Community acquired pneumonia in adults: a study comparing clinical features and outcome in Africa (Republic of Guinea) and Europe (France)

Variation in clinical outcomes and process of care measures in community acquired pneumonia: a systematic review

Background

Variation in outcomes of patients with community acquired pneumonia (CAP) has been reported in some, but not all, studies. Although some variation is expected, unwarranted variation in healthcare impacts patient outcomes and equity of care. The aim of this systematic review was to: i) summarise current evidence on regional and inter-hospital variation in the clinical outcomes and process of care measures of patients hospitalised with CAP and ii) assess the strength of this evidence.

Methods

Databases were systematically searched from inception to February 2018 for relevant studies and data independently extracted by two investigators in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Included studies enrolled adults hospitalised with CAP and reported a measure of variation between two or more units in healthcare outcomes or process of care measures. Outcomes of interest were mortality, length of hospital stay (LOS) and re-admission rates. A structured synthesis of the studies was performed.

Results

Twenty-two studies were included in the analysis. The median number of units compared across studies was five (IQR 4–15). Evidence for variation in mortality between units was inconsistent; of eleven studies that performed statistical significance testing, five found significant variation. For LOS, of nine relevant studies, all found statistically significant variation. Four studies reported site of admission accounted for 1–24% of the total observed variation in LOS. A shorter LOS was not associated with increased mortality or readmission rates. For readmission, evidence was mixed; of seven studies, 4 found statistically significant variation. There was consistent evidence for variation in the use of intensive care, obtaining blood cultures on admission, receiving antibiotics within 8 h of admission and duration of intravenous antibiotics. Across all outcome measures, only one study accounted for natural variation between units in their analysis.

Conclusion

There is consistent evidence of moderate quality for significant variation in length of stay and process of care measures but not for in-patient mortality or hospital re-admission. Evidence linking variation in outcomes with variation in process of care measures was limited; where present no difference in mortality was detected despite POC variation. Adjustment for natural variation within studies was lacking; the proportion of observed variation due to chance is not quantified by existing evidence.

A Comparative Cost Analysis of Antibiotic Treatment for Community Acquired Pneumonia (CAP) in Adult Inpatients at Piggs Peak Government Hospital in Swaziland

Background: Of the different types of pneumonia, community acquired pneumonia (CAP), has been identified as the leading cause of infectious morbidity and mortality in the western and developing countries. To eradicate the bacterial cause of CAP, medical doctors) often tend to prescribe a differing cocktail of medicine which may be costly for the health care system.

Aim: To analyze the cost of oral and/or intravenous antibiotic medicine use in different treatment approaches for treating CAP in adult inpatients from the health care system perspective.

Settings: This study was undertaken at Piggs Peak Government Hospital, a 220 bed tertiary hospital located in the rural northern Hhohho region of Swaziland.

Method: Seventy-one (n = 71) medical records of adult patients, hospitalized and diagnosed with CAP at Piggs Peak Government Hospital from July 2014 to June 2015, were retrieved and entered into the database once confirmed as having met the selection criteria. Only direct antibiotic medicine(s) costs were considered. The total cost per treatment option was calculated by multipling the unit cost of the medicine by the administration frequency and the length of hospital stay. The Kruskal-Wallis test was used to compare the cost difference between more than two treatment options.

Results: Medical doctors at Piggs Peak Government Hosptial use a range of antibiotics to treat community acquire pneumonia. Furthermore, doctors prefer using dual antibiotics combination as first line treatment of CAP in adult inpatients. The cost of treating community acquire pneumonia at the hospital ranged from ZAR 70.98 to ZAR 467.60 per adult inpatient admitted into care. A statistically significant difference in the cost of the different treatment approaches used for treating CAP was noted.

Conclusion: This cost-exploratory study has highlighted a significant difference in the monetary cost of the differing approaches used for treating CAP at the hospital. It is evident therefore that the use of different treatment approaches in treating CAP significantly influences the cost of CAP treatment. There is therefore need for cost minimization measure to be put in place at the facility.

