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BACKGROUND: Elderly patients surviving community-acquired pneumonia (CAP) have subsequent increased mortality. However, little is known regarding long-term survival in younger adults or those with healthcare-associated pneumonia (HCAP). OBJECTIVES: To identify factors associated with mortality and compare long-term survival in patients hospitalized with HCAP to that of patients with CAP. METHODS: We determined survival after discharge as of December 2002 in a patient cohort admitted with pneumonia between June 1994 and May 1996. We used the Cox proportional hazard model to estimate differences in survival after controlling for confounders. RESULTS: Of the 522 patients hospitalized with pneumonia, 457 survived to discharge. One hundred sixty-four patients (36%, 95% confidence interval, CI, 31-40%) were admitted with HCAP, while 293 (64%, 95% CI 60-69%) were admitted with CAP. Of the 181 deaths in the follow-up period, 70 occurred in patients under age 65 years admitted with HCAP (53% death rate, 95% CI 44-62%). Nineteen of these deaths (27%, 95% CI 17-39%) occurred in the absence of HIV infection. In patients under the age of 65 whose only risk factor for HCAP was treatment for pneumonia or hospitalization in the previous 90 days, 4 of 13 patients (31%, 95% CI 9-61%) died. Twenty percent (95% CI 15-26%) of patients under age 65 years admitted with CAP died during the follow-up. CONCLUSIONS: Admission for HCAP, and to a lesser degree CAP, is associated with increased long-term mortality even in young patients. Future studies are warranted to identify interventions to improve survival in this population.

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CONTEXT: There are up to 1 million patients treated in acute-care hospitals for community-acquired pneumonia (CAP), with an estimated annual cost > 8 billion dollars. A newly validated CAP outcomes prediction rule developed by Fine and colleagues has been advocated as a guide to hospitalization decisions. OBJECTIVE: To evaluate the clinical characteristics, costs of care, and resource utilization of patients with low-risk CAP at an urban public hospital serving an indigent population. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study from June 1, 1994 to May 31, 1996. MAIN OUTCOME MEASURES: Clinical characteristics and costs of care of patients with low-risk CAP and features associated with low-risk CAP in this population. RESULTS: A total of 522 patients were identified at the time of hospital admission as having CAP; 97 patients (19%) were HIV positive on hospital admission and excluded. Of the remaining 425 patients, 253 patients (60%) were classified as pneumonia severity index (PSI) class I-III (low risk). Of the patients with low-risk CAP, only four patients (1.6%; 95% confidence interval, 0.4 to 4.0%) died during hospitalization. Low-risk CAP was both costly and accounted for significant resource use (35.4% of total CAP costs, and 45% of all CAP bed days). Of the patients with low-risk CAP, there were 138 patients (55%) who could potentially have been treated as outpatients (absence of altered mental status, hypotension, hypoxia on hospital admission, or direct ICU admission). However, 49% of these patients had a history of alcoholism, 20% had a blood alcohol level > 50 mg/dL, and 44% were homeless. CONCLUSIONS: A significant proportion of the patients admitted with CAP to a public hospital had low-risk CAP and accounted for a significant proportion of the CAP bed days and costs. The use of the PSI accurately predicted which patients would be at low risk for death; however, the utility of using the PSI to reduce low-risk CAP hospital admissions would have been of limited benefit. High rates of homelessness, substance abuse, and medical needs not captured in the PSI would preclude many of these patients from unsupervised outpatient treatment.

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OBJECTIVE: To determine the safety and efficacy of filgrastim (r-metHuG-CSF) in combination with intravenous antibiotics to reduce the rate of mortality in patients with pneumonia and sepsis. DESIGN: This study was multicenter, double-blind, and randomized. SETTING: Intensive care units PATIENTS Adult patients with bacterial pneumonia, either acquired or nosocomial, as confirmed by chest radiograph and positive culture or Gram-negative stain, and severe sepsis, defined as sepsis-induced hypotension or organ dysfunction. INTERVENTIONS: Standard antibiotic therapy with or without filgrastim (300 microg/day) or placebo administered as a 30-min intravenous infusion. The study drug was started within 24 hrs of enrollment and was continued for 5 days or until the white blood cell count reached >75.0 x 10(9) cells/L. MEASUREMENTS AND MAIN RESULTS: The primary end point was the occurrence of mortality through day 29; secondary end points included occurrence of subsequent organ dysfunction, time to discharge from intensive care unit, number of days on mechanical ventilatory support, and time to death. Study-related observations were recorded through day 10 and included vital signs, onset of organ dysfunction, clinical laboratory variables, and adverse events. Filgrastim increased the white blood cell count to a median peak of 31.7 x 10(9) cells/L from a baseline of 12.3 x 10(9) cells/L. The two groups were well matched and did not differ significantly with regard to severe adverse events, time to death, occurrence of end-organ dysfunction, days of intensive care unit hospitalization, or days on mechanical ventilatory support. Mortality was low in both treatment groups; the mortality rate in patients with adult respiratory distress syndrome was similar between the two groups. CONCLUSIONS: The addition of filgrastim to the antibiotic and supportive care treatment of patients with pneumonia complicated by severe sepsis appeared to be safe, but not efficacious in reducing mortality rates or complications from this infection.

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