Predictors of one-year mortality after hospitalization for an exacerbation of COPD.

BACKGROUND: Hospitalization for a severe exacerbation of COPD (eCOPD) is an important event in the natural history of COPD. Identifying factors related to mortality 1 year after hospitalization could help determine interventions to reduce mortality. METHODS: In a prospective, observational, multicentre study, we evaluated data from two cohorts: the Spanish audit of hospital COPD exacerbation care (our derivation sample) and the Spanish cohort of the European audit of COPD exacerbation care (our validation sample). The endpoint was all-cause mortality. Mortality was determined by local research managers of the participating hospitals and matched the official national index records in Spain. RESULTS: In the multivariate analysis, factors independently related to an increase in mortality were older age, cardio-cerebro-vascular and/or dementia comorbidities, PaCO2 > 55 mmHg measured at emergency department arrival, hospitalizations for COPD exacerbations in the previous year, and hospital characteristics. The area under the receiver-operating curve for this model was 0.75 in the derivation cohort and 0.76 in the validation cohort. CONCLUSION: One-year mortality following the index hospitalization for an exacerbation of COPD was related to clinical characteristics of the patient and of the index event, previous events of similar severity, and characteristics of the hospital where the patient was treated.

Age-related differences in management and outcomes in hospitalized healthy and well-functioning bacteremic pneumococcal pneumonia patients: a cohort study.

BACKGROUND: Limited data are available regarding fit and healthy patients with pneumonia at different ages. We evaluated the association of age with clinical presentation, serotype and outcomes among healthy and well-functioning patients hospitalized for bacteremic pneumococcal community-acquired pneumonia. METHODS: We performed a prospective cohort study of consecutive healthy and well-functioning patients hospitalized for this type of pneumonia. Patients were stratified into younger (18 to 64 years) and older (≥65 years) groups. RESULTS: During the study period, 399 consecutive patients were hospitalized with bacteremic pneumococcal pneumonia. We included 203 (50.8%) patients who were healthy and well-functioning patients, of whom 71 (35%) were classified as older. No differences were found in antibiotic treatment, treatment failure rate, antibiotic resistance, or serotype, except for serotype 7F that was less common in older patients. In the adjusted multivariate analysis, the older patients had higher 30-day mortality (OR 6.83; 95% CI 1.22-38.22; P = 0.028), but were less likely to be admitted to the ICU (OR 0.14; 95% CI 0.05-0.39; P < 0.001) and had shorter hospital stays (OR 0.71; 95% CI 0.54-0.94; P = 0.017). CONCLUSIONS: Healthy and well-functioning older patients have higher mortality than younger patients, but nevertheless, ICU admission was less likely and hospital stays were shorter. These results suggest that the aging process is a determinant of mortality, beyond the functional status of patients with bacteremic pneumococcal pneumonia.

Age-related risk factors for bacterial aetiology in community-acquired pneumonia.

BACKGROUND AND OBJECTIVE: The objective of this study was to evaluate the effect of age and comorbidities, smoking and alcohol use on microorganisms in patients with community-acquired pneumonia (CAP). METHODS: A prospective multicentre study was performed with 4304 patients. We compared microbiological results, bacterial aetiology, smoking, alcohol abuse and comorbidities in three age groups: young adults (<45 years), adults (45-64 years) and seniors (>65 years). RESULTS: Bacterial aetiology was identified in 1522 (35.4%) patients. In seniors, liver disease was independently associated with Gram-negative bacteria (Haemophilus influenzae and Enterobacteriaceae), COPD with Pseudomonas aeruginosa (OR = 2.69 (1.46-4.97)) and Staphylococcus aureus (OR = 2.8 (1.24-6.3)) and neurological diseases with S. aureus. In adults, diabetes mellitus (DM) was a risk factor for Streptococcus pneumoniae and S. aureus, and COPD for H. influenzae (OR = 3.39 (1.06-10.83)). In young adults, DM was associated with S. aureus. Smoking was a risk factor for Legionella pneumophila regardless of age. Alcohol intake was associated with mixed aetiology and Coxiella burnetii in seniors, and with S. pneumoniae in young adults. CONCLUSION: It should be considered that the bacterial aetiology may differ according to the patient's age, comorbidities, smoking and alcohol abuse. More extensive microbiological testing is warranted in those with risk factors for infrequent microorganisms.

