Trends in hospitalizations for pneumonia among persons aged 65 years or older in the United States, 1988-2002

Epidemiology of community-acquired pneumonia in older adults: a population-based study

OBJECTIVE

This study assessed incidence, aetiology, clinical outcomes and risk factors for community-acquired pneumonia (CAP) in older adults.

METHODS

This was a population-based cohort study that included 11,241 community-dwelling individuals aged 65 years or more, who were followed between 2002 and 2005 in the region of Tarragona, Spain. Primary endpoints were all-cause CAP (hospitalised and outpatient) and 30-day mortality after the diagnosis. All cases were radiographically proved and validated by checking clinical records.

RESULTS

Incidence rate of overall CAP was 14 cases per 1000 person-years (10.5 and 3.5 for hospitalised and outpatient cases, respectively). Incidence was almost three-fold higher among immunocompromised patients (30.9 per 1000) than among immunocompetent subjects (11.6 per 1000). Maximum incidences were observed among patients with chronic lung disease and long-term corticosteroid therapy (46.5 and 40.1 cases per 1000 person-years, respectively). Overall 30-day case-fatality rate was 12.7% (2% in cases managed as outpatient and 15% in hospitalised patients). Among 358 patients with an aetiological work-up, a total of 142 pathogens were found (single pathogen in 121 cases and mixed pathogens in 10 cases). Streptococcus pneumoniae was the most common pathogen (49%), followed by Pseudomonas aeruginosa (15%), Chlamydia pneumoniae (9%) and Haemophilus influenzae (6%). In multivariable analysis, the variables most strongly associated with increasing risk of CAP were history of hospitalisation for CAP in the previous 2 years and presence of any chronic lung disease.

CONCLUSIONS

CAP remains a major cause of morbidity and mortality in older adults. Incidence rates in this study largely doubled prior rates reported in Southern European regions.

Diabetes, glycemic control, and risk of hospitalization with pneumonia: a population-based case-control study

OBJECTIVE

To examine whether diabetes is a risk factor for hospitalization with pneumonia and to assess the impact of A1C level on such risk.

RESEARCH DESIGN AND METHODS

In this population-based, case-control study we identified patients with a first-time pneumonia-related hospitalization between 1997 and 2005, using health care databases in northern Denmark. For each case, 10 sex- and age-matched population control subjects were selected from Denmark's Civil Registration System. We used conditional logistic regression to compute relative risk (RR) for pneumonia-related hospitalization among subjects with and without diabetes, controlling for potential confounding factors.

RESULTS

The study included 34,239 patients with a pneumonia-related hospitalization and 342,390 population control subjects. The adjusted RR for pneumonia-related hospitalization among subjects with diabetes was 1.26 (95% CI 1.21-1.31) compared with nondiabetic individuals. The adjusted RR was 4.43 (3.40-5.77) for subjects with type 1 diabetes and 1.23 (1.19-1.28) for subjects with type 2 diabetes. Diabetes duration >or=10 years increased the risk of a pneumonia-related hospitalization (1.37 [1.28-1.47]). Compared with subjects without diabetes, the adjusted RR was 1.22 (1.14-1.30) for diabetic subjects whose A1C level was <7% and 1.60 (1.44-1.76) for diabetic subjects whose A1C level was >or=9%.

CONCLUSIONS

Type 1 and type 2 diabetes are risk factors for a pneumonia-related hospitalization. Poor long-term glycemic control among patients with diabetes clearly increases the risk of hospitalization with pneumonia.

Increased hospitalizations of elderly patients

This issue of Emerging Infectious Diseases contains 2 articles that report increases in England in the incidence of hospitalizations for specific diseases, one on pneumonias and the other on community-acquired staphylococcal diseases. Both articles report increases in disease among those >65 years of age.

Increasing hospital admissions for pneumonia, England

This rise in recorded incidence from 2001 to 2005 was particularly marked among the elderly.

Pneumonia is an important cause of illness and death in England. To describe trends in pneumonia hospitalizations, we extracted information on all episodes of pneumonia that occurred from April 1997 through March 2005 recorded in the Hospital Episode Statistics (HES) database by searching for International Classification of Diseases 10th revision codes J12–J18 in any diagnostic field. The age-standardized incidence of hospitalization with a primary diagnosis of pneumonia increased by 34% from 1.48 to 1.98 per 1,000 population between 1997–98 and 2004–05. The increase was more marked in older adults, in whom the mortality rate was also highest. The proportion of patients with recorded coexisting conditions (defined by using the Charlson Comorbidity Index score) increased over the study period. The rise in pneumonia hospital admissions was not fully explained by demographic change or increasing coexisting conditions. It may be attributable to other population factors, changes in HES coding, changes to health service organization, other biologic phenomenon, or a combination of these effects.

The burden of community-acquired pneumonia in the elderly: the Spanish EVAN-65 study

BACKGROUND

Community-acquired pneumonia (CAP) is generally considered a major cause of morbidity and mortality in the elderly. However, population-based data are very limited and its overall burden is unclear. This study assessed incidence and mortality from CAP among Spanish community-dwelling elderly.

METHODS

Prospective cohort study that included 11,240 individuals aged 65 years or older, who were followed from January 2002 until April 2005. Primary endpoints were all-cause CAP (hospitalised and outpatient) and 30-day mortality after the diagnosis. All cases were radiographically proved and validated by checking clinical records.

RESULTS

Incidence rate of overall CAP was 14 cases per 1,000 person-year (95% confidence interval: 12.7 to 15.3). Incidence increased dramatically by age (9.9 in people 65-74 years vs 29.4 in people 85 years or older), and it was almost double in men than in women (19.3 vs 10.1). Hospitalisation rate was 75.1%, with a mean length-stay of 10.4 days. Overall 30-days case-fatality rate was 13% (15% in hospitalised and 2% in outpatient cases).

