Filipe Froes

Hospital admissions of adults with community-acquired pneumonia in Portugal between 2000 and 2009

Recent studies in the USA and northern Europe have shown an increase in community-acquired pneumonia (CAP). In southern Europe, this increase has not yet been documented. We carried out a retrospective analysis from encoded information from the Portuguese database for hospital admissions that included all individuals aged ≥18 years, with a primary diagnosis of pneumonia, who were discharged between 2000 and 2009. We excluded patients infected with HIV, individuals immunocompromised as a result of anti-cancer or immunosuppressive treatment, and transplant recipients. Of the 294 027 admissions for CAP, 56% were male. The mean age was 73.1 years and the median age 77 years. Between 2000 and 2009, there was a 5% increase in the average age of patients admitted with CAP. Admissions for CAP represented 3.7% of total admissions of adult patients. The average annual rate of hospital admissions for adults with CAP was 3.61 per 1000 total population, rising to 13.4 for those aged ≥65 years. Between 2000–2004 and 2005–2009 the average annual rate of hospital admission for CAP per 1000 population increased by 28.2%. Hospital admissions for CAP in Portugal increased between 2000 and 2009. It has grown consistently over time, varying according to age with males over-represented.

Pneumonia da comunidade no adulto em Portugal Continental – Incidência e mortalidade dos internamentos hospitalares nos anos de 1998 a 2000

Objective: To characterise the incidence and mortality in adult inpatients with community-acquired pneumonia at a global and regional level in mainland Portugal. Patients and methods: We used the clinical database belonging to the Ministry of Health’s Instituto de Gestao e Informatica Financeira (Institute of Financial Management and Informatics), which contains the encoded information from the discharge letters from all hospitalisations at National Health Service institutions in mainland Portugal. We conducted a retrospective analysis of all hospitalisations in 1998, 1999 and 2000 with a main diagnosis of pneumonia on admission (ICD9: 480 to 486 and 487.0), excluding patients infected with the human immunodeficiency virus. Results: From 1998 to 2000, hospitalisation of adults with pneumonia represented about 3 of the total number of admissions. We determined an average annual incidence of 2.66 hospitalisations for pneumonia per 1 000 adult inhabitants and of 9.78 per 1 000 inhabitants aged ≥ 65. The average age of the adults interned was 70, with 71.6 of the patients aged ≥ 65. We believe that 25 to 50 of adults with community-acquired pneumonia are hospitalised. The mortality rate of adults hospitalised was 17.3 , with no significant difference between the sexes. Mortality rose to 21.5 and 24.8 in individuals aged ≥ 65 and ≥ 75, respectively. On average, 2.8 of the adults admitted were given mechanical ventilation and their mortality rate was 43.9 . The incidence of hospitalisations for community-acquired pneumonia and its mortality differed from region to region in mainland Portugal. The annual incidence of admissions for pneumonia per 1 000 adult inhabitants in the central region was double that in the northern region and the Algarve and the mortality rate increased from north to south of the country, with a difference of more than 50% in the Algarve in relation to the northern region. Conclusions: The incidence of hospitalisations for community-acquired pneumonia is comparable to the figures published in the international literature, though the hospital mortality rate is higher. We feel that it is essential to conduct more studies with a view to a more detailed characterisation of the situation in Portugal and a better understanding of the reasons for the discrepancies between the regions. This would possibly also enable us to implement measures to reduce the mortality rate. REV PORT PNEUMOL 2003; IX (3): 187-194

Impact of antibiotic therapy in severe community-acquired pneumonia: Data from the Infauci study

