METHOD

Sixty-three patients with NAFLD confirmed by liver biopsy (29 females and 34 males, mean age 42.70±9.82 years) and 46 healthy controls (16 females and 30 males, mean age 37.54±8.56 years) were included in the study. International Diabetes Federation criteria were used for MetS diagnosis. Insulin resistance was determined according to the Homeostasis Model of Assessment (HOMA-IR) method. The groups were compared for 25-(OH)D levels and MetS frequencies. Correlation analysis was used to evaluate relationships between 25-(OH)D and metabolic parameters and/or NAFLD histology.

RESULTS

25-(OH)D levels were lower in the NAFLD group compared to the control group (36.06±13.07 ng/mL vs. 51.19±23.45 ng/mL, respectively, P<0.01), while MetS frequency was higher (66.7% vs. 15.2%, P<0.01). In the NAFLD group, 25-(OH)D levels were negatively correlated with non-alcoholic steatohepatitis scores and HOMA-IR (r=-0.317, P=0.011 and r=-0.437, P=0.001, respectively).

CONCLUSION

The present study demonstrated higher frequency of MetS and lower levels of 25-(OH)D in patients with NAFDL, and a negative association of 25-(OH)D levels with non-alcoholic steatohepatitis scores and insulin resistance.

Incidence of community-acquired lower respiratory tract infections and pneumonia among older adults in the United Kingdom: a population-based study

Community-acquired lower respiratory tract infections (LRTI) and pneumonia (CAP) are common causes of morbidity and mortality among those aged ≥65 years; a growing population in many countries. Detailed incidence estimates for these infections among older adults in the United Kingdom (UK) are lacking. We used electronic general practice records from the Clinical Practice Research Data link, linked to Hospital Episode Statistics inpatient data, to estimate incidence of community-acquired LRTI and CAP among UK older adults between April 1997-March 2011, by age, sex, region and deprivation quintile. Levels of antibiotic prescribing were also assessed. LRTI incidence increased with fluctuations over time, was higher in men than women aged ≥70 and increased with age from 92.21 episodes/1000 person-years (65-69 years) to 187.91/1000 (85-89 years). CAP incidence increased more markedly with age, from 2.81 to 21.81 episodes/1000 person-years respectively, and was higher among men. For both infection groups, increases over time were attenuated after age-standardisation, indicating that these rises were largely due to population aging. Rates among those in the most deprived quintile were around 70% higher than the least deprived and were generally higher in the North of England. GP antibiotic prescribing rates were high for LRTI but lower for CAP (mostly due to immediate hospitalisation). This is the first study to provide long-term detailed incidence estimates of community-acquired LRTI and CAP in UK older individuals, taking person-time at risk into account. The summary incidence commonly presented for the ≥65 age group considerably underestimates LRTI/CAP rates, particularly among older individuals within this group. Our methodology and findings are likely to be highly relevant to health planners and researchers in other countries with aging populations.

Procalcitonin guidance to reduce antibiotic treatment of lower respiratory tract infection in children and adolescents (ProPAED): a randomized controlled trial

Background

Antibiotics are overused in children and adolescents with lower respiratory tract infection (LRTI). Serum-procalcitonin (PCT) can be used to guide treatment when bacterial infection is suspected. Its role in pediatric LRTI is unclear.

Methods

Between 01/2009 and 02/2010 we randomized previously healthy patients 1 month to 18 years old presenting with LRTI to the emergency departments of two pediatric hospitals in Switzerland to receive antibiotics either according to a PCT guidance algorithm established for adult LRTI or standard care clinical guidelines. In intention-to-treat analyses, antibiotic prescribing rate, duration of antibiotic treatment, and number of days with impairment of daily activities within 14 days of randomization were compared between the two groups.

Results

In total 337 children, mean age 3.8 years (range 0.1–18), were included. Antibiotic prescribing rates were not significantly different in PCT guided patients compared to controls (OR 1.26; 95% CI 0.81, 1.95). Mean duration of antibiotic exposure was reduced from 6.3 to 4.5 days under PCT guidance (−1.8 days; 95% CI −3.1, −0.5; P = 0.039) for all LRTI and from 9.1 to 5.7 days for pneumonia (−3.4 days 95% CI −4.9, −1.7; P<0.001). There was no apparent difference in impairment of daily activities between PCT guided and control patients.

