Risk factors and severity scores in hospitalized patients with community-acquired pneumonia: prediction of severity and mortality

Retrospective study on the health and economic burden of hospitalized patients due to pneumonia and invasive pneumococcal infections in Belgium settings

INTRODUCTION

pneumococcal infections are associated with high morbidity, hospitalisation and mortality. The objective of this study was to investigate the health and economic burden of all-cause pneumonia and invasive pneumococcal disease in Belgian hospital settings, by patient's age and risk profile.

METHODS

This descriptive retrospective study was conducted in 17 Belgian hospitals. Univariate and multivariate logistic linear regression models were performed. The Health Insurance and patient's cost perspectives were considered because a few studies report these costs.

RESULTS

The analysis has included 4,712 hospital admissions over the year 2018. Median hospitalization costs were higher for invasive pneumococcal infection diagnosis than for all-cause pneumonia (p < 0,001), respectively 4,051€ and 3,362€. Other factors associated with higher hospitalization cost were patient's high-risk profile, admission to emergency unit, transfer from nursing home, admission to intensive care unit and length of stay.

CONCLUSION

Streptococcus pneumoniae infections remain a public health problem with significant cost for the Health Insurance and poor prognosis. Invasive pneumococcal infections are associated with longer hospital stays and required more intensive care than all other causes of pneumonia, in addition to be more costly, which justifies more attention for vaccination. This study also suggests an increase of economic and health burden with age and presence of underlying conditions.

Analysis of Correlation Between Serum Oncostatin-M and Disease Severity and Mortality in Hospitalized Patients with Community-Acquired Pneumonia

Purpose

The aim of this study was to investigate the level of serum tumor suppressor factor (Oncostatin-M, OSM) in patients with community-acquired pneumonia (CAP) and evaluate its predictive value for the severity and prognosis of pneumonia, so as to improve the ability to identify the risk of death in CAP patients.

Patients and Methods

A total of 110 patients with CAP admitted to the hospital from November 2020 to November 2021 were enrolled in this prospective study. Clinical data of all patients were collected. According to the 2016 edition of "Guidelines for the Diagnosis and Treatment of Community-acquired Pneumonia in Chinese Adults", the patients were divided into non-severe CAP (NSCAP)(n=55) and severe CAP (SCAP)(n=55). At the same time, they were divided into a survival group (n=96) and a death group (n=14) by tracking the survival of patients in the hospital. The OSM concentration of CAP patients on the first day after admission was determined by enzyme-linked immunosorbent assay. All clinical data were statistically and graphed using SPSS V23.0 and Grahpad Prim 8.

Results

Compared with NSCAP, patients with SCAP had higher serum OSM concentration on the day of admission, which was negatively correlated with LYM and positively correlated with WBC, NEU, CRP, IL-6, IL-8, IL-10, CURB-65 score, and PSI score. The level of OSM in the dead patient group was significantly higher than that in the surviving patient group. OSM and PSI scores were independent risk factors for in-hospital mortality in CAP patients. Kaplan-Meier survival curve showed that OSM≥76pg/mL was more advantageous in predicting mortality in patients with CAP.

Conclusion

The level of the OSM is closely related to the severity and prognosis of CAP and may be a new biomarker for the prognosis of CAP patients.

Community-Acquired Pneumococcal Pneumonia in Highly Vaccinated Population: Analysis by Serotypes, Vaccination Status, and Underlying Medical Conditions

BACKGROUND

Targeted risk population has been highly vaccinated against pneumococcal diseases in South Korea. Despite this, the pneumococcal serotype distribution is evolving, which impedes efficient roll-out of vaccines.

METHODS

This prospective cohort study included patients aged ≥ 19 years with community-acquired pneumonia (CAP) from five university hospitals in South Korea between September 2018 and July 2021. The outcomes of interest were the demographic and clinical characteristics of patients with CAP, pneumococcal serotype distribution, and risk factors of 30-day mortality in patients with pneumococcal CAP (pCAP). Considering the high seroprevalence, we analyzed the clinical characteristics of serotype 3 pCAP.

RESULTS

A total of 5,009 patients hospitalized with CAP was included (mean age ± standard deviation, 70.3 ± 16.0 years; 3,159 [63.1%] men). Streptococcus pneumoniae was the leading causative agent of CAP (11.8% overall, 17.7% in individuals aged < 65 years with chronic medical conditions). Among the 280 serotyped Streptococcus pneumococcus, serotype 3 was the most common (10.0%), followed by serotypes 19A (8.9%), 34 (8.9%), and 35B (8.9%). Non-vaccine serotypes (serotype 35B [13.9%] and 34 [12.0%]) were the most prevalent in 108 individuals vaccinated with 23-valent pneumococcal polysaccharide vaccine (PPSV23). Serotype 3 was prevalent, irrespective of PPSV23 vaccination status, and more common in individuals with chronic lung disease (P = 0.008). Advanced age (adjusted odds ratio [aOR], 1.040; 95% confidence interval [CI], 1.011-1.071), long-term care facility residence (aOR, 2.161; 95% CI, 1.071-4.357), and bacteremia (aOR, 4.193; 95% CI, 1.604-10.962) were independent risk factors for 30-day mortality in patients with pCAP. PPSV23 vaccination reduced the risk of mortality (aOR, 0.507; 95% CI, 0.267-0.961).

CONCLUSION

Serotype 3 and 19A were still the most common serotypes of pCAP in South Korea despite the national immunization program of 13-valent pneumococcal conjugated vaccine in children and PPSV23 in old adults. PPSV23 vaccination might reduce the risk of mortality in patients with pCAP.

