Microsoft PowerPoint - Case-\251x\247\273\300Mt.ppt

•PE–No obvious wheezing or rales over anterior andlateral chest–Heart: no murmur•Lab data–WBC 10070, N. band 57%, N. seg. 38%–Hb 11.0 g/dl–Na 135 K 3.78 BUN/CRE 30/1.8–ABG (N/C 2 L/min): pH 7.439, pCO2 32.0 mmHg,pO2 65.3 mmHg, HCO3 21.9 mmol/L.

CXR•Infiltration atright lung & leftlower lung

•Diagnosis–Community-acquired pneumonia•Treatment–Moxifloxacin 400 mg QD–Ceftriaxone 1000 mg QD

•Patients:PICO problem–A 83 y/o male was hospitalized because of CAP•Interventions:–guideline-concordant antimicrobial therapy•Comparisons:–not guideline-concordant antimicrobial therapy•Outcomes:–mortality

Search method•Data base: MD consult, PubMed•Key words:–Antibiotic, community-acquire pneumonia (CAP),mortality•Exclusion:–studies that do not focus CAP

Antibiotic Therapy and 48-HourMortality for Patients withPneumoniaEric M. Mortensen, MD, MS Marcos I. Restrepo, MD, MS AntonioAnzueto, MD, Jacqueline A. Pugh, MDFrom The American Journal of Medicine (2006) 119, 859-864

Purpose•Determine whether the use of guidelineconcordantantibiotic therapy is associatedwith decreased mortality within the first 48 hrsafter admission for Pts with pneumonia.

Methods•A retrospective cohort study•Two tertiary teaching hospitals in Texas.•A propensity score was used to balance thecovariates associated with the use of guidelineconcordantantimicrobial therapy.•A multivariable logistic regression model wasused to assess the association

Study Sites/Inclusion and Exclusion Criteria•Jan. 1, 1999, and Dec. 1, 2002•Community-acquired pneumonia•> 18 yrs•a confirmed infiltrate or other findingconsistent with CAP on CXR or CT obtainedwithin 24 hours of admission.

•Exclusion criteria–discharge from an acute care facility within 14days of admission–transfer after being admitted to another acute carehospital–receiving comfort measures only on thisadmission.–If admitted >1 time, only the 1st time

Risk Adjustment•The pneumonia severity index (PSI)–3 demographic characteristics, 5 comorbidillnesses, 5 physical examination findings, and 7laboratory and radiographic findings–Class I~V

2003 IDSA/2001 ATS guidelines•Pts in wards–a beta-lactam with doxycycline or a macrolide, oran antipneumococcal fluoroquinolone alone.•Pts in ICU–a beta-lactam with a macrolide orantipneumococcal fluoroquinolone,antipseudomonal beta-lactam+aminoglycoside+macrolide, or an antipneumococcalfluoroquinolone with clindamycin, vancomycin, oran aminoglycoside

Results•787 Pts with CAP.•The median age was 60 yrs, 79% were male,and 20% were initially admitted to ICU.•At presentation 52% were low risk (PSI I~III),34% were moderate risk (IV), and 14% werehigh risk (V).•Within the first 48 hours, 20 Pts died.•Mortality was 2.5% at 48 hours, 9.2% at 30days, and 13.6% at 90 days.

•63 Pts with positive blood cultures–Streptococcus pneumoniae in 34 Pts (54%).•The initial empiric antimicrobial therapy–guideline concordant in 79.4% : 82% (519/633) ofward Pts and 69% (106/154) of ICU Pts.•Pts who died within 48 hrs–67% of ICU Pts received guideline-concordantantibiotics compared with 38% of ward patients.

•There were no significant differences betweenthe mortality rates for patients in the ICU whoreceived guideline-concordant therapy versusnon–guideline-concordant (67% vs 69%,P=0.9).

•Use of guideline concordant antibiotics wasassociated with decreased mortality at 48 hours(odds ratio=0.37; 95% confidence interval [CI],0.15-0.95, P=.04).

Conclusion•Too many variates•A small number of deaths with in 48 hrs hard to explore the predictors•To our Pt–CAP with ICU hospitalized.–We use Guideline-concordant antibiotics

Comments•Dr. 李 宜 恭– 要 先 確 認 清 楚 疾 病 的 定 義 , 再 深 入 討 論– 對 病 人 做 PE 時 要 夠 仔 細 , 並 把 自 己 的 想 法 用 文字 表 現 出 來–PICO 要 用 更 精 確 的 文 字 來 表 達– 搜 尋 文 章 時 的 key words 也 要 很 精 確– 搜 尋 文 章 儘 量 不 要 用 私 人 團 體 的 資 料 庫 , 易 出現 偏 差

•Dr. 李 宜 恭– 需 徹 底 了 解 文 章 中 所 用 的 評 估 方 法– 文 中 內 容 若 用 在 ICU 病 人 身 上 可 能 會 出 現 不 少偏 差 , 因 ICU 病 人 的 預 後 可 由 太 多 不 同 的 原 一來 影 響 , 也 許 抗 生 素 並 不 是 最 主 要 的 因 素 。