Pneumonia Severity Index Research Articles

Significance of the physician’s and the patient’s sex in hospitalized patients with community-acquired pneumonia

Background Numerous studies have revealed that the sex of the patient or of the attending physician have impact on patient care, treatment, morbidity and mortality. Community-acquired pneumonia (CAP) is a common cause of hospitalization, antibiotic treatment and intensive care unit (ICU) admission. The purpose of this study was to examine if the patient’s or the attending physicians’ sex may influence the management of hospitalized patients with CAP. Methods Our study included 826 consecutive inpatients with CAP (404 females, and 422 male patients, 429 patients initially treated by a female physician and 397 patients initially treated by a male physician). We examined if the patient’s, or the initial attending physician’s sex, affected treatment and outcome in patients with CAP. Results Patients mean age was 69 years, 30-day mortality 9%. By use of the pneumonia severity index, male patients were found to be more severely ill at admission (p = .0008). Fewer female physicians’ patients were admitted from the emergency department (ED) to the ICU when compared to male physicians’ patients, 5% versus 10% (p = .006), and female physicians’ patients received their first intravenous (IV) antibiotic dose later than male physicians’ patients in the ED (p = .003). Conclusion Our study indicates that the sex of the attending physician may affect the chosen level of care and antibiotic treatment, and that admitted male patients with CAP were more seriously ill than admitted female patients with CAP.

Clinical characteristics of COVID-19 in young patients differ from middle-aged and elderly patients.

IntroductionCoronavirus disease-2019 (COVID-19) has spread worldwide. The study aimed to understand the clinical characteristics of young COVID-19 patients.Material and methodsNinety patients with severe COVID-19 infection in western Chongqing were collected from 21 January to 14 March 2020. They were divided into 4 groups based on age: youth (< 39 years), middle-aged (39–48 years), middle-elderly aged (49–60 years), and elderly (> 60 years). The clinical symptoms, laboratory findings, imaging findings, and treatment effects were compared among the groups.ResultsThere were 22, 27, 19, and 22 cases in the youth, middle-aged, middle-elderly, and elderly groups, respectively. There were no significant differences with respect to gender or smoking status among the four groups. The clinical indicators of severe disease in the youth group were significantly different from the other three groups, and included the lymphocyte count (p < 0.001), C-reactive protein level (p = 0.03), interleukin-6 level (p = 0.01), chest computed tomography (CT) findings (p < 0.001), number of mild cases (p = 0.02), education level (p < 0.001), and CD4 + T lymphocyte level (p = 0.02) at the time of admission, and the pneumonia severity index (PSI) at the time of discharge (p < 0.001). The complications (p < 0.001) among the youth group were also significantly different from the other groups.ConclusionsYoung patients have milder clinical manifestations, which may be related to higher education level, higher awareness and higher acceptance of the prevention and control of the COVID-19 epidemic, as well as their good immune function.

Effect of artificial liver blood purification treatment on the survival of critical ill COVID-19 patients.

Our aim was to investigate the effect of artificial liver blood purification treatment on the survival of severe/critical patients with coronavirus disease 2019 (COVID‐19). A total of 101 severe and critical patients with coronavirus SARS‐CoV‐2 infection were enrolled in this open, case‐control, multicenter, prospective study. According to the patients’ and their families’ willingness, they were divided into two groups. One was named the treatment group, in which the patients received artificial liver therapy plus comprehensive treatment (n = 50), while the other was named the control group, in which the patients received only comprehensive treatment (n = 51). Clinical data and laboratory examinations, as well as the 28‐day mortality rate, were collected and analyzed. Baseline data comparisons on average age, sex, pre‐treatment morbidity, initial symptoms, vital signs, pneumonia severity index score, blood routine examination and biochemistry indices etc. showed no difference between the two groups. Cytokine storm was detected, with a significant increase of serum interleukin‐6 (IL‐6) level. The serum IL‐6 level decreased from 119.94 to 20.49 pg/mL in the treatment group and increased from 40.42 to 50.81 pg/mL in the control group (P < .05), indicating that artificial liver therapy significantly decreased serum IL‐6. The median duration of viral nucleic acid persistence was 19 days in the treatment group (ranging from 6 to 67 days) and 17 days in the control group (ranging from 3 to 68 days), no significant difference was observed (P = .36). As of 28‐day follow‐up,17 patients in the treatment group experienced a median weaning time of 24 days, while 11 patients in the control group experienced a median weaning time of 35 days, with no significant difference between the two groups (P = .33). The 28‐day mortality rates were 16% (8/50) in the treatment group and 50.98% (26/51) in the control group, with a significant difference (z = 3.70, P < .001). Cytokine storm is a key factor in the intensification of COVID‐19 pneumonia. The artificial liver therapy blocks the cytokine storm by clearing inflammatory mediators, thus preventing severe cases from progressing to critically ill stages and markedly reducing short‐term mortality.