CONCLUSION

CAP remains as a major health problem in older adults. Incidence rates in this study are comparable with rates described in Northern Europe and America, but they largely doubled prior rates reported in other Southern European regions.

A 30-month experience of thoracic empyema in a tertiary hospital: emphasis on differing bacteriology and outcome between the medical intensive care unit (MICU) and medical ward

OBJECTIVES

To analyze the causative pathogens and outcomes of patients with thoracic empyema admitted to the medical intensive care unit (MICU) and medical ward.

METHODS

We prospectively studied the empyemic patients in the MICU and retrospectively analyzed the medical records of empyemic patients in the medical ward treated in a tertiary university hospital from April 2001 to September 2003.

RESULTS

During this period, 116 patients in the medical ward and 78 patients in MICU had complicated parapneumonic effusions or empyemas. Effusion cultures were positive in 164 patients (85%); a total of 147 and 78 microorganisms were isolated from the 106 medical ward patients and 58 MICU patients, respectively. No matter whether medical ward or MICU patients, aerobic gram-negative organisms were the most common bacteria in positive-culture effusions (110, 67%). Klebsiella pneumoniae (14, 24%) was the predominant pathogen among the MICU patients, and Streptococcus spp. (28, 26%) was the main pathogen among the medical ward patients. Compared with these positive-culture empyemic patients in the medical ward, MICU patients had a significantly higher percentage of aerobic gram-negative organism infections (P = 0.034) and a higher infection-related mortality rate (P = 0.01).

CONCLUSION

The mortality and predominant pathogens in patients with complicated parapneumonic effusions or thoracic empyemas in the medical ward and MICU were different. The increasing gram-negative pathogens in empyemas have become an urgent problem.

Hospital charges attributable to a primary diagnosis of infectious diseases in older adults in the United States, 1998 to 2004

OBJECTIVES

To describe total and average hospital charges associated with infectious disease (ID) hospitalizations and specific ID categories and to estimate ID hospitalization rates in adults aged 65 and older in the United States from 1998 through 2004.

DESIGN

Retrospective analysis of hospital discharge data obtained from the Nationwide Inpatient Sample for 1998 through 2004.

SETTING

United States.

PATIENTS

Older adults hospitalized in the United States from 1998 through 2004.

MEASUREMENTS

Hospital charges and hospitalization rates for IDs described according to year, age group, sex, U.S. Census region, and ID category. Charges for non-ID hospitalizations were also described. Hospital charges were adjusted for inflation.

RESULTS

From 1998 through 2004, total charges for ID hospitalizations exceeded $261 billion and accounted for 13% of all hospital charges for older adults. Total charges for ID hospitalizations increased from $31.4 billion in 1998 to $45.7 billion in 2004. The average annual ID hospital charge was lower than the average annual non-ID hospital charge during the study period ($21,342 vs $22,787, P<.001). The average annual rate for ID hospitalizations was 503 per 10,000 older adults, which remained stable during the study period.

CONCLUSION

The total charges for ID hospitalizations and for all hospitalizations in older adults in the United States increased 45% and nearly 40%, respectively, during the 7-year study period, whereas the population of older adults grew by only 5%. Sustained increases of such magnitude will have major implications for the U.S. healthcare system as it prepares for the more than doubling of the older U.S. adult population during the first 30 years of this century.

Prior outpatient antibiotic use as predictor for microbial aetiology of community-acquired pneumonia: hospital-based study

OBJECTIVE

The causative micro-organism in community-acquired pneumonia (CAP) is often difficult to predict. Different studies have examined chronic morbidity and clinical symptoms as predictors for microbial aetiology of pneumonia. The aim of our study was to assess whether prior outpatient antimicrobial treatment is predictive for determining the microbial aetiology of CAP.

METHODS

This was a hospital-based prospective observational study including all patients admitted with CAP between 1 October 2004 and 1 August 2006. Microbial investigations included sputum, blood culture, sputum PCR, antigen testing and serology. Exposure to antimicrobial drugs prior to hospital admission was ascertained through community pharmacy dispensing records. Multivariate logistic regression analysis was conducted to assess whether prior outpatient antimicrobial treatment is a predictor of microbial aetiology. Patient demographics, co-morbidities and pneumonia severity were considered to be other potential predictors.

RESULTS

Overall, 201 patients were included in the study. The microbial aetiology was determined in 64% of the patients. The five most prevalent pathogens were Streptococcus pneumoniae, Heamophilus influenzae, Legionella spp., Mycoplasma pneumoniae and Influenza virus A+B. Forty-seven of the patients (23%) had received initial antimicrobial treatment as outpatients. Multivariate analyses revealed that initial outpatient beta-lactam treatment was associated with a threefold increased chance of finding atypical pathogens and a threefold decreased probability of pneumococcal infection; the corresponding odds ratios were 3.51 (95% CI 1.25-9.99) and 0.30 (95% CI 0.10-0.90), respectively. Patients who received macrolides prior to hospitalisation had an increased probability of viral pneumonia.

CONCLUSION

Prior outpatient antimicrobial therapy has a predictive value in the diagnostic workup aimed at identifying the causative pathogen and planning corresponding antimicrobial treatment in patients hospitalised for pneumonia.

Antipsychotic drug use and risk of pneumonia in elderly people

OBJECTIVES

To investigate the association between antipsychotic drug use and risk of pneumonia in elderly people.

DESIGN

A nested case-control analysis.

SETTING

Data were used from the PHARMO database, which collates information from community pharmacies and hospital discharge records.

PARTICIPANTS

A cohort of 22,944 elderly people with at least one antipsychotic prescription; 543 cases of hospital admission for pneumonia were identified. Cases were compared with four randomly selected controls matched on index date.

