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PURPOSE: Patients with pneumonia often present to the emergency department and require prompt diagnosis and treatment. Clinical decision support systems for the diagnosis and management of pneumonia are commonly utilized in emergency departments to improve patient care. The purpose of this study is to investigate whether a deep learning model for detecting radiographic pneumonia and pleural effusions can improve functionality of a clinical decision support system for pneumonia management (ePNa) operating in 20 emergency departments. MATERIALS AND METHODS: In this retrospective cohort study, a dataset of 7,434 prior chest radiographic studies from 6,551 emergency department patients was used to develop and validate a deep learning model to identify radiographic pneumonia, pleural effusions, and evidence of multilobar pneumonia. Model performance was evaluated against three radiologists’ adjudicated interpretation and compared to performance of the natural language processing of radiology reports used by ePNa. RESULTS: The deep learning model achieved an area under the receiver operating characteristic curve of 0.833 (95% CI 0.795, 0.868) for detecting radiographic pneumonia, 0.939 (95% CI 0.911, 0.962) for detecting pleural effusions, and 0.847 (95% CI 0.800, 0.890) for identifying multilobar pneumonia. On all three tasks, the model achieved higher agreement with the adjudicated radiologist interpretation compared to ePNa. CONCLUSIONS: A deep learning model demonstrated higher agreement with radiologists than the ePNa clinical decision support system in detecting radiographic pneumonia and related findings. Incorporating deep learning models into pneumonia clinical decision support systems could enhance diagnostic performance and improve pneumonia management.

Pneumonia causes a significant burden of disease worldwide. Although all populations are at risk of pneumonia, those at extremes of age and those with immunosuppressive disorders, underlying respiratory disease, and critical illness are particularly vulnerable. Although clinical practice guidelines addressing the management and treatment of pneumonia exist, few of the supporting studies focus on the crucial contributions of the host in pneumonia pathogenesis and recovery. Such essential considerations include the host risk factors that lead to susceptibility to lung infections; biomarkers reflecting the host response and the means to pursue host-directed pneumonia therapy; systemic effects of pneumonia on the host; and long-term health outcomes after pneumonia. To address these gaps, the Pneumonia Working Group of the Assembly on Pulmonary Infection and Tuberculosis led a workshop held at the American Thoracic Society meeting in May 2018 with overarching objectives to foster attention, stimulate research, and promote funding for short-term and long-term investigations into the host contributions to pneumonia. The workshop involved participants from various disciplines with expertise in lung infection, pneumonia, sepsis, immunocompromised patients, translational biology, data science, genomics, systems biology, and clinical trials. This workshop report summarizes the presentations and discussions and important recommendations for future clinical pneumonia studies. These recommendations include establishing consensus disease and outcome definitions, improved phenotyping, development of clinical study networks, standardized data and biospecimen collection and protocols, and development of innovative trial designs.

Background Community-acquired pneumonia (CAP) guidelines have improved the treatment and outcomes of patients with CAP, primarily by standardization of initial empirical therapy. But current society-published guidelines exclude immunocompromised patients. Research Question There is no consensus regarding the initial treatment of immunocompromised patients with suspected CAP. Study Design and Methods This consensus document was created by a multidisciplinary panel of 45 physicians with experience in the treatment of CAP in immunocompromised patients. The Delphi survey methodology was used to reach consensus. Results The panel focused on 21 questions addressing initial management strategies. The panel achieved consensus in defining the population, site of care, likely pathogens, microbiologic workup, general principles of empirical therapy, and empirical therapy for specific pathogens. Interpretation This document offers general suggestions for the initial treatment of the immunocompromised patient who arrives at the hospital with pneumonia.

Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia. Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions. Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.

Rationale: Computerized severity assessment for community-acquired pneumonia could improve consistency and reduce clinician burden. Objectives: To develop and compare 30-day mortality-prediction mo...

Pneumonia continues to be a leading cause of hospitalization and mortality. Implementation of health information technology (HIT) can lead to cost savings and improved care. In this review, we examine the literature on the use of HIT in the management of community-acquired pneumonia. We also discuss barriers to adoption of technology in managing pneumonia, the reliability and quality of electronic health data in pneumonia research, how technology has assisted pneumonia diagnosis and outcomes research. The goal of using HIT is to develop and deploy generalizable, real-time, computerized clinical decision support integrated into usual pneumonia care. A friendly user interface that does not disrupt efficiency and demonstrates improved clinical outcomes should result in widespread adoption.

