Current Clinical Practice in the Management of Community-Acquired Pneumonia: An Appraisal

Ma. Lourdes A. Villa, M.D.,1 Ismael Sumagaysay, M.D., Maribel We, M.D.,3 Vilma Co, M.D.,4 Myrna T. Mendoza, M.D.,5 Thelma E. Tupasi, M.D.6 and Remedios F. Coronel, M.D.7
(1Fellow, Infectious Disease Section, Department of Medicine, Makati Medical Center, 2Fellow, Infectious and Tropical Diseases Section, Department of Medicine, Santo Tomas University Hospital, 3Fellow, Infectious Diseases Section, Department of Medicine, UP-PGH, 4Consultant, Infectious Disease Section, Department of Medicine, Makati Medical Center, 5Chief, Infectious Diseases Section, Department of Medicine, UP-PGH, 6Chief, Infectious Disease Section, Department of Medicine, Makati Medical Center and 7Chief, Infectious and Tropical Diseases Section, Department of Medicine, Santo Tomas University Hospital) ABSTRACT A retrospective and descriptive study to determine current practices of physicians in the management of patients with community acquired pneumonia (CAP) was done in 3 Metro Manila Hospitals. Clinical charts of 198 hospitalized adult patients with CAP were reviewed. Data on age, sex, severity of illness, comorbidity, bacteriologic findings, chest X-ray, antibiotic therapy, length of hospital stay (LOS), and outcome were analyzed. Forty one (20.7%) of these patients did not require hospitalization (20 minimal and 21 low-risk CAP). Of the remaining patients, 120 were moderate and 37 had high-risk CAP. Only 6(16%) of the latter were appropriately admitted at ICU. Recommended antibiotics were used in 4 (20%), 10 (48%), 36 (30%), and 5 (14%) for minimal, low-risk, moderate, and highrisk CAP, respectively. Case fatality rate was 5.5% for moderate and 20% for high-risk CAP treated with recommended drugs, compared to 3.5% and 37.5% respectively, for those given other agents. The management of 72.2% of patients studied was not in conformity to the recommended guideline. Unnecessary hospitalization was noted in 20.7% of patients. Although no significant difference in case fatality rate and LOS was noted in the patients given recommended versus other drugs, following the guidelines could possibly reduce the cost of treatment. (Phil J Microbiol Infect Dis 1999; 28(4):121-127) Key words: community-acquired pneumonia, clinical practice guideline

INTRODUCTION Community acquired pneumonia (CAP) remains a major cause of death worldwide accounting for an estimated 5 million deaths per year. In developed countries, the antimicrobial era has brought a 66% reduction in the crude mortality rate associated with the disease. It remains the most frequent infectious cause of death and the 6th leading cause overall in the United States, resulting in more than 500,000 hospital admissions annually in adults, with a mortality rate at 20 to 40%.1,2 In the Philippines, there are more than 40,000 cases of CAP annually. More than 50% are admitted in the hospital. Pneumonia is considered the 3rd leading cause of death and the 4th leading cause of morbidity.3 Clinical practice guidelines on CAP have recently been developed by a multi-disciplinary task force utilizing evidence based approach and consensus building in collaboration with the consortium of societies and organizations comprising the Philippine Guidelines Group in Infectious Diseases (PPGGID).4 This study was undertaken to determine baseline data on the current clinical practices in the management of CAP among Filipino physicians. Management decisions on hospitalization, utilization of bacteriologic studies, and empiric initial therapy in 3 major tertiary hospitals in Metro Manila were

