The cost of treating community-acquired pneumonia

Effects of Device-Facilitated Isometric Progressive Resistance Oropharyngeal Therapy on Swallowing and Health-Related Outcomes in Older Adults with Dysphagia

Swallowing disorders (dysphagia) are associated with malnutrition, aspiration pneumonia, and mortality in older adults. Strengthening interventions have shown promising results, but the effectiveness of treating dysphagia in older adults remains to be established. The Swallow STRengthening OropharyNGeal (Swallow STRONG) Program is a multidisciplinary program that employs a specific approach to oropharyngeal strengthening-device-facilitated (D-F) isometric progressive resistance oropharyngeal (I-PRO) therapy-with the goal of reducing health-related sequelae in veterans with dysphagia. Participants completed 8 weeks of D-F I-PRO therapy while receiving nutritional counseling and respiratory status monitoring. Assessments were completed at baseline, 4, and 8 weeks. At each visit, videofluoroscopic swallowing studies were performed. Dietary and swallowing-related quality of life questionnaires were administered. Long-term monitoring for 6-17 months after enrollment allowed for comparison of pneumonia incidence and hospitalizations to the 6-17 months before the program. Veterans with dysphagia confirmed with videofluoroscopy (N = 56; 55 male, 1 female; mean age 70) were enrolled. Lingual pressures increased at anterior (effect estimate = 92.5, P < .001) and posterior locations (effect estimate = 85.4, P < .001) over 8 weeks. Statistically significant improvements occurred on eight of 11 subscales of the Quality of Life in Swallowing Disorders (SWAL-QOL) Questionnaire (effect estimates = 6.5-19.5, P < .04) and in self-reported sense of effort (effect estimate = -18.1, P = .001). Higher Functional Oral Intake Scale scores (effect estimate = 0.4, P = .02) indicated that participants were able to eat less-restrictive diets. There was a 67% reduction in pneumonia diagnoses, although the difference was not statistically significant. The number of hospital admissions decreased significantly (effect estimate = 0.96; P = .009) from before to after enrollment. Findings suggest that the Swallow STRONG multidisciplinary oropharyngeal strengthening program may be an effective treatment for older adults with dysphagia.

Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia

BACKGROUND

Pleural effusions are present in 15% to 44% of hospitalized patients with pneumonia. It is unknown whether effusions at first presentation to the ED influence outcomes or should be managed differently.

METHODS

We studied patients in seven hospital EDs with International Statistical Classification of Disease and Health Related Problems-Version 9 codes for pneumonia, or empyema, sepsis, or respiratory failure with secondary pneumonia. Patients with no confirmatory findings on chest imaging were excluded. Pleural effusions were identified with the use of radiographic imaging.

RESULTS

Over 24 months, 4,771 of 458,837 adult ED patients fulfilled entry criteria. Among the 690 (14.5%) patients with pleural effusions, their median age was 68 years, and 46% were male. Patients with higher Elixhauser comorbidity scores (OR, 1.13 [95% CI, 1.09-1.18]; P < .001), brain natriuretic peptide levels (OR, 1.20 [95% CI, 1.12-1.28]; P < .001), bilirubin levels (OR, 1.07 [95% CI, 1.00-1.15]; P = .04), and age (OR, 1.15 [95% CI, 1.09-1.21]; P < .001) were more likely to have parapneumonic effusions. In patients without effusion, electronic version of CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years accurately predicted mortality (4.7% predicted vs 5.0% actual). However, eCURB underestimated mortality in those with effusions (predicted 7.0% vs actual 14.0%; P < .001). Patients with effusions were more likely to be admitted (77% vs 57%; P < .001) and had a longer hospital stay (median, 2.8 vs 1.3 days; P < .001). After severity adjustment, the likelihood of 30-day mortality was greater among patients with effusions (OR, 2.6 [CI, 2.0-3.5]; P < .001), and hospital stay was disproportionately longer (coefficient, 0.22 [CI, 0.14-0.29]; P < .001).

CONCLUSIONS

Patients with pneumonia and pleural effusions at ED presentation in this study were more likely to die, be admitted, and had longer hospital stays. Why parapneumonic effusions are associated with adverse outcomes, and whether different management of these patients might improve outcome, needs urgent investigation.

Validation of modified early warning score using serum lactate level in community-acquired pneumonia patients. The National Early Warning Score-Lactate score

STUDY OBJECTIVE

The aim of this study was to investigate the prognostic prediction power of a newly introduced early warning score modified by serum lactate level, the National Early Warning Score-Lactate (NEWS-L) score, among community-acquired pneumonia (CAP) patients. We also compared the NEWS-L score with the pneumonia severity index (PSI) and CURB-65.

METHODS

We designed a retrospective observational study and collected data on confirmed adult CAP patients who visited the study hospital between October 2013 and September 2014. Variables relevant to, the NEWS-L score, PSI, and CURB-65 were extracted from electronic medical records. Survival status at hospital discharge was determined in the same manner. The NEWS-L score was calculated as NEWS-L=NEWS+serum lactate level (mmol/L). The NEWS-L was divided into quartiles. The ability to predict mortality was assessed through area under the receiver operating characteristic curve analysis and calibration analysis.

RESULTS

A total of 553 patients were enrolled, and the inpatient mortality rate was 10.8% (n=60). Mortality rates increased incrementally in conjunction with the NEWS-L quartiles: first quartile, 2.2%; second quartile, 7.9%; third quartile, 9.6%; and fourth quartile, 23.9%. The area under the receiver operating characteristic curve of the NEWS-L score was 0.73 (95% confidence interval [CI], 0.66-0.80), which showed no significant difference from that of the PSI (0.68; 95% CI, 0.61-0.76; P=.28) and CURB-65 (0.66; 95% CI, 0.59-0.73; P=.06).

CONCLUSIONS

The newly introduced early warning score modified by serum lactate level, NEWS-L score, was comparable to PSI and CURB-65, for predicting inpatient mortality among adult CAP patients.

Comparative Treatment Failure Rates of Respiratory Fluoroquinolones or β-Lactam + Macrolide Versus β-Lactam Alone in the Treatment for Community-Acquired Pneumonia in Adult Outpatients: An Analysis of a Nationally Representative Claims Database

No comparative effectiveness study has been conducted for the following 3 antibiotics: respiratory fluoroquinolones, β-lactam, and β-lactam + advanced macrolide. To gain insights into the real-world clinical effectiveness of these antibiotics for community-acquired pneumonia in adult outpatients, our study investigated the treatment failure rates in 2 million representative participants from the National Health Informatics Project (NHIP) of Taiwan. A new-user cohort design was used to follow NHIP participants from January 2000 until December 2009. Treatment failure was defined by either one of the following events: a second antibiotic prescription, hospitalization due to CAP, an emergency department visit with a diagnosis of CAP, or 30-day nonaccident-related mortality. From 2006 to 2009, we identified 9256 newly diagnosed CAP outpatients, 1602 of whom were prescribed levofloxacin, 2100 were prescribed moxifloxacin, 5049 were prescribed β-lactam alone, and 505 were prescribed advanced macrolide + β-lactam. Compared with the β-lactam-based regimen, the propensity score-matched odds ratio for composite treatment failure was 0.81 (95% CI, 0.67-0.97) for moxifloxacin, 1.10 (95% CI, 0.90-1.35) for levofloxacin, and 0.95 (95% CI, 0.67-1.35) for macrolide +β-lactam. Moxifloxacin was associated with lower treatment failure rates compared with β-lactam alone, or levofloxacin in Taiwanese CAP outpatients. However, due to inherent limitations in our claims database, more randomized controlled trials are required before coming to a conclusion on which antibiotic is more effective for Taiwanese CAP outpatients. More population-based comparative effectiveness studies are also encouraged and should be considered as an integral piece of evidence in local CAP treatment guidelines.

