Inmaculada Gorordo

Validation of a predictive rule for the management of community-acquired pneumonia

The CURB-65 score (Confusion, Urea >7 mmol·L−1, Respiratory rate ≥30·min−1, low Blood pressure, and age ≥65 yrs) has been proposed as a tool for augmenting clinical judgement for stratifying patients with community-acquired pneumonia (CAP) into different management groups. The six-point CURB-65 score was retrospectively applied in a prospective, consecutive cohort of adult patients with a diagnosis of CAP seen in the emergency department of a 400-bed teaching hospital from March 1, 2000 to February 29, 2004. A total of 1,100 inpatients and 676 outpatients were included. The 30-day mortality rate in the entire cohort increased directly with increasing CURB-65 score: 0, 1.1, 7.6, 21, 41.9 and 60% for CURB-65 scores of 0, 1, 2, 3, 4, and 5, respectively. The score was also significantly associated with the need for mechanical ventilation and rate of hospital admission in the entire cohort, and with duration of hospital stay among inpatients. The CURB-65 score (Confusion, Urea >7 mmol·L−1, Respiratory rate ≥30·min−1, low Blood pressure, and age ≥65 yrs), and a simpler CRB-65 score that omits the blood urea measurement, helps classify patients with community-acquired pneumonia into different groups according to the mortality risk and significantly correlates with community-acquired pneumonia management key points. The new score can also be used as a severity adjustment measure.

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

BACKGROUND Studies investigating the impact of guideline implementation for inpatient management of community-acquired pneumonia (CAP) usually have methodological limitations. We present a controlled study that compared interventions before and after the implementation of a practice guideline. METHODS Clinical and demographic characteristics, as well as process-of-care and outcome indicators, were recorded for all patients with CAP who were admitted to Galdakao Hospital (Galdakao, Spain) in the 19-month period after the implementation, on 1 March 2000, of a guideline for the treatment of CAP. These data were also recorded for all patients with CAP who were admitted to this hospital during the year before the guideline was implemented, as well as for randomly selected inpatients with CAP at 4 other hospitals during both periods (i.e., before and after guideline implementation) who were chosen as an external comparison group. Multivariate linear and logistic regression models were employed for adjustment. RESULTS Guideline implementation resulted in shorter durations of antibiotic treatment (P<.001) and intravenous treatment (P<.001), better coverage of atypical pathogens (P<.001), and improved appropriateness of antibiotic treatment (P<.001), compared with the period before the guideline was implemented. The adjusted analyses revealed decreases in 30-day mortality (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.23-3.72) and in-hospital mortality (OR, 2.46; 95% CI, 1.37-4.41) and a 1.8-day reduction in the duration of hospital stay. In the control hospitals, there were small but statistically insignificant changes in these indicators for admitted patients. CONCLUSIONS This study, which was performed with an adequate, controlled before-and-after intervention design, demonstrated significant improvements in both process-of-care and outcome indicators after implementation of a guideline for treating CAP.

Prospective Comparison of Severity Scores for Predicting Clinically Relevant Outcomes for Patients Hospitalized With Community-Acquired Pneumonia

BACKGROUND The comparative accuracy and discriminatory power of three validated rules for predicting clinically relevant outcomes other than mortality in patients hospitalized with community-acquired pneumonia (CAP) are unknown. METHODS We prospectively compared the newly developed severe community-acquired pneumonia (SCAP) score, pneumonia severity index (PSI), and the British Thoracic Society confusion, urea > 7 mmol/L, respiratory rate > or = 30 breaths/min, BP < 90 mm Hg systolic or < 60 mm Hg diastolic, age > or = 65 years (CURB-65) rule in an internal validation cohort of 1,189 consecutive adult inpatients with CAP from one hospital and an external validation cohort of 671 consecutive adult inpatients from three other hospitals. Major adverse outcomes were admission to ICU, need for mechanical ventilation, progression to severe sepsis, or treatment failure. Mean hospital length of stay (LOS) was also evaluated. The rules were compared based on sensitivity, specificity, and area under the curve (AUC) of the receiver operating characteristic. RESULTS The rate of all adverse outcomes and hospital LOS increased directly with increasing SCAP, PSI, or CURB-65 scores (p < 0.001) in both cohorts. Patients classified as high risk by the SCAP score showed higher rates of adverse outcomes (ICU admission, 35.8%; mechanical ventilation, 16.4%; severe sepsis, 98.5%; treatment failure, 22.4%) than PSI and CURB-65 high-risk classes. The discriminatory power of SCAP, as measured by AUC, was 0.75 for ICU admission, 0.76 for mechanical ventilation, 0.79 for severe sepsis, and 0.61 for treatment failure in the external validation cohort. AUC differences with PSI or CURB-65 were found. CONCLUSIONS The SCAP score is as accurate or better than other current scoring systems in predicting adverse outcomes in patients hospitalized with CAP while helping classify patients into different categories of increasing risk for potentially closer monitoring.

