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Han X, Zhou F, Li H, Xing X, Chen L, Wang Y, Zhang C, Liu X, Suo L, Wang J, Yu G, Wang G, Yao X, Yu H, Wang L, Liu M, Xue C, Liu B, Zhu X, Li Y, Xiao Y, Cui X, Li L, Purdy JE, Cao B. Effects of age, comorbidity and adherence to current antimicrobial guidelines on mortality in hospitalized elderly patients with community-acquired pneumonia. BMC Infect Dis 2018; 18:192. [PMID: 29699493 PMCID: PMC5922029 DOI: 10.1186/s12879-018-3098-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 04/16/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Limited information exists on the clinical characteristics predictive of mortality in patients aged ≥65 years in many countries. The impact of adherence to current antimicrobial guidelines on the mortality of hospitalized elderly patients with community-acquired pneumonia (CAP) has never been assessed. METHODS A total of 3131 patients aged ≥65 years were enrolled from a multi-center, retrospective, observational study initiated by the CAP-China network. Risk factors for death were screened with multivariable logistic regression analysis, with emphasis on the evaluation of age, comorbidities and antimicrobial treatment regimen with regard to the current Chinese CAP guidelines. RESULTS The mean age of the study population was 77.4 ± 7.4 years. Overall in-hospital and 60-day mortality were 5.7% and 7.6%, respectively; these rates were three-fold higher in those aged ≥85 years than in the 65-74 group (11.9% versus 3.2% for in-hospital mortality and 14.1% versus 4.7% for 60-day mortality, respectively). The mortality was significantly higher among patients with comorbidities compared with those who were otherwise healthy. According to the 2016 Chinese CAP guidelines, 62.1% of patients (1907/3073) received non-adherent treatment. For general-ward patients without risk factors for Pseudomonas aeruginosa (PA) infection (n = 2258), 52.3% (1094/2090) were over-treated, characterized by monotherapy with an anti-pseudomonal β-lactam or combination with fluoroquinolone + β-lactam; while 71.4% of intensive care unit (ICU) patients (120/168) were undertreated, without coverage of atypical bacteria. Among patients with risk factors for PA infection (n = 815), 22.9% (165/722) of those in the general ward and 74.2% of those in the ICU (69/93) were undertreated, using regimens without anti-pseudomonal activity. The independent predictors of 60-day mortality were age, long-term bedridden status, congestive heart failure, CURB-65, glucose, heart rate, arterial oxygen saturation (SaO2) and albumin levels. CONCLUSIONS Overtreatment in general-ward patients and undertreatment in ICU patients were critical problems. Compliance with Chinese guidelines will require fundamental changes in standard-of-care treatment patterns. The data included herein may facilitate early identification of patients at increased risk of mortality. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov ( NCT02489578 ).
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Affiliation(s)
- Xiudi Han
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Road, Chao-yang District, Beijing, China
- Department of Respiratory Medicine, Qingdao Municipal Hospital Group, Jiaozhou Road, Qingdao City, Shandong Province China
| | - Fei Zhou
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Road, Chao-yang District, Beijing, China
| | - Hui Li
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
| | - Xiqian Xing
- Department of Respiratory Medicine, Yan’an Hospital Affiliated to Kunming Medical University, Renmin East Road, Kunming City, Yunnan Province China
| | - Liang Chen
- Department of Infectious Disease, Beijing Jishuitan Hospital, Xinjiekou East Street, Xi-cheng District, Beijing, China
| | - Yimin Wang
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
| | - Chunxiao Zhang
- Department of Respiratory Medicine, Beijing Huimin Hospital, Youanmen Street, Xi-cheng District, Beijing, China
| | - Xuedong Liu
- Department of Respiratory Medicine, Qingdao Municipal Hospital Group, Jiaozhou Road, Qingdao City, Shandong Province China
| | - Lijun Suo
- Department of Respiratory Medicine, Linzi District People’s Hospital, Huangong Road, Zibo City, Shandong Province China
| | - Jinxiang Wang
- Department of Respiratory Medicine, Beijing Luhe Hospital, Capital Medical University, Xinhua South Road, Tongzhou District, Beijing, China
| | - Guohua Yu
- Department of Pulmonary and Critical Care Medicine, Weifang No. 2 People’s Hospital, Yuanxiao Street, Weifang City, Shandong Province China
| | - Guangqiang Wang
- Department of Respiratory Medicine, Shandong University Affiliated Qilu Hospital (Qingdao), Hefei Road, Qingdao City, Shandong Province China
| | - Xuexin Yao
- Department of Respiratory Medicine, The 2nd Hospital of Beijing Corps, Chinese Armed Police Forces, Yuetan North Street, Xi-cheng District, Beijing, China
| | - Hongxia Yu
- Department of Infectious Disease, Qingdao University Medical College Affiliated Yantaiyuhuangding Hospital, Yudong Road, Yantai City, Shandong Province China
| | - Lei Wang
- Department of Respiratory Medicine, Rizhao Chinese Medical Hospital Affiliated to Shandong Chinese Medical University, Wanghai Road, Rizhao City, Shandong Province China
| | - Meng Liu
- Department of Respiratory Medicine, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Meishuguan Street, Dong-cheng District, Beijing, China
| | - Chunxue Xue
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Road, Chao-yang District, Beijing, China
| | - Bo Liu
- Department of Respiratory Medicine, Linzi District People’s Hospital, Huangong Road, Zibo City, Shandong Province China
| | - Xiaoli Zhu
- Department of Occupational Medicine and Toxicology, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Road, Chao-yang District, Beijing, China
| | - Yanli Li
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Road, Chao-yang District, Beijing, China
| | - Ying Xiao
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Road, Chao-yang District, Beijing, China
| | - Xiaojing Cui
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
| | - Lijuan Li
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
| | - Jay E. Purdy
- Senior Director, Anti-infectives, Pfizer Inc, 500 Arcola Rd, F3203, Collegeville, PA 19426 USA
| | - Bin Cao
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
- Department of Pulmonary Medicine, Capital Medical University, Yinghuayuan East Street, Chao-yang District, Beijing, China
| | - for the CAP-China network
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Road, Chao-yang District, Beijing, China
- Department of Respiratory Medicine, Qingdao Municipal Hospital Group, Jiaozhou Road, Qingdao City, Shandong Province China
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Yinghuayuan East Street, Chao-yang District, Beijing, China
- Department of Respiratory Medicine, Yan’an Hospital Affiliated to Kunming Medical University, Renmin East Road, Kunming City, Yunnan Province China
