Prognostic value of severity indicators of nursing-home-acquired pneumonia versus community-acquired pneumonia in elderly patients

Prognostic factors of poor outcomes in pneumonia in older adults: aspiration or frailty?

PURPOSE

Little is known about the long-term and functional prognoses of older adults with pneumonia, which complicates their management. There is a common belief that aspiration is a poor prognostic factor; however, the diagnosis of aspiration pneumonia (AP) lacks consensus criteria and is mainly based on clinical characteristics typical of the frailty syndrome. Therefore, the poor prognosis of AP may also be a result of frailty rather than aspiration. This study investigated the impact of AP and other prognostic factors in older patients with pneumonia.

METHODS

We performed a retrospective cohort study of patients aged 75 years and older, admitted with pneumonia in 2021. We divided patients according to their initial diagnosis (AP or non-AP), compared outcomes using Kaplan-Meier curves, and used logistic regression to identify independent prognostic factors.

RESULTS

803 patients were included, with a median age of 84 years and 52.7% were male. 17.3% were initially diagnosed with AP. Mortality was significantly higher in those diagnosed with AP than non-AP during admission (27.6% vs 19.0%, p = 0.024) and at 1 year (64.2% vs 53.1%, p = 0.018), with survival analysis showing a median survival time of 62 days and 274 days in AP and non-AP, respectively (χ2 = 9.2, p = 0.002). However, the initial diagnosis of AP was not an independent risk factor for poor prognosis in multivariable analysis. Old age, frailty and cardio-respiratory comorbidities were the main factors associated with death.

CONCLUSION

The greater mortality in AP may be a result of increased frailty rather than the diagnosis of aspiration itself. This supports our proposal for a paradigm shift from making predictions based on the potentially futile labelling of AP or non-AP, to considering frailty and overall condition of the patient.

The predictive value of anticholinergic drug exposure and the outcome of pneumonia: a Danish database study

INTRODUCTION

Older adults are susceptible to anticholinergic effects. Dysphagia and pneumonia are associated with anticholinergic usage, though a definitive causative relationship has not been established. There is no effective way to predict the prognosis of older adults with pneumonia; therefore, this study investigates the predictive value of anticholinergic burden.

METHODS

Patients aged 65 years and above admitted for community-acquired pneumonia from 2011 to 2018 in Denmark were included through Danish registries. We calculated anticholinergic drug exposure using the CRIDECO Anticholinergic Load Scale (CALS). The primary outcome was in-hospital mortality, and other outcomes included intensive care unit admission, ventilator usage, length of stay, 30-day/90-day/1-year mortality, institutionalisation, home care utilisation and readmission.

RESULTS

186,735 patients were included in the in-hospital outcome analyses, 165,181 in the readmission analysis, 150,791 in the institutionalisation analysis, and 95,197 and 73,461 patients in the home care analysis at follow-up. Higher CALS score was associated with higher in-hospital mortality, with a mean risk increasing from 9.9% (CALS 0) to 16.4% (CALS >10), though the risk plateaued above a CALS score of 8. A higher CALS score was also associated with greater mortality after discharge, more home health care, more institutionalizations and higher readmission rates.

CONCLUSIONS

High anticholinergic burden levels were associated with poor patient outcomes including short-/long-term mortality, dependence and readmission. It may be useful to calculate the CALS score on admission of older patients with pneumonia to predict their prognosis. This also highlights the importance of avoiding the use of drugs with a high anticholinergic burden in older patients.

Protein C activity as a potential prognostic factor for nursing home-acquired pneumonia

Introduction

Despite the poor prognosis for nursing home acquired pneumonia (NHAP), a useful prognostic factor is lacking. We evaluated protein C (PC) activity as a predictor of in-hospital death in patients with NHAP and community-acquired pneumonia (CAP).

Methods

This prospective, observational study included all patients hospitalized with pneumonia between July 2007 and December 2012 in a single hospital. We measured PC activity at admission and investigated whether it was different between survivors and non-survivors. We also examined whether PC activity < 55% was a predictor for in-hospital death of pneumonia by logistic regression analysis with CURB-65 items (confusion, blood urea >20 mg/dL, respiratory rate >30/min, and blood pressure <90/60 mmHg, age >65). When it was a useful prognostic factor for pneumonia, we combined PC activity with the existing prognostic scores, the pneumonia severity index (PSI) and CURB-65, and analyzed its additional effect by comparing the areas under the receiver operating characteristic curves (AUCs) of the modified and original scores.

