Respiratory infections. An opportunity for integrated disease management.

TO espiratory infections are a major source of mor-"-*-bidity for patients in the community and for those who are admitted to the hospital. In the United States, pneumonia and influenza together are the sixth lead¬ ing cause of death and the number one cause of death from infectious diseases.1 Community-acquired pneu¬ monia (CAP) occurs in 4 to 6 million people annually, while nosocomial pneumonia (NP) is the hospital-ac¬ quired infection most likely to lead to mortality. In the setting of chronic obstructive lung disease, bronchial infection is common and a frequent source of mor¬ bidity. As new tools for diagnosis and therapy become available, pathogens continue to evolve, making dis¬ eases such as tuberculosis and pneumococcal pneu¬ monia a continuing challenge, rather than a distant memory.2,3 The clinical, epidemiologic, and economic implications of respiratory infections have made them a target ofintense interest for physicians, scientists, and health-care administrators. The complexity and con¬ troversies associated with these conditions were re¬ cently examined in a symposium, published as a sup¬ plement to CHEST, titled "Contemporary Issues in Pulmonary Infections."4 The discussions in this sup¬ plement serve to highlight ongoing areas of contro¬ versy, while suggesting directions for future research and patient care. The complexities surrounding the management of respiratory infections make them an ideal target for a new and integrated approach in health care, termed "disease management." This involves multidisciplinary input for providing care, but more importantly, a glo¬ bal view of patient outcome and the management of illness. The concept of disease management requires that patients, physicians, hospitals, insurers, and the pharmaceutical industry work together to develop an effective and efficient care plan that reduces overall costs while assuring an excellent outcome. The appli¬ cation of such an approach requires a radical rethink¬ ing of a number of traditional approaches. For exam¬ ple, if a patient with an acute exacerbation of chronic bronchitis (AECB) is treated with an antibiotic, what is the most cost-effective choice? Is it the drug which costs the least to buy? Is it an agent which leads to the most rapid recovery, at a higher acquisition cost, but thereby prevents lost work days and the need for hos¬ pitalization? Is it an agent that minimizes the chance of antimicrobial resistance, thereby preventing future episodes of costly care? If such an agent can be iden¬ tified and selected, will it be prescribed and who will accrue the cost …