- Department of Infectious Disease, Beijing Jishuitan Hospital, Xinjiekou East Street, Xi-cheng District, Beijing, China
- Department of Respiratory Medicine, Beijing Huimin Hospital, Youanmen Street, Xi-cheng District, Beijing, China
- Department of Respiratory Medicine, Linzi District People’s Hospital, Huangong Road, Zibo City, Shandong Province China
- Department of Respiratory Medicine, Beijing Luhe Hospital, Capital Medical University, Xinhua South Road, Tongzhou District, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Weifang No. 2 People’s Hospital, Yuanxiao Street, Weifang City, Shandong Province China
- Department of Respiratory Medicine, Shandong University Affiliated Qilu Hospital (Qingdao), Hefei Road, Qingdao City, Shandong Province China
- Department of Respiratory Medicine, The 2nd Hospital of Beijing Corps, Chinese Armed Police Forces, Yuetan North Street, Xi-cheng District, Beijing, China
- Department of Infectious Disease, Qingdao University Medical College Affiliated Yantaiyuhuangding Hospital, Yudong Road, Yantai City, Shandong Province China
- Department of Respiratory Medicine, Rizhao Chinese Medical Hospital Affiliated to Shandong Chinese Medical University, Wanghai Road, Rizhao City, Shandong Province China
- Department of Respiratory Medicine, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Meishuguan Street, Dong-cheng District, Beijing, China
- Department of Occupational Medicine and Toxicology, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Road, Chao-yang District, Beijing, China
- Senior Director, Anti-infectives, Pfizer Inc, 500 Arcola Rd, F3203, Collegeville, PA 19426 USA
- Department of Pulmonary Medicine, Capital Medical University, Yinghuayuan East Street, Chao-yang District, Beijing, China
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Tokgoz Akyil F, Yalcinsoy M, Hazar A, Cilli A, Celenk B, Kilic O, Sayiner A, Kokturk N, Sakar Coskun A, Filiz A, Cakir Edis E. Prognosis of hospitalized patients with community-acquired pneumonia. Pulmonology 2018; 24:S2173-5115(17)30156-2. [PMID: 29463455 DOI: 10.1016/j.rppnen.2017.07.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 07/09/2017] [Accepted: 07/13/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The long-term prognosis of patients with community-acquired pneumonia (CAP) has attracted increasing interest in recent years. The objective of the present study is to investigate the short and long-term outcomes in hospitalized patients with CAP and to identify the predictive factors associated with mortality. PATIENTS AND METHODS The study was designed as a retrospective, multicenter, observational study. Hospitalized patients with CAP, as recorded in the pneumonia database of the Turkish Thoracic Society between 2011 and 2013, were included. Short-term mortality was defined as 30-day mortality and long-term mortality was assessed from those who survived 30 days. Predictive factors for short- and long-term mortality were analyzed. RESULTS The study included 785 patients, 68% of whom were male and the mean age was 67±16 (18-92). The median duration of follow-up was 61.2±11.8 (37-90) months. Thirty-day mortality was 9.2% and the median survival of patients surviving 30 days was 62.8±4.4 months. Multivariate analysis revealed that advanced age, the absence of fever, a higher Charlson comorbidity score, higher blood urea nitrogen (BUN)/albumin ratios and lower alanine aminotransferase (ALT) levels were all predictors of long-term mortality. CONCLUSION Long-term mortality following hospitalization for CAP is high. Charlson score and lack of fever are potential indicators for decreased long-term survival. As novel parameters, baseline BUN/albumin ratios and ALT levels are significantly associated with late mortality. Further interventions and closer monitoring are necessary for such subgroups of patients.
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Affiliation(s)
- F Tokgoz Akyil
- Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Department of Chest Diseases, İstanbul, Turkey.
| | - M Yalcinsoy
- Inonu University, Faculty of Medicine, Department of Chest Diseases, Battalgazi/Malatya, Turkey
| | - A Hazar
- Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Department of Chest Diseases, İstanbul, Turkey
| | - A Cilli
- Akdeniz University, Faculty of Medicine, Department of Chest Diseases, Konyaaltı/Antalya, Turkey
| | - B Celenk
- Akdeniz University, Faculty of Medicine, Department of Chest Diseases, Konyaaltı/Antalya, Turkey
| | - O Kilic
- Dokuz Eylul University, Faculty of Medicine, Department of Chest Diseases, Konak/İzmir, Turkey
| | - A Sayiner
- Ege University, Faculty of Medicine, Department of Chest Diseases, Bornova/İzmir, Turkey
| | - N Kokturk
- Gazi University, Faculty of Medicine, Department of Chest Diseases, Yenimahalle/Ankara, Turkey
| | - A Sakar Coskun
- Celal Bayar University, Faculty of Medicine, Department of Chest Diseases, Yunusemre - Manisa, Turkey
| | - A Filiz
- Gaziantep University, Faculty of Medicine, Department of Chest Diseases, Şehitkamil/Gaziantep, Turkey
| | - E Cakir Edis
- Trakya University, Faculty of Medicine, Department of Chest Diseases, İskender Köyü/Edirne Merkez/Edirne, Turkey
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Uranga A, Quintana JM, Aguirre U, Artaraz A, Diez R, Pascual S, Ballaz A, España PP. Predicting 1-year mortality after hospitalization for community-acquired pneumonia. PLoS One 2018; 13:e0192750. [PMID: 29444151 PMCID: PMC5812619 DOI: 10.1371/journal.pone.0192750] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/30/2018] [Indexed: 12/27/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is a major public health problem with high short- and long-term mortality. The main aim of this study was to develop and validate a specific prognostic index for one-year mortality in patients admitted for CAP. Methods This was an observational, prospective study of adults aged ≥18 years admitted to Galdakao-Usansolo Hospital (Bizkaia, Spain) from January 2001 to July 2009 with a diagnosis of CAP surviving the first 15 days. The entire cohort was divided into two parts, in order to develop a one-year mortality predictive model in the derivation cohort, before validation using the second cohort. Results A total of 2351 patients were included and divided into a derivation and a validation cohort. After deaths within 15 days were excluded, one-year mortality was 10.63%. A predictive model was created in order to predict one-year mortality, with a weighted score that included: aged over 80 years (4 points), congestive heart failure (2 points), dementia (6 points), respiratory rate ≥30 breaths per minute (2 points) and blood urea nitrogen >30 mg/dL (3 points) as predictors of higher risk with C-index of 0.76. This new model showed better predictive ability than current risk scores, PSI, CURB65 and SCAP with C-index of 0.73, 0.69 and 0.70, respectively. Conclusions An easy-to-use score, called the one-year CAPSI, may be useful for identifying patients with a high probability of dying after an episode of CAP.
