Improving Diagnostic Accuracy for Older Emergency Department Patients with Suspected Pneumonia: The Role of Diagnostic Criteria and Novel Antimicrobial Peptides

项目摘要/摘要 目前，美国50多万老年人在急诊科就诊时被诊断为肺炎 成年人每年的ICU住院率为16%，30天死亡率高达16%。然而，我们和 其他人发现，对ED老年人肺炎的准确诊断是不准确的；紧急情况 31%的患者存在医生诊断的不确定性，与住院医生的意见不一致 ≥47%的患者和急诊医生报告说，他们在诊断肺炎时感到不舒服 他们没有遵守已公布的指导方针。诊断不足会导致治疗失败和过度- 诊断使患者面临治疗副作用和潜在的未能治疗正确诊断的风险。 急诊医生诊断的不确定性导致住院率、住院时间、再发 入院率和一年内死亡。我们发现，呼吸困难的老年人不成比例 受这些挑战的影响，47%的人患有肺炎、充血性心力衰竭或慢性阻塞性肺病(三种最常见的原因 呼吸困难)，而年轻患者的比例为20%。因此，提高急诊科肺炎的诊断率 准确性，特别是在老年人中，应该是优先事项。 生物标记物检测提高了对老年人呼吸困难的某些原因的诊断准确性(例如： 脑利钠肽在急性充血性心力衰竭中的应用)，可提高肺炎的诊断水平。抗菌肽(AMPs) 是先天免疫系统的关键效应者，随着感染而增加，并可被排泄到 肺炎时的血流。我们的初步数据表明，两个AMP，人-防御素5(HD5)和 人类-防御素-2(HBD2)在患有肺炎的老年ED呼吸困难患者中升高。进一步的研究是 需要确认这些发现并确定它们在改善肺炎诊断方面的作用或补充 目前的方法是作为临床决策规则的一部分。 本项目旨在(目标1)检查为其他环境开发的现有风险分层工具 (Loeb标准、McGeer标准、疾病控制中心等)因为它们仅适用于ED环境 并与(目标2)抗菌肽联合使用，以提高诊断的准确性。如果成功，这将是 建议书将确定可在急诊室使用的现有诊断工具，或通知未来的研究 开发特定于ED的诊断工具。

PROJECT SUMMARY/ABSTRACT Pneumonia is currently diagnosed in over half a million U.S. emergency department (ED) visits by older adults each year with an ICU admission rate of 16% and 30-day mortality as high as 16%. However, we and others have found that the accurate diagnosis of pneumonia in ED older adults is inaccurate; emergency physician diagnostic uncertainty is present in 31% of patients, disagreement with inpatient physician occurs in ≥47% of patients, and emergency physicians report they are uncomfortable diagnosing pneumonia in this population and they do not follow published guidelines. Under-diagnosis then leads to failure to treat and over- diagnosis exposes patients to treatment side effects and potential failure to treat the correct diagnosis. Emergency physician diagnostic uncertainty leads to increased admission rates, hospital length of stay, re- admission rates, and death within one year. We have found that dyspneic older adults are disproportionately affected by these challenges as 47% have pneumonia, CHF or COPD (the three most common causes of dyspnea) vs. 20% of younger patients. Therefore, improving emergency department pneumonia diagnosis accuracy specifically in older adults should be a priority. Biomarker testing has improved diagnostic accuracy in some causes of dyspnea in older adults (e.g. brain natriuretic peptide in acute CHF) and could improve pneumonia diagnosis. Antimicrobial peptides (AMPs) are key effectors of the innate immune system which increase with infection and can be excreted into the bloodstream in pneumonia. Our preliminary data suggests that two AMPs, Human -Defensin 5 (HD5) and Human -Defensin-2 (HBD2), are increased in dyspneic older ED adults with pneumonia. Further study is required to confirm these findings and determine their role in improving pneumonia diagnosis or to supplement current approaches as part of a clinical decision rule. This project seeks to (Aim #1) examine the existing risk stratification tools developed for other settings (Loeb Criteria, McGeer criteria, Centers for Disease Control, etc.) for their applicability to the ED setting alone and in combination with (Aim #2) antimicrobial peptides to improve diagnostic accuracy. If successful, this proposal will either identify an existing diagnostic tool that can be used in the ED or inform a future study to develop an ED-specific diagnostic tool.