Higher Pneumonia Severity Index Scores Research Articles

Clinical features of patients with Legionnaires disease showing initial clinical improvement but radiological deterioration: A retrospective single-center analysis.

Patients with Legionnaires disease occasionally experience initial clinical improvement but radiological progression. However, data on this issue are so far limited. The aim of this study was to investigate changes in chest radiograph findings in patients with Legionnaires disease who showed initial clinical improvement and to identify risk factors and outcomes in these patients.All patients diagnosed with Legionnaires disease at a tertiary hospital in South Korea between March 2011 and May 2020 were retrospectively enrolled. Legionnaires disease was defined as abnormal chest radiographs accompanied by a positive finding on at least one of the following tests: urinary antigen test, sputum Legionella polymerase chain reaction, and sputum Legionella culture. Clinical improvement was defined as defervescence and decreased C-reactive protein level. Clinical and radiological records were reviewed on treatment days 7 and 14 and at discharge. We describe the characteristics of patients with clinical improvement but radiological deterioration on treatment for Legionnaires disease and compared them with patients with initial clinical improvement and stable or resolving chest radiograph findings.Of 140 patients with Legionnaires disease, 33 (24%) showed initial clinical deterioration, while the remaining 107 (76%) showed initial clinical improvement on day 7. The latter 107 patients were analyzed in this study; 22 (21%) showed radiological progression despite the clinical improvement. Risk factors for these patients were a high pneumonia severity index score and the use of mechanical ventilation. Mortality did not significantly differ between those with initial clinical improvement but radiological deterioration and those with both initial clinical and radiological improvement (28% vs 12%, P = .49).About one-fifth of patients with Legionnaires disease, especially those who had a high pneumonia severity index score and underwent mechanical ventilation, showed radiological deterioration despite of clinical improvement 1 week after appropriate treatment, while outcomes were not significantly worse in these patients. Therefore, our findings support that close monitoring without modification of antibiotics use is warranted in those who have clinical improvement regardless of radiologic findings.

Risk factors associated with methicillin-resistant Staphylococcus aureus isolation from serially collected sputum samples of patients hospitalized with pneumonia

IntroductionRisk factors associated with the new detection of methicillin-resistant Staphylococcus aureus (MRSA) during hospitalization remain unclear. This study aimed to identify risk factors associated with MRSA isolation from the sputum of patients admitted with pneumonia, during their hospitalization. MethodsPatients were prospectively enrolled from 2003 to 2012. Sputum samples were collected for bacterial cultures on days 1, 4, 7, 11, and 14 of hospitalization and thereafter. Cases of MRSA first isolated from sputum obtained before day 4 were defined as “carriage on admission.” Cases of MRSA first isolated on day 4 and thereafter, were defined as “new detection after admission.” Statistical analysis was used to investigate the risk factors associated with MRSA isolation. ResultsMRSA was isolated from 167 of 1,008 patients (carriage: 47; new detection: 120). Multivariate analysis revealed that the risk factors for MRSA carriage were activities of daily living (ADL) disability prior to admission (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.37–6.22) and hospitalization within the previous 90 days (OR, 3.75; 95% CI, 1.90–7.41). ADL disability prior to admission (risk ratio [RR], 1.82; 95% CI, 1.17–2.84) and a high pneumonia severity index score upon admission (RR, 2.20; 95% CI, 1.37–3.65) were risk factors for new detection of MRSA. ConclusionsSeveral risk factors were found to be associated with MRSA carriage and/or its new detection, based on the sputum samples from patients admitted with pneumonia. These factors may be indicators for selective surveillance and the early implementation of infection control measures.

