Angiotensin-converting enzyme inhibitor use and pneumonia risk in a general population.

The aim of the present study was to assess whether the use of angiotensin-converting enzyme (ACE) inhibitors is associated with a decreased risk of hospitalisation for community-acquired pneumonia (CAP) in a general, essentially white population. Data were obtained from the Dutch PHARMO Record Linkage System. Cases were defined as patients with a first hospital admission for CAP. For each case, up to four population controls were matched by age and sex. The study population comprised 1,108 patients with a first hospital admission for CAP and 3,817 matched controls. After adjusting for several confounders, ACE inhibitor use was not associated with a decreased incidence of pneumonia (adjusted odds ratio (OR) 1.12; 95% confidence interval (CI) 0.88-1.43). Additionally, no significant association was observed in patients with diabetes, respiratory diseases, heart failure, or patients with both of the last two conditions. Furthermore, adjustment of treatment effects on pneumonia risk using stratification on balancing score also showed no significant association between ACE inhibitor use and pneumonia risk within the different strata (overall adjusted OR 1.09; 95% CI 0.87-1.36). In contrast with previous findings in Asian populations, the current authors were not able to confirm the beneficial effect of angiotensin-converting enzyme inhibitors on pneumonia risk in a general, essentially white population.     

Hospital admissions for community-acquired,ventilator-associated and nonventilator hospital-acquired pneumonia in COPD patients in Spain (2016-2017).

BackgroundTo examine the incidence, characteristics and outcomes of community-acquired pneumonia (CAP), ventilator-associated pneumonia (VAP) and nonventilator hospital-acquired pneumonia (NV-HAP) in patients with or without COPD; compare in-hospital outcomes; and identify factors associated with in-hospital mortality (IHM) for pneumonia.MethodsWe carried out a retrospective observational study using the hospital discharge records from 2016-17 of the Spanish National Health System. Propensity score matching was used for data analysis.ResultsWe found 245,905 patients (≥40 years) with pneumonia; we identified CAP in 228,139 patients (19.85% with COPD), VAP in 2,771 patients (8.55% with COPD) and NV-HAP in 14,995 patients (14.17% with COPD). The incidence for the three types of pneumonia was higher in COPD patients (CAP: incidence rate ratio (IRR) 2.23, 95% CI 2.21-2.26; VAP: IRR 1.25, 95% CI 1.08-1.42; and NV-HAP: IRR 1.55, 95% CI 1.48-1.63). The IHM for CAP was 10.35% in COPD patients and 12.91% in the controls (p<0.001). In patients with VAP and NV-HAP, IHM was not significantly different between those with and without COPD (43.88% vs. 41.77%;p=0.643 and 29.21% vs. 30.57%;p=0.331, respectively). Factors associated with IHM for all types of pneumonia analyzed in COPD patients were older age and receiving dialysis.ConclusionsThe incidence of hospitalizations for all types of pneumonia was significantly higher in COPD patients than in the non-COPD population. In contrast, IHM was significantly lower among COPD patients with CAP than among matched non-COPD patients. Higher mortality rates in COPD patients with any pneumonia type were associated with increasing age and receiving dialysis.     

Influence of prior pneumococcal and influenza vaccination on outcomes of older adults with community-acquired pneumonia

OBJECTIVES: To determine whether prior pneumococcal and seasonal influenza vaccination improves outcomes in older adults hospitalized for community‐acquired pneumonia (CAP). DESIGN: Prospective, observational, multicenter study. SETTING: Five public hospitals providing universal free care to the whole population in three Spanish regions. PARTICIPANTS: Individuals aged 65 and older admitted to the hospital with CAP through the emergency department. MEASUREMENTS: Pneumococcal and influenza vaccination status. The primary study outcomes were intensive care unit (ICU) admission, length of hospital stay (LOS), and overall case‐fatality rate. Outcome variables of individuals vaccinated with both vaccines were compared with outcomes of those who were unvaccinated. RESULTS: Two hundred thirty‐eight individuals had received 23‐valent pneumococcal polysaccharide vaccine and seasonal influenza vaccination and were compared with 195 unvaccinated individuals. No differences were found with respect to combined antibiotic therapy between groups (38.0% vs 39.7%; P=.80). Similar percentages of vaccinated and unvaccinated individuals required ICU admission (7.2% vs 8.2%; P=.69). Mean LOS was significantly shorter in vaccinated individuals (9.9 vs 12.4 days; P=.04). Overall case‐fatality rates were similar in both groups (5.9% vs 5.1%; P=.73). After adjustment, LOS, risk of ICU admission, and overall case‐fatality rate were not associated with prior pneumococcal and seasonal influenza vaccination. CONCLUSION: The clinical outcomes of vaccinated older adults hospitalized with CAP were not better than those observed in unvaccinated individuals.     

