Older Adults Hospitalized for Pneumonia in the United States: Incidence, Epidemiology, and Outcomes

Rates of Lower Respiratory Tract Illness in US Adults by Age and Comorbidity Profile

INTRODUCTION

While it is widely recognized that older adults, adults with chronic medical conditions (CMC), and adults with immunocompromising conditions (IC) are at increased risk of lower respiratory tract illness (LRTI), evidence of the magnitude of increased risk is limited. This study was thus undertaken to characterize rates of hospitalized and ambulatory LRTI among United States (US) adults by age and comorbidity profile.

METHODS

A retrospective cohort design and US healthcare claims database (2016-2019) were employed. Study population included adults aged ≥ 18 years and was stratified by age and comorbidity profile (CMC-, CMC+ , IC). LRTI was ascertained overall and by pathogen pathogen (e.g., respiratory syncytial virus [RSV]), and was classified by care setting (hospital, emergency department [ED], physician office/hospital outpatient [PO/HO]).

RESULTS

Relative rates (RR) of LRTI generally increased with older age across care settings (vs. 18-49 years), with the most marked increase for hospitalizations: for LRTI-hospitalized, RRs ranged from 3.3 for 50-64 years to 46.6 for ≥ 85 years; for LRTI-ED and LRTI-PO/HO, RRs ranged from 1.0 to 2.7 and from 1.3 to 1.5, respectively. Within age groups, LRTI rates were also consistently higher among CMC+ and IC adults (vs. CMC- adults). Age-specific RRs of LRTI patients hospitalized due to RSV were largely comparable to overall LRTI; age-specific RRs for other care settings, and RRs for CMC+ and IC adults (vs. CMC- adults), were generally higher for LRTI due to RSV.

CONCLUSIONS

Incidence of LRTI, including that due to RSV, especially for events requiring acute inpatient care, is markedly higher among older adults and adults of all ages with CMC or IC.

Health Care Provider Knowledge and Attitudes Regarding Adult Pneumococcal Conjugate Vaccine Recommendations - United States, September 28-October 10, 2022

Despite the availability of effective vaccines against pneumococcal disease, pneumococcus is a common bacterial cause of pneumonia, causing approximately 100,000 hospitalizations among U.S. adults per year. In addition, approximately 30,000 invasive pneumococcal disease (IPD) cases and 3,000 IPD deaths occur among U.S. adults each year. Previous health care provider surveys identified gaps in provider knowledge about and understanding of the adult pneumococcal vaccine recommendations, and pneumococcal vaccine coverage remains suboptimal. To assess the feasibility and acceptability domains of the Advisory Committee on Immunization Practices (ACIP) Evidence to Recommendations (EtR) framework, a health care provider knowledge and attitudes survey was conducted during September 28-October 10, 2022, by the Healthcare and Public Perceptions of Immunizations Survey Collaborative before the October 2022 ACIP meeting. Among 751 provider respondents, two thirds agreed or strongly agreed with the policy option under consideration to expand the recommendations for the new 20-valent pneumococcal conjugate vaccine (PCV20) to adults who had only received the previously recommended 13-valent pneumococcal conjugate vaccine (PCV13). Gaps in providers' knowledge and perceived challenges to implementing recommendations were identified and were included in ACIP's EtR framework discussions in late October 2022 when ACIP updated the recommendations for PCV20 use in adults. Currently, use of PCV20 is recommended for certain adults who have previously received PCV13, in addition to those who have never received a pneumococcal conjugate vaccine. The survey findings indicate a need to increase provider awareness and implementation of pneumococcal vaccination recommendations and to provide tools to assist with patient-specific vaccination guidance. Resources available to address the challenges to implementing pneumococcal vaccination recommendations include the PneumoRecs VaxAdvisor mobile app and other CDC-developed tools, including summary documents and overviews of vaccination schedules and CDC's strategic framework to increase confidence in vaccines and reduce vaccine-preventable diseases, Vaccinate with Confidence.