Incorporation of Suppression of Tumorigenicity 2 into Random Survival Forests for Enhancing Prediction of Short-Term Prognosis in Community-ACQUIRED Pneumonia

(1) Background: Biomarker and model development can help physicians adjust the management of patients with community-acquired pneumonia (CAP) by screening for inpatients with a low probability of cure early in their admission; (2) Methods: We conducted a 30-day cohort study of newly admitted adult CAP patients over 20 years of age. Prognosis models to predict the short-term prognosis were developed using random survival forest (RSF) method; (3) Results: A total of 247 adult CAP patients were studied and 208 (84.21%) of them reached clinical stability within 30 days. The soluble form of suppression of tumorigenicity-2 (sST2) was an independent predictor of clinical stability and the addition of sST2 to the prognosis model could improve the performance of the prognosis model. The C-index of the RSF model for predicting clinical stability was 0.8342 (95% CI, 0.8086–0.8598), which is higher than 0.7181 (95% CI, 0.6933–0.7429) of CURB 65 score, 0.8025 (95% CI, 0.7776–8274) of PSI score, and 0.8214 (95% CI, 0.8080–0.8348) of cox regression. In addition, the RSF model was associated with adverse clinical events during hospitalization, ICU admissions, and short-term mortality; (4) Conclusions: The RSF model by incorporating sST2 was more accurate than traditional methods in assessing the short-term prognosis of CAP patients.

All-cause community acquired pneumonia cost by age and risk in real-world conditions of care in Spain

BACKGROUND

: Economic burden of Community-acquired pneumonia (CAP) is recognized. Few studies have documented such burden in adults stratified by age, risk status, and by care setting. Spanish data available is scarce.

METHOD

: A retrospective, multicenter study in seven regions of Spain (2017-2019) was conducted. Patients ≥18 years with a primary all-cause CAP episode diagnosis were identified. Episode-level variables included risk-stratum based on presence of an immunocompromising/chronic condition, age, number and length of hospitalized and outpatient episodes, and CAP-related healthcare costs/sick leaves were included.

RESULTS

: 7,108 episodes [mean age (SD): 59.2 (19.6), 50.42% male, 31.0% hospitalized] were analyzed. Low-risk group accounted for 47.7% of all CAP episodes, 31.5% moderate-risk and 20.8% high-risk. Pneumococcus was identified in 42.2% of cases. Mean CAP episode length was 22.9 days for hospitalized and 13.7 days for outpatient episode. Total healthcare cost for episode was higher in inpatient vs. outpatient: €3,955 vs. €511, p<0.001, with higher sick leave cost (€3,281 vs. €2,632, p<0.001), respectively.

CONCLUSION

: CAP required hospitalization cost is high regardless of age or comorbidities for the Spanish NHS. Given that almost half of the patients in this study did not have traditional risk factors for CAP, better preventative strategies should seriously be considered.

Amoxicillin duration and dose for community-acquired pneumonia in children: the CAP-IT factorial non-inferiority RCT

BACKGROUND

Data are limited regarding the optimal dose and duration of amoxicillin treatment for community-acquired pneumonia in children.

OBJECTIVES

To determine the efficacy, safety and impact on antimicrobial resistance of shorter (3-day) and longer (7-day) treatment with amoxicillin at both a lower and a higher dose at hospital discharge in children with uncomplicated community-acquired pneumonia.

DESIGN

A multicentre randomised double-blind 2 × 2 factorial non-inferiority trial in secondary care in the UK and Ireland.

SETTING

Paediatric emergency departments, paediatric assessment/observation units and inpatient wards.

PARTICIPANTS

Children aged > 6 months, weighing 6-24 kg, with a clinical diagnosis of community-acquired pneumonia, in whom treatment with amoxicillin as the sole antibiotic was planned on discharge.

INTERVENTIONS

Oral amoxicillin syrup at a dose of 35-50 mg/kg/day compared with a dose of 70-90 mg/kg/day, and 3 compared with 7 days' duration. Children were randomised simultaneously to each of the two factorial arms in a 1 : 1 ratio.

MAIN OUTCOME MEASURES

The primary outcome was clinically indicated systemic antibacterial treatment prescribed for respiratory tract infection (including community-acquired pneumonia), other than trial medication, up to 28 days after randomisation. Secondary outcomes included severity and duration of parent/guardian-reported community-acquired pneumonia symptoms, drug-related adverse events (including thrush, skin rashes and diarrhoea), antimicrobial resistance and adherence to trial medication.

RESULTS

A total of 824 children were recruited from 29 hospitals. Ten participants received no trial medication and were excluded. Participants [median age 2.5 (interquartile range 1.6-2.7) years; 52% male] were randomised to either 3 (n = 413) or 7 days (n = 401) of trial medication at either lower (n = 410) or higher (n = 404) doses. There were 51 (12.5%) and 49 (12.5%) primary end points in the 3- and 7-day arms, respectively (difference 0.1%, 90% confidence interval -3.8% to 3.9%) and 51 (12.6%) and 49 (12.4%) primary end points in the low- and high-dose arms, respectively (difference 0.2%, 90% confidence interval -3.7% to 4.0%), both demonstrating non-inferiority. Resolution of cough was faster in the 7-day arm than in the 3-day arm for cough (10 days vs. 12 days) (p = 0.040), with no difference in time to resolution of other symptoms. The type and frequency of adverse events and rate of colonisation by penicillin-non-susceptible pneumococci were comparable between arms.

LIMITATIONS

End-of-treatment swabs were not taken, and 28-day swabs were collected in only 53% of children. We focused on phenotypic penicillin resistance testing in pneumococci in the nasopharynx, which does not describe the global impact on the microflora. Although 21% of children did not attend the final 28-day visit, we obtained data from general practitioners for the primary end point on all but 3% of children.