413. Association of SARS-CoV-2 Genomic Load in Nasopharyngeal Samples with Adverse COVID-19 Patient Outcomes: A Retrospective Analysis from an Academic Hospital Center in New York City

BackgroundSARS-CoV-2, the cause of COVID-19 pneumonia, is associated with heterogenous presentations ranging from asymptomatic infection to severe respiratory failure. We explored the association of SARS-CoV-2 genomic load as a risk factor for adverse patient outcomes.MethodsWe included adult patients admitted to the hospital with clinical and radiographic findings of pneumonia and a confirmatory polymerase chain reaction (PCR) test of SARS-CoV-2 within 24 hours of admission. We segregated patients into 3 genomic load status groups: low (Cycle threshold (Ct) ≥35) intermediate (25< Ct< 35) and high (Ct ≤25) using real-time PCR. The primary outcome was a composite outcome of death, intubation and/or use of extracorporeal membrane oxygenation. Secondary outcomes included severity of pneumonia on admission, as measured by the Pneumonia Severity Index (PSI). Sensitivity analyses were performed to include Acute Respiratory Distress Syndrome (ARDS) in the composite outcome and varying Ct classification breakpoints.ResultsOf 457 patients positive for SARS-CoV-2 assay from March 31st to April 10th 2020, 316 met inclusion criteria and were included in the final analysis. Included patients were followed for a median of 25 days (IQR 21–28). High genomic load at presentation was associated with higher Charlson Comorbidity Index scores (p=0.005), transplant recipient status (p< 0.001) and duration of illness less than 7 days (p=0.005). Importantly, patients with high genomic load were more likely to reach the primary endpoint (p=0.001), and had higher PSI scores on admission (p=0.03). In multivariate analysis, high genomic load remained an independent predictor of primary outcome. Results remained significant in sensitivity analyses.Flow Chart Prediction of Outcomes Based on Genomic Load Prediction of Outcomes Based on Genomic Load and Pneumonia Severity Index ConclusionHigh genomic load of SARS-CoV-2 in nasopharyngeal samples at the time of admission is independently associated with mortality and intubation. This finding should prompt further research on the role of viral load as a clinical predictor and possible modifiable risk factor for adverse outcomes as treatment strategies evolve in this global pandemic.Disclosures All Authors: No reported disclosures

Aggressive fluid accumulation is associated with acute kidney injury and mortality in a cohort of patients with severe pneumonia caused by influenza A H1N1 virus.

IntroductionFluid accumulation is associated with adverse outcomes such as acute kidney injury (AKI) in critically ill patients. This study aimed to describe the factors associated with AKI in individuals with influenza A H1N1 severe pneumonia, and explore the relation of fluid accumulation with AKI and mortality.Material and methodsWe reviewed medical records of individuals with influenza A H1N1 severe pneumonia and no history of chronic kidney disease, attending a national referral center for respiratory diseases between November 2014 and May 2015. Demographic information, risk factors for AKI, physiologic and laboratory data, outcomes and information on fluid intake and output were recorded. Categorical variables were compared using the chi-square test. Quantitative variables were compared using the Mann-Whitney test. Factors associated with AKI and mortality were identified by binary logistic regression. Linear models of fluid accumulation rates for individuals and groups were estimated using segmented linear regression.ResultsOf 60 patients studied, 43 developed AKI (71.6%). Male gender was protective for AKI (p = 0.019). AKI was associated with nephrotoxic drugs (p = 0.016); PEEP>10 cm H2O on admission (p = 0.031); mortality (p = 0.037); and fluid accumulation ≥10% (fluid overload) at day 7 of hospitalization (p = 0.00026). Mortality was associated with older age (p = 0.009); nephrotoxic drugs (p = 0.034); and higher Pneumonia Severity Index score (112 vs. 76, p = 0.008) on admission. The Deceased-AKI group had a higher rate of fluid accumulation (expressed as ml/kg/body weight) than the Survivors-No AKI group during the study period of 7 days (Survivors-No AKI = 13.31 vs. Deceased-AKI = 22.76, p = 0.019). During the highest phase of fluid accumulation, the Survivors-No AKI group had a slower rate of fluid accumulation than the Survivors-AKI group (14.91 vs. 28.49, p = 0.001).ConclusionsA high rate of fluid accumulation was associated with AKI and mortality. We support the approach of resuscitation in acute illness, with an early transition to neutral and then negative fluid balances.

Microbial etiology in hospitalized North Indian adults with community-acquired pneumonia.