Guidelines recommend a switch from intravenous to oral antibiotics once patients who are hospitalized with pneumonia achieve clinical stability. However, little evidence guides the selection of an oral antibiotic for patients with health care-associated pneumonia, especially where no microbiological diagnosis is made.To compare outcomes between patients who were transitioned to broad- versus narrow-spectrum oral antibiotics after initially receiving broad-spectrum intravenous antibiotic coverage.We performed a secondary analysis of an existing database of adults with community-onset pneumonia admitted to seven Utah hospitals. We identified 220 inpatients with microbiology-negative health care-associated pneumonia from 2010 to 2012. After excluding inpatient deaths and treatment failures, 173 patients remained in which broad-spectrum intravenous antibiotics were transitioned to an oral regimen. We classified oral regimens as broad-spectrum (fluoroquinolone) versus narrow-spectrum (usually a β-lactam). We compared demographic and clinical characteristics between groups. Using a multivariable regression model, we adjusted outcomes by severity (electronically calculated CURB-65), comorbidity (Charlson Index), time to clinical stability, and length of intravenous therapy.Age, severity, comorbidity, length of intravenous therapy, and clinical response were similar between the two groups. Observed 30-day readmission (11.9 vs. 21.4%; P = 0.26) and 30-day all-cause mortality (2.3 vs. 5.3%; P = 0.68) were also similar between the narrow and broad oral antibiotic groups. In multivariable analysis, we found no statistically significant differences for adjusted odds of 30-day readmission (adjusted odds ratio, 0.56; 95% confidence interval, 0.06-5.2; P = 0.61) or 30-day all-cause mortality (adjusted odds ratio, 0.55; 95% confidence interval, 0.19-1.6; P = 0.26) between narrow and broad oral antibiotic groups.On the basis of analysis of a limited number of patients observed retrospectively, our findings suggest that it may be safe to switch from broad-spectrum intravenous antibiotic coverage to a narrow-spectrum oral antibiotic once clinical stability is achieved for hospitalized patients with health care-associated pneumonia when no microbiological diagnosis is made. A larger retrospective study with propensity matching or regression-adjusted test of equivalence or ideally a prospective comparative effectiveness study will be necessary to confirm our observations.

Successful treatment of life-threatening community-acquired pneumonia requires appropriate empiric antibiotic coverage. But using conventional diagnostic techniques, a microbiological diagnosis is often not achieved. The diagnostic usefulness of tracheal aspirate at the time of intubation in patients with severe pneumonia has not been well studied.The purpose of this study was to evaluate the use of tracheal aspirate culture in identifying pneumonia pathogens.We identified all patients older than 18 years of age with International Classification of Disease, Ninth Revision codes and radiographic evidence of pneumonia seen in the emergency departments at 2 university-affiliated Utah hospitals from December 2009 to November 2010 and from December 2011 to November 2012. Patients intubated within 24 hours of arrival were then identified electronically. Postintubation orders instructed respiratory therapists to obtain tracheal aspirate for culture. All culture results were reviewed individually and defined as positive if a pneumonia pathogen was identified. Results of other microbiology studies were obtained from the electronic medical record.Of 2,011 patients with pneumonia, 94 were intubated and 84 had a tracheal aspirate obtained. Of these 84 patients, 47 (56%) had a pulmonary pathogen identified by tracheal aspirate culture, 80 also had blood cultures, and 71 underwent Pneumococcal and Legionella urinary antigen testing. A microbiological diagnosis was made in 55 patients (65.5%) by any diagnostic method. In 39% of patients (32 of 82), the tracheal aspirate culture was the only positive test, resulting in a unique microbiological diagnosis in patients who would have otherwise been classified as "culture negative."Tracheal aspirate cultures obtained as part of routine care identified a plausible pneumonia pathogen in more than one-half of emergency department adult patients with severe pneumonia requiring intubation. Tracheal aspirate culture offers important additive diagnostic value to other routine tests.

QuestionIs broad-spectrum antibiotic use associated with poor outcomes in community-onset pneumonia after adjusting for confounders?MethodsWe performed a retrospective, observational cohort study of 1995 adults with pneumonia admitted from four US hospital emergency departments. We used multivariable regressions to investigate the effect of broad-spectrum antibiotics on 30-day mortality, length of stay, cost and Clostridioides difficile infection (CDI). To address indication bias, we developed a propensity score using multilevel (individual provider) generalised linear mixed models to perform inverse-probability of treatment weighting (IPTW) to estimate the average treatment effect in the treated. We also manually reviewed a sample of mortality cases for antibiotic-associated adverse events.Results39.7% of patients received broad-spectrum antibiotics, but drug-resistant pathogens were recovered in only 3%. Broad-spectrum antibiotics were associated with increased mortality in both the unweighted multivariable model (OR 3.8, 95% CI 2.5–5.9; pConclusionBroad-spectrum antibiotics appear to be associated with increased mortality and other poor outcomes in community-onset pneumonia.

