Hypocapnia and hypercapnia are predictors for ICU admission and mortality in hospitalized patients with community-acquired pneumonia

OBJECTIVE

The purpose of our study was to examine in patients hospitalized with community acquired pneumonia (CAP) the association between abnormal Pa CO 2 and ICU admission and 30-day mortality.

METHODS

A retrospective cohort study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of CAP. Arterial blood gas analyses were obtained with measurement of PaCO2 on admission. Multivariate analyses were performed using 30-day mortality and ICU admission as the dependent measures.

RESULTS

Data were abstracted on 453 subjects with a documented arterial blood gas analysis. One hundred eighty-nine patients (41%) had normal PaCO2 (35-45 mm Hg), 194 patients (42%) had aPa CO 2 , 35 mm Hg (hypocapnic), and 70 patients (15%) had a Pa CO 2 . 45 mm Hg (hypercapnic).In the multivariate analysis, after adjusting for severity of illness, hypocapnic patients had greater 30-day mortality (OR= 2.84; 95% CI, 1.28-6.30) and a higher need for ICU admission (OR= 2.88;95% CI, 1.68-4.95) compared with patients with normal PaCO2. In addition, hypercapnic patients had a greater 30-day mortality (OR= 3.38; 95% CI, 1.38-8.30) and a higher need for ICU admission(OR =5.35; 95% CI, 2.80-10.23). When patients with COPD were excluded from the analysis,the differences persisted between groups.

CONCLUSION

In hospitalized patients with CAP, both hypocapnia and hypercapnia were associated with an increased need for ICU admission and higher 30-day mortality. These findings persisted after excluding patients with CAP and with COPD. Therefore, PaCO2 should be considered for inclusion in future severity stratification criteria to appropriate identified patients who will require a higher level of care and are at risk for increased mortality.

Effects of inhaled corticosteroids on pneumonia severity and antimicrobial resistance

BACKGROUND

Limited information is available regarding the impact of prior use of inhaled corticosteroids (ICS) in patients subsequently developing community-acquired pneumonia (CAP). We assessed the effects of prior ICS use on severity of illness and microbiology in CAP hospitalized patients.

METHODS

A retrospective cohort study of subjects with CAP (by the International Classification of Diseases, 9th Revision, Clinical Modification) was conducted over a 4-year period at 2 tertiary teaching hospitals. Subjects were considered to be ICS users if they received ICS prior to admission. Primary outcomes were severity of illness and microbiology at admission.

RESULTS

Data were abstracted on 664 subjects: 89 prior ICS users (13.4%) and 575 non-users (86.6%). Prior ICS users had higher severity of illness at admission: mean ± SD Pneumonia Severity Index 100.8 ± 31.4 vs 68.8 ± 33.4, P = .001, and CURB-65 (confusion, urea nitrogen, respiratory rate, blood pressure, ≥ 65 years of age) score 1.56 ± 1.02 vs 1.19 ± 1.02, P = .002. Prior ICS use was independently associated with antimicrobial-resistant pathogens: 11.2% vs 5.9%, odds ratio 2.6, 95% CI 1.1-6.1, P = .04.

CONCLUSIONS

Prior ICS use was associated with higher severity of illness at admission and higher incidence of antimicrobial-resistant pathogens in CAP hospitalized patients.

Pneumonia: an arrhythmogenic disease?

BACKGROUND

Recent studies suggest that there is an increase in cardiovascular disease after pneumonia; however, there is little information on cardiac arrhythmias after pneumonia. The aims of this study were to assess the incidence of, and examine risk factors for, cardiac arrhythmias after hospitalization for pneumonia.

METHODS

We conducted a national cohort study using Department of Veterans Affairs administrative data including patients aged ≥65 years hospitalized with pneumonia in fiscal years 2002-2007, receiving antibiotics within 48 hours of admission, having no prior diagnosis of a cardiac arrhythmia, and having at least 1 year of Veterans Affairs care. We included only the first pneumonia-related hospitalization, and follow-up was for the 90 days after admission. Cardiac arrhythmias included atrial fibrillation, ventricular tachycardia/fibrillation, cardiac arrest, and symptomatic bradycardia. We used a multilevel regression model, adjusting for hospital of admission, to examine risk factors for cardiac arrhythmias.

