Predictors of mortality in nursing-home residents with pneumonia: a multicentre study

Utility of pneumonia severity assessment tools for mortality prediction in healthcare-associated pneumonia: a systematic review and meta-analysis

Accurate prognostic tools for mortality in patients with healthcare-associated pneumonia (HCAP) are needed to provide appropriate medical care, but the efficacy for mortality prediction of tools like PSI, A-DROP, I-ROAD, and CURB-65, widely used for predicting mortality in community-acquired and hospital-acquired pneumonia cases, remains controversial. In this study, we conducted a systematic review and meta-analysis using PubMed, Cochrane Library (trials), and Ichushi web database (accessed on August 22, 2022). We identified articles evaluating either PSI, A-DROP, I-ROAD, or CURB-65 and the mortality outcome in patients with HCAP, and calculated the pooled sensitivities, specificities, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the summary area under the curves (AUCs) for mortality prediction. Additionally, the differences in predicting prognosis among these four assessment tools were evaluated using overall AUCs pooled from AUC values reported in included studies. Eventually, 21 articles were included and these quality assessments were evaluated by QUADAS-2. Using a cut-off value of moderate in patients with HCAP, the range of pooled sensitivity, specificity, PLR, NLR, and DOR were found to be 0.91-0.97, 0.15-0.44, 1.14-1.66, 0.18-0.33, and 3.86-9.32, respectively. Upon using a cut-off value of severe in those patients, the range of pooled sensitivity, specificity, PLR, NLR, and DOR were 0.63-0.70, 0.54-0.66, 1.50-2.03, 0.47-0.58, and 2.66-4.32, respectively. Overall AUCs were 0.70 (0.68-0.72), 0.70 (0.63-0.76), 0.68 (0.64-0.73), and 0.67 (0.63-0.71), respectively, for PSI, A-DROP, I-ROAD, and CURB-65 (p = 0.66). In conclusion, these severity assessment tools do not have enough ability to predict mortality in HCAP patients. Furthermore, there are no significant differences in predictive performance among these four severity assessment tools.

Adverse Outcomes of Patients with Non-Ventilator-Associated Hospital-Acquired Pneumonia (nvHAP)-A Single Centre Cohort Study

Non-ventilator associated hospital-acquired pneumonia (nvHAP) is a common nosocomial infection, but little is known about the outcomes of patients with nvHAP and the risk factors for adverse outcomes. In this retrospective study conducted in a Swiss tertiary care centre, adverse outcomes like in-hospital mortality, intensive care unit (ICU) admission, and mechanical ventilation, both all-cause and nvHAP-associated, were investigated. Of 244 patients with nvHAP, 72 (30%) died, 35 (14%) deaths were attributed to nvHAP. While 36 (15%) patients acquired nvHAP on the ICU, another 173 patients were eligible for ICU-transferral, and 76 (43.9%) needed ICU-admission. Of all patients hospitalized on the ICU 58 (51.8%) needed intubation due to nvHAP. Multivariable logistic regression analysis identified lower body mass index (OR per unit increase: 0.90, 95%CI: 0.82-0.98) and lower haemoglobin on admission (OR per unit in g/l increase: 0.98, 95%CI: 0.97-1.00) as patient specific factors independently associated with nvHAP-associated mortality. Given the frequency of nvHAP adverse outcomes, hospitals should evaluate increasing nvHAP prevention efforts, especially for patients at high risk for nvHAP mortality. To what extent pneumonia prevention interventions do lower nvHAP mortality in these patients is still to be evaluated.

COVID-19 infection rate and mortality in a local health authority in Italy: Differences between home-dwelling and residential older adults

Objectives

The health emergency following the COVID-19 pandemic has seen hospital structures collapse and put in crisis nursing homes and other long-term care facilities worldwide. Our study aims to analyze and comparing the data relating to the infection rate and mortality for COVID-19 in the elderly over 75 living in the long-term care facilities and in the home-dwelling population.

Study design

The study adopts a retrospective cohort design and was conducted in Italy, in the Lazio region, in the area of the Local Health Authority (LHA) named "Azienda Sanitaria Locale Roma 6".

Methods

Data were extracted from the COVID-19 surveillance system of the Lazio region. The primary outcome is the SARS-CoV-2 incidence rate in the period between 1st September 2020 and 31st May 2021. The secondary outcome is the mortality rate.