Declining Length of Hospital Stay for Pneumonia and Postdischarge Outcomes

OBJECTIVE This study was designed to assess 8-year trends in the duration of hospitalization for community-acquired pneumonia and to evaluate the impact of declining length of stay on postdischarge short-term readmission and mortality. METHODS We conducted a prospective observational cohort study of 1886 patients with community-acquired pneumonia who were discharged from a single hospital between March 1, 2000, and June 30, 2007. The main outcomes measured were all-cause mortality and hospital readmission during the 30-day period after discharge. Regression models were used to identify risk factors associated with hospital length of stay and the adjusted associations between length of stay and mortality and readmission. RESULTS Factors associated with a longer hospital stay included the number of comorbid conditions, high risk classification on the Pneumonia Severity Index, bilateral or multilobe radiographic involvement, and treatment failure. Patients treated with an appropriate antibiotic were less likely to have an increased length of stay. The mean length of stay was significantly shorter during the 2006 to 2007 period (3.6 days) than during the 2000 to 2001 period (5.6 days, P<.001). Despite the reduction in length of stay, there were no significant differences in the likelihood of death or readmission at 30 days between the 2 time periods. Adjusted multivariate analysis showed that patients with hospital stays less than 3 days did not have significant increases in postdischarge outcomes. CONCLUSION The marked decreased in the length of stay for patients hospitalized with community-acquired pneumonia since 2000 has not been accompanied by an increase in short-term mortality or hospital readmission.

Etiology of community-acquired pneumonia in a population-based study: Link between etiology and patients characteristics, process-of-care, clinical evolution and outcomes

BackgroundThe etiologic profile of community-acquired pneumonia (CAP) for each age group could be similar among inpatients and outpatients. This fact brings up the link between etiology of CAP and its clinical evolution and outcome. Furthermore, the majority of pneumonia etiologic studies are based on hospitalized patients, whereas there have been no recent population-based studies encompassing both inpatients and outpatients.MethodsTo evaluate the etiology of CAP, and the relationship among the different pathogens of CAP to patients characteristics, process-of-care, clinical evolution and outcomes, a prospective population-based study was conducted in Spain from April 1, 2006, to June 30, 2007. Patients (age >18) with CAP were identified through the family physicians and the hospital area.ResultsA total of 700 patients with etiologic evaluation were included: 276 hospitalized and 424 ambulatory patients. We were able to define the aetiology of pneumonia in 55.7% (390/700). The most frequently isolated organism was S. pneumoniae (170/390, 43.6%), followed by C. burnetti (72/390, 18.5%), M. pneumoniae (62/390, 15.9%), virus as a group (56/390, 14.4%), Chlamydia species (39/390, 106%), and L. pneumophila (17/390, 4.4%). The atypical pathogens and the S. pneumoniae are present in pneumonias of a wide spectrum of severity and age. Patients infected by conventional bacteria were elderly, had a greater hospitalization rate, and higher mortality within 30 days.ConclusionsOur study provides information about the etiology of CAP in the general population. The microbiology of CAP remains stable: infections by conventional bacteria result in higher severity, and the S. pneumoniae remains the most important pathogen. However, atypical pathogens could also infect patients in a wide spectrum of severity and age.

Study of community-acquired pneumonia: incidence, patterns of care, and outcomes in primary and hospital care.