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Affiliation(s)
- Ane Uranga
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
- * E-mail:
| | - Jose M. Quintana
- Research Unit, Galdakao-Usansolo Hospital - Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain
| | - Urko Aguirre
- Research Unit, Galdakao-Usansolo Hospital - Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain
| | - Amaia Artaraz
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Rosa Diez
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Silvia Pascual
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Aitor Ballaz
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Pedro P. España
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
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Breitling LP, Saum KU, Schöttker B, Holleczek B, Herth FJ, Brenner H. Pneumonia in the Noninstitutionalized Older Population. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:607-614. [PMID: 27697144 DOI: 10.3238/arztebl.2016.0607] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 06/09/2016] [Accepted: 06/09/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pneumonia is a common and potentially serious disease, with an incidence of ca. 300 per 100 000 persons per year. Until now, there have been only a few population-based studies of risk factors for pneumonia. METHODS From 2000 to 2002, nearly 10 000 persons aged 50 to 75 were recruited into the prospective ESTHER cohort study while visiting their family physician for a check-up. The mean duration of follow-up was 10.6 years. Data on newly diagnosed pneumonia were acquired from the participants and their physicians by means of standardized questionnaires. Potential associations with various predictors were studied in survival-time regression models. RESULTS 435 participants had pneumonia at least once during follow-up. The cumulative 10-year-incidence was 4.5% (95% confidence interval [4.0; 4.9]). Multiple regression revealed that age (relative risk [RR]: 1.43 [1.22; 1.67] per 10 years), current cigarette smoking (RR: 1.56 [1.19; 2.05], compared with never having smoked), and known congestive heart failure (RR: 1.65 [1.24; 2.20]) were independently associated with an elevated risk of pneumonia. The risk was insignificantly elevated in persons with diabetes mellitus (RR: 1.29 [0.98; 1.68]). Alcohol consumption, obesity, stroke, and cancer were not associated with an elevated risk of pneumonia in age- and sex-adjusted analyses. CONCLUSION Pneumonia plays an important role in the medical care of non-institutionalized older people. With the aid of the predictors identified in this study, primary care physicians can identify patients at risk, smokers can gain additional motivation to quit, treatment compliance can be increased, and patients may become more willing to be vaccinated as recommended in the current guidelines.
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Affiliation(s)
- Lutz P Breitling
- Division of Clinical Epidemiology and Aging Research and Division of Preventive Oncology, German Cancer Research Center (DKFZ), Heidelberg, Pneumology and Respiratory Critical Care Medicine, Thorax Clinic at Heidelberg University Hospital:, Heidelberg, Network Aging Research (NAR), University of Heidelberg, Heidelberg, Saarland Cancer Registry, Saarbrücken, Translational Lung Research Center, Universität Heidelberg, Heidelberg
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Welte T, Pletz M. Pneumonia and the Risk of Cardiovascular Death. Time to Change Our Strategy. Am J Respir Crit Care Med 2017; 196:541-543. [PMID: 28723315 DOI: 10.1164/rccm.201707-1421ed] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Tobias Welte
- 1 Department of Respiratory Medicine Medizinische Hochschule Hannover, Member of the German Center of Lung Research Hannover, Germany and
| | - Mathias Pletz
- 2 Center for Infectious Diseases and Infection Control Jena University Hospital Jena, Germany
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Kolditz M, Ewig S. Community-Acquired Pneumonia in Adults. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:838-848. [PMID: 29271341 PMCID: PMC5754574 DOI: 10.3238/arztebl.2017.0838] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 01/29/2017] [Accepted: 04/13/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND The clinical spectrum of community-acquired pneumonia ranges from infections that can be treated on an outpatient basis, with 1% mortality, to those that present as medical emergencies, with a mortality above 40%. METHODS This article is based on pertinent publications and current guidelines retrieved by a selective search of the literature. RESULTS The radiological demonstration of an infiltrate is required for the differentiation of pneumonia from acute bronchitis regardless of whether the patient is seen in the outpatient setting or in the emergency room. For risk prediction, it is recommended that the CRB-65 criteria, unstable comorbidities, and oxygenation should be taken into account. Amoxicillin is the drug of choice for mild pneumonia; it should be given in combination with clavulanic acid if there are any comorbid illnesses. The main clinical concerns in the emergency room are the identification of acute organ dysfunction and the management of sepsis. Intravenous beta-lactam antibiotics should be given initially, in combination with a macrolide if acute organ dysfunction is present. The treatment should be continued for 5-7 days. Cardiovascular complications worsen the patient's prognosis and should be meticulously watched for. Structured followup care includes the follow-up of comorbid conditions and the initiation of recommended preventive measures such as antipneumococcal and anti-influenza vaccination, the avoidance of drugs that increase the risk, smoking cessation, and treatment of dysphagia, if present. CONCLUSION Major considerations include appropriate risk stratification and the implementation of a management strategy adapted to the degree of severity of the disease, along with the establishment of structured follow-up care and secondary prevention, especially for patients with comorbidities.
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Affiliation(s)
- Martin Kolditz
- Department of Respiratory Diseases, University Hospital Carl Gustav Carus, Dresden
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, EVK Herne and Augusta-Kranken-Anstalt Bochum, Departments of Respiratory and Infectious Diseases, Bochum
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Hadfield J, Bennett L. Determining best outcomes from community-acquired pneumonia and how to achieve them. Respirology 2017; 23:138-147. [PMID: 29150897 DOI: 10.1111/resp.13218] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 10/12/2017] [Accepted: 10/19/2017] [Indexed: 12/12/2022]
Abstract
Community-acquired pneumonia (CAP) is a common acute medical illness with a standard, effective treatment that was introduced before the evidenced-based medicine era. Mortality rates have improved in recent decades but improvements have been minimal when compared to other conditions such as acute coronary syndromes. The standardized approach to treatment makes CAP a target for comparative performance and outcome measures. While easy to collect, simplistic outcomes such as mortality, readmission and length of stay are difficult to interpret as they can be affected by subjective choices and health care resources. Proposed clinical- and patient-reported outcomes are discussed below and include measures such as the time to clinical stability (TTCS) and patient satisfaction, which can be compared between health institutions. Strategies to improve these outcomes include use of a risk stratification tool, local antimicrobial guidelines with antibiotic stewardship and care bundles to include early administration of antibiotics and early mobilization.
