Long-term mortality of hospitalized pneumonia in the EPIC-Norfolk cohort

The dose-response relationship between physical activity and the risk of death from pneumonia in middle-aged and older adults: A meta-analysis

BACKGROUND

Deaths from COVID-19 are concentrated in older adults, and studies have reported that physical activity (PA) can reduce the risk of death from pneumonia.

METHODS

Eight cohort studies and 2 case-control studies were included according to the inclusion and exclusion criteria established in this meta-analysis study followed the PRISMA guideline, 8 cohort studies and 2 case-control studies were finally included. Then, the research objects in these studies were classified to further study the dose-response relationship and non-dose-response relationship.

RESULTS

The highest dose of PA reduced the risk of death by 59% (risk ratio = 0.41; 95% confidence interval: 0.23-0.58) compared with the lowest dose of PA in middle-aged and elderly people. Furthermore, when the PA level was <10 m/wk, the risk of death from pneumonia was reduced by 6% every 4.5 MET-h/wk increase. At a PA level > 10 m/wk, the risk of death from pneumonia increased by 5% every 4.5 MET-h/wk increase. At a PA level > 30 m/wk, PA is a risk factor for pneumonia-related death in middle-aged and elderly people.

CONCLUSIONS

This meta-analysis showed that PA was associated with a reduced risk of dying from pneumonia in middle-aged and older adults, and that there was a significant nonlinear negative dose-response relationship between PA levels and the risk of dying from pneumonia. Therefore, moderate exercise was recommended.

Long-Term Outcomes in Severe Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is globally one of the major causes of hospitalization and mortality. Severe CAP (sCAP) presents great challenges and need a comprehensive understanding of its long-term outcomes. Cardiovascular events and neurological impairment, due to persistent inflammation and hypoxemia, contribute to long-term outcomes in CAP, including mortality. Very few data are available in the specific population of sCAP. Multiple studies have reported variable 1-year mortality rates for patients with CAP up to 40.7%, with a clear influence by age, comorbidities, and disease severity. In terms of treatment, the potential protective role of macrolides in reducing mortality emphasizes the importance of appropriate empiric antibiotic therapy. This narrative review explores the growing interest in the literature focusing on the long-term implications of sCAP. Improved understanding of long-term outcomes in sCAP can facilitate targeted interventions and enhance posthospitalization care protocols.

Cost-effectiveness analysis of adult pneumococcal conjugate vaccines for pneumococcal disease in Japan

BACKGROUND

The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is used in the Japanese National Immunization Program for older adults and adults with increased risk for pneumococcal disease, however, disease incidence and associated burden remain high. We evaluated the cost-effectiveness of pneumococcal conjugate vaccines (PCVs) for adults aged 65 years and high-risk adults aged 60-64 years in Japan.

RESEARCH DESIGN AND METHODS

Using a Markov model, we evaluated lifetime costs using societal and healthcare payer perspectives and estimated quality-adjusted life-years (QALYs), and number of prevented cases and deaths caused by invasive pneumococcal disease (IPD) and non-IPD. The base case analysis used a societal perspective.

RESULTS

In comparison with PPSV23, the 20-valent PCV (PCV20) prevented 127 IPD cases 10,813 non-IPD cases (inpatients: 2,461, outpatients: 8,352) and 226 deaths, and gained more QALYs (+0.0015 per person) with less cost (-JPY22,513 per person). All sensitivity and scenario analyses including a payer perspective analysis indicated that the incremental cost-effectiveness ratios (ICERs) were below the cost-effectiveness threshold value in Japan (JPY5 million/QALY).

CONCLUSIONS

PCV20 is both cost saving and more effective than PPSV23 for adults aged 65 years and high-risk adults aged 60-64 years in Japan.