MEASUREMENTS

Antipsychotic drug use in the year before the index date was classified as current, recent, or past use. No prescription for an antipsychotic in the year before the index date was classified as no use. The strength of the association between use of antipsychotics and the development of pneumonia was estimated using multivariate logistic regression analysis and expressed as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Current use of antipsychotics was associated with an almost 60% increase in the risk of pneumonia (adjusted OR=1.6, 95% CI=1.3-2.1). The risk was highest during the first week after initiation of an antipsychotic (adjusted OR=4.5, 95% CI=2.8-7.3). Similar associations were found after exclusion of elderly people with a diagnosis of delirium. Current users of atypical agents showed a higher risk of pneumonia (adjusted OR=3.1, 95% CI=1.9-5.1) than users of conventional agents (adjusted OR=1.5, 95% CI=1.2-1.9). There was no clear dose-response relationship.

CONCLUSION

Use of antipsychotics in elderly people is associated with greater risk of pneumonia. This risk is highest shortly after the initiation of treatment, with the greatest increase in risk found for atypical antipsychotics.

An intervention program to reduce the number of hospitalizations of elderly patients in a primary care clinic

BACKGROUND

The elderly population consumes a large share of medical resources in the western world. A significant portion of the expense is related to hospitalizations.

OBJECTIVES

To evaluate an intervention program designed to reduce the number of hospitalization of elderly patients by a more optimal allocation of resources in primary care.

METHODS

A multidimensional intervention program was conducted that included the re-engineering of existing work processes with a focus on the management of patient problems, improving communication with outside agencies, and the establishment of a system to monitor quality of healthcare parameters. Data on the number of hospitalizations and their cost were compared before and after implementation of the intervention program.

RESULTS

As a result of the intervention the mean expenditure per elderly patient was reduced by 22.5%. The adjusted number of hospitalizations/1,000 declined from 15.1 to 10.7 (29.3%). The number of adjusted hospitalization days dropped from 132 to 82 (37.9%) and the mean hospitalization stay declined from 8.2 to 6.7 days (17.9%). The adjusted hospitalization cost ($/1,000 patients) dropped from $32,574 to $18,624 (42.8%). The overall clinic expense, for all age groups, dropped by 9.9%.

CONCLUSION

Implementation of the intervention program in a single primary care clinic led to a reduction in hospitalizations for the elderly patient population and to a more optimal allocation of healthcare resources.

Pneumonia in the older patient

This article examines the bacteriology, clinical features, therapy for, and prevention of pneumonia in older patients. The discussion focuses on patients who develop pneumonia out of the hospital, including individuals with community-acquired pneumonia and health care-associated pneumonia. Health care-associated pneumonia incorporates patients who live in nursing homes when they develop pneumonia and in many instances requires management similar to nosocomial pneumonia. We have chosen not to discuss nosocomial pneumonia in older patients because it does not have distinctive features or a different management approach than when this illness arises in younger patients.

Community-Acquired Pneumonia—Back to Basics

Lower respiratory tract infections are among the most common infectious diseases worldwide and are caused by the inflammation and consolidation of lung tissue due to an infectious agent.¹ The clinical criteria for the diagnosis include chest pain, cough, auscultatory findings such as rales or evidence of pulmonary consolidation, fever, or leukocytosis.

Age-related trends in the timeliness and prediction of medical visits, hospitalizations and deaths due to pneumonia and influenza, British Columbia, Canada, 1998-2004

The influenza immunization program in North America has been primarily designed to provide direct benefit to vaccinated individuals at highest risk of serious influenza outcomes. Some evidence suggests that immunization of certain age groups may also extend indirect protective benefit to vulnerable populations. Our goal was to identify age groups associated earliest with seasonal influenza activity and who may have the greatest indirect impact at the population level. We examined age-based associations between influenza medical visits and population-wide hospitalization/mortality due to pneumonia & influenza (P&I) using administrative datasets in British Columbia, Canada. A peak week was identified for each age group based on the highest rates observed in a given week for that study year. Mean rates at the peak week were averaged over the study years per age group. Timeliness (T) was defined as the mean difference in days between the first peak in influenza medical visits and population-wide P&I hospitalizations/deaths. Poisson regression was applied to calculate prediction (Pr) as the average proportion of deviance in P&I explained by influenza medical visits. T and Pr were derived by age group, and the product (T x Pr) was used as a summary measure to rank potential indirect effects of influenza by age group. Young children (0-23 months) and the elderly (> or = 65 years) had the highest peak rates of P&I hospitalization. Children < 6m and the elderly had the highest peak rates of P&I mortality. We found no significant differences by age for influenza medical visits in predicting population-wide P&I hospitalizations or deaths. School-aged children (5-19 years) showed the best relative combination of T x Pr, followed by preschool-aged children (2-4 years). We conclude that the very young and old suffer the greatest morbidity due to P&I, and an indirect role for school-aged children in anticipating the risk to others warrants further evaluation.

No intention to comply with influenza and pneumococcal vaccination: behavioural determinants among smokers and non-smokers

OBJECTIVE

Smoking increases the risk for influenza and pneumococcal disease, but vaccination uptake is lower among smokers than non-smokers. We therefore aimed to determine reasons for not complying with vaccination among smokers and non-smokers.

METHOD

In 2005 a self-administered questionnaire was sent to a random sample of Dutch patients (n=4,000) assessing medical, social and behavioural determinants. Independent factors associated with not complying with influenza and pneumococcal vaccination among smokers and non-smokers were assessed by multivariate logistic regression analysis.

RESULTS

In all, 1,725 of 4,000 patients returned the questionnaire (response rate: 43%), 426 (25%) were smokers. Among smokers self-reported flu vaccine uptake was 42% and among non-smokers 52% among both only 0,2% received both vaccines. Most important predictors of not complying in smokers and non-smokers were patient's beliefs not to be susceptible to disease (odds ratio (OR) 4.0, 95% confidence interval (CI): 2.0, 8.0 and OR 2.8, CI: 2.0, 3.9), finding it difficult to go to the GP for vaccination (OR 2.5, CI: 1.3, 4.8 and OR 1.8, CI: 1.3, 2.6) and being against vaccination (OR 2.4 CI: 1.3, 4.4 and OR 1.8, CI: 1.3, 2.6), respectively.

