Efficacy and safety of oral and early-switch therapy for community-acquired pneumonia: a randomized controlled trial.

PURPOSE: We sought to determine the safety, efficacy, and cost of oral therapy for patients with community-acquired pneumonia. In patients with nonsevere pneumonia, conventional (parenteral) treatment was compared with the oral route; in patients with severe pneumonia, conventional treatment was compared with early switch from parenteral to oral therapy. SUBJECTS AND METHODS: We randomly assigned 85 hospitalized patients with nonsevere pneumonia to one of two groups: 41 received oral antimicrobials from admission, and 44 received parenteral antimicrobials until they had been afebrile for 72 hours before switching to oral treatment. We randomly assigned 103 patients with severe pneumonia who had initially been treated with parenteral antimicrobials to one of two groups: 48 were switched to oral therapy after 48 hours of treatment (early switch), and 55 received a full 10-day course of parenteral antibiotics. RESULTS: Among patients with nonsevere pneumonia, there were no deaths in the oral treatment group, and one death (2%) in the parenteral treatment group (95% confidence interval [CI] for between-group [oral minus parenteral] difference: -7% to 2%, P = 0.3). The time to resolution of morbidity was < or =5 days in 34 (83%) patients in the oral treatment group and 39 (88%) patients in the parenteral treatment group (P = 0.5); there were treatment failures in 4 (10%) patients in the oral treatment group and 14 (32%) patients in the parenteral treatment group (P = 0.02). Among patients with severe pneumonia, there was one (2%) death in the early-switch group and no deaths in the full course of parenteral antibiotics groups (95% CI for between-group [early switch vs. full course] difference: -2% to 6%, P = 0.5). The time to resolution of morbidity was < or =5 days in 38 (79%) patients in the early-switch group and 41 (75%) in the full-course group (P = 0.3). There were 12 (25%) treatment failures in the early-switch group and 13 (24%) in the full-course group (P = 0.9). There were fewer adverse events in the oral and early-switch groups, primarily due to lower rates of infusion-related phlebitis. Significant cost savings, mainly due to a shorter hospitalization, occurred among patients with severe pneumonia in the early-switch group. CONCLUSION: Inpatients with nonsevere community-acquired pneumonia can be effectively and safely treated with oral antimicrobials from the time of admission, whereas those with severe pneumonia can be treated with early-switch therapy.

Differential diagnosis between community-acquired pneumonia and non-pneumonia diseases of the chest in the emergency ward.

Background: The differential diagnosis of community-acquired pneumonia and some non-pneumonia diseases involving the chest may sometimes be cumbersome. Adding some objective variables to the diagnostic strategy may be helpful.We evaluated the main objective variables that are usually available in the emergency ward and that may be valuable in this differential diagnosis. Methods: We recorded epidemiological, clinical, and analytical data, as well as that obtained from physical examination, from 284 consecutive patients diagnosed in the emergency ward as having community-acquired pneumonia. The diagnosis was reviewed by the investigators applying pre-set diagnostic criteria. Statistical analysis was then performed comparing data from patients with a definitive diagnosis of community-acquired pneumonia with those with a final diagnosis of non-pneumonia disease excluding acute exacerbations of chronic bronchitis. Results: In the univariate analysis, C-reactive protein (difference of means 93 mg/l; 95% C.I. 47, 140), erythrocyte sedimentation rate (d.m. 19 mm/h; 95% C.I. 3, 35), leukocyte count (d.m. 3.5x10(9)/l; 95% C.I. 0.5, 6.4), and temperature (d.m. 0.5 degrees C; 95% C.I. 0.1, 0.9) discriminated between community-acquired pneumonia and non-pneumonia diseases. In the multivariate analysis, only C-reactive protein remained in the equation. Conclusions: C-reactive protein, erythrocyte sedimentation rate, leukocyte count, and temperature were measurable variables that proved to be useful in the differential diagnosis between community-acquired pneumonia and non-pneumonia diseases. C-reactive protein appears to be the most suitable for this purpose.

[Prospective study of 198 community acquired pneumonias in a general hospital]. / Estudio prospectivo de 198 neumonías adquiridas en la comunidad atendidas en un hospital general.

BACKGROUND: Pneumonia is a common medical problem with a significant mortality and morbidity. It is the leading infectious disease in hospital admissions. We conducted a one year prospective study of the patients over 14 years of age that had been diagnosed of community-acquired pneumonia in our institution. The objective was to determinate the clinical characteristics and the aetiological agents of pneumonia in our geographic area and to know which factors are related with the evolution and prognosis of this disease. PATIENTS AND METHODS: A medical team evaluated and followed-up all the patients diagnosed of community-acquired pneumonia. Epidemiological, clinical, radiological and laboratory data were recorded. An attempt to obtain an aetiological diagnosis was done by means of sputum, blood cultures and serologic studies at admission and between third and fourth week later. In individualized patients invasive techniques were performed. We classified the patients in five groups according to previous criteria defined in the guidelines of our hospital based in age, the presence of an underlying disease and the severity in the initial presentation. RESULTS: 274 patients received an initial diagnosis of pneumonia, in 76 (28%) this initial diagnosis was not confirmed. The mean age of the remaining 198 was 55 years. 62% were men. 40% had an identifiable microbiological etiology. The main causal microorganism was Streptococcus pneumoniae followed by Mycoplasma pneumoniae. Gram stain and sputum culture were the most useful laboratory tests for the aetiological diagnosis. Blood cultures and serological test had a lower efficiency. There was no relationship between the clinical presentation, typical or atypical pneumonia, and the causal microorganism. Complications developed in 11% of the patients and the mortality rate was of 3%. CONCLUSIONS: There was a high rate of initial erroneous diagnoses of pneumonia. The epidemiological, clinical and roentgenographic characteristics were similar to other studies conducted in our country with a lower number of microbiological agents identified. Patients who were admitted at hospital only because their age or the presence of chronic disease had a good evolution. In this series patients with severe presentation also had a good prognosis. It would be interesting to investigate about which parameters could be useful as indicators of prognosis and evolution at initial presentation of pneumonia.

[16 cases of infection by Cryptococcosis neoformans in patients with AIDS]. / Estudio de 16 casos de infección por Cryptococcus neoformans en pacientes con SIDA.

Sixteen patients with AIDS (6% of the total AIDS patients) who had infection by Cryptococcus neoformans were studied. Most of these patients (94%) had cryptococcal meningitis. Only 50% of the cases showed clinical manifestations of neurological involvement. Blood cultures and antigen level measurement were the diagnostic techniques with best results due to their high percentage of positivity. Sixty nine percent of patients survived the acute phase of the infection and only 3 of those who died in this period showed evidence of active infection patients by the fungus.