CONCLUSIONS

Antibiotic retreatment, adverse events and nasopharyngeal colonisation by penicillin-non-susceptible pneumococci were similar with the higher and lower amoxicillin doses and the 3- and 7-day treatments. Time to resolution of cough and sleep disturbance was slightly longer in children taking 3 days' amoxicillin, but time to resolution of all other symptoms was similar in both arms.

FUTURE WORK

Antimicrobial resistance genotypic studies are ongoing, including whole-genome sequencing and shotgun metagenomics, to fully characterise the effect of amoxicillin dose and duration on antimicrobial resistance. The analysis of a randomised substudy comparing parental electronic and paper diary entry is also ongoing.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN76888927, EudraCT 2016-000809-36 and CTA 00316/0246/001-0006.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 60. See the NIHR Journals Library website for further project information.

Comparative clinical characteristics among different age group of adult COVID-19 patients: A multicenter study

Background

Coronavirus disease (COVID‐19) is a global infectious disease with a large burden of illness and high health care costs. This study aimed to compare clinical features among adult COVID‐19 patients in different age groups.

Methods

Laboratory‐confirmed adult COVID‐19 infection cases between December 31, 2019 to March 8, 2020 obtained from Neighboring Cities. Patients were divided into five age groups. Clinical characteristics were compared among different age groups.

Results

Of 299 cases, median age was 44 and 158 (53%) were male. A total of 53.3% of 30–40 years, 50% of 40–50 years, 36.6% of <30 years and 36.2% of 50–60 years were primary case, none of the elderly were primary case. Among all the observed symptoms, only symptom of dyspnea was significantly different between the elderly group and other groups (p < .001). Proportion of severe or critical type was 2.4%, 5.3%, 9.5%, 14.5%, and 35% in patients with age <30, 30–40, 40–50, 50–65, ≥65, respectively. A total of 285 patients (95.3%) were cured and discharged, 12 patients (4.0%) were still on medical treatment in hospital. There were 2 (0.7%) deaths which occurred among persons ≥65 years. Patients with a history of chronic heart disease had a more than a 56 times higher risk for severe or critical type of COVID‐19 than those without a history of chronic heart disease (odds ratio [OR]: 56.038, 95% confidence interval [CI]: 2.764–1136.053, p = .009). Old age (OR: 1.055, 95% CI: 1.016–1.095, p = .006), high heart rate in admission (OR: 1.085, 95% CI: 1.03–1.144, p = .002), high respiratory rate in admission (OR: 1.635, 95% CI: 1.093–2.431, p = .017) were independently associated with severe or critical type in COVID‐19.

Conclusions

Proportion of severe or critical type increased with old age groups. Adults with old age and high heart rate, respiratory rate in admission and history of chronic heart disease were associated with severe or critical type in COVID‐19.

Respiratory viruses in the patient environment

OBJECTIVE

To characterize the presence and magnitude of viruses in the air and on surfaces in the rooms of hospitalized patients with respiratory viral infections, and to explore the association between care activities and viral contamination.

DESIGN

Prospective observational study.

SETTING

Acute-care academic hospital.

PARTICIPANTS

In total, 52 adult patients with a positive respiratory viral infection test within 3 days of observation participated. Healthcare workers (HCWs) were recruited in staff meetings and at the time of patient care, and 23 wore personal air-sampling devices.

METHODS

Viruses were measured in the air at a fixed location and in the personal breathing zone of HCWs. Predetermined environmental surfaces were sampled using premoistened Copan swabs at the beginning and at the end of the 3-hour observation period. Preamplification and quantitative real-time PCR methods were used to quantify viral pathogens.

RESULTS

Overall, 43% of stationary and 22% of personal air samples were positive for virus. Positive stationary air samples were associated with ≥5 HCW encounters during the observation period (odds ratio [OR], 5.3; 95% confidence interval [CI], 1.2-37.8). Viruses were frequently detected on all of the surfaces sampled. Virus concentrations on the IV pole hanger and telephone were positively correlated with the number of contacts made by HCWs on those surfaces. The distributions of influenza, rhinoviruses, and other viruses in the environment were similar.

CONCLUSIONS

Healthcare workers are at risk of contracting respiratory virus infections when delivering routine care for patients infected with the viruses, and they are at risk of disseminating virus because they touch virus-contaminated fomites.

Community-Acquired Pneumonia: A Focused Review

Community-acquired pneumonia (CAP) is a common cause for admission to the hospital and contributes significantly to patient morbidity and healthcare cost. We present a review of the epidemiology, pathophysiology, risk factors, symptoms, diagnosis, presentations, risk-stratification, markers, and management of CAP in the United States (US). The overall incidence of CAP is 16 to 23 cases per 1000 persons per year, and the rate increases with age. Some of the risk factors for CAP include comorbidities such as, chronic obstructive pulmonary disease (COPD), asthma, and heart failure. CAP symptoms vary, and typically include productive cough, dyspnea, pleuritic pain, abnormal vital signs (e.g., fever, tachycardia), and abnormal lung examination findings. A diagnosis can be made by radiography, which has the additional benefit of helping to identify patterns associated with typical and atypical CAP. There are risk-stratification calculators that can be used routinely by physicians to triage patients, and to determine adequate management. The Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) developed the Pneumonia Severity Index (PSI) which incorporates 20 risk factors to place patients into 5 classes correlated with mortality risk. In addition, the British Thoracic Society (BTS) established the original severity score CURB (confusion, uremia, respiratory rate, low blood pressure) to identify patients with CAP who may be candidates for outpatient vs. inpatient treatment. Inflammatory markers, such as procalcitonin (PCT), can be used to guide management throughout hospital stay. Antibiotic coverage will vary depending on whether outpatient vs. inpatient management is required.

