(Chest. 2001;120:185-192.)
© 2001
American College of Chest Physicians
Clinical Evaluation of the Management of Community-Acquired Pneumonia by General Practitioners in France*
Bruno Fantin, MD;
Jean Pierre Aubert, MD;
Philippe Unger, MD;
Hervé Lecoeur, MD and
Claude Carbon, MD
*
From the Institut National de la Santé et de la Recherche Médicale EMI9933, and Service de Médecine Interne, Hôpital Beaujon (Dr. Fantin), Clichy; Société de Formation Thérapeutique du Généraliste (Dr. Aubert), Paris; EURAXI (Dr. Unger), Truyes; MEDILOG (Dr. Lecoeur), Roissy CDG; Institut National de la Santé et de la Recherche Médicale, EMi9933, and Service de Médecine Interne, hôpital Bichat (Dr. Carbon), Paris, France.
A list of the general practitioners who included patients in the
study is given in the Appendix.
Correspondence to: Bruno Fantin, MD, Service de Médecine Interne, Hôpital Beaujon, 100 boulevard du général Leclerc, 92118 Clichy Cedex, France; e-mail: bruno.fantin{at}bjn.ap-hop-paris.fr
 |
Abstract
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Study objectives: To evaluate the management of
community-acquired pneumonia (CAP) by general practitioners (GPs) in
terms of clinical efficiency and adherence to official
recommendations.
Design: Prospective cohort
study.
Setting: Community-based study from 11 French
counties.
Patients: Adult patients clinically
suspected of having CAP who were seen by GPs were included after
confirmation of the presence of an infiltrate on chest
radiographs.
Intervention: The management of the
patients was left to the discretion of the GP.
Measurements
and results: One hundred thirty patients were included in the
study, and 13 patients (10%) were immediately hospitalized because of
the severity of the pneumonia. The remaining 117 patients were treated
as outpatients: 108 of 117 patients (92%) were cured, and 9 patients
were subsequently hospitalized because of the failure of ambulatory
treatment. Diagnostic error (n = 6) rather than antibiotic failure
(n = 3) was the most frequent cause of the failure of ambulatory
treatment. Only 40% of the patients received an initial antibiotic
treatment that was in agreement with French recommendations. However,
the rate of antibiotic failure leading to hospitalization was low (3 of
117 patients; 2.6%) and similar for patients treated or not according
to recommendations (p > 0.5). Overall, five patients (4%) died; all
deaths occurred during hospitalization and were related to the severity
of the underlying disease but not to the choice of antibiotic
treatment.
Conclusions: The management of CAP by GPs
was clinically effective despite a poor adherence to official
recommendations. Our results suggest that adequate assessment of
severity rather than adherence to recommendations for antibiotic
treatment had an impact on clinical outcome of CAP managed by
GPs.
Key Words: antibiotics • community • health planning guidelines • pneumonia
|
Introduction
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Community
-acquired pneumonia (CAP) is a potentially serious infection that
results in numerous general practitioner (GP) visits and hospital
admissions each year, and accounts for a considerable amount of
antibiotic prescribing.1
2
The mortality rate has been
increasing since the early 1980s, particularly for the elderly, despite
the use of broad-spectrum antibiotics and of more sophisticated
investigations and advances in supportive care.3
4
The
choice of initial treatment is usually empirical because of the serious
nature of the illness, which makes it necessary to start treatment
before a definitive etiologic diagnosis. Therefore, in order to improve
the appropriateness of the management of CAP, a number of official
recommendations5
6
7
have been published in the United
States and in Europe regarding the need for hospitalization, diagnostic
procedures, and choice of initial empirical antimicrobial treatment,
according to local epidemiology. However, these guidelines relied on
expert opinion to supplement objective data that derived mostly from
academic studies, or were restricted to the subpopulation of patients
who were sufficiently ill to require hospitalization, or to
immunocompetent patients only.1
8
9
10
11
Consequently, even
the authors1
12
who participated in these guidelines have
advocated caution in their clinical adoption on a country basis by GPs
until clinical and economic validations have been performed.