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Affiliation(s)
- Jane Hadfield
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Lesley Bennett
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, WA, Australia
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Gorelik O, Tzur I, Barchel D, Almoznino-Sarafian D, Swarka M, Beberashvili I, Feldman L, Cohen N, Izhakian S. A rise in mean platelet volume during hospitalization for community-acquired pneumonia predicts poor prognosis: a retrospective observational cohort study. BMC Pulm Med 2017; 17:137. [PMID: 29084523 PMCID: PMC5663044 DOI: 10.1186/s12890-017-0483-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 10/26/2017] [Indexed: 12/27/2022] Open
Abstract
Background Clinical characteristics and the prognostic significance of changes in mean platelet volume (MPV) during hospitalization for community-acquired pneumonia (CAP) have not been investigated. Methods Among 976 adults hospitalized for CAP, clinical characteristics, in-hospital outcomes (transfer to the intensive care unit, treatment with mechanical ventilation, prolonged hospital stay and death), and all-cause mortality following discharge, were compared according to ΔMPV (MPV on discharge minus MPV on admission): groups A (no rising MPV, ΔMPV < 0.6 fL) and B (rising MPV, ΔMPV ≥ 0.6 fL). Results Groups A and B comprised 83.8% and 16.2% of patients, respectively. Patients with a rise in MPV were more likely to be older, and to present with renal dysfunction, cerebrovascular disorder and severe pneumonia than were patients with no rise in MPV. On discharge, lower values of platelets and higher levels of neutrophils were observed in group B. Rising MPV strongly predicted a need for mechanical ventilation and in-hospital death (the respective relative risks: 2.62 and 6.79; 95% confidence intervals: 1.54–4.45 and 3.48–13.20). The respective 90-day, 3-year and total (median follow-up of 54 months) mortality rates were significantly higher in group B (29.1%, 43.0% and 50.0%) than group A (7.3%, 24.2% and 32.6%), p < 0.001 for all comparisons. A rise in MPV was a powerful predictor of all-cause mortality (relative risk 1.26 and 95% confidence interval 1.11–1.43). Conclusions Rising MPV during hospitalization for CAP is associated with a more severe clinical profile than no rise in MPV. A rise in MPV strongly predicts in-hospital and long-term mortality.
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Affiliation(s)
- Oleg Gorelik
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel.
| | - Irma Tzur
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Dana Barchel
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Dorit Almoznino-Sarafian
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Muhareb Swarka
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Ilia Beberashvili
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Leonid Feldman
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Natan Cohen
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Shimon Izhakian
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
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Arnold FW. How Antibiotics Should be Prescribed to Hospitalized Elderly Patients with Community-Acquired Pneumonia. Drugs Aging 2017; 34:13-20. [PMID: 27928779 DOI: 10.1007/s40266-016-0423-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Elderly patients hospitalized with community-acquired pneumonia (CAP) should be administered antimicrobials in the emergency department prior to transfer to the ward or intensive care unit (ICU). For ward patients, a β-lactam with a macrolide or a respiratory fluoroquinolone alone should be given to cover typical and atypical pathogens. For ICU patients, a β-lactam with either a macrolide or a fluoroquinolone should be given. Other regimens are indicated if methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa is a concern. Patients who are hemodynamically stable and can tolerate oral intake can be considered for switch therapy as well as discharge if other co-morbidities are stable and a safe disposition plan exists. A number of special concerns for the elderly include noting adverse effects from antimicrobials, being watchful of comorbidity exacerbations, and vaccinating for pneumococcus and influenza.
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Affiliation(s)
- Forest W Arnold
- Division of Infectious Diseases, School of Medicine, University of Louisville, 501 E. Broadway, Suite 140 B, Louisville, KY, 40202, USA.
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Viglianti EM, Prescott HC, Liu V, Escobar GJ, Iwashyna TJ. Individual and health system variation in rehospitalizations the year after pneumonia. Medicine (Baltimore) 2017; 96:e7695. [PMID: 28767603 PMCID: PMC5626157 DOI: 10.1097/md.0000000000007695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Little is known about variation in patterns of recovery among patients discharged alive from hospitalizations for pneumonia.The aim of the is observational cohort study was to characterize the variation in patterns of hospital readmission and survival in the year after discharge for pneumonia in 3 different health systems.The 3 cohorts consisted of (1) the Health and Retirement Study participants enrolled in Fee-for-service Medicare (FFS), (2) Veterans Administration (VA) Healthcare system, and (3) Kaiser Permanente of Northern California (KPNC). The 365-day survival and re-hospitalizations were determined for each cohort. Multinomial logistic regression was used to identify potential contributors to the different patterns.We identified 2731, 23,536, and 39,147 hospitalizations for pneumonia in FFS Medicare, VA, and KPNC, respectively, of whom 88.1%, 92.8%, and 89.7% survived to hospital discharge. The median patient survived to 1 year and was rehospitalized twice in FFS (9.0%), once in VA (14.1%) and KPNC (9.1%). Of the patients who survived the hospitalization, 33.3% (FFS), 30.2% (VA), and 26.8% (KPNC) died during the subsequent year. Of those who survived, 29.8% (FFS), 35.9% (VA), and 46.1% (KPNC) were never rehospitalized. 11.9% (FFS), 11.9% (VA), and 11.7% (KPNC) had greater than 3 hospitalizations. Age, race, gender, comorbidity, ICU use, and hospital length stay collectively explained little (5-7%) of the variation in the recovery pattern.There is significant variation in the year after the hospitalization for pneumonia across individuals, but less so across health systems. There may be important opportunities to better classify these heterogeneous individual-level pathways.
