Risk Of Pneumonia In Patients Research Articles

Exploring the Influence of Dysphagia and Tracheostomy on Pneumonia in Patients with Stroke: A Retrospective Cohort Study.

Pneumonia is common in patients with tracheostomy and dysphagia. However, the influence of dysphagia and tracheostomy on pneumonia in patients with stroke remains unclear. The aim of this study was to explore the risk factors related to pneumonia, and the association between dysphagia, tracheostomy and pneumonia in patients with stroke was investigated. Patients with stroke who experienced tracheostomy and dysphagia were included and divided into two groups based on record of pneumonia at discharge. Clinical manifestations and physical examination were used to diagnose pneumonia, whereas clinical swallowing examination, and videofluoroscopy swallowing studies (VFSS) were used to evaluate swallowing function. There were significant differences between the pneumonia group and the no pneumonia group in total tracheostomy time (6.3 ± 5.9 vs. 4.3 ± 1.7 months, p = 0.003), number of instances of ventilator support (0.41 ± 0.49 vs. 0.18 ± 0.38, p = 0.007), PAS score (5.2 ± 1.92 vs. 4.3 ± 1.79, p = 0.039), impaired or absent cough reflex (76.4 vs. 55.6%, p = 0.035), oropharyngeal phase dysfunction (60.6 vs. 40.8%, p = 0.047), length of hospital stay (36.0 ± 7.2 vs. 30.5 ± 11.7 days, p = 0.025) and direct medical costs (15,702.21 ± 14,244.61 vs. 10,923.99 ± 7250.14 United States dollar [USD], p = 0.042). Multivariate logistic regression showed that the total tracheostomy time (95% confidence interval [CI], 1.966-12.922, p = 0.001), impaired or absent cough reflex (95% CI, 0.084-0.695, p = 0.008), and oropharyngeal phase dysfunction (95% CI, 1.087-8.148, p = 0.034) were risk factors for pneumonia. Spearman's correlation analysis demonstrated that PAS scores were significantly correlated with cough reflex dysfunction (r = 0.277, p = 0.03), oropharyngeal phase dysfunction (r = 0.318, p < 0.01) and total tracheostomy time (r = 0.178, p = 0.045). The oropharyngeal phase dysfunction was significantly correlated with cough reflex (r = 0.549, p < 0.001) and UES opening (r = 0.643, p < 0.01). Tracheostomy and dysphagia increased the risk of pneumonia in patients with stroke. Total tracheostomy time, duration of ventilator support, degree of penetration and aspiration, and oropharyngeal phase dysfunction are risk factors. Given this, we also found that there may be a correlation between tracheostomy and dysphagia.

Radiographic Phenotypes Affect the Risk of Inhaled Corticosteroid-Associated Pneumonia in Patients with COPD.

PurposeFew studies have reported the association between the radiographic characteristics and the development of pneumonia in patients with chronic obstructive pulmonary disease (COPD) treated with inhaled corticosteroids (ICSs). Our study aimed to assess the effect of radiographic phenotypes on the risk of pneumonia in patients treated with ICSs.Patients and MethodsThis study retrospectively analysed all patients with COPD treated with ICSs in a subset of the Korea Chronic Obstructive Pulmonary Disorders Subgroup Study registry between January 2017 and December 2019. The association between radiographic phenotypes including the presence and severity of emphysema, airway wall thickening, or bronchiectasis on chest computed tomography were determined visually/qualitatively and the risk of pneumonia was analyzed using the Cox regression model.ResultsAmong the 90 patients with COPD treated with ICSs, 41 experienced pneumonia more than once during the median follow-up of 29 (interquartile range, 8–35) months. In univariate Cox regression analysis, older age, longer use of ICSs, use of fluticasone propionate or metered dose inhaler, and severe exacerbation events increased the risk of pneumonia. In multivariate analysis, the presence of emphysema (adjusted hazard ratio [aHR]=3.73, P=0.033), severity measured using the visual sum score (mild-to-moderate, aHR=8.58, P=0.016; severe, aHR=3.58, P=0.042), Goddard sum score (mild-to-moderate, aHR=3.31, P=0.058; severe, aHR=5.38, P=0.014), and the upper lobe distribution of emphysema (aHR=3.76, P=0.032) were associated with a higher risk of pneumonia. Subtypes of centrilobular and panlobular emphysema had a higher risk of pneumonia compared with paraseptal emphysema (aHR=3.98, P=0.033; HR=3.91, P=0.041 vs HR=2.74, P=0.304). The presence of bronchiectasis (aHR=2.41, P=0.02) and emphysema/bronchiectasis overlap phenotype (aHR=2.19, P=0.053) on chest CT was a risk factor for pneumonia in this population. However, severity of bronchiectasis and the presence or severity of bronchial wall thickening according to the visual sum score were not associated with the risk of pneumonia.ConclusionAmong patients with COPD treated with ICSs, radiographic phenotypes including the presence of emphysema, bronchiectasis or emphysema/bronchiectasis overlap phenotype, severity with emphysema, subtypes of centrilobular or panlobular emphysema, and upper lobe distribution of emphysema may help predict the risk of pneumonia.

