Ethical planning for an influenza pandemic.

A U.K. Pandemic Influenza Contingency Plan was developed in 2006 but little research has since been carried out as to how ethically acceptable it will be to society. A survey containing two hypothetical scenarios was distributed to 1,018 hospital staff. The survey considered their attitudes to the professional and ethical responsibilities of healthcare workers, and to resource allocation on the intensive care unit (ICU). Of those distributed, 406 (40%) surveys were returned. During a pandemic, 320 (79%) healthcare professionals would continue to work and 339 (83%) felt it would be unprofessional for doctors to leave work. Only 218 (54%) chose the same patient for the last ICU bed. Most staff surveyed felt they should (professionally) and would (voluntarily) work during a pandemic despite high personal risk. A wide diversity of opinion existed regarding resource allocation of ICU beds. These ethical issues require open debate to ensure U.K. pandemic plans are ethically acceptable and practically applicable.

Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study.

BACKGROUND: In the assessment of severity in community acquired pneumonia (CAP), the modified British Thoracic Society (mBTS) rule identifies patients with severe pneumonia but not patients who might be suitable for home management. A multicentre study was conducted to derive and validate a practical severity assessment model for stratifying adults hospitalised with CAP into different management groups. METHODS: Data from three prospective studies of CAP conducted in the UK, New Zealand, and the Netherlands were combined. A derivation cohort comprising 80% of the data was used to develop the model. Prognostic variables were identified using multiple logistic regression with 30 day mortality as the outcome measure. The final model was tested against the validation cohort. RESULTS: 1068 patients were studied (mean age 64 years, 51.5% male, 30 day mortality 9%). Age >/=65 years (OR 3.5, 95% CI 1.6 to 8.0) and albumin <30 g/dl (OR 4.7, 95% CI 2.5 to 8.7) were independently associated with mortality over and above the mBTS rule (OR 5.2, 95% CI 2.7 to 10). A six point score, one point for each of Confusion, Urea >7 mmol/l, Respiratory rate >/=30/min, low systolic(<90 mm Hg) or diastolic (/=65 years (CURB-65 score) based on information available at initial hospital assessment, enabled patients to be stratified according to increasing risk of mortality: score 0, 0.7%; score 1, 3.2%; score 2, 3%; score 3, 17%; score 4, 41.5% and score 5, 57%. The validation cohort confirmed a similar pattern. CONCLUSIONS: A simple six point score based on confusion, urea, respiratory rate, blood pressure, and age can be used to stratify patients with CAP into different management groups.

Percutaneous lung biopsies: a survey of UK practice based on 5444 biopsies.

Percutaneous transthoracic lung biopsies are commonly performed for the investigation of lung masses. We describe current practice and complication rates in the UK. A postal questionnaire was sent to all centres in the British Thoracic Society directory. 157 replies (61% response rate) were received, providing data on 5444 biopsies. Mean number of biopsies performed per annum was 30.5 per centre; 8% of centres did not perform biopsies, 36% performed <25 biopsies per annum, 34% <50, 16% <100 and 6% >100. Consultant radiologists perform 91% of biopsies. Written consent was obtained at all centres. The operator obtained consent at 50% of centres. Written information for patients was provided at 35 (24%) centres. Biopsies are performed on a day case basis at 103 (71%) centres. Prior to biopsy the following were obtained routinely: CT scan (73% of centres), platelet count (73%), full clotting screen (70%), lung function (55%). Complications included pneumothorax (20.5% of biopsies), pneumothorax requiring chest drain (3.1%), haemoptysis (5.3%) and death (0.15%). The timing of post-procedure chest radiography was variable. Those centres that performed predominantly cutting needle biopsies had similar pneumothorax rates to centres performing mainly fine needle biopsies (18.9% vs 18.3%). There is great variation in practice throughout the UK. Most procedures are performed on a daycase basis. Small pneumothoraces are common but infrequently require treatment. National guidelines are needed to ensure consistency of standards.

Respiratory rate measurement in adults--how reliable is it?

Measurement of respiratory rate (RR) is essential in the evaluation of respiratory disorders. However, the variability in RR measurement in adults has never been adequately assessed. Respiratory rate was measured twice in 245 patients; the two measurements were performed by the same observer in 137 patients, by different observers in 58 patients and simultaneously by different observers in 50 patients. The mean (SD) difference between the first and second measurements was 0.03 (3); 95% limits of agreement-4.86-4.94 breaths min(-1), -5.7-5.7 breaths min(-1), and -4.2 to 4.4 breaths min(-1) for the same observer, different observer and simultaneous observer groups, respectively. The difference in RR measurements did not vary with RR. In conclusions on average, there is very good agreement between observers in RR measurement. Inter-observer variability may account for a difference of up to 6 breaths min(-1). This is relevant when applying clinical prediction rules based on threshold RR values.