Results

Living in a residential versus a home-dwelling setting was associated with a higher infection rate (OR 5.03, CI 4.67-5.43; p < 0.001). The mortality rate was higher for individuals living in a residential setting (19.3 %, CI 17.1%-21.7 %) than those living at home (13.0 %, CI 11.7%-14.5 %).

Conclusions

These findings confirm the high mortality in Long-Term Care Facilities and provide new information on the infection rate. The containment measures adopted in the Long-Term Care Facilities during the COVID-19 pandemic, show limited correlation with reduced risk of contagion, but could have created unintended harm for the residents by increasing the social isolation and all other causes of mortality.

Development of a new prognostic index PNPI for prognosis prediction of CKD patients with pneumonia at hospital admission

Background

The aim of this study was to investigate the relationship between pneumonia and chronic kidney disease (CKD), to elucidate potential risk factors, and to develop a new predictive model for the poor prognosis of pneumonia in CKD patients.

Method

We conducted a retrospective observational study of CKD patients admitted to Tongji Hospital between June 2012 and June 2022. Demographic information, comorbidities or laboratory tests were collected. Applying univariate and multivariate logistic regression analyses, independent risk factors associated with a poor prognosis (i.e., respiratory failure, shock, combined other organ failure, and/or death during hospitalization) for pneumonia in CKD patients were discovered, with nomogram model subsequently developed. Predictive model was compared with other commonly used pneumonia severity scores.

Result

Of 3,193 CKD patients with pneumonia, 1,013 (31.7%) met the primary endpoint during hospitalization. Risk factors predicting poor prognosis of pneumonia in CKD patients were selected on the result of multivariate logistic regression models, including chronic cardiac disease; CKD stage; elevated neutrophil to lymphocyte ratio (NLR) and D-dimer; decreased platelets, PTA, and chloride iron; and significant symptom presence and GGO presentation on CT. The nomogram model outperformed other pneumonia severity indices with AUC of 0.82 (95% CI: 0.80, 0.84) in training set and 0.83 (95% CI: 0.80, 0.86) in testing set. In addition, calibration curve and decision curve analysis (DCA) proved its efficiency and adaptability.

Conclusion

We designed a clinical prediction model PNPI (pneumonia in nephropathy patients prognostic index) to assess the risk of poor prognosis in CKD patients with pneumonia, which may be generalized after more external validation.

Prediction models of all-cause mortality among older adults in nursing home setting: A systematic review and meta-analysis

Background and Aims

Few studies have meta-analyzed different prognostic models developed for older adults, especially nursing home residents. We aimed to systematically review and meta-analyze the performance of all published models that predicted all-cause mortality among older nursing home residents.

Methods

We systematically searched PubMed and EMBASE from the databases' inception to January 1, 2020 to capture studies developing and/or validating a prognostic/prediction model for all-cause mortality among nursing home residents. We then carried out both qualitative and quantitative analyses evaluating these models' risks of bias and applicability.

Results

The systematic search yielded 23,975 articles. We identified 28 indices that predicted the risk of all-cause mortality from 14 days to 39 months among older adults in nursing homes. The most used predictors were age, sex, body weight, swallowing problem, congestive heart failure, shortness of breath, body mass index, and activities of daily living. Of the 28 indices, 8 (29%) and 3 (11%) were internally and externally validated, respectively. None of the indices was validated in more than one cohort. Of the 28 indices, 22 (79%) reported the C-statistic, while only 6 (6%) reported the 95% confidence interval for the C statistic in the development cohorts. In the validation cohorts, 11 (39%) reported the C-statistic and 8 (29%) reported the 95% confidence interval. The meta-analyzed C statistic for all indices is 0.733 (95% prediction interval: 0.669-0.797). All studies/indices had high risks of bias and high concern for applicability according to PROBAST.

Conclusion

We identified 28 indices for predicting all-cause mortality among older nursing home residents. The overall quality of evidence was low due to a high degree of bias and poor reporting of model performance statistics. Before any prediction model could be recommended in routine care, future research is needed to rigorously validate existing prediction models and evaluate their applicability and develop new prediction models.