Results

Participants comprised 75 NHAP and 315 CAP patients. PC activity was lower among non-survivors than among survivors in NHAP and all-pneumonia (CAP+NHAP). PC activity <55% was a useful prognostic predictor for NHAP (Odds ratio 7.39 (95% CI; 1.59–34.38), and when PSI or CURB-65 was combined with PC activity, the AUC improved (from 0.712 to 0.820 for PSI, and 0.657 to 0.734 for CURB-65).

Conclusions

PC activity was useful for predicting in-hospital death of pneumonia, especially in NHAP, and became more useful when combined with the PSI or CURB-65.

Prognostic utility of CURB-65 and E-CURB-65 scoring systems in healthcare associated pneumonia patients: Short- and long-term mortality

Background

The aim of our study is to evaluate whether the CURB-65 or expanded-CURB-65 score can be used in healthcare-associated pneumonia (HCAP) and subgroups of HCAP patients at the same efficiency. Thirty and 90-day mortality rates of the patients and predictive values of CURB-65 and E-CURB-65 scores were compared.

Patients and Methods

This is a retrospective study of patients who presented to the Emergency Department between January 2015 and January 2016. All patient charts above 18 years of age were evaluated according to American Thoracic Society and the Infectious Diseases Society of America (ATS/IDSA) pneumonia diagnostic criteria and pneumonia diagnoses were confirmed.

Results

167 pneumonia patients (27.8%) of all pneumonia cases were grouped as HCAP and 433 (54.4%) were grouped as community-acquired pneumonia (CAP). 43% (n = 72) of HCAP patients were classified as nursing home-associated pneumonia (NHAP) and 57% (n = 95) were classified as HCAP (except NHAP) group. NHAP patients were older than the other groups. HCAP (except NHAP) group had somehow more comorbid diseases when compared with the other groups. However, the NHAP group had more unstable vital signs and confusion rates. Hospital and ICU admissions, 30-90-day mortality rates were all significantly higher in NHAP group E-CURB-65 was found to have better predictive values than CURB-65 for 30-day and 90-day mortalities overall.

Conclusion

According to our results, commonly used scoring systems, CURB 65 and E-CURB 65, are not suitable for HCAP, NHAP, and HCAP (except NHAP) patients. NHAP patients have significant worse prognosis compared with CAP and HCAP (except NHAP) in terms of admission to intensive care and 30 and 90-day mortality rates.

Urea-to-Albumin Ratio and In-Hospital Mortality in Severe Pneumonia Patients

Objective

The urea-to-albumin ratio (UAR), as a new marker of the systemic inflammatory response, is associated with the mortality in pneumonia patients. However, the association between the UAR and in-hospital mortality in severe pneumonia (SP) has received little attention.

Methods

In this single-center retrospective cohort study, 212 SP patients in intensive care unit (ICU) from June 1, 2016, to June 1st, 2020, with baseline UAR were enrolled. The primary outcome was in-hospital mortality. The association of UAR with in-hospital mortality was assessed using a multivariable-adjusted Cox model.

Results

Of 212 patients, the median age was 73.0 (61.0, 82.8) years, 70.8% of patients were male, and the APACHE II score was 20.0 (16.0, 26.0). During the hospital period, 101 (47.6%) patients died. In-hospital mortality rates for the lower and higher UAR were 16 (27.6%) and 85 (55.2%), respectively (P < 0.001). Kaplan–Meier analysis revealed that survival rates were significantly different between the two groups (log rank = 13.71, P < 0.001). After adjusted for confounding factors, the higher UAR group was significantly associated with a hazard ratio (HR) for in-hospital mortality of 2.234 (95% confidence interval: 1.146–4.356, P=0.018). Besides, this pattern persisted in subgroup analyses considering sex (HR = 9.380; 95% CI: 2.248–39.138; P=0.002).

Conclusions

Higher UAR levels at the commencement of admission to ICU may be independently associated with increased in-hospital mortality in SP patients.