&NA; Antibiotic therapy (AT) is the cornerstone of the management of severe community‐acquired pneumonia (CAP). However, the best treatment strategy is far from being established. To evaluate the impact of different aspects of AT on the outcome of critically ill patients with CAP, we performed a post hoc analysis of all CAP patients enrolled in a prospective, observational, multicentre study. Of the 502 patients included, 76% received combination therapy, mainly a &bgr;‐lactam with a macrolide (80%). AT was inappropriate in 16% of all microbiologically documented CAP (n = 177). Hospital and 6 months mortality were 34% and 35%. In adjusted multivariate logistic regression analysis, combination AT with a macrolide was independently associated with a reduction in hospital (OR 0.17, 95%CI 0.06–0.51) and 6 months (OR 0.21, 95%CI 0.07–0.57) mortality. Prolonged AT (>7 days) was associated with a longer ICU (14 vs. 7 days; p < 0.001) and hospital length of stay (LOS) (25 vs. 17 days; p < 0.001). Combination AT with a macrolide may be the most suitable AT strategy to improve both short and long term outcome of severe CAP patients. AT >7 days had no survival benefit and was associated with a longer LOS. Highlights:In SCAP, combination of antibiotics that includes a macrolide is associated a better hospital and 6 months survival.Courses of therapy longer than 7 days are not associated with survival benefit but lead to longer ICU and hospital LOS.Serum lactate showed to be a good prognostic marker of hospital mortality in SCAP patients.

Diabetes hinders community-acquired pneumonia outcomes in hospitalized patients.

Objectives This study aimed to estimate the prevalence of diabetes mellitus (DM) in hospitalized patients with community-acquired pneumonia (CAP) and its impact on hospital length of stay and in-hospital mortality. Research design and methods We carried out a retrospective, nationwide register analysis of CAP in adult patients admitted to Portuguese hospitals between 2009 and 2012. Anonymous data from 157 291 adult patients with CAP were extracted from the National Hospital Discharge Database and we performed a DM-conditioned analysis stratified by age, sex and year of hospitalization. Results The 74 175 CAP episodes that matched the inclusion criteria showed a high burden of DM that tended to increase over time, from 23.7% in 2009 to 28.1% in 2012. Interestingly, patients with CAP had high DM prevalence in the context of the national DM prevalence. Episodes of CAP in patients with DM had on average 0.8 days longer hospital stay as compared to patients without DM (p<0.0001), totaling a surplus of 15 370 days of stay attributable to DM in 19 212 admissions. In-hospital mortality was also significantly higher in patients with CAP who have DM (15.2%) versus those who have DM (13.5%) (p=0.002). Conclusions Our analysis revealed that DM prevalence was significantly increased within CAP hospital admissions, reinforcing other studies’ findings that suggest that DM is a risk factor for CAP. Since patients with CAP who have DM have longer hospitalization time and higher mortality rates, these results hold informative value for patient guidance and healthcare strategies.

Achoo, achis, ATCHIN! Vaccine you

Community-acquired pneumonia (CAP) is an important cause of morbidity, mortality and expenditure of health resources. Globally, lower respiratory tract infection, which includes CAP, was the fourth leading cause of death in 2015 [1]. In developed countries CAP is the leading cause of death by infectious disease [2], and in 2014 it was the eighth cause of death in the USA [3]. Take every opportunity to act on modifiable risk factors for CAP. ATCHIN! http://ow.ly/lscV30i00iU

PSI, CURB-65, SMART-COP or SCAP? And the winner is... SMART DOCTORS

Community-acquired pneumonia (CAP) is one of the most common diseases in adults with an estimated average annual incidence of 5 to 11 cases per 1000 inhabitants, which increases significantly with age. It is a major cause of hospital admission but the percentage of patients hospitalized for CAP varies greatly depending on country or region, the populations studied and the way the health systems are organised. In Portugal, it is estimated that 25 to 50% of adults with CAP are admitted to hospital and, in the period from 2000 to 2009, CAP was one of the principle causes of hospitalization, representing 3,7% of total adult hospital admissions. Although the majority of patients are treated as outpatients, hospital admissions for treatment of patients with CAP represent a big percentage of the cost of treating CAP patients. Studies carried out in the United States of America (USA), at the end of the last century, worked out that the total annual cost was 8,4 billion US dollars, of which 8,0 billion (95%) was the result of hospital admission. To deal with this, Michael Fine et al developed the first score for CAP, the Pneumonia Severity Index (PSI), with the goal of predicting mortality and identifying patients at low risk of mortality who did not need to be admitted to hospital. The PSI stratifies patients into 5 risk classes, based on evaluation of more than twenty clinical and laboratory parameters, heavily weighted for age and comorbidities. The complexity of the PSI, led to the development of another score, the CURB-65 (acronym for Confusion, Urea, Respiratory rate, Blood pressure and age ≥65) by the British Thoracic Society. Various studies have evaluated the PSI and the CURB-65 in the same populations with comparable results for predicting mortality and identifying low-risk patients, although in one study the CURB-65 had better results in predicting mortality in the most serious cases. It should be pointed out that neither the PSI nor the CURB-65 were developed to identify patients needing to