RESULTS

We identified 32,689 patients who met the inclusion criteria. Of these, 3919 (12%) had a new diagnosis of cardiac arrhythmia within 90 days of admission. Variables significantly associated with increased risk of cardiac arrhythmia included increasing age, history of congestive heart failure, and a need for mechanical ventilation or vasopressors. Beta-blocker use was associated with a decreased incidence of events.

CONCLUSION

An important number of patients have new cardiac arrhythmia during and after hospitalization for pneumonia. Additional research is needed to determine whether use of cardioprotective medications will improve outcomes for patients hospitalized with pneumonia. At-risk patients hospitalized with pneumonia should be monitored for cardiac arrhythmias during the hospitalization.

THE PARADOXICAL EFFECT ON PNEUMONIA OF CHRONIC INHALED CORTICOSTEROIDS

Community-acquired pneumonia (CAP) is the leading infectious cause of death in developed countries. Several studies have shown that the risk of pneumonia is increased in patients with Chronic Obstructive Pulmonary Disease (COPD) who are receiving chronic inhaled corticosteroids (ICS). The impact of ICS On pneumonia prognosis is controversial. Recent studies have shown that COPD patients with prior ICS use have less mortality after developing CAP as compared with patients with COPD without prior ICS use. This review discusses the association of ICS and the risk of CAP and its association with clinical outcomes in patients with COPD and pneumonia.

Improving the 2007 Infectious Disease Society of America/American Thoracic Society severe community-acquired pneumonia criteria to predict intensive care unit admission

PURPOSE

To improve 2007 Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) severity criteria to predict intensive care unit (ICU) admission in patients hospitalized with pneumonia.

METHODS

A composite score that included the 2007 IDSA/ATS criteria for severe pneumonia and additional significant variables identified by recent publications was tested in patients hospitalized with community-acquired pneumonia.

RESULTS

Among 787 patients hospitalized with community-acquired pneumonia, 156 (19.8%) required admission to the ICU. We identified one major criterion (arterial pH <7.30), and 4 minor criteria (tachycardia >125 bpm, arterial pH 7.30-7.34, sodium <130 mEq/L and glucose >250 mg/dL) to be associated with ICU admission. Adding arterial pH <7.30 to the 2 2007 IDSA/ATS major criteria increased sensitivity from 61.5% to 71.8% and area under the curve (AUC) from 0.80 to 0.86. Adding in sequence the four minor criteria to the 2007 IDSA/ATS minor criteria, increased sensitivity from 41.7% to 53.8%, and AUC from 0.65 to 0.69. In the new composite score, combining 1 of 3 major criteria with 3 of 12 minor criteria showed a sensitivity of 92.9% and an AUC of 0.88.

CONCLUSION

The addition of arterial pH <7.30 to the 2007 IDSA/ATS major criteria improves sensitivity and AUC to identify patients who will require ICU care.

Population-based study of statins, angiotensin II receptor blockers, and angiotensin-converting enzyme inhibitors on pneumonia-related outcomes

BACKGROUND

Studies suggest that statins and angiotensin-converting enzyme (ACE) inhibitors might be beneficial for the treatment of infections. Our purpose was to examine the association of statin, ACE inhibitor, and angiotensin II receptor blocker (ARB) use with pneumonia-related outcomes.

METHODS

We conducted a retrospective cohort study using Department of Veterans Affairs data of patients aged ≥ 65 years hospitalized with pneumonia. We performed propensity-score matching for 3 medication classes simultaneously.

RESULTS

Of 50119 potentially eligible patients, we matched 11498 cases with 11498 controls. Mortality at 30 days was 13%; 34% used statins, 30% ACE inhibitors, and 4% ARBs. In adjusted models, prior statin use was associated with decreased mortality (odds ratio [OR], 0.74; 95% confidence interval [CI], .68-.82) and mechanical ventilation (OR, 0.81; 95% CI, .70-.94), and inpatient use with decreased mortality (OR, 0.68; 95% CI, .59-.78) and mechanical ventilation (OR, 0.68; 95% CI, .60-.90). Prior (OR, 0.88; 95% CI, .80-.97) and inpatient (OR, 0.58; 95% CI, .48-.69) ACE inhibitor use was associated with decreased mortality. Prior (OR, 0.73; 95% CI, .58-.92) and inpatient ARB use (OR, 0.47; 95% CI, .30-.72) was only associated with decreased mortality. Use of all 3 medications was associated with reduced length of stay.

