Guidelines for the management of adult lower respiratory tract infections

Woodhead, Mark

doi:10.1183/09031936.05.00055705

Cited by 683 publications

(642 citation statements)

References 356 publications

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“…Of the recalibrated models, only the PSI was sensitive enough to accurately identify low-risk patients suitable for outpatient management. Three different prediction rules, namely the PSI, CURB65 and CRB65 scores, have been proposed and extensively validated for risk stratification in CAP [3][4][5][6]. All three rules are originally designed to identify patients who are at low risk of death and who may hence qualify for outpatient management.…”

Section: Discussionmentioning

confidence: 99%

“…In comparison with 11 % of low-risk patients according to the recalibrated PSI score, the management of CAP patients was reasonable after all. As outlined by guidelines, mortality prediction rules should be used to support but not replace physician decision-making about outpatient or in-patient management [3,4]. Patients may have rare medical conditions, and patients designated as 'low risk ' may have medical and psychosocial contraindications to outpatient care.…”

Section: Discussionmentioning

confidence: 99%

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Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

et al. 2008

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SUMMARYIn patients with community-acquired pneumonia (CAP) prediction rules based on individual predicted mortalities are frequently used to support decision-making for in-patient vs. outpatient management. We studied the accuracy and the need for recalibration of three risk prediction scores in a tertiary-care University hospital emergency-department setting in Switzerland. We pooled data from patients with CAP enrolled in two randomized controlled trials. We compared expected mortality from the original pneumonia severity index (PSI), CURB65 and CRB65 scores against observed mortality (calibration) and recalibrated the scores by fitting the intercept a and the calibration slope b from our calibration model. Each of the original models underestimated the observed 30-day mortality of 11 %, in 371 patients admitted to the emergency department with CAP (8 . 4%, 5 . 5 % and 5 . 0% for the PSI, CURB65 and CRB65 scores, respectively). In particular, we observed a relevant mortality within the low risk classes of the original models (2 . 6%, 5 . 3%, and 3 . 7% for PSI classes I-III, CURB65 classes 0-1, and CRB65 class 0, respectively). Recalibration of the original risk models corrected the miscalibration. After recalibration, however, only PSI class I was sensitive enough to identify patients with a low risk (i.e. <1%) for mortality suitable for outpatient management. In our tertiary-care setting with mostly referred in-patients, CAP risk scores substantially underestimated observed mortalities misclassifying patients with relevant risks of death suitable for outpatient management. Prior to the implementation of CAP risk scores in the clinical setting, the need for recalibration and the accuracy of low-risk re-classification should be studied in order to adhere with discharge guidelines and guarantee patients' safety.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

et al. 2008

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“…These findings appear to be clinically relevant and plausible as, for example older patients are at higher risk of adverse outcomes from community acquired pneumonia [11]. Patients with previous smoking history are at risk of abnormal lung architecture, COPD and hence atypical bacterial infections [12,13]. Higher BMI may impair clearing of secretions but the mean difference in BMI was only 0.4 between groups which is unlikely to relate to clinical significance.…”

Section: Discussionmentioning

confidence: 99%

“…Further work should be undertaken as these groups may have different needs for drugs and durations for LRTI due to co-morbidities and different lung architecture. Amoxicillin treats Streptococcus pneumoniae , the most common bacterial cause of LRTI, hence our finding of fewer repeat prescriptions after initial amoxicillin therapy could be clinically plausible [12]. Whilst the effect sizes were small, LRTI are very common [9].…”

Section: Discussionmentioning

confidence: 99%

Amoxicillin is associated with a lower risk of further antibiotic prescriptions for lower respiratory tract infections in primary care – A database analysis spanning over 30 years

Stolbrink

Bonnett

Blakey

2018

European Clinical Respiratory Journal

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Antibiotic prescriptions for lower respiratory tract infections occur commonly in primary care but there is uncertainty about the most effective initial treatment strategy. Both increasing antimicrobial resistance and awareness of preventable harm from medicines make resolving this uncertainty a priority. Pragmatic, real-life epidemiological investigations are needed to inform future interventional studies.In this cross-sectional database study we analysed antibiotic prescriptions for non-pneumonic, lower respiratory tract infections (LRTI) in primary care as captured in the Optimum Care Database from 1984 to 2017. The primary outcome was a second antibiotic prescription for a LRTI code within 14 days of index prescription, the secondary outcome further antibiotic prescription for any indication. Only individuals without chronic respiratory diseases were included. We conducted univariable analysis to identify factors associated with repeat prescriptions and generate hypotheses for forthcoming projects.We analysed 367,188 index prescriptions for LRTI. Amoxicillin was the commonest used index drug (65.1%). In 6% a second antibiotic course coded for a further LRTI was prescribed (11.2% without this coding restriction). Further antibiotic prescriptions for LRTI were significantly associated with older age, previous smoking, seven day index courses and not using amoxicillin initially. The largest effect size was seen when amoxicillin was not used as index drug (odds ratio (OR) 1.15, p < 0.001). This would support current prescribing practice for amoxicillin as index drug in those without respiratory disease. Prospective studies are needed to explore the observed differences.

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“…[281][282][283] This may explain the increased antibiotic prescription rate for older people with LRTI, 284 although large trials underpinning the assumption that the elderly will benefit from antibiotic treatment in acute bronchitis are still lacking. 285 Clinical prediction rules to determine high and low risk elderly patients show promise in assisting primary care clinicians to decide who may be managed at home and who need closer monitoring or hospital care. 286,287 Morbidity and mortality from respiratory infections are greater in patients with co-morbidities such as COPD, asthma, diabetes, renal failure, alcohol abuse, and immunosuppression.…”

Section: Vulnerable Subgroups and Co-morbiditiesmentioning

confidence: 99%

The International Primary Care Respiratory Group (IPCRG) Research Needs Statement 2010

Pinnock

Thomas

Tsiligianni

et al. 2010

Primary Care Respiratory Journal

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Guidelines for the management of adult lower respiratory tract infections

Cited by 683 publications

References 356 publications

Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

Amoxicillin is associated with a lower risk of further antibiotic prescriptions for lower respiratory tract infections in primary care – A database analysis spanning over 30 years

The International Primary Care Respiratory Group (IPCRG) Research Needs Statement 2010

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