BackgroundChanges over the last 5 years (2013–18) in the serotypes implicated in adult pneumococcal pneumonia and the patient groups associated with vaccine-type disease are largely unknown.MethodsWe conducted a population-based prospective cohort study of adults admitted to two large university hospitals with community-acquired pneumonia (CAP) between September 2013 and August 2018. Pneumococcal serotypes were identified using a novel 24-valent urinary monoclonal antibody assay and from blood cultures. Trends in incidence rates were compared against national invasive pneumococcal disease (IPD) data. Persons at risk of vaccine-type pneumonia (pneumococcal conjugate vaccine (PCV)13 and pneumococcal polysaccharide vaccine (PPV)23) were determined from multivariate analyses.FindingsOf 2934 adults hospitalised with CAP, 1075 (36.6%) had pneumococcal pneumonia. The annual incidence of pneumococcal pneumonia increased from 32.2 to 48.2 per 100 000 population (2013–18), predominantly due to increases in PCV13non7-serotype and non-vaccine type (NVT)-serotype pneumonia (annual incidence rate ratio 1.12, 95% CI 1.04 to 1.21 and 1.19, 95% CI 1.10 to 1.28, respectively). Incidence trends were broadly similar to IPD data. PCV13non7 (56.9% serotype 3) and PPV23non13 (44.1% serotype 8) serotypes were identified in 349 (32.5%) and 431 (40.1%) patients with pneumococcal pneumonia, respectively. PCV13-serotype pneumonia (dominated by serotype 3) was more likely in patients in the UK pneumococcal vaccination clinical risk group (adjusted OR (aOR) 1.73, 95% CI 1.31 to 2.28) while PPV23-serotype pneumonia was more likely in patients outside the clinical risk group (aOR 1.54, 95% CI 1.13 to 2.10).InterpretationThe incidence of pneumococcal CAP is increasing, predominantly due to NVT serotypes and serotype 3. PPV23-serotype pneumonia is more likely in adults outside currently identified clinical risk groups.
Background Vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPV23) is available in the United Kingdom to adults aged 65 years or older and those in defined clinical risk groups. We evaluated the vaccine effectiveness (VE) of PPV23 against vaccine-type pneumococcal pneumonia in a cohort of adults hospitalised with community-acquired pneumonia (CAP). Methods and findings Using a case-control test-negative design, a secondary analysis of data was conducted from a prospective cohort study of adults (aged ≥16 years) with CAP hospitalised at 2 university teaching hospitals in Nottingham, England, from September 2013 to August 2018. The exposure of interest was PPV23 vaccination at any time point prior to the index admission. A case was defined as PPV23 serotype-specific pneumococcal pneumonia and a control as non-PPV23 serotype pneumococcal pneumonia or nonpneumococcal pneumonia. Pneumococcal serotypes were identified from urine samples using a multiplex immunoassay or from positive blood cultures. Multivariable logistic regression was used to derive adjusted odds of case status between vaccinated and unvaccinated individuals; VE estimates were calculated as (1 − odds ratio) × 100%. Of 2,357 patients, there were 717 PPV23 cases (48% vaccinated) and 1,640 controls (54.5% vaccinated). The adjusted VE (aVE) estimate against PPV23 serotype disease was 24% (95% CI 5%–40%, p = 0.02). Estimates were similar in analyses restricted to vaccine-eligible patients ( n = 1,768, aVE 23%, 95% CI 1%–40%) and patients aged ≥65 years ( n = 1,407, aVE 20%, 95% CI −5% to 40%), but not in patients aged ≥75 years ( n = 905, aVE 5%, 95% CI −37% to 35%). The aVE estimate in relation to PPV23/non-13-valent pneumococcal conjugate vaccine (PCV13) serotype pneumonia ( n = 417 cases, 43.7% vaccinated) was 29% (95% CI 6%–46%). Key limitations of this study are that, due to high vaccination rates, there was a lack of power to reject the null hypothesis of no vaccine effect, and that the study was not large enough to allow robust subgroup analysis in the older age groups. Conclusions In the setting of an established national childhood PCV13 vaccination programme, PPV23 vaccination of clinical at-risk patient groups and adults aged ≥65 years provided moderate long-term protection against hospitalisation with PPV23 serotype pneumonia. These findings suggest that PPV23 vaccination may continue to have an important role in adult pneumococcal vaccine policy, including the possibility of revaccination of older adults.
Symptomatic and functional recovery are important patient-reported outcome measures (PROMs) in community-acquired pneumonia (CAP) that are increasingly used as trial end-points. This systematic review summarises the literature on PROMs in CAP.Comprehensive searches in accordance with the PRISMA statement were conducted to March 2017. Eligible studies included adults discharged from hospital following confirmed CAP and reporting PROMs.15 studies (n=5644 patients) were included; most were of moderate quality. Studies used a wide range of PROMs and assessment tools. At 4–6 weeks post-discharge, the commonest symptom reported was fatigue (45.0–72.6% of patients, three studies), followed by cough (35.3–69.7%) and dyspnoea (34.2–67.1%); corresponding values from studies restricted by age <65 years (two studies) were lower: fatigue 12.1–25.7%, cough 19.9–31.9% and dyspnoea 16.8–27.5%. Functional impairment 4 weeks post-discharge was reported in 18–51% of patients (two studies), while median time to return to normal activities was between 15 and 28 days (three studies).Substantial morbidity is reported by patients up to 6 weeks post-discharge. There is weak methodological consistency across existing studies. A core set of PROMs for use in future studies is suggested.
