245 Low-dose-CT versus X-ray in patients with pneumonia Introduction The presence of a parenchymal consolidation on chest X-ray (CXR), combined with systemic signs of infection and symptoms of acute lower respiratory infection, defines a diagnosis of community-acquired pneumonia (CAP) [1]. Performing a CXR is currently the standard diagnostic procedure in patients suspected of CAP. However, chest computed tomography (CT) scan has a higher diagnostic accuracy for CAP as compared to CXR [2, 3]. Recently, ultra-low-dose chest-CT (ULDCT) scans have become available, with a radiation dose comparable to the CXR radiation dose [4, 5]. ULDCT might therefore replace CXR as preferred diagnostic procedure in patients clinically suspected of CAP, provided that ULDCT proves to be an accurate diagnostic for CAP, improves antibiotic management, and, most importantly, results in better patient outcomes. We recently reported on the results of the OPTIMACT study, a large multicenter randomized controlled trial (RCT) designed to evaluate ULDCT versus CXR in patients suspected of non-traumatic pulmonary disease [6, 7]. Short-term functional health was comparable between ULDCT and CXR, as were hospital admissions, length of hospital stay and mortality rates [7]. However, among the 2418 included patients in this RCT, a higher number of patients was diagnosed with CAP in the ULDCT group, which is in line with previous studies indicating the higher sensitivity of ULDCT [8]. We here investigated whether the higher sensitivity of ULDCT affected clinical management and patient outcomes in the patients clinically (i.e. before imaging) suspected of CAP. Methods This is a preplanned subgroup analysis of data prospectively collected in the OPTIMACT trial between 31 January 2017 and 31 May 2018 (The Netherlands Trial Register identifier NTR6163)[6, 7, 9]. ED patients older than 18 years were eligible for inclusion in the OPTIMACT trial if presenting with symptoms of non-traumatic pulmonary disease and requiring a CXR according to the attending physician. During randomly assigned periods of one calendar month, either ULDCT or conventional CXR was used in the two participating Dutch hospitals. Patients were eligible for this preplanned subgroup analysis if there was, prior to imaging, a clinical suspicion of CAP, defined as at least one clinical sign or symptom of an acute lower respiratory tract infection (cough, sputum production, dyspnoea, chest pain, or abnormal breathing sounds at auscultation suggestive of pneumonia), and new onset of systemic infection (fever (>38°C) or hypothermia (<36°C)). Patients were not eligible in case of a concurrent active infection requiring antibiotic treatment, admission to a hospital in the two weeks prior to ED presentation, or admission to the Intensive Care Unit (ICU) in the 28 days after ED presentation. Details of the study design and data collection are reported elsewhere [7]. The Medical Ethics Committee approved the study protocol. Written informed consent was provided by all study participants. We report the proportion of patients who were discharged from the ED with a diagnosis of CAP after initial work-up (including imaging) and the proportion of patients who had a definite diagnosis of CAP assigned after 28 days of follow-up. We assigned this definite diagnosis based on a review of all clinical, radiological, and 10
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