7%) had findings suggestive of high-risk CAP. Of the older patients. Using a standard clinical research form. cardiovascular disease (52%) was most commonly seen. MATERIALS AND METHODS This is a retrospective analysis of patients admitted for CAP at the Philippine General Hospital (PGH). and chronic liver disease (14%). Results of blood sputum culture and sensitivity test (CS). The T-test was used to assess significant difference of mean days of hospital stay. Analysis. was assessed based on the number of polymorphonuclear cells per power field (PMN/LPF) and the number of epithelial cells (EC/LPF) by gram stain. has been confined only to moderate and high-risk CAP. Ages ranged from 18 to 103 years with a mean age of 62 years. while 120(60. bacteriologic findings. co-morbidity. The association was considered statistically significant if p <0. There were 109 (55%) females and 89 (45%) males. socio-demographic data such as age.5 Chi-square test and Fischer exact test were used to detect significant difference of proportion between specified groups. Majority of patients. 21(10. Tachycardia > 125/min and tachypnea > 30/min were each seen in 18% and both were seen more frequently in the younger patients < 65 years of age (25% and 32%. severity of illness. The quality of sputum specimens. diabetes mellitus (14%).6%) had co-morbid conditions and were classified as low-risk. Vital signs and radiographic findings predictive of a complicated course were noted in 157 patients. Among patients younger than . Of the co-morbid conditions. Of these 157 patients. 37(18. sex.5. followed by COPD/bronchiectasis (33%). 113 (57%) were 65 years of age. respectively). Temperature > 40oC or < 35oC was noted in 53 (34%) patients including 43% of patients younger than 65 years and 30% of the older patients. days of hospitalization and clinical outcome were noted. were analyzed. Determination of frequencies was done using the software SPSS version 7. RESULTS Risk Stratification of CAP A total of 198 patients were included in the review. thereafter. neoplastic disease (14%). Findings of chronic renal failure and chronic alcohol abuse were seen in 1 (5%) patient each. Multi-lobar radiographic involvement was seen in 69 (44%) patients. if obtained. 84 (74%) had chest radiographic finding or physical findings predictive for a complicated course of CAP and the remaining 29 (26%) were so classified based solely on age. This was more commonly noted among patients <65 years (59%) compared to the older patients (38%). Santo Tomas University Hospital (STUH) and the Makati Medical Center (MMC) from July to September 1997. Table 1 shows the findings predictive of a complicated course of CAP in 157 patients including 113 aged 65 years and above and 44 younger than 65 years. Aspiration was suspected in 5 (3%) and extra-pulmonary evidence of sepsis was noted in 6 (4%) patients. Outcome variables included case fatality rate. The risk stratification of the 198 patients is shown in Figure 1. The initial empiric antibiotic therapy was classified as consistent with recommended drugs or not. Eight of these 21 patients had more than 1 co-morbid condition. The decision to hospitalize a patient was evaluated based on the presence or absence of risk factors for a complicated course. Of the remaining 41 patients. The clinical outcome of patients was correlated with management decisions. Abscess was seen in only 1 (2%) patient who was <65 years. mean days of hospital stay.analyzed utilizing the guidelines as basis. Pleural effusion was noted in 13 (8%) and was more commonly seen in those < 65 years (14%) compared to older patients (6%).6%) were considered as moderate-risk CAP.1%) were considered as minimal-risk category. and modification of antibiotics either for purposes of streamlining or because of treatment failure. chest X-rays. while 20 (10. if done.05. respectively) compared to the older patients (15% and 13%.

