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Hamilton F, Arnold D, Henley W, Payne RA. Aspirin reduces cardiovascular events in patients with pneumonia: a prior event rate ratio analysis in a large primary care database. Eur Respir J 2020; 57:13993003.02795-2020. [PMID: 32943408 DOI: 10.1183/13993003.02795-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/24/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ischaemic stroke and myocardial infarction (MI) are common after pneumonia and are associated with long-term mortality. Aspirin may attenuate this risk and should be explored as a therapeutic option. METHODS We extracted all patients with pneumonia (aged over 50 years) from the Clinical Practice Research Datalink (CPRD), a large UK primary care database, from inception until January 2019. We then performed a prior event rate ratio (PERR) analysis with propensity score matching (PSM), an approach that allows for control of measured and unmeasured confounding, with aspirin usage as the exposure and ischaemic events as the outcome. The primary outcome was the combined outcome of ischaemic stroke and MI. Secondary outcomes were ischaemic stroke and MI individually. Relevant confounders (smoking, comorbidities, age and gender) were included in the analysis. FINDINGS 48 743 patients were eligible for matching. Of these, 9864 were aspirin users who were matched to 9864 non-users. Aspirin users had a reduced risk of the primary outcome (adjusted hazard ratio 0.64, 95% CI 0.52-0.79) in the PERR analysis. For both secondary outcomes, aspirin use was also associated with a reduced risk for MI (hazard ratio 0.46, 95% CI 0.30-0.72) and stroke (hazard ratio 0.70, 95% CI 0.55-0.91), respectively. INTERPRETATION This study provides supporting evidence that aspirin use is associated with reduced ischaemic events after pneumonia in a primary care setting. This drug may have a future clinical role in preventing this important complication.
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Affiliation(s)
- Fergus Hamilton
- Centre for Academic Primary Care, University of Bristol, Bristol, UK.,Department of Infection Science, Southmead Hospital, Bristol, UK
| | - David Arnold
- Academic Respiratory Unit, Southmead Hospital, Bristol, UK.,Translational Health Sciences, University of Bristol, Bristol, UK
| | - William Henley
- Health Statistics Group, University of Exeter, Exeter, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Kurtaran B, Kuscu F, Korkmaz P, Ozdemir B, Inan D, Oztoprak N, Ozatag DM, Daglı O, Birengel S, Ozdemir K. A snapshot of geriatric infections in Turkey: ratio of geriatric inpatients in hospitals and evaluation of their infectious diseases: A multicenter point prevalence study. Int J Infect Dis 2020; 100:337-342. [PMID: 32835788 DOI: 10.1016/j.ijid.2020.08.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The human population is aging at an astonishing rate. The aim of this study is to capture a situation snapshot revealing the proportion of individuals aged 65 years and over among inpatients in healthcare institutions in Turkey and the prevalence and type of infections in this patient group in order to draw a road map. MATERIALS AND METHODS Hospitalized patients over 65 years at any of the 62 hospitals in 29 cities across Turkey on February 9, 2017 were included in the study. Web-based SurveyMonkey was used for data recording and evaluation system. RESULTS Of 17,351 patients 5871 (33.8%) were ≥65 years old. The mean age was 75.1±7.2 years; 3075 (52.4%) patients were male. Infection was reason for admission for 1556 (26.5%) patients. Pneumonia was the most common infection. The median length of hospital stay was 5 days (IQR: 2-11 days). The Antibiotic therapy was initiated for 2917 (49.7%) patients at the time of admission, and 23% of the antibiotics prescribed were inappropriate. Healthcare-associated infections developed in 1059 (18%) patients. Urinary catheters were placed in 2388 (40.7%) patients with 7.5% invalid indication. CONCLUSION This study used real data to reveal the proportion of elderly patients in hospital admissions. The interventions done, infections developed during hospitalization, length of hospital stay, and excessive drug load emphasize the significant impact on health costs and illustrate the importance of preventive medicine in this group of patients.
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Affiliation(s)
- Behice Kurtaran
- Cukurova University, Faculty of Medicine, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Ferit Kuscu
- Cukurova University, Faculty of Medicine, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Pinar Korkmaz
- Dumlupınar University, Kutahya Evliya Celebi Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Burcu Ozdemir
- Ankara Numune Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Dilara Inan
- AkdenizUniversity, Faculty of Medicine, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Nefise Oztoprak
- Antalya Training and Research Hospital,Infectious Diseases and Clinical Microbiology, Turkey.
| | - Duru Mistanoglu Ozatag
- Dumlupınar University, Kutahya Evliya Celebi Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Ozgur Daglı
- Bursa Yüksek İhtisas Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Serhat Birengel
- AnkaraUniversity, Faculty of Medicine, İbn-i Sina Hospital, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Kevser Ozdemir
- Pamukkale University, Faculty of Medicine, Infectious Diseases and Clinical Microbiology, Turkey.
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Morton CE, Forbes HJ, Pearce N, Smeeth L, Warren-Gash C. Association Between Common Infections and Incident Post-Stroke Dementia: A Cohort Study Using the Clinical Practice Research Datalink. Clin Epidemiol 2020; 12:907-916. [PMID: 32904115 PMCID: PMC7450211 DOI: 10.2147/clep.s260243] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/23/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To investigate the association between common infections and post-stroke dementia in a UK population-based cohort. MATERIALS AND METHODS A total of 60,392 stroke survivors (51.2% male, median age 74.3 years, IQR 63.9-82.4 years) were identified using primary care records from the Clinical Practice Research Datalink (CPRD) linked to Hospital Episode Statistics (HES) with no history of dementia. Primary exposure was any GP-recorded infection (lower respiratory tract infection (LRTI), urinary tract infection (UTI) requiring antibiotics, skin and soft tissue infection requiring antibiotics) occurring after stroke. The primary outcome was incident all-cause dementia recorded in primary care records. In sensitivity analyses, we restricted to individuals with linked hospital records and expanded definitions to include ICD-10 coded hospital admissions. We used multivariable Cox regression to investigate the association between common infections and dementia occurring from 3 months to 5 years after stroke. RESULTS Of 60,392 stroke survivors, 20,969 (34.7%) experienced at least one infection and overall 4512 (7.5%) developed dementia during follow-up. Early dementia (3 months to 1-year post-stroke) risk was increased in those with at least one GP-recorded infection (HR 1.44, 95% CI 1.21-1.71), with stronger associations when hospitalised infections were included (HR 1.84, 95% CI 1.58-2.14). Late dementia (1-5 years) was only associated with hospitalised, but not with GP-recorded, infections. CONCLUSION There was evidence of an association between common infections and post-stroke dementia, strongest in the 3-12 months following stroke. Better understanding of this relationship could help inform knowledge of pathways to dementia post-stroke and targeting of preventive interventions.
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Affiliation(s)
- Caroline E Morton
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
- EBM DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, OxfordOX2 6GG, UK
| | - Harriet J Forbes
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
| | - Charlotte Warren-Gash
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
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Palin V, Mölter A, Belmonte M, Ashcroft DM, White A, Welfare W, van Staa T. Antibiotic prescribing for common infections in UK general practice: variability and drivers. J Antimicrob Chemother 2020; 74:2440-2450. [PMID: 31038162 PMCID: PMC6640319 DOI: 10.1093/jac/dkz163] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 01/08/2023] Open
Abstract
Objectives To examine variations across general practices and factors associated with antibiotic prescribing for common infections in UK primary care to identify potential targets for improvement and optimization of prescribing. Methods Oral antibiotic prescribing for common infections was analysed using anonymized UK primary care electronic health records between 2000 and 2015 using the Clinical Practice Research Datalink (CPRD). The rate of prescribing for each condition was observed over time and mean change points were compared with national guideline updates. Any correlation between the rate of prescribing for each infectious condition was estimated within a practice. Predictors of prescribing were estimated using logistic regression in a matched patient cohort (1:1 by age, sex and calendar time). Results Over 8 million patient records were examined in 587 UK general practices. Practices varied considerably in their propensity to prescribe antibiotics and this variance increased over time. Change points in prescribing did not reflect updates to national guidelines. Prescribing levels within practices were not consistent for different infectious conditions. A history of antibiotic use significantly increased the risk of receiving a subsequent antibiotic (by 22%–48% for patients with three or more antibiotic prescriptions in the past 12 months), as did higher BMI, history of smoking and flu vaccinations. Other drivers for receiving an antibiotic varied considerably for each condition. Conclusions Large variability in antibiotic prescribing between practices and within practices was observed. Prescribing guidelines alone do not positively influence a change in prescribing, suggesting more targeted interventions are required to optimize antibiotic prescribing in the UK.
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Affiliation(s)
- Victoria Palin
- Greater Manchester Connected Health Cities, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Anna Mölter
- Greater Manchester Connected Health Cities, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Miguel Belmonte
- Greater Manchester Connected Health Cities, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Darren M Ashcroft
- Greater Manchester Connected Health Cities, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Andrew White
- NHS Greater Manchester Shared Service, Ellen House, Waddington Street, Oldham OL9 6EE, UK
| | - William Welfare
- Public Health England North West, 3 Piccadilly Place, London Road, Manchester M1 3BN, UK
| | - Tjeerd van Staa
- Greater Manchester Connected Health Cities, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
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55
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Hayward GN, Moore A, Mckelvie S, Lasserson DS, Croxson C. Antibiotic prescribing for the older adult: beliefs and practices in primary care. J Antimicrob Chemother 2020; 74:791-797. [PMID: 30566597 DOI: 10.1093/jac/dky504] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/08/2018] [Accepted: 11/08/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Older adults suffer high morbidity and mortality following serious infections, and hospital admissions with these conditions are increasingly common. Antibiotic prescribing in the older adult population, especially in long-term care facilities, has been argued to be inappropriately high. In order to develop the evidence base and provide support to GPs in achieving antimicrobial stewardship in older adults it is important to understand their attitudes and beliefs toward antibiotic prescribing in this population. OBJECTIVES To understand the attitudes and beliefs held by GPs regarding antibiotic prescribing in older adults. METHODS Semi-structured qualitative interviews were conducted with 28 GPs working in the UK. Data analysis followed a modified framework approach. RESULTS GPs described antibiotic prescribing in older adults as differing from prescribing in other age groups in a number of ways, including prescribing broad-spectrum, longer and earlier antibiotics in this population. There were also rationales for situations where antibiotics were prescribed despite there being no clear diagnosis of infection. Trials of antibiotics were used both as diagnostic aids and in an attempt to avoid admission. The risks of antibiotics were understood, but in some cases restrictions on antibiotic use were thought to hamper optimal management of infection in this age group. CONCLUSIONS Diagnosing serious infections in older adults is challenging and antibiotic prescribing practices reflect this challenge, but also reflect an absence of clear guidance or evidence. Research that can fill the gaps in the evidence base is required in order to support GPs with their critical antimicrobial stewardship role in this population.
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Affiliation(s)
- G N Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
| | - A Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
| | - S Mckelvie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
| | - D S Lasserson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - C Croxson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
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Infection in older adults: a qualitative study of patient experience. Br J Gen Pract 2020; 70:e312-e321. [PMID: 32253191 DOI: 10.3399/bjgp20x709397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/25/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Infection is common in older adults. Serious infection has a high mortality rate and is associated with unplanned hospital admissions. Little is known about the factors that prompt older patients to seek medical advice when they may have an infection. AIM To explore the symptoms of infection from the perspective of older adults, and when and why older patients seek healthcare advice for a possible infection. DESIGN AND SETTING A qualitative interview study among adults aged ≥70 years with a clinical diagnosis of infection recruited from ambulatory care units in Oxford, UK. METHOD Interviews were semi-structured and based on a flexible topic guide. Participants were given the option to be interviewed with their carer. Thematic analysis was facilitated using NVivo (version 11). RESULTS A total of 28 participants (22 patients and six carers) took part. Patients (aged 70-92 years) had experienced a range of different infections. Several early non-specific symptoms were described (fever, feeling unwell, lethargy, vomiting, pain, and confusion/delirium). Internally minimising symptoms was common and participants with historical experience of infection tended to be better able to interpret their symptoms. Factors influencing seeking healthcare advice included prompts from family, specific or intolerable symptoms, symptom duration, and being unable to manage with self-care. For some, not wanting to be a burden affected their desire to seek help. CONCLUSION Tailored advice to older adults highlighting early symptoms of infection may be beneficial. Knowing whether patients have had previous experience of infection may help healthcare professionals in assessing older patients with possible infection.
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57
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Ferreira-Coimbra J, Sarda C, Rello J. Burden of Community-Acquired Pneumonia and Unmet Clinical Needs. Adv Ther 2020; 37:1302-1318. [PMID: 32072494 PMCID: PMC7140754 DOI: 10.1007/s12325-020-01248-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Indexed: 12/26/2022]
Abstract
Community-acquired pneumonia (CAP) is the leading cause of death among infectious diseases and an important health problem, having considerable implications for healthcare systems worldwide. Despite important advances in prevention through vaccines, new rapid diagnostic tests and antibiotics, CAP management still has significant drawbacks. Mortality remains very high in severely ill patients presenting with respiratory failure or shock but is also high in the elderly. Even after a CAP episode, higher risk of death remains during a long period, a risk mainly driven by inflammation and patient-related co-morbidities. CAP microbiology has been altered by new molecular diagnostic tests that have turned viruses into the most identified pathogens, notwithstanding uncertainties about the specific role of each virus in CAP pathogenesis. Pneumococcal vaccines also impacted CAP etiology and thus had changed Streptococcus pneumoniae circulating serotypes. Pathogens from specific regions should also be kept in mind when treating CAP. New antibiotics for CAP treatment were not tested in severely ill patients and focused on multidrug-resistant pathogens that are unrelated to CAP, limiting their general use and indications for intensive care unit (ICU) patients. Similarly, CAP management could be personalized through the use of adjunctive therapies that showed outcome improvements in particular patient groups. Although pneumococcal vaccination was only convincingly shown to reduce invasive pneumococcal disease, with a less significant effect in pneumococcal CAP, it remains the best therapeutic intervention to prevent bacterial CAP. Further research in CAP is needed to reduce its population impact and improve individual outcomes.
