Nutritional risk as predictor for healthcare-associated infection among hospitalized elderly patients in the acute care setting

Derivation and validation of a nomogram for predicting nonventilator hospital-acquired pneumonia among older hospitalized patients

Background

Currently, there is no effective tool for predicting the risk of nonventilator hospital-acquired pneumonia (NV-HAP) in older hospitalized patients. The current study aimed to develop and validate a simple nomogram and a dynamic web-based calculator for predicting the risk of NV-HAP among older hospitalized patients.

Methods

A retrospective evaluation was conducted on 15,420 consecutive older hospitalized patients admitted to a tertiary hospital in China between September 2017 and June 2020. The patients were randomly divided into training (n = 10,796) and validation (n = 4624) cohorts at a ratio of 7:3. Predictors of NV-HAP were screened using the least absolute shrinkage and selection operator method and multivariate logistic regression. The identified predictors were integrated to construct a nomogram using R software. Furthermore, the optimum cut-off value for the clinical application of the model was calculated using the Youden index. The concordance index (C-index), GiViTI calibration belts, and decision curve were analysed to validate the discrimination, calibration, and clinical utility of the model, respectively. Finally, a dynamic web-based calculator was developed to facilitate utilization of the nomogram.

Results

Predictors included in the nomogram were the Charlson comorbidity index, NRS-2002, enteral tube feeding, Barthel Index, use of sedatives, use of NSAIDs, use of inhaled steroids, and "time at risk". The C-index of the nomogram for the training and validation cohorts was 0.813 and 0.821, respectively. The 95% CI region of the GiViTI calibration belt in the training (P = 0.694) and validation (P = 0.614) cohorts did not cross the diagonal bisector line, suggesting that the prediction model had good discrimination and calibration. Furthermore, the optimal cut-off values for the training and validation cohorts were 1.58 and 1.74%, respectively. Analysis of the decision curve showed that the nomogram had good clinical value when the threshold likelihood was between 0 and 49%.

Conclusion

The developed nomogram can be used to predict the risk of NV-HAP among older hospitalized patients. It can, therefore, help healthcare providers initiate targeted medical interventions in a timely manner for high-risk groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01941-z.

Nutritional risk screening score as an independent predictor of nonventilator hospital-acquired pneumonia: a cohort study of 67,280 patients

BACKGROUND

Currently, the association of nutritional risk screening score with the development of nonventilator hospital-acquired pneumonia (NV-HAP) is unknown. This study investigated whether nutritional risk screening score is an independent predictor of NV-HAP.

METHODS

This retrospective cohort study was conducted between September 2017 and June 2020 in a tertiary hospital in China. The tool of Nutritional Risk Screening 2002 (NRS-2002) was used for nutritional risk screening. A total score of ≥3 indicated a patient was "at nutritional risk." Logistic regression was applied to explore the association between the NRS score and NV-HAP.

RESULTS

A total of 67,280 unique patients were included in the study. The incidence of NV-HAP in the cohort for the NRS < 3 and ≥ 3 NRS group was 0.4% (232/62702) and 2.6% (121/4578), respectively. In a multivariable logistic regression model adjusted for all of the covariates, per 1-point increase in the NRS score was associated with a 30% higher risk of NV-HAP (OR = 1.30; 95%CI:1.19-1.43). Similarly, patients with NRS score ≥ 3 had a higher risk of NV-HAP with an odds ratio (OR) of 2.06 (confidence interval (CI): 1.58-2.70) than those with NRS score < 3. Subgroup analyses indicated that the association between the NRS score and the risk of NV-HAP was similar for most strata. Furthermore, the interaction analyses revealed no interactive role in the association between NRS score and NV-HAP.

CONCLUSION

NRS score is an independent predictor of NV-HAP, irrespective of the patient's characteristics. NRS-2002 has the potential as a convenient tool for risk stratification of adult hospitalized patients with different NV-HAP risks.

