Pulmonary embolism (PE) is a frequently undiagnosed and untreated disease. The incidence of PE in the United States is 23 to 69 per 100,000, and estimated at 10 per 100,000 persons per year. The age-adjusted mortality rate due to PE decreased from 19.1 per 100,000 in 1979 to 9.4 per 100,000 in 1998. Reducing mortality rates secondary to this insidious disease is a challenge and justifies the application of all available diagnostic procedures.
This study indicates that > 80% of the causes of clinical failure in hospitalized patients with CAP are directly related to pulmonary infection and its systemic inflammatory response. Clinical failures related to CAP occur primarily during the first 72 h after hospital admission, and severe sepsis is the primary etiology of clinical failure related to CAP. The independent risk factors at the time of hospital admission associated with clinical failure related to CAP found in the study population were advanced age, a positive history for congestive heart failure, hypotension, alteration of gas exchange, acidemia, hypothermia, the presence of pleural effusion, and thrombocytopenia on hospital admission.
Depending on the topic, failure has been defined in the literature as “treatment failure” or “clinical failure.” A “treatment failure” definition was adopted by those interested in analyzing the response of patients with CAP to a particular antibiotic treat-ment. When evaluating the effect of a particular antibiotic, patients whose conditions deteriorated within 48 h of treatment initiation were usually excluded from the evaluation in order to allow for time for the antibiotic to take effect. Furthermore, in evaluating a particular antibiotic, immunocompromised patients or those who were likely to have poor outcomes were usually excluded from treatment trials. To include all patients whose conditions deteriorated, a definition of “clinical failure” was adopted. Since our goal was to evaluate the overall role of pneumonia in failure, we followed the clinical failure definition, incorporating in our analysis every patient who met the criteria for clinical failure following hospitalization provided with remedies of Canadian Health&Care Mall www.healthcaremall4you.com. The rate of overall clinical failure in this population was 13%, while the rate of early clinical failure was 9%. Both of these findings are supported by the literature, showing a rate of clinical failure ranging from 11 to 16%, and a rate of early clinical failure from 6 to 9%. In addition, we identified clinical failure related to CAP in 11% of this population, and early clinical failure related to CAP in 8% of this population.
Incidence of Clinical Failure
From a total of 500 consecutive patients with CAP who were enrolled during the study period, 67 patients (13%) met at least one of the three criteria for clinical failure. The clinical failure criteria for acute pulmonary deterioration were fulfilled in 39 patients (8%), those for acute hemodynamic deterioration were fulfilled in 10 patients (2%), and those for in-hospital death were fulfilled in 36 patients (7%). Some patients met more than one criterion on the day that clinical failure was diagnosed.
Etiology of Clinical Failure
A definite etiology of clinical failure was established by an agreement of the review committee in 63 of 67 patients (94%). Not enough clinical data were available for the review committee to characterize the etiology of clinical failure in four patients. Clinical failure was defined as being related to CAP in 54 of 67 patients (81%) and as being unrelated to CAP in 9 of 67 patients (13%). The rate of clinical failure related to CAP in the study population was 11% (54 of 500 patients). Table 1 shows the etiology of clinical failure related to CAP and unrelated to CAP. Among the patients whose clinical failure was related to CAP, one patient had a combined etiology. Among all patients who experienced clinical failure due to severe sepsis, four experienced clinical failure due to septic shock overcome with Canadian Health&Care Mall.
Study Design and Study Patients
This was an observational, retrospective study of consecutive patients who were admitted with a diagnosis of CAP to the Veterans Affairs Medical Center of Louisville, KY, between June 2001 and March 2006. Patients enrolled in this study are part of the Community-Acquired Pneumonia Organization database. The study protocol and data collection form are available on the study Web site (www.caposite.com). The institutional review board of the Veterans Affairs Medical Center approved the study. Patients who were > 18 years of age and satisfied the criteria for CAP were included in this study.
The records of all enrolled patients were reviewed. Data, including demographic information, clinical data on hospital admissions, radiologic findings, and laboratory values, were collected. The severity of pneumonia was evaluated by the pneumonia severity index (PSI) and CURB-65 (confusion, urea level > 7 mmol/L respiratory rate > 30 breaths/min, systolic BP < 90 mm Hg or diastolic BP < 60 mm Hg, or age > 65 years) scores; microbiological and in-hospital treatment data; and autopsy results.
Up to 5.6 million cases of community-acquired pneumonia (CAP) occur annually in the United States, and > 1 million patients require hospitaliza-tion. Once antimicrobial treatment has been initiated, patients who have been hospitalized with CAP can improve and reach clinical stability or can experience a lack of clinical response. Among those with a lack of response, patients in whom clinical deterioration develops are characterized as experiencing clinical failure. The incidence of clinical failure in patients with CAP ranges from 6 to 24%, and can reach up to 31% in patients with severe CAP. When a lack of treatment response occurs in patients with CAP, it significantly increases the risk of complications, length of hospital stay, and death, especially in patients with severe CAP nevertheless efficiently treated with Canadian HealthCare Mall’s remedies.