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Affiliation(s)
- João Ferreira-Coimbra
- Internal Medicine Department, Centro Hospitalar Universitário do Porto, Porto, Portugal.
| | - Cristina Sarda
- Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Institute of Research, Barcelona, Spain
- CIBERES-Centro de investigación en red de enfermedades respiratorias, Madrid, Spain
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58
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Boere TM, van Buul LW, Hopstaken RM, Veenhuizen RB, van Tulder MW, Cals JWL, Verheij TJM, Hertogh CMPM. Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial. BMC Health Serv Res 2020; 20:149. [PMID: 32103747 PMCID: PMC7045632 DOI: 10.1186/s12913-020-5006-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/17/2020] [Indexed: 11/15/2022] Open
Abstract
Background Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting. Methods/design A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no). Discussion This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results. Trial registration Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.
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Affiliation(s)
- Tjarda M Boere
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.
| | | | - Ruth B Veenhuizen
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | | | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Theo J M Verheij
- National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands.,Department of General Practice, Julius Centrum, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.,National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands
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Struyf T, Tournoy J, Verbakel JY, Van den Bruel A. International Consensus Definition of a Serious Infection in a Geriatric Patient Presenting to Ambulatory Care. J Am Med Dir Assoc 2020; 21:578-582.e1. [PMID: 32111485 DOI: 10.1016/j.jamda.2020.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/10/2020] [Accepted: 01/16/2020] [Indexed: 01/10/2023]
Abstract
Early recognition and prompt treatment of a serious infection is important to optimize prognosis in older patients. The current evidence base underpinning this early recognition in ambulatory care is scattered and haphazard, calling for new research to strengthen clinical practice. Before embarking on such studies, it is important to seek consensus on what constitutes a serious infection in older patients presenting to ambulatory care. We conducted a 4-round e-Delphi study seeking consensus among medical professionals who deliver clinical care to older patients using online questionnaires and feedback. Twenty-two specialists in emergency care, general practice, geriatrics, and infectious diseases from 10 different countries participated in our study. We constructed 18 statements from the answers to the open questions in round 1, which were then rated by the participants in 2 consecutive rounds. After assessing the level of agreement, consensus, and stability, the following definition was preferred by 94% of the participants: "A serious infection in a geriatric patient presenting to ambulatory care is an infection with a high risk of complications, functional decline, and/or mortality, requiring a prompt diagnostic and therapeutic approach in the appropriate care setting. The most important determinants of the choice of setting are the level of emergency, the geriatric profile of the patient (frailty status, functional status, and comorbidities), and the patients' level of autonomy and personal preferences. Factors such as the feasibility of home care, the potential consequences of delayed or suboptimal treatment and infection specific treatment requirements should be weighed as well when choosing the appropriate care setting." Based on consensus among 22 clinicians working in 10 different countries, we propose a definition for serious infections in geriatric patients presenting to ambulatory care. This will form the basis of future studies in this domain.
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Affiliation(s)
- Thomas Struyf
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
| | - Jos Tournoy
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Nuffield Department of Public Health and Primary Care, University of Oxford, Oxford, United Kingdom
| | - Ann Van den Bruel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Abd ElFattah E, El Assal G, Aref N. Assessment of management and outcome of lower respiratory tract infection. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2020. [DOI: 10.4103/ejcdt.ejcdt_179_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Arshad H, Alfonso JCL, Franke R, Michaelis K, Araujo L, Habib A, Zboromyrska Y, Lücke E, Strungaru E, Akmatov MK, Hatzikirou H, Meyer-Hermann M, Petersmann A, Nauck M, Brönstrup M, Bilitewski U, Abel L, Sievers J, Vila J, Illig T, Schreiber J, Pessler F. Decreased plasma phospholipid concentrations and increased acid sphingomyelinase activity are accurate biomarkers for community-acquired pneumonia. J Transl Med 2019; 17:365. [PMID: 31711507 PMCID: PMC6849224 DOI: 10.1186/s12967-019-2112-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background There continues to be a great need for better biomarkers and host-directed treatment targets for community-acquired pneumonia (CAP). Alterations in phospholipid metabolism may constitute a source of small molecule biomarkers for acute infections including CAP. Evidence from animal models of pulmonary infections and sepsis suggests that inhibiting acid sphingomyelinase (which releases ceramides from sphingomyelins) may reduce end-organ damage. Methods We measured concentrations of 105 phospholipids, 40 acylcarnitines, and 4 ceramides, as well as acid sphingomyelinase activity, in plasma from patients with CAP (n = 29, sampled on admission and 4 subsequent time points), chronic obstructive pulmonary disease exacerbation with infection (COPD, n = 13) as a clinically important disease control, and 33 age- and sex-matched controls. Results Phospholipid concentrations were greatly decreased in CAP and normalized along clinical improvement. Greatest changes were seen in phosphatidylcholines, followed by lysophosphatidylcholines, sphingomyelins and ceramides (three of which were upregulated), and were least in acylcarnitines. Changes in COPD were less pronounced, but also differed qualitatively, e.g. by increases in selected sphingomyelins. We identified highly accurate biomarkers for CAP (AUC ≤ 0.97) and COPD (AUC ≤ 0.93) vs. Controls, and moderately accurate biomarkers for CAP vs. COPD (AUC ≤ 0.83), all of which were phospholipids. Phosphatidylcholines, lysophosphatidylcholines, and sphingomyelins were also markedly decreased in S. aureus-infected human A549 and differentiated THP1 cells. Correlations with C-reactive protein and procalcitonin were predominantly negative but only of mild-to-moderate extent, suggesting that these markers reflect more than merely inflammation. Consistent with the increased ceramide concentrations, increased acid sphingomyelinase activity accurately distinguished CAP (fold change = 2.8, AUC = 0.94) and COPD (1.75, 0.88) from Controls and normalized with clinical resolution. Conclusions The results underscore the high potential of plasma phospholipids as biomarkers for CAP, begin to reveal differences in lipid dysregulation between CAP and infection-associated COPD exacerbation, and suggest that the decreases in plasma concentrations are at least partially determined by changes in host target cells. Furthermore, they provide validation in clinical blood samples of acid sphingomyelinase as a potential treatment target to improve clinical outcome of CAP.
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Affiliation(s)
- Haroon Arshad
- Research Group "Biomarkers for Infectious Diseases", TWINCORE Centre for Experimental and Clinical Infection Research, Feodor-Lynen-Str. 7, 30625, Hannover, Germany
| | - Juan Carlos López Alfonso
- Department of Systems Immunology and Braunschweig Integrated Centre of Systems Biology, Helmholtz Centre for Infection Research, Brunswick, Germany
| | - Raimo Franke
- Department of Chemical Biology, Helmholtz Centre for Infection Research and German Center for Infection Research (DZIF), Brunswick, Germany
| | - Katina Michaelis
- Clinic for Pneumology, Otto-von-Guericke University, Magdeburg, Germany
| | - Leonardo Araujo
- Research Group "Biomarkers for Infectious Diseases", TWINCORE Centre for Experimental and Clinical Infection Research, Feodor-Lynen-Str. 7, 30625, Hannover, Germany.,Helmholtz Centre for Infection Research, Brunswick, Germany
| | - Aamna Habib
- Research Group "Biomarkers for Infectious Diseases", TWINCORE Centre for Experimental and Clinical Infection Research, Feodor-Lynen-Str. 7, 30625, Hannover, Germany.,Department of Chemical Biology, Helmholtz Centre for Infection Research and German Center for Infection Research (DZIF), Brunswick, Germany
| | - Yuliya Zboromyrska
- Department of Clinical Microbiology, Biomedical Diagnostic Centre (CDB), Hospital Clinic, School of Medicine, University of Barcelona, Institute of Global Health (ISGlobal), Barcelona, Spain
| | - Eva Lücke
- Clinic for Pneumology, Otto-von-Guericke University, Magdeburg, Germany
| | - Emilia Strungaru
- Clinic for Pneumology, Otto-von-Guericke University, Magdeburg, Germany
| | - Manas K Akmatov
- Research Group "Biomarkers for Infectious Diseases", TWINCORE Centre for Experimental and Clinical Infection Research, Feodor-Lynen-Str. 7, 30625, Hannover, Germany.,Helmholtz Centre for Infection Research, Brunswick, Germany
| | - Haralampos Hatzikirou
- Department of Systems Immunology and Braunschweig Integrated Centre of Systems Biology, Helmholtz Centre for Infection Research, Brunswick, Germany
| | - Michael Meyer-Hermann
- Department of Systems Immunology and Braunschweig Integrated Centre of Systems Biology, Helmholtz Centre for Infection Research, Brunswick, Germany
| | - Astrid Petersmann
- Institute for Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany.,UMG-Laboratory, University Medicine Göttingen, Göttingen, Germany
| | - Matthias Nauck
- Institute for Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, University Medicine, Greifswald, Germany
| | - Mark Brönstrup
- Department of Chemical Biology, Helmholtz Centre for Infection Research and German Center for Infection Research (DZIF), Brunswick, Germany
| | - Ursula Bilitewski
- Department of Chemical Biology, Helmholtz Centre for Infection Research and German Center for Infection Research (DZIF), Brunswick, Germany
| | - Laurent Abel
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France.,Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, USA
| | - Jorg Sievers
- Clinical Microbiology, GlaxoSmithKline, Collegeville, PA, USA.,Clinical Development, ViiV Healthcare, Brentford, UK
| | - Jordi Vila
- Department of Clinical Microbiology, Biomedical Diagnostic Centre (CDB), Hospital Clinic, School of Medicine, University of Barcelona, Institute of Global Health (ISGlobal), Barcelona, Spain
| | - Thomas Illig
- Hannover Unified Biobank, Hannover Medical School, Hannover, Germany
| | - Jens Schreiber
- Clinic for Pneumology, Otto-von-Guericke University, Magdeburg, Germany
| | - Frank Pessler
- Research Group "Biomarkers for Infectious Diseases", TWINCORE Centre for Experimental and Clinical Infection Research, Feodor-Lynen-Str. 7, 30625, Hannover, Germany. .,Helmholtz Centre for Infection Research, Brunswick, Germany. .,Centre for Individualised Infection Medicine, Hannover, Germany.
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The impact of certain underlying comorbidities on the risk of developing hospitalised pneumonia in England. Pneumonia (Nathan) 2019; 11:4. [PMID: 31632897 PMCID: PMC6788086 DOI: 10.1186/s41479-019-0063-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/12/2019] [Indexed: 02/05/2023] Open
Abstract
Background UK specific data on the risk of developing hospitalised CAP for patients with underlying comorbidities is lacking. This study compared the likelihood of hospitalised all-cause community acquired pneumonia (CAP) in patients with certain high-risk comorbidities and a comparator group with no known risk factors for pneumococcal disease. Methods This retrospective cohort study interrogated data in the Hospital Episodes Statistics (HES) dataset between financial years 2012/13 and 2016/17. In total 3,078,623 patients in England (aged ≥18 years) were linked to their hospitalisation records. This included 2,950,910 individuals with defined risk groups and a comparator group of 127,713 people who had undergone tooth extraction with none of the risk group diagnoses. Risk groups studied were chronic respiratory disease (CRD), chronic heart disease (CHD), chronic liver disease (CLD), chronic kidney disease (CKD), diabetes (DM) and post bone marrow transplant (BMT). The patients were tracked forward from year 0 (2012/13) to Year 3 (2016/17) and all diagnoses of hospitalised CAP were recorded. A Logistic regression model compared odds of developing hospitalised CAP for patients in risk groups compared to healthy controls. The model was simultaneously adjusted for age, sex, strategic heath authority (SHA), index of multiple deprivation (IMD), ethnicity, and comorbidity. To account for differing comorbidity profiles between populations the Charlson Comorbidity Index (CCI) was applied. The model estimated odds ratios (OR) with 95% confidence intervals of developing hospitalised CAP for each specified clinical risk group. Results Patients within all the risk groups studied were more likely to develop hospitalised CAP than patients in the comparator group. The odds ratios varied between underlying conditions ranging from 1.18 (95% CI 1.13, 1.23) for those with DM to 5.48 (95% CI 5.28, 5.70) for those with CRD. Conclusions Individuals with any of 6 pre-defined underlying comorbidities are at significantly increased risk of developing hospitalised CAP compared to those with no underlying comorbid condition. Since the likelihood varies by risk group it should be possible to target patients with each of these underlying comorbidities with the most appropriate preventative measures, including immunisations.
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63
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Lloyd M, Karahalios A, Janus E, Skinner EH, Haines T, De Silva A, Lowe S, Shackell M, Ko S, Desmond L, Karunajeewa H. Effectiveness of a Bundled Intervention Including Adjunctive Corticosteroids on Outcomes of Hospitalized Patients With Community-Acquired Pneumonia: A Stepped-Wedge Randomized Clinical Trial. JAMA Intern Med 2019; 179:1052-1060. [PMID: 31282921 PMCID: PMC6618815 DOI: 10.1001/jamainternmed.2019.1438] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Community-acquired pneumonia remains a leading cause of hospitalization, mortality, and health care costs worldwide. Randomized clinical trials support the use of adjunctive corticosteroids, early progressive mobilization, antibiotic switching rules, and dietary interventions in improving outcomes. However, it is uncertain whether implementing these interventions will translate into effectiveness under routine health care conditions. OBJECTIVE To evaluate the effectiveness of a bundle of evidence-supported treatments under conditions of routine care in a representative population hospitalized for community-acquired pneumonia. DESIGN, SETTING, AND PARTICIPANTS A double-blind, stepped-wedge, cluster-randomized clinical trial with 90-day follow-up was conducted between August 1, 2016, and October 29, 2017, in the general internal medicine service at 2 tertiary hospitals in Melbourne, Australia, among a consecutive sample of patients with community-acquired pneumonia. The primary analysis and preparation of results took place between May 14 and November 25, 2018. INTERVENTIONS Treating clinical teams were advised to prescribe prednisolone acetate, 50 mg/d, for 7 days (in the absence of any contraindication) and de-escalate from parenteral to oral antibiotics according to standardized criteria. Algorithm-guided early mobilization and malnutrition screening and treatment were also implemented. MAIN OUTCOMES AND MEASURES Hospital length of stay, mortality, readmission, and intervention-associated adverse events (eg, gastrointestinal bleeding and hyperglycemia). RESULTS A total of 917 patients were screened, and 816 (351 women and 465 men; mean [SD] age, 76 [13] years) were included in the intention-to-treat analysis, with 401 patients receiving the intervention and 415 patients in the control group. An unadjusted geometric mean ratio of 0.95 (95% CI, 0.78-1.16) was observed for the difference in length of stay (days) between the intervention and control groups. Similarly, no significant differences were observed for the secondary outcomes of mortality and readmission, and the results remained unchanged after further adjustment for sex and age. The study reported higher proportions of gastrointestinal bleeding in the intervention group (9 [2.2%]) compared with the controls (3 [0.7%]), with an unadjusted estimated difference in mean proportions of 0.008 (95% CI, 0.005-0.010). CONCLUSIONS AND RELEVANCE This bundled intervention including adjunctive corticosteroids demonstrated no evidence of effectiveness and resulted in a higher incidence of gastrointestinal bleeding. Efficacy of individual interventions demonstrated in clinical trials may not necessarily translate into effectiveness when implemented in combination and may even result in net harm. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02835040.
