Association Between Alcohol Use Disorders and Outcomes of Patients Hospitalized With Community-Acquired Pneumonia

Abstract

Importance: Patients with alcohol use disorder (AUD) are at elevated risk of developing pneumonia, but few studies have assessed the outcomes of pneumonia in patients with AUD.

Objectives: To compare the causes, treatment, and outcomes of pneumonia in patients with and without AUD and to understand the associations of comorbid illnesses, alcohol withdrawal, and any residual effects due to alcohol itself with patient outcomes.

Design, setting, and participants: A retrospective cohort study was conducted of 137 496 patients 18 years or older with pneumonia who were admitted to 177 US hospitals participating in the Premier Healthcare Database from July 1, 2010, to June 30, 2015. Statistical analysis was conducted from October 27, 2017, to August 20, 2018.

Exposure: Alcohol use disorders identified from International Classification of Diseases, Ninth Revision, Clinical Modification codes.

Main outcomes and measures: Pneumonia cause, antibiotic treatment, inpatient mortality, clinical deterioration, length of stay, and cost. Associations of AUD with these variables were studied using generalized linear mixed models.

Results: Of 137 496 patients with community-acquired pneumonia (70 358 women and 67 138 men; mean [SD] age, 69.5 [16.2] years), 3.5% had an AUD. Patients with an AUD were younger than those without an AUD (median age, 58.0 vs 73.0 years; P < .001), more often male (77.3% vs 47.8%; P < .001), and more often had principal diagnoses of aspiration pneumonia (10.9% vs 9.8%; P < .001), sepsis (38.6% vs 30.7%; P < .001), or respiratory failure (9.3% vs 5.5%; P < .001). Their cultures more often grew Streptococcus pneumoniae (43.7% vs 25.5%; P < .001) and less frequently grew organisms resistant to guideline-recommended antibiotics (25.0% vs 43.7%; P < .001). Patients with an AUD were treated more often with piperacillin-tazobactam (26.2% vs 22.5%; P < .001) but equally as often with anti-methicillin-resistant Staphylococcus aureus agents (32.9% vs 31.8%; P = .11) compared with patients without AUDs. When adjusted for demographic characteristics and insurance, AUD was associated with higher mortality (odds ratio, 1.40; 95% CI, 1.25-1.56), length of stay (risk-adjusted geometric mean ratio, 1.24; 95% CI, 1.20-1.27), and costs (risk-adjusted geometric mean ratio, 1.33; 95% CI, 1.28-1.38). After additional adjustment for differences in comorbidities and risk factors for resistant organisms, AUD was no longer associated with mortality but remained associated with late mechanical ventilation (odds ratio, 1.28; 95% CI, 1.12-1.46), length of stay (risk-adjusted geometric mean ratio, 1.04; 95% CI, 1.01-1.06), and costs (risk-adjusted geometric mean ratio, 1.06; 95% CI, 1.03-1.09). Models segregating patients undergoing alcohol withdrawal showed that poorer outcomes among patients with AUD were confined to the subgroup undergoing alcohol withdrawal.

Conclusions and relevance: This study suggests that, compared with hospitalized patients with community-acquired pneumonia but without AUD, those with AUD less often harbor resistant organisms. The higher age-adjusted risk of death among patients with AUD appears to be largely attributable to differences in comorbidities, whereas greater use of health care resources may be attributable to alcohol withdrawal.

Figure 1.. Cultured Organisms in Patients With Community-Acquired Pneumonia (CAP) by Presence or Absence of Alcohol Use Disorder (AUD)

Heights of the bars are proportional to the fractions of patients among all patients with positive cultures.

Figure 2.. Associations of Alcohol Use Disorder (AUD) With Outcomes of Hospitalization for Community-Acquired Pneumonia

A, Overall association of AUD with outcomes of hospitalization for community-acquired pneumonia. B, Association of AUD with outcomes of hospitalization for community-acquired pneumonia stratified by presence of alcohol withdrawal syndrome (AWS). Late intensive care unit (ICU) admission, late invasive mechanical ventilation (IMV), and late vasopressor use were defined as arising on day 2 or later and were studied only among patients for whom the respective late outcome was not present earlier. Costs were studied conditionally only among patients with positive costs and from hospitals with greater than 50% of all patients also with positive costs. Patients with no cost were excluded. Reduced models were adjusted for age, sex, race, and insurance status. Full models were adjusted for the preceding variables as well as the presence of comorbidities and components of the health care–associated pneumonia definition. LOS indicates length of stay; OR, odds ratio.