Epidemiologia de la neumonía adquirida en la comunidad en el anciano

Introducción: la neumonía adquirida en la comunidad (NAC) es generalmente considerada como una causa importante de morbilidad y mortalidad en los ancianos. Sin embargo, los datos poblacionales son muy limitados y su verdadera incidencia no está clara. Objetivo: Analizar la epidemiología, forma de presentación, características clínicas, lugar de tratamiento, etiología y factores de riesgo de la neumonía adquirida en la comunidad en la población mayor de 65 años del área de Tarragona.Metodología: Estudio de cohortes prospectivo que incluyó un total de 11.240 personas mayores de 65 años adscritas a 8 Áreas Básicas de Salud de Tarragona-Valls. Se reclutaron todos los casos de NAC ocurridos en la cohorte de estudio entre enero de 2002 y abril de 2005. Todos los casos incluidos fueron radiográficamente confirmados y validados mediante revisión de historia clínica.Resultados: La incidencia anual global de NAC fue de 14 casos por mil personas-año (10,5 para neumonías hospitalizadas y 3,5 para neumonías ambulatorias). La incidencia fue al menos tres veces más alta en los pacientes inmunocomprometidos (30,9 por mil personas-año) respecto a los pacientes inmunocompetentes (11,6 por mil personas-año). Las máximas incidencias fueron observadas en los pacientes con EPOC y en pacientes con corticoterapia crónica (46,5 y 40,1 casos por mil personas año, respectivamente). La tasa de mortalidad a los 30 días fue de 12,7 (2% en los casos ambulatorios y 15% en los hospitalizados). De las 473 NAC estudiadas, en 358 pacientes se realizó estudio diagnóstico, en 131 casos se identificó el agente patógeno (en 121 casos un agente único y 10 casos de flora mixta). Streptococcus pneumoniae fue el patógeno más frecuente (49%), seguido de Pseudomona aeruginosa (15%), Chlamydia pneumoniae (9%) y Haemophilus influenzae (6%). La sintomatología más frecuente fueron los síntomas respiratorios y la fiebre. La mortalidad se correlacionó directamente con la puntuación de la escala Fine de severidad. En el análisis multivariante, las variables más fuertemente asociadas con el incremento de riesgo de neumonía fueron hospitalización previa por neumonía en los dos años previos y la presencia de enfermedad pulmonar crónica. Al evaluar la efectividad de la vacuna antineumocócica polisacárida 23-valente para la prevención de neumonía adquirida en la comunidad (NAC) en una subcohorte compuesta por 1298 sujetos mayores de 65 años con enfermedades respiratorias crónicas (bronquitis, enfisema o asma) la recepción de la vacuna antineumocócica se asoció con un significativo menor riesgo de hospitalización por NAC en la cohorte estudiada. La vacunación antineumocócica no alteró significativamente el riesgo global de la NAC (hazard ratio [HR]: 0,77; 95% intervalo de confianza [IC]: 0,56-1,07) y la mortalidad a los 30 días de la NAC (HR: 0,87; IC 95%: 0,33 - 2,28). Sin embargo, se observó una reducción discretamente significativa del 30% en el riesgo de hospitalización por NAC de cualquier etiología entre los sujetos vacunados (HR: 0,70, IC 95%: 0,48-1,00; p = 0,052). La efectividad de la vacuna sobre el evento combinado neumonía neumocócica y neumonía por gérmen desconocido alcanzó el 34% (HR: 0,66; IC95%:0,43-1,01; p=0,059). Conclusiones: La NAC sigue siendo una importante causa de morbimortalidad en personas ancianas. S. pneumoniae es el causante de aproximadamente la mitad de los casos en los que se identifica un microorganismo. La presencia de enfermedad pulmonar obstructiva crónica es la condición clínica que se asocia con un mayor riesgo de padecer NAC mientras que haber recibido la vacunación antineumocócica se asocia con un significativo menor riesgo de NAC entre la población general mayor de 65 años. En el sector de población con más riesgo de padecer NAC, los pacientes EPOC, nuestros resultados sugieren moderados beneficios de la vacunación antineumocócica, aunque la evidencia sobre su efectividad clínica es limitada.Background: Community-acquired pneumonia (CAP) is generally considered a major cause of morbidity and mortality in the elderly. However, population-based data are very limited and its overall burden is unclear. Objective: This study assessed epidemiology, aetiology, clinical outcomes and risk factors for community-acquired pneumonia (CAP) among Spanish community-dwelling 65 years or older from Tarragona.Methods: Prospective cohort study that included 11,240 individuals aged 65 years or older, who were followed from January 2002 until April 2005. Primary endpoints were all-cause CAP (hospitalised and outpatient) and 30-day mortality after the diagnosis. All cases were radiographically proved and validated by checking clinical records. Results: Incidence rate of overall CAP was 14 cases per 1,000 person-year (10.5 for hospitalised CAP and 3.5 for outpatient CAP). Incidence was almost three-fold higher among immunocompromised patients (30.9 per 1000) than among immunocompetent subjects (11.6 per 1000). Maximum incidences were observed among patients with chronic lung disease and long-term corticosteroid therapy (46.5 and 40.1 cases per 1000 person-year, respectively). Overall 30-days case-fatality rate was 12.7% (2% in cases managed as outpatient and 15% in hospitalised patients). Among 358 patients with an aetiological workup, a total of 142 pathogens were found (single pathogen in 121 cases and mixed pathogens in 10 cases). Streptococcus pneumoniae was the most common pathogen (49%), followed by Pseudomona aeruginosa (15%), Chlamydia pneumoniae (9%) and Haemophillus influenzae (6%). The most common symptoms were respiratory symptoms and fever. The mortality was directly correlated with the Fine score.In multivariable analysis, the variables most strongly associated with increasing risk of CAP were history of hospitalisation for CAP in the previous 2 years and presence of any chronic lung disease.The assesment of clinical effectiveness of the 23-valent pneumococcal polysaccharide vaccine was conducted among 1298 Spanish older adults with chronic respiratory diseases (bronchitis, emphysema or asthma) who were followed between 2002 and 2005. Pneumococcal vaccination did not alter significantly the risk of overall CAP (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.56-1.07) and 30-days mortality from CAP (HR: 0.87; 95% CI: 0.33-2.28). However, a borderline significant reduction of 30% in the risk of all-cause hospitalisation for CAP was observed among vaccinated subjects (HR: 0.70; 95% CI: 0.48-1.00; p=0.052). The effectiveness of the vaccine on the combined endpoint of pneumococcal and unknown organism infections reached 34% (HR: 0.66; 95% CI: 0.43-1.01; p=0.059). Conclusions: CAP remains a major cause of morbidity and mortality in older adults. S. pneumoniae is the cause of about half the cases in which an organism is identified. The presence of chronic obstructive pulmonary disease is the clinical condition that is associated with an increased risk of CAP while receiving the pneumococcal vaccination is associated with a significant lower risk of CAP in the general population over 65 years. In COPD patients, the populations with increased risk of CAP, our findings suggest moderate benefits from the vaccination