Association between the mid-upper arm circumference (MUAC) and calf circumference (CC) screening indicators of sarcopenia with the risk of pneumonia in stable patients diagnosed with schizophrenia.

AimHere, we investigate the relationship between mid-upper arm circumference (MUAC) and calf circumference (CC) screening indicators of sarcopenia and the risk of pneumonia in stable patients diagnosed with schizophrenia.MethodThe study is prospective and includes inpatients with schizophrenia from two mental health centers in Western China. The studied screening indicators, MUAC and CC were assessed in standing patients. The relationship between MUAC and CC as sarcopenia screening indicators with the risk of pneumonia in patients with schizophrenia was analyzed by performing a statistical logistic regression analysis.ResultFor this study, 339 patients with schizophrenia, aged 50 years and over were recruited. Moreover, four patients with pneumonia that occurred within 1 week of the relapse of schizophrenia were excluded. As a result, only 335 patients were included in the analysis. Pneumonia has been reported in 82 (24.5%) of all included patients with schizophrenia. Our data analysis confirmed that in the male patients, the higher CC was associated with a lower risk of pneumonia (odds ratio [OR] = 0.751, 95% CI: 0.635–0.889). We have divided men into two cohorts following the values of CC. Our analysis further showed that the patients with CC ≥ 34 cm had a lower risk of pneumonia in men (OR = 0.36, 95% CI: 0.163–0.795).ConclusionWe demonstrate that CC is associated with pneumonia risk in stable men with schizophrenia.

Predictive Ability of Systemic Inflammation Response Index for the Risk of Pneumonia in Patients with Acute Ischemic Stroke

Introduction: Several studies have examined the crucial role of inflammatory indexes such as the ratio of monocyte and lymphocyte (MLR), systemic-immune-inflammation-index, and the ratio of neutrophil and lymphocyte (NLR) in stroke-associated pneumonia (SAP). However, the function of the systemic inflammation response index (SIRI) in SAP is not known. This study investigated whether SIRI at admission could predict the incidence of SAP in patients with acute ischemic stroke (AIS). Patients and Methods: 2,802 AIS patients collected from 2013 to 2021 were divided into the SAP and non-SAP groups. The predictive performance of SIRI in SAP was evaluated by the receiver operating characteristic curve. Multivariate regression analysis and the restricted cubic spline (RCS) were performed to explore the relationship between SIRI and SAP risk. Results: The SIRI at admission in SAP patients was significantly higher than that in non-SAP patients (median [IQR]: 3.75 [2.05, 6.99] vs. 1.51 [0.94, 2.62], p < 0.001). SIRI had a predictive ability for predicting the incidence of SAP with area under the curve of 0.757, better than NLR and MLR (both p < 0.05). SIRI ≥2.74 was an independent risk factor for the incidence of SAP (odds ratio: 5.82, 95% confidence interval: 4.54, 7.49, p < 0.001). The RCS model showed an increasing trend of the SAP risk with the increase of SIRI. Conclusion: SIRI showed a good predictive value for SAP. In clinical practice, AIS patients with high SIRI levels (SIRI ≥2.74) should be aware of the risk of SAP.

Human genetic factors associated with pneumonia risk, a cue for COVID-19 susceptibility.

