The relative burden of community-acquired pneumonia hospitalizations in older adults: a retrospective observational study in the United States

Disease burden and high-risk populations for complications in patients with acute respiratory infections: a scoping review

Background

Acute respiratory infections (ARIs) represent a significant public health concern in the U.S. This study aimed to describe the disease burden of ARIs and identify U.S. populations at high risk of developing complications.

Methods

This scoping review searched PubMed and EBSCO databases to analyze U.S. studies from 2013 to 2022, focusing on disease burden, complications, and high-risk populations associated with ARIs.

Results

The study included 60 studies and showed that ARI is associated with a significant disease burden and healthcare resource utilization (HRU). In 2019, respiratory infection and tuberculosis caused 339,703 cases per 100,000 people, with most cases being upper respiratory infections and most deaths being lower respiratory infections. ARI is responsible for millions of outpatient visits, especially for influenza and pneumococcal pneumonia, and indirect costs of billions of dollars. ARI is caused by multiple pathogens and poses a significant burden on hospitalizations and outpatient visits. Risk factors for HRU associated with ARI include age, chronic conditions, and socioeconomic factors.

Conclusion

The review underscores the substantial disease burden of ARIs and the influence of age, chronic conditions, and socioeconomic status on developing complications. It highlights the necessity for targeted strategies for high-risk populations and effective pathogen detection to prevent severe complications and reduce HRU.

Societal Cost of Racial Pneumococcal Disease Disparities in US Adults Aged 50 Years or Older

OBJECTIVE

This study aimed to estimate the societal cost of racial disparities in pneumococcal disease among US adults aged ≥  50 years.

METHODS

In a model-based analysis, societal costs of invasive pneumococcal disease (IPD) and hospitalized nonbacteremic pneumococcal pneumonia (NBP) were estimated using (1) direct medical costs plus indirect costs of acute illness; (2) indirect costs of pneumococcal mortality; and (3) direct and indirect costs of related disability. Disparities costs were calculated as differences in average per-person pneumococcal disease cost between Black and non-Black adults aged ≥  50 years multiplied by the Black population aged ≥  50 years. Costs were in 2019 US dollars (US$), with future costs discounted at 3% per year.

RESULTS

Total direct and indirect costs per IPD case were US$186,791 in Black populations and US$182,689 in non-Black populations; total hospitalized NBP costs per case were US$100,632 (Black) and US$96,781 (non-Black). The difference in population per-person total pneumococcal disease costs between Black and non-Black adults was US$47.85. Combined societal costs of disparities for IPD and hospitalized NBP totaled US$673.2 million for Black adults aged ≥  50 years. Disease and disability risks, life expectancy, and case-fatality rates were influential in one-way sensitivity analyses, but the lowest cost across all analyses was US$194 million. The 95% probability range of racial disparity costs were US$227.2-US$1156.9 million in a probabilistic sensitivity analysis.

CONCLUSIONS

US societal cost of racial pneumococcal disease disparities in persons aged ≥ 50 years is substantial. Successful pneumococcal vaccination policy and programmatic interventions to mitigate these disparities could decrease costs and improve health.

Predictors of Length of Stay, Rehospitalization and Mortality in Community-Acquired Pneumonia Patients: A Retrospective Cohort Study

BACKGROUND

Community-acquired pneumonia (CAP) represents one of the leading causes of hospitalization and has a substantial impact on the financial burden of healthcare. The aim of this study was to identify factors associated with the length of hospital stay (LOHS), rehospitalization and mortality of patients admitted for CAP.

METHODS

A retrospective cohort study was conducted with patients presenting to a Swiss public hospital between January 2019 and December 2019. Zero-truncated negative binomial and multivariable logistic regression analyses were performed to assess risk factors.

RESULTS

A total of 300 patients were analyzed (median 78 years, IQR [67.56, 85.50] and 53% males) with an average LOHS of 7 days (IQR [5.00, 9.00]). Of the 300 patients, 31.6% (97/300) were re-hospitalized within 6 months, 2.7% (8/300) died within 30 days and 11.7% (35/300) died within 1 year. The results showed that sex (IRR = 0.877, 95% CI = 0.776-0.992, p-value = 0.036), age (IRR = 1.007, 95% CI = 1.002-1.012, p-value = 0.003), qSOFA score (IRR = 1.143, 95% CI = 1.049-1.246, p-value = 0.002) and atypical pneumonia (IRR = 1.357, 95% CI = 1.012-1.819, p-value = 0.04) were predictive of LOHS. Diabetes (OR = 2.149, 95% CI = 1.104-4.172, p-value = 0.024), a higher qSOFA score (OR = 1.958, 95% CI = 1.295-3.002, p-value = 0.002) and rehabilitation after discharge (OR = 2.222, 95% CI = 1.017-4.855, p-value = 0.044) were associated with a higher chance of being re-hospitalized within 6 months, whereas mortality within 30 days and within one year were both associated with older age (OR = 1.248, 95% CI = 1.056-1.562, p-value = 0.026 and OR = 1.073, 95% CI = 1.025-1.132, p-value = 0.005, respectively) and the presence of a cancer diagnosis (OR = 32.671, 95% CI = 4.787-369.1, p-value = 0.001 and OR = 4.408, 95% CI = 1.680-11.43, p-value = 0.002, respectively).

CONCLUSION

This study identified routinely available predictors for LOHS, rehospitalization and mortality in patients with CAP, which may further advance our understanding of CAP and thereby improve patient management, discharge planning and hospital costs.

Pneumococcal Disease: Global Disease Prevention Strategies with a Focus on the Challenges in Iraq

Pneumococcal disease is a global public health concern that significantly contributes to clinical disease burden and economic burden. Patients frequently afflicted are young children and older adults, as well as the immunocompromised population. Immunization is the most effective public health strategy to combat pneumococcal disease and several vaccine formulations have been developed in this regard. Although vaccines have had a significant global impact in reducing pneumococcal disease, there are several barriers to its success in Iraq. The war and conflict situation, increasing economic crises and poverty, poor vaccine accessibility in the public sector, and high vaccine costs are a few of the major obstacles that impede a successful immunization program. The last reported third dose pneumococcal conjugate vaccine coverage for Iraq was 37% in 2019, which is expected to reduce even further owing to the COVID-19 pandemic. Thus, strategies and policies to improve pneumococcal vaccine availability and coverage need to be strengthened to achieve maximum benefits of immunization. In the current review, we provide an overview of the existing knowledge on pneumococcal disease-prevention strategies across the globe. The main aim of this manuscript is to discuss the current status and challenges of pneumococcal vaccination in Iraq as well as the strategies to prevent pneumococcal infections.

Burden of Acute-Care Hospitalization for Community-Acquired Pneumonia in Canadian Adults Aged 50 Years or Older: Focusing on Most Responsible Diagnosis Tells Only Part of the Story

The burden of all-cause community-acquired pneumonia (CAP), including pneumococcal pneumonia, is typically estimated using ICD codes where pneumonia is coded as the most responsible diagnosis (MRDx). Pneumonia may also be coded as other than most responsible diagnosis (ODx) based on administrative and reimbursement criteria. Analyses including pneumonia as MRDx only likely underestimate hospitalized CAP incidence. The aim of this study was to estimate the burden of hospitalized all-cause CAP in Canada and to assess the contribution of ODx-coded cases to the overall disease burden. This longitudinal retrospective study obtained data from the Canadian Institutes of Health Information (CIHI) for adults 50+ years hospitalized for CAP between 1 April 2009 and 31 March 2019. Cases were identified as those where pneumonia was either diagnosis code type M (MRDx) or pre-admit comorbidity type 1 (ODx). Reported outcomes include pneumonia incidence rate, in-hospital mortality, hospital length of stay, and cost. Outcomes were stratified by age group, case coding, and comorbidity. Between 2009–2010 and 2018–2019, CAP incidence increased from 805.66 to 896.94 per 100,000. During this time, 55–58% of cases had pneumonia coded as ODx. Importantly, these cases had longer hospital stays, higher in-hospital mortality, and higher cost of hospitalization. The burden of CAP remains substantial and is significantly greater than that estimated by solely focusing on MRDx-coded cases. Our findings have implications for policy decision making related to current and future immunization programs.

Social network and severe lower respiratory tract infections in older adults: findings from a Swedish longitudinal population-based study

OBJECTIVES

To investigate the association between social network and the risk and prognosis of severe lower respiratory tract infections (LRTIs) in older adults.

METHODS

Data from Swedish hospital records were matched with the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K). Social network was operationalized as social connections and social support, based on different self-reported variables, and categorized as low, medium, and high. The risk of severe LRTI and related outcomes were assessed using Cox, Poisson, and logistic regression models where appropriate.