A prospective comparison of nursing home acquired pneumonia with community acquired pneumonia.

Nursing home acquired pneumonia (NHAP) is thought to be clinically distinct from community acquired pneumonia (CAP). This observation, based on studies conducted mainly in North America, may not be relevant in countries with a different healthcare system. The authors describe an 18-month prospective cohort study of 437 patients admitted to hospital with CAP, 40 (9%) of whom came from nursing homes. Detailed microbiological tests were performed in a subset of patients over 12 months. Patients with NHAP were less likely to have a productive cough (odds ratio (OR) 0.4, p=0.02) or pleuritic pain (OR 0.1, p=0.03), but they were more likely to be confused (OR 2.6, p<0.001). They had poorer functional status (p<0.001) and more severe disease (p=0.03). Mortality was higher compared to CAP (53% versus 13%), but this was mainly explained by prior functional status (OR 0.5, after adjustment for functional status). Pathogens were identified in 68% of 22 NHAP and 80% of 44 matched CAP patients. Streptococcus pneumoniae was the most common (55% NHAP, 43% CAP). Atypical pathogens, enteric Gram negative bacilli and Staphylococcus aureus were uncommon. In conclusion, differences in functional status accounted for the increased mortality in nursing home acquired pneumonia compared to community acquired pneumonia. The pathogens implicated were similar. No grounds for a difference in choice of empirical antibiotics were apparent.

Defining prognostic factors in the elderly with community acquired pneumonia: a case controlled study of patients aged > or = 75 yrs.

Severity assessment in the elderly with community acquired pneumonia (CAP) may be different compared with younger patients. In particular, age per se may not be of prognostic significance in older patients. A case-control study in 158 patients aged > or = 75 yrs with CAP was conducted to determine the factors associated with in-hospital mortality. Cases were drawn from all patients aged > or = 75 yrs with CAP who died in 1997 in five hospitals in the mid-Trent region of the UK (Nottingham City Hospital, University Hospital Nottingham, Derby Royal Infirmary, Derby City General Hospital and Kings Hill Hospital). Controls were randomly selected from survivors also aged > or = 75 yrs. Factors associated with mortality were identified following a review of the medical casenotes and the contribution of these factors to mortality was determined using multivariate analysis. Absence of fever, tachycardia and chest radiograph features of bilateral involvement or an effusion were independently associated with mortality on multivariate analysis. The British Thoracic Society (BTS) severity rule was 50% sensitive and 64% specific in predicting death while the modified BTS rule displayed 67% sensitivity and 58% specificity. Age was not significantly associated with mortality in this group of patients aged > or = 75 yrs. Similarly, the clinical features employed in the British Thoracic Society rule, namely respiratory rate, diastolic blood pressure and blood urea, were not of prognostic significance and the rule itself performed poorly. The modified British Thoracic Society rule performed better.

Symptoms, signs, and prescribing for acute lower respiratory tract illness.

BACKGROUND: Most patients who consult with acute lower respiratory symptoms receive antibiotics, usually without evidence of significant infection. The physical signs at presentation of acute lower respiratory tract illness and the rate at which symptoms resolve and normal activities recover is not well documented. AIM: To examine in patients with lower respiratory tract infection (LRTi), their physical signs at presentation, their relationship to antibiotic prescribing, and symptom resolution and resumption of normal activities. DESIGN OF STUDY: Analysis of data collected prospectively during presentation of acute LRTi in primary care and from patient symptom diary cards. SETTING: Forty GPs who were members of an informal Community Respiratory Infection Interest Group recruited 391 patients to the study. METHOD: Information was collected on pulse, oral temperature, respiratory rate, abnormalities on auscultation, and details of any antibiotic prescription. Patients completed symptom diary cards for the following 10 days. RESULTS: Of the 391 patients who consulted 71% received antibiotics. A minority had abnormal physical signs: 17% had a pulse greater than 90 bpm, 15% a respiratory rate greater than 20 breaths per minute, 4% had a temperature greater than 38 degrees C, and 25% had an abnormality on auscultation. Antibiotic prescribing was more common in the presence of abnormal chest signs (odds ratio = 8.71, 95% confidence interval = 3.69-20.61) or discoloured sputum (OR = 2.67, 95% CI = 1.57-4.56). Ten days after consultation, 58% of patients were still coughing and 29% had not returned to normal activities. CONCLUSION: Abnormal physical signs at presentation do not explain the high rates of antibiotic prescribing nor do they predict persisting cough and functional impairment at 10 days. Reconsultation for the same symptoms within a month is common and is strongly related to persisting cough, but not abnormalities at presentation.

Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines.

BACKGROUND: Since the last British study of the microbial aetiology of community acquired pneumonia (CAP) about 20 years ago, new organisms have been identified (for example, Chlamydia pneumoniae), new antibiotics introduced, and fresh advances made in microbiological techniques. Pathogens implicated in CAP in adults admitted to hospital in the UK using modern and traditional microbiological investigations are described. METHODS: Adults aged 16 years and over admitted to a teaching hospital with CAP over a 12 month period from 4 October 1998 were prospectively studied. Samples of blood, sputum, and urine were collected for microbiological testing by standard culture techniques and new serological and urine antigen detection methods. RESULTS: Of 309 patients admitted with CAP, 267 fulfilled the study criteria; 135 (50.6%) were men and the mean (SD) age was 65.4 (19.6) years. Aetiological agents were identified from 199 (75%) patients (one pathogen in 124 (46%), two in 53 (20%), and three or more in 22 (8%)): Streptococcus pneumoniae 129 (48%), influenza A virus 50 (19%), Chlamydia pneumoniae 35 (13%), Haemophilus influenzae 20 (7%), Mycoplasma pneumoniae 9 (3%), Legionella pneumophilia 9 (3%), other Chlamydia spp 7 (2%), Moraxella catarrhalis 5 (2%), Coxiella burnetii 2 (0.7%), others 8 (3%). Atypical pathogens were less common in patients aged 75 years and over than in younger patients (16% v 27%; OR 0.5, 95% CI 0.3 to 0.9). The 30 day mortality was 14.9%. Mortality risk could be stratified by the presence of four "core" adverse features. Three of 60 patients (5%) infected with an atypical pathogen died. CONCLUSION: S pneumoniae remains the most important pathogen to cover by initial antibiotic therapy in adults of all ages admitted to hospital with CAP. Atypical pathogens are more common in younger patients. They should also be covered in all patients with severe pneumonia and younger patients with non-severe infection.

A novel method for collecting and detecting amoxycillin in urine: a tool for testing antibiotic compliance in the community.

Assessing compliance to prescribed antibiotics in community studies of respiratory tract infections is difficult. We describe a simple method for collecting and detecting amoxycillin in urine using urine dip-sticks in conjunction with a bioassay. Urine was collected at timed intervals from eight healthy volunteers following oral amoxycillin administration. Dip-sticks inoculated with urine collected 1 and 8 h after antibiotic resulted in mean zones of inhibition of 1.75 and 1.37 cm, respectively. Amoxycillin activity remained demonstrable 14 days after inoculation of dip-sticks with urine. Dip-sticks inoculated with urine from control subjects who had not taken amoxycillin did not cause inhibition.

A national confidential enquiry into community acquired pneumonia deaths in young adults in England and Wales. British Thoracic Society Research Committee and Public Health Laboratory Service.

BACKGROUND: The aim of this study was to describe the frequency, causal pathogens, management, and outcome of a population of young adults who died from community acquired pneumonia (CAP). METHODS: Pneumonia deaths in England and Wales in adults aged 15-44 were identified between September 1995 and August 1996. Patients with underlying chronic illness including HIV infection were excluded. Clinical details for each case were collected from the hospital and general practitioner records. RESULTS: Death from CAP was identified in 27 previously well young adults (1.2 per million population per year). Twenty were known to have consulted a GP for this illness. Nine received antibiotics before hospital admission. A causative pathogen was identified in 17 cases (Streptococcus pneumoniae in eight). Bacteraemia was present in seven. All patients who reached a hospital ward received antibiotics (69% within two hours of admission). The British Thoracic Society antibiotic guidelines for severe CAP were followed in only 10 cases. Cardiac arrest at home or on arrival at hospital occurred in six cases, one of whom was successfully resuscitated. Of the remaining 21 patients, 71% had two or more markers of severe CAP. All 22 who were admitted reached an intensive care unit, but 11 of these required transfer to another hospital for some aspect of intensive care. One third of patients died within 24 hours of presenting to the hospital. CONCLUSIONS: Death from CAP in previously fit young adults still occurs. While some deaths might be preventable by better patient management, most are unlikely to be preventable by current management practices.

Risk factors for community-acquired pneumonia diagnosed by general practitioners in the community.