Pneumonia, an acute respiratory tract infection, is one of the major causes of mortality worldwide. Depending on the site of acquisition, pneumonia can be community acquired pneumonia (CAP) or nosocomial pneumonia (NP). The risk of pneumonia, is partially driven by host genetics. CYP1A1 is a widely studied pulmonary CYP family gene primarily expressed in peripheral airway epithelium. The CYP1A1 genetic variants, included in this study, alter the gene activity and are known to contribute in lung inflammation, which may cause pneumonia pathogenesis. In this study, we performed a meta-analysis to establish the possible contribution of CYP1A1 gene, and its three variants (rs2606345, rs1048943 and rs4646903) towards the genetic etiology of pneumonia risk. Using PRISMA guidelines, we systematically reviewed and meta-analysed case-control studies, evaluating risk of pneumonia in patients carrying the risk alleles of CYP1A1 variants. Heterogeneity across the studies was evaluated using I2 statistics. Based on heterogeneity, a random-effect (using maximum likelihood) or fixed-effect (using inverse variance) model was applied to estimate the effect size. Pooled odds ratio (OR) was calculated to estimate the overall effect of the risk allele association with pneumonia susceptibility. Egger's regression test and funnel plot were used to assess publication bias. Subgroup analysis was performed based on pneumonia type (CAP and NP), population, as well as age group. A total of ten articles were identified as eligible studies, which included 3049 cases and 2249 healthy controls. The meta-analysis findings revealed CYP1A1 variants, rs2606345 [T vs G; OR = 1.12 (0.75–1.50); p = 0.02; I2 = 84.89%], and rs1048943 [G vs T; OR = 1.19 (0.76–1.61); p = 0.02; I2 = 0.00%] as risk markers whereas rs4646903 showed no statistical significance for susceptibility to pneumonia. On subgroup analysis, both the genetic variants showed significant association with CAP but not with NP. We additionally performed a spatial analysis to identify the key factors possibly explaining the variability across countries in the prevalence of the coronavirus disease 2019 (COVID-19), a viral pneumonia. We observed a significant association between the risk allele of rs2606345 and rs1048943, with a higher COVID-19 prevalence worldwide, providing us important links in understanding the variability in COVID-19 prevalence.

Metformin use and the risk of bacterial pneumonia in patients with type 2 diabetes

Persons with type 2 diabetes (T2D) have neutrophil dysfunction with a higher risk of infection than those without diabetes. We conducted this study aiming to compare the risk of pneumonia between metformin use and nonuse in persons with T2D. We identified 49,012 propensity score-matched metformin users and nonusers from Taiwan’s National Health Insurance Research Database between January 1, 2000, and December 31, 2017. We used the Cox proportional hazards model to compare the risks of pneumonia and respiratory death. The mean (SD) age of the participants was 57.46 (12.88) years, and the mean follow-up time for metformin users and nonusers was 5.47 (3.71) years and 5.15 (3.87) years, respectively. Compared with the nonuse of metformin, the adjusted hazard ratios (95% CI) for metformin use in bacterial pneumonia, invasive mechanical ventilation, and respiratory cause of death were 0.89 (0.84–0.94), 0.77 (0.73–0.82), and 0.64 (0.56–0.74), respectively. A longer cumulative duration of metformin use had further lower adjusted hazard ratios in these risks compared with nonuse. In patients with T2D, metformin use was associated with significantly lower risks of bacterial pneumonia, invasive mechanical ventilation, and respiratory cause of death; moreover, longer metformin use duration was associated with lower hazard ratios of these risks.

Discordant diagnostic criteria for pneumonia in COPD trials: a review.

Inhaled corticosteroids (ICS) have a class effect of increasing pneumonia risk in patients with COPD. However, pneumonia incidence varies widely across clinical trials of ICS use in COPD. This review clarifies methodological differences in defining and recording pneumonia events in these trials and discusses factors that could contribute to the varying pneumonia incidence. Literature searches and screening yielded 40 relevant references for inclusion. Methods used to capture pneumonia events in these studies included investigator-reported pneumonia adverse events, standardised list of signs or symptoms, radiographic confirmation of suspected cases and/or confirmation by an independent clinical end-point committee. In general, more stringent pneumonia diagnosis criteria led to lower reported pneumonia incidence rates. In addition, studies varied in design and population characteristics, including exacerbation history and lung function, factors that probably contribute to the varying pneumonia incidence. As such, cross-trial comparisons are problematic. A minimal set of standardised criteria for diagnosis and reporting of pneumonia should be used in COPD studies, as well as reporting of patients' pneumonia history at baseline, to allow comparison of pneumonia rates between trials. Currently, within-trial comparison of ICS-containing versus non-ICS-containing treatments is the appropriate method to assess the influence of ICS on pneumonia incidence.