Clinical characteristics and outcomes among older nursing home residents hospitalized with pneumonia

Background: Due to population aging, the number of cases of pneumonia in nursing homes in South Korea has been increasing. This study investigated the characteristics and clinical outcomes in nursing home residents with pneumonia admitted to a tertiary hospital. Methods: A retrospective cohort study was conducted of patients transferred to the tertiary hospital from nursing homes between August 2009 and October 2016. The in-hospital mortality, Pneumonia Severity Index, bacterial pathogens in sputum cultures, and antibiotic sensitivity profile were assessed. Results: The analysis included a total of 174 patients hospitalized with pneumonia. Their median age was 78 years, and 109 patients (62.6%) were male. 108 patients (62.1%) were admitted to the intensive care unit. The in-hospital mortality rate was 12.6% (22/174). Culture of a multidrug-resistant (MDR) pathogen was an independent risk factor for mortality (odds ratio [OR]: 3.72, 95% confidence interval [CI]: 1.16–11.89). Male sex and a history of antibiotic use within the previous 3 months were independent risk factors for MDR pathogen isolation (OR: 3.32, 95% CI, 1.38–7.98 and OR: 3.93, 95% CI: 1.82–8.49, respectively). Conclusions: Detection of an MDR pathogen, rather than host factors such as old age, bedridden status, and comorbidities, was the most important risk factor for in-hospital mortality in patients with nursing home pneumonia. Patients with a history of antibiotic use within the previous 3 months had a higher probability of MDR pathogen identification. Identifying MDR pathogens is important in treating older nursing home residents with pneumonia.

Lipid profiles and differential lipids in serum related to severity of community-acquired pneumonia: A pilot study.

This study aimed to characterize the lipidomic responses to community-acquired pneumonia (CAP) and provide new insight into the underlying mechanisms of pathogenesis and potential avenues for diagnostic and therapeutic treatments. This study was performed from January 2017 to October 2018. Lipidomic profiles were generated using ultra high-performance liquid chromatography with tandem mass spectrometry (UHPLC-MS/MS) platform. Spearman’s rank correlation test and multiple linear regression analysis were applied to explore the correlation between changes in the relative abundance of lipids and clinical parameters. Kaplan–Meier methods were used to build 30-day survival curves. From the UHPLC-MS/MS results, a total of 509 and 195 lipid species were detected in the positive and negative ionization mode respectively. Positive ionization covered six lipid classes (glycerol-phospholipids, glycerolipids, sphingolipids, sterol-lipids, prenol-lipids, and fatty acid), whilst negative ionization covered three (glycerol-phospholipids, sphingolipids, fatty acid). Four lipids were selected as targets: PC (16:0_18:1), PC (18:2_20:4), PC (36:4), and PC (38:6). The relative increase of the areas under the curves for all four lipids were superior to the pneumonia severity index and CURB-65 (confusion, urea, respiratory rate, blood pressure, and age ≥65 years old) for discriminating severe CAP from CAP. Decreasing relative levels of PC (18:2_20:4), PC (38:6), and PC (36:4) were negatively related to fraction of inspiration O2; Changes in the relative abundance of PC (16:0_18:1) and PC (18:2_20:4) had significantly linear relationship with procalcitonin. Patients with an elevated level of PC (16:0_18:1) had significantly longer duration of hospital stays. As the relative abundance of PC (18:2_20:4), PC (36:4), and PC (38:6) decreased, the length of hospitalization days and 30-day mortality rate increased significantly (all log-rank p<0.05). Therefore, using the UHPLC-MS/MS platform’s serum lipidomic approach can help reveal changes in lipid abundance during CAP and establish lipid profiles related to disease severity.

The Performance of CURB-65 and PSI for Predicting In-Hospital Mortality of Community-Acquired Pneumonia in Patients with Type 2 Diabetes Compared with the Non-Diabetic Population.