Association between physical therapy frequency and postacute care for a national cohort of patients hospitalized with pneumonia

BACKGROUND

Annually more than 300,000 patients hospitalized for pneumonia need postacute care. Patients and systems prefer home discharge, but physical limitations often necessitate postacute care. It is unknown whether frequency of physical therapy in the hospital affects postacute care discharges.

OBJECTIVE

Examine the relationship between physical therapy visit frequency and disposition among a national sample of patients hospitalized with pneumonia.

DESIGNS

Observational cohort study.

SETTING

Acute care hospital.

PARTICIPANTS

Adult patients with primary diagnosis of pneumonia in the Premier Data Set who received physical therapy in the hospital during a 5-day window, with therapy on at least days 1 and 5.

INTERVENTION

Physical therapy visit frequency.

MAIN OUTCOME AND MEASURES

Discharge disposition (home or postacute care).

RESULTS

We included 18,886 patients from 595 hospitals. Just over half were discharged home (n = 9638; 51.0%) and 558 (2.95%) died. Patients getting more frequent therapy were older, non-Hispanic white, treated in small non-teaching rural hospitals in the West, Midwest, or South, and had fewer severe illness indicators. In adjusted models, patients who received physical therapy on 100% of days were 7% [(95% confidence interval, 4.3-9.7), p < .0001] more likely to go home than patients who received physical therapy on 40% of days. As a falsification test, we found that there was no relationship between physical therapy frequency and all-cause mortality. Physical therapy visit frequency was positively associated with discharge to home. Increasing visit frequency of physical therapy in hospitals might reduce the need for postacute care, but randomized controlled trials are needed to confirm the effect.

Interventions to improve outcomes in community-acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is a common infection associated with high morbimortality and a highly deleterious impact on patients' quality of life and functionality. We comprehensively review the factors related to the host, the causative microorganism, the therapeutic approach and the organization of health systems (e.g. setting for care and systems for allocation) that might have an impact on CAP-associated outcomes. Our main aims are to discuss the most controversial points and to provide some recommendations that may guide further research and the management of patients with CAP, in order to improve their outcomes, beyond mortality.

AREA COVERED

In this review, we aim to provide a critical account of potential measures to improve outcomes of CAP and the supporting evidence from observational studies and clinical trials.

EXPERT OPINION

CAP is associated with high mortality and a highly deleterious impact on patients' quality of life. To improve CAP-associated outcomes, it is important to understand the factors related to the patient, etiology, therapeutics, and the organization of health systems.

Herd immunity in older adults from a middle-income country: A time-series trend analysis of community-acquired pneumonia mortality 2003-2017

Background and Aims

Community-acquired pneumonia is responsible for substantial mortality, and pneumococcus is commonly accepted as a major cause of pneumonia, regardless of laboratory confirmation. Child immunization programs have reported success in decreasing pneumonia mortality: directly in young children and indirectly (herd immunity) in unvaccinated adult populations in some countries. We assess changes in mortality trends for all-cause pneumonia in older adults associated with the introduction of pneumococcal vaccination for children in Peru.

Methods

This is a secondary analysis on administrative data collected periodically by the Peruvian Ministry of Health. An observational retrospective time series analysis was conducted using longitudinal population-based data from death certificates in Peru between 2003 and 2017. The time series includes 6 years before and 9 years after the introduction of the pneumococcal-conjugated vaccines in the national child immunization program in 2009. Monthly frequencies and annual rates for all-cause pneumonia deaths in children under 5 years of age and adults over 65 years of age are presented. Linear and quadratic trends are analyzed.

Results

Deaths among older adults accounted for 75.6% of all-cause pneumonia mortality in Peru, with 94.4% of these reporting "pneumonia due to unspecified organism" as the underlying cause of death. Comparing pre- and post-child immunization program periods, annual average mortality rates from unspecified pneumonia decreased by 22.7% in young children but increased by 19.6% in older adults. A linear trend model supports this overall tendency, but a quadratic curve explains the data better.