Use of ticagrelor and the risks of pneumonia and pneumonia-specific death in patients with non-acute coronary syndrome conditions: a population-based cohort study

Previous studies have shown that ticagrelor reduced risk of pneumonia in patients with acute coronary syndrome (ACS) compared to clopidogrel, however, its effect in patients with non-ACS cardiovascular diseases remains uncertain. The aim was to investigate the effect of ticagrelor on pneumonia and pneumonia-specific death compared to clopidogrel in non-ACS patients in Hong Kong. This was a population-based cohort study. We included consecutive patients using ticagrelor or clopidogrel admitted for non-ACS conditions in Hong Kong public hospitals from March 2012 to September 2019. Patients using both drugs were excluded. The outcomes of interest were incident pneumonia, all-cause death, and pneumonia-specific death. Multivariable survival analysis models were used to estimate the effects [hazard ratio (HR) and 95% confidence interval (CI)]. Propensity score matching, adjustment and weighting were performed as sensitivity analyses. In total, 90,154 patients were included (mean age 70.66 years, males 61.7%). The majority of them (97.2%) used clopidogrel. Ticagrelor was associated with a lower risk of incident pneumonia [0.59 (0.46–0.75)], all-cause death [0.83 (0.73–0.93)] and pneumonia-specific death [0.49 (0.36–0.67)]. Sensitivity analyses yielded similar results. Ticagrelor was associated with lower risk of all-cause death, pneumonia-specific death, and incident pneumonia in patients with non-ACS cardiovascular conditions, consistent with previous evidence in patients with ACS. This additional effect of anti-pneumonia should be considered when choosing a proper P2Y12 inhibitor for patients with high risk of pneumonia.

Statin use and pneumonia risk in Parkinson's disease

IntroductionPrevious studies reported that statin use was related to a lower risk of pneumonia in the general population. This study investigated the association between statin use and pneumonia risk in patients with Parkinson's disease (PD). MethodsPatients that had been newly diagnosed with PD between 2004 and 2006 in the 2002–2017 National Health Insurance Service database in South Korea were identified. PD patients who had received one or more statin prescriptions, and experienced pneumonia during the observation period were included in the self-controlled case series (SCCS) analysis. Patients who had no previous statin prescription record were included in the Cox proportional hazard model with a time-varying covariate (statin use). The risk of pneumonia in PD patients with statin use was estimated after adjusting potential confounders. ResultsOf the 10,159 patients with PD, 337 individuals were eligible for the SCCS analysis. The median duration of statin exposure was 2.63 years (IQR, 0.83–5.83). The incidence of pneumonia was reduced in the statin-exposed period compared to the unexposed period (incidence rate ratio, 0.88; 95% CI, 0.86–0.91). A total of 8,022 patients were included in the Cox proportional hazard model. Statin use was related to a significantly reduced pneumonia risk (adjusted hazard ratio, 0.69; 95% CI, 0.62–0.78). ConclusionsStatin use was associated with a lower risk of pneumonia in PD patients. Statins might affect pneumonia occurrence by lowering cholesterol levels or slowing the progression of PD as neuroprotective agents. Further clinical studies are needed to delineate our findings with the underlying biological mechanisms.

Inhaled Corticosteroids and the Pneumonia Risk in Patients With Chronic Obstructive Pulmonary Disease: A Meta-analysis of Randomized Controlled Trials.

