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• W3023798251 abstract "To the Editor:We thank Dr. Barnes for his comments and agree with him that results from sputum culture for aerobic bacterial pathogens that cause acute pneumonia are so inaccurate that this test should no longer be used routinely. There are exceptions, such as culture for the various Legionella species. Despite ample published reports questioning the value of sputum culture, most studies of the etiology of community-acquired pneumonia have relied upon cultures of expectorated sputum. This means that the collected knowledge over time regarding the common bacterial pathogens causing pneumonia should be reevaluated.Dr. Barnes and co-workers found that among patients in New Guinea with acute pneumonia the most common pathogens (as established by blood culture and culture of lung aspirate obtained by percutaneous needle aspiration) were S pneumoniae, H influenzae, and S aureus. The difference noted between the two studies may reflect differences in the study populations and the diagnostic tests employed. No detailed description of the types of patients enrolled in Dr. Barnes's study was provided—only that the patients were adults not known to be immunocompromised. The mean age for our study patients was 64, and many had coexisting abnormalities including COPD, cancer, alcohol abuse, and neurologic abnormalities. The approach to diagnosis also differed between the two studies. In Dr. Barnes's study, emphasis was placed on diagnosing aerobic bacterial pathogens identified by cultures collected from blood and lung aspirates. In our study, we obtained cultures of blood in more than 90 percent of patients (only 16 percent were positive), but were unable to collect lower respiratory tract samples by invasive tests as frequently as Barnes and co-workers did. We also performed a number of serologic tests for other pulmonary pathogens. These factors together with the differences in geography and epidemiology may explain the differences between the two studies.It is disturbing that most medical textbooks continue to advocate Cram stain and culture of sputum as an important guide for the selection of antimicrobial therapy for patients hospitalized with community-acquired pneumonia. In addition, phase 3 trials testing the value of new antimicrobial agents for the treatment of pneumonia almost always require a Cram stain and culture of sputum prior to and after treatment, and these data are used in the assessment of therapeutic efficacy. Finally, third-party payers provide a strong financial incentive for physicians to obtain a sputum culture prior to treating patients with pneumonia since hospital payment for care of patients with complex bacterial pneumonia of “known etiology,” as determined by sputum culture, is substantially greater than payment for the same illness when the microbial etiology is given as “unspecified.” Thus, there are a number of incentives for healthcare providers to use a test that is of little value. It is difficult indeed to change practice patterns, particularly the use of tests that are “time honored,” even if they are of questionable scientific validity. To the Editor: We thank Dr. Barnes for his comments and agree with him that results from sputum culture for aerobic bacterial pathogens that cause acute pneumonia are so inaccurate that this test should no longer be used routinely. There are exceptions, such as culture for the various Legionella species. Despite ample published reports questioning the value of sputum culture, most studies of the etiology of community-acquired pneumonia have relied upon cultures of expectorated sputum. This means that the collected knowledge over time regarding the common bacterial pathogens causing pneumonia should be reevaluated. Dr. Barnes and co-workers found that among patients in New Guinea with acute pneumonia the most common pathogens (as established by blood culture and culture of lung aspirate obtained by percutaneous needle aspiration) were S pneumoniae, H influenzae, and S aureus. The difference noted between the two studies may reflect differences in the study populations and the diagnostic tests employed. No detailed description of the types of patients enrolled in Dr. Barnes's study was provided—only that the patients were adults not known to be immunocompromised. The mean age for our study patients was 64, and many had coexisting abnormalities including COPD, cancer, alcohol abuse, and neurologic abnormalities. The approach to diagnosis also differed between the two studies. In Dr. Barnes's study, emphasis was placed on diagnosing aerobic bacterial pathogens identified by cultures collected from blood and lung aspirates. In our study, we obtained cultures of blood in more than 90 percent of patients (only 16 percent were positive), but were unable to collect lower respiratory tract samples by invasive tests as frequently as Barnes and co-workers did. We also performed a number of serologic tests for other pulmonary pathogens. These factors together with the differences in geography and epidemiology may explain the differences between the two studies. It is disturbing that most medical textbooks continue to advocate Cram stain and culture of sputum as an important guide for the selection of antimicrobial therapy for patients hospitalized with community-acquired pneumonia. In addition, phase 3 trials testing the value of new antimicrobial agents for the treatment of pneumonia almost always require a Cram stain and culture of sputum prior to and after treatment, and these data are used in the assessment of therapeutic efficacy. Finally, third-party payers provide a strong financial incentive for physicians to obtain a sputum culture prior to treating patients with pneumonia since hospital payment for care of patients with complex bacterial pneumonia of “known etiology,” as determined by sputum culture, is substantially greater than payment for the same illness when the microbial etiology is given as “unspecified.” Thus, there are a number of incentives for healthcare providers to use a test that is of little value. It is difficult indeed to change practice patterns, particularly the use of tests that are “time honored,” even if they are of questionable scientific validity. Cardiac SurgeryCHESTVol. 103Issue 5PreviewHe held my heart in his hand— That mere man— With those wonderful hands. But he couldn't hold my spirit, Nobody can hold my spirit, I can't hold my spirit! It wasn't in my chest, They'll never find it in my brain, It is in me! He couldn't see it—he couldn't touch it— So he doesn't believe in it. But he counts on it. And so do I! Full-Text PDF" @default.
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• W3023798251 title "Microbial Etiology of Acute Pneumonia in Hospitalized Patients" @default.
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