ObjectiveTo compare the performance of CURB-65 and Pneumonia Severity Index (PSI) for predicting in-hospital mortality of community-acquired pneumonia (CAP) between patients with and without type 2 diabetes (T2DM).MethodsA retrospective study was conducted on 2365 CAP patients in The First Hospital of Qinhuangdao, China. The primary outcome was in-hospital mortality. The area under curves (AUCs) was used to evaluate the abilities of CRB-65, CURB-65, and PSI class for predicting in-hospital mortality in patients with CAP.ResultsAmong CAP patients, 127 patients (5.4%) died, 80 patients were without diabetes, and 47 patients had T2DM. In-hospital mortality increased with the risk stratification defined as CURB-65 and PSI class in both non-diabetes and T2DM patients (P<0.05). The AUCs for predicting in-hospital mortality were 0.728～0.798 in patients without T2DM (CRB-65: 0.728, CURB-65: 0.757 and PSI class: 0.798) and 0.641～0.716 in patients with T2DM (CRB-65: 0.641, CURB-65: 0.677 and PSI class: 0.716)(P<0.001). The AUC of the PSI class was lower in patients with T2DM than in patients without T2DM (P<0.05).ConclusionCURB-65 and PSI class are correlated with in-hospital mortality of CAP in patients with and without T2DM. Compared with non-diabetes patients, the predictive performance of CURB-65 and PSI class decreased in patients with T2DM. A prediction model for evaluating the CAP severity in the T2DM population should be developed by future studies.

The expression and clinical significance of serum soluble programmed cell death ligand-1 in adult patients with community-acquired pneumonia

To investigate the clinical significance of serum soluble programmed cell death ligand-1 (PD-L1) in adult patients with community-acquired pneumonia (CAP). A total of 44 CAP patients, 54 severe CAP patients and 30 healthy volunteers were recruited in this study. Serum soluble PD-L1 were detected. Univariate and multivariate regression analyses were used to assess the influence of multiple clinical variables on prognosis. Serum soluble PD-L1 level in severe CAP group was 98.20(57.94, 128.90) ng/L, which was significantly higher than that in the CAP group [59.32(33.55, 92.58) ng/L] and healthy controls [20.44(12.15, 36.20) ng/L] (all P<0.001). PD-L1 level was positively correlated with CRUB-65(r=0.481, P<0.001) and the pneumonia severity index (PSI) score (r=0.442, P<0.001). Univariate regression analysis showed that CURB-65 (HR=2.544, 95%CI 1.324-4.889, P=0.005), PSI score (HR=1.036, 95%CI 1.012-1.061, P=0.004), soluble PD-L1(HR=1.013, 95%CI 1.001-1.026, P=0.041) were risk factors of mortality during hospitalization. Multivariate regression analysis suggested that PSI score (HR=1.042, 95%CI 1.012-1.073, P=0.005), soluble PD-L1 (HR=1.011, 95%CI 1.002-1.071, P=0.020) were independent predictors for mortality risk in CAP patients. CAP patients with soluble PD-L1≥98.20 ng/L had a significantly lower survival rate than those with soluble PD-L1<98.20 ng/L (P=0.033). In conclusion, this study indicates that serum soluble PD-L1 level in CAP patients is correlated with the survival prognosis.

An Early Screening Tool for Discharge Planning Shortened Length of Hospital Stay for Elderly Patients with Community-Acquired Pneumonia.

BackgroundCommunity-acquired pneumonia is one of the most common diseases in elderly persons and usually results in a prolonged hospital stay. Discharge planning plays an important role in reducing the length of hospitalization. This study was designed to determine whether early screening for risk factors for delayed discharge could improve the quality of discharge planning.MethodsThis retrospective, observational study was conducted in two medical facilities from January 2016 to December 2018. Hospital A used a screening tool on admission (screening group): screening for risk factors for delayed discharge and initiating discharge planning immediately for those for whom it was applicable, and discharge planning in the stable phase for those for whom it was not applicable; and Hospital B initiated discharge planning without screening (usual group). Propensity score-matched pneumonia patients in the two groups were then compared. The primary outcome was length of hospital stay.ResultsA total of 648 patients were enrolled in this study. After adjusting for age, sex, aspiration, comorbidity, pneumonia severity index, and key person, 118 pairs underwent analysis. Length of stay was significantly different (20 days vs 13 days, p<0.001) between the groups. There were no differences in duration of antibiotic treatment, in-hospital mortality, and 30-day readmission (9 days vs 9 days, p=0.744; 10 (8.5%) vs 10 (8.5%), p=1.000; 10 (8.5%) vs 9 (7.6%), p=0.811, respectively).ConclusionEarly screening for delayed discharge improved the quality of discharge planning by reducing the length of stay in pneumonia patients.

