Initial diagnosis and management of adult community-acquired pneumonia: a 5-day prospective study in Shanghai

Abstract

Background: Despite the release of a national guideline in 2016, the actual practices with respect to adult community-acquired pneumonia (CAP) remain unknown in China. We aimed to investigate CAP patient management practices in Shanghai to identify potential problems and provide evidence for policy making.

Methods: A short-period, 5-day prospective cross-sectional study was performed with sampled pulmonologists from 36 hospitals, encompassing all the administrative districts of Shanghai, during January 8-12, 2018. The medical information was recorded and analyzed for the patients with the diagnosis of CAP who were cared for by 46 pulmonologists during the study period.

Results: Overall, 435 patients were included in the final analysis, and 94.3% had a low risk of death in terms of CRB-65 criteria (C: disturbance of consciousness, R: respiratory rate, B: blood pressure, 65: age). When diagnosed with CAP, 70.1% of patients were not evaluated using the CURB-65 score (CRB-65 + U: urea nitrogen), but most patients (95.4%) were evaluated using CRB-65. Time to achieve clinical stability was longer in patients with hypoxemia than in those without hypoxemia (8.42±6.36 vs. 5.53±4.12 days, P=0.004). Overall, 84.4% of patients with a CRB-65 score of 0 were administered antibiotics intravenously, and 19.4% were still hospitalized after excluding hypoxemia and comorbidities. The average duration of antibiotic treatment was 10.4±4.9 days. Overall, 72.6% of patients received antibiotics covering atypical pathogens whose time to clinical stability was significantly shortened compared with those without coverage, but the antibiotic duration was similar and not correspondingly shortened.

Conclusions: CRB-65 seems to be more practical than CURB-65 for the initial evaluation of CAP in the context of local practice, and oxygenation assessment should be included in the evaluation of severity. Overtreatment may be relatively common in patients at low risk of death, including unreasonable hospitalization, intravenous administration, and antibiotic duration.

Keywords: CRB-65; Community-acquired pneumonia (CAP); antibiotic overuse; cross-sectional study.

Figure 1

CRB-65 was more practical than CURB-65 in different settings and departments. In the emergency room, respiratory outpatient departments, and general outpatient departments, the use of CRB-65 was consistently more than that of CURB-65. The difference in the usage rates was analyzed using Pearson’s Chi-Squared test. CRB-65 and CURB-65, C: disturbance of consciousness, U: urea nitrogen, R: respiratory rate, B: blood pressure, 65: age. Y, having the corresponding assessment; N, not having the corresponding assessment; Respiratory D., respiratory department; Non-respiratory D., non-respiratory department; OD, outpatient department; ER, emergency room.

Figure 2

Patients receiving atypical coverage therapy have shorter recovery time but similar treatment course compared with those having uncovered therapy. For patients who had only oral antibiotics, the value of their I.V. antibiotic treatment course was zero. Mann-Whitney U tests were adopted to compare the two groups. I.V., intravenous administration.