COMMUNITY-ACQUIRED PNEUMONIA REQUIRING HOSPITALIZATION - FACTORS OF IMPORTANCE FOR THE SHORT-AND LONG-TERM PROGNOSIS

In 277 patients admitted to hospital for community-acquired pneumonia (CAP) an aetiologic diagnosis was established in 68% with S.pneumoniae being the predominating agent. Four percent of the patients (12/277) died during their hospital stay, and only one of these patients was be low 60 years of age. On admission, the most important factor, independ ently associated with fatal disease was a low serum albumin concentrat ion, which was also a negative prognostic factor for the course of the survivors. In patients admitted to hospital for CAP, the finding of a low serum albumin level should therefore lead to intensified observat ion and treatment. Of 241 patients discharged after treatment for CAP, 50 patients were readmitted to hospital with recurrence of pneumonia during a 31 month follow-up period. This pneumonia incidence rate was more than five times that in a control population. Fifty-one of the pa tients (21%) died during follow-up, with 13 (25%) of the deaths direct ly associated with pneumonia. Systemic treatment with corticosteroids was associated with a higher risk of recurrence of pneumonia and death , while airway colonisation with Gram-negative enteric bacteria and a serum albumin below 30 g/l during hospital treatment of the initial pn eumonia were associated with death from pneumonia after discharge. In 97 middle-aged and elderly patients admitted to hospital for CAP, maln utrition reflected by low triceps skinfold (TSF) and body mass index ( BMI) values was associated with death during a six-month follow-up per iod, as was severity of disease on admission classified according to a cute physiology and chronic health evaluation (APACHE II). Admission s erum concentrations of orosomucoid and alpha-1-antitrypsin were most c losely correlated with in-hospital morbidity measured as days spent in hospital and duration of fever. The risk of readmission within six mo nths of discharge was higher in patients with high admission levels of APACHE II and TSF. Measurement of serum concentrations of alpha-1-ant itrypsin and orosomucoid on admission should be considered in order to better predict hospital morbidity in these patients. Measurement of A PACHE II and TSF on admission may give additional prognostic informati on on the interval from admission to six months after discharge. On ad mission 64% of the patients were hypoalbuminaemic, but only 6-10% were so at follow-up visits. Admission serum albumin concentration correla ted negatively with investigated acute-phase proteins, and positively with other serum transport proteins, but no association with investiga ted nutritional measurements was found. The main reason for depressed serum albumin in elderly patients with pneumonia thus seems to be not malnutrition, but the inflammatory reaction per se. In 203 hospital-tr eated patients with CAP, the diagnostic and prognostic value of admiss ion serum levels of interleukin-6 (IL-6) and C-reactive protein was in vestigated. The highest levels of IL-6 and CRP were found in patients with pneumococcal pneumonia, especially when bacteraemic. Patients wit h high IL-6- or CRP levels had longer duration of fever, longer hospit al stay, and fewer had recovered clinically or radiographically at fol low-up eight weeks after discharge. A high IL-6, but not a high CRP, a lso seemed to be associated with a higher mortality. The type-specific antibody responses to six pneumococcal capsular polysaccharide antige ns included in the 23-valent vaccine as well as antibodies against the vaccine were measured by use of an enzyme-linked immunosorbent assay in 65 middle-aged and elderly individuals treated in hospital for pneu monia eight weeks prior to vaccination. The antibody concentrations be fore and after the vaccination were comparable with those in a vaccina ted age-matched control group who had not recently been treated for pn eumonia. Since elderly patients discharged after treatment in hospital have a high risk of recurrence of pneumonia and death, a follow-up vi sit eight weeks after treatment for pneumonia may be a suitable occasi on to offer the patient pneumococcal vaccination.