Streptococcus pneumoniae antigen in urine: diagnostic usefulness and impact on outcome of bacteraemic pneumococcal pneumonia in a large series of adult patients.

BACKGROUND AND OBJECTIVE: Urinary pneumococcal antigen detection provides good results in the diagnosis of pneumococcal pneumonia but has rarely been used in bacteraemic pneumococcal pneumonia and it is not known whether it is associated with outcome in this type of pneumonia. Our objectives were to assess the usefulness of an immunochromatographic technique for detecting the pneumococcal antigen in urine in a large prospective study of patients with bacteraemic pneumococcal pneumonia and explore any potential association with outcomes. METHODS: This study, carried out over 8 years, included all adult immunocompetent patients admitted for bacteraemic pneumococcal pneumonia. An immunochromatographic test for the Streptococcus pneumoniae antigen in urine was performed in the first 24 h. The sensitivity of test was assessed and patients were divided into two groups according to test results to explore differences on admission and during the course of the illness using logistic regression models. RESULTS: Of the 350 patients with bacteraemic pneumococcal pneumonia included, 261 (74.6%) were positive for the antigen. Patient characteristics were very similar on admission and differences in severity (Pneumonia Severity Index) were not statistically significant. In the adjusted analysis, antigen-positive patients had a higher risk of intensive care unit admission, treatment failure and adverse outcome. CONCLUSIONS: The sensitivity of the immunochromatographic urinary antigen test was 74.6% and positive results were associated with poorer clinical outcome. We therefore recommend systematic use of this test when pneumonia is diagnosed in the emergency department.

Influence of changes in physical activity on frequency of hospitalization in chronic obstructive pulmonary disease.

BACKGROUND AND OBJECTIVE: To evaluate whether changes in regular physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) affect the rate of hospitalizations for COPD exacerbation (eCOPD). METHODS: Five hundred forty-three ambulatory clinic patients being treated for COPD were prospectively identified. PA was self-reported by patients, and the level was established by the distance they walked (km/day) at least 3 days per week. Hospitalizations were recorded from hospital databases. All patients with at least a 2-year follow-up after enrollment were included in the analysis. The response variable was the number of hospitalizations for eCOPD within the 3-year period from 2 to 5 years after study enrollment. RESULTS: Three hundred ninety-one survivors were studied. Mean forced expiratory volume in 1 s was 52% (±14%) of the predicted value. Patients who maintained a lower level of PA had an increased rate of hospitalization (odds ratio 1.901; 95% confidence interval 1.090-3.317). After having had the highest level of PA, those patients who decreased their PA in the follow-up showed an increasing rate of hospitalizations (odds ratio 2.134; 95% confidence interval 1.146-3.977). CONCLUSIONS: Patients with COPD with a low level of PA or who reduced their PA over time were more likely to experience a significant increase in the rate of hospitalization for eCOPD. Changes to a higher level of PA or maintaining a moderate or high level of PA over time, with a low intensity activity such as walking for at least 3-6 km/day, could reduce the rate of hospitalizations for eCOPD.

Pneumococcal pneumonia: differences according to blood culture results.