Effectiveness of the 23-valent polysaccharide pneumococcal vaccine against invasive pneumococcal disease in people 60 years or older

<p>Abstract</p> <p>Background</p> <p>The 23-valent polysaccharide pneumococcal vaccine (PPV) is currently recommended in elderly and high-risk adults. However, its efficacy in preventing pneumococcal infections remains controversial. This study assessed the clinical effectiveness of vaccination against invasive pneumococcal disease (IPD) among people over 60 years.</p> <p>Methods</p> <p>Population-based case-control study that included 88 case patients over 60 years-old with a laboratory-confirmed IPD (bacteraemic pneumonia, meningitis or sepsis) and 176 outpatient control subjects who were matched by primary care centre, age, sex and risk stratum. Adjusted odds ratios (ORs) for vaccination were calculated using conditional logistic regression, controlling for underlying conditions. Vaccine effectiveness was estimated as (1 - OR) ×100.</p> <p>Results</p> <p>Pneumococcal vaccination rate was significantly lower in cases than in control subjects (38.6% <it>vs </it>59.1%; p = 0.002). The adjusted vaccine effectiveness was 72% (OR: 0.28; 95% CI: 0.15-0.54) against all IPD and 77% (OR: 0.23; 95% CI: 0.08-0.60) against vaccine-type IPD. Vaccination was significantly effective against all IPD in both age groups: 60-79 years-old (OR 0.32; 95% CI: 0.14-0.74) and people 80 years or older (OR: 0.29; 95% CI: 0.09-0.91). Vaccination appears significantly effective as for high-risk immunocompetent subjects (OR: 0.29; 95% CI: 0.11-0.79) as well as for immunocompromised subjects (OR: 0.12; 95% CI: 0.03-0.53).</p> <p>Conclusion</p> <p>These findings confirm the effectiveness of the 23-valent PPV against IPD, and they also support the benefit of vaccination in preventing invasive infections among high-risk and older people.</p

Rationale and design of the CAPAMIS study: Effectiveness of pneumococcal vaccination against community-acquired pneumonia, acute myocardial infarction and stroke