Noticing Acute Changes in Health in Long-Term Care Residents

PURPOSE

Early signs of acute conditions and increased fall risk often go unrecognized in patients in long-term care facilities. The aim of this study was to examine how healthcare staff identify and act on changes in health status in this patient population.

DESIGN

A qualitative study design was used for this study.

METHODS

Six focus groups across two Department of Veterans Affairs long-term care facilities were conducted with 26 interdisciplinary healthcare staff members. Using thematic content analysis, the team preliminarily coded based on interview questions, reviewed and discussed emerging themes, and agreed on the resultant coding scheme for each category with additional independent scientist review.

RESULTS

Themes included describing and explaining how "normal" or expected behavior is identified by staff, noticing changes in a resident, determining the significance of the change, hypothesizing reasons for an observed change, response to an observed change, and resolution of the clinical change.

CONCLUSIONS

Despite limited training in formal assessment methods, long-term care staff have developed methods to conduct ongoing assessments of the residents. This technique, individual phenotyping, often identifies acute changes; however, the lack of formal methods, language, or tools to communicate the changes means that these assessments are not often formalized in a manner that informs the residents' changing care needs.

CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING

More formal objective measures of health change are needed to assist long-term care staff in expressing and interpreting the subjective phenotype changes into objective, easily communicated health status changes. This is particularly important for acute health changes and impending falls, both of which are associated with acute hospitalization.

Nursing homes and mortality in Europe: Uncertain causality

The current health crisis has particularly affected the elderly population. Nursing homes have unfortunately experienced a relatively large number of deaths. On the basis of this observation and working with European data (from SHARE), we want to check whether nursing homes were lending themselves to excess mortality even before the pandemic. Controlling for a number of important characteristics of the elderly population in and outside nursing homes, we conjecture that the difference in mortality between those two samples is to be attributed to the way nursing homes are designed and organized. Using matching methods, we observe excess mortality in Sweden, Belgium, Germany, Switzerland, Czech Republic and Estonia but not in the Netherlands, Denmark, Austria, France, Luxembourg, Italy and Spain. This raises the question of the organization and management of these nursing homes, but also of their design and financing.

Oral care measures for preventing nursing home-acquired pneumonia

BACKGROUND

Pneumonia in residents of nursing homes can be termed nursing home-acquired pneumonia (NHAP). NHAP is one of the most common infections identified in nursing home residents and has the highest mortality of any infection in this population. NHAP is associated with poor oral hygiene and may be caused by aspiration of oropharyngeal flora into the lung. Oral care measures to remove or disrupt oral plaque might reduce the risk of NHAP. This is the first update of a review published in 2018.

OBJECTIVES

To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities.

SEARCH METHODS

An information specialist searched CENTRAL, MEDLINE, Embase, one other database and three trials registers up to 12 May 2022. We also used additional search methods to identify published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of oral care measures (brushing, swabbing, denture cleaning mouthrinse, or combination) in residents of any age in nursing homes and other long-term care facilities.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed search results, extracted data, and assessed risk of bias in the included studies. We contacted study authors for additional information. We pooled data from studies with similar interventions and outcomes. We reported risk ratios (RRs) for dichotomous outcomes, mean differences (MDs) for continuous outcomes, and hazard ratios (HRs) or incidence rate ratio (IRR) for time-to-event outcomes, using random-effects models.

MAIN RESULTS

We included six RCTs (6244 participants), all of which were at high risk of bias. Three studies were carried out in Japan, two in the USA, and one in France. The studies evaluated one comparison: professional oral care versus usual oral care. We did not include the results from one study (834 participants) because it had been stopped at interim analysis.  Consistent results from five studies, with 5018 participants, provided insufficient evidence of a difference between professional oral care and usual (simple, self-administered) oral care in the incidence of pneumonia. Three studies reported HRs, one reported IRRs, and one reported RRs. Due to the variation in study design and follow-up duration, we decided not to pool the data. We downgraded the certainty of the evidence for this outcome by two levels to low: one level for study limitations (high risk of performance bias), and one level for imprecision. There was low-certainty evidence from meta-analysis of two individually randomised studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24 months' follow-up (RR 0.43, 95% CI 0.25 to 0.76, 454 participants). Another study (2513 participants) reported insufficient evidence of a difference for this outcome at 18 months' follow-up. Three studies measured all-cause mortality and identified insufficient evidence of a difference between professional and usual oral care at 12 to 30 months' follow-up. Only one study (834 participants) measured the adverse effects of the interventions. The study identified no serious events and 64 non-serious events, the most common of which were oral cavity disturbances (not defined) and dental staining. No studies evaluated oral care versus no oral care.

