PSI Class Research Articles

Prediction of new-onset atrial fibrillation with the C2HEST score in patients admitted with community-acquired pneumonia

PurposePatients hospitalized for community-acquired pneumonia (CAP) may have a higher risk of new-onset atrial fibrillation (NOAF). The C2HEST score was developed to evaluate the NOAF risk in the general population. Data on the value of the C2HEST score in acute patients admitted with CAP are lacking. We want to establish the predictive value of C2HEST score for NOAF in patients with CAP.MethodsPatients with CAP enrolled in the SIXTUS cohort were enrolled. C2HEST score was calculated at baseline. In-hospital NOAF was recorded. Receiver-operating Characteristic (ROC) curve and multivariable Cox proportional hazard regression analysis were performed.ResultsWe enrolled 473 patients (36% women, mean age 70.6 ± 16.5 years), and 54 NOAF occurred. Patients with NOAF were elderly, more frequently affected by hypertension, heart failure, previous stroke/transient ischemic attack, peripheral artery disease and hyperthyroidism. NOAF patients had also higher CURB-65, PSI class and CHA2DS2-VASc score. The C-index of C2HEST score for NOAF was 0.747 (95% confidence interval [95%CI] 0.705–0.786), higher compared to CURB-65 (0.611, 95%CI 0.566–0.655, p = 0.0016), PSI (0.665, 95%CI 0.621–0.708, p = 0.0199) and CHA2DS2-VASc score (0.696, 95%CI 0.652–0.737, p = 0.0762). The best combination of sensitivity (67%) and specificity (70%) was observed with a C2HEST score ≥ 4. This result was confirmed by the multivariable Cox analysis (Hazard Ratio [HR] for C2HEST score ≥ 4 was 10.7, 95%CI 2.0–57.9; p = 0.006), independently from the severity of pneumonia.ConclusionThe C2HEST score was a useful predictive tool to identify patients at higher risk for NOAF during hospitalization for CAP.Clinical Trial Registrationwww.clinicaltrials.gov (NCT01773863)

An Assessment of Clinical Profile & Outcome in Patients with Community Acquired Pneumonia (CAP)

Introduction: Pneumonia is a disease known to mankind from antiquity.
 Objectives: The study objective is to assess demographic profile of patients and correlate with clinical & radiological findings and to identify various etiological factors & correlate in different types of pneumonia.
 Methodology: A Prospective clinical observational study was conducted in October 2018 to March 2019 among 50 patients admitted under Department of General Medicine who were diagnosed as community acquired pneumonia during admission at GMERS General Hospital Junagadh, Gujarat.
 Results: The incidence of CAP was more common in female (56%) than in men (44%). Fever was the commonest (47, 94%) presenting complaint followed by cough 42(84%) and breathlessness 36(72%). Lobar pneumonia was most common (85.7%) in the patients having predisposing lung pathology and Bronchopneumonia was most common (71.4%) in diabetic patients (Table-5). Majority (17, 34%) patients had PSI class I followed by PSI class II (14, 28%).
 Conclusions: Mean age was 47+1.6. Significant difference noted between types of pneumonia and different etiological factors. In bacterial pneumonia, Pleural effusion (20.8%) was major complication whereas in viral pneumonia, Respiratory failure (47.3%) was major complication.

Performance of CURB-65, PSI, and APACHE-II for predicting COVID-19 pneumonia severity and mortality

No prognostic tools for the prediction of COVID-19 pneumonia severity and mortality are available. We explored whether CURB-65, PSI, and APACHE-II could predict COVID-19 pneumonia severity and mortality. We included 167 patients with confirmed COVID-19 pneumonia in this retrospective study. The severity and 30-day mortality of COVID-19 pneumonia were predicted using PSI, CURB-65, and APACHE-II scales. Kappa test was performed to compare the consistency of the three scales. There was a significant difference in the distribution of the scores of the three scales ( P < 0.001). Patients with PSI class ⩽III, CURB-65 ⩽1, and APACHE-II-I all survived. The ROC analysis showed the areas under the curve of the PSI, CURB-65, and APACHE-II scales were 0.83 (95% CI, 0.74–0.93), 0.80 (95% CI, 0.69–0.90), and 0.83 (95% CI, 0.75–0.92), respectively. Our findings suggest that PSI and CURB-65 might be useful to predict the severity and mortality of COVID-19 pneumonia.