Long-term care status for the elderly with different levels of physical ability: a cross-sectional survey in first-tier cities of China

BACKGROUND

Long term care (LTC) services for functionally impaired senior citizens are crucial for addressing the challenges of aging. However, research on eligibility criteria and coverage of LTC in China is lacking. Our objective is to assess the current status of LTC and explore eligibility criteria and coverage for the elderly.

METHODS

This is a cross-sectional study conducted in two first-tier cities in China. Residents aged 65 or over were recruited from a nursing home and four primary hospitals. Participants were divided into three groups (bedridden, domestic, and community), then six grades (grade one to six) according to the Longshi Scale, and their functional ability was assessed using the Modified Barthel Index. Information such as diseases, complications, and daily care needs were collected. Nursing staff were invited to indicate patients' needs for care. A one-way ANOVA test, Kruskal Wallis H test and Mann-Whitney U test were used to explore the differences of variables in three Longshi groups or Longshi grades.

RESULTS

Among all 1157 participants, with an average age of 80.54, 69.3% were in the bedridden group. The most common diagnosis was stroke (71.4%), with the most prevalent complication being pulmonary infection (25.2%). In the nursing assessment, basic health care, disease care, activity care, complication prevention care and psychosocial care were summarized as the five main aspects of LTC for the elderly. Feeding, bathing, drinking, bowel management and bladder management were identified as the basic care which fulfills participants' basic physical needs in each Longshi group. Mouth care, artificial airway management, and body reposition, which can prevent immobility complications, were highly demanded by bedridden elderly.

CONCLUSIONS

The elderly in grade one to three are the ones in need of LTC most. The content of LTC for elderly should include basic care which fulfills their basic physical needs and complication care which can prevent immobility complications. The evidence of this research may contribute to the design of LTC in China.

TRIAL REGISTRATION

The study design was registered in the Chinese Clinical Trial Registry (ChiCTR-2000034067, Registered 22 Jun 2020, http://www.chictr.org.cn/showproj.aspx?proj=54770 ).

Cost-utility analysis of the use of the 20-valent anti-pneumococcal vaccine (PCV20) in adults older than 60 years in Spain

BACKGROUND AND OBJECTIVES

A cost-utility analysis was conducted to assess the efficiency of implementing a PCV20 vaccination strategy in the Spanish adult population older than 60 years, for the prevention of non-bacteremic pneumococcalpneumonia (NBP) and invasive pneumococcal disease (IPD).

METHODS

A Markov model, with annual cycles and a time horizon of 10 years was used. The analysis population was stratified by age and risk groups. The comparator was the sequential vaccination with the 15-valent pneumococcal conjugate vaccine (PCV15) followed by one dose of the pneumococcal polysaccharide vaccine (PPV23). The base case analysis was performed from the National Healthcare System (NHS) perspective including direct costs (€2018) and applying a discount of 3% to future costs and outcomes. Alternative scenarios explored a shorter time horizon (5 years), the societal perspective and other available vaccination strategies. All the parameters and assumptions were validated by a panel of experts. To evaluate the robustness of the model, deterministic and probabilistic sensitivity analyses (PSA) were carried out.

RESULTS

The results of the study showed that the vaccination strategy with PCV20 is a dominant option compared to the sequential regimen (PCV15 + PPSV23), resulting in direct cost savings of €85.7 M over 10 years, with a small increase in quality-adjusted life years (QALYs). PCV20 vaccination avoided 2,161 cases of IPD, 19,470 of NBP and 3,396 deaths and according to the PSA, the probability of PCV20 being cost-effective compared to a sequential regimen (PCV15 + PPSV23) was 100%.

CONCLUSIONS/RECOMMENDATIONS

In the Spanish adult population older than 60 years, the vaccination strategy with one dose of PCV20 is more effective and less expensive (dominant) than vaccination with a sequential schedule with PCV15 and PPSV23.

Systemic corticosteroid use and cardiovascular risk in patients hospitalized for pneumonia

BACKGROUND

Limited data are available concerning cardiovascular risk with respect to adjunctive corticosteroid use in patients with pneumonia. We aimed to assess the associations between systemic corticosteroid use and the occurrence of major adverse cardiovascular events (MACEs) in patients hospitalized for pneumonia.