RESULTS

A total of 362 individuals experienced LRTI-related hospitalizations between 2001 and 2016 (479 total hospitalizations). High levels of social support decreased the hazard of incident LRTI by 29% (hazard ratio 0.71, 95% confidence interval [CI] 0.52-0.96), the hospital length of stay by 21% (incidence rate ratio 0.79, 95% CI 0.65-0.97), and the risk of 30-day mortality by 92% (odds ratio 0.08, 95% CI 0.01-0.68), but was a risk factor for 30-day readmission (odds ratio 3.16, 95% CI 1.38-7.24). High levels of social connections were associated with a higher risk of incident LRTI in women and those with dementia and/or slow walking speed (P_interaction <0.05).

CONCLUSION

Older individuals' quality of social support seems to be a stronger determinant of LRTI incidence and prognosis than the quantity of their social connections. These findings may inform evidence-based policies aimed at preventing LRTIs in older adults.

Development and validation of a survival prediction model in elder patients with community-acquired pneumonia: a MIMIC-population-based study

BACKGROUND

To develop a prediction model predicting in-hospital mortality of elder patients with community-acquired pneumonia (CAP) admitted to the intensive care unit (ICU).

METHODS

In this cohort study, data of 619 patients with CAP aged ≥ 65 years were obtained from the Medical Information Mart for Intensive Care III (MIMIC III) 2001-2012 database. To establish the robustness of predictor variables, the sample dataset was randomly partitioned into a training set group and a testing set group (ratio: 6.5:3.5). The predictive factors were evaluated using multivariable logistic regression, and then a prediction model was constructed. The prediction model was compared with the widely used assessments: Sequential Organ Failure Assessment (SOFA), Pneumonia Severity Index (PSI), systolic blood pressure, oxygenation, age and respiratory rate (SOAR), CURB-65 scores using positive predictive value (PPV), negative predictive value (NPV), accuracy (ACC), area under the curve (AUC) and 95% confidence interval (CI). The decision curve analysis (DCA) was used to assess the net benefit of the prediction model. Subgroup analysis based on the pathogen was developed.

RESULTS

Among 402 patients in the training set, 90 (24.63%) elderly CAP patients suffered from 30-day in-hospital mortality, with the median follow-up being 8 days. Hemoglobin/platelets ratio, age, respiratory rate, international normalized ratio, ventilation use, vasopressor use, red cell distribution width/blood urea nitrogen ratio, and Glasgow coma scales were identified as the predictive factors that affect the 30-day in-hospital mortality. The AUC values of the prediction model, the SOFA, SOAR, PSI and CURB-65 scores, were 0.751 (95% CI 0.749-0.752), 0.672 (95% CI 0.670-0.674), 0.607 (95% CI 0.605-0.609), 0.538 (95% CI 0.536-0.540), and 0.645 (95% CI 0.643-0.646), respectively. DCA result demonstrated that the prediction model could provide greater clinical net benefits to CAP patients admitted to the ICU. Concerning the pathogen, the prediction model also reported better predictive performance.

CONCLUSION

Our prediction model could predict the 30-day hospital mortality in elder patients with CAP and guide clinicians to identify the high-risk population.

Combining a Frailty Index Based on Laboratory Data and Pneumonia Severity Assessments to Predict In-Hospital Outcomes in Older Adults with Community-Acquired Pneumonia

OBJECTIVES

Due to the increased morbidity, mortality, and cost of community-acquired pneumonia (CAP) in older people, strategies directed at improving disease evaluation and prevention are imperative. We independently compared the 30-day in-hospital mortality prediction ability of a frailty index based on laboratory data (FI-Lab) with that of the CURB-65 and the Pneumonia Severity Index (PSI) and then proposed combining them to further improve prediction efficiency.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Patients aged ≥ 65 years (n = 2039) with CAP who were admitted to Jiangsu Provincial People's Hospital of Nanjing Medical University and Jiangsu Provincial Hospital of Chinese Medicine from January 2019 to June 2022.

MEASURES

The 29-item FI-Lab, PSI and, CURB-65 were administered at admission. We defined frailty by the cut-off value of the FI-Lab score (> 0.43). Multivariable logistic regression analysis, together with the calculation of the area under the receiver operating characteristic curve (ROC-AUC), was conducted to identify stratified risks and relationships between the three indices and 30-day mortality. Participants were divided into the following three groups based on age: 65-74 years, 75-84 years, and ≥ 85 years. Hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality due to frailty were calculated.

RESULTS

A total of 495 participants ranging from 65 to 100 years of age were ultimately included and divided into age groups (65-74 years, n = 190, 38.4%; 75-84 years, n = 183, 37.0%; ≥ 85 years, n = 122, 24.6%). A total of 142 (28.7%) of the 495 patients were defined as having frailty. All three scores tested in this study were significantly associated with 30-day mortality in the total sample. The ORs were as follows: 1.06 (95% CI: 1.03-1.09, P < 0.001) and 2.33 (95% CI: 1.26-4.31, P = 0.007) for the FI-Lab when the score was treated as a continuous and categorical variable, respectively; 1.04 (95% CI: 1.02-1.05, P < 0.001) for the PSI; and 3.70 (95% CI: 2.48-5.50, P < 0.001) for the CURB-65. In the total sample, the ROC-AUCs were 0.783 (95% CI: 0.744-0.819) for the FI-Lab, 0.812 (95% CI: 0.775-0.845) for the PSI, and 0.799 (95% CI: 0.761-0.834) for the CURB-65 (P < 0.001). The ROC-AUC slightly improved when the FI-Lab was added to the PSI (AUC 0.850, 95% CI: 0.809-0.892, P = 0.031) and to the CURB-65 (AUC 0.839, 95% CI: 0.794-0.885, P = 0.002). Older patients with frailty showed a higher risk of in-hospital mortality, with an HR of 2.25 (95% CI: 1.14-3.58, P < 0.001).

CONCLUSION AND IMPLICATIONS

The FI-Lab seems to generate simple and readily available data, suggesting that it could be a useful complement to the CURB-65 and the PSI as effective predictors of 30-day mortality due to CAP in older populations.

Clinical and economic burden of pneumococcal disease among individuals aged 16 years and older in Germany

This study assessed the incidence rate of all-cause pneumonia (ACP) and invasive pneumococcal disease (IPD) and associated medical costs among individuals aged ≥16 in the German InGef database from 2016 to 2019. Incidence rate was expressed as the number of episodes per 100 000 person-years (PY). Healthcare resource utilisation was investigated by age group and by risk group (healthy, at-risk, high-risk). Direct medical costs per ACP/IPD episode were estimated as the total costs of all inpatient and outpatient visits. The overall incidence rate of ACP was 1345 (95% CI 1339-1352) and 8.25 (95% CI 7.76-8.77) per 100 000 PY for IPD. For both ACP and IPD, incidence rates increased with age and were higher in the high-risk and at-risk groups, in comparison to the healthy group. ACP inpatient admission rate increased with age but remained steady across age-groups for IPD. The mean direct medical costs per episode were €8075 (95% CI 7121-9028) for IPD and €1454 (95% CI 1426-1482) for ACP. The aggregate direct medical costs for IPD and ACP episodes were estimated to be €8.5 million and €248.9 million respectively. The clinical and economic burden of IPD and ACP among German adults is substantial regardless of age.

Frontline workers: Mediators of mucosal immunity in community acquired pneumonia and COVID-19

The current COVID-19 pandemic has highlighted a need to further understand lung mucosal immunity to reduce the burden of community acquired pneumonia, including that caused by the SARS-CoV-2 virus. Local mucosal immunity provides the first line of defence against respiratory pathogens, however very little is known about the mechanisms involved, with a majority of literature on respiratory infections based on the examination of peripheral blood. The mortality for severe community acquired pneumonia has been rising annually, even prior to the current pandemic, highlighting a significant need to increase knowledge, understanding and research in this field. In this review we profile key mediators of lung mucosal immunity, the dysfunction that occurs in the diseased lung microenvironment including the imbalance of inflammatory mediators and dysbiosis of the local microbiome. A greater understanding of lung tissue-based immunity may lead to improved diagnostic and prognostic procedures and novel treatment strategies aimed at reducing the disease burden of community acquired pneumonia, avoiding the systemic manifestations of infection and excess morbidity and mortality.