Background:There is a paucity of literature regarding the microbial etiology of community-acquired pneumonia (CAP) in India. The current study was aimed to study the microbial etiology of hospitalized adults with CAP.Methods:The study was conducted in a 700-bedded North Indian hospital. Consecutive adults admitted with CAP over a period of 2 years from 2013 to 2015 were recruited for the study, and apart from clinical evaluation underwent various microbiological studies in the form of blood culture, sputum culture, urinary antigen for pneumococcus and Legionella, serology for Mycoplasma and Chlamydia and real-time reverse transcriptase polymerase chain reaction for influenza viruses. Radiographic studies were performed in all patients and repeated as required. The patients were treated with standard antibiotic/antiviral therapy and outcomes were recorded.Results:A total of 225 patients (median age: 59 years) were enrolled. Streptococcus pneumoniae was the most common organism found (30.5%), followed by Legionella pneumophila (17.5%), influenza viruses (15.4%), Mycoplasma pneumoniae (7.2%), Chlamydia pneumonia (5.5%), Mycobacterium tuberculosis (4.8%), Klebsiella pneumoniae (4.8%), methicillin-resistant Staphylococcus aureus (3.5%), Pseudomonas aeruginosa (3.1%), methicillin-sensitive S. aureus (1.7%), and Acinetobacter sp. (0.8%) with 4% of patients having multiple pathogens etiologies. High Pneumonia Severity Index score correlated with the severity and outcome of the CAP but was not predictive of any definite etiological pathogen. In-hospital mortality was 8%.Conclusion:Streptococcus pneumoniae, Legionella, and influenza constitute the most common etiological agents for north Indian adults with CAP requiring hospitalization. Appropriate antibiotic therapy and preventive strategies such as influenza and pneumococcal vaccination need to be considered in appropriate groups.

A survey on hospitalised communityacquired pneumonia in Italy

Community Acquired Pneumonia (CAP) remains a major cause of disease and death. We evaluated the levels of care, the outcome and the characteristics of hospitalised patients with CAP in a primary hospital in Italy. We also investigated the value of both the Pneumonia Severity Index (PSI) and the modified Appropriateness Evaluation Protocol (AEP) for recognising both the outcome and the unnecessary admissions and stay of hospitalised patients with CAP. A retrospective review of all the charts of adult patients with CAP at Manerbio, Brescia, Italy between January 2001 and December 2002 was performed. We evaluated 148 patients; their mean age (+/-SD) was 70 (+/-17) years; 34% were female. Most patients (87%) had at least a concomitant co-morbid disease. The overall survival rate at 30 days was 88%. All but one death occurred in the high-risk group of patients according to the PSI. On the contrary, the death rate of patients with inappropriate hospital admission according to the AEP was high. Patients with high PSI score had a significantly longer hospital length of stay than the low-risk group. However, a substantial part of the hospital stay did not show any justification into the charts. The PSI, but not the AEP, upon hospital admission, was useful for evaluating the outcome of patients with CAP. The PSI score and the modified AEP can be useful for assessing the appropriateness of hospitalisation for patients with CAP. There is the need for a practical and validated tool to support physicians in their decision making regarding the early and safe discharge of hospitalised patients with CAP.

Emergence of Community-Acquired Adenovirus Type 55 as a Cause of Community-Onset Pneumonia