<p>Abstract</p> <p>Background</p> <p>The 23-valent polysaccharide pneumococcal vaccine (PPV-23) is recommended for elderly and high-risk people, although its effectiveness is controversial. Some studies have reported an increasing risk of acute vascular events among patients with pneumonia, and a recent case-control study has reported a reduction in the risk of myocardial infarction among patients vaccinated with PPV-23. Given that animal experiments have shown that pneumococcal vaccination reduces the extent of atherosclerotic lesions, it has been hypothesized that PPV-23 could protect against acute vascular events by an indirect effect preventing pneumonia or by a direct effect on oxidized low-density lipoproteins. The main objective of this study is to evaluate the clinical effectiveness of PPV-23 in reducing the risk of pneumonia and acute vascular events (related or nonrelated with prior pneumonia) in the general population over 60 years.</p> <p>Methods/Design</p> <p>Cohort study including 27,000 individuals 60 years or older assigned to nine Primary Care Centers in the region of Tarragona, Spain. According to the reception of PPV-23 before the start of the study, the study population will be divided into vaccinated and nonvaccinated groups, which will be followed during a consecutive 30-month period. Primary Care and Hospitals discharge databases will initially be used to identify study events (community-acquired pneumonia, hospitalisation for acute myocardial infarction and stroke), but all cases will be further validated by checking clinical records. Multivariable Cox regression analyses estimating hazard ratios (adjusted for age, sex and comorbidities) will be used to estimate vaccine effectiveness.</p> <p>Discussion</p> <p>The results of the study will contribute to clarify the controversial effect of the PPV-23 in preventing community-acquired pneumonia and they will be critical in determining the posible role of pneumococcal vaccination in cardiovascular prevention.</p

Pneumococcal vaccination coverages by age, sex and specific underlying risk conditions among middle-aged and older adults in Catalonia, Spain, 2017

Background: Recent published data on pneumococcal vaccination coverages among adults are scarce. Aim: To update on pneumococcal vaccination uptakes among middle-aged and older adults in Catalonia. Methods: We conducted a population-based retrospective observational study including 2,057,656 individuals ≥ 50 years old assigned to primary care centres managed by the Catalonian Health Institute on 1 January 2017 (date of data collection). An institutional clinical research database (SIDIAP) was used to classify persons by vaccination status for both 23-valent pneumococcal polysaccharide (PPsV23) and 13-valent pneumococcal conjugate (PCV13) vaccines, as well as to identify underlying risk conditions. Results: Overall, 796,879 individuals (38.7%) had received PPsV23 and 13,607 (0.7%) PCV13. PPsV23 coverage increased with age: 9.2% (95,409/1,039,872) in 50-64 year olds, 63.1% (434,408/688,786) in 65-79 year olds and 81.2% (267,062/328,998) in ≥ 80 year olds (p < 0.001). PCV13 coverage also increased with age, although percentages were smaller in all age strata (4,250/1,039,872: 0.4%; 6,005/688,786: 0.9% and 3,352/328,998: 1.0%, respectively; p < 0.001). By sex, no substantial coverage differences were observed. Considering publi-cally funded target groups for PPsV23 vaccination in Catalonia (i.e. < 65 year olds with at least one risk factor, plus all adults aged ≥ 65 years), PPsV23 coverage reached 52.8% (771,722/1,462,261) in our study population. Regarding PCV13 publicly funded targets (i.e. all-age immunocompromised persons), PCV13 coverage was 3.3% (6,617/202,348). By risk conditions, the highest PPsV23 coverage appeared in congestive heart failure (51,909/63,596; 81.6%), chronic renal disease (122,791/158,726; 77.4%) and chronic bronchitis/ emphysema (96,453/132,306; 72.9%). Maximum PCV13 coverage appeared in cirrhosis (294/7,957; 3.7%), chronic renal disease (5,633/158,726; 3.5%) and chronic bronchitis/emphysema (2,859/132,306; 2.2%). Conclusion: Pneumococcal vaccination coverages in Catalonian adults are suboptimal, especially for PCV13

The burden of community-acquired pneumonia in the elderly: the Spanish EVAN-65 Study

BACKGROUND: Community-acquired pneumonia (CAP) is generally considered a major cause of morbidity and mortality in the elderly. However, population-based data are very limited and its overall burden is unclear. This study assessed incidence and mortality from CAP among Spanish community-dwelling elderly. METHODS: Prospective cohort study that included 11,240 individuals aged 65 years or older, who were followed from January 2002 until April 2005. Primary endpoints were all-cause CAP (hospitalised and outpatient) and 30-day mortality after the diagnosis. All cases were radiographically proved and validated by checking clinical records. RESULTS: Incidence rate of overall CAP was 14 cases per 1,000 person-year (95% confidence interval: 12.7 to 15.3). Incidence increased dramatically by age (9.9 in people 65–74 years vs 29.4 in people 85 years or older), and it was almost double in men than in women (19.3 vs 10.1). Hospitalisation rate was 75.1%, with a mean length-stay of 10.4 days. Overall 30-days case-fatality rate was 13% (15% in hospitalised and 2% in outpatient cases). CONCLUSION: CAP remains as a major health problem in older adults. Incidence rates in this study are comparable with rates described in Northern Europe and America, but they largely doubled prior rates reported in other Southern European regions