Discontinuing β-lactam treatment after 3 days for patients with community-acquired pneumonia in non-critical care wards (PTC): a double-blind, randomised, placebo-controlled, non-inferiority trial

Shortening the duration of antibiotic therapy for patients admitted to hospital with community-acquired pneumonia should help reduce antibiotic consumption and thus bacterial resistance, adverse events, and related costs. We aimed to assess the need for an additional 5-day course of β-lactam therapy among patients with community-acquired pneumonia who were stable after 3 days of treatment. We did this double-blind, randomised, placebo-controlled, non-inferiority trial (the Pneumonia Short Treatment [PTC]) in 16 centres in France. Adult patients (aged ≥18 years) admitted to hospital with moderately severe community-acquired pneumonia (defined as patients admitted to a non-critical care unit) and who met prespecified clinical stability criteria after 3 days of treatment with β-lactam therapy were randomly assigned (1:1) to receive β-lactam therapy (oral amoxicillin 1 g plus clavulanate 125 mg three times a day) or matched placebo for 5 extra days. Randomisation was done using a web-based system with permuted blocks with random sizes and stratified by randomisation site and Pneumonia Severity Index score. Participants, clinicians, and study staff were masked to treatment allocation. The primary outcome was cure 15 days after first antibiotic intake, defined by apyrexia (temperature ≤37·8°C), resolution or improvement of respiratory symptoms, and no additional antibiotic treatment for any cause. A non-inferiority margin of 10 percentage points was chosen. The primary outcome was assessed in all patients who were randomly assigned and received any treatment (intention-to-treat [ITT] population) and in all patients who received their assigned treatment (per-protocol population). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT01963442, and is now complete. Between Dec 19, 2013, and Feb 1, 2018, 706 patients were assessed for eligibility, and after 3 days of β-lactam treatment, 310 eligible patients were randomly assigned to receive either placebo (n=157) or β-lactam treatment (n=153). Seven patients withdrew consent before taking any study drug, five in the placebo group and two in the β-lactam group. In the ITT population, median age was 73·0 years (IQR 57·0-84·0) and 123 (41%) of 303 participants were female. In the ITT analysis, cure at day 15 occurred in 117 (77%) of 152 participants in the placebo group and 102 (68%) of 151 participants in the β-lactam group (between-group difference of 9·42%, 95% CI -0·38 to 20·04), indicating non-inferiority. In the per-protocol analysis, 113 (78%) of 145 participants in the placebo treatment group and 100 (68%) of 146 participants in the β-lactam treatment group were cured at day 15 (difference of 9·44% [95% CI -0·15 to 20·34]), indicating non-inferiority. Incidence of adverse events was similar between the treatment groups (22 [14%] of 152 in the placebo group and 29 [19%] of 151 in the β-lactam group). The most common adverse events were digestive disorders, reported in 17 (11%) of 152 patients in the placebo group and 28 (19%) of 151 patients in the β-lactam group. By day 30, three (2%) patients had died in the placebo group (one due to bacteraemia due to Staphylococcus aureus, one due to cardiogenic shock after acute pulmonary oedema, and one due to heart failure associated with acute renal failure) and two (1%) in the β-lactam group (due to pneumonia recurrence and possible acute pulmonary oedema). Among patients admitted to hospital with community-acquired pneumonia who met clinical stability criteria, discontinuing β-lactam treatment after 3 days was non-inferior to 8 days of treatment. These findings could allow substantial reduction of antibiotic consumption. French Ministry of Health.

Computerized Mortality Prediction for Community-acquired Pneumonia at 117 Veterans Affairs Medical Centers.

Rationale: Computerized severity assessment for community-acquired pneumonia could improve consistency and reduce clinician burden. Objectives: To develop and compare 30-day mortality-prediction models using electronic health record data, including a computerized score with all variables from the original Pneumonia Severity Index (PSI) except confusion and pleural effusion ("ePSI score") versus models with additional variables. Methods: Among adults with community-acquired pneumonia presenting to emergency departments at 117 Veterans Affairs Medical Centers between January 1, 2006, and December 31, 2016, we compared an ePSI score with 10 novel models employing logistic regression, spline, and machine learning methods using PSI variables, age, sex and 26 physiologic variables as well as all 69 PSI variables. Models were trained using encounters before January 1, 2015; tested on encounters during and after January 1, 2015; and compared using the areas under the receiver operating characteristic curve, confidence intervals, and patient event rates at a threshold PSI score of 970. Results: Among 297,498 encounters, 7% resulted in death within 30 days. When compared using the ePSI score (confidence interval [CI] for the area under the receiver operating characteristic curve, 0.77-0.78), performance increased with model complexity (CI for the logistic regression PSI model, 0.79-0.80; CI for the boosted decision-tree algorithm machine learning PSI model using the Extreme Gradient Boosting algorithm [mlPSI] with the 19 original PSI factors, 0.83-0.85) and the number of variables (CI for the logistic regression PSI model using all 69 variables, 0.84-085; CI for the mlPSI with all 69 variables, 0.86-0.87). Models limited to age, sex, and physiologic variables also demonstrated high performance (CI for the mlPSI with age, sex, and 26 physiologic factors, 0.84-0.85). At an ePSI score of 970 and a mortality-risk cutoff of <2.7%, the ePSI score identified 31% of all patients as being at "low risk"; the mlPSI with age, sex, and 26 physiologic factors identified 53% of all patients as being at low risk; and the mlPSI with all 69 variables identified 56% of all patients as being at low risk, with similar rates of mortality, hospitalization, and 7-day secondary hospitalization being determined. Conclusions: Computerized versions of the PSI accurately identified patients with pneumonia who were at low risk of death. More complex models classified more patients as being at low risk of death and as having similar adverse outcomes.

