Nathan C. Dean

Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults

Lionel A. Mandell, Richard G. Wunderink, Antonio Anzueto, John G. Bartlett, G. Douglas Campbell, Nathan C. Dean, Scott F. Dowell, Thomas M. File, Jr. Daniel M. Musher, Michael S. Niederman, Antonio Torres, and Cynthia G. Whitney McMaster University Medical School, Hamilton, Ontario, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, and Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas; Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; Division of Pulmonary and Critical Care Medicine, LDS Hospital, and University of Utah, Salt Lake City, Utah; Centers for Disease Control and Prevention, Atlanta, Georgia; Northeastern Ohio Universities College of Medicine, Rootstown, and Summa Health System, Akron, Ohio; State University of New York at Stony Brook, Stony Brook, and Department of Medicine, Winthrop University Hospital, Mineola, New York; and Cap de Servei de Pneumologia i Allergia Respiratoria, Institut Clinic del Torax, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biomediques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain.

Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia.

PURPOSE We developed a pneumonia guideline at Intermountain Health Care that included admission decision support and recommendations for antibiotic timing and selection, based on the 1993 American Thoracic Society guideline. We hypothesized that guideline implementation would decrease mortality. SUBJECTS AND METHODS We included all immunocompetent patients > 65 years with community-acquired pneumonia from 1993 through 1997 in Utah; nursing home patients were excluded. We compared 30-day mortality rates among patients before and after the guideline was implemented, as well as among patients treated by physicians who did not participate in the guideline program. RESULTS We observed 28,661 cases of pneumonia, including 7,719 (27%) that resulted in hospital admission. Thirty-day mortality was 13.4% (1,037 of 7,719) among admitted patients and 6.3% (1,801 of 28,661) overall. Mortality rates (both overall and among admitted patients) were similar among patients of physicians affiliated and not affiliated with Intermountain Health Care before the guideline was implemented. For episodes that resulted in hospital admission after guideline implementation, 30-day mortality was 11.0% among patients treated by Intermountain Health Care-affiliated physicians compared with 14.2% for other Utah physicians. Analysis that adjusted by logistic regression for age, sex, rural versus urban residences, and year confirmed that 30-day mortality was lower among admitted patients who were treated by Intermountain Health Care-affiliated physicians (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.49 to 0.97; P = 0.04) and was somewhat lower among all pneumonia patients (OR: 0.81; 95% CI: 0.63 to 1.03; P = 0.08). CONCLUSION Implementation of a pneumonia practice guideline in the Intermountain Health Care system was associated with a reduction in 30-day mortality among elderly patients with pneumonia.

Accuracy of administrative data for identifying patients with pneumonia.

The goal of this study was to determine the accuracy and the impact of 5 different claims-based pneumonia definitions. Three International Classification of Diseases, Version 9, (ICD-9), and 2 diagnosis-related group (DRG)-based case identification algorithms were compared against an independent, clinical pneumonia reference standard. Among 10748 patients, 272 (2.5%) had pneumonia verified by the reference standard. The sensitivity of claims-based algorithms ranged from 47.8% to 66.2%. The positive predictive values ranged from 72.6% to 80.8%. Patient-related variables were not significantly different from the reference standard among the 3 ICD-9-based algorithms. DRG-based algorithms had significantly lower hospital admission rates (57% and 65% vs 73.2%), lower 30-day mortality (5.0% and 5.8% vs 10.7%), shorter length of stay (3.9 and 4.1 days vs 5.6 days), and lower costs (US

Clinical Findings and Demographic Factors Associated With ICU Admission in Utah Due to Novel 2009 Influenza A(H1N1) Infection

4543 and US

Validation of the Infectious Disease Society of America/American Thoracic Society 2007 Guidelines for Severe Community-Acquired Pneumonia

5159 vs US

Validation of the 2001 American Thoracic Society criteria for severe community-acquired pneumonia

8585). Claims-based identification algorithms for defining pneumonia in administrative databases are imprecise. ICD-9-based algorithms did not influence patient variables in our population. Identifying pneumonia patients with DRG codes is significantly less precise.

Effect of mobile paramedic units on outcome in patients with myocardial infarction

BACKGROUND Novel 2009 influenza A(H1N1) infection has significantly affected ICUs. We sought to characterize our regions clinical findings and demographic associations with ICU admission due to novel A(H1N1). METHODS 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. RESULTS 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 BMI > or = 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. CONCLUSIONS 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.

