Management of patients with community-acquired pneumonia in a primary carehospital: a critical evaluation

The aim of the study was to evaluate routine management of patients with co mmunity-acquired pneumonia (CAP) with regard to severity patterns, diagnost ic approaches and results, as well as initial empiric antimicrobial treatme nt and its impact on outcome. Two hundred and thirty-two consecutive patients with CAP admitted to a prim ary care hospital were studied prospectively. Patients were classified acco rding to Fine's severity score. Severe pneumonia was defined as admission a t the ICU. Diagnostic approaches and initial antimicrobial treatment were j udged according to the guidelines of the European Respiratory Society (ERS) . Fifty-five patients (24%) had mild, 156 (67%) moderate, and 21 (9%) severe CAP. At least one microbial examination was performed in 124 patients (54%) . There was no association between microbial investigation and severity of CAP. Inadequate initial antimicrobial treatment was significantly more freq uent in severe (18/21, 86%), than in mild (5/55, 9%) and moderate CAP (39/1 56, 25%, P < 0.0001). Conversely, antimicrobial overtreatment occurred sign ificantly more often in mild (30/55, 55%) and moderate (77/156, 49%) than i n severe CAP (0/21, 0%, P < 0.0001). Inadequate initial antimicrobial treat ment was more frequent in non-responders [18/62 (29%) ps. 31/170, (18%), RR 1.6 95% CI 0.9-2.6, P = 0.07] and was associated with a longer duration of hospitalization (17 +/- 11 rs. 14 +/- 8 days, P=0.03). Mortality was not a ffected by inadequate initial antimicrobial treatment [5/62 (8%) cs. 10/170 (6%), RR 1.4 95% CI 0.5-3.9, P = 0.55]. Principal conceptual weaknesses which might be subject to intervention were (1) the hospitalization of patients with mild pneumonia at low risk of mor tality; (2) the lack of association between microbial investigation and sev erity of CAP; (3) antimicrobial overtreatment of patients with non-severe C AP; and (4) inadequate antimicrobial treatment with increased number of pri mary treatment failures and duration of hospitalization.