[Antibiotic treatment onset delay and clinical evolution in admitted patients with community-acquired pneumonia]. / Demora del tratamiento antibiótico y evolución de los pacientes con neumonía adquirida en la comunidad que requieren hospitalización.

BACKGROUND AND OBJECTIVE: The delay in the initiation of antibiotic treatment in patients with community-acquired pneumonia (CAP) could influence their prognostic. The aim of our study was to evaluate the influence of a delay in antibiotic treatment on mortality, occurrence of complications, and length of stay in the hospital, in relation to the prior duration of the fever. PATIENTS AND METHOD: This is a cohort study which includes all patients over 18 years of age admitted with CAP over a 4 year period. The response variables analysed were in-hospital mortality, average stay in days and occurrence of complications during evolution. The relationship between the delay in antibiotic treatment and the outcome variables was estimated by logistic regression models, adjusting the estimations by PSI (Pneumonia Severity Index) and APACHE II (Acute Physiology and Chronic Health Evaluation). RESULTS: Six hundred fifty-nine patients were included (average age of 71 years, 71% males). Seventy-six (11.6%) patients died, 12.1% of those who arrived after 48 hours (55.4% of patients) and 10.9% of those who came early. The delay in antibiotic treatment was associated with a higher mortality (odds ratio [OR] = 3.05; 95% confidence interval [CI], 0.86-10.9; threshold of 8 h), prolonged stay (OR = 2.38; CI 95%, 1.11-5.14; threshold of 5 h) and a higher rate of complications (OR = 2.24; CI 95%, 0.90-5.53; threshold of 3 h). CONCLUSIONS: Our results suggest the importance of the early administration of antibiotics in patients with CAP. There is also an increased risk for each of these outcomes in those patients with a history of fever of more than 2 days before arriving in hospital.

Demora del tratamiento antibiótico y evolución de los pacientes con neumonía adquirida en la comunidad que requieren hospitalización / Antibiotic treatment onset delay and clinical evolution in admitted patients with community-acquired pneumonia

Fundamento y objetivo: La demora del tratamiento antibiótico en pacientes con neumonía adquirida en la comunidad (NAC) puede influir en su pronóstico. El objetivo del estudio ha sido estimar la influencia del retraso en el tratamiento antibiótico sobre la mortalidad, la estancia hospitalaria y la aparición de complicaciones, teniendo en cuenta la duración previa de la fiebre. Pacientes y método: Se trata de un estudio de cohortes en pacientes mayores de 18 años que ingresaron por NAC durante un período de 4 años. La relación entre la demora del tratamiento (para diferentes umbrales) y las variables de respuesta (mortalidad, estancia prolongada y complicaciones) se estimó mediante regresión logística, ajustando por la gravedad inicial. Resultados: Incluimos a 659 pacientes (un 71% varones), con una edad media de 71 años. Fallecieron 76 (11,6%), un 12,1% de los que acudieron con más de 2 días de fiebre (el 55,4% de los pacientes) y un 10,9% de los que acudieron precozmente. La demora del tratamiento antibiótico se asoció con un incremento de la mortalidad (odds ratio [OR] = 3,05; intervalo de confianza [IC] del 95%, 0,86-10,9; umbral de 8 h), una estancia prolongada (OR = 2,38; IC del 95%, 1,11-5,14; umbral de 5 h) y una mayor incidencia de complicaciones (OR = 2,24; IC del 95%, 0,90-5,53; umbral de 3 h). Las asociaciones fueron de mayor magnitud en los casos con fiebre de más de 48 h. Conclusiones: Nuestros resultados apoyan la importancia de la administración precoz de antibióticos en los pacientes con NAC. El incremento del riesgo es mayor si la demora del tratamiento se asocia a una duración previa de la fiebre superior a 2 días