Comparison between Ceftriaxone and Sulbactam-Ampicillin as Initial Treatment of Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis

Current guidelines recommend the use of ceftriaxone and sulbactam-ampicillin for the initial treatment of community-acquired pneumonia (CAP). However, there are no clear data on these guidelines. Therefore, this systematic review and meta-analysis aims to evaluate the effectiveness of ceftriaxone and sulbactam-ampicillin in the initial treatment of CAP. The Embase, Scopus, PubMed, Ichushi, and Cumulative Index to Nursing and Allied Health Literature databases were systematically searched from inception to July 2022. The studies included patients who received ceftriaxone or sulbactam-ampicillin as the initial antibiotic therapy for CAP. The mortality and clinical cure rates were evaluated. Of the 2152 citations identified for screening, four studies were included. Results of the pooled analysis indicated no significant differences in the mortality and clinical cure rates between patients treated with ceftriaxone and those treated with sulbactam-ampicillin (mortality, odds ratio [OR]: 1.85, 95% confidence interval [CI]: 0.57–5.96; clinical cure rate, OR: 1.08, 95% CI: 0.18–6.44). This study supports the guidelines for CAP treatment, though further studies are needed to obtain a deeper understanding.

Association between Pneumonia, Fracture, Stroke, Heart Attack and Other Hospitalizations with Changes in Mobility Disability and Gait Speed in Older Adults

Pathophysiological changes after acute hospitalizations may influence physical functioning in older adults, which can lead to disability and loss of independence. This study evaluated the association between pneumonia, fracture, heart attack, stroke, and other hospitalizations with major mobility disability (MMD) and gait speed. This was a secondary analysis of the Lifestyle Interventions and Independence for Elders (LIFE) Study, which was conducted across eight sites during 2010–2013 with longitudinal follow-up for 1635 individuals over an average of 2.6 years. Participants included adults ≥70 years old with pre-existing mobility limitations randomized to a physical activity intervention or a health education control arm. Hospitalizations were recorded via self-report and adjudicated by medical reviewers. MMD was measured by the inability to complete a 400 m walk test, or other proxies, as a binary outcome. Gait speed was recorded during the walk test in meters per second (m/s) and measured on a linear scale. Mixed-effects repeated measures regression adjusted for baseline demographics, comorbid conditions, and frailty. Among the 1635 participants, there were 1458 hospitalizations, which included 80 (5.5% of all hospitalizations) cases of pneumonia, 92 (6.3%) hospitalized fractures, 87 (6.0%) heart attacks, and 61 (4.2%) strokes. In the short-term measurement period immediately following hospitalization (1 day to 6 months), stroke (OR = 3.98 (3.41–4.54)) had the strongest association with MMD followed by fracture (OR = 3.03 (2.54–3.52)), pneumonia (OR = 2.76 (2.23–3.30)), and heart attack (OR = 2.03 (1.52–2.53)). Associations with long-term (6–12 months after) MMD were decreased or not significant for all causes. Pneumonia, fracture, stroke, and other hospitalizations were associated with short-term relative gait speed changes between −4.8% up to −19.5%, and only fracture was associated with long-term changes. Hospitalizations for pneumonia, heart attack, stroke, and fractures were associated with short-term decreases in mobility in older adults. Older adults may be at risk for decreased mobility and disability following acute hospitalizations, with the magnitude determined by the cause of the precipitating event.

Population-based incidence and mortality of community-acquired pneumonia in Germany

Background

Little information on the current burden of community-acquired pneumonia (CAP) in adults in Germany is available.

Methods

We conducted a retrospective cohort study using a representative healthcare claims database of approx. 4 million adults to estimate the incidence rates (IR) and associated mortality of CAP in 2015. IR and mortality were stratified by treatment setting, age group, and risk group status. A pneumonia coded in the primary diagnosis position or in the second diagnosis position with another pneumonia-related condition coded in the primary position was used as the base cases definition for the study. Sensitivity analyses using broader and more restrictive case definitions were also performed.

Results

The overall IR of CAP in adults ≥18 years was 1,054 cases per 100,000 person-years of observation. In adults aged 16 to 59 years, IR for overall CAP, hospitalized CAP and outpatient CAP was 551, 96 and 466 (with a hospitalization rate of 17%). In adults aged ≥60 years, the respective IR were 2,032, 1,061 and 1,053 (with a hospitalization rate of 52%). If any pneumonia coded in the primary or secondary diagnosis position was considered for hospitalized patients, the IR increased 1.5-fold to 1,560 in the elderly ≥60 years. The incidence of CAP hospitalizations was substantially higher in adults ≥18 years with at-risk conditions and high-risk conditions (IR of 608 and 1,552, respectively), compared to adults without underlying risk conditions (IR 108). High mortality of hospitalized CAP in adults ≥18 was observed in-hospital (18.5%), at 30 days (22.9%) and at one-year (44.5%) after CAP onset. Mortality was more than double in older adults in comparison to younger patients.

Conclusion

CAP burden in older adults and individuals with underlying risk conditions was high. Maximizing uptake of existing vaccines for respiratory diseases may help to mitigate the disease burden, especially in times of strained healthcare resources.

Clinical characteristics and outcomes of community-acquired pneumonia in western Saudi Arabia: A four-year retrospective analysis of medical records

BACKGROUND

Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality, especially for the elderly and people who suffer from chronic conditions. This study was conducted to assess the clinical and microbiological characteristics and disease outcomes associated with the occurrence of CAP.

METHODS

This retrospective chart review was conducted at King Abdulaziz Medical City, Jeddah, Saudi Arabia. Cases with documented clinical diagnosis of CAP during the period from 2016 to 2019 were included. Data were collected on demographic, clinical, and microbiological characteristics, used antimicrobials and patients' outcomes, including length of hospital stay, intensive care unit admission, and mortality. Multivariate regression analysis was performed to identify risk factors for increased length of hospital stay.

RESULTS

A total of two hundred and eighteen CAP episodes were identified. Patients had a median age of 64.5 years, and 54.1% were males. Microbiological diagnosis was established in 33 patients (15.1%). Admission to ICU and diagnosis of a neurological disease were significantly associated with longer hospital stay (>7 days). An average of 2.7 antimicrobials were used per patient, and the most common antibiotics used were Piperacillin/Tazobactam (46.3%), Doxycycline (44%), then Ceftriaxone (42.7%). Four patients (1.8%) died during hospital stay.

CONCLUSIONS

This retrospective analysis of CAP cases identified a lack of microbiological diagnosis and increased burden associated with disease severity and the need for hospitalization. The ability to identify CAP at an earlier stage will be a cornerstone to mitigate its impact on the healthcare system and ICU units.

Serotype distribution and antimicrobial susceptibility of Streptococcus pneumoniae isolates from a Phase III community-acquired bacterial pneumonia (CABP) trial

Objectives

To report Streptococcus pneumoniae serotyping and susceptibility data from a recent clinical trial (ML-3341-306) comparing delafloxacin with moxifloxacin in the treatment of adults with community-acquired bacterial pneumonia (CABP).

Methods

Serotyping and susceptibility testing were conducted on 142 baseline S. pneumoniae isolates recovered from subjects participating in a CABP clinical trial.

Results

Overall, 113/142 (79.6%) isolates were vaccine serotypes. 76.8% (109/142) of serotyped isolates were PPSV23 serotypes and 59.9% (85/142) of isolates were PCV13 serotypes. 15.5% (22/142) of serotyped isolates were serotypes not covered by either vaccine; 4.9% (7/142) of tested isolates were non-typeable. The most common serotypes were serotypes 3 (19.0%; 27/142), 19F (9.9%; 14/142) and 23F (7.0%; 10/142). All of the 142 isolates were susceptible to delafloxacin and moxifloxacin, 76.1% were susceptible to azithromycin and 71.8% were susceptible to penicillin. Multidrug resistance was found among 19A (4/5; 80%), 6A (1/4; 25%), 6B (1/4; 25%), 14 (1/4; 25%), 19F (1/14; 7.1%), and 23F serotypes (2/10; 20%), and among non-typeable S. pneumoniae isolates (1/7; 14.3%).

Conclusions

S. pneumoniae vaccine-targeted serotypes were the main cause of CABP in this Phase 3 CABP study. Fluoroquinolones including delafloxacin remain a good treatment option for CABP in adults caused by S. pneumoniae.

Can Prophylactic High Flow of Humidified and Warmed Filtered Air Improve Survival from Bacterial Pneumonia and SARS-CoV-2 in Elderly Individuals? The Role of Surfactant Protein A

In this opinion article, we discuss a serendipitous observation we made in a study investigating survival in aged mice after bacterial infection. This observation involved a non-invasive ventilation approach that led to variable and higher survival in male and female mice with different genetic backgrounds for the innate immune molecule, surfactant protein A (SP-A). We suggest that employing the best ventilatory modality, whether that be HFNC or another method, may augment the role of other factors such as SP-A genetics and sex in a personalized approach, and may ultimately improve the outcome.

Incidence, risk factors, and viral etiology of community-acquired acute lower respiratory tract infection among older adults in rural north India

BACKGROUND

There are limited data on incidence, risk factors and etiology of acute lower respiratory tract infection (LRTI) among older adults in low- and middle-income countries.

