Given the dramatic advances in antimicrobials since penicillin was introduced, why has the mortality rate associated with community-acquired pneumonia (CAP) remained essentially unchanged?
Given the dramatic advances in antimicrobials since penicillin was introduced, why has the mortality rate associated with community-acquired pneumonia (CAP) remained essentially unchanged? Inadequate application of practice guidelines may be the chief reason, according to a committee from the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS).1 The committee bases its assertion on evidence showing that sensible application of guidelines for the diagnosis and management of CAP can reduce associated mortality and hospitalizations.2-5
Slavish adherence to guidelines is not the goal. Rather, the committee strongly recommends that communities adapt the guidelines--newly revised jointly by the IDSA and the ATS--to reflect local circumstances.1
A common feature of the studies analyzed by the committee was a comprehensive process of care encompassing several elements, such as objective criteria for admission, assessment of oxygenation, diagnostic testing, initiation of antibiotics, and follow-up evaluation. Local application of guidelines need not include all these elements, but it should be appropriately comprehensive for a given community. Local guidelines should aim to improve specific outcomes, and outcome parameters should be tracked over time to determine effectiveness.
DETERMINING THE SEVERITY OF ILLNESS
As the diagnosis of CAP is being confirmed, assess the condition of the patient to determine the optimal site of medical care.
Use objective measures. The use of objective admission criteria helps identify patients who require hospitalization and reduce the number of inappropriate admissions. The committee favors either of 2 scoring systems: CURB-656 or Pneumonia Severity Index (PSI).7 One system has not been proved more accurate than the other.
CURB-65 uses the following criteria to assess the patient's severity of illness: confusion; uremia with blood urea nitrogen (BUN) level of 20 mg/dL or higher; respiration rate of 30 or more breaths per minute; systolic blood pressure lower than 90 mm Hg or diastolic blood pressure 60 mm Hg or lower; and age 65 or older.6 A person who meets only 1 (or none) of these criteria can be treated as an outpatient. The presence of 2 factors supports a decision for hospitalization, and 3 or more could warrant admission to the ICU. (If assessment occurs in the office setting, the BUN measurement may be omitted.8)
The PSI predicts the risk of death and is calculated with values obtained from several physical findings and laboratory measurements.7 Five levels of risk are possible. Patients at level I or II may be treated as outpatients; those at level III require closer observation, perhaps with brief hospitalization; and those at levels IV and V require inpatient treatment.
Temper scoring results with clinical judgment. The committee warns that "sole reliance on a score for the hospital admission decision is unsafe."1 Factors disregarded in objective assessments may nevertheless influence a decision on how and where to treat a patient. For instance, even if an objective score is low, a decision to admit the patient might be made because of pneumonia complications, exacerbation of underlying disease, inadequate outpatient support, a patient's inability to take oral medication, or a concern that several of the measured risk factors are hovering at the threshold.
If your perception of a patient's condition differs from what is suggested by results of the CURB-65 or PSI, consider repeating the measures over several hours to yield a dynamic and more accurate objective assessment.
ICU admission. Either of 2 major criteria dictates ICU admission: septic shock requiring vasopressors and acute respiratory failure requiring intubation and mechanical ventilation. Patients who do not exhibit septic shock or respiratory failure may still qualify for ICU admission. Three or more minor criteria appearing together indicate severe CAP. The last 3 items in the following list were newly added by the IDSA/ATS committee:
Typical features of CAP are cough, fever, sputum production, and pleuritic chest pain. However, this constellation of features may be altered or even absent, particularly in elderly patients. The diagnosis of CAP is confirmed by the finding of a pulmonary infiltrate on chest radiography or other imaging modality (Figure). Pulse oximetry can also support the diagnosis of pneumonia in the absence of other clear signs; it may detect hypoxemia in confirmed cases of pneumonia.
Microbiological tests to pinpoint the causative agent are warranted when clinical signs or epidemiological clues suggest that empiric therapy may not be effective. Consider such testing for patients who are ill enough to be hospitalized, since their condition may be caused by unusual pathogens or treatment-resistant strains of more common ones. Blood and sputum collections are best done before initiating treatment. Sputum collection is valuable only if a good-quality specimen is obtained and proper transport and processing can be guaranteed.
Such testing is optional for outpatients. The Table lists adverse clinical features that may prompt further assessment and the tests most likely to yield answers to aid treatment decisions.
Blood culture: use selectively. Blood cultures are valuable in patients with severe CAP because of the possibility of uncommon pathogens. In less dire circumstances, testing is optional because Streptococcus pneumoniae is the most likely causative organism and is adequately covered by empiric treatment. One risk in obtaining a blood culture in an optional setting is the possibility that a false-positive result may unnecessarily alter treatment and prolong hospitalization.
Sputum culture and Gram stain. Severe CAP warrants obtaining a sputum culture, and it is preferable to collect a specimen before antibiotics are given. Keep in mind that 40% or more of patients either cannot produce sputum or cannot produce an adequate sample for testing. With intubated patients, a culture of endotracheal aspirates is highly recommended.
The result of a sputum culture depends heavily on the quality of the process--collection, transport, laboratory procedure, appropriate cytological criteria, and interpretation. Any deficiency in the process will jeopardize the outcome. If a high-quality process is adhered to, a negative culture result is helpful. (For example, the absence of Staphylococcus aureus or Gram-negative bacilli supports ruling out these pathogens as causative agents.) Gram stain also aids diagnosis in 2 ways: it can prompt rethinking of empiric coverage to include less common pathogens, and it can validate later culture results.
Culture methods for special situations. Thoracentesis is indicated for patients with pleural effusions larger than 5 cm on a lateral chest radiograph. Yield generally is low, but a positive result could have a substantial effect on treatment.
Bronchoscopic bronchoalveolar lavage, specimen brushing, or transthoracic lung aspiration are best reserved for patients who are immunocompromised or for whom therapy has failed.
Urinary antigen testing. This test may help in evaluating patients with severe CAP, particularly when culture samples are difficult to obtain or when antibiotic therapy has been initiated and may confound culture results. The sensitivity of tests approved for S pneumoniae is 50% to 80%, and the specificity is greater than 90%. Tests for Legionella pneumophila have a specificity approaching 99%.
Two caveats with antigen testing are the cost and the uncertainty of its contribution to treatment decisions, since empiric therapy covers both S pneumoniae and L pneumophila.
Additional tests. Acute-phase serological testing is reserved for cases in which atypical pathogens are most likely involved. Poor reproducibility is an issue with this testing.
Polymerase reaction testing is also available for identifying atypical pathogens. However, according to the CDC, only 4 of the 18 commercial reagents have proved to yield valid results.
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.
Clin Infect Dis.
Nathwani D, Rubenstein E, Barlow G, Davey P. Do guidelines for community-acquired pneumonia improve the cost-effectiveness of hospital care?
Clin Infect Dis.
Dean NC, Silver MP, Bateman KA, et al. Decreased mortality after implementation of treatment guideline for community-acquired pneumonia.
Am J Med.
Marrie TJ, Lau CY, Wheeler SL, et al. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin.
Capelastegui A, Espana PP, Quintana JM, et al. Improvement of process-of-care and outcomes after implementing a guideline for the management of community-acquired pneumonia: a controlled before-and-after design study.
Clin Infect Dis.
Lim WS, van der Eerden MM, Laing R, et al. Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study.
Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia.
N Engl J Med.
Capelastegui A, Espana PP, Quintana JM, et al. Validation of a predictive rule for the management of community-acquired pneumonia.
Eur Respir J.