Findings of shock or signs of hypoperfusion such as hypotension and altered mental state were comparable among high-risk CAP patients admitted at the ward (48%) and ICU . Figure 1. these were noted in 1 (2%) and 4(9%) patients respectively while in older patients this was noted in 4 (3%) and 2(2%). age ≥ 65 2. altered mental state. extrapulmonary evidence of sepsis NO Any of the ff: 1. severe hypoxemia or acute hypercapnea was seen in 57%. PaO2 < 60 mmHg or acute hypercapnea (PaCO2 > 50 mmHg) at room temperature YES YES HIGH RISK CAP (IV) ICU ADMISSION YES UNSTABLE NO LOW RISK (CAP II) OUTPATIENT YES MODERATE RISK CAP (III) WARD ADMISSION Chest X-ray Multi-lobar involvement Pleural effusion Abscess Temperature >40 °C or <35 °C PR >125/min RR >30/min Suspected aspiration Extrapulmonary evidence of sepsis Patients with none of the above Among the 157 patients with features predictive of a complicated course. urine output at 30 cc/hr seen in 49%. Algorithm: Management-oriented risk stratification of community-acquired pneumonia in immunocompetent adults. Renal insufficiency 6. Congestive heart failure 5. Among patients with high-risk CAP. and 16% of patients. urine output < 30 ml/hr 2. pleural effusion. respectively. followed by shock or signs of hypoperfusion such as hypotension. Findings predictive of a complicated course in patients with community-acquired pneumonia Clinical Findings Age >65 years N=113 n (%) 43 7 0 34 17 15 4 2 29 (38) (6) (30) (15) (13) (3) (2) (26) Age <65 years N=44 n (%) 26 6 1 19 11 14 1 4 0 (59) (14) (2) (43) (25) (32) (2) (9) Total N=157 n (%) 69 13 1 53 28 29 5 6 29 (44) (8) (1) (34) (18) (18) (3) (4) (18) NO Any of the following: 1. only 6 were admitted to the ICU. Diabetes mellitus 2. Shock or signs of hypoperfusion: (altered mental state. Neoplastic diseases 3. progression of lesion to 50% within 24 hours 6. T ≥ 40 or ≤ 35oC 5. 37 patients had features of high-risk CAP as shown in Table 2. Of the 37. CXR: multilobar. COPD 8. CAP Any of the following: 1. Neurologic disease 4. PR ≥ 125/min 4. suspected aspiration 7. Modified from TFCAP guideline. Chronic alcohol abuse NO MINIMAL RISK (CAP I) OUTPATIENT Table 1.65 years. respectively. RR ≥ 30/min 3. 46%. abscess.

S pneumoniae was isolated in 9 patients. 37 patients were considered to have high risk CAP who should have required ICU admission. A predominant organism was reported in only 9 of 32 specimens. All patients admitted at the ICU had severe hypoxemia or acute hypercapnea at room air.O. Of the remaining 157 patients. The last patient had no blood culture done. 41(34%) moderate and 13(35%) high-risk patients.4) Bacteriologic Studies Bacteriologic studies included sputum GS in 74 patients including 10 (50%) minimal.7) Total N=37 n % 18 17 6 21 (49) (46) (16) (57) 13 (35. Evaluation of Management Decisions Table 4 shows the evaluation of decisions on hospitalization based on risk categories of patients with CAP. Forty-one (20%) of the 198 patients admitted were of minimal (20) or low-risk (21) category who would have been suitable for outpatient care. Blood culture is the gold standard in the etiologic diagnosis of CAP. Only 32 (43%) of these specimens fulfilled the criteria for an adequate or appropriate specimen. It is specifically recommended in those with moderate to high risk CAP requiring hospitalization.4% and was 16. Of 157. Since this study only reviewed hospitalized patients. 1 had gram (+) cocci in clusters but grew Klebsiella sp. Of the 32 patients with appropriate sputum specimens. only 6 (16%) were admitted in the ICU while 31 (84%) were admitted in a regular ward or room.7% of those admitted in the regular ward. Staphylococcus aureus (2) and Pseudomonas sp. with 1 patient expiring after 1 day following modification of antibiotics.7% in the ICU compared to 38. Escherichia coli (7).7) ICU admission N=6 n % in 3 (50) 3 (50) 2 (33) 6 1 (100) (16. 14 (48%) of 29 patients with moderate risk and 12(63%) of 19 patients with high-risk CAP. Table 2. Of the remaining 4 patients with a predominant organism reported from sputum gram stain. 