Community-acquired lower respiratory tract infections. Prevention and cost-control strategies.

The treatment of patients with community-acquired pneumonia can be expensive, particularly if care is hospital-based. Cost control begins with prevention. Current influenza vaccines are about 80 percent protective, but grossly underused. Amantadine and rimantadine are effective chemoprophylactic agents against influenza A, but also underused. Use of pneumococcal vaccine is controversial, but patients who are thought to be at increased risk should be immunized. Management decisions in patients with pneumonia that have major cost implications include the need for hospitalization and choice of diagnostic tests and therapy. The need for hospitalization has not been well studied. In general, young patients with atypical pneumonia are treated at home, whereas older patients with complicating illnesses are admitted to hospitals. Length of hospitalization has decreased in recent years. Diagnostic tests have traditionally emphasized chest roentgenography, Gram staining of the sputum, and sputum culture. Published data suggest that a Gram staining of the sputum can be useful. Sputum cultures are frequently confusing and should be discontinued. Intermittent positive pressure breathing treatments have no value, and chest physiotherapy is unnecessary for most patients.