Clinical presentation, processes and outcomes of care for patients with pneumococcal pneumonia
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
OBJECTIVE: To describe the presentation, resolution of symptoms, processes of care, and outcomes of pneumococcal pneumonia, and to compare features of the bacteremic and nonbacteremic forms of this illness.
DESIGN: A prospective cohort study.
SETTING: Five medical institutions in 3 geographic locations.
PARTICIPANTS: Inpatients and outpatients with communityacquired pneumonia (CAP).
MEASUREMENTS: Sociodemographic characteristics, respiratory and nonrespiratory symptoms, and physical examination findings were obtained from interviews or chart review. Severity of illness was assessed using a validated prediction rule for short-term mortality in CAP. Pneumococcal pneumonia was categorized as bacteremic; nonbacteremic, pure etiology; or nonbacteremic, mixed etiology.
MAIN RESULTS: One hundred fifty-eight (6.9%) of 2,287 patients (944 outpatients, 1,343 inpatients) with CAP had pneumococcal pneumonia. Sixty-five (41%) of the 158 with pneumococcal pneumonia were bacteremic; 74 (47%) were nonbacteremic with S. pneumoniae as sole pathogen; and 19 (12%) were nonbacteremic with S. pneumoniae as one of multiple pathogens. The pneumococcal bacteremia rate for outpatients was 2.6% and for inpatients it was 6.6%. Cough, dyspnea, and pleuritic pain were common respiratory symptoms. Hemopytsis occurred in 16% to 22% of the patients. A large number of nonrespiratory symptoms were noted. Bacteremic patients were less likely than nonbacteremic patients to have sputum production and myalgias (60% vs 82% and 33% vs 57%, respectively; P<.01 for both), more likely to have elevated blood urea nitrogen and serum creatinine levels, and more likely to receive pencillin therapy. Half of bacteremic patients were in the low risk category for short-term mortality (groups I to III), similar to the nonbacteremic patients. None of the 32 bacteremic patients in risk groups I to III died, while 7 of 23 (30%) in risk group V died. Intensive care unit admissions and pneumonia-related mortality were similar between bacteremic and nonbacteremic groups, although 46% of the bacteremic group had respiratory failure compared with 32% and 37% for the other groups. The nonbacteremic pure etiology patients returned to household activities faster than bacteremic patients. Symptoms frequently persisted at 30 days: cough (50%); dyspnea (53%); sputum production (48%); pleuritic pain (13%); and fatigue (63%).
CONCLUSIONS: There were few differences in the presentation of bacteremic and nonbacteremic pneumococcal pneumonia. About half of bacteremic pneumococcal pneumonia patients were at low risk for mortality. Symptom resolution frequently was slow.
- Heffron R. Pneumonia with special reference to pneumococcus lobar pneumonia. Cambridge, Mass: Harvard University Press; 1979;302–8.
- Norby SR, Pope KA. Pneumococcal pneumonia. J Infect. 1979;1:109–20. CrossRef
- Mundy LM, Auwaerter PG, Oldach D, et al. Community-acquired pneumonia: impact of immune status. Am J Respir Crit Care Med. 1995;152:1309–15.
- Fang G-D, Fine M, Orloff J, Arisumi D, et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicentre study of 359 cases. Medicine. 1990;69:307–16. CrossRef
- Ortqvist A, Kalin M, Julander J, Mufson MA. Deaths in bacteremic pneumococcal pneumonia. A comparison of two populations—Huntington, WVa and Stockholm, Sweden. Chest. 1993;103:710–6.
- Austrian R, Gold J. Pneumococcal bacteremia with special reference to bacteremic pneumococcal pneumonia. Arch Intern Med. 1964;60:759–66.
- Kramer MR, Rudensky B, Hadas-Halperin IN, et al. Pneumococcal bacteremia: no change in mortality over 30 years—analysis of 104 cases and review of the literature. Isr J Med Sci. 1987;23:174–80.
- Hook EW III, Horton CA, Schaberg DR. Failure of intensive care unit support to influence mortality from pneumococcal pneumonia. JAMA. 1983;249:1055–7. CrossRef
- Hofmann J, Cetron MS, Farley MM, et al. The prevalence of drugresistant Streptococcus pneumoniae in Atlanta. N Engl J Med. 1995;333:481–6. CrossRef
- Pallares R, Linares J, Vadillo M, et al. Resistance to penicillin and cephalosporins and mortality from severe pneumococcal pneumonia in Barcelona, Spain. N Engl J Med. 1995;333:474–80. CrossRef
- Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243–50. CrossRef
- Fine MJ, Stone RA, Singer DE, et al. Processes and outcomes of care for patients with community-acquired pneumonia. Results from the pneumonia patient outcomes research team. Arch Intern Med. 1999;159:970–80. CrossRef
- Manual of the international statistical classification of diseases, injuries, and causes of death. Geneva, Switzerland: World Health Organization; 1977.
