Blog | Wednesday, October 9, 2013

QD: News Every Day--'Soft' pneumonia diagnosis on the rise, including cases without classic criteria

The definition of pneumonia has been stretched to include cases without the classic criteria of elevated white blood cell count, fever, cough, dyspnea, pleurisy, egophany and lobular infiltrate, and even sometimes when chest radiography is negative, according to an article in the October issue of the Cleveland Clinic Journal of Medicine.

Hospitalizations with discharge codes listing pneumonia increased 20% from the late 1980s to the early 2000s, according to a study that appeared in 2012 in The Journal of Infectious Diseases, while hospitalizations for the 10 other most frequent causes of admission did not change significantly in the same period. And, the risk of death from pneumonia improved similarly to the other 10 common conditions while discharge rates to a long-term care facility did not change.

The article called for definitive research from observational data to put an end to pneumoania’s “fuzzy edge” of diagnosis.

The author wrote, “Data already demonstrate that a short course of antibiotics is no worse than a long course for many hospitalized and outpatients with pneumonia, but many other patients may require no treatment at all. The time has come to find out.”

Not so fast, according to an editorial by Thomas M. File, MD, MACP. Pneumonia is still a leading cause of death in the United States, and the number of cases of invasive pneumococcal disease (mostly bacteremic pneumonia) as determined by a positive culture from a sterile site in people over age 65 has increased over the past decade.

He continued that polymerase chain reaction testing and assessment of the biomarker procalcitonin offer rapidly available results at the point of care. And, procalcitonin testing can differentiate viral from bacterial causes. Because a significant percent of cases of pneumonia in adults are caused by viruses alone, more specific therapy may prevent the unnecessary use of antibacterials, which leads to antibiotic resistance.

Dr. File concluded, “Thus, the question will not be, ‘Should we treat community-acquired pneumonia with antibacterials’ but rather, ‘What is the optimal treatment for pneumonia with a defined cause?’ This is a major change from an empirical broad-spectrum regimen (treat all likely pathogens) to a more specific approach that has several potential benefits, including better patient outcomes and less emergence of resistance.”