One-Year Mortality in Patients with Community-Acquired Pneumonia

Pneumonia remains a common cause of morbidity and mortality in the US. Although, communityacquired pneumonia (CAP) has traditionally been considered an acute process, more recently, data have emerged showing that patients surviving an episode of CAP are at increased risk of death long after hospital discharged. In this descriptive review, we examine the current knowledge of long-term mortality and propose a hypothesis explaining the pathogenesis of long-term mortality in patients with CAP

Characteristics and Clinical Outcomes of Hospitalized Patients with Community-Acquired Pneumonia who are Active Intravenous Drug Users

Background: Intravenous drug users (IVDU) have a 10-fold increased risk of community-acquired pneumonia (CAP) compared to the general population. There is scarce data available evaluating the clinical outcomes of IVDU hospitalized patients with CAP and that data mostly focuses on mortality. The objective of this study was to evaluate the clinical characteristics, incidence and outcomes of hospitalized patients with CAP in active intravenous drug users in Louisville, Kentucky. Methods: This was a secondary data analysis of the University of Louisville Pneumonia study. IVDU patients were propensity score matched to a non-IVDU group. Study outcomes were time to clinical stability (TCS), length of stay (LOS), mortality at discharge, and mortality at 1 year. Stratified Cox proportional hazard regression was performed to evaluate TCS and LOS. Conditional logistic regression was performed to evaluate mortality. Statistical significance was defined as p ≤ 0.05. Results:From a total of 8,284 hospitalized patients with CAP reviewed, 113 patients were matched per group. Median (IQR) age for the IVDU was 33 (28-43) versus 36 (28-48) for the matched non-IVDU group (p Conclusions: This study shows that active IVDU hospitalized patients with CAP do not have worse outcomes when compared with non-IVDU hospitalized patients with CAP. Patients in the IVDU group were significantly younger. Since severity scores commonly used are heavily influenced by age, these will not likely be useful tools to assist the physicians with the site for care and management

The Community-Acquired Pneumonia Organization (CAPO) Cloud-Based Research Platform (the CAPO-Cloud): Facilitating Data Sharing in Clinical Research

Background: Pneumonia is a costly and deadly respiratory disease that afflicts millions every year. Advances in pneumonia care require significant research investment and collaboration among pneumonia investigators. Despite the importance of data sharing for clinical research it remains difficult to share datasets with old and new investigators. We present CAPOCloud, a web-based pneumonia research platform intended to facilitate data sharing and make data more accessible to new investigators. Methods: We establish the first two use cases for CAPOCloud to be the automatic subsetting and constraining of the CAPO database and the automatic summarization of the database in aggregate. We use the REDCap data capture software and the R programming language to facilitate these use cases. Results: CAPOCloud allows CAPO investigators to access the CAPO clinical database and explore subsets of the data including demographics, comorbidities, and geographic regions. It also allows them to summarize these subsets or the entire CAPO database in aggregate while preserving privacy restrictions. Discussion: CAPOCloud demonstrates the viability of a research platform combining data capture, data quality, hypothesis generation, data exploration and data sharing in one interface. Future use cases for the software include automated univariate hypothesis testing, automated bivariate hypothesis testing, and principal component analysis

Adult Patients Living with Human Immunodeficiency Virus Hospitalized for Community-Acquired Pneumonia in the United States: Incidence and Outcomes

Background: Community-acquired pneumonia (CAP) is a common infectious reason for hospitalization of adults in the United States (US), including those with Human Immunodeficiency Virus (HIV). While there are studies detailing the incidence and outcomes for all adults with CAP we are not aware of a recent study detailing incidence and outcomes in adult HIV patients hospitalized with CAP. The objectives of this study were (1) to define the current incidence and outcomes of adult HIV patients hospitalized with CAP in Louisville, Kentucky, and (2) to estimate the burden of CAP in the US HIV adult population. Methods: This was a secondary analysis of The University of Louisville Pneumonia Study; a prospective population-based cohort study of all hospitalized adults with CAP who were residents of Louisville, Kentucky, from 1 June 2014 to 31 May 2016. Results: A total of 110 unique patients living with HIV were hospitalized with CAP during our two-year study. The annual incidence of adults living with HIV hospitalized with CAP is estimated to be 1,950 per 100,000. Of the estimated 1.1 million adults living with HIV in the US currently we predict that 21,450 will be hospitalized with CAP annually. The median time to clinical stability in adult patients living with HIV hospitalized with CAP was 2 (IQR: [1, 3]) days. The median length of stay for adult patients living with HIV hospitalized with CAP was 4 (IQR: [3, 7]) days. Mortality occurred as follows; in-hospital: 1.8%, 30-day 6.8%, 6-month 15.5%, and 1 year 20.2%. Conclusion: The estimated annual incidence of adult patients living with HIV and hospitalized with CAP was found to be 1,950 per 100,000 suggesting that 21,450 adults living with HIV will be admitted with CAP yearly across the US. This is a similar incidence to that recently predicted for the elderly. Mortality occurred as follows; in-hospital: 1.8%, 30-day 6.8%, 6-month 15.5%, and 1 year 20.2%. Our 30-day mortality rate for adult patients living with HIV hospitalized for CAP was similar to other figures in the literature