CONCLUSION

There are no substantial differences in determinants associated with not complying with influenza and pneumococcal vaccination between smokers and non-smokers but there is a trend towards stronger associations in smokers.

Effectiveness of influenza vaccine in the community-dwelling elderly

BACKGROUND

Reliable estimates of the effectiveness of influenza vaccine among persons 65 years of age and older are important for informed vaccination policies and programs. Short-term studies may provide misleading pictures of long-term benefits, and residual confounding may have biased past results. This study examined the effectiveness of influenza vaccine in seniors over the long term while addressing potential bias and residual confounding in the results.

METHODS

Data were pooled from 18 cohorts of community-dwelling elderly members of one U.S. health maintenance organization (HMO) for 1990-1991 through 1999-2000 and of two other HMOs for 1996-1997 through 1999-2000. Logistic regression was used to estimate the effectiveness of the vaccine for the prevention of hospitalization for pneumonia or influenza and death after adjustment for important covariates. Additional analyses explored for evidence of bias and the potential effect of residual confounding.

RESULTS

There were 713,872 person-seasons of observation. Most high-risk medical conditions that were measured were more prevalent among vaccinated than among unvaccinated persons. Vaccination was associated with a 27% reduction in the risk of hospitalization for pneumonia or influenza (adjusted odds ratio, 0.73; 95% confidence interval [CI], 0.68 to 0.77) and a 48% reduction in the risk of death (adjusted odds ratio, 0.52; 95% CI, 0.50 to 0.55). Estimates were generally stable across age and risk subgroups. In the sensitivity analyses, we modeled the effect of a hypothetical unmeasured confounder that would have caused overestimation of vaccine effectiveness in the main analysis; vaccination was still associated with statistically significant--though lower--reductions in the risks of both hospitalization and death.

CONCLUSIONS

During 10 seasons, influenza vaccination was associated with significant reductions in the risk of hospitalization for pneumonia or influenza and in the risk of death among community-dwelling elderly persons. Vaccine delivery to this high-priority group should be improved.

Angiotensin-converting enzyme insertion/deletion polymorphism and risk and outcome of pneumonia

BACKGROUND

Recent studies have suggested involvement of the angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism in the susceptibility to and severity of community-acquired pneumonia (CAP) in Asian populations. We have explored the hypothesis that the ACE I/D polymorphism affects the risk and outcome of CAP in a Dutch white population.

METHODS

This is a hospital-based prospective observational study including patients with CAP admitted between October 2004 and August 2006. All patients were genotyped, and pneumonia severity and clinical outcome were compared between patients with II, ID, and DD genotypes of the ACE gene. Pneumonia severity was assessed on day of hospital admission and consecutively on days 2, 3, 5, and 10 of hospital stay using the acute physiology score (APS). Outcomes evaluated were duration of hospital stay, ICU admittance, and in-hospital and 28-day mortality rates. To study the association between ACE genotype and risk of pneumonia, the distribution of the ACE I/D polymorphism was compared with healthy control subjects from the same geographic region.

RESULTS

In total, 200 patients with pneumonia and 200 control subjects were included in the study. Mean age of the patients was 63 years. APS scores were not different between the genotype groups on any of the days, and all clinical outcomes (duration of hospital stay, ICU admittance, in-hospital and 28-day mortality rates) were comparable between the three genotype groups. The ACE I/D genotype distribution was identical for patients and control subjects (p = 0.973).

CONCLUSIONS

The ACE I/D polymorphism is not associated with risk and outcome of CAP in the Dutch white population.

Extraintestinal pathogenic Escherichia coli

Extraintestinal pathogenic Escherichia coli (ExPEC) possesses virulence traits that allow it to invade, colonize, and induce disease in bodily sites outside of the gastrointestinal tract. Human diseases caused by ExPEC include urinary tract infections, neonatal meningitis, sepsis, pneumonia, surgical site infections, as well as infections in other extraintestinal locations. ExPEC-induced diseases represent a large burden in terms of medical costs and productivity losses. In addition to human illnesses, ExPEC strains also cause extraintestinal infections in domestic animals and pets. A commonality of virulence factors has been demonstrated between human and animal ExPEC, suggesting that the organisms are zoonotic pathogens. ExPEC strains have been isolated from food products, in particular from raw meats and poultry, indicating that these organisms potentially represent a new class of foodborne pathogens. This review discusses various aspects of ExPEC, including its presence in food products, in animals used for food or as companion pets; the diseases ExPEC can cause; and the virulence factors and virulence mechanisms that cause disease.

Type 2 diabetes and pneumonia outcomes: a population-based cohort study

OBJECTIVE

We sought to examine whether type 2 diabetes increases risk of death and complications following pneumonia and to assess the prognostic value of admission hyperglycemia.

RESEARCH DESIGN AND METHODS

This was a population-based cohort study of adults with a first-time hospitalization for pneumonia between 1997 and 2004 (n = 29,900) in northern Denmark. Information on diabetes, comorbidity, laboratory findings, pulmonary complications, and bacteremia was obtained from medical databases. We used regression to compute adjusted relative risks of pulmonary complications, bacteremia, and mortality rate ratios (MRRs) within 90 days following hospitalization among patients with and without type 2 diabetes. The prognostic impact of admission hyperglycemia was studied in a subcohort (n = 13,574).