26 (54%) yielded positive results. This finding was seen in 48% of patients admitted at the ward. The case fatality rate for patients with high-risk CAP was 35. which had to be corrected accordingly. Features of high-risk community acquired pneumonia Findings Shock or signs of hypoperfusion Hypotension Altered mental state U. those with minimal or lowrisk CAP seen at that time and not admitted were not included. blood cultures were done in 13 and blood cultures were likewise done in another 35 patients. Hospital admission for these 41 patients was therefore deemed inappropriate.(50%). Two were continued on their initial antibiotic therapy. The choice of regular rooms was therefore deemed inappropriate in these 31 patients. aureus bacteremia. only 48 (30%) . The treatment of the 26 patients with (+) blood cultures was based on the isolated pathogen in 18. Figure 2 shows the analysis of sputum gram stain done in 74 patients.(1). pneumoniae and cefuroxime in another patient with S. followed by Klebsiella spp (7). ciprofloxacin in 1 patient with S. 10 (48%) low-risk. Both patients improved. in blood culture. Five died and 1 patient was discharged before blood culture results were available.< 30 cc/hr PaO2 < 60 mmHg or acute hypercapnea (PaCO2 > 50 mmHg) at room air Case Fatality Rate Ward Admission N=31 n % 15 14 4 15 12 (48) (45) (13) (48) (38. Of the 48 blood cultures done. 2 had gram (+) cocci reported singly or in pairs and blood cultures grew Staphylococcus aureus. 3 of these had moderate to heavy growth of Streptococcus pneumoniae in sputum culture. There was correlation of the gram stain [predominant organism: gram (+) cocci in pairs] and blood cultures in 5 patients who all had Streptococcus pneumoniae bacteremia. These 48 patients included 29 with moderate and 19 high-risk patients (Table 3).

Analysis of sputum gram stain done in 74 patients Sputum smears (N=74) PMN>25/lpf EC<10/lpf (N=32) Predominant organism reported (N=9) G (+) cocci.pneumoniae S.5 + 6. There was no modification of the initial choice of antimicrobials due to treatment failure among patients with minimal and low-risk CAP.7 + 3.coli Moderate-Risk CAP N=19 6 1 3 3 1 14 (48) High-Risk CAP N=29 3 1 4 .3 days for those given other agents. for low-risk CAP it was 5. Blood cultures S. and beta lactam/beta-lacatamase inhibitor IV (5). Other agents used were parenteral coamoxiclav in 8 patients. All 1 26 (54) 12 (63) Table 4. 5. Evaluation of management decisions made on 198 patients with CAP According to CAP Guidelines 41 37 157 Appropriate No.9 days for those given recommended antibiotics vs. 91 moderate and 18 high-risk CAP patients. respectively. . Cotrimoxazole. Total N=48 9 2 7 7 4 0 Pseudomonas spp.2 + 1.of these patients had a blood culture taken. Figure 2.aureus Klebsiella spp E. For minimal-risk CAP. quinolones (2).pneumoniae (N=5) Table 3.4 + 2. It was deemed inappropriate that blood cultures were not obtained in the remaining 109 (70%) patients. these included macrolide in 3 and amoxicillin in 1 patient. For low-risk CAP.7. Pathogens isolated from blood cultures obtained from patients with moderate risk and high risk CAP Pathogen S. There was no mortality among these patients. Other agents used were cephalosporins (9). Mean hospital stay for minimal-risk CAP was 4. the recommended agents included second generation cephalosporin alone in 6 patients or in combination with macrolides in another 4 patients.aureus (N=2) G (+) cocci clusters (N=2) Blood cultures Klebsiella sp (N=1) No blood culture (N=1) PMN>25/lpf EC >10/lpf (N=25) Inappropriate PMN <25/lpf (N=17) S. (%) (16) Inappropriate No.pairs (N=7) . 41 31 (%) (100) (84) Outpatient Care For minimal and low-risk CAP ICU admission for high-risk CAP Blood cultures recommended for moderate and high-risk CAP 6 48 (30) 109 (70) Treatment and Clinical Outcome The recommended empiric agents were used in a minority of cases reviewed.1 vs 7. beta lactam/beta-lactamase inhibitor (PO) alone or in combination with macrolide was each given in 1 patient each.

