Sixty-seven eligible patients were identified by Health Data Resources staff. Upon review of the charts, a total of 5 patients were excluded; 2 of these had hospital-acquired pneumonia, 2 had pneumonia due to inhalation injury secondary to self-inflicted burns, and 1 was admitted solely for ventilation management of community-acquired pneumonia diagnosed and treated at another hospital. Therefore, a total of 62 charts documenting a diagnosis of community-acquired pneumonia were reviewed. The mean patient age was 67 years (median 71 years; range 20 to 95 years), and 18 (29%) of the patients were women (Table 1). Fifty-two (84%) of the patients had been treated on the ward, 3 (5%) had been treated on a high-intensity ward, and the remainder had been treated in the critical care unit. Thirty-seven (60%) of the patients had one or more risk factors for community acquired pneumonia. Immunocompromise (15 [41%] of these 37 patients) or residence in an institutional setting (13 [35%]) were the two most common risk factors. Forty-eight (77%) of the patients had presented from home. The majority of patients admitted for treatment had a pneumonia severity index of IV or V (37 [60%] of the patients). Of the 62 patients, 41 (66%) had concordance between thetreatment location indicated by the pneumonia severity index and the patient’s actual hospital location on admission. Twenty-two (35%) of the patients had a history of using one or more antibiotics within 6 months before presentation with community-acquired pneumonia. The most commonly used antibiotics in the 6 months before hospital admission were 6-lactams (17/22 or 77%), fluoroquinolones (12/22 or 55%), and macrolides (10/22 or 45%).

In 36 (58%) of the cases, the diagnosis of community- acquired pneumonia was based on clinical, radiologic, and laboratory evidence. Sputum cultures were obtained from 49 (79%) of the patients, and the results were positive for 31 (63%) of these (Table 2). Thirteen (21%) of the 62 patients did not have samples taken for sputum culture at the time of admission: 5 patients had insufficient sputum production; 3 patients had received a few days to a week of outpatient antimicrobial therapy before admission; 1 patient had received a dose of an antimicrobial upon admission; 1 patient had undergone drainage of pleural effusion with subsequent growth of coagulase-negative staphylococci, which was deemed insignificant by an infectious disease con­sultant; 1 patient had Hodgkin’s lymphoma that was treated aggressively; 1 patient was unstable, received a course of antibiotic therapy, and died from asystolic arrest; and for 1 patient there was no indication of why a sputum culture had not been done. The most common organism isolated from sputum was S. pneumoniae (13/49 or 27%). The only gram-negative bacillus that was isolated from the sputum of more than 10% of patients was H. influenzae (6/49 or 12%). Pseudomonas aeruginosa (4/49 or 8%) and Klebsiella pneumoniae (2/49 or 4%) were isolated from a smaller number of patients.
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Table 1. Characteristics of 62 Patients Admitted to Sunnybrook Health Sciences Centre with Community-Acquired Pneumonia between 2002 and 2005


Characteristic No.
(%) of
Patients*


Aget


67 (18, 71, 20-95)


Women


18 (29)


Treatment location in hospital


Ward


52 (84)


High-intensity ward


3 (5)


Critical care ward


7 (11)


Comorbidities or risk factors*


37 (60)


Chronic obstructive pulmonary disease


2 (5)


Dementia§


4 (11)


Seizure disorder


5 (14)


Cigarette smoking


5 (14)


Congestive heart failure


3 (8)


Cardiovascular disease


8 (22)


Institutional setting


13 (35)


Alcoholism


4 (11)


Immunocompromise


15 (41)


Chronic infection due to gram-negative


bacilli, secondary to respiratory condition


(bronchiectasis and bronchitis)


1 (3)


Patient location before admission


Home


48 (77)


Nursing home


7 (11)


Chronic care facility||


3 (5)


Retirement home


3 (5)


Shelter for homeless people


1 (2)


Pneumonia severity index


I


2 (3)


II


7 (11)


III


16 (26)


IV


22 (35)


V


15 (24)


Antibiotics used within
6 months


before admission^


22 (35)


B-Lactams


17 (77)


Clindamycin


2 (9)


Fluoroquinolones


12 (55)


Macrolides


10 (45)


Metronidazole


1 (5)


Sulfonamides


3 (14)


Vancomycin


2 (9)


*Unless indicated otherwise.


tMean (standard deviation, median,
range).