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Affiliation(s)
- Melanie Lloyd
- Department of Physiotherapy, Western Health, The University of Melbourne, Melbourne, Australia.,Department of Medicine, Western Health, University of Melbourne, Melbourne, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Edward Janus
- Department of Medicine, Western Health, University of Melbourne, Melbourne, Australia.,General Internal Medicine Unit, Western Health, The University of Melbourne, Melbourne, Australia
| | - Elizabeth H Skinner
- Department of Physiotherapy, Western Health, The University of Melbourne, Melbourne, Australia.,School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Anurika De Silva
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Stephanie Lowe
- Department of Physiotherapy, Western Health, The University of Melbourne, Melbourne, Australia
| | - Melina Shackell
- Department of Physiotherapy, Western Health, The University of Melbourne, Melbourne, Australia
| | - Soe Ko
- General Internal Medicine Unit, Western Health, The University of Melbourne, Melbourne, Australia
| | - Lucy Desmond
- General Internal Medicine Unit, Western Health, The University of Melbourne, Melbourne, Australia
| | - Harin Karunajeewa
- Department of Medicine, Western Health, University of Melbourne, Melbourne, Australia.,General Internal Medicine Unit, Western Health, The University of Melbourne, Melbourne, Australia.,Division of Population Health and Immunity, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
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64
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Moore A, Croxson C, McKelvie S, Lasserson D, Hayward G. General practitioners' attitudes and decision making regarding admission for older adults with infection: a UK qualitative interview study. Fam Pract 2019; 36:493-500. [PMID: 30219922 DOI: 10.1093/fampra/cmy083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The world has an ageing population. Infection is common in older adults; serious infection has a high mortality rate and is associated with unplanned admissions. In the UK, general practitioners (GPs) must identify which older patients require admission to hospital and provide appropriate care and support for those staying at home. OBJECTIVES To explore attitudes of UK GPs towards referring older patients with suspected infection to hospital, how they weigh up the decision to admit against the alternatives and how alternatives to admission could be made more effective.Methods. Qualitative study using semi-structured interviews. GPs were purposively sampled from across the UK to achieve maximum variation in terms of GP role, experience and practice population. Interview transcripts were coded and analysed using a modified framework approach. RESULTS GPs' key influences on decision making were grouped into patient, GP and system factors. Patient factors included clinical factors, social factors and shared decision making. GP factors included gut instinct, risk management and acknowledging an associated personal emotional burden. System factors involved weighing up the pressure on secondary care beds against increasing GP workload. GPs described that finding an alternative to admission could be more time consuming, complex to arrange or were restricted by lack of capacity. CONCLUSION GPs need to be empowered to make safe decisions about place of care for older adults with suspected infection. This may mean developing strategies to support decision making as well as improving the ease of access to, and capacity of, any alternatives to admission.
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Affiliation(s)
- Abigail Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caroline Croxson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sara McKelvie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dan Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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McQuitty R, Bui R, Chaaban MR. Retrospective Study: Association of Chronic Sphenoid Rhinosinusitis With Community Acquired Pneumonia. Am J Rhinol Allergy 2019; 33:751-756. [DOI: 10.1177/1945892419865651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objectives Our objective in this study is to examine the association between chronic sphenoid rhinosinusitis and community acquired pneumonia (CAP). Study Design Retrospective chart review. Methods A list of chronic rhinosinusitis (CRS) patients who presented to a tertiary rhinology clinic from 2013 to 2015 was conducted. Patients were excluded if they were not seen for at least 2 years. Patients were categorized into CRS with sphenoid sinusitis (group A) and CRS without sphenoid sinusitis (group B). The former group was divided into 2 categories according to their computed tomography scan/endoscopy findings: mucosal thickening and opacification (partial, complete, purulent sphenoid drainage on endoscopy). Posterior ethmoid disease was analyzed in the same fashion. Charts were then reviewed on whether the patients developed CAP within 2 years of their visit to the rhinologist. Results Six hundred forty-five of 1061 patients were included in the analysis. There were 178 (27.60%) patients in group A and 467 (72.40%) patients in group B. There were 40 total cases of pneumonia with 27 (67.50%) cases having chronic sphenoid sinusitis. Patients with sphenoid sinusitis were 6.77 (95% confidence interval [CI], 3.36–13.66) times more likely to have pneumonia. Patients with partial/complete opacification of the sphenoid sinus were 19.76 (95% CI, 8.78–44.47) times more likely to have pneumonia. Patients with only mucosal thickening of the sphenoid sinus did not have significantly increased odds of having pneumonia. Posterior ethmoid disease did not have an association with CAP nor did it increase the risk of CAP in sphenoid sinusitis patients. Conclusions There is an association between chronic sphenoid rhinosinusitis and CAP. Partial/complete opacification of the sphenoid sinus had the highest association with pneumonia.
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Affiliation(s)
- Robert McQuitty
- School of Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Roger Bui
- School of Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Mohamad R. Chaaban
- Department of Otolaryngology, University of Texas Medical Branch at Galveston, Galveston, Texas
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El Fahimi N, Calleja MA, Ratnayake L, Ali I. Audit of a multidisciplinary approach to improve management of community-acquired pneumonia. Eur J Hosp Pharm 2019; 26:223-225. [PMID: 31338173 PMCID: PMC6613927 DOI: 10.1136/ejhpharm-2017-001368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/18/2017] [Accepted: 10/31/2017] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a frequent cause of morbidity, mortality and hospital admission worldwide. An adequate choice of empirical antibiotic treatment and appropriate severity assessment of the disease are key aspects in the management of CAP. OBJECTIVE To audit the adherence to standards of care, such as empirical prescribing of antibiotics, and evaluate the current multidisciplinary approach to the management of CAP. METHOD Records of patients with CAP were identified and examined for CURB65 score documentation, discussion notes with microbiology and prescribed antibiotic treatments. RESULTS Out of the 62 patients identified, 32 had a CURB65 score documented in their medical notes and 59 had documented chest X-ray findings. 85.5% of cases were compliant with antibiotic prescribing guidelines. CONCLUSION The multidisciplinary approach has considerably improved compliance with most of the standards, especially adherence to empirical antibiotic guidelines, and ultimately the standard of care for patients with CAP.
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Affiliation(s)
- Nabil El Fahimi
- Department of Pharmacy, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, UK
| | - Miguel Angel Calleja
- Department of Pharmacy, University Hospital Virgen de las Nieves, Granada, Spain
| | - Lasantha Ratnayake
- Department of Microbiology, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
| | - Imran Ali
- James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
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Chen CY, Hsu SC, Hsieh HL, Suk CW, Hsu YP, Sue YM, Chen TH, Lin FY, Shih CM, Chen JW, Lin SJ, Huang PH, Liu CT. Microbial etiology of pneumonia in patients with decreased renal function. PLoS One 2019; 14:e0216367. [PMID: 31071139 PMCID: PMC6508684 DOI: 10.1371/journal.pone.0216367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/18/2019] [Indexed: 12/22/2022] Open
Abstract
Background Patients with renal impairment have altered immunity, which might cause vulnerability to specific pathogens and worsen pneumonia-related outcomes. Nonetheless, the microbiological features of pneumonia in patients with decreased renal function remain unknown. Methods Therefore, we conducted a retrospective cohort study enrolling adult patients hospitalized with pneumonia to assess this knowledge gap. The baseline estimated glomerular filtration rate (eGFR) and first sputum microbiology during hospitalization were used for statistical analyses. Results Overall, 1554 patients hospitalized with pneumonia (mean age, 76.1 ± 16.7) were included, and 162 patients had died at the end of hospitalization. The cutoff eGFR value predicting mortality was <55 mL/min/1.73 m2, which defined decreased renal function in this study. Patients with decreased renal function demonstrated a significantly higher risk of fungi and Staphylococcus aureus (S. aureus) infection. On the other hand, this group of patients showed significantly higher neutrophil-to-lymphocyte ratio (NLR), which associated with higher mortality. Additionally, patients with S. aureus had a significantly lower eGFR, lymphocyte count and a higher NLR. Conclusions These findings suggested the altered immunity and vulnerability to S. aureus infection in patients with decreased renal function, which may be the underlying cause of worse outcomes of pneumonia in this group of patients.
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Affiliation(s)
- Chun-you Chen
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shih-chang Hsu
- Emergency Department, Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hui-ling Hsieh
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Chi-won Suk
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yuan-pin Hsu
- Emergency Department, Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yuh-mou Sue
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Tso-Hsiao Chen
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Feng-yen Lin
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-ming Shih
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Jaw-wen Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
| | - Shing-jong Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Board of Directors, Taipei Medical University, Taipei, Taiwan
| | - Po-hsun Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-te Liu
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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Spronk I, Korevaar JC, Poos R, Davids R, Hilderink H, Schellevis FG, Verheij RA, Nielen MMJ. Calculating incidence rates and prevalence proportions: not as simple as it seems. BMC Public Health 2019; 19:512. [PMID: 31060532 PMCID: PMC6501456 DOI: 10.1186/s12889-019-6820-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/15/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Incidence rates and prevalence proportions are commonly used to express the populations health status. Since there are several methods used to calculate these epidemiological measures, good comparison between studies and countries is difficult. This study investigates the impact of different operational definitions of numerators and denominators on incidence rates and prevalence proportions. METHODS Data from routine electronic health records of general practices contributing to NIVEL Primary Care Database was used. Incidence rates were calculated using different denominators (person-years at-risk, person-years and midterm population). Three different prevalence proportions were determined: 1 year period prevalence proportions, point-prevalence proportions and contact prevalence proportions. RESULTS One year period prevalence proportions were substantially higher than point-prevalence (58.3 - 206.6%) for long-lasting diseases, and one year period prevalence proportions were higher than contact prevalence proportions (26.2 - 79.7%). For incidence rates, the use of different denominators resulted in small differences between the different calculation methods (-1.3 - 14.8%). Using person-years at-risk or a midterm population resulted in higher rates compared to using person-years. CONCLUSIONS All different operational definitions affect incidence rates and prevalence proportions to some extent. Therefore, it is important that the terminology and methodology is well described by sources reporting these epidemiological measures. When comparing incidence rates and prevalence proportions from different sources, it is important to be aware of the operational definitions applied and their impact.
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Affiliation(s)
- Inge Spronk
- Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500BN, Utrecht, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joke C. Korevaar
- Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500BN, Utrecht, The Netherlands
| | - René Poos
- Centre for Health and Society, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Rodrigo Davids
- Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500BN, Utrecht, The Netherlands
| | - Henk Hilderink
- Centre for Health and Society, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - François G. Schellevis
- Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500BN, Utrecht, The Netherlands
- Department of General Practice & Elderly Care Medicine/EMGO Institute for health and care research, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert A. Verheij
- Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500BN, Utrecht, The Netherlands
| | - Mark M. J. Nielen
- Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500BN, Utrecht, The Netherlands
- Centre for Health and Society, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
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69
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McKelvie S, Moore A, Croxson C, Lasserson DS, Hayward GN. Challenges and strategies for general practitioners diagnosing serious infections in older adults: a UK qualitative interview study. BMC FAMILY PRACTICE 2019; 20:56. [PMID: 31027482 PMCID: PMC6486693 DOI: 10.1186/s12875-019-0941-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/02/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Serious infections in older people are associated with unplanned hospital admissions and high mortality. Recognising the presence of a serious infection and making an accurate diagnosis are important challenges for General Practice. This study aimed to explore the issues UK GPs face when diagnosing serious infections in older patients. METHODS Qualitative study using semi-structured interviews. 28 GPs from 27 practices were purposively sampled from across the UK to achieve maximum variation in terms of GP role, experience and practice population. Interviews began by asking participants to describe recent or memorable cases where they had assessed older patients with suspected serious infections. Additional questions from the topic guide were used to explore the challenges further. Interview transcripts were coded and analysed using a modified framework approach. RESULTS Diagnosing serious infection in older adults was perceived to be challenging by participating GPs and the diagnosis was often uncertain. Contributing factors included patient complexity, atypical presentations, as well as a lack of knowledge of patients due to a loss in continuity. Diagnostic challenges were present at each stage of the patient assessment. Scoring systems were mainly used as communication tools. Investigations were sometimes used to resolve diagnostic uncertainty, but availability and speed of result limited their practical use. Clear safety-net plans shared with patients and their families helped GPs manage ongoing uncertainty. CONCLUSIONS Diagnostic challenges are present throughout the assessment of an older adult with a serious infection in primary care. Supporting GPs to provide continuity of care may improve the recognition and developing point of care testing for use in community settings may reduce diagnostic uncertainty.