Background: Whether all types of inhaled corticosteroids (ICSs) would increase the pneumonia risk in patients with chronic obstructive pulmonary disease (COPD) remains controversial. We aimed to assess the association between ICSs treatment and pneumonia risk in COPD patients, and the impact of medication details and baseline characteristics of patients on the association. Methods: Four databases (PubMed, Embase, Cochrane Library, and Clinical Trials.gov) were searched to identify eligible randomized controlled trials (RCTs) comparing ICSs treatment with non-ICSs treatment on the pneumonia risk in COPD patients. Pooled results were calculated using Peto odds ratios (Peto ORs) with corresponding 95% confidence intervals (CIs). Results: A total of 59 RCTs enrolling 103,477 patients were analyzed. All types of ICSs significantly increased the pneumonia risk (Peto OR, 1.43; 95% CI, 1.34–1.53). Subgroup analysis showed that there was a dose-response relationship between ICSs treatment and pneumonia risk (low-dose: Peto OR, 1.33; 95% CI, 1.22–1.45; medium-dose: Peto OR, 1.50; 95% CI, 1.28–1.76; and high-dose: Peto OR, 1.64; 95% CI, 1.45–1.85). Subgroup analyses based on treatment durations and baseline characteristics (severity, age, and body mass index) of patients were consistant with the above results. Subgroup analysis based on severity of pneumonia showed that fluticasone (Peto OR, 1.75; 95% CI, 1.44–2.14) increased the risk of serious pneumonia, while budesonide and beclomethasone did not. Conclusions: ICSs treatment significantly increased the risk of pneumonia in COPD patients. There was a dose-response relationship between ICSs treatment and pneumonia risk. The pneumonia risk was related with COPD severity.

Impact of Enteral Tube Feeding Compared to Oral Hand Feeding on Mortality, Pneumonia, Hospitalization and Quality of Life in Patients With Advanced Dementia: A Review

ObjectivesTo assess the effectiveness of enteral tube feeding in comparison to oral hand feeding in improving survival, hospitalization, pneumonia incidence, and quality of life in adults 60 years and older with advanced dementia. MethodsPubMed, CINAHL, Cochrane Library, and Academic Search Premier, supplemented by hand-searching, were probed for articles published between January 2006-June 2020. Eligible articles compared clinical outcomes (mortality, survival, pneumonia, hospitalization, and quality of life) amongst patients 60 years and older with advanced dementia, fed via an enteral tube or oral hand-feeding route. Of the 53 articles screened and assessed, 4 cohort studies involving 508 patients were extracted after excluding based on the above criteria and summarized for this review. ResultsOf the 4 articles, 3 were prospective cohort studies and 1 was a retrospective cohort study. Half of the studies reported significantly increased rates of mortality in groups of advanced dementia patients fed via enteral tube. Meanwhile, 1 study reported a similar nonsignificant increase in mortality rates in those fed via oral hand route. Half of the studies indicated a nonsignificant increase in hospitalization frequency for those fed via enteral tube. Additionally, 1 study reported an increased risk of pneumonia in patients fed via nasogastric tube. Regarding quality of life, 1 article reported significantly increased complaints of pain and discomfort from patients fed via oral hand feeding, that severity of dementia may have contributed to. ConclusionsConcerning clinical outcomes and mortality, these findings suggest no significant advantage to using enteral tube feeding options in older patients with advanced dementia. Thus, the healthcare professional should place primary emphasis on the patient’s advance directives and provide the primary caregiver a thorough review of feeding options. Funding SourcesNone.

Association Between Aspirin Use and Decreased Risk of Pneumonia in Patients With Cardio-Cerebra-Vascular Ischemic Disease: A Population-Based Cohort Study.

This study evaluated the association between long-term low-dose aspirin use and decreased risk of pneumonia in patients with cardio-cerebra-vascular ischemic diseases (CCVDs). This retrospective cohort study used records from Taiwan's National Health Insurance Research Database of claims made between 1997 and 2013. After propensity score matching (PSM), patients who took a low dose of aspirin for more than 90 days within 1 year of diagnosis with CCVDs were identified as the exposure group (n = 15,784). A matched total of 15,784 individuals without aspirin use were selected for the non-aspirin group. The main outcome was the development of pneumonia after the index date. Multivariable Cox regression analysis and Kaplan–Meier survival analysis were performed to estimate the adjusted hazard ratio (aHR) and cumulative probability of pneumonia. The result after PSM indicated a lower hazard ratio for pneumonia in aspirin users (aHR = 0.890, 95% confidence interval = 0.837–0.945). Therefore, patients with CCVDs who took aspirin had a lower risk of developing pneumonia than those who did not. In conclusion, this population-based cohort study demonstrated that long-term low-dose aspirin use is associated with a slightly decreased risk of pneumonia in patients with CCVDs.