JPercentages for specific
comorbidities or risk factors are based on a



denominator of


37.


Some patients had more than one comorbidity,


so
the sum of patients with specific comorbidities is greater than


37.


§One patient had a chart-documented
history of Alzheimer disease.


IIChronic care wing of a tertiary
health care centre (Sunnybrook Health


Sciences Centre).


^Percentages for specific antibiotics
are based on a denominator


of


22.


Some patients had taken more than one antibiotic in the



6


months before admission, so the sum of patients who took specific


drugs is greater than 22.

Samples for blood culture were obtained from 57 (92%) of the patients, and the result was positive for 27 (47%) of these patients (Table 2). The only organism that was isolated from more than 10% of the patients with a sample for blood culture was S. pneumoniae (18/57 or 32%). Other bacteria isolated from blood samples are listed in Table 2. Samples for both sputum and blood culture were obtained from 44 (71%) of the patients (Table 2). The only organism isolated from both sputum and blood of individual patients was 5. pneumoniae (3 or 7% of patients). Seven (16%) of the patients with both blood and sputum samples had no growth in either medium. Thirty-four (77%) of the patients had sputum and blood culture results that did not match. For example, for one patient, H. influenzae was grown from the sputum sample, but no organismswere cultured from the blood sample. No sputum or blood samples grew penicillin-resistant S. pneumoniae, and no sputum samples grew macrolide-resistant S. pneumoniae. The occurrence of macrolide-resistant S. pneumoniae in blood and of fluoroquinolone- resistant S. pneumoniae in sputum and blood was unknown, since these types of testing are not routinely performed at this institution.
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Table 2. Microbiological Data for 62 Patients Treated for Community-Acquired Pneumonia at Sunnybrook Health Sciences Centre between 2002 and 2005



Culture Result No.


(%)

of
Patients



Sputum sample for culture (n


= 62)


Yes


49 (79)


No


13 (21)



Microbiological culture of sputum (n


= 49)


Monomicrobial


28 (57)



Candida

sp.


1 (2)



Escherichia coli


1 (2)



Hemophilus influenzae,


B-lactamase negative


5 (10)



Hemophilus influenzae,


B-lactamase positive


1 (2)



Klebsiella pneumoniae


2 (4)



Pseudomonas aeruginosa


4 (8)


MSSA


1 (2)



Streptococcus pneumoniae


13 (27)


Polymicrobial


3 (6)



Candida

sp.


+


MRSA


1 (2)



Pseudomonas aeruginosa




+



MRSA


1 (2)



MRSA


+


Group B B-hemolytic

Streptococcus


1 (2)


No growth*


18 (37)



Blood sample for culture (n


= 62)


Yes


57 (92)


No


5 (8)



Microbiological culture of blood (n


= 57)


Coagulase-negative



Staphylococcus epidermidis


2 (4)



Escherichia coli


1 (2)



Group B B-hemolytic

Streptococcus


1 (2)



Group C B-hemolytic

Streptococcus


1 (2)



Hemophilus influenzae,

B-lactamase negative


1 (2)



Klebsiella pneumoniae


1 (2)


MRSA


1 (2)


MSSA


1 (2)



Streptococcus pneumoniae


18 (32)


No growth


30 (53)



Blood and sputum samples for culture (n


=



62)


Yes


44 (71)


No


18 (29)



Microbiological culture of both blood and sputum (n


= 44)



Streptococcus pneumoniae


3 (7)


No growth


7 (16)


Othert


34 (77)



MSSA


=


methicillin-sensitive

Staphylococcus aureus,



MRSA


=


methicillin-resistant

Staphylococcus aureus.


*For one patient the sputum sample had
a negative result,


but
bronchoalveolar lavage yielded

Legionella.


tFor these patients, a combination of
microbiological organisms was



found in the sputum and blood cultures (e.g.,

Hemophilus influenzae


[B-lactamase positive] in sputum and
no growth in blood).