Pedro Pablo España

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.

Drug-Resistant Pneumococcal Pneumonia: Clinical Relevance and Related Factors

A multicenter study of 638 cases of community-acquired pneumonia due to Streptococcus pneumoniae (SP-CAP) was performed to assess current levels of resistance. Of the pneumococcal strains, 35.7% had an minimum inhibitory concentration (MIC) of penicillin of > or =0.12 microg/mL (3 isolates had an MIC of 4 microg/mL), 23.8% had an MIC of erythromycin of 128 microg/mL, and 22.2% were multidrug resistant. Logistic regression determined that chronic pulmonary disease (odds ratio [OR], 1.44], human immunodeficiency virus infection (OR, 1.98), clinically suspected aspiration (OR, 2.12), and previous hospital admission (OR, 1.69) were related to decreased susceptibility to penicillin, and previous admission (OR, 1.89) and an MIC of penicillin of MIC > or =0.12 microg/mL (OR, 15.85) were related to erythromycin resistance (MIC, > or =1 microg/mL). The overall mortality rate was 14.4%. Disseminated intravascular coagulation, empyema, and bacteremia were significantly more frequent among patients with penicillin-susceptible SP-CAP. Among isolates with MICs of penicillin of > or =0.12 microg/mL, serotype 19 was predominant and was associated with a higher mortality rate. In summary, the rate of resistance to beta -lactams and macrolides among S. pneumoniae that cause CAP remains high, but such resistance does not result in increased morbidity.

Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multicenter Randomized Clinical Trial

IMPORTANCE The optimal duration of antibiotic treatment for community-acquired pneumonia (CAP) has not been well established. OBJECTIVE To validate Infectious Diseases Society of America/American Thoracic Society guidelines for duration of antibiotic treatment in hospitalized patients with CAP. DESIGN, SETTING, AND PARTICIPANTS This study was a multicenter, noninferiority randomized clinical trial performed at 4 teaching hospitals in Spain from January 1, 2012, through August 31, 2013. A total of 312 hospitalized patients diagnosed as having CAP were studied. Data analysis was performed from January 1, 2014, through February 28, 2015. INTERVENTIONS Patients were randomized at day 5 to an intervention or control group. Those in the intervention group were treated with antibiotics for a minimum of 5 days, and the antibiotic treatment was stopped at this point if their body temperature was 37.8°C or less for 48 hours and they had no more than 1 CAP-associated sign of clinical instability. Duration of antibiotic treatment in the control group was determined by physicians. MAIN OUTCOMES AND MEASURES Clinical success rate at days 10 and 30 since admission and CAP-related symptoms at days 5 and 10 measured with the 18-item CAP symptom questionnaire score range, 0-90; higher scores indicate more severe symptoms. RESULTS Of the 312 patients included, 150 and 162 were randomized to the control and intervention groups, respectively. The mean (SD) age of the patients was 66.2 (17.9) years and 64.7 (18.7) years in the control and intervention groups, respectively. There were 95 men (63.3%) and 55 women (36.7%) in the control group and 101 men (62.3%) and 61 women (37.7%) in the intervention group. In the intent-to-treat analysis, clinical success was 48.6% (71 of 150) in the control group and 56.3% (90 of 162) in the intervention group at day 10 (P = .18) and 88.6% (132 of 150) in the control group and 91.9% (147 of 162) in the intervention group at day 30 (P = .33). The mean (SD) CAP symptom questionnaire scores were 24.7 (11.4) vs 27.2 (12.5) at day 5 (P = .10) and 18.6 (9.0) vs 17.9 (7.6) at day 10 (P = .69). In the per-protocol analysis, clinical success was 50.4% (67 of 137) in the control group and 59.7% (86 of 146) in the intervention group at day 10 (P = .12) and 92.7% (126 of 137) in the control group and 94.4% (136 of 146) in the intervention group at day 30 (P = .54). The mean (SD) CAP symptom questionnaire scores were 24.3 (11.4) vs 26.6 (12.1) at day 5 (P = .16) and 18.1 (8.5) vs 17.6 (7.4) at day 10 (P = .81). CONCLUSIONS AND RELEVANCE The Infectious Diseases Society of America/American Thoracic Society recommendations for duration of antibiotic treatment based on clinical stability criteria can be safely implemented in hospitalized patients with CAP. TRIAL REGISTRATION clinicaltrialsregister.eu Identifier: 2011-001067-51.

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.

Predictors of Mortality in Patients with Stable COPD

OBJECTIVESTo determine which easily available clinical factors are associated with mortality in patients with stable COPD and if health-related quality of life (HRQoL) provides additional information.DESIGNFive-year prospective cohort study.SETTINGFive outpatient clinics of a teaching hospital.PARTICIPANTSSix hundred stable COPD patients recruited consecutively.MEASUREMENTSThe variables were age, FEV1%, dyspnea, previous hospital admissions and emergency department visits for COPD, pack-years of smoking, comorbidities, body mass index, and HRQoL measured by Saint George’s Respiratory Questionnaire (SGRQ), Chronic Respiratory Questionnaire (CRQ), and Short-Form 36 (SF-36). Logistic and Cox regression models were used to assess the influence of these variables on mortality and survival.RESULTSFEV1%(OR: 0.62, 95% CI 0.5 to 0.75), dyspnea (OR 1.92, 95% CI 1.2 to 3), age (OR 2.41, 95% CI 1.6 to 3.6), previous hospitalization due to COPD exacerbations (OR 1.53, 1.2 to 2) and lifetime pack-years (OR 1.15, 95% CI 1.1 to 1.2) were independently related to respiratory mortality. Similarly, these factors were independently related to all-cause mortality with dyspnea having the strongest association (OR 1.54, 95% CI 1.1 to 2.2). HRQoL was an independent predictor of respiratory and all-cause mortality only when dyspnea was excluded from the models, except scores on the SGRQ were associated with all-cause mortality with dyspnea in the model.CONCLUSIONSAmong patients with stable COPD, FEV1% was the main predictor of respiratory mortality and dyspnea of all-cause mortality. In general, HRQoL was not related to mortality when dyspnea was taken into account, and CRQ and SGRQ behaved in similar ways regarding mortality.