AUTHORS' CONCLUSIONS

Although low-certainty evidence suggests that professional oral care may reduce mortality compared to usual care when measured at 24 months, the effect of professional oral care on preventing NHAP remains largely unclear. Low-certainty evidence was inconclusive about the effects of this intervention on incidence and number of first episodes of NHAP. Due to differences in study design, effect measures, follow-up duration, and composition of the interventions, we cannot determine the optimal oral care protocol from current evidence.  Future trials will require larger samples, robust methods that ensure low risk of bias, and more practicable interventions for nursing home residents.

Emergency readmissions following geriatric ground-level falls: How does frailty factor in?

BACKGROUND

Ground-level falls (GLFs) in older adults are increasing as life expectancy increases, and more patients are being discharged to skilled nursing facilities (SNFs) for continuity of care. However, GLF patients are not a homogenous cohort, and the role of frailty remains to be assessed. Thus, the aim of this study is to examine the impact of frailty on the in-hospital and 30-day outcomes of GLF patients.

MATERIALS AND METHODS

This is a cohort analysis from the Nationwide Readmissions Database 2017. Geriatric (age ≥65 years) trauma patients presenting following GLFs were identified and grouped based on their frailty status. The associations between frailty and 30-day mortality and emergency readmission were examined by multivariate regression analyses adjusting for patient demographics and injury characteristics.

RESULTS

A total of 100,850 geriatric GLF patients were identified (frail: 41% vs. non-frail: 59%). Frail GLF patients were younger (81[74-87] vs. 83[76-89] years; p<0.001) and less severely injured-Injury Severity Score [ISS] (4[1-9] vs. 5[2-9]; p<0.001). Frail patients had a higher index mortality (2.9% vs. 1.9%; p<0.001) and higher 30-day readmissions (14.0% vs. 9.8%; p<0.001). Readmission mortality was also higher in the frail group (15.2% vs. 10.9%; p<0.001), with 75.2% of those patients readmitted from an SNF. On multivariate analysis, frailty was associated with 30-day mortality (OR 1.75; p<0.001) and 30-day readmission (OR 1.49; p<0.001).

CONCLUSION

Frail geriatric patients are at 75% higher odds of mortality and 49% higher odds of readmission following GLFs. Of those readmitted on an emergency basis, more than one in seven patients died, 75% of whom were readmitted from an SNF. This underscores the need for optimization plans that extend to the post-discharge period to reduce readmissions and subsequent high-impact consequences.

Empiric Treatment in HAP/VAP: “Don’t You Want to Take a Leap of Faith?”

Ventilator-associated pneumonia is a frequent cause of ICU-acquired infections. These infections are associated with high morbidity and mortality. The increase in antibiotic resistance, particularly among Gram-negative bacilli, makes the choice of empiric antibiotic therapy complex for physicians. Multidrug-resistant organisms (MDROs) related infections are associated with a high risk of initial therapeutic inadequacy. It is, therefore, necessary to quickly identify the bacterial species involved and their susceptibility to antibiotics. New diagnostic tools have recently been commercialized to assist in the management of these infections. Moreover, the recent enrichment of the therapeutic arsenal effective on Gram-negative bacilli raises the question of their place in the therapeutic management of these infections. Most national and international guidelines recommend limiting their use to microbiologically documented infections. However, many clinical situations and, in particular, the knowledge of digestive or respiratory carriage by MDROs should lead to the discussion of the use of these new molecules, especially the new combinations with beta-lactamase inhibitors in empirical therapy. In this review, we present the current epidemiological data, particularly in terms of MDRO, as well as the clinical and microbiological elements that may be taken into account in the discussion of empirical antibiotic therapy for patients managed for ventilator-associated pneumonia.