The purpose of this study was to identify risk factors for pneumonia diagnosed in the community by general practitioners, using a case control study in 29 general practices in Nottingham, U.K. Patients with radiographically confirmed pneumonia were compared with adults randomly selected from electoral registers corresponding to the catchment areas of the general practices taking part in the study. Sixty-six cases and 489 controls participated. Significant risk factors in univariate analysis included age, chronic obstructive pulmonary disease, congestive heart failure and lifetime consumption of cigarettes. Multiple logistic regression analysis of these four variables showed that age [adjusted odds ratio = 2.69 (for 30 year increment), 95%CI = 1.66-4.35] and chronic obstructive pulmonary disease (adjusted odds ratio= 1.99, 95%CI = 1.15-3.45) were independent risk factors. Only age and chronic obstructive pulmonary disease were independent risk factors for pneumonia in this study. Since cigarette smoking is the major cause of chronic obstructive pulmonary disease, these data suggest that cigarette smoking is the main avoidable risk factor for community-acquired pneumonia in adults.

Severity prediction rules in community acquired pneumonia: a validation study.

BACKGROUND: The British Thoracic Society (BTS) developed a rule (BTSr) based on severity criteria to predict short term mortality in adults admitted to hospital with community acquired pneumonia (CAP). However, neither the BTSr nor a recent modification of it (mBTSr) have been validated in the UK. A case-control study was conducted in a typical UK population to determine the clinical factors predictive of mortality and to assess the performance of these rules. METHODS: Cases were drawn from all patients with CAP who died in 1997 in five large hospitals in the Mid Trent area. Controls were randomly selected from survivors. Factors associated with mortality were identified following review of medical case notes and performance of the severity prediction rules assessed. RESULTS: Age >65 years, temperature <37 degrees C, respiratory rate >24 breaths/min, mental confusion, urea concentration of >7 mmol/l, sodium concentration of <135 mmol/l, and the presence of a pleural effusion, all determined on admission, were independently associated with in-hospital mortality on multivariate analysis. The BTSr was 52% sensitive and 79% specific in predicting death while the mBTSr displayed 66% sensitivity and 73% specificity. CONCLUSIONS: The value of three of the four factors (presence of mental confusion, raised respiratory rate, raised urea) used in the mBTSr as predictors of mortality is confirmed. However, the BTSr and mBTSr did not perform as well in this validation study which included a high proportion (48%) of elderly patients (> or =75 years) compared with the derivation studies.

How do general practitioners respond to reports of abnormal chest X-rays?

General practitioners (GPs) in the UK have long had direct access to hospital radiological services, which in theory shortens investigation time and improves the quality of service. Chest X-rays (CXRs) account for a substantial proportion of requests, and we investigated what happened when an abnormality was detected. In one year, 204 GPs in the Nottingham area requested CXRs in 605 patients. 362 were reported normal, 165 abnormal but hospital follow-up not indicated and 71 abnormal with radiological follow-up or hospital referral indicated (mass lesion suspicious of tumours 27, infective shadowing 35, other 9). 64 of the 71 were seen in hospital within three months, and in those with suspected cancer the median time to follow-up was 20 days. These results show that GPs do act on the results of abnormal CXRs, but only 37% of those with a mass suspicious of cancer were seen in hospital within two weeks as recommended by the British Thoracic Society. Time might be saved if GPs agreed to direct referral from the radiology department to respiratory physicians.

Impact of management guidelines on the outcome of severe community acquired pneumonia.

BACKGROUND: Ten years ago we published a study of 50 adults with severe community acquired pneumonia admitted to our intensive care unit and subsequently introduced guidelines for the management of severe community acquired pneumonia which are largely in accordance with those of the British Thoracic Society. The results of a follow up study are now reported in order to assess their impact on the outcome of this disease. METHODS: Fifty seven cases of severe community acquired pneumonia admitted to our ICU between 1984 and 1993 were studied. Causal pathogens, clinical and laboratory features of severity, antibiotic therapy and mortality were studied and, where possible, compared with results from the previous study. RESULTS: Streptococcus pneumoniae, Legionella pneumophila and Staphylococcus aureus were the most frequent causes of severe community acquired pneumonia, as in the previous study. The intensity of microbial investigation has increased, particularly with regard to pneumococcal and Legionella antigen testing, the latter allowing earlier diagnosis of Legionella infection than previously. In spite of this, no pathogen was identified in 33% of cases compared with 18% previously. Indices of severity of illness were widely recognised, and a decrease in unplanned transfers to the ICU following "unexpected" cardiorespiratory arrest from 25% to 7% (p < 0.02) was found. Antibiotic therapy largely reflected guideline recommendations with 98% receiving a beta-lactam agent and 91% erythromycin. The overall mortality was 58% compared with 54% previously. CONCLUSIONS: Management guidelines for severe community acquired pneumonia have been widely adopted but without a reduction in mortality in our hospital. Factors other than early diagnosis, appropriate antibiotics, or prompt ICU transfer may influence the outcome in severe community acquired pneumonia.