Conclusion

Pneumococcal-conjugated vaccines are developed using serotypes prevalent in selected countries from less common (invasive) pneumococcal disease and expected to prevent mortality worldwide from widespread (noninvasive) pneumonia. Our results do not support the presence of herd immunity from pneumococcal vaccination of children for community-acquired pneumonia in the increasingly ageing population of Peru. This should direct future research and could influence public health policy.

Effect of 0.12% Chlorhexidine Oral Rinse on Preventing Hospital-Acquired Pneumonia in Nonventilator Inpatients

BACKGROUND

Nonventilator hospital-associated pneumonia (NV-HAP) is a nosocomial infection with a multifactorial etiology that is particularly prevalent in individuals with poor oral health.

PURPOSE

This study was designed to determine the effect of a 0.12% chlorhexidine gluconate oral rinse intervention on oral health and on reducing NV-HAP in inpatients.

METHODS

A randomized, double-blind, and triple-arm clinical trial was conducted on a sample of 103 patients aged ≥ 50 years. Using the blocking sample method, patients were randomly assigned into three groups. These included Group A, using an oral rinse solution of 0.12% chlorhexidine; Group B, using Listerine; and Group C, using a standard saline oral rinse. In addition to routine hospital-associated pneumonia preventative nursing care, the participants used the oral rinse solutions twice a day with a period of at least 9 hours between each use. Oral health, the degree of bacterial exposure, and the clinical pneumonia index scale were evaluated in each of the groups at baseline (first day), on Intervention Days 3 and 7, and at discharge. The clearance rate was calculated by dividing the number of bacteria cleared by the total frequency of oral bacteria in the collected culture × 100%.

RESULTS

Each arm of the study was composed of 34-35 participants, with an average hospitalization duration of 7.5 days. There was no incidence of NV-HAP or any changes in clinical pulmonary infection score among the three groups. Group A achieved a more significant improvement in oral health assessment tool scores between baseline and discharge than either Group B or C ( p = .03), particularly in the tongue, gums, and tissues; saliva; and oral cleanliness subscales. In addition, Group A reported higher clearance rates for Staphylococcus (100.00% vs. 66.67% vs. 66.67%, respectively), Escherichia coli (100.00% vs. 60.00% vs. 66.67%, respectively), and Pseudomonas aeruginosa (75.00% vs. 46.30% vs. 25.00%, respectively) than Groups B and C.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Although the results do not provide evidence supporting the use of a 0.12% chlorhexidine oral rinse as better in terms of preventing NV-HAP in middle-aged and elderly inpatients, nursing supervision was found to have an overall positive effect on oral health. The use of oral rinse with 0.12% chlorhexidine for nonventilated patients with poor oral health may be recommended.

Bacterial pneumonia and subsequent dementia risk: A nationwide cohort study

BACKGROUND

Bacterial pneumonia is associated with an increased risk of dementia. However, the association between different pathogens of bacterial pneumonia and the risk of dementia remains unclear.

METHODS

Using the Taiwan National Health Insurance Research Database, we recruited 11,712 patients with bacterial pneumonia and 11,120 controls between 1997 and 2012 and followed them up until the end of 2013. A diagnosis of dementia, Alzheimer's disease (AD), vascular dementia (VaD), and unspecified dementia were identified during the follow-up period. Cox regression analyses were performed with adjustments for confounders. Sensitivity analysis was conducted to exclude patients with prodromal dementia.

RESULTS

Patients with bacterial pneumonia were more likely to develop dementia (hazard ratio [HR]: 2.83, 95% confidence interval [CI]: 2.53-3.18), AD (HR: 2.44, 95% CI: 1.65-3.61), VaD (HR: 4.15, 95% CI: 3.20-5.38), and unspecified dementia (HR: 2.62, 95% CI: 2.29-3.00) compared with controls after adjusting for potential confounders. Subgroup pathogen analyses showed that the HR of AD was 3.85 (1.66-8.96) for Hemophilus, and the HR of VaD was 5.40 for Staphylococcus. The risks of dementia and VaD were associated with repeated hospitalization due to bacterial pneumonia in a dose-dependent manner. Sensitivity analyses after exclusion of the first three years or first five years of observation and after exclusion case enrollment before 2010 or 2008 showed consistent findings.

