Eric M. Mortensen

The effect of prior statin use on 30-day mortality for patients hospitalized with community-acquired pneumonia.

BackgroundRecent studies suggest that HMG-CoA reductase inhibitors (statins) may have beneficial effects for patients at risk for some types of infections. We examined the effect of prior outpatient use of statins on mortality for patients hospitalized with community-acquired pneumonia.MethodsA retrospective cohort study conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of, had a chest x-ray consistent with, and had a discharge ICD-9 diagnosis of pneumonia. Subjects were excluded if they were comfort measures only or transferred from another acute care hospital. Subjects were considered to be on a medication if they were taking it at the time of presentation.ResultsData was abstracted on 787 subjects at the two hospitals. Mortality was 9.2% at 30-days and 13.6% at 90-days. At presentation 52% of subjects were low risk, 34% were moderate risk, and 14% were high risk based on the pneumonia severity index. In the multivariable regression analysis, after adjusting for potential confounders including a propensity score, the use of statins at presentation (odds ratio 0.36, 95% confidence interval 0.14–0.92) was associated with decreased 30-day mortality.DiscussionPrior outpatient statin use was associated with decreased mortality in patients hospitalized with community-acquired pneumonia despite their use being associated with comorbid illnesses likely to contribute to increased mortality. Confirmatory studies are needed, as well as research to determine the mechanism(s) of this protective effect.

COPD is associated with increased mortality in patients with community-acquired pneumonia

Patients with chronic obstructive pulmonary disease (COPD) who develop community-acquired pneumonia (CAP) may experience worse clinical outcomes. However, COPD is not included as a distinct diagnosis in validated instruments that predict mortality in patients with CAP. The aim of the present study was to evaluate the impact of COPD as a comorbid condition on 30- and 90-day mortality in CAP patients. A retrospective observational study was conducted at two hospitals. Eligible patients had a discharge diagnosis and radiological confirmation of CAP. Among 744 patients with CAP, 215 had a comorbid diagnosis of COPD and 529 did not have COPD. The COPD group had a higher mean pneumonia severity index score (105±32 versus 87±34) and were admitted to the intensive care unit more frequently (25 versus 18%). After adjusting for severity of disease and processes of care, CAP patients with COPD showed significantly higher 30- and 90-day mortality than non-COPD patients. Chronic obstructive pulmonary disease patients hospitalised with community-acquired pneumonia exhibited higher 30- and 90-day mortality than patients without chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease should be evaluated for inclusion in community-acquired pneumonia prediction instruments.

Impact of macrolide therapy on mortality for patients with severe sepsis due to pneumonia.

Recent studies suggest that macrolides may have beneficial effects for patients at risk for certain infections. The current authors examined the effect of macrolide therapy on 30- and 90-day mortality for patients with severe sepsis caused by pneumonia. A retrospective cohort study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of, had chest radiography consistent with, and had a discharge diagnosis of pneumonia and clinical criteria of severe sepsis. Subjects were considered to be on macrolides if they received at least one dose within 48u2005h of admission. Severe sepsis was present in 237 (30.1%) subjects, out of whom 104 (43.9%) received macrolides. Mortality was 20.3% at 30u2005days and 24.5% at 90u2005days. In the multivariable analysis, the use of macrolide was associated with decreased mortality at 30u2005days (hazard ratio (HR) 0.3, 95% confidence interval (CI) 0.2–0.7) and at 90u2005days (HR 0.3, 95% CI 0.2–0.6) in patients with severe sepsis and in patients with macrolide-resistant pathogens (HR 0.1, 95% CI 0.02–0.5). Macrolide use was associated with decreased mortality in patients with severe sepsis due to pneumonia and macrolide-resistant pathogens. Confirmatory studies are needed to determine whether macrolide therapy may be protective for patients with sepsis.

Assessment of Mortality after Long-Term Follow-Up of Patients with Community-Acquired Pneumonia

Although studies have assessed short-term mortality among patients with community-acquired pneumonia, there is limited data on prognosis and risk factors that affect long-term mortality. The mortality among patients enrolled at 4 sites of the Pneumonia Patient Outcome Research Team cohort study who survived at least 90 days after presentation to the hospital was compared with that among age-matched control subjects. Overall, 1419 of 1555 patients survived for >90 days, with a mean follow-up period of 5.9 years. There was significantly higher long-term mortality among patients with pneumonia than among age-matched controls. Factors significantly associated with long-term mortality were age (stratified by decade), do-not-resuscitate status, poor nutritional status, pleural effusion, glucocorticoid use, nursing home residence, high school graduation level or less, male sex, preexisting comorbid illnesses, and the lack of feverishness. This study demonstrates that there is significantly higher long-term mortality among patients with pneumonia than among age-matched controls and that long-term mortality largely is not affected by acute physiologic derangements.

