Hon Ming Ma

A Randomized, controlled trial of an intensive community nurse-supported discharge program in preventing hospital readmissions of older patients with chronic lung disease

Objectives: To evaluate the effectiveness of an intensive community nurse (CN)‐supported discharge program in preventing hospital readmissions of older patients with chronic lung disease (CLD).

Predictors of in-hospital mortality of older patients admitted for community-acquired pneumonia

BACKGROUND there were a few studies on the case mortality of pneumonia in older people, of which results were conflicting. OBJECTIVES this study aimed to identify risk factors associated with in-hospital mortality in older patients admitted for community-acquired pneumonia (CAP). DESIGN a prospective cohort study. SETTING hospital sample. SUBJECTS during the 1-year study period (from October 2009 to September 2010), 488 older patients aged 65 or above were recruited. METHODS demographic characteristics, medical illnesses (Charlsons comorbidity index (CCI)), premorbid functional status (Katzs index) and baseline blood tests were recorded. The outcome was in-hospital mortality. RESULTS in this cohort of patients, the mean age was 81.0 years (±7.9) and 282 (57.8%) were male. Nursing home residents accounted for 23.8% (116/488) of study subjects. The median CCI was 2 (inter-quartile range (IQR): 1-3); 60 (12.3%) patients succumbed during hospital stay. Logistic regression showed that comorbidities, mid-arm circumference, serum albumin level and severity of pneumonia (Confusion, blood Urea nitrogen, Respiratory rate and low Blood pressure (CURB) score) were independent predictors of in-hospital mortality of pneumonia. CONCLUSION in keeping with previous studies, CURB score and comorbidities were the most significant independent predictors of mortality of CAP in older patients. Our study concluded that nutritional status was also an important factor affecting their survival. This study failed to demonstrate functional status as a predictor of mortality due to limitation of Katzs index.

Should Nursing Home-Acquired Pneumonia Be Treated as Nosocomial Pneumonia?

OBJECTIVES It is contentious whether nursing home-acquired pneumonia (NHAP) should be treated as community-acquired pneumonia (CAP) or health care-associated pneumonia. This study aimed to compare NHAP with CAP, and to examine whether multidrug-resistant (MDR) bacteria were significantly more common in NHAP than CAP. DESIGN A prospective, observational cohort study SETTING The medical unit of a tertiary teaching hospital PARTICIPANTS Patients 65 years and older, hospitalized for CAP and NHAP confirmed by radiographs from October 2009 to September 2010 MEASUREMENTS Demographic characteristics, Katz score, Charlson comorbidity index (CCI), pneumonia severity (CURB score), microbiology, and clinical outcomes were measured. RESULTS A total of 488 patients were recruited and 116 (23.8%) patients were nursing home residents. Compared with patients with CAP, patients with NHAP were older and had more comorbidities and higher functional dependence level. A larger proportion of patients with NHAP had severe pneumonia (CURB ≥2) than patients with CAP (30.2% vs 20.7%, P = .034). Similar percentages of patients had identified infective causes in the CAP and NHAP groups (27.7% vs 29.3%, P = .734). Viral infection accounted for more than half (55.9%) of NHAP, whereas bacterial infection was the most frequent (69.9%) cause of CAP. MDR bacteria were found in 6 patients of all study subjects. Nursing home residence and history of MDR bacterial infection were risk factors for MDR bacterial pneumonia, which had more severe pneumonia (CURB ≥2). Logistic regression analysis was limited by the small number of patients with MDR bacterial pneumonia. CONCLUSION In both CAP and NHAP, MDR bacterial infections were uncommon. Most cases of NHAP were caused by unknown etiology or viral pathogens. We suggest that NHAP should not be treated as nosocomial infection. The empirical treatment of broad-spectrum antibiotics in NHAP should be reserved for patients with severe pneumonia or at high risk of MDR bacterial infection.

Serotype Distribution and Antimicrobial Susceptibilities of Nasopharyngeal Isolates of Streptococcus pneumoniae from Children Hospitalized for Acute Respiratory Illnesses in Hong Kong

ABSTRACT Five hundred nineteen Streptococcus pneumoniae isolates from nasopharyngeal aspirates of 3,157 children (age, <16 years) participating in a respiratory surveillance study in Hong Kong in 2005 and 2006 indicated that 64.9% and 37.2% of the isolates were not susceptible to penicillin and cefotaxime, respectively. The rate of potential coverage by the seven-valent conjugate vaccine was 72.3%, and the rate increased to 74.6% for serogroup-specific types.

Recurrent hospitalisation with pneumonia is associated with higher 1-year mortality in frail older people

Previous studies persistently showed that functional dependence was associated with higher long‐term (≥1 year) mortality of older patients hospitalised with community‐acquired pneumonia (CAP). The importance of other factors was, however, not well reported.

