BACKGROUND: Evidence supporting antibiotic treatment guidelines and respiratory quinolones (RQs) in community-acquired pneumonia (CAP) is limited.OBJECTIVE: To study associations among guideline adherence, specific antibiotics, clinical outcomes and antibiotic costs.METHODS: A retrospective cohort study in three tertiary care university
teaching hospitals in Toronto, Ontario, studying CAP inpatients
between November 1997 and June 2000. The period
encompassed 12 months when an early version of empirical antibiotic
guidelines was used (early cohort) and 18 months when recent guidelines
(including RQs) were used (recent cohort).RESULTS: Six hundred ninety-eight cases of CAP were reviewed,
and 91% were guideline adherent. In multivariable analyses, no association
was observed between guideline adherence and mortality or
duration of hospitalization. Guideline-adherent cases received fewer
antibiotics in both cohorts and 0.9 days less of intravenous antibiotics
(P=0.04) in the recent cohort. There was no significant difference in
antibiotic cost according to guideline adherence, but recent cohort
guideline-adherent cases had lower drug costs than early cohort
guideline-adherent cases. Antibiotic selection was associated with illness
severity and was mirrored by clinical outcomes, despite controlling
for the pneumonia severity index (PSI). Treatment with
anaerobic agents (odds ratio 2.7, P=0.001) or cephalosporin plus
macrolide (odds ratio 2.7, P=0.02) was associated with higher mortality.
Treatment with RQ monotherapy was associated with a 2.3 day
shorter duration of intravenous therapy (P&#x3c;0.0001) and a $19.19
lower total antibiotic cost (P&#x3c;0.0001).CONCLUSION: Findings support empirical treatment guidelines
for CAP and their recommendations regarding RQs. The association
between mortality and anaerobic coverage or combination therapy
may reflect prognostic information available at presentation but not
captured by the PSI.

Theodore K Marras

Linda Jamieson

Charles K Chan

Inpatient Care of Community-Acquired Pneumonia: The Effect of Antimicrobial Guidelines on Clinical Outcomes and Drug Costs in Canadian Teaching Hospitals

OBJECTIVE: To compare the systemic safety and efficacy of hydrofluoroalkane beclomethasone dipropionate (HFA-BDP) extra-fine aerosol 800 µg/day with chlorofluorocarbon (CFC)-BDP 1500 µg/day.DESIGN: Six-month, randomized, parallel-group, double-blind, double-dummy study.PATIENTS: Patients (n=141) with moderate to severe asthma adequately controlled by CFC-BDP 1000 µg/day to 2000 µg/day.INTERVENTIONS: Patients received CFC-BDP 1500 µg/day during a two-week run-in period and were then randomized to either HFA-BDP (n=70) or CFC-BDP (n=71).RESULTS: Similar proportions of HFA-BDP and CFC-BDP patients had a 24 h urinary free cortisol values below the reference range at month 6 (15% versus 25%, P=0.35). Measures of adrenocorticotrophic hormone stimulation and morning plasma cortisol levels were also similar in each group. The frequency of skin bruising and oral candidiasis was low for both treatments. No change in intraocular pressure was reported for either treatment. Pulmonary function was similar in both groups; however, the onset of the first asthma exacerbation or increased asthma symptoms tended to be earlier for CFC-BDP than for HFA-BDP (P=0.076); 27% of CFC-BDP patients reported increased asthma symptoms, compared with 14% of HFA-BDP patients (P=0.095).CONCLUSIONS: HFA-BDP 800 µg/day has a systemic adverse event profile comparable to that of CFC-BDP 1500 µg/day, and further control of asthma symptoms may be achieved after a switch from CFC-BDP 1500 µg/day to HFA-BDP 800 µg/day.