CONCLUSION

Different pathogens are associated with different risks of AD, VaD, and unspecified dementia. Further studies are necessary to investigate the underlying mechanisms of bacterial pneumonia and dementia.

Long-term postoperative pneumonia in elderly patients with early gastric cancer

Background

Pneumonia is a major cause of death in the elderly population. Considering body weight loss, muscle loss, and reflux after gastrectomy, elderly patients are considered to be at very high risk for pneumonia, which could decrease overall survival because early gastric cancer is mostly curable only by surgery. We aimed to clarify the incidence of pneumonia in the long-term period after gastrectomy in elderly patients who were diagnosed with early gastric cancer and its risk factors.

Methods

We retrospectively examined patients of > 75 years of age who underwent R0 gastrectomy for gastric cancer and who were diagnosed with T1 disease at National Cancer Center Hospital between 2005 and 2012. Long-term postoperative pneumonia was diagnosed by chest computed tomography every year until 2 years after surgery. The presence of preoperative sarcopenia was assessed using preoperative L3 skeletal muscle index.

Results

167 patients were included in this study. Long-term postoperative pneumonia was observed in 44 (26%) patients. Of the 44 people diagnosed with long-term postoperative pneumonia, 33 were diagnosed in the 1st year and 11 in the 2nd year. 117 patients (70%) were diagnosed with sarcopenia which was significantly frequently found in the patients who developed long-term postoperative pneumonia (91%) than those without (63%). Preoperative sarcopenia was the only independent risk factor in multivariate analysis. Type of gastrectomy was not a significant risk factor.

Conclusions

Long-term postoperative pneumonia was frequently observed in the elderly patients. Preoperative sarcopenia was associated with long-term postoperative pneumonia in elderly patients who underwent curative surgery for gastric cancer. After gastrectomy, long-term special care would be required for elderly patients, especially with sarcopenia.

Performance of the CORB (Confusion, Oxygenation, Respiratory Rate, and Blood Pressure) Scale for the Prediction of Clinical Outcomes in Pneumonia

Background. Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality due to misdiagnosis and inappropriate treatment approaches. Objective. To assess the performance of the CORB score in subjects with CAP for predicting in-hospital mortality, death within 30 days of admission, and requirement for invasive mechanical ventilation (IMV) and vasopressor support. Methods. A retrospective, cohort study with diagnostic test analysis of CORB and CURB-65 scores in subjects with CAP according to ATS criteria was undertaken. An alternative CORB score was estimated by replacing SpO2 ≤90% by the SpO2/FiO2 ratio. Crude and adjusted odd ratios (AOR) were calculated for each variable. The area under the receiver operating characteristics curve (AUROC) was constructed for each score, and outcomes were analyzed. AUROCs were compared with the DeLong test, considering a p value $<\mathrm{0,05}$ statistically significant. Results. From 1,811 subjects who entered the analysis, 15.1% (273/1,811) died in hospital, 8.78% required IMV (159/1,811), and 9.77% (177/1,811) needed vasopressor support. CORB had an AUROC of 0,660 (95% CI: 0,623–0,697) for in-hospital mortality; an AUROC of 0,657 (95% CI: 0,621–0,692) for 30-day mortality; an AUROC of 0,637 (CI 95%: 0,589–0,685) for IMV requirement; and an AUROC of 0,635 (95% CI: 0,589–0,681) for vasopressor support. CORB performance increases when the SpO2/FiO2 ratio <300 is used as oxygenation criterion in the prediction of requirement for IMV and vasopressor support, with AUROC of 0,700 (95% CI: 0,654–0,746; $p<0.001$ ) and AUROC of 0,702 (95% CI: 0,66–0,745; $p<0.001$ ), respectively. CURB-65 score presents an in-hospital mortality AUROC of 0,727 (95% CI: 0,695–0,759) and 30-day mortality AUROC of 0,726 (95% CI: 0,695–0,756). Conclusions. CORB score has a good performance in predicting the need for IMV and vasopressor support in CAP patients. This performance improves when the SpO2/FiO2 ratio <300 is used instead of the SpO2 ≤90% as the oxygenation parameter. CURB-65 score is superior in the prediction of mortality.

