Article Figures & Data
Figures
- Figure 1.
Flowchart and antibiotic prescription.
CAP = community-acquired pneumonia; CR = chest radiography.
aIncomplete investigations = patients with suspected CAP who could not have CR within 6 hours either due to unavailability of the radiology office or because they were unable to go to the radiology office.
bData missing for 1 patient (n = 143).
Tables
- Table 1.
Comparison of CAP CR+ and CAP CR−: Patient Characteristics, Conditions With Increased Risk of Invasive Pneumococcal Disease, History of Pneumonia, Vaccination Status, Symptoms on Inclusion and Clinical Examination, Follow-Up, and Data on Day 28
Total N = 259 (100.0%) CAP CR+ n = 144 (55.6%) CAP CR− n = 115 (44.4%) P Value Age at inclusion, y, median (IQR) 58.0 (41.0-71.0) 60.5 (41.5-72.0) 57.0 (40.0-70.0) .430 Sex (female), No. (%) 139 (53.7) 71 (49.3) 68 (59.1) .133 Antibiotics started before inclusion, No. (%) 10 (3.9) 9 (6.3) 1 (0.9) .046 CRB-65 score, No. (%) 0 128 (51.8) 67 (49.6) 61 (54.5) .383 1 100 (40.5) 54 (40.0) 46 (41.1) 2 16 (6.5) 12 (8.9) 4 (3.6) 3 3 (1.2) 2 (1.5) 1 (0.9) CAP risk factors, No. (%) Risk factors for invasive pneumococcal infection (none)a 189 (73.3) 100 (69.9) 89 (77.4) .204 Chronic respiratory disease (COPD, emphysema, other cause) 26 (10.1) 17 (11.9) 9 (7.8) .306 Diabetes 19 (7.4) 16 (11.2) 3 (2.6) .008 Chronic heart failure 7 (2.7) 3 (2.1) 4 (3.5) .704 History of pneumonia 41 (15.9) 25 (17.5) 16 (13.9) .495 Vaccination status, No. (%) Antipneumococcal 17 (6.6) 9 (6.3) 8 (7.1) .806 Anti-influenza for previous season 82 (32.2) 49 (34.3) 33 (29.5) .500 Anti-influenza for current or next season 48 (18.9) 24 (17.0) 24 (21.2) .423 Symptoms present at inclusion Cough, No. (%) 251 (96.9) 138 (95.8) 113 (98.3) .306 Sputum, No. (%) 154 (59.5) 86 (59.7) 68 (59.1) >.99 Dyspnea, No. (%) 123 (47.5) 77 (53.5) 46 (40.0) .034 Aches and pains, No. (%) 175 (67.8) 99 (68.8) 76 (66.7) .789 Tiredness, No. (%) 244 (94.2) 135 (93.8) 109 (94.8) .794 Chills/sweats, No. (%) 166 (64.1) 100 (69.4) 66 (57.4) .051 Unilateral chest pain, No. (%) 78 (30.1) 53 (36.8) 25 (21.7) .010 Headache, No. (%) 98 (37.8) 51 (35.4) 47 (40.9) .439 Ear, nose, and throat symptoms (sore throat, colds, sinus pain, etc), No. (%) 141 (54.4) 77 (53.5) 64 (55.7) .802 Fever reported by patient, No. (%) 180 (70.0) 105 (73.4) 75 (65.8) .218 Digestive signs (nausea, vomiting, diarrhea, abdominal pain), No. (%) 47 (18.1) 30 (20.8) 17 (14.8) .257 Confusion (altered mental status), No. (%) 7 (2.7) 4 (2.8) 3 (2.6) >.99 Duration of symptoms on day of inclusion (days), median (IQR) 4.0 (2.0-7.0) 4.0 (2.0-8.0) 4.0 (2.0-7.0) .280 Physical examination at inclusion Body temperature (°C), median (IQR) 37.5 (37.0-38.0) 37.7 (37.0-38.3) 37.3 (37.0-38.0) .008 Heart rate (bpm), median (IQR) 86.0 (77.0-100.0) 90.0 (80.0-102.0) 82.0 (71.0-95.0) .002 Respiratory