Comparative analyses and structural insights of new class glutathione transferases in Cryptosporidium species

Cryptosporidiosis, caused by protozoan parasites of the genus Cryptosporidium, is estimated to rank as a leading cause in the global burden of neglected zoonotic parasitic diseases. This diarrheal disease is the second leading cause of death in children under 5 years of age. Based on the C. parvum transcriptome data, glutathione transferase (GST) has been suggested as a drug target against this pathogen. GSTs are diverse multifunctional proteins involved in cellular defense and detoxification in organisms and help pathogens to alleviate chemical and environmental stress. In this study, we performed genome-wide data mining, identification, classification and in silico structural analysis of GSTs in fifteen Cryptosporidium species. The study revealed the presence three GSTs in each of the Cryptosporidium species analyzed in the study. Based on the percentage identity and comprehensive comparative phylogenetic analysis, we assigned Cryptosporidium species GSTs to three new GST classes, named Vega (ϑ), Gamma (γ) and Psi (ψ). The study also revealed an atypical thioredoxin-like fold in the C. parvum GST1 of the Vega class, whereas C. parvum GST2 of the Gamma class and C. melagridis GST3 of the Psi class has a typical thioredoxin-like fold in the N-terminal region. This study reports the first comparative analysis of GSTs in Cryptosporidium species.

Clinical Impact of N-Terminal Prohormone of Brain Natriuretic Peptide on Patients Hospitalized with Community-Acquired Pneumonia

Risk stratification is important for the management of community-acquired pneumonia (CAP). The present study aimed to investigate the clinical impact of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) on prognosis and to identify clinical characteristics associated with NT-proBNP elevation in CAP patients. This retrospective study included patients hospitalized for CAP at a tertiary referral center and who underwent measurement plasma NT-proBNP levels. Based on 30-day mortality, patients (n=1,821) were divided into 2 groups, survivors (n=150) and nonsurvivors (n=1,671), and clinical and laboratory findings were compared. In multivariate analysis, blood levels of NT-proBNP (>942.5 pg/mL), albumin (<3.3 g/dL), and troponin I (>0.018 ng/mL) independently predicted 30-day mortality. Of these blood biomarkers, NT-proBNP exhibited the highest C-statistic, followed by albumin. NT-proBNP level/CURB-65 score and NT-proBNP level/pneumonia severity index (PSI) class exhibited significantly higher C-statistics than CURB-65 score and PSI class alone, respectively. The 3-test combinations of CURB-65 score/NT-proBNP level/albumin level and PSI class/NT-proBNP level/albumin level exhibited significantly higher C-statistics than the 2-test combinations. NT-proBNP elevation was associated with increased age, heart disease and chronic kidney disease and NT-proBNP levels only weakly or moderately correlated with other blood biomarkers. NT-proBNP level was a useful marker for the prediction of 30-day mortality in patients hospitalized with CAP, and provided additional prognostic value to PSI or CURB-65 alone.

The alveolar-arterial gradient, pneumonia severity scores and inflammatory markers to predict 30-day mortality in pneumonia

ObjectiveThe objective of this study was to evaluate the association of elevated alveolar-arterial oxygen (A-a O2) gradient with risk of mortality in hospitalized patients with community-acquired pneumonia (CAP). MethodsThis prospective study included 206 patients diagnosed with CAP admitted to the ED. Demographics, comorbidities, arterial blood gas, serum electrolytes, liver-renal functions, complete blood count, NLR, PLR, CRP, CAR, procalcitonin, A-a O2 gradient, expected A-a O2 and A-a O2 difference were evaluated. PSI and CURB-65 scores were classified as follow: a) PSI low risk (I-III) and moderate-high risk (IV-V) groups; b) CURB-65; low risk (0–2) and high risk (3–5) groups. ResultsThe survival rates of the PSI class (I-III) were significantly higher than the ones of the PSI class (IV-V) (92.1% vs. 62.9%, respectively). The percentage of survivors of the CURB-65 score (0–2) group (81.9%) was higher than the survivors of CURB-65 score (3–5) group (27.8%). Creatinine, BUN, uric acid, phosphorus, RDW, CRP, CAR, procalcitonin, lactate, A-a 02 gradient, expected A-a 02 and A-a 02 difference were significantly higher and basophil was lower in non-survivors. A-a O2 gradient (AUC 0.78), A-a O2 difference (AUC 0.74) and albumin (AUC 0.80) showed highest 30-day mortality prediction. NLR (AUC 0.58) and PLR (AUC 0.55) showed lowest 30-day mortality estimation. Procalcitonin (AUC 0.65), PSI class (AUC 0.81) and PSI score (AUC 0.86) indicated statistically significant higher 30-day mortality prediction. ConclusionA-a O2 gradient, A-a O2 difference and albumin are potent predictors of 30-day mortality in CAP patients in the ED.