Pneumonic versus Nonpneumonic Exacerbations of Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) often suffer acute exacerbations (AECOPD) and community-acquired pneumonia (CAP), named nonpneumonic and pneumonic exacerbations of COPD, respectively. Abnormal host defense mechanisms may play a role in the specificity of the systemic inflammatory response. Given the association of this aspect to some biomarkers at admission (e.g., C-reactive protein), it can be used to help to discriminate AECOPD and CAP, especially in cases with doubtful infiltrates and advanced lung impairment. Fever, sputum purulence, chills, and pleuritic pain are typical clinical features of CAP in a patient with COPD, whereas isolated dyspnea at admission has been reported to predict AECOPD. Although CAP may have a worse outcome in terms of mortality (in hospital and short term), length of hospitalization, and early readmission rates, this has only been confirmed in a few prospective studies. There is a lack of methodologically sound research confirming the impact of severe AECOPD and COPD + CAP. Here, we review studies reporting head-to-head comparisons between AECOPD and CAP + COPD in hospitalized patients. We focus on the epidemiology, risk factors, systemic inflammatory response, clinical and microbiological characteristics, outcomes, and treatment approaches. Finally, we briefly discuss some proposals on how we should orient research in the future.

[Surfactant proteins A and D: role in the pathogenesis of community-acquired pneumonia and possible predictive perspectives]

Community-acquired pneumonia is one of the most common infectious diseases and remains one of the leading causes of death in this group of diseases. Studies of community-acquired pneumonia are extremely relevant for modern clinical practice. One of the important role in the pathogenesis of bacterial, viral, fungal invasion in the system of a human lung system belongs to the pulmonary surfactant, in particular, its proteins SP-A and SP-D. This article reviews the well-known mechanisms of important biological properties of immunomodulatory activity of the proteins SP-A and SP-D in response to microbial infection in the lungs. The mechanisms of participation of surfactant proteins SP-A and SP-D in the cascade of reactions that lead to severe life-threatening complications in community-acquired pneumonia are considered. The use of serum levels of surfactant proteins SP-A and SP-D can help finding new diagnostic and prognostic approaches in patients with community-acquired pneumonia.

Macrolide combination therapy for patients hospitalised with community-acquired pneumonia? An individualised approach supported by machine learning

BACKGROUND

The role of macrolide/β-lactam combination therapy in community-acquired pneumonia (CAP) of moderate severity is a matter of debate. Macrolides expand the coverage to atypical pathogens and attenuate pulmonary inflammation, but have been associated with cardiovascular toxicity and drug interactions. We developed a decision tree based on aetiological and clinical parameters, which are available ex ante to support a personalised decision for or against macrolides for the best clinical outcome of the individual patient.

METHODS

We employed machine learning in a cross-validation scheme based on a well-balanced selection of 4898 patients after propensity score matching to data available on admission of 6440 hospitalised patients with moderate severity (non-intensive care unit patients) from the observational, prospective, multinational CAPNETZ study. We aimed to improve the primary outcome of 180-day survival.

RESULTS

We found a simple decision tree of patient characteristics comprising chronic cardiovascular and chronic respiratory comorbidities as well as leukocyte counts in the respiratory secretion at enrolment. Specifically, we found that patients without cardiovascular or patients with respiratory comorbidities and high leukocyte counts in the respiratory secretion benefit from macrolide treatment. Patients identified to be treated in compliance with our treatment suggestion had a lower mortality of 27% (OR 1.83, 95% CI 1.48-2.27; p<0.001) compared to the observed standard of care.

CONCLUSION

Stratifying macrolide treatment in patients following a simple treatment rule may lead to considerably reduced mortality in CAP. A future randomised controlled trial confirming our result is necessary before implementing this rule into the clinical routine.

NACHT, LRR, and PYD domains-containing Protein 3 and LL-37: prognostic value of new biomarkers in community-acquired pneumonia

Objective

This study aimed to determine the serum levels of NACHT, Leucine-rich repeat (LRR), and Pyrin (PYD) domains-containing Protein 3 (NLRP3) and cathelicidin LL-37, and investigate their prognostic significance in community-acquired pneumonia (CAP).

Methods

The sample of this prospective study was composed of 76 consecutive patients with CAP. Demographic data and clinical characteristics were collected. Serum levels of NLRP3 and LL-37 were determined by ELISA. Spearman’s analysis was used to evaluate the correlation between NLRP3 and LL-37. Association of NLRP3 and LL-37 with 30-day survival and mortality rates was assessed using the Kaplan-Meier curve and logistic regression analysis.

Results

Serum NLRP3 significantly increased whereas serum LL-37 significantly decreased in patients with severe CAP. Significant correlation was observed between serum NLRP3 and LL-37 in CAP patients. Patients with higher levels of NLRP3 and lower levels of LL-37 showed lower 30-day survival rate and higher mortality compared with those with lower NLRP3 and higher LL-37 levels.

Conclusion

Severe CAP patients tend to present higher serum NLRP3 and lower serum LL-37, which might serve as potential biomarkers for CAP prognosis.

Clinical prognostic significance of serum high mobility group box-1 protein in patients with community-acquired pneumonia

Objective

To investigate the relationship between serum high mobility group box-1 protein (HMGB-1) levels and prognosis in patients with community-acquired pneumonia (CAP).

Methods

This prospective study included 35 patients who attended our hospital from January 2016 to December 2016. Pneumonia severity was defined by pneumonia severity index (PSI). Serum levels of C-reactive protein (CRP), cortisol, and HMGB-1 were analyzed in relation to disease severity and clinical outcome.