Conclusion

PCT guidance reduced antibiotic exposure by reducing the duration of antibiotic treatment, while not affecting the antibiotic prescribing rate. The latter may be explained by the low baseline prescribing rate in Switzerland for pediatric LRTI and the choice of an inappropriately low PCT cut-off level for this population.

Trial Registration

Controlled-Trials.com ISRCTN17057980 ISRCTN17057980

Why some children hospitalized for pneumonia do not consult with a general practitioner before the day of hospitalization

BACKGROUND

Early consultation in primary care may provide an opportunity for early intervention in children developing pneumonia, but little is known about why some children do not consult a general practitioner (GP) before hospitalization.

OBJECTIVES

To identify differences between children who consulted a GP and children who did not consult a GP before the day of hospital presentation with pneumonia or empyema.

METHODS

Carers of children aged six months to 16 years presenting to hospital with pneumonia or empyema completed a questionnaire, with a subset participating in an interview to identify physical, organizational and psychological barriers to consultation. Responses from those who had consulted a GP before the day of hospital presentation were compared with those who had not on a range of medical, social and environmental variables.

RESULTS

Fifty seven (38%) of 151 participants had not consulted a GP before the day of hospital presentation. On multivariate analysis, illness duration ≥ 3 days (odds ratio [OR] 4.36, 95% confidence interval [CI]: 1.67-11.39), prior antibiotic use (OR: 10.35, 95% CI: 2.16-49.55) and home ownership (OR: 3.17, 95% CI: 1.07-9.37) were significantly associated with early GP consultation (P < 0.05). Interviews with 28 carers whose children had not seen a GP before the day of presentation revealed that most had not considered it and/or did not think their child's initial symptoms were serious or unusual; 11 (39.3%) had considered consulting a GP but reported barriers to access.

CONCLUSION

Lack of early GP consultation was strongly associated with rapid evolution of pneumonia.

A new simple primary care morbidity score predicted mortality and better explains between practice variations than the Charlson index

OBJECTIVES

Adjustment for morbidity is important to ensure fair comparison of outcomes between patient groups and health care providers. The Quality and Outcomes Framework (QOF) in UK primary care offers potential for developing a standardized morbidity score for low-risk populations.

STUDY DESIGN AND SETTING

Retrospective cohort study of 653,780 patients aged 60 years or older registered with 375 practices in 2008 in a large primary care database (The Health Improvement Network). Half the practices were randomly selected to derive a morbidity score predicting 1-year mortality; the others assessed predictive performance.

RESULTS

Nine chronic conditions were robust copredictors (hazard ratio = ≥1.2) of mortality independent of age and sex, producing high predictive discrimination (c-statistic = 0.82). An individual's QOF score explained more between practice variation in mortality than the Charlson index (46% vs. 32%). At practice level, mean QOF score was strongly correlated with practice standardized mortality ratios (r = 0.64), explaining more variation in practice death rates than the Charlson index.

CONCLUSION

A simple nine-item score derived from routine primary care recording provides a morbidity index highly predictive of mortality and between practice variation in older UK primary care populations. This has utility in research and health care outcome monitoring and can be easily implemented in other primary and ambulatory care settings.

Predictors for antibiotic prescribing in patients with exacerbations of COPD in general practice

BACKGROUND

The aim of this study was to describe the antibiotic prescribing rate in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), to analyse predictors for antibiotic prescribing and to explore the influence of the use C-reactive protein (CRP) rapid test.

METHODS

A cross-sectional study was carried out in January and February 2008 in primary care. General practitioners (GPs) from six countries (Denmark, Sweden, Lithuania, Russia, Spain and Argentina) registered all patients with AECOPD during a 3-week period. A multilevel logistic regression model was estimated using two hierarchical levels, (i) patients and (ii) physicians, and was used to analyse the association between antibiotic prescribing and potential predictors for antibiotic use: patients' age and gender, duration and symptoms and signs of exacerbations (fever, cough, dyspnoea, sputum volume and purulence) and the results of the CRP test.

RESULTS

A total of 617 GPs registered 1233 patients with AECOPD. A total of 970 patients (79%) were prescribed antibiotics, varying from 49% (Denmark) to 93% (Russia). The presence of purulent sputum was the strongest predictor for antibiotic treatment (odds ratio [OR] 8.7; 95% confidence interval [CI] 5.9-12.8). CRP determination was carried out mainly in Denmark and Sweden and its use was the strongest protective factor for antibiotic therapy (OR 0.3; 95% CI 0.2-0.6). GPs that used CRP testing weighted purulent sputum lower than GPs who did not use CRP testing. CRP values had a strong influence on the antibiotic prescribing rate.

