Clinical Evidence: A Publication of BMJ Publishing Group
Am Fam Physician. 2002 Jul 1;66(1):135-138.
What are the effects of antibiotics in outpatient settings?
What are the effects of treatments in people admitted to the hospital?
What are the effects of treatments in people in intensive care?
What are the effects of guidelines?
What are the effects of preventive interventions?
Summary of Interventions
Summary of Interventions
Likely to be beneficial
Prompt administration of antibiotics in people severely ill with community-acquired pneumonia
Specific combinations of antibiotics in intensive care settings
Guidelines for treating pneumonia (for clinical outcomes)
Unlikely to be beneficial
New antibiotics versus older antibiotics in outpatient settings, unless microbes are resistant to older drugs
New antibiotics versus older antibiotics in the hospital, unless microbes are resistant to older drugs
Intravenous antibiotics versus oral antibiotics in immunocompetent people in the hospital without a life-threatening illness
Pneumococcal vaccine in immunocompetent adults
Likely to be beneficial
Influenza vaccine in elderly people
Pneumococcal vaccine in chronically ill, immunosuppressed, or elderly people
Related topics covered in Clinical Evidence
Antivirals for influenza
To be covered in future issues of Clinical Evidence
Other antiviral treatments
Community-acquired pneumonia is pneumonia contracted in the community rather than in the hospital.
In the northern hemisphere, community-acquired pneumonia affects about 12 per 1,000 people a year, particularly during winter and at the extremes of age (incidence: <1 year of age, 30 to 50 per 1,000 a year; 15 to 45 years of age, 1 to 5 per 1,000 a year; 60 to 70 years of age, 10 to 20 per 1,000 a year; 71 to 85 years of age, 50 per 1,000 a year).1–6
Severity varies from mild to life-threatening illness within days of the onset of symptoms. One systematic review (search date 1995, 33,148 people) of prognosis studies for community-acquired pneumonia found overall mortality to be 13.7 percent, ranging from 5.1 percent for ambulant people to 36.5 percent for people requiring intensive care.9 The following prognostic factors were significantly associated with mortality: male sex (overall risk [OR]: 1.3; 95 percent confidence interval [CI]: 1.2 to 1.4); pleuritic chest pain (OR: 0.5; 95 percent CI: 0.3 to 0.8 [i.e., lower mortality]); hypothermia (OR: 5; 95 percent CI: 2.4 to 10.4); systolic hypotension (OR: 4.8; 95 percent CI: 2.8 to 8.3); tachypnea (OR: 2.9; 95 percent CI: 1.7 to 4.9); diabetes mellitus (OR: 1.3; 95 percent CI: 1.1 to 1.5); neoplasticdisease (OR: 2.8; 95 percent CI: 2.4 to 3.1); neurologic disease (OR: 4.6; 95 percent CI: 2.3 to 8.9); bacteremia (OR: 2.8; 95 percent CI: 2.3 to 3.6); leukopenia (OR: 2.5; 95 percent CI: 1.6 to 3.7); and multilobar radiographic pulmonary infiltrates (OR: 3.1; 95 percent CI: 1.9 to 5.1).
Treatment: to cure infection; to prevent death; to alleviate symptoms; to enable return to normal activities; and to prevent recurrence, while minimizing adverse effects of treatments. Prevention: to prevent onset of pneumonia.
Clinical cure (defined as return to premorbid health status); relief of symptoms; admission to hospital; complications (empyema, endocarditis, lung abscess); death; adverse effects of antibiotics.
ANTIBIOTICS IN OUTPATIENTS
One systematic review comparing different oral antibiotics in outpatient settings has found cure or improvement in more than 90 percent of people.
ANTIBIOTICS IN HOSPITALIZED PATIENTS
Randomized controlled trials (RCTs) found no significant difference between new and older antibiotics in cure of people with community-acquired pneumonia admitted to the hospital. However, most trials were small and were designed to show equivalence between treatments rather than superiority of one over another.
INTRAVENOUS VS. ORAL ANTIBIOTICS
Two RCTs found that, in immunocompetent people admitted to the hospital who were not suffering from life-threatening illness, intravenous antibiotics were no more effective than oral antibiotics and increased the length of hospital stay.
One unblinded RCT found limited evidence that bottle blowing physiotherapy (blowing bubbles via a narrow tube inserted in water) plus early mobilization plus encouragement to regularly sit up and take deep breaths versus early mobilization alone significantly reduced hospital stay.
ANTIBIOTICS IN ICU PATIENTS
We found no RCTs comparing one combination of antibiotics versus another in intensive care units.
EARLY VS. LATE ANTIBIOTICS
Two retrospective studies found that prompt administration of antibiotics significantly improved survival.
One systematic review comparing a guideline incorporating early switch from intravenous to oral antibiotics and/or early discharge strategies versus usual care has found no significant difference in clinical outcomes.
One RCT found that influenza vaccine versus placebo significantly reduced the incidence of influenza in people 60 years and older. Another RCT found that intranasal live vaccine plus parenteral vaccine versus parenteral vaccine alone significantly reduced the incidence of influenza A in elderly people. Two RCTs found that the offer of vaccination of health care workers versus no offer of vaccination significantly reduced mortality in elderly people in long-term care hospitals.
One systematic review has found that pneumococcal vaccination versus no vaccination significantly reduces pneumococcal pneumonia in immunocompetent people, but found no significant difference between pneumococcal vaccination versus no vaccination in elderly people or people likely to have an impaired immune system.
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8. Almirall J, Gonzalez CA, Balanco X, Bolibar I. Proportion of community-acquired pneumonia attributable to tobacco smoking. Chest. 1999;116:375–9.
9. Fine MJ, Smith MA, Carson CA, Mutha SS, Sankey SS, Weiss-feld LA, et al. Prognosis and outcomes of patients with community-acquired pneumonia: a meta-analysis. JAMA. 1995;274:134–41.
This is one in a series of chapters excerpted from Clinical Evidence , published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence is published in print twice a year and is updated monthly online. The complete text for this topic, as well as additional information, is available to subscribers at www.clinicalevidence.com. This series is part of AFP's CME. See “Clinical Quiz” on page 21.
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