The aim of the present study was to evaluate the management of CAP by
GPs in France in terms of treatment decisions and clinical outcomes in
an unrestricted population of patients in the community with
radiologically proven pneumonia, and to analyze its efficiency
according to its consistency with French recommendations13
available during the study period.
|
Materials and Methods
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Patients
The study was prospectively conducted between October 1, 1995,
and March 31, 1997, in 11 French counties. These counties represented
three different areas in France (Paris and suburbs, Middle West, and
South East). The investigators were primary-care physicians from two
networks (Société de Formation Thérapeutique du
Généraliste and EURAXI). The patients were included
in the study and considered as having CAP if they met the following
three criteria: (1) age > 18 years; (2) recent onset of fever
(> 38.3°C) and/or presence of at least one of the following
findings: purulent expectoration, chest pain, crackles, new onset of
dyspnea, or worsening dyspnea; and (3) presence of an infiltrate on
chest radiography performed within 72 h after the first clinical
examination. Patients without radiography performed or with normal
chest radiographic findings were excluded from the study. Also,
patients living in convalescent centers or nursing homes were excluded.
Because the aim of the study was to describe the management and outcome
of the patients with CAP initially seen by primary-care physicians,
there were no other criteria for exclusion. Therefore, patients known
to be positive for HIV or with any comorbid illnesses were not
excluded. Similarly, patients whose initial clinical status justified
immediate hospitalization after the initial evaluation by the
primary-care physician were also included provided the chest radiograph
performed at hospital admission confirmed the initial suspicion of CAP.
All patients gave informed consent to participate in the study. The
study protocol was approved by the Committee for Research on Human
Beings of Bichat Hospital in June 1995
Study Protocol
During the initial visit by the GP, all clinical variables of
interest (Table 1
) were recorded for each patient. The management of the patients was
entirely left to physician discretion initially and during follow-up.
The physician could see the patient as many times as thought necessary.
However, the study protocol requested that the patients be seen at
least a second time by the physician, approximately 2 weeks after the
initial visit, for those who were not hospitalized, in order to
determine the final clinical outcome: cured, hospitalized, or dead. For
the patients who were hospitalized, the principal diagnosis,
microorganisms identified (if any), and outcomes (cure or death) were
recorded.
Evaluation of the Management
The evaluation of the management included clinical outcome and
adherence to official recommendations. The final clinical outcome for
each patient fell into two categories: cure or death from CAP or from
other reason. In addition, for the patients who were not immediately
hospitalized after the first visit and were treated as ambulatory
patients, the ambulatory management was evaluated in terms of need for
a subsequent hospitalization after an initial phase of ambulatory
treatment. The adherence to recommendations was measured by the
agreement between the choice of antibiotic treatment prescribed by the
GP for patients who did not receive antibiotics prior to the initial
visit and the official recommendations that were available during the
study period.13
Recommendations that were applicable for
initial treatment by the GP suggested the use of amoxicillin or a
macrolide for patients who were assumed previously healthy, without
vital symptoms, and the use of amoxicillin-clavulanate or oral
cephalosporins for patients with risk factors. In the latter case, a
macrolide or a fluoroquinolone could be associated if legionellosis was
suspected.