CONCLUSIONS

Antibiotic treatment for AECOPD is very high. This study shows that GPs performing CRP rapid tests prescribe fewer antibiotics than those who do not.

Community-acquired pneumonia distinguished from influenza infection based on clinical signs and symptoms during a novel (swine) influenza A/H1N1 pandemic

AIMS

The numbers of patients with influenza-like illnesses increase during influenza outbreaks. A study was undertaken to distinguish community-acquired pneumonia (CAP) from influenza based on clinical signs and symptoms.

METHODS

This retrospective study investigated patients with positive results in the rapid influenza antigen test and those diagnosed with CAP during an influenza A/H1N1 pandemic. Significant factors for predicting risk for CAP within 48 hrs from onset and at diagnosis were selected by multiple regression analysis.

RESULTS

Within 48 hrs of onset and at diagnosis, age and coarse crackles significantly increased the risk of CAP whereas sick contact, sore throat, and rhinorrhoea significantly decreased the risk of CAP. Duration of illness, sputum, dyspnoea, chest pain, and coarse crackles also significantly increased the risk of CAP at diagnosis.

CONCLUSIONS

CAP differed somewhat from influenza even within 48 hrs of onset and the differences became even more evident thereafter.

Errors in Administrative-Reported Ventilator-Associated Pneumonia Rates: Are Never Events Really So?

Ventilator-associated pneumonia (VAP) is a common problem in an intensive care unit (ICU), although the incidence is not well established. This study aims to compare the VAP incidence as determined by the treating surgical intensivist with that detected by the hospital Infection Control Service (ICS). Trauma and surgical patients admitted to the surgical critical care service were prospectively evaluated for VAP during a 5-month time period. Collected data included the surgical intensivist's clinical VAP (SIS-VAP) assessment using Centers for Disease Control and Prevention (CDC) VAP criteria. As part of the hospital's VAP surveillance program, these patients’ medical records were also reviewed by the ICS for VAP (ICS-VAP) using the same CDC VAP criteria. All patients suspected of having VAP underwent bronchioalveolar lavage (BAL). The SIS-VAP and ICS-VAP were then compared with BAL-VAP. Three hundred twenty-nine patients were admitted to the ICU during the study period. One hundred thirty-three were intubated longer than 48 hours and comprised our study population. Sixty-two patients underwent BAL evaluation for the presence of VAP on 89 occasions. SIS-VAP was diagnosed in 38 (28.5%) patients. ICS-VAP was identified in 11 (8.3%) patients ( P < 0.001). The incidence of VAP by BAL criteria was 23.3 per cent. When compared with BAL, SIS-VAP had 61.3 per cent sensitivity and ICS-VAP had 29 per cent sensitivity. VAP rates reported by hospital administrative sources are significantly less accurate than physician-reported rates and dramatically underestimate the incidence of VAP. Proclaiming VAP as a never event for critically ill for surgical and trauma patients appears to be a fallacy.

Reducing uncertainty in managing respiratory tract infections in primary care

Respiratory tract infections (RTIs) remain the commonest reason for acute consultations in primary care in resource-rich countries. Their spectrum and severity has changed from the time that antibiotics were discovered, largely from improvements in the socioeconomic determinants of health as well as vaccination. The benefits from antibiotic treatment for common RTIs have been shown to be largely overstated. Nevertheless, serious infections do occur. Currently, no clinical features or diagnostic test, alone or in combination, adequately determine diagnosis, aetiology, prognosis, or response to treatment. This narrative review focuses on emerging evidence aimed at helping clinicians reduce and manage uncertainty in treating RTIs. Consultation rate and prescribing rate trends are described, evidence of increasing rates of complications are discussed, and studies and the association with antibiotic prescribing are examined. Methods of improving diagnosis and identifying those patients who are at increased risk of complications from RTIs, using clinical scoring systems, biomarkers, and point of care tests are also discussed. The evidence for alternative management options for RTIs are summarised and the methods for changing public and clinicians' beliefs about antibiotics, including ways in which we can improve clinician-patient communication skills for management of RTIs, are described.

Differences in the epidemiological characteristics and clinical outcomes of pandemic (H1N1) 2009 influenza, compared with seasonal influenza

BACKGROUND

There are limited data comparing the clinical presentations, comorbidities, and outcomes of patients with infections due to seasonal influenza with patients with infections due to pandemic (H1N1) 2009 influenza.