Incidence of Antibiotic Treatment Failure in Patients with Nursing Home-Acquired Pneumonia and Community Acquired Pneumonia

Purpose: Nursing home-acquired pneumonia (NHAP) patients are at higher risk of multi-drug resistant infection (MDR) than those with community-acquired pneumonia (CAP). Recent evidence suggests a single risk factor for MDR does not accurately predict the need for broad-spectrum antibiotics. The goal of this study was to compare the rate antibiotic failure between NHAP and CAP patients. Methods: Demographic characteristics, co-morbidities, clinical and laboratory variables, antibiotic therapy, and mortality data were collected retrospectively for all patients with pneumonia admitted to an Internal Medicine Service between April 2017 and April 2018. Results: In total, 313 of 556 patients had CAP and 243 had NHAP. NHAP patients were older, and were more likely to be dependent, to have recent antibiotic use, and to experience treatment failure (odds ratio (OR) 1.583; 95% CI 1.102–2.276; p = 0.013). In multivariate analysis, patient’s origin did not predict treatment failure (OR 1.083; 95% CI 0.726–1.616; p = 0.696). Discussion: Higher rates of antibiotic failure and mortality in NHAP patients were explained by the presence of other risk factors such as comorbidities, more severe presentation, and age. Admission from a nursing home is not a sufficient condition to start broader-spectrum antibiotics.

Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial

Background

Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting.

Methods/design

A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no).

Discussion

This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results.

Trial registration

Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.

Evaluation of pneumonia severity scoring systems in nursing and healthcare-associated pneumonia for predicting prognosis: A prospective, cohort study

The usefulness of existing pneumonia severity indices for predicting mortality in nursing and healthcare-associated pneumonia (NHCAP) is unclear. This study compared the usefulness of existing pneumonia severity indices for predicting mortality in NHCAP and community-acquired pneumonia (CAP). Consecutive hospitalized pneumonia patients including NHCAP and CAP patients were prospectively enrolled between October 2010 and November 2017. Admission pneumonia severity was assessed using CURB-65, Pneumonia Severity Index (PSI), A-DROP, Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) severe pneumonia criteria, and I-ROAD. The primary outcome was 30-day mortality. The discriminatory ability of each severity index was evaluated by receiver operating characteristic curve analysis. Overall, 828 patients had NHCAP, and 1330 patients had CAP. Thirty-day mortality was 12.8% and 5.6% in NHCAP and CAP patients, respectively. The area under the curve of PSI (0.717, 95% confidence interval 0.673-0.761) was the highest among all pneumonia severity indices, with significant differences compared with CURB-65 (0.651, 95% confidence interval 0.598-0.705, P = 0.02) and IDSA/ATS severe pneumonia criteria (0.659, 95% confidence interval 0.612-0.707, P = 0.03). The predictive abilities for 30-day mortality of the pneumonia severity indices, excluding PSI and I-ROAD, were significantly inferior for NHCAP than for CAP. PSI may be the most useful pneumonia severity score for predicting mortality in NHCAP. However, the predictive ability for mortality of each pneumonia severity score was worse for NHCAP than for CAP; therefore, the prognostic factors in NHCAP need to be identified for better management of NHCAP patients.

Mortality and Prognostic Prediction in Very Elderly Patients With Severe Pneumonia

INTRODUCTION

Although prognostic prediction scores for pneumonia such as CURB-65 score or pneumonia severity index (PSI) are widely used, there were a few studies in very elderly patients. The aim of the study was to validate prognostic prediction scores for severe pneumonia and investigate risk factors associated with in-hospital mortality of severe pneumonia in very elderly patients.

METHODS

During the 6-year study period (from October 2012 to May 2018), 160 patients aged 80 or older admitted to medical intensive unit were analyzed retrospectively. Pneumonia severity was evaluated using CURB-65 score, PSI, Sequential Organ Failure Assessment (SOFA) scores, A-DROP, I-ROAD, UBMo index, SOAR score, and lactate. The outcome was in-hospital mortality.

RESULTS

The median age was 85 years (interquartile range: 82-88). Nursing home residents accounted for 71 (44.4%) and in-hospital mortality was 40 (25.0%). Logistic regression showed that chronic lung, mechanical ventilation, hemodialysis, and albumin were associated with in-hospital mortality of pneumonia. Using the receiver operating characteristics curve for predicting mortality, the area under the curve in pneumonia was 0.65 for the SOFA score, 0.61 for the CURB-65 score, 0.52 for the PSI, 0.58 for the A-DROP, 0.52 for the I-ROAD, 0.54 for UBMo index, 0.59 for SOAR score, and 0.65 for lactate.

CONCLUSION

The performances of the CURB-65 and PSI are not excellent in very elderly patients with pneumonia. Further studies are needed to improve the performance of prognostic prediction scores in elderly patients.