BACKGROUND: Bacteremia by Streptococcus pneumoniae has been traditionally associated with poor outcomes in patients with pneumonia; however, data on its impact on outcomes are limited and are sometimes contradictory. METHODS: We performed a prospective study in two hospitals in northern Spain in which cases diagnosed with pneumococcal pneumonia were selected from a cohort of hospitalized patients with pneumonia between January 2001 and July 2009. We compared patients with pneumococcal bacteremic pneumonia with those with pneumococcal non-bacteremic pneumonia. RESULTS: We compared 492 patients with negative blood culture and 399 with positive culture results. Host related factors were very similar in both groups. Severity of illness on admission measured by CURB-65 score was similar in both groups. Adjusted analysis showed a greater likelihood of septic shock during in-hospital course among patients with pneumococcal bacteremia (OR, 2.1; 95% CI, 1.2-3.5; P=0.006). Likewise, patients with positive blood culture had greater in-hospital mortality (OR 2.1; 95% CI, 1.1- -3.9; P=0.02), 15-day mortality (OR 3.6; 95% CI, 1.7-7.4; P=0.0006), and 30-day mortality (OR, 2.7; 95% CI, 1.5-5; P=0.002). CONCLUSIONS: Although host related factors and severity on admission were very similar in the two groups, bacteremic patients had worse in-hospital course and outcomes. Bacteraemia in pneumococcal pneumonia is of prognostic significance.

Predictive factors of severe multilobar pneumonia and shock in patients with influenza.

PURPOSE: To identify risk factors present at admission in adult patients hospitalised due to influenza virus infection during the 2009/10 and 2010/11 seasons--including whether infection was from pandemic or seasonal influenza A infections--that were associated with the likelihood of developing severe pneumonia with multilobar involvement and shock. METHODS: Prospective cohort study. Patients hospitalised due to influenza virus infection were recruited. We collected information on sociodemographic characteristics, pre-existing medical conditions, vaccinations, toxic habits, previous medications, exposure to social environments, and EuroQoL-5D (EQ-5D). Severe pneumonia with multilobar involvement and/or shock (SPAS) was the primary outcome of interest. We constructed two multivariate logistic regression models to explain the likelihood of developing SPAS and to create a clinical prediction rule for developing SPAS that includes clinically relevant variables. RESULTS: Laboratory-confirmed A(H1N1)pdm09, EQ-5D utility score 7 days before admission, more than one comorbidity, altered mental status, dyspnoea on arrival, days from onset of symptoms, and influenza season were associated with SPAS. In addition, not being vaccinated against seasonal influenza in the previous year, anaemia, altered mental status, fever and dyspnoea on arrival at hospital, difficulties in performing activities of daily living in the previous 7 days, and days from onset of symptoms to arrival at hospital were related to the likelihood of SPAS (area under the curve value of 0.75; Hosmer-Lemeshow p value of 0.84). CONCLUSIONS: These variables should be taken into account by physicians evaluating a patient affected by influenza as additional information to that provided by the usual risk scores.

Microbial aetiology of healthcare associated pneumonia in Spain: a prospective, multicentre, case-control study.

INTRODUCTION: Healthcare-associated pneumonia (HCAP) is actually considered a subgroup of hospital-acquired pneumonia due to the reported high risk of multidrug-resistant pathogens in the USA. Therefore, current American Thoracic Society/Infectious Diseases Society of America guidelines suggest a nosocomial antibiotic treatment for HCAP. Unfortunately, the scientific evidence supporting this is contradictory. METHODS: We conducted a prospective multicentre case-control study in Spain, comparing clinical presentation, outcomes and microbial aetiology of HCAP and community-acquired pneumonia (CAP) patients matched by age (±10 years), gender and period of admission (±10 weeks). RESULTS: 476 patients (238 cases, 238 controls) were recruited for 2 years from June 2008. HCAP cases showed significantly more comorbidities (including dysphagia), higher frequency of previous antibiotic use in the preceding month, higher pneumonia severity score and worse clinical status (Charslon and Barthel scores). While microbial aetiology did not differ between the two groups (HCAP and CAP: Streptococcus pneumoniae: 51% vs 55%; viruses: 22% vs 12%; Legionella: 4% vs 9%; Gram-negative bacilli: 5% vs 4%; Pseudomonas aeruginosa: 4% vs 1%), HCAP patients showed worse mortality rates (1-month: HCAP, 12%; CAP 5%; 1-year: HCAP, 24%; CAP, 9%), length of hospital stay (9 vs 7 days), 1-month treatment failure (5.5% vs 1.5%) and readmission rate (18% vs 11%) (p<0.05, each). CONCLUSIONS: Despite a similar clinical presentation, HCAP was more severe due to patients' conditions (comorbidities) and showed worse clinical outcomes. Microbial aetiology of HCAP did not differ from CAP indicating that it is not related to increased mortality and in Spain most HCAP patients do not need nosocomial antibiotic coverage.

