Identification of Streptococcus pneumoniae in hospital-acquired pneumonia in adults

Hospital-acquired pneumonia (HAP) is often more severe and life-threatening than community-acquired pneumonia (CAP). The role of Streptococcus pneumoniae in CAP is well-understood, but its role in HAP is unclear. The objective of this study was to summarize the available literature on the prevalence of S. pneumoniae in HAP episodes. We searched MEDLINE for peer-reviewed articles on the microbiology of HAP in individuals aged ≥18 years, published between 2008 and 2018. We calculated pooled estimates of the prevalence of S. pneumoniae in episodes of HAP using a random-effects, inverse-variance-weighted meta-analysis. Forty-seven of 1908 articles met the inclusion criteria. Bacterial specimen isolation techniques for microbiologically defined HAP episodes included bronchoalveolar lavage, protective specimen brush, tracheobronchial aspirate and sputum, as well as blood culture. Culture was performed in all studies; five studies also used urine antigen detection (5/47; 10.6%). S. pneumoniae was identified in 5.1% (95% confidence interval (CI): 3.8-6.6%) of microbiologically defined HAP episodes (N = 20), with 5.4% (95% CI: 4.3-6.7%, N = 29) in ventilator-associated HAP and 6.0% (95% CI: 4.1-8.8%, N = 6) in non-ventilator-associated HAP. S. pneumoniae was identified in 5.3% (95% CI: 4.5-6.3%) of HAP occurring in the intensive care unit (ICU, N = 41) and in 5.6% (95% CI: 3.3-9.5%, N = 5) outside the ICU. A higher proportion of early-onset HAP (10.3%; 95% CI: 8.3-12.8%, N = 16) identified S. pneumoniae as compared with late-onset HAP (3.3%; 95% CI: 2.5-4.4%, N = 16). In conclusion, S. pneumoniae was identified by culture in 5.1% of microbiologically defined HAP episodes. The importance of HAP as part of the disease burden caused by S. pneumoniae merits further research.

Outcome misclassification: Impact, usual practice in pharmacoepidemiology database studies and an online aid to correct biased estimates of risk ratio or cumulative incidence

PURPOSE

It is well documented that outcome misclassification can bias a point estimate. We aimed to understand current practice in addressing this bias in pharmacoepidemiology database studies and to develop an open source application (app) from existing methodology to demonstrate the impact and mechanism of this bias on results.

METHODS

Studies of an exposure and a clinical outcome were selected from all Pharmacoepidemiology and Drug Safety publications during 2017 and any reference to outcome misclassification described. An app to correct risk ratio (RR) and cumulative incidence for outcome misclassification was developed from a published methodology and used to demonstrate the impact of correction on point estimates.

RESULTS

Eight (19%) of 43 papers selected reported estimates of outcome ascertainment accuracy with positive predictive value (PPV) the most commonly reported measure (7 of 8 studies). Three studies (7%) corrected for the bias, 1 by exposure strata, and 5 (12%) restricted analyses to confirmed cases. The app (app http://apps.p-95.com/ISPE/) uses values of PPV and sensitivity (or a range of possible values) in each exposure strata and returns corrected point estimates and confidence intervals. The app demonstrates that small differences between comparison groups in PPV or sensitivity can introduce bias even when accuracy estimates are high.

CONCLUSIONS

Outcome misclassification is not usually corrected in pharmacoepidemiology database studies although correction methods using routinely measured indices are available. Error indices are needed for each comparison group to correct RR estimates for these errors. The app should encourage understanding of this bias and increase adjustment.

