Risk Factors for Community-Acquired Pneumonia in Adults: A Systematic Review of Observational Studies.

We performed a systematic review of the literature to establish conclusive evidence of risk factors for community-acquired pneumonia (CAP). Observational studies (cross-sectional, case-control, and cohort studies) the primary outcome of which was to assess risk factors for CAP in both hospitalized and ambulatory adult patients with radiologically confirmed pneumonia were selected. The Newcastle-Ottawa Scale specific for cohort and case-control designs was used for quality assessment. Twenty-nine studies (20 case-control, 8 cohort, and 1 cross-sectional) were selected, with 44.8% of them focused on elderly subjects ≥65 years of age and 34.5% on mixed populations (participants' age >14 years). The median quality score was 7.44 (range 5-9). Age, smoking, environmental exposures, malnutrition, previous CAP, chronic bronchitis/chronic obstructive pulmonary disease, asthma, functional impairment, poor dental health, immunosuppressive therapy, oral steroids, and treatment with gastric acid-suppressive drugs were definitive risk factors for CAP. Some of these factors are modifiable. Regarding other factors (e.g., gender, overweight, alcohol use, recent respiratory tract infections, pneumococcal and influenza vaccination, inhalation therapy, swallowing disorders, renal and liver dysfunction, diabetes, and cancer) no definitive conclusion could be established. Prompt assessment and correction of modifiable risk factors could reduce morbidity and mortality among adult CAP patients, particularly among the elderly.

DianaHealth.com, an On-Line Database Containing Appraisals of the Clinical Value and Appropriateness of Healthcare Interventions: Database Development and Retrospective Analysis.

OBJECTIVE: To describe the development of a novel on-line database aimed to serve as a source of information concerning healthcare interventions appraised for their clinical value and appropriateness by several initiatives worldwide, and to present a retrospective analysis of the appraisals already included in the database. METHODS AND FINDINGS: Database development and a retrospective analysis. The database DianaHealth.com is already on-line and it is regularly updated, independent, open access and available in English and Spanish. Initiatives are identified in medical news, in article references, and by contacting experts in the field. We include appraisals in the form of clinical recommendations, expert analyses, conclusions from systematic reviews, and original research that label any health care intervention as low-value or inappropriate. We obtain the information necessary to classify the appraisals according to type of intervention, specialties involved, publication year, authoring initiative, and key words. The database is accessible through a search engine which retrieves a list of appraisals and a link to the website where they were published. DianaHealth.com also provides a brief description of the initiatives and a section where users can report new appraisals or suggest new initiatives. From January 2014 to July 2015, the on-line database included 2940 appraisals from 22 initiatives: eleven campaigns gathering clinical recommendations from scientific societies, five sets of conclusions from literature review, three sets of recommendations from guidelines, two collections of articles on low clinical value in medical journals, and an initiative of our own. CONCLUSIONS: We have developed an open access on-line database of appraisals about healthcare interventions considered of low clinical value or inappropriate. DianaHealth.com could help physicians and other stakeholders make better decisions concerning patient care and healthcare systems sustainability. Future efforts should be focused on assessing the impact of these appraisals in the clinical practice.

Características de los pacientes y carga asistencial durante la pandemia de gripe A (H1N1) 2009 en el Hospital Universitario Vall d’Hebron de Barcelona / Patient characteristics and health care burden during the influenza A (H1N1) 2009 pandemic in the university Hospital Vall d’Hebron of Barcelona