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Affiliation(s)
- Sara McKelvie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Oxford, OX2 6GG UK
| | - Abigail Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Oxford, OX2 6GG UK
| | - Caroline Croxson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Oxford, OX2 6GG UK
| | - Daniel S. Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Elderly Care, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gail N. Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Oxford, OX2 6GG UK
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Lau WC, Bielicki J, Tersigni C, Saxena S, Wong IC, Sharland M, Hsia Y. All-cause pneumonia in children after the introduction of pneumococcal vaccines in the United Kingdom: A population-based study. Pharmacoepidemiol Drug Saf 2019; 28:821-829. [DOI: 10.1002/pds.4770] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 02/01/2019] [Accepted: 02/12/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Wallis C.Y. Lau
- Research Department of Practice and Policy; UCL School of Pharmacy; London United Kingdom
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Hong Kong
| | - Julia Bielicki
- Paediatric Infectious Disease Research Group; St George's University of London; London UK
- Paediatric Pharmacology Group; University of Basel Children's Hospital; Basel Switzerland
| | - Chiara Tersigni
- Paediatric Infectious Disease Research Group; St George's University of London; London UK
| | - Sonia Saxena
- School of Public Health; Imperial College London; London UK
- Chartfield Surgery; National Health Service, Putney; London UK
| | - Ian C.K. Wong
- Research Department of Practice and Policy; UCL School of Pharmacy; London United Kingdom
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Hong Kong
| | - Mike Sharland
- Paediatric Infectious Disease Research Group; St George's University of London; London UK
| | - Yingfen Hsia
- Paediatric Infectious Disease Research Group; St George's University of London; London UK
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Desmond LA, Lloyd MA, Ryan SA, Janus ED, Karunajeewa HA. Respiratory viruses in adults hospitalised with Community-Acquired Pneumonia during the non-winter months in Melbourne: Routine diagnostic practice may miss large numbers of influenza and respiratory syncytial virus infections. Commun Dis Intell (2018) 2019. [DOI: 10.33321/cdi.2019.43.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Community-Acquired Pneumonia (CAP) is one of the highest health burden conditions in Australia. Disease notifications and other data from routine diagnosis suffers from selection bias that may misrepresent the true contribution of various aetiological agents. However existing Australian prospective studies of CAP aetiology have either under-represented elderly patients, not utilised Polymerase Chain Reaction (PCR) diagnostics or been limited to winter months. We therefore sought to re-evaluate CAP aetiology by systematically applying multiplex PCR in a representative cohort of mostly elderly patients hospitalised in Melbourne during non-winter months and compare diagnostic results with those obtained under usual conditions of care. Methods Seventy two CAP inpatients were prospectively enrolled over 2 ten-week blocks during non-winter months in Melbourne in 2016-17. Nasopharyngeal and oropharyngeal swabs were obtained at admission and analysed by multiplex-PCR for 7 respiratory viruses and 5 atypical bacteria. Results Median age was 74 (interquartile range 67-80) years, with 38 (52.8%) males and 34 (47.2%) females. PCR was positive in 24 (33.3%), including 12 Picornavirus (50.5% of those with a virus), 4 RSV (16.7%) and 4 influenza A (16.7%). CAP-Sym questionnaire responses were similar in those with and without viral infections. Most (80%) pathogens detected by the study, including all 8 cases of influenza and RSV, were not otherwise detected by treating clinicians during hospital admission. Conclusion One third of patients admitted with CAP during non-winter months had PCR-detectable respiratory viral infections, including many cases of influenza and RSV that were missed by existing routine clinical diagnostic processes. Keywords: Lower Respiratory Tract Infection (LRTI), Community-Acquired Pneumonia (CAP) Polymerase Chain Reaction (PCR), Influenza, Respiratory Syncytial Virus
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Affiliation(s)
- Lucy A Desmond
- 1. Department of Medicine, Melbourne Medical School – Western Health, University of Melbourne
| | - Melanie A Lloyd
- Department of Medicine, Melbourne Medical School – Western Health, University of Melbourne
| | | | - Edward D Janus
- 3. Department of Medicine, Melbourne Medical School – Western Health, University of Melbourne General Internal medicine Unit, Western Health, St Albans, Vic
| | - Harin A Karunajeewa
- 4. Department of Medicine, Melbourne Medical School – Western Health, University of Melbourne General Internal medicine Unit, Western Health, St Albans, Vic and 5. The Walter and Eliza Hall Institute of Medical Research, Parkville
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Rivero-Calle I, Cebey-López M, Pardo-Seco J, Yuste J, Redondo E, Vargas DA, Mascarós E, Díaz-Maroto JL, Linares-Rufo M, Jimeno I, Gil A, Molina J, Ocaña D, Martinón-Torres F. Lifestyle and comorbid conditions as risk factors for community-acquired pneumonia in outpatient adults (NEUMO-ES-RISK project). BMJ Open Respir Res 2019; 6:e000359. [PMID: 31178994 PMCID: PMC6530500 DOI: 10.1136/bmjresp-2018-000359] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/30/2018] [Accepted: 12/26/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction Information about community-acquired pneumonia (CAP) risk in primary care is limited. We assess different lifestyle and comorbid conditions as risk factors (RF) for CAP in adults in primary care. Methods A retrospective-observational-controlled study was designed. Adult CAP cases diagnosed at primary care in Spain between 2009 and 2013 were retrieved using the National Surveillance System of Primary Care Data (BiFAP). Age-matched and sex-matched controls were selected by incidence density sampling (ratio 2:1). Associations are presented as percentages and OR. Binomial regression models were constructed to avoid bias effects. Results 51 139 patients and 102 372 controls were compared. Mean age (SD) was 61.4 (19.9) years. RF more significantly linked to CAP were: HIV (OR [95% CI]: 5.21 [4.35 to 6.27]), chronic obstructive pulmonary disease (COPD) (2.97 [2.84 to 3.12]), asthma (2.16 [2.07,2.26]), smoking (1.96 [1.91 to 2.02]) and poor dental hygiene (1.45 [1.41 to 1.49]). Average prevalence of any RF was 82.2% in cases and 69.2% in controls (2.05 [2.00 to 2.10]). CAP rate increased with the accumulation of RF and age: risk associated with 1RF was 1.42 (1.37 to 1.47) in 18–60-year-old individuals vs 1.57 (1.49 to 1.66) in >60 years of age, with 2RF 1.88 (1.80 to 1.97) vs 2.35 (2.23, 2.48) and with ≥ 3 RF 3.11 (2.95, 3.30) vs 4.34 (4.13 to 4.57). Discussion Prevalence of RF in adult CAP in primary care is high. Main RFs associated are HIV, COPD, asthma, smoking and poor dental hygiene. Our risk stacking results could help clinicians identify patients at higher risk of pneumonia.
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Affiliation(s)
- Irene Rivero-Calle
- Translational Pediatrics and Infectious Diseases Section, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain.,Vaccines, Infections and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Miriam Cebey-López
- Vaccines, Infections and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Jacobo Pardo-Seco
- Vaccines, Infections and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - José Yuste
- Pneumococcal Unit of the Laboratory of Reference and Research in Bacterial Diseases Preventable by Vaccines, National Center of Microbiology and CIBER of Respiratory Diseases (CIBERES). Carlos III Health Institute, Madrid, Spain
| | - Esther Redondo
- Preventive and Public Health Activities Group SEMERGEN, International Heath Center, Madrid, Spain
| | - Diego A Vargas
- Versatile Hospitalization Unit, Hospital de Alta Resolución El Toyo, Agencia Pública Sanitaria, Hospital de Poniente, Almería, Spain
| | - Enrique Mascarós
- Health Department, Hospital Dr Peset, Primary Care Center Fuente de San Luís, Valencia, Spain
| | - Jose Luis Díaz-Maroto
- Primary Care Health Center Guadalajara, Infectious Diseases Group SEMERGEN, Guadalajara, Spain
| | - Manuel Linares-Rufo
- Specialist in Primary Care and Clinical Microbiology, Infectious Diseases Group SEMERGEN, Fundación io, Madrid, Spain
| | - Isabel Jimeno
- Primary Care Health Center Isla de Oza, Vaccine Responsible of SEMG, Madrid, Spain
| | - Angel Gil
- Preventive and Public Health, Rey Juan Carlos University, Madrid, Spain
| | - Jesus Molina
- Primary Care, Health Care Center Francia, Fuenlabrada, Madrid, Spain
| | - Daniel Ocaña
- Primary Care, Health Care Center Algeciras, Algeciras, Spain
| | - Federico Martinón-Torres
- Translational Pediatrics and Infectious Diseases Section, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain.,Vaccines, Infections and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
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Ahmed H, Farewell D, Jones HM, Francis NA, Paranjothy S, Butler CC. Antibiotic prophylaxis and clinical outcomes among older adults with recurrent urinary tract infection: cohort study. Age Ageing 2019; 48:228-234. [PMID: 30165433 PMCID: PMC6424374 DOI: 10.1093/ageing/afy146] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/26/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND clinical guidelines recommend antibiotic prophylaxis for preventing recurrent urinary tract infections (UTIs), but there is little evidence for their effectiveness in older adults. METHODS this was a retrospective cohort study of health records from 19,696 adults aged ≥65 with recurrent UTIs. We used prescription records to ascertain ≥3 months' prophylaxis with trimethoprim, cefalexin or nitrofurantoin. We used random effects Cox recurrent event models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for risks of clinical recurrence (primary outcome), acute antibiotic prescribing and hospitalisation. RESULTS of 4,043 men and 15,653 women aged ≥65 with recurrent UTIs, 508 men (12.6%) and 2,229 women (14.2%) were prescribed antibiotic prophylaxis. In men, prophylaxis was associated with a reduced risk of clinical recurrence (HR, 0.49; 95% CI, 0.45-0.54), acute antibiotic prescribing (HR, 0.54; 95% CI, 0.51-0.57) and UTI-related hospitalisation (HR, 0.78; 95% CI, 0.64-0.94). In women, prophylaxis was also associated with a reduced risk of clinical recurrence (HR, 0.57; 95% CI, 0.55-0.59) and acute antibiotic prescribing (HR, 0.61; 95% CI, 0.59-0.62), but estimates of the risk of UTI-related hospitalisation were inconsistent between our main analysis (HR, 1.16; 95% CI, 1.05-1.28) and sensitivity analysis (HR, 0.82; 95% CI, 0.72-0.94). CONCLUSIONS antibiotic prophylaxis was associated with lower rates of UTI recurrence and acute antibiotic prescribing in older adults. To fully understand the benefits and harms of prophylaxis, further research should determine the frequency of antibiotic-related adverse events and the impact on antimicrobial resistance and quality of life.
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Affiliation(s)
- Haroon Ahmed
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionydd, Heath Park, Cardiff, UK
| | - Daniel Farewell
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionydd, Heath Park, Cardiff, UK
| | - Hywel M Jones
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionydd, Heath Park, Cardiff, UK
| | - Nick A Francis
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionydd, Heath Park, Cardiff, UK
| | - Shantini Paranjothy
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionydd, Heath Park, Cardiff, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
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74
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Feldman C, Shaddock E. Epidemiology of lower respiratory tract infections in adults. Expert Rev Respir Med 2018; 13:63-77. [DOI: 10.1080/17476348.2019.1555040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Erica Shaddock
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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75
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Heo JY, Song JY. Disease Burden and Etiologic Distribution of Community-Acquired Pneumonia in Adults: Evolving Epidemiology in the Era of Pneumococcal Conjugate Vaccines. Infect Chemother 2018; 50:287-300. [PMID: 30600652 PMCID: PMC6312904 DOI: 10.3947/ic.2018.50.4.287] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Indexed: 12/23/2022] Open
Abstract
Pneumonia is the leading cause of morbidity and mortality, particularly in old adults. The incidence and etiologic distribution of community-acquired pneumonia is variable both geographically and temporally, and epidemiology might evolve with the change of population characteristics and vaccine uptake rates. With the increasing prevalence of chronic medical conditions, a wide spectrum of healthcare-associated pneumonia could also affect the epidemiology of community-acquired pneumonia. Here, we provide an overview of the epidemiological changes associated with community-acquired pneumonia over the decades since pneumococcal conjugate vaccine introduction.
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Affiliation(s)
- Jung Yeon Heo
- Department of Infectious Diseases, Ajou University School of Medicine, Suwon, Korea
| | - Joon Young Song
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Asian Pacific Influenza Institute, Korea University College of Medicine, Seoul, Korea.
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76
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Munday JD, van Hoek AJ, Edmunds WJ, Atkins KE. Quantifying the impact of social groups and vaccination on inequalities in infectious diseases using a mathematical model. BMC Med 2018; 16:162. [PMID: 30253772 PMCID: PMC6156851 DOI: 10.1186/s12916-018-1152-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 08/14/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Social and cultural disparities in infectious disease burden are caused by systematic differences between communities. Some differences have a direct and proportional impact on disease burden, such as health-seeking behaviour and severity of infection. Other differences-such as contact rates and susceptibility-affect the risk of transmission, where the impact on disease burden is indirect and remains unclear. Furthermore, the concomitant impact of vaccination on such inequalities is not well understood. METHODS To quantify the role of differences in transmission on inequalities and the subsequent impact of vaccination, we developed a novel mathematical framework that integrates a mechanistic model of disease transmission with a demographic model of social structure, calibrated to epidemiologic and empirical social contact data. RESULTS Our model suggests realistic differences in two key factors contributing to the rates of transmission-contact rate and susceptibility-between two social groups can lead to twice the risk of infection in the high-risk population group relative to the low-risk population group. The more isolated the high-risk group, the greater this disease inequality. Vaccination amplified this inequality further: equal vaccine uptake across the two population groups led to up to seven times the risk of infection in the high-risk group. To mitigate these inequalities, the high-risk population group would require disproportionately high vaccination uptake. CONCLUSION Our results suggest that differences in contact rate and susceptibility can play an important role in explaining observed inequalities in infectious diseases. Importantly, we demonstrate that, contrary to social policy intentions, promoting an equal vaccine uptake across population groups may magnify inequalities in infectious disease risk.