To guide rational antibiotic selection in community-onset pneumonia, we previously derived and validated a novel prediction tool, the Drug-Resistance in Pneumonia (DRIP) score. In 2015, the DRIP score was integrated into an existing electronic pneumonia clinical decision support tool (ePNa).We conducted a quasi-experimental, pre-post implementation study of ePNa with DRIP score (2015) vs ePNa with health-care-associated pneumonia (HCAP) logic (2012) in ED patients admitted with community-onset pneumonia to four US hospitals. Using generalized linear models, we used the difference-in-differences method to estimate the average treatment effect on the treated with respect to ePNa with DRIP score on broad-spectrum antibiotic use, mortality, hospital stay, and cost, adjusting for available patient-level confounders.We analyzed 2,169 adult admissions: 1,122 in 2012 and 1,047 in 2015. A drug-resistant pathogen was recovered in 3.2% of patients in 2012 and 2.8% in 2015; inadequate initial empirical antibiotics were prescribed in 1.1% and 0.5%, respectively (P = .12). A broad-spectrum antibiotic was administered in 40.1% of admissions in 2012 and 33.0% in 2015 (P .001). Vancomycin days of therapy per 1,000 patient days in 2012 were 287.3 compared with 238.8 in 2015 (P .001). In the primary analysis, the average treatment effect among patients using the DRIP score was a reduction in broad-spectrum antibiotic use (OR, 0.62; 95% CI, 0.39-0.98; P = .039). However, the average effects for ePNa with DRIP on mortality, length of stay, and cost were not statistically significant.Electronic calculation of the DRIP score was more effective than HCAP criteria for guiding appropriate broad-spectrum antibiotic use in community-onset pneumonia.

Background and objective Assessment of oxygenation in patients with community-acquired pneumonia is critical for treatment. The accuracy of percutaneous oxygen saturation (SpO2) determined by pulse oximetry is uncertain, and it has limited value in patients receiving supplemental oxygen. We hypothesized that calculation of partial arterial oxygen concentration/inspired oxygen faction (PaO2/FiO2) from SpO2 by the Ellis or Rice equations might adequately correlate with PaO2/FiO2 measured by arterial blood gases. Methods We studied 1004 patients with pneumonia in the emergency department with simultaneous measurement of SpO2 and PaO2 from two cohorts from Valencia, Spain and Utah, USA. We compared SpO2 with measured SaO2, compared the equations' accuracy in calculating PaO2/FiO2 and determined how often patients would be misclassified at clinically important thresholds. We compared estimated PaO2/FiO2 to measured PaO2/FiO2 using the Spearman correlation. Results Pairwise correlation of SpO2 with SaO2 was moderate (rho = 0.66; P

The relationship between air pollution and pneumonia is poorly understood.To examine relationships between short-term air pollution exposure and number and severity of pneumonia cases along the Wasatch Front in Utah, a region with periodic high levels of outdoor air pollution.We applied time-stratified case-crossover analyses with distributed lag to patients presenting to seven emergency departments with pneumonia over a 2-year period. We compared levels of particulate matter less than or equal to 2.5 μm in aerodynamic diameter, nitrogen dioxide, and ozone at patient residences with emergency department cases, hospitalizations, objectively defined severe pneumonia, and mortality. We calculated direct cost impacts of particulate matter less than or equal to 2.5 μm in aerodynamic diameter reduction.We evaluated 4,336 pneumonia cases in seven hospitals. Among adults aged 65 years and older, we found consistently positive associations between particulate matter less than or equal to 2.5 μm in aerodynamic diameter within 6 days of presentation and instances of pneumonia (Lag Day 1 adjusted odds ratio, 1.35 per 10 μg/mAmong older adults, short-term ambient particulate matter less than or equal to 2.5 μm in aerodynamic diameter exposure is associated with more emergency department visits and hospitalizations for pneumonia, severe pneumonia, increased mortality, and increased healthcare costs. Nitrogen dioxide and ozone modestly increase pneumonia risk and illness severity.

Community-acquired pneumonia (CAP) combined with influenza is the eighth leading cause of death in the United States. This article examines the literature to understand and describe whether technology implementation has impacted the outcomes of patients with CAP. We conducted an electronic search of PubMed and scanned references of articles meeting inclusion criteria. Twenty-six articles were included in this review. We surveyed this literature for answers to the following questions: Can technology be used to improve quality of care and guideline compliance in CAP? How can we overcome the behavioral bottleneck that prevents adoption of computerized decision support systems? How reliable are our data in the era of electronic medical records? What are the risks associated with technology implementation? No articles demonstrated that technology implementation improves outcomes in the care of patients with CAP.