Interrater Reliability of the Pediatric Neuromuscular Recovery Scale in Children with Spina Bifida

Purpose: The purpose of this study was to examine the interrater reliability of the Pediatric Neuromuscular Recovery Scale (Peds NRS) to classify motor capacity in children with myelomeningocele (MMC) form of spina bifida.Methods: Twenty-one children with MMC (1.5-10 years of age) were each scored on the Peds NRS three times: two live testing sessions and one video recorded session. Every child was scored by two physical therapists and one occupational therapist. Interrater reliability was analyzed using intraclass correlation coefficients (ICC) for individual items and the summary score.Results: Strong interrater reliability was determined for the overall Peds NRS score (ICC = 0.89; 95% CI, .80-.95). Eleven of 16 individual items exhibited good to excellent reliability (ICC ≥ 0.80). Pediatric clinicians were able to reliably administer and score the Peds NRS on children with MMC, representing a wide range of ages and functional levels.

The impact of routine childhood immunization with higher-valent pneumococcal conjugate vaccines on antimicrobial-resistant pneumococcal diseases and carriage: a systematic literature review

Introduction: The introduction of 7-valent pneumococcal conjugate vaccine (PCV7) in childhood immunization programs reduced antimicrobial-resistant pneumococcal infections by vaccine serotypes. However, emerging antimicrobial-resistant non-vaccine serotypes, particularly serotype 19A, attenuated the overall effect. In 2010, higher-valent PCVs became available containing serotypes that are prone to become antimicrobial-resistant, like serotype 7F in PCV10 and PCV13, and serotype 19A in PCV13.Areas covered: This review evaluated literature published between June 1, 2008 and June 1, 2017 reporting on the effect of PCV10 or PCV13 implementation in routine infant immunization schedules on antimicrobial-resistant invasive pneumococcal disease (IPD), otitis media (OM), and nasopharyngeal carriage (NPC) in children and adults.Expert opinion: In countries with relatively high prior pneumococcal antimicrobial resistance (AMR), PCV13 childhood vaccination programs have reduced antimicrobial-resistant IPD, OM, and NPC in children and IPD in adults. The effectiveness of PCV13 against serotype 19A is likely an important contributing factor. Only few studies have documented the impact of PCV10 on AMR. Multiple factors may influence observed decreases in pneumococcal AMR including antimicrobial stewardship, case definition, time since PCV10/13 introduction, and pre-PCV10/13 AMR levels. This review emphasizes the importance of including impact on AMR when evaluating the full public health of pneumococcal vaccination programs.

Short communication: Production performance and nutrient digestibility of lactating dairy cows fed diets with and without addition of a live-yeast supplement

The objective of this study was to evaluate the use of a live-yeast product when feeding relatively high-forage diets to high-producing cows in mid lactation. Eight primiparous [607 ± 43 kg of body weight (BW) and 130 ± 16 d in milk (DIM) at the beginning of the experiment] and 16 multiparous (706 ± 63 kg of BW and 137 ± 22 DIM at the beginning of the experiment) Holstein cows were blocked by parity and DIM, and randomly assigned to 1 of 2 diets (control vs. yeast) for a 12-wk period according to a randomized complete block design. The formulated diets contained 50.4% corn silage, 10.4% alfalfa hay, and 39.2% concentrate. The yeast diet was formulated to provide approximately 5.4 × 10¹¹ cfu/d of Saccharomyces cerevisiae (BeneSacc; Global Nutritech Biotechnology LLC, Richmond, VA). Total-tract nutrient digestibility was estimated using 240-h undigested neutral detergent fiber (NDF) as an internal marker. Supplementing live yeast to lactating dairy cows did not affect dry matter intake (25.0 kg/d), milk yield (38.6 kg/d), milk fat concentration (4.78%), milk fat yield (1.83 kg/d), milk protein concentration (3.09%), milk protein yield (1.18 kg/d), milk lactose concentration (4.79%), milk lactose yield (1.84 kg/d), BW gain (-0.05 kg/d), or body condition score gain (0.16 units). The digestibility of dry matter was greater for the control treatment than for the yeast treatment (69.3 and 67.1%, respectively), but the digestibilities of crude protein (61.5%), NDF (40.5%), and starch (98.6%) were not affected by treatment. In conclusion, supplementation of live yeast did not affect production performance or nutrient digestibility of high-producing cows in mid lactation. The reasons for the lack of effect are not clear, but an evaluation of interactions between yeast and rumen buffer supplementation is warranted.