Etiology of community-acquired pneumonia in a population-based study: link between etiology and patients characteristics, process-of-care, clinical evolution and outcomes.

BACKGROUND: The 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. METHODS: To 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. RESULTS: A 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. CONCLUSIONS: Our 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.

BODE-Index vs HADO-score in chronic obstructive pulmonary disease: Which one to use in general practice?

BACKGROUND: Forced expiratory volume in one second (FEV1) is used to diagnose and establish a prognosis in chronic obstructive pulmonary disease (COPD). Using multi-dimensional scores improves this predictive capacity.Two instruments, the BODE-index (Body mass index, Obstruction, Dyspnea, Exercise capacity) and the HADO-score (Health, Activity, Dyspnea, Obstruction), were compared in the prediction of mortality among COPD patients. METHODS: This is a prospective longitudinal study. During one year (2003 to 2004), 543 consecutively COPD patients were recruited in five outpatient clinics and followed for three years. The endpoints were all-causes and respiratory mortality. RESULTS: In the multivariate analysis of patients with FEV1 < 50%, no significant differences were observed in all-cause or respiratory mortality across HADO categories, while significant differences were observed between patients with a lower BODE (less severe disease) and those with a higher BODE (greater severity). Among patients with FEV1 > or = 50%, statistically significant differences were observed across HADO categories for all-cause and respiratory mortality, while differences were observed across BODE categories only in all-cause mortality. CONCLUSIONS: HADO-score and BODE-index were good predictors of all-cause and respiratory mortality in the entire cohort. In patients with severe COPD (FEV1 < 50%) the BODE index was a better predictor of mortality whereas in patients with mild or moderate COPD (FEV1 > or = 50%), the HADO-score was as good a predictor of respiratory mortality as the BODE-index. These differences suggest that the HADO-score and BODE-index could be used for different patient populations and at different healthcare levels, but can be used complementarily.

[Three-month course of rifampicin and isoniazid for the treatment of latent tuberculous infection]. / Pauta de tres meses de rifampicina e isoniacida para el tratamiento de la infección latente tuberculosa.

BACKGROUND AND OBJECTIVES: Isoniazid (I) is the drug of choice for treating latent tuberculous infection (LTI). Duration of treatment with I and its liver toxicity represent a serious drawback for a correct enforceability. In several clinical guides, a 3-month course with rifampicin (Rif) and I is recommended as an acceptable alternative to the 6-9 month course with I. Here we present our experience with this new regimen. PATIENTS AND METHODS: From 2001, the 3-month regimen with Rif and I was offered to patients older than 14 years, who were recruited in the contacts study. A good adherence was considered when the patient manifested so and he/she went to the scheduled monthly controls. We performed baseline liver analyses in those patients at risk of hepatotoxicity and in all patients older than 35 years. In all cases, a liver laboratory control was done at the first month of treatment and whenever patients had symptoms suggestive of intolerance. Databases of tuberculosis controls and contacts were crossed to evaluate the number of individuals who developed tuberculosis. RESULTS: Between 2000 and 2008, treatment for LTI was indicated in 547 contacts (7.8% refused treatment, 34.1% with the 6-month I course, 63.5% with the 3-month Rif and I course and 2.3% with other regimens). A total of 84.97% (147/173) patients with the 6-month I regimen and 92.55% (302/322) with the 3-month Rif and I course fulfilled the treatment (p=0.024). 2.37% (4/169) and 1.6% (5/313) patients with the 6-month I course and 3-month Rif and I course, respectively, withdrew because of hepatotoxicity (p=0.33). There were no patients among those who fulfilled the treatment in any of the 2 study arms. CONCLUSION: There was a higher adherence (statistically significant) and lower hepatotoxicity with the 3-month Rif and I regimen. Both regimens showed a full effectivity.