Incidence of potentially disruptive medical and social events in older adults with and without dementia

BACKGROUND

Potentially disruptive medical, surgical, and social events-such as pneumonia, hip fracture, and widowhood-may accelerate the trajectory of decline and impact caregiving needs in older adults, especially among people with dementia (PWD). Prior research has focused primarily on nursing home residents with dementia. We sought to assess the incidence of potentially disruptive events in community-dwelling people with and without dementia.

METHODS

Retrospective cohort study of participants aged 65+ enrolled in the Health and Retirement Study between 2010 and 2018 (n = 9346), including a subset who were married-partnered at baseline (n = 5105). Dementia was defined with a previously validated algorithm. We calculated age-adjusted and gender-stratified incidence per 1000 person-years and incidence rate ratios of: 1) hospitalization for pneumonia, 2) hip fracture, and 3) widowhood in people with and without dementia.

RESULTS

PWD (n = 596) were older (mean age 84 vs. 75) and a higher proportion were female (67% vs. 57%) than people without dementia (PWoD) (n = 8750). Age-adjusted incidence rates (per 1000 person-years) of pneumonia were higher in PWD (113.1; 95% CI 94.3, 131.9) compared to PWoD (62.1; 95% CI 54.7, 69.5), as were hip fractures (12.3; 95% CI 9.1, 15.6 for PWD compared to 8.1; 95% CI 6.9, 9.2 in PWoD). Point estimates of widowhood incidence were slightly higher for PWD (25.3; 95% CI 20.1, 30.5) compared to PWoD (21.9; 95% CI 20.3, 23.5), but differences were not statistically significant. The association of dementia with hip fracture-but not pneumonia or widowhood-was modified by gender (male incidence rate ratio [IRR] 2.24, 95% CI 1.34, 3.75 versus female IRR 1.31 95% CI 0.92,1.86); interaction term p = 0.02).

CONCLUSIONS

Compared to PWoD, community-dwelling PWD had higher rates of pneumonia and hip fracture, but not widowhood. Knowing how often PWD experience these events can aid in anticipatory guidance and care planning for this growing population.

Effect of Anemia on Readmission and Death in Octogenarian Patients with Lower Respiratory Tract Infections: A Retrospective Cohort Study

OBJECTIVES

Lower respiratory tract infection (LRTI) in the octogenarian population is a highly prevalent disorder associated with increased mortality rates. Anemia is a common disorder in older adults and is often left untreated. We investigated whether anemia was a risk factor for LRTI-caused readmission and death in octogenarian patients.

DESIGN

A retrospective cohort study was designed. Participants. Old patients (age: ≥80 years) hospitalized at the Department of Geriatrics to undergo treatment for LRTIs were included. A total of 215 patients (mean age: 88.73 years; 77.2% men) were studied. The patients were divided into two groups (anemia and non-anemia) based on the hemoglobin level. They were followed up for 1 year after discharge or until mortality event. The primary follow-up outcome was LRTI-caused readmission and/or death.

RESULTS

The risk of readmission due to LTRI within 1 year of discharge was 2.308 times higher in the anemia group than the risk for the non-anemia group. The number of patients experiencing ≥2 readmissions in the anemia group was significantly higher than that in the non-anemia group (35 (23.5%) vs. 2 (3%), P < 0.001). To prevent readmission of one case, only 2.65 cases with anemia needed to be treated. Furthermore, the risk of LRTI-related deaths was 6.644 times higher in the anemia group than the risk for the non-anemia group. To prevent death of one case, only 3.9 cases with anemia needed to be treated. Statistic results revealed that hemoglobin was an independent protective factor for LRTI-caused readmission (logistic regression method, OR, 0.969; 95% CI, 0.950-0.989) and deaths (Cox regression method, β, -0.037, HR, 0.964; 95% CI, 0.934-0.994).