Herpes zoster related healthcare burden and costs in immunocompromised (IC) and IC-free populations in England: an observational retrospective database analysis

OBJECTIVE

Individuals with immunocompromised (IC) conditions are at a higher risk of developing herpes zoster (HZ) than IC-free individuals. This study assessed the healthcare resource utilisation (HCRU) burden and costs, of HZ in IC and IC-free individuals ≥18 years of age (YOA).

METHODS

We conducted an observational retrospective study in a cohort of IC (n=621 588) and IC-free (n=621 588) individuals, matched by age, gender and General Practitioner practice region, contributing to the Clinical Practice Research Datalink database from 2000 to 2012 and linked to the Hospital Episode Statistics inpatient data. HCRU (ie, primary and secondary care consultations, hospital inpatient stays and treatment prescriptions) was analysed from 7 days before to: (1) 30, (2) 365 days after the HZ diagnosis date for individuals with (1) HZ only (no postherpetic neuralgia (PHN)) and (2) individuals with HZ and PHN only. Healthcare costs were computed by multiplying the number of units of resources used by the unit costs, summed across all HCRU categories to obtain a total cost per subject. Values were expressed in 2014 UK pound sterling (£) and presented for HZ cases overall, stratified by age (ie, 18-49, 50-59, 60-69, 70-79 and ≥80 YOA) and IC status.

RESULTS

The percentage of HZ cases requiring hospitalisation was higher in IC individuals (2.7% vs 0.4% in IC and IC-free individuals aged 18-49 YOA, respectively and 9.5% vs 7.5% in IC and IC-free individuals aged ≥80 YOA, respectively). Similarly, HZ-related mean treatment costs per subject were higher in IC individuals (£189 vs £104 in IC and IC-free individuals aged 18-49 YOA, respectively and £557 vs £401 in IC and IC-free individuals aged ≥80 YOA, respectively). Costs varied considerably by IC condition.

CONCLUSIONS

Individuals with IC conditions, have a high burden of HZ, associated with an increased risk of HZ and high HZ-related healthcare costs.

Production performance and nutrient digestibility of lactating dairy cows fed low-forage diets with and without the addition of a live-yeast supplement

We aimed to evaluate the use of a live-yeast product as a means to attenuate plausible nutritional disturbances when feeding relatively low-forage diets containing rapidly fermentable carbohydrates (i.e., wheat) to high-producing cows in early to mid lactation. Eight primiparous [mean ± SD; 569 ± 35 kg of body weight (BW) and 80 ± 29 d in milk (DIM) at the beginning of the experiment] and 16 multiparous (665 ± 67 kg of BW and 64 ± 10 DIM at the beginning of the experiment) Holstein cows were blocked by parity and DIM, and randomly assigned to 1 of 2 diets (control vs. yeast) for a 12-wk-long period according to randomized complete block design. The formulated diets contained 36.7% corn silage, 8.3% alfalfa hay, and 55% concentrate. The yeast diet was formulated to provide approximately 5.4 × 10¹¹ cfu/d of Saccharomyces cerevisiae (BeneSacc; Global Nutritech Biotechnology LLC, Richmond, VA). Total-tract nutrient digestibility was estimated using 240-h undigested neutral detergent fiber (NDF) as an internal marker. Dry matter intake, milk yield, and milk component concentrations and yields were analyzed using repeated measures. The statistical model for these variables included the effects of block, treatment, the block by treatment interaction, week, the treatment by week interaction, and the random residual error. The statistical model for analyzing BW gain, body condition score gain, and dry matter and nutrient digestibilities included the effects of block, treatment, and the random residual error. Supplementing live yeast to lactating dairy cows did not affect dry matter intake (26.0 kg/d), milk yield (48.1 kg/d), milk fat concentration (3.61%), milk fat yield (1.72 kg/d), milk protein concentration (2.96%), milk protein yield (1.43 kg/d), milk lactose concentration (4.84%), milk lactose yield (2.35 kg/d), milk urea nitrogen (7.99 mg/dL), body weight gain (0.62 kg/d), and body condition score gain (0.02 units; all averages of the 2 treatments). The digestibilities of dry matter (70.2%), crude protein (71.4%), NDF (36.4%), and starch (99.8%) were not affected by treatments. In conclusion, the supplementation of the live yeast did not affect production performance and nutrient digestibility of high-producing dairy cows. A potential interaction between live-yeast supplementation and NDF passage rate, which may have hindered the beneficial effects of live-yeast supplementation on production performance and nutrient utilization, deserves further research.

