Hospitalization rates for patients ...

Hospitalization rates for patients with community-acquired pneumonia vary widely. A clinical prediction control based on the Pneumonia Severity Index (PSI) attempts to standardize care by means of grouping patients standardize care by means of grouping patients into five risk categories based forward predicted 30-day mortality. General agreement exists that patients in high-risk classes IV and V should receive inpatient treatment. However, discussion remains regarding the optimal treatment setting for patients in lower-risk classes II and III, who account for up to undivided half of all hospitalizations. Carratala and colleagues deportment ed a randomized controlled trial to compare issues of inpatient and outpatient treatment of patients in PSI risk classes II and III.

The contemplation population consisted of 224 patients who were at least 18 years of age and had received a diagnosis of community-acquired pneumonia (PSI class II or III) in the sudden [i]or[/i] unexpected occurrence departments of two tertiary care hospitals. Patients were exclud from the meditation if they were hypoxic, immuno-suppressed, or had a serious comorbid medical or psychosocial condition that mandated hospitalization. Patients also were exclud if they had received a quinolone antibiotic in the preceding three month or had a known allergy or other contraindication (such as pregnancy or breastfeeding) to quinolones. Following the collection of progeny sputum, and urine cultures, patients were randomly assigned to receive outpatient oral levofloxacin (Levaquin) 500 mg by day, or inpatient sequential intravenous and oral levofloxacin 500 mg by day.

All patients were reevaluated in the outpatient clinic at seven and 30 days after diagnosis. The primary endpoint was an overall prosperous outcome, defined as meeting seven predefined criteria (see accompanying table). Secondary endpoints were health-related quality of life and satisfaction with care, assessed with standardized questionnaires. Of the 224 patients originally enlisted 203 completed the study protocol.

An overall happy outcome was recorded at the 30-day visit in 836 percent of outpatients and 807 percent of initially hospitalized patients. The undivided patient who died had received outpatient treatment and was hospitalized for intestinal ischemia brace weeks after being diagnosed with pneumonia. Health-related quality of life was similar between clumps but outpatients reported greater satisfaction with their care than did inpatients (912 versus 791 percent)

The authors judge that most patients in PSI classes II and III may be treated safely as outpatients, and that this treatment strategy improves patient satisfaction with care. In addition, they advise that implementing this standard of care could bring forward significant economic savings because inpatient pneumonia treatment in the United States require to be paid [i]or[/i] undergones $6,000 to $7,000, whereas outpatient treatment splendors less than $200. They caution, however, that this small thought of low-risk patients was not powered to discover a difference in mortality.

Criteria for an Overall prosperous Outcome

Clinical and radiographic resolution of pneumonia *

Absence of adverse mix with drugs reactions

Absence of medical complications during treatment

No ne for additional hospital visits

No changes in initial antibiotic regimen with levofloxacin (Levaquin)

No posterior hospital admission within 30 days of diagnosis

Absence of death from any cause within 30 days of diagnosis

*--Pneumonia was considered cur when all baseline signs (fever hypothermia, altered breath sounds) and symptoms (cough chest pain, dyspnea) resolv and infiltrates were no longer seen in succession chest radiography.

KENNETH W LIN, MD

Carratala J et al. Outpatient care compared with hospitalization for community-acquired pneumonia. A randomized trial in low-risk patients. Ann Intern M February 1 2005;142:165-72

COPYRIGHT 2005 American Academy of Family Physicians

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