BackgroundSince 2008, severe cases of emerging human adenovirus (HAdV) type 55 (HAdV-55) were reported sporadically in China. But no comparative studies had been conducted to discern the differences in epidemiologic and clinical abnormalities between HAdV-55 and other types (HAdV-7, HAdV-3, HAdV-14, HAdV-50, and HAdV-C).MethodsA multicenter surveillance study for adult and adolescent community-acquired pneumonia (CAP) was conducted prospectively in Beijing and Yan Tai between November 2010 and April 2012. A standardized data form was used to record clinical information. The viral DNA extracted from the clinical samples or adenovirus viral isolates was sequenced.ResultsAmong 969 cases, 48 (5%) were identified as adenovirus pneumonia. Six branches were clustered: HAdV-55 in 21, HAdV-7 in 11, HAdV-3 in nine, HAdV-14 in four, HAdV-50 in two, and HAdV-C in one. Most HAdV-55 cases were identified during February and March. All the hypervariable regions of the hexon genes of the 21 HAdV-55 strains were completely identical. Patients who had HAdV-55 were about 10 years older (P = .027) and had higher pneumonia severity index scores (P = .030) compared with those with other types (HAdV-7, HAdV-3, HAdV-14, HAdV-50, and HAdV-C). Systemic BP was also higher among patients in the HAdV-55 group (P = .006). Unilateral or bilateral consolidations were the most common radiologic findings in both patients with HAdV-55 and those with other types (57.9% vs 36%). More than one-half of the patients were admitted to hospital; oxygen therapy was given to 29.2% of the 48 patients, and two needed mechanical ventilation.ConclusionsHAdV-55 has established itself as a major pneumonia pathogen in the Chinese population, and further surveillance and monitoring of this agent as a cause of CAP is warranted.

Proadrenomedullin, a useful tool for risk stratification in high Pneumonia Severity Index score community acquired pneumonia

The aim of the present study was, first, to evaluate the prognostic value of mid-regional proadrenomedullin (proADM) in emergency department (ED) patients with a diagnosis of community acquired pneumonia (CAP) and, second, to analyze the added value of proADM as a risk stratification tool in comparison with other biomarkers and clinical severity scores.We evaluated proADM, C-reactive protein and procalcitonin, along with the Pneumonia Severity Index (PSI) score in consecutive CAP patients. Ability to predict 30-day mortality was assessed using receiver operating characteristic curve analysis, logistic regression, and reclassification metrics for all patients and for patients with high PSI scores. Primary outcome was death within 30 days after ED admission.One hundred nine patients were included (median age [interquartile range] 71 [27] years). Nine patients died within 30 days. A significant correlation between proADM and PSI was found (ρ = 0.584, P < .001). PSI and proADM levels were significantly predictive of risk of death. In patients with PSI class IV and V (score >90), proADM levels significantly predicted risk of death (OR [95% CI], 4.681 (1.661-20.221), P = .012) whereas PSI score did not (P = .122). ROCAUC (area under the receiver operating characteristic curve) was higher for proADM than for PSI score (ROCAUC [95% CI], 0.810 [0.654-0.965] and 0.669 [0.445-0.893] respectively). Reclassification analysis revealed that combination of PSI and proADM allows a better risk assessment than PSI alone (P = .001).MR-proADM may be helpful in individual risk stratification of CAP patients with a high PSI score in the ED, allowing to a better identification of patients at risk of death.

Concomitant Pulmonary Tuberculosis in Hospitalized Healthcare-Associated Pneumonia in a Tuberculosis Endemic Area: A Multi-center Retrospective Study

BackgroundIn tuberculosis (TB) endemic areas, Mycobacterium tuberculosis is an important but easily misdiagnosed pathogen in community-acquired pneumonia (CAP). However, the occurrence of concomitant pulmonary tuberculosis (PTB) in hospitalized healthcare-associated pneumonia (HCAP) has never been investigated.Methods and FindingsSeven hundred and one hospitalized HCAP and 934 hospitalized CAP patients from six medical centers in Taiwan were included in this nationwide retrospective study. Concomitant PTB was defined as active PTB diagnosed within 60 days of admission due to HCAP or CAP. The predictors for concomitant PTB and the impact of PTB on the outcomes of pneumonia were investigated. Among the enrolled subjects, 21/701 (3%) of the HCAP patients and 25/934 (2.7%) of the CAP patients were documented to have concomitant PTB. In multivariate analysis, a history of previous anti-TB treatment (OR = 5.84, 95% CI: 2.29–20.37 in HCAP; OR = 3.33, 95% CI: 1.09–10.22 in CAP) and escalated pneumonia severity index (PSI) scores (OR = 1.014, 95% CI: 1.002–1.026, in HCAP; OR = 1.013, 95% CI: 1.001–1.026, in CAP) were independent predictors for concomitant PTB in both CAP and HCAP patients. Regarding treatment outcomes, HCAP patients with concomitant PTB were associated with more acute respiratory failure within 48 hours of admission (47.6% vs. 22.6%, p = 0.008), higher intensive care unit admission rate (61.9% vs. 35.7%, p = 0.014), longer hospitalization (39.6±34.1 vs. 23.7±27 days, p = 0.009), and higher in-hospital mortality (47.6% vs. 26.3%, p = 0.03) than those without concomitant PTB. Exposure to certain groups of antibiotics for the treatment of pneumonia was not associated with the occurrence of concomitant PTB.ConclusionsIn HCAP patients, the occurrence of concomitant PTB is comparable with that in CAP patients and associated with higher PSI scores, more acute respiratory failure, and higher in-hospital mortality.

