Incidence, direct costs and duration of hospitalization of patients hospitalized with community acquired pneumonia: A nationwide retrospective claims database analysis

Cost-effectiveness of high-dose influenza vaccination in the Netherlands: Incorporating the impact on both respiratory and cardiovascular hospitalizations

OBJECTIVES

We assess the cost-effectiveness of switching from standard-dose quadrivalent influenza vaccination (SD-QIV) to high-dose vaccination (HD-QIV) for Dutch adults aged 60 years and older.

METHODS

A health-economic model was used to compare the scenario where HD-QIV was implemented compared to the current standard, SD-QIV. This model used a lifetime horizon and assessed the cost-effectiveness from a societal perspective. A recently published meta-analysis was used to incorporate the benefits of HD-QIV, including cardiorespiratory hospitalizations, in analyses considering RCT only or combining RCT and RWE estimates in a scenario analysis.

RESULTS

Implementing HD-QIV is cost effective at its list price, with an ICER of €5,400 per QALY gained. The main driver of these results is the prevention of cardiorespiratory hospitalizations. Other public health benefits are the prevention of GP consults and deaths. HD-QIV is highly likely to be cost-effective, reaching a 100% probability of being cost effective at the Dutch willingness-to-pay threshold of €20,000 per QALY.

CONCLUSIONS

Implementing HD-QIV for adults aged 60 and over within the existing influenza vaccination campaign is highly cost effective. HD-QIV may support alleviating potential capacity issues in Dutch hospitals in the winter respiratory season.

Comparison of outcomes and characteristics of patients admitted to the ICU with COVID-19 and other community-acquired pneumonia based on propensity score matching

OBJECTIVE

To compare the similarities and differences between patients with Coronavirus Disease 2019 (COVID-19) and those with other community-acquired pneumonia (CAP) admitted to the intensive care unit (ICU), utilizing propensity score matching (PSM), regarding hospitalization expenses, treatment options, and prognostic outcomes, aiming to inform the diagnosis and treatment of COVID-19.

METHODS

Patients admitted to the ICU of the Third People's Hospital of Datong City, diagnosed with COVID-19 from December 2022 to February 2023, constituted the observation group, while those with other CAP admitted from January to November 2022 formed the control group. Basic information, clinical data at admission, and time from symptom onset to admission were matched using PSM.

RESULTS

A total of 70 patients were included in the COVID-19 group and 119 in the CAP group. The patients were matched by the propensity matching method, and 37 patients were included in each of the last two groups. After matching, COVID-19 had a higher failure rate than CAP, but the difference was not statistically significant (73% vs. 51%, p = 0.055). The utilization rate of antiviral drugs (40% vs. 11%, p = 0.003), γ-globulin (19% vs. 0%, p = 0.011) and prone position ventilation (PPV) (27% vs. 0%, p < 0.001) in patients with COVID-19 were higher than those in the CAP, and the differences were statistically significant. The total hospitalization cost of COVID-19 patients was lower than that of CAP patients, and the difference was statistically significant (27889.5 vs. 50175.9, p = 0.007). The hospital stay for COVID-19 patients was shorter than for CAP patients, but the difference was not statistically significant (10.9 vs. 16.6, p = 0.071).

CONCLUSION

Our findings suggest that limited medical resources influenced patient outcomes during the COVID-19 pandemic. Addressing substantial demands for ICU capacity and medications during this period could have potentially reduced the mortality rate among COVID-19 patients.

Efficacy and Safety of Corticosteroid Therapy for Community-Acquired Pneumonia: A Meta-Analysis and Meta-Regression of Randomized, Controlled Trials

BACKGROUND

Community-acquired pneumonia (CAP) is associated with high morbidity and mortality. In the present study, we aimed to assess the effect of corticosteroids on all-cause mortality in patients hospitalized with CAP.

METHODS

For this meta-analysis and meta-regression, we conducted a systematic search of trials that evaluated the effect of corticosteroid therapy in patients hospitalized with CAP through March 2023. We included randomized, controlled trials, comparing adjunctive corticosteroid therapy with the standard of care alone for treatment of patients hospitalized with CAP and reporting all-cause mortality. We excluded retrospective analyses, observational data, and trial protocols. The primary outcome was all-cause mortality within 30 days after hospital admission. The safety analysis included the frequency of adverse events and steroid-associated adverse events.

RESULTS

The literature search identified 35 713 citations, of which 15 studies and 3367 patients were eligible for the final analysis. The all-cause mortality at 30 days was significantly lower in the corticosteroid group (104 of 1690, 6.15%) than in the control group (152 of 1677, 9.06%; risk ratio [RR], 0.67; 95% confidence interval [CI], .53 to .85; P = .001; I2 = 0%). In 9 studies (2549 patients) that reported the occurrence of adverse events, corticosteroid therapy was not associated with an increased risk of developing any adverse event compared with standard care (RR, 0.90; 95% CI, .65 to 1.24; P = .5; I2 = 88%).

CONCLUSIONS

Adjunctive systemic corticosteroid therapy in patients hospitalized with CAP was associated with a reduction in all-cause mortality by day 30. The benefits were more pronounced in patients with severe pneumonia.

Reducing antimicrobial overuse through targeted therapy for patients with community-acquired pneumonia: a study protocol for a cluster-randomized factorial controlled trial (CARE-CAP)

BACKGROUND

Community-acquired pneumonia (CAP) is a significant public health concern and a leading cause of hospitalization and inpatient antimicrobial use in the USA. However, determining the etiologic pathogen is challenging because traditional culture methods are slow and insensitive, leading to prolonged empiric therapy with extended-spectrum antibiotics (ESA) that contributes to increased hospital length of stay, and antimicrobial resistance. Two potential ways to reduce the exposure to ESA are (a) rapid diagnostic assays that can provide accurate results within hours, obviating the need for empiric therapy, and (b) de-escalation following negative bacterial cultures in clinically stable patients.

METHODS

We will conduct a large pragmatic 2 × 2 factorial cluster-randomized controlled trial across 12 hospitals in the Cleveland Clinic Health System that will test these two approaches to reducing the use of ESA in adult patients (age ≥ 18 years) with CAP. We will enroll over 12,000 patients and evaluate the independent and combined effects of routine use of rapid diagnostic testing at admission and pharmacist-led de-escalation after 48 h for clinically stable patients with negative cultures vs usual care. We hypothesize that both approaches will reduce days on ESA. Our primary outcome is the duration of exposure to ESA therapy, a key driver of antimicrobial resistance. Secondary outcomes include detection of respiratory viruses, treatment with anti-viral medications, positive pneumococcal urinary antigen test, de-escalation by 72 h from admission, re-escalation to ESA after de-escalation, total duration of any antibiotic, 14-day in-hospital mortality, intensive care unit transfer after admission, healthcare-associated C. difficile infection, acute kidney injury, total inpatient cost, and hospital length-of-stay.

DISCUSSION

Our study aims to determine whether identifying an etiological agent early and pharmacist-led de-escalation (calling attention to negative cultures) can safely reduce the use of ESA in patients with CAP. If successful, our findings should lead to better antimicrobial stewardship, as well as improved patient outcomes and reduced healthcare costs. Our findings may also inform clinical guidelines on the optimal management of CAP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05568654 . Registered on October 4, 2022.

Predictors of prolonged hospitalization among children aged 2-59 months with severe community-acquired pneumonia in public hospitals of Benishangul-Gumuz Region, Ethiopia: a multicenter retrospective follow-up study

Background

Pneumonia is a leading cause of morbidity and mortality among children aged under 5 years in Ethiopia. Prolonged hospitalization of severe community-acquired pneumonia is a significant problem in resource-limited countries. This study seeks to provide insights that can help improve the management and outcomes of severe community-acquired pneumonia, which is particularly important in the context of the Benishangul-Gumuz Region, Ethiopia, where access to quality healthcare services is limited, and childhood pneumonia is a significant health challenge.

Objective

The aim of the study was to determine the predictors of prolonged hospitalization among children aged 2-59 months admitted with severe community-acquired pneumonia between 1 January 2016 and 30 December 2020 in the public hospitals in Benishangul-Gumuz Region, Ethiopia.

Method

A retrospective follow-up study design was conducted among randomly selected samples of 526 children. Data were entered into EPI data version 4.6 and analyzed using STATA version 14.0. The Cox proportional hazard regression model was fitted to identify the independent predictors of prolonged hospitalization, and variables with a p-value <0.05 in the multivariable model were considered statistically significant.