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Affiliation(s)
| | - Hallie C. Prescott
- Department of Internal Medicine, University of Michigan
- Veterans Affairs Center for Clinical Management Research, HSR&D Center for Excellence, Ann Arbor, MI
| | - Vincent Liu
- Kaiser Permanente Division of Research, Oakland, CA
| | | | - Theodore J. Iwashyna
- Department of Internal Medicine, University of Michigan
- Veterans Affairs Center for Clinical Management Research, HSR&D Center for Excellence, Ann Arbor, MI
- Institute for Social Research, Ann Arbor, MI
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Ramirez JA, Wiemken TL, Peyrani P, Arnold FW, Kelley R, Mattingly WA, Nakamatsu R, Pena S, Guinn BE, Furmanek SP, Persaud AK, Raghuram A, Fernandez F, Beavin L, Bosson R, Fernandez-Botran R, Cavallazzi R, Bordon J, Valdivieso C, Schulte J, Carrico RM. Adults Hospitalized With Pneumonia in the United States: Incidence, Epidemiology, and Mortality. Clin Infect Dis 2017; 65:1806-1812. [DOI: 10.1093/cid/cix647] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/25/2017] [Indexed: 12/26/2022] Open
Affiliation(s)
| | | | - Paula Peyrani
- Department of Medicine, Division of Infectious Diseases
| | | | - Robert Kelley
- Department of Medicine, Division of Infectious Diseases
| | | | | | - Senen Pena
- Department of Medicine, Division of Infectious Diseases
| | - Brian E Guinn
- Department of Medicine, Division of Infectious Diseases
| | | | | | | | | | - Leslie Beavin
- Department of Medicine, Division of Infectious Diseases
| | - Rahel Bosson
- Department of Medicine, Division of Infectious Diseases
| | | | - Rodrigo Cavallazzi
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, Kentucky
| | - Jose Bordon
- Infectious Diseases, Providence Hospital, Washington, District of Columbia
| | | | - Joann Schulte
- Louisville Metro Department of Public Health and Wellness, Kentucky
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Wootton DG, Dickinson L, Pertinez H, Court J, Eneje O, Keogan L, Macfarlane L, Wilks S, Gallagher J, Woodhead M, Gordon SB, Diggle PJ. A longitudinal modelling study estimates acute symptoms of community acquired pneumonia recover to baseline by 10 days. Eur Respir J 2017; 49:49/6/1602170. [PMID: 28619956 PMCID: PMC5898948 DOI: 10.1183/13993003.02170-2016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 02/22/2017] [Indexed: 12/14/2022]
Abstract
Our aims were to address three fundamental questions relating to the symptoms of community-acquired pneumonia (CAP): Do patients completely recover from pneumonia symptoms? How long does this recovery take? Which factors influence symptomatic recovery? We prospectively recruited patients at two hospitals in Liverpool, UK, into a longitudinal, observational cohort study and modelled symptom recovery from CAP. We excluded patients with cancer, immunosuppression or advanced dementia, and those who were intubated or palliated from admission. We derived a statistical model to describe symptom patterns. We recruited 169 (52% male) adults. Multivariable analysis demonstrated that the time taken to recover to baseline was determined by the initial severity of symptoms. Severity of symptoms was associated with comorbidity and was inversely related to age. The pattern of symptom recovery was exponential and most patients’ symptoms returned to baseline by 10 days. These results will inform the advice given to patients regarding the resolution of their symptoms. The recovery model described here will facilitate the use of symptom recovery as an outcome measure in future clinical trials. Severity of CAP symptoms is inversely related to age and resolution to baseline symptoms takes on average 10 dayshttp://ow.ly/dV0h30befE3
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Affiliation(s)
- Daniel G Wootton
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK .,Dept of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Laura Dickinson
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Henry Pertinez
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joanne Court
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Odiri Eneje
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Lynne Keogan
- Dept of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Laura Macfarlane
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Sarah Wilks
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Mark Woodhead
- Dept of Respiratory Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.,Manchester Academic Health Science Centre and Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Stephen B Gordon
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK.,The Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Peter J Diggle
- CHICAS, Lancaster University Medical School, Lancaster University, Lancaster, UK
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63
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Waterer G. Recovery from community acquired pneumonia: the view from the top of the iceberg. Eur Respir J 2017; 49:49/6/1700571. [DOI: 10.1183/13993003.00571-2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 03/20/2017] [Indexed: 11/05/2022]
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Research in community-acquired pneumonia: the next steps. Intensive Care Med 2017; 43:1395-1397. [PMID: 28421245 PMCID: PMC7095202 DOI: 10.1007/s00134-017-4774-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/11/2017] [Indexed: 12/23/2022]
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Eurich DT, Marrie TJ, Minhas-Sandhu JK, Majumdar SR. Risk of heart failure after community acquired pneumonia: prospective controlled study with 10 years of follow-up. BMJ 2017; 356:j413. [PMID: 28193610 PMCID: PMC5421448 DOI: 10.1136/bmj.j413] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective To determine the attributable risk of community acquired pneumonia on incidence of heart failure throughout the age range of affected patients and severity of the infection.Design Cohort study.Setting Six hospitals and seven emergency departments in Edmonton, Alberta, Canada, 2000-02.Participants 4988 adults with community acquired pneumonia and no history of heart failure were prospectively recruited and matched on age, sex, and setting of treatment (inpatient or outpatient) with up to five adults without pneumonia (controls) or prevalent heart failure (n=23 060).Main outcome measures Risk of hospital admission for incident heart failure or a combined endpoint of heart failure or death up to 2012, evaluated using multivariable Cox proportional hazards analyses.Results The average age of participants was 55 years, 2649 (53.1%) were men, and 63.4% were managed as outpatients. Over a median of 9.9 years (interquartile range 5.9-10.6), 11.9% (n=592) of patients with pneumonia had incident heart failure compared with 7.4% (n=1712) of controls (adjusted hazard ratio 1.61, 95% confidence interval 1.44 to 1.81). Patients with pneumonia aged 65 or less had the lowest absolute increase (but greatest relative risk) of heart failure compared with controls (4.8% v 2.2%; adjusted hazard ratio 1.98, 95% confidence interval 1.5 to 2.53), whereas patients with pneumonia aged more than 65 years had the highest absolute increase (but lowest relative risk) of heart failure (24.8% v 18.9%; adjusted hazard ratio 1.55, 1.36 to 1.77). Results were consistent in the short term (90 days) and intermediate term (one year) and whether patients were treated in hospital or as outpatients.Conclusion Our results show that community acquired pneumonia substantially increases the risk of heart failure across the age and severity range of cases. This should be considered when formulating post-discharge care plans and preventive strategies, and assessing downstream episodes of dyspnoea.