Lower long-term mortality in obese patients with community-acquired pneumonia: possible role of CRP

OBJECTIVE

The present study aimed to investigate the relationship between obesity and mortality in patients with community-acquired pneumonia (CAP) in China.

METHODS

In total, 909 patients with CAP were recruited for this study from January 2010 to June 2015. All patients were selected and divided into 4 groups according to their body mass index (BMI) values. All patients' clinical information was recorded. The associations among mortality; BMI; the 30-day, 6-month and 1-year survival rates for different BMI classes; the etiology of pneumonia in each BMI group; and the risk factors for 1-year mortality in CAP patients were analyzed.

RESULT

With the exception of the level of C-reactive protein (CRP), no other clinical indexes showed significant differences among the different BMI groups. No significant differences were observed among all groups in terms of the 30-d and 6-month mortality rates (p>0.05). There was a significantly lower risk of 1-year mortality in the obese group than in the nonobese group, (p<0.05). Logistic regression analysis showed that there were seven independent risk factors for 1-year mortality in CAP patients, namely, age, cardiovascular disease, cerebrovascular disease, obesity, APACHE II score, level of CRP and CAP severity.

CONCLUSION

Compared with nonobese patients with CAP, obese CAP patients may have a lower mortality rate, especially with regard to 1-year mortality, and CRP may be associated with the lower mortality rate in obese individuals than in nonobese individuals.

Antimicrobial Resistance and Clinical Outcomes in Nursing Home-Acquired Pneumonia, Compared to Community-Acquired Pneumonia

PURPOSE

Patients with nursing home-acquired pneumonia (NHAP) should be treated as hospital-acquired pneumonia (HAP) according to guidelines published in 2005. However, controversy still exists on whether the high mortality of NHAP results from multidrug resistant pathogens or underlying disease. We aimed to outline differences and factors contributing to mortality between NHAP and community-acquired pneumonia (CAP) patients.

MATERIALS AND METHODS

We retrospectively evaluated patients aged 65 years or older with either CAP or NHAP from 2008 to 2014. Patients with healthcare-associated pneumonia other than NHAP or HAP were excluded.

RESULTS

Among 317 patients, 212 patients had CAP and 105 had NHAP. Patients with NHAP had higher mortality, more frequently used a ventilator, and had disease of higher severity than CAP. The incidences of aspiration, tube feeding, and poor functional status were higher in NHAP. Twenty three out of 54 NHAP patients and three out of 62 CAP patients had multidrug resistant pathogens (p<0.001). Eleven patients with NHAP died at discharge, compared to 7 patients with CAP (p=0.009). However, there was no association between mortality rate and presence of multidrug-resistant pathogens. The number of involved lobes on chest X-ray [odds ratio (OR)=1.708; 95% confidence interval (CI), 1.120 to 2.605] and use of mechanical ventilation (OR=9.537; 95% CI, 1.635 to 55.632) were significantly associated with in-hospital mortality.

CONCLUSION

Patients with NHAP had higher mortality than patients with CAP. The excess mortality among patients with NHAP and CAP was related to disease severity but not to the presence of multidrug resistant pathogens.

Nursing home-acquired pneumonia presenting at the emergency department

Nursing home-acquired pneumonia (NHAP) is one of the most common infections arising amongst nursing home residents, and its incidence is expected to increase as population ages. The NHAP recommendation for empiric broad-spectrum antibiotic therapy, arising from the concept of healthcare-associated pneumonia, has been challenged by recent studies reporting low rates of multidrug-resistant (MDR) bacteria. This single center study analyzes the results of NHAP patients admitted through the Emergency Department (ED) at a tertiary center during the year 2010. There were 116 cases, male gender corresponded to 34.5 % of patients and median age was 84 years old (IQR 77-90). Comorbidities were present in 69.8 % of cases and 48.3 % of patients had used healthcare services during the previous 90 days. In-hospital mortality rate was 46.6 % and median length-of-stay was 9 days. Severity assessment at the Emergency Department provided CURB65 index score and respective mortality (%) results: zero: n = 0; one: n = 7 (0 %); two: n = 18 (38.9 %); three: n = 26 (38.5 %); four: n = 30 (53.3 %); and five; n = 22 (68.2 %); and sepsis n = 50 (34.0 %), severe sepsis n = 43 (48.8 %) and septic shock n = 22 (72.7 %). Significant risk factors for in-hospital mortality in multivariate analysis were polypnea (p = 0.001), age ≥ 75 years (p = 0.02), and severe sepsis or shock (p = 0.03) at the ED. Microbiological testing in 78.4 % of cases was positive in 15.4 % (n = 15): methicillin-resistant Staphylococcus aureus (26.7 %), Pseudomonas aeruginosa (20.0 %), S. pneumoniae (13.3 %), Escherichia coli (13.3 %), others (26.7 %); the rate of MDR bacteria was 53.3 %. This study reveals high rates of mortality and MDR bacteria among NHAP hospital admissions supporting the use of empirical broad-spectrum antibiotic therapy in these patients.

