Of 211 referred patients, 14 were not included due to inconclusive results or iodine intolerance. Of 197 enrolled patients, 25% had PE. There was no difference between the PE and non-PE groups with respect to referral location, clinical symptoms (dyspnea, pleuritic pain, hemoptysis, tachycardia, lower limb edema), need for long term oxygen therapy, admission P02 or PC02, recent trauma, recent surgery, obesity, or immobilization for more than seven days. Factors associated with PE on bivariate analysis included a decrease in PC02 >5mmHg from baseline, previous thromboembolism, and malignancy.
Researchers then calculated these patient’s Geneva score (a PE predictor score based on age, history, pulse, ABG, and chest X-ray findings. Those with a low probability Geneva score had a 9% incidence of PE, those with an intermediate score had a 47% incidence, and those with a high Geneva score had a 100% incidence.
In conclusion, in this study population of non-ICU patients with unexplained exacerbations of COPD, one in four had evidence of thromboembolic disease. Significant risk ratios between groups were found for patients with a prior history of thromboembolism, malignancy, or a decrease in their baseline PC02. These factors should be weighted heavily in determining which patients with unexplained COPD exacerbations should undergo workup to exclude a PE. The Geneva score also correlated well with PE incidence in this population.
Telithromycin in Asthma Exacerbations
Johnston SL, Blasi FB, Black PN, et al. The effect of telithromycin in acute exacerbations of asthma. New Engl J Med. 2006 Apr 13;354(15):1589-1600.
The use of antibiotics for uncomplicated asthma exacerbations is not currently considered standard of care. This randomized placebo controlled trial was designed to determine if telithromycin (a ketolide, structurally similar to macrolides, with efficacy against mycoplasma and chlamydia pneumonia) improves symptoms and peak flow rates in patients with asthma exacerbations. Researchers enrolled 278 patients age 18 to 55 with a history of asthma (less than six months) with an exacerbation (peak flow <80% and symptoms of wheeze and dyspnea). They excluded those requiring ICU care, smokers, known infection/recent antibiotic use, or regular use of oral steroids. Baseline demographics, pulmonary function, and acute medication use (steroids and beta agonists) were similar between the groups.
Intervention patients received telithromycin 800 mg a day for 10 days. The primary outcome was change in their asthma symptom score (rated on a seven-point scale) and change in their peak flows (recorded every morning for the study duration). Secondary outcomes were clinic pulmonary function tests (PFTs).
The intervention group had a mean decrease in their symptom score of 1.3 versus 1.0 in the placebo group (40% versus 27% reduction, p=.004). There was no difference between the groups in home peak flow measurements. There were statistically significant differences between the groups in clinic PFTs (FEV1, FVC, FEF 25%-75%), although the P values were not adjusted for multiple outcomes. The intervention group had a higher percentage of symptom-free days (16% versus 8%, P=.006). A total of 61% of the patients had serologic evidence of chlamydia or mycoplasma infection. Nausea (seven versus 0) and LFT elevations (two versus 0) were more frequent in the intervention group.
In conclusion, this is the first trial to report a benefit of antibiotic use in uncomplicated asthma exacerbations. This conclusion must be tempered by the underwhelming clinical improvement (1.3 versus 1.0 improvement in symptom scores), lack of peak flow improvement, recent reports of serious hepatotoxicity associated with telithromycin, and the possibility for antibiotic over-prescribing in unrefined patient populations.
Pneumonia Quality and Outcomes by Volume of Care
Lindenauer PK, Behal R, Murray CK, et al. Volume, quality of care, and outcome in pneumonia. Ann Intern Med. 2006 Feb 21;144(4):262-269.