Prognostic value of serum albumin levels in hospitalized adults with community-acquired pneumonia

Serum Albumin Trend Is a Predictor of Mortality in ICU Patients With Sepsis

INTRODUCTION

Patients admitted to the hospital with sepsis are 8 times more likely to die than patients with other diagnoses. There is no diagnostic test that clearly identifies the presence of the dysregulated host response that is central to sepsis. Researchers have identified serum albumin as a possible predictor of mortality in a number of critically ill patient populations. However, these studies primarily focus on the levels on admission, neglecting the clinically significant decrease that occurs subsequently. The purpose of this study was to examine the relationship between the trend of serum albumin over time and mortality in adults admitted to the intensive care unit (ICU) with sepsis.

METHODS

This retrospective, correlational study used existing medical record data. All patients admitted to the ICU at a Midwestern regional medical center with a primary sepsis diagnosis were included in the initial sample. Logistic regression analysis was used to assess the ability of serum albumin to predict mortality.

RESULTS

Serum albumin trend, admission serum albumin level, and lowest serum albumin level were significant unique predictors of mortality. The probability of survival decreases by 70.6% when there is a strong negative trend in serum albumin level, by 63.4% when admission serum albumin is ≤2.45 g/dl, and by 76.4% when the lowest serum albumin is ≤1.45 g/dl.

CONCLUSION

Clinicians are encouraged to measure serum albumin levels in patients with sepsis. Low serum albumin levels and a strong negative trend in serial measurements should instigate aggressive monitoring and treatment in this population.

Procalcitonin is not an independent predictor of 30-day mortality, albeit predicts pneumonia severity in patients with pneumonia acquired outside the hospital

Background

Procalcitonin (PCT) is a useful marker for pneumonia. However, its clinical usefulness in elderly patients has not been studied extensively. This study aimed to assess the relationship between PCT and prognosis and pneumonia severity in elderly patients with pneumonia acquired outside the hospital.

Methods

Data considered relevant to pneumonia severity and prognosis were retrospectively obtained from clinical charts of all patients with pneumonia who were admitted to our hospital from 2010 to 2017. The primary outcome was 30-day mortality in elderly patients (aged ≥75 years), and the relationship between PCT levels and pneumonia severity, as determined by the pneumonia severity index (PSI) was also examined.

Results

Data were collected from 667 patients, of which 436 were elderly patients. Multivariate and receiver operating characteristic curve analysis revealed that albumin, body mass index, and PSI class rather than PCT are important factors related to 30-day mortality in elderly patients. PCT was also not an independent prognostic factor in younger patients. PCT levels significantly differed by pneumonia severity (mild, moderate, and severe) in both younger (p < 0.001) and elderly (p < 0.0001) patients, with levels increasing as severity increased. In contrast, C-reactive protein (CRP) levels and white blood cell counts did not significantly differ by pneumonia severity in younger and elderly patients. A subgroup analysis focused on Streptococcus pneumoniae pneumonia revealed that PCT levels differed by severity in elderly patients (p = 0.03), with levels increasing as severity increased.

Conclusion

PCT was not an independent predictor of 30-day mortality in both of elderly and younger patients. PCT levels, but not CRP levels, significantly increased with increasing pneumonia severity in younger and elderly patients, although the degree of increase tended to be lower in elderly patients compared to younger patients for the same severity. PCT levels also significantly increased with increasing pneumonia severity in elderly patients with Streptococcus pneumoniae pneumonia.

Utility of the Quick Sequential Organ Failure Assessment in Japanese patients with nursing- and healthcare-associated pneumonia

AIM

To clarify the utility of sepsis evaluation using the Quick Sequential Organ Failure Assessment (qSOFA) tool in addition to the Pneumonia Severity Index (PSI); age, dehydration, respiration, orientation and blood pressure (A-DROP) index; and immunodeficiency, respiration, orientation, age and dehydration (I-ROAD) scoring systems, and risk factor evaluation of potentially drug-resistant (PDR) pathogens are suggested in the 2017 guidelines for pneumonia of the Japanese Respiratory Society in nursing- and healthcare-associated pneumonia patients.

METHODS

We included 289 hospitalized nursing- and healthcare-associated pneumonia patients between April 2016 and March 2017, and investigated the ability of PSI, A-DROP, I-ROAD and qSOFA to predict pneumonia-related mortality. We also evaluated the associations among the risk factors for PDR pathogens, the detection ratio of PDR pathogens and pneumonia-related mortality.

RESULTS

The mortality rate of pneumonia during hospitalization was 6.9% (20/289). The area under the curve for pneumonia-related mortality predicted using PSI, A-DROP, I-ROAD and qSOFA was 0.697 (95% confidence interval [CI] 0.59-0.80), 0.63 (95% CI 0.51-0.76), 0.61 (95% CI 0.52-0.70) and 0.701 (95% CI 0.59-0.81), respectively. In addition, higher areas under the curve were observed for pneumonia-related mortality predicted according to a combination of PSI and hypoalbuminemia (<2.5 g/dL) (0.75, 95% CI 0.64-0.86), and qSOFA and hypoalbuminemia (0.74, 95% CI 0.62-0.86) than for PSI and qSOFA alone. No significant associations were observed among the risk factors for PDR pathogens, the detection ratios of PDR pathogens and pneumonia-related mortality.