13 In our study. Among the recommended agents for moderate-risk CAP. Only 6 of these patients were actually admitted at the ICU.8 (95% CI=1.4 + 7 . cephalosporins (IV) with macrolide were used in 34 patients or co-amoxiclav (IV) with macrolide in 2.0 + 4.4+/-7. pulse rate > 125 beats/min.9 Chest X-ray findings of multi-lobar involvement was associated with mortality with Odds ratio of 3. Table 5. the decision to hospitalize patients is based on a number of prognostic indicators that are significantly associated with a complicated course or with a fatal outcome. these patients improved. case fatality rate was 20% for those who used the recommended antibiotic therapy against 37.4 days. The mean days of hospitalization for moderate-risk CAP was 7. or combination therapy in 8 patients. cotromoxazole (2). and for diagnostic and therapeutic approaches. Among patients with high risk CAP. Recommended Other agents Recommended Other agents 36 84 5 32 Treatment modified for streamlining 18 36 0 Treatment modified due to failure 4 4 2 7 (11) (5) (40) (22) Case fatality rate % 2 3 1 Mean hospital stay 7. and for high-risk CAP. Modification of initial antibiotic therapy due to treatment failure was seen in 8 of moderate (4 of whom were given recommended agents) and 9 of high-risk CAP patients (2 of whom were given recommended agents).9-5.5% who received other antibiotics. case fatality rates for moderate and high-risk CAP patients who received recommended antibiotic therapy was lower at 7.6% against 3.1 vs 12. Streamlining of initial parenteral antimicrobial therapy to an oral agent in patients who show adequate clinical response was noted in 18 of 58 patients given the recommended drugs and 58 of 140 patients who were given other agents.6) (20) 10 12 (37. . beta-lactam/beta-lactamase inhibitor (6). After the modification of therapy. Because of the small number of cases studied.8 and a complicated course.5% who received other antibiotics.2+1-3.1 12. anti-pseudomonal agents (3).4-5. Non-adherence to the guidelines on admission may impose danger to patients. High-risk CAP requiring ICU treatment is frequent and represents some 18-36 % of CAP patients requiring hospitalization.5) (3.7 In the initial assessment of a patient with CAP.6. Empiric antibiotic therapy and outcome of patients with CAP Stratification Moderate Risk High Risk Empiric Antibiotic Therapy No.Table 5 shows the use of recommended and other drugs and the clinical outcome of patients with moderate and high-risk CAP.0+/-4. co-amoxiclav (26). Case fatality rate for mode-rate risk CAP patients who received recommended antibiotic therapy was 5. Other agents used included monotherapy with antipseudomonal agents (8).7% among those not admitted to ICU. other drugs.7% among these patients compared to 38. respectively.3% compared to 12.3 vs 7.1 (95% CI=1.3 7. The case fatality rate was 16. the use of recommended agents such as anti-pseudomonal agents with erythromycin IV was seen in 5 patients.4 (50) (43) (31) (5.0+/-10. respectively.11 and respiratory rate > 30/min12 were also considered predictive factors for a complicated course. thirty-seven (23.1 for those given recommended drugs vs. Overall.2 + 3. differences in the mean hospital days and case fatality rate among patients given recommended and other agents showed no statistical significance.8)10 Temperature of > 40oC or < 35. Among high-risk CAP patients.1 11. it was 11.5) DISCUSSION Management guidelines for patients with CAP have been devised to provide bases for hospitalization. Several studies have shown a direct association between age > 65 years and mortality. other cephalosporins (5).4. or macrolide (10) or quinolones (10). Combination therapy with any of the above other agents was seen in 13 patients.9% who received other antibiotics.1) and pleural effusion was associated with a complicated course with odds ratio of 2.0 + 10. Other agents given for these patients were monotherapy of cephalosporins (25).6%) of the 157 patients who should be hospitalized were high-risk CAP.