Pneumonia: criteria for patient instability on hospital discharge.

BACKGROUND: A study was undertaken to identify and weigh at the time of hospital discharge simple clinical variables that could predict short-term outcomes in patients with pneumonia. METHODS: In a prospective observational cohort study of 870 patients discharged alive after hospitalization for pneumonia, we collected oxygenation and vital signs on discharge and assessed mortality and readmission within 30 days. From the beta-parameter obtained in a multivariate Cox proportional hazard regression model, a score was assigned to each predictive variable. The effects of instability at discharge on outcomes within 30 days thereafter were examined by adjusted models with use of the pneumonia severity index at hospital admission, the length of stay, the Charlson comorbidity index, or the preillness functional status. RESULTS: Four variables related to a 30-day mortality rate from all causes were identified in the multivariate model; these included one major criterion (temperature >37.5 degrees C) and three minor criteria (systolic BP < 90 mm Hg or diastolic BP < 60 mm Hg, respiratory rate > 24 breaths/min, and oxygen saturation < 90%). The developed score remained significantly associated with a higher risk-adjusted rate of death. Patients with a score > or = 2 (one major criterion or two minor criteria) had a sixfold-greater risk-adjusted hazard ratio (HR) of death (HR, 5.8; 95% confidence interval, 2.5 to 13.1). CONCLUSIONS: Four criteria of instability on discharge seem to be related to the mortality rate after discharge, but each of the factors must be weighed differently. The resulting score is a simple alternative that can be used by clinicians in the discharge process.

Predictors of mortality in patients with stable COPD.

OBJECTIVES: To 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. DESIGN: Five-year prospective cohort study. SETTING: Five outpatient clinics of a teaching hospital. PARTICIPANTS: Six hundred stable COPD patients recruited consecutively. MEASUREMENTS: The variables were age, FEV(1%), 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. RESULTS: FEV(1%)(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. CONCLUSIONS: Among patients with stable COPD, FEV(1%) 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.

[Longitudinal incidence of tuberculosis in a cohort of contacts: factors associated with the disease]. / Incidencia longitudinal de la tuberculosis en una cohorte de contactos: factores asociados a la enfermedad.

OBJECTIVE: To investigate the incidence of tuberculosis (TB) in a cohort of contacts and to analyze the variables associated with the disease. METHODS: A prospective analysis was undertaken of all the contact investigations carried out in a health district in the Basque Country in northern Spain between January 1, 1995 and December 31, 2004. The dependent variable was the number of cases of TB detected among the contacts. Independent variables were age, sex, tuberculin skin test result, and the degree of contact. In index cases, additional variables were the site of the disease and smear test result. RESULTS: Analysis of 5444 contacts of 596 patients with TB yielded 66 secondary cases of TB (40 at the time of the contact investigation and 26 at a later stage); the majority (73%) developed the disease within 12 months. Multivariate analysis revealed a significant relationship between the detection of secondary cases and the following variables: close contact (odds ratio [OR], 3.05; 95% confidence interval [CI], 1.75-5.31), positive smear test (OR, 8.54; 95% CI, 2.06-35.43), induration of 10 mm or larger (OR, 10.18; 95% CI, 4.27-24.26), and age under 30 years (OR, 3.35; 95% CI, 1.88-5.98). The final predictive model constructed on the basis of these 3 variables had a sensitivity of 77.4%, a specificity of 80.3%, and an area under the curve of 0.83 (95% CI, 0.78-0.88). CONCLUSIONS: The contact investigation is a valid strategy for the detection of new cases of TB. Prophylactic treatment should be implemented at an early stage and priority should be given to young contacts of smear positive patients using an induration size of 10 mm or more as a reference.

