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Predictors of timely antibiotic administration for patients hospitalized with community-acquired pneumonia from the cluster-randomized EDCAP trial.

Am J Med Sci. 2010 Apr;339(4):307-13

Authors: Hsu DJ, Stone RA, Obrosky DS, Yealy DM, Meehan TP, Fine JM, Graff LG, Fine MJ

INTRODUCTION: To identify factors associated with timely initiation of antibiotic therapy for patients hospitalized with pneumonia. DESIGN: Secondary analysis of a cluster-randomized, controlled trial. SETTING: Thirty- two emergency departments (EDs) in Pennsylvania and Connecticut. SUBJECTS: Patients with a clinical and radiographic diagnosis of community-acquired pneumonia. INTERVENTIONS: From January to December 2001, EDs were randomly allocated to guideline implementation strategies of low (n = 8), moderate (n = 12), and high intensity (n = 12) to improve the initial site of treatment and the performance of evidence-based processes of care. Our primary outcome was antibiotic initiation within 4 hours of presentation, which at that time was the recommended process of care for inpatients. RESULTS: Of the 2076 inpatients enrolled, 1632 (78.6%) received antibiotic therapy within 4 hours of presentation. Antibiotic timeliness ranged from 55.6% to 100% (P < 0.001) by ED and from 77.0% to 79.7% (P = 0.2) across the 3 guideline implementation arms. In multivariable analysis, heart rate > or =125 per minute (OR = 1.6, 95% CI 1.1-2.3), respiratory rate > or =30 per minute (OR = 2.3, 95% CI 1.6-3.4), and aspiration pneumonia (OR = 3.7, 95% CI 1.1-12.7) were positively associated with timely initiation of antibiotic therapy, whereas a hematocrit <30% (OR = 0.6, 95% CI 0.4-1.0) was negatively associated with this outcome. CONCLUSIONS: Timely initiation of antibiotic therapy is associated primarily with patient-related factors that reflect severity of illness at presentation. Although this study demonstrates an opportunity to improve performance on this quality measure in nearly one quarter of inpatients with pneumonia, we failed to identify any modifiable patient, provider, or hospital level factors to target in such quality improvement efforts.

PMID: 20224313 [PubMed - indexed for MEDLINE]

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New onset atrial fibrillation developing in medical inpatients.

Am J Med Sci. 2009 Mar;337(3):169-72

Authors: Chen SX, Amir KA, Bobba RK, Arsura EL

BACKGROUND: The outcome of patients who develop new onset atrial fibrillation (AF) after admission to an Internal Medicine service for acute medical illnesses is unknown. METHODS: In a retrospective review, we compared patients in the study group: patients who were admitted to hospital for acute medical illnesses and subsequently developed new onset AF during hospitalization, with a control group 1: patients whose admitting diagnosis was new onset AF and a control group 2: patients who were admitted for acute medical illnesses and never developed AF. We analyzed clinical characteristics and all-cause mortality rate during the first 30 days, 6 months, and 1 year after admission. RESULTS: The 1-year mortality rates in study group were significantly higher than control group 1 (62% versus 8%, P < 0.001) and control group 2 (62% versus 29%, P < 0.05). These results suggest that AF and acute medical illness both are risk factors for increased mortality. The odds ratios were 4.05 (P = 0.023) and 18.33 (P = 0.001) for AF and acute medical illnesses, respectively, indicating that acute medical illness is the better predictor for mortality. Troponin I levels were elevated in 46% of patients in study group versus 12% in control group 1 and 42% in control group 2 (P < 0.05). CONCLUSIONS: Medical inpatients who develop new onset AF during hospitalization for acute medical illnesses have an increased mortality when compared with patients who were admitted solely for new onset AF. Acute medical illness rather than AF plays a more important role on the increased mortality in this subset of patient population.

PMID: 19204559 [PubMed - indexed for MEDLINE]

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Austrian syndrome (pneumococcal pneumonia, meningitis, and endocarditis): a case report.

Am J Med Sci. 2008 Oct;336(4):354-5

Authors: Dalal A, Ahmad H

This report describes a case of Austrian syndrome (pneumonia, meningitis, and endocarditis, as a result of Streptococcus pneumoniae infection). A computerized medline search was performed for review of literature. In the review of literature, 54 cases including our case were found. Complete clinical and microbiological information was available only for 20 cases. Most invasive pneumococcal infections occurred in debilitated middle aged men with chronic alcoholism. Native aortic valve insufficiency was the commonest cause of cardiac failure among these patients, requiring valve replacement. Austrian syndrome is seen infrequently in this antibiotic era but is still associated with a poor outcome. Hence early recognition and appropriate medical or combined medical-surgical treatment needs to be considered promptly.

PMID: 18854681 [PubMed - indexed for MEDLINE]

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The value of pleural fluid analysis.

Am J Med Sci. 2008 Jan;335(1):7-15

Authors: Sahn SA

Pleural fluid analysis in isolation may have clinical value. To have the greatest diagnostic impact, the clinician must formulate a prethoracentesis diagnosis based on the clinical presentation, blood tests, and radiographic imaging. With this approach, a definitive or confident clinical diagnosis can be expected in up to 95% of patients. The information in this report should allow the clinician to achieve this goal.

PMID: 18195577 [PubMed - indexed for MEDLINE]

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Fluoroquinolones in community-acquired pneumonia when tuberculosis is around: an instructive case.

Am J Med Sci. 2008 Feb;335(2):141-4

Authors: Grupper M, Potasman I

Fluoroquinolones are increasingly used for the treatment of community-acquired pneumonia. However, their use has been associated with a delay in the diagnosis and treatment of pulmonary tuberculosis. We describe the clinical and insightful bacteriological course of a 39-year-old patient with pulmonary tuberculosis who had presented as having community-acquired pneumonia and was treated empirically with levofloxacin. The case highlights a major problem associated with the indiscriminate use of fluoroquinolones.

PMID: 18277123 [PubMed - indexed for MEDLINE]

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