Practice Guidelines
ACCP Releases Consensus Statement on Outpatient Treatment for CAP
The American College of Chest Physicians (ACCP) recently issued a clinical position statement on outpatient management of community-acquired pneumonia (CAP). "Management of Community-Acquired Pneumonia in the Home" was published in the May 2005 issue of Chest and can be accessed online at http://www.chestjournal.org/cgi/content/full/127/5/1752.
Pneumonia is the most common cause of death from infectious disease, and CAP affects up to 3 million persons in the United States each year. The number of patients being treated in their homes for CAP is increasing because of cost considerations, patient preference, and the availability of effective oral antibiotics.
The ACCP Home Care Network Working Group concluded that the current evidence is insufficient to support an evidence-based practice guideline on outpatient treatment of CAP, but because of the importance of the issue, the working group developed a clinical position statement. The ACCP statement seeks to address the requirements of treating patients with CAP at home while providing the same level of care, recovery, and functional status that is available at an inpatient facility.
Diagnosing CAP in Outpatients
The diagnosis of CAP should be made by a qualified health care professional and based on clinical history and classic symptoms (e.g., new-onset cough, sputum production or shortness of breath, fever, rales). Older or immunocompromised patients should be monitored closely for CAP. Chest radiography should be performed on patients who have a goal of complete recovery (as opposed to patients who are receiving palliative care) to confirm the diagnosis of CAP, assess its severity, and establish a baseline for confirming the resolution of the disease. Physicians also should consider other tests to guide treatment, including a chemistry panel evaluation, hemoglobin/hematocrit determination, and blood cultures.
Choosing the Site of Care
According to the statement, the decision to treat a patient on an outpatient basis as opposed to in the hospital should be based on the severity of the illness, the ability of the patient or caregiver to manage the treatment, and the patient's wishes. Patients who live alone or have abnormal vital signs, mental instability, alcoholism, chronic obstructive pulmonary disease, aspiration, cardiovascular instability, uremia, or malnutrition, and those who have been hospitalized for pneumonia in the past year have a poor prognosis for in-home treatment. A respiratory rate of more than 30 breaths per minute, hypotension, a temperature of more than 38.3°C (101.0°F), extrapulmonary infection, confusion, and decreased consciousness are also risk factors for poor outcome of outpatient care. Whether to treat CAP in the home or in a health care facility ultimately must be a joint decision between the physician and patient.
Outpatients who are diagnosed with CAP should be transferred to an acute care facility if they meet at least one of the following criteria: (1) the need for aggressive medical or surgical intervention is urgent, (2) critical diagnostic tests are not available in the home, (3) necessary therapy is not available in the home or is beyond the abilities of the caregiver, (4) patient comfort cannot be ensured in the home, or (5) infection control measures are not possible in the home.
The patient and/or caregiver always should be informed of the risks, benefits, and cost of outpatient care compared with hospitalization.
Treatment Needs of the Outpatient
The ACCP maintains that the physician is responsible for confirming the availability of all aspects of the treatment plan in the patient's home before initiating outpatient treatment. Physicians should evaluate the caregiver's ability to respond to the patient's needs in regard to hydration, nutrition, pain, cough, and shortness of breath. Oral administration of antibiotics is recommended by the ACCP for outpatient treatment, but the choice of antibiotic should be made on a case-by-case basis.
The use of a macrolide antibiotic, doxycycline (Vibramycin), or fluoroquinolone agent may be appropriate empiric outpatient treatment for low-risk patients (i.e., young, otherwise healthy persons). Alternatives to these agents in low-risk patients are amoxicillin-clavulanate (Augmentin) and some second-generation cephalosporins (e.g., cefuroxime [Ceftin], cefpodoxime [Vantin], cefprozil [Cefzil]).
