Pneumococcal immunization in older adults: implications for the long-term-care setting

[Influenzae and pneumococcal vaccination rate in an internal medicine ward]

INTRODUCTION

Vaccination against influenza virus and Streptococcus pneumoniae is a global health priority and authorities, on the basis of recent publications, have recently updated French recommendations. The aim of this study was to describe the influenzae and pneumococcal vaccination's rate in an internal medicine ward.

MATERIAL AND METHODS

All patients consecutively hospitalized during a 10 week-period in an internal medicine ward were included. The reasons for non-vaccination and the impact of an educational program for corrective measures were reported.

RESULTS

Overall, 198 consecutive patients were included; 93 (47%) were immunocompromised; 142 (71.2%) had an indication for pneumococcal vaccination and 171 (86.4%) for influenza vaccination but only 16.2% and 55% of them were vaccinated against these microorganisms, respectively. Prior pneumococcal vaccination was more frequently observed in immunocompromised patients than in non-immunocompromised patients (21.1 versus 6.4%; P=0.029), but no significant difference was observed for influenza vaccine. Corrective measures were initiated in 46 patients (39%), non-immunized against S. pneumoniae.

CONCLUSION

These results underline the very low prevalence of pneumococcal vaccination rate in at-risk hospitalized patients, as compared with influenza, despite recent recommendations.

Comparison of the bacterial isolates and antibiotic resistance patterns of elderly nursing home and general community patients

BACKGROUND

Nursing home-acquired infections may differ from general community-acquired infections in bacteriology and antibiotic resistance. However, there are currently limited data on this topic in the Australian setting.

AIMS

To compare bacterial isolates and antibiotic resistance patterns, from pathology specimens of nursing home and community patients, and to comment on the suitability of empiric antibiotic guidelines for nursing home-acquired infection.

METHODS

This was a retrospective cohort study of patients, aged ≥ 65 years, who resided in either nursing homes or the general community. Patients with a hospital admission in the previous 28 days were excluded. Positive specimen cultures, collected between July 2003 and June 2008 in the Emergency Department and Outpatient Clinics of the Austin Hospital (Melbourne), were examined. The main outcome measures were the bacterial isolates, and their antibiotic resistance patterns, of patients from nursing homes and the general community.

RESULTS

Specimens of blood (638), sputum (425), urine (4044) and wound cultures (785) were examined. The bacteriology of blood culture isolates did not differ between the two groups (P= 0.3). However, the bacteriology of sputum, urine and wound cultures differed significantly between the groups (P= 0.025, P < 0.001, P= 0.004 respectively). There were also higher proportions of antibiotic resistance among some bacteria in nursing home patients, especially methicillin resistance among Staphylococcus aureus isolates across all specimen types, and resistance to several empiric antibiotics among Enterobacteriaceae isolates in urine cultures.

CONCLUSION

Empiric antibiotic guidelines appear adequate to treat nursing home-acquired septicaemia and pneumonia. However, guidelines for urinary tract infections and wound infections may need to be refined.

Increasing influenza and pneumococcal immunization rates in a nursing home network

INTRODUCTION AND RATIONALE

Influenza and pneumonia remain serious health concerns for long-term care (LTC) residents. Vaccination of LTC residents and health care workers are reasonable preventive strategies, although most facilities fall short of Healthy People 2010 goals. Improving immunization rates across multiple LTC facilities remains an elusive challenge. This quality improvement study sought to improve immunization rates across 6 LTC facilities and identify persistent barriers to better performance.

METHODS

In 2002, 6 facilities associated with the University of Pittsburgh Institute on Aging established a quality improvement network addressing immunization rates. The facilities were provided with a written educational toolkit and shared information through an e-mail distribution list. To help determine optimal program structure in future years, 3 of the facilities participated in a single half-day collaborative training session. Change in immunization rates from baseline to year 2 were compared between those participating in the collaborative training and those not participating. Barriers to improved performance were sought from all groups through focus group analysis.

RESULTS

Facilities participating in the single collaborative training program improved immunization rates modestly, whereas facilities not participating in the collaborative training saw decreases in immunization rates. Staff turnover was cited as a significant barrier to improved performance.

DISCUSSION

It may be possible to improve immunization rates in LTC facilities, at least modestly, using a collaborative training process. Staff turnover may be an important barrier to improved LTC immunization rates.

Infections in the Long-Term Care Setting

In the long-term care setting

The diagnosis of infection is primarily based from the clinical assessment.

Infection is a common cause of fever, when present, and acute change in functional status.

Infection can often present atypically; usual symptoms, physical findings, and diagnostic abnormalities may be lacking.

Evaluation of fever and suspected infection should initially focus on the most common clinical syndromes.

Treatment should initially focus on the most common organisms that are present at the most likely suspect site of infection.