RESULTS

In total, 2,931 (9.8%) pneumonia patients had type 2 diabetes. Mortality among diabetic patients was greater than that among other patients: 19.9 vs. 15.1% after 30 days and 27.0 vs. 21.6% after 90 days, respectively, corresponding to adjusted 30- and 90-day MRRs of 1.16 (95% CI 1.07-1.27) and 1.10 (1.02-1.18). Presence of type 2 diabetes did not predict pulmonary complications or bacteremia. Adjustment for hyperglycemia attenuated the association between type 2 diabetes and mortality. High glucose level on admission was a predictor of death among patients with diabetes and more so among those without diagnosed diabetes: adjusted 30-day MRRs for glucose level >or=14 mmol/l were 1.46 (1.01-2.12) and 1.91 (1.40-2.61), respectively.

CONCLUSIONS

Type 2 diabetes and admission hyperglycemia predict increased pneumonia-related mortality.

4G/5G plasminogen activator inhibitor-1 polymorphisms and haplotypes are associated with pneumonia

RATIONALE

Plasminogen activator inhibitor (PAI)-1 inhibits urokinase and tissue plasminogen activator, required for host response to infection. Whether variation within the PAI-1 gene is associated with increased susceptibility to infection is unknown.

OBJECTIVES

To ascertain the role of the 4G/5G polymorphism and other genetic variants within the PAI-1 gene. We hypothesized that variants associated with increased PAI-1 expression would be associated with an increased occurrence of community-acquired pneumonia (CAP).

METHODS

Longitudinal analysis (>12 yr) of the Health, Aging, and Body Composition cohort, aged 65-74 years at start of analysis.

MEASUREMENTS AND MAIN RESULTS

We genotyped the 4G/5G PAI-1 polymorphism and six additional single nucleotide polymorphisms. Of the 3,075 subjects, 272 (8.8%) had at least one hospitalization for CAP. Among whites, variants at the PAI4G,5G, PAI2846, and PAI7343 sites had higher risk of CAP (P = 0.018, 0.021, and 0.021, respectively). At these sites, variants associated with higher PAI-1 expression were associated with increased CAP susceptibility. Compared with the 5G/5G genotypes at PAI4G,5G site, the 4G/4G and 4G/5G genotypes were associated with a 1.98-fold increased risk of CAP (95% confidence interval, 1.2-3.2; P = 0.006). In whole blood stimulation assay, subjects with a 4G allele had 3.3- and 1.9-fold increased PAI-1 expression (P = 0.043 and 0.034, respectively). In haplotype analysis, the 4G/G/C/A haplotype at the PAI4G,5G, PAI2846, PAI4588, and PAI7343 single nucleotide polymorphisms was associated with higher CAP susceptibility, whereas the 5G/G/C/A haplotype was associated with lower CAP susceptibility. No associations were seen among blacks.

CONCLUSIONS

Genotypes associated with increased expression of PAI-1 were associated with increased susceptibility to CAP in elderly whites.

Infections in the elderly

Infectious diseases remain a significant cause of morbidity and mortality in the growing number of adults over the age of 65 years in the United States. Declining immunity coupled with aging anatomy and physiology set the stage for increased vulnerability to infections and the development of atypical presentations in the elderly. Pneumonia, urinary tract infection, and skin and soft tissue infections are illnesses commonly encountered in the care of this unique population. This article explores the etiology, diagnosis, and constantly evolving treatment of these conditions in the context of the elderly patient.

Radiological imaging in pneumonia: recent innovations

PURPOSE OF REVIEW

Pneumonia is one of the major infectious diseases responsible for significant morbidity and mortality throughout the world. Radiological imaging plays a prominent role in the evaluation and treatment of patients with pneumonia. This paper reviews recent innovations in the radiologic diagnosis and management of suspected pulmonary infections.

RECENT FINDINGS

Chest radiography is the most commonly used imaging tool in pneumonias because of availability and an excellent cost-benefit ratio. Computed tomography is mandatory in unresolved cases or when complications of pneumonia are suspected. A specific radiologic pattern can suggest a diagnosis in many cases. Bacterial pneumonias are classified into four main groups: community-acquired, aspiration, healthcare-associated and hospital-acquired pneumonia. The radiographic patterns of community-acquired pneumonia may be variable and are often related to the causative agent. Aspiration pneumonia involves the lower lobes with bilateral multicentric opacities. The radiographic patterns of healthcare-associated and hospital-acquired pneumonia are variable, most commonly showing diffuse multifocal involvement and pleural effusion.

SUMMARY

Combination of pattern recognition with knowledge of the clinical setting is the best approach to the radiologic interpretation of pneumonia. Radiological imaging will narrow the differential diagnosis of direct additional diagnostic measures and serve as an ideal tool for follow-up examinations.

Observed association between antidepressant use and pneumonia risk was confounded by comorbidity measures

OBJECTIVE

A prior study suggested that antidepressants might increase the risk of hospitalization for pneumonia in the elderly. This study sought to confirm or refute this hypothesis.

STUDY DESIGN AND SETTING

Case-control study of persons aged 65 and above nested in the UK General Practice Research Database.

RESULTS

We identified 12,044 cases of the hospitalization for pneumonia (the primary outcome) and 48,176 controls. The odds ratio (OR) for any antidepressant use, adjusting for age, sex, and calendar year was 1.61 (95% confidence interval 1.46-1.78). After further adjustment for comorbidity measures, the OR was 0.89 (0.79-1.00). We also identified 159 cases of hospitalization for aspiration pneumonia (the secondary outcome) and 636 controls. The OR for any antidepressant use, adjusted for age, sex, and calendar year was 1.45 (0.65-3.24). After further adjustment for comorbidity measures, the OR was 0.63 (0.23-1.71).

CONCLUSION

These findings refute the prior hypothesis that use of antidepressants by elderly patients increases the risk of hospitalization for pneumonia or for aspiration pneumonia. Decisions regarding use of antidepressants in elderly persons should not be affected by concern about pneumonia risk. Data-derived hypotheses should be independently confirmed before being acted upon.