Louis-Philippe Boulet

Andr&#xe9; Cartier

Pierre Ernst

Pierre Lariv&#xe9;e

Michel Laviolette

Safety and Efficacy of HFA-134a Beclomethasone Dipropionate Extra-Fine Aerosol over Six Months

RATIONALE: The aim of this study was to evaluate the outcome of intensive care unit (ICU) admission in patients with idiopathic pulmonary fibrosis (IPF) who develop acute respiratory failure of unknown etiology.METHODS: A retrospective study at University of Manitoba hospitals reviewed all patients admitted to the ICU from November 1988 to December 2000 with IPF requiring mechanical ventilation for unknown causes of acute respiratory failure. Survival at hospital discharge was assessed as the primary end point and ICU length of stay as a secondary end point. In the absence of open lung biopsy, major and minor clinical criteria (as per American Thoracic Society statements) were used for the diagnosis of IPF. Infections were ruled out by extensive surveillance cultures and/or bronchoscopy with bronchoalveolar lavage.RESULTS: Eighty-eight charts were reviewed and 25 patients met the inclusion criteria. The mean (± SD) age was 69±11 years (range 42 to 96 years) and 23 patients were male. With the exception of one survivor who was discharged home, 21 patients died while receiving mechanical ventilation, and three patients died in hospital shortly after ICU discharge (one day, 22 days and 67 days). Intubation and mechanical ventilation were administered to 21 patients, with a mean duration of 11±6 days (range two to 27 days); the other four patients were treated with noninvasive ventilation. The average duration of symptoms before ICU admission was 22±26 days. All patients were treated with systemic corticosteroids, while eight patients received additional chemotherapy.CONCLUSIONS: In the absence of a reversible cause, patients with IPF who develop acute exacerbation of IPF may not benefit from ICU admission and mechanical ventilation. However, it is imperative that a diagnostic workup be performed to rule out an infectious or other reversible cause of respiratory failure before admission to the ICU is denied.

Fahad M Al-hameed

Sat Sharma

Outcome of Patients Admitted to Intensive Care Unit for Acute Exacerbation of Idiopathic Pulmonary Fibrosis

BACKGROUND: Overdiagnosis of asthma may be an emerging problem after years of attention to the rising prevalence and reported underdiagnosis of the disease.OBJECTIVES: A sample of adult asthmatics from the community was investigated to determine whether they met the current diagnostic criteria for asthma.METHODS: Ninety participants were studied from a self-referred sample of physician-labelled, adult asthmatics from the community. The setting was a tertiary care, university-affiliated teaching hospital in Halifax, Nova Scotia. Three diagnostic criteria from the Canadian Thoracic Society Asthma Guidelines were used to demonstrate the presence of asthma: first, positive symptom history, and either, second, reversible airflow obstruction demonstrable on spirometry or documented peak expiratory flow rate diurnal variability, or, third, bronchial hyperreactivity to methacholine.RESULTS: At the time of the study, 41% of a sample of physician-labelled asthmatics showed no evidence of reversible airflow obstruction and had a negative methacholine challenge. By backward logistical regression analysis, a higher mean number of medications used (P&#x3c;0.01), a lower forced expiratory volume in 1 s (P&#x3c;0.05) and using inhaled steroids (P&#x3c;0.05) were predictive of meeting the diagnostic criteria for asthma. Sixty-two per cent of subjects who did not meet the criteria for asthma were currently taking medications for 'asthma'. Only 52.2% of the subjects reported ever having undergone pulmonary function testing.CONCLUSIONS: Overdiagnosis of asthma is a potential problem, which may result in unnecessary or inappropriate medication use, increased health care costs and mislabelling of patients. The authors recommend greater use of objective diagnostic tests such as spirometry, peak flow diaries and bronchial provocation to establish a clinical diagnosis of asthma.

Jorin Lindensmith

Debra Morrison

Carole Deveau

Paul Hernandez

Overdiagnosis of Asthma in the Community

The advent of severe acute respiratory syndrome (SARS) in March 2003 reminded us that health care workers are at risk of being stricken with the very diseases that we are treating. Health care workers accounted for 65% of the SARS cases in Canada (1) and represented at least one-quarter of the cases in Hong Kong (2). Because SARS presents as a severe pneumonia and is diagnosed by certain epidemiological characteristics, history and a positive chest x-ray, respirologists are often the first-line consultants to see patients with an unusual pneumonia. If we are lucky, there may be telling clues to the diagnosis such as a travel history or contact with other cases. However, in the absence of these clues, it behooves the medical profession to use universal precautions.