Cost-Effectiveness Of Culture-Based Versus Empirical Antibiotic Treatment For Hospitalized Adults With Community-Acquired Pneumonia In Indonesia: A Real-World Patient-Database Study.

ObjectiveThis study analyzes the cost-effectiveness of culture-based treatment (CBT) versus empirical treatment (ET) as a guide to antibiotic selection and use in hospitalized patients with community-acquired pneumonia (CAP).Patients and methodsA model was developed from the individual patient data of adults with CAP hospitalized at an academic hospital in Indonesia between 2014 and 2017 (ICD-10 J.18x). The directed antibiotic was assessed based on microbiological culture results in terms of the impact on hospital costs and life expectancy (LE). We conducted subgroup analyses for implementing CBT and ET in adults under 60 years, elderly patients (≥ 60 years), moderate-severe CAP (PSI class III-V) cases, and ICU patients. The model was designed with a lifetime horizon and adjusted patients’ ages to the average LE of the Indonesian population with a 3% discount each for cost and LE. We applied a sensitivity analyses on 1,000 simulation cohorts to examine the economic acceptability of CBT in practice. Willingness to pay (WTP) was defined as 1 or 3 times the Indonesian GDP per capita (US$ 3,570).ResultsCBT would effectively increase the patients’ LE and be cost-saving (dominant) as well. The ET group’s hospitalization cost had the greatest influence on economic outcomes. Subgroup analyses showed that CBT’s dominance remained for Indonesian patients aged under 60 years or older, patients with moderate-severe CAP, and patients in the ICU. Acceptability rates of CBT over ET were 74.9% for 1xWTP and 82.8% for 3xWTP in the base case.ConclusionBoth sputum and blood cultures provide advantages for cost-saving and LE gains for hospitalized patients with CAP. CBT is cost-effective in patients all ages, PSI class III or above patients, and ICU patients.

COMMUNITY ACQUIRED PNEUMONIA;

Background: The treatment cost of community acquired pneumonia in Pakistanis a heavy economic burden for the society. Objectives: To assess the component of directcost (ward cost, medication cost, laboratory and diagnosis cost and the length of stay cost) oftreatment of community acquired pneumonia patients admitted in hospital ward. Study Design:Prospective study. Period: 15 months. Setting: Three private hospitals among these hospitalsone of the hospital was a tertiary care university hospital situated in Karachi. Method: The studyenrolled 514 patients and the patients were included from three private hospitals. Spearmancorrelation statistical tool was used to determine the correlation among variables Whitney U testwas used to determine the cost in different groups. Results: A total of 514 cases were examined322 cases were male and 192 cases were females. The CAP cases were mostly prevalentin patients with the age between 1-5 years (192), in male, low socioeconomic status and inunmarried patients. The mean length of hospital stay was 5.31days found in patients admittedin the hospitals due to CAP. In this study the median medication cost of CAP per episode oftreatment was Rs 2423($24.25), median laboratory diagnosis cost was found Rs 1310($13.11),median length of stay in hospital cost was found Rs 5700($57.04) and the median total costof treatment was found Rs 9889($98.96). Conclusion: length of stay, laboratory diagnosisand the medication cost were the main components of direct cost of treatment of hospitalizedcap patients. Age, comorbidity, PSI, laboratory diagnosis and length of stay was positivelycorrelated with the direct cost of treatment of CAP. Gender difference was not correlated withthe direct cost of treatment of CAP. The direct cost, drug cost, hospital stay cost increases asthe pneumonia severity index increases, but in case of laboratory diagnosis cost is initially lessin PSI I and increases in the PSI class II but remain same from PSI III to PSI V.