Hospital Treatment Costs and Factors Affecting These Costs in Community-Acquired Pneumonia

OBJECTIVES

Community-acquired pneumonia (CAP) accounts for an important part of hospital admissions and health expenses worldwide. The cost increases when treated in a hospital, and reports on this issue are limited in Turkey. This study aimed to investigate direct hospital costs and factors affecting these costs for patients who were hospitalized in our clinic because of the diagnosis of CAP.

MATERIAL AND METHODS

The records of patients who had been hospitalized for the diagnosis of CAP were retrospectively reviewed. Demographic features, radiological features, pneumonia severity index (PSI), CURB-65 scorings, duration of hospitalization, treatments, and the results of treatments were examined. Total hospitalization costs and the expenses for intervention, medication, examinations, and additional services were recorded. The effect of data on the cost was evaluated.

RESULTS

The study was conducted with 87 patients with CAP. The mean duration of hospitalization was 15.6 days and nine patients (10.3%) were exitus. The median total hospital cost was 2062 (451-11690) TL [952 euros (€), 1305 dollars ($)], and the median hospitalization expense per day was 148 Turkish Lira (TL) (68.3 €, 93.7 $). Medication expenses and total cost were higher in male patients than in female patients. Abscess/necrotizing pneumonia increased the cost depending on the infiltration that occurred either alone or with parapneumonic pleurisy. Whereas an increase in the PSI stage increased the total cost and expenses for intervention and medication, medication expenses increased in patients with CURB-65 score of 3 and 4 (p<0.05). Age, smoking, and low oxygen saturation level did not affect the cost. No statistically significant difference was found between the expenses of exitus patients and the expenses of patients who recovered.

CONCLUSION

CAP can lead to high costs and result in death. In our study, it was concluded that the cost increased in male patients, patients with abscess/necrotizing pneumonia, and patients with high PSI scores.

The irregular diaphragmatic pleural interface: a novel sonographic sign facilitating the diagnosis of pneumonia

Pneumonia, a disease that has been reported to be the sixth leading cause of death in the United States, has worsening mortality with delays in diagnosis. As the history and physical examination are excessively inaccurate in the diagnosis of pneumonia, we often rely on chest radiography to rule in or out disease. However, it is found to lack sufficient accuracy when computed tomography is used as the reference standard. Sonography has emerged as a viable alternative to chest radiography in the diagnosis of pneumonia. Here, we describe a novel sonographic sign that can be used to assist in the diagnosis of pneumonia.

Clinical and economic burden of community-acquired pneumonia in the Veterans Health Administration, 2011: a retrospective cohort study

Purpose

The burden of community-acquired pneumonia (CAP) is not well described in the US Veterans Health Administration (VHA).

Methods

CAP was defined as having a pneumonia diagnosis with evidence of chest X-ray, and no evidence of prior (90 days) hospitalization/long-term care. We calculated incidence rates of adult CAP occurring in inpatient or outpatient VHA settings in 2011. We also estimated the proportion of VHA CAP patients who were hospitalized, were readmitted within 30 days of hospital discharge, and died (any cause) in the year following diagnosis. Incremental costs during the 90 days following a CAP diagnosis were estimated from the perspective of the VHA.

Results

In 2011, 34,101 Veterans developed CAP (35,380 episodes) over 7,739,757 VHA person-years. Median age of CAP patients was 65 years (95 % male). CAP incidence rates were higher for those aged ≥50 years. A majority of Veterans aged 50–64 (53 %) and ≥65 (66 %) years had ≥1 chronic medical (moderate risk) or immunocompromising (high risk) condition. Compared to those at low-risk (healthy), moderate- and high-risk Veterans were >3 and >6 times more likely to develop CAP, respectively. The percentage of CAP patients who were hospitalized was 45 %, ranging from 12 % (age 18–49, low risk) to 57 % (age ≥65, high risk). One-year all-cause mortality rates ranged from 1 % (age 18–49, low risk) to 36 % (age ≥65, high risk). Annual VHA medical expenditure related to CAP was estimated to be $750 million (M) ($415M for those aged ≥65 years).

Conclusion

A focus on CAP prevention among older Veterans and those with comorbid or immunocompromising conditions is important.

Electronic supplementary material

The online version of this article (doi:10.1007/s15010-015-0789-3) contains supplementary material, which is available to authorized users.

Assessment of time to clinical response, a proxy for discharge readiness, among hospitalized patients with community-acquired pneumonia who received either ceftaroline fosamil or ceftriaxone in two phase III FOCUS trials

The primary driver of health care costs for patients with community-acquired pneumonia (CAP) is the hospital length of stay (LOS). Unfortunately, hospital LOS comparisons are difficult to make from phase III CAP trials because of their structured designs and prespecified treatment durations. However, an opportunity still exists to draw inferences about potential LOS differences between treatments through the use of surrogates for hospital discharge. The intent of this study was to quantify the time to a clinical response, a proxy for the time to discharge readiness, among hospitalized CAP patients who received either ceftaroline or ceftriaxone in two phase III CAP FOCUS clinical trials. On the basis of the Infectious Diseases Society of America and American Thoracic Society CAP management guidelines and recent FDA guidance documents for community-acquired bacterial pneumonia, a post hoc adjudication algorithm was constructed a priori to compare the time to a clinical response, a proxy for the time to discharge readiness, between patients who received ceftaroline or ceftriaxone. Overall, 1,116 patients (ceftaroline, n=562; ceftriaxone, n=554) from the pooled FOCUS trials met the selection criteria for this analysis. Kaplan-Meier analyses showed that ceftaroline was associated with a shorter time, measured in days, to meeting the clinical response criteria (P=0.03). Of the patients on ceftaroline, 61.0, 76.1, and 83.6% achieved a clinical response by days 3, 4, and 5, compared to 54.3, 69.8, and 79.3% of the ceftriaxone-treated patients. In the Cox regression, ceftaroline was associated with a shorter time to a clinical response (HR, 1.16, P=0.02). The methodology employed here provides a framework to draw comparative effectiveness inferences from phase III CAP efficacy trials. (The FOCUS trials whose data were analyzed in this study have been registered at ClinicalTrials.gov under registration no. NCT00621504 and NCT00509106.).

Disease burden of pneumonia in Korean adults aged over 50 years stratified by age and underlying diseases

BACKGROUND/AIMS

This study was conducted to assess the disease burden of pneumonia according to age and presence of underlying diseases in patients admitted with community-acquired pneumonia (CAP).

METHODS

We performed a retrospective, observational study and collected data targeting patients with CAP (≥ 50 years) from 11 hospitals. Disease burden was defined as total per-capita medical fee, severity (CURB-65), hospital length of stay (LOS), and mortality.

RESULTS

Of the 693 enrolled subjects, elderly subjects (age, ≥ 65 years) had a higher mean CURB-65 score (1.56 vs. 0.25; p < 0.01) and higher mortality than nonelderly subjects (4.4% [n = 21] vs. 0.5% [n = 1]; p = 0.00). In addition, the total cost of pneumonia treatment was higher in elderly patients compared to in nonelderly patients (KRW 2,088,190 vs. US $1,701,386; p < 0.01). Those with an underlying disease had a higher CURB-65 score (1.26 vs. 0.68; p < 0.01), were much older (mean age, 71.24 years vs. 64.24 years; p < 0.01), and had a higher mortality rate than those without an underlying disease (3.5% [n = 20] vs. 1.7% [n = 2]; p = 0.56). Total per-capita medical fees were higher (KRW 2,074,520 vs. US $1,440,471; p < 0.01) and hospital LOS was longer (mean, 8.38 days vs. 6.42 days; p < 0.01) in patients with underlying diseases compared to those without.