METHODS

We established a cohort of community dwelling older adults ≥60 years and conducted weekly follow-up for acute respiratory infections (ARI) during 2015-2017. Nurses assessed ARI cases for LRTI, collecting combined nasal/throat swabs from all LRTI cases and an equal number of age- and sex-matched asymptomatic neighbourhood controls. Swabs were tested for influenza viruses, respiratory syncytial virus (RSV), human metapneumovirus (hMPV), and parainfluenza viruses (PIV) using polymerase chain reaction. LRTI and virus-specific LRTI incidence was calculated per 1000 person-years. We estimated adjusted incidence rate ratios (IRR) for risk factors using Poisson regression and calculated etiologic fractions (EF) using adjusted odds ratios for detection of viral pathogens in LRTI cases vs controls.

RESULTS

We followed 1403 older adults for 2441 person-years. LRTI and LRTI-associated hospitalization incidences were 248.3 (95% confidence interval (CI) = 229.3-268.8) and 12.7 (95% CI = 8.9-18.1) per 1000 person-years. Persons with pre-existing chronic bronchitis as compared to those without (incidence rate ratio (IRR) = 4.7, 95% CI = 3.9-5.6); aged 65-74 years (IRR = 1.6, 95% CI = 1.3-2.0) and ≥75 years (IRR = 1.8, 95% CI = 1.4-2.4) as compared to 60-64 years; and persons in poorest wealth quintile (IRR = 1.4, 95% CI = 1.1-1.8); as compared to those in wealthiest quintile were at higher risk for LRTI. Virus was detected in 10.1% of LRTI cases, most commonly influenza (3.8%) and RSV (3.0%). EF for RSV and influenza virus was 83.9% and 83.6%, respectively.

CONCLUSION

In this rural cohort of older adults, the incidence of LRTI was substantial. Chronic bronchitis was an important risk factor; influenza virus and RSV were major viral pathogens.

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.

Effect of Inpatient and Outpatient Pneumonia on Mobility Disability, Gait Speed, and Physical Activity in Older Adults

Pathophysiological changes caused by pneumonia may influence physical functioning in older adults. This study was a secondary analysis of the Lifestyle Interventions and Independence for Elders (LIFE) Study. The LIFE Study included 1635 individuals over an average follow-up of 2.6 years at eight clinical sites during 2010–2013. Adults ≥70 years-old with mobility limitations (Short Physical Performance Battery score ≤9) were randomized to a physical activity (exercise) intervention or health education control arm. This analysis evaluated the association between pneumonia events and major mobility disability (MMD), gait speed, and physical activity levels. Pneumonia events, classified as inpatient or outpatient, were assessed by self-report during longitudinal follow-up. MMD was measured by the inability to complete a 400-m walk test, or other proxies, as a binary outcome and separately analyzed as “short-term” and “long-term” MMD. Short-term MMD was defined as MMD occurring in the assessment period immediately following (between 1-day to 6-months after) a pneumonia event and long-term was in the following assessment period (6 to 12 months after the event). Short- and long-term gait speed was similarly recorded during the walk test in meters per second (m/s) and measured on a linear scale. Physical activity levels were captured via accelerometry and shown visually. Mixed-effects repeated measures regression adjusted for intervention assignment, baseline demographics, comorbid conditions, and frailty. Among the 1635 participants, n = 174 (10.7%) had a pneumonia event of which 80 (46% of events) were hospitalized. Those with pneumonia during follow-up had higher baseline medication use, prior hospitalizations, and higher prevalence of lung disorders but similar baseline functioning. Pneumonia hospitalization was associated with a 4-fold increase [OR = 4.1 (3.2–5.0)] and outpatient events were associated with a 2-fold increase [OR = 2.6 (2.1–3.1)] in the odds of short-term MMD. Pneumonia hospitalizations, but not outpatient events, were associated with a nearly 10% decrement in short-term gait speed. Pneumonia events were not associated with either long-term MMD or gait speed outcomes. Physical activity levels decreased from baseline immediately following the pneumonia episode (10–30% reductions) and returned to baseline after 6 months. These results emphasize the importance of managing pneumonia risk factors to prevent disease in order to maintain physical independence and activity in older adults.

Oral 5-Day Lefamulin for Outpatient Management of Community-Acquired Bacterial Pneumonia: Post-hoc Analysis of the Lefamulin Evaluation Against Pneumonia (LEAP) 2 Trial

BACKGROUND

Safe and effective oral antibiotics are needed for outpatient management of moderate to severe community-acquired bacterial pneumonia (CABP).

OBJECTIVE

We describe a post-hoc analysis of adults with CABP managed as outpatients from the Lefamulin Evaluation Against Pneumonia (LEAP) 2 double-blind, noninferiority, phase 3 clinical trial.

METHODS

LEAP 2 compared the efficacy and safety of oral lefamulin 600 mg every 12 h (5 days) vs. oral moxifloxacin 400 mg every 24 h (7 days) in adults (inpatients and outpatients) with Pneumonia Outcomes Research Team (PORT) risk classes II‒IV.

RESULTS

Overall, 41% (151 of 368) of patients receiving lefamulin and 43% (159 of 368) of patients receiving moxifloxacin started treatment as outpatients-44% and 40%, respectively, were PORT risk class III/IV, and 21% in both groups had CURB-65 scores of 2‒3. Early clinical response (at 96 ± 24 h) and investigator assessment of clinical response success rates at test of cure (5‒10 days after last study drug dose) were high and similar in both groups among all (lefamulin, 91% vs. moxifloxacin, 89‒90%), PORT risk class III/IV (89‒91% vs. 88‒91%), and CURB-65 score 2‒3 (87‒90% vs. 82‒88%) outpatients. Few outpatients (lefamulin, 2.6%; moxifloxacin, 2.5%) discontinued the study drug because of treatment-emergent adverse events (TEAEs). No outpatient in the lefamulin group was hospitalized for a TEAE, compared with 5 patients (3%), including two deaths, in the moxifloxacin group.

CONCLUSIONS

These data suggest that 5 days of oral lefamulin can be given in lieu of fluoroquinolones for outpatient treatment of adults with CABP and PORT risk class III/IV or CURB-65 scores of 2‒3.

Treatment of Community-Acquired Pneumonia: A Focus on Lefamulin

OBJECTIVE

The goal of this article is to review the clinical pharmacology, pharmacokinetics, efficacy, and safety of lemafulin.

DATA SOURCES

We performed a systematic literature review using the search terms of lefamulin and BC-3781 in the PubMed and EMBASE databases. We also cross-referenced the pertinent articles and searched ClinicalTrials.gov to identify ongoing and nonpublished studies.

STUDY SELECTION AND DATA EXTRACTION

Published data from 2005 to 2019 evaluating the clinical pharmacology, efficacy, and safety studies of lefamulin were analyzed.

DATA SYNTHESIS

In phase 3 clinical trials, two multicenter, randomized double-blinded studies-Lefamulin Evaluation Against Pneumonia 1 and 2 (LEAP 1 and 2)-compared the efficacy and safety of lemafulin with moxifloxacin in patients diagnosed with community-acquired bacterial pneumonia (CABP). Lemafulin given in doses of 600 mg orally or 150 mg intravenously were reported to have comparable efficacy to those of moxifloxacin with or without linezolid in patients with CABP. After the trial, the lefamulin group had an early clinical response (ECR) of 87.3% and the moxifloxacin group had an ECR of 90.2%. The difference of - 2.9% in the ECR was non-significant (CI - 8.5, 2.8).

RELEVANCE TO PATIENTS AND CLINICAL PRACTICE

Lemafulin exhibits a unique binding property; therefore, it possess a potentially lower predisposition for the development of bacterial resistance and cross-resistance to other antimicrobial classes. Lefamulin is active against gram-positive including methicillin-resistant strains and atypical organisms which are often implicated in CABP. Lefamulin may be a safe alternative for adult patients with CABP who may not be candidates for respiratory fluoroquinolones. Lefamulin demonstrates both bactericidal and bacteriostatic activity against gram-positive, fastidious gram-negatives, atypical pathogens, and some gram-negative anaerobes. It is bactericidal in vitro against Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae (including macrolide-resistant strains) at concentrations of 0.06, 0.5, and 0.008 µg/ml respectively, and bacteriostatic against Staphylococcus aureus and Streptococcus pyogenes. The agent also demonstrates both time- and concentration-dependent killing against the pathogens S. pneumoniae and S. aureus. In vitro susceptibility testing demonstrated an MIC50/90 of 0.06/0.12 µg/ml against S. pneumoniae and S. aureus. The SENTRY Antimicrobial Surveillance Program found that at a concentration ≤ 1 µg/ml, lefamulin inhibited 100% S. pneumoniae isolates, 99.8% of S. aureus isolates, and 99.6% of methicillin-resistant S. aureus isolates. It was not affected by resistance to various antibiotic classes such as beta-lactams, fluoroquinolones, or macrolides.