CONCLUSIONS

Statins, and to a lesser extent ACE inhibitors and ARBs, are associated with improved pneumonia-related outcomes. Prospective cohort and randomized controlled trials are needed to examine potential mechanisms of action and whether acute initiation at the time of presentation with these infections is beneficial.

Impact of prior systemic corticosteroid use in patients admitted with community-acquired pneumonia

BACKGROUND AND OBJECTIVE

Limited information is available regarding the impact of prior outpatient use of systemic corticosteroids (SCS) in patients subsequently developing community-acquired pneumonia (CAP). We investigate the effects of prior SCS on severity of illness, microbiology and clinical outcomes for patients hospitalized with CAP.

METHODS

A retrospective cohort study of subjects with CAP (according to International Classification of Diseases, 9th edition codes) was conducted over a 3-year period at two tertiary teaching hospitals. Subjects were considered to be SCS users if they received oral corticosteroids prior to admission. Primary outcomes were severity of illness, microbiology and 30-day mortality.

RESULTS

Data were abstracted on 698 patients [prior SCS users, 75 (10.7%) versus prior non-SCS users 623 (89.3%)]. Prior SCS users were more likely to have chronic obstructive pulmonary disease. No differences were found in severity of disease at admission, microbiological etiology including opportunistic and drug-resistant pathogens and clinical outcomes, including 30-day mortality, intensive care unit admission, length of hospital stay, need for mechanical ventilation and need for vasopressors.

CONCLUSION

Prior SCS use is not associated with increased 30-day mortality for patients hospitalized with CAP. In addition, no differences were found in either the severity of the disease at the time of presentation or in the presence of the resistant or opportunistic pathogens among groups.

Comparison of two guideline-concordant antimicrobial combinations in elderly patients hospitalized with severe community-acquired pneumonia

OBJECTIVE

Two of the guideline-concordant therapies for severe community-acquired pneumonia are either a beta-lactam and fluoroquinolone or beta-lactam and macrolide. However it is unclear if there is a benefit for one vs. the other for elderly patients with severe community-acquired pneumonia.

DESIGN

A retrospective population-based cohort study of patients with community-acquired pneumonia.

SETTING

Patients admitted to an intensive care unit of any Department of Veterans Affairs hospital during 5-yr period.

PATIENTS

We included only those patients>65 yrs of age admitted to the intensive care unit with community-acquired pneumonia who received either beta-lactam+fluoroquinolone or beta-lactam+macrolide antibiotic therapy for pneumonia.

INTERVENTION

Not applicable.

MEASUREMENTS

We used multilevel regression models to examine the effect of beta-lactam+fluoroquinolone vs. beta-lactam+macrolide on each of the outcomes after adjusting for potential confounders using propensity scores.

MAIN RESULTS

The cohort consisted of 1,989 patients: 98.5% male and a mean age of 74 yrs. For treatment, 44% of subjects received beta-lactam+fluoroquinolone and 56% received beta-lactam+macrolide. Unadjusted 30-day mortality was 27% for beta-lactam+fluoroquinolone and 24% for beta-lactam+macrolide (p=.11). In the multilevel models, the use of beta-lactam+fluoroquinolone was not significantly associated with 30-day mortality (odds ratio 1.05, 95% confidence interval 0.85-1.30). However, the use of beta-lactam+fluoroquinolone was significantly associated with increased mean length of stay (incidence rate ratio 1.30, 95% confidence interval 1.27-1.33).

CONCLUSIONS

We found no significant difference for 30-day mortality but did demonstrate an association with increase in length of stay associated with the use of beta-lactam + fluoroquinolone. Randomized controlled trials are needed to determine the most effective antibiotics regimes for patients with severe pneumonia.

The need to further understand who gets hospitalized for a COPD exacerbation

Not available.

Outcome of tracheotomized patients following reintubation

OBJECTIVE

To evaluate the outcome of tracheotomized patients after reintubation.