High mortality rates may be due to late admission in the course of illness. New and emerging etiologies for community acquired pneumonia with implications for therapy. respectively. 9. Streamlining was done in 54 (45%) and 10 (27%) of mode-rate and high-risk CAP patients. there was a trend for a higher case fatality rate among high-risk patients and a longer hospital stay among those given other agents. pneumoniae bacteremia and possibly in 2 patients with S. Of the 74 sputum specimens studied. In a meta-analysis of prognosis and outcomes of patients with CAP10 overall mortality rates ranged from 5.5 for Windows. 8. 1994. Yates L.5% for ICU patients. Bartlett JG.11 This is consistent with our findings of a case fatality rate among high-risk CAP patients of 37.7% among those not admitted at the ICU. Guidelines from the Infectious Diseases Society of America. it was done in 8 low-risk patients initially given parenteral antibiotics. Empiric Management and Prevention of Community Acquired Pneumonia in Immunocompetent Adults 1998. and initial antimicrobial therapy. 69:307-316. several factors influence one’s decision regarding its management. On the other hand. 7. File TM. 4.A judicious use of bacteriologic studies is important in the management of CAP. Mortality rate for severe CAP remains high. Fine MJ. 2. concomitant life-threatening co-morbidities.15 Although clinical response has been seen with the use of other drugs not recommended by the guidelines it is anticipated that compliance to the guidelines in the future may improve the final outcome of patients with CAP and possibly diminish the cost of management. Statistical Package for Social Sciences. Published guidelines have reiterated the necessity of initial empiric treatment based on the likely pathogen involved. streamlining was unnecessary. Republic of the Philippines. Although many studies and recommendations have been made. Fang GB. host factors. anecdotal experiences. Current concepts: community-acquired pneumonia. only 9 reported a predominant organism. Use of recommended antibiotics was seen in only a minority of patients reviewed. no statistically significant differences were noted in the case fatality rate and the mean duration of hospital stay in those given recommended versus those given other drugs. a positive yield was obtained in more than half of cases and was utilized as bases for treatment in 18 of 26 patients with a positive yield. social and moral issues. 3. Cost considerations favor streamlining of initial parenteral empiric broad-spectrum therapy to a narrowspectrum parenteral agent or an oral agent among patients who show adequate clinical response after 2-3 days. guidelines for management. Medicine 1990. 26:811-838. This indicates that in the majority of sputum specimens studied. Am J Med 1990.14 With the use of recommended agents among minimal and low-risk CAP. Because of the small numbers studied. Chicago: SPSS Inc. or inadequate assessment and inappropriate antibiotics. severely deranged physiologic parameters. Clin Infect Dis 1998. the specimen was inappropriate and no useful information was derived from them. Durrant H. In this retrospective study. However. Health Intelligence Service. N Engl J Med 1995. Community acquired pneumonia in adults. Fine M. Rev Infect Dis 1989.6% among those given other agents and 38. aureus bacteremia. we observed the nonconformity to set guidelines in the majority of cases as also previously noted.6% of mode-rate and 24% of high-risk CAP. assessment of severity. Bartlett JG. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis. Hospitalizaton decisions in patients with community-acquired pneumonia: a prospective cohort study. Community-acquired pneumonia requiring hospitalization: 5 year prospective study. Such factors include cost-effectiveness of the therapy. American Thoracic Society. Orloff J. only 32 (43%) were appropriate and of these. Mandell LA. This may go as high as 47-76%. 6. Mundy LM. 89:713-721. Philippine Health Statistics. Base 7.1% for hospitalized and ambulatory patients to 36. Am Rev Respir Dis 1993. A correlation of the sputum GS was seen in only 5 of S. Marrie TJ. Modification of initial antibiotics due to treatment failure was noted in 6. Breiman RF. Philippine Practice Guidelines Group Infectious Diseases. drug factors (like the influence of pharmaceutical companies). . 5. REFERENCES 1. 11(4):586-599. of the small number of patients with moderate to high-risk CAP with blood cultures. This illustrates the importance of blood cultures in the management of moderate to high-risk CAP. 333:1618-1623. Department of Health. The physician’s management of community-acquired pneumonia has been known to be varied. 1418:1426. The Philippine Clinical Practice Guidelines on the Diagnosis.

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