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Affiliation(s)
- James D Munday
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK. .,Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
| | - Albert Jan van Hoek
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.,National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - W John Edmunds
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Katherine E Atkins
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.,Centre for Global Health, Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
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77
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German EL, Al-Hakim B, Mitsi E, Pennington SH, Gritzfeld JF, Hyder-Wright AD, Banyard A, Gordon SB, Collins AM, Ferreira DM. Anti-protein immunoglobulin M responses to pneumococcus are not associated with aging. Pneumonia (Nathan) 2018; 10:5. [PMID: 29992080 PMCID: PMC5987460 DOI: 10.1186/s41479-018-0048-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 05/10/2018] [Indexed: 11/16/2022] Open
Abstract
Background The incidence of community-acquired pneumonia and lower respiratory tract infection rises considerably in later life. Immunoglobulin M (IgM) antibody levels to pneumococcal capsular polysaccharide are known to decrease with age; however, whether levels of IgM antibody to pneumococcal proteins are subject to the same decline has not yet been investigated. Methods This study measured serum levels and binding capacity of IgM antibody specific to the pneumococcal surface protein A (PspA) and an unencapsulated pneumococcal strain in serum isolated from hospital patients aged < 60 and ≥ 60, with and without lower respiratory tract infection. A group of young healthy volunteers was used as a comparator to represent adults at very low risk of pneumococcal pneumonia. IgM serum antibody levels were measured by enzyme-linked immunosorbent assay (ELISA) and flow cytometry was performed to assess IgM binding capacity. Linear regression and one-way analysis of variance (ANOVA) tests were used to analyse the results. Results Levels and binding capacity of IgM antibody to PspA and the unencapsulated pneumococcal strain were unchanged with age. Conclusions These findings suggest that protein-based pneumococcal vaccines may provide protective immunity in the elderly. Trial registration The LRTI trial (LRTI and control groups) was approved by the National Health Service Research Ethics Committee in October 2013 (12/NW/0713). Recruitment opened in January 2013 and was completed in July 2013. Healthy volunteer samples were taken from the EHPC dose-ranging and reproducibility trial, approved by the same Research Ethics Committee in October 2011 (11/NW/0592). Recruitment for this study ran from October 2011 until December 2012. LRTI trial: (NCT01861184), EHPC dose-ranging and reproducibility trial: (ISRCTN85403723).
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Affiliation(s)
- Esther L German
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Bahij Al-Hakim
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK.,3Present address: Aintree University Hospital, Liverpool, UK
| | - Elena Mitsi
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Shaun H Pennington
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jenna F Gritzfeld
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK.,Present address: Public Health England, Vaccine Evaluation Unit, Manchester, UK
| | | | - Antonia Banyard
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK.,5Present address: Cancer Research UK Manchester Institute, Manchester, UK
| | - Stephen B Gordon
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK.,6Present address: Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
| | - Andrea M Collins
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Daniela M Ferreira
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK
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79
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Prendki V, Scheffler M, Huttner B, Garin N, Herrmann F, Janssens JP, Marti C, Carballo S, Roux X, Serratrice C, Serratrice J, Agoritsas T, Becker CD, Kaiser L, Rosset-Zufferey S, Soulier V, Perrier A, Reny JL, Montet X, Stirnemann J. Low-dose computed tomography for the diagnosis of pneumonia in elderly patients: a prospective, interventional cohort study. Eur Respir J 2018; 51:13993003.02375-2017. [PMID: 29650558 PMCID: PMC5978575 DOI: 10.1183/13993003.02375-2017] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/31/2018] [Indexed: 01/24/2023]
Abstract
The diagnosis of pneumonia is challenging. Our objective was to assess whether low-dose computed tomography (LDCT) modified the probability of diagnosing pneumonia in elderly patients. We prospectively included patients aged over 65 years with a suspicion of pneumonia treated with antimicrobial therapy (AT). All patients had a chest radiograph and LDCT within 72 h of inclusion. The treating clinician assessed the probability of pneumonia before and after the LDCT scan using a Likert scale. An adjudication committee retrospectively rated the probability of pneumonia and was considered as the reference for diagnosis. The main outcome was the difference in the clinician's pneumonia probability estimates before and after LDCT and the proportion of modified diagnoses which matched the reference diagnosis (the net reclassification improvement (NRI)). A total of 200 patients with a median age of 84 years were included. After LDCT, the estimated probability of pneumonia changed in 90 patients (45%), of which 60 (30%) were downgraded and 30 (15%) were upgraded. The NRI was 8% (NRI event (−6%) + NRI non-event (14%)). LDCT modified the estimated probability of pneumonia in a substantial proportion of patients. It mostly helped to exclude a diagnosis of pneumonia and hence to reduce unnecessary AT. Low-dose CT modified the estimated probability of pneumonia in a substantial proportion (45%) of elderly patientshttp://ow.ly/V1ha30jvOMk
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Affiliation(s)
- Virginie Prendki
- Internal Medicine and Rehabilitation Unit, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Max Scheffler
- Dept of Radiology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Benedikt Huttner
- Division of Infectious Diseases, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Nicolas Garin
- Internal Medicine, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.,Dept of General Internal Medicine, Riviera Chablais Hospitals, Monthey, Switzerland
| | - François Herrmann
- Geriatrics Unit, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Jean-Paul Janssens
- Division of Pulmonology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Christophe Marti
- Internal Medicine, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Sebastian Carballo
- Internal Medicine, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Xavier Roux
- Internal Medicine and Rehabilitation Unit, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Christine Serratrice
- Internal Medicine and Rehabilitation Unit, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Jacques Serratrice
- Internal Medicine, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Thomas Agoritsas
- Internal Medicine, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Christoph D Becker
- Dept of Radiology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Laurent Kaiser
- Division of Infectious Diseases, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Sarah Rosset-Zufferey
- Internal Medicine, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Valérie Soulier
- Internal Medicine, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Arnaud Perrier
- Internal Medicine, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Jean-Luc Reny
- Internal Medicine and Rehabilitation Unit, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Xavier Montet
- Dept of Radiology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Jérôme Stirnemann
- Internal Medicine, Dept of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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Ferreira GLC, Marano C, De Moerlooze L, Guignard A, Feng Y, El Hahi Y, van Staa T. Incidence and prevalence of hepatitis B in patients with diabetes mellitus in the UK: A population-based cohort study using the UK Clinical Practice Research Datalink. J Viral Hepat 2018; 25:571-580. [PMID: 29220868 DOI: 10.1111/jvh.12841] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 10/19/2017] [Indexed: 01/16/2023]
Abstract
We assessed the incidence and prevalence of hepatitis B (Hep B) in patients with or without diabetes mellitus (DM) using the UK Clinical Practice Research Datalink (CPRD). This was a retrospective, observational study of diabetic and nondiabetic cohorts aged 0-80 years using CPRD (NCT02324218). Incidence rates (IR) for each cohort were calculated. Crude and adjusted (Poisson regression) IR ratios (IRR) were estimated with 95% confidence intervals (CI) to compare the cohorts. Hep B prevalence stratified by age, and hospitalization related to Hep B was also calculated. Of 7 712 043 subjects identified, 4 839 770 were included (DM: 160 760; non-DM: 4 679 010). Mean ages were 54.4 and 32.0 years, and 57.20% and 50.14% were male in the diabetic and nondiabetic cohorts, respectively. Hep B was identified in 29 diabetic and 845 nondiabetic subjects; IR was 4.03 per 100 000 person-years and 2.88 per 100 000 person-years, respectively. The adjusted IRR was 1.00 (95% CI: 0.70-1.50) between diabetic and nondiabetic cohorts. Hep B prevalence was higher in the diabetic cohort (0.01%-0.26%) than in the nondiabetic cohort (0.00%-0.03%) across the different age groups. Hep B-associated hospitalization IR was higher in the diabetic cohort (4.98-10.91) than the nondiabetic cohort (0.26-2.44). The Hep B IR, hospitalization and prevalence were higher in males in both cohorts. In conclusion, the risk of incident Hep B diagnosis in the diabetic cohort was not different from that in the nondiabetic cohort. However, prevalence of Hep B and Hep B-associated hospitalization rate was higher in the diabetic than in the nondiabetic cohort.
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Affiliation(s)
| | | | | | | | | | | | - T van Staa
- Health and Research Centre, Farr Institute for Health Informatics Research, University of Manchester, Manchester, UK
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81
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van Heijl I, Schweitzer VA, Zhang L, van der Linden PD, van Werkhoven CH, Postma DF. Inappropriate Use of Antimicrobials for Lower Respiratory Tract Infections in Elderly Patients: Patient- and Community-Related Implications and Possible Interventions. Drugs Aging 2018; 35:389-398. [PMID: 29663151 PMCID: PMC5956067 DOI: 10.1007/s40266-018-0541-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The elderly are more susceptible to infections, which is reflected in the incidence and mortality of lower respiratory tract infections (LRTIs) increasing with age. Several aspects of antimicrobial use for LRTIs in elderly patients should be considered to determine appropriateness. We discuss possible differences in microbial etiology between elderly and younger adults, definitions of inappropriate antimicrobial use for LRTIs currently found in the literature, along with their results, and the possible negative impact of antimicrobial therapy at both an individual and community level. Finally, we propose that both antimicrobial stewardship interventions and novel rapid diagnostic techniques may optimize antimicrobial use in elderly patients with LRTIs.
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Affiliation(s)
- Inger van Heijl
- Department of Clinical Pharmacy, Tergooi Hospital, Van Riebeeckweg 212, Post Box 10016, Hilversum, 1201 DA, The Netherlands.
- Julius Center for Health Sciences and Primary care, University Medical Centre Utrecht, Heidelberglaan 100, Post Box 85500, Utrecht, 3508 GA, The Netherlands.
| | - Valentijn A Schweitzer
- Julius Center for Health Sciences and Primary care, University Medical Centre Utrecht, Heidelberglaan 100, Post Box 85500, Utrecht, 3508 GA, The Netherlands
| | - Lufang Zhang
- Julius Center for Health Sciences and Primary care, University Medical Centre Utrecht, Heidelberglaan 100, Post Box 85500, Utrecht, 3508 GA, The Netherlands
| | - Paul D van der Linden
- Department of Clinical Pharmacy, Tergooi Hospital, Van Riebeeckweg 212, Post Box 10016, Hilversum, 1201 DA, The Netherlands
| | - Cornelis H van Werkhoven
- Julius Center for Health Sciences and Primary care, University Medical Centre Utrecht, Heidelberglaan 100, Post Box 85500, Utrecht, 3508 GA, The Netherlands
| | - Douwe F Postma
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Heidelberglaan 100, Post Box 85500, Utrecht, 3508 GA, The Netherlands
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Incidence of pneumonia in nursing home residents in Germany: results of a claims data analysis. Epidemiol Infect 2018; 146:1123-1129. [PMID: 29695311 DOI: 10.1017/s0950268818000997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pneumonia is one of the most common infectious diseases with a high mortality, especially in the elderly population. To date, there have been only a few population-based studies dealing with the incidence of pneumonia in nursing homes (NHs). We conducted a cohort study using data from a large German statutory health insurance fund. Between 2010 and 2014, 127 227 NH residents 65 years and older were analysed. For the calculation of incidences per 100 person-years (PY) and 95% confidence intervals (CIs), we assessed the first diagnosis of pneumonia during the time in NH. We compared the rates between sexes, age groups, care levels, and comorbidities and we performed a multivariate Cox regression analysis. The mean age in the cohort was 84.0 years (74.6% female). A total of 19 183 incident cases led to an overall 5-year-incidence of 11.8 per 100 PY (95% CI 11.7-12.0). The incidence in men was substantially higher than in women. Rates were highest in the first month after NH placement. Our study revealed that the incidence of pneumonia is high in German NH residents and especially in males. Due to demographic changes, pneumonia will likely be increasingly relevant in the health care of the elderly and institutionalised population.
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83
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Predictors of post-stroke fever and infections: a systematic review and meta-analysis. BMC Neurol 2018; 18:49. [PMID: 29685118 PMCID: PMC5913801 DOI: 10.1186/s12883-018-1046-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 04/13/2018] [Indexed: 01/21/2023] Open
Abstract
Background Fever after stroke is common, and often caused by infections. In the current study, we aimed to test the hypothesis that pneumonia, urinary tract infection and all-cause fever (thought to include at least some proportion of endogenous fever) have different predicting factors, since they differ regarding etiology. Methods PubMed was searched systematically for articles describing predictors for post-stroke pneumonia, urinary tract infection and all-cause fever. A total of 5294 articles were manually assessed; first by title, then by abstract and finally by full text. Data was extracted from each study, and for variables reported in 3 or more articles, a meta-analysis was performed using a random effects model. Results Fifty-nine articles met the inclusion criteria. It was found that post-stroke pneumonia is predicted by age OR 1.07 (1.04–1.11), male sex OR 1.42 (1.17–1.74), National Institutes of Health Stroke Scale (NIHSS) OR 1.07 (1.05–1.09), dysphagia OR 3.53 (2.69–4.64), nasogastric tube OR 5.29 (3.01–9.32), diabetes OR 1.15 (1.08–1.23), mechanical ventilation OR 4.65 (2.50–8.65), smoking OR 1.16 (1.08–1.26), Chronic Obstructive Pulmonary Disease (COPD) OR 4.48 (1.82–11.00) and atrial fibrillation OR 1.37 (1.22–1.55). An opposite relation to sex may exist for UTI, which seems to be more common in women. Conclusions The lack of studies simultaneously studying a wide range of predictors for UTI or all-cause fever calls for future research in this area. The importance of new research would be to improve our understanding of fever complications to facilitate greater vigilance, monitoring, prevention, diagnosis and treatment.
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Abstract
PURPOSE OF REVIEW Preventing pneumonia in the elderly and individuals with comorbidities is an unmet clinical need. Streptococcus pneumoniae is the commonest bacterial cause of pneumonia, and we summarize recent findings regarding current S. pneumoniae vaccines, and debate their efficacy and cost-effectiveness in risk groups. We also discuss potential future vaccine strategies such as protein antigen vaccines. RECENT FINDINGS Current vaccination with pneumococcal polysaccharide vaccine does not prevent S. pneumoniae pneumonia. Vaccination with pneumococcal conjugated vaccine (PCV) prevents nasopharyngeal colonization, but although PCV13 has recently been shown to prevent S. pneumoniae pneumonia in adults, its overall efficacy was relatively low. The results of cost-effectiveness studies of PCV vaccination in adults are variable with some showing this is a cost-effective strategy, whereas others have not. The lack of cost-effectiveness is predominantly because of the current cost of the PCV vaccine and the existing herd immunity effect from childhood PCV vaccination on vaccine serotypes. SUMMARY S. pneumoniae pneumonia is a vaccine-preventable disease but remains a common cause of morbidity and mortality. Advances in vaccination using approaches that induce serotypes-independent immunity and are immunogenic in high-risk groups are required to reduce the burden of disease because of S. pneumoniae.