Comparison of CURB-65, PSI, and qSOFA for predicting pneumonia mortality in patients with idiopathic pulmonary fibrosis

Some patients with idiopathic pulmonary fibrosis (IPF) require hospitalization due to pneumonia. Although predictive scoring tools have been developed and validated for community-acquired pneumonia (CAP), their usefulness in IPF is unknown. The Confusion, Urea, Respiratory Rate, Blood Pressure and Age (CURB-65) score and the Pneumonia Severity Index (PSI) are validated for CAP. The quick Sequential Organ Failure Assessment (qSOFA) is also reported to be useful. The aim of this study was to investigate the ability of these tools to predict pneumonia mortality among hospitalized patients with IPF. A total of 79 patients with IPF and pneumonia were hospitalized for the first time between January 2008 and December 2017. The hospital mortality rate was 15.1%. A univariate logistic regression analysis revealed that the CURB-65 (odds ratio 4.04, 95% confidence interval 1.60–10.2, p = 0.003), PSI (4.00, 1.48–10.7, 0.006), and qSOFA (5.00, 1.44–1.72, 0.01) scores were significantly associated with hospital mortality. There was no statistically significant difference between the three receiver operating characteristic curves (0.712, 0.736, and 0.692, respectively). The CURB-65, PSI, and qSOFA are useful tools for predicting pneumonia mortality among hospitalized patients with IPF. Because of its simplicity, the qSOFA may be most suitable for early assessment.

Medium-term impact of COVID-19 on pulmonary function, functional capacity and quality of life.

BackgroundCoronavirus disease 2019 (COVID-19) has spread worldwide, having a dramatic impact on healthcare systems. The aim of this study is to evaluate mid-term clinical impact of COVID-19 on respiratory function.Methods379 patients were evaluated 4 months after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diagnosis. Patients were divided in two groups based on the presence of pneumonia during COVID-19. Clinical conditions, quality of life, symptomatology, 6-min walk test, pulmonary function test with spirometry and diffusing capacity of the lung for carbon monoxide were analysed. Data were compared to clinical evolution during COVID-19 (development of acute respiratory distress syndrome, need of invasive mechanical ventilation, partial oxygen saturation (SpO2)/inspiratory oxygen fraction (FIO2) ratio and pneumonia severity index (PSI)).ResultsAfter a median 135 days, 260 (68.6%) out of 379 patients referred at least one symptom. Patients who developed pneumonia during COVID-19 showed lower SpO2 at rest (p<0.001), SpO2 during 6-min walk test (p<0.001), total lung capacity (p<0.001), airway occlusion pressure after 0.1 s (P0.1) (p=0.02), P0.1/maximal inspiratory pressure ratio (p=0.005) and higher Borg category-ratio scale (p=0.006) and modified Medical Research Council breathlessness scale (p=0.003), compared to patients without pneumonia. SpO2/FIO2 ratio and PSI during SARS-CoV-2 pneumonia were directly associated with mid-term alteration of SpO2 at rest (p<0.001) and during 6-min walk test (p<0.001), residual volume (p<0.001), total lung capacity (p<0.001 and p=0.003, respectively) and forced vital capacity (p=0.004 and p=0.03, respectively).ConclusionLung damage during COVID-19 correlates to the reduction of pulmonary function 4 months after acute infection.

A deep learning-based quantitative computed tomography model for predicting the severity of COVID-19: a retrospective study of 196 patients.