Predictors of viral pneumonia: The need for viral testing in all patients hospitalized for nursing home-acquired pneumonia

Community‐acquired pneumonia (CAP) is presumed to be bacterial in origin and empirical antibiotics are almost always given on admission. However, early detection of viral infection is also very important for hospital infection control and timely use of antiviral agents. The present study aimed to compare patients with viral and bacterial pneumonia, and identify independent predictors of viral pneumonia.

Risk factors for drug-resistant bacterial pneumonia in older patients hospitalized with pneumonia in a Chinese population

BACKGROUND The relationship between healthcare-associated pneumonia (HCAP) and resistant bacteria is unclear. The aim of this study was to identify the risk factors for pneumonia caused by drug-resistant bacteria (DRB). METHODS A prospective cohort study was conducted at a tertiary teaching hospital in Hong Kong. Consecutive older patients (aged ≥65 years) were hospitalized with pneumonia from January 2004 to June 2005. DRB comprised methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae and Acinetobacter baumannii. RESULTS The entire cohort consisted of 1176 older patients. Of 472 (40.1%) patients with etiological diagnosis established, bacterial pneumonia was found in 354 (30.1%) cases. DRB were isolated in 48 patients: P. aeruginosa (41), MRSA (5) and ESBL producing enteric bacilli (3). Co-infection with P. aeruginosa and MRSA was found in one patient. The prevalence of DRB in culture-positive pneumonia was 20.1% (48/239). Patients with DRB were more likely to have limitation in activities of daily living, bronchiectasis, dementia, severe pneumonia, recent hospitalization and recent antibiotic use. Logistic regression revealed that bronchiectasis [relative risk (RR) 14.12, P = 0.002], recent hospitalization (RR 4.89, P < 0.001) and severe pneumonia (RR 2.42, P = 0.010) were independent predictors of drug-resistant bacterial pneumonia. CONCLUSION Recent hospitalization is the only risk factor for HCAP which is shown to be associated with DRB. Nursing home residence is not a risk factor. The concept of HCAP may not be totally applicable in Hong Kong where the prevalence of drug-resistant pathogens in pneumonia is low.

Development and validation of a clinical risk score for predicting drug-resistant bacterial pneumonia in older Chinese patients.

Health care‐associated pneumonia (HCAP) and drug‐resistant bacterial pneumonia may not share identical risk factors. We have shown that bronchiectasis, recent hospitalization and severe pneumonia (confusion, blood urea level, respiratory rate, low blood pressure and 65 year old (CURB‐65) score ≥3) were independent predictors of pneumonia caused by potentially drug‐resistant (PDR) pathogens. This study aimed to develop and validate a clinical risk score for predicting drug‐resistant bacterial pneumonia in older patients.

A New Model for End-of-Life Care in Nursing Homes

OBJECTIVES This study aimed to promote quality end-of-life (EOL) care for nursing home residents, through the establishment of advance care plan (ACP) and introduction of a new care pathway. This pathway bypassed the emergency room (ER) and acute medical wards by facilitating direct clinical admission to an extended-care facility. DESIGN An audit on a new clinical initiative that entailed the Community Geriatrics Outreach Service, ER, acute medical wards, and an extended-care facility during winter months in Hong Kong. METHODS The participants were older nursing home residents enrolled in an EOL program. We monitored the ratio of clinical to emergency admissions, ACP compliance rate, average length of stay (ALOS) in both acute hospital and an extended-care facility, and mortality rates. RESULTS A total of 76 patients were hospitalized from January to March 2013. Of them, 30 (39%) were directly admitted to the extended-care facility, either through the liaison of Community Geriatrics Outreach Service (group A, 19/76, 25%) or transferred from the ER (group B, 11/76, 14%). The remaining 46 patients (group C, 61%) were admitted via the ER to acute medical wards following the usual pathway, followed by transfer to an extended-care facility if indicated. The ACP compliance rate was nearly 100%. In the extended-care unit, groups A and C had similar ALOS of 11.8 and 11.1 days, respectively, whereas group B had a shorter stay of 7.6 days. The ALOS of group C in acute medical wards was 3.5 days. The in-hospital mortality rates were comparable in groups A and C of 26% and 28%, respectively, whereas group B had a lower mortality rate of 18%. CONCLUSIONS Nearly 40% of EOL patients could be managed entirely in an extended-care setting without compromising the quality of care and survival. A greater number of patients may benefit from the EOL program by improving the collaboration between community outreach services and ER; and extending hours for direct clinical admission to an extended-care facility.

Effect of age and residential status on the predictive performance of CURB-65 score.

The CURB‐65 score was designed to predict 30‐day mortality and decide the site of care of pneumonia. It is uncertain how age and residential status affect the accuracy of CURB‐65 score in older patients.