Analysis of the Local and Systemic Cytokine Response Profiles in Patients with Community-Acquired Pneumonia. Relationship with Disease Severity and Outcomes.

The goals of this study were to investigate the relationship of systemic and local cytokine responses with time to clinical stability (TCS) in patients with community-acquired pneumonia (CAP) and to develop a model to integrate multiple cytokine data into “cytokine response profiles” based on local vs. systemic and pro- vs. anti-inflammatory cytokine patterns in order to better understand their relationships with measures of CAP severity and outcomes. Forty hospitalized patients enrolled through the Community Acquired Pneumonia Inflammatory Study Group (CAPISG) were analyzed. Based on the ranked distribution of the levels of eight different pro-inflammatory cytokines and chemokines (IL-1b, IL-6, IL-8, IL-12p40, IL-17A, IFNg, TNFa and CXCL10) in plasma and sputum on hospital admission, a “pro-inflammatory cytokine score (PICS)” was defined. PICS in plasma and sputum were plotted against each other and quadrants used to define profiles based on the four possible high/low combinations. A similar approach was used to contrast sputum PICS vs. anti-inflammatory cytokines (IL-1ra and IL-10). Some of the “profiles” thus defined were found to group patients with common etiologic characteristics and/or associate with similar measures of disease severity and/or clinical outcomes, suggesting the predictive value of the use of cytokine data in CAP patients

Impact of Obesity on Mortality in Hospitalized Patients with Pneumonia Due to 2009 H1N1 Influenza A Virus Versus Other Etiologies

Background: Reports from the 2009 H1N1 influenza A virus (2009 H1N1) pandemic indicate increased mortality in obese patients hospitalized with pneumonia. However, articles published prior to the pandemic have suggested that obesity may be a protective factor for mortality in these patients. The objective of this study was to compare the impact of obesity on mortality in hospitalized patients with pneumonia due to the 2009 H1N1 versus pneumonia due to other etiologies. Methods: This was a secondary analysis of the CAPO international cohort study. Study groups were defined as follows: Group One, pneumonia due to 2009 H1N1: Patients hospitalized with pneumonia after March 2009 with a positive RT-PCR for 2009 H1N1 and Group Two, pneumonia due to other etiologies: Patients hospitalized with pneumonia before March 2009. Body Mass Index (BMI) was used to predict the influence of obesity on mortality. The effect of BMI on mortality was analyzed using a propensity-adjusted logistic regression model. Results: From the total of 897 patients, 215 (24%) had pneumonia due to 2009 H1N1. After adjustment, increased BMI was associated with increased mortality in patients with pneumonia due to 2009 H1N1 and with decreased mortality in patients with pneumonia due to other etiologies. Conclusions: Obesity is associated with poor outcomes in patients with pneumonia due to 2009 H1N1 but is protective in patients with pneumonia due to other etiologies. Defining the molecular mechanisms by which obesity influences outcomes in patients with pneumonia may help to develop novel therapeutic strategies. Funding: US Department of Homeland Security

Impact of Temperature Relative Humidity and Absolute Humidity on the Incidence of Hospitalizations for Lower Respiratory Tract Infections Due to Influenza, Rhinovirus, and Respiratory Syncytial Virus: Results from Community-Acquired Pneumonia Organization (CAPO) International Cohort Study