Evaluation of a risk score to predict future Clostridium difficile disease using UK primary care and hospital data in Clinical Practice Research Datalink

We evaluated the applicability of a Clostridium difficile infection (CDI) risk index developed for patients at hospital discharge to identify persons at high-risk of CDI in a primary care population. This retrospective observational study used data from the UK Clinical Practice Research Datalink, linked with Hospital Episodes Statistics. The risk index was based on the following patient characteristics: age, previous hospitalizations, days in hospital, and prior antibiotics use. Individual risk scores were calculated by summing points assigned to pre-defined categories for each characteristic. We assessed the association of risk factors with CDI by multivariate logistic regression. The estimated CDI incidence rate was 4/10,000 and 2/10,000 person-years in 2008 and 2012, respectively. On an index with a maximal risk of 19, a cut-off for high risk of ≥7 had sensitivity, specificity and positive predictive values of 80%, 87% and 12%, respectively. A high-risk person had a ~ 35% higher risk of CDI than a low-risk person. Multivariate risk factor analysis indicated a need to reconsider the relative risk scores. The CDI risk index can be applied to the UK primary care population and help identify study populations for vaccine development studies. Reassessing the relative weights assigned to risk factors could improve the index performance in this setting.

Peptide receptor radionuclide therapy with 177Lu-DOTA-TATE as a promising treatment of malignant insulinoma: a series of case reports and literature review

INTRODUCTION

Insulinomas are a rare type of pancreatic neuroendocrine tumours characterized by insulin hypersecretion. They are considered malignant when metastases are present. Traditional therapies often promote only temporarily symptomatic relief and may be associated with severe adverse effects. There is scarce experience in treating malignant insulinomas with peptide receptors radionuclide therapy (PRRNT).

PATIENTS AND METHODS

We describe PRRNT results in four patients with inoperable malignant insulinomas with poorly controllable hypoglycaemia. All patients received therapy with ¹⁷⁷Lu-DOTA-TATE after conventional therapies failed in controlling disease progression and symptoms. The activity administered per cycle was 4.8-7.4 GBq. The interval between cycles was 10-16 weeks. Haematology, liver and kidney function tests were performed before treatment initiation and 5 and 10 weeks after each cycle.

RESULTS

Patient 1 presented significant clinical benefit for 13 months after PRRNT, with imaging improvement. Patient 2 obtained reduction of the number and severity of hypoglycaemic episodes during 15 months after therapy. Patient 3 is asymptomatic since PRRNT first cycle performed 23 months ago and revealed significant imaging improvement. Patient 4 had resolution of hypoglycaemia only 3 days after PRRNT first cycle and today, 16 months after therapy, the disease seems to be in remission and the patient maintains euglycaemic state. PRRNT was well tolerated, with only hematologic grade 2 toxicity in patient 1 and mild kidney toxicity in patient 3.

CONCLUSIONS

After the start of ¹⁷⁷Lu-DOTA-TATE all patients achieved hypoglycaemia symptomatic control and had evident improvement of their quality of life. Three patients showed imagiological improvement suggesting reduced tumour load.

