The association between pre-hospital antibiotic therapy and subsequent in-hospital mortality in adults presenting with community-acquired pneumonia: an observational study

Retrospective cohort analysis of outpatient antibiotic prescribing for community-acquired pneumonia in Canadian older adults

BACKGROUND

This retrospective cohort study is the first in North America to examine population-level appropriate antibiotic use for community-acquired pneumonia (CAP) in older adults, by agent, dose and duration. With the highest rates of CAP reported in the elderly populations, appropriate antibiotic use is essential to improve clinical outcomes. Given the ongoing crisis of antimicrobial resistance, understanding inappropriate antibiotic prescribing is integral to direct community stewardship efforts.

METHODS

All outpatient primary care visits for CAP (aged ≥65 years) were identified using physician billing codes between January 1 2014 to December 31 2018 in British Columbia (BC) and Ontario (ON). Categories of prescribing were derived from existing literature, and constructed for clinical relevance using Canadian and international guidelines available during the study period. Categories were mutually exclusive and included: guideline adherent (first-line agent, adherent dose/duration), clinically appropriate (non-first line agent, presence of comorbidities), effective but unnecessary (first-line agent, excess dose/duration), undertreatment (first-line agent, subtherapeutic dose/duration), and not recommended (non-first line agent, absence of comorbidities). Proportions of prescribing were examined by category. Temporal trends in prescribing were examined using Poisson regression.

RESULTS

A total of 436,441 episodes of CAP were identified, with 46% prescribed an antibiotic in BC, and 52% in Ontario. Guideline adherent prescribing was minimal for both provinces (BC: 2%; ON: 1%) however the largest magnitude of increase was reported in this category by the final study year (BC-Rate Ratio [RR]: 3.4, 95% Confidence Interval [CI]: 2.7-4.3; ON-RR: 4.62, 95% CI: 3.4-6.5). Clinically appropriate prescribing accounted for the most antibiotics issued, across all study years (BC: 61%; ON: 74%) (BC-RR: 0.8, 95% CI: 0.8-0.8; ON-RR: 0.9, 95% CI: 0.8-0.9). Excess duration of therapy was the hallmark characteristic for effective but unnecessary prescribing (BC: 92%; ON: 99%). The most common duration prescribed was 7 days, followed by 10. Not recommended prescribing was minimal in both provinces (BC: 4%; ON: 7%) and remained stable by the final study year (BC-RR: 1.1, 95% CI: 0.9-1.2; ON-RR: 0.9, 95% CI: 0.9-1.1).

CONCLUSION

Three quarters of antibiotic prescribing for CAP was appropriate in Ontario, but only two thirds in BC. Shortening durations-in line with evidence for 3 to 5-day treatment presents a focused target for stewardship efforts.

Effect of Prehospital Antibiotic Therapy on Clinical Outcome and Pathogen Detection in Children With Parapneumonic Pleural Effusion/Pleural Empyema

BACKGROUND

Parapneumonic pleural effusion and pleural empyema (PPE/PE) are complications of community-acquired pneumonia. The objective of this study was to analyze prehospital antibiotic therapy (PH-ABT) of children with PPE/PE and investigate its effects on clinical outcome and pathogen detection.

METHODS

Prospective nationwide active surveillance in Germany between October 2010 and June 2018. Children and adolescents <18 years of age with pneumonia-associated PE or PPE requiring drainage or with persistence of PPE/PE >7 days were included.

RESULTS

A total of 1724 children with PPE/PE were reported, of whom 556 children (32.3% of 1719 with available data) received PH-ABT. Children with PH-ABT had a shorter median hospital length of stay (15 vs. 18 days, P < 0.001), a longer time from onset of symptoms until hospital discharge (25 vs. 23 days, P = 0.002), a lower rate of intensive care unit admission (58.3% vs. 64.4%, P = 0.015) and fewer infectious complications (5.9% vs. 10.0%; P = 0.005). Bacterial pathogens in blood or pleural fluid culture were detected in 597 (34.5%) of 1513 children. Positive culture results were less frequent in children with than without PH-ABT (81/466 [17.4%] vs. 299/1005 [29.8%]; P < 0.001), whereas detection rates in pleural fluid samples by polymerase chain reaction were similar (91/181 [50.3%] vs. 220/398 [55.3%]; P = 0.263).