Comparing the Clinical Characteristics and Mortality of Residential and Non-Residential Older People with COVID-19: Retrospective Observational Study

Nursing homes have accounted for a significant part of SARS-CoV-2 mortality, causing great social alarm. Using data collected from electronic medical records of 1,319,839 institutionalised and non-institutionalised persons ≥ 65 years, the present study investigated the epidemiology and differential characteristics between these two population groups. Our results showed that the form of presentation of the epidemic outbreak, as well as some risk factors, are different among the elderly institutionalised population with respect to those who are not. In addition to a twenty-fold increase in the rate of adjusted mortality among institutionalised individuals, the peak incidence was delayed by approximately three weeks. Having dementia was shown to be a risk factor for death, and, unlike the non-institutionalised group, neither obesity nor age were shown to be significantly associated with the risk of death among the institutionalised. These differential characteristics should be able to guide the actions to be taken by the health administration in the event of a similar infectious situation among institutionalised elderly people.

Community-acquired pneumonia

Community-acquired pneumonia is not usually considered a high-priority problem by the public, although it is responsible for substantial mortality, with a third of patients dying within 1 year after being discharged from hospital for pneumoniae. Although up to 18% of patients with community-acquired pneumonia who were hospitalised (admitted to hospital and treated there) have at least one risk factor for immunosuppression worldwide, strong evidence on community-acquired pneumonia management in this population is scarce. Several features of clinical management for community-acquired pneumonia should be addressed to reduce mortality, morbidity, and complications related to community-acquired pneumonia in patients who are immunocompetent and patients who are immunocompromised. These features include rapid diagnosis, microbiological investigation, prevention and management of complications (eg, respiratory failure, sepsis, and multiorgan failure), empirical antibiotic therapy in accordance with patient's risk factors and local microbiological epidemiology, individualised antibiotic therapy according to microbiological data, appropriate outcomes for therapeutic switch from parenteral to oral antibiotics, discharge planning, and long-term follow-up. This Seminar offers an updated view on community-acquired pneumonia in adults, with suggestions for clinical and translational research.

Fostering healthy aging: The interdependency of infections, immunity and frailty

Untangling the interdependency of infections, immunity and frailty may help to clarify their roles in the maintenance of health in aging individuals, and the recent COVID-19 pandemic has further highlighted such priority. In this scoping review we aimed to systematically collect the evidence on 1) the impact of common infections such as influenza, pneumonia and varicella zoster on frailty development, and 2) the role played by frailty in the response to immunization of older adults. Findings are discussed under a unifying framework to identify knowledge gaps and outline their clinical and public health implications to foster a healthier aging. Twenty-nine studies (113,863 participants) selected to answer the first question provided a moderately strong evidence of an association between infections and physical as well as cognitive decline - two essential dimensions of frailty. Thirteen studies (34,520 participants) investigating the second aim, showed that frailty was associated with an impaired immune response in older ages, likely due to immunosenescence. However, the paucity of studies, the absence of tools to predict vaccine efficacy, and the lack of studies investigating the efficacy of newer vaccines in presence of frailty, strongly limit the formulation of more personalized immunization strategies for older adults. The current evidence suggests that infections and frailty repeatedly cross each other pathophysiological paths and accelerate the aging process in a vicious circle. Such evidence opens to several considerations. First, the prevention of both conditions pass through a life course approach, which includes several individual and societal aspects. Second, the maintenance of a well-functioning immune system may be accomplished by preventing frailty, and vice versa. Third, increasing the adherence to immunization may delay the onset of frailty and maintain the immune system homeostasis, beyond preventing infections.

Diagnostic stewardship based on patient profiles: differential approaches in acute versus chronic infectious syndromes

Introduction: New diagnostics may be useful in clinical practice, especially in contexts of high prevalence of multidrug-resistant organisms (MDRO). However, misuse of diagnostic tools may lead to increased costs and worse patient outcome. Conventional and new techniques should be appropriately positioned in diagnostic algorithms to guide an appropriate use of antimicrobial therapy.Areas covered: A panel of experts identified 4 main areas in which the implementation of diagnostic stewardship is needed. Among chronic infections, bone and prosthetic joint infections and subacute-chronic intravascular infections and endocarditis represent common challenges for clinicians. Among acute infections, bloodstream infections and community-acquired pneumonia may be associated with high mortality and require appropriate diagnostic approach.Expert opinion: Diagnostic stewardship aims to improve the appropriate use of microbiological diagnostics to guide therapeutic decisions through appropriate and timely diagnostic testing. Here, diagnostic algorithms based on different patient profiles are proposed for chronic and acute clinical syndromes. In each clinical scenario, combining conventional and new diagnostic techniques is crucial to make a rapid and accurate diagnosis and to guide the selection of antimicrobial therapy. Barriers related to the implementation of new rapid diagnostic tools, such as high initial costs, may be overcome through their rational and structured use.