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.     

Mixed community-acquired pneumonia in hospitalised patients.

The role of mixed community-acquired pneumonia (CAP) is controversial. The aim of the present study was to determine the incidence, principal microbial patterns, clinical predictors and course of mixed CAP. The current study included 1,511 consecutive hospitalised patients with CAP. Of these, 610 (40%) patients had an established aetiology. One pathogen was demonstrated in 528 patients and 82 (13%) patients had mixed pneumonia. Cases including CAP, by a pyogenic bacteria and a complete paired serology for "atypicals", revealed that 82 (13%) patients had definite single pyogenic pneumonia and 28 patients (5%) had mixed pyogenic pneumonia. In patients with mixed CAP, Streptococcus pneumoniae was the most prevalent microorganism (44 out of 82; 54%). The most frequent combination was S. pneumoniae with Haemophilus influenzae (17 out of 82; 21%). Influenza virus A and S. pneumoniae (five out of 28; 18%) was the most frequent association in the mixed pyogenic pneumonia group. No clinical predictors for mixed pneumonias could be identified. Patients with mixed pyogenic pneumonia more frequently developed shock when compared with patients with single pyogenic pneumonia (18 versus 4%). In conclusion, mixed pneumonia occurs in >10% of cases with community-acquired pneumonia requiring hospitalisation.     

Epidemiological survey on incidence and treatment of community acquired pneumonia in Italy

STUDY OBJECTIVES: To estimate annual incidence of community acquired pneumonia (CAP) in an Italian general population sample. DESIGN AND PARTICIPANTS: Two hundred and eighty-seven family practitioners (64.6% of those selected) recorded suspected or ascertained CAP cases for 1 year. Information on smoking habit, respiratory symptoms and signs, co-morbidity, antibiotic and corticosteroid therapy, hospitalization, mortality and recovery were obtained. RESULTS: Six hundred and ninety-nine case forms were collected (53.1% females, mean age 59.6+/-19.5, 20.6% smokers). CAP incidence rates per 1000 population were: 1.69 in men vs. 1.71 in women; 2.33 in the North vs. 1.29 in the Centre-South of Italy; between 0.73 in 14-, and 3.34 in 64+year-old subjects. Main symptoms and signs were cough (73.3%), crackles (72.8%), dullness (57.3%), asthenia (53.4%). 59.5% of subjects had concurrent diseases, mostly cardiac and respiratory. 77.2% of cases had chest X-ray (with parenchymal density in 90.6%). Phlegm microbiological examination was performed in 12.8% of cases. First choice antibiotics were cephalosporins (45.8%), macrolides (20.2%), other beta-lactams (18.6%), and fluoroquinolones (12.2%). Rates of hospitalization and of mortality were 31.8% and 6.0%, respectively. CONCLUSION: This study confirmed that the annual CAP incidence rate in the general population of South Europe is about 2 per 1000 population and showed a wide choice of antibiotic treatment.     

Tuberculosis incidence, hospitalisation prevalence and mortality in Lazio, Italy, 1997-2003.

