Correspondence

A Prediction Rule for Community-Acquired Pneumonia

N Engl J Med 1997; 336:1913-1915June 26, 1997

Article

To the Editor:

Fine and colleagues (Jan. 23 issue)1 present a detailed analysis of community-acquired pneumonia. An important complicating factor not specifically addressed in their prediction rule is pregnancy. Pneumonia is one of the most common and serious nonobstetrical infections during pregnancy. Before 1940, maternal mortality from pneumonia was as high as 30 percent. Substantial maternal and perinatal morbidity and mortality still result from antepartum pneumonia (Table 1Table 1Maternal and Perinatal Outcomes in Pregnancies Complicated by Pneumonia.).2-6

The risk-scoring system derived by Fine and colleagues favors outpatient therapy for young, otherwise healthy women. In the two maternal–fetal deaths in our series at Parkland Hospital,4 both women would have been in risk class II and could have been assigned to outpatient management by the prediction rule.

We support the development of standardized treatment plans for the management of pneumonia in pregnant women. Until this scheme is evaluated prospectively, however, we continue our policy of promptly hospitalizing all pregnant women with radiographically confirmed pneumonia in order to ensure that optimal respiratory support is provided and to determine the responsiveness of the infection to therapy.

Steven L. Bloom, M.D.
Susan Ramin, M.D.
F. Gary Cunningham, M.D.
University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75235-9032

6 References

1. 1

   Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-250
   Full Text | Web of Science | Medline

2. 2

   Madinger NE, Greenspoon JS, Ellrodt AG. Pneumonia during pregnancy: has modern technology improved maternal and fetal outcome? Am J Obstet Gynecol 1989;161:657-662
   Web of Science | Medline

3. 3

   Berkowitz K, LaSala A. Risk factors associated with the increasing prevalence of pneumonia during pregnancy. Am J Obstet Gynecol 1990;163:981-985
   Web of Science | Medline

4. 4

   Richey SD, Roberts SW, Ramin KD, Ramin SM, Cunningham FG. Pneumonia complicating pregnancy. Obstet Gynecol 1994;84:525-528
   Web of Science | Medline

5. 5

   Briggs RG, Mabie WC, Sibai BM. Community-acquired pneumonia in pregnancy. Am J Obstet Gynecol 1996;174:389-389 abstract.
   

6. 6

   Munn MB, Groome LJ, Baker SL, Atterbury JL, Hoff C. Pneumonia as a complication of pregnancy. Am J Obstet Gynecol 1997;176:S186-S186 abstract.
   CrossRef

To the Editor:

. . . The elderly nursing home residents whom we are called to admit with the diagnosis of pneumonia usually have underlying disorders such as congestive heart failure, stroke, and renal dysfunction. These patients easily meet the criteria for class IV and, according to the prediction rule of Fine et al., should be admitted. Many of these patients are clinically stable enough to be treated with intravenous antibiotics in the monitored environment of the long-term care facility. Would there be a way to prevent unnecessary admissions in this patient population?

Sotirios Tsiodras, M.D.
Gaurav Malhotra, M.D.
Albert Einstein Medical Center, Philadelphia, PA 19141

Author/Editor Response

The authors reply:

To the Editor: On the basis of anecdotal clinical experience and five published articles on the maternal and fetal outcomes of pneumonia during pregnancy, Bloom and colleagues recommended hospitalization for all pregnant women with community-acquired pneumonia. However, the studies they cite differed from ours in that they focused exclusively on hospitalized pregnant women, potentially biasing the study populations toward more severely ill patients.

Among the 2287 patients enrolled in the Pneumonia Patient Outcomes Research Team (Pneumonia PORT) study, there were only five pregnant women. Three were classified as being in risk class I and two as being in risk class II. Two patients in risk class I and one in risk class II were treated as outpatients. None of the five patients died or were admitted to intensive care units because of respiratory failure or hemodynamic compromise. However, the low prevalence of pregnant women in our study precluded the assessment of pregnancy as a predictor of short-term mortality or of the implications of our proposed hospitalization strategy for this patient population. Given the potential risk to both mother and fetus, the threshold for hospitalization of pregnant women with pneumonia may need to be lowered. Future studies are required to assess maternal and fetal outcomes in the full spectrum of pregnant women with community-acquired pneumonia.

Our data support the point of Drs. Tsiodras and Malhotra that most nursing home patients with community-acquired pneumonia who are referred for hospitalization are elderly and have multiple coexisting illnesses. There were a total of 195 Pneumonia PORT study patients who resided in nursing homes (8.5 percent), of whom 86 percent were older than 70, 95 percent had one or more coexisting illnesses, and 91 percent were in risk class IV or V. Thirty-day mortality was 16 percent in class IV nursing home patients and 36 percent in class V.

Although our findings demonstrate that nursing home residents with community-acquired pneumonia who are referred for hospital admission have a high risk of short-term mortality, our proposed threshold for hospitalization based on the prediction rule may require modification. The nursing home environment permits both clinical observation and many of the treatments (e.g., oxygen therapy and intravenous antimicrobial therapy) that often dictate the need for hospitalization among noninstitutionalized patients.1 Furthermore, for some nursing home residents with terminal illnesses, palliative care is desired by both the patients and their families.2

Our study did not address the prognosis or outcomes of patients with pneumonia diagnosed and treated at nursing homes without subsequent hospital referral, so the validity of our prediction rule in this patient population still needs to be assessed.

Michael J. Fine, M.D.
Thomas E. Auble, Ph.D.
Barbara H. Hanusa, Ph.D.
University of Pittsburgh, Pittsburgh, PA 15213-2582

Daniel E. Singer, M.D.
Massachusetts General Hospital, Boston, MA 02114

2 References

1. 1

   Fine MJ, Hough LJ, Medsger AR, et al. The hospital admission decision for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med 1997;157:36-44
   CrossRef | Web of Science | Medline

2. 2

   Mehr DR. Nursing-home-acquired pneumonia: how and where to treat? J Am Board Fam Pract 1997;10:168-170
   Medline

Citing Articles (1)

Citing Articles

1. 1

   Mirna Djuric, Djordje Povazan, Nevena Secen, Branislav Perin. (2009) Frequency and relevance of concomitant diseases in elderly patients hospitalized for community acquired pneumonia. Srpski arhiv za celokupno lekarstvo 137:11-12, 619-626
   CrossRef