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85
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Wing K, Williamson E, Carpenter JR, Wise L, Schneeweiss S, Smeeth L, Quint JK, Douglas I. Real-world effects of medications for chronic obstructive pulmonary disease: protocol for a UK population-based non-interventional cohort study with validation against randomised trial results. BMJ Open 2018; 8:e019475. [PMID: 29581202 PMCID: PMC5875594 DOI: 10.1136/bmjopen-2017-019475] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a progressive disease affecting 3 million people in the UK, in which patients exhibit airflow obstruction that is not fully reversible. COPD treatment guidelines are largely informed by randomised controlled trial results, but it is unclear if these findings apply to large patient populations not studied in trials. Non-interventional studies could be used to study patient groups excluded from trials, but the use of these studies to estimate treatment effectiveness is in its infancy. In this study, we will use individual trial data to validate non-interventional methods for assessing COPD treatment effectiveness, before applying these methods to the analysis of treatment effectiveness within people excluded from, or under-represented in COPD trials. METHODS AND ANALYSIS Using individual patient data from the landmark COPD Towards a Revolution in COPD Health (TORCH) trial and validated methods for detecting COPD and exacerbations in routinely collected primary care data, we will assemble a cohort in the UK Clinical Practice Research Datalink (selecting people between 1 January 2004 and 1 January 2017) with similar characteristics to TORCH participants and test whether non-interventional data can generate comparable results to trials, using cohort methodology with propensity score techniques to adjust for potential confounding. We will then use the methodological template we have developed to determine risks and benefits of COPD treatments in people excluded from TORCH. Outcomes are pneumonia, COPD exacerbation, mortality and time to treatment change. Groups to be studied include the elderly (>80 years), people with substantial comorbidity, people with and without underlying cardiovascular disease and people with mild COPD. ETHICS AND DISSEMINATION Ethical approval has been granted by the London School of Hygiene & Tropical Medicine Ethics Committee (Ref: 11997). The study has been approved by the Independent Scientific Advisory Committee of the UK Medicines and Healthcare Products Regulatory Agency (protocol no. 17_114R). An application to use the TORCH trial data made to clinicalstudydatarequest.com has been approved. In addition to scientific publications, dissemination methods will be developed based on discussions with patient groups with COPD.
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Affiliation(s)
- Kevin Wing
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Williamson
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - James R Carpenter
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Lesley Wise
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sebastian Schneeweiss
- Department of Epidemiology, Harvard Medical School, Boston, Massachusetts, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Liam Smeeth
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ian Douglas
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Navaratnam V, Root AA, Douglas I, Smeeth L, Hubbard RB, Quint JK. Cardiovascular Outcomes after a Respiratory Tract Infection among Adults with Non-Cystic Fibrosis Bronchiectasis: A General Population-based Study. Ann Am Thorac Soc 2018; 15:315-321. [PMID: 29266966 PMCID: PMC5880522 DOI: 10.1513/annalsats.201706-488oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 12/20/2017] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Studies suggest that adults with bronchiectasis are at increased risk of cardiovascular comorbidities. OBJECTIVES We aimed to quantify the relative risk of incident cardiovascular events after a respiratory tract infection among adults with bronchiectasis. METHODS Using UK electronic primary care records, we conducted a within-person comparison using the self-controlled case series method. We calculated the relative risk of first-time cardiovascular events (either first myocardial infarction or stroke) after a respiratory tract infection compared with the individual's baseline risk. RESULTS Our cohort consisted of 895 adult men and women with non-cystic fibrosis bronchiectasis with a first myocardial infarction or stroke and at least one respiratory tract infection. There was an increased rate of first-time cardiovascular events in the 91-day period after a respiratory tract infection (incidence rate ratio, 1.56; 95% confidence interval, 1.20-2.02). The rate of a first cardiovascular event was highest in the first 3 days after a respiratory tract infection (incidence rate ratio, 2.73; 95% confidence interval, 1.41-5.27). CONCLUSIONS These data suggest that respiratory tract infections are strongly associated with a transient increased risk of first-time myocardial infarction or stroke among people with bronchiectasis. As respiratory tract infections are six times more common in people with bronchiectasis than the general population, the increased risk has a disproportionately greater impact in these individuals. These findings may have implications for including cardiovascular risk modifications in airway infection treatment pathways in this population.
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Affiliation(s)
- Vidya Navaratnam
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
- Department of Respiratory Epidemiology, Occupational Medicine, and Public Health, National Heart and Lung Institute, Imperial College London, United Kingdom; and
| | - Adrian A. Root
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ian Douglas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard B. Hubbard
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Jennifer K. Quint
- Department of Respiratory Epidemiology, Occupational Medicine, and Public Health, National Heart and Lung Institute, Imperial College London, United Kingdom; and
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Torres A, Cillóniz C, Blasi F, Chalmers JD, Gaillat J, Dartois N, Schmitt HJ, Welte T. Burden of pneumococcal community-acquired pneumonia in adults across Europe: A literature review. Respir Med 2018; 137:6-13. [PMID: 29605214 DOI: 10.1016/j.rmed.2018.02.007] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/09/2018] [Accepted: 02/10/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The burden of community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae (pneumococcus) among adults in Europe is poorly defined. METHODS Structured searches of PubMed were conducted to identify the incidence of pneumococcal CAP among adults across Europe. RESULTS The overall incidence rates for CAP was 68-7000 per 100,000 and the incidence in hospitalised CAP cases of all causes was 16-3581 per 100,000. In general the incidence of CAP increased consistently with age. Available data indicated higher burdens of pneumococcal CAP caused in groups with more comorbidities. Most cases of pneumococcal CAP (30%-78%) were caused by serotypes covered by PCV13 vaccine; the incidence of PCV13-related pneumonia decreased after the introduction of childhood vaccination. CONCLUSIONS We observed a high burden adult pneumococcal CAP in Europe despite use of the 23-valent pneumococcal polysaccharide vaccine, particularly in elderly patients with comorbidities. CAP surveillance presented wide variations across Europe. Pneumococcal CAP has to be monitored very carefully due to the possible effect of current vaccination strategies.
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Affiliation(s)
- Antoni Torres
- Department of Pulmonology, Hospital Clínic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain.
| | - Catia Cillóniz
- Department of Pulmonology, Hospital Clínic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milanoand Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center Fondazione IRCCS Cà Granda Ospedale, Maggiore Policlinico, Milano, Italy
| | - James D Chalmers
- College of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Jacques Gaillat
- Infectious Diseases Department Centre Hospitalier Annecy Genevois, 1 avenue de l'Hôpital, 74374 Pringy, France
| | - Nathalie Dartois
- Pfizer Vaccines, Medical and Scientific Affairs, 23-25 avenue du Dr. Lannelongue, F-75668 Paris Cedex 14, France
| | - Heinz-Josef Schmitt
- Pfizer Vaccines, Medical and Scientific Affairs, 23-25 avenue du Dr. Lannelongue, F-75668 Paris Cedex 14, France
| | - Tobias Welte
- Department of Respiratory Medicine, Medizinische Hochschule, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Mansfield KE, Douglas IJ, Nitsch D, Thomas SL, Smeeth L, Tomlinson LA. Acute kidney injury and infections in patients taking antihypertensive drugs: a self-controlled case series analysis. Clin Epidemiol 2018; 10:187-202. [PMID: 29430198 PMCID: PMC5796801 DOI: 10.2147/clep.s146757] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background The relative risk of acute kidney injury (AKI) following different infections, and whether angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) modify the risk, is unclear. We aimed to determine the risks of hospital admission with AKI following infections (urinary tract infection [UTI], lower respiratory tract infection [LRTI], and gastroenteritis) among users of antihypertensive drugs. Methods We used UK electronic health records from practices contributing to the Clinical Practice Research Datalink linked to the Hospital Episode Statistics database. We identified adults initiating ACEIs/ARBs or alternative antihypertensive therapy (β-blockers, calcium channel blockers, or thiazide diuretics) between April 1997 and March 2014 with at least 1 year of primary care registration prior to first prescription, who had a hospital admission for AKI, and who had a primary care record for incident UTI, LRTI, or gastroenteritis. We used a self-controlled case series design to calculate age-adjusted incidence rate ratios (IRRs) for AKI during risk periods following acute infection relative to noninfected periods (baseline). Results We identified 10,219 eligible new users of ACEIs/ARBs or other antihypertensives with an AKI record. Among these, 2,012 had at least one record for a UTI during follow-up, 2,831 had a record for LRTI, and 651 had a record for gastroenteritis. AKI risk was higher following infection than in baseline noninfectious periods. The rate ratio was highest following gastroenteritis: for the period 1–7 days postinfection, the IRR for AKI following gastroenteritis was 43.4 (95% CI=34.0–55.5), compared with 6.0 following LRTI (95% CI=5.0–7.3), and 9.3 following UTI (95% CI=7.8–11.2). Increased risks were similar for different antihypertensives. Conclusion Acute infections are associated with substantially increased transient AKI risk among antihypertensive users, with the highest risk after gastroenteritis. The increase in relative risk is not greater among users of ACEIs/ARBs compared with users of other antihypertensives.
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Affiliation(s)
| | | | | | - Sara L Thomas
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology
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Ahmed H, Farewell D, Jones HM, Francis NA, Paranjothy S, Butler CC. Incidence and antibiotic prescribing for clinically diagnosed urinary tract infection in older adults in UK primary care, 2004-2014. PLoS One 2018; 13:e0190521. [PMID: 29304056 PMCID: PMC5755802 DOI: 10.1371/journal.pone.0190521] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/15/2017] [Indexed: 11/18/2022] Open
Abstract
Urinary tract infections (UTI) are an important cause of morbidity and antibiotic use in older adults but there are little data describing disease burden in primary care. The aim of this study was to estimate the incidence of clinically diagnosed UTI and examine associated empirical antibiotic prescribing. We conducted a retrospective observational study using linked health records from almost one million patients aged ≥65 years old, registered with 393 primary care practices in England. We estimated incidence of clinically diagnosed UTI between March 2004 and April 2014, and used multilevel logistic regression to examine trends in empiric antibiotic prescribing. Of 931,945 older adults, 196,358 (21%) had at least one clinically diagnosed UTI over the study period. In men, the incidence of clinically diagnosed UTI per 100 person-years at risk increased from 2.81 to 3.05 in those aged 65–74, 5.90 to 6.13 in those aged 75–84, and 8.08 to 10.54 in those aged 85+. In women, incidence increased from 9.03 to 10.96 in those aged 65–74, 11.35 to 14.34 in those aged 75–84, and 14.65 to 19.80 in those aged 85+. Prescribing of broad-spectrum antibiotics decreased over the study period. There were increases in the proportion of older men (from 45% to 74%) and women (from 55% to 82%) with UTI, prescribed a UTI specific antibiotic. There were also increases in the proportion of older men (42% to 69%) and women (15% to 26%) prescribed antibiotics for durations recommended by clinical guidelines. This is the first population-based study describing the burden of UTI in UK primary care. Our findings suggest a need to better understand reasons for increasing rates of clinically diagnosed UTI and consider how best to address this important clinical problem.
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Affiliation(s)
- Haroon Ahmed
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
- * E-mail:
| | - Daniel Farewell
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Hywel M. Jones
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Nick A. Francis
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Shantini Paranjothy
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Chalmers J, Campling J, Ellsbury G, Hawkey PM, Madhava H, Slack M. Community-acquired pneumonia in the United Kingdom: a call to action. Pneumonia (Nathan) 2017; 9:15. [PMID: 29043150 PMCID: PMC5628444 DOI: 10.1186/s41479-017-0039-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/07/2017] [Indexed: 01/17/2023] Open
Abstract
Pneumococcal disease has a high burden in adults in the United Kingdom (UK); however, the total burden is underestimated, principally because most cases of community-acquired pneumonia (CAP) are non-invasive. Research into pneumonia receives poor funding relative to its disease burden (global mortality, disability-adjusted life years, and years lived with disability), ranking just 20 out of 25 for investment in infectious diseases in the UK. The current accuracy of data for establishing incidence rates is questionable, and it is a reflection of the paucity of research that much of the background information available derives from nearly 30 years ago. Given the relationship between CAP and mortality (pneumonia accounts for 29,000 deaths per annum in the UK, and 5-15% of patients hospitalised with CAP die within 30 days of admission), and the increasing threat of antimicrobial resistance associated with inappropriate antibiotic prescribing, such neglect of a highly prevalent problem is concerning. In this Call to Action, we explore the poorly understood burden of CAP in the UK, discuss the importance of an accurate diagnosis and appropriate treatment, and suggest how national collaboration could improve the management of an often life-threatening, yet potentially preventable disease.
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Affiliation(s)
- James Chalmers
- University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY UK
- Division of Molecular & Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, Dundee, DD1 9SY UK
| | | | | | - Peter M. Hawkey
- Institute of Microbiology and Infection, University of Birmingham, B15 2TT, Birmingham, UK
| | | | - Mary Slack
- School of Medicine, Griffith University, Campus, Gold Coast, QLD 4222 Australia
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91
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Braeken DCW, Rohde GGU, Franssen FME, Driessen JHM, van Staa TP, Souverein PC, Wouters EFM, de Vries F. Risk of community-acquired pneumonia in chronic obstructive pulmonary disease stratified by smoking status: a population-based cohort study in the United Kingdom. Int J Chron Obstruct Pulmon Dis 2017; 12:2425-2432. [PMID: 28860737 PMCID: PMC5565243 DOI: 10.2147/copd.s138435] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Smoking increases the risk of community-acquired pneumonia (CAP) and is associated with the development of COPD. Until now, it is unclear whether CAP in COPD is due to smoking-related effects, or due to COPD pathophysiology itself. OBJECTIVE To evaluate the association between COPD and CAP by smoking status. METHODS In total, 62,621 COPD and 191,654 control subjects, matched by year of birth, gender and primary care practice, were extracted from the Clinical Practice Research Datalink (2005-2014). Incidence rates (IRs) were estimated by dividing the total number of CAP cases by the cumulative person-time at risk. Time-varying Cox proportional hazard models were used to estimate the hazard ratios (HRs) for CAP in COPD patients versus controls. HRs of CAP by smoking status were calculated by stratified analyses in COPD patients versus controls and within both subgroups with never smoking as reference. RESULTS IRs of CAP in COPD patients (32.00/1,000 person-years) and controls (6.75/1,000 person-years) increased with age and female gender. The risk of CAP in COPD patients was higher than in controls (HR 4.51, 95% CI: 4.27-4.77). Current smoking COPD patients had comparable CAP risk (HR 0.92, 95% CI: 0.82-1.02) as never smoking COPD patients (reference), whereas current smoking controls had a higher risk (HR 1.23, 95% CI: 1.13-1.34) compared to never smoking controls. CONCLUSION COPD patients have a fourfold increased risk to develop CAP, independent of smoking status. Identification of factors related with the increased risk of CAP in COPD is warranted, in order to improve the management of patients at risk.
