Pneumonia is a major global health issue, particularly for critically ill patients in ICUs. It encompasses various types, such as community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP), each with distinct diagnostic and treatment challenges. Annually, pneumonia contributes to over 2.5 million deaths and costs approximately $10 billion worldwide. Despite international guidelines for managing CAP, HAP, and VAP, their clinical application remains inconsistent due to inadequate training, guideline complexity, and organisational barriers.
Advancements in diagnostic tools, such as lung ultrasound (LUS) and syndromic molecular tests, offer improved pathogen detection but require specialised equipment and training. Challenges include variability in operator expertise, detection limitations, and resource constraints, particularly in low- and middle-income countries (LMICs) where pneumonia's burden is highest.
The D-PRISM study, a multinational effort, aimed to address gaps in understanding the clinical practices for diagnosing and managing pneumonia in ICUs. It focused on CAP, HAP, and VAP, excluding ventilator-associated tracheitis (VAT) due to definitional uncertainties. The study explored adherence to guidelines, diagnostic challenges, and practice variations to enhance pneumonia management globally.
The D-PRISM study evaluates the diagnosis and treatment of pneumonia in ICUs. Intensive care clinicians from 72 countries completed a self-administered online questionnaire covering professional profiles, clinical practices for managing CAP, HAP, and VAP, and the availability of microbiology diagnostic tools. The study analysed 1,296 responses from ICU clinicians, with 51% from LMICs. Diagnostic practices varied widely, including differences in clinical assessments, with 30% not requiring radiological evidence for pneumonia diagnosis, inconsistent microbiological sample collection, and bronchoscopy use. Microbiological diagnostics were least available in LMICs. The typical intended antibiotic treatment duration for all pneumonia types was 5–7 days, with shorter durations linked to antimicrobial stewardship programmes, higher national income levels, and formal intensive care training.
The study highlights significant variations in practices and diagnostic capabilities, particularly between low- and high-income settings. Key findings include:
- Diagnosis and Guidelines: While clinical and radiological assessments were commonly used, 30% of clinicians did not consider radiological evidence essential for diagnosing pneumonia, reflecting a gap between guidelines and practice. Microbiological sampling rates were suboptimal across all pneumonia types, and bronchoscopy use often fell short of recommended standards due to training and equipment limitations.
- Antimicrobial Therapy: Most respondents adhered to guideline-recommended antibiotic durations (5–7 days for CAP), but longer durations were reported for HAP and VAP due to concerns over resistant organisms. Shorter durations were linked to antimicrobial stewardship programmes, higher-income settings, and structured interventions like antibiotic time-outs.
- Diagnostic Tools: Access to microbiological testing and advanced diagnostic tools like multiplex PCR varied significantly, with limited availability in low- and middle-income countries. Despite the potential of these tools to improve outcomes, barriers such as cost and training persist.
The study reveals significant variations in clinical practices and diagnostic capabilities for pneumonia, particularly limited access to diagnostic tools in LMICs. It emphasies the need for better adherence to guidelines and standardised approaches to diagnosing and managing pneumonia in ICUs.
Source: Critical Care
Image Credit: iStock
