Evaluation of pneumonia severity scoring systems in nursing and healthcare-associated pneumonia for predicting prognosis: A prospective, cohort study

Utility of pneumonia severity assessment tools for mortality prediction in healthcare-associated pneumonia: a systematic review and meta-analysis

Accurate prognostic tools for mortality in patients with healthcare-associated pneumonia (HCAP) are needed to provide appropriate medical care, but the efficacy for mortality prediction of tools like PSI, A-DROP, I-ROAD, and CURB-65, widely used for predicting mortality in community-acquired and hospital-acquired pneumonia cases, remains controversial. In this study, we conducted a systematic review and meta-analysis using PubMed, Cochrane Library (trials), and Ichushi web database (accessed on August 22, 2022). We identified articles evaluating either PSI, A-DROP, I-ROAD, or CURB-65 and the mortality outcome in patients with HCAP, and calculated the pooled sensitivities, specificities, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the summary area under the curves (AUCs) for mortality prediction. Additionally, the differences in predicting prognosis among these four assessment tools were evaluated using overall AUCs pooled from AUC values reported in included studies. Eventually, 21 articles were included and these quality assessments were evaluated by QUADAS-2. Using a cut-off value of moderate in patients with HCAP, the range of pooled sensitivity, specificity, PLR, NLR, and DOR were found to be 0.91-0.97, 0.15-0.44, 1.14-1.66, 0.18-0.33, and 3.86-9.32, respectively. Upon using a cut-off value of severe in those patients, the range of pooled sensitivity, specificity, PLR, NLR, and DOR were 0.63-0.70, 0.54-0.66, 1.50-2.03, 0.47-0.58, and 2.66-4.32, respectively. Overall AUCs were 0.70 (0.68-0.72), 0.70 (0.63-0.76), 0.68 (0.64-0.73), and 0.67 (0.63-0.71), respectively, for PSI, A-DROP, I-ROAD, and CURB-65 (p = 0.66). In conclusion, these severity assessment tools do not have enough ability to predict mortality in HCAP patients. Furthermore, there are no significant differences in predictive performance among these four severity assessment tools.

Practical Utility of a Clinical Pathway for Older Patients with Aspiration Pneumonia: A Single-Center Retrospective Observational Study

Introduction: Clinical pathways (CPWs) are patient management tools based on a standardized treatment plan aimed at improving quality of care. This study aimed to investigate whether CPW-guided treatment has a favorable impact on the outcomes of hospitalized older patients with aspiration pneumonia. Method: This retrospective study included patients with aspiration pneumonia, aged ≥ 65 years, and hospitalized at a community hospital in Japan. CPW implementation was arbitrarily determined by the attending physician upon admission. Outcomes were compared according to with or without the CPW (CPW-group and non-CPW groups). Propensity score (PS)-based analyses were used to control for confounding factors. Logistic regression analyses were conducted to evaluate the impact of CPW on the clinical course and outcomes. Results: Of 596 included patients, 167 (28%) received the CPW-guided treatment. The mortality rate was 16.4%. In multivariable model, CPW implementation did not increase the risk for total and 30-day mortality, and resulted in shorter antibiotic therapy duration (≤9 days) (PS matching (PSM): odds ratio (OR) 0.50, p = 0.001; inverse provability of treatment weighting (IPTW): OR 0.48, p < 0.001) and length of hospital stay (≤21 days) (PSM: OR 0.67, p = 0.05; IPTW: OR 0.66, p = 0.03). Conclusions: This study support CPW utility in this population.

