11. tbl. 98. árg. 2012
Diagnosis, treatment and prognosis of community acquired pneumonia – results from three primary care centers in Iceland
Greining, meðferð og horfur lungnabólgu: niðurstöður frá þremur heilsugæslustöðvum
Aims: To study how general practitioners diagnose and treat adult patients with community acquired pneumonia (CAP) and evaluate outcomes.
Method:Retrospective chart review for one year on patients 18 years and older diagnosed with CAP in three different primary care centers in Iceland.
Results: A total of 215 patients were diagnosed with CAP. Of those 195 were both diagnosed and treated in the primary health care and 20 patients were referred for specialized care. Mean age was 50.3 years (SD= 21.0) and 126 (65%) of the patients were women. Most patients had been ill for less than a week and did not have a previously diagnosed lung disease. Cough was the most common symptom (71%) and 96% had abnormal chest auscultation. Vital signs were frequently not recorded. A chest radiograph was done in third of the cases and showed abnormality in over 80%. Most patients (94%) were treated with antibiotics usually extended spectrum penicillin. Phone consultations were the most common form of communication after diagnosis and about 12% of subjects had their antibiotics changed and about 10% had a chest radiograph done after diagnosis had been made. There was no mortality from CAP during the study period.
Conclusions: CAP was diagnosed clinically and managed in primary care in most cases. CAP was more common in women and a minority of patients had underlying lung diseases. Vital sign measurements were used less than expected. Broad spectrum antibiotics were widely used for treatment. CAP had no mortality.
Gustafsson AO1, Steingrimsson S1,2, Jonsson JS1,2, Gudmundsson G2,3
1Primary Health Care of the Capital Area, 2Faculty of Medicine, University of Iceland, 3Department of Respiratory Medicine and Sleep, Landspítali, The National University Hospital of Iceland.
| Table I. Demographics of patients diagnosed with pneumonia. | |||
|
Total group n=195 (%) |
Young (<65 years) n=141 (%) |
Old (≥65 years) n=54 (%) |
|
| Female sex | 126 (65) | 91 (65) | 35 (65) |
| Reported length of illness | |||
| Week or less | 115 (59) | 79 (56) | 36 (67) |
| Over one week to three weeks | 44 (23) | 34 (24) | 10 (19) |
| Over three weeks | 25 (13) | 17 (12) | 8 (15) |
| Not available | 11 (6) | 11 (8) | 0 (0) |
| COPD | 16 (8) | 7 (5) | 9 (17) |
| Asthma | 27(14) | 22 (16) | 5 (9) |
| Type of communication | |||
| Scheduled appointment | 89 (46) | 63 (45) | 26 (48) |
| Unscheduled appointment | 91 (47) | 69 (49) | 22 (41) |
| Phone call | 15 (8) | 9 (6) | 6 (11) |
| Symptoms | |||
| Cough | 139 (71) | 108 (77) | 31 (57) |
| Fever | 77 (39) | 59 (42) | 18 (33) |
| Cold | 61 (31) | 46 (46) | 15 (28) |
| Phlegm | 40 (21) | 26 (18) | 14 (26) |
| Malaise | 38 (19) | 26 (18) | 12 (22) |
| Chest pain | 21 (11) | 16 (11) | 5 (9) |
| Coloured sputum | 14 (7) | 12 (9) | 2 (4) |