Dual bronchodilator versus inhaled corticosteroid/long-acting β2-agonist in patients with chronic obstructive pulmonary disease: A meta-analysis of randomized controlled trials

BackgroundLong-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA, also known as dual bronchodilator) and inhaled corticosteroid/LABA (ICS/LABA) are the cornerstone of maintenance treatment for stable chronic obstructive pulmonary disease (COPD) patients. We aimed to comprehensively compare the efficacy and safety of the two maintenance treatment in COPD patients. MethodsWe searched the database Embase, Cochrane Library, PubMed, and Clinical Trials.gov systematically (from inception until September 2020). Randomized controlled trials (RCTs) comparing dual bronchodilator with ICS/LABA in the treatment of COPD were included. Efficacy and safety endpoints were pooled as mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs). This meta-analysis was registered with PROSPERO prospectively # CRD42020203314). ResultsFourteen RCTs including 21,496 patients were included. Dual bronchodilator showed a greater improvement in both trough FEV1 (MD = 0.06 L, 95% CI: 0.04–0.07, P < 0.001) and FVC (FVC: MD = 0.12 L, 95% CI: 0.07–0.16, P < 0.001), and a lower risk of pneumonia (RR = 0.62, 95% CI: 0.53–0.72, P < 0.001) in patients with COPD. There were no significant differences neither in the improvement of exacerbations, symptoms, and quality of life, nor in the incidence of cardiovascular events, serious adverse events, all-cause mortality, and withdrawals due to adverse events of treatment between these two maintenance treatments. ConclusionsDual bronchodilator is superior to ICS/LABA in improving lung function and is associated with a lower risk of pneumonia in patients with COPD. There are no significant differences in other efficacy and safety profiles between these two maintenance treatments.

Pneumonia risk in patients receiving clozapine

Clozapine is highly effective in the treatment of drug‐resistant schizophrenia, but its use can be associated with significant side effects, including agranulocytosis. Adverse cardiopulmonary effects, including tachycardia, orthostatic hypotension, and pneumonia, have also been reported. According to one study, the occurrence of pneumonia was much higher within 30 days of receiving clozapine.

Comparison of infection risks and clinical outcomes in patients with and without SARS-CoV-2 lung infection under renin-angiotensin-aldosterone system blockade: Systematic review and meta-analysis.

AimsAngiotensin‐converting enzyme‐2 (ACE2) is the receptor for SARS‐CoV‐2. Animal studies suggest that renin–angiotensin–aldosterone system (RAAS) blockers might increase the expression of ACE2 and potentially increase the risk of SARS‐CoV‐2 infection.Methods and ResultsThe effect of ACE inhibitor (ACEI) treatment on the pneumonia incidence in non‐COVID‐19 patients (25 studies, 330 780 patients) was associated with a 26% reduction of pneumonia risk (odds ratio [OR]: 0.74, P < .001). Pneumonia‐related death cases in ACEI‐treated non‐COVID‐19 patients were reduced by 27% (OR: 0.73, P = .004). However, angiotensin II receptor blockers (ARB) treatment (10 studies, 275 621 non‐COVID‐19 patients) did not alter pneumonia risk in patients. Pneumonia‐related death cases in ARB‐treated non‐COVID‐19 patients was analysed only in 1 study and was significantly reduced (OR, 0.47; 95% confidence interval, 0.30 to 0.72). Results from 11 studies (8.4 million patients) showed that the risk of getting infected with the SARS‐CoV‐2 virus was reduced by 13% (OR: 0.87, P = .014) in patients treated with ACEI, whereas analysis from 10 studies (8.4 million patients) treated with ARBs showed no effect (OR, 0.92, P = .354). Results from 34 studies in 67 644 COVID‐19 patients showed that RAAS blockade reduces all‐cause mortality by 24% (OR = 0.76, P = .04).ConclusionACEIs reduce the risk of getting infected with the SARS‐CoV‐2 virus. Blocking the RAAS may decrease all‐cause mortality in COVID‐19 patients. ACEIs also reduce the risk of non‐COVID pneumonia. All‐cause mortality due to non‐COVID pneumonia is reduced by ACEI and potentially by ARBs.

Glycemic Control and Risk of Cellulitis.