Dennis Bowie

The Hazards of a Practicing Respirologist

In this issue of the Canadian Respiratory Journal, LindenSmith et al (pages 111 to 116) present data that strongly suggest that patients who do not have asthma frequently acquire this diagnosis. They recruited 90 adults who thought that they had asthma and, in fact, had symptoms of asthma, and found that over 40% of them did not have objective evidence of the disease; of these, 43% were taking inhaled corticosteroids. Objective evidence was defined as demonstrable reversible airways obstruction, meaning spirometric response to inhaled bronchodilators, diurnal peak flow variability and/or methacholine responsiveness. Of these, methacholine response was by far the most important; in fact, a confirmed diagnosis amounted to symptoms plus methacholine sensitivity. The authors discussed possible reasons for lack of methacholine responsiveness in people who really have asthma, but were unconvinced that these were important confounders in their study and cited other studies that have also found that asthma is overdiagnosed.

Nick R Anthonisen

The Diagnosis of Asthma

The case of a patient that developed pulmonary fibrosis two months after initiation of danazol for treatment of idiopathic thrombocytopenic purpura is described. Bilateral pneumothoraxes and pneumomediastinum complicated the rapidly fatal pulmonary fibrosis. An association between danazol therapy and the development of pulmonary fibrosis is suspected. There is only one other case report with this connection in the literature.

Smita Pakhale

Yuri Moltyaner

Dean Chamberlain

Neil Lazar

Rapidly Progressive Pulmonary Fibrosis in a Patient Treated with Danazol for Idiopathic Thrombocytopenic Purpura

In this issue of the Canadian Respiratory Journal, Blais et al (pages 27 to 32) publish an interesting study of the use of inhaled steroids in chronic obstructive pulmonary disease (COPD). Using the Quebec provincial database from the years 1990 to 1996, they found that these medications were given to more and more patients during the period of the study, and that the patients tended to be sicker than those who were not given inhaled steroids: they saw more physicians, including specialists; took more bronchodilators; and had more exacerbations. This is the result that I would have predicted if asked and is therefore not surprising. What surprised me is the fact that patients did not continue to use inhaled steroids once they had been started on them; of those given these drugs for the first time, one-half stopped them after approximately 18 months, and after five years, approximately only 20% were still taking them. Further, as the number of patients given inhaled steroids increased, persistence decreased. What are we to make of this? One could argue that the dates covered by the study of Blais et al preceded the clinical trials (1) showing that inhaled steroids reduced exacerbations in COPD and that they were not prescribed with the conviction that present-day physicians would employ. On the other hand, it seems unlikely that COPD patients were given these medications as a temporary expedient; presumably, most prescriptions for inhaled steroids were for chronic maintenance therapy. It is therefore unlikely that the prescribing physicians told COPD patients to take the drugs until they felt better and then discontinue them. It is also possible that inhaled steroids were unique respiratory drugs in that they were expensive and that this impacted persistence negatively. Although these patients had provincial drug insurance coverage, it was probably on a reimbursement basis, as in Manitoba, and inhaled steroids presented a cash flow problem.

Persistence and Compliance

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Canadian Respiratory Journal provides a multidisciplinary forum for research in all areas of respiratory medicine. The journal publishes research related to asthma, allergy, COPD, non-invasive ventilation, therapeutic intervention etc.

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Chief Editor, Dr Alice M Turner, is based at the University of Birmingham, UK. Her main research interests are the clinical aspects of alpha 1 antitrypsin deficiency and chronic obstructive pulmonary disease.

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Canadian Respiratory Journal - Table of contents 2004

title

Canadian Respiratory Journal provides a multidisciplinary forum for research in all areas of respiratory medicine. The journal publishes research related to asthma, allergy, COPD, non-invasive ventilation, therapeutic intervention etc.

Canadian Respiratory Journal