Production performance, nutrient digestibility, and milk fatty acid profile of lactating dairy cows fed corn silage- or sorghum silage-based diets with and without xylanase supplementation

The objective of this study was to evaluate the effects of supplementing xylanase on production performance, nutrient digestibility, and milk fatty acid profile in high-producing dairy cows consuming corn silage- or sorghum silage-based diets. Conventional corn (80,000 seeds/ha) and brown midrib forage sorghum (250,000 seeds/ha) were planted, harvested [34 and 32% of dry matter (DM), respectively], and ensiled for more than 10 mo. Four primiparous and 20 multiparous Holstein cows were randomly assigned to 1 of 4 diets in a replicated 4 × 4 Latin square design with a 2 × 2 factorial arrangement of treatments and 19-d periods. Treatment diets consisted of (1) corn silage-based diet without xylanase, (2) corn silage-based diet with xylanase, (3) sorghum silage-based diet without xylanase, and (4) sorghum silage-based diet with xylanase. The xylanase product was supplemented at a rate of 1.5 g of product/kg of total DM. Corn silage had higher concentrations of starch (31.2 vs. 29.2%), slightly higher concentrations of crude protein (7.1 vs. 6.8%) and fat (3.7 vs. 3.2%), and lower concentrations of neutral detergent fiber (36.4 vs. 49.0%) and lignin (2.1 vs. 5.7%) than sorghum silage. Xylanase supplementation did not affect DM intake, milk yield, milk fat percentage and yield, milk protein percentage and yield, lactose percentage and yield, and 3.5% fat-corrected milk yield. Cows consuming corn silage-based diets consumed 13% more DM (28.8 vs. 25.5 kg/d) and produced 5% more milk (51.6 vs. 48.9 kg/d) than cows consuming sorghum silage-based diets. Milk from cows consuming sorghum silage-based diets had 16% greater fat concentrations (3.84 and 3.30%) than milk from cows consuming corn silage-based diets. This resulted in 8% greater fat yields (1.81 vs. 1.68 kg/d). Silage type did not affect milk protein and lactose concentrations. Xylanase supplementation did not affect nutrient digestibility. Cows consuming corn silage-based diets showed greater DM (77.3 vs. 73.5%), crude protein (78.0 vs. 72.4), and starch (99.2 vs. 96.5%) digestibilities than cows consuming sorghum silage-based diets. In conclusion, xylanase supplementation did not improve production performance when high-producing dairy cows were fed corn silage- or sorghum silage-based diets. In addition, production performance can be sustained by feeding sorghum silage in replacement of corn silage.

Short communication: Effect of corn planting population on phosphorus concentration and uptake in corn silage

Greater utilization of nutrients reduces the potential runoff of nutrients to bodies of water. The objective of this study was to determine the concentration of P in corn biomass to estimate the removal of P from the soil when planting corn at different population levels. Whole-plant corn samples were collected during an on-farm research project conducted previously. The study included 7 different growing and harvesting conditions. In each cornfield, corn was planted in plots at a theoretical seeding rate of 55,000, 70,000, 85,000, and 100,000 seeds/ha. Each seeding rate had 4 replicates within each field. At harvesting time, 5 consecutive plants from the 2 center rows and at 2 randomly selected spots within each plot were cut by hand at 15 cm above ground. Whole plants were weighed and chopped. After mixing thoroughly, a sample of the chopped material was placed in a bag, immediately placed in a cooler with dry ice, and transferred to the laboratory for storage. After thawing and drying, samples were ground and analyzed for P concentration. Single plant biomass and the number of standing plants at harvesting were used to determine dry matter yield. Total extraction of P was estimated as the product between plant biomass and P concentration. All variables were analyzed using a statistical model that included the effects of field, planting population, planting population nested within field, and random residual error. The concentration of P in the corn plant was greatest for 55,000 and 70,000 plants/ha (0.250% dry matter) and least for 85,000 and 100,000 plants/ha (0.235% dry matter), whereas the uptake of P through the harvested biomass increased when corn planting population increased. In conclusion, increasing the planting population of corn for silage can increase P uptake from the soil, therefore reducing the potential runoff of P to bodies of water.