CONCLUSIONS

Anemia is a widely prevalent and relevant risk factor associated with LRTI-caused readmission and death within 1 year of discharge in octogenarian patients. Trial Registration. This trial is registered with NCT05355324.

Efficacy of phentolamine combined with ambroxol aerosol inhalation in the treatment of pediatric severe pneumonia and its effect on serum IL-10 and CRP levels

BACKGROUND

The aim of the present study was to determine the therapeutic effect of phentolamine combined with Ambroxol aerosol inhalation on pediatric severe pneumonia and its effect on serum interleukin-10 (IL-10) and C-reactive protein (CRP) levels.

METHODS

Eighty-five children with severe pneumonia treated in our hospital from November 2019 to November 2020 were selected as the research participants, and were divided into the routine group (n=41) and treatment group (n=44) according to odd and even admission numbers, respectively. Children in the first group received routine treatment, namely symptomatic treatment such as cough relief (e.g., expectorant) and defervescence, while those in the second group received phentolamine combined with Ambroxol aerosol inhalation. Clinical indexes of both groups before and after treatment were analyzed to determine the therapeutic effect of different treatment methods and serum IL-10 and CRP level changes.

RESULTS

There was no significant difference in general clinical data between the 2 groups (P>0.05). The duration of cough, fever, abnormal lung sound and lung shadow, and hospitalization time in the treatment group was significantly shorter than those in the routine group (P<0.001). The total clinical effective rate in the treatment group was significantly higher than that in the routine group (P<0.05). Forced vital capacity and peak expiratory flow rate levels were higher in both groups after treatment (P<0.05), and these were higher in the treatment group compared with the routine group after treatment (P<0.05). Serum IL-10 and CRP levels at T1 (2 days after treatment), T2 (5 days after treatment), and T3 (7 days after treatment) in the treatment group were significantly lower than those in the routine group (P<0.001). The total incidence of adverse reactions in the treatment group was significantly lower than that in the routine group (P<0.05).

CONCLUSIONS

Phentolamine combined with Ambroxol aerosol inhalation can significantly improve the clinical symptoms of children with severe pneumonia, reduce the body's inflammatory response, and improve lung function safely.

Infectious diseases as a cause of death among cancer patients: a trend analysis and population-based study of outcome in the United States based on the Surveillance, Epidemiology, and End Results database

Background

Infectious diseases are a major cause of morbidity and mortality among cancer patients. We aimed to determine the incidence of infectious diseases as a cause of death among cancer patients and analyze the trends and risk factors associated with mortality.

Methods

In total, 151,440 cancer patients who died from infectious diseases in the US diagnosed between 1973 and 2014 from the Surveillance, Epidemiology, and End Results program were enrolled. A trend analysis of annual cancer deaths caused by infectious diseases was conducted. Cox proportional hazards model and survival decision tree model were performed.

Result

The most common infectious diseases were pneumonia and influenza (n = 72,133), parasitic and other infectious (n = 47,310) diseases, and septicemia (n = 31,119). The patients’ mean age was 66.33 years; majority of them were male (62%). The overall incidence from 1973 to 2014 showed an insignificant decrease (annual percentage change =  − 0.3, 95% confidence interval [CI] =  − 2.2–1.7, P = 0.8). Parasitic and other infectious diseases, including HIV (standardized incidence ratio [SIR] = 1.77, 95% CI = 1.69–1.84), had the highest incidence, followed by septicemia (SIR = 0.84, 95% CI = 0.81–0.88), tuberculosis (SIR = 0.72, 95% CI = 0.51–0.99), and pneumonia (SIR = 0.63, 95% CI = 0.61–0.64). Based on the Cox regression analysis, old black male patients with intrahepatic tumor or acute leukemia of different grades, except the well-differentiated grade, had the highest risk of dying from infectious diseases.