Results

The median hospital stay was 5 days (interquartile range 2-8 = 6). Approximately 149 (28.93%) children had prolonged hospitalization (>5 days) and the recovery rate from severe community-acquired pneumonia was 19.69 per 100 person-day observations. The significant predictors of prolonged hospitalization were as follows: having facility referral sources [0.79, 95% confidence interval (CI), 0.63-0.98]; a nutritional status of wasting (0.64, 95% CI, 0.44-0.94); anemia (0.65, 95% CI, 0.46-0.90); no identified hemoglobin level (0.53, 95% CI, 0.41-0.70); no identified blood film (0.65, 95% CI, 0.53-0.80); no chest x-ray investigation (0.81, 95% CI, 0.65-0.99); pulmonary effusion (0.31, 95% CI, 0.15-0.66); and late presenters to hospital (0.67, 95% CI, 0.53-0.84) at admission.

Conclusions

The median length of stay in hospital was delayed compared to other studies. Wasting, late presenting to hospital, pulmonary effusion, anemia, absence of investigations of hemoglobin level, chest x-ray, and blood film at admission time were factors that significantly prolonged the hospitalization time. Hence, attention should be given to the prevention of malnutrition and anemia in children, increasing early health-seeking behavior in the community. Attention should be given to complications such as pleural effusion, and investigations, such as chest x-ray, hemoglobin levels, and blood films, should be performed when the child is admitted.

Assessing Public Health Impact of Four Pediatric Pneumococcal Conjugate Vaccination Strategies in the Netherlands

INTRODUCTION

The 10-valent pneumococcal conjugate vaccine (PCV10, Synflorix) was introduced into the Dutch pediatric national immunization program (NIP) starting in 2011. However, there is substantial pneumococcal disease burden due to increases in non-PCV10 covered serotypes. Higher-valent vaccines for pediatrics (PCV13, PCV15, and PCV20) may alleviate much of the remaining disease burden upon implementation through broader serotype coverage. This article assesses the public health impact of different pediatric vaccination strategies (switching to PCV13, PCV15 or PCV20) versus maintaining PCV10 at different time intervals in the Netherlands.

METHODS

A population-based, decision-analytic model was developed using historical pneumococcal disease surveillance data to forecast future invasive pneumococcal disease (IPD), pneumonia, and otitis media (OM) cases over a 7-year period (2023-2029) under the following strategies: continued use of PCV10, switching to PCV13 in 2023, switching to PCV15 in 2023, and switching to PCV20 in 2024. Scenario analyses were performed to account for uncertainties in future serotype distributions, disease incidence reductions, and epidemiologic parameters.

RESULTS

Switching to PCV13 in 2023 was found to avert 26,666 cases of pneumococcal disease compared to continuing PCV10 over a 7-year period (2023-2029). Switching to PCV15 in 2023 was found to avert 30,645 pneumococcal cases over the same period. Switching to PCV20 once available in 2024 was estimated to avert 45,127 pneumococcal cases from 2024-2029. Overall conclusions were maintained after testing uncertainties.

CONCLUSIONS

For the Dutch pediatric NIP, switching to PCV13 in 2023 would be an effective strategy compared with continued use of PCV10 for averting pneumococcal disease cases. Switching to PCV20 in 2024 was estimated to avert the most pneumococcal disease cases and provide the highest protection. However, in the face of budget constraints and the undervaluation of prevention strategies, it remains challenging to implement higher valent vaccines. Further research is needed to understand the cost-effectiveness and feasibility of a sequential approach.

Cost-Effectiveness of Venetoclax Plus Obinutuzumab Versus Chlorambucil Plus Obinutuzumab for the First-Line Treatment of Adult Patients With Chronic Lymphocytic Leukemia: An Extended Societal View

OBJECTIVES

Efficacy of venetoclax plus obinutuzumab (VenO) compared with chlorambucil plus obinutuzumab (ClbO) for treatment-naïve adult patients with chronic lymphocytic leukemia (CLL) with coexisting medical conditions was investigated in CLL14 (NCT02242942). Our aim was to evaluate the cost-effectiveness of VenO versus ClbO for these patients from a Dutch societal perspective.

METHODS

A 3-state partitioned survival model was constructed to evaluate the cost-effectiveness of VenO. The outcome of the analysis was the incremental cost-effectiveness ratio (ICER) with effectiveness measured in quality-adjusted life-years (QALYs) gained. Uncertainty was explored through deterministic and probabilistic sensitivity analyses, scenario analyses, and value of information analysis (VOI).

RESULTS

The base case resulted in a discounted ICER -49 928 EUR/QALY gained (with incremental negative costs and positive effects). None of the ICERs resulted from deterministic sensitivity and scenario analyses exceeded the chosen willingness-to-pay threshold of 20 000 EUR/QALY, and > 99% of the iterations in the probabilistic sensitivity analysis were cost-effective. VOI analyses showed a maximum expected value of eliminating all model parameter uncertainty of 183 591 EUR.

CONCLUSIONS

Our study demonstrated VenO being dominant over ClbO in treatment-naïve adult patients with CLL assuming a Dutch societal perspective. We concluded that our results are robust as tested through sensitivity and scenario analyses. Additionally, the VOI analyses confirmed that our current evidence base is strong enough to generate reliable results for our study. Nevertheless, further research based on real-world data or longer follow-up period could further contribute to the robustness of the current study's conclusions.

Cost-Effectiveness of Vaccination of Older Adults with an MF59®-Adjuvanted Quadrivalent Influenza Vaccine Compared to Standard-Dose and High-Dose Vaccines in Denmark, Norway, and Sweden

Individuals aged 65 years and above are at increased risk of complications and death from influenza compared with any other age group. Enhanced vaccines, as the MF59®-adjuvanted quadrivalent influenza vaccine (aQIV) and the high-dose quadrivalent influenza vaccine (HD-QIV), provide increased protection for older adults in comparison to the traditional standard-dose quadrivalent influenza vaccines (SD-QIV). This study aimed to assess the cost-effectiveness of aQIV compared to SD-QIV and HD-QIV in Denmark, Norway, and Sweden for adults aged ≥65 years. A static decision tree model was used to evaluate costs and outcomes of different vaccination strategies from healthcare payer and societal perspectives. This model projects that compared to SD-QIV, vaccination with aQIV could prevent a combined total of 18,772 symptomatic influenza infections, 925 hospitalizations, and 161 deaths in one influenza season across the three countries. From a healthcare payer perspective, the incremental costs per quality adjusted life year (QALY) gained with aQIV versus SD-QIV were EUR 10,170/QALY in Denmark, EUR 12,515/QALY in Norway, and EUR 9894/QALY in Sweden. The aQIV was cost saving compared with HD-QIV. This study found that introducing aQIV to the entire population aged ≥65 years may contribute to reducing the disease and economic burden associated with influenza in these countries.

Machine learning and artificial intelligence: applications in healthcare epidemiology

Artificial intelligence (AI) refers to the performance of tasks by machines ordinarily associated with human intelligence. Machine learning (ML) is a subtype of AI; it refers to the ability of computers to draw conclusions (ie, learn) from data without being directly programmed. ML builds from traditional statistical methods and has drawn significant interest in healthcare epidemiology due to its potential for improving disease prediction and patient care. This review provides an overview of ML in healthcare epidemiology and practical examples of ML tools used to support healthcare decision making at 4 stages of hospital-based care: triage, diagnosis, treatment, and discharge. Examples include model-building efforts to assist emergency department triage, predicting time before septic shock onset, detecting community-acquired pneumonia, and classifying COVID-19 disposition risk level. Increasing availability and quality of electronic health record (EHR) data as well as computing power provides opportunities for ML to increase patient safety, improve the efficiency of clinical management, and reduce healthcare costs.

Hospitalization costs for children with pneumonia in Shanghai, China from 2019 to 2020

Pneumonia is the leading cause of death in children under 5 years of age worldwide. In this study, we primarily analyzed the hospitalization costs for children diagnosed with pneumonia in one of the leading public hospitals in Shanghai, China. Furthermore, factors affecting the hospitalization costs for children with pneumonia were evaluated. Data on case diagnosis, hospitalization time, age and various hospitalization expenses were collected. Total hospitalization expense for the 149 cases was $177,750, with an average total cost of $1,193 per person and an average out-of-pocket cost of $642. The highest per capita expenses included fees for laboratory diagnosis ($418), general medical service ($235), western medicine ($253), and antibacterial drugs ($158). The leading diagnosis was bronchopneumonia, with 68 (46%) cases, an average hospital stays of 7.4 days, and average hospitalization expenses of $1,068. Considering the high burden of pneumonia in children, hospitals and governments must make more reasonable use of limited resources of the medical system. At the same time, various types of medical insurance should be added into the children’s medical security system, encourage vaccination with pneumonia vaccines (13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine), and ensure that more children benefit from the vaccine by including it in the national immunization program.