BackgroundThe assessment of the severity of coronavirus disease 2019 (COVID-19) by clinical presentation has not met the urgent clinical need so far. We aimed to establish a deep learning (DL) model based on quantitative computed tomography (CT) and initial clinical features to predict the severity of COVID-19.MethodsOne hundred ninety-six hospitalized patients with confirmed COVID-19 were enrolled from January 20 to February 10, 2020 in our centre, and were divided into severe and non-severe groups. The clinico-radiological data on admission were retrospectively collected and compared between the two groups. The optimal clinico-radiological features were determined based on least absolute shrinkage and selection operator (LASSO) logistic regression analysis, and a predictive nomogram model was established by five-fold cross-validation. Receiver operating characteristic (ROC) analyses were conducted, and the areas under the receiver operating characteristic curve (AUCs) of the nomogram model, quantitative CT parameters that were significant in univariate analysis, and pneumonia severity index (PSI) were compared.ResultsIn comparison with the non-severe group (151 patients), the severe group (45 patients) had a higher PSI (P<0.001). DL-based quantitative CT indicated that the mass of infection (MOICT) and the percentage of infection (POICT) in the whole lung were higher in the severe group (both P<0.001). The nomogram model was based on MOICT and clinical features, including age, cluster of differentiation 4 (CD4)+ T cell count, serum lactate dehydrogenase (LDH), and C-reactive protein (CRP). The AUC values of the model, MOICT, POICT, and PSI scores were 0.900, 0.813, 0.805, and 0.751, respectively. The nomogram model performed significantly better than the other three parameters in predicting severity (P=0.003, P=0.001, and P<0.001, respectively).ConclusionsAlthough quantitative CT parameters and the PSI can well predict the severity of COVID-19, the DL-based quantitative CT model is more efficient.

Community-acquired versus nosocomial Legionella pneumonia: factors associated with Legionella-related mortality.

Over the past decade, changes in the diagnosis and management of Legionella pneumonia occurred and risk factors for severe infection and increased mortality were identified. Previous reports found that nosocomial infection is associated with higher mortality while others showed no differences. We aimed to evaluate the differences in the clinical course and mortality rates between hospital-acquired pneumonia (HAP) and community-acquired pneumonia (CAP) caused by Legionella pneumophila. A retrospective cohort study of patients admitted due to Legionella pneumonia between January 2012 through November 2019 was conducted in a tertiary referral center (Rambam Health Care Campus, Haifa, Israel). The primary outcome was 30-day Legionella pneumonia-related mortality. A multivariable logistic regression was performed to determine whether a nosocomial infection is an independent predictor of mortality. One hundred nine patients were included. Seventy (64.2%) had CAP and 39 (35.8%) had HAP. The groups were comparable regarding age, gender, and comorbidities. Time to diagnosis was longer and the number of patients receiving initial empiric anti-Legionella spp. treatment was smaller in the HAP group (8 days [IQR 5.5-12.5] vs. 5 days [IQR 3-8], p < 0.001 and 65.5% vs. 78.6%, p = 0.003, respectively). Patients with HAP had higher 30-day mortality, 41% vs. 18.6%, p = 0.02. In a multivariable logistic regression model, only pneumonia severity index and nosocomial source were independently associated with increased mortality. HAP caused by Legionella spp. is independently associated with increased mortality when compared to CAP caused by the same pathogen. The possible reasons for this increased mortality include late diagnosis and delayed initiation of appropriate treatment.

Age is not the only risk factor in COVID-19: the role of comorbidities and of long staying in residential care homes

BackgroundThe actual SARS-CoV-2 outbreak caused a highly transmissible disease with a tremendous impact on elderly people. So far, few studies focused on very elderly patients (over 80 years old). In this study we examined the clinical presentation and the outcome of the disease in this group of patients, admitted to our Hospital in Rome.MethodsThis is a single-center, retrospective study performed in the Sant’Andrea University Hospital of Rome. We included patients older than 65 years of age with a diagnosis of COVID-19, from March 2020 to May 2020, divided in two groups according to their age (Elderly: 65–80 years old; Very Elderly > 80 years old). Data extracted from the each patient record included age, sex, comorbidities, symptoms at onset, the Pneumonia Severity Index (PSI), the ratio of the partial pressure of oxygen in arterial blood (PaO2) to the inspired oxygen fraction (FiO2) (P/F) on admission, laboratory tests, radiological findings on computer tomography (CT), length of hospital stay (LOS), mortality rate and the viral shedding.The differences between the two groups were analyzed by the Fisher’s exact test or the Wilcoxon signed-rank test for categorical variables and the Mann-Whitney U test for continuous variables. To assess significance among multiple groups of factors, we used the Bonferroni correction.The survival time was estimated by Kaplan-Meier method and Log Rank Test. Univariate and Multivariate logistic regression were performed to estimate associations between age, comorbidities, provenance from long-stay residential care homes (LSRCH) s and clinical outcomes.ResultsWe found that Very Elderly patients had an increased mortality rate, also due to the frequent occurrence of multiple comorbidities. Moreover, we found that patients coming from LSRCHs appeared to be highly susceptible and vulnerable to develop severe manifestations of the disease.ConclusionWe demonstrate that there were considerable differences between Elderly and Very Elderly patients in terms of inflammatory activity, severity of disease, adverse clinical outcomes. To establish a correct risk stratification, comorbidities and information about provenience from LSRCHs should be considered.

Adjunctive treatment with oral dexamethasone in non-ICU patients hospitalised with community-acquired pneumonia: a randomised clinical trial.