Global Leadership Initiative on Malnutrition Criteria Predict Pulmonary Complications and 90-Day Mortality after Major Abdominal Surgery in Cancer Patients

Although several studies have reported an association between malnutrition and the risk of severe complications after abdominal surgery, there have been no studies evaluating the use of Global Leadership Initiative on Malnutrition (GLIM) criteria for predicting postoperative pulmonary complications (PPCs) following major abdominal surgery in cancer patients. This study aimed to investigate the association among the diagnosis of malnutrition by GLIM criteria, PPCs risk and 90-day all-cause mortality rate following major abdominal surgery in cancer patients. We prospectively analyzed 218 patients (45% male, mean age 70.6 ± 11.2 years) with gastrointestinal cancer who underwent major abdominal surgery at our hospital between October 2018 and December 2019. Patients were assessed preoperatively using GLIM criteria of malnutrition, and 90-day all-cause mortality and PPCs were recorded. In total, 70 patients (32.1%) were identified as malnourished according to GLIM criteria, of whom 41.1% fulfilled the criteria for moderate and 12.6% for severe malnutrition. PPCs were detected in 48 of 218 patients (22%) who underwent major abdominal surgery. Univariate logistic regression analysis revealed that the diagnosis of malnutrition was significantly associated with the risk of PPCs. Furthermore, in multivariate model analysis adjusted for other clinical confounding factors, malnutrition remained an independent factor associated with the risk of PPCs (RR = 1.82; CI = 1.21–2.73) and 90-day all-cause mortality (RR = 1.97; CI = 1.28–2.63, for severely malnourished patients). In conclusion, preoperative presence of malnutrition, diagnosed by the use of GLIM criteria, is associated with the risk of PPCs and 90-day mortality rate in cancer patients undergoing major abdominal surgery.

Usefulness of the Geriatric Nutritional Risk Index to predict the severity of cholecystitis among older patients in the emergency department

AIM

We sought to investigate whether the Geriatric Nutritional Risk Index is associated with systemic organ dysfunction among older patients who present with cholecystitis to the emergency department.

METHODS

This was an observational retrospective study among consecutive older patients with cholecystitis in the emergency department from 2012 to 2018. We collected baseline characteristics and laboratory data, and re-categorized the Geriatric Nutritional Risk Index into three risk groups. We carried out univariate and multivariate analyses to identify factors associated with systemic organ dysfunction. Logistic regression was used for statistical analysis.

RESULTS

A total of 303 patients were included in this study. The median age of participants was 74 years (interquartile range 68-79 years). The overall proportion of systemic organ dysfunction was 26.4%. The Geriatric Nutritional Risk Index was stratified as: ≥98 (n = 183, systemic organ dysfunction 15.3%), 87 to <98 (n = 90, systemic organ dysfunction 38.9%) and <87 (n = 30, systemic organ dysfunction 56.7%). Multivariate analysis using a logistic regression model showed that age, respiratory rate, temperature, geriatric nutritional risk index and quick Sepsis-related Organ Failure Assessment score in the emergency department were independently associated with systemic organ dysfunction in patients with cholecystitis.

CONCLUSIONS

The Geriatric Nutritional Risk Index was recognized as an independent factor associated with systemic organ dysfunction in older patients in the emergency department who presented with cholecystitis. This index might be helpful in screening patient risk and deciding whether to carry out further tests. Geriatr Gerontol Int 2020; 20: 455-460.

Food for thought. Malnutrition risk associated with increased risk of healthcare-associated infection

BACKGROUND

Infection and malnutrition are interconnected. UK and Irish guidelines recommend the Malnutrition Universal Screening Tool (MUST) for nutritional risk screening. Patients with a MUST score of ≥2 are considered at high risk of malnutrition and referral for nutritional assessment is recommended.

AIM

To explore the association between healthcare-associated infection (HCAI) and the MUST score categories of patients.

METHODS

This was a cross-sectional study in May 2017 on ten representative wards in our institution. Patient demographics, MUST score, presence of medical devices, HCAI and antimicrobial use were collected.

