Medical Section pf the American Lung Association: Guidelines for the Initial Management of Adults with Community-acquired Pneumonia: Diagnosis, Assessment of Severity, and Initial Antimicrobial Therapy

Niederman, Michael S.; Bass, John B.; Campbell, G. Douglas; Fein, Alan M.; Grossman, Ronald F.; Mandell, Lionel A.; Marrie, Thomas J.; Sarosi, George A.; Torres, Antônio; Yu, Victor L.

doi:10.1164/ajrccm/148.5.1418

Cited by 1,460 publications

(1,483 citation statements)

References 44 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%

“…Particularly, the ability to maintain oral intake, cognitive impairment, and ability to carry out activities of daily living need to be considered. Thus, determination of the initial site of care still remains an 'art of medicine ' decision that, yet, may not be replaced by prediction rules [3].…”

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%

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

et al. 2008

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“…Prior to evaluating antibiotic prescribing practices, the MAI instructions were modified to be more specific to antibiotic therapy guidelines for the management of patients with community-acquired pneumonia (CAP), acute exacerbations of chronic bronchitis (AECB), and sinusitis in CAP, sinusitis, and AECB. [16][17][18][19] In addition, MAI instructions for appropriate antibiotic doses for patients with renal impairment and clinically important antibiotic drug interactions were specified using a standard pharmacotherapy information source. 20 The developer of the instrument (JTH) trained the two clinical pharmacists (CCT and SLA) in the use of the modified MAI.…”

Section: Assessment Using the Medication Appropriateness Indexmentioning

confidence: 99%

Appropriateness of antibiotic prescribing in veterans with community-acquired pneumonia, sinusitis, or acute exacerbations of chronic bronchitis: A cross-sectional study

Tobia

Aspinall

Good

et al. 2008

Clinical Therapeutics

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“…Due to concerns about increasing pneumococcal resistance to penicillin, and to provide coverage for atypical pathogens, the American Thoracic Society and Infectious Disease Society of America now recommend considering the use of a macrolide antibiotic plus high dose beta-lactam antibiotic for the empiric outpatient treatment of community acquired pneumonia. (1)(2)(3)(4) Recent surveillance studies of invasive pneumococcal isolates have demonstrated that only 73% of isolates remain susceptible to penicillin, and 78% susceptible to erythromycin. (5) The use of low dosages and long treatment duration with beta-lactam antibiotics have been identified as risk factors for the nasopharyngeal carriage of penicillin resistant organisms.…”

Section: Introductionmentioning

confidence: 99%

Factors Associated With Antimicrobial Resistance and Mortality in Pneumococcal Bacteremia

Neuman

Kelley

Harper

et al. 2007

The Journal of Emergency Medicine

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We conducted a multicenter, retrospective cohort study of patients with Streptococcus pneumoniae bacteremia to determine factors associated with antibiotic resistance and mortality. Risk factors were identified using multivariate logistic regression. 1,574 patients at 34 sites were enrolled. Compared to isolates from patients not receiving an antibiotic before the index blood culture, patients receiving an antibiotic were less likely to harbor an antibiotic susceptible organism. Susceptibility to penicillin decreased from 78% (95% confidence interval [CI], 75−80) to 49% (95%CI, 39−59); to cefotaxime/ ceftriaxone, from 92% (95%CI, 90−93) to 82% (95%CI, 72−89); and to macrolide, from 84% (95% CI, 82−87) to 55% (95%CI, 41−68). Factors associated with macrolide non-susceptibility include: >24 hours of antibiotic therapy at time of the index culture (odds ratio [OR] 4.0), residing in southern U.S. (OR 1.7), and having an antibiotic allergy (OR 1.7). Harboring an antibiotic non-susceptible strain (OR 1.4) and male sex (OR 1.4) were associated with increased risk of mortality, whereas Black race (OR 0.6) and evidence of focal infection (OR 0.6) were associated with decreased risk.

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Medical Section pf the American Lung Association: Guidelines for the Initial Management of Adults with Community-acquired Pneumonia: Diagnosis, Assessment of Severity, and Initial Antimicrobial Therapy

Cited by 1,460 publications

References 44 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

Appropriateness of antibiotic prescribing in veterans with community-acquired pneumonia, sinusitis, or acute exacerbations of chronic bronchitis: A cross-sectional study

Factors Associated With Antimicrobial Resistance and Mortality in Pneumococcal Bacteremia

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