Value of D-dimer in predicting various clinical outcomes following community-acquired pneumonia: A network meta-analysis

Background

Whether high D-dimer level before treatment has any impact on poor outcomes in patients with community-associated pneumonia (CAP) remains unclear. Therefore, we conducted the first meta-analysis focusing specifically on prognostic value of high D-dimer level before treatment in CAP patients.

Methods

Pubmed, Embase, the Cochrane Central Register of Controlled Trials and World Health Organization clinical trials registry center were searched up to the end of March 2021. Randomized clinical trials (RCT) and observational studies were included to demonstrate the association between the level of D-dimer and clinical outcomes. Data were extracted using an adaptation of the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies (CHARMS-PF). When feasible, meta-analysis using random-effects models was performed. Risk of bias and level of evidence were assessed with the Quality in Prognosis Studies tool and an adaptation of Grading of Recommendations Assessment, Development, and Evaluation. Data were analyzed using STATA 14.0 to complete meta and network analysis.

Main outcomes and measures

Besides d-dimer levels in CAP patients with poor outcomes, we also analyzed proportion of patients with or without poor outcomes correctly classified by the d-dimer levels as being at high or low risk. The poor outcome includes severe CAP, death, pulmonary embolism (PE) and invasive mechanical ventilators.

Results

32 studies with a total of 9,593 patients were eventually included. Pooled effect size (ES) suggested that d-dimer level was significantly higher in severe CAP patients than non-severe CAP patients with great heterogeneity (SMD = 1.21 95%CI 0.87–1.56, I² = 86.8% p = 0.000). D-dimer level was significantly elevated in non-survivors compared to survivors with CAP (SMD = 1.22 95%CI 0.67–1.77, I² = 85.1% p = 0.000). Prognostic value of d-dimer for pulmonary embolism (PE) was proved by hierarchical summary receiver operating characteristic curve (HSROC) with good summary sensitivity (0.74, 95%CI, 0.50–0.89) and summary specificity (0.82, 95%CI, 0.41–0.97). Network meta-analysis suggested that there was a significant elevation of d-dimer levels in CAP patients with poor outcome than general CAP patients but d-dimer levels weren’t significantly different among poor outcomes.

Conclusion

The prognostic ability of d-dimer among patients with CAP appeared to be good at correctly identifying high-risk populations of poor outcomes, suggesting potential for clinical utility in patients with CAP.

Incidence and disease burden of community-acquired pneumonia in southeastern China: data from integrated medical resources

Community-acquired pneumonia (CAP) is a lower respiratory tract infection. It is one of the commonest infectious diseases and the third leading cause of death worldwide. However, the epidemiological profiles of CAP in southeastern China are unknown. Data of inpatients and outpatients diagnosed with CAP from January 1, 2015 to December 31, 2020 were obtained from the National Healthcare Big Data in Fuzhou (Fuzhou Database). This database covers medical data from 37 hospitals and 159 community health service stations. The incidence rate, treatment pattern, and direct medical costs of CAP were assessed using clinical data. A total of 8,156,237 patients were enrolled, with a mean age of 33.72 ± 20.88 years. The overall incidence rate of CAP was 3.13 (95% confidence interval [CI]: 3.11-3.15) per 1000 person-years (PY), with 15.97 (95% CI: 15.85-16.08) per 1000 PY in children below 5 years old and 2.62 (95% CI: 2.57-2.66) per 1000 PY in the elderly ≥60 years. The cost per outpatient was $242.83 ± 341.62, and the cost per inpatient was $4,530.4 ± 9,151.68. The three most used therapeutic drugs in patients with CAP are cefotaxime, moxifloxacin, and azithromycin. In addition, despite the ability of both imported and domestic pneumococcal conjugate vaccines to reduce the incidence rate of CAP, the current vaccination coverage rates were relatively low. We suggest that more attention should be paid to the disease burden of CAP, especially due to its great economic burden in China.

Association between angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and community-acquired pneumonia: A nationwide population propensity-score matching study

BACKGROUND

Few large-scale cohort studies have investigated the association between community-acquired pneumonia and the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs). We aimed to study whether using ACEIs or ARBs had protective effects for community-acquired pneumonia.

METHODS

This database cohort study was conducted retrospectively in Taiwan. The hypertensive patients were the target population of this study. Patients with ARB use were defined as our first study cohort. The second study cohort comprised patients who used ACEI. Propensity-score matching at 1:1 was used between ARB users and non-ARB users. We recruited 67 944 participants for the ARB study and 58 062 participants for the ACEI study. The same matching was also performed between ACEI users and non-ACEI users. Cox proportional hazard regression was used to analyse the risk of the outcome of viral pneumonia.

RESULTS

The hazard ratio of community-acquired pneumonia for ARB users relative to non-ARB users was 0.33. The hazard ratio of community-acquired pneumonia was 0.71 times in ACEI users compared with ACEI nonusers. In stratification analysis, both ARB and ACEI both exhibited a protective effect for community-acquired pneumonia in each age and sex group. In the analysis of the effects of therapy duration, patients using ARB for fewer than 100 days exhibited a greater reduction in the risk of community-acquired pneumonia (adjusted HR = 0.58) compared with the non-ARB cohort. For the ACEI study, patients who used ACEI for 121-450 days were more likely to exhibit reduced risks of community-acquired pneumonia (adjusted HR = 0.5).

CONCLUSION

Both ACEI and ARB uses were associated with decreased risk of community-acquired pneumonia infection.

Community-acquired pneumonia: Trends in and research on drug resistance and advances in new antibiotics

Community-acquired pneumonia (CAP) refers to infectious inflammation of the lung parenchyma developing outside of a hospital. CAP has quite a high mortality and morbidity rate worldwide, and especially among elderly patients. The increasing burden of CAP is due to antibiotic resistance, the growth of the elderly population, and underlying comorbidities. Streptococcus pneumoniae remains the most common bacterial pathogen causing CAP, but multi-drug resistance bacteria and potential pathogens have increased the difficulty and challenges of managing CAP. Although preventive measures, diagnostic techniques, and treatment strategies are constantly advancing and improving, the susceptibility of multi-drug resistant pathogens, such as including Methicillin-Resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae, and Pseudomonas aeruginosa, has not improved significantly in recent decades, thus highlighting the importance and necessity of developing new antibiotics for the treatment of CAP. New antimicrobials have been approved over the past few years that will expand treatment options for CAP, and especially for patients with potential comorbidities. This situation also offers the chance to reduce the abuse of antibiotics, their toxicities, and their adverse reactions and to provide effective personalized antibiotic treatment.

Have Dutch Hospitals Saved Lives and Reduced Costs? A longitudinal patient-level analysis over the years 2013-2017

The purpose of this paper is to shed light on the ongoing Dutch health system reforms and identify whether hospital costs and hospital outcomes have changed over time. We present an empirical analysis that is based on granular micro-costing data and focuses on conditions for which mortality is indicative of outcome quality, that is, acute myocardial infarction (AMI), chronic heart failure (CHF), and pneumonia (PNE). We deploy a dataset of more than 80,000 inpatient episodes over 5 years (2013-2017) to estimate regression models that control for variation between patients and hospitals. We have three main findings. First, our results do not indicate significant outcome improvements over the years; that is, there is no time trend for mortality. Second, there is heterogeneity in cost developments: for patients who survive their inpatient stay, our data indicate that costs increase significantly by 0.9% per year for AMI patients, while costs decrease significantly by 1.7% per year for CHF patients and by 1.9% per year for PNE patients. For patients who pass away during their inpatient stay, our data do not indicate significant time trends. Third and finally, our results suggest the existence of substantial cost variation between hospitals.

The cost-saving switch from inhaled corticosteroid-containing treatments to dual bronchodilation: a two-country projection of epidemiological and economic burden in chronic obstructive pulmonary disease

Purpose:

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018 recommendations support maintenance treatment with long-acting bronchodilators in most symptomatic patients with chronic obstructive pulmonary disease (COPD). While restricting the overuse of inhaled corticosteroids (ICS) may influence healthcare utilization required to treat inadvertent respiratory (exacerbations and pneumonia) and diabetes-related events, it may also change the total medication cost. This analysis was performed to estimate the 5-year budget impact of switching from ICS-containing treatment combinations to dual bronchodilation, in line with the recommendations.

Methods:

The model quantified the budget impact of treatment and healthcare resource utilization when COPD patients were anticipated to switch from ICS-containing treatments to dual bronchodilation. Three switch scenarios were calculated with increasing proportions of patients on dual long-acting bronchodilators, to the detriment of ICS-containing double and triple combinations. Clinical and cost input data were based on results from clinical trials and Greek and Portuguese healthcare cost databases.