Validity Study of Catalan, Galician and Basque Language Versions of the COPD Assessment Test and Equivalence With the Spanish Version. / Estudio de la validez de las versiones en catalán, gallego y vasco del cuestionario COPD assessment test y equivalencia con la versión en castellano.

OBJECTIVES: To assess the linguistic equivalence of the COPD Assessment Test versions in Catalan (CAT-C), Galician (CAT-G) and Basque (CAT-V) with the validated Spanish version (CAT) in COPD patients able to use both official languages. METHODS: Study performed in primary care centers in Catalonia, Galicia and the Basque Country. Half of the patients completed the questionnaire in their local language followed by the CAT in Spanish, while the other half did so in reverse order. RESULTS: 151 COPD patients were included in the study, with a mean age of 69.0 (SD: 9.7) years. Most (79.5%) were men, 11.3% were educated up touniversity level, and 31.8% were current smokers. Mean FEV1 was 61.4% (SD: 16.8) predicted and 83.9% of patients were GOLD grade i or ii. Concordance between CAT-C, CAT-G and CAT-V and CAT was high, with differences between scores from 0.4 to-0.5. Reliability (Cronbach's alpha) ranged from0.72 to0.86. Convergent validity, when correlated with the Medical Research Council Dyspnea scale (P=.003) and Saint George's Respiratory Questionnaire (ICC, r=0.74) scores, was significant. CONCLUSIONS: CAT-C, CAT-G and CAT-V scores were similar to CAT scores, with high correlation and concordance. These results show the equivalence between the validated Spanish CAT and the versionin other languages, so CAT-C, CAT-G and CAT-V can be used in individuals whose main language is Catalan, Galician or Basque.

Use of medication and quality of life among patients with COPD.

STUDY OBJECTIVES: To determine the medications prescribed to patients with chronic obstructive pulmonary disease (COPD) and their relationship to health-related quality of life (HRQL). METHODS: Cross-sectional study of 611 consecutive patients with stable, mild-to-severe COPD who attended at the respiratory service of a single hospital during a 1-year period. HRQL was evaluated using the St. George Respiratory Questionnaire (SGRQ) and the Short Form 36-item (SF-36) questionnaires. Linear regression analysis was used to determine the influence of the number or type of medication on the total SGRQ score, adjusting by disease severity and other relevant variables. RESULTS: Significant differences were observed among the number of drugs prescribed according to dyspnea levels, percentage of predicted FEV1 (FEV1%), SGRQ scores and some areas of SF-36. Fifty-nine percent of patients with an FEV1%>50% were prescribed inhaled corticosteroids (ICS). Those who took an ICS had a worse HRQL than patients with an FEV1%>50% who did not receive ICS. CONCLUSIONS: A relationship exists between the number of medicines prescribed to patients with COPD and their HRQL, measured by the total SGRQ score, after adjustment by severity of the disease. Within the group of patients who should not have been prescribed ICS, there are subgroups that might benefit from this medication.

[Evaluation of clinical practice in patients admitted with community-acquired pneumonia over a 4-year period]. / Evaluación de la práctica clínica en los pacientes ingresados por neumonía adquirida en la comunidad durante un período de 4 años.