SETTING: Lazio region (5.15 million, including Rome, 2.8 million), Italy. OBJECTIVE: To monitor pulmonary tuberculosis (TB) epidemiology from 1997 to 2003. DESIGN: We used data from the mandatory National Infectious Diseases Surveillance system, the regional Hospital Information System and the regional Mortality Register. The number of prevalent pulmonary TB cases hospitalised was determined by linking notifications and hospitalisations. To estimate incidence, we excluded all cases with previous TB hospitalisations since 1995, and those reported as a secondary diagnosis in the Hospital Information System. Mortality rates were ascertained from mortality records reporting TB as the principal cause of death. RESULTS: The record linkage identified 4885 incident cases, 9010 hospital prevalent cases and 217 deaths. Incidence decreased from 15/100000 in 1997 to 11 in 2003, and consistent decreases were also observed in hospitalisation prevalence and mortality (P for trend <0.0005, <0.0005 and =0.063, respectively). The number of AIDS-related TB cases dropped from 85 to 49 (P < 0.0005). The number of incident cases in non-Italians increased significantly, from 171 to 267 (P < 0.0005). Notification underreporting was estimated at 39%. CONCLUSIONS: Despite a decreasing trend, TB incidence is still over 10/100000 in Lazio region. Targeted interventions for immigrant populations are essential for controlling TB.     

Pneumonia: still the old man's friend?

BACKGROUND: Hospital mortality of patients admitted with community-acquired pneumonia (CAP) has been well described. However, the long-term survival of those discharged alive is less clear. We sought to determine long-term survival of patients hospitalized with CAP and compare the outcome with controls hospitalized for reasons other than CAP. METHODS: We performed a matched case-control analysis using the Medicare hospital discharge database from the first quarter of 1997. We compared all Medicare recipients 65 years or older hospitalized with CAP and controls matched for age, sex, and race hospitalized for reasons other than CAP. We measured 1-year mortality determined from the Medicare Beneficiary Entitlement file and the Social Security Administration. RESULTS: We identified 158 960 CAP patients and 794 333 hospitalized controls. Hospital mortality rates for the CAP cohort and hospitalized controls were 11.0% and 5.5%, respectively (P<.001). One-year mortality rates for the CAP cohort and hospitalized controls were 40.9% and 29.1%, respectively (P<.001). One-year mortality rates in hospital survivors of the CAP and control cohorts were 33.6% and 24.9%, respectively (P<.001). The difference in mortality between the CAP and control cohorts was not explained by underlying disease. Standardized against the general population, the risk of death for both cohorts decreased monthly but was still elevated 1 year after hospital discharge. The standardized mortality ratio was 2.69 (95% confidence interval, 2.47-2.93) for CAP patients and 1.93 (95% confidence interval, 1.79-2.08) for hospital controls. CONCLUSIONS: Almost half of all elderly patients admitted for CAP die in the subsequent year, with most deaths occurring after hospital discharge. The mortality is considerably higher than that of either the general population or a control population hospitalized for reasons other than CAP.     

Influenza and pneumococcal vaccination in patients with rheumatoid arthritis in comparison with age- and sex-matched controls: results of a claims data analysis

The aim of this study was to assess the vaccination status for influenza and pneumonia and the prevalence of hospitalised pneumonia in rheumatoid arthritis (RA) patients and population controls in Germany. Members of a large statutory health insurance fund in Germany who were continuously insured between 2009 and 2013 and had a diagnosis of RA in 2013 were age and sex matched 1:5 to members without RA. Pneumococcal and influenza vaccinations were evaluated with regard to age, sex and region of residence. Logistic regression models were used to determine predictors for influenza vaccination in RA patients. Prevalences of pneumonia that required hospitalisation were compared to regional vaccination rates. The data of 111,482 RA patients and 557,410 matched controls were available for analysis. Compared to controls, RA patients were vaccinated more frequently against influenza (40.8 vs. 32.2 %) and pneumonia (15.0 vs. 10.0 %). Vaccination rates increased with older age and differed between the federal states (highest in East Germany, lowest in South Germany). The region of residence, comorbidities, rheumatologic care and biologic treatment was associated with a higher probability of an influenza vaccination. Prevalences of pneumonia that required hospitalisation were 2–3 times higher in patients compared to controls and tended to be higher in regions with low vaccination rates. The increased pneumonia prevalence in RA patients confirms their status as a risk group. RA patients are vaccinated more frequently than controls, but vaccination rates are still low. The lower pneumonia prevalence in East Germany indicates that vaccination may help to reduce pneumonia in RA.     

