Antipsychotic medications linked to increased risk of pneumonia in persons with Alzheimer's disease

Antipsychotic medications are associated with an increased risk of pneumonia in persons with Alzheimer's disease (AD), according to new research from the University of Eastern Finland. The risk of pneumonia was the highest at the beginning of antipsychotic treatment, remaining elevated also in long-term use. No major differences were observed between the most commonly used antipsychotics.

01 sept 2016--Pneumonia was listed as one of the leading causes of death in the FDA's 2005 warning on the use of antipsychotics for the treatment of behavioural and psychological symptoms of dementia. Since then, antipsychotics have been linked to an increased risk of pneumonia in in several studies, but studies among persons with dementia have been scarce. However, almost one third of Finns with Alzheimer's disease use antipsychotic medication.
The association between antipsychotic medication and hospitalisations or deaths due to pneumonia in 2005-2012 was investigated in the nationwide register-based cohort study MEDALZ at the University of Eastern Finland. The study included 60,584 persons with a clinically verified diagnosis of Alzheimer's disease. Persons who had used antipsychotic medication or had pneumonia within one year before the beginning of the follow- up and those who had schizophrenia and bipolar disorder were excluded from the study. The results were compared to a matched cohort of persons without Alzheimer's disease.
The age-adjusted pneumonia incidence during antipsychotic use periods was similar in the AD and non-AD cohort (9.5/100 person-years and 10.2/100 person-years, respectively) while the higher risk of pneumonia among persons with Alzheimer's disease was more evident during non-use (4.8/100 person years in those with Alzheimer's disease and 2.4/100 person-years in those without Alzheimer's disease). Thus, antipsychotic use was associated with a two-fold risk of pneumonia in persons with Alzheimer's disease and even a higher relative risk increase (3.43-fold) among those without Alzheimer's disease.
The findings indicate that antipsychotic use is linked to a higher pneumonia risk regardless of age, applied study design, treatment duration, choice of medication or comorbidities. In addition, the study only included cases of pneumonia leading to hospitalisation or death, which means that the actual risk increase may be even higher. Consequently, the risk-benefit balance should be carefully considered when antipsychotics are prescribed, and the treatment period should be as short as clinically possible.
The study also involved researchers from the University of Helsinki and Karolinska Institutet.

More information: Anna-Maija Tolppanen et al, Antipsychotic use and risk of hospitalisation or death due to pneumonia in persons with and without Alzheimer's disease, Chest (2016). DOI: 10.1016/j.chest.2016.06.004


Provided by University of Eastern Finland

Oral hygiene curbs pneumonia risk in elderly

NEW YORK , 27 oct 2008– Among nursing home residents, having a nursing aide help them maintain good oral hygiene lowers the odds of them dying from pneumonia, a study suggests.
Pneumonia is the leading cause of death in elderly nursing home residents, Dr. Carol W. Bassim and colleagues point out in the Journal of the American Geriatrics Society. "Several studies have shown that poor oral hygiene or inadequate oral care are also associated with pneumonia," they add.
Bassim, now at the National Institute of Dental and Craniofacial Research in Bethesda, Maryland, and her associates studied the impact of enhanced oral hygiene care for residents in two wards at a Florida nursing home compared with residents in two other wards.
Initially, there was no difference in the mortality rate from pneumonia between the two groups. However, patients in the oral care group were older and more disabled than those who did not receive oral care, and once this was taken into account the risk of dying from pneumonia was more than three times higher in patients who did not receive oral care.
Pneumonia in the elderly is often triggered by aspirating saliva or food. It is likely that the risk of pneumonia "depends on the quality and the quantity of the oropharyngeal contents of a patient at the time of respiratory inoculation or introduction," Bassim and colleagues explain.
"The quantity of saliva inhaled and a predisposition to gross aspiration events may not be modified through oral care," they add, "but this study indicates that oral care may be involved in significantly reducing the harmful quality of the intra-oral environment, reducing the risk of a patient dying from pneumonia."
SOURCE: Journal of the American Geriatrics Society, September 2008.