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Affiliation(s)
- Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
- ACHORD, 2-040 Li Ka Shing Center, University of Alberta, Edmonton, Alberta, Canada, T6G 2E1
| | - Thomas J Marrie
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Sumit R Majumdar
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
- ACHORD, 2-040 Li Ka Shing Center, University of Alberta, Edmonton, Alberta, Canada, T6G 2E1
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Baldo V, Cocchio S, Gallo T, Furlan P, Romor P, Bertoncello C, Buja A, Baldovin T. Pneumococcal Conjugated Vaccine Reduces the High Mortality for Community-Acquired Pneumonia in the Elderly: an Italian Regional Experience. PLoS One 2016; 11:e0166637. [PMID: 27846277 PMCID: PMC5112912 DOI: 10.1371/journal.pone.0166637] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/01/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is an important cause of illness and death worldwide, particularly among the elderly. Previous studies on the factors associated with mortality in patients hospitalized for CAP revealed a direct association between the type of microorganism involved, the characteristics of the patient and mortality. Vaccination status against pneumococcal disease was not considered. We conducted a retrospective analysis on the mortality rates after a first hospitalization for CAP in north-east Italy with a view to examining especially the role of anti-pneumococcal vaccination as a factor associated with pneumonia-related mortality at one year. METHOD Between 2012-2013, patients aged 65+ hospitalized with a primary diagnosis of CAP, identified based on International Classification of Diseases, Ninth Revision, Clinical Modification codes 481-486, were enrolled in the study only once. Patients were divided into three groups by pneumococcal vaccination status: 1) 13-valent pneumococcal conjugate vaccine (PCV13) prior to their hospitalization; 2) 23-valent pneumococcal polysaccharide vaccine (PPV23) within 5 years before hospitalization and 3) unvaccinated or PPV23 more than 5 years prior to admission. Gender, age, length of hospital stay and influenza vaccination were considered. Comorbidities were ascertained by means of a properly coded diagnosis. Every patient was followed up for 1 year and the outcome investigated was mortality for any cause and for pneumonia. RESULTS A total of 4,030 patient were included in the study; mean age at the time of admission to hospital was 84.3±7.7; 50.9% were female. 74.2% of subjects had at least one comorbidity; 73.7% has been vaccinated against influenza. Regard to pneumococcal vaccine, 80.4% of patients were not vaccinated, 14.5% vaccinated with PPV23 and 5.1% with PCV13. The 1-year survival rates after hospitalization for pneumonia were 83.6%, 85.9% and 89.3% in the unvaccinated, PPV23 and PCV13 groups, respectively. Regression analysis indicated that the risk of death due to pneumonia increased significantly with age (adjusted OR: 1.073; 1.061-1.085), shorter hospital stay (adjusted OR: 0.981; 0.971-0.990), and male gender (adjusted OR: 1.372; 1.165-1.616). The model also confirmed the pneumococcal 13-valent conjugated vaccine as an independent protective factor for mortality-related pneumonia (adjusted OR: 0.599; 0.390-0.921). CONCLUSION The main finding of our observational cohort study is a high mortality rate among elderly patients admitted to hospital for pneumonia. The present study suggests a protective role for PCV13 vaccination.
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Affiliation(s)
- Vincenzo Baldo
- Department of Cardiac, Thoracic, and Vascular Sciences, Hygiene and Public Health Unit, University of Padua, Padua, Italy
| | - Silvia Cocchio
- Department of Cardiac, Thoracic, and Vascular Sciences, Hygiene and Public Health Unit, University of Padua, Padua, Italy
| | - Tolinda Gallo
- EuroHealth Net, Friuli Venezia Giulia Region Health Directorate, Udine, Italy
| | - Patrizia Furlan
- Department of Cardiac, Thoracic, and Vascular Sciences, Hygiene and Public Health Unit, University of Padua, Padua, Italy
| | - Pierantonio Romor
- EuroHealth Net, Friuli Venezia Giulia Region Health Directorate, Udine, Italy
| | - Chiara Bertoncello
- Department of Cardiac, Thoracic, and Vascular Sciences, Hygiene and Public Health Unit, University of Padua, Padua, Italy
| | - Alessandra Buja
- Department of Cardiac, Thoracic, and Vascular Sciences, Hygiene and Public Health Unit, University of Padua, Padua, Italy
| | - Tatjana Baldovin
- Department of Cardiac, Thoracic, and Vascular Sciences, Hygiene and Public Health Unit, University of Padua, Padua, Italy
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Cilloniz C, Ceccato A, San Jose A, Torres A. Clinical management of community acquired pneumonia in the elderly patient. Expert Rev Respir Med 2016; 10:1211-1220. [DOI: 10.1080/17476348.2016.1240037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Risk factors for the severity and mortality of pneumococcal pneumonia: Importance of premorbid patients' performance status. J Infect Chemother 2016; 22:685-91. [DOI: 10.1016/j.jiac.2016.07.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/02/2016] [Accepted: 07/11/2016] [Indexed: 11/15/2022]
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Gorelik O, Izhakian S, Barchel D, Almoznino-Sarafian D, Tzur I, Swarka M, Beberashvili I, Feldman L, Cohen N, Shteinshnaider M. Changes in Red Cell Distribution Width During Hospitalization for Community-Acquired Pneumonia: Clinical Characteristics and Prognostic Significance. Lung 2016; 194:985-995. [PMID: 27650510 DOI: 10.1007/s00408-016-9942-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 09/12/2016] [Indexed: 01/04/2023]
Abstract
PURPOSE We investigated outcomes of patients hospitalized with community-acquired pneumonia (CAP) according to the changes in red cell distribution width (RDW). METHODS For 980 adults, clinical characteristics, outcomes during hospitalization for CAP (transfer to the intensive care unit, treatment with mechanical ventilation, prolonged hospital stay, and death), and all-cause mortality following discharge were compared: according to RDW changes versus stable RDW during hospitalization, and according to normal (≤14.7 %) versus high (>14.7 %) RDW values on admission/discharge. RESULTS RDW changes (n = 386) during hospitalization were associated with more severe clinical and laboratory characteristics than stable RDW (n = 594). Changes in RDW strongly predicted poor in-hospital outcomes (p < 0.001). The respective 30, 90-day, and total (median follow-up 54 months) mortality rates were significantly higher (9.8, 16.0 and 43.5 %) among patients with RDW changes, compared to 4.0, 7.6 and 30.5 % among those with stable RDW (p < 0.001 for all comparisons). RDW changes, as well as high RDW (each 1 % increment) on admission and discharge, were powerful predictors of mortality (the respective relative risks 1.41, 1.13, and 1.15, and 95 % confidence intervals 1.13-1.74, 1.08-1.19, and 1.10-1.21). CONCLUSIONS RDW changes during hospitalization for CAP are common and associated with a severe clinical profile. Time-dependent RDW changes strongly predict poor in-hospital outcomes and increased short- and long-term mortality. Repeated RDW determinations during hospitalization for CAP may provide useful prognostic information.