We know that diabetes predisposes to common infections, such as cellulitis and pneumonia. However, the correlation between the level of glycemic control and the rate of infection is unknown. We examined the association between glycemic control in patients with diabetes and the incidence of infection in the entire population of patients with diabetes in a large HMO. During the study period, we first selected an HbA1c test for each patient and then searched for an infection diagnosis in the 60 days that followed the test. A multivariate logistic regression analysis was performed to determine the independent effect of HbA1c on the likelihood of being diagnosed with an infection. We were able to control for many confounders, such as other chronic illness, time since the diagnosis of diabetes, and use of steroids before the infection. We identified 407 cases of cellulitis. Multivariate logistic regressions for cellulitis showed a 1.4-fold increased risk among patients with HbA1c >7.5% (58 mmol/mol). Factors such as obesity, Parkinson's disease, peripheral vascular disease, and prior treatment with prednisone predisposed to cellulitis. There was an increase of 12% in the odds of cellulitis for every 1% (11 mmol/mol) elevation in HbA1c (odds ratio [OR] 1.12; CI 1.05-1.19). A similar analysis showed a trend toward an increased risk of pneumonia in patients with HbA1c >7.5% (58 mmol/mol) (OR 1.1; CI 0.9-1.4). Poor glycemic control was associated in this study with the development of cellulitis. The study also suggests that exposure to oral prednisolone increases the risk of cellulitis, pneumonia, and upper respiratory infection.

Risk of Pneumonia Associated with Inhaled Corticosteroid in Patients with Chronic Obstructive Pulmonary Disease: A Korean Population-Based Study.

IntroductionInhaled corticosteroids (ICSs) are recommended for patients with frequent exacerbation of chronic obstructive pulmonary disease (COPD). However, accumulating evidence has indicated the risk of pneumonia from the use of ICS. This study aimed to investigate the association between ICS and pneumonia in the real-world clinical setting.MethodsA retrospective cohort study was performed using nationwide population data from the Korea National Health Insurance Service. Subjects who had a new diagnosis of COPD and who received inhaled bronchodilators without a diagnosis of pneumonia before the initiation of bronchodilators were identified. Subjects were followed up until their first diagnosis of pneumonia. The risk of pneumonia in ICS users was compared to that in non-ICS users.ResultsA total of 87,594 subjects were identified and 1:1 matched to 22,161 ICS users and non-ICS users. More ICS users were diagnosed with pneumonia compared to non-ICS users (33.73% versus 24.51%, P<0.0001). The incidence rate per 100,000 person-years was 8904.98 for ICS users and 6206.79 for non-ICS users. The hazard ratio (HR) of pneumonia for ICS users was 1.62 (95% CI 1.54–1.70). The HR of subjects prescribed with the lowest ICS cumulative dose was 1.35 (1.27–1.43). The HR increased to 1.51 (1.42–1.60), 1.96 (1.85–2.09), and 2.03 (1.89–2.18) as the cumulative dose increased. Pneumonia was strongly associated with fluticasone propionate (1.79 (1.70–1.89)) and fluticasone furoate (1.80 (1.61–2.01)) use, compared to the use of other types of ICS.ConclusionICS increases the risk of pneumonia in patients with COPD. Hence, ICS should be carefully prescribed in patients with risk factors for pneumonia while considering the cumulative doses and subtypes of ICS.

Triple Versus Dual Combination Therapy in Chronic Obstructive Pulmonary Disease in Asian Countries: Analysis of the IMPACT Trial.