Usefulness of Procalcitonin in the Assessing the Severity of Community-Acquired Pneumonia Patient

Background: Thus far, research studies on community-acquired pneumonia (CA P) have focused on its clinical severity. Recently, it has been determined that procalcitonin ( PCT) level is correlated with severity of CAP. A retrospective study conducted at our hospital used risk predict ability and PCT to determine whether or no PCT is useful in assessing the severity of CAP.Methods: This study covered 92 CAP cases that were admitted to the resp iratory department at Changwon Fatima Hospital between July 1, 2008 and June 30, 2009. All enrolled subjects were measured for infection markers and risk predictability.Results: Based on hospital admission data, enrolled subjects had Pneumo nia Severity Index (PSI) scores serving as risk predictors showed that both PCT and white blood cell (W BC) were statistically significant as infection markers (p=0.001, 0.037). Thus, this study used ROC curves in P SI for data analysis. As a result, it was determined that the area under curve (AUC) of PCT and WBC was 0.694 and 0. 593 respectively, indicating that PCT has a higher test value for WBC, when PCT was higher than 0.745 ng/mL . In addition, it was found that PCT levels higher than 0.745 ng/mL had higher PSI scores than the group wi th PCT lower than 0.745 ng/mL (p=0.032).Conclusion: In order to predict risk of pneumonia cases admitted due to sy mptoms of CAP, it is important to consider PCT as well as PSI, and follow-up monitoring of PCT ca ses.Key Words: Pneumonia; Community-Acquired Infections; Procalcitonin; Sever ity Illness Index

Impact of initial antibiotic choice on mortality from pneumococcal pneumonia

To determine the impact of initial antimicrobial choice on 30-day mortality rate in patients with community-acquired pneumonia due to Streptococcus pneumoniae (CAP-SP), a prospective, observational study was conducted in 35 Spanish hospitals. A total of 638 patients with CAP-SP were identified. Antimicrobials were chosen by the attending physician. Patients were grouped into the following categories: beta-lactam monotherapy (n = 251), macrolide monotherapy (n = 37), beta-lactam plus macrolide (n = 198), levofloxacin alone/combination (n = 48), and other combinations (n = 104). The reference category was beta-lactam+macrolide. The 30-day survival probability was 84.9%. Using multivariate survival analysis, factors related to mortality in the entire population were: bilateral disease, suspected aspiration, shock, HIV infection, renal failure and pneumonia severity index (PSI) score Class IV versus I-III and categories V versus I-III. The association of beta-lactams+macrolides was not better than the use of beta-lactams alone. The current authors analysed the different groups of patients with significant mortality/morbidity: intensive care unit, PSI Class >III, renal failure, chronic lung disease and bacteraemia. Only in patients with PSI Class >III, who had undergone initial antimicrobial choice classified as other combinations, were associated with higher mortality. In conclusion, the current authors have not demonstrated an independent association between initial antimicrobial regimen and 30-day mortality in community-acquired pneumococcal pneumonia patients, except for those with a higher pneumonia severity index score.