Results

High HMGB-1 levels were associated with high cortisol levels. High HMGB-1 and high cortisol were both significantly associated with high white blood cell count and high serum CRP, compared with low HMGB-1 and low cortisol, respectively. PSI score and 30-day mortality were also significantly higher in patients with high HMGB-1 or high cortisol levels compared with patients with low HMGB-1 or cortisol levels, respectively. CRP, cortisol, and HMGB-1 levels were all significantly higher in patients who died compared with survivors.

Conclusion

HMGB-1 was associated with clinical outcomes and was an independent risk factor for 30-day mortality in patients with CAP. Serum HMGB-1 levels were also positively correlated with serum levels of cortisol. These results demonstrate a role for HMGB-1 in CAP, and suggest possible new therapeutic targets for patients with CAP.

Delirium is associated with increased mortality in the geriatric population

OBJECTIVE

The aim of this study was to investigate the prevalence of delirium and its association with mortality rates in elderly inpatients.

METHODS

The medical records of 1435 patients over 65 years old who were treated at a regional university hospital and were referred to the university's Consultation and Liaison Psychiatry Clinic for psychological evaluation were retrospectively analyzed. Patients with and without a diagnosis of delirium were compared. The National Survival Database was used to determine mortality rates.

RESULTS

The prevalence of delirium was 25.5%. The delirium group was older (p < .0001) and had a larger proportion of males (p < .0001). Mortality rate was higher in the delirium group at 1, 2, 3, 4, and 5 years (p < .0001 for all). Age, gender, lower urinary system diseases, chronic liver disease, solid hematologic malignancy, infections, and Alzheimer's disease emerged as significant parameters associated with mortality. Multivariate analysis of these parameters indicated that comorbid diseases (lower urinary system diseases, chronic liver disease, solid hematologic malignancy, infections, and Alzheimer's disease) are risk factors for mortality independent of demographic data such as age and gender.

CONCLUSIONS

Independent of all other factors, delirium is associated with higher mortality risk.

Nrf2 regulates the inflammatory response, including heme oxygenase-1 induction, by mycoplasma pneumoniae lipid-associated membrane proteins in THP-1 cells

A series of inflammatory responses caused by Mycoplasma pneumoniae largely depend on the lipid-associated membrane proteins (LAMPs). Nuclear factor E2-related factor 2 (Nrf2), a transcription factor, is considered to be a critical modulator of inflammatory responses and cellular redox homeostasis. Monocytes play an important role in the invasion and immunity to resist pathogens. Here, we investigated the role of Nrf2 in the anti-inflammatory response stimulated by LAMPs using the human monocyte cell line THP-1. LAMPs were shown to affect the localization of Nrf2, and the levels of reactive oxygen species and inflammatory reactants, including nitric oxide (NO), prostaglandin E2 (PGE2) and cytokines (IL-6, IL-8), were highly elevated in LAMP-stimulated Nrf2-silenced THP-1 cells. Moreover, LAMPs induced the levels of mRNA and the expression of heme oxygenase-1 (HO-1). In summary, our results demonstrated that LAMPs cause nuclear translocation of Nrf2, which further suppresses the expression of inflammatory reactants in THP-1 cells.

Irradiation enhanced risks of hospitalised pneumonopathy in lung cancer patients: a population-based surgical cohort study

OBJECTIVE

Pulmonary radiotherapy has been reported to increase a risk of pneumonopathy, including pneumonitis and secondary pneumonia, however evidence from population-based studies is lacking. The present study intended to explore whether postoperative irradiation increases occurrence of severe pneumonopathy in lung cancer patients.

DESIGN, SETTING AND PARTICIPANTS

The nationwide population-based study analysed the Taiwan National Health Insurance Research Database (covered >99% of Taiwanese) in a real-world setting. From 2000 to 2010, 4335 newly diagnosed lung cancer patients were allocated into two groups: surgery-RT (n=867) and surgery-alone (n=3468). With a ratio of 1:4, propensity score was used to match 11 baseline factors to balance groups.

INTERVENTIONS/EXPOSURES

Irradiation was delivered to bronchial stump and mediastinum according to peer-audited guidelines.

OUTCOMES/MEASURES

Hospitalised pneumonia/pneumonitis-free survival was the primary end point. Risk factors and hazard effects were secondary measures.

RESULTS

Multivariable analysis identified five independent risk factors for hospitalised pneumonopathy: elderly (>65 years), male, irradiation, chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD). Compared with surgery-alone, a higher risk of hospitalised pneumonopathy was found in surgery-RT patients (HR, 2.20; 95% CI, 1.93-2.51; 2-year hospitalised pneumonia/pneumonitis-free survival, 85.2% vs 69.0%; both p<0.0001), especially in elderly males with COPD and CKD (HR, 13.74; 95% CI, 6.61-28.53; p<0.0001). Unexpectedly, we observed a higher risk of hospitalised pneumonopathy in younger irradiated-CKD patients (HR, 13.07; 95% CI, 5.71-29.94; p<0.0001) than that of elderly irradiated-CKD patients (HR, 4.82; 95% CI, 2.88-8.08; p<0.0001).

CONCLUSIONS

A high risk of hospitalised pneumonopathy is observed in irradiated patients, especially in elderly males with COPD and CKD. For these patients, close clinical surveillance and aggressive pneumonia/pneumonitis prevention should be considered. Further investigations are required to define underlying biological mechanisms, especially for younger CKD patients.

