Community-Acquired Pneumonia Requiring
Hospitalization
Pneumonia is a leading infectious cause of hospitalization and death among adults in the United
States, with medical costs exceeding $10 billion in 2011. Routine administration of the
pneumococcal conjugate vaccine in children has resulted in an overall reduction in the rate of
invasive disease and pneumonia among adults, owing to herd immunity. The last U.S.
populationbased incidence estimates of hospitalization due to community-acquired pneumonia
were made in the 1990s, before the availability of the pneumococcal conjugate vaccine and
more sensitive molecular and antigen-based laboratory diagnostic tests. Thus, contemporary
population-based etiologic studies involving U.S. adults with pneumonia are needed.
The Centers for Disease Control and Prevention (CDC) Etiology of Pneumonia in the
Community (EPIC) study was a prospective, multicenter, population-based, active surveillance
study. Radiographic confirmation and extensive diagnostic methods were used to determine the
incidence and microbiologic causes of community-acquired pneumonia requiring hospitalization
among U.S. adults.
Methods
Active Population-Based Surveillance
From January 1, 2010, to June 30, 2012, adults 18 years of age or older were enrolled at three
hospitals in Chicago (John H. Stroger, Jr., Hospital of Cook County, Northwestern Memorial
Hospital, and Rush University Medical Center) and at two in Nashville (University of Tennessee
Health Science CenterSaint Thomas Health and Vanderbilt University Medical Center). We
sought to enroll all eligible adults; therefore, trained staff screened adults for enrollment at least
18 hours per day, 7 days per week. Written informed consent was obtained from all the patients
or their caregivers before enrollment. The study protocol was approved by the institutional
review board at each participating institution and at the CDC. Weekly teleconferences,
enrollment reports, data audits, and annual study-site visits were conducted to ensure uniform
procedures among the study sites. Patients or their caregivers provided demographic and
epidemiologic data, and medical charts were abstracted for clinical data. All the authors vouch
for the accuracy and completeness of the data and analyses reported and for the fidelity of the
study to the protocol. All the authors made the decision to submit the manuscript for publication.
Adults were eligible for enrollment if they were admitted to a study hospital on the basis of a
clinical assessment by the treating clinician; resided in the study catchment area (see the
Supplementary Appendix, available with the full text of this article at NEJM.org); had evidence of
acute infection, defined as reported fever or chills, documented fever or hypothermia,
leukocytosis or leukopenia, or new altered mental status; had evidence of an acute respiratory
illness, defined as new cough or sputum production, chest pain, dyspnea, tachypnea, abnormal
lung examination, or respiratory failure; and had evidence consistent with pneumonia as
assessed by means of chest radiography by the clinical team within 48 hours before or after
admission.
Patients were excluded if they had been hospitalized recently (<28 days for immunocompetent
patients and <90 days for immunosuppressed patients), had been enrolled in the EPIC study
within the previous 28 days, were functionally dependent nursing home residents or had a clear
alternative diagnosis (see the Supplementary Appendix). Patients were also excluded if they
had undergone tracheotomy, if they had a percutaneous endoscopic gastrostomy tube, if they
had cystic fibrosis, if they had cancer with neutropenia, if they had received a solid-organ or
hematopoietic stem-cell transplant within the previous 90 days, if they had active graft-versus-
host disease or bronchiolitis obliterans, or if they had human immunodeficiency virus infection
with a CD4 cell count of less than 200 per cubic millimeter.
Source:
Dr.P.H., for the CDC EPIC Study Team*
N Engl J Med 2015; 373:415-427July 30, 2015