Vitamin and micronutrient intake and the risk of community-acquired pneumonia in US women

BACKGROUND

There are limited data regarding the role of dietary and supplemental vitamin intake and the risk of community-acquired pneumonia.

METHODS

We prospectively examined, during a 10-year period, the association between dietary and supplemental vitamin intake and the risk of community-acquired pneumonia among 83,165 women in Nurses' Health Study II who were between the ages of 27 and 44 years in 1991. We excluded women who had pneumonia before 1991, those who did not provide complete dietary information, or those with a history of cancer, cardiovascular disease, or asthma. Self-administered food frequency questionnaires were used to assess dietary and supplemental vitamin intake. Cases of pneumonia required a diagnosis by a physician and confirmation with a chest radiograph. The independent associations between specific vitamins and pneumonia risk were evaluated.

RESULTS

There were 925 new cases of community-acquired pneumonia during 650,377 person-years of follow up. After adjusting for age, cigarette smoking, body mass index, physical activity, total energy intake, and alcohol consumption, there were no associations between dietary or total intake of any individual vitamin and risk of community-acquired pneumonia. Specifically, women in the highest quintile of vitamin A intake did not have a significantly lower risk of pneumonia than women in the lowest quintile (multivariate relative risk [RR]=0.88; 95% confidence interval [CI], 0.70-1.09, P for trend=.16). Similarly, vitamin C (RR=0.94; 95% CI, 0.76-1.16, P for trend=.81) and E (RR=0.95; 95% CI, 0.76-1.17, P for trend=.74) intake did not alter risk of pneumonia.

CONCLUSIONS

Higher vitamin intake from diet and supplements is unlikely to reduce pneumonia risk in well nourished women.

Performance measures for pneumonia: are they valuable, and are process measures adequate?

PURPOSE OF REVIEW

Pneumonia has been the target of large national initiatives to measure and report quality of care. Measures of pneumonia care are now being used for public reporting and pay-for-performance in an effort to increase provider accountability for healthcare quality in the USA. Increasingly, concerns have been raised about the potential for unintended consequences of performance measurement and reporting that might lead to patient harm.

RECENT FINDINGS

Since 1999, there have been substantial improvements in performance on measures of pneumonia processes of care, and patient clinical outcomes have improved. The association between improved clinical outcomes and processes of care for pneumonia, however, is not clear based on available national data. The increasing use of process measures for hospital accountability has created the continual need to re-evaluate the relationship between processes being measured and desired patient outcomes. While there is little direct evidence of unintended consequences of performance measurement, concerns have been raised about the potential for direct or indirect harm to patients.

SUMMARY

Measuring processes of care for pneumonia is feasible and appears to have accelerated the pace of quality improvement. There is an ongoing need to develop new measures of pneumonia quality that focus on patient outcomes, care transitions, and efficiency of care.

Pneumonia After Inhalation Injury

We sought to evaluate the incidence, morbidity, and mortality of pneumonia among inhalation injury patients requiring admission to our burn unit. We undertook a retrospective study of 228 consecutive patients with inhalation injury who were admitted to the burn unit of a level one trauma center between 2001 and 2004. Of the remaining 117 patients with inhalation injury and requiring hospitalization for at least 48 hours, 32 (27%) developed pneumonia. The average patient with inhalation injury and pneumonia developed their infiltrate on day 6 +/- 5 days and required 3 +/- 4 burn operations. There was no difference seen in age, sex, or carboxyhemoglobin level between inhalation injury patients with and without pneumonia (P > .05). The inhalation injury patients that had an associated TBSA burn of at least 20% had a 60% (12/20) pneumonia rate, which was significantly higher then the 21% (20/97) pneumonia rate observed in patients with an association burn less then 20%. The overall mortality of patients with inhalation injury and pneumonia was 19% (6/32), double the mortality rate of 9% (8/85) found in patients with inhalation injury and no pneumonia. The average length of stay of inhalation injury patients with pneumonia was significantly longer (47 +/- 44 days) then inhalation injury patients without pneumonia (26 +/- 54 days; P < .05). The presence of pneumonia among inhalation injury patients significantly increased length of stay and doubled mortality rates. Admission carboxyhemoglobin levels, age, and sex had no relationship to the development of pneumonia. An increase in TBSA burn was associated with a higher pneumonia rate.

An urgent problem of aerobic gram-negative pathogen infection in complicated parapneumonic effusions or empyemas

OBJECTIVES

Complicated parapneumonic effusion or empyema is a troublesome disease with a high mortality. The most common involved microorganisms seem to have changed over recent decades, influenced by the introduction of new antibiotics, and the increase of immunocompromised hosts, and the elderly population. More epidemiological studies on the current bacteriology are needed to help us to empirically select adequate antibiotics.

DESIGN

A retrospective study via chart review in a university-affiliated tertiary medical center was conducted to assess the underlying bacterial pathogens and outcome of patients with complicated parapneumonic effusions or empyemas.

RESULTS

During the 43-month study period (from December 2000 to June 2004), 304 patients were diagnosed with complicated parapneumonic effusions or empyemas and the mortality of these patients was 23% (69/304). Among these 304 patients, a total of 292 microorganisms were cultured from the pleural fluid samples of 207 patients (to yield a positive microbiological culture rate of 68% (207/304). Isolated bacteria included aerobic Gram-negative bacteria (n=129), aerobic Gram-positive bacteria (n=105), anaerobic bacteria (n=51), and M. tuberculosis (n=7). Of these aerobic bacterial infections, Gram-negative bacteria were isolated more frequently from the older population and involved a significantly higher mortality rate and longer stay, compared to those with other bacteria (p=0.001 and p<0.001 respectively).

CONCLUSION

The increasing incidence of infection with aerobic Gram-negative pathogens may cause more critical conditions in complicated parapneumonic effusions or empyemas.