CONCLUSIONS

qSOFA and the combination of qSOFA and hypoalbuminemia might be simple and useful evaluation tools for predicting pneumonia-related mortality in nursing- and healthcare-associated pneumonia patients. Geriatr Gerontol Int 2019; 19: 177-183.

Bloodstream infection in patients with head and neck cancer: a major challenge in the cetuximab era

PURPOSE

To assess the impact of bloodstream infection (BSI) in patients with head and neck cancer (HNC) in the cetuximab era.

METHODS

We prospectively analysed the epidemiology, microbiology and outcomes of 51 BSI episodes occurring in 48 patients with HNC (2006-2017). We performed a retrospective matched-cohort study (1:2) to determine the risk factors for BSI. Finally, we compared patients who died with those who survived to identify risk factors for mortality.

RESULTS

The most frequent HNC localization was the oropharynx (43%), and pneumonia was the most frequent source (25%). Gram-positive BSI occurred in 55% cases, mainly due to Streptococcus pneumoniae (21%), and among Gram-negatives, Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the most frequent. Hypoalbuminemia (OR 8.4; 95% CI, 3.5-19.9), previous chemotherapy (OR, 3.2; 95% CI, 1.3-7.4) and cetuximab therapy (OR, 2.8; 95% CI, 1.6-6.7) were significant risk factors for BSI. Patients with BSI had a higher overall case-fatality rate than patients without BSI (OR, 4.4; 95% CI, 1.7-11.8). Hypoalbuminemia was an independent risk factor for the early (7 day) and overall (30 day) case-fatalities, with ORs of 0.8 (95% CI, 0.6-0.9) and 0.8 (95% CI, 0.7-0.97), respectively. The presence of comorbidities (OR, 7; 95% CI, 1.4-34) was also an independent risk factor for overall case-fatality.

CONCLUSIONS

BSI causes high mortality in patients with HNC and is most often secondary to pneumonia. It occurs mainly among patients with hypoalbuminemia who receive treatment with cetuximab or chemotherapy. The development of BSI in patients with HNC impairs their outcome, especially in the presence of hypoalbuminemia and comorbidities.

The Impact of Nutritional Status and Complete Blood Count Parameters on Clinical Outcome in Geriatric Critically Ill Patients

Background

The geriatric population in intensive care units (ICUs) has recently increased. The aim of this study was to analyse the impact of initial complete blood count (CBC)-related parameters and nutritional status on morbidity and mortality in geriatric ICU patients.

Methods

A retrospective analysis was made of geriatric patients admitted to our tertiary adult ICU for 1 year. Patients with a length of stay (LOS) of < 48 h, with hematological malignancy or age < 65 years age were excluded from the study. Initial albumin level was considered to reflect nutritional status. The prevelance and risk factors of mortality and microbiologically documented infection (MDI) were analysed.

Results

The study included a total of 243 patients with a mean age of 78.96 ± 6.62 years. The overall mortality rate was 40.7%. The most common cause for admission was acute respiratory failure and sepsis (17.2% vs. 16.8%). The most common MDI sources were lower respiratory tract, bloodstream, and urinary tract infections. Patients with thrombocytopenia on admission had a higher mortality rate than patients with normal platelet count (P = 0.019). The initial albumin level of non-survivors was significantly lower than that of survivors (P = 0.001). There was a significant negative correlation between albumin level and LOS (r = -0.157; P = 0.000). Patients with hypoalbuminemia (albumin < 3.2 g/dL) at the time of diagnosis had higher mortality, LOS and MDI rates than those with normal albumin levels (P < 0.05). There was no significant relationship between any other CBC-related parameter and infection and mortality (P > 0.05).

Conclusions

Thrombocytopenia and hypoalbuminemia may be considered as major risk factors for morbidity and mortality in critically ill elderly patients.

Relationship between low-density lipoprotein cholesterol and severe acute pancreatitis ("the lipid paradox")

BACKGROUND AND AIM

The aim of this study was to investigate the association between low-density lipoprotein cholesterol (LDL-C) and the development of severe acute pancreatitis (SAP).

PATIENTS AND METHODS

A total of 674 patients with acute pancreatitis were enrolled. Non-linearity in the relationship between LDL-C and SAP was assessed by restricted cubic spline analysis. Univariable and multivariable regression analyses were used to identify independent risk factors of SAP.

RESULTS

The restricted cubic spline analysis suggested a nonlinear association between high-density lipoprotein cholesterol (HDL-C), LDL-C and triglyceride levels and incidence of SAP. The incidence of SAP in patients with low LDL-C (<90 mg/dL), moderate LDL-C (90-150 mg/dL) and high LDL-C (>150 mg/dL) levels was 15.1%, 3.7% and 9.8%, respectively. Multivariable analysis confirmed that low LDL-C levels (odds ratio [OR] 3.05; 95% confidence interval [CI] 1.35-6.90), high LDL-C levels (OR 4.42; 95% CI 1.41-13.87) and low HDL-C levels (OR 6.90; 95% CI 2.61-18.23) but not high triglyceride levels (OR 1.05; 95% CI 0.40-2.72) were associated with the development of SAP.

CONCLUSION

Both low LDL-C (<90 mg/dL) and high LDL-C (>150 mg/dL) levels within 24 hours from admission are independently associated with an increased risk of SAP.