Conclusion

Infectious diseases remain the major cause of morbidity and mortality among cancer patients. Early recognition of risk factors and timely intervention may help mitigate the negative consequences on patients’ quality of life and prognosis, improving the prognosis and preventing early death from infection, which is preventable in most cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13027-021-00413-z.

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.

Early in-hospital course of critically ill nontrauma patients in a resuscitation room of a German emergency department (OBSERvE2 study)

BACKGROUND

Management of critically ill nontrauma (CINT) patients in the resuscitation room of the emergency department (ED) is very challenging. Detailed data describing the patient characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the resuscitation room.

METHODS

This prospective, single center observational study included all adult patients who were consecutively admitted to the ED resuscitation room during 2 periods of 1 year (September 2014-August 2015 vs. September 2017- August 2018). Patient characteristics, out-of-hospital/in-hospital treatment, admission-related conditions, time intervals for diagnostics and interventions and outcome were recorded using a self-developed questionnaire.

RESULTS

A total of 34,303 patients in the first and 35,039 patients in the second study period were admitted to the ED, of whom 532 and 457 patients, respectively, were admitted to the nontrauma resuscitation room due to acute life-threatening conditions. The patient characteristics did not differ significantly between the study periods (male: 58% vs. 59%, age: 68 ± 17 years vs. 65 ± 17 years). Time intervals for diagnostic and therapeutic interventions were similar. The CINT patients during the second study period were treated faster compared to the first study period (end of ED management: 53 ± 33 min vs. 41 ± 24 min, p < 0.0001). The 30-day all-cause mortality was comparable (34.0% vs. 36.3%).

CONCLUSION

Observation of critically ill patient management in the ED resuscitation room showed reliable results between both study periods. Structured ED management guidelines for CINT patients may provide comparable results at one institution.

Burden of infections on older patients presenting to general practice: a registry-based study

BACKGROUND

Estimates on the incidence rates of infections are needed to assess the burden of disease in the community.

OBJECTIVE

To assess incidence rates of potentially serious infections in patients aged 65 years and over presenting to Flemish general practice from 2000 to 2015, and to describe patient characteristics.

METHODS

We performed a retrospective study, based on data provided by the Intego morbidity registry of the KU Leuven, which includes the electronic medical records of 111 general practitioners. Incidence rates were calculated taking person-time at risk into account, and longitudinal trends from 2000 to 2015 were analysed using autoregressive time-series analyses.

RESULTS

On average, a person aged 65 years or older has an 8.0% risk of getting a potentially serious infection each year. Acute cystitis was the most often occurring potentially serious infection [39.8/1000 person-years; 95% confidence interval (CI): 39.4-40.2], followed by influenza like illness (ILI, 24.3/1000 person-years; 95% CI: 24.0-24.6) and pneumonia (9.7/1000 person-years; 95% CI: 9.5-9.9). The incidence rates of pneumonia were higher in older age groups and in men, whereas they were markedly lower for ILI at older ages, in both genders. From 2000 to 2015, overall incidence rates decreased significantly for ILI, while they increased in women for pneumonia, acute cystitis and pyelonephritis. Common chronic comorbidities were non-insulin dependent diabetes, chronic obstructive pulmonary disease, asthma, heart failure and chronic renal insufficiency.

CONCLUSIONS

Potentially serious infections are quite common in an older patient population presenting to primary care. They are accompanied by several chronic comorbidities, which may differ by infection type.

Pneumonia in older adults

PURPOSE OF REVIEW

The purpose of this review is to address the relevant issues surrounding older adults with community-acquired pneumonia (CAP) today.

RECENT FINDINGS

Approximately 1 million people >65 years have CAP in the US per year, which is more than previously reported (or realized). Older adults are vulnerable to the increasing prevalence of viral CAP, as the SARS-CoV-2 pandemic emphasizes, but pneumococcus is still the most common pathogen to cause CAP. Racial disparities continue to need to be addressed in order to improve early and late outcomes of older adults with CAP.

