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

项目总结/摘要 目前，美国急诊室（艾德）就诊的老年人中有超过50万人被诊断出肺炎 每年有16%的成年人入住ICU，30天死亡率高达16%。然而，我们和 其他人发现，艾德老年人肺炎的准确诊断是不准确的; 31%的患者存在医生诊断不确定性，与住院医生发生分歧 ≥47%的患者和急诊医生报告说，他们在这种情况下诊断肺炎感到不舒服。 人口，他们不遵循公布的准则。诊断不足则导致治疗失败和过度- 诊断使患者暴露于治疗副作用和治疗正确诊断的潜在失败。 急诊医生诊断的不确定性导致入院率增加，住院时间延长，再住院， 一年内的死亡率和死亡率。我们发现呼吸困难的老年人 受这些挑战的影响，47%的人患有肺炎，CHF或COPD（三种最常见的原因）。 呼吸困难）vs. 20%的年轻患者。因此，提高急诊科肺炎诊断 准确性，特别是在老年人应该是一个优先事项。 生物标志物检测提高了老年人呼吸困难某些原因的诊断准确性（例如， 脑利钠肽在急性CHF中），并可提高肺炎的诊断。抗菌肽 是先天免疫系统的关键效应物，其随着感染而增加，并且可以被排泄到 肺炎的血液循环我们的初步数据表明，两种AMP，人β-防御素5（HD 5）和 人β-防御素-2（HBD 2）在患有肺炎的呼吸困难的老年艾德成人中增加。进一步研究 需要确认这些发现并确定其在改善肺炎诊断中的作用， 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）仅适用于艾德环境 并与（目标#2）抗微生物肽组合以提高诊断准确性。如果成功，这 提案将确定可用于艾德的现有诊断工具，或告知未来的研究， 开发ED专用诊断工具。

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.