Accurate severity assessment is crucial to the initial management of community-acquired pneumonia (CAP). The CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years) score contains data that are entered routinely in electronic medical records and are, thus, electronically calculable. The aim of this study was to determine whether an electronically generated severity estimate using CURB-65 elements as continuous and weighted variables better predicts 30-day mortality than the traditional CURB-65.In a retrospective cohort study at a US university-affiliated community teaching hospital, we identified 2,069 patients aged 18 years or older with CAP confirmed by radiographic findings in the ED. CURB-65 elements were extracted from the electronic medical record, and 30-day mortality was identified with the Utah Population Database. Performance of a severity prediction model using continuous and weighted CURB-65 variables was compared with the traditional CURB-65 in the US derivation population and validated in the original 1,048 patients from the CURB-65 international derivation study.The traditional, binary CURB-65 score predicted mortality in the US cohort with an area under the curve (AUC) of 0.82. Our severity prediction model generated from continuous, weighted CURB-65 elements was superior to the traditional CURB-65, with an out-of-bag AUC of 0.86 (P.001). This finding was validated in the international database, with an AUC of 0.85 for the electronic model compared with 0.80 for the traditional CURB-65 (P = .01).Using CURB-65 elements as continuous and weighted data improved prediction of 30-day mortality and could be used as a real-time, electronic decision support tool or to adjust outcomes by severity when comparing processes of care.

Patients with acute lung injury have impaired function of the lung surfactant system. Prior clinical trials have shown that treatment with exogenous recombinant surfactant protein C (rSP-C)-based surfactant results in improvement in blood oxygenation and have suggested that treatment of patients with severe direct lung injury may decrease mortality.Determine the clinical benefit of administering an rSP-C-based synthetic surfactant to patients with severe direct lung injury due to pneumonia or aspiration.A prospective randomized blinded study was performed at 161 centers in 22 countries. Patients were randomly allocated to receive usual care plus up to eight doses of rSP-C surfactant administered over 96 hours (n = 419) or only usual care (n = 424).Mortality to 28 days after treatment, the requirement for mechanical ventilation, and the number of nonpulmonary organ failure-free days were not different between study groups. In contrast to prior studies, there was no improvement in oxygenation in patients receiving surfactant compared with the usual care group. Investigation of the possible reasons underlying the lack of efficacy suggested a partial inactivation of rSP-C surfactant caused by a step of the resuspension process that was introduced with this study.In this study, rSP-C-based surfactant was of no clinical benefit to patients with severe direct lung injury. The unexpected lack of improvement in oxygenation, coupled with the results of in vitro tests, suggest that the administered suspension may have had insufficient surface activity to achieve clinical benefit.

Novel 2009 influenza A(H1N1) infection has significantly affected ICUs. We sought to characterize our region's clinical findings and demographic associations with ICU admission due to novel A(H1N1).We conducted an observational study from May 19, 2009, to June 30, 2009, of descriptive clinical course, inpatient mortality, financial data, and demographic characteristics of an ICU cohort. A case-control study was used to compare the ICU cohort to Salt Lake County residents.The ICU cohort of 47 influenza patients had a median age of 34 years, Acute Physiology and Chronic Health Evaluation II score of 21, and BMI of 35 kg/m2. Mortality was 17% (8/47). All eight deaths occurred among the 64% of patients (n = 30) with ARDS, 26 (87%) of whom also developed multiorgan failure. Compared with the Salt Lake County population, patients with novel A(H1N1) were more likely to be obese (22% vs 74%; P.001), medically uninsured (14% vs 45%; P.001), and Hispanic (13% vs 23%; P.01) or Pacific Islander (1% vs 26%; P.001). Observed ICU admissions were 15-fold greater than expected for those with BMIor = 40 kg/m2 (standardized morbidity ratio 15.8, 95% CI, 8.3-23.4) and 1.5-fold greater than expected among those with BMI of 30 to 39 kg/m(2) for age-adjusted and sex-adjusted rates for Salt Lake County.Severe ARDS with multiorgan dysfunction in the absence of bacterial infection was a common clinical presentation. In this cohort, young nonwhites without medical insurance were disproportionately likely to require ICU care. Obese patients were particularly susceptible to critical illness due to novel A(H1N1) infection.

