New perspectives on community-acquired pneumonia in 388,406 patients

Santiago Ewig ¹, Norbert Birkner ^2*, Richard Strauss ³, Elke Schaefer ², Juergen Pauletzki ⁴, Helge Bischoff ⁵, Peter Schraeder ², Tobias Welte ⁶ and Gert Hoeffken ⁷

¹ Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, Herne und Bochum, Germany
² BQS Bundesgeschäftsstelle für Qualitätssicherung, Germany
³ Universitaetsklinikum Erlangen, Germany
⁴ SRH Kliniken Heidelberg, Germany
⁵ Thoraxklinik Heidelberg, Germany
⁶ Medizinische Hochschule Hannover, Germany
⁷ Universitaetsklinikum Carl Gustav Carus, Dresden; Fachkliniken Coswig, Germany

^* To whom correspondence should be addressed. E-mail: norbert.birkner{at}bqs-online.de.

Accepted 27 April 2009

Abstract

Background: The database of the German program for quality in healthcare including data of every hospitalized patient with community-acquired pneumonia (CAP) during a two year period (n = 388,406 patients in 2005 and 2006) was analyzed.

Methods: Endpoints of the analysis were: 1) incidence 2) outcome 3) performance of CRB-65 score in predicting death 4) lack of ventilatory support as possible indicator of treatment restrictions. The CRB-65 score was calculated resulting in three risk classes (RC).

Results: The incidence of hospitalized CAP was 2.75 and 2.96 per 1,000 inhabitants/year in 2005 and 2006, respectively, higher for males (3.21 versus 2.52), and strongly age-related, with an incidence of 7.65 per 1,000 inhabitants/year in patients aged 60 years over two years. Mortality (13.72 and 14.44%) was higher than reported in previous studies. The CRB-65 risk classes (RC) accurately predicted death in a three class pattern (mortality 2.40% in CRB-65-RC 1, 13.43% in CRB-65-RC 2, and 34.39% in CRB-65-RC 3). The first days after admission were consistently associated with the highest risk of death throughout all risk classes. Only a minority of patients who died had received mechanical ventilation during hospitalization (15.74%).

Conclusions: Hospitalized CAP basically is a condition of the elderly associated with a higher mortality than previously reported. It bears a considerable risk of early mortality, even in low risk patients. CRB-65 is a simple and powerful tool for the assessment of CAP severity. Hospitalized CAP is a frequent terminal event in chronic debilitated patients, and a ceiling of care is frequently set.