Acute care for the three leading causes of mortality in lower-middle-income countries: A systematic review

According to the World Health Organization, the three leading causes of mortality in lower-middle-income countries (LMIC) are ischemic heart disease (IHD), stroke, and lower respiratory infections (LRIs), causing 111.8, 68.8, and 51.5 annual deaths per 100,000, respectively. Due to barriers to healthcare, patients frequently present in critical stages of these diseases. Measured implementations in critical care in LMIC have been published; however, the literature has not been formally reviewed. We performed a systematic review of the literature indexed in PubMed as of October 2017. Abstracts were limited to human studies in English, French, and Spanish, conducted in LMIC, and containing quantitative data on acute care of IHD, stroke, and LRI. The search resulted in 4994 unique abstracts. Through multiple rounds of screening using criteria determined a priori, 161 manuscripts were identified: 38 for IHD, 20 for stroke, 26 for adult LRI, and 78 for pediatric LRI. These studies, predominantly from Asia, demonstrate successful diagnostic and treatment measures used in providing acute care for patients in LMIC. Given that, only four manuscripts originated in Central or South America, original research from these areas is lacking. IHD, stroke, and LRIs are significant causes of mortality, especially in LMIC. Diagnostic and therapeutic interventions for IHD (monitoring, medications, thrombolytics, percutaneous intervention, coronary artery bypass graft), stroke (therapeutic hypothermia, medications, and thrombolytics), and LRI (oxygen saturation measurement, diagnostic ultrasound, administration of oxygen, appropriate antibiotics, and other medications) have been studied in LMIC and published.

Risk factors for community-acquired pneumonia among adults in Kenya: a case-control study

BACKGROUND

Pneumonia is a leading cause of morbidity and mortality among adults worldwide; however, the risk factors for community-acquired pneumonia in Africa are not well characterized.

METHODS

The authors recruited 281 cases of community-acquired pneumonia and 1202 hospital controls among patients aged ≥15 years who attended Kilifi District Hospital/Coast Provincial General Hospital in Kenya between 1994 and 6. Cases were admissions with an acute illness with ≥2 respiratory signs and evidence of consolidation on a chest radiograph. Controls were patients without signs of pneumonia, frequency matched by age, sex and hospital. Risk factors related to socio-demographic factors, drug use, clinical history, contact patterns and exposures to indoor air pollution were investigated by questionnaire, anthropometric measurements and laboratory assays. Associations were evaluated using a hierarchical logistic regression model.

RESULTS

Pneumonia was associated with human immunodeficiency virus (HIV) infection (Odds Ratio [OR] 2.06, 95% CI 1.44-3.08), anemia (OR 1.91, 1.31-2.74), splenomegaly (OR 2.04, 95% CI 1.14-3.41), recent history of pneumonia (OR 4.65, 95% CI 1.66-12.5), history of pneumonia >2 years previously (OR 17.13, 95% CI 5.01-60.26), coryza in the 2 weeks preceding hospitalization (OR 2.09, 95% CI 1.44-3.03), current smoking (2.19, 95% CI 1.39-3.70), use of khat (OR 3.44, 95% CI 1.72-7.15), use of snuff (OR 2.67, 95% CI 1.35-5.49) and contact with several animal species. Presence of a Bacillus Calmette-Guerin (BCG) scar was associated with protection (OR 0.51, 95% CI 0.32-0.82). The risk factors varied significantly by sex.

CONCLUSION

Pneumonia in Kenyan adults was associated with global risk factors, such as HIV and smoking, but also with specific local factors like drug use and contact with animals. Intervention strategies should account for sex-specific differences in risk factors.

Pneumonia in the developing world: Characteristic features and approach to management

Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality in adults worldwide, but its epidemiology varies markedly by region. Whilst in high-income countries, the predominant burden of CAP is in the elderly and those with chronic cardiovascular and pulmonary co-morbidity, CAP patients in low-income settings are often of working age and, in sub-Saharan Africa, frequently HIV-positive. Although region-specific aetiological data are limited, they are sufficient to highlight major trends: in high-burden settings, tuberculosis (TB) is a common cause of acute CAP; Gram-negative pathogens such as Klebsiella pneumoniae are regionally important; and HIV-associated opportunistic infections are common but difficult to diagnose. These differences in epidemiology and aetiological profile suggest that modified approaches to diagnosis, severity assessment and empirical antimicrobial therapy of CAP are necessary, but tailored individualized management approaches are constrained by limitations in the availability of radiological and laboratory diagnostic services, as well as medical expertise. The widespread introduction of the Xpert MTB/RIF platform represents a major advance for TB diagnosis, but innovations in rapid diagnostics for other opportunistic pathogens are urgently needed. Severity assessment tools (e.g. CURB65) that are used to guide early management decisions in CAP have not been widely validated in low-income settings and locally adapted tools are required. The optimal approach to initial antimicrobial therapy choices such as the need to provide early empirical cover for atypical bacteria and TB remain poorly defined. Improvements in supportive care such as correcting hypoxaemia and intravenous fluid management represent opportunities for substantial reductions in mortality.