Epidemiology of severe pneumonia caused by Legionella longbeachae, Mycoplasma pneumoniae, and Chlamydia pneumoniae: 1-year, population-based surveillance for severe pneumonia in Thailand.

BACKGROUND: Legionella species, Mycoplasma pneumoniae, and Chlamydia pneumoniae are recognized as important causes of pneumonia in high-income countries, but their significance in middle-income countries, such as Thailand, is unknown. METHODS: Population-based surveillance identified inpatient 3489 cases of clinically-defined pneumonia in a rural Thai province for 1 year. Patients who had a chest radiograph performed (for 2059 cases of pneumonia) were enrolled in an etiology study (which included 755 cases of pneumonia among 738 patients). Paired serum, nasopharyngeal swab, and urine specimens were obtained for diagnostic immunologic and molecular tests. Patients aged <18 years were not systematically tested for Legionella species. We report a lower limit of incidence (observed incidence) and an upper limit extrapolated to persons not tested or not enrolled in the study. RESULTS: The incidence of pneumonia due to Legionella longbeachae requiring hospitalization was 5-29 cases per 100,000 population. No case of Legionella pneumophila pneumonia was observed. The definite C. pneumoniae pneumonia incidence was 3-23 cases per 100,000 population; rates were highest among patients aged <1 year (18-166 cases per 100,000 population) and those aged >or=70 years (23-201 cases per 100,000 population). M. pneumoniae pneumonia had a similar age distribution, with an overall incidence of 6-44 cases per 100,000 population. These pathogens were associated with 15% of all cases of pneumonia. A nonsignificantly higher proportion of patients with pneumonia associated with L. longbeachae, compared with patients with pneumonia associated with M. pneumoniae or C. pneumoniae, required supplemental oxygen or mechanical ventilation (45% vs. 18%; P<.1). Among patients with atypical pneumonia, only 15% received antibiotics with activity against the associated pathogen. CONCLUSION: M. pneumoniae, C. pneumoniae, and L. longbeachae, but not L. pneumophila, are frequently associated with severe pneumonia in rural Thailand. Few patients receive antibiotics that cover atypical pathogens.     

Sequential IV/PO moxifloxacin treatment of patients with severe community-acquired pneumonia

BACKGROUND: IV/PO moxifloxacin was evaluated in the treatment of hospitalized patients with severe community-acquired pneumonia (CAP). METHODS: Data were pooled from two prospective, randomized studies. In the multinational study, patients received 7-14 days IV/PO moxifloxacin 400 mg QD or IV/ PO amoxicillin clavulanate 1200/625 mg TID +/- IV/PO clarithromycin 500 mg BID. In the North American study, patients received 7-14 days IV/PO moxifloxacin 400 mg QD, IV/ PO alatrofloxacin/trovafloxacin 200 mg QD, or IV/PO levofloxacin 500 mg QD. The primary endpoint was clinical success at the test-to-cure visit. Severe CAP was defined according to the 1993 ATS criteria. RESULTS: In the clinically valid population, clinical success rates were 88% (167/190) for moxifloxacin- and 83% (155/186) for comparator-treated patients (95% CI = -1.9%, 12.2%). Corresponding clinical success rates for the microbiologically valid population were 87% (59/68) and 84% (54/64), respectively (95% CI = 8.6%, 15.0%). A switch from IV to PO therapy was made by day 5 of therapy for 73% of moxifloxacin- vs. 60% of comparator-treated patients (P < 0.01). Clinical success rates were similar in a retrospective analysis using the revised 2001 ATS definition of severe CAP. Mortality rates were 6% (15/241) and 10% (24/238) in the moxifloxacin and comparator treatment groups, respectively. The incidence of drug-related adverse events was similar in both treatment groups. CONCLUSION: Sequential IV/PO moxifloxacin 400 mg QD is as safe and effective as other fluoroquinolones and a beta-lactam/macrolide combination for treating hospitalized patients with severe CAP.     

