Anticholinergic medications and risk of community-acquired pneumonia in elderly adults: a population-based case-control study.

OBJECTIVES: To determine whether use of anticholinergics is associated with risk of community-acquired pneumonia in older adults. DESIGN: Population-based case-control study. SETTING: An integrated healthcare delivery system in Washington State. PARTICIPANTS: Data from a nested case-control study of community-dwelling immunocompetent adults aged 65 to 94 were analyzed. Pneumonia cases (n=1,039) were ascertained according to International Classification of Diseases, Ninth Revision, codes from 2000 to 2003 and validated using chart review. Controls (n=2,022) were matched 2:1 to cases according to age, sex, and year. MEASUREMENTS: Anticholinergic medication exposure was ascertained using prescription data; acute use was defined as one or more prescription fills 90 days or less before the index date (date of pneumonia diagnosis), past use was defined as one or more prescription fills within the prior year but none within 90 days, and chronic use was defined as three or more prescription fills within the prior year. The reference group was those with no fills in the prior year. Conditional logistic regression was used to analyze the association between anticholinergic use and pneumonia, adjusted for comorbidities. RESULTS: Acute use of anticholinergics was observed in 59% of cases and 35% of controls (adjusted odds ratio (aOR)=2.55, 95% confidence interval (CI)=2.08-3.13) and past use in 17% of cases and 23% of controls (aOR=1.19, 95% CI=0.92-1.53). Chronic use of anticholinergics was observed in 53% of cases and 36% of controls (aOR 2.07, 95% CI=1.68-2.54). Results were not different for high- and low-potency anticholinergic medications. CONCLUSION: In older adults, anticholinergic medication use is associated with pneumonia risk, adding to substantial evidence suggesting that these medications are high risk.

Use of opioids or benzodiazepines and risk of pneumonia in older adults: a population-based case-control study.

OBJECTIVES: To examine whether use of opioids or benzodiazepines is associated with risk of community-acquired pneumonia in older adults. DESIGN: Population-based case-control study. SETTING: An integrated healthcare delivery system. PARTICIPANTS: Community-dwelling, immunocompetent adults aged 65 to 94 from 2000 to 2003. Presumptive pneumonia cases were identified from health plan automated data and validated through medical record review. Two controls were selected for each case with pneumonia, matched on age, sex, and calendar year. MEASUREMENTS: Information about opioid and benzodiazepine use came from computerized pharmacy data. Information on covariates including comorbid illnesses and functional and cognitive status came from medical record review and electronic health data. RESULTS: One thousand thirty-nine validated cases of pneumonia and 2,022 matched controls were identified. One hundred forty-four (13.9%) cases and 161 (8.0%) controls used prescription opioids (adjusted odds ratio (OR) = 1.38, 95% confidence interval (CI) = 1.08-1.76 vs nonuse). Risk was highest for opioids categorized as immunosuppressive based on immunological studies (OR = 1.88, 95% CI = 1.26-1.79 vs nonuse), whereas for nonimmunosuppressive opioids the OR was 1.23 (95% CI = 0.89-1.69). Risk was highest in the first 14 days of use (OR = 3.24, 95% CI = 1.64-6.39 vs nonuse). For long-acting opioids, the OR was 3.43 (95% CI = 1.44-8.21) versus nonuse, whereas for short-acting opioids, it was 1.27 (95% CI = 0.98-1.64). No greater risk was seen for current benzodiazepine use compared to nonuse (OR = 1.08, 95% CI = 0.80-1.47). CONCLUSION: Use of opioids but not benzodiazepines was associated with pneumonia risk. The differences in risk seen for different opioid regimens warrant further study.

Pharmacotherapy and the risk for community-acquired pneumonia.