La pandemia de gripe A (H1N1) 2009 repercutió inicialmente de forma leve en los hospitales de Cataluña, pero en el otoño se produjo una destacada onda pandémica. Se describen las principales características de los pacientes atendidos en el Hospital Universitaro Vall d’Hebron de Barcelona (HUVH) en el transcurso de la pandemia, la factores asociados a riesgo de hospitalización y la carga asistencial generada. Pacientes y métodos. Se incluyen todos los casos de gripe A (H1N1) 2009 con confirmación microbiológica, atendidos desde el 2 de julio de 2009 al 22 de enero de 2010. Se ha realizado un análisis descriptivo de los casos y un análisis multivariado para conocer las variables asociadas al riesgo de hospitalización. Resultados El diagnóstico se confirmó en 741 pacientes, de los que el 56,8% tenían menos de 16 años, mientras que los de 65 y más años representaron únicamente el 2,8%. Un 33% de los niños no presentaron ningún factor de riesgo de complicaciones, en cambio en los adultos fueron el 45%. Fueron hospitalizados 190 casos, de ellos 26 en UCI con 5 defunciones. La edad inferior a un año, la inmunodeficiencia y la patología neuromuscular fueron los factores asociados de forma significativa al riesgo de hospitalización en niños, y la patología crónica pulmonar en los adultos. El diagnóstico de neumonía en urgencias fue un factor determinante de hospitalización, tanto en niños como adultos. La máxima carga asistencial se registró el 19 de noviembre con 43 pacientes hospitalizados, 6 de ellos en UCI.(..) (AU)

Background and objective: The influenza A(H1N1) 2009 pandemic initially had a mild impact in Catalonian hospitals, but in the autumn there was an important pandemic wave. We describe the main characteristics of patients seen in the Vall d’Hebron University Hospital in Barcelona (HUVH) during this pandemic, the risk factors associated with hospitalization and the health-care burden generated. Material and method: We included all cases of influenza A (H1N1) 2009 with laboratory confirmation seen in the HUVH from July 2, 2009 to January 22, 2010. We performed a descriptive analysis of the cases and a multivariate analysis to identify variables associated with the risk of hospitalization. Results: The diagnosis was confirmed in 741 patients; 56.8% were under 16 years, while only 2.8% were 65and over. Thirty three per cent of children had no risk factor for complications, whereas in adults itwas45%.One hundred and ninety cases were hospitalized, 26 of them in the intensive care unit (ICU) with 5 deaths. The factors associated with risk of hospitalization were, age less than one year, immunodeficiency, and neuromuscular disease in children; and chronic lung disease in adults. The diagnosis of pneumonia in the emergency department was an important predictor of hospitalization in both children and adults. The maximum caseload was recorded on November 19, with 43 hospital admissions, 6 of them in the ICU. Conclusions: Between July and September 2009 the pandemic had a low impact on hospital resources, but in autumn there was a marked increase in emergency department visits and hospitalizations. Children had higher rates of confirmed cases, while adults had higher rates of hospitalizations. The risk of hospitalization was higher in patients with certain conditions especially in those with pneumonia. The pandemic wave was a moderate work load for HUVH, since it did not involve any modification of the usual healthcare programs (AU)

[Patient characteristics and health care burden during the influenza A (H1N1) 2009 pandemic in the university Hospital Vall d'Hebron of Barcelona]. / Características de los pacientes y carga asistencial durante la pandemia de gripe A (H1N1) 2009 en el Hospital Universitario Vall d'Hebron de Barcelona.

BACKGROUND AND OBJECTIVE: The influenza A (H1N1) 2009 pandemic initially had a mild impact in Catalonian hospitals, but in the autumn there was an important pandemic wave. We describe the main characteristics of patients seen in the Vall d'Hebron University Hospital in Barcelona (HUVH) during this pandemic, the risk factors associated with hospitalization and the health-care burden generated. MATERIAL AND METHOD: We included all cases of influenza A (H1N1) 2009 with laboratory confirmation seen in the HUVH from July 2, 2009 to January 22, 2010. We performed a descriptive analysis of the cases and a multivariate analysis to identify variables associated with the risk of hospitalization. RESULTS: The diagnosis was confirmed in 741 patients; 56.8% were under 16 years, while only 2.8% were 65 and over. Thirty three per cent of children had no risk factor for complications, whereas in adults it was 45%. One hundred and ninety cases were hospitalized, 26 of them in the intensive care unit (ICU) with 5 deaths. The factors associated with risk of hospitalization were, age less than one year, immunodeficiency, and neuromuscular disease in children; and chronic lung disease in adults. The diagnosis of pneumonia in the emergency department was an important predictor of hospitalization in both children and adults. The maximum caseload was recorded on November 19, with 43 hospital admissions, 6 of them in the ICU. CONCLUSIONS: Between July and September 2009 the pandemic had a low impact on hospital resources, but in autumn there was a marked increase in emergency department visits and hospitalizations. Children had higher rates of confirmed cases, while adults had higher rates of hospitalizations. The risk of hospitalization was higher in patients with certain conditions especially in those with pneumonia. The pandemic wave was a moderate work load for HUVH, since it did not involve any modification of the usual health care programs.

Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission.

BACKGROUND: The recent Infectious Disease Society of America/American Thoracic Society guidelines for the management of community-acquired pneumonia (CAP) in adults defined a predictive rule to identify patients with severe CAP to determine the need for intensive care unit (ICU) admission. We clinically validated this rule. METHODS: We analyzed 2102 episodes of CAP in consecutively hospitalized patients over a 7-year period. The predictive rule consists of at least 1 of 2 major severity criteria (septic shock and invasive mechanical ventilation) or at least 3 of 9 minor severity criteria. We assessed the association of the predictive rule with ICU admission and mortality. RESULTS: A total of 235 episodes of CAP (11%) occurred in patients who were admitted to the ICU, whereas the predictive rule identified 397 (19%) of 2102 episodes as severe CAP. The predictive rule and the decision for ICU admission agreed in 1804 (86%) of the episodes (kappa coefficient, 0.45), with a sensitivity of 71% and a specificity of 88%, similar to the 2001 American Thoracic Society guidelines (sensitivity, 66%; specificity, 90%) in predicting ICU admission. Severe CAP criteria had higher sensitivity (58% vs. 46%) and similar specificity (88% vs. 90%), compared with the 2001 American Thoracic Society guidelines in predicting hospital mortality. Invasive mechanical ventilation was the main determinant for ICU admission, followed by septic shock. In the absence of major criteria, ICU admission was not related to survival of patients with minor severity criteria. CONCLUSIONS: The predictive rule to identify severe CAP is accurate for ICU admission and improved the prediction of mortality, compared with the previous American Thoracic Society guidelines. The need for ICU admission derived from minor severity criteria alone is uncertain and deserves further investigation.

Prior use of carbapenems may be a significant risk factor for extended-spectrum beta-lactamase-producing Escherichia coli or Klebsiella spp. in patients with bacteraemia.

BACKGROUND: The increasing prevalence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae will probably trigger a rise in the use of carbapenems. The effect of these antibiotics on the risk of involvement of ESBL-producing organisms in serious infections is unclear. METHODS: Retrospective analysis of 2172 episodes of healthcare-associated bacteraemia diagnosed during a 3 year period in a teaching hospital. Putative risk factors included demographics, co-morbidities, previous isolation of an ESBL-producing organism and exposure to antibiotics. Univariate and multivariate analysis of the association of risk factors with ESBL-producing organisms was performed in the entire series of bacteraemic episodes and in those due to Escherichia coli or Klebsiella spp. RESULTS: In the entire series, prior isolation of an ESBL-producing organism [odds ratio (OR) 5.9 (3.02, 11.5)]; an ultimately/finally fatal co-morbidity [OR 2.8 (1.55, 4.95)]; renal transplantation [OR 4.3 (1.96, 9.63)]; a urinary source [OR 4.2 (2.22, 7.84)]; shock [OR 2.4 (1.35, 4.1)] and previous use of cephalosporins [OR 2.6 (1.54, 4.51)], carbapenems [OR 2.5 (1.24, 5.05)] and glycopeptides [OR 0.4 (0.13, 0.93)] were significantly associated with ESBL-producing E. coli or Klebsiella spp. by multivariate analysis. Prior isolation of an ESBL-producing organism, an ultimately/finally fatal co-morbidity, renal transplantation, and previous use of cephalosporins and carbapenems were also significant in the analysis restricted to episodes due to E. coli or Klebsiella spp. CONCLUSIONS: In patients with healthcare-associated bacteraemia, prior use of carbapenems may be only second to cephalosporins as the most significant antibiotic exposure associated with the involvement of ESBL-producing organisms.