English

Background: The treatment cost of community acquired pneumonia in Pakistanis a heavy economic burden for the society. Objectives: To assess the component of directcost (ward cost, medication cost, laboratory and diagnosis cost and the length of stay cost) oftreatment of community acquired pneumonia patients admitted in hospital ward. Study Design:Prospective study. Period: 15 months. Setting: Three private hospitals among these hospitalsone of the hospital was a tertiary care university hospital situated in Karachi. Method: The studyenrolled 514 patients and the patients were included from three private hospitals. Spearmancorrelation statistical tool was used to determine the correlation among variables Whitney U testwas used to determine the cost in different groups. Results: A total of 514 cases were examined322 cases were male and 192 cases were females. The CAP cases were mostly prevalentin patients with the age between 1-5 years (192), in male, low socioeconomic status and inunmarried patients. The mean length of hospital stay was 5.31days found in patients admittedin the hospitals due to CAP. In this study the median medication cost of CAP per episode oftreatment was Rs 2423($24.25), median laboratory diagnosis cost was found Rs 1310($13.11),median length of stay in hospital cost was found Rs 5700($57.04) and the median total costof treatment was found Rs 9889($98.96). Conclusion: length of stay, laboratory diagnosisand the medication cost were the main components of direct cost of treatment of hospitalizedcap patients. Age, comorbidity, PSI, laboratory diagnosis and length of stay was positivelycorrelated with the direct cost of treatment of CAP. Gender difference was not correlated withthe direct cost of treatment of CAP. The direct cost, drug cost, hospital stay cost increases asthe pneumonia severity index increases, but in case of laboratory diagnosis cost is initially lessin PSI I and increases in the PSI class II but remain same from PSI III to PSI V.

Prognostic values of pneumonia severity index, CURB-65 and expanded CURB-65 scores in community-acquired pneumonia in Zagazig University Hospitals

IntroductionAssessment of severity and site of care decisions for community-acquired pneumonia patients (CAP) are very important for patients’ safety and optimal use of resources. Late admission to the intensive care unit (ICU) leads to increase the rate of mortality in CAP. We aimed to evaluate the effectiveness of the new expanded CURB-65 score in comparison with other pneumonia severity scoring systems (PSI, CURB-65) in predicting CAP patients’ outcomes. Methodsa prospective study included 250 consecutive patients hospitalized for CAP at Chest and Tropical medicine Departments and ICUs at Zagazig University Hospitals, Egypt in the period between May 2016 and November 2016. ResultsThe mean age of patients was 59.17±14.04years, 56% of all patients had comorbid diseases. As regards patients, outcomes (ICU admission rate, the median length of hospital stay, the overall 30-day mortality rate and need for invasive mechanical ventilation) were 29.6%, 8days 11.2% and 23.6% respectively. COPD and liver cirrhosis were significantly associated with increased the 30-day mortality in our CAP patients. Mortality rate increased with the severity of liver cirrhosis. In the multivariate analysis (age⩾65years, LDH>230u/L, Albumin<3.5g/dL, Platelet count<100×109/L, SBP<90mmHg or DBP⩽60mmHg, septic shock and Confusion) were the independent predictors of the 30-day mortality. Expanded CURB-65 was correlated with severity of liver disease guided by Child Pugh score (r (0.34), p-value (0.01). The 30-day mortality was lower in expanded CURB-65 score (1–4) about 4.1% than PSI class (I–III) and CURB-65 score (0–2). While, the 30-day mortality was higher in expanded CURB-65 score (5–8) about 25.9% than PSI class (IV–V) 14.2% and lastly CURB-65 score (3–5) 18.4%. Expanded CURB-65 score (5–8) was associated with more frequent ICU admission about 49.4% than other two scores. The expanded CURB-65 scoring system was the best predictor of 30-day mortality, ICU admission and need for mechanical ventilation in CAP patients as it had the highest sensitivity, negative predictive value and largest area under the ROC curve. ConclusionsExpanded CURB-65 score is simple, objective and more accurate scoring system for evaluation of CAP severity and can improve the efficiency of predicting the mortality in CAP patients, better than CURB-65 and PSI scores. Also, Expanded CUEB-65 may generate new therapeutic and prognostic modality in CAP especially in patients with liver cirrhosis.

PNEUMONIA SEVERITY INDEX (PSI)