SUMMARY

The epidemiology of CAP, specifically for older adults is changing. More recent pathogen incidence studies have included culture, as well as newer microbiological methods to determine etiology. Current disparities among disadvantaged populations, including African-Americans, result in more comorbidities which predisposes to more severe CAP. However, outcomes in the hospital between races tend to be similar, and outcomes between age groups tends to be worse for older compared to younger adults. Finally, the cost of CAP is significant compared to diabetes mellitus, myocardial infarction and stroke.

Variation in Acute Care Rehabilitation and 30-Day Hospital Readmission or Mortality in Adult Patients With Pneumonia

IMPORTANCE

Pneumonia often leads to functional decline during and after hospitalization and is a leading cause of hospital readmissions. Physical and occupational therapists help improve functional mobility and may be of help in this population.

OBJECTIVE

To evaluate whether use of physical and occupational therapy in the acute care hospital is associated with 30-day hospital readmission risk or death.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included the electronic health records and administrative claims data of 30 746 adults discharged alive with a primary or secondary diagnosis of pneumonia or influenza-related conditions from January 1, 2016, to March 30, 2018. Patients were treated at 12 acute care hospitals in a large health care system in western Pennsylvania. Data for this study were analyzed from September 2019 through March 2020.

EXPOSURES

Number of physical and occupational therapy visits during the acute care stay categorized as none, low (1-3), medium (4-6), or high (>6).

MAIN OUTCOMES AND MEASURES

Outcomes were 30-day hospital readmission or death. Generalized linear mixed models were estimated to examine the association of therapy use and outcomes, controlling for patient demographic and clinical characteristics. Subgroup analyses were conducted for patients older than 65 years, for patients with low functional mobility scores, for patients discharged to the community, and for patients discharged to a post-acute care facility (ie, skilled nursing or inpatient rehabilitation facility).

RESULTS

Of 30 746 patients, 15 507 (50.4%) were men, 26 198 (85.2%) were White individuals, and the mean (SD) age was 67.1 (17.4) years. The 30-day readmission rate was 18.4% (5645 patients), the 30-day death rate was 3.7% (1146 patients), and the rate of either outcome was 19.7% (6066 patients). Relative to no therapy visits, the risk of 30-day readmission or death decreased as therapy visits increased (1-3 visits: odds ratio, 0.98; 95% CI, 0.89-1.08; 4-6 visits: odds ratio, 0.89; 95% CI, 0.79-1.01; >6 visits: odds ratio, 0.86; 95% CI, 0.75-0.98). The association was stronger in the subgroup with low functional mobility and in individuals discharged to a community setting.

CONCLUSIONS AND RELEVANCE

In this study, the number of therapy visits received was inversely associated with the risk of readmission or death. The association was stronger in the subgroups of patients with greater mobility limitations and those discharged to the community.

Risk indices that predict in-hospital mortality of elderly patients

Background/aim

Mortality in the elderly population tends to be higher than in all other age groups; the risk factors that predict mortality among those in this age cohort are not fully understood. This large-scale clinical study aimed to identify effective risk factors that predict mortality in the elderly population with a particular focus on age and hospitalization status.

Material and methods

We retrospectively analyzed outcomes from patients with clinical follow-up between July 2015 and January 2020 at 29 Mayıs State Hospital, Ankara, Turkey. Patient records with missing or ambiguous data were excluded. Age, sex, length of hospital stay, comorbidities, consultation requests and diagnoses that include infectious diseases were evaluated for their role in predicting in-hospital mortality using binary logistic regression analysis. Primary outcomes focused on factors that had an impact on overall in-hospital mortality in the elderly population.

Results

Our study included 11,430 patients; of this group, 39.9% were elderly, which we defined as 65 years of age or older. Risk factors for in-hospital mortality in this cohort included consultation requests (AOR = 1.95, CI (1.53–2.49), P < 0.001) and length of hospital stay of ≥4 days (AOR = 2.49, CI (1.90–3.26), P < 0.001).

Conclusion

Elderly patients are at significantly higher risk for in-hospital mortality than are younger patients. Among the factors that may be used to predict the risk of in-hospital mortality in the elderly patient cohort, the most important factor is the length of hospital stay.