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* From the Medizinische Universitätsklinik und Poliklinik Bonn (Dr. Ewig), Bonn, Germany; Dreifaltigkeits-Krankenhaus Wesseling (Drs. Schlochtermeier and Göke), Wesseling, Germany; and Winthrop University Hospital (Dr. Niederman), Mineola, NY.
Correspondence to: Santiago Ewig, MD, Medizinische Universitätsklinik und Poliklinik Bonn, Innere Medizin/Kardiologie und Pneumologie, Sigmund-Freud-Strasse 25, 53105 Bonn, Germany; e-mail: santiago.ewig{at}ukb.uni-bonn.de
Study objectives: We evaluated the role of sputum examination in the management of patients with community-acquired pneumonia (CAP) in a primary-care hospital without microbiologic laboratory facilities.
Design and interventions: A diagnostic strategy using regular collection of sputum samples, Gram staining in a local laboratory, and mailing of samples to a commercial laboratory for culture analysis.
Setting: A 200-bed primary-care hospital without subspeciality physicians.
Patients: One hundred sixteen consecutive patients with a diagnosis of CAP were prospectively evaluated during a 12-month period.
Results: Of 116 patients, 42 patients (36%) were capable of producing a sputum sample. Age 
75 years (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.18 to 0.93) and prior ambulatory antimicrobial treatment (OR, 3.2; 95% CI, 1.2 to 8.4) were independent predictors of sputum production. A delay in collection and processing of sputum samples of > 24 h was present in 31% and 39%, respectively. A delay in collection yielded an increased number of Gram-negative enteric bacilli and nonfermenters (44% vs 7%, p = 0.056). A delay in processing was associated with an increased number of Candida spp isolates (33% vs 9%, p = 0.16). The overall diagnostic yield was low (10 of 116 patients, 9%) due to a limited number of valid samples (n = 23 of 42 patients, 55%) and a limited number of definitely or probably positive samples on Gram’s stain and culture (n = 10 of 42 patients, 24%). Prior ambulatory antimicrobial treatment was associated with a reduction in diagnostic yield (14% vs 56%, p = 0.09). The impact of diagnostic results on antimicrobial treatment decisions was minimal, with antimicrobial treatment directed to diagnostic results in only one patient.
Conclusions: We conclude that in this setting representative of primary-care hospitals in Germany, sputum had a low diagnostic yield and did not contribute significantly to patient management.
Key Words: antimicrobial treatment • diagnosis • Gram stain • outcome • pneumonia • sputum
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