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Abstract:
NYU physicians successfully treat patients with complex cases of pneumonia, but these patients may have difficulty fighting the infection and therefore require prolonged hospitalization, careful management of antibiotic therapy, and treatment of comorbidities. Drs.
Joseph Lowy and
Roger Wetherbee, specialists in pulmonology and infectious disease (ID), lead a taskforce that has been developing guidelines for the treatment of pneumonia. The physicians are investigating the role of sputum testing, early recognition and treatment of comorbidities, ID and pulmonary consults, and the transition from intravenous to oral antibiotic therapy.
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Meeting the Challenge of Complex Cases
This is especially true at NYU Medical Center, where many of the pneumonia patients are elderly, debilitated by chronic illness, or suffer concurrently from another significant ailment that makes the eradication of infection more difficult.
The physicians at NYU meet this challenge: they provide highly effective treatment for these patients, and the recovery rate is excellent. Nonetheless, Drs. Lowy and Wetherbee are dedicated to finding the optimal way to treat pneumonia. Working with other members of the Pneumonia Taskforce, as well as analysts from the Department of Clinical Evaluation, they have been conducting a series of studies to refine the existing clinical guidelines.
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Investigating the Treatment of Pneumonia
Providing Answers: The Pneumonia Guidelines at NYU
Taskforce Seeks Answers to Perplexing Questions
Do You Need to Name the Bug to Kill It?
At NYU, where many patients recover slowly due to advanced age and severe illness, routine efforts to obtain high-quality sputum samples for diagnostic testing may be worthwhile. Since most of NYU's pneumonia patients still exhibit significant symptoms after three days, when sputum culture results would be available, and often remain hospitalized another four to seven days, identification of the infecting organism could have a significant impact on the patient's treatment.
The value of sputum testing is being assessed in a study that began in February 1997 and is scheduled to continue until July. During the study, emergency room staff will routinely procure specimens from patients with a suspected diagnosis of pneumonia. The microbiology lab will culture the specimens and communicate the results to the attending physicians as expeditiously as possible. At the end of the study period, Dr. Lowy, Dr. Wetherbee, and Dr. Philip Tierno, the director of the Medical Center's microbiology lab, will evaluate the quality and usefulness of the sputum tests to determine their impact on clinical practice.
Treating the Patient Who Has a History of Severe Illness
Drs. Lowy and Wetherbee will evaluate proposed guidelines for early detection and treatment of these ailments.
Some suggestions include:
When to Wean the Patient From IV Antibiotics
According to a recent chart-review study, the physicians at NYU have generally been switching patients two or more days after evidence of substantial recovery (improvement in temperature, white blood count, and respiratory function). Drs. Lowy and Wetherbee believe that an earlier transition may often be appropriate. They will continue to evaluate the timing of this transition and refine the guidelines accordingly. They also plan to review the clinical criteria signaling that patients can be discharged safely to complete a course of oral antibiotics at home.
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Potential Benefits of the Current Studies
Routine sputum testing to pinpoint the infectious agent may lead to the more frequent use of precisely targeted antibiotic therapy, which may provide confidence for a timely switch to oral antibiotics and lead to an earlier discharge. Additionally, identifying the causative agent may make it possible to prescribe a more affordable oral antibiotic for home use, increasing the likelihood of patient compliance. More information on pathogens would also clarify the etiology of pneumonia in the community, helping to update the guidelines for initial antibiotic selection.
In addition to preparing the patients for discharge, the switch to oral antibiotic therapy improves patient comfort, eliminates the risks associated with intravenous administration of drugs (inflammation of a vein, clotting, and subcutaneous bleeding), and reduces costs for the remainder of the stay. If feasible, switching patients earlier would improve their hospital stay and expedite their recovery.
Finally, early treatment of any concurrent illness would also improve patient comfort and hasten recovery. It might also further reduce the risk of serious clinical complications during and after the patient's hospital stay.