Case-control study of pneumonia patients with Streptococcus anginosus group bacteria in their sputum

BACKGROUND AND OBJECTIVE

In recent years, Streptococcus anginosus group (SAG) bacteria are becoming increasingly recognized as important pneumonia-causing pathogens. Although several small studies have been reported, the features of SAG pneumonia remain unclear, because the identification of SAG from sputum cultures is not routinely performed in most microbiology laboratories. The aim of this study was to elucidate the clinical characteristics of SAG pneumonia.

PATIENT AND METHODS

This was a retrospective case-control study utilizing data obtained in our hospital between September 2009 and June 2016. We investigated 31 patients with SAG pneumonia (PWP), and also assessed the difference between the 31 PWP and 37 patients without pneumonia (PWOP) in whose sputum SAG was detected.

RESULTS

Seventy-one percent of the patients were men and the median age was 78 years in the PWP. Univariate analysis indicated that the PWP were significantly more often a bed-ridden (p < 0.01) with comorbid aspiration than were the PWOP (p < 0.05). Among the PWP, nursing and healthcare-associated pneumonia (NHCAP) was the more common type of pneumonia (54.8%). S. anginosus was detected significantly more frequently in sputum cultures of PWP than PWOP (p < 0.01), and multiple pathogens were detected more frequently in PWP (p < 0.01). Streptococcus constellatus was the most frequently detected pathogen in patients with a single bacterial infection. Empyema was observed only in patients with multiple bacteria.

CONCLUSIONS

SAG should be recognized as important causative pathogens of pneumonia, particularly among elderly patients with underlying disease associated with aspiration. NHCAP was the more common type of SAG pneumonia in this study.

Defining characteristics and risk indicators for diagnosing nursing home-acquired pneumonia and aspiration pneumonia in nursing home residents, using the electronically-modified Delphi Method

BACKGROUND

In nursing home residents, it is not possible to distinguish pneumonia and aspiration pneumonia clinically. International literature reveals no consensus on which and how many characteristics and risk indicators must be present to diagnose (nursing home-acquired) pneumonia and aspiration pneumonia. The aim of this survey was to reach consensus among a panel of clinical medical experts in geriatrics and pulmonology about the characteristics required for diagnosing pneumonia, and about the risk indicators needed to consider the diagnosis aspiration pneumonia in nursing home residents with pneumonia.

METHODS

Literature review and three expert-rating iterations using the electronically-modified Delphi Method were carried out. After each expert rating iteration, data analysis was performed. Qualitative responses and additional (nursing home-acquired) pneumonia characteristics which were mentioned in reply to structured open-ended questions were summarised, whilst similar responses were combined and these combinations were ordered by frequency in order to use them in the next iteration. Characteristics which failed to reach consensus were considered as inconclusive and eliminated. Consensus was reached when at least 70 % of the participants agreed.

RESULTS

Literature review revealed 16 currently used common characteristics for diagnosing (nursing home-acquired) pneumonia. No consensus was reached about characteristics and the number of characteristics required for diagnosing (nursing home-acquired) pneumonia. However, 57 % agreed that dyspnea, fever, deterioration of general functioning, tachypnea and crepitation with auscultation are the most important characteristics and the responses by the participants suggested that two or three characteristics should be present. Subsequently, 80 % of the participants agreed on the risk indicators dysphagia, choking incident, (history of) tube feeding, neurological disease and cognitive impairment for considering the diagnosis aspiration pneumonia in nursing home residents with pneumonia.

CONCLUSIONS

No final consensus could be reached about which and how many characteristics are required for diagnosing pneumonia in nursing home residents. However, the results indicated that dyspnea, fever, deterioration of general functioning, tachypnea and crepitation with auscultation are characteristics of some importance and that at least two or three characteristics should be present. With regard to considering aspiration pneumonia in nursing home residents with pneumonia, final consensus was reached about the risk indicators dysphagia, choking incident, (history of) tube feeding, neurological disease and cognitive impairment.