Late admission to the ICU in patients with community-acquired pneumonia is associated with higher mortality

BACKGROUNDnLimited data are available on the impact of time to ICU admission and outcomes for patients with severe community acquired pneumonia (CAP). Our objective was to examine the association of time to ICU admission and 30-day mortality in patients with severe CAP.nnnMETHODSnA retrospective cohort study of 161 ICU subjects with CAP (by International Classification of Diseases, 9th edition, codes) was conducted over a 3-year period at two tertiary teaching hospitals. Timing of the ICU admission was dichotomized into early ICU admission (EICUA, direct admission or within 24 h) and late ICU admission (LICUA, >or= day 2). A multivariable analysis using Cox proportional hazard model was created with the primary outcome of 30-day mortality (dependent measure) and the American Thoracic Society (ATS) severity adjustment criteria and time to ICU admission as the independent measures.nnnRESULTSnEighty-eight percent (n = 142) were EICUA patients compared with 12% (n = 19) LICUA patients. Groups were similar with respect to age, gender, comorbidities, clinical parameters, CAP-related process of care measures, and need for mechanical ventilation. LICUA patients had lower rates of ATS severity criteria at presentation (26.3% vs 53.5%; P = .03). LICUA patients (47.4%) had a higher 30-day mortality compared with EICUA (23.2%) patients (P = .02), which remained after adjusting in the multivariable analysis (hazard ratio 2.6; 95% CI, 1.2-5.5; P = .02).nnnCONCLUSIONnPatients with severe CAP with a late ICU admission have increased 30-day mortality after adjustment for illness severity. Further research should evaluate the risk factors associated and their impact on clinical outcomes in patients admitted late to the ICU.

Impact of statins and ACE inhibitors on mortality after COPD exacerbations

BackgroundThe purpose of our study was to examine the association of prior outpatient use of statins and angiotensin converting enzyme (ACE) inhibitors on mortality for subjects ≥ 65 years of age hospitalized with acute COPD exacerbations.MethodsWe conducted a retrospective national cohort study using Veterans Affairs administrative data including subjects ≥65 years of age hospitalized with a COPD exacerbation. Our primary analysis was a multilevel model with the dependent variable of 90-day mortality and hospital as a random effect, controlling for preexisting comorbid conditions, demographics, and other medications prescribed.ResultsWe identified 11,212 subjects with a mean age of 74.0 years, 98% were male, and 12.4% of subjects died within 90-days of hospital presentation. In this cohort, 20.3% of subjects were using statins, 32.0% were using ACE inhibitors or angiotensin II receptor blockers (ARB). After adjusting for potential confounders, current statin use (odds ratio 0.51, 95% confidence interval 0.40–0.64) and ACE inhibitor/ARB use (0.55, 0.46–0.66) were significantly associated with decreased 90-day mortality.ConclusionUse of statins and ACE inhibitors prior to admission is associated with decreased mortality in subjects hospitalized with a COPD exacerbation. Randomized controlled trials are needed to examine whether the use of these medications are protective for those patients with COPD exacerbations.

Causes and Risk Factors for Rehospitalization of Patients Hospitalized with Community-Acquired Pneumonia

BACKGROUNDnRehospitalization after inpatient treatment of community-acquired pneumonia occurs in one-tenth of all hospitalizations, but the clinical circumstances surrounding readmission to the hospital have not been well studied. The objective of this study was to identify the causes and risk factors for rehospitalization of inpatients with community-acquired pneumonia.nnnMETHODSnThis project was performed as part of a randomized, multicenter, controlled trial of the implementation of practice guidelines to reduce the duration of intravenous antibiotic therapy and duration of hospitalization for patients who have received a clinical and radiographic diagnosis of pneumonia. The trial was conducted at 7 hospitals in Pittsburgh, Pennsylvania, from February 1998 through March 1999. The primary outcome for these analyses was rehospitalization within 30 days after the index hospitalization. Two physicians independently assigned the cause of rehospitalization as pneumonia related, comorbidity related, or both; consensus was reached for all assignments. Patient demographic characteristics and clinical factors independently associated with rehospitalization were identified using multiple logistic regression analysis.nnnRESULTSnOf the 577 patients discharged after hospitalization for community-acquired pneumonia, 70 (12%) were rehospitalized within 30 days. The median time to rehospitalization was 8 days (interquartile range, 4-13 days). Overall, 52 rehospitalizations (74%) were comorbidity related, and 14 (20%) were pneumonia related. The most frequent comorbid conditions responsible for rehospitalization were cardiovascular (n = 19), pulmonary (n = 6) and neurological (n = 6) in origin. Less than a high school education (odds ratio, 2.0; 95% confidence interval, 1.1-3.4), unemployment (odds ratio, 3.7; 95% confidence interval, 1.1-12.3), coronary artery disease (odds ratio, 2.7; 95% confidence interval, 1.5-4.7), and chronic obstructive pulmonary disease (odds ratio, 2.3; 95% confidence interval, 1.3-4.1) were independently associated with rehospitalization.nnnCONCLUSIONSnThe majority of rehospitalizations following pneumonia are comorbidity related and are the result of underlying cardiopulmonary and/or neurologic diseases. Careful attention to the clinical stability of patients with these coexisting conditions at and following hospital discharge may decrease the frequency of rehospitalization of patients with community-acquired pneumonia.