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BackgroundCommunity-acquired pneumonia (CAP) is one of the most common communicable diseases worldwide associated with significant levels of morbidity and mortality causing a substantial economic burden. 30-day hospital readmission rate is often used as a secondary outcome in studies of CAP. This data can be used to define the burden of disease and the reasons for readmissions potentially amenable to intervention.A systematic review and random meta-analysis were conducted to estimate the pooled 30-day readmission rate of adult patients with CAP and 30-day pneumonia-related/non-pneumonia-related and cardiovascular-related readmission rates of such patients.MethodsMEDLINE, EMBASE, AMED (until October 2017) and reference lists of papers were searched to identify studies of CAP including 30-day hospital readmission rate of adult patients. Each step of the study selection process was conducted by two independent reviewers. The quality was assessed using a pre-tested form based on the Newcastle-Ottawa Scale. Pooled proportions of patients readmitted within 30 days with 95% confidence intervals (CI), were estimated. Additional subgroup analyses were conducted.ResultsA total of 63 studies were included in the statistical analysis, covering the period from 1994 to 2017. The pooled 30-day readmission rate estimate was 0.10 (CI 0.08–0.11). High levels of heterogeneity were identified, I2=98.95%. Only two subgroups analysis reported statistically significant differences (p-value <0.05). Retrospective studies had a higher readmission rate of 0.12 (95% CI 0.10 to 0.14, I2=99.39%) compared to prospective studies, 0.07 (95% CI 0.06 to 0.09, I2=93.35%). Europe had significantly lower 30-day readmission rate, 0.08 (95% CI 0.07 to 0.10, I2=94.98%) than North America, which reported 0.11 (95% CI 0.09 to 0.14, I2=99.50%). Non-pneumonia-related readmissions accounted for 0.60 (95% CI 0.48 to 0.72, I2=89.00%) of all 30-day readmissions. Additionally, 0.31 (95% CI 0.25 to 0.37, I2=79.74%) of 30-day readmissions were pneumonia-related, while 0.20 (95% CI 0.14 to 0.26, I2=33.55%) were cardiovascular-related. The studied populations were mostly composed of elderly patients. High levels of heterogeneity may have been due to different selection criteria of included studies and variations among health-care systems and treatment practices.ConclusionAmong all adult patients with CAP, 10% are readmitted to the hospital within 30 days. The majority of all-cause readmissions are non-pneumonia-related, specifically 20% are cardiovascular related. Only one third of 30-day readmissions are due to pneumonia.
knock on effects on antibiotic use and length of hospital stay, ways of preventing HAP would be of potential importance to health services. S14 TIME TRENDS AND RISK FACTORS FOR HOSPITALISATION AFTER COMMUNITY-ACQUIRED PNEUMONIA IN OLDER ADULTS IN ENGLANDERC Millett, BL De Stavola, JK Quint, L Smeeth, SL Thomas. London School of Hygiene and Tropical Medicine, London, UK 10.1136/thoraxjnl-2014-206260.20 Introduction and objectives Hospitalisation rates for community-acquired pneumonia (CAP) among older individuals have increased in Europe, but the reasons for this remain unclear. It may be due to increasing incidence of CAP in older adults, or an increasing tendency to hospitalise -either due to worsening comorbidities, and/or changes in service provision. We used English linked electronic health records to investigate trends in hospitalisation after a CAP diagnosis independent of CAP incidence, and determinants of any increasing trend. Methods General practice records from the Clinical Practice Research Datalink (1998Datalink ( -2011 were linked to hospital admission records and mortality data, and CAP episodes among patients aged ≥65 years were identified. Episodes resulting in hospitalisation within 28 days of CAP diagnosis were compared to non-hospitalised CAP episodes, and multilevel logistic regression models built to estimate odds ratios for co-morbidities, frailty, and other factors, and to predict the probability of hospitalisation over time. Indicators of CAP severity (including mortality in the 28 days post-CAP) and pathways of care were also examined as explanations for hospitalisation trends. Results Hospitalisation after CAP increased markedly over the time period; after controlling for a wide range of comorbidities and other factors, the predicted probability of hospitalisation rose from 57% (1998)(1999)(2000) to 86% (2009-2010). Factors associated with hospitalisation included 14 co-morbidities, five frailty factors, and four medications/vaccinations. In the fully adjusted model most of these factors were associated with increased odds of hospitalisation, but some (including dementia and terminal illness) lowered the odds of hospitalisation. Over the study period, a growing proportion of CAP patients were admitted to hospital via A and E and the proportion referred by general practitioners decreased. 28-day mortality decreased over time. Conclusions Hospitalisation after CAP among those aged ≥65 years has increased in England, independent of co-morbidity and frailty factors, while mortality has decreased. Changes in service provision, patient and physician behaviours may play a role in increasing CAP hospitalisations. If the incidence of CAP in this age group also continues to increase, these combined trends will place an expanding burden on the health service.
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