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Outpatient Care Compared with Hospitalization for Community-Acquired Pneumonia: A Randomized Trial in Low-Risk Patients

Jordi Carratalà, MD; Núria Fernández-Sabé, MD; Lucía Ortega, MD; Xavier Castellsagué, MD; Beatriz Rosón, MD; Jordi Dorca, MD; Ana Fernández-Agüera, RN; Ricard Verdaguer, MD; Joaquín Martínez, MD; Frederic Manresa, MD; and Francesc Gudiol, MD
[+] Article and Author Information

From IDIBELL-Hospital Universitari de Bellvitge, University of Barcelona, and SCIAS-Hospital de Barcelona, Barcelona, Spain.


Trial ISRCTN41238928.

Acknowledgments: The authors thank Ginesa Albero for data management and statistical analyses and Dr. Tom Gottlieb for his review of the manuscript. They also thank the staff members and residents of the Infectious Disease, Respiratory, Internal Medicine, and Emergency Medicine Services of the IDIBELL-Hospital Universitari de Bellvitge and the SCIAS-Hospital de Barcelona for their valuable cooperation.

Grant Support: By research grants from the Spanish National Health Service (FIS 00/0438) and from Aventis, Madrid, Spain. Dr. Fernández-Sabé is the recipient of a fellowship grant from the University of Barcelona, Barcelona, Spain.

Potential Financial Conflicts of Interest: Honoraria: J. Dorca (Aventis), F. Gudiol (Aventis); Grants received: F. Gudiol (Aventis).

Requests for Single Reprints: Jordi Carratalà, MD, Infectious Disease Service, Hospital Universitari de Bellvitge, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907 Barcelona, Spain; e-mail, jcarratala@wanadoo.es.

Current Author Addresses: Drs. Carratalà, Fernández-Sabé, Rosón, and Gudiol and Miss Fernández-Agüera: Infectious Disease Service, Hospital Universitari de Bellvitge, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.

Drs. Ortega and Martínez: Internal Medicine Service, SCIAS-Hospital de Barcelona, Diagonal 660, 08034 Barcelona, Spain.

Dr. Castellsagué: Cancer Epidemiology and Registration Unit, Institut Català d'Oncologia, Gran Via s/n, Km 2.7, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.

Drs. Dorca and Manresa: Respiratory Medicine Service, Hospital Universitari de Bellvitge, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.

Dr. Verdaguer: Microbiology Service, Hospital Universitari de Bellvitge, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.

Author Contributions: Conception and design: J. Carratalà, F. Gudiol.

Analysis and interpretation of the data: J. Carratalà, N. Fernández-Sabé, L. Ortega, X. Castellsagué, B. Rosón, J. Dorca, A. Fernández-Agüera, R. Verdaguer, J. Martínez, F. Manresa, F. Gudiol.

Drafting of the article: J. Carratalà, N. Fernández-Sabé, X. Castellsagué, F. Gudiol.

Critical revision of the article for important intellectual content: J. Carratalà, N. Fernández-Sabé, L. Ortega, X. Castellsagué, B. Rosón, J. Dorca, A. Fernández-Agüera, R. Verdaguer, J. Martínez, F. Manresa, F. Gudiol.

Final approval of the article: J. Carratalà, N. Fernández-Sabé, L. Ortega, X. Castellsagué, J. Dorca, A. Fernández-Agüera, R. Verdaguer, J. Martínez, F. Manresa, F. Gudiol.

Provision of study materials or patients: J. Carratalà, N. Fernández-Sabé, L. Ortega.

Statistical expertise: X. Castellsagué, B. Rosón.

Obtaining of funding: J. Carratalà, F. Gudiol.

Collection and assembly of data: J. Carratalà, N. Fernández-Sabé, L. Ortega, B. Rosón, J. Dorca, A. Fernández-Agüera, R. Verdaguer, J. Martínez, F. Manresa, F. Gudiol.