Results:

Healthcare resource use to manage exacerbations, pneumonia and diabetes-related events were projected to increase between 2019 and 2023 in parallel with the growing COPD patient population and associated costs were estimated at 52–57% of the total disease cost in the Greek and Portuguese base case scenarios. Total cost savings between 21 and 112 million EUR were projected when the proportion of patients on double and triple ICS-containing treatments was gradually reduced to 50% in scenario A, 20% in scenario B and 7% in scenario C. Sensitivity analyses showed that none of the model assumptions had a major impact on the projected savings.

Conclusion:

The alignment of COPD treatment with current recommendations may bring clinical benefits to patients, without substantial cost increases and even cost savings for payers.

The reviews of this paper are available via the supplemental material section.

Pneumonia in older adults

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

The role of qSOFA score and biomarkers in assessing severity of community-acquired pneumonia in adults

Introduction: Community-acquired pneumonia (CAP) is the primary cause of severe sepsis. Severity assessment scores have been created, in order to help physicians decide the proper management of CAP. The purpose of this study was to examine the correlations between different CAP severity scores, including qSOFA, several biomarkers and their predictive value in the 30 day follow-up period, regarding adverse outcome.

Materials and methods: One hundred and thirty nine adult patients with CAP, admitted in the Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania from December 2015 to February 2017, were enrolled in this study. Pneumonia Severity Index (PSI), CURB-65, SMART-COP and the qSOFA scores were calculated at admittance. Also, C-reactive protein (CRP), procalcitonin (PCT) and albumin levels were used to determine severity.

Results: The mean PSI of all patients was 93.30±41.135 points, for CURB-65 it was 1.91±0.928 points, for SMART-COP it was 1.69±1.937 points. The mean qSOFA was 1.06±0.522 points, 21 (14.9%) were at high risk of in-hospital mortality. In the group of patients with qSOFA of ≥2, all pneumonia severity scores and all biomarkers tested were higher than those with scores <2. We found significant correlations between biomarkers and severity scores, but none regarding adverse outcome.

Conclusion: The qSOFA score is easier to use and it is able to accurately evaluate the severity of CAP, similar to other scores. Biomarkers are useful in determining the severity of the CAP. Several studies are needed to assess the prediction of these biomarkers and severity scores in pneumonia regarding adverse outcome.

Cost-Effectiveness of Pediatric Influenza Vaccination in The Netherlands

OBJECTIVE

This study evaluates the cost-effectiveness of extending the Dutch influenza vaccination program for elderly and medical high-risk groups to include pediatric influenza vaccination, taking indirect protection into account.

METHODS

An age-structured dynamic transmission model was used that was calibrated to influenza-associated GP visits over 4 seasons (2010-2011 to 2013-2014). The clinical and economic impact of different pediatric vaccination strategies were compared over 20 years, varying the targeted age range, the vaccine type for children or elderly and high-risk groups. Outcome measures include averted symptomatic infections and deaths, societal costs and quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Costs and QALYs were discounted at 4% and 1.5% annually.

RESULTS

At an assumed coverage of 50%, adding pediatric vaccination for 2- to 17-year-olds with quadrivalent live-attenuated vaccine to the current vaccination program for elderly and medical high-groups with quadrivalent inactivated vaccine was estimated to avert, on average, 401 820 symptomatic cases and 72 deaths per year. Approximately half of averted symptomatic cases and 99% of averted deaths were prevented in other age groups than 2- to 17-year-olds due to herd immunity. The cumulative discounted 20-year economic impact was 35 068 QALYs gained and €1687 million saved, that is, the intervention was cost-saving. This vaccination strategy had the highest probability of being the most cost-effective strategy considered, dominating pediatric strategies targeting 2- to 6-year-olds or 2- to 12-year-olds or strategies with trivalent inactivated vaccine.

CONCLUSION

Modeling indicates that introducing pediatric influenza vaccination in The Netherlands is cost-saving, reducing the influenza-related disease burden substantially.

Randomised placebo-controlled multicentre effectiveness trial of adjunct betamethasone therapy in hospitalised children with community-acquired pneumonia: a trial protocol for the KIDS-STEP trial

INTRODUCTION

Community-acquired pneumonia (CAP) causes around 10 hospitalisations per 1000 child-years, each associated with an average 13 non-routine days experienced and more than 4 parent workdays lost. In adults, steroid treatment shortens time to clinical stabilisation without an increase in complications in patients with CAP. However, despite promising data from observational studies, there is a lack of high-quality evidence for the use of steroids.

METHODS AND ANALYSIS

The KIDS-STEP trial is a multicentre, randomised, double-blind, placebo-controlled superiority trial of betamethasone treatment on outcome of hospitalised children with CAP. Children are enrolled in paediatric emergency departments of hospitals across Switzerland and randomised to adjunct oral betamethasone for 2 days or matching placebo in addition to standard of care treatment. The co-primary outcomes are the proportion of children clinically stable 48 hours after randomisation and the proportion of children with CAP-related readmission within 28 days after randomisation. Secondary outcomes include length of hospital stay, time away from routine childcare and healthcare utilisation and total antibiotic prescriptions within 28 days from randomisation.Each of the co-primary outcomes will be analysed separately. We will test clinical stability rates using a proportion test; to test non-inferiority in readmission rates, we will construct 1-α % CI of the estimated difference and test if it contains the pre-defined margin of 7%. Success is conditional on both tests. A simulation-based sample size estimation determined that recruiting 700 patients will ensure a power of 80% for the study.

ETHICS AND DISSEMINATION

The trial protocol and materials were approved by ethics committees in Switzerland (lead: Ethikkommission Nordwest und Zentralschweiz) and the regulatory authority Swissmedic. Participants and caregivers provide informed consent prior to study procedures commencing. The trial results will be published in peer-reviewed journals and at national and international conferences. Key messages will also be disseminated via press and social media where appropriate.

TRIAL REGISTRATION NUMBER

NCT03474991 and SNCTP000002864.

Community-Acquired Bacterial Pneumonia-Changing Epidemiology, Resistance Patterns, and Newer Antibiotics: Spotlight on Delafloxacin

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality both in the USA and globally. As the burden of CAP continues to increase due to several factors, the advances in its diagnosis, prevention, and treatment have taken on even greater interest and importance. The majority of CAP patients are treated empirically, and selection of appropriate antibiotic treatment is increasingly difficult because the epidemiology of CAP is changing, in part due to antimicrobial resistance, and the causative CAP pathogens differ between countries and regions. There is also an increasing prevalence of chronic co-morbid diseases among CAP patients. Treatment of CAP has become challenging because of these factors along with the varying safety profiles and efficacy of well-established antibiotics, as well as limited new therapeutic options. Recently, however, new antibiotics have been approved, which will expand the treatment options for CAP, particularly in those patients with underlying complications. Recently approved delafloxacin, an anionic fluoroquinolone, has a unique structure and distinct chemical characteristics; it demonstrated non-inferiority to moxifloxacin in a phase III clinical trial, but was shown to be superior to moxifloxacin at early clinical response in CAP patients who also have chronic obstructive pulmonary disease (COPD) or asthma as a co-morbidity, and in CAP patients who may have severe illness. Delafloxacin could offer an additional therapy against resistant isolates and among these difficult-to-treat patients. This review summarizes the development, latest research, and safety profile of the new antibiotic delafloxacin, and its potential future role in the treatment of CAP.

Incidence of community-acquired pneumonia in urban China: A national population-based study

BACKGROUND

Community-acquired pneumonia (CAP) is one of the major global health problems worldwide. However, the epidemiological information of CAP is limited in China. This study aimed to estimate the incidence rate of CAP and describe the epidemiologic characteristics among the Chinese population.

METHODS

We conducted a retrospective analysis of CAP incidence using the Chinese Urban Basic Medical Insurance database of 23 provinces in 2016, which covered 427.52 million urban beneficiaries of all age groups in Mainland China. CAP episodes were identified using a diagnosis-term-derived algorithm, and multiple CAP records of one single person within 90 continuous days were considered as one single episode. The incidence rates were calculated and described by sex, age, region, and season.

RESULTS

A total of 1.42 million patients were identified as having one or more CAP episodes, and finally a sum of 1.48 million CAP episodes were counted. The overall incidence of CAP was 7.13 (95% CI: 6.11-8.15) per 1000 person-years, in males 7.32 (95% CI: 6.28-8.35) and females 6.93 (95% CI: 5.92-7.94) per 1000 person-years, respectively. The incidence varied by age with a U-shaped curve peaking in children aged < 5 years old [65.80 (95% CI: 62.52-69.08)] and elderly population aged ≥ 80 years old [14.98 (95% CI: 13.63-16.34)]. The incidence varied markedly by regions. Furthermore, the rate showed a clear seasonal trend, which peaked in spring, decreased in summer and autumn, and re-ascended in winter.