Clinical effectiveness of pneumococcal vaccination against acute myocardial infarction and stroke in people over 60 years: the CAPAMIS study, one-year follow-up

<p>Abstract</p> <p>Background</p> <p>Conflicting results have been recently reported evaluating the relationship between pneumococcal vaccination and the risk of thrombotic vascular events. This study assessed the clinical effectiveness of the 23-valent polysaccharide pneumococcal vaccine (PPV23) against acute myocardial infarction and ischaemic stroke in older adults.</p> <p>Methods</p> <p>Population-based prospective cohort study conducted from December 1, 2008 until November 30, 2009, including all individuals ≥ 60 years-old assigned to nine Primary Care Centres in Tarragona, Spain (N = 27,204 individuals). Primary outcomes were hospitalisation for acute myocardial infarction and/or ischaemic stroke. All cases were validated by checking clinical records. The association between pneumococcal vaccination and the risk of each outcome was evaluated by Multivariable Cox proportional-hazard models (adjusted by age, sex, influenza vaccine status, presence of comorbidities and cardiovascular risk factors).</p> <p>Results</p> <p>Cohort members were followed for a total of 26,444 person-years, of which 34% were for vaccinated subjects. Overall incidence rates (per 1000 person-years) were 4.9 for myocardial infarction and 4.6 for ischaemic stroke. In the multivariable analysis, vaccination was associated with a marginally significant 35% lower risk of stroke (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.42-0.99; <it>p </it>= 0.046). We found no evidence for an association between pneumococcal vaccination and reduced risk of myocardial infarction (HR: 0.83; 95% CI: 0.56-1.22; <it>p </it>= 0.347).</p> <p>Conclusions</p> <p>Our data supports a benefit of PPV23 against ischaemic stroke among the general population over 60 years, suggesting a possible protective role of pneumococcal vaccination against some acute thrombotic events.</p

Evolution of vaccination rates after the implementation of a free systematic pneumococcal vaccination in Catalonian older adults: 4-years follow-up

BACKGROUND: The systematic vaccination with 23-valent polysaccharide pneumococcal vaccine (PPV) was introduced as a strategic objective of health for all the people over 65 in Catalonia in 1999. We analysed the evolution of the pneumococcal vaccination rates from 2000 to 2003. METHODS: We conducted a retrospective population-based study including all the individuals 65 years or older assigned to 8 Primary Care Centres (PCCs) in Tarragona (Catalonia, Spain), who figured in the administrative population databases on 31 December 2003 (n = 10,410 persons). We assessed whether every person had received PPV during the last four years (2000 to 2003) or whether they had received it before January 2000. Data sources were the computerised clinical records of the 8 participating PCCs, which included adult vaccination registries and diagnoses coded of International Classification of Diseases 9(th )Review RESULTS: The overall vaccination uptake increased to 38.6% at the end of 2000. Global accumulated coverages increased more slowly the following years: 44.4% in 2001, 50.9% in 2002, and 53.1% at the end of 2003. Vaccine uptake varied significantly according to age (46.7% in people 65–74 years-old, 60.9% in people 75 years or more; p < 0.001) and number of diseases or risk factors (DRFs) for pneumonia (47.1% vaccinated in people without DRFs, 56.8% in patients with one DRF, and 62.2% in patients with two or more DRFs; p < 0.001). The highest coverages were observed among those patients with: diabetes (65.9%), active neoplasia (64.8%), history of stroke (63.7%), and chronic lung disease (63.5%). The lowest uptake was observed among smokers (48.7%). DISCUSSION: The pneumococcal vaccination coverage increased quickly after the introduction of the recommendation for free vaccination in all the elderly people (with and without risk factors), but two years after the improvement the coverage became stable and increased slowly

Pla funcional del Programa d’incorporació de fisioterapeutes a l’atenció primària i comunitària: programa d’incorporació de fisioterapeutes per a la promoció del funcionament i la prevenció de la discapacitat a l’atenció primària i comunitària

Fisioterapeutes; Atenció primària; IncorporacióFisioterapeutas; Atención primaria; IncorporaciónPhysiotherapists; Primary care; IncorporationEl present pla funcional és una eina de suport per a l’acollida i la incorporació dels nous fisioterapeutes1 d’atenció primària i comunitària (FisioAPiC) als equips d’atenció primària (EAP) d’arreu de Catalunya. Aquest és un document dinàmic que requerirà les aportacions dels professionals dels EAP que han incorporat aquest nou rol per tal de fer-lo evolucionar i enriquir-lo en les versions següents