Danger of Pneumonia Increases with Veterans’ Worsened Health Status

by U.S. Medicine

December 9, 2014

Higher Pneumonia Vaccine Rates Urged

By Brenda L. Mooney

PROVIDENCE, RI – With influenza season each year comes an even greater challenge for VA hospitals — a spate of pneumonia cases in older veterans. Recent research suggests the problem will get worse before it gets better.

Between 2002 and 2011, the baseline health status of veterans with serious pneumococcal infections at the VA worsened — a trend that is predicted to continue as the population ages and even more patients have chronic diseases.

The best response, according to the authors of a study published earlier this year in the Journal of Infectious Diseases & Therapy, is increased use of pneumococcal vaccination.

The study, conducted by researchers from the Providence, RI, VAMC, the University of Rhode Island and Brown University, identified 45,983 unique episodes of pneumococcal disease defined by positive cultures during the nine-year period. While disease incidence decreased significantly by 3.5% per year in outpatients, representing 2.6 infections per 100,000 clinic visits/hospitalizations, it also increased, albeit nonsignificantly, by 0.2% per year in inpatients where the rate was 328.1 per 100,000 visits.

“Our aging veteran population may also explain the slight increase in inpatient pneumococcal infections we observed. Incidence increased in patients aged 65 years and older, while incidence decreased in younger patients,” the authors wrote. “Elderly patients are at the highest risk for pneumococcal disease and disease incidence in these patients is up to 50 times greater than that of adolescents. As the general population ages, the burden of pneumococcal disease is expected to dramatically increase. This increase may be exacerbated in the veteran population, which is older than the general population and is aging at a disproportionate rate compared to the general population.”

In addition, chronic disease risk factors for pneumococcal disease rose significantly among inpatients, including:

  • respiratory disease (1.9% annually),
  • diabetes (1.3%), and
  • renal failure (1.0%).

Yet, only 30.2% of inpatients with serious infections had a pneumococcal immunization in the previous five years, according to study authors who pointed out that both invasive disease and mortality were both higher in non-vaccinated patients compared to vaccinated patients.

“Overall, one-third of the patients in our study with serious infections had a history of pneumococcal vaccination, which is much lower than the previously reported vaccination rate of 85% for patients at VA facilities nationally in 2003,” according to the report. “As we conducted our study in older adults and observed significant increases in risk factors for S. pneumonia, it is likely that a number of these non-vaccinated patients had indications for vaccination. This is extremely concerning as non-vaccinated patients with indications for vaccination are more likely to become infected with pneumococcus than those without indications, and non-vaccinated patients are also twice as likely to die if they develop invasive pneumococcal disease.”

Interestingly, the researchers found that the sickest patients in their study were the most likely to have received pneumococcal vaccination, probably because their ill health meant they had more healthcare exposures and, therefore, more opportunities to be vaccinated.

“Increased pneumococcal vaccination awareness may be needed for patients who are at risk of pneumococcal disease and have indications for vaccination but have fewer healthcare exposures,” the authors wrote. “The administration of vaccination in non-traditional settings, such as pharmacies and shopping malls, may improve vaccine coverage in these patients.” (See Pharmacy Update, pg. xx)

New Recommendations

Based on new recommendations from the national Centers for Disease Control and Prevention (CDC), adults 65 years or older should now receive both the pneumococcal conjugate vaccine (PCV13, Prevnar-13) and the pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23).

The advisory, published in a recent edition of the CDC’s Morbidity and Mortality Weekly Report, also said that adults 65 years of age or older who have not previously received any pneumococcal vaccines or whose previous vaccination history is unknown should receive a dose of PCV13 first, followed later by a dose of PPSV23.

Those who previously received PPSV23 should receive the additional vaccine at least one year since their most recent dose of PPSV23, the CDC noted.

The Advisory Committee on Immunization Practices (ACIP) recommended routine use of 13-valent pneumococcal conjugate vaccine in August. The determination was made after reviewing evidence of a randomized placebo-controlled trial evaluating efficacy of PCV13 for preventing community-acquired pneumonia among approximately 85,000 adults 65 and older with no prior pneumococcal vaccination history in the CAPiTA trial.

Both PCV13 and PPSV23 should be administered routinely in a series to all adults aged 65 or older, according to the ACIP recommendations. The two vaccines should not be co-administered, however, and the minimum acceptable interval between PCV13 and PPSV23 is eight weeks, the advisory committee said.

Less Treatment Effective

When pneumonia occurs in either vaccinated or unvaccinated patients, less may be more in terms of antibiotic treatment.

Daniel M. Musher MD

Daniel M. Musher MD

Daniel M. Musher MD, of the Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, both in Houston, was the lead author in a recent review article recommending that initial antibiotic therapy for community acquired pneumonia should be limited to five to seven days for outpatients and for inpatients who have a prompt response to therapy.

The article, published recently in the New England Journal of Medicine and co-written with Anna R. Thorner, MD, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, pointed out that early in the antibiotic era pneumonia was treated for about five days or less, according to the article. In fact, Musher and Thorner noted that “some studies even showed that a single dose of penicillin G procaine was curative.”

“The standard duration of treatment later evolved to 5 to 7 days. A meta-analysis of studies comparing treatment durations of 7 days or less with durations of 8 days or more showed no differences in outcomes, and prospective studies have shown that 5 days of therapy are as effective as 10 days, and 3 days are as effective as 8,” Musher and Thorner wrote. “Nevertheless, practitioners have gradually increased the duration of treatment for CAP to 10  to 14 days. A responsible approach to balancing antibiotic stewardship with concern about insufficient antibiotic therapy would be to limit treatment to 5 to 7 days, especially in outpatients, or in inpatients who have a prompt response to therapy.”

The authors explained that clinicians often choose to use the longer therapy because of concerns about small abscesses caused by Staph. aureus or gram-negative bacilli.

“Hematogenous Staph. aureus pneumonia mandates treatment for at least 4 weeks, but segmental or lobar pneumonia that is caused by this organism may be treated for 2 weeks,” according to the review. “Cavitating pneumonia and lung abscesses are usually treated for several weeks; some experts continue treatment until cavities have resolved. The lack of a response to seemingly appropriate treatment in a patient with CAP should lead to a complete reappraisal, rather than simply to selection of alternative antibiotics.”

1 Morrill HJ, Caffrey AR, Noh E, LaPlante KL. Epidemiology of pneumococcal disease in a national cohort of older adults. Infect Dis Ther. 2014 Jun;3(1):19-33. doi: 10.1007/s40121-014-0025-y. Epub 2014 Apr 12. PubMed PMID: 25134809; PubMed Central PMCID: PMC4108120.

2 Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med. 2014 Oct23;371(17):1619-28. doi: 10.1056/NEJMra1312885. Review. PubMed PMID: 25337751.

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