CONCLUSION

This study reveals a relatively high level of CAP incidence in China. These findings provide baseline data for establishing effective prevention strategies, targeted at susceptible populations, regions, and seasons in China.

Cost Study of a Cluster Randomized Trial on a Clinical Decision Rule Guiding Antibiotic Treatment in Children With Suspected Lower Respiratory Tract Infections in the Emergency Department

BACKGROUND

Children with fever and respiratory symptoms represent a large patient group at the emergency department (ED). A decision rule-based treatment strategy improved targeting of antibiotics in these children in a recent clinical trial. This study aims to evaluate the impact of the decision rule on healthcare and societal costs, and to describe costs of children with suspected lower respiratory tract infections (RTIs) in the ED in general.

METHODS

In a stepped-wedge, cluster randomized trial, we collected cost data of children 1 month to 5 years of age with fever and cough/dyspnea in 8 EDs in The Netherlands (2016-2018). We calculated medical costs and societal costs per patient, during usual care (n = 597), and when antibiotic prescription was guided by the decision rule (n = 402). We calculated cost-of-illness of this patient group and estimated their annual costs at national level.

RESULTS

The cost-of-illness of children under 5 years with suspected lower RTIs in the ED was on average &OV0556;2130 per patient. At population level this is &OV0556;15 million per year in The Netherlands (&OV0556;1.7 million/100,000 children under 5). Mean costs per patient in usual care (&OV0556;2300) were reduced to &OV0556;1870 in the intervention phase (P = 0.01). Main cost drivers were hospitalization and lost parental workdays.

CONCLUSIONS

Implementation of a decision rule-based treatment strategy in children with suspected lower RTI was cost-saving, due to a reduction in hospitalization and parental absenteeism. Given the high frequency of this disease in children, the decision rule has the potential to result in a considerable cost reduction at population level.

Incidence and costs of hospitalized adult influenza patients in The Netherlands: a retrospective observational study

OBJECTIVE

Influenza virus infections cause a high disease and economic burden during seasonal epidemics. However, there is still a need for reliable disease burden estimates to provide a more detailed picture of the impact of influenza. Therefore, the objectives of this study is to estimate the incidence of hospitalisation for influenza virus infection and associated hospitalisation costs in adult patients in the Netherlands during two consecutive influenza seasons.

METHODS

We conducted a retrospective study in adult patients with a laboratory confirmed influenza virus infection in three Dutch hospitals during respiratory seasons 2014-2015 and 2015-2016. Incidence was calculated as the weekly number of hospitalised influenza patients divided by the total population in the catchment populations of the three hospitals. Arithmetic mean hospitalisation costs per patient were estimated and included costs for emergency department consultation, diagnostics, general ward and/or intensive care unit admission, isolation, antibiotic and/or antiviral treatment. These hospitalisation costs were extrapolated to national level and expressed in 2017 euros.

RESULTS

The study population consisted of 380 hospitalised adult influenza patients. The seasonal cumulative incidence was 3.5 cases per 10,000 persons in respiratory season 2014-2015, compared to 1.8 cases per 10,000 persons in 2015-2016. The arithmetic mean hospitalisation cost per influenza patient was €6128 (95% CI €4934-€7737) per patient in 2014-2015 and €8280 (95% CI €6254-€10,665) in 2015-2016, potentially reaching total hospitalisation costs of €28 million in 2014-2015 and €20 million in 2015-2016.

CONCLUSIONS

Influenza virus infections lead to 1.8-3.5 hospitalised patients per 10,000 persons, with mean hospitalisation costs of €6100-€8300 per adult patient, resulting in 20-28 million euros annually in The Netherlands. The highest arithmetic mean hospitalisation costs per patient were found in the 45-64 year age group. These influenza burden estimates could be used for future influenza cost-effectiveness and impact studies.

Estimating the Impact of Switching from a Lower to Higher Valent Pneumococcal Conjugate Vaccine in Colombia, Finland, and The Netherlands: A Cost-Effectiveness Analysis

INTRODUCTION

Widespread use of ten-valent (Synflorix™, GSK) or 13-valent (Prevenar 13™; Pfizer) conjugate vaccination programs has effectively reduced invasive pneumococcal disease (IPD) globally. However, IPD caused by serotypes not contained within the respective vaccines continues to increase, notably serotypes 3, 6A, and 19A in countries using lower-valent vaccines. Our objective was to estimate the clinical and economic benefit of replacing PCV10 with PCV13 in Colombia, Finland, and The Netherlands.

METHODS

Country-specific databases, supplemented with published and unpublished data, informed the historical incidence of pneumococcal disease as well as direct and indirect medical costs. A decision-analytic forecasting model was applied, and both costs and outcomes were discounted. The observed invasive pneumococcal disease (IPD) trends from each country were used to forecast the future number of IPD cases given a PCV13 or PCV10 program.

RESULTS

Over a 5-year time horizon, a switch to a PCV13 program was estimated to reduce overall IPD among 0-2 year olds by an incremental - 37.6% in Colombia, - 32.9% in Finland, and - 26% in The Netherlands, respectively, over PCV10. Adults > 65 years experienced a comparable incremental decrease in overall IPD in Colombia (- 32.2%), Finland (- 15%), and The Netherlands (- 3.7%). Serotypes 3, 6A, and 19A drove the incremental decrease in disease for PCV13 over PCV10 in both age groups. A PCV13 program was dominant in Colombia and Finland and cost-effective in The Netherlands at 1 × GDP per capita (€34,054/QALY).

CONCLUSION

In Colombia, Finland, and The Netherlands, countries with diverse epidemiologic and population distributions, switching from a PCV10 to PCV13 program would significantly reduce the burden of IPD in all three countries in as few as 5 years.

Burden of Community-Acquired Pneumonia and Unmet Clinical Needs

Community-acquired pneumonia (CAP) is the leading cause of death among infectious diseases and an important health problem, having considerable implications for healthcare systems worldwide. Despite important advances in prevention through vaccines, new rapid diagnostic tests and antibiotics, CAP management still has significant drawbacks. Mortality remains very high in severely ill patients presenting with respiratory failure or shock but is also high in the elderly. Even after a CAP episode, higher risk of death remains during a long period, a risk mainly driven by inflammation and patient-related co-morbidities. CAP microbiology has been altered by new molecular diagnostic tests that have turned viruses into the most identified pathogens, notwithstanding uncertainties about the specific role of each virus in CAP pathogenesis. Pneumococcal vaccines also impacted CAP etiology and thus had changed Streptococcus pneumoniae circulating serotypes. Pathogens from specific regions should also be kept in mind when treating CAP. New antibiotics for CAP treatment were not tested in severely ill patients and focused on multidrug-resistant pathogens that are unrelated to CAP, limiting their general use and indications for intensive care unit (ICU) patients. Similarly, CAP management could be personalized through the use of adjunctive therapies that showed outcome improvements in particular patient groups. Although pneumococcal vaccination was only convincingly shown to reduce invasive pneumococcal disease, with a less significant effect in pneumococcal CAP, it remains the best therapeutic intervention to prevent bacterial CAP. Further research in CAP is needed to reduce its population impact and improve individual outcomes.

Community-acquired pneumonia in critically ill very old patients: a growing problem

Very old (aged ≥80 years) adults constitute an increasing proportion of the global population. Currently, this subgroup of patients represents an important percentage of patients admitted to the intensive care unit. Community-acquired pneumonia (CAP) frequently affects very old adults. However, there are no specific recommendations for the management of critically ill very old CAP patients. Multiple morbidities, polypharmacy, immunosenescence and frailty contribute to an increased risk of pneumonia in this population. CAP in critically ill very old patients is associated with higher short- and long-term mortality; however, because of its uncommon presentation, diagnosis can be very difficult. Management of critically ill very old CAP patients should be guided by their baseline characteristics, clinical presentation and risk factors for multidrug-resistant pathogens. Hospitalisation in intermediate care may be a good option for critical ill very old CAP patients who do not require invasive procedures and for whom intensive care is questionable in terms of benefit.

There is currently no international recommendation for the management of critically ill older patients over 80 years of age with CAP. We report and discuss recent literature in order to help physicians in the decision-making process of these patients.http://bit.ly/2ql0mIz

Factors associated with in-hospital mortality from community-acquired pneumonia in Portugal: 2000-2014

Background

Community-acquired pneumonia (CAP) is one of the leading causes of morbidity and mortality worldwide, often leading to hospital admissions. In Portugal, the factors associated with in-hospital mortality due to CAP are not fully documented. The aim of this study was to characterize the trends of CAP hospitalization in all age groups and the factors associated with their mortality between 2000 and 2014.

Methods

We conducted a cross-sectional study using CAP hospitalization data in all age groups, in Portugal Mainland. Logistic regression was used to identify the factors associated with in-hospital mortality.