rate (breaths/min), median (IQR) 18.0 (15.0-20.0) 18.0 (16.0-22.0) 16.0 (15.0-20.0) .001 Systolic blood pressure (mm Hg), median (IQR) 130.0 (120.0-140.0) 130.0 (120.0-140.0) 126.0 (120.0-136.0) .101 Diastolic blood pressure (mm Hg), median (IQR) 80.0 (70.0-80.0) 80.0 (70.0-82.0) 80.0 (70.0-80.0) .402 SaO2 (%), median (IQR) 97.0 (95.0-98.0) 96.0 (95.0-98.0) 97.0 (95.0-98.0) .134 Global impression of severity, No. (%) 68 (26.4) 42 (29.2) 26 (22.8) .259 Auscultatory abnormalities compatible with CAP, No. (%) Crackles 166 (64.1) 100 (69.4) 66 (57.4) .510 Wheezing 42 (16.2) 17 (11.8) 25 (21.7) .041 Ronchi 83 (32.0) 41 (28.5) 42 (36.5) .182 Decreased breath sounds 71 (27.4) 48 (33.3) 23 (20.0) .018 Dullness on percussion 21 (8.3) 16 (11.3) 5 (4.5) .065 Prescriptions, No. (%) Initiated antibiotic treatments 221 (85.7) 142b (99.3) 79 (68.7) <.001 Amoxicillin 127 (57.5) 78 (54.9) 49 (62.0) .636 Amoxicillin + clavulanic acid 45 (20.4) 32 (22.5) 13 (16.5) Macrolides 23 (10.4) 14 (9.9) 9 (11.4) Other antibiotics 26 (11.8) 18 (12.7) 8 (10.1) Duration of clinical evolution of the following symptoms, median (IQR) Fever (>38.5 °C) since beginning of symptoms (days) 3.0 (0-5.0) 3.0 (1.0-5.0) 2.0 (0-4.0) .001 Fever (>38.5 °C) with antibiotics (days) 1.0 (0-2.0) 1.5 (0-3.0) 0 (0-2.0) .001 Cough (days) 10.0 (7.0-21.0) 10.0 (7.0-21.0) 10.0 (7.0-21.0) .837 Chest pain (days) 0 (0-5.0) 0 (0-7.0) 0 (0-2.0) .016 Dyspnea (days) 3.0 (0-10.0) 4.0 (0-12.0) 0 (0-10.0) .035 Tiredness with impact on daily activities (days) 7.0 (3.0-15.0) 8.0 (4.0-15.0) 7.0 (3.0-14.0) .143 Tiredness without impact on daily activities (days) 7.0 (0.5-17.0) 10.0 (1.0-18.0) 7.0 (0-16.0) .275 Data on day 28, No. (%) Number of patients with ≥1 additional consultation between day 0 and day 28 56 (21.6) 56 (38.9) 0 (0) <.001 Hospitalization since initial consultation and day 28 7 (2.9) 5 (3.6) 2 (1.9) .702 Death 0 (0) 0 (0) 0 (0) na bpm = beats per minute; CAP = community-acquired pneumonia; COPD = chronic obstructive pulmonary disease; CR+ = chest radiography positive; CR− = chest radiography negative; CRB-65 = confusion, respiratory rate, blood pressure, age; CSF = cerebrospinal fluid; IQR = interquartile range; na = not applicable; SaO2 = oxygen saturation of arterial blood.
↵a Risk factors for invasive pneumococcal infection according to the French vaccine schedule 2017: chronic respiratory disease (COPD, emphysema, chronic bronchitis, chronic pulmonary failure), asthma, chronic heart failure, nephrotic syndrome, asplenia or splenectomy (functional or anatomic asplenia), chronic liver disease, homozygous sickle cell disease, HIV infection, immunocompromising conditions (congenital immune deficiency, chemotherapy, immune modulators, corticosteroids, transplantation), diabetes, CSF leak, cochlear implant.14
↵b Data missing for 1 patient (n = 143).
- Table 2.