Pneumonia prevention in the elderly patients: the other sides

Pneumonia is one of the leading causes of morbidity and mortality from infection in elderly patients. The increased frequency of pneumonia among elderly subjects can be explained by the physiological changes linked to the progressive aging of the respiratory tree and the diminished immunological response. A spiral of event leads to frailty, infection and possible death; preventing pneumonia consists of controlling the risk factors. Dysphagia, which is associated with malnutrition and dehydration, is recognized as one of the major pathophysiological mechanism leading to pneumonia and its screening is crucial for the pneumonia risk assessment. The impairment in the oropharyngeal reflexes results in stagnation of foreign material in the lateral cavities of the pharynx which may then get aspirated repeatedly in the lungs and cause pneumonia. Pneumonia prevention starts with lifestyle modifications such as alcohol and tobacco cessation. A careful review of the risk-benefit of the prescribed medication is critical and adaptation may be required in elders with multiple morbidities. Respiratory physiotherapy and mobilization improve the functional status and hence may help reduce the risk of pneumonia. Maintaining teeth and masticatory efficiency is important if malnutrition and its consequences are to be avoided. Daily oral hygiene and regular professional removal of oral biofilm can prevent the onset of periodontitis and can avoid an oral environment favoring the colonization of respiratory pathogens than can then be aspirated into the lungs.

Prevention of the spread of multidrug-resistant organisms in nursing homes

The increase in the aged population led to a global rise in the demand for elderly healthcare services, such as long-term care facilities (LTCFs), nursing homes, residential homes. Unfortunately, the spread of multidrug-resistant organisms (MDROs) in these structures represent an urgent public health threat requiring immediate action. The aim of this review is to provide a practice guide for the prevention of infections in European LTCFs. A team of experts identify specific problems and proposed practical solutions for the management of colonized and infected patients residing in LTCFs. The heterogeneity of LTCF represents one of the main problems for the implementation of standardized surveillance and infection control programs. Crucial steps involved in the spread of infections among LTCF residents are represented by patient's accommodation, MDRO screening on admission, management of patients with rectal colonization by MDROs, management of patients at high risk of MDRO infections, MDRO transmission by staff and implementation of antimicrobial stewardship. Efforts to implement specific actions in each of these fields are required to reduce the infections in this setting.

Factors associated with lethality from pneumonia in an acute care for the elderly unit: a retrospective cohort

Introduction: Pneumonia is the leading cause of death due to infection in the world, mainly affecting the older adult population. Objective: To determine the risk factors associated with lethality at 30 days in patients with pneumonia in an acute care for the elderly unit. Materials and methods: We conducted an observational, analytical retrospective cohort study including 114 patients aged 60 years and older hospitalized in an acute care geriatric unit with a diagnosis of pneumonia. The primary outcome was lethality at 30 days. Bivariate and multivariable log-binomial regression analyzes were performed to explore the relationship between independent variables and the primary outcome. Results: The 30-day lethality was 26.3% and the mean age was 84.45 ± 7.37 years; 54.4% of participants were men. In the multivariable analysis, age ≥90 years (Relative Risk, RR=1.62, 95% CI: 1.05-2.68, p=0.04), multilobar commitment (RR=1.92, 95% CI:1.12-3.32, p=0.02), elevated urea nitrogen (≥22.5 the median; RR=3.93, 95% CI:1.67-9.25, p<0.01), and a score of zero in the Lawton index at admission (RR=3.20, 95% CI:1.05-9.78, p=0.04) were independent predictors of 30-day lethality from pneumonia. Conclusion: In older adults hospitalized for pneumonia in an acute care geriatric unit, advanced age, the presence of multilobar commitment, dependency in functional status, and elevated ureic nitrogen levels were the main predictors of short-term lethality risk.