Abstract Background: Transmissibility of several etiologies of lower respiratory tract infections (LRTI) may vary based on outdoor climate factors. The objective of this study was to evaluate the impact of outdoor temperature, relative humidity, and absolute humidity on the incidence of hospitalizations for lower respiratory tract infections due to influenza, rhinovirus, and respiratory syncytial virus (RSV). Methods: This was a secondary analysis of an ancillary study of the Community Acquired Pneumonia Organization (CAPO) database. Respiratory viruses were detected using the Luminex xTAG respiratory viral panel. Climate factors were obtained from the National Weather Service. Adjusted Poisson regression models with robust error variance were used to model the incidence of hospitalization with a LRTI due to: 1) influenza, 2) rhinovirus, and 3) RSV (A and/or B), separately. Results: A total of 467 hospitalized patients with LRTI were included in the study; 135 (29%) with influenza, 41 (9%) with rhinovirus, and 27 (6%) with RSV (20 RSV A, 7 RSV B). The average, minimum, and maximum absolute humidity and temperatur e variables were associated with hospitalization due to influenza LRTI, while the relative humidity variables were not. None of the climate variables were associated with hospitalization due to rhinovirus or RSV. Conclusions: This study suggests that outdoor absolute humidity and temperature are associated with hospitalizations due to influenza LRTIs, but not with LRTIs due to rhinovirus or RSV. Understanding factors contributing to the transmission of respiratory viruses may assist in the prediction of future outbreaks and facilitate the development of transmission prevention interventions

Refugee-Centered Medical Home:A New Approach to Care at the University of Louisville Global Health Center

Refugees arrive to the United States with a full spectrum of health conditions, many of which involve intense case management requiring significant financial investments and use of healthcare resources. Kentucky receives more than 3,000 new refugees each year and ranked 10th in the nation for numbers of new arrivals resettled during 2015. These refugees arrive from diverse countries representing different cultures and speaking different languages. In addition, they arrive with diverse health conditions and medical needs. The aims of this paper are to share experiences from the University of Louisville Global Health Center regarding conceptualization, implementation and evaluation of a new care model. This model focuses on the complexities of caring for refugees from diverse populations and backgrounds. The foundation for this model aligns with the patient-centered medical home approach outlined by the Agency for Healthcare Research and Quality. Recognizing the need for a new paradigm for care, a refugee-centered medical home model was designed and implemented as an ideal approach

Early administration of the first antimicrobials should be considered a marker of optimal care of patients with community-acquired pneumonia rather than a predictor of outcomes

Summary Background The effect of time of the first antimicrobial dose (TFAD) on the outcomes of community-acquired pneumonia (CAP) remains a controversy. Methods This was an observational, retrospective study of consecutive adult patients hospitalized with CAP. TFAD was defined as the time in hours from arrival at the emergency department to the intravenous infusion of antimicrobial. All patients received appropriate antibiotic therapy according to available Infectious Diseases Society of America/American Thoracic Society guidelines during the time of our study. Multivariable analysis and a propensity score adjusted methodology were used to measure the association of TFAD with mortality, time to clinical stability (TCS), and length of stay in the hospital (LOS). Results Data of 372 patients with CAP were studied. A total 29 (8.4%) patients died within 30 days of hospitalization. Our propensity-adjusted logistic regression model did not show a significant association between TFAD and mortality ( p =0.148). Patients who died received antimicrobials significantly earlier than survivors: 5.7h vs. 7.5h, respectively ( p =0.04). The LOS and TCS were not significantly affected by the TFAD; the LOS hazard ratio was 0.996 (95% confidence interval 0.97–1.02; p =0.774) and the TCS hazard ratio was 1.01 (95% confidence interval 0.98–1.03; p =0.604). Conclusions TFAD does not seem to be associated with the clinical outcome of patients with CAP. Early TFAD should be considered as an important marker of optimal care of patients with CAP rather than as a factor predicting outcomes

Short Duration of Antibiotic Therapy in Hospitalized Patients with Community-Acquired Pneumonia: Results from the CAPO International Cohort Study

Introduction: Experts suggest a short duration of antibiotic therapy (DOT) in responding patients with community-acquired pneumonia (CAP). The aim of this study was to evaluate clinical outcomes after hospital discharge among patients treated with short-course antibiotic therapy (SCT) vs. long-course antibiotic therapy (LCT) for CAP. Methods: A secondary analysis of the Community-Acquired Pneumonia Organization (CAPO) database from January 2007 to June 2013 was performed, including hospitalized CAP patients who reached clinical stability within 5 days. Two groups were identified: patients who were treated with antibiotic therapy for a total duration of 5 days or less (SCT Group) vs. longer than 5 days (LCT Group). Rehospitalization and mortality were evaluated at 30 days after discharge. Results: 1,849 patients were enrolled (58% males; median age: 65 years), 179 (10%) were included in the SCT and 1,670 (90%) in the LTC group. Median DOT was 5 days in the SCT and 10 days in the LTC group, p Conclusions: A duration of antibiotic therapy of ≤ 5 days does not adversely impact clinical outcomes at 30-days after discharge compared to \u3e5 days in patients who reached early clinical stability