Pneumolysin Mediates Platelet Activation In Vitro

This study has explored the role of the pneumococcal toxin, pneumolysin (Ply), in activating human platelets. Following exposure to Ply (10-80 ng/ml), platelet activation and cytosolic Ca(2+) concentrations were measured flow cytometrically according to the level of expression of CD62P (P-selectin) and spectrofluorimetrically, respectively. Exposure to Ply resulted in marked upregulation of expression of platelet CD62P, achieving statistical significance at concentrations of 40 ng/ml and higher (P < 0.05), in the setting of increased influx of Ca(2+). These potentially pro-thrombotic actions of Ply were attenuated by depletion of Ca(2+) from the extracellular medium or by exposure of the cells to a pneumolysoid devoid of pore-forming activity. These findings are consistent with a mechanism of Ply-mediated platelet activation involving sub-lytic pore formation, Ca(2+) influx, and mobilization of CD62P-expressing α-granules, which, if operative in vivo, may contribute to the pathogenesis of associated acute lung and myocardial injury during invasive pneumococcal disease.

Clinical and economic burden of community-acquired pneumonia in the Veterans Health Administration, 2011: a retrospective cohort study

Purpose

The burden of community-acquired pneumonia (CAP) is not well described in the US Veterans Health Administration (VHA).

Methods

CAP was defined as having a pneumonia diagnosis with evidence of chest X-ray, and no evidence of prior (90 days) hospitalization/long-term care. We calculated incidence rates of adult CAP occurring in inpatient or outpatient VHA settings in 2011. We also estimated the proportion of VHA CAP patients who were hospitalized, were readmitted within 30 days of hospital discharge, and died (any cause) in the year following diagnosis. Incremental costs during the 90 days following a CAP diagnosis were estimated from the perspective of the VHA.

Results

In 2011, 34,101 Veterans developed CAP (35,380 episodes) over 7,739,757 VHA person-years. Median age of CAP patients was 65 years (95 % male). CAP incidence rates were higher for those aged ≥50 years. A majority of Veterans aged 50–64 (53 %) and ≥65 (66 %) years had ≥1 chronic medical (moderate risk) or immunocompromising (high risk) condition. Compared to those at low-risk (healthy), moderate- and high-risk Veterans were >3 and >6 times more likely to develop CAP, respectively. The percentage of CAP patients who were hospitalized was 45 %, ranging from 12 % (age 18–49, low risk) to 57 % (age ≥65, high risk). One-year all-cause mortality rates ranged from 1 % (age 18–49, low risk) to 36 % (age ≥65, high risk). Annual VHA medical expenditure related to CAP was estimated to be $750 million (M) ($415M for those aged ≥65 years).

Conclusion

A focus on CAP prevention among older Veterans and those with comorbid or immunocompromising conditions is important.

Electronic supplementary material

The online version of this article (doi:10.1007/s15010-015-0789-3) contains supplementary material, which is available to authorized users.

Increased Severity and Mortality of CAP in COPD: Results from the German Competence Network, CAPNETZ

Background:Mortality of community acquired pneumonia (CAP) remains high despite significant research efforts. Knowledge about comorbidities including chronic obstructive pulmonary disease (COPD) might help to improve management and ultimately, survival. The impact of COPD on CAP severity and mortality remains a point of discussion. Objectives:Assess the prevalence and clinical characteristics of COPD in the observational German Competence Network for CAP, CAPNETZ, and to study the impact of COPD on CAP severity and mortality. Methods:1307 consecutive patients with CAP (57.0% males, age 59.0±18.5), classified as CAP-only (n=1043; 78.0%) and CAP-COPD (n=264; 20.2%) were followed up for 180 days. Associations between CAP, COPD and mortality were evaluated by univariate/multivariate and Kaplan-Meier survival analyses. Results:CAP-COPD patients were older, more often males, current/former smokers, with higher confusion-urea-respiratory rate-blood pressure, (CURB) scores. Length of hospital stay, urea, glucose and leucocytes plasma levels, and arterial carbon dioxide tension (PaCO2) were significantly increased in CAP-COPD. Thirty, 90- and 180-day mortality rates were significantly increased in CAP-COPD (p=0.046, odds ratio [OR]=2.48, 95% confidence interval [CI] 1.015-6.037; p=0.003, OR=2.80, 95%CI 1.430-5.468; p=0.001, OR=2.57, 95%CI 1.462-4.498; respectively). Intensive care unit (ICU)-admission and age, but not COPD, were identified as independent predictors of short- and long-term mortality. Conclusion:Severity as well as mortality was significantly higher in COPD patients with CAP. To improve CAP management with the aim to decrease its still-too-high mortality, underlying comorbidities, particularly COPD, need to be assessed.

Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis

OBJECTIVES

A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department (ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death.

METHODS

A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related MeSH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome.

RESULTS

A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post-ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome (LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality (LR- = 0.27) and nursing home placement (LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased (LR+ range for various outcomes = 0.98 to 1.40) or decreased (LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%.

CONCLUSIONS

Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult.

Guía de consenso para el abordaje de la neumonía adquirida en la comunidad en el paciente anciano

La incidencia de la neumonía adquirida en la comunidad se incrementa con la edad y se asocia a una elevada morbimortalidad debido a los cambios fisiológicos asociados al envejecimiento y a una mayor presencia de enfermedades crónicas. Debido a la importancia que tiene desde un punto de epidemiológico y pronóstico, y a la enorme heterogeneidad descrita en el manejo clínico, creemos que existía la necesidad de realizar un documento de consenso específico para este perfil de paciente. El propósito de este fue realizar una revisión de las evidencias en relación con los factores de riesgo para la etiología, la presentación clínica, el manejo y el tratamiento de la neumonía adquirida en la comunidad en los ancianos con el fin de elaborar una serie de recomendaciones específicas basadas en el análisis crítico de la literatura. Este documento es fruto de la colaboración de diferentes especialistas en representación de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Sociedad Española de Geriatría y Gerontología (SEGG), Sociedad Española de Quimioterapia (SEQ), Sociedad Española de Medicina Interna (SEMI), Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Sociedad Española de Hospitalización a Domicilio (SEHAD) y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC).