OBJECTIVE: Since March 2000 we have been using a clinical practice guideline in the management of patients diagnosed with community-acquired pneumonia (CAP). The objective of this study was to analyze the evolution of quality of care received by these patients. PATIENTS AND METHODS: This was a prospective observational study comparing the process of care and outcomes of 4 consecutive 1-year periods (March 1, 2000 through February 29, 2004) in patients admitted for CAP. RESULTS: Over the 4 years studied, the following statistically significant trends were observed: reductions in hospital admissions (P< .001), length of hospital stay (P< .05), and total duration of antibiotic treatment (P< .05); and increases in the coverage of atypical pathogens (P< .001) and administration of antibiotics within 8 hours of hospital arrival (P< .001). No significant differences were found in readmissions within 30 days, or in-hospital and 30-day mortality. Two other areas for improvement were also identified: a low percentage of admissions to the intensive care unit (4.4%) and the rate of unnecessary hospitalization of low-risk patients (36.8%). CONCLUSIONS: Systematic monitoring of the indicators of our clinical guidelines provided us with information about our clinical practice and facilitated an evaluation of the same. Many of these indicators were found to have evolved favorably and areas of improvement were identified.

Outcomes of a telemonitoring-based program (telEPOC) in frequently hospitalized COPD patients.

BACKGROUND: The increasing prevalence of chronic diseases requires changes in health care delivery. In COPD, telemedicine appears to be a useful tool. Our objective was to evaluate the efficacy (in improving health care-resource use and clinical outcomes) of a telemonitoring-based program (telEPOC) in COPD patients with frequent hospitalizations. MATERIALS AND METHODS: We conducted a nonrandomized observational study in an intervention cohort of 119 patients (Galdakao-Usansolo Hospital) and a control cohort of 78 patients (Cruces Hospital), followed up for 2 years (ClinicalTrials.gov identifier: NCT02528370). The inclusion criteria were two or more hospital admissions in the previous year or three or more admissions in the previous 2 years. The intervention group received telemonitoring plus education and controls usual care. RESULTS: Most participants were men (13% women), and the sample had a mean age of 70 years, forced expiratory volume in 1 second of 45%, Charlson comorbidity index score of 3.5, and BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index score of 4.1. In multivariate analysis, the intervention was independently related to lower rates of hospital admission (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.27-0.54; P<0.0001), emergency department attendance (OR 0.56, 95% CI 0.35-0.92; P<0.02), and 30-day readmission (OR 0.46, 95% CI 0.29-0.74; P<0.001), as well as cumulative length of stay (OR 0.58, 95% CI 0.46-0.73; P<0.0001). The intervention was independently related to changes in several clinical variables during the 2-year follow-up. CONCLUSION: An intervention including telemonitoring and education was able to reduce the health care-resource use and stabilize the clinical condition of frequently admitted COPD patients.

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.

Chronic Obstructive Pulmonary Disease Subtypes. Transitions over Time.

BACKGROUND: Although subtypes of chronic obstructive pulmonary disease are recognized, it is unknown what happens to these subtypes over time. Our objectives were to assess the stability of cluster-based subtypes in patients with stable disease and explore changes in clusters over 1 year. METHODS: Multiple correspondence and cluster analysis were used to evaluate data collected from 543 stable patients included consecutively from 5 respiratory outpatient clinics. RESULTS: Four subtypes were identified. Three of them, A, B, and C, had marked respiratory profiles with a continuum in severity of several variables, while the fourth, subtype D, had a more systemic profile with intermediate respiratory disease severity. Subtype A was associated with less dyspnea, better health-related quality of life and lower Charlson comorbidity scores, and subtype C with the most severe dyspnea, and poorer pulmonary function and quality of life, while subtype B was between subtypes A and C. Subtype D had higher rates of hospitalization the previous year, and comorbidities. After 1 year, all clusters remained stable. Generally, patients continued in the same subtype but 28% migrated to another cluster. Together with movement across clusters, patients showed changes in certain characteristics (especially exercise capacity, some variables of pulmonary function and physical activity) and changes in outcomes (quality of life, hospitalization and mortality) depending on the new cluster they belonged to. CONCLUSIONS: Chronic obstructive pulmonary disease clusters remained stable over 1 year. Most patients stayed in their initial subtype cluster, but some moved to another subtype and accordingly had different outcomes.