Bacterial Pneumonia in Older Adults

The incidence of pneumonia increases with age, and is particularly high in patients who reside in long-term care facilities (LTCFs). Mortality rates for pneumonia in older adults are high and have not decreased in the last decade. Atypical symptoms and exacerbation of underlying illnesses should trigger clinical suspicion of pneumonia. Risk factors for multidrug-resistant organisms are more common in older adults, particularly among LTCF residents, and should be considered when making empiric treatment decisions. Monitoring of clinical stability and underlying comorbid conditions, potential drug-drug interactions, and drug-related adverse events are important factors in managing elderly patients with pneumonia.

Low serum albumin predicts early mortality in patients with severe hypoxic hepatitis

AIM

To evaluate the incidence, etiology, and predictors of mortality of severe hypoxic hepatitis.

METHODS

We used computerized patient records to identify consecutive cases of severe hypoxic hepatitis admitted to a tertiary hospital in Singapore over a one-year period. We defined severe hypoxic hepatitis as elevation of serum transaminases more than 100 times upper limit of normal in the clinical setting of cardiac, circulatory or respiratory failure after exclusion of other causes of hepatitis. We used multivariable regression analysis to determine predictors for mortality.

RESULTS

We identified 75 cases of severe hypoxic hepatitis out of 71380 hospital admissions over one year, providing an incidence of 1.05 cases per 1000 admissions. Median age was 65 years (range 19-88); 57.3% males. The most common etiologies of severe hypoxic hepatitis were acute myocardial infarction and sepsis. Fifty-three patients (71%) died during the hospitalization. The sole independent predictive factor for mortality was serum albumin measured at the onset of severe hypoxic hepatitis. Patients with low serum albumin of less than 28 g/L have more than five-fold increase risk of death (OR = 5.39, 95%CI: 1.85-15.71).

CONCLUSION

Severe hypoxic hepatitis is uncommon but has a high mortality rate. Patients with low serum albumin are at highest risk of death.

Diagnostic performance of initial serum albumin level for predicting in-hospital mortality among aspiration pneumonia patients

PURPOSE

The predictive value of serum albumin in adult aspiration pneumonia patients remains unknown.

METHODS

Using data collected during a 3-year retrospective cohort of hospitalized adult patients with aspiration pneumonia, we evaluated the predictive value of serum albumin level at ED presentation for in-hospital mortality.

RESULTS

248 Patients were enrolled; of these, 51 cases died (20.6%). The mean serum albumin level was 3.4±0.7g/dL and serum albumin levels were significantly lower in the non-survivor group than in the survivor group (3.0±0.6g/dL vs. 3.5±0.6g/dL). In the multivariable logistic regression model, albumin was associated with in-hospital mortality significantly (adjusted odds ratio 0.30, 95% confidential interval (CI) 0.16-0.57). The area under the receiver operating characteristics (AUROC) for in-hospital survival was 0.72 (95% CI 0.64-0.80). The Youden index was 3.2g/dL and corresponding sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratio were 68.6%, 66.5%, 34.7%, 89.1%, 2.05 and 0.47, respectively. High sensitivity (98.0%) was shown at albumin level of 4.0g/dL and high specificity (94.9%) was shown at level of 2.5g/dL.

CONCLUSION

Initial serum albumin levels were independently associated with in-hospital mortality among adult patients hospitalized with aspiration pneumonia and demonstrated fair discriminative performance in the prediction of in-hospital mortality.

Prognostic factors in hospitalized community-acquired pneumonia: a retrospective study of a prospective observational cohort

Background

To date, only few studies have examined the prognostic factors of community-acquired pneumonia (CAP) defined according to the latest criteria, which excludes healthcare-associated pneumonia (HCAP). Therefore, we aimed to investigate the factors that affect prognosis, and evaluate the usefulness of existing pneumonia severity scores for predicting the prognosis of CAP.

Methods

We retrospectively analyzed patients with CAP, excluding HCAP, who were enrolled prospectively between April 2007 and February 2016. Four patients who used macrolides other than azithromycin (AZM) were excluded. We used age, sex, comorbidities, laboratory findings and antimicrobial therapy as prognostic variables. The primary outcome was 30-day mortality and secondary outcome was ICU admission. We also performed receiver operating characteristic curve analysis of Pneumonia Severity Index (PSI), Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) severe criteria, CURB-65 and A-DROP pneumonia severity scores.

Results

Among 1834 CAP patients, mean age was 73.5 ± 14.3 years; 1281 (69.8%) were men; and 30-day mortality was 6.7% (122/1834). In total, 1830 patients were analyzed. Multivariate analysis identified age [Odds Ratio (OR): 1.04, 95% Confidence Interval (CI): 1.02–1.07], chronic obstructive pulmonary disease (COPD) [OR: 1.77, 95% CI: 1.13–2.76], malignancy (OR: 2.25, 95% CI: 1.25–4.06), body temperature (OR: 0.81, 95% CI: 0.67–0.99), respiratory rate (OR: 1.04, 95% CI: 1.01–1.07), PaO₂/FiO₂ ≤ 250 (OR: 3.15, 95% CI: 1.93–5.14), Alb (OR: 0.27, 95% CI: 0.19–0.39), BUN (OR: 1.01, 95% CI: 1.00–1.02), and mechanical ventilation (OR: 2.99, 95% CI: 1.75–5.12) as prognostic factors. AZM and β-lactam combination therapy significantly reduced 30-day mortality (OR: 0.50, 95% CI: 0.26–0.97). Areas under the curve of PSI, IDSA/ATS severe criteria, CURB-65 and A-DROP were 0.759, 0.746, 0.754 and 0.764, respectively.