Ten Issues to Update in Nosocomial or Hospital-Acquired Pneumonia: An Expert Review

Nosocomial pneumonia, or hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) are important health problems worldwide, with both being associated with substantial morbidity and mortality. HAP is currently the main cause of death from nosocomial infection in critically ill patients. Although guidelines for the approach to this infection model are widely implemented in international health systems and clinical teams, information continually emerges that generates debate or requires updating in its management. This scientific manuscript, written by a multidisciplinary team of specialists, reviews the most important issues in the approach to this important infectious respiratory syndrome, and it updates various topics, such as a renewed etiological perspective for updating the use of new molecular platforms or imaging techniques, including the microbiological diagnostic stewardship in different clinical settings and using appropriate rapid techniques on invasive respiratory specimens. It also reviews both Intensive Care Unit admission criteria and those of clinical stability to discharge, as well as those of therapeutic failure and rescue treatment options. An update on antibiotic therapy in the context of bacterial multiresistance, in aerosol inhaled treatment options, oxygen therapy, or ventilatory support, is presented. It also analyzes the out-of-hospital management of nosocomial pneumonia requiring complete antibiotic therapy externally on an outpatient basis, as well as the main factors for readmission and an approach to management in the emergency department. Finally, the main strategies for prevention and prophylactic measures, many of them still controversial, on fragile and vulnerable hosts are reviewed.

Positive Rate and Utility of Blood Culture among Nursing and Healthcare-associated Pneumonia Inpatients: A Cross-sectional Study

Objective Although blood cultures to identify the presence of bacteremia are recommended for nursing- and healthcare-associated pneumonia (NHCAP), the incidence of true bacteremia and the relationship between true bacteremia and the outcome remain unclear. Physicians can therefore sometimes be confused regarding whether or not blood cultures should be obtained for NHCAP patients. This study assessed the incidence of true bacteremia and the relationship between true bacteremia and the outcome of NHCAP in a Japanese hospital setting. Methods We retrospectively analyzed NHCAP patients hospitalized between April 2016 and March 2021. The primary outcome was the incidence of true bacteremia in blood cultures. The incidence of true bacteremia was also examined according to quick Sequential Organ Failure Assessment (qSOFA) and A-DROP scores. In addition, we compared the incidence of true bacteremia between survivors and non-survivors. Results In total, 205 patients were included in this study. Blood cultures were obtained from 150 of the 205 patients (73.2%). Positive blood cultures were detected in 26 patients (17.3%), of which only 8 cases (5.3%; 95% confidence interval, 2.3-10.2%) were considered true bacteremia. Trend analyses for the incidence of true bacteremia according to qSOFA and A-DROP scores did not show any statistically significant results (p=0.49 for qSOFA; p=0.14 for A-DROP). The proportion of true bacteremia cases did not differ significantly between survivors and non-survivors. Conclusions The incidence of true bacteremia among NHCAP patients was very low. A strategy for determining indications for obtaining blood cultures from NHCAP patients needs to be established.

Establishment and Validation of the Risk Nomogram of Poor Prognosis in Patients with Severe Pulmonary Infection Complicated with Respiratory Failure

Objective

To investigate the prognosis of patients with severe pulmonary infection combined with respiratory failure and analyze the influencing factors of prognosis.

Methods

The clinical data of 218 patients with severe pneumonia complicated with respiratory failure were retrospectively analyzed. The risk factors were analyzed by univariate and multivariate logistic regression analyses. The risk nomogram and Bootstrap self-sampling method were used for internal inspection. Calibration curves and receiver operating characteristic (ROC) curve were drawn to assess the predictive ability of the model.

Results

Among 218 patients, 118 (54.13%) cases had a good prognosis and 100 (45.87%) cases had a poor prognosis. Multivariate logistic regression analysis showed that the number of complicated basic diseases ≥5, APACHE II score >20, MODS score >10, PSI score >90, and multi-drug resistant bacterial infection were independent risk factors affecting the prognosis (P<0.05), and the level of Alb was an independent protective factor (P<0.05). The consistency index (C-index) was 0.775, and the Hosmer Lemeshow goodness-of-fit test showed that the model was not significant (P>0.05). The area under the curve (AUC) was 0.813 (95% CI: 0.778~0.895), with the sensitivity of 83.20%, and the specificity of 77.00%.

Conclusion

The risk nomograph model had good discrimination and accuracy in predicting the prognosis of patients with severe pulmonary infection combined with respiratory failure, which may provide a basis for early identification and intervention of patients at clinical risk and improve the prognosis.

