Volume 3 • Issue 1 • 1000140 J Pulmon Resp Med ISSN: 2161-105X JPRM, an open access journal Creutz et al, J Pulmon Resp Med 2013, 3:1 DOI: 10.4172/2161-105X.1000140 Case Report Open Access Failure of Ambulatory Treatment in CAP Patients Leading to Subsequent Hospitalization and its Association to Risk Factors - Prospective Cohort Study Creutz P 1 *, Kothe H 2 , Braun M 2 , Bauer T 3 , Suttorp N 1 , Welte T 4 , Dalhoff K 2 and the CAPNETZ study group 1 Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité, Humboldt-University – Medicine, Berlin, Germany 2 University of Luebeck, Medical Clinic III, Department of Respiratory Medicine, Luebeck, Germany 3 Center for Pneumology and Thoracic Surgery Heckeshorn, HELIOS Clinic Emil von Behring, Berlin, Germany 4 Department of Pneumology, Hannover Medical School, Hannover, Germany Abstract Background: Outpatient treatment is an increasingly used option in Community-Acquired Pneumonia (CAP). Risk factors for deterioration and subsequent hospitalization are poorly characterized. Material and Methods: A prospective study was conducted to assess risk factors associated with hospitalization of CAP-patients initially treated in an outpatient setting. Clinical history, severity of disease, physical examination fndings, laboratory test results, initial treatment and outcome were prospectively documented in both groups. Data derived from a multicenter prospective study initiated by the German competence network for community- acquired pneumonia CAPNETZ. The network includes 10 clinical centers representing hospital and outpatient facilities from all levels of health care. 5431 patients with CAP were screened for inclusion. 1517 of these patients were initially treated as outpatients and included. 1403 patients were treated exclusively in an outpatient setting, 114 (8.1%) were hospitalized after initial outpatient treatment. Results: Compared to patients treated exclusively in an outpatient setting patients with subsequent hospitalization had a signifcantly higher 28-day mortality rate (4.2% vs. 0.2%, p=<0.001), advanced mean age (56.7 vs. 50.9 years, p=<0.05), and a higher CRB-65 score. However 53.3% of subsequently admitted patients had CRB-65=0, and 23% had CRB-65=1 with age >65 years as the only risk factor. Cerebrovascular disease, chronic kidney disease and diabetes mellitus were overrepresented in this patient group. In addition, cephalosporin monotherapy was identifed as independent risk factor for hospitalization. Conclusion: In ambulatory CAP patients subsequent hospitalization was observed mainly in low CRB-65 risk classes and was associated with comorbidities and the choice of initial therapy. *Corresponding author: Petra Creutz, Medizinische Klinik M.S. Infektiologie und Pneumologie Charité, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany, Tel: +49 30-20645837; Fax: +4930-20645839; E-mail: petra.creutz@charite.de Received January 23, 2013; Accepted February 20, 2013; Published February 25, 2013 Citation: Creutz P, Kothe H, Braun M, Bauer T, Suttorp N, et al. (2013) Failure of Ambulatory Treatment in CAP Patients Leading to Subsequent Hospitalization and its Association to Risk Factors - Prospective Cohort Study. J Pulmon Resp Med 3: 140. doi:10.4172/2161-105X.1000140 Copyright: © 2013 Creutz P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Keywords: Community-acquired pneumonia; Outpatient treatment; Terapy; Hospitalisation Introduction Community Acquired Pneumonia (CAP) represents a public health problem of substantial magnitude. In western countries CAP remains the leading cause of morbidity and mortality due to infectious diseases [1,2]. An increasing proportion of these patients is treated as outpatients since ambulatory care has improved considerably and new concepts such as “hospital at home” are implemented [3]. Outpatient management is the most efective approach to cost reduction since the magnitude of resource use for CAP is directly related to inpatient treatment, with costs approximately 20 times higher than in ambulatory care [4]. In addition, outpatient treatment is ofen preferred by the patients and may be associated with better functional outcomes, particularly in the elderly [4]. Previous investigators have demonstrated that physicians may overestimate the severity of illness in CAP patients, leading to unnecessary hospitalizations [4]. Conversely, a small proportion of patients with CAP initially treated in the outpatient setting are subsequently hospitalized. Little is known regarding the etiology of CAP, risk factors, the role of antimicrobial therapy, and outcomes in this patient group [5-10]. Prognostic scoring systems for CAP have been developed to assess the severity of illness and the mortality risk [11,12]. Te Pneumonia Severity Index (PSI) and the Confusion, Urea, Respiratory rate, Blood pressure and Age Score (CURB-65) are used as predictors of mortality. In addition the PSI has been used in clinical pathways for site of care decisions [13]. In a previous study from the CAPNETZ group Bauer et al. demonstrated that scoring by both the CURB score and Confusion, Respiratory rate, Blood pressure, Age Score (CRB-65) can be used with equivalent results to assess pneumonia severity and the risk of death [14]. CRB-65 scoring appears to be preferable in the ambulatory setting where blood urea nitrogen measurement is not readily available. To defne risk factors associated with hospitalization of patients initially treated in the outpatient setting we analyzed data from the German network for community-acquired pneumonia (CAPNETZ). A prospective multicentre study was conducted in order to assess risk factors infuencing hospitalization afer initial CAP treatment in an outpatient setting, with a special emphasis on age, residence status, underlying conditions and antimicrobial treatment. CAPNETZ is funded by the German Ministry of Education and Research (BMBF) and recruits nationwide CAP-patients in Germany. J o u r n a l o f P u l m o n a r y & R e s p i r a t o r y M e d i c i n e ISSN: 2161-105X Journal of Pulmonary & Respiratory Medicine