High excess mortality in areas with young and socially vulnerable populations during the COVID-19 outbreak in Stockholm Region, Sweden

INTRODUCTION

We aimed to describe the distribution of excess mortality (EM) during the first weeks of the COVID-19 outbreak in the Stockholm Region, Sweden, according to age, sex and sociodemographic context.

METHODS

Weekly all-cause mortality data were obtained from Statistics Sweden for the period 1 January 2015 to 17 May 2020. EM during the first 20 weeks of 2020 was estimated by comparing observed mortality rates with expected mortality rates during the five previous years (N=2 379 792). EM variation by socioeconomic status (tertiles of income, education, Swedish-born, gainful employment) and age distribution (share of 70+-year-old persons) was explored based on Demographic Statistics Area (DeSO) data.

RESULTS

EM was first detected during the week of 23-29 March 2020. During the peak week of the epidemic (6-12 April 2020), an EM of 150% was observed (152% in 80+-year-old women; 183% in 80+-year-old men). During the same week, the highest EM was observed for DeSOs with lowest income (171%), lowest education (162%), lowest share of Swedish-born (178%) and lowest share of gainfully employed residents (174%). EM was further increased in areas with higher versus lower proportion of younger people (magnitude of increase: 1.2-1.7 times depending on socioeconomic measure).

CONCLUSION

Living in areas characterised by lower socioeconomic status and younger populations was linked to excess mortality during the COVID-19 pandemic in the Stockholm Region. These conditions might have facilitated viral spread. Our findings highlight the well-documented vulnerability linked to increasing age and sociodemographic context for COVID-19-related death.

Which Nursing Home Residents With Pneumonia Are Managed On-Site and Which Are Hospitalized? Results from 2 Years' Surveillance in 14 US Homes

OBJECTIVES

Pneumonia is a frequent cause of hospitalization among nursing home (NH) residents, but little information is available as to how clinical presentation and other characteristics relate to hospitalization, and the differential use of antimicrobials based on hospitalization status. This study examined how hospitalized and nonhospitalized NH residents with pneumonia differ.

DESIGN

Data from a 2-year prospective study of residents who participated in a randomized controlled trial.

SETTING AND PARTICIPANTS

All residents from 14 NHs in North Carolina followed for pneumonia over a 2-year period.

METHODS

Clinical features, antimicrobial treatment, hospitalization, and demographic data on residents with a pneumonia diagnosis were abstracted from charts; NH information was obtained from NH administrators.

RESULTS

A total of 509 pneumonia episodes were reported for 395 unique residents; the incidence was not higher in the winter months, and 28% were hospitalized. The likelihood of hospitalization did not differ by clinical characteristics except that residents with a respiratory rate >25 breaths per minute were more likely to be hospitalized. Being on hospice [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.5-7.4] and not having dementia (OR 1.9, 95% CI 1.1-3.2) also related to increased likelihood of hospitalization. Fluoroquinolone (usually levofloxacin) monotherapy was the most common treatment (54%) in both settings, and ceftriaxone monotherapy varied by hospitalization status (7% of hospitalized vs 16% treated on-site). Approximately 36% of nonhospitalized residents received antimicrobials for more than 7 days.

CONCLUSIONS/IMPLICATIONS

Respiratory rate is associated with hospitalization but was not documented for more than a quarter of residents, suggesting the clinical benefit of more consistently conducting this assessment. Differential hospitalization rates for persons with dementia and on hospice suggest that care is being tailored to individuals' wishes, but this assumption merits study, as does use of fluoroquinolones (due to side effects) and treatment duration (due to potential contribution to antibiotic resistance).

