Medical Discussions

The original study of the PORT score (NEJM 336:243, 1997) was validated in more than 28,000 patients predominantly in hospital emergency rooms, and the severity of illness ranged from not so sick (0.1% mortality, Class I) to very sick (29.3% mortality, Class V). Beware that the PORT score, which has evolved into the Pneumonia Severity Index (PSI), was derived to determine expected mortality for a given clinical profile. This rule has then been prospectively studied to ask the question, can the PSI determine the need for hospitalization and reduce costs, and its performance hasn’t been great. American Thoracic Society (ATS) guidelines from 2001 emphasize its limits, resting the decision to hospitalize on your clinical judgment. Thus, I strongly agree with Dr. Mints (and the ATS 2001 guidelines and the Infectious Disease Society of America (IDSA) 2003 guidelines) that over-reliance on clinical prediction rules generally, and specifically for pneumonia, is risky and in no way replaces clinical judgment. That said, by knowing the PSI criteria, we as residents may better appreciate our tools for evaluating the severity of an infection. It may surprise you to learn that hyponatremia, hyperglycemia, and a BUN of >30 add +50 to your points.

I share Dr. Mints’ chagrin that the suggested coverage for microbes associated with aspiration (i.e anaerobes) is pip/tazo and not amp/sulbactam. In my review of the 2001 ATS guidelines, they suggest high dose ampicillin, amp/sulbactam, or “other active beta-lactams” – which sounds consistent with Mints’ comment that anaerobes are likely still susceptible to ceftriaxone. Also, in our practice at Bellevue, we tend to avoid the use of fluoroquinolones when there is a question of TB infection, as levofloxacin is an important component of our armamentarium against drug-resistant TB.

To me, the NYPH guidelines do not seem to suggest a need to observe patients on PO antibiotics. Rather, they apply discharge criteria that are identical to the IDSA 2003 guidelines (temp 36hrs without antipyretics, pulse 90 ,O2sat >90%, taking POs). If these criteria are met, these NYPH guidelines suggest no reason to hold-up discharge.

One principle of CAP therapy not mentioned in the NYPH guide is the IDSA guideline to initiate antibiotic therapy within 4 hours (this is a national hospital “quality of care” measure).

Generally, when I have questions about management of CAP, I turn to the ATS and IDSA websites, which publish their guidelines as PDFs for free. IDSA plans to update their CAP recommendations in the spring of 2007.