Delirium is a predictor of in-hospital mortality in elderly patients with community acquired pneumonia

Community acquired pneumonia (CAP) is a common reason for hospitalization and death in elderly people. Many predictors of in-hospital outcome have been studied in the general population with CAP. However, data are lacking on the prognostic significance of conditions unique to older patients, such as delirium and the coexistence of multiple comorbidities. The aim of this study was to evaluate predictors of in-hospital outcome in elderly patients hospitalized for CAP. In this retrospective study, consecutive patients with CAP aged ≥65 years were enrolled between January 2011 and June 2012 in two general wards. Clinical and laboratory characteristics were collected from electronic medical records. The end-point of the study was the occurrence of in-hospital death. 443 patients (mean age 81.8 ± 7.5, range 65-99 years) were enrolled. More than 3 comorbidities were present in 31 % of patients. Mean confusion, blood urea nitrogen, respiratory rate, blood pressure and age ≥65 years (CURB-65) score was 2.5 ± 0.7 points. Mean length of stay was 7.6 ± 5.7 days. In-hospital death occurred in 54 patients (12.2 %). At multivariate analysis, independent predictors of in-hospital death were: chronic obstructive pulmonary disease (COPD) (OR 6.21, p = 0.005), occurrence of at least one episode of delirium (OR 5.69, p = 0.017), male sex (OR 5.10, p < 0.0001), and CURB-65 score (OR 3.98, p < 0.0001). Several predictors of in-hospital death (COPD, male gender, CURB-65) in patients with CAP older than 65 years are similar to those of younger patients. In this cohort of elderly patients, the occurrence of delirium was highly prevalent and represented a distinctive predictor of death.

Overview of community-acquired pneumonia and the role of inflammatory mechanisms in the immunopathogenesis of severe pneumococcal disease

Community-acquired pneumonia (CAP) remains a leading cause of morbidity and mortality among the infectious diseases. Despite the implementation of national pneumococcal polyvalent vaccine-based immunisation strategies targeted at high-risk groups, Streptococcus pneumoniae (the pneumococcus) remains the most common cause of CAP. Notwithstanding the HIV pandemic, major challenges confronting the control of CAP include the range of bacterial and viral pathogens causing this condition, the ever-increasing problem of antibiotic resistance worldwide, and increased vulnerability associated with steadily aging populations in developed countries. These and other risk factors, as well as diagnostic strategies, are covered in the first section of this review. Thereafter, the review is focused on the pneumococcus, specifically the major virulence factors of this microbial pathogen and their role in triggering overexuberant inflammatory responses which contribute to the immunopathogenesis of invasive disease. The final section of the review is devoted to a consideration of pharmacological, anti-inflammatory strategies with adjunctive potential in the antimicrobial chemotherapy of CAP. This is focused on macrolides, corticosteroids, and statins with respect to their modes of anti-inflammatory action, current status, and limitations.

Should clinicians use average or peak scores on a dynamic risk-assessment measure to most accurately predict inpatient aggression?

Recent advancements in risk assessment have led to the development of dynamic risk-assessment measures that are predictive of inpatient aggression in the short term. However, there are several areas within this field that warrant further empirical investigation, including whether the average, maximum, or most recent risk state assessment is the most valid for predicting subsequent aggression in the medium term. This prospective study compared the predictive validity of three indices (i.e. mean score, peak score, and most recent single time-point rating) of the Dynamic Appraisal of Situational Aggression (DASA) for inpatient aggression. Daily risk ratings were completed for 60 psychiatric inpatients (from the acute wards of a forensic psychiatric hospital) for up to 6 months; a total of 1054 DASA ratings were obtained. Results showed that mean and peak scores on the DASA were better predictors of interpersonal violence, verbal threat, and any inpatient aggression than the DASA single time-point most recent ratings. Overall, the results support the use of the prior week's mean and peak scores to aid the prediction of inpatient aggression within inpatient forensic psychiatric settings in the short to medium term. These results also have practical implications for clinicians considering risk-management strategies and the scoring of clinically-relevant items on risk-assessment measures.

Impact of diabetes mellitus on pneumonia mortality in a senior population: results from the NHANES III follow-up study

Objective

To examine whether diabetes mellitus increases the risk of pneumonia mortality among seniors in the U.S. general population.

Methods & Results

The NHANES III follow-up study data were used. After excluding individuals from other minorities, being hospitalized with pneumonia in the previous year at baseline, or death of pneumonia during the first year of follow-up, a total of 3,707 subjects aged 65 years or older (1,794 men and 1,913 women) who had no missing information on variables for the analysis were included. Approximately 16% of seniors at baseline were diabetics, which was defined as either having been diagnosed by a physician, currently taking pills/insulin lowering blood glucose, or HbA1c higher than 6.4%. During an average 11 years of follow-up, a total of 98 deaths due to pneumonia were recorded (ICD-10: J12–J18). Cox-regression models were used to estimate the risk association between pneumonia mortality and diabetes mellitus. After adjustment for the covariates at baseline, the hazard ratios of pneumonia death were 1.30 (95% CI: 0.64–2.70) for pre-diabetics and 2.28 (95% CI: 1.18–4.39) for diabetics, respectively. Among those covariates, only age (HR (95% CI); 1.16 (1.13–1.20)), gender as female (0.35 (0.22–0.61)) and physical fitness measured as having no problem walking 1⁺ mile during the previous month (0.38 (0.20–0.67)) reached statistical significance.