FINDINGS

Of 240 patients, the HCAI prevalence was 10.4% (N = 25) and 26% (N = 63) were at high risk of malnutrition (MUST score ≥2). Patients with HCAI were more likely to have had surgery (odds ratio (OR): 5.5; confidence interval (CI): 2.1-14.3; P < 0.001), a central vascular catheter (OR: 10.0; CI: 3.6-27.2; P < 0.001), or a urinary catheter in situ (OR: 7.5; CI: 2.8-20.0; P < 0.001), and to have a high risk of malnutrition (OR: 4.3; CI: 1.7-11.2; P < 0.001). A higher MUST score remained a significant predictor of a patient having HCAI on multivariate regression analysis (CI: 0.2-0.6; P < 0.001).

CONCLUSION

Patients at risk of malnutrition when assessed with the MUST were more likely to have HCAI. However, prospective studies are required to investigate the temporal association between MUST and HCAI and which interventions best address malnutrition risk and HCAI reduction in different settings.

Geriatric Nutritional Risk Index as a prognostic factor in patients with esophageal squamous cell carcinoma -retrospective cohort study

PURPOSE

The Geriatric Nutritional Risk Index (GNRI) is a new index recently introduced to predict the risk of nutrition-related complications and mortality. Our aim is to examine the association between the GNRI and long-term prognosis in patients with esophageal squamous cell carcinoma (ESCC) who underwent esophagectomy.

METHODS

The present study enrolled consecutive 216 patients with ESCC who underwent esophagectomy. The GNRI at admission to the hospital was calculated as follows: (1.489 × albumin, g/l) + (41.7 × present/ideal body weight). The characteristics and long-term prognosis were compared between four groups: the severe risk (GNRI: <82), moderate risk (GNRI: 82 to <92), low risk (GNRI: 92 to <98) and no risk (GNRI: >98) groups. The 5-year overall survival and independent prognostic factors were investigated, respectively.

RESULTS

A decreased GNRI significantly correlated with unfavorable overall survival (p < 0.001). In all patients, a multivariate analysis demonstrated that the severe and moderate risk groups (GNRI: <92) (hazard ratio 0.50; p = 0.002), T factor (≥T2) (hazard ratio 0.52; p = 0.026), and N positive factor (hazard ratio 0.47; p = 0.004) were independent prognostic factors. In the subgroup analysis, which excluded patients with preoperative chemoradiotherapy, the severe and moderate risk groups (GNRI: <92) (hazard ratio 0.48; p = 0.0057), and T factor (≥T2) (hazard ratio; p = 0.021) were independent prognostic factors.

CONCLUSIONS

GNRI is considered to be a useful prognostic factor in patients with ESCC undergoing esophagectomy.

The Geriatric Nutritional Risk Index Predicts Survival in Elderly Esophageal Squamous Cell Carcinoma Patients with Radiotherapy

The impact of nutritional status on survival among elderly esophageal squamous cell carcinoma (ESCC) patients undergoing radiotherapy is unclear. In this study, we aimed at validating the performance of the geriatric nutritional risk index (GNRI) in predicting overall survival time in elderly ESCC patients with radiotherapy. A retrospective cohort study was conducted on 239 ESCC patients aged 60 and over admitted consecutively from January 2008 to November 2014 in the Department of Radiotherapy, Henan Tumor Hospital (Affiliated Tumor Hospital of Zhengzhou University), Zhengzhou, Henan, China. All patients were subjected to nutritional screening using GNRI, and were followed for the occurrence of lymphatic node metastasis, radiation complication and mortality. The Kaplan-Meier method with Log-rank test was used to estimate survival curves. Univariable Cox regression analysis was used to identify variables associated with overall survival time. Among the 239 patients, 184 patients (76.9%) took no nutritional risk, 32 patients (13.4%) took moderate risk of malnutrition, and 23 patients (9.7%) took a high risk of malnutrition. Univariable Cox regression showed that both high nutritional risk group and moderate nutritional risk group were significantly less likely to survive than no nutritional risk patients (hazard ratio (HR) = 1.688, 95% confidence interval (CI) = 1.019-2.798 for moderate risk group, and HR = 2.699, 95% CI = 1.512-4.819 for high risk group, respectively). The GNRI is an independent prognostic factor for overall survival time in elderly ESCC patients with radiotherapy. A GNRI ≤98 can be suggested as an indicator of surviving less.

