Management of patients with community-acquired pneumonia
Community-acquired pneumonia (CAP) remains the main cause of morbidity and mortality from infectious diseases in developed countries. The pneumonia severity scale is most often used to assess the severity of a patient with CAP and the need for hospitalization.
The world's most famous medical journal New England Journal of Medicine has published a talk on an extremely urgent problem - the choice of treatment for adult patients with community-acquired pneumonia (CAP). Arguing the relevance of the problem under discussion, the authors provide the following information: each year in the United States, approximately 4 million cases of CAP are diagnosed, of which approximately 1 million patients are hospitalized. Hospital treatment is approximately 20 times more expensive than at home and represents approximately $ 9 billion per year, and length of hospital stay is a key determinant of the cost of hospital treatment.
30-50% of patients hospitalized for VP are characterized as prognostically “favorable” and can be successfully treated at home. However, in practice, clinicians tend to exaggerate the likelihood of an unfavorable (including fatal) outcome of the disease.
The decision on whether to hospitalize a patient with pneumonia involves taking into account the stability of the patient's clinical condition, the risk of death and the development of complications of the disease, the presence or absence of other medical problems and the patient's psychosocial status.
Among the existing prognostic systems for evaluating CAP results, the pneumonia severity index scale (PSI), developed on the basis of a retrospective analysis of the results of pneumonia in more than 50,000 patients (ambulatory and hospitalized), is the most popular. According to this prognostic scale, there are five risk classes for which the probability of death within the next 30 days from the start of the development of the disease is predicted from 0.1% (minimum) to 27% (maximum). Easy-to-use rating systems at this scale are currently available on the Internet (here, here and here).
Patients assigned to grades 1, 2 and 3 (in the absence of known medical and social problems) can be successfully treated at home. This situation is all the more relevant today because of the availability of high bioavailability oral antibiotics. The age of patients over 65 is not an independent indication of hospitalization.
Some patients assigned to class 3 are candidates for short-term hospitalization or for a 23-hour observation in a hospital (admission service). In this period, antibiotic therapy begins, hydration is carried out. The risk of aggravation in this category of patients is minimal; it turns out to be the largest in 1 day. The few patients who do not have an adequate “response” to current medical procedures should be hospitalized.
Patients belonging to the 4th and 5th risk classes must of course be hospitalized. These are, in general, elderly and elderly patients with at least 2 risk factors for poor prognosis (serious concomitant diseases, deviations of vital signs and / or laboratory parameters). All patients suffering from hypoxemia (SaO2 less than 90% or PaO2 less than 60 mm Hg when breathing ambient air) or suffering from serious hemodynamic disorders must, of course, be hospitalized, regardless of the final score on the PSI scale. Other indications for hospitalization are destructive or metastatic purulent diseases / complications (empyema, lung abscess, endocarditis, meningitis, osteomyelitis) or high-risk infections (Staphylococcus aureus, Gram-negative pathogens, anaerobes).
Several studies have been conducted confirming the efficacy and safety of this approach in determining the treatment site for adult patients with CAP.