CONCLUSIONS

Due to the relatively high disease burden in Korea, particularly in the elderly and in those with an underlying disease, closer and more careful observation is needed to improve the outcomes of patients with CAP.

Validating hospital admission criteria for decision support in pneumonia

Background

We evaluated our previously derived admission criteria for agreement with physician decisions and outpatient failure among patients presenting to emergency departments (EDs) with pneumonia.

Methods

Among patients presenting to seven Intermountain EDs in the urban region of Utah with pneumonia December 1 2009-December 1 2010, we measured hospital admission rates and outpatient failure, defined as either 7-day secondary hospitalization or death in 30 days for patients initially discharged home from the ED. We measured our admission criteria’s ability to predict hospital admission and its hypothetical rates of admission and outpatient failure with strict adherence to the criteria. We compared our admission criteria to other electronically calculable criteria, CURB-65 and A-DROP.

Results

In 2,308 patients, admission rate was 57%, 30-day mortality 6.1%, 7-day secondary hospitalization 5.8%, and outpatient failure rate 6.4%. Our admission criteria predicted hospital admission with an AUC of 0.77, compared to 0.73 for CURB-65 ≥ 2 and 0.78 for A-DROP≥ 2. Hypothetical 100% concordance with our admission criteria decreased the hospitalization rate to 52% and reduced the outpatient failure rate to 3.9%, slightly better than A-DROP ≥ 2 (54% and 4.3%) and CURB-65 ≥ 2 (49% and 5.1%).

Conclusions

Our admission criteria agreed acceptably with overall observed admission decisions for patients presenting to EDs with pneumonia, but may safely reduce hospital admission rates and increase recognition of patients at risk for outpatient failure compared to CURB-65 ≥ 2 or A-DROP ≥ 2.

Management of community-acquired pneumonia in older adults

Community-acquired pneumonia (CAP) is an increasing problem among the elderly. Multiple factors related to ageing, such as comorbidities, nutritional status and swallowing dysfunction have been implicated in the increased incidence of CAP in the older population. Moreover, mortality in patients with CAP rises dramatically with increasing age. Streptococcus pneumoniae is still the most common pathogen among the elderly, although CAP may also be caused by drug-resistant microorganisms and aspiration pneumonia. Furthermore, in the elderly CAP has a different clinical presentation, often lacking the typical acute symptoms observed in younger adults, due to the lower local and systemic inflammatory response. Several independent prognostic factors for mortality in the elderly have been identified, including factors related to pneumonia severity, inadequate response to infection, and low functional status. CAP scores and biomarkers have lower prognostic value in the elderly, and so there is a need to find new scales or to set new cut-off points for current scores in this population. Adherence to the current guidelines for CAP has a significant beneficial impact on clinical outcomes in elderly patients. Particular attention should also be paid to nutritional status, fluid administration, functional status, and comorbidity stabilizing therapy in this group of frail patients. This article presents an up-to-date review of the main aspects of CAP in elderly patients, including epidemiology, causative organisms, clinical features, and prognosis, and assesses key points for best practices for the management of the disease.

Ceftaroline fosamil for the treatment of community-acquired bacterial pneumonia in elderly patients

The Clinical Assessment Program and Teflaro Utilization Registry (CAPTURE) is a multicenter study, assessing the contemporary use of ceftaroline fosamil in patients with community-acquired bacterial pneumonia (CABP) or acute bacterial skin and skin structure infection. This article discusses the data collected from 528 evaluable patients with CABP, from 39 sites in the United States, between August 2011 and April 2013. The majority of patients (51%) were elderly (aged ≥ 65 years), most of whom were treated in general hospital wards (70%). Approximately one quarter of elderly patients had ≥ 2 comorbidities (26%), the most common of which was structural lung disease (51%). The majority of elderly patients received ceftaroline fosamil as second-line therapy (85%), concurrently with other antibiotics (61%). Similar patterns of ceftaroline fosamil usage were noted in younger patients (aged < 65 years). Fifteen patients died (3%), 10 of whom were elderly. The overall clinical success of ceftaroline fosamil was 81% for elderly patients with CABP and 82% for younger patients. These data suggest that ceftaroline fosamil is a potentially effective treatment option for CABP in the elderly.

Studying the burden of community-acquired pneumonia in adults aged ≥50 years in primary health care: an observational study in rural Crete, Greece

Background:

Community-acquired pneumonia (CAP) is a potentially life-threatening condition that often requires hospitalisation particularly in the elderly population or in patients with comorbidities.

Aims:

The aims of this study were to estimate the CAP frequency and severity in a well-defined primary healthcare setting in rural Crete, to record patient characteristics, their immunisation status and to estimate hospitalisation frequency and determinants.

Methods:

An observational study was designed and implemented in a rural setting within the prefecture of Heraklion in the island of Crete, Greece. Eligible patients were those aged 50 years or above, presenting with CAP based on signs and symptoms and positive X-ray findings.

Results:

A total of 124 CAP cases were recorded, 40 of which (32.3%) were hospitalised. Τhe age-standardised CAP incidence was estimated to be 236.7 cases per 100,000 persons aged ⩾50 years. Forty-three patients (35.2%) were vaccinated against pneumococcus. The most frequent chronic illnesses were heart disease (64.5%), chronic obstructive pulmonary disease (32.5%), and type 2 diabetes (21%). Hospitalisation determinants included advanced age (⩾74 years, Odds ratio (OR) 7.13; P value=0.001; 95% confidence interval (CI), 2.23–22.79), obesity (OR 3.36, P=0.037; 95% CI, 1.08–10.52), ⩾40 pack-years of smoking (OR 3.82, P value=0.040; 95% CI, 1.07–18.42), presence of multimorbidity (OR 5.77, P value=0.003; 95% CI, 1.81–18.42) and pneumococcal vaccination (OR 0.29, P value=0.041; 95% CI, 0.09–0.95).

Conclusions:

This study highlighted patient characteristics and aspects of CAP epidemiology in the context of a rural primary care setting in southern Europe where limited data have been published until now.

Rates and risk factors for recurrent pneumonia in patients hospitalized with community-acquired pneumonia: population-based prospective cohort study with 5 years of follow-up

BACKGROUND

The rates and risk factors for developing recurrent pneumonia following hospitalization with community-acquired pneumonia (CAP) are poorly understood.

METHODS

We examined a population-based cohort of patients with CAP who survived hospital admission and who were free of pneumonia for at least 3 months. We collected clinical, functional, and medication-related information and pneumonia severity index (PSI). Using linked databases we followed patients for 5 years and captured any clinical episode of pneumonia 90 days or more post-discharge. We used Cox proportional hazards models (adjusted for age, sex, PSI, functional status, medications) to determine rates and independent correlates of recurrent pneumonia.

RESULTS

The final cohort included 2709 inpatients; 43% were 75 years or older, 34% were not fully independent, and 56% had severe pneumonia. Over 5 years of follow-up, 245 (9%; 95% confidence interval [CI], 8%-10%) patients developed recurrent pneumonia, and 156 (64%) of these episodes required hospitalization. Rate of recurrence was 3.0/100 person-years and median time to recurrence was 317 days (interquartile range, 177-569); 32 (13%) patients had 2 or more recurrences. In multivariable analyses only age >75 years (adjusted P = .047) and less than fully independent functional status (12% recurrence rate with impaired functional status vs 7% for fully independent; adjusted hazard ratio, 1.7; 95% CI, 1.3-2.2; P < .001) were significantly associated with recurrent pneumonia.