Pneumococcal vaccination and chronic respiratory diseases

Patients with COPD and other chronic respiratory diseases are especially vulnerable to viral and bacterial pulmonary infections, which are major causes of exacerbations, hospitalization, disease progression, and mortality in COPD patients. Effective vaccines could reduce the burden of respiratory infections and acute exacerbations in COPD patients, but what is the evidence for this? This article reviews and discusses the existing evidence for pneumococcal vaccination efficacy and its changing role in patients with chronic respiratory diseases, especially COPD. Specifically, the recent Community-Acquired Pneumonia Immunization Trial in Adults (CAPITA) showed the efficacy of pneumococcal conjugate vaccine in older adults, many of whom had additional risk factors for pneumococcal disease, including chronic lung diseases. Taken together, the evidence suggests that pneumococcal and influenza vaccinations can prevent community-acquired pneumonia and acute exacerbations in COPD patients, while pneumococcal vaccination early in the course of COPD could help maintain stable health status. Despite the need to prevent pulmonary infections in patients with chronic respiratory diseases and evidence for the efficacy of pneumococcal conjugate vaccine, pneumococcal vaccine coverage and awareness are low and need to be improved. Respiratory physicians need to communicate the benefits of vaccination more effectively to their patients who suffer from chronic respiratory diseases.

Intensive care unit patients with lower respiratory tract nosocomial infections: The ENIRRIs project

The clinical course of intensive care unit (ICU) patients may be complicated by a large spectrum of lower respiratory tract infections (LRTI), defined by specific epidemiological, clinical and microbiological aspects. A European network for ICU-related respiratory infections (ENIRRIs), supported by the European Respiratory Society, has been recently established, with the aim at studying all respiratory tract infective episodes except community-acquired ones. A multicentre, observational study is in progress, enrolling more than 1000 patients fulfilling the clinical, biochemical and radiological findings consistent with a LRTI. This article describes the methodology of this study. A specific interest is the clinical impact of non-ICU-acquired nosocomial pneumonia requiring ICU admission, non-ventilator-associated LRTIs occurring in the ICU, and ventilator-associated tracheobronchitis. The clinical meaning of microbiologically negative infectious episodes and specific details on antibiotic administration modalities, dosages and duration are also highlighted. Recently released guidelines address many unresolved questions which might be answered by such large-scale observational investigations. In light of the paucity of data regarding such topics, new interesting information is expected to be obtained from our network research activities, contributing to optimisation of care for critically ill patients in the ICU. Methodology for the first European network for ICU-related respiratory infections (ENIRRIs) project http://ow.ly/sud930fU1e7

Pneumonia na Grávida

RESUMO Os autores reveem a pneumonia durante a gravidez, cuja incidencia tern vindo a aumentar, realcando as diferencas fisiologicas e na abordagem diagnostica e terapeutica em relacao a pneumonia na mulher nao gravida. REV PORT PNEUMOL 2001; VII (1): 43-47

Hemorragia Alveolar Difusa - a propósito de um caso clínico de Hemossiderose Pulmonar Idiopática.

RESUMO Devido a sua raridade, a Hemorragia Alveolar Difusa (HAD) e muitas vezes urn diagnostico esquecido. Os autores apresentam uma revisiao desta entidade a proposito do caso clinico de um homem de 71 anos, internado por febre, tosse seu, falencia respiratoria progressiva e com o diagnostico de admissao de pneumonia da comunidade. Os exames efectuados foram compativeis com HAD e apos realizacao de biopsia pulmonar cirurgica foi admitido Hemossiderose Pulmonar Idiopatica como diagnostico de exclusao. REV PORT PNEUMOL 1999; V (5): 499-505