A lack of response to treatment with macrolides and fluoroquinolones has been reported. Some experts prefer to reserve the use of fluoroquinolones for older patients, patients who are allergic to or intolerant of macrolides, patients who have received recent macrolide treatment, patients with comorbidities, patients with documented infections with highly resistant pneumococci, or patients with a lack of response to treatment with another agent. There have been reports of a lack of response to outpatient therapy with azithromycin (Zithromax) and clarithromycin (Biaxin) as the primary treatment for CAP.
Patients who are at high risk because of complicated comorbidities or extensive prior antibiotic use may be a candidate for treatment with a beta lactam-macrolide combination or a antipneumococcal fluoroquinolone. Double therapy with a beta lactam-macrolide combination or a beta lactam-antipneumococcal fluoroquinolone should be considered in patients who normally would be considered for admission to an intensive care unit but have chosen to be treated on an outpatient basis.
Table 1 lists the pathogens and factors that increase a patient's risk of infection. Because of increasing resistance of Streptococcus pneumoniae to antimicrobial drugs, physicians should monitor patients after initiation of antibiotic therapy. The first dose of antibiotics should be administered within four hours of presentation, if possible. Mortality rates have been shown to increase in hospitalized patients with CAP who do not receive antibiotics within eight hours of presentation.
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table 1 Modifying Factors That Increase the Risk of Infection with Specific Pathogens |
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Pathogens |
Modifying factors |
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Penicillin-resistant and drug-resistant pneumococci |
Age older than 65 years; beta-lactam therapy within the past three months; alcoholism; immunosuppressive illness (including therapy with corticosteroids); multiple medical comorbidities; exposure to a child in a day care center |
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Enteric gram-negative |
Residence in a nursing home; underlying cardiopulmonary disease; multiple medical comorbidities; recent antibiotic therapy |
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Pseudomonas aeruginosa |
Structural lung disease (e.g., bronchiectasis); corticosteroid therapy (10 mg of prednisone per day); broad-spectrum antibiotic therapy for seven days in the past month; malnutrition |
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Reprinted with permission from Ramsdell J, Narsavage GL, Fink JB; for the American College of Chest Physicians' Home Care Network Working Group. Management of community-acquired pneumonia in the home. An American College of Chest Physicians clinical position statement. Chest 2005;127:1759. |
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The ACCP recommends that patients who wish to have outpatient care and their physicians and caregivers have a written care plan that outlines the risks and benefits of outpatient care. It should be made clear that hospitalization is not without risk. Hospitalized patients are at increased risk for deconditioning, pressure ulcers, infection by drug-resistant organisms, and translocation trauma. The care plan is not a legal document, but it serves as an educational tool. The care plan should include a plan for transfer to an inpatient facility should the patient fail to respond to outpatient treatment.
Monitoring Outpatients with CAP
After the initial evaluation, all patients with CAP should have a follow-up assessment. Patients who are considered to be high risk should be assessed 24 hours after the initial diagnosis. At every follow-up visit the health care professional should observe vital signs, cardiopulmonary symptoms, mental status, nutrition and hydration status, urinary frequency and output, skin integrity and turgor, lower extremity symptoms, mobility, the use of assistive devices, psychosocial status, and medication compliance. The health care professional should document the patient's achievement of the following goals:
• Understanding of pneumonia
• Recognizing worsening symptoms and knowing what to do if they occur
• Making and keeping medical appointments
• Adapting the lifestyle to control and recover from symptoms
• Monitoring body temperature and sputum production
• Understanding and complying with the medication and diet regimens
• Understanding the proper use and care of respiratory equipment
• Following the care plan to maintain vital signs within established parameters
• Maintaining the activity level prescribed by the physician
• Maintaining a smoke-free environment
Resolution of Symptoms
The physician should confirm resolution of symptoms with chest radiography and evaluate the patient's status eight weeks after the diagnosis of CAP. The patient should be made aware of preventive measures for the future, including smoking cessation, influenza vaccination, initial pneumococcal vaccination, and revaccination with the pneumococcal vaccine every five to seven years if appropriate.