Ann Intern Med. 2005;142(3):165-172. doi:10.7326/0003-4819-142-3-200502010-00006
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A total of 224 patients were randomly assigned and included in an intention-to-treat analysis for the primary end point. Of these, 110 received outpatient care and 114 were hospitalized. After excluding 21 patients after enrollment who could not be evaluated, we analyzed the remaining 203 for the primary and secondary end points per protocol. The baseline characteristics of the patients in the 2 treatment groups were similar (Table 1) and did not differ significantly by hospital site. An etiologic diagnosis was established in 37 of 103 outpatients (35.9%) and 28 of 104 hospitalized patients (26.9%) who had pneumonia. The distribution of causative organisms did not differ between groups. Streptococcus pneumoniae(22 outpatients vs. 16 hospitalized patients) and L. pneumophila(6 outpatients vs. 5 hospitalized patients) were the most frequently isolated pathogens, followed by atypical agents (4 outpatients vs. 3 hospitalized patients) and Haemophilus influenzae(3 outpatients vs. 3 hospitalized patients). Bacteremia occurred in 3 outpatients (S. pneumoniae in 2 and Escherichia coli in 1) and in 1 hospitalized patient (S. pneumoniae). Forty-one percent of S. pneumoniae isolates were penicillin-resistant (MIC range, 0.5 µg/mL to 4 µg/mL), and 35% of the strains were resistant to erythromycin (MIC >256 µg/mL for all strains). Only 1 pneumococcal strain was resistant to ceftriaxone (MIC, 2 µg/mL). All S. pneumoniae isolates were susceptible to levofloxacin (MIC range, 0.5 µg/mL to 1 µg/mL).

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Use of the Pneumonia Severity Index to Determine Site of Care
Posted on March 8, 2005
John H. Kvasnicka
St. Joseph's Hospital, St. Paul, MN
Conflict of Interest: None Declared

As noted by Carratalà, et. al.(1), "The Pneumonia Severity Index (PSI) has been advocated as an objective measure of risk stratification to help determine the initial site of treatment for patients with community- acquired pneumonia." Unfortunately this study does little to test that hypothesis. Fully 47% of PSI class II or III patients were excluded prior to randomization because they were judged to be too sick to manage as outpatients or were otherwise not suitable for outpatient therapy. Thus this study actually tested a combined approach of using the PSI along with several additional criteria devised by the investigators.

This finding is remarkably consistent with prior studies of attempts to apply the PSI to actual decisions to treat patients with pneumonia as outpatients. Fine, et.al.(2) validated the PSI criteria in the Pneumonia Patient Outcomes Research Team (PORT) cohort. In this cohort, 24% of PSI class I patients, 49% of class II patients, and 78% of class III patients were treated initially as inpatients. Marrie, et.al.(3) studied a critical pathway that included PSI scoring for pneumonia patients. In the intervention arm, 31% of class I-III patients were admitted. In all these studies, the PSI was augmented by additional criteria of some type to determine admission criteria.

The concept of using the PSI to determine treatment decisions in an unselected population remains an untested hypothesis. Carratalà, et. al. used the PSI in a very highly selected group of already low-risk patients. It would be a mistake to conclude that this study validates use of the PSI to determine treatment decisions in other populations of patients.

(1) J. Carratalà, N. Fernández-Sabé, L. Ortega, X. Castellsagué, B. Rosón, J. Dorca, A. Fernández-Agüera, R. Verdaguer, J. Martínez, F. Manresa and F. Gudiol. Outpatient Care Compared with Hospitalization for Community-Acquired Pneumonia: A Randomized Trial in Low-Risk Patients. Ann Intern Med 2005; 165-172. (2) Fine, Michael J., Auble, Thomas E., Yealy, Donald M., Hanusa, Barbara H., Weissfeld, Lisa A., Singer, Daniel E., Coley, Christopher M., Marrie, Thomas J., Kapoor, Wishwa N. A Prediction Rule to Identify Low-Risk Patients with Community-Acquired Pneumonia. N Engl J Med 1997; 336: 243- 250. (3) Thomas J. Marrie; Catherine Y. Lau; Susan L. Wheeler; Cindy J. Wong; Margaret K. Vandervoort; Brian G. Feagan; for the CAPITAL Study Investigators. A Controlled Trial of a Critical Pathway for Treatment of Community-Acquired Pneumonia. JAMA 2000; 283: 749-755

Conflict of Interest:

None declared

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Summary for Patients

Can Patients with Pneumonia Take Their Antibiotics at Home?

The summary below is from the full report titled “Outpatient Care Compared with Hospitalization for Community-Acquired Pneumonia. A Randomized Trial in Low-Risk Patients.” It is in the 1 February 2005 issue of Annals of Internal Medicine (volume 142, pages 165-172). The authors are J. Carratalà, N. Fernández-Sabé, L. Ortega, X. Castellsagué, B. Rosón, J. Dorca, A. Fernández-Agüera, R. Verdaguer, J. Martínez, F. Manresa, and F. Gudiol.

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