IntroductionIn the IMPACT trial, single-inhaler triple therapy fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) reduced moderate/severe exacerbation rates versus FF/VI or UMEC/VI dual therapy in patients with chronic obstructive pulmonary disease (COPD); however, pneumonia incidence was higher in FF-containing arms. As COPD is a growing problem in Asia, we compared the efficacy and safety of FF/UMEC/VI in Asia versus non-Asia regions.MethodsIMPACT was a double-blind, 52-week trial in symptomatic COPD patients with ≥ 1 moderate/severe exacerbation in the prior year. This pre-specified analysis evaluated the annual rate of moderate/severe exacerbations, change from baseline in trough forced expiratory volume in 1 s, and St George’s Respiratory Questionnaire total score, mortality, and safety (including pneumonia) in Asia versus non-Asia regions.ResultsThe intent-to-treat population comprised 10,355 patients (Asia n = 1644 [16%]). Rate ratios (95% confidence intervals) for moderate/severe exacerbations with FF/UMEC/VI were 0.89 (0.76–1.05) versus FF/VI and 0.86 (0.71–1.04) versus UMEC/VI in Asia, and 0.84 (0.79–0.90) and 0.74 (0.68–0.80) in non-Asia. Efficacy of FF/UMEC/VI on other endpoints was similar in both regions. There was an increased incidence of investigator-reported pneumonia in patients in Asia (FF/UMEC/VI: 13%; FF/VI: 14%; UMEC/VI: 6%) compared with non-Asia (FF/UMEC/VI: 6%; FF/VI: 5%; UMEC/VI: 4%). The increased risk of pneumonia in patients in Asia was most marked in patients with lower body mass index, lower lung function, and taking inhaled corticosteroids. In post hoc analysis of adjudicated on-treatment all-cause mortality, probabilities of death were numerically lower in both regions with FF/UMEC/VI (Asia: 1.16%; non-Asia: 1.35%) and FF/VI (Asia: 1.77%; non-Asia: 1.21%) versus UMEC/VI (Asia: 1.91%; non-Asia: 2.23%).ConclusionsFF/UMEC/VI provides similar benefits in COPD patients in Asia and non-Asia regions. Clinical benefits of treatment, including reduction in mortality risk, should be weighed against risk of pneumonia, taking account of all known risk factors.Trial RegistrationClinicalTrials.gov identification, NCT02164513.Electronic supplementary materialThe online version of this article (10.1007/s41030-020-00136-3) contains supplementary material, which is available to authorized users.

Simplified cough test can predict the risk for pneumonia in patients with acute stroke.

We investigated the association between the results of a simplified cough test and pneumonia onset in 226 patients with acute stroke admitted to Suiseikai Kajikawa Hospital from April to December, 2018. For the simplified cough test, performed on admission, patients orally inhaled a mist of 1% citric acid-physiological saline using a portable mesh nebulizer. When the first cough was evoked or if it remained absent for 30 seconds (indicating an abnormal result), the test was ended. Patients also completed the repetitive saliva swallowing test (RSST) and modified water swallowing test. We monitored patients for pneumonia signs for 30 days post-admission. Eighteen patients exhibited an abnormal simplified cough test result. On multivariate analysis, an abnormal RSST result was independently associated with an abnormal simplified cough test result. Seventeen patients developed pneumonia. The adjusted Cox proportional hazard model for pneumonia onset revealed that the simplified cough test had predictive power for pneumonia onset (hazard ratio, 10.52; 95% confidence interval, 3.72-29.72). The simplified cough test is a strong indicator for predicting the pneumonia development in patients with acute stroke; it should be added to existing bedside screening tests for predicting pneumonia risk, allowing appropriate and timely intervention.

Cardiothoracic Patients with Unilateral Vocal Fold Paralysis: Pneumonia Rates Following Injection Laryngoplasty.

Recurrent laryngeal nerve injury is a potential complication of cardiothoracic surgery and cause of unilateral vocal fold paralysis (UVFP). Injection laryngoplasty (IL) is an intervention offered to patients with UVFP to alleviate symptoms including dysphagia, dysphonia and weak cough. There is no definitive evidence that IL prevents pneumonia. In this study, we compare rates of pneumonia in patients with UVFP secondary to cardiothoracic surgery who did or did not undergo IL. A retrospective chart review identified patients diagnosed with UVFP by an otolaryngologist using flexible laryngoscopy following cardiothoracic surgery from January 1, 2008 to December 31, 2017. Each subject was grouped by IL status and assessed for subsequent pneumonia within 6 months of their diagnosis of UVFP. The association of IL with pneumonia was evaluated using Cox proportional hazards regression. Of 92 patients who met inclusion criteria, 35 (38%) underwent IL and 57 (62%) did not. Twenty patients developed pneumonia, four who had undergone IL and 16 who had not; 12 patients developed aspiration pneumonia including two having undergone IL and 10 who had not. Those who had IL were less likely to develop total pneumonia compared to those who had not (HR = 0.33, P = .045). The protective effect of IL was not as clearly sustained when measuring for aspiration pneumonia, specifically (HR = 0.34; P = .10). Injection laryngoplasty may reduce the risk of pneumonia in patients with UVFP secondary to cardiothoracic surgery; however, further research is needed to quantify the potential protective nature of IL in this patient population. 3 (A retrospective cohort study).