Impact of hospitalisations for exacerbations of COPD on health-related quality of life

Exacerbations of chronic obstructive pulmonary disease (COPD) impair health-related quality of life (HRQoL). It is unknown whether exacerbations requiring hospitalisation have an impact on HRQoL. 611 ambulatory COPD patients were prospectively identified. The average age (SD) was 65.5 (8.6), FEV(1) (SD) was 52% (14%) of the predicted value. All patients completed the Saint Georges Respiratory Questionnaire (SGRQ) and the Medical Outcomes Study Short Form (SF-36) questionnaire at the beginning of the study. After five years of follow-up, the 391 survivors again completed these HRQoL instruments. No changes in HRQoL were observed among patients not hospitalised for COPD exacerbations. Those hospitalised during follow-up experienced significant declines in HRQoL. The largest changes were observed among patients with >or=3 hospitalisations, with a 13.6 unit increase in the total SGRQ and a 10.5 unit decrease in the physical component summary scale of the SF-36. Similar changes were observed among patients with FEV(1)>or=50% at baseline. In the multivariate analysis, after adjustment by FEV(1%), age, comorbidities, and HRQoL in the respective HRQoL domain at baseline, hospitalisations were an independent predictor of the change in HRQoL. Hospitalisations for exacerbations of COPD have an independent and negative impact on the evolution of HRQoL, regardless of COPD severity.

Validation and comparison of SCAP as a predictive score for identifying low-risk patients in community-acquired pneumonia.

PURPOSES (1) To validate the Severe Community Acquired Pneumonia (SCAP) score in predicting 30-day mortality. (2) To validate its ability to identifying patients at low risk of death. (3) To compare it against the Pneumonia Severity Index (PSI), and the British Thoracic Societys CURB-65 rules. METHODS The SCAP score was validated to predict 30-day mortality in an internal validation cohort of consecutive adult patients seen in one hospital. Consecutive inpatients from other three hospitals were used to externally validate the score and compare the SCAP with the PSI and CURB-65. The discriminatory power of these rules to predict 30-day mortality was tested by the Area under Curve (AUC), and their predictive accuracy with the sensitivity, specificity and predictive values. RESULTS The 30-day mortality rate increased directly with increasing SCAP score (class 0: 0.5%, to class 4: 66.5% risk) in the internal validation cohort, and from 1.3% to 29.2% in external cohort (P<0.001) with an AUC of 0.83 and 0.75, respectively (P=0.024). The SCAP score identified 62.4% (95% IC 58.8-66.0) low-risk patients, 52.5% (95% IC 48.8-56.2) the PSI and 46.2% (95% CI 42.5-49.9) the CURB-65 in the external cohort. Patients classified as low risk by the three rules had similar 30-day mortality (SCAP: 2.5%, PSI: 1.6% and CURB-65: 2.7%). CONCLUSION The SCAP is valid to predict 30-day mortality among low-risk patients and identifies a larger proportion of patients as low-risk than the other studied rules.

The health, activity, dyspnea, obstruction, age, and hospitalization: Prognostic score for stable COPD patients

UNLABELLED Multidimensional instruments for determining the severity and prognosis of chronic obstructive pulmonary disease (COPD) must be used in daily clinical practice. OBJECTIVE To develop and validate a new COPD severity score using variables readily obtained in clinical practice and to compare its predictive capacity with that of other multidimensional indexes. Data collected from a prospective cohort of 611 stable COPD patients were used to derive a clinical prediction rule that was later validated in a separate prospective cohort of 348 patients. In the multivariate analyses, six independent predictive factors were correlated with overall and respiratory mortality: health status, physical activity, dyspnea, airway obstruction (FEV(1)), age, and hospitalizations for COPD exacerbations in the previous two years. These create the HADO-AH score. Based on the β parameter obtained in the multivariate model, a score was assigned to each predictive variable. The area under the curve for 5-year mortality was 0.79 (95% CI, 0.74-0.83) in the derivation cohort and 0.76 (95% CI, 0.71-0.81) in the validation cohort. The HADO-AH score was a significantly better predictor of mortality than the HADO-score and the Body-mass index, Obstruction, Dyspnea, Exercise-index were statistically significant (p < 0.0004 and p = 0.021, respectively), but was similar to the Age, Dyspnea, and Obstruction-index (p = 0.345). The HADO-AH score provides estimates of all-cause and respiratory mortality that are equal to, or better than, those of other multidimensional instruments. Because it uses only easily accessible measures, it could be useful at all levels of care.