Household Air Pollution and Acute Lower Respiratory Infections in Adults: A Systematic Review

Introduction

Household air pollution from solid fuel burning kills over 4 million people every year including half a million children from acute lower respiratory infections. Although biologically plausible, it is not clear whether household air pollution is also associated with acute lower respiratory infections in adults. We systematically reviewed the literature on household air pollution and acute lower respiratory infection in adults to identify knowledge gaps and research opportunities.

Methods

Ten bibliographic databases were searched to identify studies of household air pollution and adult acute lower respiratory infection. Data were extracted from eligible studies using standardised forms.

Results

From 4617 titles, 513 abstracts and 72 full-text articles were reviewed. Eight studies met the inclusion criteria of which 2 found a significant adjusted increased risk of acute lower respiratory infection, 2 identified a univariate association whilst 4 found no significant association. Study quality was generally limited. Heterogeneity in methods and findings precluded meta-analysis.

Discussion

A systematic review of the literature found limited evidence for an association between household air pollution and risk of acute lower respiratory infection in adults. Additional research, with carefully defined exposure and outcome measures, is required to complete the risk profile caused by household air pollution in adults.

Registration number

CRD42015028042.

Study protocol: the effects of air pollution exposure and chronic respiratory disease on pneumonia risk in urban Malawian adults--the Acute Infection of the Respiratory Tract Study (The AIR Study)

Background

Pneumonia is the 2nd leading cause of years of life lost worldwide and is a common cause of adult admissions to hospital in sub-Saharan Africa. Risk factors for adult pneumonia are well characterised in developed countries, but are less well described in sub-Saharan Africa where HIV is a major contributing factor. Exposure to indoor and outdoor air pollution is high, and tobacco smoking prevalence is increasing in sub-Saharan Africa, yet the contribution of these factors to the burden of chronic respiratory diseases in sub-Saharan Africa remains poorly understood. Furthermore, the extent to which the presence of chronic respiratory diseases and exposure to air pollution contribute to the burden of pneumonia is not known.

Design

The Acute Infection of the Respiratory Tract Study (The AIR Study) is a case–control study to identify preventable risk factors for adult pneumonia in the city of Blantyre, Malawi. Cases will be adults admitted with pneumonia, recruited from Queen Elizabeth Central Hospital, the largest teaching hospital in Malawi. Controls will be adults without pneumonia, recruited from the community. The AIR Study will recruit subjects and analyse data within strata defined by positive and negative HIV infection status. All participants will undergo thorough assessment for a range of potential preventable risk factors, with an emphasis on exposure to air pollution and the presence of chronic respiratory diseases. This will include collection of questionnaire data, clinical samples (blood, urine, sputum and breath samples), lung function data and air pollution monitoring in their home. Multivariate analysis will be used to identify the important risk factors contributing to the pneumonia burden in this setting. Identification of preventable risk factors will justify research into the effectiveness of targeted interventions to address this burden in the future.

Discussion

The AIR Study is the first study of radiologically confirmed pneumonia in which air pollution exposure measurements have been undertaken in this setting, and will contribute important new information about exposure to air pollution in urban SSA. Through identification of preventable risk factors, the AIR Study aims to facilitate future research and implementation of targeted interventions to reduce the high burden of pneumonia in SSA.

Prescription of antibiotics for adults hospitalized with community-acquired pneumonia in Korea in 2004: a population-based descriptive study

BACKGROUND AND OBJECTIVE

Community-acquired pneumonia (CAP) is generally considered to be a major cause of morbidity and mortality. There is much controversy regarding the optimal choice of antibiotics for patients with CAP. The aim of this study was to identify the antibiotics prescribed for adults hospitalized with CAP in Korea during a calendar year.

METHODS

This population-based, descriptive epidemiological study was performed using data from nationwide health insurance claims from 1 January 2004 to 31 December 2004. The study population was adults (≥18 years old), who had been hospitalized with CAP as determined by discharge diagnosis, and who had been treated with antibiotics for ≥3 days. The exclusion criteria were tuberculosis, underlying malignancies and potential nosocomial pneumonia, based on the department providing care, or surgery reports during the admission.