METHOD

Secondary analysis from a prospective, multicenter and observational study including 36 Intensive Care Units (ICUs) from 8 countries.

PATIENTS

A total of 180 patients under mechanical ventilation for more than 48 hours, extubated and reintubated within 48 hours.

INTERVENTIONS

None.

OUTCOMES

ICU mortality, length of ICU stay, organ failure.

RESULTS

Fifty-two patients (29%) underwent tracheotomy after reintubation. The median time from reintubation to tracheotomy was 2.5 days (interquartile range (IQR) 1-8 days). The length of ICU stay was significantly longer in the tracheotomy group compared with the group without tracheotomy (median time 25 days, IQR 17-43 versus 16.5 days (IQR 11-25); p<0.001). ICU mortality in the tracheotomy group was not significantly different (31% versus 27%; p 0.57).

CONCLUSIONS

In our cohort of reintubated patients, tracheotomy is a common procedure in the ICU. Patients with tracheotomy had an outcome similar to those without tracheotomy.

Evaluation of the IDSA/ATS minor criteria for severe community-acquired pneumonia

INTRODUCTION

Our aim was to evaluate the minor criteria recommended by the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) as predictors of 30-day mortality, the need for invasive mechanical ventilation, and/or the need for vasopressor support as markers of severity in patients hospitalized with community-acquired pneumonia (CAP).

METHODS

Patients admitted to 2 academic teaching hospitals over a 4-year period (January 1, 1999 to December 1, 2002) were identified as having CAP. We used modified minor criteria established by the 2007 IDSA/ATS guidelines. The primary outcome measure was 30-day mortality, and the secondary outcome measures were need for invasive mechanical ventilation and/or need for vasopressor support.

RESULTS

About half of the patients in the cohort (n = 352/787 [46%]) had ≥ 1 minor criterion, but only 128 (16.3%) had ≥ 3 minor criteria present at hospital admission. In the multivariable analysis, hypoxemia, multilobar infiltrates, and leukopenia were associated with 30-day mortality (P < 0.05). In addition, hypoxemia and confusion/disorientation were associated with the need for invasive mechanical ventilation and/or vasopressor support (P < 0.05). The presence of ≥ 3 minor criteria was associated with 30-day mortality (odds ratio, 4.82), and the need for invasive mechanical ventilation and/or vasopressor support (odds ratio, 2.59).

CONCLUSION

Our results show that hypoxemia, multilobar infiltrates, and leukopenia were the most predictive minor criteria for 30-day mortality. In contrast, hypoxemia and confusion/disorientation were the 2 individual minor severe criteria that were more likely to require invasive mechanical ventilation and/or vasopressor support. At least 3 2007 IDSA/ATS minor severe criteria were associated with 30-day mortality and need for invasive mechanical ventilation and/or vasopressor support.

Clinical evaluation of the role of ceftaroline in the management of community acquired bacterial pneumonia

Ceftaroline fosamil (ceftaroline) was recently approved for the treatment of community- acquired pneumonia (CAP) and complicated skin infections. This newly developed cephalosporin possesses a broad spectrum of activity against gram-positive and gram-negative bacteria. Most importantly, ceftaroline demonstrates potent in vitro antimicrobial activity against multi-drug resistant Streptococcus pneumoniae and methicillin-resistant strains of Staphylococcus aureus. In two Phase III, double-blinded, randomized, prospective trials (FOCUS 1 and FOCUS 2), ceftaroline was shown to be non-inferior to ceftriaxone for the treatment of CAP in hospitalized patients. Ceftaroline exhibits low resistance rates and a safety profile similar to that of other cephalosporins. In this review, we will evaluate the pharmacological characteristics, safety, antimicrobial properties, and efficacy of ceftaroline and its applications in the treatment of CAP.

Efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support

BACKGROUND

Randomized trials assessing the effect of systemic corticosteroids on chronic obstructive pulmonary disease (COPD) exacerbations excluded patients who were mechanically ventilated or admitted to the intensive care unit (ICU). Critically ill patients constitute a population of persons who are prone to develop complications that are potentially associated with the use of corticosteroids (eg, infections, hyperglycemia, ICU-acquired paresis) that could prolong the duration of mechanical ventilation and even increase mortality.