Conclusions

Increasing age, presence of COPD and malignancy as comorbidities, hypothermia, tachypnea, PaO₂/FiO₂ ratio ≤250 mmHg, low Alb level, high BUN level and mechanical ventilatory support predict a worse prognosis; AZM combination therapy should be considered for CAP, excluding HCAP. All four pneumonia severity scores are useful for assessing the severity of CAP defined by the latest criteria.

Trial registration

UMIN-CTR UMIN000004353. Registered 7 October 2010. Retrospectively registered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-017-0424-4) contains supplementary material, which is available to authorized users.

Percutaneous endoscopic gastrostomy for aspiration pneumonia: A 10-year single-center experience

BACKGROUND

The significance of percutaneous endoscopic gastrostomy (PEG) in patients with aspiration pneumonia is unknown. The purpose of this study was to evaluate the clinical characteristics and outcomes of aspiration pneumonia patients who underwent PEG.

METHODS

A retrospective cohort study of consecutive patients hospitalized with pneumonia who underwent PEG from 2005 to 2014.

RESULTS

Of 2281 cases of pneumonia, 92 patients with aspiration pneumonia underwent PEG during their hospital stay. The rate of PEG insertion significantly decreased after 2011, when Japanese therapeutic guidelines for pneumonia in the elderly were published (5.9% vs. 1.6% before and after guideline publication, respectively; p<0.01). The study population was male dominant (63%), with a mean age of 80.7 years. They had several risk factors for aspiration pneumonia, such as dementia (63.0%), cerebrovascular disorders (37.0%), and neurologic diseases (28.3%). Survival after PEG was 88.0% at day 30, 84.3% at 3 months, 73.8% at 6 months, and 61.1% at 1 year with a median survival of 751 days. Pneumonia was the most common cause of death during the follow-up period (22 of 51 patients, 43.1%). Cox proportional hazard model showed that independent predictors of mortality were older age, male gender, comorbidity of heart failure, and lower serum albumin values before PEG.

CONCLUSIONS

The rate of PEG placement is decreasing after the Japanese guidelines were published in 2011. While the overall median survival was approximately 2 years, the most common cause of death was pneumonia and mortality was associated with some significant factors.

Serum Albumin Is Independently Associated with Persistent Organ Failure in Acute Pancreatitis

BACKGROUND AND AIMS

To investigate the association between serum albumin levels within 24 hrs of patient admission and the development of persistent organ failure in acute pancreatitis.

METHODS

A total of 700 patients with acute pancreatitis were enrolled. Multivariate logistic regression and subgroup analysis determined whether decreased albumin was independently associated with persistent organ failure and mortality. The diagnostic performance of serum albumin was evaluated by the area under Receiver Operating Characteristic (ROC) curves.

RESULTS

As levels of serum albumin decrease, the risk of persistent organ failure significantly increases (P_trend < 0.001). The incidence of organ failure was 3.5%, 10.6%, and 41.6% in patients with normal albumin and mild and severe hypoalbuminaemia, respectively. Decreased albumin levels were also proportionally associated with prolonged hospital stay (P_trend < 0.001) and the risk of death (P_trend < 0.001). Multivariate analysis suggested that biliary etiology, chronic concomitant diseases, hematocrit, blood urea nitrogen, and the serum albumin level were independently associated with persistent organ failure. Blood urea nitrogen and the serum albumin level were also independently associated with mortality. The area under ROC curves of albumin for predicting organ failure and mortality were 0.78 and 0.87, respectively.

CONCLUSION

A low serum albumin is independently associated with an increased risk of developing of persistent organ failure and death in acute pancreatitis. It may also be useful for the prediction of the severity of acute pancreatitis.

Tools for outcome prediction in patients with community acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is one of the most common causes of mortality world-wide. The mortality rate of patients with CAP is influenced by the severity of the disease, treatment failure and the requirement for hospitalization and/or intensive care unit (ICU) management, all of which may be predicted by biomarkers and clinical scoring systems. Areas covered: We review the recent literature examining the efficacy of established and newly-developed clinical scores, biological and inflammatory markers such as C-Reactive protein (CRP), procalcitonin (PCT) and Interleukin-6 (IL-6), whether used alone or in conjunction with clinical severity scores to assess the severity of CAP, predict treatment failure, guide acute in-hospital or ICU admission and predict mortality. Expert commentary: The early prediction of treatment failure using clinical scores and biomarkers plays a developing role in improving survival of patients with CAP by identifying high-risk patients requiring hospitalization or ICU admission; and may enable more efficient allocation of resources. However, it is likely that combinations of scoring systems and biomarkers will be of greater use than individual markers. Further larger studies are needed to corroborate the additive value of these markers to clinical prediction scores to provide a safer and more effective assessment tool for clinicians.

Pulmonary Fungal Diseases in Immunocompetent Hosts: A Single-Center Retrospective Analysis of 35 Subjects

BACKGROUND

Pulmonary fungal disease is an emerging issue in immunocompetent patients, for whom the characteristics are only partially understood.