Impact of statins and angiotensin-converting enzyme inhibitors on mortality of subjects hospitalised with pneumonia

Recent studies suggest that statins and angiotensin-converting enzyme (ACE) inhibitors may have beneficial effects for some types of infections. The present study aimed to examine the association of outpatient use of these medications on 30-day mortality for subjects aged >65u2005yrs and hospitalised with community-acquired pneumonia. A retrospective national cohort study was conducted using the Department of Veterans Affairs administrative data including subjects aged ≥65u2005yrs hospitalised with community-acquired pneumonia, and having ≥1u2005yr of prior Veterans Affairs outpatient care. In total, 8,652 subjects were identified with a mean age of 75u2005yrs, 98.6% were male, and 9.9% of subjects died within 30u2005days of presentation. In this cohort, 18.1% of subjects were using statins and 33.9% were using ACE inhibitors. After adjusting for potential confounders, current statin use (odds ratio (OR) 0.54, 95% confidence interval (CI) 0.42–0.70) and ACE inhibitor use (OR 0.80, 95% CI 0.68–0.89) were significantly associated with decreased 30-day mortality. Use of statins and angiotensin-converting enzyme inhibitors prior to admission is associated with decreased mortality in subjects hospitalised with community-acquired pneumonia. Randomised controlled trials are needed to examine whether the use of these medications in patients hospitalised with community-acquired pneumonia may be beneficial.

Guideline-Concordant Antibiotic Use and Survival Among Patients With Community-Acquired Pneumonia Admitted to the Intensive Care Unit

OBJECTIVEnThis study evaluated the survival benefit of US community-acquired pneumonia (CAP) practice guidelines in the intensive care unit (ICU) setting.nnnMETHODSnWe conducted a retrospective cohort study of adult patients with CAP who were admitted to 5 community hospital ICUs between November 1, 1999, and April 30, 2000. The guidelines for antibiotic prescriptions were the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines. Guideline-concordant antimicrobial therapy was defined as a beta-lactam plus fluoroquinolone or macrolide, antipseudomonal beta-lactam plus fluoroquinolone, or antipseudomonal beta-lactam plus aminoglycoside plus fluoroquinolone or macrolide. Patients with a documented beta-lactam allergy were considered to have received guideline-concordant therapy if they received a fluoroquinolone with or without clindamycin, or aztreonam plus fluoroquinolone with or without aminoglycoside. All other antibiotic regimens were considered to be guideline discordant. Time to clinical stability, time to oral antibiotics, length of hospital stay, and in-hospital mortality were evaluated with regression models that included the outcome as the dependent variable, guideline-concordant antibiotic therapy as the independent variable, and the Pneumonia Severity Index (PSI) score and facility as covariates.nnnRESULTSnThe median age of the 129 patients included in the study was 71 years (interquartile range, 60-79 years). Sixty-two of 129 patients (48%) were male. Comorbidities included liver dysfunction (7 patients [5%]), heart failure (62 [48%]), renal dysfunction (39 [30%]), cerebrovascular disease (21 [16%]), and cancer (14 [11%]). The median (25th-75th percentile) PSI score was 119 (98-142), and overall mortality was 19% (25 patients). Patient demographics were similar between groups. Fifty-three patients (41%) received guideline-endorsed therapies. Guideline-discordant therapy was associated with an increase in inpatient mortality (25% vs 11%; odds ratio = 2.99 [95% CI, 1.08-9.54]). Receipt of guideline-concordant antibiotics was not associated with reductions in time to clinical stability, time to oral antibiotics, or length of hospital stay when patients who died were excluded from the analysis.nnnCONCLUSIONnGuideline-concordant empiric antibiotic therapy was associated with improved survival among these patients with CAP who were admitted to 5 ICUs.

Inhaled corticosteroid use is associated with lower mortality for subjects with COPD and hospitalised with pneumonia.

Recent studies suggest that use of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) may be associated with a higher incidence of pneumonia. However, it is unclear whether COPD subjects on ICS who develop pneumonia have worse outcomes. Therefore, our aim was to examine the association of prior outpatient ICS therapy with mortality in hospitalised COPD subjects with pneumonia. We included subjects ≥64 yrs of age, hospitalised with pneumonia in US Veterans Affairs hospitals, and assessed the association of ICS exposure with mortality for hospitalised COPD subjects with pneumonia in a covariate-adjusted regression model. We identified 6,353 subjects with a diagnosis of pneumonia and prior COPD, of whom 38% were on ICS. Mortality was 9% at 30 days and 16% at 90 days. In regression analyses, outpatient ICS therapy was associated with lower mortality at both 30 days (OR 0.76, 95% CI 0.70–0.83), and 90 days (OR 0.80, 95% CI 0.75–0.86). Outpatient therapy with ICS was associated with a significantly lower 30- and 90-day mortality in hospitalised COPD patients with pneumonia.