Comparison of CAP CR− With Antibiotic and CAP CR− Without Antibiotic: Patient Characteristics, Conditions With Increased Risk of Invasive Pneumococcal Disease, History of Pneumonia, Vaccination Status, Symptoms on Inclusion and Clinical Examination, Follow-Up, and Data on Day 28
Total N = 115 (100.0%) CR−With Antibiotic Initiation n = 79 (68.7%) CR−Without Antibiotic Initiation n = 36 (31.3%) P Value Age at inclusion, y, median (IQR) 57.0 (40.0-70.0) 57.0 (40.0-70.0) 57.5 (40.5-71.0) .890 Sex (female), No. (%) 68 (59.1) 45 (57.0) 23 (63.9) .543 Antibiotics started before inclusion, No. (%) 1 (0.9) 1 (1.3) 0 (0) >.99 CRB-65 score, No. (%) 0 61 (54.5) 45 (57.7) 16 (47.1) .629 1 46 (41.1) 29 (37.2) 17 (50.0) 2 4 (3.6) 3 (3.8) 1 (2.9) 3 1 (0.9) 1 (1.3) 0 (0) CAP risk factors, No. (%) Risk factors for invasive pneumococcal infection (none)a 89 (77.4) 60 (75.9) 29 (80.6) .639 Chronic respiratory disease (COPD, emphysema, other cause) 9 (7.8) 5 (6.3) 4 (11.1) .458 Diabetes 3 (2.6) 3 (3.8) 0 (0) .551 Chronic heart failure 4 (3.5) 3 (3.8) 1 (2.8) >.99 History of pneumonia 16 (13.9) 11 (13.9) 5 (13.9) >.99 Vaccination status, No. (%) Antipneumococcal 8 (7.1) 7 (9.1) 1 (2.8) .432 Anti-influenza for previous season 33 (29.5) 27 (35.1) 6 (17.1) .073 Anti-influenza for current or next season 24 (21.2) 16 (20.8) 8 (22.2) >.99 Symptoms present at inclusion Cough, No. (%) 113 (98.3) 78 (98.7) 35 (97.2) .530 Sputum, No. (%) 68 (59.1) 51 (64.6) 17 (47.2) .102 Dyspnea, No. (%) 46 (40.0) 34 (43.0) 12 (33.3) .413 Aches and pains, No. (%) 76 (66.7) 55 (70.5) 21 (58.3) .208 Tiredness, No. (%) 109 (94.8) 78 (98.7) 31 (86.1) .011 Chills/sweats, No. (%) 66 (57.4) 46 (58.2) 20 (55.6) .840 Unilateral chest pain, No. (%) 25 (21.7) 16 (20.3) 9 (25.0) .628 Headache, No. (%) 47 (40.9) 31 (39.2) 16 (44.4) .684 Ear, nose, and throat symptoms (sore throat, colds, sinus pain, etc), No. (%) 64 (55.7) 50 (63.3) 14 (38.9) .017 Fever reported by patient, No. (%) 75 (65.8) 52 (66.7) 23 (63.9) .833 Digestive signs (nausea, vomiting, diarrhea, abdominal pain), No. (%) 17 (14.8) 13 (16.5) 4 (11.1) .577 Confusion (altered mental state), No. (%) 3 (2.6) 3 (3.8) 0 (0) .551 Duration of symptoms on the day of inclusion (days), median (IQR) 4.0 (2.0-7.0) 4.0 (2.0-7.0) 3.0 (2.0-7.0) .442 Physical examination at inclusion Body temperature (°C), median (IQR) 37.3 (37.0-38.0) 37.3 (37.0-38.0) 37.2 (36.6-37.8) .166 Heart rate (bpm), median (IQR) 82.0 (71.0-95.0) 86.0 (72.0-100.0) 80.0 (70.0-88.0) .024 Respiratory rate (breaths/min), median (IQR) 16.0 (15.0-20.0) 17.0 (15.0-20.0) 15.0 (14.0-17.5) .001 Systolic blood pressure (mm Hg), median (IQR) 126.0 (120.0-136.0) 128.5 (120.0-140.0) 125.0 (112.5-135.0) .348 Diastolic blood pressure (mm Hg), median (IQR) 80.0 (70.0-80.0) 80.0 (70.0-80.0) 80.0 (75.0-89.0) .108 SaO2 (%), median (IQR) 97.0 (95.0-98.0) 97.0 (94.5-98.0) 97.0 (96.0-98.0) .037 Global impression of severity, No. (%) 26 (22.8) 21 (26.9) 5 (13.9) .153 Auscultatory abnormalities compatible with CAP, No. (%) Crackles 66 (57.4) 48 (60.8) 18 (50.0) .313 Wheezing 25 (21.7) 19 (24.1) 6 (16.7) .468 Ronchi 42 (36.5) 31 (39.2) 11 (30.6) .410 Decrease in breath sounds 23 (20.0) 16 (20.3) 7 (19.4) >.99 Dullness on percussion 5 (4.5) 4 (5.1) 1 (2.9) >.99 Duration of clinical evolution of the following symptoms, median (IQR) Fever (>38.5 °C) since beginning of symptoms (days) 2.0 (0-4.0) 2.0 (0-4.0) 3.0 (0-4.0) .991 Fever (>38.5 °C) with antibiotics (days) 0 (0-2.0) 0 (0-2.0) 0 (0) .005 Cough (days) 10.0 (7.0-21.0) 10.0 (7.0-21.0) 10.0 (7.0-21.0) .894 Chest pain (days) 0 (0-2.0) 0 (0-3.0) 0 (0-1.0) .523 Dyspnea (days) 0 (0-10.0) 3.0 (0-10.0) 0 (0-6.0) .038 Tiredness with impact on daily activities (days) 7.0 (3.0-14.0) 7.0 (3.0-15.0) 5.0 (2.0-10.0) .229 Tiredness without impact on daily activities (days) 7.0 (0-16.0) 7.0 (0-15.0) 7.0 (0-20.0) .793 Hospitalization since initial consultation and day 28, No. (%) 2 (1.9) 1 (1.4) 1 (2.9) .549 bpm = beats per minute; CAP = community-acquired pneumonia; COPD = chronic obstructive pulmonary disease; CR− = chest radiography negative; CRB-65 = confusion, respiratory rate, blood pressure, age; CSF = cerebrospinal fluid; IQR = interquartile range; SaO2 = oxygen saturation of arterial blood.
