pneumonia in primary care subgroup analysis Jolien Teepe Paul Little Nori Elshof Lidewij Broekhuizen Michael Moore Beth Stuart Chris Butler Kerry Hood Greet Ieven ID: 911689
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Slide1
Effects of antibiotics for pneumonia in primary care:subgroup analysis
Jolien Teepe, Paul Little, Nori Elshof, Lidewij Broekhuizen, Michael Moore, Beth Stuart, Chris Butler, Kerry Hood, Greet Ieven, Samuel Coenen, Herman Goossens, Theo VerheijNHG wetenschapsdag 2015
Slide2Lower respiratory tract infection (LRTI)Incidence: 44 per 1000 adults
Acute bronchitisPneumonia
Slide3Slide4Lancet Infect Dis 2013;13: 123–29
Slide5MethodsPatients ≥ 18 yearsAcute LRTI (cough of ≤ 28 days’ duration)Pneumonia was not suspected clinically Randomly assigned to:
Amoxicillin PlaceboOR
Slide6Results2061 patients includedNo meaningful effect of antibiotics on outcomes:symptom severity, duration of more severe symptomsHowever, new or worsening
symptoms were less common in amoxicillin (16%) vs. placebo (19%) but NNT was high (30); and equivalent to NNH (21)
Slide7Effects of antibiotics in pneumoniaNever evaluated!No randomised placebo-controlled trials
Slide8Study aimTo assess whether antibiotic treatment influenced outcome in patients with:
ANDBUT
Slide9Methods: Study designSubgroup analysis of a randomised, placebo-controlled trial From 2007- 2010At primary care practicesIn 12 European countries
www.grace-lrti.org
Slide10Methods: Study populationInclusion criteria:Patients ≥ 18 years Acute LRTI (cough of ≤ 28 days’ duration)Exclusion criteria:Clinically suspected pneumoniaPregnancyAllergy to penicillin
Treatment with antibiotics in the previous month
Slide11Methods: InterventionThree times daily for 7 daysOR
Amoxicillin 1 gPlacebo
Slide12Methods: MeasurementsCRF = case report form
Slide13Diary- 12 symptomsCoughPhlegmShortness of breathWheezeBlocked/runny noseCheast
painFeverMuscle achingHeadacheDisturbed sleepFeeling generally unwellInterference with normal activities/work
Slide14Methods: Definition pneumoniaAND
Slide15Methods: Outcome measuresSymptom duration2. Symptom severity3. New or worsening symptoms
Slide16Methods: Data analysisCox regressionSimple linear regressionLogistic regressionInteraction terms to adjust for illness duration before consultation and illness severity
Slide17Results: Flow chart
Slide18Patients characteristics Pneumonia present N=56
Pneumonia absentN=1829 P valueAge, mean 54
49
0.052
Male gender
48%
41%
0.251
Current smoking
29%
28%
0.896
Co morbidity (pulmonary, cardiac, DM)
36%
25%
0.070
Illness duration before index consultation, mean
11
9
0.606
Severity score (all symptoms), mean
32
30
0.439
Respiratory rate (breaths per min), mean
17
17
0.214
Body temperature
(°C
), mean
36.9
36.7
0.088
Allocated to amoxicillin
41%
51%
0.141
Slide19Patients characteristics in pneumonia
AmoxicillinN=23 PlaceboN=33 P valueAge, mean
54
54
0.947
Male gender
48%
49%
0.961
Current smoking
26%
30%
0.731
Co morbidity (pulmonary, cardiac, DM)
35%
36%
0.903
Illness duration before index consultation, mean
15
8
0.106
Severity score (all symptoms), mean
30
34
0.253
Respiratory rate (breaths per min), mean
17
18
0.626
Body temperature
(°C
), mean
36.9
36.9
0.757
Slide20Outcomes
Slide21Strengths:First large multicentre randomised placebo controlled trial of antibiotics for acute LRTI with radiologically confirmed pneumoniaLimitations:Possible selection biasRandomisation
was not applicable on the pneumonia subgroupStrengths and limitations
Slide22ConclusionsIn patients presenting with acute LRTI who have a radiologically confirmed, but clinically unsuspected pneumoniaAntibiotic treatment:duration of more severe symptoms by almost a week,symptom severity highlights the importance of diagnosing pneumonia