Results

Between 2001 and 2011, CAP hospitalization rate increased from 2.8 to 4.3 per 1000 population. Hospitalization rates were higher in the extreme ages ( ≤ 4 and  ≥ 75 years). However, a decrease in the hospitalization rate and its mortality was observed, in the younger ages.

A total of 548,699 hospitalization CAP episodes, between 2000 and 2014, were analyzed, with male (56.2%) and elderly ≥65 years (91.7%) predominance, resulting in 101,740 deaths (18.5%). Men had a significantly lower mean age (64.3 ± 26.4 years versus 67.9 ± 27.5 years; p < 0.001). During the studied 15 years, there was an increase of 45.2% in the number of annual hospitalizations, concomitant with the admission increase of individuals aged over 75 years. Since 2012 a decrease in hospitalizations and associated deaths were detected.

The increase in age represented a progressive and significant rise in the probability of death, except for the age group 1–4 years. The age group ≥85 years old (Adjusted OR = 124.256; 95%CI: 97.838–157.807) and males (Adjusted OR = 1.261; 95%CI: 1.243–1.280) were significantly associated with death risk for CAP hospitalization. After 2010, this risk decreased (Adjusted OR = 0.961; 95%CI: 0.940–0.982). The main factors affecting mortality were age, sex, unemployment rate, number of performed procedures and admission quinquennia.

Conclusions

Despite a trend of decrease in CAP hospitalizations and associated death since 2012, the numbers of in-hospital mortality showed, in the 15 years under analysis, an overall increase over time, mainly associated with age, in particular very old people ( ≥ 75 years), males and a higher parish unemployment rate. Therefore, the implementation of CAP preventive measures should be reinforced in these vulnerable groups.

A Phase 3 Study to Compare Delafloxacin With Moxifloxacin for the Treatment of Adults With Community-Acquired Bacterial Pneumonia (DEFINE-CABP)

BACKGROUND

The clinical and economic burden of community-acquired bacterial pneumonia (CABP) is significant and is anticipated to increase as the population ages and pathogens become more resistant. Delafloxacin is a fluoroquinolone antibiotic approved in the United States for the treatment of adults with acute bacterial skin and skin structure infections. Delafloxacin's shape and charge profile uniquely impact its spectrum of activity and side effect profile. This phase 3 study compared the efficacy and safety of delafloxacin with moxifloxacin for the treatment of CABP.

METHODS

A randomized, double-blind, comparator-controlled, multicenter, global phase 3 study compared the efficacy and safety of delafloxacin 300 mg twice daily or moxifloxacin 400 mg once daily in adults with CABP. The primary end point was early clinical response (ECR), defined as improvement at 96 (±24) hours after the first dose of study drug. Clinical response at test of cure (TOC) and microbiologic response were also assessed.

RESULTS

In the intent-to-treat analysis population (ITT), ECR rates were 88.9% in the delafloxacin group and 89.0% in the moxifloxacin group. Noninferiority of delafloxacin compared with moxifloxacin was demonstrated. At TOC in the ITT population, the success rates were similar between groups. Treatment-emergent adverse events that were considered at least possibly related to the study drug occurred in 65 subjects (15.2%) in the delafloxacin group and 54 (12.6%) in the moxifloxacin group.

CONCLUSIONS

Intravenous/oral delafloxacin monotherapy is effective and well tolerated in the treatment of adults with CABP, providing coverage for Gram-positive, Gram-negative, and atypical pathogens.

CLINICALTRIALSGOV IDENTIFIER

NCT03534622.

Economic evaluation of community acquired pneumonia management strategies: A systematic review of literature

Background

Community-acquired pneumonia (CAP) is a major cause of mortality and morbidity worldwide. Efficient use of resources is fundamental for best use of money among the available and novel treatment options for the management of pneumonia. The objective of this study was to systematically review the economic analysis of management strategies of pneumonia.

Methods

A systematic search was performed using Academic Search Complete, MEDLINE, EconLit, Global health, MEDLINE complete and Embase databases using specific subject headings or key words in May 2018 without restricting publication year. All search results were recorded and any type of economic evaluation for management of CAP was included for detailed review. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used for quality appraisal.

Results

Nineteen studies met the inclusion criteria; ten studies were trial based, five conducted analysis using model based techniques and the rest of the studies were either based on observational, record review or pre-post intervention studies. Most of the studies conducted cost-effectiveness analysis (n = 15) and compared different combinations of antimicrobials. Most were based on developed countries (n = 17), considered adult age groups (n = 16) and used a provider perspective (n = 14). Nine studies reported dominant alternatives (lower cost with higher benefit). Sensitivity analysis was performed by the majority of studies (n = 15). Fourteen studies were assessed as either being excellent, very good or good quality, with no relationship found between publication year and study quality. Methodological variation, type of microbial used, perspective, costs and outcome measures limit the compatibility among the results of the included studies.

Conclusion

Economic evaluation of interventions for management of CAP to date supports cost-effectiveness of studied interventions. However, evidence relates largely to antimicrobials choice in older populations in developed countries. Parallel economic evaluation of different management strategies of CAP is recommended for both developed and developing countries to support rigorous and robust comparative economic analysis within health care systems.

PROSPERO registration no: CRD42018097174

Monitoring of community-acquired pneumonia hospitalisations before the introduction of pneumococcal conjugate vaccine into Polish National Immunisation Programme (2009-2016): A nationwide retrospective database analysis

PURPOSE

Community-acquired pneumonia (CAP) is a common infection with significant morbidity and mortality. In January 2017, Poland introduced pneumococcal conjugate vaccine (PCV) into their national immunisation programme to protect children against invasive pneumococcal disease. This study was designed to investigate pneumonia-related hospitalisation rates and trends from 2009 to 2016 prior to the introduction of nationally funded PCV vaccination.

METHODS

Using national public statistic data available from the National Institute of Public Health - National Institute of Hygiene, annual hospitalisation rates for pneumonia were analysed, categorised by aetiology and age (<2, 2-3, 4-5, 6-19, 20-59, 60+ years). Trends over time were assessed, as well as in-hospital mortality.

RESULTS

The overall hospitalisation rate due to pneumonia varied between 325.9 and 372.2/100,000 population. Higher rates of hospitalisation were seen in older adults and children ≤5 years. Trends were observed when analysing hospitalisations by pneumonia aetiology within age groups: between 2009 and 2016, Streptococcus pneumoniae hospitalisations significantly increased for children aged <2, 2-3, and 4-5 years, from 5.3 to 12.4, 5.2 to 8.2, and 1.9 to 4.6/100,000 population respectively. Whereas hospitalisations due to Haemophilus influenzae pneumonia decreased significantly from 7.8 to 1.8 and 4.8 to 1.9/100,000 children aged <2 and 2-3 years respectively. The numbers of in-hospital deaths increased from 5578 in 2009 to 8149 in 2016, with >85% of deaths in the 60+ age group.

CONCLUSIONS

This is the first national study of pneumonia hospitalisations in Poland, providing the baseline data from which to investigate the impact of the change in vaccination policy on pneumonia hospitalisations in Poland.

Mortality and costs of pneumococcal pneumonia in adults: a cross-sectional study

Objective

Pneumococcal pneumonia is a significant cause of morbidity and mortality among adults. The study’s main aim was to evaluate the in-hospital mortality and related costs of community-acquired pneumococcal pneumonia in adults.

Methods

This cross-sectional study used medical records of adult patients with pneumococcal pneumonia hospitalized in a university hospital in Brazil from October 2009 to April 2017. All patients aged ≥ 18 years diagnosed with pneumococcal pneumonia were included. Risk factors, intensive care unit admission, length of hospital stay, in-hospital mortality, and direct and indirect costs were analyzed.

Results

In total, 186 patients were selected. The mean in-hospital mortality rate was 18% for adults aged < 65 years and 23% for the elderly (≥ 65 years). Bacteremic pneumococcal pneumonia affected 20% of patients in both groups, mainly through chronic respiratory disease (adjusted OR: 3.07, 95% CI: 1.23–7.65, p < 0.01). Over 7 years, annual total direct and indirect costs were USD 28,188 for adults < 65 years (USD 1,746 per capita) and USD 16,350 for the elderly (USD 2,119 per capita).

Conclusion

Pneumococcal pneumonia remains an important cause of morbidity and mortality among adults, significantly affecting direct and indirect costs. These results suggest the need for prevention strategies for all adults, especially for patients with chronic respiratory diseases.

Hospital and economic burden of influenza-like illness and lower respiratory tract infection in adults ≥50 years-old

BACKGROUND

Influenza-like illnesses (ILIs) and lower respiratory tract infections (LRTIs) cause substantial morbidity and mortality worldwide. The study assessed the health and economic burden of ILI and LRTI according to age and comorbidities, since available evidence is limited and heterogeneous.