Immunizations in older adults

Older adults disproportionately sustain morbidity and mortality due to vaccine-preventable illnesses. Despite this observation, adult immunization rates continue to lag behind national goals. Reduced vaccine efficacy in older adults leading to apathy regarding the need for vaccine administration, unrealistic expectations for disease prevention rather than reduced illness severity, and system issues that make vaccine administration and tracking difficult all contribute to this problem. In this review, the biologic and system-based causes for vaccine failure in aged adults are reviewed, issues of efficacy and cost-effectiveness in older adults are summarized for influenza and pneumococcal vaccine, and ways to improve vaccine effectiveness in older adults, now and in the future, are outlined.

Pneumonia and Lower Respiratory Infections in Nursing Home Residents: Predictors of Hospitalization and Mortality

OBJECTIVES

To compare predictors of hospitalization and death in nursing home residents with pneumonia and other lower respiratory infections (LRIs).

DESIGN

A nested cohort study.

SETTING

Nine nursing homes in southern Ontario.

PARTICIPANTS

Three hundred fifty-three nursing home residents with LRIs (enrolled in the control arm of a clinical trial).

MEASUREMENTS

Comorbidities, vaccination status, age, health-related quality of life, functional status, and vital statistics were evaluated as potential predictors of hospitalization and mortality at 30 days.

RESULTS

Moderate to high disease severity score on a practical severity scale was a strong independent predictor of hospitalization (odds ratio (OR)=7.12, P<.001) and mortality (OR=5.04, P=.003). Diagnosis of pneumonia, established using chest radiograph, was also associated with hospitalization (OR=2.43, P=.008) and mortality (OR=2.35, P=.02). Oxygen saturation (<90%) was a strong independent predictor of hospitalization (OR=3.02, P=.004) but was not a significant predictor of mortality in multivariable analyses. Diagnosis of congestive heart failure (OR=2.26, P=.02) was an independent predictor of hospitalization, whereas receipt of pneumococcal vaccine (OR=0.36, P=.01) and greater functional independence (OR=0.92, P=.02) were negatively associated with hospitalization.

CONCLUSION

In nursing home residents with LRI, severity of illness and radiographically confirmed pneumonia are predictive of death and hospitalization.

Emerging drugs for the treatment of chronic obstructive pulmonary disease

By 2020 chronic obstructive pulmonary disease (COPD) will be the third leading cause of mortality and fifth leading cause of morbidity. Research over the past two decades has shed important insights on the pathobiology of COPD, leading to the development of novel drugs. In the past, symptomatic treatment with bronchodilators was the predominant focus of COPD management. With increased awareness of the importance of airway inflammation in COPD progression, there has been a shift in emphasis to drugs that attack various targets in the inflammatory cascade. These drugs include phosphodiesterase 4 inhibitors, leukotriene modifiers and TNF antagonists, which are poised to enter the COPD market in the very near future. Tyrosine kinase antagonists, inhibitors of NF-kappaB, neutrophil elastase inhibitors, chemokine antagonists, mucolytics and novel antibiotics are being evaluated for possible effectiveness in COPD. Many of these drugs may enter the COPD market within the next decade. This paper reviews the molecular rationale for these emerging drugs and their potential efficacy in COPD.

Prior pneumococcal vaccination is associated with reduced death, complications, and length of stay among hospitalized adults with community-acquired pneumonia

BACKGROUND

Vaccination with pneumococcal polysaccharide reduces the incidence of bacteremic pneumococcal disease in adults. We investigated the impact of prior pneumococcal vaccination on in-hospital mortality and the probability of respiratory failure among hospitalized adults with community-acquired pneumonia.

METHODS

Consecutive individuals hospitalized with community-acquired pneumonia (diagnosed by International Classification of Diseases, Ninth Revision, Clinical Modification codes 480.0-487.0) at 109 community and teaching hospitals in the United States were identified using the Quality and Resource Management System, a database constructed by Tenet HealthCare to improve the quality of patient care. Vaccination status, comorbidities, and outcomes were abstracted by case managers concurrently with patient care. Associations between vaccination, survival, and respiratory failure were defined using multivariable logistic regression models.

RESULTS

Of 62,918 adults hospitalized with community-acquired pneumonia between 1999 and 2003, 7390 (12%) had a record of prior pneumococcal vaccination. Vaccine recipients were less likely to die of any cause during hospitalization than were individuals with no record of vaccination (adjusted odds ratio [OR], 0.50; 95% confidence interval [CI], 0.43-0.59), even after adjustment for the presence of comorbid illnesses, age, smoking, and influenza vaccination and under varying assumptions about missing vaccination data. Vaccination also lowered the risk of respiratory failure (adjusted OR, 0.67; 95% CI, 0.59-0.76) and other complications and reduced median length of stay by 2 days, compared with nonvaccination (P<.001).

CONCLUSIONS

Prior vaccination against pneumococcus is associated with improved survival, decreased chance of respiratory failure or other complications, and decreased length of stay among hospitalized patients with community-acquired pneumonia. These observations reinforce current efforts to improve compliance with existing pneumococcal vaccination recommendations for adults.