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Affiliation(s)
- Oleg Gorelik
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
| | - Shimon Izhakian
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Dana Barchel
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Dorit Almoznino-Sarafian
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Irma Tzur
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Muhareb Swarka
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Ilia Beberashvili
- Nephrology Division, Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Leonid Feldman
- Nephrology Division, Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Natan Cohen
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Miriam Shteinshnaider
- Department of Internal Medicine "F", Assaf Harofeh Medical Center, 70300, Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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Horita N, Otsuka T, Haranaga S, Namkoong H, Miki M, Miyashita N, Higa F, Takahashi H, Yoshida M, Kohno S, Kaneko T. Beta-lactam plus macrolides or beta-lactam alone for community-acquired pneumonia: A systematic review and meta-analysis. Respirology 2016; 21:1193-200. [PMID: 27338144 DOI: 10.1111/resp.12835] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 03/10/2016] [Accepted: 03/11/2016] [Indexed: 02/05/2023]
Abstract
It is unclear whether in the treatment of community-acquired pneumonia (CAP) beta-lactam plus macrolide antibiotics lead to better survival than beta-lactam alone. We report a systematic review and meta-analysis. Trials and observational studies published in English were included, if they provided sufficient data on odds ratio for all-cause mortality for a beta-lactam plus macrolide regimen compared with beta-lactam alone. Two investigators independently searched for eligible articles. Of 514 articles screened, 14 were included: two open-label randomized controlled trials (RCTs) comprising 1975 patients, one non-RCT interventional study comprising 1011 patients and 11 observational studies comprising 33 332 patients. Random-model meta-analysis yielded an odds ratio for all-cause death for beta-lactam plus macrolide compared with beta-lactam alone of 0.80 (95% CI 0.69-0.92, P = 0.002) with substantial heterogeneity (I(2) = 59%, P for heterogeneity = 0.002). Severity-based subgroup analysis and meta-regression revealed that adding macrolide had a favourable effect on mortality only for severe CAP. Of the two RCTs, one suggested that macrolide plus beta-lactam lead to better outcome compared with beta-lactam alone, while the other did not. Subgrouping based on study design, that is, RCT versus non-RCT, which was almost identical to subgrouping based on severity, revealed substantial inter-subgroup heterogeneity. Compared with beta-lactam alone, beta-lactam plus macrolide may decrease all-cause death only for severe CAP. However, this conclusion is tentative because this was based mainly on observational studies.
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Affiliation(s)
- Nobuyuki Horita
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Tatsuya Otsuka
- Department of Pulmonology, Tohoku Rosai Hospital, Sendai, Japan
| | - Shusaku Haranaga
- Department of Infectious Diseases, Respiratory and Digestive Medicine, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Ho Namkoong
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Miki
- Department of Respiratory Medicine, Japanese Red Cross Sendai Hospital, Sendai, Japan
| | - Naoyuki Miyashita
- Department of Internal Medicine I, Kawasaki Medical School, Okayama, Japan
| | - Futoshi Higa
- National Hospital Organization Okinawa National Hospital, Okinawa, Japan
| | - Hiroshi Takahashi
- Department of Respiratory Medicine, Saka General Hospital, Miyagi, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Chemotheraphy Research Institute, International University of Health and Welfare, Ichikawa, Japan
| | - Shigeru Kohno
- Department of Molecular Microbiology and Immunology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Chalmers JD, Campling J, Dicker A, Woodhead M, Madhava H. A systematic review of the burden of vaccine preventable pneumococcal disease in UK adults. BMC Pulm Med 2016; 16:77. [PMID: 27169895 PMCID: PMC4864929 DOI: 10.1186/s12890-016-0242-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/01/2016] [Indexed: 11/15/2022] Open
Abstract
Background Invasive pneumococcal disease (IPD) and pneumococcal pneumonia are common and carry a significant morbidity and mortality. Current strategies to prevent pneumococcal disease are under review in the United Kingdom (UK). We conducted a systematic review to evaluate the burden of vaccine type adult pneumococcal disease specifically in the UK. Methods A systematic review conducted and reported according to MOOSE guidelines. Relevant studies from 1990 to 2015 were included. The primary outcome was the incidence of vaccine type pneumococcal disease, focussing on the pneumococcal polysaccharide vaccine (PPSV), the 13-valent conjugate vaccine (PCV13) and the 7-valent conjugate vaccine (PCV7). Results Data from surveillance in England and Wales from 2013/14 shows an incidence of 6.85 per 100,000 population across all adult age groups for IPD, and an incidence of 20.58 per 100,000 population in those aged >65 years. The corresponding incidences for PCV13 serotype IPD were 1.4 per 100,000 and 3.72 per 100,000. The most recent available data for community-acquired pneumonia (CAP) including non-invasive disease showed an incidence of 20.6 per 100,000 for adult pneumococcal CAP and 8.6 per 100,000 population for PCV13 serotype CAP. Both IPD and CAP data sources in the UK suggest an ongoing herd protection effect from childhood PCV13 vaccination causing a reduction in the proportion of cases caused by PCV13 serotypes in adults. Despite this, applying the incidence rates to UK population estimates suggests more than 4000 patients annually will be hospitalised with PCV13 serotype CAP and more than 900 will be affected by IPD, although with a trend for these numbers to decrease over time. There was limited recent data on serotype distribution in high risk groups such as those with chronic respiratory or cardiac disease and no data available for vaccine type (VT) CAP managed in the community where there is likely to be a considerable unmeasured burden. Conclusion The most recent available data suggests that VT pneumococcal disease continues to have a high burden in UK adults despite the impact of childhood PCV13 vaccination. IPD estimates represent only a fraction of the total burden of pneumococcal disease. Study registration PROSPERO CRD42015025043 Electronic supplementary material The online version of this article (doi:10.1186/s12890-016-0242-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Alison Dicker
- School of Medicine, University of Dundee, Dundee, DD1 9SY, UK
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Egger ME, Myers JA, Arnold FW, Pass LA, Ramirez JA, Brock GN. Cost effectiveness of adherence to IDSA/ATS guidelines in elderly patients hospitalized for Community-Aquired Pneumonia. BMC Med Inform Decis Mak 2016; 16:34. [PMID: 26976388 PMCID: PMC4791973 DOI: 10.1186/s12911-016-0270-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 02/29/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Adherence to guidelines for the treatment of hospitalized elderly patients with community-acquired pneumonia (CAP) has been associated with improved clinical outcomes. This study evaluated the cost-effectiveness of adherence to guidelines for the treatment of CAP in an elderly hospitalized patient cohort. METHODS Data from an international, multicenter observational study for patients age 65 years or older hospitalized with CAP from 2001 to 2007 were used to estimate transition probabilities for a multi-state Markov model traversing multiple health states during hospitalization for CAP. Empiric antibiotic therapy was classified as adherent, over-treated, and under-treated according to 2007 Infectious Disease Society of America/American Thoracic Society IDSA/ATS guidelines. Utilities were estimated from an expert panel of active clinicians. Costs were estimated from a tertiary referral hospital and adjusted for inflation to 2013 US dollars. Costs, utilities, and transition probabilities were all modeled using probability distributions to handle their inherit uncertainty. Cost-effectiveness analysis was based on the first 14 days of hospitalization. Patients admitted to the intensive care unit (ICU) were analyzed separately from those admitted to the ward. Sensitivity analyses with regards to time frame (out to 30 days hospitalization), cost estimates, and willingness to pay values were performed. RESULTS The model parameters were estimated using data from 1635 patients (1438 admitted to the ward and 197 admitted to the ICU). For the ward model, adherence to antibiotic guidelines was the dominant strategy and associated with lower costs (-$1379 and -$799) and improved quality of life compared to over- and under-treatment. In the ICU model, however, adherence to guidelines was associated with greater costs (+$13,854 and + $3461 vs. over- and under-treatment, respectively) and lower quality of life. Acceptance rates across the willingness to pay ranges evaluated were 42-48 % for guideline adherence on the ward and 61-64 % for over-treatment on the ICU. Results were robust over sensitivity analyses concerning cost and utility estimates. CONCLUSIONS While adherence to antibiotic guidelines was the most cost-effective strategy for elderly patients hospitalized with CAP and admitted to the ward, in the ICU over-treatment of patients relative to the guidelines was the most cost-effective strategy.