Adjunctive intravenous corticosteroid treatment has been shown to reduce length of stay (LOS) in adults hospitalised with community-acquired pneumonia (CAP). We aimed to assess the effect of oral dexamethasone on LOS and whether this effect is disease severity dependent. In this multicentre, stratified randomised, double-blind, placebo-controlled trial, immunocompetent adults with CAP were randomly assigned (1:1 ratio) to receive oral dexamethasone (6 mg once daily) or placebo for 4 days in four teaching hospitals in the Netherlands. Randomisation (blocks of four) was stratified by CAP severity (pneumonia severity index class I-III and IV-V). The primary outcome was LOS. Between December 2012 and November 2018, 401 patients were randomised to receive dexamethasone (n=203) or placebo (n=198). Median LOS was shorter in the dexamethasone group (4.5 days, 95% CI 4.0-5.0 days) than in the placebo group (5.0 days, 95% CI 4.6-5.4 days; p=0.033). Within both CAP severity subgroups, differences in LOS between treatment groups were not statistically significant. The secondary ICU admission rate was lower in the dexamethasone arm (5 (3%) versus 14 (7%); p=0.030); 30-day mortality did not differ between groups. In the dexamethasone group the rate of hospital readmission tended to be higher (20 (10%) versus 9 (5%); p=0.051) and hyperglycaemia (14 (7%) versus 1 (1%); p=0.001) was more prevalent. Oral dexamethasone reduced LOS and ICU admission rate in adults hospitalised with CAP. It remains unclear for which patients the risk-benefit ratio is optimal.

The Effectiveness of Geriatric Pneumonia Severity Index in Predicting Mortality

Background: Pneumonia severity index (PSI) estimates the risk of 30-day mortality in patients with pneumonia. In this study, we aim to develop a simplified version of the PSI (G-PSI) to estimate the risk of mortality in geriatric patients with community-acquired pneumonia (CAP). Methods: This retrospective study included 186 patients aged 65 and older with a diagnosis of CAP. PSI score and 30-day mortality rate of each patient were calculated. PSI parameters were analyzed using univariate regression analysis and the G-PSI scoring system was established to predict 30-day mortality and compared with PSI. Results: Significant effectiveness of the values of cancer (odds ratio (OR) = 3.67; 95% confidence interval (CI): 1.42-9.48), altered mental status (OR = 0.79; 95% CI: 0.68-0.92), systolic blood pressure (OR = 0.98; 95% CI: 0.97-1.00), haematocrit (Hct) (OR = 0.87; 95% CI: 0.81-0.93) and blood urea nitrogen (BUN) (OR = 1.04; 95% CI: 1.02-1.06) were observed for predicting mortality in univariate regression analysis. G-PSI scoring system, like PSI score (if cancer + 30 points, if altered mental status +20 points, if systolic blood pressure ＜ 90mmHg+ 20 points, if Hct ＜ 30% + 10 points and if BUN ≥ 30 mg/dl + 30 points) was created. The area under the receiver operating characteristic curve (AUC)was 0.762 (95% CI 0.673-0.851), revealing the excellent discriminatory ability of the G-PSI model. The AUC for the PSI score was 0.719 (95% CI 0.631-0.806).When G-PSI and PSI were compared, G-PSI had a high level of significance in predicting 30-day mortality. Conclusion: Calculated with only five parameters from standard PSI information, G-PSI accurately displays the 30-day mortality risk of geriatric patients with CAP. The applicability of the G-PSI is easier in a busy emergency service environment with similar prognostic accuracy and clinical prediction.

Comparative Study Of Pneumonia Severity Index (psi) &amp; Curb-65 Score In Assessing Severity Of Community Acquired Pneumonia