Pleural effusions are present in 15% to 44% of hospitalized patients with pneumonia. It is unknown whether effusions at first presentation to the ED influence outcomes or should be managed differently.We studied patients in seven hospital EDs with International Statistical Classification of Disease and Health Related Problems-Version 9 codes for pneumonia, or empyema, sepsis, or respiratory failure with secondary pneumonia. Patients with no confirmatory findings on chest imaging were excluded. Pleural effusions were identified with the use of radiographic imaging.Over 24 months, 4,771 of 458,837 adult ED patients fulfilled entry criteria. Among the 690 (14.5%) patients with pleural effusions, their median age was 68 years, and 46% were male. Patients with higher Elixhauser comorbidity scores (OR, 1.13 [95% CI, 1.09-1.18]; P .001), brain natriuretic peptide levels (OR, 1.20 [95% CI, 1.12-1.28]; P .001), bilirubin levels (OR, 1.07 [95% CI, 1.00-1.15]; P = .04), and age (OR, 1.15 [95% CI, 1.09-1.21]; P .001) were more likely to have parapneumonic effusions. In patients without effusion, electronic version of CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years accurately predicted mortality (4.7% predicted vs 5.0% actual). However, eCURB underestimated mortality in those with effusions (predicted 7.0% vs actual 14.0%; P .001). Patients with effusions were more likely to be admitted (77% vs 57%; P .001) and had a longer hospital stay (median, 2.8 vs 1.3 days; P .001). After severity adjustment, the likelihood of 30-day mortality was greater among patients with effusions (OR, 2.6 [CI, 2.0-3.5]; P .001), and hospital stay was disproportionately longer (coefficient, 0.22 [CI, 0.14-0.29]; P .001).Patients with pneumonia and pleural effusions at ED presentation in this study were more likely to die, be admitted, and had longer hospital stays. Why parapneumonic effusions are associated with adverse outcomes, and whether different management of these patients might improve outcome, needs urgent investigation.

Background We previously reported decreased mortality following implementation of a community-acquired pneumonia guideline derived from specialty society recommendations. However, patients with respiratory failure and sepsis from pneumonia were not included, adjustment for comorbidities was limited, and no guideline compliance data were available. We also questioned whether decreased mortality continued after 1997. Methods We utilized Utah data from the Centers for Medicare and Medicaid from 1993 to 2003 to determine if pneumonia guideline implementation was associated with 30-day all-cause mortality, length of hospital stay, and readmission rate. We adjusted outcomes by age, gender, Deyo comorbidity score, prior hospitalizations, and race. Guideline compliance was measured by initial default guideline antibiotic administration. We included patients ≥ 66 years old with primary International Classification of Diseases, Ninth Revision, Clinical Modification codes 480.0–483.9, 485.0–486.9, 487.0, 507.0 or 518.81, and 038.x with secondary code pneumonia. We excluded patients with prior hospitalization within 10 days, patients with HIV infection or transplant recipients, and patients not treated by physicians closely affiliated with study hospitals. Results Mean (± SD) age of 17,728 pneumonia patients admitted to the hospital was 72.3 ± 12.0 years, 55.2% were female, and 96.0% were white. Within Intermountain Healthcare hospitals, a 1-SD increase (10%) in guideline compliance (range, 61 to 100%) was associated with mortality odds ratio (OR) of 0.92 (95% confidence interval[CI], 0.87 to 0.98; p = 0.007). Mortality OR at 16 Intermountain Healthcare hospitals was 0.89 (95% CI, 0.82 to 0.97; p = 0.007) compared with 19 other Utah hospitals. This mortality difference corresponds to approximately 20 lives saved yearly. The readmission rate was also lower. Conclusion Improved clinical outcomes were associated with pneumonia guideline utilization.

A previously healthy 28-yr-old Caucasian female presented to the emergency department with a 1-week history of generalised body swelling that was followed by pleuritic chest pain radiating to the patient’s back. She had mild shortness of breath, cough and palpitations, but no fever, chills, nausea, vomiting or diarrhoea. No medications were taken except oral contraceptives. She denied any history of tobacco or alcohol use, recent travel or sick contacts. The patient’s vital signs were as follows: 1) blood pressure 135/94 mmHg; 2) body temperature 39.4°C; 3) respiratory rate 16 breaths·min-1; 4) pulse 105 beats·min-1; and 5) oxygen saturation 95%, while breathing room air. Her physical examination was remarkable for decreased breath sounds diffuse with minimal crackles, as well as facial swelling and pitting oedema of the lower extremities. Pertinent laboratory results of the blood tests performed on admission are shown in table 1⇓. View this table: Table 1— Laboratory results of the blood tests After significant respiratory distress, requiring noninvasive positive pressure ventilation, the patient was admitted to the intensive care unit and was started empirically on i.v. ceftriaxone, azithromycin and furosamide. Over the next few days, she remained febrile with worsening hypoxaemia. Her white blood cell count dropped to 2.2×109 cells·L-1 with a haemoglobin level of 90 g·L-1 and platelet count of 82×109 cells·L-1. …