Bacterial infections in adult patients with the acquired immune deficiency syndrome (AIDS) and AIDS-related complex

Sixty-four episodes of bacterial infection were identified over a 44-month period in 16 of 28 patients with the acquired immune deficiency syndrome (AIDS) and 14 of 31 patients with AIDS-related complex. Nineteen of the 30 infected patients were parenteral drug abusers, 10 were from Caribbean Islands and had no identified risk factor, and one was a homosexual male. Fourteen patients had 21 episodes of community-acquired pneumonia: Streptococcus pneumoniae (10), Haemophilus influenzae (three), other Haemophilus species (three), group B beta-hemolytic streptococci (one), Staphylococcus aureus (one), Branhamella catarrhalis (one), Legionella pneumophila (one), and Mycoplasma pneumoniae (one). Seven patients had eight episodes of nosocomial pneumonia caused by gram-negative bacilli. Twenty-five episodes of community-acquired bacteremia and nine episodes of nosocomial bacteremia were associated with specific sites of infection. Other infections included meningitis (two), urinary tract infection (one), and abscesses involving subcutaneous and deep tissues (12). Sixteen patients had recurrent infections; 11 of these had or eventually had AIDS. Community-acquired bacterial infections in patients with AIDS or AIDS-related complex are common and may be recurrent but have low fatality rates. In comparison, nosocomial bacterial infections occur primarily in patients with AIDS and have high fatality rates.     

Incidence of community-acquired pneumonia in children caused by Mycoplasma pneumoniae: serological results of a prospective, population-based study in primary health care

OBJECTIVE: The objective of the present study was to assess the incidence of community-acquired pneumonia (CAP) in children caused by Mycoplasma pneumoniae. METHODOLOGY: During 12 months in 1981-1982, all CAP cases in a defined child population were registered. M. pneumoniae aetiology, initially measured by complement fixation (CF) test, was in 1999 supplemented by measurement of IgG and IgM antibodies using enzyme immunoassays (EIA). RESULTS: M. pneumoniae was detected in 61 (30%) of 201 paediatric CAP cases, being the most common aetiological agent in those 5 years of age or over. At that age, M. pneumoniae was responsible for over 50% of cases, and over 90% of mycoplasmal cases were treated as outpatients. The EIA detected 17 new cases over and above the 44 detected by CF, while CF alone revealed 10 cases. The incidence of M. pneumoniae CAP increased with age, being over 10/1000 children at the age of 10 years or more. Co-infections with Streptococcus pneumoniae and Chlamydia pneumoniae were present in over 30% and 15%, respectively, of mycoplasmal CAP cases. CONCLUSION: M. pneumoniae is a common cause of paediatric CAP in primary health care, and co-infections with S. pneumoniae are common. Both S. pneumoniae and M. pneumoniae should be taken into account when starting antibiotics for children with CAP.     

Phase II trial of a novel chemotherapy regimen CVEP (cyclophosphamide,vinblastine, etoposide and prednisolone) for acquired immunodeficiency syndrome (AIDS)-associated lymphomas

Management of acquired immunodeficiency syndrome (AIDS)-related diffuse large B-cell (DLBCL) and plasmablastic lymphomas (PBL) poses significant challenges. The evidence supports use of dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin) with or without rituximab as first-line therapy. The need for central venous access, growth factors and significant toxicities limits its use in resource-constrained settings. To address these challenges, we have developed a novel regimen, CVEP (cyclophosphamide, vinblastine, etoposide, and prednisolone) based on the pharmacodynamic principles of dose-adjusted EPOCH. This single-centre phase II study evaluated the efficacy and safety of CVEP regimen in patients with de novo systemic AIDS-related DLBCL and PBL. The primary objective was complete response (CR) rates as assessed by positron emission tomography-computed tomography. The secondary objectives were incidence of Grade 3/4 toxicities, toxicities requiring hospitalisation, and disease-free survival. From May 2011 to February 2017, 42 patients were enrolled. At the end of therapy the CR rates were 69% (29/42) in the intention-to-treat population and 80.5% (29/36) in evaluable patients. At a median follow-up of 69 months, the 5-year disease-free survival was 65.3%. Out of 217 cycles administered, febrile neutropenia occurred in 19.3% and hospitalisation was required in 18.3% of cycles. There were two treatment-related deaths. The CVEP regimen is an active and safe regimen for AIDS-related DLBCL and PBL.     