OBJECTIVE

To compare the epidemiological characteristics and outcomes of pandemic (H1N1) 2009 influenza with those of seasonal influenza.

METHODS

A cross-sectional study was conducted among patients who received diagnoses during emergency department and inpatient encounters at 2 affiliated academic medical centers in Philadelphia, Pennsylvania. Cases of seasonal influenza during the period November 1, 2005, through June 1, 2008, and cases of pandemic influenza during the period from May 1, 2009, through August 7, 2009, were identified retrospectively.

RESULTS

Forty-nine cases of pandemic influenza and 503 cases of seasonal influenza were identified. Patients with pandemic H1N1 were younger (median age, 29 years) than patients with seasonal influenza (median age, 59 years) (P<.001). More patients with pandemic H1N1 (35 [71%] of 49) were African American, compared with patients with seasonal influenza (267 [53%] of 503; P=.02). Several symptoms were more common among patients with pandemic influenza infections than among patients with seasonal influenza infections: cough (98% vs 83%; P=.007), myalgias (71% vs 46%; P=.001), and pleuritic chest pain (45% vs 15%; P<.001). Pregnancy was the only comorbidity that occurred significantly more often in the pandemic influenza group than in the seasonal influenza group (16% vs 1%; P<.001). There were no significant differences in frequencies of deaths of hospitalized patients, intensive care unit admission, or length of hospitalization between groups.

CONCLUSION

Other than pregnancy, there were few clinically important differences between infections due to seasonal influenza and those due to pandemic influenza. The greater rate of lower respiratory tract symptoms in pandemic cases might serve to differentiate pandemic influenza from seasonal influenza.

Selective decrease in consultations and antibiotic prescribing for acute respiratory tract infections in UK primary care up to 2006

BACKGROUND

The aim of this study was to estimate trends in primary care consultations and antibiotic prescribing for acute respiratory tract infections (RTIs) in the UK from 1997 to 2006.

METHODS

Data were analysed for 100,000 subjects registered with 78 family practices in the UK General Practice Research Database; the numbers of consultations for RTI and associated antibiotic prescriptions were enumerated.

RESULTS

The consultation rate for RTI declined in females from 442.2 per 1000 registered patients in 1997 to 330.9 in 2006, and in males from 318.5 to 249.0. The rate of consultations for colds, rhinitis and upper respiratory tract infection (URTI) declined by 4.2 (95% CI 2.3-6.1) per 1000 per year in females and by 3.6 (2.3-4.8) in males. The rate of antibiotic prescribing for RTI was higher in females and declined by 8.5 (2.0-15.1) per 1000 in females and 6.7 (2.7-10.8) in males. For colds, rhinitis and URTI, the proportion of consultations with antibiotics was prescribed declined by 1.7% per year in females and 1.8% in males.

CONCLUSIONS

Decreasing frequency of consultation and antibiotic prescription for colds, rhinitis and 'URTI' continues to drive a reduction in the rate of antibiotic utilization for RTIs.

Prescription of anti-influenza drugs for healthy adults: a systematic review and meta-analysis

In publicly funded health systems with finite resources, management decisions are based on assessments of clinical effectiveness and cost-effectiveness. The UK National Institute for Health and Clinical Excellence commissioned a systematic review to inform their 2009 update to guidance on the use of antiviral drugs for the treatment of influenza. We searched databases for studies of the use of neuraminidase inhibitors for the treatment of seasonal influenza. We present the results for healthy adults (ie, adults without known comorbidities) and people at-risk of influenza-related complications. There was an overall reduction in the median time to symptom alleviation in healthy adults by 0.57 days (95% CI -1.07 to -0.08; p=0.02; 2701 individuals) with zanamivir, and 0.55 days (95% CI -0.96 to -0.14; p=0.008; 1410 individuals) with oseltamivir. In those at risk, the median time to symptom alleviation was reduced by 0.98 days (95% CI -1.84 to -0.11; p=0.03; 1252 individuals) with zanamivir, and 0.74 days (95% CI -1.51 to 0.02; p=0.06; 1472 individuals) with oseltamivir. Little information was available on the incidence of complications. In view of the advantages and disadvantages of different management strategies for controlling seasonal influenza in healthy adults recommending the use of antiviral drugs for the treatment of people presenting with symptoms is unlikely to be the most appropriate course of action.