Morbidity and mortality due to community acquired pneumonia has beenincreased in our country. Children and old age patients are mostly effected due to communityacquired pneumonia Study design: Cross sectional study. Setting: Patients hospitalized forCommunity acquired pneumonia in four different hospitals located at different areas werestudied. Period: Three years period from August 2011 to August 2014. Objectives: To assessdemographic profile, pneumonia severity index and length of stay of community acquiredpneumonia patients hospitalized at different hospitals in Karachi. Method: 800 patients bothmale and females patients were included in this study. Results: It was found that 480 (60%)were males and 320 (40%) were females, males were significantly more frequent (c2=0.48,p˂0.05) than the females patients. There was a significance difference in numbers of differentage group patients. According to the age distribution, there were 222(27.75%) from 1-5 years,which was the highest among the patients and there were 44(5.5%) from 81-90 years of agegroup patients, which was least among the different age group patients. According to thecomorbidity most of the patients were found without comorbidity there were 456(57%) patientspossess no comorbidity. Patients with comorbidity were 344(43%), and comorbidity was foundin patients with hypertension were 131(16.4%) and patients with diabetes were 105(13.1%) thesewere the two most commonly comorbidity disease found. According to the socioeconomicstatus (SES) status there were 482(60.25%) patients from lower SES class, 270(33.8%) patientfrom middle SES class and 54(6.8%) patients from high Socioeconomic class. patient with lowSES were much higher at hospital C and hospital D.(c2=127.88,p˂0.05). CAP is more frequentin married patients, married patients status were much higher at hospital C and hospital D(c2=60.31, p˂0.05). According to the PSI segregation there were 424(53%) patients from PSIclass I, 168(21%) were from PSI class II, 128(16%) patients were from PSI class III, 44(5.5%)were from class IV and 36(4.5%) were from PSI class V. Mean length of stay (LOS) was greaterat hospital C and D as compare to other two hospitals. Conclusion: CAP is frequent amongmales, low socio-economic, hypertensive individuals and patients from 1-5 years of age. Theshortest mean length found was 3.6days at hospital A and the longest mean length of stayfound was 7.6 days at hospital D.

English

Morbidity and mortality due to community acquired pneumonia has beenincreased in our country. Children and old age patients are mostly effected due to communityacquired pneumonia Study design: Cross sectional study. Setting: Patients hospitalized forCommunity acquired pneumonia in four different hospitals located at different areas werestudied. Period: Three years period from August 2011 to August 2014. Objectives: To assessdemographic profile, pneumonia severity index and length of stay of community acquiredpneumonia patients hospitalized at different hospitals in Karachi. Method: 800 patients bothmale and females patients were included in this study. Results: It was found that 480 (60%)were males and 320 (40%) were females, males were significantly more frequent (c2=0.48,p˂0.05) than the females patients. There was a significance difference in numbers of differentage group patients. According to the age distribution, there were 222(27.75%) from 1-5 years,which was the highest among the patients and there were 44(5.5%) from 81-90 years of agegroup patients, which was least among the different age group patients. According to thecomorbidity most of the patients were found without comorbidity there were 456(57%) patientspossess no comorbidity. Patients with comorbidity were 344(43%), and comorbidity was foundin patients with hypertension were 131(16.4%) and patients with diabetes were 105(13.1%) thesewere the two most commonly comorbidity disease found. According to the socioeconomicstatus (SES) status there were 482(60.25%) patients from lower SES class, 270(33.8%) patientfrom middle SES class and 54(6.8%) patients from high Socioeconomic class. patient with lowSES were much higher at hospital C and hospital D.(c2=127.88,p˂0.05). CAP is more frequentin married patients, married patients status were much higher at hospital C and hospital D(c2=60.31, p˂0.05). According to the PSI segregation there were 424(53%) patients from PSIclass I, 168(21%) were from PSI class II, 128(16%) patients were from PSI class III, 44(5.5%)were from class IV and 36(4.5%) were from PSI class V. Mean length of stay (LOS) was greaterat hospital C and D as compare to other two hospitals. Conclusion: CAP is frequent amongmales, low socio-economic, hypertensive individuals and patients from 1-5 years of age. Theshortest mean length found was 3.6days at hospital A and the longest mean length of stayfound was 7.6 days at hospital D.

High variability among Emergency Departments in 3rd-generation cephalosporins and fluoroquinolones use for community-acquired pneumonia

Fluoroquinolones and 3rd-generation cephalosporins that are prescribed for pneumonia may be avoided and replaced by a penicillin in some cases. We aimed to determine if the proportion of patients treated for pneumonia with a cephalosporin, a fluoroquinolone or both varies among Emergency Departments (EDs), and to estimate the proportion of avoidable prescriptions. This was a retrospective study of patients treated for pneumonia in eight French EDs, and subsequently hospitalized in non-ICU wards. Third-generation cephalosporins or respiratory fluoroquinolones were presumed unavoidable if they met both criteria: (1) age ≥65 years or comorbid condition; and (2) allergy or intolerance to penicillin, or failure of penicillin, or previous treatment with penicillin, or for fluoroquinolones only, suspected legionellosis. We included 832 patients. Thirty-four percent (95 % CI, 31-38 %) of patients were treated with a cephalosporin, a respiratory fluoroquinolone or both (range among EDs 19-44 %). Four EDs were independent risk factors for prescription of a cephalosporin, a fluoroquinolone or both [adjusted OR, 2.27 (1.64-3.15)], as were immune compromise [aOR 2.54 (1.56-4.14)], antibacterial therapy started before arrival in the ED [aOR 3.32 (2.30-4.81)], REA-ICU class III or IV [aOR 1.93 (1.15-3.23)], PSI class V [aOR 1.49 (1.00-2.20)], fluid resuscitation [aOR 3.98 (2.49-6.43)] and non-invasive ventilation in the ED [aOR, 7.18 (1.7-50.1)]. Treatment with a cephalosporin, a fluoroquinolone or both was avoidable in 67 % (62-73 %) of patients. Cephalosporins and fluoroquinolones use in pneumonia is highly variable among EDs. The majority of these prescriptions are avoidable. Antibiotic stewardship programs should be implemented to restrict their use in EDs.

