Respir Res. 2013 Apr 15;14(1):44.

Current management of patients hospitalized with community-acquired pneumonia across Europe: outcomes from REACH.

Blasi F, Garau J, Medina J, Ávila M, McBride K, Ostermann H, on behalf of the REACH study group.

 

Abstract

BACKGROUND: Data describing real-life management and treatment of community-acquired pneumonia (CAP) in Europe are limited. REACH (NCT01293435) was a retrospective, observational study collecting data on the management of European patients hospitalized with CAP.The purpose of this study was to understand patient and disease characteristics in patients hospitalized with CAP and to review current clinical practices and outcomes.

METHODS: Patients were aged >=18 years, hospitalized with CAP between March 2010 and February 2011, and requiring in-hospital treatment with intravenous antibiotics. An electronic Case Report Form was used to collect patient, disease and treatment variables, including type of CAP, medical history, treatment setting, antibiotics administered and clinical outcomes.

RESULTS: Patients (N = 2,039) were recruited from 128 centres in ten European countries (Belgium, France, Germany, Greece, Italy, the Netherlands, Portugal, Spain, Turkey, UK). The majority of patients were aged >=65 years (56.4%) and had CAP only (78.8%). Initial antibiotic treatment modification occurred in 28.9% of patients and was more likely in certain groups (patients with comorbidities; more severely ill patients; patients with healthcare-associated pneumonia, immunosuppression or recurrent episodes of CAP). Streamlining (de-escalation) of therapy occurred in 5.1% of patients. Mean length of hospital stay was 12.6 days and overall mortality was 7.2%.

CONCLUSION: These data provide a current overview of clinical practice in patients with CAP in European hospitals, revealing high rates of initial antibiotic treatment modification. The findings may precipitate reassessment of optimal management regimens for hospitalized CAP patients.

PMID: 23586347

 

Supplement:

Community-acquired pneumonia (CAP) is a leading cause of illness and death (1–4). If patients require hospitalization—and up to two-thirds do—costs are substantial (1–4). Mortality varies widely across health care settings and patient populations, and has been reported to be as high as 48%, with the greatest risk in older patients, those with more severe illness and those with comorbidities (2). If appropriate treatment decisions are not made promptly, the length of illness, risk of complications and mortality are all elevated (5).

Current evidence is vital to inform such critical treatment decisions. However, until recently, we have simply not known enough about how CAP is treated in European hospitals, and how this affects patient outcomes. Our group of independent experts, a health economist and clinical investigators came together to find answers.

We set out to design a study that would provide an accurate picture of current management of CAP and complicated skin infections in European hospitals. It was important to us that these were real-life data, unhindered by the potentially artificial conditions of clinical trials. We designed a retrospective, observational study, known as REACH (Retrospective Study to assess the Clinical Management of Patients With Moderate-to-Severe Complicated Skin and Soft Tissue Infections or CAP; NCT01293435). The CAP component of REACH, reported here, aimed to provide a summary of current treatment practices and their impact on outcomes such as mortality.

Our methodology allowed us to capture a snapshot of more than 2,000 patients hospitalized with CAP, the majority of whom were hospitalized during just a 4-month window. All patients hospitalized with CAP were put forward for randomization, from which the analysis population was selected using an automatic randomization tool to avoid selection bias. Patients came from 128 hospitals across ten European countries.

When the results were in, the most striking finding for us was the unexpectedly high rate of initial antibiotic treatment modification, once cases of streamlining (changes to narrower-spectrum antibiotics when patients improved or had a confirmed microbiological diagnosis) were excluded. Nearly one-third of patients (28.9%) had their initial antibiotic treatment modified, with the most common reason being insufficient response to treatment (12%). Rates of treatment modification were highest in patients with more complicated or more severe illness. Associated outcomes, such as mortality, were also higher in these patients. This emphasizes the importance of adopting management strategies that reduce the likelihood of initial antibiotic treatment modification.

Another key finding was the time to clinical stability. Figure 1 shows the distribution of patients according to time to clinical stability. Most patients achieved clinical stability in 2–5 days. This relatively rapid time to clinical stability is notable in that it confirms previous studies (6,7) and adds European data to the evidence base.

 1013243 v1Figure 1. Distribution of patients according to time to clinical stability (8)

 

We saw a number of variations in mortality rates that stood out for attention. The overall mortality rate was 7.2%; however, in patients with health care-associated pneumonia (HCAP), classified as those who had been resident in settings commonly linked with HCAP, such as nursing homes, mortality was 16.3%—almost three times higher than in those with CAP (5.5%). Mortality rates were also higher in patients who were immunocompromised or immunosuppressed (9.7%). This seems consistent with the higher rates of initial antibiotic treatment modification in these subgroups (HCAP: 31.8%; immunocompromised/immunosuppressed: 40.3%) and suggests that careful monitoring and judicial treatment decisions are particularly important in patients at greater levels of concern.

Another finding that interested us was the apparent higher rate of mortality in northern Europe versus southern Europe. With the exception of Germany, where the sample size was small and no deaths were recorded, rates varied from 1% in Italy and 2.3% in Greece to 17.5% in the UK. The reason behind this is unclear and warrants further research; we were not able to adjust mortality for severity due to the unexpectedly low use of severity scoring systems. Of 2,039 patients included in the analysis population, only 17.4% had their disease severity recorded with the PORT/PSI index and 25.8% with CURB-65.

We were somewhat surprised by the low rate of microbiological diagnosis in REACH. Although almost every patient underwent a microbiological test, only 28.5% of patients had a diagnosis. The results, however, were largely in line with existing evidence (5, 9–13), with Streptococcus pneumoniae the most common pathogen identified (39.2%). The relatively high levels of Staphylococcus aureus (7.2%) and Pseudomonas aeruginosa (7.0%) were interesting findings and may be an important consideration for clinicians deciding how to treat CAP and HCAP.

There was large variability in the treatment options chosen by clinicians in REACH. Consistent with the broad range of potential pathogens implicated in CAP and the low rates of microbiological diagnosis, the majority of patients were treated empirically. However, more than 48 antibiotic regimens (monotherapy or combinations) were used as initial therapy. The majority of treatment choices were consistent with guidelines, but it is unclear precisely why particular treatment decisions were made and why there is not more consistency.

The REACH study is important because it provides the most current, real-life picture of the characteristics and management of patients hospitalized with CAP in Europe. The findings reveal wide variations in treatment practices across the region. The high rate at which initial antibiotic treatment is modified, particularly in patients with complicated or severe illness, and the high risk of mortality in these patients, leads our group to believe that a reassessment of optimal management regimens is timely. Rapid initiation of the most effective antibiotic agent, efficient diagnosis and early identification of patients with additional concerns are paramount.

 

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Acknowledgments: The REACH study was sponsored and funded by AstraZeneca. Editorial assistance was provided by Carol Mason of MediTech Media, funded by AstraZeneca.

 

Blasi photoContact:

Professor Francesco Blasi

Department of Pathophysiology and Transplantation

Università degli Studi di Milano

IRCCS Fondazione Ca’ Granda

Ospedale Maggiore Policlinico

Via Francesco Sforza 35

20122

Milan

Italy

francesco.blasi@unimi.it

 

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