Practice Guideline Briefs
CDC Updates 2005-2006 Influenza Vaccine Recommendations
Delays in influenza vaccine distribution or vaccine supply shortages have occurred in the United States in three of the past five influenza seasons. In previous years, prioritization was implemented to ensure the availability of vaccine for persons at the highest risk of complications from influenza. The Centers for Disease Control and Prevention (CDC) has released updated recommendations for priority use of trivalent inactivated influenza vaccine (TIV) during the 2005-2006 influenza season. Additional information is available online at http://www.cdc.gov/flu.
Four manufacturers are expected to provide influenza vaccine during the 2005-2006 influenza season (see accompanying table). Because of uncertainties about the number of available vaccine doses and the timing of distribution, the CDC recommends that the following groups be given priority to receive TIV until October 24, 2005:
• Persons 65 years and older with or without comorbid conditions
• Persons two to 64 years of age with comorbid conditions
• Children six to 23 months of age
• Residents of long-term care facilities
• Pregnant women
• Health care professionals who provide direct patient care
• Household contacts and out-of-home caregivers of children younger than six months
Starting October 24, 2005, all persons will be eligible for vaccination.
The tiered use of prioritization is not recommended for LAIV administration. LAIV may be administered at any time for vaccination of nonpregnant healthy persons five to 49 years of age, including most health care professionals and other persons in close contact with groups at high risk for influenza-related complications.
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Influenza Vaccine Manufacturers and Projected Supply for 2005-2006 Season |
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Contains |
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Projected doses |
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Sanofi Pasteur, Inc. |
Fluzone TIV |
Multidose vial |
Yes |
6 months and older |
60 million* |
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Single-dose
prefilled |
No |
3 years and older |
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Single-dose
prefilled |
No |
6 to 35 months |
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Chiron Corp. |
Fluvirin TIV |
Multidose vial |
Yes |
4 years and older |
18 to 26 million† |
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Single-dose
prefilled |
No‡ |
4 years and older |
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GlaxoSmithKline, Inc. |
Fluarix TIV |
Single-dose
prefilled |
No‡ |
18 years and older |
8 million |
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MedImmune |
FluMist LAIV |
Single-dose nasal |
No |
Healthy, nonpregnant persons 5 to 49 years of age |
3 million |
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TIV = trivalent inactivated influenza vaccine; LAIV = live, attenuated influenza vaccine. *-Sanofi Pasteur, Inc., plans to distribute approximately 6 to 8 million of the 60 million projected doses in single-dose prefilled syringes or vials. †-Chiron Corp. plans to distribute most of its vaccine by the end of October 2005; the exact timing of distribution was uncertain as of press time. A minimal number of doses of thimerosal-free vaccine may be available late in the influenza season. ‡-These preparations may contain traces of thimerosal. Adapted from Centers for Disease Control and Prevention. Update: influenza vaccine supply and recommendations for prioritization during the 2005-06 influenza season. MMWR Morb Mortal Wkly Rep 2005;54:850. Accessed online September 17, 2005, at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a4.htm. |
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AHRQ Releases Updated Guide to Clinical Preventive Services
The Agency for Healthcare Research and Quality (AHRQ) has published an updated version of evidence-based clinical guidelines from the U.S. Preventive Services Task Force (USPSTF). The Guide to Clinical Preventive Services 2005 includes the USPSTF's recommendations on prevention and early detection of cancer; heart and vascular diseases; infectious diseases; injury and violence; mental health conditions and substance abuse; metabolic, nutritional, and endocrinologic conditions; musculoskeletal conditions; and obstetric and gynecologic conditions. Free single copies of the new guide are available online at http://www.ahrq.gov/clinic/pocketgd.htm or by calling the AHRQ Publications Clearinghouse at (800) 358-9295.