A Phase 2 Randomized, Double-Blind, Placebo- Controlled Study of the Safety and Efficacy of Talactoferrin in Patients With Severe Sepsis*

Objectives: Validate the Infectious Disease Society of America/American Thoracic Society 2007 (IDSA/ATS 2007) criteria for predicting severe community-acquired pneumonia (SCAP) and evaluate a health-services definition for SCAP. Design: Retrospective cohort study. Setting: LDS Hospital, an academic tertiary care facility in the western United States. Patients: Consecutive patients with International Classification of Diseases, Ninth Edition, codes and chest radiographs consistent with community-acquired pneumonia from 1996 to 2006 seen at LDS Hospital. Interventions: None. Measurements and Main Results: We utilized the electronic medical record to examine intensive care unit admission, intensive therapies received, and predictors of severity, as well as 30-day mortality. We also developed logistic regression models of mortality and disease severity. We calculated the IDSA/ATS 2007 criteria as well as three other pneumonia severity scores. We defined SCAP as receipt of intensive therapy in the intensive care unit. In 2413 episodes of pneumonia, 1540 were admitted to the hospital, while 379 were admitted to the intensive care unit. Overall 30-day mortality was 3.7% but was 16% among intensive care patients. The IDSA/ATS 2007 minor criteria predicted SCAP with an area under the curve of 0.88 (95% confidence interval 0.85–0.90), which improved to 0.90 (95% confidence interval 0.88–0.92) with weighting. Competing models had area under the curve of 0.76 to 0.83. Using four rather than three minor criteria improved the positive predictive value from 54% to 81%, with a stable negative predictive value of 94% to 92%. Conclusions: The IDSA/ATS 2007 criteria predicted pneumonia severity better than other models. Using four rather than three minor criteria may be a superior cutoff, although this will depend on institutional characteristics.

Mortality, morbidity, and disease severity of patients with aspiration pneumonia

Study Objective:Ewig et al. proposed a new definition of severe community-acquired pneumonia in 1999, which was adopted by the American Thoracic Society in 2001. We evaluated this definition in an independent population of emergency department patients. Design:We compared the 2001 American Thoracic Society definition of severe community-acquired pneumonia using emergency department data to intensive care unit (ICU) admission, use of mechanical ventilation, and administration of vasopressors. Setting:LDS Hospital, a tertiary care, university-affiliated hospital with 520 total beds and 68 ICU beds in Salt Lake City, UT. Patients:We studied 980 consecutive emergency department patients with a radiographically confirmed diagnosis of pneumonia between June 1995 and June 1999. Of these patients, 498 were admitted to the hospital, immunocompetent, and without a “do-not-resuscitate” order within 24 hrs of admission. Measurements and Main Results:Forty-seven patients met the criteria for severe community-acquired pneumonia in the emergency department and were admitted to the ICU. Three hundred eighty patients did not meet the criteria and were admitted to a hospital unit. Nineteen patients met the definition but were admitted to a hospital unit; only one required subsequent ICU admission. Two of the 19 died after a do-not-resuscitate order was entered >24 hrs after admission; the remainder recovered. Fifty-two patients were triaged to the ICU but did not initially meet the definition of severe pneumonia. Sixteen of these 52 patients required mechanical ventilation, 13 of the 16 within 24 hrs of admission to the ICU. The sensitivity for the 2001 American Thoracic Society definition in our population was 44%, specificity was 95%, positive predictive value was 71%, and negative predictive value was 88%. Conclusion:The 2001 American Thoracic Society definition of severe community-acquired pneumonia had high specificity but lower sensitivity in our population compared with the derivation population. Additional factors not reflected in the definition may contribute to ICU admission and the need for mechanical ventilation.

CURB-65 Pneumonia Severity Assessment Adapted for Electronic Decision Support

To investigate the effect of mobile paramedic units on outcome, we prospectively studied for two years all patients with myocardial infarction admitted to the LDS Hospital emergency department who sought aid prior to cardiac arrest. One hundred thirty-four patients who received prehospital care from a mobile paramedic unit were compared with 101 patients who selected another means of initial care. Mortality, occurrence of life-threatening arrhythmias, and change in Killip class at 24 and 48 hours were the outcome variables. Data analysis by multiple logistic regression revealed that outcome was not improved, but a 29-minute median delay in hospital arrival occurred in paramedic-treated patients. Defibrillation was the only beneficial treatment performed by paramedics that could be identified. Current mobile paramedic unit procedures may need to be streamlined to eliminate the delay in hospital arrival resulting from extensive prehospital care.