CONCLUSIONS

One of 11 patients who survived CAP hospitalization had recurrent pneumonia over 5 years and those with impaired functional status were at particularly high risk. Recurrent pneumonia is common and more attention to preventive strategies at discharge and closer follow-up over the long-term seem warranted.

Macrolides and mortality in critically ill patients with community-acquired pneumonia: a systematic review and meta-analysis

OBJECTIVE

Some studies suggest better outcomes with macrolide therapy for critically ill patients with community-acquired pneumonia. To further explore this, we performed a systematic review of studies with mortality endpoints that compared macrolide therapy with other regimens in critically ill patients with community-acquired pneumonia.

DATA SOURCES

Studies were identified via electronic databases, grey literature, and conference proceedings through May 2013.

STUDY SELECTION

Using prespecified criteria, two reviewers selected studies; studies of outpatients and hospitalized noncritically ill patients were excluded.

DATA EXTRACTION

Two reviewers extracted data and evaluated bias using the Newcastle-Ottawa Scale. Random effects models were used to generate pooled risk ratios and evaluate heterogeneity (I).

DATA SYNTHESIS

Twenty-eight observational studies (no randomized control trials) were included. Average age ranged from 58 to 78 years and 14-49% were women. In our primary analysis of 9,850 patients, macrolide use was associated with statistically significant lower mortality compared with nonmacrolides (21% [846 of 4,036 patients] vs 24% [1,369 of 5,814]; risk ratio, 0.82; 95% CI, 0.70-0.97; p = 0.02; I = 63%). When macrolide monotherapy was excluded, the macrolide mortality benefit was maintained (21% [737 of 3,447 patients] vs 23% [1,245 of 5,425]; risk ratio, 0.84; 95% CI, 0.71-1.00; p = 0.05; I = 60%). When broadly guideline-concordant regimens were compared, there was a trend to improved mortality and heterogeneity was reduced (20% [511 of 2,561 patients] mortality with beta-lactam/macrolide therapy vs 23% [386 of 1,680] with beta-lactam/fluoroquinolone; risk ratio, 0.83; 95% CI, 0.67-1.03; p = 0.09; I = 25%). When adjusted risk estimates were pooled from eight studies, macrolide therapy was still associated with a significant reduction in mortality (risk ratio, 0.75; 95% CI, 0.58-0.96; p = 0.02; I = 57%).

CONCLUSIONS

In observational studies of almost 10,000 critically ill patients with community-acquired pneumonia, macrolide use was associated with a significant 18% relative (3% absolute) reduction in mortality compared with nonmacrolide therapies. After pooling data from studies that provided adjusted risk estimates, an even larger mortality reduction was observed. These results suggest that macrolides be considered first-line combination treatment in critically ill patients with community-acquired pneumonia and support current guidelines.

Resource use by patients hospitalized with community-acquired pneumonia in Europe: analysis of the REACH study

Background

Management of community-acquired pneumonia (CAP) places a considerable burden on hospital resources. REACH was a retrospective, observational study (NCT01293435) involving adults ≥18 years old hospitalized with CAP and requiring in-hospital treatment with intravenous antibiotics conducted to collect data on current clinical management patterns and resource use for CAP in hospitals in ten European countries.

Methods

Data were collected via electronic Case Report Forms detailing patient and disease characteristics, microbiological diagnosis, treatments before and during hospitalization, clinical outcomes and health resource consumption.

Results

Patients with initial antibiotic treatment modification (n = 589; 28.9%) had a longer mean hospital stay than those without (16.1 [SD: 13.1; median 12.0] versus 11.1 [SD: 8.9; median: 9.0] days) and higher ICU admission rate (18.0% versus 11.9%). Septic shock (6.8% versus 3.0%), mechanical ventilation (22.2% versus 9.7%), blood pressure support (fluid resuscitation: 19.4% versus 11.4%), parenteral nutrition (6.5% versus 3.9%) and renal replacement therapy (4.2% versus 1.4%) were all more common in patients with treatment modification than in those without. Hospital stay was longer in patients with comorbidities than in those without (mean 13.3 [SD: 11.1; median: 10.0] versus 10.0 [SD: 7.5; median: 8.0] days).

Conclusions

Initial antibiotic treatment modification in patients with CAP is common and is associated with considerable additional resource use. Reassessment of optimal management paradigms for patients hospitalized with CAP may be warranted.

Antibiotic expected effectiveness and cost under real life microbiology: evaluation of ertapenem and ceftriaxone in the treatment of community-acquired pneumonia for elderly patients in Spain

Background

Clinical efficacy of antibiotics may be affected by changes in the susceptibility of microorganisms to antimicrobial agents. The purpose of this study is to assess how these changes could affect the initial efficacy of ertapenem and ceftriaxone in the treatment of community-acquired pneumonia (CAP) in elderly patients and the potential consequences this may have in health care costs.

Methods

Initial efficacy in elderly was obtained from a combined analysis of two multicenter, randomized studies. An alternative scenario was carried out using initial efficacy data according to the pneumonia severity index (PSI). Country-specific pathogens distribution was obtained from a national epidemiological study, and microbiological susceptibilities to first- and second-line therapies were obtained from Spanish or European surveillance studies. A decision analytic model was used to compare ertapenem versus ceftriaxone for CAP inpatient treatment. Inputs of the model were the expected effectiveness previously estimated and resource use considering a Spanish national health system perspective. Outcomes include difference in proportion of successfully treated patients and difference in total costs between ertapenem and ceftriaxone. The model performed one-way and probabilistic sensitivity analyses.

Results

First-line treatment of CAP with ertapenem led to a higher proportion of successfully treated patients compared with ceftriaxone in Spain. One-way sensitivity analysis showed that length of stay was the key parameter of the model. Probabilistic sensitivity analysis showed that ertapenem can be a cost-saving strategy compared with ceftriaxone, with a 59% probability of being dominant (lower costs with additional health benefits) for both, elderly patients (>65 years) and patients with PSI >3.

Conclusion

The incorporation of the current antimicrobial susceptibility into the initial clinical efficacy has a significant impact in outcomes and costs in CAP treatment. The treatment with ertapenem compared with ceftriaxone resulted in better clinical outcomes and lower treatment costs for two segments of the Spanish population: elderly patients and patients with severe pneumonia (PSI >3).

Extended release amoxicillin/clavulanate: optimizing a product for respiratory infections based on pharmacodynamic principles

Acute bacterial respiratory tract infections cause a great deal of human morbidity and mortality. Treatment guidelines for these infections include macrolides, doxycycline, beta-lactams and beta-lactam/beta-lactamase inhibitor combinations such as amoxicillin/clavulanic acid to provide coverage for the common respiratory pathogens, including penicillin and macrolide nonsusceptible Streptococcus pneumoniae, as well as beta-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis. In response to recent guidelines recommending higher dose amoxicillin to extend coverage to a higher percentage of S. pneumoniae, a new formulation of amoxicillin/clavulanic acid was developed. This formulation includes a higher amoxicillin dose, with part of the amoxicillin dose being in an extended release formulation, without increasing the clavulanate dose, for twice-daily oral treatment of these infections. Clinical studies of community-acquired pneumonia and acute rhinosinusitis have shown that the new formulation is well tolerated and highly efficacious, with clinical outcomes equivalent to comparators.