Microbiological Procedures
A laboratory network (MEDILOG) that paralleled the physician’s
location was included in the design of the study. Physicians could call
a nurse from the corresponding laboratories to yield sputum examination
if the patient could expectorate. Similarly, blood was drawn by the
nurse within 3 to 4 days after the initial visit and 2 to 3 weeks later
for serologic tests. Sputum and serologic tests were performed in order
to describe the microbiological epidemiology of the study population,
but were not requested for inclusion of the patients. Sputum samples
were examined after Gram’s staining. A sputum sample was considered
valid when < 10 epithelial cells and > 25 polymorphonuclear cells
were present per microscopic field
(magnification x 100).14
Sputum was considered positive
if the Gram’s stain showed Gram-positive diplococci suggestive of
Streptococcus pneumoniae confirmed by culture, and for other
respiratory pathogens if the Gram’s stain showed only one morphologic
type of bacteria and the culture yielded at least 105 cfu/mL of the
same pathogen after 24 h of incubation.2
14
Pathogens
were identified and then tested for susceptibility to antibiotics by
disk diffusion on agar. Blood samples drawn for serologic testing were
centrifuged and serum was frozen at - 20°C until the tests were
performed. All the sera were sent to the reference laboratory and run
simultaneously in triplicate. Serologic tests were performed for
influenza virus A and B, respiratory syncytial virus 1 and 2,
Chlamydia pneumoniae, Mycoplasma pneumoniae, and
Legionella pneumophila. Antibody titers were determined by
indirect immunofluorescent method for serotypes 1 to 6 of L
pneumophila, agglutination assay for M pneumoniae,
microimmunofluorescence method for C pneumoniae, indirect
immunofluorescence for respiratory syncytial virus IgG titers, and
hemagglutination for IgG titers against influenza virus type A and
B.5
The tests were considered positive if there was at
least a fourfold rise in titers between the first and the second
sample.
Statistical Analysis
Comparisons of proportions were performed by the
2 test or the Fisher’s Exact Test, when
appropriate.
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Results
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Clinical Presentation of the Patients With CAP at the Initial Visit
Among the 170 patients seen by GPs and suspected of having CAP,
130 patients showed an infiltrate on chest radiography, gave their
informed consent, and were included in the study. The overall outcome
of the study patients is shown in Figure 1
. The clinical and demographic characteristics of the 130 patients
included at the initial visit are presented in Table 1
. Thirteen
patients (10%) were considered as immunosuppressed: 8 patients were
HIV infected, 2 patients had solid cancer, 2 patients were treated with
steroids, and 1 patient had leukemia.
Management of the Patients With CAP by GPs at the Initial Visit
Thirteen of the patients (10%) were immediately hospitalized
after the initial visit (Fig 1)
. None of these patients had received
any antibiotic treatment prior to the initial visit by the GP. As shown
in Table 2
, these patients were characterized by the severity of their underlying
diseases (two patients had lung cancer, four patients were HIV
infected, six patients had COPD), and by the invasive nature of the
involved pathogens (S pneumoniae in two patients, and
L pneumophila, Klebsiella pneumoniae, and
Pneumocystis carinii in one patient each). Findings in blood
cultures drawn from these patients were positive in the two cases of
pneumococcal pneumonia only.
The remaining 117 patients were initially managed by GPs as
outpatients. Of these, 94 patients did not receive antibiotics before
the initial visit. As shown in Table 3
, the antibiotic treatment prescribed did not significantly differ among
patients with or without risk factors (p = 0.33). The choice of
antibiotic treatment was in agreement with the recommendations in only
40% of the cases (Table 4
). This result was quite similar in patients with or without risk
factors (p > 0.5).
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Table 3. Antibiotic Treatment Prescribed by GPs for Patients
With CAP Who Did Not Receive Previous Treatment According to the
Presence or Absence of Risk Factors (n = 94)*
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Table 4. Agreement Between Initial Antibiotic Treatment
Prescribed by GPs and French Recommendations for Ambulatory Patients
With CAP Who Did Not Receive Previous Treatment
(n = 94)*
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Efficiency of the Management of CAP by GPs
Of the 117 patients initially treated as outpatients, 108 patients
(92%) were cured without hospitalization and 9 patients required a
subsequent hospitalization because of a failure of the ambulatory
management. The clinical characteristics, final diagnosis, and outcomes
of these nine patients are shown in Table 5
. Six of these nine patients actually did not have pneumonia but had a
pulmonary disease or involvement that initially mimicked CAP, with new
onset of pulmonary symptoms, fever, and new pulmonary infiltrate on
chest radiographs (Table 5)
. Pulmonary embolism was responsible for the
diagnosis error in four cases, and alveolar hemorrhage and leukemia
were responsible for the diagnosis in one case each. The remaining
three patients were actually considered to have pneumonia (patient 3,
patient 4, and patient 9; Table 5
). Only in these three patients could
the hospitalization be attributed to a failure of the antibiotic
treatment prescribed before the hospitalization; in one case (patient
4), the patient had been treated according to recommendations, while
the two patients (patient 3 and patient 9) had not been treated
according to recommendations (Table 5)
. The rate of antibiotic
treatment failure in outpatients leading to a subsequent
hospitalization was 1 of 38 patients (2.6%) for the patients who were
treated according to recommendations, and 2 of 56 patients (3.6%) for
the patients who were not treated according to recommendations
(p > 0.5; Table 6
).