Staph-caused pneumonia more common in U.S., CDC says

By Will Dunham
Pneumonia contracted outside a hospital caused by a staph bacterium, including a "superbug" strain, may be more common in U.S. children than previously thought, health officials said on Wednesday.
The U.S. Centers for Disease Prevention and Control focused on pneumonia cases caused by the bacterium Staphylococcus aureus at three Atlanta-area children's hospitals. Almost half involved a drug-resistant strain known as Methicillin-resistant Staphylococcus aureus, or MRSA, the CDC said.
MRSA is sometimes called a "superbug" because it resists treatments by all but the most powerful antibiotics.
A team led by the CDC's Dr. Alexander Kallen identified 53 children, average age 8-1/2, with pneumonia caused by this bacterium -- more than they expected -- at the three hospitals over seven months during the 2006-2007 flu season. Of these, 22 involved MRSA, the CDC said.
Of six children who died, three had pneumonia involving MRSA, the CDC said. Death occurred an average of 13 days after the onset of symptoms.
Staph bacteria typically are found on the skin or in the nose of about a third of people.
The findings were presented at an infectious diseases conference in Atlanta.
Kallen said in recent years the CDC had heard a large number of reports of rapidly fatal Staphylococcus aureus pneumonia occurring in children.
"We did find a fair number of cases -- more than we would have expected initially," Kallen said in a telephone interview, although the death rate was lower than anticipated.
Kallen said the proportion of the cases involving MRSA was a matter of concern. "It's basically a Staphylococcus aureus bug that's resistant to certain types of antibiotics that are frequently used to treat staph," he said.
While the study involved pediatric pneumonia cases, the same trends may be occurring in adult patients. "We don't have any reason to believe it would be any different," Kallen said.
Pneumonia is an infection of the lungs that can be caused by bacteria, viruses and fungi. Its severity can be based on the type of organism causing it.
This study looked at "community acquired pneumonia" -- cases contracted outside the setting of a medical care facility.
Kallen also expressed concern that close to 40 percent of the children with pneumonia related to MRSA were not given antibiotics that covered this drug-resistant strain.

Ventilator-Associated Pneumonia Linked to ICU Nursing Shortages

GENEVA, Switzerland, July 19 -- The risk of late-onset ventilator-associated pneumonia in ICU patients rises as the nurse-to-patient ratio declines, reported investigators here.
Among critically ill patients on mechanical ventilation, the risk of late-onset pneumonia (occurring six days or more after intubation) was 58% lower when there were two or more nurses for each patient than when nurse:patient ratios were lower, reported Stephan Hugonnet, M.D., and colleagues, of the University of Geneva Hospitals.
Nurse staffing levels did not appear to affect the incidence of early-onset disease, however, the authors noted in the study, published online in Critical Care.
"At a time of universal cost containment policies, there is growing evidence that high workload or low staffing level increases the risk for negative patient outcomes, such as death and nosocomial infection," the investigators wrote.
The current study is just one in a long line suggesting that penny-wise hospital staffing practices may translate into pound-foolish increases in the human and financial costs of care related to poorer outcomes, including higher mortality rates.
For example, in 2003 investigators from the Oregon Health and Sciences University in Portland published a study indicating that lower nurse-to-patient ratios were associated with higher rates of nonfatal adverse outcomes at both the hospital and the nursing unit levels.
And in a 2002 paper published in the Journal of the American Medical Association, Linda H. Aiken, Ph.D., R.N., of the University of Pennsylvania, and colleagues reported that, after adjusting for patient and hospital characteristics, each additional patient per nurse was associated with a 7% increase in the likelihood of death within 30 days of admission and a 7% increase in the odds of failure-to-rescue.
Dr. Hugonnet and colleagues conducted a prospective, observational study of all patients who were at risk for ICU-acquired infection admitted from January 1999 through December 2002.
They looked at patient characteristics, admission diagnosis, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, comorbidities, exposure to invasive devices, daily number of patients and nurses on duty, nurse training level and all-site ICU-acquired infections.
They found that of the 936 patients who were put on ventilators, 209 (22.3%) developed ventilator acquired pneumonia. The median time spent on the ventilator was three days (interquartile range two to six days) among patients who did not develop pneumonia, and 11 days (interquartile range six to 19 days) among patients who developed ventilator-associated pneumonia.
Nearly two-thirds of the pneumonia episodes (61%) were late onset. The rate of ventilator-associated pneumonia was 37.6 episodes per 1,000 days at risk (95% confidence interval 33.2 to 42.4 episodes).
During the study period, the median daily nurse-to-patient ratio was 1.9 (interquartile range 1.8 to 2.2).
When they created multivariate Cox regression models, the authors found that a high nurse-to-patient ratio was associated with a decreased risk for late-onset pneumonia (hazard ratio 0.42, 95% CI 0.18 to 0.99), but not early onset pneumonia.
"We hypothesize that increased workload results in noncompliance with basic hygiene measures and infection control recommendations," they wrote. "Time constraints can increase the probability of error by creating a busy, stressful environment with distractions and interruptions, leading to low compliance with hand hygiene recommendations and isolation procedures, or inadequate care for the ventilated patient."
Although the ICU ratio of two nurses to one patient described by the Swiss researchers may be one that few American hospitals want to pay for, the severity of illness seen among patients in major urban teaching hospitals warrants it, nursing advocates say.
"It's very clear, that never, ever should a nurse in an ICU have more than two patients," said David Schildmeier, a spokesman for the Massachusetts Nurses Association. "This has been known for years and there was great research done on this at Johns Hopkins, which showed that the costs of care go up dramatically when nurses have more than two patients."
The authors of the current study noted that ventilator-associated pneumonia alone prolongs length of stay by up to 50 days and generates $10,000 to $40,000 in extra costs per episode.
"We did a study of ICUs in Massachusetts, and found that in more than 35% of the cases, hospitals had assigned as many as three patients to a nurse, which is patently dangerous," noted Schildmeier. "All of the studies confirm that when you increase the patient to nurse ratio beyond two in the ICU and beyond four on medical/surgical floors, bad things start happening."
Last month, the association's members staged a two-hour demonstration outside a Boston teaching hospital to protest nursing staff shortages and working conditions in the emergency department, post-anesthesia care unit, and medical floors.
Dr. Hugonnet and colleagues noted that their study, and all similar studies, may be limited by the fact that all patients in the ICU at a given time are exposed to the same nurse-to-patient ratios, which could affect the results. Additionally, the authors determined staffing levels by reviewing schedules drawn up in advance for the days in question, which may not necessarily reflect what occurred during the actual shifts.
The study was supported by the Swiss National Science Foundation. The authors declared that they had no competing interests.Primary source: Critical CareSource reference: Hugonnet S et al. "Staffing level: a determinant of late-onset ventilator-associated pneumonia." Critical Care 2007, 11:R80 doi:10.1186/cc5974