Rationale and design of the costs, health status and outcomes in community-acquired pneumonia (CHO-CAP) study in elderly persons hospitalized with CAP

Background

Vaccine effectiveness is usually determined in randomized controlled trials (RCT) and if effective, additional information, e.g. on cost-effectiveness, is required to allow evidence-based decision making. A prerequisite for proper health economic modelling is the availability of good quality data on health care resources use, health outcomes and quality-of-life (QoL) data. The “Collecting health outcomes and economic data on hospitalized Community Acquired Pneumonia (CHO-CAP) – a prospective cohort study” is executed alongside the Community Acquired Pneumonia Immunization Trial with Adults (CAPiTA trial) to capture health outcomes and economic data of elderly hospitalized with CAP and matched controls without CAP.

Methods/Design

CAPiTA is a placebo-controlled double-blind RCT evaluating the effectiveness of a 13-valent conjugated pneumococcal vaccine in preventing vaccine-type pneumococcal CAP in 84,496 elderly in the Netherlands. Participants of CAPiTA, who consented and provided information on health status (EQ-5D) and socio-demographic background at the time of vaccination, constitute the source population of CHO-CAP and are eligible for the nested matched cohort study. CHO-CAP patients hospitalized with CAP form the “diseased” cohort and the “non-diseased” cohort consists of unaffected persons (i.e. no CAP). Observations in the diseased cohort and in matched controls from the non-diseased cohort are used to determine excess costs and QoL changes attributable to CAP.

Based on an estimated 2,000 CAPiTA participants being hospitalized with CAP and an assumed CHO-CAP participation rate of 30% of all CAPiTA participants (±25,000), 600 CAP episodes are expected among CHO-CAP participants (the “diseased” cohort). For each patient with CAP, two non-diseased CHO-CAP subjects will be selected from the CHO-CAP cohort, with matching for age, gender and EQ-5D baseline-score. Data on healthcare and non-healthcare resources use, quality-of-life (using EQ-5D and SF-36 questionnaires) and selected health outcomes will be collected at 0, 1, 6 and 12 months after hospitalization for CAP.

The CHO-CAP study was approved by the Central Committee on Research involving Human Subjects in the Netherlands.

Discussion

With an expected 600 CAP episodes this study will be one of the biggest prospectively studied cohorts of hospitalized elderly with CAP with regard to resources use and Qol data. Strengths of this study further include collection of out-of-pocket costs of patients and productivity losses of both patients and their caregivers and the follow-up period of up to one year post-discharge. This study is therefore expected to add more in-depth knowledge on the short and longer term outcomes of pneumonia in elderly.

Trial registration

ClinicalTrials.gov, NCT00812084.

Community-acquired pneumonia team decreases length of stay in hospitalized, low-risk patients with pneumonia

BACKGROUND

Team-focused intervention to improve the care of low-risk patients with community-acquired pneumonia (CAP) is a matter of controversy. Our aim was to determine if a community-acquired pneumonia team (CAPT) would shorten hospital length of stay (LOS) and improve health care utilization in low-risk patients with CAP compared with management by a general pulmonary team (GPT).

METHODS

We performed a prospective cohort study of hospitalized, low-risk patients with CAP (Pneumonia Severity Index [PSI] score class I or II) at a single tertiary hospital from June 2007 to June 2008. Study patients were stratified to management by the CAPT treating group (n = 35), following the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) CAP guideline recommendations, or to management by the GPT (n = 30) following the standard of care. Primary outcome measure for comparison of the efficacy of the 2 different team-focused interventions was hospital LOS for patients with CAP. Secondary study outcome measures included patient 30- and 90-day all-cause readmission rate, rate of mortality at 30 and 90 days, antibiotic-treatment duration, time to switch patient from intravenous (IV) to oral antibiotic treatment, and time to achieve clinical stability for patients.

RESULTS

Hospitalized, low-risk patients with CAP, who were assisted by a CAPT were more likely to have a shorter hospital stay (9 days less; P < 0.001), shorter time to switch from IV to oral antibiotic therapy (8 days less; P <0.001), and total shorter duration of antibiotic treatment (6 days less; P <0.001), when compared with low-risk patients with CAP who were assisted by a GPT. In addition, for both groups of assisted patients, there were no differences in the time to achieve clinical stability, use of guideline-concordant antibiotic therapy, rate of mortality, or rate of readmissions at 30 and 90 days.

CONCLUSIONS

Management by a dedicated CAPT reduced patient hospital LOS, time to switch from IV to oral antibiotic therapy, and duration of antibiotic treatment, without causing adverse events, compared with standard of care, in low-risk patients with CAP.

Rates of emergency department visits due to pneumonia in the United States, July 2006-June 2009

OBJECTIVES

Pneumonia hospitalization rates are frequently reported as a measure of pneumonia disease burden in the United States. However, a detailed understanding of pneumonia burden in all health care settings, including the emergency department (ED), is essential for measuring the full effect of this disease on the population and planning and evaluating interventions to reduce pneumonia-related morbidity. The aim of this study was to quantify pneumonia-attributable ED visits in the United States among children and adults during the 3-year period July 2006 through June 2009.

METHODS

Rates of pneumonia ED visits were calculated using the Nationwide Emergency Department Sample (NEDS), the largest source of U.S. ED data. Pneumonia ED visits were identified using International Classification of Diseases (ICD) codes within NEDS. A pneumonia ED visit was defined by a primary (first-listed) pneumonia discharge diagnosis or a secondary pneumonia diagnosis with an accompanying primary diagnosis of respiratory failure, shock, septicemia, a sign or symptom consistent with pneumonia, another acute respiratory infection, or an acute exacerbation of a chronic pulmonary disease. Population-based annual rates of pneumonia ED visits stratified by age group and geographic region from July 2006 through June 2009 were calculated. The percentages of pneumonia ED visits resulting in treat-and-release outpatient ED visits were also calculated within each age stratum.

RESULTS

During the study period, 6,917,025 ED visits for pneumonia were identified, representing 2.2% of all U.S. ED visits. During the 3 study years, defined as July through June of 2006-2007, 2007-2008, and 2008-2009, pneumonia ED visit rates per 1,000 person-years were 7.4 (95% confidence interval [CI] = 7.0 to 7.8), 7.8 (95% CI = 7.3 to 8.2), and 7.6 (95% CI = 7.1 to 8.0), respectively. Annual rates were stable over the 3 years within each age group and geographic region. Overall, 39.3% of pneumonia ED visits, including 74.5% of pediatric and 28.1% of adult visits, were managed as treat-and-release outpatient visits.

CONCLUSIONS

Pneumonia accounts for 2.2% of ED visits in the United States and results in approximately seven to eight ED visits per 1000 persons per year. A substantial proportion of pneumonia cases diagnosed in the ED are managed in treat-and-release ED outpatient visits, highlighting that enumeration of ED visit rates provides important complementary information to hospitalization rates for the assessment of pneumonia burden.

Using the electronic medical record to identify community-acquired pneumonia: toward a replicable automated strategy

BACKGROUND

Timely information about disease severity can be central to the detection and management of outbreaks of acute respiratory infections (ARI), including influenza. We asked if two resources: 1) free text, and 2) structured data from an electronic medical record (EMR) could complement each other to identify patients with pneumonia, an ARI severity landmark.

METHODS

A manual EMR review of 2747 outpatient ARI visits with associated chest imaging identified x-ray reports that could support the diagnosis of pneumonia (kappa score  = 0.88 (95% CI 0.82∶0.93)), along with attendant cases with Possible Pneumonia (adds either cough, sputum, fever/chills/night sweats, dyspnea or pleuritic chest pain) or with Pneumonia-in-Plan (adds pneumonia stated as a likely diagnosis by the provider). The x-ray reports served as a reference to develop a text classifier using machine-learning software that did not require custom coding. To identify pneumonia cases, the classifier was combined with EMR-based structured data and with text analyses aimed at ARI symptoms in clinical notes.