METHOD

The prevalence of comorbidities, the seasonal incidence rates and the mean and per capita direct costs of ED accesses for ILI/LRTI, whether followed by hospitalization or not, recorded in adults aged ≥50 years over the last 6 years, in the referral hospitals located in the Genoese metropolitan area (Liguria, Italy) where the syndromic surveillance system is active, were evaluated through a retrospective observational study. Comorbidities were estimated through the Chronic Condition Data Warehouse that integrates multiple Medicare data sources. A comparison with the administrative healthcare International Classification of Diseases-9th revision-Clinical Modification (ICD-9-CM)-based data was also conducted.

RESULTS

The prevalence of subjects with ≥1 comorbidity ranged from 23.49 to 59.92%. The most prevalent all-age comorbidities were cardiovascular diseases and cancer. The overall ILI/LRTI incidence rate was 6.73/1000 person-years, almost double the value derived from routine data, and increased with age. The highest rates were observed in patients with renal failure and bronchopneumopathies. The mean cost of ED accesses/hospitalization for ILI/LRTI was €3353 and was almost twice as high in the ≥85 years as in the youngest age-group. The highest mean costs were observed in patients with renal failure and cancer. The per capita costs increased from €4 to €71 with age, and were highest in patients with renal failure and bronchopneumopathy.

CONCLUSION

The burden of ILIs/LRTIs in terms of ED accesses and hospitalizations in adults aged ≥50 years is heavy, and is related to increasing age and, especially, to specific comorbidities. These results could contribute to revising age- and risk-based anti-influenza and -pneumococcus immunization strategies.

Vaccines to Prevent Pneumococcal Community-Acquired Pneumonia

Streptococcus pneumoniae is the most frequent pathogen in community-acquired pneumonia and also causes invasive diseases like bacteremia and meningitis. Young children and elderly are especially at risk for pneumococcal diseases and are, therefore, eligible for pneumococcal vaccination in most countries. This reviews provides an overview of the current epidemiology of pneumococcal infections, history and evidence of available pneumococcal polysaccharide and conjugate vaccines, and current recommendations.

Systemic interleukins levels in community-acquired pneumonia and their association with adverse outcomes

Introduction: Community-acquired pneumonia (CAP) is still one of the major causes of morbidity and mortality worldwide. Pro-inflammatory and anti-inflammatory interleukins have been studied to elucidate the role that inflammation plays in its pathogenesis. The aim of this study is to investigate inflammation in CAP, by analyzing in dynamic, serum levels of six interleukins (IL) and their predictive value regarding adverse outcomes.

Materials and methods: Forty adult patients with CAP, admitted in the Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania from December 2015 to February 2017, were enrolled in this study. Serum levels of pro-inflammatory: IL1β, TNF-α, IL-6, anti-inflammatory: IL-10 and IL-4, along with IL-17A were analyzed in dynamic, on day 1 and day 4.The receiver – operator curves (ROC) were used to analyze the outcome prediction of IL.

Results: Serum levels of IL-1β, IL-6, TNF-α and IL-10 have decreased significantly in dynamic, while IL-4 increases. IL-17A has acted like a pro-inflammatory cytokine. We have found a correlation between IL-6 and IL-10 (r=0.429, p=0.000), IL-6 and IL-17A (r=0.295, p=0.008) and IL-10 and IL-17A (r=0.475, p=0.000). Out of 40 patients, 9 had adverse outcomes, consisting in 9 relapses from which 1 died. IL-6 discriminates alone between adverse and favorable outcomes. With multivariate analysis and multiple regression of all combined IL, we have found that there is a predictive model regarding adverse outcomes.

Conclusion: IL-10 and IL-17A behave like pro-inflammatory cytokines. IL-6 is a predictive marker for adverse outcomes alone. All IL studied together have an impact on adverse outcomes.

Investing in antibiotics to alleviate future catastrophic outcomes: What is the value of having an effective antibiotic to mitigate pandemic influenza?

Over 95% of post-mortem samples from the 1918 pandemic, which caused 50 to 100 million deaths, showed bacterial infection complications. The introduction of antibiotics in the 1940s has since reduced the risk of bacterial infections, but growing resistance to antibiotics could increase the toll from future influenza pandemics if secondary bacterial infections are as serious as in 1918, or even if they are less severe. We develop a valuation model of the option to withhold wide use of an antibiotic until significant outbreaks such as pandemic influenza or foodborne diseases are identified. Using real options theory, we derive conditions under which withholding wide use is beneficial, and calculate the option value for influenza pandemic scenarios that lead to secondary infections with a resistant Staphylococcus aureus strain. We find that the value of withholding an effective novel oral antibiotic can be positive and significant unless the pandemic is mild and causes few secondary infections with the resistant strain or if most patients can be treated intravenously. Although the option value is sensitive to parameter uncertainty, our results suggest that further analysis on a case-by-case basis could guide investment in novel agents as well as strategies on how to use them.

Effects of the bass brushing method on dental plaque and pneumonia in older adults hospitalized with pneumonia after discharge: A randomized controlled trial

AIM

The purpose of this pilot study was to evaluate the effects of the Bass brushing method on dental plaque and pneumonia in older adults hospitalized with pneumonia after discharge.

BACKGROUND

Poor oral hygiene may lead to pneumonia. Complications of pneumonia in older adults can be life-threatening during hospitalization and after discharge.

METHODS

Older adults hospitalized with pneumonia (n = 30) were randomly assigned to intervention (with the Bass brushing method; n = 15) or control (with usual care; n = 15) groups. Dental plaque index and pneumonia as detected on chest x-rays were evaluated prior to the intervention (baseline) and every month for six months after discharge.

RESULTS

Participants in the intervention group experienced a sustained reduction in dental plaque from the fourth to the sixth months (p = .024; p = .025; p = .000, respectively) that was not found in the control group. There were no group differences in detected pneumonia throughout the follow-up period. Pneumonia as detected on the chest x-rays at baseline (p = .001) and dental plaque index (p = .021) were significant predictors of the risk of pneumonia across groups.

CONCLUSIONS

The Bass brushing method is a simple and effective oral hygiene practice that reduces dental plaque in older adults hospitalized with pneumonia after discharge.

Population-based estimates of the burden of pneumonia hospitalizations in Hong Kong, 2011-2015

Up-to-date data on the burden of disease are important to identify patients with unmet needs and to optimize healthcare resources. We aimed to characterize the burden of pneumonia hospitalizations in Hong Kong and inform targeted healthcare policies for pneumonia control in the era of global aging. This was a population-based study using a territory-wide administrative electronic health record system that covers all public hospitals of Hong Kong. Patients admitted to public hospitals, from 2011 to 2015, with a diagnosis of pneumonia at discharge were identified based on the International Classification of Diseases-Ninth Revision-Clinical Modification Codes (480-486 and 487.0). Incidence, inpatient case-fatality, all-cause fatality, 28-day readmission, hospital length of stay, and healthcare costs were assessed for seven age strata. We identified 323,992 patients (median age 80 years, 44.4% female) with hospitalized pneumonia (organism unspecified 84.2%; bacterial pneumonia 12.3%; viral pneumonia 2.5%; others 1.0%). Annual incidence was 955.1 per 100,000 population, with a 10.6% decrease from 2011 to 2015. Case-fatality, all-cause fatality, and 28-days readmission risks were 13.8, 21.6, and 19.5%, respectively. The average hospital length of stay was 14.1 days with corresponding direct costs of $9348 USD per episode in the monetary value of 2015. Individuals aged ≥ 65 years accounted for over 75% of pneumonia-related hospitalizations, 90% of deaths, and the majority of healthcare costs. Hospitalized pneumonia represents a considerable health and economic burden in Hong Kong, especially in older adults. The study provides a population-level baseline estimate for further cost-effective evaluation of targeted strategies for pneumonia control.

Radiologic Diagnosis and Hospitalization among Children with Severe Community Acquired Pneumonia: A Prospective Cohort Study

Objectives

This study was designed to assess the role of chest radiography for the diagnosis of pneumonia and assess the association of clinical characteristics with radiologic findings and predictors of hospitalization among children with severe community acquired pneumonia.

Methods

A prospective study was conducted on 122 children between ages of 3 month and 14 years admitted to pediatric emergency unit with diagnosis of severe pneumonia from September 1^st to November 30^th, 2017. Eligible children were subjected to chest radiography which was read by two senior radiologists independently (R1 and R2). Disagreements between R1 and R2 were resolved by a third senior radiologist (R3). Level of agreement between radiologists was assessed using Cohen's kappa coefficient. Clinical and laboratory parameters which could explain the variability in the duration of hospital stay were assessed using a linear regression mode. Independent predictors were assessed using multiple linear regression.