METHODS

Among study participants enrolled via surveillance for severe acute respiratory infection from July 2016 to January 2017, the clinical course of patients with pneumonia was retrospectively investigated until December 2019. We evaluated the occurrence of in-hospital and after-discharge MACEs according to steroid use during hospitalization.

RESULTS

Of the 424 patients hospitalized for pneumonia, 118 (28.8%) received systemic corticosteroids during hospitalization. The most common reason for steroid use was acute exacerbation of chronic lung disease (75.4%). Systemic steroid use was significantly associated with an increased risk of in-hospital MACEs; it was not associated with after-discharge MACEs. The risk of in-hospital MACEs was significantly greater in patients with more comorbidities, more severe pneumonia, and a higher inflammatory marker level; moreover, it was positively associated with duration and cumulative dose of steroid treatment.

CONCLUSION

Systemic corticosteroid use was associated with an increased risk of in-hospital MACEs in patients hospitalized for pneumonia.

Cost-effectiveness of use of 20-valent pneumococcal conjugate vaccine among adults in Germany

OBJECTIVES

Despite national recommendations for use of pneumococcal vaccines, rates of community-acquired pneumonia (CAP) and invasive pneumococcal disease (IPD) remain high in Germany. New pneumococcal conjugate vaccines (PCVs) with expanded coverage have the potential to reduce the pneumococcal disease burden among adults.

METHODS

Using a Markov model, we evaluated the lifetime outcomes/costs comparing 20-valent PCV (PCV20) with standard of care (SC) vaccinations for prevention of CAP and IPD among adults aged ≥60 years and at-risk adults aged 18-59 years in Germany. PCV20 also was compared with sequential vaccination with 15-valent PCV (PCV15) followed by PPSV23 in a scenario analysis.

RESULTS

Over the course of a lifetime (82 years), use of PCV20vs. SC would prevent 54,333 hospitalizations, 26368 outpatient CAP cases, 10946 disease-related deaths yield 74,694 additional life-years (LYs), while lowering total medical costs by 363.2 M €. PCV20 remained cost saving (i.e. dominant) versus SC even in numerous sensitivity analyses, including a sensitivity analysis assuming moderate effectiveness of the SC pneumococcal polysaccharide vaccine against noninvasive pneumococcal CAP. In several scenario analyses and a probabilistic sensitivity analysis, PCV20 was also cost-saving compared toPCV15 PPSV23 vaccination.

CONCLUSIONS

One dose of PCV20 among adults aged ≥60 years and adults aged 18-59 years with moderate- and high-risk conditions wouldsubstantially reduce pneumococcal disease, save lives, and be cost saving compared with SC.

A review of evidence for pneumococcal vaccination in adults at increased risk of pneumococcal disease: risk group definitions and optimization of vaccination coverage in the United Kingdom

INTRODUCTION

Pneumococcal disease (PD) significantly contributes to morbidity and mortality, carrying substantial economic and public health burden. This article is a targeted review of evidence for pneumococcal vaccination in the UK, the definitions of groups at particular risk of PD and vaccine effectiveness.

AREAS COVERED

Relevant evidence focusing on UK data from surveillance systems, randomized controlled trials, observational studies and publicly available government documents is collated and reviewed. Selected global data are included where appropriate.

EXPERT OPINION

National vaccination programs have reduced the incidence of vaccine-type PD, despite the rising prominence of non-vaccine serotypes in the UK. The introduction of higher-valency conjugate vaccines provides an opportunity to improve protection against PD for adults in risk groups. Several incentives are in place to encourage general practitioners to vaccinate risk groups, but uptake is low-suboptimal particularly among at-risk individuals. Wider awareness and understanding among the public and healthcare professionals may increase vaccination uptake and coverage. National strategies targeting organizational factors are urgently needed to achieve optimal access to vaccines. Finally, identifying new risk factors and approaches to risk assessment for PD are crucial to ensure those at risk of PD can benefit from pneumococcal vaccination.