Seasonal pattern of incidence and case fatality of acute myocardial infarction in a Japanese population (from the Takashima AMI Registry, 1988 to 2003)

We examined the seasonal variations in the incidence and case fatality of acute myocardial infarction (AMI) in a geographically defined population using 16-year AMI registration data. It remains unclear whether the incident events of AMI display any seasonal variation. Documentation of such a pattern may foster investigation for understanding the potential mechanisms responsible for these effects and may provide novel avenues for prevention of AMI. Data were obtained from the Takashima AMI Registry, which covers an entire community of approximately 55,000 in central Japan. There were 335 definite cases of AMI during 1988 to 2003 (217 men, 118 women). Of these, there were 96 fatal cases (53 men, 43 women) within 28 days of onset. Incidence rates (per 100,000 person-years) and case fatality rates with 95% confidence intervals (CI) were calculated across seasons. Poisson regression analysis was used to calculate the incidence rate, and case fatality ratios adjusted for age and gender. The AMI incidence rate was higher in winter (44.9, 95% CI 35.9 to 53.9) and spring (44.1, 95% CI 35.3 to 52.9) than the other seasons. After adjustment for age and gender, AMI risk was 1.4 (95% CI 1.03 to 1.9) times higher in winter and was 1.4 (95% CI 1.01 to 1.9) times higher in spring than summer. The 28-day AMI case fatality rate was also higher in winter (34.4%, 95% CI 24.9 to 43.9) and spring (32.3%, 95% CI 22.9 to 41.7). Age- and gender-adjusted fatality risk was 2.4 (95% CI 1.2 to 4.9) times higher in winter and 2.3 (95% CI 1.1 to 4.6) times higher in spring than summer. In conclusion, higher AMI incidence and case fatality rates were observed in winter and spring in a Japanese population.     

Low levels of serum cholesterol and albumin and the risk of community-acquired pneumonia in young soldiers.

SETTING: The risk factors of community-acquired pneumonia (CAP) in high-risk groups have been examined in many studies. Such studies, however, have limited application for young people in special environments. OBJECTIVE: To study the risk factors of CAP in young soldiers. DESIGN: A hospital-based case-control study was carried out during the two winters between 2003 and 2005. A total of 255 CAP cases aged 18-23 years were enrolled and were matched by age and date of hospitalisation with 255 controls. RESULTS: All CAP cases and 148 controls (58.0%) were military trainees. Most cases (96.1%) were non-severe CAP (pneumonia severity index risk class 1). Serum levels of total cholesterol, albumin, total protein and body mass index (BMI) were lower in CAP cases than in controls. In conditional logistic regression analysis, an increased risk of CAP was independently associated with military trainees, low levels of cholesterol and albumin. However, low BMI (<18.5 kg/m(2)) was not found to be associated with the risk of CAP after adjusting for other factors. CONCLUSION: In Korea, the risk of CAP is significantly high in military trainees, with low levels of cholesterol and albumin being associated with the development of CAP in young soldiers.     

Bacteraemic pneumococcal pneumonia: A continuously evolving disease

During an 8 year prospective study of community-acquired pneumonia (CAP) requiring hospitalisation we found that 47 of 1118 (4.2%) patients had Streptococcus pneumoniae bacteraemia. Females outnumbered males 27:20. The mean age was 63.4 years and 25% of our patients were admitted from a nursing home. A comparison with the 1071 other patients with CAP showed that patients with bacteraemic pneumococcal pneumonia (BPP) were more likely to be female and to have alcoholism, diabetes mellitus, and chronic obstructive pulmonary disease as co-morbidities. The mortality rate of 19% in BPP was not significantly lower than the 22% rate for the remaining patients with CAP. Four of the nine (44%) patients with BPP who died, did so within 24 h of admission, compared with 29 of 236 (12.3%) (P less than 0.02) who died of CAP. A notable clinical feature was the absence of cough in 19% while overall in only 66% was the cough productive. Most of the patients had a non-specific clinical presentation. Fifty-three per cent had an uncomplicated stay in hospital. We conclude that bacteraemic pneumococcal pneumonia is a continuously evolving disease and for the first time may now be more common in women.     