Prognostic value of severity indicators of nursing-home-acquired pneumonia versus community-acquired pneumonia in elderly patients

BackgroundThe credibility of prognostic indicators in nursing-home-acquired pneumonia (NHAP) is not clear. We previously reported a simple prognostic indicator in community-acquired pneumonia (CAP): blood urea nitrogen to serum albumin (B/A) ratio. This retrospective study investigated the prognostic value of severity indicators in NHAP versus CAP in elderly patients.MethodsPatients aged ≥65 years and hospitalized because of NHAP or CAP within the previous 3 years were enrolled. Demographics, coexisting illnesses, laboratory and microbiological findings, and severity scores (confusion, urea, respiratory rate, blood pressure, and age ≥65 [CURB-65] scale; age, dehydration, respiratory failure, orientation disturbance, and pressure [A-DROP] scale; and pneumonia severity index [PSI]) were retrieved from medical records. The primary outcome was mortality within 28 days of admission.ResultsIn total, 138 NHAP and 307 CAP patients were enrolled. Mortality was higher in NHAP (18.1%) than in CAP (4.6%) (P<0.001). Patients with NHAP were older and had lower functional status and a higher rate of do-not-resuscitate orders, heart failure, and cerebrovascular diseases. The NHAP patients more frequently had typical bacterial pathogens. Using the receiver-operating characteristics curve for predicting mortality, the area under the curve in NHAP was 0.70 for the A-DROP scale, 0.69 for the CURB-65 scale, 0.67 for the PSI class, and 0.65 for the B/A ratio. The area under the curve in CAP was 0.73 for the A-DROP scale, 0.76 for the CURB-65 scale, 0.81 for the PSI class, and 0.83 for the B/A ratio.ConclusionPatient mortality was greater in NHAP than in CAP. Patient characteristics, coexisting illnesses, and detected pathogens differed greatly between NHAP and CAP. The existing severity indicators had less prognostic value for NHAP than for CAP.

Obesity and outcomes in patients hospitalized with pneumonia

Studies suggest obesity is paradoxically associated with better outcomes for patients with pneumonia. Therefore, we examined the impact of obesity on short-term mortality in patients hospitalized with pneumonia. For 2 years clinical and radiographic data were prospectively collected on all consecutive adults admitted with pneumonia to six hospitals in Edmonton, Alberta, Canada. We identified 907 patients who also had body mass index (BMI, kg/m2) collected and categorized them as underweight (BMI < 18.5), normal (18.5 to <25), overweight (25 to <30) and obese (>30). Overall, 65% were >65 years, 52% were female, and 15% reported recent weight loss. Eighty-four (9%) were underweight, 358 (39%) normal, 228 (25%) overweight, and 237 (26%) obese. Two-thirds had severe pneumonia (63% PSI Class IV/V) and 79 (9%) patients died. In-hospital mortality was greatest among those that were underweight (12 [14%]) compared with normal (36 [10%]), overweight (21 [9%]) or obese (10 [4%], p <0.001 for trend). Compared with those of normal weight, obese patients had significantly lower rates of in-hospital mortality in multivariable logistic regression analyses: adjusted odds ratio (OR), 0.46; 95% CI, 0.22–0.97; p 0.04. However, compared with patients with normal weight, neither underweight (adjusted OR, 1.13; 95% CI, 0.54–2.4; p 0.7) nor overweight (adjusted OR, 0.94; 95% CI, 0.52–1.69; p 0.8) were associated with in-hospital mortality. In conclusion, in patients hospitalized with pneumonia, obesity was independently associated with lower short-term mortality, while neither being underweight nor overweight were. This suggests a protective influence of BMIs > 30 kg/m2 that requires better mechanistic understanding.