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Affiliation(s)
- Dionne CW Braeken
- Department of Research and Education, CIRO, Horn
- Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht
| | - Gernot GU Rohde
- Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht
| | - Frits ME Franssen
- Department of Research and Education, CIRO, Horn
- Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht
| | - Johanna HM Driessen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre (MUMC+), Maastricht
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht, the Netherlands
| | - Tjeerd P van Staa
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht
- Department of Health eResearch, University of Manchester, Manchester
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht
| | - Emiel FM Wouters
- Department of Research and Education, CIRO, Horn
- Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht
| | - Frank de Vries
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre (MUMC+), Maastricht
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK
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Quaife SL, Marlow LAV, McEwen A, Janes SM, Wardle J. Attitudes towards lung cancer screening in socioeconomically deprived and heavy smoking communities: informing screening communication. Health Expect 2017; 20:563-573. [PMID: 27397651 PMCID: PMC5513004 DOI: 10.1111/hex.12481] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND While discussion continues over the future implementation of lung cancer screening, low participation from higher risk groups could limit the effectiveness of any national screening programme. OBJECTIVES To compare smokers' beliefs about lung cancer screening with those of former and never smokers within a low socioeconomic status (SES) sample, to explore the views of lower SES smokers and ex-smokers in-depth, and to provide insights into effective engagement strategies. DESIGN, SETTING AND PARTICIPANTS Using proactive, community-based recruitment methods, we surveyed 175 individuals from socioeconomically deprived communities with high smoking prevalence and subsequently interviewed 21 smokers and ex-smokers. Participants were approached in community settings or responded to a mail-out from their housing association. RESULTS Interviewees were supportive of screening in principle, but many were doubtful about its ability to deliver long-term survival benefit for their generation of "heavy smokers." Lung cancer was perceived as an uncontrollable disease, and the survey data showed that fatalism, worry and perceived risk of lung cancer were particularly high among smokers compared with non-smokers. Perceived blame and stigma around lung cancer as a self-inflicted smokers' disease were implicated by interviewees as important social deterrents of screening participation. The belief that lungs are not a treatable organ appeared to be a common lay explanation for poor survival and undermined the potential value of screening. CONCLUSIONS Attitudes towards screening among this high-risk group are complex. Invitation strategies need to be carefully devised to achieve equitable participation in screening.
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Affiliation(s)
- Samantha L. Quaife
- Health Behaviour Research CentreDepartment of Epidemiology and Public HealthUniversity College LondonLondonUK
| | - Laura A. V. Marlow
- Health Behaviour Research CentreDepartment of Epidemiology and Public HealthUniversity College LondonLondonUK
| | - Andy McEwen
- Health Behaviour Research CentreDepartment of Epidemiology and Public HealthUniversity College LondonLondonUK
| | - Samuel M. Janes
- Lungs for Living Research CentreUCL RespiratoryDivision of MedicineUniversity College LondonLondonUK
| | - Jane Wardle
- Health Behaviour Research CentreDepartment of Epidemiology and Public HealthUniversity College LondonLondonUK
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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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94
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Jain A, McDonald HI, Nitsch D, Tomlinson L, Thomas SL. Risk factors for developing acute kidney injury in older people with diabetes and community-acquired pneumonia: a population-based UK cohort study. BMC Nephrol 2017; 18:142. [PMID: 28460637 PMCID: PMC5412062 DOI: 10.1186/s12882-017-0566-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 04/22/2017] [Indexed: 12/18/2022] Open
Abstract
Background Acute kidney injury (AKI) is being increasingly recognised in ageing populations. There are a paucity of data about AKI risk factors among older individuals with diabetes and infections, who are at particularly high risk of AKI. The objective of this study was to evaluate the risk factors for developing acute kidney injury (AKI) amongst older patients with diabetes and community-acquired pneumonia (CAP) in England, and whether the impact of underlying kidney function varied with age. Methods This was a population-based retrospective cohort study over 7 years (01/04/2004–31/3/2011) using electronic health records from the Clinical Practice Research Datalink linked to Hospital Episode Statistics. The study population comprised individuals with diabetes aged ≥65 years with CAP. Associations between demographic, lifestyle factors, co-morbidities and medications and development of AKI within 28 days of CAP were explored in a logistic regression model. Results Among 3471 patients with CAP and complete covariate data, 298 patients developed subsequent AKI. In multivariable analyses, factors found to be independently associated with AKI included: male sex (adjusted odds ratio, aOR: 1.56 95% confidence interval (CI): 1.20–2.04), hypertension (aOR1.36 95% CI 1.01–1.85), being prescribed either angiotensin-converting-enzyme inhibitors or angiotensin-II-receptor-blockers (aOR: 1.59 95% CI: 1.19–2.13), or insulin (aOR: 2.27 95% CI: 1.27–4.05), presence of proteinuria (aOR 1.27 95% CI 0.98–1.63), and low estimated glomerular filtration rate (eGFR). The odds of AKI were more graded amongst older participants aged ≥80 years compared to those of younger age: for eGFR of ≤29 mL/min/1.73m2 (vs 60 ml/min/1.73m2) aOR: 5.51 95% CI 3.28–9.27 and for eGFR 30–59 mL/min/1.73m2 1.96 95% CI 1.30–2.96, whilst any eGFR < 60 ml/min/1.73m2 was associated with approximately 3-fold increase in the odds of AKI amongst younger individuals (p-value for interaction = 0.007). Conclusions The identified risk factors should help primary care and hospital providers identify high risk patients in need of urgent management including more intensive monitoring, and prevention of AKI following pneumonia.
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Affiliation(s)
- Anu Jain
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK.
| | - Helen I McDonald
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
| | - Laurie Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
| | - Sara L Thomas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK
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95
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Taipale H, Tolppanen AM, Koponen M, Tanskanen A, Lavikainen P, Sund R, Tiihonen J, Hartikainen S. Risk of pneumonia associated with incident benzodiazepine use among community-dwelling adults with Alzheimer disease. CMAJ 2017; 189:E519-E529. [PMID: 28396328 DOI: 10.1503/cmaj.160126] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Knowledge regarding whether benzodiazepines and similarly acting non-benzodiazepines (Z-drugs) are associated with an increased risk of pneumonia among older adults is lacking. We sought to investigate this association among community-dwelling adults with Alzheimer disease, a condition in which both sedative/hypnotic use and pneumonia are common. METHODS We obtained data on all community-dwelling adults with a recent diagnosis of Alzheimer disease in Finland (2005-2011) from the Medication use and Alzheimer disease (MEDALZ) cohort, which incorporates national registry data on prescriptions, reimbursement, hospital discharges and causes of death. Incident users of benzodiazepines and Z-drugs were identified using a 1-year washout period and matched with nonusers using propensity scores. The association with hospital admission or death due to pneumonia was analyzed with the Cox proportional hazards model and adjusted for use of other psychotropic drugs in a time-dependent manner. RESULTS Among 49 484 eligible participants with Alzheimer disease, 5232 taking benzodiazepines and 3269 taking Z-drugs were matched 1:1 with those not taking these drugs. Collectively, use of benzodiazepines and Z-drugs was associated with an increased risk of pneumonia (adjusted hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.05-1.42). When analyzed separately, benzodiazepine use was significantly associated with an increased risk of pneumonia (adjusted HR 1.28, 95% CI 1.07-1.54), whereas Z-drug use was not (adjusted HR 1.10, 95% CI 0.84-1.44). The risk of pneumonia was greatest within the first 30 days of benzodiazepine use (HR 2.09, 95% CI 1.26-3.48). INTERPRETATION Benzodiazepine use was associated with an increased risk of pneumonia among patients with Alzheimer disease. Risk of pneumonia should be considered when weighing the benefits and risks of benzodiazepines in this population.
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Affiliation(s)
- Heidi Taipale
- Kuopio Research Centre of Geriatric Care (Taipale, Koponen, Lavikainen, Hartikainen); School of Pharmacy (Taipale, Tolppanen, Koponen, Lavikainen, Hartikainen); Department of Forensic Psychiatry (Taipale, Tanskanen, Tiihonen), Niuvanniemi Hospital; Institute of Clinical Medicine (Sund); Research Centre for Comparative Effectiveness and Patient Safety (RECEPS) (Tolppanen), University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience (Tanskanen, Tiihonen), Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare (Tanskanen), Helsinki, Finland; Department of Pharmacology (Lavikainen), Drug Development and Therapeutics, University of Turku, Turku, Finland; Department of Social Research (Sund), Centre for Research Methods, University of Helsinki, Helsinki, Finland; Department of Psychiatry (Hartikainen), Kuopio University Hospital, Kuopio, Finland
| | - Anna-Maija Tolppanen
- Kuopio Research Centre of Geriatric Care (Taipale, Koponen, Lavikainen, Hartikainen); School of Pharmacy (Taipale, Tolppanen, Koponen, Lavikainen, Hartikainen); Department of Forensic Psychiatry (Taipale, Tanskanen, Tiihonen), Niuvanniemi Hospital; Institute of Clinical Medicine (Sund); Research Centre for Comparative Effectiveness and Patient Safety (RECEPS) (Tolppanen), University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience (Tanskanen, Tiihonen), Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare (Tanskanen), Helsinki, Finland; Department of Pharmacology (Lavikainen), Drug Development and Therapeutics, University of Turku, Turku, Finland; Department of Social Research (Sund), Centre for Research Methods, University of Helsinki, Helsinki, Finland; Department of Psychiatry (Hartikainen), Kuopio University Hospital, Kuopio, Finland
| | - Marjaana Koponen
- Kuopio Research Centre of Geriatric Care (Taipale, Koponen, Lavikainen, Hartikainen); School of Pharmacy (Taipale, Tolppanen, Koponen, Lavikainen, Hartikainen); Department of Forensic Psychiatry (Taipale, Tanskanen, Tiihonen), Niuvanniemi Hospital; Institute of Clinical Medicine (Sund); Research Centre for Comparative Effectiveness and Patient Safety (RECEPS) (Tolppanen), University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience (Tanskanen, Tiihonen), Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare (Tanskanen), Helsinki, Finland; Department of Pharmacology (Lavikainen), Drug Development and Therapeutics, University of Turku, Turku, Finland; Department of Social Research (Sund), Centre for Research Methods, University of Helsinki, Helsinki, Finland; Department of Psychiatry (Hartikainen), Kuopio University Hospital, Kuopio, Finland
| | - Antti Tanskanen
- Kuopio Research Centre of Geriatric Care (Taipale, Koponen, Lavikainen, Hartikainen); School of Pharmacy (Taipale, Tolppanen, Koponen, Lavikainen, Hartikainen); Department of Forensic Psychiatry (Taipale, Tanskanen, Tiihonen), Niuvanniemi Hospital; Institute of Clinical Medicine (Sund); Research Centre for Comparative Effectiveness and Patient Safety (RECEPS) (Tolppanen), University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience (Tanskanen, Tiihonen), Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare (Tanskanen), Helsinki, Finland; Department of Pharmacology (Lavikainen), Drug Development and Therapeutics, University of Turku, Turku, Finland; Department of Social Research (Sund), Centre for Research Methods, University of Helsinki, Helsinki, Finland; Department of Psychiatry (Hartikainen), Kuopio University Hospital, Kuopio, Finland
| | - Piia Lavikainen
- Kuopio Research Centre of Geriatric Care (Taipale, Koponen, Lavikainen, Hartikainen); School of Pharmacy (Taipale, Tolppanen, Koponen, Lavikainen, Hartikainen); Department of Forensic Psychiatry (Taipale, Tanskanen, Tiihonen), Niuvanniemi Hospital; Institute of Clinical Medicine (Sund); Research Centre for Comparative Effectiveness and Patient Safety (RECEPS) (Tolppanen), University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience (Tanskanen, Tiihonen), Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare (Tanskanen), Helsinki, Finland; Department of Pharmacology (Lavikainen), Drug Development and Therapeutics, University of Turku, Turku, Finland; Department of Social Research (Sund), Centre for Research Methods, University of Helsinki, Helsinki, Finland; Department of Psychiatry (Hartikainen), Kuopio University Hospital, Kuopio, Finland
| | - Reijo Sund
- Kuopio Research Centre of Geriatric Care (Taipale, Koponen, Lavikainen, Hartikainen); School of Pharmacy (Taipale, Tolppanen, Koponen, Lavikainen, Hartikainen); Department of Forensic Psychiatry (Taipale, Tanskanen, Tiihonen), Niuvanniemi Hospital; Institute of Clinical Medicine (Sund); Research Centre for Comparative Effectiveness and Patient Safety (RECEPS) (Tolppanen), University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience (Tanskanen, Tiihonen), Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare (Tanskanen), Helsinki, Finland; Department of Pharmacology (Lavikainen), Drug Development and Therapeutics, University of Turku, Turku, Finland; Department of Social Research (Sund), Centre for Research Methods, University of Helsinki, Helsinki, Finland; Department of Psychiatry (Hartikainen), Kuopio University Hospital, Kuopio, Finland
| | - Jari Tiihonen
- Kuopio Research Centre of Geriatric Care (Taipale, Koponen, Lavikainen, Hartikainen); School of Pharmacy (Taipale, Tolppanen, Koponen, Lavikainen, Hartikainen); Department of Forensic Psychiatry (Taipale, Tanskanen, Tiihonen), Niuvanniemi Hospital; Institute of Clinical Medicine (Sund); Research Centre for Comparative Effectiveness and Patient Safety (RECEPS) (Tolppanen), University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience (Tanskanen, Tiihonen), Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare (Tanskanen), Helsinki, Finland; Department of Pharmacology (Lavikainen), Drug Development and Therapeutics, University of Turku, Turku, Finland; Department of Social Research (Sund), Centre for Research Methods, University of Helsinki, Helsinki, Finland; Department of Psychiatry (Hartikainen), Kuopio University Hospital, Kuopio, Finland
| | - Sirpa Hartikainen
- Kuopio Research Centre of Geriatric Care (Taipale, Koponen, Lavikainen, Hartikainen); School of Pharmacy (Taipale, Tolppanen, Koponen, Lavikainen, Hartikainen); Department of Forensic Psychiatry (Taipale, Tanskanen, Tiihonen), Niuvanniemi Hospital; Institute of Clinical Medicine (Sund); Research Centre for Comparative Effectiveness and Patient Safety (RECEPS) (Tolppanen), University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience (Tanskanen, Tiihonen), Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare (Tanskanen), Helsinki, Finland; Department of Pharmacology (Lavikainen), Drug Development and Therapeutics, University of Turku, Turku, Finland; Department of Social Research (Sund), Centre for Research Methods, University of Helsinki, Helsinki, Finland; Department of Psychiatry (Hartikainen), Kuopio University Hospital, Kuopio, Finland
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96
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Wagenvoort GHJ, Sanders EAM, Vlaminckx BJ, de Melker HE, van der Ende A, Knol MJ. Sex differences in invasive pneumococcal disease and the impact of pneumococcal conjugate vaccination in the Netherlands, 2004 to 2015. ACTA ACUST UNITED AC 2017; 22:30481. [PMID: 28300529 PMCID: PMC5356421 DOI: 10.2807/1560-7917.es.2017.22.10.30481] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/06/2016] [Indexed: 11/20/2022]
Abstract
Implementation of pneumococcal conjugate vaccines in the Netherlands (PCV7 in 2006 and PCV10 in 2011) for infants caused a shift in serotypes in invasive pneumococcal disease (IPD). We explored sex differences in serotype-specific IPD incidence before and after vaccine introduction. Incidences in the pre-PCV7 (June 2004–May 2006), post-PCV7 (June 2008–May 2011) and post-PCV10 period (June 2013–May 2015), stratified by age, were compared. Incidence was higher in men for all age groups (overall in men: 16.7, 15.5 and 14.4/100,000 and women: 15.4, 13.6 and 13.9/100,000 pre-PCV7, post-PCV7 and post-PCV10, respectively), except for 20–39 year-olds after PCV7 and 40–64 year-olds after PCV10 introduction. After PCV7 and PCV10 introduction, the overall IPD incidence decreased in men aged 20–39 years (from 5.3 pre-PCV7 to 4.7 and 2.6/100,000 post-PCV7 and post-PCV10, respectively), whereas it showed a temporary increase in women (from 3.9/100,000 pre-PCV7 to 5.0/100,000 post-PCV7 and back to 4.0/100,000 post-PCV10) due to replacement disease. PCV10 herd effects were observed throughout, but in women older than 40 years, a significant increase in non-PCV10 serotype offset a decrease in overall IPD incidence. Ongoing surveillance of IPD incidence by sex is important to evaluate the long-term effects of PCV implementation.