RESULTS

Of the 5592 adults hospitalized with CAP, data for 3662 (65.5%) patients was eligible for inclusion in the analysis. This included data for 1899 (51.9%) males, and 2045 (55.8%) patients ≥65 years of age. The most frequently prescribed antimicrobial regimen was β-lactam/β-lactamase inhibitors and fluoroquinolones in combination (31.0%), followed by β-lactam/β-lactamase inhibitors plus macrolides (30.2%), monotherapy (17.0%), β-lactam/β-lactamase inhibitors plus aminoglycosides (12.9%), β-lactam/β-lactamase inhibitors plus clindamycin (4.9%), and cephalosporins plus fluoroquinolones (2.5%). Monotherapy included, in decreasing order of use, cephalosporins (6.0%), fluoroquinolones (3.5%), β-lactam/β-lactamase inhibitors (2.3%) and macrolides (2.2%).

CONCLUSIONS

In this study, patterns of antimicrobial prescription for patients hospitalized with CAP were assessed for the first time in Korea. There was divergence from the 2009 Korean guidelines for the treatment of CAP, reinforcing the need for assessment of physicians' adherence to the guidelines.

Estimating the proportion of pneumonia attributable to pneumococcus in Kenyan adults: latent class analysis

BACKGROUND

Community-acquired pneumonia is a common cause of hospitalization among African adults, and Streptococcus pneumoniae is assumed to be a frequent cause. Pneumococcal conjugate vaccine is currently being introduced into childhood immunization programs in Africa. The case for adult vaccination is dependent on the contribution of the pneumococcus to the hospital pneumonia burden.

METHODS

Pneumococcal diagnosis is complex because there is no gold standard, and culture methods are invalidated by antibiotic use. We used latent class analysis to estimate the proportion of pneumonia episodes caused by pneumococcus. Furthermore, we extended this methodology to evaluate the effect of antimicrobial treatment on test accuracies and the prevalence of the disease. The study combined data from 5 validation studies of pneumococcal diagnostic tests performed on 281 Kenyan adults with pneumonia.

RESULTS

The proportion of pneumonia episodes attributable to pneumococcus was 0.46 (95% confidence interval = 0.36-0.57). Failure to account for the effect of antimicrobial exposure underestimates this proportion as 0.32. A history of antibiotic exposure was a poor predictor of antimicrobial activity in patients' urine. Blood culture sensitivity for pneumococcus was estimated at 0.24 among patients with antibiotic exposure, and 0.75 among those without.

CONCLUSIONS

The large contribution of pneumococcus to adult pneumonia provides a strong case for the investigation of pneumococcal vaccines in African adults.

Admission profile and management of community acquired pneumonia in Nigeria--5 year experience in a tertiary hospital

BACKGROUND

Studies examining the prevalence, baseline characteristics and outcome of patients admitted with Community Acquired Pneumonia (CAP) are not readily available in Nigeria. This study aims to evaluate the management of CAP at a tertiary hospital in Nigeria with a view to determining the prevalence, characteristics, severity and outcome of the admitted patients.

METHODS

We retrospectively collected data from 160 admitted patients with final diagnosis of CAP who met the inclusion criteria. Data relating to their age, gender, clinical details, severity assessment using CURB65 score, laboratory results, initial antibiotics prescribed, and outcome (length of stay, hospital mortality) were collected. Descriptive statistics of demographic and clinical variables were calculated and presented as frequencies, percentage, means, standard deviation and range.

RESULTS

CAP accounted for 2.5% of all medical admissions during the study period. The mean age of the admitted patients was 52.9 ± 18.98 years with about 35% of the patients being at least 65 years and above. Sputum culture, Fasting blood sugar and HIV screening were requested for in 49(30.6%), 50(31.3%) 56(35%) patients respectively. None of the patients had severity score documented on admission and only 32(20%) patients had severity score of ≥ 3 when calculated. Commonly prescribed antibiotics were a combination of intravenous ceftriaxone and metronidazole. Hospital mortality rate was 11.9%

CONCLUSION

We suggest multicenter prospective studies to determine the prevalence and burden of CAP in Nigeria. There is need for an improved assessment and appropriate use of guidelines in the management of patients presenting with CAP.