Background and objective: The delay in the initiation of antibiotic treatment in patients with community-acquired pneumonia (CAP) could influence their prognostic. The aim of our study was to evaluate the influence of a delay in antibiotic treatment on mortality, occurrence of complications, and length of stay in the hospital, in relation to the prior duration of the fever. Patients and method: This is a cohort study which includes all patients over 18 years of age admitted with CAP over a 4 year period. The response variables analysed were in-hospital mortality, average stay in days and occurrence of complications during evolution. The relationship between the delay in antibiotic treatment and the outcome variables was estimated by logistic regression models, adjusting the estimations by PSI (Pneumonia Severity Index) and APACHE II (Acute Physiology and Chronic Health Evaluation). Results: Six hundred fifty-nine patients were included (average age of 71 years, 71% males). Seventy-six (11.6%) patients died, 12.1% of those who arrived after 48 hours (55.4% of patients) and 10.9% of those who came early. The delay in antibiotic treatment was associated with a higher mortality (odds ratio [OR] = 3.05; 95% confidence interval [CI], 0.86-10.9; threshold of 8 h), prolonged stay (OR = 2.38; CI 95%, 1.11-5.14; threshold of 5 h) and a higher rate of complications (OR = 2.24; CI 95%, 0.90-5.53; threshold of 3 h). Conclusions: Our results suggest the importance of the early administration of antibiotics in patients with CAP. There is also an increased risk for each of these outcomes in those patients with a history of fever of more than 2 days before arriving in hospital

Plasma d-dimer levels correlate with outcomes in patients with community-acquired pneumonia.

STUDY OBJECTIVES: The aim of this study was to investigate the prognostic value of plasma d-dimer levels in patients with community-acquired pneumonia (CAP). DESIGN: Prospective observational study. SETTING: Hospital Lluis Alcanyis of Xativa, Spain. PATIENTS: Consecutive adult patients admitted to the hospital with CAP from January 2000 to October 2002. MEASUREMENTS AND RESULTS: A total of 302 patients were included. Plasma d-dimer was measured using an automated latex assay. The relationships between plasma d-dimer and prognostic variables included in the pneumonia severity index (PSI) were examined using univariate and multivariate linear and logistic regression analyses. d-Dimer levels were negative (ie, < 500 ng/mL) in 16.9% of the patients. In nonsurvivors, the d-dimer plasma level mean value was 3,786 ng/mL, while in survivors it was 1,609 ng/mL (p < 0.0001). A significant relationship was found between the presence of elevated d-dimer levels and the PSI and APACHE (acute physiology and chronic health evaluation) II score. Elevated d-dimer levels were associated with radiologic pneumonia extension. The d-dimer predictive value for mechanical ventilation therapy showed an area under the curve of 0.78 (95% confidence interval, 0.71 to 0.81). CONCLUSIONS: d-Dimer plasma levels could be useful for predicting clinical outcome in patients with CAP.

[Validation of the Pneumonia Severity Index for hospitalizing patients with community-acquired pneumonia]. / Validación del Pneumonia Severity Index en la hospitalización de los pacientes con neumonía adquirida en la comunidad.

BACKGROUND AND OBJECTIVE: Our main objective was to assess the utility of the Pneumonia Severity Index (PSI) to decide the site of care home or hospital of patients with community-acquired pneumonia (CAP). PATIENTS AND METHOD: All CAP patients who came to the emergency department from 1 January to 31 December, 2000, were prospectively assessed with a protocol based on the PSI and additional admission criteria applied to classes I, II and III. Mortality within 30 days and poor outcome were used as endpoints. We tested the diagnostic efficacy of the PSI scale in predicting mortality or unfavourable events by calculating the area below the ROC curve. RESULTS: Of the 243 CAP patients included, 124 (51%) belonged to classes I, II and III, and 119 (49%) belonged to classes IV and V. One hundred and fifty six (64%) patients were admitted. Fifteen (6.2%) patients died, all of them belonging to classes IV and V. Forty four (18%) patients showed a poor outcome. Only one patient who was initially sent home had a poor outcome. The prognostic value of the PSI scale to predict mortality (ROC = 0.92; CI 95%, 0.88-0.95) was high. CONCLUSIONS: Our results confirm that the PSI scale is a good prognostic index in clinical practice for predicting mortality due to CAP. In order to use the PSI to decide the site of care of patients with CAP, not only the score obtained but also additional factors should be taken into account.