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Table 5. Characteristics of Patients With an Initial Diagnosis
of CAP Made by GPs Who Subsequently Justified Hospitalization Because
of the Failure of Ambulatory Treatment (n = 9)
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Table 6. Efficiency of Antibiotic Treatment Prescribed by GPs
According to Their Consistency With Recommendations for Ambulatory
Patients With CAP Who Did Not Receive Prior Antibiotic Treatment
(n = 94)*
|
|
Overall, of the 130 patients included in the study, 125 patients were
cured and 5 patients died (3.8%). The mortality rates were 0 of 108
patients for outpatients and 5 of 22 patients for hospitalized patients
(23%). All deaths were directly attributed to the severity of the
pulmonary or underlying diseases (cancer in three patients, alveolar
hemorrhage in one patient, and pneumocystosis in one patient), and none
could be related to the initial management of the GP in terms of
antibiotic treatment or hospitalization decision (Tables 2
, 5)
.
Outcome of the Patients With Ambulatory Treatment of CAP According
to Microorganism Identification
Of the 108 outpatients with CAP, a sputum sample could be examined
in 43 patients (40%). The reason for the lack of sputum examination in
the remaining 65 patients was the absence of expectoration in 51
patients and the impossibility to rapidly perform the examination for
logistic reasons in the remaining 14 patients. The sputum examination
was positive in 13 patients (30% of those performed; 12% of the
outpatient population). The microorganisms that were identified are
shown in Table 7
. Of the 108 outpatients, 86 patients actually had two serum samples for
serologic studies. The serology finding was positive for the diagnosis
of atypical pathogen or viruses in 12 patients, which represented 14%
of the 86 outpatients tested and 11% of the outpatient population
(Table 7 ).
Outcomes of HIV-Infected Patients
Of the study population, eight patients (6%) were HIV infected.
Of these patients, six patients (75%) were hospitalized (vs 17% for
the overall study population) and five patients (62.5%) had a
microbiologically proven pulmonary infection (vs 24% for the overall
population). Infecting pathogens were S pneumoniae in two
patients, P carinii in two patients, and L
pneumophila in one patient. One patient died from pneumocystosis.
|
Discussion
|
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The main finding of our study was the discrepancy between the poor
adherence of GPs to French recommendations and, overall, the good
outcome of CAP managed by the GP. Indeed, evaluation of antibiotic
treatments showed that GPs prescribed antibiotics that were in
agreement with recommendations in only 40% of the cases, and that the
choice of antibiotics did not take into account the presence or absence
of underlying conditions. Furthermore, this study did not
systematically examine the dose given for each antibiotic, a parameter
that was previously characterized by its inappropriateness among French
office-based physicians.15
16
Nevertheless, management of CAP by GPs was indisputably associated with
an excellent clinical evaluation of the initial severity of the
disease, and an appropriate indication of the need of hospitalization
of patients whose conditions failed to improve with initial ambulatory
treatment. All patients who were initially hospitalized had a worrisome
clinical condition due to either a severe underlying disease or an
extreme age, and/or a final identification of an invasive microorganism
that justified, retrospectively, the initial decision (Table 2)
. The
analysis of the nine patients who were subsequently hospitalized
disclosed, in two thirds of the cases, a disease mimicking CAP, and in
one third of the cases only a failure of antibiotic treatment (Table 5) . Noninfectious illnesses mimicking CAP are part of the differential
diagnosis when there is no response or deterioration after initiation
of empirical therapy.5
These conditions include pulmonary
embolism, cancer, or pulmonary hemorrhage, as observed in our patients
(Table 5) . Thus, in only 3 of the 130 study patients could
hospitalization be related to an ineffectiveness of ambulatory
antibiotic regimen. It is important to outline that the rate of
antibiotic failure in outpatients leading to a subsequent
hospitalization was similar for outpatients who were treated or not
according to recommendations (2.6% vs 3.6%; p > 0.5) and that two
of these three patients were HIV positive.