Cost-effectiveness of using a 20-valent pneumococcal conjugate vaccine to directly protect adults in England at elevated risk of pneumococcal disease

OBJECTIVES

Despite the current pneumococcal vaccination program in England for older adults and adults with underlying conditions, disease burden remains high. We evaluated cost-effectiveness of 20-valent pneumococcal conjugate vaccine (PCV20) compared to current pneumococcal recommendations for adults in England.

METHODS

Lifetime outcomes/costs of invasive pneumococcal disease (IPD) and community-acquired pneumonia (CAP) among adults aged 65-99 years and adults aged 18-64 years with underlying conditions in England were projected using a probabilistic cohort model. Vaccination with PCV20 was compared with 23-valent pneumococcal polysaccharide vaccine (PPV23) from the National Health Service perspective.

RESULTS

PCV20 was cost saving compared with PPV23 in base case and most sensitivity analyses. In the base case, replacing PPV23 with PCV20 prevented 7,789 and 140,046 cases of IPD and hospitalized CAP, respectively, and 22,199 associated deaths, resulting in incremental gain of 91,375 quality-adjusted life-years (QALYs) and incremental savings of £160M. In probabilistic sensitivity analyses, PCV20 (vs. PPV23) was cost saving in 85% of simulations; incremental cost per QALY was below £30,000 in 99% of simulations.

CONCLUSIONS

PCV20 vaccination in adults aged 65-99 years and those aged 18-64 years with underlying comorbidities in England is expected to prevent more hospitalizations, save more lives, and yield lower overall costs than current recommendations for PPV23.

Public health and budgetary impact of 20-valent pneumococcal conjugate vaccine for adults in England

BACKGROUND

. Despite use of 23-valent pneumococcal polysaccharide vaccine (PPV23) in England, disease burden among at-risk adults remains high. We evaluated the public health and budgetary impact of 20-valent pneumococcal conjugate vaccine (PCV20) compared to the current adult pneumococcal vaccination program.

METHODS

Five-year outcomes and costs of invasive pneumococcal disease (IPD) and community-acquired pneumonia (CAP) among adults aged 65-99 years and adults aged 18-64 years with underlying conditions in England were projected using a deterministic cohort model. Hypothetical vaccination with PCV20 versus PPV23 was compared from National Health Service (NHS) perspective.

RESULTS

Replacing PPV23 with PCV20 would prevent 785 IPD hospitalizations, 11,751 CAP hospitalizations, and 1,414 deaths over five years, and would reduce medical care costs by £48.5M. With vaccination costs higher by £107.2M, projected net budgetary impact is £58.7M. The budgetary impact would be greatest in year one (£26.3M), and would decrease over time (to £1.6M by year five). The average budget increase (£11.7M/year) represents <0.01% of the Department of Health and Social Care budget and <3% of the vaccines budget.

CONCLUSIONS

Use of PCV20 among adults currently eligible for PPV23 in England would substantially reduce the burden of pneumococcal disease, with modest budgetary impact.

A review of current data to support decision making for introduction of next generation higher valency pneumococcal conjugate vaccination of immunocompetent older adults in the UK

INTRODUCTION

The burden of pneumococcal disease in older UK adults remains substantial. Higher valency pneumococcal conjugate vaccines (PCVs) are currently in development with adult formulations for two of these anticipated to become available in 2022. This article collates and reviews relevant candidate data now available that may be used to support cost effectiveness assessments of vaccinating immunocompetent UK adults aged ≥65-years with PCVs.

AREAS COVERED

This article uses published data from surveillance systems, randomized controlled trials and observational studies. It focuses on local data from the UK but where these are either limited or not available relevant global data are considered.