RESULTS

370 reference cases with Possible Pneumonia and 250 with Pneumonia-in-Plan were identified. The x-ray report text classifier increased the positive predictive value of otherwise identical EMR-based case-detection algorithms by 20-70%, while retaining sensitivities of 58-75%. These performance gains were independent of the case definitions and of whether patients were admitted to the hospital or sent home. Text analyses seeking ARI symptoms in clinical notes did not add further value.

CONCLUSION

Specialized software development is not required for automated text analyses to help identify pneumonia patients. These results begin to map an efficient, replicable strategy through which EMR data can be used to stratify ARI severity.

Incidence and cost of pneumonia in medicare beneficiaries

BACKGROUND

Pneumonia is a frequent and serious illness in elderly people, with a significant impact on mortality and health-care costs. Lingering effects may influence clinical outcomes and medical service use beyond the acute hospitalization. This study describes the incidence and mortality of pneumonia in elderly Medicare beneficiaries based on treatment setting (outpatient, inpatient) and location of origin (health-care associated, community acquired) and estimates short- and long-term direct medical costs and mortality associated with an inpatient episode of pneumonia.

METHODS

Administrative claims from a 5% sample of fee-for-service Medicare beneficiaries aged ≥ 65 years from 2005 through 2007 were used. Total direct medical costs for patients during and after hospitalization for pneumonia compared with similar patients without pneumonia (the excess cost of pneumonia) were estimated using propensity score matching.

RESULTS

The age-adjusted annual cumulative incidence of any pneumonia was 47.4 per 1,000 beneficiaries (13.3 per 1,000 inpatient primary pneumonia), increasing with age; one-half of pneumonia cases were treated in the hospital. Thirty-day mortality was twice as high among beneficiaries with health-care-associated pneumonia than among those hospitalized with community-acquired pneumonia (13.4% vs 6.4%). Total medical costs for beneficiaries during and 1 year following a pneumonia hospitalization were $15,682 higher than matched control patients without pneumonia. The total annual excess cost of hospital-treated pneumonia as a primary diagnosis in the elderly fee-for-service Medicare population in 2010 is estimated conservatively at > $7 billion.

CONCLUSIONS

Pneumonia in elderly people is associated with high acute-care costs and an overall impact on total direct medical costs and mortality during and after an acute episode.

My Patient is Short of Breath: Is the Problem in the Lung Tissue?

Undifferentiated dyspnoea is a common patient presentation in the intensive care unit, medical and surgical floors, and in the emergency department. Physical examination and chest radiography are notoriously insensitive for detection and differentiation of various lung pathologies while computed tomography consumes significant resources and exposes the patient to ionizing radiation. Point-of-care ultrasound (PoCUS) is a highly sensitive and specific diagnostic tool that, with appropriate operator experience, is capable of diagnosing and differentiating between the various causes of dyspnoea. PoCUS machines are readily available, images are rapidly generated and repeatable, and technical skills are easily taught during short training sessions. Furthermore, the development of PoCUS skills in one specific area enables and enhances the development of skills in other non-related areas. This article describes the benefits, technical aspects, and challenges associated with using PoCUS to examine the lung parenchyma in the acutely dyspnoeic patient.

Hypocapnia and hypercapnia are predictors for ICU admission and mortality in hospitalized patients with community-acquired pneumonia

OBJECTIVE

The purpose of our study was to examine in patients hospitalized with community acquired pneumonia (CAP) the association between abnormal Pa CO 2 and ICU admission and 30-day mortality.

METHODS

A retrospective cohort study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of CAP. Arterial blood gas analyses were obtained with measurement of PaCO2 on admission. Multivariate analyses were performed using 30-day mortality and ICU admission as the dependent measures.

RESULTS

Data were abstracted on 453 subjects with a documented arterial blood gas analysis. One hundred eighty-nine patients (41%) had normal PaCO2 (35-45 mm Hg), 194 patients (42%) had aPa CO 2 , 35 mm Hg (hypocapnic), and 70 patients (15%) had a Pa CO 2 . 45 mm Hg (hypercapnic).In the multivariate analysis, after adjusting for severity of illness, hypocapnic patients had greater 30-day mortality (OR= 2.84; 95% CI, 1.28-6.30) and a higher need for ICU admission (OR= 2.88;95% CI, 1.68-4.95) compared with patients with normal PaCO2. In addition, hypercapnic patients had a greater 30-day mortality (OR= 3.38; 95% CI, 1.38-8.30) and a higher need for ICU admission(OR =5.35; 95% CI, 2.80-10.23). When patients with COPD were excluded from the analysis,the differences persisted between groups.

CONCLUSION

In hospitalized patients with CAP, both hypocapnia and hypercapnia were associated with an increased need for ICU admission and higher 30-day mortality. These findings persisted after excluding patients with CAP and with COPD. Therefore, PaCO2 should be considered for inclusion in future severity stratification criteria to appropriate identified patients who will require a higher level of care and are at risk for increased mortality.

Emergency management of community-acquired bacterial pneumonia: what is new since the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines

Community-acquired pneumonia (CAP) is a major health problem in the United States and is associated with substantial morbidity, mortality, and health care costs. Patients with CAP commonly present to emergency departments where physicians must make critical decisions regarding diagnosis and management of pneumonia in a timely fashion, with emphasis on efficient and cost-effective diagnostic choices, consideration of emerging antimicrobial resistance, timely initiation of antibiotics, and appropriate site-of-care decisions. In light of the burden that pneumonia places on health care systems and the emergency department in particular, this article reviews significant developments in the management of CAP in the United States 5 years since the publication of the 2007 Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of CAP in adults, focusing on recent studies and recommendations for managing CAP, the primary bacterial pathogens responsible for CAP, and trends in resistance, new diagnostic technologies, and newer antimicrobials approved for the treatment of CAP. These new data and additional guidelines pertaining to the treatment of CAP further our knowledge and understanding of this challenging infection. Furthermore, appreciation of the availability of new diagnostic testing and therapeutic options will help meet the demand for improved management of CAP.

Improving the 2007 Infectious Disease Society of America/American Thoracic Society severe community-acquired pneumonia criteria to predict intensive care unit admission

PURPOSE

To improve 2007 Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) severity criteria to predict intensive care unit (ICU) admission in patients hospitalized with pneumonia.

METHODS

A composite score that included the 2007 IDSA/ATS criteria for severe pneumonia and additional significant variables identified by recent publications was tested in patients hospitalized with community-acquired pneumonia.

RESULTS

Among 787 patients hospitalized with community-acquired pneumonia, 156 (19.8%) required admission to the ICU. We identified one major criterion (arterial pH <7.30), and 4 minor criteria (tachycardia >125 bpm, arterial pH 7.30-7.34, sodium <130 mEq/L and glucose >250 mg/dL) to be associated with ICU admission. Adding arterial pH <7.30 to the 2 2007 IDSA/ATS major criteria increased sensitivity from 61.5% to 71.8% and area under the curve (AUC) from 0.80 to 0.86. Adding in sequence the four minor criteria to the 2007 IDSA/ATS minor criteria, increased sensitivity from 41.7% to 53.8%, and AUC from 0.65 to 0.69. In the new composite score, combining 1 of 3 major criteria with 3 of 12 minor criteria showed a sensitivity of 92.9% and an AUC of 0.88.