CONCLUSIONS

In children with PPE/PE, PH-ABT significantly reduced the overall rate of bacterial pathogen detection by culture, but not by polymerase chain reaction. PH-ABT was associated with a lower rate of infectious complications but did not affect the overall duration of disease. We therefore speculate that the duration of PPE/PE is mainly a consequence of an infection-induced inflammatory process, which can only partially be influenced by antibiotic treatment.

Predictors of 30-day readmission following hospitalisation with community-acquired pneumonia

Background

There is a paucity of UK data to aid healthcare professionals in predicting which patients hospitalised with community-acquired pneumonia (CAP) are at greatest risk of 30-day readmission and to determine which readmissions may occur soonest.

Methods

An analysis of CAP cases admitted to nine UK hospitals participating in the Advancing Quality Pneumonia Programme.

Results

An analysis was performed of 12 157 subjects hospitalised with CAP in the Advancing Quality Programme Database. 26% of those discharged were readmitted within 30 days with readmission predicted by comorbidity including non-metastatic cancer, diabetes with complications and chronic kidney disease. 41% and 66% of readmissions occurred within 7 and 14 days of discharge, respectively. Patients readmitted within 14 days were more likely to have metastatic cancer (6.6% vs 4.5%; p=0.03) compared with those readmitted at 15–30 days.

Conclusions

A quarter of patients hospitalised for CAP are readmitted within 30 days; of those, two-thirds are readmitted within 2 weeks. Further research is required to determine whether such readmissions might be preventable through imple menting measures including in-hospital cross-specialty comorbidity management, convalescence in intermediate care, targeted rehabilitation and advanced care planning.

Gender differences in community-acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is the most common type of lower respiratory tract infection and a major cause of morbidity and mortality in adults worldwide. Sex and gender play an active role in the incidence and outcomes of major infectious diseases, including CAP.

EVIDENCE ACQUISITION

We searched the following electronic databases from January 2001 to December 2018: MEDLINE, EMBASE, CINHAIL, CENTRAL (Cochrane Central register of Controlled Trials), DARE (Database of Abstracts of Reviews of Effectiveness), Cochrane Database of Systematic Reviews and ACP Journal Club database.

EVIDENCE SYNTHESIS

Several studies have reported higher male susceptibility to pulmonary infections and higher risk of death due to sepsis. Biological differences (e.g. hormonal cycles and cellular immune-mediated responses) together with cultural, behavioral and socio-economic differences are important determinants of the course and outcome of CAP. However, gender-related bias in the provision of care and use of hospital resources has been reported among women, resulting in delayed hospital admission and consequently necessary care.

CONCLUSIONS

CAP is more severe in males than in females, leading to higher mortality in males, especially in older age. To identify gender differences in CAP can guide patient's prognostication and management.

Factors predicting in-hospital mortality among patients admitted with community acquired pneumonia at a tertiary care hospital Karachi, Pakistan

INTRODUCTION

Community Acquired Pneumonia (CAP) is associated with significant morbidity and mortality globally, but unfortunately there is limited data available from South East Asia.

OBJECTIVE

To determine the risk factors associated with in-hospital mortality in patients with CAP in a tertiary care hospital of Pakistan.

METHODS

A retrospective study was conducted on adult patients admitted with a diagnosis of CAP from January 2011 till December 2016. Their clinical records were reviewed and a multivariable analysis was done to determine the factors associated with in-hospital mortality.

RESULTS

A total of 1100 files were reviewed, of which 509 were included in the analysis. The mean age was 63.6 ± 16.5 years and 302 (52.16%) were males. The most Common isolated pathogen was Staphylococcus aureus (23%). Overall mortality was 10.8%. On univariate analysis factors associated with mortality were old age patients (P = 0.02); history of pneumonia in last 12 months (P = 0.008); CURB 65 score ≥ 3 (P < 0.001) and high dependency units as initial site of care (P < 0.001). On multivariable analysis CURB65 ≥ 3 score; high dependency unit as initial site of care; bedridden status; presence of bilateral infiltrates on chest X-ray and hemoglobin of 10.4 g/dL or less at the time of admission were key determinants of in-hospital mortality.

CONCLUSION

We found CURB65 ≥ 3 score; high dependency unit as initial site of care; bedridden status; bilateral infiltrates on chest X-ray and low hemoglobin (10.4 g/dL or less) at the time of admission as independent risk factors of in-hospital mortality. Staphylococcus aureus was the most common organism isolated in patients.