Influenza- and RSV-associated hospitalizations among adults

We estimated influenza- and respiratory syncytial virus (RSV)-associated hospitalizations by age, high-risk status and outcome, during the 1996/1997-1999/2000 respiratory seasons among adults who did not receive influenza vaccine. Using three health maintenance organization (HMO) databases and local viral surveillance data, we identified weeks when influenza and RSV were circulating and estimated influenza- and RSV-associated hospitalizations. Persons aged > or = 65 years with and without high-risk conditions had significantly increased rates of influenza-associated hospitalizations for pneumonia and influenza, and circulatory and respiratory diseases. Persons aged > or = 65 years with high-risk conditions also had significantly increased rates of influenza-associated hospitalizations for cardiac conditions (16.9 per 10,000 person periods). Relative to the influenza estimates for high-risk persons > or = 65 years, we found lower rates of RSV-associated hospitalizations for pneumonia and influenza diseases (23.4 per 10,000 person periods), cardiac diseases (4.3 per 10,000 person periods) and circulatory and respiratory diseases (44.0 per 10,000 person periods). Among low-risk persons aged 50-64 years, we did not identify significantly elevated rates of influenza- or RSV-associated hospitalizations. Excess hospitalization estimates among adults aged > or = 65 years and high-risk 50-64 year olds during the influenza season suggest that these groups should have priority for influenza vaccine during vaccine shortages.

Community-Acquired Respiratory Complications in the Intensive Care Unit: Pneumonia and Acute Exacerbations of COPD

This chapter will review the two most common lower respiratory tract infections in the intensive care unit (ICU), community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In addition we will provide an overview of the topics including recommendations for the diagnosis and treatment.

Acute respiratory tract infection visits of veterans with spinal cord injuries and disorders: rates, trends, and risk factors

BACKGROUND/OBJECTIVES

Respiratory complications are a major cause of illness and death in persons with spinal cord injuries and dysfunction (SCI&Ds). The objectives of this study were to examine rates of outpatient visits over 5 years for acute respiratory tract infections (ARIs), including pneumonia and influenza (P&I), lower respiratory tract infections (LRIs), and upper respiratory tract infections (URIs), in veterans with SCI&Ds and to determine whether individual characteristics were associated with the number of annual visits for each type of ARI.

METHODS

This was a longitudinal (fiscal years 1998-2002) study of ARI visits at the Veterans Health Administration (VA) in 18,693 veterans with SCI&Ds. To examine the associations between time, patient characteristics, and annual number of ARI visits, we used random effect negative binomial models.

RESULTS

Veterans with SCI&Ds had a total of 11,113 ARI visits over the 5-year period. There was a slightly decreasing trend for LRI visits over time (P < 0.01) but no significant change for other ARIs over time. There were 30 to 35 pneumonia visits and 21 to 30 acute bronchitis visits per 1,000 SCI&D veterans per year. Older veterans were more likely than younger to have P&I visits and less likely to have URI visits (P < 0.01). Veterans with paraplegia had fewer P&I visits than subjects with tetraplegia (IRR = 0.58; Cl = 0.51-0.67).

CONCLUSIONS

Visit rates for ARIs are stable for veterans with SCI&Ds. Identifying risk factors associated with ARI visits is an important first step to improve prevention and treatment of ARIs and to improve the health of veterans with SCI&Ds.

Community-acquired pneumonia: defining quality care

BACKGROUND

Community-acquired pneumonia (CAP) is one of 3 initial conditions for which the Joint Commission for Accreditation of Healthcare Organizations and the Centers for Medicare & Medicaid Services have defined quality measures. Eight "core measures" of pneumonia care have been targeted for reporting by U.S. hospitals to facilitate performance monitoring.

METHODS

A review of the literature supporting the core measures was performed.

RESULTS

Indicators encouraging influenza vaccination and appropriate antibiotic selection had the most robust evidence. Rapid delivery of antibiotics also showed significant reduction in mortality, though the actual timing (4 versus 8 hours) varied between studies. Other measures, such as performance of blood cultures, pneumococcal vaccination, smoking cessation, and oxygenation assessment, demonstrated less obvious clinical benefit.

CONCLUSIONS

There is inherent value in setting standards of care for high-impact conditions such as CAP, but these standards should be chosen on the basis of high-quality research. Public reporting of the current measures is problematic, as it implies they represent best practices for CAP despite relatively weak evidence.

Aetiology and resistance patterns of community-acquired pneumonia in León, Nicaragua

We conducted a prevalence study to gain greater insight into the aetiology, bacterial resistance and risk factors for community-acquired pneumonia (CAP) in the region of León, Nicaragua. During the period from July 2002 to January 2005, all consecutive patients with signs and symptoms suggestive of CAP were included in the study. Sputum samples, paired serum samples and urinary samples were collected for the detection of respiratory pathogens. The most frequently identified pathogens were Streptococcus pneumoniae (17%), followed by Staphylococcus aureus (5%), Chlamydia pneumoniae (5%) and Mycoplasma pneumoniae (4%). Pseudomonas aeruginosa was cultured from 5% of patients. No pathogens were identified in 55%. All tested S. pneumoniae were sensitive to erythromycin and penicillin. In contrast, resistance of S. aureus to penicillin and erythromycin was high.