| Dyspnoea | 12 (6) | 10 (7) | 2 (4) |
| Soar throat | 10 (5) | 8 (6) | 2 (4) |
| Signs | |||
| Auscultation recorded | 175 (90) | 127 (90) | 48 (89) |
| Rales | 52 (30) | 39 (31) | 13 (27) |
| Rhonchi | 36 (21) | 31 (24) | 5 (10) |
| Crepitations | 96 (55) | 68 (54) | 28 (58) |
| Pulse or BP recorded | 25 (13) | 10 (7) | 15 (28) |
| Pulse >120 beats/minute | 0 (0) | 0 (0) | 0 (0) |
| Systolic BP < 100 mmHg | 2 (8) | 2 (20) | 0 (0) |
| Diastolic BP < 60 mmHg | 3 (12) | 2 (20) | 1 (7) |
| Body temperature recorded | 7 (4) | 2 (1) | 5 (9) |
| Body temperature >38.5°C | 3 (43) | 0 (0) | 3 (60) |
| Respiratory rate recorded | 3 (2) | 2 (1) | 1 (2) |
| Respiratory rate >20 breaths/minute | 0 (0) | 0 (0) | 0 (0) |
| Chest radiograph | 63 (32) | 45 (32) | 18 (33) |
| Consolidation | 51 (81) | 38 (84) | 13 (72) |
| Blood test | 22 (11) | 16 (11) | 6 (11) |
| Abnormal* | 12 (55) | 11 (69) | 1 (17) |
| Table II. Treatment and referral. | |||
|
Total group n=195 (%) |
Young (<65 years) n=141 (%) |
Old (≥65 years) n=54 (%) |
|
| Antibiotic | 183 (94) | 136 (96) | 47 (87) |
| Amoxicillin | 60 (33) | 46 (34) | 14 (30) |
| Amoxicillin + clavulan acid | 45 (25) | 30 (22) | 15 (32) |
| Azithromycin | 40 (22) | 32 (24) | 8 (17) |
| Doxycycline | 26 (14) | 19 (14) | 7 (15) |
| Erythromycin | 9 (5) | 9 (7) | 0 (0) |
| Reported allergy | 11 (6) | 4 (3) | 7 (13) |
| Inhalation prescription | 27 (14) | 25 (18) | 2 (4) |
| Short-acting beta agonist (ventolin, bricanyl) | 16 (59) | 14 (56) | 2 (100) |
| Combination of SABA and glucocorticoid | 5 (19) | 5 (20) | 0 (0) |
| Combination of LABA and glucocorticoid | 6 (22) | 6 (24) | 0 (0) |
| Other drug treatment* | 17 (9) | 16 (11) | 1 (2) |
| Referral by GP to hospital | 11 (6) | 3 (2) | 8 (15) |
| Emergency room visit without referral | 4 (2) | 3 (2) | 1 (2) |
| Admitted to hospital | 5 (3) | 2 (1) | 3 (6) |
*E.g. acetylcysteine, paracetamol with codeine, mixture
Abbreviations: SABA: short acting beta agonist, LABA: long acting beta agonist
| Table III. Patients that contact the primary care center within 30 days of diagnosis and treatment of pneumonia. | |||
|
Total group n=96 (%) |
Younger (<65 years) n=66 (%) |
Older (≥65 years) n=30 (%) |
|
| Type of communication | |||
| Scheduled appointment | 38 (40) | 29 (44) | 9 (30) |
| Unscheduled appointment | 11 (11) | 9 (14) | 2 (7) |
| Phone call | 47 (49) | 28 (42) | 19 (63) |
| Chest radiograph | 21 (22) | 14 (21) | 7 (23) |
| Consolidation | 11 (52) | 6 (43) | 5 (71) |
| CT-scan | 6 (6) | 3 (5) | 3 (10) |
| Abnormal | 6 (100) | 3 (100) | 3 (100) |
| Blood test | 8 (8) | 6 (9) | 2 (7) |
| Abnormal* | 2 (25) | 1 (17) | 1 (50) |
| Change in antibiotic treatment | 25 (26) | 20 (30) | 5 (17) |
| Renewal of prescription | 16 (17) | 6 (9) | 10 (33) |
| Referral to hospital | 3 (3) | 1 (2) | 2 (7) |
*Defined as C-reactive peptide >10 mg/L, White blood cell >10.5 x109/L or erythrocyte sedimentation rate >15 mm/hour (male) and >23 mm/hour (female).