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Clinical Question
Does a bundled intervention that includes adjunctive corticosteroids improve outcomes in patients hospitalized with community-acquired pneumonia?
Bottom line
For patients hospitalized with community-acquired pneumonia (CAP), the implementation of 4 evidence-based interventions, including adjunctive treatment with steroids, did not affect length of stay (LOS), mortality, readmission rate, or need for intensive care support. The median length of stay for study patients was only 3 days, and half the patients had low-risk pneumonia. There was a slightly higher incidence of gastrointestinal bleeding in the intervention group, likely attributed to the use of steroids; however, the total number of events was small. 1b
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Government
Setting: Inpatient (ward only)
Synopsis
Prior evidence has shown improved outcomes for CAP using specific interventions, including early mobilization, nutrition screening, an early switch from intravenous to oral antibiotics, and adjunctive treatment with steroids. In this trial, investigators randomized patients hospitalized with CAP in 1 of 8 general medicine wards in Australia to receive either a bundle of interventions (n = 401) or usual care (n = 415). The intervention bundle included the following: (1) getting out of bed for more than 20 minutes on day of admission and progressive mobilization daily, (2) screening for malnutrition with targeted nutritional therapy, (3) switching from intravenous to oral antibiotics according to predefined criteria, and (4) receiving prednisolone acetate 50 mg daily, or its equivalent, for 7 days. These interventions were recommended, but complied with at the discretion of the treating team. Randomization was at the ward level using a stepped wedge process. After a 10-week control period, 2 of the 8 wards were transitioned to the intervention model every 10 weeks. Patients in the 2 groups were similar at baseline with a mean age of 76 years and similar co-morbidities. Half the patients had a pneumonia severity score of 0 or 1, corresponding to low risk. Analysis was by intention to treat. More patients in the intervention group received steroid prescriptions (76% vs 25%), early mobilization (72% vs 19%), and nutritional support (83% vs 55%); de-escalation to oral antibiotics was common for both groups (77% in the intervention group vs 69% in the control group). For the primary outcome of LOS, no significant difference was detected between the 2 groups. Notably, the median LOS in this study was only 3 days as compared with 6 or 7 days in prior studies of these interventions. Additionally, there were no differences detected in mortality, readmission rate, admission to the intensive care unit, or need for mechanical ventilation. Patients in the intervention group had higher rates of gastrointestinal bleeding (2.2% vs 0.7%).
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Comments
Subject: The disease /health problem of patients: PNEUMONIA.
Dear Respected Team-CMA-Canada,
I have carefully read the above discussion by you on PNEUMONIA disease of patients/clients.
Only observation/medication by doctors /nurse practitioners/Family Doctors with good care /supervision/humanity /nursing /Treatment can make recovery towards sick patients. We can see the guidelines about this disease towards good Treatment.
Respectfully.
Dr.Muhammad Arif Rana.
Global Family Doctor(LDM Roll-224)-WONCA at SIG Based in Manikganj-Bangladesh.
International Resident Member (IMG)-CMAID-680777-CMA-Canada.
Working Place as Postgraduate Librarian for the last more than 16 years from 2002 To 2019-still serving:
Muhammad Arif Rana
Assistant Librarian (AL-843687)
Rajibpur Adarsha College
Manikganj-Bangladesh.
Date : September 30-2019-Monday-05:32 PM.
Email: muhammadarifrana3@gmail.com
NOTE: My discussion/comments serial at CMA-Canada including this comments /discussion is : Date : September -30-2019-Serial No# 03.
Respectfully.
Bundled interventions for community acquired pneumonia
One takeaway is the increased risk of gastro-intestinal bleeding in the treatment group. This is presumably related to the course of prednisolone. Some of the subjects are obviously elderly. A lesser dose and shorter duration may be of benefit with less risk.
The interventions are reasonable if individualized:
(1) getting out of bed for more than 20 minutes on day of admission and progressive mobilization daily,
(2) screening for malnutrition with targeted nutritional therapy,
(3) switching from intravenous to oral antibiotics according to predefined criteria, and
(4) receiving prednisolone acetate 50 mg daily, or its equivalent, for 7 days.
Perhaps there are other outcomes, related to quality and life and wellbeing, that may benefit from some of these individualized interventions.