METHODS

We conducted a single-center retrospective study of histologically verified pulmonary fungal disease in Eastern China from 2006 to 2014 to understand the demographics, clinical manifestations, therapeutic approaches, and factors associated with prognosis in this population. All cases were diagnosed according to the 2008 European Organization for the Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infection Diseases Mycoses Study Group definition criteria.

RESULTS

A total of 112 cases of pulmonary fungal diseases were enrolled (35 proven, 16 probable, 61 possible), and we analyzed the 35 patients with histologically proven pulmonary fungal diseases in this study. The main fungal species identified were Aspergillus (51.4 %), Cryptococcus (22.9 %), and Mucor (2.4 %). Treatment consisted of antifungal therapeutic agents (54.3 %), surgery and postsurgical agents (25.7 %), or surgery alone (14.3 %). The overall crude mortality rate was 14.3 %, and the mortality due to pulmonary fungal infections was 2.9 %. Significant predictors of mortality by univariate analysis were hypoalbuminemia (P = 0.005), cancer (P = 0.008), and positive culture (P = 0.044). Additionally, hypoalbuminemia was the only risk factor for mortality by multivariate analysis (RR = 7.56, 95 % CI 1.38-41.46).

CONCLUSION

Pulmonary fungal disease in immunocompetent patients, with Aspergillus as the most common identified species, had a prognosis that was influenced by the level of serum albumin.

Expanded CURB-65: a new score system predicts severity of community-acquired pneumonia with superior efficiency

Aim of this study was to develop a new simpler and more effective severity score for community-acquired pneumonia (CAP) patients. A total of 1640 consecutive hospitalized CAP patients in Second Affiliated Hospital of Zhejiang University were included. The effectiveness of different pneumonia severity scores to predict mortality was compared, and the performance of the new score was validated on an external cohort of 1164 patients with pneumonia admitted to a teaching hospital in Italy. Using age ≥ 65 years, LDH > 230 u/L, albumin < 3.5 g/dL, platelet count < 100 × 10⁹/L, confusion, urea > 7 mmol/L, respiratory rate ≥ 30/min, low blood pressure, we assembled a new severity score named as expanded-CURB-65. The 30-day mortality and length of stay were increased along with increased risk score. The AUCs in the prediction of 30-day mortality in the main cohort were 0.826 (95% CI, 0.807–0.844), 0.801 (95% CI, 0.781–0.820), 0.756 (95% CI, 0.735–0.777), 0.793 (95% CI, 0.773–0.813) and 0.759 (95% CI, 0.737–0.779) for the expanded-CURB-65, PSI, CURB-65, SMART-COP and A-DROP, respectively. The performance of this bedside score was confirmed in CAP patients of the validation cohort although calibration was not successful in patients with health care-associated pneumonia (HCAP). The expanded CURB-65 is objective, simpler and more accurate scoring system for evaluation of CAP severity, and the predictive efficiency was better than other score systems.

Risk Factors for Long-Term Mortality after Hospitalization for Community-Acquired Pneumonia: A 5-Year Prospective Follow-Up Study

BACKGROUND

Contributors to long-term mortality in patients with community-acquired pneumonia (CAP) remain unclear, with little attention paid to pneumonia etiology. We examined long-term survival, causes of death, and risk factors for long-term mortality in adult patients who had been hospitalized for CAP, with emphasis on demographic, clinical, laboratory, and microbiological characteristics.

METHODS

Two hundred and sixty-seven consecutive patients admitted in 2008-2011 to a general hospital with CAP were prospectively recruited and followed up. Patients who died during hospital stay were excluded. Demographic, clinical, and laboratory data were collected within 48 hours of admission. Extensive microbiological work-up was performed to establish the etiology of CAP in 63% of patients. Mortality data were obtained from the Norwegian Cause of Death Registry. Cox regression models were used to identify independent risk factors for all-cause mortality.

RESULTS

Of 259 hospital survivors of CAP (median age 66 years), 79 (30.5%) died over a median of 1,804 days (range 1-2,520 days). Cumulative 5-year survival rate was 72.9% (95% CI 67.4-78.4%). Standardized mortality ratio was 2.90 for men and 2.05 for women. The main causes of death were chronic obstructive pulmonary disease (COPD), vascular diseases, and malignancy. Independent risk factors for death were the following (hazard ratio, 95% CI): age (1.83 per decade, 1.47-2.28), cardiovascular disease (2.63, 1.61-4.32), COPD (2.09, 1.27-3.45), immunocompromization (1.98, 1.17-3.37), and low serum albumin level at admission (0.75 per 5 g/L higher, 0.58-0.96), whereas active smoking was protective (0.32, 0.14-0.74); active smokers were younger than non-smokers (P < 0.001). Microbial etiology did not predict mortality.

CONCLUSIONS

Results largely confirm substantial comorbidity-related 5-year mortality after hospitalization for CAP and the impact of several well-known risk factors for death, and extend previous findings on the prognostic value of serum albumin level at hospital admission. Pneumonia etiology had no prognostic value, but this remains to be substantiated by further studies using extensive diagnostic microbiological methods in the identification of causative agents of CAP.