Overall, the efficiency of the management of CAP by GPs was
characterized by a clinical cure without request of subsequent
hospitalization in 108 of the 117 ambulatory patients (92%) and no
mortality in outpatients. Mortality in hospitalized patients was 5 of
22 patients (23%) and was mainly due to the severity of the underlying
disease (Table 5)
. These results compared favorably with the literature
(average mortality < 1% in outpatients and 14% in hospitalized
patients),5
taking into account the fact that
immunocompromised patients, including HIV-infected patients, were not
excluded from our study, contrary to other studies.9
10
11
The apparent discrepancy between poor adherence to guidelines for the
antibiotic treatment for CAP and favorable outcome of CAP managed by
GPs in our study may have several explanations. (1) GPs promptly
identified at the initial visit the patients requiring immediate
hospitalization because of the severity of CAP; therefore, those
patients requiring urgent empirical antibiotic treatment active against
the suspected microorganism because of life-threatening conditions were
not treated by the GP. (2) GPs also hospitalized patients with severe
underlying conditions, either initially or subsequently, for whom any
inappropriateness of antibiotic treatment might have vital
consequences. As shown in Tables 2
, 5
, mortality was restricted to this
subgroup of patients. Therefore, ambulatory patients treated by GPs
were logically selected for the absence of vital symptoms and of severe
underlying disease. HIV-infected patients were particularly
representative of this aspect, since they represented 8 of 130 patients
(6%) of the overall population, 6 of 22 patients (27%) of the
hospitalized patients, and 2 of the 3 patients who were considered as
hospitalized because of a failure of ambulatory antibiotic treatment
(Tables 2 , 5)
. Thus, GPs hospitalized the subgroup of patients for whom
the inappropriateness of antibiotic treatment would have had a major
impact on clinical outcome. (3) Microbiological studies of outpatients
showed that microorganisms identified as responsible for CAP were
bacteria susceptible to common antibiotics, or were viruses, and that
no microorganism was identified in the majority of the cases (Table 7)
.
This result is in accordance with the fact that almost one half of the
cases of CAP that necessitate hospitalization are of unknown origin
despite extensive diagnosis procedures.2
17
This point
suggests that the impact of the choice of antibiotic treatment may, in
fact, be limited in this subpopulation of patients with unidentified
microorganisms.
When studying sputum examination, our aim was not to defend this
practice (which is uncommon in France), but rather to examine its yield
in the community and in general practice. A valid sputum sample could
only be obtained in 40% of the patients; of those 40%, 30% had a
positive examination result (12% of the overall outpatient
population). This sensitivity of 30% may be considered as low as
compared to the 50 to 60% sensibility reported in some
studies.8
18
19
20
However, it is important to outline that
our microbiological study was community based, that 18% of the
patients received an antibiotic treatment prior to the initial visit,
and that the patients were not specifically suspected of having
pneumococcal pneumonia. All these factors may have contributed to a
decrease in the sensitivity of the test. Therefore, we believe that
this result is more realistic for GPs dealing with CAP than optimal
results obtained from hospital laboratories in hospitalized patients.