Feasibility of Using a Risk Assessment Tool to Predict Hospital Transfers or Death for Older People in Australian Residential Aged Care. A Retrospective Cohort Study

Residents of Aged Care Facilities (RACF) experience burdensome hospital transfers in the last year of life, which may lead to aggressive and potentially inappropriate hospital treatments. Anticipating these transfers by identifying risk factors could encourage end-of-life discussions that may change decisions to transfer. The aim was to examine the feasibility of identifying an end-of-life risk profile among RACF residents using a predictive tool to better anticipate predictors of hospital transfers, death or poor composite outcome of hospitalisation and/or death after initial assessment. A retrospective cohort study of 373 permanent residents aged 65+ years was conducted using objective clinical factors from records in nine RACFs in metropolitan Sydney, Australia. In total, 26.8% died and 34.3% experienced a composite outcome. Cox proportional hazard regression models confirmed the feasibility of estimating the level of risk for death or a poor composite outcome. Knowing this should provide opportunities to initiate advance care planning in RACFs, facilitating decision making near the end of life. We conclude that the current structure of electronic RACF databases could be enhanced to enable comprehensive assessment of the risk of hospital re-attendance without admission. Automation tools to facilitate the risk score calculation may encourage the adoption of prediction checklists and evaluation of their association with hospital transfers.

Clinical features, therapy and outcome of patients hospitalized or not for nursing-home acquired pneumonia

BACKGROUND

nursing home-acquired pneumonia (NHAP), is among the main causes of hospitalization and mortality of frail elderly patients. Aim of this study was analysis of patients residing in long-term care facilities (LTCF) and developing pneumonia to reach a better knowledge of criteria for hospitalization and outcomes.

MATERIALS/METHODS

this is a prospective, observational study in which patients residing in 3 LTCFs (metropolitan area of Rome, Italy) and developing pneumonia, hospitalized or treated in LTCF, were recruited and followed up from January 2017 to June 2019. Primary endpoint was 30-day mortality, secondary endpoint was analysis of risk factors associated with hospitalization.

RESULTS

Overall, 146 episodes of NHAP were enrolled in the study: 57 patients were treated in LTCF, while 89 patients were hospitalized. Overall incidence rates of NHAP varied from 2.6 to 7.5 per 1000 residents. Methicillin-resistant Staphylococcus aureus was the most frequently isolated pathogen (25%), and in 28 (55%) patients was documented a MDR pathogen. For hospitalized patients was reported a higher 30-day mortality (43.8% Vs 7%, p < 0.001). Multivariate analysis showed that severe pneumonia, neoplasm, chronic hepatitis, antibiotic monotherapy, and malnutrition were independent risk factors for hospitalization from LTCF. MDR pathogen, severe pneumonia, COPD, and moderate to severe renal disease were independently associated with death at 30 days.

CONCLUSION

frail elderly patients in LTCF have a high risk of MDR etiology with a higher risk to receive an inadequate antibiotic therapy and a fatal outcome. These results point to the need for increased provision of acute care and strategies in LTCF.

Antimicrobial consumption and impact of antimicrobial stewardship programmes in long-term care facilities

BACKGROUND

Antimicrobials are among the most frequently prescribed drugs in long-term care facilities (LTCFs). Implementation of antimicrobial stewardship programmes (ASPs) is often challenging because of scarce data in this setting.

OBJECTIVES

This narrative review aimed to provide data about antibiotic consumption in LTCFs and the need, implementation, and organization of ASPs in this setting.

SOURCE

PubMed was searched for studies assessing antimicrobial consumption and implementation of ASPs in LTCFs. The search was restricted to articles published in English in the last 10 years. Experts belonging to the ESCMID Study Group for Infections in the Elderly (ESGIE) reviewed the selected studies and evaluated the studies on ASPs according to the GRADE approach. Moreover, the quality of reporting has been assessed according to TREND and CONSORT checklists for quasi-experimental and cluster randomized clinical trials (cRCT), respectively.

CONTENT

Data on antibiotic consumption in LTCFs show great variability in LTCFs across and within countries. Reasons for this variability are difficult to analyse because of the differences in the types of LTCFs, their organization, and the population cared-for in the different LTCFs. However, studies show that the use of antibiotics among elderly patients in LTCFs, especially in cases of asymptomatic bacteriuria and influenza-like syndromes, is often inappropriate. High-quality cRCTs and low to moderate quality quasi-experimental studies show that educational interventions direct at nurse and physicians are effective in reducing unnecessary antibiotic prescriptions.

IMPLICATIONS

There is an urgent need for ASPs tailored for LTCFs. Multifaceted organized educational interventions, involving both clinicians and nursing staff, should be advocated and require institutional intervention by health authorities. Future studies assessing the impact of well-defined ASPs in LTCFs should produce compelling evidence in this setting.