Results

The median age of the cohort was 10.0 months (interquartile range (IQR): 6.75-24.0); 76 (62.3%) were male. Nearly half, 63 (51.6%) did not have radiologic evidence of pneumonia. There was low level of agreement between R1 and R2 in reporting consolidation (kappa=0.435, p-value≤0.001), haziness (kappa=0.375, p-value≤0.001), and infiltration (kappa=0.267, p-value=0.008). Children with higher recorded temperature were more likely to have radiologic abnormalities suggesting pneumonia (p-value=0.033). The median duration of hospitalization was 3 days (IQR: 1-4 days); 118 (96.7%) were discharged with improvement. Height-for-age z-score (Coef.=0.203, R²=0.041, p-value=0.027); and hemoglobin level (Coef.=-0.249, R²=0.062, p-value=0.006) explained 4.1% and 6.2% of the variability in the duration of hospital stay, respectively.

Conclusion

Radiologic evidence of pneumonia was absent in half of the children with severe pneumonia. There was low agreement between senior radiologists in reporting chest radiographic findings, potentially necessitating harmonization activities to uniformly implement the WHO guidelines in reading chest radiographs.

Pneumonia

Pneumonia remains the main cause of morbidity and mortality from infectious diseases in the world. The important reason for the increased global mortality is the impact of pneumonia on chronic diseases especially in the elderly population and the virulence factors of the causative microorganisms. Because elderly individuals present with comorbidities, particular attention should be paid for multidrug-resistant pathogens. Streptococcus pneumoniae remains the most frequently encountered pathogen. Enteric gram-negative rods, as well as anaerobes, should be considered in patients with aspiration pneumonia. Interventions for modifiable risk factors will reduce the risk of this infection. The adequacy of the initial antimicrobial therapy and determination of patients’ follow-up place is a key factor for prognosis. Also, vaccination is one of the most important preventive measures. In this section it was focused on several aspects, including the atypical presentation of pneumonia in the elderly, the methods to evaluate the severity of illness, the appropriate take care place and the management with prevention strategies.

The burden of community-acquired bacterial pneumonia in the era of antibiotic resistance

INTRODUCTION

Community-acquired pneumonia (CAP) is a significant global health problem and leading cause of death and hospitalization in both the US and abroad. Increasing macrolide resistance among Streptococcus pneumoniae and other pathogens results in a greater disease burden, along with changing demographics and a higher preponderance of comorbid conditions. Areas covered: This review summarizes current data on the clinical and economic burden of CAP, with particular focus on community-acquired bacterial pneumonia (CABP). Incidence, morbidity and mortality, and healthcare costs for the US and other regions of the world are among the topics covered. Major factors that are believed to be contributing to the increased impact of CABP, including antimicrobial resistance, the aging population, and the incidence of comorbidities are discussed, as well as unmet needs in current CABP management. Expert commentary: The clinical and economic burden of CABP is staggering, far-reaching, and expected to increase in the future as new antibiotic resistance mechanisms emerge and the world's population ages. Important measures must be initiated to stabilize and potentially decrease this burden. Urgent needs in CABP management include the development of new antimicrobials, adjuvant therapies, and rapid diagnostics.

Hospitalization Rate and Population-based Incidence of Hospitalization for Community-acquired Pneumonia Among Children in Suzhou, China

BACKGROUND

Data on hospitalization burden of community-acquired pneumonia (CAP) in children are very limited in China. This study aimed to estimate the hospitalization rate (HR) and population-based incidence of hospitalization of CAP for children <15 years of age in Suzhou, China.

METHODS

This was a retrospective study of children hospitalized in Soochow University Affiliated Children's Hospital from January 2010 to December 2014. Children who were residents of downtown Suzhou, 29 days to <15 years of age, with discharge diagnosis codes (International Classification of Diseases, 10th revision) including J09-J18 and J20-J22 were included. All-cause clinical community-acquired pneumonia (CCAP) and radiographically confirmed pneumonia (RCAP) were identified based on individual medical chart review. The HR and population-based cumulative incidence of hospitalization (HI) were calculated.

RESULTS

Among 184,734 children <15 years of age admitted to Soochow University Affiliated Children's Hospital during the study period, 31,302 children were identified as having CCAP and 24,218 (77.4%) children confirmed as having RCAP. CCAP hospitalization occurred year round and peaked during winter and early spring. The overall HRs for CCAP and RCAP were 189.0 [95% confidence interval (CI): 187.1-190.9] and 146.2 (95% CI: 144-148) per 1000 hospitalizations, respectively, and the HIs per 100,000 children annually were CCAP, 3235.8 (95% CI: 3207.3-3264.2) and RCAP, 2503.5 (95% CI: 2478.3-2528.6). For children <5 years of age, the HR for CCAP was 248.4 (95% CI: 245.9-250.9) and RCAP was 194.0 (95% CI: 191.4-196.3) per 1000 hospitalizations; the HI for CCAP was 6956.2 (95% CI: 6892.8-7019.6) and 5431.9 (95% CI: 5375.4-5488.4) per 100,000 children for RCAP. The highest HR and HI were observed in children 29 days to <6 months of age: HR for CCAP was 407.4 (95% CI: 400.9-413.9) per 1000 hospitalizations and HI for CCAP was 11,203.7 (95% CI: 11,026.8-11,380.6) per 100,000 children annually.

CONCLUSIONS

There is a considerable burden of CAP among children <15 years of age in Suzhou, particularly among children 29 days to <6 months of age and during winter and early spring. These data provide valuable information to monitor CAP trends over time in children of Suzhou, China.

Cardiovascular risk profile in individuals initiating treatment for overactive bladder - Challenges and learnings for comparative analysis using linked claims and electronic medical record databases

For managing overactive bladder (OAB), mirabegron, a β3 adrenergic receptor agonist, is typically used as second-line pharmacotherapy after antimuscarinics. Therefore, patients initiating treatment with mirabegron and antimuscarinics may differ, potentially impacting associated clinical outcomes. When using observational data to evaluate real-world safety and effectiveness of OAB treatments, residual bias due to unmeasured confounding and/or confounding by indication are important considerations. Falsification analysis, in which clinically irrelevant endpoints are tested as a reference, can be used to assess residual bias. The objective in this study was to compare baseline cardiovascular risk among OAB patients by treatment, and assess the presence of residual bias via falsification analysis of OAB patients treated with mirabegron or antimuscarinics, to determine whether clinically relevant comparisons across groups would be feasible. Linked electronic health record and claims data (Optum/Humedica) for OAB patients in the United States from 2011-2015 were available, with index defined as first date of OAB treatment during this period. Unadjusted characteristics were compared across groups at index and propensity-matching conducted. Falsification endpoints (hepatitis C, shingles, community-acquired pneumonia) were compared between groups using odds ratios (ORs) and 95% confidence intervals (CI). The study identified 10,311 antimuscarinic- and 408 mirabegron-treated patients. Mirabegron patients were predominantly older males, with more comorbidities. The analytic sample included 1,188 antimuscarinic patients propensity-matched to 396 mirabegron patients; after matching, no significant baseline differences remained. Estimates of falsification ORs were 0.7 (CI:0.3-1.7) for shingles, 1.5 (CI:0.3-8.2) for hepatitis C, 0.8 (CI:0.4-1.8) and 0.9 (CI:0.6-1.4) for pneumonia. While propensity matching successfully balanced observed covariates, wide CIs prevented definitive conclusions regarding residual bias. Accordingly, further observational comparisons by treatment group were not pursued. In real-world analysis, bias-detection methods could not confirm that differences in cardiovascular risk in patients receiving mirabegron versus antimuscarinics were fully adjusted for, precluding clinically relevant comparisons across treatment groups.

Characteristics and Management of Community-Acquired Pneumonia in the Era of Global Aging

Community-acquired pneumonia (CAP) can occur at any time of life, but its incidence and risk of death are linked to increasing age. CAP in the elderly is a major health problem associated with high rates of readmission, morbidity, and mortality. Since the clinical presentation of pneumonia in the elderly may be atypical, clinicians should suspect pneumonia in older patients presenting symptoms such as falls and altered mental status, fatigue, lethargy, delirium, anorexia, in order to avoid the complications associated with delayed diagnosis and therapy. Streptococcus pneumoniae remains the most frequently reported pathogen in this population. However, particular attention should be paid to patients with risk factors for multidrug resistant pathogens, because a large proportion of elderly persons present multimorbidity. Vaccination is one of the most important preventive approaches for CAP in the elderly. In addition, lifestyle-tailored interventions for different modifiable risk factors will help to reduce the risk of pneumonia in elderly persons. Surveillance of etiological pathogens may improve vaccination policies in this population.