Is the Geriatric Nutritional Risk Index a Significant Predictor of Postoperative Complications in Patients with Esophageal Cancer Undergoing Esophagectomy?

Background: The Geriatric Nutritional Risk Index (GNRI) is a new index recently introduced for predicting the risk of nutrition-related complications. The GNRI has mainly been reported as a simple and accurate tool to assess the nutritional status and prognosis of elderly patients. So far, there have been no reports of the GNRI in patients with gastrointestinal cancer. Our objective was to examine the association between the GNRI and short-term outcomes, especially postoperative complications, in patients with esophageal cancer who underwent esophagectomy and gastric tube reconstruction. Materials and Methods: The present study enrolled 122 consecutive patients with esophageal cancer who underwent esophagectomy and gastric tube reconstruction. The GNRI at admission to the hospital was calculated as follows: (1.489 × albumin in g/l) + (41.7 × present/ideal body weight). The characteristics and short-term outcomes were compared between two groups: the high (GNRI ≥90) and the low (GNRI <90) GNRI group. The mortality and morbidity rates, especially the rates regarding respiratory complications and anastomotic leakage, were investigated. Results: The mean age of the 122 patients was 63.9 ± 9.1 years (range 43-83). There were no significant differences in either patient or operative characteristics. The low GNRI group had a significantly higher rate of respiratory complications (p = 0.002). A multivariate analysis demonstrated that the GNRI was the only independent significant factor predicting respiratory complications (hazard ratio 3.41, 95% confidence interval 1.19-9.76; p = 0.022). Conclusion: The GNRI is considered to be a clinically useful marker that can be used to assess the nutritional status and predict the development of postoperative respiratory complications in patients with esophageal cancer undergoing esophagectomy and gastric tube reconstruction.

The Geriatric Nutritional Risk Index predicts hospital length of stay and in-hospital weight loss in elderly patients

BACKGROUND & AIMS

Nutritional derangements are common in elderly patients, but how nutritional risk affects outcome in this subset of hospital inpatients deserves further investigation. We evaluated the impact of nutritional risk on length of stay (LOS) and in-hospital weight loss (WL) in elderly patients (>65 yrs).

METHODS

Nutritional risk was assessed by the Geriatric Nutritional Risk Index (GNRI) in a prospective multicentre hospital-based cohort study. The outcomes were LOS and in-hospital WL.

RESULTS

In the whole sample (N = 667), the prevalence of high (GNRI < 92) and mild (GNRI: 92-98) nutritional risk were 33% and 25%, respectively. Patients with a high nutritional risk were more likely (OR = 1.89; 95%CI: 1.22-2.92) to stay longer in hospital (fourth quartile, LOS ≥ 20 days) compared to those without. Other factors associated with prolonged LOS were cancer diagnosis (OR = 2.52; 95%CI: 1.69-3.75), the presence of comorbidities (OR = 1.24; 95%CI: 1.11-1.40) and surgical setting (OR = 1.65; 95%CI: 1.10-2.47). In-hospital WL ≥ 5% was recorded in 75 ambulant patients from a representative subgroup (N = 583). It was independently associated with prolonged LOS (OR = 1.80; 95%CI: 1.03-3.06) and was more frequent among cancer patients (OR = 1.88; 95%CI: 1.09-3.24), in patients with a high nutritional risk (OR = 2.23; 95%CI: 1.20-4.14) or those admitted to surgical units (OR = 1.77; 95%CI: 1.02-3.05).

CONCLUSIONS

Nutritional risk assessed by the GNRI on admission, predicts LOS and in-hospital WL in elderly patients.