Community-acquired pneumonia--implementation of a prediction rule to guide selection of patients for outpatient treatment

The aim of this study was to determine the outcomes of outpatient treatment of community-acquired pneumonia (CAP) when a prediction rule was followed by emergency physicians to guide the selection of patients. This was a prospective observational study conducted at the emergency department of a university-affiliated hospital in Hong Kong, China. A clinical prediction rule was implemented to guide the selection of patients with CAP for outpatient treatment. All subsequent hospitalizations gial presentation were recorded, and the reasons were assessed. The utilization of the observation unit was incorporated into the treatment algorithm. Of 72 patients with CAP followed up as outpatients, 60 (83.3%) were treated successfully, nine (12.5%) required subsequent hospitalization within 30 days, and three (4.2%) were lost to follow-up. None of the patients died, and none required admission to the intensive care unit. Factors associated with subsequent hospitalization include: tuberculosis, underlying malignancy, persistent fever, comorbidity (rheumatoid arthritis and severe osteoporosis), intravenous drug addiction and alcoholism. The observation ward was utilized in 10 (16.7%) patients successfully treated as outpatients. It is concluded that the prediction rule can be safely implemented as a guide for emergency physicians. The short-stay observation unit may be usefully employed for treating low-risk CAP.

Aetiology, outcome, and risk factors for mortality among adults with acute pneumonia in Kenya

BACKGROUND

Despite a substantial disease burden, there is little descriptive epidemiology of acute pneumonia in sub-Saharan Africa. We did this study to define the aetiology of acute pneumonia, to estimate mortality at convalescence, and to analyse mortality risk-factors.

METHODS

We studied 281 Kenyan adults who presented to two public hospitals (one urban and one rural) with acute radiologically confirmed pneumonia during 1994-96. We did blood and lung-aspirate cultures, mycobacterial cultures, serotype-specific pneumococcal antigen detection, and serology for viral and atypical agents.

FINDINGS

Aetiology was defined in 182 (65%) patients. Streptococcus pneumoniae was the most common causative agent, being found in 129 (46%) cases; Mycobacterium tuberculosis was found in 26 (9%). Of 255 patients followed up for at least 3 weeks, 25 (10%) died at a median age of 33 years. In multivariate analyses, risk or protective factors for mortality were age (odds ratio 1.51 per decade [95% CI 1.04-2.19]), unemployment (4.42 [1.21-16.1]), visiting a traditional healer (5.26 [1.67-16.5]), visiting a pharmacy (0.30 [0.10-0.91]), heart rate (1.64 per 10 beats [1.24-2.16]), and herpes labialis (15.4 [2.22-107]). HIV-1 seropositivity, found in 52%, was not associated with mortality. Death or failure to recover after 3 weeks was more common in patients with pneumococci of intermediate resistance to benzylpenicillin, which comprised 28% of pneumococcal isolates, than in those infected with susceptible pneumococci (5.60 [1.33-23.6]).

INTERPRETATION

We suggest that tuberculosis is a sufficiently common cause of acute pneumonia in Kenyan adults to justify routine sputum culture, and that treatment with benzylpenicillin remains appropriate for clinical failure due to M. tuberculosis, intermediate-resistant pneumococci, and other bacterial pathogens. However, interventions restricted to hospital management will fail to decrease mortality associated with socioeconomic, educational, and behavioural factors.

Causes of pleural exudates in a region with a high incidence of tuberculosis

OBJECTIVE

To define the causes of exudative pleural effusions in our region.

METHODOLOGY

A retrospective study was performed on consecutive patients with exudative pleural effusion seen in our hospital during a 4-year period.

RESULTS

Of 186 patients with a mean age (+/- SD) of 51.2 (+/- 19.2) years with exudative pleural effusions, 131 (70.4%) were males and 55 (29.6%) were females. The most frequent cause of exudative pleural effusions was tuberculosis (44.1%), followed by malignancy (29.6%). The majority (94.5%) of malignant pleural effusions were due to lung cancer. Apart from a patient with bilateral pleural effusions due to cryptococcosis, patients with tuberculous pleural effusion (mean age (+/- SD), 39.7 (+/- 17.5)) were significantly younger than the rest (P < 0.05). Tuberculous effusions were most frequent in the first five decades (60/82, 73.2%) and were the most common type of pleural effusion, accounting for 60 (69.8%) of 86 cases, in this age range. Malignant effusions were more frequent among the older age groups, 74.5% (41/55) of patients with malignant effusions being older than 50 years. Most types of pleural effusions showed a preference for the right side. Of the 44 cases of large effusions, 28 (63.6%) were caused by malignancy.

CONCLUSIONS

In our region with a high incidence of tuberculosis, the most frequent cause of pleural exudates is tuberculosis followed by malignancy, particularly lung cancer.