The Ongoing Battle with Pneumonia
In any case, the Taskforce remains dedicated to the optimization of pneumonia care. They will continue to thoughtfully investigate clinical practice and provide advice to the many physicians who treat patients with pneumonia at NYU.
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The Pneumonia Taskforce (headed by Dr. Joseph Lowy, a pulmonologist, and Dr. Roger Wetherbee, an infectious disease specialist) was convened in November 1995 to optimize the highly effective treatment of community-acquired pneumonia at NYU Medical Center. In April 1996, after analyzing data from NYU and other academic hospitals, the clinical practices of leading institutions, and the professional literature, the Taskforce produced a set of guidelines for the many NYU physicians who treat patients with pneumonia.
Since then, Drs. Lowy and Wetherbee have been working with other Taskforce members to refine the guidelines. As a first step in that process, researchers from the Department of Clinical Evaluation analyzed the medical records of 97 patients treated at NYU for community-acquired pneumonia. In light of the findings, the Taskforce has focused on three issues for further analysis and action. They are studying the possible value of more frequent sputum testing, developing guidelines for the early identification and treatment of respiratory comorbidity, and evaluating the timing of the switch from IV to oral antibiotics.
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Even a common condition like pneumonia is challenging when it strikes a frail, elderly patient who has a chronic heart or lung disease. These complicated pneumonia cases are relatively uncommon at some hospitals but typical at NYU Medical Center: among 97 randomly selected pneumonia cases at NYU, only 20% of the patients had "simple" pneumonia; 80% had complicating conditions.
The treatment of pneumonia can be summarized with one word: antibiotics. But this cursory description does not do justice to the challenges involved. To administer antimicrobials (and supportive care) expertly, a physician must have a sophisticated understanding of both human physiology and microbiology, as well as up-to-date information on the strengths and weaknesses of the many drugs available.
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Physicians have historically considered it essential to identify the infecting organism through sputum testing when treating pneumonia, but many now rely on powerful broad-spectrum antibiotics and only obtain sputum samples if the response to the initial antibiotic is deemed inadequate. The American Thoracic Society has endorsed this empiric approach, but it remains controversial. Indeed, in a review article on pneumonia published in the
New England Journal of Medicine (December, 1995), John Bartlett, MD, states that "few diseases are so characterized by disputes about diagnostic evaluation ...."
Many of the pneumonia patients at NYU have a history of respiratory disease, most often a chronic obstructive pulmonary disease (COPD) such as emphysema or chronic bronchitis, or cardiac conditions such as
congestive heart failure (CHF). These illnesses tend to further debilitate the patient, retard recovery, and made assessment of the patient's progress more complicated.
When a patient has a severe case of pneumonia, the physician will usually administer the antibiotics intravenously (IV) to ensure rapid delivery of the medication; when the patient begins to recover, the doctor can switch the patient to oral antibiotics in preparation for discharge. The conventional wisdom had been that physicians should keep hospitalized pneumonia patients on IV antibiotics until they have been afebrile for at least 24 hours. Various other clinical indicators have been proposed for timing the switch from IV to oral therapy. However, there is a surprising lack of objective information pertaining to the relative merits of different approaches. Consequently, pneumonia patients are switched relatively early at some hospitals, later at others.
The information the Taskforce obtains from these ongoing studies should help physicians at NYU provide the best possible care.
In addition to refining the use of currently available methods for treating pneumonia, the Taskforce will monitor newly emerging technologies. The techniques of molecular biology are theoretically capable of enabling physicians to rapidly and conclusively identify any known pathogen and completely analyze its sensitivity to antimicrobial drugs. Alternatively, molecular biologists may provide physicians with powerful new tools (vaccines, monoclonal antibodies) for preventing pneumonia, which may be increasingly important if the development of new antibiotics does not keep pace with the evolution of drug resistance.
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(NEJM; 23Jan97; Vol. 336, No. 4)
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