Impact of guideline-concordant antibiotics and macrolide/β-lactam combinations in 3203 patients hospitalized with pneumonia: prospective cohort study

For patients hospitalized with pneumonia, guidelines provide empirical antibiotic recommendations and some studies suggest that macrolide/β-lactam combinations are preferable. We hypothesized that guideline-concordant regimens, particularly macrolide/β-lactams, would reduce mortality and ICU admissions. All patients hospitalized with pneumonia in Edmonton, Alberta, Canada, were managed according to a clinical pathway and enrolled in a population-based registry. Clinical data, Pneumonia Severity Index and treatments were collected. Guideline-concordant regimens were macrolides/β-lactams or respiratory fluoroquinolone monotherapy. The main outcome was in-hospital mortality. The study included 3203 patients and most had severe pneumonia (63% PSI Class IV-V). Three hundred and twenty-one (10.0%) patients died, 306 (9.6%) were admitted to the ICU and 570 (17.8%) achieved the composite of death or ICU admission. Most (n = 2506) patients received guideline-concordant antibiotics. Receipt of guideline-concordant antibiotics was not associated with a reduction in mortality alone (231 (9.2%) vs. 90 (12.9%); adjusted odds ratio (aOR), 0.82; 95% CI, 0.61–1.09; p 0.16), but was associated with decreased death or ICU admission (14.7% vs. 29.0%; aOR, 0.44; 95% CI, 0.36–0.54; p <0.0001). Within guideline-concordant subgroups, there was no difference in mortality between macrolide/β-lactams and respiratory fluoroquinolone monotherapy (22 (8.3%) vs. 209 (9.3%); aOR, 1.09; 95% CI, 0.66–1.81; p 0.73) but macrolide/β-lactams were associated with increased odds of death or ICU admission (17.4% vs. 14.4%; aOR, 1.58; 95% CI, 1.09–2.27; p 0.01). In conclusion, guideline-concordant antibiotics were not associated with decreased mortality for patients hospitalized with pneumonia, but were associated with a decrease in the composite endpoint of death or ICU admission. Our findings do not support any clinical advantage of macrolide/β-lactam compared with respiratory fluoroquinolone monotherapy.

Comparison of clinical characteristics between healthcare-associated pneumonia and community-acquired pneumonia in patients admitted to secondary hospitals

BackgroundSince healthcare-associated pneumonia (HCAP) is heterogeneous, clinical characteristics and outcomes are different from region to region. There can also be differences between HCAP patients hospitalized in secondary or tertiary hospitals. This study aimed to evaluate the clinical characteristics of HCAP patients admitted into secondary community hospitals. MethodsThis was a retrospective study conducted in patients with HCAP or community-acquired pneumonia (CAP) hospitalized in two secondary hospitals between March 2009 and January 2011. ResultsOf a total of 303 patients, 96 (31.7%) had HCAP. 42 patients (43.7%) resided in a nursing home or long-term care facility, 36 (37.5%) were hospitalized in an acute care hospital for ≥ 2 days within 90 days, ten received outpatient intravenous therapy, and eight attended a hospital clinic or dialysis center. HCAP patients were older. The rates of patients with CURB-65 scores of 3 or more (22.9% vs. 9.1%; p=0.001) and PSI class IV or more (82.2% vs. 34.7%; p<0.001) were higher in the HCAP group. Drug-resistant pathogens were more frequently detected in the HCAP group (23.9% vs. 0.4%; p<0.001). However, Streptococcus pneumoniae was the most common pathogen in both groups. The rates of antibiotic change, use of inappropriate antibiotics, and failure of initial antibiotic therapy in the HCAP group were significantly higher. Although the overall survival rate of the HCAP group was significantly lower (82.3% vs. 96.8%; p<0.001), multivariate analyses failed to show that HCAP itself was a prognostic factor for mortality (p=0.826). Only PSI class IV or more was associated with increased mortality (p=0.005). ConclusionsHCAP should be distinguished from CAP because of the different clinical features. However, the current definition of HCAP does not appear to be a prognostic for death. In addition, the use of broad-spectrum antibiotics for HCAP should be reassessed because S. pneumoniae was most frequently identified even in HCAP patients.