Lower Respiratory Tract Infection Trends in East and South-East Asia: In the Light of Economic and Health Care Development

This study explored to what degree economic development and improvement of healthcare are associated with lower respiratory tract infection (LRTI) mortality. A correlation analysis between LRTI mortality and Gross Domestic Product (GDP) per capita, and the Health Access and Quality Index (HAQI), respectively was conducted for 15 countries in East and South-East Asia. The results revealed a dramatic decrease in LRTI mortality in total populations for lower-middle income (LMI) countries but at the same time an increase in upper-middle income (UMI) and high-income (HI) countries. A highly significant (P < .001) growth-dependent relationship between LRTI mortality and economic growth was observed. Improvements in HAQI were significantly associated with a decrease in LRTI mortality in LMI countries, but an increase in UMI and HI countries. The decline of LRTI mortality amongst children in LMI countries is an encouraging trend and efforts against LRTI must be continued, though not at the expense of preparing health systems for the growing burden.

The Role of Delafloxacin in Patients with Community-Acquired Bacterial Pneumonia in the Outpatient Setting: A Budget Impact Model

Background and Objective

Community-acquired bacterial pneumonia (CABP) affects millions of people each year in the USA. The majority of patients with CABP are treated in the community setting with empirical antimicrobial therapy. Delafloxacin is an anionic fluoroquinolone approved for the treatment of adult patients with CABP. This de novo analysis sought to estimate the budget impact of delafloxacin in the treatment of adult patients with CABP in the outpatient setting from the payer’s perspective.

Methods

A budget impact model (BIM) was developed from the perspective of a US third-party payer to estimate the cost of introducing delafloxacin for the outpatient treatment of CABP over a 1-year time horizon. Population, clinical, and cost inputs were based on the available literature, clinical trial data, and real-world evidence studies. Scenario analyses were conducted to evaluate the potential budget impact among COPD/asthma patients based on the findings from the phase III trial of delafloxacin for CABP, which indicated that patients with COPD or asthma may experience improved effectiveness with delafloxacin compared to moxifloxacin.

Results

In the base-case analysis, with a hypothetical plan of 1,000,000 members, the model estimated that adding delafloxacin to the formulary resulted in a total budget impact of $58,987. This increase was mainly attributed to treatment acquisition costs. In the scenario analysis that was restricted to COPD/asthma patients, adding delafloxacin to the formulary was estimated to result in a total budget impact of $5,042.

Conclusion

The results of the budget impact analyses provide conservative estimates of the impact of adding delafloxacin to outpatient formularies in substitution of moxifloxacin.

Electronic supplementary material

The online version of this article (10.1007/s40261-020-00938-y) contains supplementary material, which is available to authorized users.

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

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

Etiology of community-acquired pneumonia in adults: a systematic review

Background

The etiology of community-acquired pneumonia (CAP) has evolved since the beginning of the antibiotic era. Recent guidelines encourage immediate empiric antibiotic treatment once a diagnosis of CAP is made. Concerns about treatment recommendations, on the one hand, and antibiotic stewardship, on the other, motivated this review of the medical literature on the etiology of CAP.

Methods

We conducted a systematic review of English-language literature on the etiology of CAP using methods defined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed using a combination of the keywords ‘pneumonia’, ‘CAP’, ‘etiology’, ‘microbiology’, ‘bacteriology’, and ‘pathogen’. We examined articles on antibiotics that were develop to treat pneumonia. We reviewed all ‘related articles’ as well as studies referenced by those that came up in the search. After we excluded articles that did not give sufficient microbiological data or failed to meet other predetermined criteria, 146 studies remained. Data were stratified into diagnostic categories according to the microbiologic studies that were done; results are presented as the percentage in each category of all cases in which an etiology was established.

Results

Streptococcus pneumoniae remains the most common cause of CAP although declining in incidence; this decline has been greater in the US than elsewhere. Haemophilus influenzae is the second most common cause of CAP, followed by Staphylococcus aureus and Gram negative bacilli. The incidence of all bacteria as causes of CAP has declined because, with routine use of PCR for viruses, the denominator, cases with an established etiology, has increased. Viruses were reported on average in about 10% of cases, but recent PCR-based studies identified a respiratory virus in about 30% of cases of CAP, with substantial rates of viral/bacterial coinfection.

Conclusion

The results of this study justify current guidelines for initial empiric treatment of CAP. With pneumococcus and Haemophilus continuing to predominate, efforts at antibiotic stewardship might be enhanced by greater attention to the routine use of sputum Gram stain and culture. Because viral/bacterial coinfection is relatively common, the identification of a virus by PCR does not, by itself, allow for discontinuation of the antibiotic therapy.

Longitudinal, multidisciplinary, resident-driven intervention to increase immunisation rates for Medicaid, low-income and uninsured patients

Introduction

More payers are closely linking reimbursement to high-value care outcomes such as immunisation rates. Despite this, there remain high rates of pneumonia and influenza-related hospitalisations generating hospital expenditures as high as $11 000 per hospitalisation. Vaccinating the public is an integral part of preventing poor health and utilisation outcomes and is particularly relevant to high-risk patients. As part of a multidisciplinary effort between family and internal medicine residency programmes, our goal was to improve vaccination rates to an average of 76% of eligible Medicaid, low-income and uninsured (MLIU) patients at an academic primary care practice.

Methods

The quality improvement project was completed over 3 months by three primary care resident groups. The setting was a suburban academic primary care practice and eligible patients were 18 years of age or older. Our aim was to increase immunisation rates of pneumococcal, influenza, varicella, herpes zoster virus and tetanus and diphtheria vaccination. There were 1690 patients eligible for the vaccination composite metric. Data were derived from the electronic health record and administrative data.

Interventions

Cohort 1 developed an initial intervention that consisted of a vaccine questionnaire for patients to complete while in the waiting room. Cohort 2 modified questionnaire after reviewing results from initial intervention. Cohort 3 recommended elimination of questionnaire and implementation of a bundled intervention approach.

Results

There were minimal improvements in patient immunisation rates after using a patient-directed paper questionnaire. After implementation of multiple interventions via an improvement bundle, there were improvements in immunisation rates which were sustained and the result of special cause variation.

Conclusion

A key to improving immunisation rates for MLIU patients in this clinic was developing relationships with faculty and staff stakeholders. We received feedback from all the medical staff and then applied it to the interventions and made an impact in the average of vaccinations.

Declined Functional Status Prolonged Hospital Stay for Community-Acquired Pneumonia in Seniors

Purpose

Among senior community-acquired pneumonia (CAP) survivors, functional status after hospitalization is often decreased. This study investigated the change of functional status affecting delayed discharge.

Patients and Methods

This retrospective observational study was conducted in two medical facilities from January 2016 to December 2018. Hospitalized CAP patients >64 years old were divided into two groups: an early group discharged ≤1 week after ending antibiotic treatment and a delayed group discharged >1 week after ending antibiotic treatment. The primary outcome was decline in functional status.

Results

The early group comprised 170 patients and the delayed group comprised 155 patients (median age: 78 vs 82 years; p = 0.007). Distribution of the causative microorganisms and initial prescription of antibiotics showed no significant differences in the two groups (p=0.38; p=0.83, respectively) More patients showed decline in functional status in the delayed group than the early group (16 (9.4%) vs 49 (31.6%), p<0.001), even if rehabilitation was more frequently conducted (77 (45.3%) vs 118 (76.1%); p<0.001). Higher medical expenses were observed in the delayed group ($8631 vs $3817, respectively; p<0.001). Multivariable regression analysis of factors contributing delayed discharge revealed that decreased functional status, pneumonia severity index (PSI) categories, rehabilitation enrolled, aspiration and age were independently associated with delayed discharge (odds ratio 4.31, 95% confidence interval (CI) 2.32–7.98; 2.34, 95% CI 1.43–3.82; 15.96, 95% CI 4.56–55.82 (PSI V vs II); 2.48, 95% CI 1.11–5.98; and 1.03, 95% CI 1.01–1.06; respectively).

Conclusion

Functional status decline was independently associated with extended hospitalization.