CONCLUSION

The addition of arterial pH <7.30 to the 2007 IDSA/ATS major criteria improves sensitivity and AUC to identify patients who will require ICU care.

Retrospective epidemiological study for the characterization of community- acquired pneumonia and pneumococcal pneumonia in adults in a well-defined area of Badalona (Barcelona, Spain)

Background

Community-acquired pneumonia (CAP) has large impact on direct healthcare costs, especially those derived from hospitalization. This study determines impact, clinical characteristics, outcome and economic consequences of CAP in the adult (≥18 years) population attended in 6 primary-care centers and 2 hospitals in Badalona (Spain) over a two-year period.

Methods

Medical records were identified by codes from the International Classification of Diseases in databases (January 1^st 2008-December 31^st 2009).

Results

A total of 581 patients with CAP (55.6% males, mean age 57.5 years) were identified. Prevalence: 0.64% (95% CI: 0.5%-0.7%); annual incidence: 3.0 cases/1,000 inhabitants (95% CI: 0.2-0.5). Up to 241 (41.5%) required hospitalization. Hospital admission was associated (p<0.002) with liver disease (OR=5.9), stroke (OR=3.6), dementia (OR=3.5), COPD (OR=2.9), diabetes mellitus (OR=1.9) and age (OR=1.1 per year). Length of stay (4.4±0.3 days) was associated with PSI score (β=0.195), in turn associated with age (r=0.827) and Charlson index (r=0.497). Microbiological tests were performed in all inpatients but only in 35% outpatients. Among patients with microbiological tests, results were positive in 51.7%, and among them, S pneumoniae was identified in 57.5% cases. Time to recovery was 29.9±17.2 days. Up to 7.5% inpatients presented complications, 0.8% required ICU admission and 19.1% readmission. Inhospital mortality rate was 2.5%. Adjusted mean total cost was €2,332.4/inpatient and €698.6/outpatient (p<0.001). Patients with pneumococcal CAP (n=107) showed higher comorbidity and hospitalization (76.6%), higher PSI score, larger time to recovery and higher overall costs among inpatients.

Conclusions

Strategies preventing CAP, thus reducing hospital admissions could likely produce substantial costs savings in addition to the reduction of CAP burden.

Comorbidities as a driver of the excess costs of community-acquired pneumonia in U.S. commercially-insured working age adults

BACKGROUND

Adults with certain comorbid conditions have a higher risk of pneumonia than the overall population. If treatment of pneumonia is more costly in certain predictable situations, this would affect the value proposition of populations for pneumonia prevention. We estimate the economic impact of community-acquired pneumonia (CAP) for adults with asthma, diabetes, chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) in a large U.S. commercially-insured working age population.

METHODS

Data sources consisted of 2003 through 2007 Thomson Reuters MarketScan Commercial Claims and Encounters and Thomson Reuters Health Productivity and Management (HPM) databases. Pneumonia episodes and selected comorbidities were identified by ICD-9-CM diagnosis codes. By propensity score matching, controls were identified for pneumonia patients. Excess direct medical costs and excess productivity cost were estimated by generalized linear models (GLM).

RESULTS

We identified 402,831 patients with CAP between 2003 through 2007, with 25,560, 32,677, 16,343, and 5,062 episodes occurring in patients with asthma, diabetes, COPD and CHF, respectively. Mean excess costs (and standard error, SE) of CAP were $14,429 (SE=44) overall. Mean excess costs by comorbidity subgroup were lowest for asthma ($13,307 (SE=123)), followed by diabetes ($21,395 (SE=171)) and COPD ($23,493 (SE=197)); mean excess costs were highest for patients with CHF ($34,436 (SE=549)). On average, indirect costs comprised 21% of total excess costs, ranging from 8% for CHF patients to 27% for COPD patients.

CONCLUSIONS

Compared to patients without asthma, diabetes, COPD, or CHF, the excess cost of CAP is nearly twice as high for patients with diabetes and COPD and nearly three times as high for patients with CHF. Indirect costs made up a significant but varying portion of excess CAP costs. Returns on prevention of pneumonia would therefore be higher in adults with these comorbidities.

Clinical and economic burden of community-acquired pneumonia in the Medicare fee-for-service population

OBJECTIVES

To estimate current community-acquired pneumonia (CAP) incidence and its associated economic burden in the Medicare fee-for-service (FFS) population.

DESIGN

Retrospective.

SETTING

The 2007/08 Medicare Standard Analytic Files, a nationally representative random sample (5%) of Medicare beneficiaries enrolled in the FFS program.

PARTICIPANTS

Residents of one of the 50 U.S. states or the District of Columbia aged 18 and older on July 1, 2007, with continuous Part A and Part B coverage during calendar year 2007.

MEASUREMENTS

Incidence, episode length, mortality, and costs were assessed. All-cause costs were assessed using three methodologies: costs during the episode, and incremental costs using CAP cases as self-control (before-after) and with matched controls (case-control).

RESULTS

Sixty-five thousand eight hundred four CAP episodes (39% inpatient-treated episodes) were identified. Average inpatient and outpatient episode lengths were 32.8 ± 46.9 and 12.4 ± 27.3 days, respectively, and overall incidence was 4,482/100,000 person-years. Thirty-day case fatality was 8.5% for inpatient and 3.8% for outpatient CAP. The average CAP episode cost was $8,606 ($18,670 for inpatient, $2,394 for outpatient). The incremental cost of a CAP episode in the before-and-after and case-control analyses was approximately $10,000.

CONCLUSION

An estimated 1.3 million CAP cases and 74,000 CAP-related deaths were found, with an economic burden of $13 billion annually in the Medicare fee-for-service population. Preventing CAP in this population may substantially reduce healthcare costs.

Once-daily moxifloxacin therapy for community-acquired pneumonia in general practice : evidence from a post-marketing surveillance study of 1467 patients

OBJECTIVE

To assess the efficacy, safety and tolerability of oral moxifloxacin in outpatients with respiratory tract infections treated in general practices in Germany with the focus on community-acquired pneumonia (CAP). METHODS, DESIGN AND PATIENTS: This was an open-label, prospective, uncontrolled, post-marketing surveillance study undertaken between October 2001 and June 2002. Symptoms associated with pneumonia were documented at baseline and at follow-up visits. A general assessment was given and the number of days until improvement/cure were recorded by the attending physician at the end of therapy.

RESULTS

A total of 9036 patients were treated with moxifloxacin, of which 1467 had CAP. The recommended dosage of moxifloxacin (400mg once daily) was used in 97.8% of all CAP patients. Between the initial and final follow-up visits, symptoms of CAP were either improved or cured in 90-99% of patients. More than half of the patients showed improvement after 3 days (54.2%); 89.2% of patients were improved after 5 days. The mean time for patients to recover was 8.0 +/- 2.7 days, with 88.7% of patients recovered by day 10 of treatment. Physicians rated moxifloxacin therapy as 'very good' or 'good' in 96.6% of patients and virtually all favoured prescribing moxifloxacin again. Ten patients (0.7%) reported adverse events during moxifloxacin therapy, mostly gastrointestinal disturbances.

CONCLUSIONS

Moxifloxacin is a very effective and safe treatment for patients with CAP and is highly accepted by physicians and patients because of rapid symptom improvement and good tolerability.

Efficacy and tolerability of sequential intravenous/oral moxifloxacin therapy in pneumonia: results of the first post-marketing surveillance study with intravenous moxifloxacin in hospital practice

OBJECTIVE

This study aimed to investigate the efficacy, safety and tolerability of sequential intravenous (IV)/oral therapy with moxifloxacin in pneumonia under general hospital treatment conditions.