Burden of herpes zoster in 16 selected immunocompromised populations in England: a cohort study in the Clinical Practice Research Datalink 2000-2012

OBJECTIVES

Herpes zoster (HZ) is caused by reactivation of varicella-zoster virus which remains latent in individuals after a varicella infection. It is expected that HZ will be more frequent in immunocompromised (IC) individuals than in immunocompetent (IC-free). This study assessed the incidence rate (IR) of HZ in individuals with a wide set of IC conditions and in IC-free individuals.

SETTING

A retrospective cohort study was conducted in England using data (January 2000 to March 2012) from the Clinical Practice Research Datalink with linkage to the Hospital Episodes Statistics.

PARTICIPANTS

A cohort of 621 588 individuals with 16 selected IC conditions and a gender/age-matched cohort of IC-free individuals were identified. The IC conditions included haematopoietic stem cell transplant (HSCT), solid organ transplant, malignancies, autoimmune diseases and users of immunosuppressive medications.

OUTCOMES

IR of HZ per 1000 person-years (PY) was estimated. Proportions of postherpetic neuralgia (PHN) and other HZ complications within 90 days of HZ onset were also estimated among patients with HZ. Risk factors for PHN in IC individuals with HZ were assessed by a multivariate regression model.

RESULTS

The overall IR of HZ in the IC cohort was 7.8/1000 PY (95% CI 7.7 to 7.9), increasing with age from 3.5/1000 PY (3.4-3.7) in individuals aged 18-49 years to 12.6/1000 PY (12.2-13.0) in individuals aged ≥80 years. This IR in the IC-free cohort was 6.2/1000 PY (6.1-6.3). The overall IR of HZ varied across IC conditions, ranging from 5.3 (5.1-5.5) in psoriasis to 41.7/1000 PY (35.7-48.4) in HSCT. The proportions of PHN and other HZ complications were 10.7% (10.2-11.1) and 2.9% (2.7-3.2) in the IC cohort, but 9.1% (8.7-9.5) and 2.3% (2.1-2.6) in the IC-free cohort, respectively.

CONCLUSION

IC population contributes to the public health burden of HZ in England. Vaccination might be the most preferable HZ preventive measure for the IC population.

Nutritional composition and in vitro digestibility of grass and legume winter (cover) crops

In dairy farming systems, growing winter crops for forage is frequently limited to annual grasses grown in monoculture. The objectives of this study were to determine how cropping grasses alone or in mixtures with legumes affects the yield, nutritional composition, and in vitro digestibility of fresh and ensiled winter crops and the yield, nutritional composition, and in vitro digestibility of the subsequent summer crops. Experimental plots were planted with 15 different winter crops at 3 locations in Virginia. At each site, 4 plots of each treatment were planted in a randomized complete block design. The 15 treatments included 5 winter annual grasses [barley (BA), ryegrass (RG), rye (RY), triticale (TR), and wheat (WT)] in monoculture [i.e., no legumes (NO)] or with 1 of 2 winter annual legumes [crimson clover (CC) and hairy vetch (HV)]. After harvesting the winter crops, corn and forage sorghum were planted within the same plots perpendicular to the winter crop plantings. The nutritional composition and the in vitro digestibility of winter and summer crops were determined for fresh and ensiled samples. Growing grasses in mixtures with CC increased forage dry matter (DM) yield (2.84 Mg/ha), but the yield of mixtures with HV (2.47 Mg/ha) was similar to that of grasses grown in monoculture (2.40 Mg/ha). Growing grasses in mixtures with legumes increased the crude protein concentration of the fresh forage from 13.0% to 15.5% for CC and to 17.3% for HV. For neutral detergent fiber (NDF) concentrations, the interaction between grasses and legumes was significant for both fresh and ensiled forages. Growing BA, RY, and TR in mixtures with legumes decreased NDF concentrations, whereas growing RG and WT with legumes did not affect the NDF concentrations of either the fresh or the ensiled forages. Growing grasses in mixtures with legumes decreased the concentration of sugars of fresh forages relative to grasses grown in monoculture. Primarily, this decrease can be attributed to low concentrations of sugars of mixtures with HV (10.5%). Growing grasses in mixtures with legumes reduced the fiber digestibility of both winter crops (75.7% to 72.8% NDF). Growing grasses in mixtures with legumes did not affect estimated DM yield, nutritional composition, or digestibility of the succeeding summer crops. In conclusion, growing grasses in mixtures with legumes as winter forage crops can increase forage estimated DM yields and its nutritional quality in dairy farming sytems.