BACKGROUND To asses the incidence, patterns of care, and outcomes of community-acquired pneumonia (CAP) in the population of a defined geographic area. METHODS Prospective study conducted from April 1, 2006, to June 30, 2007. All adult patients (age ≥18) with CAP in the Comarca Interior region of northern Spain were identified through the regions 150 family physicians and the emergency department (ED) of the areas general teaching hospital. RESULTS During a 15-month period, 960 patients with CAP were identified: 418 hospitalized and 542 ambulatory patients. The hospitalization rate was 43.5% and the global 30-day mortality was 4% (38 patients). Of the patients treated at home, most (90.4%) had mild pneumonia, only 3.1% (17 patients) were subsequently hospitalized, with a 30-day mortality rate of 0%. However, 48.9% were not treated according to antibiotic recommendations of the Spanish Society of Pneumology. Mean duration of return to daily activity was 18.8 days for the entire population. The incidence study was restricted to the first 12 months, during which 787 patients fulfilled the inclusion criteria. This represented an incidence of pneumonia of 3.1/1000 adults per year. Both the incidence of CAP and hospitalization for it rose with age. CONCLUSIONS Our study offers information about CAP in the general population and provides feedback for the management of CAP. Although the selection of patients to be treated at home was appropriate, the choice of empiric antibiotic therapy for ambulatory CAP was problematic.

Pneumonia: Criteria for Patient Instability on Hospital Discharge

BACKGROUND A study was undertaken to identify and weigh at the time of hospital discharge simple clinical variables that could predict short-term outcomes in patients with pneumonia. METHODS In a prospective observational cohort study of 870 patients discharged alive after hospitalization for pneumonia, we collected oxygenation and vital signs on discharge and assessed mortality and readmission within 30 days. From the beta-parameter obtained in a multivariate Cox proportional hazard regression model, a score was assigned to each predictive variable. The effects of instability at discharge on outcomes within 30 days thereafter were examined by adjusted models with use of the pneumonia severity index at hospital admission, the length of stay, the Charlson comorbidity index, or the preillness functional status. RESULTS Four variables related to a 30-day mortality rate from all causes were identified in the multivariate model; these included one major criterion (temperature >37.5 degrees C) and three minor criteria (systolic BP < 90 mm Hg or diastolic BP < 60 mm Hg, respiratory rate > 24 breaths/min, and oxygen saturation < 90%). The developed score remained significantly associated with a higher risk-adjusted rate of death. Patients with a score > or = 2 (one major criterion or two minor criteria) had a sixfold-greater risk-adjusted hazard ratio (HR) of death (HR, 5.8; 95% confidence interval, 2.5 to 13.1). CONCLUSIONS Four criteria of instability on discharge seem to be related to the mortality rate after discharge, but each of the factors must be weighed differently. The resulting score is a simple alternative that can be used by clinicians in the discharge process.

Evaluation of Clinical Practice in Patients Admitted With Community-Acquired Pneumonia Over a 4-Year Period

OBJECTIVE Since March 2000 we have been using a clinical practice guideline in the management of patients diagnosed with community-acquired pneumonia (CAP). The objective of this study was to analyze the evolution of quality of care received by these patients. PATIENTS AND METHODS This was a prospective observational study comparing the process of care and outcomes of 4 consecutive 1-year periods (March 1, 2000 through February 29, 2004) in patients admitted for CAP. RESULTS Over the 4 years studied, the following statistically significant trends were observed: reductions in hospital admissions (P< .001), length of hospital stay (P< .05), and total duration of antibiotic treatment (P< .05); and increases in the coverage of atypical pathogens (P< .001) and administration of antibiotics within 8 hours of hospital arrival (P< .001). No significant differences were found in readmissions within 30 days, or in-hospital and 30-day mortality. Two other areas for improvement were also identified: a low percentage of admissions to the intensive care unit (4.4%) and the rate of unnecessary hospitalization of low-risk patients (36.8%). CONCLUSIONS Systematic monitoring of the indicators of our clinical guidelines provided us with information about our clinical practice and facilitated an evaluation of the same. Many of these indicators were found to have evolved favorably and areas of improvement were identified.

Normalización de las cifras de presión en la arteria pulmonar tras tratamiento efectivo de la enfermedad de Graves

Presentamos el caso de una paciente de 48 anos de edad con diagnostico de hipertension pulmonar e hipertiroidismo (enfermedad de Graves) en la que se objetivo la normalizacion de las cifras de presion en la arteria pulmonar tras el tratamiento de su enfermedad tiroidea. Los posibles mecanismos etiopatogenicos involucrados en esta asociacion incluirian la presencia de un fallo cardiaco hiperdinamico y/o la existencia de una alteracion de la inmunidad subyacente y comun a ambos.