[Current epidemiology of microbial low respiratory tract infections]

La littérature récente n'apporte guère de grandes nouveautés, exposant les résultats d'enquêtes parcellaires utiles, mais qui s'insèrent dans les fourchettes de prévalence déjà connues pour les différentes bactéries. La fréquence des germes retrouvés varie dans le temps et l'espace, mais les trois germes les plus fréquemment en cause dans toutes les séries se recrutent, quel que soit le lieu, parmi les cinq agents que sont Streptococcus pneumoniae, Influenza A, Mycoplasma pneumoniae, Haemophilus influenzae et Legionella pneumophila. Ainsi, parmi les pneumopathies documentées, plus de 90 % sont dues à : S. pneumoniae, le plus fréquent chez les malades hospitalisés ; Mycoplasma, Chlamydia et les virus respiratoires, prédominant en ville, avec des variations selon le lieu et l'époque ; Staphylococcus aureus et entérobactéries qui peuvent également être en cause chez le vieillard et les patients atteints de tares majeures ; des associations de germes, avec le pneumocoque notamment, qui sont de plus en plus fréquemment identifiées. Enfin, l'agent causal reste méconnu dans 25 à 50 % des cas. On voit récemment notifier des pneumonies aiguës communautaires à staphylocoques résistants à la méticilline. Le diagnostic virologique (et celui des bactéries liées aux cellules) progresse, grâce à la PCR. Il reste de nombreuses incertitudes sur l'intérêt de ce diagnostic en dehors d'études épidémiologiques, mais aussi sur sa pertinence en pratique clinique. Rien de nouveau pour l'épidémiologie des bronchites aiguës ; pour les exacerbations de bronchopneumopathie chronique obstructive (BPCO), le rôle de H. influenzae, colonisant ou infectant, dans la genèse de l'inflammation bronchique fait toujours l'objet de débats.

Preventing ventilator-associated pneumonia in adults: sowing seeds of change

Ventilator-associated pneumonia (VAP), a major cause of ICU infection, results in high morbidity, mortality, and health-care costs. Multiple risk factors for VAP involve complex host factors and ubiquitous pathogens that require several different types of prevention strategies. Prevention efforts should focus on reducing bacterial colonization, and limiting aspiration, antibiotic exposure, and use of invasive devices. Although evidence-based prevention guidelines are available, they are lengthy, often ignored, and not implemented. New insights into the barriers to implementation of effective prevention programs are emerging. This article provides highlights from recent guidelines and publications discussing VAP prevention strategies and examines barriers to their implementation. Prevention and implementation of cost-effective strategies to reduce risk and improve patient outcomes should be prioritized. Clearly, prevention programs should be population specific and may vary among hospitals, but a multidisciplinary prevention team led by a "champion" is recommended to help set priorities, benchmarking goals, analyze data, and sow the seeds of change for risk reduction.

Determinants of short and long term functional recovery after hospitalization for community-acquired pneumonia in the elderly: role of inflammatory markers

Background

Hospitalization for older patients with community-acquired pneumonia (CAP) is associated with functional decline. Little is know about the relationship between inflammatory markers and determinants of functional status in this population. The aim of the study is to investigate the association between tumor necrosis factor (TNF)-α, C-reactive protein (CRP) and Activities of Daily Living, and to identify risk factors associated with one year mortality or hospital readmission.

Methods

301 consecutive patients hospitalized for CAP (mean age 73.9 ± 5.3 years) in a University affiliated hospital over 18 month period were included. All patients were evaluated on admission to identify baseline demographic, microbiological, cognitive and functional characteristics. Serum levels for TNF-α and CRP were collected at the same time. Reassessment of functional status at discharge, and monthly thereafter till 3 months post discharge was obtained and compared with preadmission level to document loss or recovery of functionality. Outcome was assessed by the composite endpoint of hospital readmission or death from any cause up to one year post hospital discharge.

Results

36% of patients developed functional decline at discharge and 11% had persistent functional impairment at 3 months. Serum TNF-α (odds ratio [OR] 1.12, 95% CI 1.08–1.15; p < 0.001) and the Charlson Index (OR = 1.39, 95% CI 1.14 to 1.71; p = 0.001) but not age, CRP, or cognitive status were independently associated with loss of functionality at the time of hospital discharge. Lack of recovery in functional status at 3 months was associated with impaired cognitive ability and preadmission comorbidities. In Cox regression analysis, persistent functional impairment at 3 months, impaired cognitive function, and the Charlson Index were highly predictive of one year hospital readmission or death.

Conclusion

Serum TNF-α levels can be useful in determining patients at risk for functional impairment following hospitalization from CAP. Old patients with impaired cognitive function and preexisting comorbidities who exhibit delay in functional recovery at 3 months post discharge may be at high risk for hospital readmission and death. With the scarcity of resources, a future risk stratification system based on these findings might be proven helpful to target older patients who are likely to benefit from interventional strategies.

Statin treatment and reduced risk of pneumonia in patients with diabetes

BACKGROUND

Recent prognostic studies have shown that previous treatment with statins is associated with a better outcome in patients admitted to hospital with pneumonia. Because of an increased risk of pneumonia in patients with diabetes, we assessed the effects of statin use on the occurrence of pneumonia in adult diabetic patients.

METHODS

All patients with a diagnosis of diabetes (types 1 and 2) enlisted in the UK General Practice Research Database between 1 June 1987 and 21 January 2001 were included. A case-control study was performed with cases defined as patients with a first recorded diagnosis of pneumonia. For each case up to four controls were matched by age, sex, practice, and index date. Patients were classified as current users when the index date was between the start and end date of statin treatment. Conditional multiple logistic regression analysis was used to estimate the strength of the association between statin treatment and the occurrence of pneumonia.

RESULTS

Statins were used in 1.1% of 4719 cases and in 2.1% of 15 322 matched controls (crude odds ratio (OR) 0.51, 95% CI 0.37 to 0.68). After adjusting for potential confounders, treatment with statins was associated with a significant reduction in the risk of pneumonia (adjusted OR 0.49, 95% CI 0.35 to 0.69). The association was consistent among relevant subgroups (cardiovascular diseases, pulmonary diseases) and independent of the use of other prescription drugs.

CONCLUSIONS

The use of statins is associated with a considerable reduction in the risk of pneumonia in diabetic patients. In addition to lowering the risk of cardiovascular disease, statins may be useful in preventing respiratory infections.