Cigarette smoking is the strongest independent risk factor for invasive pneumococcal disease among immunocompetent, nonelderly adults. Because of the high prevalence of smoking and the large population attributable risk, programs to reduce both smoking and exposure to environmental tobacco smoke have the potential to reduce the incidence of pneumococcal disease.

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Background Although recent reports suggest that the incidence of parapneumonic empyema has increased in several regions of the USA, national trends in disease burden are unknown. National trends in the incidence of parapneumonic empyema hospitalisations and changes in empyema by associated pathogens were examined. Methods National hospitalisation data (1996e2008) were analysed and rates estimated using census estimates as denominators. Incidence rate ratios (IRR) compared 2008 with 1996 rates. Discharge diagnosis codes were used to characterise pathogens associated with empyema hospitalisations. Results Overall, national parapneumonic empyemarelated hospitalisation rates increased from 3.04 per 100 000 in 1996 to 5.98 per 100 000 in 2008, a 2.0-fold increase (95% CI 1.8 to 2.1). The increases were observed among children (IRR 1.9 (95% CI 1.4 to 2.7)) and adults aged 18e39, 40e64 and $65 years (IRR 1.8 (95% CI 1.5 to 2.1), 2.0 (95% CI 1.6 to 3.1) and 1.7 (95% CI 1.5 to 2.0), respectively). Overall, pneumococcal empyema rates remained relatively stable in all age groups whereas streptococcal-(non-pneumococcal) and staphylococcal-related empyema rates increased 1.9-fold and 3.3-fold, respectively, with consistent increases across age groups. The overall in-hospital case fatality ratio for parapneumonic empyema-related hospitalisations was 8.0% (95% CI 6.4% to 9.5%) in 1996 and 7.2% (95% CI 6.3% to 8.1%) in 2008 (p¼0.395). Of the empyemas where study pathogens were listed (37.6%), staphylococcal-related empyema had the largest absolute increases across age groups and was associated with longer hospital stay and higher in-hospital mortality than other empyemas. Conclusions Although parapneumonic empyemarelated hospitalisations remained relatively rare, they increased substantially during the study period. A number of pathogens, especially staphylococcus, contributed to this increase.

Decreases in childhood pneumonia hospitalization rates following PCV7 introduction were sustained. Although empyema complicated only a small fraction of pneumonia hospitalizations, its prevalence increased substantially. This increase was due to several pathogens and warrants continuing monitoring.

Acute otitis media-related health care utilization and associated antibiotic prescriptions for privately insured young children decreased more than expected (on the basis of efficacy estimates in prelicensure clinical trials) after the introduction of routine 7-valent pneumococcal conjugate vaccine immunization. Although other factors, such as clinical practice guidelines to reduce antibiotic use, might have contributed to the observed trend, 7-valent pneumococcal conjugate vaccine may play an important role in reducing the burden of acute otitis media, resulting in substantial savings in medical care costs.

Context The cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) compared with 23-valent pneumococcal polysaccharide vaccine (PPSV23) among US adults is unclear. Objective To estimate the cost-effectiveness of PCV13 vaccination strategies in adults to assist vaccination policy decision-making. Design, Setting, and Population A Markov state-transition model, lifetime time horizon, societal perspective. Simulations were performed in hypothetical cohorts of US 50-year-olds. Vaccination strategies and effectiveness estimates were developed by a Delphi expert panel; indirect (herd immunity) effects resulting from childhood PCV13 vaccination were extrapolated based on observed PCV7 effects. Data sources for model parameters included CDC Active Bacterial Core surveillance, National Hospital Discharge Survey and Nationwide Inpatient Sample data, and the National Health Interview Survey. Main Outcome Measures Pneumococcal disease cases prevented and incremental costs per quality-adjusted life year (QALY) gained. Results In the base case scenario, PCV13 given as a substitute for PPSV23 in current recommendations (i.e., vaccination at 65 years and at younger ages if comorbidities are present) cost $28,900/QALY gained compared with no vaccination and was more cost-effective than the currently recommended PPSV23 strategy. Routine PCV13 at ages 50 and 65 years cost $45,100/QALY compared with PCV13 substituted in current recommendations. Adding PPSV23 at age 75 to PCV13 at ages 50 and 65 years gained 0.00002 QALYs, costing $496,000/QALY gained. Results were robust in sensitivity analyses and alternative scenarios, except when low PCV13 effectiveness against nonbacteremic pneumococcal pneumonia was assumed or when greater childhood vaccination indirect effects were modeled. In these cases, PPSV23 as currently recommended was favored. Conclusions Overall, PCV13 vaccination was favored compared to PPSV23, but the analysis is sensitive to assumptions about PCV13 effectiveness against NPP and the magnitude of potential indirect effects from childhood PCV13 on pneumococcal serotype distribution.

Bloodstream infections (BSI) are a major cause of mortality, morbidity and medical cost, but few population-based studies have concomitantly evaluated BSI incidence and mortality. Data on BSI episodes reported to national, population-based surveillance by all clinical microbiology laboratories in Finland during 2004-07 were linked to vital statistics. Age-, sex and microbe-specific incidence and mortality rates were calculated. During 2004-07, 33 473 BSI episodes were identified; BSI incidence increased from 147 to 168 per 100 000 population (average annual increase, 4.4%; p <0.001). Rates were highest among persons ≥65 years and <1 year, and higher among male patients than female patients (166 versus 152 per 100 000). The most common aetiologies were Escherichia coli (27%) and Staphylococcus aureus (13%). Among male patients, 52% of BSI were caused by gram-positive bacteria compared with 42% among female patients (p <0.001). The overall 30-day case-fatality was 13%. Of the deaths, 32% occurred within 2 days, 70% were among people aged 65 years or more and 33% were caused by E. coli or S. aureus infections. The BSI mortality rate increased from 19 to 22 per 100 000 (average annual increase: 4.0%, p 0.01). Among people aged 25 years or more, the mortality rate was 1.4-fold higher in men than women (34 versus 25 per 100 000 population). Overall excess annual mortality from BSI in the population was 18 per 100 000. The substantial BSI burden among the elderly and among adult men highlights the need for developing and implementing effective interventions, particularly for BSI caused by E. coli and S. aureus. One-third of BSI deaths occurred early, emphasizing the importance of early identification and treatment.