BACKGROUND: Some forms of pharmacotherapy are shown to increase the risk of community-acquired pneumonia (CAP). The purpose of this study is to investigate whether pharmacotherapy with proton pump inhibitors (PPI), inhaled corticosteroids, and atypical antipsychotics was associated with the increased risk for CAP in hospitalized older adults with the adjustment of known risk factors (such as smoking status and serum albumin levels). METHODS: A retrospective case-control study of adults aged 65 years or older at a rural community hospital during 2004 and 2006 was conducted. Cases (N = 194) were those with radiographic evidence of pneumonia on admission. The controls were patients without the discharge diagnosis of pneumonia or acute exacerbation of chronic obstructive pulmonary disease (COPD) (N = 952). Patients with gastric tube feeding, ventilator support, requiring hemodialysis, metastatic diseases or active lung cancers were excluded. RESULTS: Multiple logistic regression analysis revealed that the current use of inhaled corticosteroids (adjusted odds ratio [AOR] = 2.89, 95% confidence interval [CI] = 1.56-5.35) and atypical antipsychotics (AOR = 2.26, 95% CI = 1.23-4.15) was an independent risk factor for CAP after adjusting for confounders, including age, serum albumin levels, sex, smoking status, a history of congestive heart failure, coronary artery disease, and COPD, the current use of PPI, beta2 agonist and anticholinergic bronchodilators, antibiotic(s), iron supplement, narcotics, and non-steroidal anti-inflammatory drugs. The crude OR and the AOR of PPI use for CAP was 1.41 [95% CI = 1.03 - 1.93] and 1.18 [95% CI = 0.80 - 1.74] after adjusting for the above confounders, respectively. Lower serum albumin levels independently increased the risk of CAP 1.89- fold by decreasing a gram per deciliter (AOR = 2.89, 95% CI = 2.01 - 4.16). CONCLUSION: Our study reaffirmed that the use of inhaled corticosteroids and atypical antipsychotics was both associated with an increased risk for CAP in hospitalized older adults of a rural community. No association was found between current PPI use and the risk for CAP in this patient population of our study.

Vitamin intake is not associated with community-acquired pneumonia in U.S. men.

The age-related decline in immune function may predispose individuals to increased infection risk. Nutrition is an important determinant of immunocompetence, but vitamin supplementation in relation to infection has not been evaluated extensively in well-nourished populations. We evaluated the associations between intakes of antioxidants and B vitamins and risk of community-acquired pneumonia in well-nourished, middle-aged and older men. This was a prospective study conducted between 1990 and 2000 among 38,378 male, U.S. health professionals, aged 44 to 79 y in 1990. Participants answered a detailed 131-item FFQ to assess diet and also provided information on vitamin supplement use. We included those who at the onset had no history of pneumonia, myocardial infarction, stroke, other heart disease, arterial surgery, cancer or asthma, and also had complete dietary data. There were 446 new cases of nonfatal community-acquired pneumonia during 145,878 person-years of follow-up. After adjustment for age, smoking, BMI, alcohol use, physical activity, diabetes and total energy intake, there were no associations between total intakes of antioxidants or B vitamins and pneumonia risk. After excluding men who took vitamin E supplements, vitamin E intake from food sources only was inversely associated with pneumonia risk (multivariate relative risk comparing extreme quintiles = 0.58, 95% CI, 0.39-0.86, P-value test for trend = 0.01). Vitamin supplements are unlikely to reduce pneumonia risk in well-nourished, middle-aged and older men.

Guidelines for the management of community-acquired pneumonia. Current recommendations and antibiotic selection issues.

Numerous guidelines for CAP have been developed, and although each is different, many principles are common to all recommendations. A guideline should focus on a wide range of issues surrounding the delivery of care, including advice about when to admit patients to the hospital or ICU; which antibiotic regimens to select for specific patient populations; which pathogens to target in empiric therapy; which diagnostic tests to order; how to assess the importance of specific causative pathogens, such as drug-resistant pneumococci, atypical pathogens, and gram-negative pathogens; how to evaluate the response to therapy and when to switch responding patients to oral therapy; and how to prevent CAP effectively through appropriate use of immunization against pneumococcus and influenza. Currently, many new antibiotic choices have emerged in the macrolide, quinolone, beta-lactam, ketolide, and oxazolidinone classes, and specific issues surrounding selection of these agents must be considered. All of the available data can be synthesized into a disease management guideline, and current therapy in the United States generally is consistent with existing recommendations. This consistency not only has led to more uniformity in patient care, but also has led to measurable benefits in patient outcomes, including reduced mortality for hospitalized patients with CAP. Guidelines not only are a useful tool for managing patients with CAP, but also they serve the purpose of defining current issues in patient care and stimulating the search for new tools and management approaches for this important clinical problem.