Hospital Admission Patterns in Adult Patients with Community-Acquired Pneumonia Who Received Ceftriaxone and a Macrolide by Disease Severity across United States Hospitals

(1) Objective: There are limited data regarding community-acquired pneumonia (CAP) admissions patterns in US hospitals. Current expert CAP guidelines advocate for outpatient treatment or an abbreviated hospital stay for CAP patients in pneumonia severity index (PSI) risk classes I-III (low risk); however, the extent of compliance with this recommendation is unclear. This study sought to estimate the proportion of admissions among CAP patients who received ceftriaxone and macrolide therapy, one of the most commonly prescribed guideline-concordant CAP regimens, by PSI risk class and Charlson comorbidity index (CCI) score. (2) Methods: A retrospective cross-sectional study of patients in the Vizient^® (MedAssets, Irving, Texas) database between 2012 and 2015 was performed. Patients were included if they were aged ≥ 18 years, had a primary diagnosis for CAP, and received ceftriaxone and a macrolide on hospital day 1 or 2. Baseline demographics and admitting diagnoses were used to calculate the PSI score. Patients in the final study population were grouped into categories by their PSI risk class and CCI score. Hospital length of stay, 30-day mortality rates, and 30-day CAP-related readmissions were calculated across resulting PSI-CCI strata. (3) Results: Overall, 32,917 patients met the study criteria. Approximately 70% patients were in PSI risk classes I-III and length of stay ranged between 4.9 and 6.2 days, based on CCI score. The 30-day mortality rate was <0.5% and <1.4% in patients with PSI risk classes I and II, respectively. (4) Conclusions: Over two-thirds of hospitalized patients with CAP who received ceftriaxone and a macrolide were in PSI risk classes I-III. Although the findings should be interpreted with caution, they suggest that there is a potential opportunity to improve the efficiency of healthcare delivery for CAP patients by shifting inpatient care to the outpatient setting in appropriate patients.

Hospitalization direct cost of adults with community-acquired pneumonia in Portugal from 2000 to 2009

INTRODUCTION

Hospitalizations due to community-acquired pneumonia (CAP) in mainland Portugal from 2000 to 2009 accounted for 3.7% of all hospital admissions in population with 18 or more years of age. There is no direct-cost data regarding these admissions.

METHODS

In this observational descriptive study all adult hospitalizations associated with CAP diagnosis were retrospectively analyzed for the period between 2000 and 2009. Patients under 18 years old, those with pneumonia as secondary diagnosis, patients with tuberculous or obstructive pneumonia, and immunocompromised patients were excluded from the study. The direct cost of hospitalization was calculated according to the diagnosis-related groups (DRG), established for the respective year of hospitalization.

RESULTS

There were 294,026 hospital admissions with an average annual direct cost of 80 million Euros, which almost doubled between 2000 and 2009. The average direct hospitalization costs per admission, including wards and Intensive Care Units (ICU), amounted to €2,707, with an increasing trend. The average hospitalization cost was €2,515 for admissions resulting in live discharge, and €3,457 for the deceased.

CONCLUSION

The average direct cost of adult hospitalizations associated with CAP amounted to €2,707 in mainland Portugal from 2000 to 2009, showing an increase of 37.5% in hospitalization cost of living and deceased patients. The economic impact of CAP-related hospital admissions justifies the need for better implementation of preventive measures.

New antibiotics for community-acquired pneumonia

PURPOSE OF REVIEW

This review provides the rationale for the development of new antibiotics to treat community-acquired pneumonia (CAP). It also provides an overview of the new antibiotics targeting CAP that have recently received approval by the regulatory agencies, and those antibiotics that are in the development pipeline.

RECENT FINDINGS

CAP is one of the most common reasons for hospitalization and carries a significant morbidity and risk of mortality. Increasing antibiotic resistance amongst the common bacterial pathogens associated with CAP, especially staphylococci and Streptococcus pneumoniae, has made the empiric treatment of this infection increasingly problematic. Moreover, failure of initial empiric therapy to cover the causative agents associated with CAP can be associated with worse clinical outcomes. There have been several antibiotics newly approved or in development for the treatment of CAP. These agents include delafloxacin, omadacycline, lefamulin, solithromycin, nemonoxacin, and ceftaroline. Their major advantages include activity against methicillin-resistant Staphylococcus aureus and macrolide-resistant Strep. pneumoniae.

SUMMARY

CAP continues to be an important infection because of its impact on patient outcomes especially in the elderly and immunocompromised hosts. The availability of new antibiotics offers an opportunity for enhanced empiric treatment of the antibiotic-resistant bacterial pathogens associated with CAP.

D-dimer as A Biomarker of Severity and Adverse Outcomes in Patients with Community Acquired Pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) stands as a main cause of hospitalization and mortality worldwide. Because of their limitation scoring systems such as CURB-65 and Pneumonia Severity Index (PSI) may underestimate the severity of the disease. Intravascular and intra-alveolar activation of coagulation factors may lead to fibrin deposition in alveoli and lung interstitium. The clinical utility of D-dimer measurement in patients with CAP is still unclear. The aim of this study was to evaluate the association of D-dimer levels with severity of CAP, need for invasive mechanical ventilation, vasopressor support, and 7 d in-hospital mortality.

METHODS

Prospective observational study from August 2016-November 2017 in a secondary care level hospital at Mexico City. CURB-65 and PSI scores were calculated on admission. D-dimer levels were measured by a fluorescence immunoassay.

RESULTS

A total of 61 adult patients with CAP were analyzed and categorized into low or high-risk groups using CURB 65 and PSI score. The average age was 71.6 ± 15 years, predominantly men (52%). Statistically significant higher D-dimer levels, vasopressor support, and mechanical ventilation were observed in high-risk groups. The AUC to predict 7 d in-hospital mortality was 0.93 (p <0.0001) for PSI, 0.853 (p = 0.01) for CURB 65, and 0.789 (p = 0.001) for D-dimer. A D-dimer cut-off point of 2400 mcg/L showed a sensitivity = 1 and a specificity = 0.614, as well as a positive predictive value = 0.154 and a negative predictive value = 1.

CONCLUSION

D-dimer plasma levels are associated with the severity of CAP. Patients with D-dimer below 2400 mcg/L have low probability of mortality at 7 d after admission to the emergency department.

Post Hoc Assessment of Time to Clinical Response Among Adults Hospitalized with Community-Acquired Bacterial Pneumonia Who Received Either Lefamulin or Moxifloxacin in 2 Phase III Randomized, Double-Blind, Double-Dummy Clinical Trials

Time to clinical response, a proxy for hospital "discharge readiness," was compared between CABP inpatients who received lefamulin or moxifloxacin in the Lefamulin Evaluation Against Pneumonia (LEAP) trials. The analysis included 926 inpatients. A short and comparable median time to clinical response (4 days) was observed in both treatment groups.

Antibiotic Treatment Failure and Associated Outcomes Among Adult Patients With Community-Acquired Pneumonia in the Outpatient Setting: A Real-world US Insurance Claims Database Study

Background

Antibiotic treatment failure is common among patients with community-acquired pneumonia (CAP) who are managed in the outpatient setting and is associated with higher mortality and increased health care costs. This study's objectives were to quantify the occurrence of antibiotic treatment failure (ATF) and to evaluate clinical and economic outcomes between CAP patients who experienced ATF relative to those who did not.

Methods

Retrospective analysis of the MarketScan Commercial & Medicare Supplemental Databases was performed, identifying patients ≥18 years old, with a pneumonia diagnosis in the outpatient setting, and who received a fluoroquinolone, macrolides, beta-lactam, or tetracycline. ATF was defined as any of the following events within 30 days of initial antibiotic: antibiotic refill, antibiotic switch, emergency room visit, or hospitalization. Outcomes included 30-day all-cause mortality and CAP-related health care costs.

Results

During the study period, 251 947 unique patients met inclusion criteria. The mean age was 52.2 years, and 47.7% were male. The majority of patients received a fluoroquinolone (44.4%) or macrolide (43.6%). Overall, 22.1% were classified as ATFs. Among 18-64-year-old patients, 21.2% experienced treatment failure, compared with 25.7% in those >65 years old. All-cause mortality was greater in the antibiotic failure group relative to the non-antibiotic failure group (18.1% vs 4.6%, respectively), and the differences in 30-day mortality between antibiotic failure groups increased as a function of age. Mean 30-day CAP-related health care costs were also higher in the patients who experienced treatment failure relative to those who did not ($2140 vs $54, respectively).

Conclusions

Treatment failure and poor outcomes from outpatient CAP are common with current guideline-concordant CAP therapies. Improvements in clinical management programs and therapeutic options are needed.

Hospital-Based Resource Use and Costs Among Patients With Idiopathic Pulmonary Fibrosis Enrolled in the Idiopathic Pulmonary Fibrosis Prospective Outcomes (IPF-PRO) Registry

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a rare and serious condition that is associated with high health-care resource use. The goal of this study was to estimate hospital-related resource use and costs by using a national, prospective registry of patients who were diagnosed with IPF or who had their diagnosis confirmed at the enrolling center in the past 6 months in the United States.

METHODS

Participants enrolled between June 5, 2014, and April 12, 2016, in the ongoing Idiopathic Pulmonary Fibrosis Prospective Outcomes Registry were included (N = 300). Time to first hospitalization was analyzed by using Kaplan-Meier methods. Annualized costs were estimated for hospitalizations, ICU admissions, and ED visits.