PATIENTS AND METHODS

Patients with pneumonia were documented in this non-interventional multicentre study. The patients were treated with IV moxifloxacin or moxifloxacin sequential therapy (IV and oral) in hospitals throughout Germany. Exclusion criteria were limited to the contraindications mentioned in the summary of product characteristics. The participating hospital-based physicians documented the patients' demography, anamnesis, antibiotic pretreatment, concomitant diseases and medications. Moxifloxacin therapy and symptom status were recorded daily up to the ninth day and on the last day of treatment. The physicians assessed the efficacy and tolerability of IV moxifloxacin therapy and reported all adverse events observed within the treatment period.

RESULTS

The 1749 documented patients had a mean age of 66.2 (SD 15.5) years; 56.4% were males and 43.5% females. The majority (99.3%) were treated with moxifloxacin 400mg once daily. On average, moxifloxacin was given for 7.6 days (SD 3.2). In cases of sequential therapy (78.9% of patients), IV moxifloxacin was switched to oral moxifloxacin after a mean of 4.1 days (SD 1.8). Moxifloxacin produced a significant clinical improvement in 58.2% of patients by day 3 of therapy, in 84.2% by day 5 and in 89.4% by day 7. Recovery occurred in 27.0% of patients by day 5, in 54.0% by day 7 and in 87.0% by day 14. It took a mean of 3.4 days (SD 1.9) until improvement and 7.2 days (SD 3.0) until cure. Overall efficacy of IV moxifloxacin therapy was rated by the physicians as 'very good' or 'good' in 82.9% of patients. Tolerability was rated in 94.3% of patients as 'very good' or 'good'. Adverse events were recorded for 92 (5.3%) patients, but events were considered by the attending physician to be related to moxifloxacin therapy for only 45 patients (2.6%).

CONCLUSIONS

IV moxifloxacin shows high efficacy in the treatment of pneumonia under routine clinical treatment conditions. IV moxifloxacin relieves pneumonia-associated symptoms rapidly and allows an early switch to oral administration. Because of its high efficacy and very good safety and tolerability profile, moxifloxacin delivers excellent benefits as first-line therapy for pneumonia.

Pneumonia in frail older patients: an up to date

Despite advances in diagnosis, antimicrobial therapy and supportive care modalities, community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality, especially in patients who require hospitalization. Elderly patients with poor functional status are characterized by a higher risk of developing severe CAP, due to the frequent presence of underlying respiratory and cardiac diseases, alteration of mental status, and immunosuppression. In recent years, changes in the healthcare system have shifted a considerable part of older patient care from hospitals to the community, and the traditional distinction between community- and hospital-acquired infections has become less clear. Pneumonia occurring among outpatients in contact with the healthcare system has been termed healthcare-associated pneumonia. Older frail patients have a high frequency of aspiration pneumonia and pneumonia due to gram-negative bacilli and other multidrug resistant pathogens. The contemporary presence of renal impairment usually requires specific dose adjustment of antibiotic therapy, which may be toxic in this specific patient population. This review produces a summary of therapeutic recommendations on the basis of the most updated clinical and pharmacological data.

Radiologic predictors of hyponatremia in children hospitalized with community-acquired pneumonia

BACKGROUND

Hyponatremia (HNa) is the most common electrolyte imbalance seen in clinical practice and a common laboratory finding in children with community-acquired pneumonia (CAP). This study investigated whether there is a link between the radiological pattern seen in patients with CAP and the occurrence of HNa, hypothesizing that children with moderate and severe HNa would have a lobar-segmental pattern on chest radiograph.

METHODS

The medical files and chest radiographs of 54 children with moderate to severe HNa (sodium <130 mmol/L) admitted with CAP over a 2-year period at our institution were retrospectively studied. Community-acquired pneumonia was defined as either lobar-segmental or interstitial by a radiologist blinded to laboratory results.

RESULTS

Hyponatremia was seen more frequently in children with lobar-segmental pneumonia: 40 (74%) compared with 14 (26%) with interstitial pneumonia (P = 0.004). There was no relationship between the pattern of pneumonia seen on chest radiograph and severity of HNa; however, all 6 cases of severe HNa had lobar-segmental CAP, and all patients with complicated CAP were from the lobar-segmental group.

CONCLUSIONS

We found an association between lobar-segmental CAP and moderate or severe HNa. In addition, all cases of severe HNa occurred in patients with lobar-segmental CAP. The presence of a lobar-segmental pattern on chest radiography in CAP suggests the need for assessment of electrolyte status even in patients with adequate respiratory status.

CURB-65 score predicted mortality in community-acquired pneumonia better than IDSA/ATS minor criteria in a low-mortality-rate setting

The CURB-65 scoring system performs well at identifying patients with pneumonia who have a low risk of death. Whether it predicts mortality in community-acquired pneumonia (CAP) better than the 2007 Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) minor criteria in low-mortality-rate settings is not clear. The purpose of this study was to determine the hypothesis.A total of 1,230 adult inpatients admitted to our hospital from 2005 to 2009 for CAP were reviewed retrospectively.The hospital mortality was 1.3 %. Percentage mortality increased significantly with CURB-65 score and the increasing number of IDSA/ATS minor criteria present. The number of CURB-65 criteria or IDSA/ATS minor criteria present had significant increased odds ratios for mortality of 7.547 and 2.711, respectively. The sensitivities of a CURB-65 score of ≥ 3 and the presence of ≥ 3 minor criteria in predicting mortality was 25 % and 37.5 %, which increased to 75 % and 62.5 %, while the cut-off values reduced to ≥ 2 criteria, respectively. The area under the receiver operating characteristic curve for CURB-65 was greater than the corresponding area for IDSA/ATS minor criteria in predicting hospital mortality (0.915 vs. 0.805, p = 0.0091).CURB-65 score predicted hospital mortality better than IDSA/ATS minor criteria, and a CURB-65 score of ≥ 2 or the presence of ≥ 2 minor criteria might be more valuable cut-off values for "severe" CAP in a low-mortality-rate setting.

The natural history of community-acquired pneumonia in COPD patients: a population database analysis

BACKGROUND

Patients with Chronic Obstructive Pulmonary Disease (COPD) are at higher risk of developing Community-Acquired Pneumonia (CAP) than patients in the general population. However, no studies have been performed in general practice assessing longitudinal incidence rates for CAP in COPD patients or risk factors for pneumonia onset.

METHODS

A cohort of COPD patients aged ≥ 45 years, was identified in the General Research Practice Database (GPRD) between 1996 and 2005, and annual and 10-year incidence rates of CAP evaluated. A nested case-control analysis was performed, comparing descriptors in COPD patients with and without CAP using conditional logistic regression generating odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The COPD cohort consisted of 40,414 adults. During the observation period, 3149 patients (8%) experienced CAP, producing an incidence rate of 22.4 (95% CI 21.7-23.2) per 1000 person years. 92% of patients with pneumonia diagnosis had suffered only one episode. Multivariate modelling of pneumonia descriptors in COPD indicate that age over 65 years was significantly associated with increased risk of CAP. Other independent risk factors associated with CAP were co-morbidities including congestive heart failure (OR 1.4, 95% CI 1.2-1.6), and dementia (OR 2.6, 95%CI 1.9-3.). Prior severe COPD exacerbations requiring hospitalization (OR 2.7, 95% CI 2.3-3.2) and severe COPD requiring home oxygen or nebulised therapy (OR 1.4, 95% CI 1.1-1.6) were also significantly associated with risk of CAP.

CONCLUSION

COPD patients presenting in general practice with specific co-morbidities, severe COPD, and age >65 years are at increased risk of CAP.