Background We evaluated our previously derived admission criteria for agreement with physician decisions and outpatient failure among patients presenting to emergency departments (EDs) with pneumonia. Methods Among patients presenting to seven Intermountain EDs in the urban region of Utah with pneumonia December 1 2009-December 1 2010, we measured hospital admission rates and outpatient failure, defined as either 7-day secondary hospitalization or death in 30 days for patients initially discharged home from the ED. We measured our admission criteria’s ability to predict hospital admission and its hypothetical rates of admission and outpatient failure with strict adherence to the criteria. We compared our admission criteria to other electronically calculable criteria, CURB-65 and A-DROP. Results In 2,308 patients, admission rate was 57%, 30-day mortality 6.1%, 7-day secondary hospitalization 5.8%, and outpatient failure rate 6.4%. Our admission criteria predicted hospital admission with an AUC of 0.77, compared to 0.73 for CURB-65 ≥ 2 and 0.78 for A-DROP≥ 2. Hypothetical 100% concordance with our admission criteria decreased the hospitalization rate to 52% and reduced the outpatient failure rate to 3.9%, slightly better than A-DROP ≥ 2 (54% and 4.3%) and CURB-65 ≥ 2 (49% and 5.1%). Conclusions Our admission criteria agreed acceptably with overall observed admission decisions for patients presenting to EDs with pneumonia, but may safely reduce hospital admission rates and increase recognition of patients at risk for outpatient failure compared to CURB-65 ≥ 2 or A-DROP ≥ 2.

Background Clinical management of community-acquired pneumonia (CAP) is increasingly complicated by antibiotic resistance. CAP due to pathogens resistant to guideline-recommended drugs (CAP-DRP) has increased. 2005 ATS/IDSA guidelines introduced a new category, healthcare-associated pneumonia (HCAP), and recommend extended-spectrum antibiotic treatment for patients meeting HCAP criteria. However, the predictive value of the HCAP model is limited and data suggest that outcomes are not improved using HCAP guideline-concordant therapy. Better methods to predict risk of CAP-DRP are needed. Methods We reviewed currently published literature on the performance status of HCAP as a predictive tool and studies describing additional risk factors for CAP-DRP. We also summarize the performance characteristics of the currently published alternative clinical prediction scores and compare them to that of the HCAP model. Results In addition to the five risk factors incorporated in HCAP, at least 13 other factors have been identified. The independent predictive value of any single factor is low, but accumulating factors results in increased risk of CAP-DRP. The performance characteristics of 9 clinical prediction scores are reviewed. Nearly all of the scores outperformed HCAP in their study populations. However, no single model has yet demonstrated adequate specificity to minimize unnecessary antibiotic use, while retaining sufficient sensitivity to prevent inadequate initial empiric antibiotic therapy when validated across a wide range of CAP-DRP prevalence. Conclusions Additional development and validation of prediction scores based upon more refined risk factors for CAP-DRP is needed. Once an accurate, adequately validated prediction score is available, an interventional trial will be needed to determine clinical impact.

Specialty societies have developed practice guidelines for the treatment of community-acquired pneumonia (CAP). To aid in adapting specialty recommendations for a pneumonia practice guideline at Intermountain Health Care, we investigated which physicians care for pneumonia patients in Utah. We wanted to understand who provides pneumonia care so as to appropriately target the guideline and design tools for implementation.Retrospective observational study.Inpatient and outpatient multicenter.The study population comprised 13,919 (16,420 episodes of pneumonia) Utah resident Medicare beneficiariesor = 65 years of age who had CAP. Nursing home residents were excluded.We used Health Care Financing Administration billing records from 1993 through 1995 to identify the physicians involved in the care of pneumonia patients by self-designated specialty. We linked patterns of physician involvement to age, sex, residential zip code, 30-day mortality rate, and whether or not the patient was hospitalized.The involvement of a pneumonia specialist was limited to 11.7% of episodes, with involvement of a pulmonary specialist in 10.6%, an infectious disease (ID) specialist in 0.9%, and the involvement of both specialties in 0.2% of episodes. Greater specialty involvement was observed in episodes resulting in pneumonia hospitalization (20.0% vs 8.6%, respectively; p0.0001), death (20.5% vs 11.2%, respectively; p0.0001), and episodes among patients with urban county residential zip codes (13.7% vs 7.5%, respectively; p0.0001).Most episodes of pneumonia, including those with serious consequences, are treated by primary care physicians with little or no involvement from pulmonary or ID specialists. It is not known whether greater or lesser specialty physician involvement would change pneumonia costs or clinical outcomes.