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Affiliation(s)
- Michael E. Egger
- />The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville, School of Medicine, Louisville, KY USA
- />Present Affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - John A. Myers
- />Department of Pediatrics, University of Louisville, School of Medicine, Louisville, KY USA
| | - Forest W. Arnold
- />Department of Medicine, Division of Infectious Diseases, University of Louisville, School of Medicine, Louisville, KY USA
| | - Leigh Ann Pass
- />Pharmacy Department, University of Louisville Health Care, Louisville, KY USA
| | - Julio A. Ramirez
- />Department of Medicine, Division of Infectious Diseases, University of Louisville, School of Medicine, Louisville, KY USA
| | - Guy N. Brock
- />Department of Bioinformatics and Biostatistics, University of Louisville, School of Public Health, Louisville, KY USA
- />Present Affiliation: Department of Biomedical Informatics, The Ohio State University, College of Medicine, Columbus, OH USA
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Welte T. Pneumococcal Conjugate Vaccine--Equally Effective for Everyone? DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:137-8. [PMID: 26987461 DOI: 10.3238/arztebl.2016.0137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School
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Holter JC, Ueland T, Jenum PA, Müller F, Brunborg C, Frøland SS, Aukrust P, Husebye E, Heggelund L. Risk Factors for Long-Term Mortality after Hospitalization for Community-Acquired Pneumonia: A 5-Year Prospective Follow-Up Study. PLoS One 2016; 11:e0148741. [PMID: 26849359 PMCID: PMC4746118 DOI: 10.1371/journal.pone.0148741] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 01/22/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Contributors to long-term mortality in patients with community-acquired pneumonia (CAP) remain unclear, with little attention paid to pneumonia etiology. We examined long-term survival, causes of death, and risk factors for long-term mortality in adult patients who had been hospitalized for CAP, with emphasis on demographic, clinical, laboratory, and microbiological characteristics. METHODS Two hundred and sixty-seven consecutive patients admitted in 2008-2011 to a general hospital with CAP were prospectively recruited and followed up. Patients who died during hospital stay were excluded. Demographic, clinical, and laboratory data were collected within 48 hours of admission. Extensive microbiological work-up was performed to establish the etiology of CAP in 63% of patients. Mortality data were obtained from the Norwegian Cause of Death Registry. Cox regression models were used to identify independent risk factors for all-cause mortality. RESULTS Of 259 hospital survivors of CAP (median age 66 years), 79 (30.5%) died over a median of 1,804 days (range 1-2,520 days). Cumulative 5-year survival rate was 72.9% (95% CI 67.4-78.4%). Standardized mortality ratio was 2.90 for men and 2.05 for women. The main causes of death were chronic obstructive pulmonary disease (COPD), vascular diseases, and malignancy. Independent risk factors for death were the following (hazard ratio, 95% CI): age (1.83 per decade, 1.47-2.28), cardiovascular disease (2.63, 1.61-4.32), COPD (2.09, 1.27-3.45), immunocompromization (1.98, 1.17-3.37), and low serum albumin level at admission (0.75 per 5 g/L higher, 0.58-0.96), whereas active smoking was protective (0.32, 0.14-0.74); active smokers were younger than non-smokers (P < 0.001). Microbial etiology did not predict mortality. CONCLUSIONS Results largely confirm substantial comorbidity-related 5-year mortality after hospitalization for CAP and the impact of several well-known risk factors for death, and extend previous findings on the prognostic value of serum albumin level at hospital admission. Pneumonia etiology had no prognostic value, but this remains to be substantiated by further studies using extensive diagnostic microbiological methods in the identification of causative agents of CAP.
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Affiliation(s)
- Jan C. Holter
- Department of Internal Medicine, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- * E-mail:
| | - Thor Ueland
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- K.G. Jebsen Inflammatory Research Center, University of Oslo, Oslo, Norway
| | - Pål A. Jenum
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medical Microbiology, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Fredrik Müller
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Microbiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Cathrine Brunborg
- Oslo Center of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Stig S. Frøland
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- K.G. Jebsen Inflammatory Research Center, University of Oslo, Oslo, Norway
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Einar Husebye
- Department of Internal Medicine, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Heggelund
- Department of Internal Medicine, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Grijalva CG. Is Pneumonia a Risk Factor or a Risk Marker for Long-Term Mortality? Am J Respir Crit Care Med 2015; 192:532-4. [PMID: 26325152 DOI: 10.1164/rccm.201506-1171ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Carlos G Grijalva
- 1 Department of Health Policy Vanderbilt University School of Medicine Nashville, Tennessee and.,2 Geriatric Research Education Clinical Center VA Tennessee Valley Nashville, Tennessee
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Clinical News. Br J Hosp Med (Lond) 2015. [DOI: 10.12968/hmed.2015.76.7.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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