Age, Dehydration, Respiratory Failure, Orientation Disturbance, and Blood Pressure Score Predicts In-hospital Mortality in HIV-negative Non-multidrug-resistant Smear-positive Pulmonary Tuberculosis in Japan

The A-DROP scoring system was originally designed to assess clinical severity of community acquired pneumonia using the following parameters: advanced Age, Dehydration, Respiratory failure, Orientation disturbance (confusion); and, low blood Pressure. Total A-DROP score ranges zero to five assigning one point for each component, wherein five indicates the poorest prognosis. The purpose of this single-center retrospective study was to determine whether A-DROP could predict the risk for death in patients with pulmonary tuberculosis. We reviewed consecutive HIV-negative, non-multidrug-resistant smear-positive adult pulmonary tuberculosis patients. The cohort consisted of 134 men (38.8%), 211 women (61.2%), 272 who discharged alive (28.8%), and 73 who died in-hospital (21.2%) with a median age of 72 (IQR: 54-82) years. A one-point increase in the A-DROP score was associated with a higher risk for in-hospital mortality with odds ratio of 3.8 (95% confidence interval 2.8-5.2, P < 0.001). The area under receiver operating characteristics curve was 0.86. The total score cutoff of 1.5 provided the best Youden Index of 0.61. Using this criteria, total score >1.5, sensitivity was 85% and specificity was 76%. Kaplan-Meier curve clearly indicated that in-hospital mortality increased with higher A-DROP scores (Log-rank test <0.001). In conclusion, A-DROP score clearly indicate pulmonary tuberculosis in-hospital mortality.

Impact of microbiological samples in the hospital management of community-acquired, nursing home-acquired and hospital-acquired pneumonia in older patients

We investigated the positivity rate, the detection rates for non-covered pathogens and the therapeutic impact of microbiological samples (MS) in community-acquired pneumonia (CAP), nursing home-acquired pneumonia (NHAP) and hospital-acquired pneumonia (HAP) in elderly hospitalised patients. Patients aged 75 years and over with pneumonia and hospitalised between 1/1/2013 and 30/6/2013 in the departments of medicine (5) and intensive care (1) of our university hospital were included. Microbiological findings, intra-hospital mortality and one-year mortality were recorded. Among the 217 patients included, there were 138 CAP, 56 NHAP and 23 HAP. MS were performed in 89.9, 91.1 and 95.6 % of CAP, NHAP and HAP, respectively. Microbiological diagnosis was made for 29, 11.8 and 27.3 % of patients for CAP, NHAP and HAP, respectively (p = 0.05). Non-covered pathogens were detected for 8 % of CAP, 2 % of NHAP and 13.6 % of HAP (p = 0.1). The antimicrobial spectrum was significantly more frequently reduced when the MS were positive (46.7 % vs. 10.8 % when MS were negative, p = 10(-7)). The MS positivity rate was significantly lower in NHAP than in CAP and HAP. MS revealed non-covered pathogens in only 2 % of NHAP. These results show the poor efficiency and weak clinical impact of MS in the management of pneumonia in hospitalised older patients and suggest that their use should be rationalised.

Predictors of mortality for nursing home-acquired pneumonia: a systematic review

Background. Current risk stratification tools, primarily used for CAP, are suboptimal in predicting nursing home acquired pneumonia (NHAP) outcome and mortality. We conducted a systematic review to evaluate current evidence on the usefulness of proposed predictors of NHAP mortality. Methods. PubMed (MEDLINE), EMBASE, and CINAHL databases were searched for articles published in English between January 1978 and January 2014. The literature search elicited a total of 666 references; 580 were excluded and 20 articles met the inclusion criteria for the final analysis. Results. More studies supported the Pneumonia Severity Index (PSI) as a superior predictor of NHAP severity. Fewer studies suggested CURB-65 and SOAR (especially for the need of ICU care) as useful predictors for NHAP mortality. There is weak evidence for biomarkers like C-reactive protein and copeptin as prognostic tools. Conclusion. The evidence supports the use of PSI as the best available indicator while CURB-65 may be an alternative prognostic indicator for NHAP mortality. Overall, due to the paucity of information, biomarkers may not be as effective in this role. Larger prospective studies are needed to establish the most effective predictor(s) or combination scheme to help clinicians in decision-making related to NHAP mortality.