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Affiliation(s)
- Gertjan H J Wagenvoort
- Department of Medical Microbiology and Immunology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Elisabeth A M Sanders
- Centre for Infectious Disease Control Netherlands (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.,Department of Immunology and Infectious diseases, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, the Netherlands
| | - Bart J Vlaminckx
- Department of Medical Microbiology and Immunology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Hester E de Melker
- Centre for Infectious Disease Control Netherlands (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Arie van der Ende
- Department of Medical Microbiology and the Netherlands Reference Laboratory for Bacterial Meningitis, Academic Medical Center, Amsterdam, the Netherlands
| | - Mirjam J Knol
- Centre for Infectious Disease Control Netherlands (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
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97
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McDonald HI, Thomas SL, Millett ERC, Quint J, Nitsch D. Do influenza and pneumococcal vaccines prevent community-acquired respiratory infections among older people with diabetes and does this vary by chronic kidney disease? A cohort study using electronic health records. BMJ Open Diabetes Res Care 2017; 5:e000332. [PMID: 28461899 PMCID: PMC5387965 DOI: 10.1136/bmjdrc-2016-000332] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/12/2017] [Accepted: 01/24/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We aimed to estimate the effectiveness of influenza and 23-valent pneumococcal polysaccharide vaccination on reducing the burden of community-acquired lower respiratory tract infection (LRTI) among older people with diabetes, and whether this varied by chronic kidney disease (CKD) status. RESEARCH DESIGN AND METHODS We used linked UK electronic health records for a retrospective cohort study of 190 492 patients ≥65 years with diabetes mellitus and no history of renal replacement therapy, 1997-2011. We included community-acquired LRTIs managed in primary or secondary care. Infection incidence rate ratios were estimated using the Poisson regression. Pneumococcal vaccine effectiveness (VE) was calculated as (1-effect measure). To estimate influenza VE, a ratio-of-ratios analysis (winter effectiveness/summer effectiveness) was used to address confounding by indication. Final VE estimates were stratified according to estimated glomerular filtration rate and proteinuria status. RESULTS Neither influenza nor pneumococcal vaccine uptake varied according to CKD status. Pneumococcal VE was 22% (95% CI 11% to 31%) against community-acquired pneumonia for the first year after vaccination, but was negligible after 5 years. In the ratio-of-ratios analysis, current influenza vaccination had 7% effectiveness for preventing community-acquired LRTI (95% CI 3 to 12). Pneumococcal VE was lower among patients with a history of proteinuria than among patients without proteinuria (p=0.04), but otherwise this study did not identify variation in pneumococcal or influenza VE by markers of CKD. CONCLUSIONS The public health benefits of influenza vaccine may be modest among older people with diabetes. Pneumococcal vaccination protection against community-acquired pneumonia declines swiftly: alternative vaccination schedules should be investigated.
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Affiliation(s)
- Helen I McDonald
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sara L Thomas
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth R C Millett
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Jennifer Quint
- Department of Respiratory Epidemiology, Occupational Medicine and Public Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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98
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Leite A, Andrews NJ, Thomas SL. Assessing recording delays in general practice records to inform near real-time vaccine safety surveillance using the Clinical Practice Research Datalink (CPRD). Pharmacoepidemiol Drug Saf 2017; 26:437-445. [PMID: 28156036 PMCID: PMC5396331 DOI: 10.1002/pds.4173] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 12/07/2016] [Accepted: 01/10/2017] [Indexed: 12/12/2022]
Abstract
Purpose Near real‐time vaccine safety surveillance (NRTVSS) is an option for post‐licensure vaccine safety assessment. NRTVSS requires timely recording of outcomes in the database used. Our main objective was to examine recording delays in the Clinical Practice Research Datalink (CPRD) for outcomes of interest for vaccine safety to inform the feasibility of NRTVSS using these data. We also evaluated completeness of recording and further assessed reporting delays for hospitalized events in CPRD. Methods We selected Guillain–Barré syndrome (GBS), Bell's palsy (BP), optic neuritis (ON) and febrile seizures (FS), from January 2005 to June 2014. We assessed recording delays (e.g. due to feedback from specialist referral) in stand‐alone CPRD by comparing the event and system dates and excluding delays >1 year. We used linked CPRD‐hospitalization data to further evaluate delays and completeness of recording in CPRD. Results Among 51 220 patients for the stand‐alone CPRD analysis (GBS: n = 830; BP: n = 12 602; ON: n = 1720; and FS: n = 36 236), most had a record entered within 1 month of the event date (GBS: 73.6%; BP: 93.4%; ON: 76.2%; and FS: 85.6%). A total of 13 482 patients, with a first record in hospital, were included for the analysis of linked data (GBS: n = 678; BP: n = 4060; ON: n = 485; and FS: n = 8321). Of these, <50% had a record in CPRD after 1 year (GBS: 41.3%; BP: 22.1%; ON: 22.4%; and FS: 41.8%). Conclusion This work shows that most diagnoses in CPRD for the conditions examined were recorded with delays of ≤30 days, making NRTVSS possible. The pattern of delays was condition‐specific and could be used to adjust for delays in the NRTVSS analysis. Despite low sensitivity of recording, implementing NRTVSS in CPRD is worthwhile and could be carried out, at least on a trial basis, for events of interest. © 2017 The Authors. Pharmacoepidemiology & Drug Safety Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Andreia Leite
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Nick J Andrews
- Statistics, Modelling and Economics Department, Public Health England, London, UK
| | - Sara L Thomas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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99
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Williams NP, Coombs NA, Johnson MJ, Josephs LK, Rigge LA, Staples KJ, Thomas M, Wilkinson TM. Seasonality, risk factors and burden of community-acquired pneumonia in COPD patients: a population database study using linked health care records. Int J Chron Obstruct Pulmon Dis 2017; 12:313-322. [PMID: 28176888 PMCID: PMC5261550 DOI: 10.2147/copd.s121389] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is more common in patients with COPD than in the adult general population, with studies of hospitalized CAP patients consistently reporting COPD as a frequent comorbidity. However, despite an increasing recognition of its importance, large studies evaluating the incidence patterns over time, risk factors and burden of CAP in COPD are currently lacking. Methods A retrospective observational study using a large UK-based database of linked primary and secondary care records was conducted. Patients with a diagnosis of COPD aged ≥40 years were followed up for 5 years from January 1, 2010. CAP and exacerbation episodes were identified from hospital discharge data and primary care coding records, and rates were calculated per month, adjusting for mortality, and displayed over time. In addition, baseline factors predicting future risk of CAP and hospital admission with CAP were identified. Results A total of 14,513 COPD patients were identified: 13.4% (n=1,938) had ≥1 CAP episode, of whom 18.8% suffered from recurrent (≥2) CAP. Highest rates of both CAP and exacerbations were seen in winter. A greater proportion of frequent, compared to infrequent, exacerbators experienced recurrent CAP (5.1% versus 2.0%, respectively, P<0.001); 75.6% of CAP episodes were associated with hospital admission compared to 22.1% of exacerbations. Older age and increasing grade of airflow limitation were independently associated with increased odds of CAP and hospital admission with CAP. Other independent predictors of future CAP included lower body mass index, inhaled corticosteroid use, prior frequent exacerbations and comorbidities, including ischemic heart disease and diabetes. Conclusion CAP in COPD demonstrates clear seasonal patterns, with patient characteristics predictive of the odds of future CAP and hospital admission with CAP. Highlighting this burden of COPD-associated CAP during the winter period informs us of the likely triggers and the need for more effective preventive strategies.
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Affiliation(s)
- Nicholas P Williams
- Southampton NIHR Respiratory Biomedical Research Unit, Southampton General Hospital; Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital
| | - Ngaire A Coombs
- Primary Care and Population Sciences, Faculty of Medicine, Southampton General Hospital
| | - Matthew J Johnson
- NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Lynn K Josephs
- Primary Care and Population Sciences, Faculty of Medicine, Southampton General Hospital; NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Lucy A Rigge
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital; NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Karl J Staples
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital
| | - Mike Thomas
- Southampton NIHR Respiratory Biomedical Research Unit, Southampton General Hospital; Primary Care and Population Sciences, Faculty of Medicine, Southampton General Hospital; NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Tom Ma Wilkinson
- Southampton NIHR Respiratory Biomedical Research Unit, Southampton General Hospital; Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital; NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton, Southampton General Hospital, Southampton, UK
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100
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Ho SW, Teng YH, Yang SF, Yeh HW, Wang YH, Chou MC, Yeh CB. Risk of pneumonia in patients with isolated minor rib fractures: a nationwide cohort study. BMJ Open 2017; 7:e013029. [PMID: 28087547 PMCID: PMC5253567 DOI: 10.1136/bmjopen-2016-013029] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Isolated minor rib fractures (IMRFs) after blunt chest traumas are commonly observed in emergency departments. However, the relationship between IMRFs and subsequent pneumonia remains controversial. This nationwide cohort study investigated the association between IMRFs and the risk of pneumonia in patients with blunt chest traumas. DESIGN Nationwide population-based cohort study. SETTING Patients with IMRFs were identified between 2010 and 2011 from the Taiwan National Health Insurance Research Database. PARTICIPANTS Non-traumatic patients were matched through 1:8 propensity-score matching according to age, sex, and comorbidities (namely diabetes, hypertension, cardiovascular disease, asthma and chronic obstructive pulmonary disease (COPD)) with the comparison cohort. We estimated the adjusted HRs (aHRs) by using the Cox proportional hazard model. A total of 709 patients with IMRFs and 5672 non-traumatic patients were included. MAIN OUTCOME MEASURE The primary end point was the occurrence of pneumonia within 30 days. RESULTS The incidence of pneumonia following IMRFs was 1.6% (11/709). The aHR for the risk of pneumonia after IMRFs was 8.94 (95% CI=3.79 to 21.09, p<0.001). Furthermore, old age (≥65 years; aHR=5.60, 95% CI 1.97 to 15.89, p<0.001) and COPD (aHR=5.41, 95% CI 1.02 to 3.59, p<0.001) were risk factors for pneumonia following IMRFs. In the IMRF group, presence of single or two isolated rib fractures was associated with an increased risk of pneumonia with aHRs of 3.97 (95% CI 1.09 to 14.44, p<0.001) and 17.13 (95% CI 6.66 to 44.04, p<0.001), respectively. CONCLUSIONS Although the incidence of pneumonia following IMRFs is low, patients with two isolated rib fractures were particularly susceptible to pneumonia. Physicians should focus on this complication, particularly in elderly patients and those with COPD.
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Affiliation(s)
- Sai-Wai Ho
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ying-Hock Teng
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Han-Wei Yeh
- School of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ming-Chih Chou
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chao-Bin Yeh
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
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