RESULTS

At enrollment, most participants were male (75%), white (95%), commercially insured (64%), smokers (68%), had an FVC between 50% and 80% predicted (66%), and received antifibrotic drugs (55%). During the first 12 months of follow-up, participants averaged 0.11 ED visit, 0.42 hospitalization, 0.08 ICU admission, 2.18 hospital days, and 0.45 ICU day. Probability of hospitalization was 18% and 30% at 6 and 12 months, respectively, and was highest for those with FVC < 50% predicted/diffusing lung capacity for carbon monoxide < 30% predicted. Mean annual costs (95% CI) for ICU admission and inpatient care were $10,098 ($4,732-$16,662) and $13,975 ($8,482-$20,918), respectively, per patient.

CONCLUSIONS

IPF is associated with a substantial economic burden incurred by patients requiring hospital care. Future research in IPF should focus on improving clinical outcomes while reducing cost of care in hospitals.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01915511; URL: www.clinicaltrials.gov.

Economic analysis of ceftaroline fosamil for treating community-acquired pneumonia in Spain

Background: Adults admitted to hospital with community-acquired pneumonia (CAP) impose significant burden upon limited hospital resources. To achieve early response and possibly early discharge, thus reducing hospital expenditure, the choice of initial antibiotic therapy is pivotal.Methods: A cost-consequences model was developed to evaluate ceftaroline fosamil (CFT) as an alternative to other antibiotic therapies (ceftriaxone, co-amoxiclav, moxifloxacin, levofloxacin) for the empiric treatment of hospitalized adults with moderate/severe CAP (PORT score III-IV) from the perspective of the Spanish National Health System (NHS).Findings: Compared with ceftriaxone, the model predicted an increase in the number of CFT-treated patients discharged early (PDE) (30.6% vs. 26.1%) while decreasing initial antibiotic failures (3.8% vs. 7.6%). For patients with pneumococcal pneumonia, CFT was cost-saving vs. ceftriaxone (by 1.2%) and significantly increased PDE (32.1% vs. 24.6%). CFT resulted in cost-saving vs. levofloxacin, due lower initial antibiotic therapy costs and increased PDE (30.6% vs. 14.9%). Moxifloxacin and co-amoxiclav early response rate of 53.63% and 54.24% resulted in cost neutrality vs. CFT, with direct comparison hampered by the significantly different early response criteria utilized in the literature.Conclusions: Despite a higher unit cost, CFT is a reasonable alternative to other agents for adults hospitalized with moderate/severe CAP, given the projected higher PDE achieved with similar or lower total costs.

The annual economic burden among patients hospitalized for community-acquired pneumonia (CAP): a retrospective US cohort study

Objective: To assess the 1-year economic burden among patients hospitalized for community-acquired pneumonia (CAP) in the US.Methods: Adult patients hospitalized for CAP between 1/2012 and 12/2016 were identified from the IQVIA hospital charge data master (CDM) linked to the IQVIA Real-World Data Adjudicated Claims - US Database (date of admission = index date). Patients had continuous enrollment 180-days pre- and 360-days post-index, and empiric antimicrobial treatment (monotherapy [EM] or combination therapy [EC]) and chest x-ray on the index date or day after. All-cause and CAP-related healthcare resource utilization and cost were assessed over the 1-year follow-up. Generalized linear models (GLM) examined adjusted total cost.Results: The cohort comprised 1624 patients hospitalized for CAP (mean age 50.3; 52.8% female). The majority (78.2%) initiated EC, most frequently with beta-lactams + macrolides (30.4%). The index hospitalization was associated with a mean length of stay (LOS) of 5.7 days and mean cost of $17,736; 22.7% had a transfer to the intensive care unit (ICU). All-cause readmission rates at 30- and 180-days were 8.8% and 20.1%, respectively. Mean annual all-cause total cost was $61,928; one-third (33.8%, $20,954) was related to CAP. The primary cost driver was inpatient care, which accounted for more than half (56.0%) of total all-cause cost and 94.3% of total CAP-related cost. Mean total inpatient cost was significantly higher among EC versus EM patients ($37,106 versus $25,999, p = .0399). Adjusted mean total all-cause cost was $55,391.Conclusions: Patients hospitalized for CAP incurred a significant annual economic burden, driven substantially by the high cost of hospitalizations.

Rates of hospitalization for community-acquired pneumonia among US adults: A systematic review

BACKGROUND

Community-acquired pneumonia (CAP) is associated with significant disease burden in adults but has not been measured uniformly. Reconciling differences across studies is critical for understanding the true burden of CAP.

METHODS

We performed a systematic literature review of the incidence of hospitalized CAP among US adults and described the impact of key study characteristics on these estimates.

RESULTS

After review of 8361 articles as of January 31, 2019, we identified 28 studies with 41 unique estimates of hospitalized CAP incidence. Among adults ≥65 years of age, annual rates of hospitalized CAP ranged from 847 to 3500 per 100,000 persons with median = 1830. Rates were lower in studies that excluded patients with healthcare-associated (but community-onset) pneumonia (HCAP; median = 2003 vs 1286; P = 0.02) or immunocompromising conditions (median = 1895 vs 1409; P = 0.27) compared to those that did not. Rates of CAP were also lower in studies that used more restrictive criteria for diagnosing pneumonia (eg, pneumonia coded in any diagnosis position [median = 2270] vs pneumonia coded in the first position only [median = 1375] in studies of administrative claims; P = 0.02). For adults <65 years of age, rates of CAP were lower (range: 89 to 1138 per 100,000; median = 199).

CONCLUSIONS

CAP causes a significant disease burden among adults, particularly among those ≥65 years of age. Commonly-applied exclusion criteria (eg, persons with HCAP or immunocompromising conditions) or restrictive case definitions (eg, only including pneumonias coded in the primary diagnosis position) have led to systematic underestimation of CAP incidence in many previous studies. In studies that did not apply these restrictive criteria, the rate of hospitalization was approximately 2000 per 100,000 annually. Understanding the true burden of adult CAP is critical for highlighting the ongoing need for expanded prevention programs, including vaccination.

Community-acquired pneumonia as an emergency condition

PURPOSE OF REVIEW

Despite the improvements in its management, community-acquired pneumonia (CAP) still exhibits high global morbidity and mortality rates, especially in elderly patients. This review focuses on the most recent findings on the epidemiology, cause, diagnosis and management of CAP.

RECENT FINDINGS

There is consistent evidence that the trend in CAP mortality has declined over time. However, the mortality of pneumococcal CAP has not changed in the last two decades, with an increase in the rate of hospitalization and more severe forms of CAP. Streptococcus pneumoniae remains the most frequent cause of CAP in all settings, age groups and regardless of comorbidities. However, the implementation of molecular diagnostic tests in the last years has identified respiratory viruses as a common cause of CAP too. The emergency of multidrug-resistance pathogens is a worldwide concern. An improvement in our ability to promptly identify the causative cause of CAP is required in order to provide pathogen-directed antibiotic therapy, improve antibiotic stewardship programs and implement appropriate vaccine strategies.

SUMMARY

It is time to apply all the knowledge generated in the last decade in order to optimize the management of CAP.

Optimal approaches to preventing severe community-acquired pneumonia

Introduction: Community-acquired pneumonia (CAP) has the highest rate of mortality of all infectious diseases, especially among the elderly. Severe CAP (sCAP) is defined as a CAP in which intensive care management is required and is associated with an unfavorable clinical course. Areas covered: This review aims to identify prevention strategies for reducing the incidence of CAP and optimized management of sCAP. We highlight the main prevention approaches for CAP, focusing on the latest vaccination plans and on the influence of health-risk behaviors. Lastly, we report the latest recommendations about the optimal approach for sCAP when CAP has already been diagnosed, including prompt admission to ICU, early empirical antibiotic therapy, and optimization of antibiotic use. Expert opinion: Despite improvements in the diagnosis and treatment of sCAP, more efforts are needed to combat preventable causes, including the implementation and improvement of vaccine coverage, anti-tobacco campaigns and correct oral hygiene. Moreover, future research should aim to assess the benefits of early antimicrobial therapy in primary care. Pharmacokinetic studies in the target population may help clinicians to adjust dosage regimens in critically ill patients with CAP and thus reduce rates of treatment failure.

Missed opportunities for pneumococcal vaccinations in high-risk and older adults in the United States

Pneumococcal vaccination rates remain sub-optimal in high-risk adult populations. This analysis quantified "missed opportunities," defined as number of healthcare encounters in unvaccinated patients who are recommended to be vaccinated. The 2015 National Health Interview Survey was used to assess vaccination status from adults 18-64 with risk factor and adults ≥65 years-old. In older adults, there was a mean of 5.15 (95% CI: 4.90-5.39) healthcare visits that could be opportunities for pneumococcal vaccination. In adults 18-64 years at high risk, there was a mean of 4.83 (95% CI: 4.66-4.99). Healthcare providers should take advantage of patient interactions to increase vaccination rates.