METHODS

A double-blind placebo-controlled trial was conducted to evaluate the efficacy and safety of systemic corticosteroid treatment in patients with an exacerbation of COPD who were receiving ventilatory support (invasive or noninvasive mechanical ventilation). A total of 354 adult patients who were admitted to the ICUs of 8 hospitals in 4 countries from July 2005 through July 2009 were screened, and 83 were randomized to receive intravenous methylprednisolone (0.5 mg/kg every 6 hours for 72 hours, 0.5 mg/kg every 12 hours on days 4 through 6, and 0.5 mg/kg/d on days 7 through 10) or placebo. The main outcome measures were duration of mechanical ventilation, length of ICU stay, and need for intubation in patients treated with noninvasive mechanical ventilation.

RESULTS

There were no significant differences between the groups in demographics, severity of illness, reasons for COPD exacerbation, gas exchange variables, and corticosteroid rescue treatment. Corticosteroid treatment was associated with a significant reduction in the median duration of mechanical ventilation (3 days vs 4 days; P = .04), a trend toward a shorter median length of ICU stay (6 days vs 7 days; P = .09), and significant reduction in the rate of NIV failure (0% vs 37%; P = .04).

CONCLUSION

Systemic corticosteroid therapy in patients with COPD exacerbations requiring mechanical ventilation is associated with a significant increase in the success of noninvasive mechanical ventilation and a reduction in the duration of mechanical ventilation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01281748.

A new perspective on optimal care for patients with COPD

Worldwide, clinicians face the task of providing millions of patients with the best possible treatment and management of COPD. Currently, management primarily involves short-term 'here-and-now' goals, targeting immediate patient benefit. However, although there is considerable knowledge available to assist clinicians in minimising the current impact of COPD on patients, relatively little is known about which dominant factors predict future risks. These predictors may vary for different outcomes, such as exacerbations, mortality, co-morbidities, and the long-term consequences of COPD. We propose a new paradigm to achieve 'optimal COPD care' based on the concept that here-and-now goals should be integrated with goals to improve long-term outcomes and reduce future risks. Whilst knowledge on risk factors for poorer outcomes in COPD is growing and some data exist on positive effects of pharmacological interventions, information on defining the benefits of all commonly used interventions for reducing the risk of various future disease outcomes is still scarce. Greater insight is needed into the relationships between the two pillars of optimal COPD care: 'best current control' and 'future risk reduction'. This broader approach to disease management should result in improved care for every COPD patient now and into the future.

Moxifloxacin versus amoxicillin/clavulanic acid in outpatient acute exacerbations of COPD: MAESTRAL results

Bacterial infections causing acute exacerbations of chronic obstructive pulmonary disease (AECOPD) frequently require antibacterial treatment. More evidence is needed to guide antibiotic choice.

The Moxifloxacin in Acute Exacerbations of Chronic Bronchitis TriaL (MAESTRAL) was a multiregional, randomised, double-blind non-inferiority outpatient study. Patients were aged ≥60 yrs, with an Anthonisen type I exacerbation, a forced expiratory volume in 1 s <60% predicted and two or more exacerbations in the last year. Following stratification by steroid use patients received moxifloxacin 400 mg p.o. q.d. (5 days) or amoxicillin/clavulanic acid 875/125 mg p.o. b.i.d. (7 days). The primary end-point was clinical failure 8 weeks post-therapy in the per protocol population.

Moxifloxacin was noninferior to amoxicillin/clavulanic acid at the primary end-point (111 (20.6%) out of 538, versus 114 (22.0%) out of 518, respectively; 95% CI -5.89–3.83%). In patients with confirmed bacterial AECOPD, moxifloxacin led to significantly lower clinical failure rates than amoxicillin/clavulanic acid (in the intent-to-treat with pathogens, 62 (19.0%) out of 327 versus 85 (25.4%) out of 335, respectively; p=0.016). Confirmed bacterial eradication at end of therapy was associated with higher clinical cure rates at 8 weeks post-therapy overall (p=0.0014) and for moxifloxacin (p=0.003). Patients treated with oral corticosteroids had more severe disease and higher failure rates.

The MAESTRAL study showed that moxifloxacin was as effective as amoxicillin/clavulanic acid in the treatment of outpatients with AECOPD. Both therapies were well tolerated.