Conclusions

The results suggest that diabetes mellitus is a strong risk predictor of pneumonia mortality and the evaluation of physical fitness may also be useful in the risk prediction of pneumonia mortality for seniors.

Current management of patients hospitalized with community-acquired pneumonia across Europe: outcomes from REACH

BACKGROUND

Data describing real-life management and treatment of community-acquired pneumonia (CAP) in Europe are limited. REACH (http://NCT01293435) was a retrospective, observational study collecting data on the management of EU patients hospitalized with CAP.

METHODS

Patients were aged ≥18 years, hospitalized with CAP between March 2010 and February 2011, and requiring in-hospital treatment with intravenous antibiotics. An electronic Case Report Form was used to collect patient, disease and treatment variables, including type of CAP, medical history, treatment setting, antibiotics administered and clinical outcomes.

RESULTS

Patients (N = 2,039) were recruited from 128 centres in ten EU countries (Belgium, France, Germany, Greece, Italy, the Netherlands, Portugal, Spain, Turkey, UK). The majority of patients were aged ≥65 years (56.4%) and had CAP only (78.8%). Initial antibiotic treatment modification occurred in 28.9% of patients and was more likely in certain groups (patients with comorbidities; more severely ill patients; patients with healthcare-associated pneumonia, immunosuppression or recurrent episodes of CAP). Streamlining (de-escalation) of therapy occurred in 5.1% of patients. Mean length of hospital stay was 12.6 days and overall mortality was 7.2%.

CONCLUSION

These data provide a current overview of clinical practice in patients with CAP in EU hospitals, revealing high rates of initial antibiotic treatment modification. The findings may precipitate reassessment of optimal management regimens for hospitalized CAP patients.

Are proton pump inhibitors associated with the development of community-acquired pneumonia? A meta-analysis

This study was presented at the American College of Chest Physicians meeting in Pittsburgh (PA, USA) in October 2011. The study objective was to evaluate the association of proton pump inhibitors (PPIs) and community-acquired pneumonia (CAP). The design was a meta-analysis of nine case-controlled and cohort studies. 120,863 pneumonia cases from 1987 to 2006 were included in the meta-analysis. PubMed and Ovid Medline were searched from inception through May 2011 by two investigators independently using keywords: PPI, pneumonia, CAP, anti-ulcer, antacid, omeprazole, esomeprazole, lansoprazole, pantoprazole and rabeprazole. This meta-analysis only included case-controlled and cohort studies that were published in full in English and evaluated PPI use and CAP incidence. Studies were excluded if they included the following patients: pediatric, Helicobacter pylori treatment and critically ill. Bibliographies of recent review articles and systematic reviews were hand-searched. Quality of studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Two investigators independently extracted data into standardized data collection forms that were confirmed by a third investigator. Data were analyzed based on current use of PPIs, duration of PPI use (<30 days or >180 days) and PPI dose (high vs low). Overall association of PPI and CAP was analyzed using the random effects model (Comprehensive Meta analysis(®) Version 2.0). Nine studies met all criteria for the primary outcome. Newcastle-Ottawa Quality Assessment Scale scores ranged from 4 to 8 out of 9. Current use of PPIs (odds ratio [OR]: 1.39; 95% CI: 1.09-1.76), PPI use <30 days (OR: 1.65; 95% CI: 1.25-2.19), PPI high dose (OR: 1.50; 95% CI: 1.33-1.68) and PPI low dose (OR: 1.17; 95% CI: 1.11-1.24) were significantly associated with CAP. There was no association between CAP and PPI use >180 days (OR: 1.10; 95% CI: 1.00-1.21). In conclusion, patients currently receiving PPIs, particularly <30 days or high dose, showed an association with CAP. Practitioners need to be vigilant about adverse effects of PPIs and consider alternative therapies.

Clinical and temporal patterns of severe pneumonia causing critical illness during Hajj

BACKGROUND

Pneumonia is a leading cause of hospitalization during Hajj and susceptibility and transmission may be exacerbated by extreme spatial and temporal crowding. We describe the number and temporal onset, co-morbidities, and outcomes of severe pneumonia causing critical illness among pilgrims.

METHOD

A cohort study of all critically ill Hajj patients, of over 40 nationalities, admitted to 15 hospitals in 2 cities in 2009 and 2010. Demographic, clinical, and laboratory data, and variables necessary for calculation of the Acute Physiology and Chronic Health Evaluation IV scores were collected.

RESULTS

There were 452 patients (64.6% male) who developed critical illness. Pneumonia was the primary cause of critical illness in 123 (27.2%) of all intensive care unit (ICU) admissions during Hajj. Pneumonia was community (Hajj)-acquired in 66.7%, aspiration-related in 25.2%, nosocomial in 3.3%, and tuberculous in 4.9%. Pneumonia occurred most commonly in the second week of Hajj, 95 (77.2%) occurred between days 5-15 of Hajj, corresponding to the period of most extreme pilgrim density. Mechanical ventilation was performed in 69.1%. Median duration of ICU stay was 4 (interquartile range [IQR] 1-8) days and duration of ventilation 4 (IQR 3-6) days. Commonest preexisting co-morbidities included smoking (22.8%), diabetes (32.5%), and COPD (17.1%). Short-term mortality (during the 3-week period of Hajj) was 19.5%.

CONCLUSION

Pneumonia is a major cause of critical illness during Hajj and occurs amidst substantial crowding and pilgrim density. Increased efforts at prevention for at risk pilgrim prior to Hajj and further attention to spatial and physical crowding during Hajj may attenuate this risk.