Cost and incidence of social comorbidities in low-risk patients with community-acquired pneumonia admitted to a public hospital

CONTEXT: There are up to 1 million patients treated in acute-care hospitals for community-acquired pneumonia (CAP), with an estimated annual cost > 8 billion dollars. A newly validated CAP outcomes prediction rule developed by Fine and colleagues has been advocated as a guide to hospitalization decisions. OBJECTIVE: To evaluate the clinical characteristics, costs of care, and resource utilization of patients with low-risk CAP at an urban public hospital serving an indigent population. Design, setting, and participants: Prospective cohort study from June 1, 1994 to May 31, 1996. MAIN OUTCOME MEASURES: Clinical characteristics and costs of care of patients with low-risk CAP and features associated with low-risk CAP in this population. RESULTS: A total of 522 patients were identified at the time of hospital admission as having CAP; 97 patients (19%) were HIV positive on hospital admission and excluded. Of the remaining 425 patients, 253 patients (60%) were classified as pneumonia severity index (PSI) class I-III (low risk). Of the patients with low-risk CAP, only four patients (1.6%; 95% confidence interval, 0.4 to 4.0%) died during hospitalization. Low-risk CAP was both costly and accounted for significant resource use (35.4% of total CAP costs, and 45% of all CAP bed days). Of the patients with low-risk CAP, there were 138 patients (55%) who could potentially have been treated as outpatients (absence of altered mental status, hypotension, hypoxia on hospital admission, or direct ICU admission). However, 49% of these patients had a history of alcoholism, 20% had a blood alcohol level > 50 mg/dL, and 44% were homeless. CONCLUSIONS: A significant proportion of the patients admitted with CAP to a public hospital had low-risk CAP and accounted for a significant proportion of the CAP bed days and costs. The use of the PSI accurately predicted which patients would be at low risk for death; however, the utility of using the PSI to reduce low-risk CAP hospital admissions would have been of limited benefit. High rates of homelessness, substance abuse, and medical needs not captured in the PSI would preclude many of these patients from unsupervised outpatient treatment.     

Process of care performance, patient characteristics, and outcomes in elderly patients hospitalized with community-acquired or nursing home-acquired pneumonia

STUDY OBJECTIVES: To compare process of care performance, patient characteristics, and outcomes in a contemporary cohort of elderly (> or = 65 years) patients hospitalized with community-acquired pneumonia (CAP) or with nursing home-acquired pneumonia (NHAP). DESIGN: State-wide retrospective cohort study. SETTING: Thirty-four acute-care hospitals in Connecticut. PATIENTS: Elderly Medicare patients hospitalized in 1995-1996 with CAP (1,131) or with NHAP (528). MEASUREMENTS: Antibiotic administration within 8 h of hospital arrival, blood culture collection within 24 h of hospital arrival, oxygenation assessment within 24 h of hospital arrival, demographic and clinical characteristics, in-hospital complications, mortality, and length of stay. RESULTS: Process of care performance rates for patients with CAP and NHAP were equivalent for antibiotic administration within 8 h of hospital arrival (76.8% vs 76.3%, respectively; p = 0.82), blood culture collection within 24 h of hospital arrival (78.1% vs 81.1%, respectively; p = 0.31), and oxygenation assessment within 24 h of hospital arrival (94.7% vs 95. 3%, respectively; p = 0.70). Patients with CAP were younger than those with NHAP (median age, 80 vs 84 years, respectively; p < 0. 001), had less cerebrovascular disease (16.8% vs 34.7%, respectively; p < or = 0.001), and lower mortality risk scores at hospital presentation (median, 100 vs 137, respectively; p < or = 0. 001) than patients with NHAP. The median length of stay was equivalent (7 days), but the in-hospital mortality rate was lower in patients with CAP than in patients with NHAP (8.0% vs 18.6%, respectively; p < or = 0.001). CONCLUSION: Initial hospital processes of care are performed at the same rate in patients hospitalized with CAP or NHAP. However, patients with CAP are younger, are less acutely and chronically ill, and have lower in-hospital mortality rates than patients with NHAP.