INTRODUCTION:Community acquired pneumonia (CAP) is a common disorder with an incidence of about 20% to 30% in developing countries compared to an incidence of 3% to 4 % in developed countries. It is very difficult to find causative organism of community acquired pneumonia in every patient despite aggressive laboratory investigation and blood or sputum culture and it takes few days for it. It is believed that definite prognostic score will be very useful for stratifying patients at high risk and require critical care unit treatment. Pneumonia severity index (PSI) score and CURB-65 Score are two prognostic scoring systems that can stratify patients requiring intensive care unit treatment. Each prognostic score has individual pros and cons and both can be used supplementary to each other. So here we want to study the reliability and validity of PSI and CURB 65 score in Indian population with pneumonia.MATERIAL & METHOD:A hospital based comparative observational study included total 50 patients with pneumonia based on inclusion and exclusion criteria. Complete clinical history and physical examination done. At the time of initial evaluation, chest radiograph was done and repeated after 48 hours. ECG, ABGA, serum electrolyte measurement, sputum for gram staining and culture, blood cultures (in selected patients), complete blood counts, blood urea nitrogen and serum creatinine and fasting blood glucose were measured in every patient. Analysis was done with help of SPSS software and using Microsoft Excel 2012.RESULTS:In our study, total 50 patients were enrolled among them 34 patients were male while 16 patients were female. Most common organism cultured was klebsiella species that was in 18 (36%) patients while 18 patients had no organisms seen in sputum culture. In our study, 8(16%) patients were died out of 50 patients admitted. PSI class 4 showed highest sensitivity in predicting mortality 50%, while specificity was highest for class 2 with 90.4%, followed by class 5 with 73.8%. The PPV was highest for class 4 22%, and NPV was highest for class 4 87.5%. Among CURB 65 score, class 4 showed highest sensitivity in predicting mortality 50%, while specificity was highest for class 4 with 92.8%, followed by class 3 with 85.7%. The PPV was highest for class 4= 57.1%, and NPV was highest for class 4= 90.6%.CONCLUSION:It is observed that PSI has better specificity and negative predictive value (NPV) but less sensitivity and positive predictive value (PPV). This is because impact of age is observed in PSI which leads to lower estimation of severity of CAP mostly in young patients who have no other comorbidities. The two scoring CURB-65 and PSI approaches have to be viewed at the most as being complementary as each has different strengths and weaknesses. With help of CURB-65 and PSI Score, we can better understand the prognosis and classify patients on basis of severity and adequate utilization of resources and proper treatment to improve outcome in developing countries like India.

Índice de Comorbidade de Charlson e outros preditores de mortalidade hospitalar em adultos com pneumonia adquirida na comunidade

ABSTRACTObjective:To compare the performance of Charlson Comorbidity Index (CCI) with those of the mental Confusion, Urea, Respiratory rate, Blood pressure, and age = 65 years (CURB-65) score and the Pneumonia Severity Index (PSI) as predictors of all-cause in-hospital mortality in patients with community-acquired pneumonia (CAP). Methods:This was a cohort study involving hospitalized patients with CAP between April of 2014 and March of 2015. Clinical, laboratory, and radiological data were obtained in the ER, and the scores of CCI, CURB-65, and PSI were calculated. The performance of the models was compared using ROC curves and AUCs (95% CI). Results:Of the 459 patients evaluated, 304 met the eligibility criteria. The all-cause in-hospital mortality rate was 15.5%, and 89 (29.3%) of the patients were admitted to the ICU. The AUC for the CCI was significantly greater than those for CURB-65 and PSI (0.83 vs. 0.73 and 0.75, respectively). Conclusions:In this sample of hospitalized patients with CAP, CCI was a better predictor of all-cause in-hospital mortality than were the PSI and CURB-65.

Endogenous Carboxyhemoglobin Concentrations in Predicting Prognosis of Patients with COVID-19 Pneumonia.

The coronavirus disease 2019 (COVID-19) outbreak has caused great difficulties in providing healthcare services worldwide. Accurate and useful indicators are needed for the effective use of resources. Carbon monoxide (CO) is also produced endogenously without exogenous exposure. Studies confirm that endogenous CO increases in conditions such as pneumonia, sepsis, and trauma. This study aimed to compare patients diagnosed with COVID-19 pneumonia and healthy people to reveal whether endogenous carboxyhemoglobin (COHb) levels differ. It was also to determine whether it could be a helpful indicator for the clinician in predicting disease severity in combating the COVID-19 pandemic. The study included 72 patients admitted to the hospital during the COVID-19 pandemic and diagnosed with COVID-19 pneumonia and a control group of 75 healthy people. The research data was collected retrospectively in a tertiary emergency department. The patients' demographic data, pneumonia severity index (PSI) score, CURB-65 score, 30-day mortality, hospitalization, need for mechanical ventilation (MV), and COHb levels were recorded. While the COHb level was 0.9% (min-max, 0.1 - 4.0) in patients with COVID-19 pneumonia, it was 1% (min-max, 0.1 - 2.6) in the control group. No significant difference was found between the patients and the control group in terms of COHb levels (p = 0.341). Also, there was no correlation between COHb levels and PSI and CURB-65 scores. No significant difference was detected between COHb levels and patients diagnosed with COVID-19 pneumonia in terms of mortality, need for MV, or hospitalization (p > 0.05). We concluded that COHb levels alone could not be used to diagnose COVID-19 pneumonia or predict disease severity. Besides, in COVID-19 pneumonia, the COHb level was not a useful indicator of mortality, need for MV, or hospitalization decision. Further studies are needed to find useful indicators to assist clinicians in their decision-making process in tackling the COVID-19 pandemic.