- Bartlett G, Mundy LM. Community-acquired pneumonia. N Engl J Med. 1995;333:1618–24. CrossRef
- Marston BJ, Plouffe JF, File TM Jr, et al. Incidence of communityacquired pneumonia requiring hospitalization. Results of a population based active surveillance study in Ohio. Arch Intern Med. 1997;157:1709–18. CrossRef
- Burman LA, Trollfors B, Andersson B, et al. Diagnosis of pneumonia by cultures, bacterial and viral antigen detection tests, and serology with special influence to antibodies against pneumococcal antigens. J Infect Dis. 1991;163:1087–93.
- Kauppinen MT, Herva E, Kujala P, et al. The etiology of community-acquired pneumonia among hospitalized patients during a Chlamydia pneumoniae epidemic in Finland. J Infect Dis. 1995;172:1330–5.
- Fay HM, Wentworth B, Kenny GE, Kloeck JM, Grayston JT. Pneumococcal isolation from patients with pneumonia and control subjects in a prepaid medical care group. Am Rev Respir Dis. 1975;111:595–603.
- Bates JH, Campbell GD, Barren AC, et al. Microbiology etiology of acute pneumonia in hospitalized patients. Chest. 1992;101:1005–112.
- Gilbert K, Gleason PP, Singer DE, et al. Variation in antimicrobial use and cost in more than 2000 patients with community-acquired pneumonia. Am J Med. 1998;104:17–27. CrossRef
- Goldstein EJC. CID Hot Page. Clinic Infect Dis. 1997;24.
- Butler JC, Hofmann J, Cetron MS, et al. The continuing emergence of drug-resistant Streptococcus pneumoniae in the United States. An update from Centers for Disease Control and Prevention’s pneumococcal sentinel surveillance system. J Infect Dis. 1996;174:986–93.
- British Thoracic Society Research Committee. The aetiology management and outcome of severe community-acquired pneumonia in the intensive care unit. Respir Med. 1992;86:7–13. CrossRef
- Rello J, Quintana E, Ausina V, Net A, Prats G. A three-year study of severe community-acquired pneumonia with emphasis on outcome. Chest. 1993;103:232–5.
- Finkelstein MS, Petkun WM, Freedman ML, Antopol SC. Pneumococcal bacteremia in adults. Age-dependent differences in presentation and outcome. J Am Geriatr Soc. 1983;31:19–27.
- Ortqvist A, Grepe A, Julander IN, Kalin M. Bacteremic pneumococcal pneumonia in Sweden: Clinical course and outcome and comparison with non-bacteremic pneumococcal and mycoplasmal pneumonias. Scand J Infect Dis. 1988;20:163–71.
- Tilghman RC, Finland M. Clinical significance of bacteremia in pneumococcic pneumonia. Arch Intern Med. 1937;59:602–19.
- Perlino CA, Rimland D. Alcoholism, leukopenia and pneumococcal sepsis. Am Rev Respir Dis. 1985;132:757–60.
- Kludt P, Lett SM, De Maria, et al. Outbreaks of pneumococcal pneumonia among unvaccinated residents in chronic care facilities—Massachusetts, October 1995, Oklahoma, February 1996 and Maryland, May–June 1996. MMWR. 1997;46:60.
- Metlay JP, Fine MJ, Schulz R, et al. Measuring symptomatic and functional recovery in patients with community-acquired pneumonia. J Gen Intern Med. 1997;12:423–30. CrossRef
- Kalin M, Ortqvist A, Almela M, et al. Prospective study of prognostic factors incommunity-acquired bacteremic pneumococcal disease in five countries. Interscience Conference on Antimicrobial Agents and Chemotherapy, San Francisco, Calif. 1999;675. Abstract 1068.
- Clinical presentation, processes and outcomes of care for patients with pneumococcal pneumonia
Journal of General Internal Medicine
Volume 15, Issue 9 , pp 638-646
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- Industry Sectors
- Author Affiliations
- 1. the School of Medicine, University of Pittsburgh, Pittsburgh, Pa
- 2. the Division of Infectious Diseases, Department of Medicine, Victoria General Hospital and Dalhousie University, Halifax, Nova Scotia, Canada
- 4. the General Medicine Division, Medical Services, Massachusetts General Hospital, and Harvard Medical School, Boston, Mass
- 5. the Division of General Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pa