Thursday, 18 January 2007

Predicting Mortality for Pneumonia

Yesterday, I did my usual conference and I asked my Residents how they would decide whether to admit a patient with pneumonia or to treat them as an outpatient. Moreover, I asked them how long they would treat an uncomplicated typical community acquired pneumonia.

Well, I got some interesting answers, with one reason for admission being the wishes of the family or the patient.

We listed many possible criteria, all of which seemed reasonable, but one Resident quoted that he would use the PORT STUDY CRITERIA to decide whether he would admit a patient. Well, I was surprised and impressed.

The PORT study was described about 10 years ago and it was a Validation Cohort testing the Pneumonia Severity Index Score (Fine et al, NEJM Vol 336, No 4, Pages 243-250) to determine the mortality of patients taking into account history, physical, laboratory and radiographic data.

From the study, the investigators were able to determine whether patients could be safely treated as an outpatient with pneumonia.

Despite this study being 10 years old, at my last hospital in the UK, it was only just being introduced in order to try and reduce inpatient admissions and obviously expenditure!

So, by using the criteria in the above study, the physician has at least some evidence based way, which has been validated, to decide whether sending a patient home with pneumonia is safe.

The next question was how long do you treat a typical community acquired pneumonia?

The Residents quite rightly gave the stock answer of at least a week and some said up to 2 weeks, whereas one Resident said just 5 days. So, there appeared to be a consensus of at least a week for treatment.

However, although UK practices for treating pneumonia are identical to Japan in the length of time, where is the evidence base that treatment for one week is actually the minimum time for treatment???

Well, a paper from a Dutch group published in the British Medical Journal from last year (el Moussaoui et al, BMJ,2006: 332:1355) addressed this question and the investigators looked at 3 day versus 8 day treatment with amoxicillin (yes, we still use this alot in the UK) in mild to moderate-severe pneumonia in the community setting.

The results were quite astounding in that, in those patients who had improvement in their pneumonia after 72 hours and who had their antibiotics stopped, they had the same resolution of their pneumonia as those patients treated for 8 days with the same antibiotic regimen.

Please read this article as it will be most enlightening!

So, it is therefore possible to be able to determine whether it is safe to send patients home or admit them for antibiotic treatment and if mild-moderate pneumonia, then treatment could be provided for just 3 days after which time, if the patient has improved enough, could have treatment stopped and could be reviewed in outpatients or, if an inpatient, could actually go home!

The short period of treatment could be justified to try and reduce bacteria becoming resistant to the antibiotic due to prolonged exposure, it would reduce expense and the possibility of adverse side-effects.

This is quite a controversial way of treating pneumonia and each patient has to be considered on a case-by-case basis as there may be social circumstances or other valid reasons that preclude the patient from returning home.

I would be interesting to know your thoughts-- so please let me know.

THOSE WITH PDAs CAN DOWNLOAD SOFTWARE RUNNING ON PALM OR POCKET PC WHICH IS CALLED PNEUMO CALC (THANKS SHIN-SAN) WHICH IS A CALCULATOR FOR THE PORT STUDY AND IS VERY CONVENIENT AND QUICK FOR MAKING YOUR DECISIONS. IT CAN BE DOWNLODED AT WWW.FREEWAREPPC.COM (ppc) OR WWW.FPPDA.COM (palm)


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