EXPERT OPINION

The body of relevant data now available suggests the UK is well placed to assess the cost effectiveness of vaccinating immunocompetent ≥65-year olds with new generation higher valency PCVs. Recent contemporary data provide important new and robust insights into the epidemiology of pneumococcal disease in older UK adults and help to address much of the uncertainty and data gaps associated with previous analyses. Using these data to make informed decisions about use of new higher valency PCVs for routine use in older adults will be important for public health in the UK.

Tropical Australian Health-Data Linkage Shows Excess Mortality Following Severe Infectious Disease Is Present in the Short-Term and Long-Term after Hospital Discharge

BACKGROUND

In this study, we aimed to assess the risk factors associated with mortality due to an infectious disease over the short-, medium-, and long-term based on a data-linkage study for patients discharged from an infectious disease unit in North Queensland, Australia, between 2006 and 2011.

METHODS

Age-sex standardised mortality rates (SMR) for different subgroups were estimated, and the Kaplan-Meier method was used to estimate and compare the survival experience among different groups.

RESULTS

Overall, the mortality rate in the hospital cohort was higher than expected in comparison with the Queensland population (SMR: 15.3, 95%CI: 14.9-15.6). The long-term mortality risks were significantly higher for severe infectious diseases than non-infectious diseases for male sex, Indigenous, residential aged care and elderly individuals.

CONCLUSION

In general, male sex, Indigenous status, age and comorbidity were associated with an increased hazard for all-cause deaths.

Leisure time physical activity and risk of pneumonia mortality: a dose-response meta-analysis

INTRODUCTION

This meta-analysis of cohort studies aimed to examine the doseresponse relationships between LPTA (Leisure time physical activity) and pneumonia mortality to provide some suggestions for the prevention of respiratory disease mortality.

EVIDENCE ACQUISITION

PubMed、WOS database was systematically searched for eligible studies until Nov.1, 2020. The prospective cohort study on the relationship between LPTA and pneumonia mortality was collected. The Meta-analysis was performed using Stata 14 software to calculate the combined effect size (HR) of pneumonia mortality and its 95% CI in a categorical dose-response relationship. The restrictive cubic spline model was used to fit the continuous dose-response relationship.

EVIDENCE SYNTHESIS

Eight cohort studies included 370045 subjects who met the inclusion criteria. The categorical dose-relational analysis revealed that the highest dose compared to the lowest LTPA dose reduced the risk of pneumonia mortality by 32%(HR=0.68.95% CI：0.64-0.73). The continuous dose-response relationship results showed a negative nonlinear relationship between LTPA and the risk of pneumonia mortality (PNon-linearity<0.05). The risk of pneumonia death HR decreased by 16%(p<0.01, HR=0.84.95%CI:0.82-0.86) for each additional 5 MET-h/week when LTPA below 20 MET-h/week. When LTPA was higher than 20 MET-h/week, the risk of pneumonia death HR decreased by 6% for each additional 5 MET-h/week(p<0.01, HR=0.94,95%CI:0.93-0.94).

CONCLUSIONS

All doses of LTPA are protective factors of pneumonia mortality risk and the protective effect on pneumonia mortality is enhanced if LTPA increases. The degree of enhancement is weakened when LTPA is higher than 20 MET-h/week.

Persistent Neuroinflammation and Brain-Specific Immune Priming in a Novel Survival Model of Murine Pneumosepsis

Pneumonia is the leading cause of sepsis and septic shock. Patients who survive pneumonia are vulnerable to long-term complications including increased risk of neurocognitive dysfunction. This study investigated the immune response and long-term complications of a non-surgical mouse model of Klebsiella pneumoniae pneumosepsis with antibiotic treatment. Pneumosepsis resulted in acutely enhanced expression of inflammatory cytokines, chemokines, and damage-associated molecular patterns in the brain and spleen. Despite resolution of infection, murine pneumosepsis survivors demonstrated a deficit in exploratory locomotor behavior at 2 weeks. This was associated with brain-specific persistent inflammatory gene expression and infiltrating myeloid cells in the brain. The brain inflammatory response was also primed in response to secondary challenge with lipopolysaccharide. The findings of this study demonstrate behavioral and inflammatory outcomes that parallel observations in other models of sepsis, but that have not previously been described in antibiotic-treated pneumonia models, highlighting a common pathway to the development of chronic brain dysfunction in sepsis survival.

