Outpatient treatment as effective as inpatient for many with pneumonia

Journal of Family Practice, May, 2005 by J. Carratala, N. Fernandez-Sabe, L. Ortega

Carratala J, Fernandez-Sabe N, Ortega L, et al. Outpatient care compared with hospitalization for community-acquired pneumonia. Ann Intern Med 2005; 142:165-172.

* Clinical Question In low-risk patients, is outpatient treatment of pneumonia as effective as inpatient therapy?

* Bottom Line

This study provides good support for 2 theories in the treatment of community-acquired pneumonia: (1) emergency physicians should calculate the Pneumonia Severity Index score for each patient; and (2) patients in risk classes I through III can be treated as outpatients. Patients who are sent home with a prescription and are visited by a nurse in 2 days are more satisfied with their care than inpatients and are just as likely to have a successful outcome. The index would be easy to use if it were available in calculator form on a computer. (LOE=lb)

Study Design Randomized controlled trial (nonblinded)

Allocation Concealed

Setting Emergency department

Synopsis

The Pneumonia Severity Index--otherwise known as the Fine or Pneumonia Patient Outcomes Research Team (PORT) criteria--is a way to stratify patients with community-acquired pneumonia into 5 risk classes. Patients in class I have the lowest pneumonia severity and class Vs have a 30-day mortality of 27.0%. Patients in class I should be treated as outpatients, and those in classes IV and V should be admitted; this study evaluated the role of hospitalization in patients with class II or III pneumonia.

The Barcelona-based researchers enrolled 224 immunocompetent adults who received a diagnosis of community-acquired pneumonia with no respiratory failure, complicated pleural effusions, or unstable comorbidities. The patients were randomized to be treated as inpatient or as outpatients. The patients had the usual pathogens of pneumonia, although (as is also typical) a cause was not determined for approximately 30%.

All patients received levofloxacin (Levaquin) 500 mg daily for an average 10.19 days; out-patients were treated with oral therapy and inpatients were treated with intravenous therapy and then oral therapy for an average of 10 days, although they were hospitalized for an average 5.1 days. Outpatients received 1 nurse visit 48 hours after discharge for assessment and received a second visit if they did not seem to be improving.

The investigators used a combined endpoint of success, including cure of pneumonia, absence of adverse drug reactions, absence of medical complications, no need for additional visits, no changes in initial treatment, and no hospital admission or death within 30 days. This outcome was achieved by 83.6% of outpatients and 80.7% of hospitalized patients. Readmission rates were similar in the 2 groups (6%-7%). Health-related quality-of-life scores measured at 7 and 30 days were similar in both groups. More outpatients than inpatients reported satisfaction with their overall care (91.2% vs 79.1%; P=.03).