Cost-Saving Opportunities with an Oral and Intravenous Once-Daily Aminomethylcycline Antibiotic for Hospitalized Patients with Community-Acquired Bacterial Pneumonia: Findings from Decision-Analytic Models

BACKGROUND

The most frequently prescribed regimens for the treatment of hospitalized adults with suspected or documented community-acquired bacterial pneumonia (CABP), an acute bacterial infection of the pulmonary parenchyma, are ceftriaxone plus a macrolide, or a respiratory fluoroquinolone. Although these regimens are consistent with expert guidelines, there are growing concerns regarding their safety and efficacy. Omadacycline is a once-daily antibiotic with oral and intravenous (IV) formulations; it was recently approved in the United States for the treatment of adults with CABP.

OBJECTIVE

To estimate the cost impact of shortening hospital stay or avoiding hospitalization when using a treatment with an IV and an oral formulation, such as omadacycline, versus an IV-only drug regimen, such as ceftriaxone plus a macrolide, in adults with CABP who are not candidates for respiratory fluoroquinolone therapy.

METHODS

We developed 2 conceptual healthcare decision models to identify potential cost-saving opportunities in hospitalized adults with CABP who receive omadacycline versus ceftriaxone plus a macrolide. The early hospital discharge model examined the cost impact of shifting patients with CABP from inpatient treatment with ceftriaxone plus a macrolide to inpatient IV omadacycline treatment and early hospital discharge with oral omadacycline. The hospital-avoidance model examined the cost impact of omadacycline treatment in the outpatient setting in patients with CABP who have low disease severity. The models defined the upper range of the daily acquisition cost for omadacycline that conferred cost-savings relative to inpatient treatment with ceftriaxone plus a macrolide.

RESULTS

In the early hospital discharge model, omadacycline showed cost-savings with a 2-day hospital stay reduction if the daily cost of omadacycline was ≤$836, almost twice its wholesale acquisition cost. In the hospital-avoidance model, the daily omadacycline thresholds that still conferred cost-savings relative to inpatient ceftriaxone plus a macrolide ranged from $1302 to $1334, based on a daily wholesale acquisition cost of $450 for omadacycline, depending on the potential use of the emergency department and an observation unit.

CONCLUSION

The study findings show that the targeted use of omadacycline for the treatment of select patient populations with CABP could result in cost-savings relative to inpatient treatment with ceftriaxone plus a macrolide.

Differences in hospitalizations, emergency room admissions, and outpatient visits among Mexican-American Medicare beneficiaries

BACKGROUND

Few studies have investigated the healthcare utilization of Mexican-American Medicare beneficiaries. We used survey data that has been linked with Medicare claims records to describe the healthcare utilization of Mexican-American Medicare beneficiaries, determine common reasons for hospitalizations, and identify characteristics associated with healthcare utilization.

METHODS

Data came from wave five (2004/05) of the Hispanic Established Populations for the Epidemiological Study of the Elderly. The final sample included 1187 participants aged ≥75 who were followed for two-years (eight-quarters). Generalized estimating equations were used to estimate the probability of ≥1 hospitalization, emergency room (ER) admissions, and outpatient visits.

RESULTS

The percentage of beneficiaries who had ≥1 hospitalizations, ER admissions, and outpatient visits for each quarter ranged from 10.12-12.59%, 14.15-19.03%, and 76.61-80.68%, respectively. Twenty-three percent of hospital discharges were for circulatory conditions and 17% were for respiratory conditions. Hospitalizations for heart failure and simple pneumonia were most common. Older age was associated with significantly higher odds for ER admissions (OR = 1.49, 95% CI = 1.21-1.84) but lower odds for outpatient visits (OR = 0.74, 95% CI = 0.57-0.96). Spanish language and female gender were associated with significantly higher odds for hospitalizations (OR = 1.53, 95% CI = 1.14-2.06) and outpatient visits (OR = 1.82, 95% CI = 1.43-2.33), respectively. Having a middle-school or higher level of education was associated with significantly lower odds for ER admissions (OR = 0.71, 95% CI = 0.56-0.91). Participants who were deceased within two-years had significantly higher odds for hospitalizations (OR = 6.15, 95% CI = 4.79-7.89) and ER admissions (OR = 3.63, 95% CI = 2.88-4.57) than participants who survived at least three-years.

CONCLUSION

We observed high healthcare utilization among Mexican-American Medicare beneficiaries. Forty percent of all hospitalizations were for circulatory and respiratory conditions with hospitalizations for heart failure and pneumonia being the most common. Older age, gender, education, language, and mortality were all associated with healthcare utilization. Continued research is needed to identify patterns and clusters of social determinants and health characteristics associated with healthcare utilization and outcomes in older Mexican-Americans.

Impact of pneumococcal conjugate vaccines on hospitalizations for pneumonia in the United States

INTRODUCTION

Pneumonia is one of the leading causes of morbidity and mortality among children and older adults. Pneumococcal conjugate vaccines (PCVs) were introduced into the US routine infant vaccination schedule leading to substantial reductions of invasive pneumococcal diseases (IPD). PCV introduction also led to reductions in all-cause pneumonia among US children, though the indirect impact of PCVs on pneumonia in adults is difficult to quantify, especially due to the recent US recommendation for direct PCV use in older adults. Areas covered: We described the existing evidence for both the direct and indirect impact of PCVs on pneumonia among children and adults in the US since PCV introduction. Expert commentary: The introduction of PCVs into the US routine infant vaccination schedule led to important reductions in the burden of IPD and non-invasive pneumonia among vaccinated and unvaccinated populations. The impact of direct vaccination of older adults in the US since 2014, though difficult to quantify, is currently being evaluated. As pneumonia remains one of the leading causes of morbidity and mortality in the US, future evaluations of the direct and indirect effects of current and expanded valency PCVs in the US population are needed.

Pneumonia-associated death in patients with dementia: A systematic review and meta-analysis

BACKGROUND

Pneumonia is a serious disease associated with mortality among patients with dementia. However, the reported frequency of pneumonia as a cause of death in patients with dementia varies, the reason for which has not been fully elucidated.

METHODS

We conducted a systematic search in PubMed and the Cochrane Database of Systematic Reviews (inception to December 2016). Two authors independently determined the suitability of studies and potential bias and extracted the data. The primary outcome was frequency of pneumonia-associated death in patients with dementia. Stratified subgroup analysis was conducted among studies grouped according to type of mortality cause (immediate or underlying), information source of mortality cause (autopsy or death certificate), and study setting (clinic, hospital, or nursing home).

RESULTS

We included 7 studies reporting the cause of death among patients with dementia and 12 studies comparing the cause of death among patients with and without dementia. The frequency of pneumonia-associated death among 19 eligible studies was 29.69% (95% confidence interval [CI], 25.86-33.53). Those frequencies differed according to whether the source for information about cause of death was an autopsy confirmation (49.98%; 95% CI, 43.75-56.71) or death certificate (19.65%; 95% CI, 15.48-23.83) and according to whether the type of mortality cause was an indirect cause of death (13.96%; 95% CI, 9.42-18.51) or direct cause of death (44.45%; 95% CI, 29.81-50.10). The risk of pneumonia-associated death in patients with dementia was twice as high as among those without dementia (odds ratio, 2.15; 95% CI, 1.63-2.83; p < 0.001).

CONCLUSION

The various frequencies of pneumonia-associated death in patients with dementia were associated with the information source, type of mortality cause, and study setting. Patients with dementia in the terminal stages urgently require careful clinical management of pneumonia, to maximize patient life expectancy and quality.

Ceftobiprole for the treatment of pneumonia

Ceftobiprole is a fifth-generation cephalosporin with potent antimicrobial activity against Gram positive and Gram-negative bacteria. It has been approved in major European countries for the treatment of community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP), excluding ventilator-associated pneumonia (VAP). Ceftobiprole is currently in a phase 3 clinical program for registration in the U.S. In 2015, it was designated as an infectious disease product qualified for the treatment of lung and skin infections by the FDA. The efficacy of ceftobiprole in pneumonia has been demonstrated in two-phase III clinical trials conducted in patients with CAP and HAP. The recommended dose in the adult with pneumonia is 500 mg every 8 h infused in 2 h; in case of renal failure, the regimen of administration must be adjusted according to the patient's renal function. It is not necessary to adjust the dose according to gender, age, body weight or liver failure. In case of hyperfiltration, an extension to 4 h infusion of the 500mg TID is required.