Fertility Treatment and Multiple Birth Rates
The Centers for Disease Control and Prevention (CDC) has released its report on assisted reproductive technology (ART) procedures conducted in the United States in 2002. Data for the report were collected from nearly all U.S. medical centers that provide fertility treatment, as mandated in 1992 by the Fertility Clinic Success Rate and Certification Act. Analysis was carried out by treatment type (e.g., patient or donor egg, freshly fertilized or thawed embryo, number of embryos transferred) and patient characteristics (e.g., age, diagnosis, previous births or procedures). The findings will help prospective parents make informed decisions about treatment.
More than 115,000 ART procedures were performed in the United States in 2002, resulting in the births of 45,751 infants. Because transfer of multiple embryos remains common, more than one half of infants born through ART are from multiple births, compared with 3 percent in the general population, and ART-born infants account for around 17 percent of all multiple births. The substantially increased risks of multiple births, such as hemorrhage and hypertension in the mother and low birth weight, mortality, and long-term disability in the infants, must be taken into account when considering the use of ART treatment. In 2002, about 95 percent of triplets and higher multiples born through ART had a low birth weight, compared with 9 percent of single-birth infants; 97 percent of triplets and higher multiples were born preterm, compared with 15 percent of single-birth infants.
Rates of pregnancy, live birth, and multiple births varied with patient and treatment factors. According to the CDC report, procedures using freshly fertilized embryos and donor eggs yielded the highest rates of multiple births (42 percent), followed by procedures using freshly fertilized embryos and the patient's own eggs (35 percent). Procedures using freshly fertilized embryos and donor eggs had around double the rates of pregnancy, live birth, and single-infant birth (58, 50, and 29 percent, respectively) compared with procedures using thawed embryos and the patient's own eggs.
Factors strongly associated with risk of multiple births included number of embryos transferred and patient age. In women who used freshly fertilized embryos from their own eggs, the most common procedure-transfer of two or more embryos-increased the chances of live birth and the risk of multiple births; this risk varied with the patient's age. Rates of live birth and multiple births increased with the number of embryos transferred in women 41 to 42 years of age, and were higher with transfer of three or more embryos in women 38 to 40 years of age. Women 37 years or younger had higher single-birth rates with transfer of two embryos than with three.
Rates of live birth and multiple births in women who used freshly fertilized embryos from their own eggs decreased as patient age increased. Live birth rates decreased from 43 percent in women younger than 35 years to 7 percent in women older than 42 years (from 26 to 6 percent, respectively, for single birth). Multiple birth rates decreased from 39 percent for women younger than 35 years to 7 percent for those older than 42 years.
The CDC report states that ART is a major risk factor for multiple births, and that efforts should be made to limit the number of embryos transferred. In most instances this would minimize the risk of multiple births without lowering the chances of success, especially for younger women. For this to become general practice, however, patients and physicians need to view treatment success in terms of single-infant pregnancies and births, which are measures of better patient outcomes.
The report cautions that because the data are recorded by procedure rather than by patient, the analysis does not account for those patients whose attempts at pregnancy fail and who undergo more than one treatment per year; thus, the report may underestimate the per-patient success rate.
label information updated for erectile dysfunction drugs
The U.S. Food and Drug Administration (FDA) has approved new label information for sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) after reports of sudden vision loss attributed to nonarteritic ischemic optic neuropathy. Although it is unclear whether the drugs caused the vision loss, the FDA advises patients to stop taking these medications and to seek medical attention if they have sudden or decreased vision loss or if they have ever had severe vision loss.
The new labeling information for each medication is provided on each FDA Web site:
• Sildenafil: http://www.fda.gov/cder/consumerinfo/Viagra/vIAGRA.htm
• Vardenafil: http://www.fda.gov/cder/drug/infopage/vardenafil/default.htm
• Tadalafil: http://www.fda.gov/cder/drug/infopage/cialis/default.htm.
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| Copyright © 2005 by the American
Academy of Family Physicians. |