Biomarkers for predicting short-term mortality in community-acquired pneumonia: A systematic review and meta-analysis

OBJECTIVES

The pneumonia severity index and CURB-65 are risk assessment tools widely used in community-acquired pneumonia (CAP). However, limitations in these prognostic scores have led to increasing interest in finding biomarkers that might provide additional information. To date, the role of these biomarkers has not been fully elucidated.

METHODS

We systematically searched the Medline, Web of Knowledge, Science Direct, and LILACS databases. We included studies that assessed the accuracy of biomarkers for the prediction of in-hospital or ≤30-day mortality, in hospitalized adults with CAP. Two independent investigators extracted patient and study characteristics, which were thereafter pooled using a random effects model. Relationships between sensitivity and specificity of biomarkers and prognostic scores were plotter using the area under the receiver operator characteristic curve (AUC).

RESULTS

We included 24 articles and 2 databases from 1069 reviewed abstracts, which provided 10,319 patients for analysis. Reported mortality rates varied from 2.4% to 34.6%. The highest AUC values for predicting mortality were associated with pro-adrenomedullin (0.80) and prohormone forms of atrial natriuretic peptide (0.79), followed by cortisol (0.78), procalcitonin (0.75), copeptin (0.71), and C-reactive protein (0.62). There were no statistically significant differences between the AUCs of the studied biomarkers, other than for copeptin and C-reactive protein, which performed comparatively poorly. When compared with the CAP-specific scores, the AUCs were not significantly different from those of most biomarkers.

CONCLUSIONS

The identified biomarkers are able to predict mortality with moderate to good accuracy in CAP. However, biomarkers have no clear advantage over CAP-specific scores for predicting mortality.

Multimarker Prognostication for Hospitalized Patients with Community-acquired Pneumonia

OBJECTIVE

The optimal prognostic model for community-acquired pneumonia (CAP) remains unclear. In this study, we sought to identify independent predictors of 30-day mortality in patients with CAP and to determine whether adding specific prognostic factors to each of the two clinical prediction scores could improve the prognostic yield.

METHODS

This retrospective study involved 797 CAP patients who had been hospitalized at a tertiary referral center. The patients were categorized into two groups: those who survived and those who had died on or before 30 days after admission. Select clinical parameters were then compared between the two groups.

RESULTS

During the 30-day period, there were 72 deaths (9%). We constructed two models for a multivariate analysis: one was based on a high CURB-65 score (3-5) and the other on a high pneumonia severity index (PSI) class (V). In both models, a high CURB-65 score or a high PSI class, along with the presence of dyspnea, high Eastern Cooperative Oncology Group (ECOG) performance status (3-4), and a low serum albumin level, were independent predictors of 30-day mortality. In both the CURB-65-based and PSI-based models, the addition of dyspnea, high ECOG performance status, and hypoalbuminemia (<3 g/dL) enhanced the prognostic assessment, and subsequently, the c-statistics calculated with the use of three- or four- predictor combinations exceeded 0.8.

CONCLUSION

In addition to the CURB-65 or PSI, the clinical factors of dyspnea, the ECOG performance status, and serum albumin level may be independent predictors of 30-day mortality in CAP patients. When combined with the CURB-65 or PSI, these parameters provide additional evidence for predicting poor prognoses.

Role of albumin in diseases associated with severe systemic inflammation: Pathophysiologic and clinical evidence in sepsis and in decompensated cirrhosis

The metabolism of albumin in inflammatory states such as sepsis or major surgery is complex and still not well characterized. Nevertheless, in inflammatory states, albumin synthesis has been observed to increase. By contrast, in decompensated cirrhosis, a disease characterized by systemic inflammation, albumin synthesis by the liver may decrease to 30% to 50% of normal values. Furthermore, in these conditions, there are high capillary leakage and altered albumin kinetics. The discussion regarding the effect of exogenous albumin administration on intravascular volume in inflammatory states should therefore address albumin turnover. To add complexity to our understanding of the effects of albumin, there are many data indicating that the therapeutic action of albumin is mediated not only through the impact on plasma volume expansion but also through a modulatory effect on inflammation and oxidative stress. All these characteristics are relevant to diseases associated with systemic inflammation including sepsis and decompensated cirrhosis.

Validation of circulating BNP level >1000 pg/ml in all-cause mortality: A retrospective study

Aim

To determine the primary diseases and prognoses of patients with highly elevated levels of B-type natriuretic peptide (BNP; >1000 pg/ml), with or without heart failure.

Methods

Medical records and echocardiograms of patients with BNP levels that fell within one of three predetermined categories (>1000 pg/ml, 200–1000 pg/ml and <200 pg/ml) were retrospectively reviewed.

Results

There were no significant between-group differences in duration of hospitalization. Patients with BNP levels >1000 pg/ml ( n = 103) or 200–1000 pg/ml ( n = 100) had significantly worse 3-year survival than those with BNP levels <200 pg/ml ( n = 100). The majority of patients (64/103) in the BNP >1000 pg/ml group had heart failure. The main cause of death in patients with other causes of BNP levels >1000 pg/ml (39/103) was community acquired pneumonia.

Conclusion

A BNP level >1000 pg/ml has clinical importance in primary care medicine and hospital settings.

Characteristics and prognosis of pulmonary infection in patients with neurologic disease and hypoproteinemia

OBJECTIVE

To examine the characteristics and the prognostic influence of pulmonary infections in neurologic disease patients with mild-to-severe hypoproteinemia.