It has been estimated that between 485,000 27 and 1 million 31 patients each year are hospitalized in the United States for treatment of communityacquired pneumonia. The costs of hospitalizing an individual patient exceed the costs of outpatient care by a factor of 15. 5 A recent estimate of total cost of care for pneumonia in the United States was $8 billion, of which 90% was related to inpatient costs. 30 Some hospital systems have achieved duration of stays of 4 days in uncomplicated pneumonia patients 34,35,37 but, for others, admitting a patient to the hospital can result in a prolonged hospitalization, averaging 9 days. 36 Pneumonia is the sixth leading cause of death overall, 29 and severely ill patients require intensive care admission. Even with intensive care, mortality averaged 36.5% among several series. 18 Inappropriate attempts to treat ill pneumonia patients at home could increase the rate of complications and mortality. The majority of pneumonia patients are treated as outpatients (77% by one estimate 19 ), however, and mortality in outpatient cohorts is low. The determination of whether or not a patient with community-acquired pneumonia can be treated as an outpatient or requires hospitalization is therefore important. Treating less ill pneumonia patients at home also has noneconomic rationales. A study in which 484 outpatients were matched for severity with 265 inpatients demonstrated that the outpatients experienced a more rapid resumption of normal activities. 17 Mortality was low in both groups (none for outpatients, 1.5% for inpatients). Admitting patients to a hospital decreases their activity level and places them at risk for thromboembolic disease. Additional hospital-related complications include catheter-related infections and exposure to resistant bacteria. Furthermore, Coley et al 7 demonstrated that 80% of patients at low risk for mortality from community-acquired pneumonia prefer outpatient treatment. Among hospitalized patients in this study, 60% indicated that they would have preferred ambulatory-based care. Site-of-care decisions were made solely by the medical practitioner in 69% of cases, however, according to a survey of the patients. Only 11% of patients recalled being asked by their physician whether they preferred home versus hospital treatment. The determination of whether or not a patient with community-acquired pneumonia requires hospital admission therefore influences clinical outcomes and patient satisfaction. Investigators have demonstrated considerable variation in hospital admission rates for patients with community-acquired pneumonia across geographic regions. Wennberg et al 38 reviewed hospital bed use for a number of medical conditions in Boston and New Haven hospitals. Based on the number of discharges per capita, Boston physicians were 1.33 times more likely to treat patients with simple pneumonia as inpatients. Similar data have been reported among different hospitals in Maine and Michigan, with some hospitals having more than double the rate of admission per capita than neighboring facilities. 28 Fine et al 16 investigated reasons for variation in the admission decision for community-acquired pneumonia patients as part of the Pneumonia Outcome Research Team (PORT) study. Practitioners making the initial site-of-care decision estimated that 5% of outpatients and 41% of inpatients had a 30-day risk of death greater than 5%. Practitioner-estimated risk of mortality greater than 5% had a strong, independent association with hospitalization, despite the fact that all patients in this study had a predicted probability of death of less than 4%. Additionally, hypoxemia, inability to maintain oral intake, and lack of patient home care support were strongly associated with hospitalization. Practitioners rated the clinical appearance of being "very sick" as important, although the method of assessing this characteristic is uncertain, and interobserver agreement is likely poor. Physician factors associated with hospitalization included the patient having been seen by a medical trainee or by an emergency department physician. Because of variability in determining the need for admission in community-acquired pneumonia, several prognostic scoring and outcome assessment tools have been developed. They are intended to provide support for the hospitalization decision by giving practitioners an objective method of assessing risk of adverse outcomes in patients with pneumonia. The hypothesis is that objective risk stratification will reduce physician uncertainty regarding prognosis, and improve admission decision making.

The impact of a new therapy that includes pressure-controlled inverse ratio ventilation followed by extracorporeal CO2 removal on the survival of patients with severe ARDS was evaluated in a randomized controlled clinical trial. Computerized protocols generated around-the-clock instructions for management of arterial oxygenation to assure equivalent intensity of care for patients randomized to the new therapy limb and those randomized to the control, mechanical ventilation limb. We randomized 40 patients with severe ARDS who met the ECMO entry criteria. The main outcome measure was survival at 30 days after randomization. Survival was not significantly different in the 19 mechanical ventilation (42%) and 21 new therapy (extracorporeal) (33%) patients (p = 0.8). All deaths occurred within 30 days of randomization. Overall patient survival was 38% (15 of 40) and was about four times that expected from historical data (p = 0.0002). Extracorporeal treatment group survival was not significantly different from other published survival rates after extracorporeal CO2 removal. Mechanical ventilation patient group survival was significantly higher than the 12% derived from published data (p = 0.0001). Protocols controlled care 86% of the time. Average PaO2 was 59 mm Hg in both treatment groups. Intensity of care required to maintain arterial oxygenation was similar in both groups (2.6 and 2.6 PEEP changes/day; 4.3 and 5.0 FIO2 changes/day). We conclude that there was no significant difference in survival between the mechanical ventilation and the extracorporeal CO2 removal groups. We do not recommend extracorporeal support as a therapy for ARDS. Extracorporeal support for ARDS should be restricted to controlled clinical trials.

Pneumonia is an important clinical and public health problem. Identification and prediction of severe pneumonia are significant concerns. Attempts to define severe pneumonia should recognize that different purposes are served by different definitions; no single definition meets all needs. At present, several prediction models have been proposed or validated. Biomarkers are not yet ready for routine use. The authors recommend careful consideration of the implications of any given definition of pneumonia severity. Outcome studies are needed to integrate human and health care system factors with the application of pneumonia severity definitions.

