Clinical Infectious Diseases
1 July 2010  Volume 51, Number 1
http://www.journals.uchicago.edu/toc/cid/current

MAJOR ARTICLE
Treatment Outcomes among Patients with Extensively Drug-Resistant Tuberculosis: Systematic Review and Meta-Analysis
Karen R. Jacobson,1; Dylan B. Tierney,1; Christie Y. Jeon,2; Carole D. Mitnick,3,4, and Megan B. Murray1,2,4

1Division of Infectious Disease, Massachusetts General Hospital, 2Department of Epidemiology, Harvard School of Public Health, 3Department of Global Health and Social Medicine, Harvard Medical School, and 4Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts

Background.There is debate surrounding the effectiveness of the 23‐valent pneumococcal polysaccharide vaccine (PPV). We determined whether PPV was associated with reduced mortality or additional hospitalization for vaccine‐preventable infections in patients previously hospitalized for community‐acquired pneumonia (CAP).

Methods.From 2000 through 2002, adults with CAP admitted to the hospital in Edmonton, Alberta, Canada, were enrolled in a population‐based cohort. Postdischarge outcomes during 5 years were ascertained using administrative databases. The primary outcome was the composite of all‐cause mortality or additional hospitalization for vaccine-preventable infections. Proportional hazards analysis was used to determine the association between PPV use and outcomes.

Results.A total of 2950 patients were followed up for a median of 3.8 years. The mean patient age was 68 years; 52% were male. One-third (n=956) received PPV: 667 (70%) before and 289 (30%) during hospitalization. After discharge, 1404 patients (48%) died, 504 (17%) were admitted with vaccine-preventable infections, and 1626 (55%) reached the composite outcome of death or infection. PPV was not associated with reduced risk of the composite outcome (589 [62%] vs 1037 [52%] for those unvaccinated; adjusted hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.79–1.04). Results were not altered in sensitivity analyses using propensity scores (adjusted HR, 0.91; 95% CI, 0.79–1.04), restricting the sample to patients 65 years or older (adjusted HR, 0.90; 95% CI, 0.77–1.04), or considering only those who received PPV at discharge (adjusted HR, 0.84; 95% CI, 0.71–1.00).

Conclusions.One-half of patients discharged from the hospital after pneumonia die or are subsequently hospitalized with a vaccine-preventable infection within 5 years. PPV was not associated with a reduced risk of death or hospitalization. Better pneumococcal vaccination strategies are urgently needed.