Severe community-acquired pneumonia as a cause of severe sepsis: Data from the PROWESS study*

To investigate community-acquired pneumonia (CAP) as a cause of severe sepsis in the PROWESS (Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis) trial and to evaluate the effect of drotrecogin alfa (activated) (DrotAA) in this subgroup. Retrospective analysis of the severe CAP subgroup in the PROWESS trial. Tertiary care institutions in 11 countries. DrotAA (n = 850), 24 microg.kg.hr for 96 hrs, or placebo (n = 840). The 1,690 patients with severe sepsis enrolled in the PROWESS trial. Patients were classified as having CAP if lung was the primary site of infection and if they were enrolled directly from home (private residence) with </=4 days in the hospital before receipt of study drug in the PROWESS trial. Survival at 28 days, hospital discharge, and 90 days was compared in DrotAA and placebo groups in the CAP subgroup of PROWESS and CAP subgroups based on disease severity. Of the 1,690 PROWESS patients, 35.6% (DrotAA, n = 324; placebo, n = 278) were classified as severe CAP. Of these severe CAP patients, 26.1% had Streptococcus pneumoniae infections. Within CAP, 79.1% were enrolled by the end of the second calendar day in the hospital, and approximately 90% of CAP patients were at high risk of death according to the Pneumonia Severity Index category. Based on their dependence on vasopressors, 59% of CAP patients were judged at high risk of death. Biomarkers of coagulation and inflammation were markedly abnormal in severe CAP patients. In severe CAP patients treated with DrotAA, a relative risk reduction in mortality of 28% was observed at 28 days, with a relative risk reduction in mortality of 14% observed at 90 days from the start of study drug infusion. The survival benefit was most pronounced in severe CAP patients with S. pneumoniae and in severe CAP patients at high risk of death as indicated by Acute Physiology and Chronic Health Evaluation II score of >/=25, Pneumonia Severity Index score of >/=4, or CURB-65 (confusion, urea, respiratory rate, blood pressure, age) score of >/=3. CAP associated with a high Pneumonia Severity Index score, bacteremia, or an intense coagulation and inflammatory response requiring intensive care unit care were indicators of a high risk of death from severe sepsis. In patients with severe sepsis resulting from CAP, a readily identifiable disease, DrotAA, improved survival compared with placebo.

Pneumonias adquiridas na comunidade em pacientes idosos: aderência ao Consenso Brasileiro sobre Pneumonias

INTRODUÇÃO: A pneumonia é uma doença comum, com alta mortalidade, e é a sexta causa de morte nos EUA e a quinta no Brasil, na população idosa. O tratamento inicial das pneumonias é empírico, porque o agente etiológico é identificado, aproximadamente, em apenas 50% dos casos. Assim, várias sociedades científicas definiram guias para orientar a terapêutica antimicrobiana inicial. OBJETIVO: Avaliar a aderência ao Consenso Brasileiro sobre Pneumonias para o tratamento de pneumonias adquiridas na comunidade por pacientes idosos. MÉTODO: Foram avaliados os pacientes com 60 anos ou mais, internados em um hospital universitário por pneumonia adquirida na comunidade, segundo a mortalidade em 30 dias, tempo médio para estabilização clínica, tempo médio de internação, custo do tratamento e índice de severidade em pneumonias, no período de 02/08/1999 a 02/08/2000. RESULTADOS: Foram estudados 54 pacientes e a idade média foi de 74,1 anos. O esquema antimicrobiano recomendado pelo consenso foi utilizado em 61,1% dos pacientes. Não houve diferenças em relação ao tempo de internação, custo do tratamento, tempo para estabilização clínica e índice de gravidade em pneumonia entre os dois grupos, mas houve em relação à mortalidade. Os pacientes tratados de acordo com o consenso e com ídice de gravidade em pneumonia mais alto (IV e V) apresentaram maior mortalidade que o grupo não tratado de acordo com o consenso (p = 0,04). Os pacientes com índice de gravidade em pneumonia classes II e III apresentaram mortalidade de 9,5% enquanto nas classes IV e V a mortalidade foi de 30,3%. CONCLUSÃO: A aderência ao Consenso Brasileiro sobre Pneumonias, para pacientes idosos hospitalizados, foi boa e não houve diferença nos resultados entre os pacientes tratados e os não tratados de acordo com o consenso. O índice de gravidade em pneumonias demonstrou associação positiva com a mortalidade.