Study objectives Considerable variation exists in hospital admission rates for patients with community-acquired pneumonia. Logic to determine need for admission has been proposed by several authors. We compared Intermountain Health Care pneumonia guideline recommendations for inpatient vs outpatient care with actual physician decision making and clinical outcomes before vs after implementation. A secondary objective was to determine whether the pneumonia severity index predicts need for admission in this population. Design Prospective study after implementation vs historic controls. Setting Four ambulatory, urgent-care facilities. Patients Four hundred sixty-three immunocompetent adults with radiographically confirmed community-acquired pneumonia. Intervention A pneumonia practice guideline including decision support logic was implemented for a 12-month period. Measurements and results After implementation, physicians used the pneumonia guideline form in 90% of cases. The percentage of patients admitted within 30 days decreased from 13.6% to 6.4% (p = 0.01). Only five patients before (2.5%) and three patients after (1.1%, p=0.3) guideline implementation required subsequent hospital admission within 30 days after initial outpatient treatment. Only two deaths occurred in the study cohort, both outpatients before implementation. The positive predictive value was 14.4%, and the negative predictive value for admission was 98.8% after guideline implementation. Guideline recommendation for admission was more likely to be followed in patients with more risk factors and hypoxemia. Conclusions Decreased admission rate was observed after implementation of admission decision support in combination with specific recommendations for outpatient antibiotic therapy. Favorable outpatient outcomes suggest that implementation of decision support was safe.

Oxygen (O2) has been reported to improve exercise tolerance in some patients with chronic obstructive pulmonary disease (COPD) despite only mild resting hypoxemia (PaO2 greater than 60 mm Hg). To confirm these prior studies and evaluate potential mechanisms of benefit, we measured dyspnea scores by numeric rating scale during cycle ergometry endurance testing and correlated the severity of dyspnea with right ventricular systolic pressure (RVSP) measured by Doppler echocardiography during a separate supine incremental exercise test. Both sets of exercise were performed according to a randomized double-blind crossover protocol in which patients breathed compressed air or 40% O2. We studied 12 patients with severe COPD (FEV1 0.89 +/- 0.09 L [mean +/- SEM], FEV1/FVC 37 +/- 2%, DLCO 9.8 +/- 1.5 ml/min/mm Hg[47% of predicted], PaO2 71 +/- 2.6 mm Hg). With endurance testing on compressed air, PaO2 did not change significantly in the group as whole (postexercise PaO2 63 +/- 5.1 mm Hg, p = NS), but did fall to less than 55 mm Hg in four patients from this group. Duration of exercise increased on 40% O2 from 10.3 +/- 1.6 to 14.2 +/- 1.5 min (p = 0.005), and the rise in dyspnea scores was delayed. Oxygen delayed the rise in RVSP with incremental exercise in all patients and lowered the mean RVSP at maximum exercise from 71 +/- 8 to 64 +/- 7 mm Hg (p less than 0.03). Improvement in duration of exercise correlated with decrease in dyspnea (r2 = 0.66, p = 0.001) but not with decreases in heart rate, minute ventilation, or RVSP.(ABSTRACT TRUNCATED AT 250 WORDS)

We cultured bronchoalveolar lavage fluid for the human immunodeficiency virus (HIV) from 23 consecutive patients with acquired immunodeficiency syndrome (AIDS) and pulmonary symptoms. We also included a nonconsecutive AIDS patient with recent worsening of respiratory symptoms who had had lymphocytic interstitial pneumonitis (LIP) diagnosed six months earlier. Infectious HIV was present in the cellular fraction from two of the 23 consecutive patients and in the patient with LIP. No virus was isolated from the cell-free portion of the centrifuged fluids. The patients from whom HIV was cultured were not distinguishable from other patients by clinical, radiographic, or laboratory data, and their subsequent course did not appear to differ. One patient with a positive HIV culture had organizing pneumonia without evidence of LIP at autopsy three weeks after lavage. This study demonstrates that HIV can be cultured from cells obtained by bronchoalveolar lavage and suggests that its presence is not associated with a single specific pulmonary histologic pattern.

Percutaneous drainage of an infected bulla was performed under fluoroscopy in a patient who was receiving positive pressure ventilation. The procedure was without complications, and the patient was later weaned from mechanical ventilation.

A 21-year-old man developed the adult respiratory distress syndrome (ARDS) within five hours of receiving antilymphocyte globulin. No other identifiable cause of ARDS was present. The mechanism for development of acute lung injury is unknown, but may be related either to direct lung cytotoxicity or to complement-mediated leukocyte and platelet destruction with secondary lung injury from inflammatory mediators.