Estimating the Burden of Medically Attended Norovirus Gastroenteritis: Modeling Linked Primary Care and Hospitalization Datasets

Background

Norovirus is the leading cause of community-acquired and nosocomial acute gastroenteritis. Routine testing for norovirus is seldom undertaken, and diagnosis is mainly based on presenting symptoms. This makes understanding the burden of medically attended norovirus-attributable gastroenteritis (MA-NGE) and targeting care and prevention strategies challenging.

Methods

We used linked population-based healthcare datasets (Clinical Practice Research Datalink General Practice OnLine Database linked with Hospital Episode Statistics Admitted Patient Care) to model the incidence of MA-NGE associated with primary care consultations or hospitalizations according to age groups in England in the period July 2007–June 2013.

Results

Mean annual incidence rates of MA-NGE were 4.9/1000 person-years and 0.7/1000 person-years for episodes involving primary care or hospitalizations, respectively. Incidence rates were highest in children aged <5 years: 34.0 consultations/1000 person-years and 3.3 hospitalizations/1000 person-years. Medically attended norovirus-attributable gastroenteritis hospitalization rates were second highest in adults aged >65 years (1.7/1000 person-years).

Conclusions

In this particular study, the burden of MA-NGE estimated from healthcare datasets was higher than previously estimated in small cohort studies in England. Routinely collected primary care and hospitalization datasets are useful resources to estimate and monitor the burden of MA-NGE in a population over time.

Effectiveness of pneumococcal vaccines in preventing pneumonia in adults, a systematic review and meta-analyses of observational studies

INTRODUCTION

S. pneumoniae can cause a wide spectrum of diseases, including invasive pneumococcal disease and pneumonia. Two types of pneumococcal vaccines are indicated for use in adults: 23-valent pneumococcal polysaccharide vaccines (PPV23) and a 13-valent pneumococcal conjugate vaccine (PCV13).

OBJECTIVE

To systematically review the literature assessing pneumococcal vaccine effectiveness (VE) against community-acquired pneumonia (CAP) in adults among the general population, the immunocompromised and subjects with underlying risk factors in real-world settings.

METHODS

We searched for peer-reviewed observational studies published between 1980 and 2015 in Pubmed, SciELO or LILACS, with pneumococcal VE estimates against CAP, pneumococcal CAP or nonbacteremic pneumococcal CAP. Meta-analyses and meta-regression for VE against CAP requiring hospitalization in the general population was performed.

RESULTS

1159 unique articles were retrieved of which 33 were included. No studies evaluating PCV13 effectiveness were found. Wide ranges in PPV23 effectiveness estimates for any-CAP were observed among adults ≥65 years (-143% to 60%). The meta-analyzed VE estimate for any-CAP requiring hospitalization in the general population was 10.2% (95%CI: -12.6; 33.0). The meta-regression indicates that VE against any-CAP requiring hospitalization is significantly lower in studies with a maximum time since vaccination ≥60 months vs. <60 months and in countries with the pediatric PCV vaccine available on the private market. However, these results should be interpreted cautiously due to the high influence of two studies. The VE estimates for pneumococcal CAP hospitalization ranged from 32% (95%CI: -18; 61) to 51% (95%CI: 16; 71) in the general population.

CONCLUSIONS

Wide ranges in PPV23 effectiveness estimates for any-CAP were observed, likely due to a great diversity of study populations, circulation of S. pneumoniae serotypes, coverage of pediatric pneumococcal vaccination, case definition and time since vaccination. Despite some evidence for short-term protection, effectiveness of PPV23 against CAP was not consistent in the general population, the immunocompromised and subjects with underlying risk factors.