Inhaled Steroids Linked to Pneumonia Hospitalizations in COPD

MONTREAL, July 16 -- Chronic obstructive pulmonary disease patients who inhaled corticosteroids had a 70% increase in the risk of pneumonia hospitalization over those not given the drugs, researchers here reported.
In a nested case-control study, the risk of dying within 30 days of hospitalization for pneumonia was 53% higher for COPD patients who inhaled corticosteroids, Pierre Ernst, M.D., of Royal Victoria Hospital, and colleagues, reported in the July 15 issue of the American Journal of Respiratory and Critical Care Medicine.
Moreover, there was a dose-dependent relationship between risk of pneumonia and corticosteroid use so that patients inhaling doses equivalent to at least 1,000 µg/day of fluticasone had a 2.25 rate ratio for pneumonia hospitalization (95% CI 2.02-2.44), they wrote.
The study was conducted within a cohort of 175, 906 COPD patients from the province of Quebec who were treated from 1988 through 2003, including 23,942 who were hospitalized for pneumonia and 95,768 matched controls.
Half of the patients were men and the average age was 77. Mean follow-up was a little more than seven years.
Among the findings:
COPD patients were hospitalized for pneumonia at a rate of 1.9 per 100 per year.
All cause mortality was for patients who used steroids and were hospitalized for pneumonia was 7.4% versus 8.4% all cause mortality for COPD patients who were hospitalized for pneumonia but didn't use steroids.
Almost half of the COPD patients hospitalized for pneumonia (48.2%) had used inhaled corticosteroids in the previous year versus 30.1% of controls.
Past use of corticosteroids was associated with only a slight increase in risk of hospitalization for pneumonia, 20% for corticosteroids dispensed nine to 12 months prior.
The adjusted rate ratio of hospitalization for pneumonia associated with current use of inhaled corticosteroids was 1.70 (95% confidence interval [CI], 1.63-1.77) and 1.53 (95% CI, 1.30-1.80) for pneumonia hospitalization followed by death within 30 days.
In an editorial Mark Woodhead, D.M., of Manchester Royal Infirmary in Manchester, England noted that the findings of this study confirm an earlier randomized trial that found corticosteroids reduced COPD exacerbations, but the price was an increase in hospitalizations for pneumonia.
Similar findings from studies using different designs suggest that link between corticosteroids and pneumonia may be "real and that these observations cannot simply be dismissed."
Dr. Ernst and colleagues wrote that COPD is a risk factor for pneumonia and higher doses of inhaled corticosteroids may be a marker of more severe disease, which may have contributed to the observed dose-dependent relationship between inhaled corticosteroids and pneumonia hospitalizations.
But they said that differences in severity of disease were accounted for by factoring in the number of prescriptions for COPD medications used by both cases and controls.
A strength of the study was the large number of pneumonia hospitalizations, "thus allowing precise estimates of risk associated with various doses of inhaled corticosteroids."
Dr. Ernst has received financial support from Altana, Astra Zeneca, GlaxoSmithKline, Merck Frost, and Novartis. Dr. Woodhead has received financial support from Pfizer and GlaxoSmithKline. The study was supported by a grant from the Canadian Foundation for Innovation and the Canadian Institute of Health Research. Primary source: American Journal of Respiratory and Critical Care MedicineSource reference: Ernst P et al "Inhaled Corticosteroid Use in Chronic Obstructive Pulmonary Disease and the Risk of Hospitalization for Pneumonia" Am J Respir Crit Care 2007; 176: 162-166
Woodhead, M "Inhaled Corticosteroids Cause Pneumonia…or Do They?" Am J Respir Crit Care 2007; 176:111-112