Linking administrative data sets of inpatient infectious diseases diagnoses in far North Queensland: a cohort profile

PURPOSE

To design a linked hospital database using administrative and clinical information to describe associations that predict infectious diseases outcomes, including long-term mortality.

PARTICIPANTS

A retrospective cohort of Townsville Hospital inpatients discharged with an International Classification of Diseases and Related Health Problems 10th Revision Australian Modification code for an infectious disease between 1 January 2006 and 31 December 2016 was assembled. This used linked anonymised data from: hospital administrative sources, diagnostic pathology, pharmacy dispensing, public health and the National Death Registry. A Created Study ID was used as the central identifier to provide associations between the cohort patients and the subsets of granular data which were processed into a relational database. A web-based interface was constructed to allow data extraction and evaluation to be performed using editable Structured Query Language.

FINDINGS TO DATE

The database has linked information on 41 367 patients with 378 487 admissions and 1 869 239 diagnostic/procedure codes. Scripts used to create the database contents generated over 24 000 000 database rows from the supplied data. Nearly 15% of the cohort was identified as Aboriginal or Torres Strait Islanders. Invasive staphylococcal, pneumococcal and Group A streptococcal infections and influenza were common in this cohort. The most common comorbidities were smoking (43.95%), diabetes (24.73%), chronic renal disease (17.93%), cancer (16.45%) and chronic pulmonary disease (12.42%). Mortality over the 11-year period was 20%.

FUTURE PLANS

This complex relational database reutilising hospital information describes a cohort from a single tropical Australian hospital of inpatients with infectious diseases. In future analyses, we plan to explore analyses of risks, clinical outcomes, healthcare costs and antimicrobial side effects in site and organism specific infections.

Factors associated with death in bedridden patients in China: A longitudinal study

BACKGROUND

Immobility is common and associated with adverse outcomes in hospitalized patients, especially older people. However, the factors contributing to mortality in bedridden patients are not well known. This study aimed to estimate short-term mortality and analyze risk factors that affect the prognosis of bedridden patients.

METHODS

This was a multicenter study in China involving 23,738 patients admitted to 25 hospitals between November 2015 and June 2016. All-cause mortality was recorded for 90 days after enrollment regardless of whether death occurred before or after discharge. Socio-demographic and clinical information was obtained from an electronic database. Univariate and multivariate Cox regression analysis was used to identify factors associated with mortality.

RESULTS

In total, 23,738 hospitalized bedridden patients, there were 1,114 (4.7%) observed deaths. The overall mortality rate was therefore 4.7%. Of these, 318 (1.4%) died while hospitalized and 796 (3.4%) after discharge. The univariate Cox regression analysis showed that variables significantly associated with 90-day mortality included total time spent bedridden, urinary tract infection and pulmonary infection (p<0.05). The multivariate Cox regression analysis showed that the independent risk factors for death were age (adjusted hazard ratio [aHR] 1.006, 95% CI 1.000-1.011), and pulmonary infection (aHR 1.439, 95% CI 1.266-1.635). The hazard ratios for mortality were reduced with urinary tract infection and more time spent bedridden.

CONCLUSIONS

The mortality after discharge was significantly higher than mortality in hospital. The factors affecting short-term mortality in bedridden patients included age, time spent bedridden, urinary tract infection and pulmonary infection. This suggests these factors may be potential predictors of mortality in bedridden patients. It is essential for medical staff to improve health education of patients and family members, pay more attention to follow up after discharge and meet care needs at home.