Prognostic value of proadrenomedullin in severe sepsis and septic shock patients with community-acquired pneumonia

Midregional proadrenomedullin (proADM) is a novel biomarker with potential prognostic utility in patients with community-acquired pneumonia. The aim of this study was to investigate the value of proADM levels for severity assessment and outcome prediction in severe sepsis and septic shock due to CAP. Prospective observational study including 49 patients admitted to ICU with both a clinical and radiologic diagnosis of pneumonia and fulfilling criteria for severe sepsis or septic shock. The prognostic accuracy of proADM levels was compared with those of pneumonia severity index and of procalcitonin (PCT) and C-reactive protein (CRP). 49 patients with severe sepsis or septic shock due to CAP were included in the study. Mortality was 24.5% for ICU and 34.7% for hospital mortality. In all cases proADM values at ICU admission were pathological (considering normal proADM levels <4nmol/L). ProADM consistently rose as PSI class advanced from II to V (p = 0.02). Median proADM levels were higher (p <0.01) in hospital non-survivors 5.0 (1.9-10.1) nmol/L vs. survivors 1.7 (1.3-3.1) nmol/L. These differences were also significant with respect to ICU mortality. The receiver-operating characteristic curve for proADM yielded an AUC of 0.72; better than the AUC for PCT and CRP (0.40 and 0.44 respectively) and similar to PSI (0.74). In our study MR-proADM levels correlate with increasing severity of illness and death. High MR-proADM levels offer additional risk stratification in high-risk CAP patients.

Oxygen Saturations Less than 92% Are Associated with Major Adverse Events in Outpatients with Pneumonia: A Population-Based Cohort Study

patients with hypoxemia (blood oxygen saturation <90%) are usually hospitalized, although validated criteria (eg, the Pneumonia Severity Index [PSI]) suggest outpatient treatment is safe. We sought evidence to support or refute the practice. all patients in Edmonton, Alberta, Canada with pneumonia assessed at any of 7 emergency departments (EDs) and then discharged were enrolled in a population-based cohort study. The independent variable of interest was oxygen saturation; the outcome was the composite endpoint of 30-day mortality or hospitalization. the study evaluated 2923 individuals with pneumonia who were treated as outpatients at any of 7 EDs. The patients' mean age (standard deviation [SD])was 52 (20) years; 47% were women; 74% were low risk (PSI Class I-II). The mean blood oxygen saturation (SD) was 95% (3%); 126 patients (4%) had blood oxygen saturations <90%, and 201 patients (7%) had blood oxygen saturations of 90%-92%. Over 30 days, 39 patients (1%) died and 252 (9%) reached the composite endpoint. Compared with patients with higher blood oxygen saturations, those discharged with saturations <90% had significantly (P < .001) higher rates of 30-day mortality (7 [6%] vs 32 [1%]), hospitalization (23 [18%] vs 201 [7%]), and composite endpoints (27 [21%] vs 225 [8%]). Blood oxygen saturation <90% was independently associated with 30-day mortality or hospitalization (adjusted odds ratio (OR), 1.7; 95% confidence interval (CI) 1.1-2.8; P = .032). If the saturation threshold for hospitalization was 92%, then there was no association with adverse events (adjusted OR 1.1, 95% CI 0.8-1.7, P = .48). Raising the admission threshold to 92% entails 1 additional hospitalization for every 14 patients discharged. among outpatients with pneumonia, oxygen saturations <90% were associated with increased morbidity and mortality. Our results indicate a hospital admission threshold of <92% would be safer and clinically better justified.

Efficacy of short course asythromycin in non-severe community-acquired pneumonia

The study was aimed to evaluate clinical efficacy, safety, and tolerability of 3 day course of azythromycin (Zitrolid forte) in comparison with a stan dard 7 to 10 day therapy with amoxicillin (Flemoxin solutab) in patients with mild community acquired pneumonia (CAP). Included patients were randomized in 2 groups: 1) 20 patients taking Zitrolid 500 mg daily for 3 days (15 males, 5 females, mean age, 40.7 ± 18.4 yrs); 2) 20 patients taking amoxicillin 500 mg t.i.d. for 7 to 10 days (13 males, 7 females, mean age, 39.8 ± 12.5 yrs). Pneumonia was confirmed by chest X ray in all the patients. Severity of pneumonia was assessed with PSI score. In the 1st group, 12 (60 %) of patients had PSI class I and 8 (40 %) had PSI class II. In the 2nd group, there were 13 (65 %) and 7 (35 %), respectively. In the 1st group patients, improvement in clinical signs and laboratory parame ters was noted at the 3rd day of therapy and complete recovery was detected at the 7th day. The 2nd group patients demonstrated similar dynamics at the 7th and the 14th days, respectively. Microbiological efficacy of the drugs was equal (100 %). The drugs did not differ in rate of adverse events. Therefore, 3 day course of azythromycin in patients with mild CAP were as effective as standard (7 to 10 days) therapy with amoxicillin. Azythromycin (Zitrolid forte) was well tolerated with no serious adverse events requiring interruption the treatment.