↵a Risk factors for invasive pneumococcal infection according to the French vaccine schedule 2017: chronic respiratory disease (COPD, emphysema, chronic bronchitis, chronic pulmonary failure), asthma, chronic heart failure, nephrotic syndrome, asplenia or splenectomy (functional or anatomic asplenia), chronic liver disease, homozygous sickle cell disease, HIV infection, immunocompromising conditions (congenital immune deficiency, chemotherapy, immune modulators, corticosteroids, transplantation), diabetes mellitus, CSF leak, cochlear implant.14
SUPPLEMENTAL MATERIALS IN PDF FILE BELOW
Supplemental Figure. PneumoCAP Study Procedure
VISUAL ABSTRACT IN PDF FILE BELOW
PLAIN-LANGUAGE ARTICLE SUMMARY AND VISUAL ABSTRACT
Original Research
Antibiotic Initiation for Suspected Community-Acquired Pneumonia High Even When Chest X-Ray Results are Negative
Background and Goal: Although clinical guidelines recommend using chest X-rays to confirm community-acquired pneumonia and limit unnecessary antibiotic use, there is ongoing debate about the role of chest X-rays in managing suspected pneumonia cases. This study explored how chest X-rays results influence antibiotic initiation by general practitioners in France when managing patients with suspected pneumonia.
Study Approach: A prospective cross-sectional study was conducted with adult patients with suspected pneumonia who received chest X-rays as part of their evaluation. To analyze factors associated with antibiotic initiation, patients’ characteristics were compared at inclusion and at 28 days between patients with positive chest X-rays (indicating pneumonia) and patients with negative chest X-rays.
Main Results:The sample included 259 adult patients. The median age was 58 years, 120 (46.3%) were male, 249 (96.1%) had not received antibiotics prior to inclusion, 69 (26.7%) had at least one risk factor for pneumococcal disease.
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Most of the general practitioners who included patients were women (55.2 %; n = 153), with a median age of 39 years and 76.1% (n = 210) were general practitioner trainers.
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55.6% of patients (144 out of 259) had positive chest X-rays results.
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Patients with positive chest X-ray results had higher body temperature, faster heart rate, faster breathing rate, more difficulty breathing, and more frequent unilateral chest pain than patients with negative chest X-rays results and their symptoms lasted for a longer time.
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99.3% of patients with positive chest X-ray results received antibiotics (142 out of 143 patients).
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Despite fewer symptoms and negative chest X-ray results, a significant portion (68.75%) of patients with negative chest X-ray results were prescribed antibiotics (79/115 patients).
Why It Matters: The findings of this study show that many general practitioners prescribe antibiotics for suspected community-acquired pneumonia even when chest X-ray results are negative, highlighting a gap between guidelines and actual practice. This may contribute to the overuse of antibiotics, a major factor in antimicrobial resistance. The findings suggest that clearer guidelines and alternative diagnostic tools may be needed to help general practitioners confidently manage patients with suspected pneumonia without over-relying on antibiotics.
Relationship Between Chest Radiography Results and Antibiotic Initiation in Community-Acquired Pneumonia Management by General Practitioners
Juliette Pinot, MD, et al
Université Paris Cité and Université Sorbonne Paris Nord, INSERM, IAME, Paris, France
Université Paris Cité, Department of General Practice, Paris, France
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