METHODS

We used a retrospective survey method to analyze the characteristics and prognoses of 220 patients with hypoproteinemia complicated with pulmonary infection in the Internal Medicine-Neurology Intensive Care Unit at the First Affiliated Hospital of Chongqing Medical University from January 2010 to December 2013. The patients were divided into mild, moderate and severe hypoproteinemia groups according to their serum albumin levels. The analysis included patient age, sex, acute physiology and chronic health evaluation (APACHE II score), and characteristics of the pulmonary infection, nutritional support and prognosis, among others.

RESULTS

Differences in the general information of the 220 cases of hypoalbuminemia patients complicated with varying degrees of pulmonary infection (APACHE II score, age, disease distribution) were statistically significant. The pulmonary infection onset time and pathogen susceptibility in the patients with mild-to-severe hypoalbuminemia were not significantly different. Pulmonary infection onset was more frequently observed within the first 3-11 days following admission in all groups. The nutritional support method did not significantly influence serum albumin protein levels. However, the neurological intensive care unit stay length, total hospitalization cost and disease distribution were significantly different among the patient groups.

CONCLUSIONS

Patients with cerebrovascular disease, intracranial infections and epilepsy complicated with pulmonary infection represent the high-risk groups for hypoalbuminemia. The Acinetobacter baumannii complex represents the main group of pathogenic bacteria causing lung infections, and the high-risk period for lung infections is 3-11 days after the occurrence of hypoalbuminemia. Patients with severe hypoalbuminemia complicated with pulmonary infection have the worst prognoses.

Multiple logistic regression analysis of risk factors in elderly pneumonia patients: QTc interval prolongation as a prognostic factor

Background

Acute pneumonia is a serious problem in the elderly and various risk factors have already been reported, but the involvement of QTc interval prolongation remains uncertain. The aim of this study was to elucidate the prognostic factors for the development of pneumonia in elderly patients and to study the possible involvement of QTc interval prolongation.

Methods

The subjects were 249 hospitalized pneumonia patients more than 65 years old in Aki-Ohta Hospital from January 2010 to December 2013. Community-acquired pneumonia patients and nursing care and healthcare-associated pneumonia patients were included in the study. The pneumonia severity index, vital signs, blood chemistry data and ECG findings were retrospectively compared using multiple logistic regression analysis.

Results

39 patients died within 30 days from onset. The clinical features related to poor prognosis were: advanced age, past history of cerebral vascular disease and/or diabetes mellitus, decreased serum albumin level, higher CURB-65 or PORT index scores and QTc interval prolongation. Patients showing a prolonged QTc interval had a higher mortality than those with a normal QTc interval. A prolonged QTc interval was not related to serum calcium concentration and/or treatment with QTc prolongation drug, clarithromycin or azithromycin, but related to age, lower albumin concentration and past history of diabetes mellitus.

Conclusions

These findings suggest potential prognostic factors for pneumonia in elderly patients, including a prolonged QTc interval (> 0.44 seconds).

Community-acquired pneumonia

PURPOSE OF REVIEW

This review examines the epidemiology, diagnosis, prognosis, treatment and prevention of community-acquired pneumonia (CAP) in adults.

RECENT FINDINGS

CAP is a significant cause of morbidity and mortality. Streptococcus pneumoniae is the most common CAP pathogen; however, microbial cause varies by geographic location and host factors. Identification of a microbial cause in CAP remains challenging - 30-65% of cases do not have a pathogen isolated. The use of molecular techniques in addition to culture, serology and urinary antigen testing has improved diagnostic yield. Scoring systems are useful for CAP prognostication and site of care decisions. Studies evaluating novel biomarkers including pro-B-type natriuretic peptide and procalcitonin suggest potential adjunctive roles in CAP prognosis. Guideline-based treatment for CAP has changed little in recent years. Effective and timely antimicrobial therapy is crucial in optimizing outcomes and should be based on local antimicrobial susceptibility patterns. Macrolides may have additional anti-inflammatory properties and a mortality benefit in severe CAP. Preventive strategies include immunization and modification of specific patient risk factors.

SUMMARY

CAP is common and causes considerable morbidity and mortality. A comprehensive approach including advanced diagnostic testing, effective and timely antimicrobial therapy and prevention is required to optimize CAP outcomes.

Prediction of prognosis by markers in community-acquired pneumonia

Early identification of patients with community-acquired pneumonia (CAP) at risk of poor outcome is critical for defining site of care and may impact on hospital resource consumption and prognosis. The Pneumonia Severity Index and CURB-65 are clinical rules that accurately identify individuals at risk of death. However, these scores have some limitations. Therefore in recent years, increasing attention has been being paid to research on biomarkers, since they have the potential to resolve fundamental issues regarding prognostic prediction that cannot be readily addressed using CAP-specific scores. Nevertheless, the use of biomarkers in this context needs to be validated in prospective trials so as to elucidate how they can best be applied in practice. This review examines the usefulness of biomarkers, whether used alone or in conjunction with other clinical severity of illness scores, for identifying CAP patients at risk of short- and long-term mortality and for predicting both the need for intensive care unit admission and the potential for treatment failure.

Procalcitonin-guided antibiotic therapy in aspiration pneumonia and an assessment of the continuation of oral intake

BACKGROUND

Procalcitonin-guided antibiotic therapy for community-acquired pneumonia is effective and safe. However, the usefulness of procalcitonin for aspiration pneumonia and its nutrition-related outcomes are unknown.