Several explanations may account for the poor adherence to guidelines
by GPs for antibiotic therapy of CAP. Recommendations that applied when
this study began were written by experts13
who may have
given too much importance to all of the possible microorganisms
involved in CAP and not enough to hospitalization decisions. Therefore,
this might lead toward the use of broad-spectrum antibiotics or
antibiotic combinations instead of the selection of patients who would
benefit from a simple first-line antibiotic strategy. Indeed, of the 47
outpatients without any risk factors, 22 patients (47%) received
amoxicillin or a macrolide antibiotic (Table 3)
. Another explanation
may be related to the fact that GPs were not involved in the process of
definition and diffusion of guidelines. This may explain the limited
adherence to the recommendations among GPs. Finally, since the end of
the present study, not less than three official recommendations have
been published on the management of community-acquired pneumonia that
would concern French GPs (one European,6
one from the
French Society of Pneumology,21
and one from the French
Agency for Drugs22
). Obviously, the multiplicity of the
recommendations available in France might be a factor limiting the
adherence of the French GP to any of these recommendations.
In conclusion, our study showed that the management of CAP by GPs in
France was effective in terms of clinical outcome despite the frequent
inappropriateness of the antibiotic regimens prescribed according to
French recommendations. This was mainly due to a good selection of the
patients requiring hospitalization. Our results do not justify the fact
that recommendations were not followed by GPs but strongly suggest that
GPs should be involved in the procedure of recommendations for the
treatment of CAP. Adherence to recommendations for antibiotic treatment
of CAP by GPs might have a more substantial impact on other parameters
than clinical outcome. In particular, the economical analysis of GP
behavior is currently being evaluated.
|
Appendix 1
|
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EURAXI: Dusset Gérard, Ramos Alain, Chemin Patrick,
Fierfol Luc, Richard Jean-Jacques, Becq Jean-Philippe, Chastan Georges,
Drugeon Michel, Duffaut Gérard, Solomiac Jacques, Breton Nicolas,
De Joux Emmanuel, Duvochel Louis, Farenc Roger, Flori Jeanne, Osseni
Bissiriou, Stefanaggi Thierry, Azzopardi Yves, Dalle Rive
Marie-Catherine, Ecochard Cirica Nadine, El Sawy Alain, Gichard
Gérard, Jallon Pascal, Mongourdin Benoît, Salembier
Alain, Constensoux Jean-Pierre, Destrube Bernard, Meker Denis, Aroun
Jean-Marc, Mercier Charles-Henry, Berthier Alain, Esnault Pierre,
Marzin Yves, Pierre Philippe, Paillard Guy-Marc, Saitta Marc, Bardin
Rémi, Bonet François-Xavier, De Sainte Lorette Eric, Gasser
Jean-Hugues, Gelin Daniel, Houdry Pavie Suzanne.
Société de Formation Thérapeutique du
Généraliste: Adorian Danielle, Aubert Jean-Pierre, Avramov
Danielle, Bernard Catherine, Block Frédérique, Bloede
François, Botte Christine, Bouix Jean-Claude, Brami Jean, Bryn
Agnès, Buffel Thierry, Caulet Marie-Cécile, Chapiro Ouri,
Chaumie Catherine, Chenay Christian, Cohen Floriane, El-Kaddi
Aïman, Gallai-Profit Maria, Graciani Pierre, Guiller Murielle,
Henry Ghislaine, Herblot Thierry, Huet Christian, Hureau Jean-Philippe,
Jean Alain, Jomier Bernard, Kartowski Estelle, Labbe Véronique,
Lacour Christiane, Langlois Pierre, Laval Sylvette, Lavielle
Maïté, Lecompte Françoise, Magnier Anne-Marie,
Mollard Jean-Marc, Moula Hervé, Nahon Françoise, Petit
Jean-François, Pirolli Christian, Pitras Jérôme,
Rance Philippe, Rey-Giraud Pierre, Ribaud Patrick, Siary Alain,
Weizmann Ledicia.
|
Acknowledgements
|
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The authors thank Drs. Michel Cadilhac and Sylvie
Fiessinger (Aventis) for their active participation to the project, and
Stephanie Chavane (MEDILOG) for her technical assistance.
|
Footnotes
|
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Abbreviations:
CAP = community-acquired pneumonia; GP = general practitioner
This study was supported by a grant from Aventis to the Institut
National de la Santé et de la Recherche Médicale.
Received for publication August 8, 2000.
Accepted for publication February 23, 2001.
|
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TOP
Abstract
Introduction