METHODS

We conducted a noninferiority randomized controlled study in patients with aspiration pneumonia who were admitted to our hospital between September 2010 and January 2012. We randomly assigned 105 patients to groups with different durations of antibiotic therapy based on the procalcitonin levels upon admission (procalcitonin group) or according to the standard guidelines (control group). The primary endpoints were relapse of aspiration pneumonia and death within 30 days, with a predefined noninferiority boundary of 10%. Secondary endpoints included duration of antibiotic exposure. Furthermore, we conducted a retrospective analysis of the prognostic factors that determined continuation of oral nutritional intake, relapse of pneumonia, and in-hospital death.

RESULTS

The rate of relapse and death within 30 days were similar in the procalcitonin and control groups (25% versus 37.5%; difference, -12.5%; 95% confidence interval, -30.9% to 5.9%). Procalcitonin-guided antibiotic therapy significantly shortened the median duration of antibiotic exposure (5 versus 8 days; p<0.0001); however, the continuation of oral intake was not increased (56% versus 50%; p=0.54). A multivariable analysis showed a significant association between the continuation of oral nutritional intake and the body mass index upon admission.

CONCLUSIONS

Procalcitonin-guided antibiotic therapy for aspiration pneumonia can shorten the duration of antibiotic exposure, but it does not increase the continuation of oral intake (UMIN000004800).

Clinical characteristics and prognostic significance of serum albumin changes in an internal medicine ward

BACKGROUND

The prognostic significance of hypoalbuminemia and the dynamic changes in serum albumin during hospitalization in internal medicine wards has not been sufficiently investigated.

METHODS

Demographic, clinical and laboratory data were collected from 276 patients admitted to our internal medicine ward for a variety of acute disorders. Following discharge, all-cause mortality was recorded. These data were compared between patient groups, according to levels of albumin: hypoalbuminemia or normoalbuminemia (serum albumin <34 g/l and ≥ 34 g/l, respectively), on admission and discharge.

RESULTS

Hypoalbuminemia on admission and on discharge was found in 46% and 54% of patients, respectively. Anemia, renal dysfunction, malignant disease, hypocholesterolemia, lymphopenia and albuminuria were more prevalent in patients with hypoalbuminemia, compared to those with normoalbuminemia (p ≤ 0.03). During a median follow-up period of 23 months, 107 of 276 patients died. Mortality was significantly higher (p<0.001) in patients with hypoalbuminemia than normoalbuminemia on admission (52.0% vs. 27.5%) and on discharge (53.7% vs. 21.2%), including those admitted with normoalbuminemia and discharged with hypoalbuminemia (43.6%). Survival rate was higher for patients admitted with hypoalbuminemia and discharged with normoalbuminemia than for those remaining with hypoalbuminemia (82.4% vs. 42.8%, p=0.004). The level of albumin on discharge (each 10 g/l decrement) was the most powerful predictor of shortened survival (relative risk 2.79, 95% confidence interval 2.04-3.70).

CONCLUSIONS

Hypoalbuminemia on admission, as well as persistence or development of hypoalbuminemia throughout hospitalization, was associated with poor prognosis. Treatment aimed at increasing low albumin or maintaining its normal level may improve survival.

Diarrhea in enterally fed patients: blame the diet?

PURPOSE OF REVIEW

Diarrhea has great impact on enteral nutrition. The purpose of this review is to identify the factors leading to diarrhea during enteral nutrition and to provide the published updates on diarrhea prevention through nutritional intervention.

RECENT FINDINGS

Diarrhea in enteral fed patients is attributed to multiple factors, including medications (major contributor), infections, bacterial contamination, underlying disease, and enteral feeding. Diet management can alleviate diarrhea in enteral feeding. High content of fermentable oligosaccharides, disaccharides, and monosaccharides and polyols (FODMAPs) in enteral formula is postulated to induce diarrhea and lower FODMAPs formula may reduce the likelihood of diarrhea in enterally fed patients. Fiber-enriched formula can reduce the incidence of diarrhea and produce short-chain fatty acids for colonocytes. Ingesting prebiotics, nonviable probiotics or probiotic derivatives, and human lactoferrin may provide alternatives for reducing/preventing diarrhea.

SUMMARY

Enteral feeding is not generally considered the primary cause of diarrhea, which is frequently linked to prescribed medications. When diarrhea is apparent, healthcare members should evaluate the possible risk factors and systematically attempt to eliminate the underlying causes of diarrhea before reducing or suspending enteral feeding. Lower FODMAPs formula, prebiotics, probiotic derivatives, and lactoferrin may be used to manage enteral feeding-related diarrhea.

What is the association of cardiovascular events with clinical failure in patients with community-acquired pneumonia?

Cardiovascular disease is the leading cause of morbidity and mortality in the United States. Several investigators recently reported an increased risk of cardiovascular events (CVEs) in hospitalized patients with community-acquired pneumonia (CAP). CVEs may be the primary determinant of clinical failure in hospitalized patients with CAP. Future research may be necessary to identify patients at risk of CVEs during or after an episode of CAP. In these patients, therapeutics beyond antibiotics (eg, heparin or aspirin) may be indicated during and after hospitalization.