Assessment of the pneumonia severity score in community-acquired and nursing and healthcare-associated pneumonia due to COVID-19

INTRODUCTION

The Japanese Respiratory Society (JRS) pneumonia guidelines recommend simple predictive rules, the A-DROP scoring system, for assessment of the severity of community-acquired pneumonia (CAP) and nursing and healthcare-associated pneumonia (NHCAP). We evaluated whether the A-DROP system can be adapted for assessment of the severity of coronavirus disease 2019 (COVID-19) pneumonia.

METHODS

Data from 1141 patients with COVID-19 pneumonia were analyzed, comprising 502 patients observed in the 1st to 3rd wave period, 338 patients in the 4th wave and 301 patients in the 5th wave in Japan.

RESULTS

The mortality rate and mechanical ventilation rate were 0% and 1.4% in patients classified with mild disease (A-DROP score, 0 point), 3.2% and 46.7% in those with moderate disease (1 or 2 points), 20.8% and 78.3% with severe disease (3 points), and 55.0% and 100% with extremely severe disease (4 or 5 points), indicating an increase in the mortality and mechanical ventilation rates in accordance with severity (Cochran-Armitage trend test; p = <0.001). This significant relationship between the severity in the A-DROP scoring system and either the mortality rate or mechanical ventilation rate was observed in patients with COVID-19 CAP and NHCAP. In each of the five COVID-19 waves, the same significant relationship was observed.

CONCLUSIONS

The mortality rate and mechanical ventilation rate in patients with COVID-19 pneumonia increased depending on severity classified according to the A-DROP scoring system. Our results suggest that the A-DROP scoring system can be adapted for the assessment of severity of COVID-19 CAP and NHCAP.

Predictive Value of the Pneumonia Severity Score on Mortality due to Aspiration Pneumonia

Objective: Designing an efficient management strategy for aspiration is of high priority in our aging society because of its high incidence. We evaluated the prognostic value of both the A-DROP (age, dehydration, respiratory, disorientation, and pressure) and the modified A-DROP scoring systems (adding respiratory rate and comorbidity to A-DROP) in patients with aspiration pneumonia.Design: This is a retrospective study using electronic medical records at Saitama Medical University (SMU) hospital.Setting: A 965-bed university tertiary medical center in Japan.Participants: Data were extracted from the electronic medical records of patients from SMU hospital.Methods: In-hospital mortality was compared between two groups: (1) those with a 'severe' to 'advanced severe' A-DROP score; and (2) those with a 'low' to 'middle' A-DROP score. Area under the curve (AUC) for mortality for both the A-DROP and modified A-DROP scoring systems were compared.Results: The in-hospital mortality rates for patients with a high and a low A-DROP score were 28.6% and 9.0%, respectively. The mortality rates in the high modified A-DROP score group and in the low modified A-DROP score group were 28.2% and 9.9%, respectively. These differences in the mortality rates between the two groups were statistically significant for both the A-DROP and the modified A-DROP scoring systems. The AUC of the receiver operating characteristics curve for the A-DROP (0.700; 95% confidence interval, 0.608-0.779) was statistically significant.Conclusion: The A-DROP and modified A-DROP scoring systems are associated with in-hospital mortality in patients with aspiration pneumonia. The A-DROP scoring system is easy to use and may be a clinically valuable tool in the management of aspiration pneumonia.

The Performance of CURB-65 and PSI for Predicting In-Hospital Mortality of Community-Acquired Pneumonia in Patients with Type 2 Diabetes Compared with the Non-Diabetic Population

OBJECTIVE

To compare the performance of CURB-65 and Pneumonia Severity Index (PSI) for predicting in-hospital mortality of community-acquired pneumonia (CAP) between patients with and without type 2 diabetes (T2DM).

METHODS

A retrospective study was conducted on 2365 CAP patients in The First Hospital of Qinhuangdao, China. The primary outcome was in-hospital mortality. The area under curves (AUCs) was used to evaluate the abilities of CRB-65, CURB-65, and PSI class for predicting in-hospital mortality in patients with CAP.

RESULTS

Among CAP patients, 127 patients (5.4%) died, 80 patients were without diabetes, and 47 patients had T2DM. In-hospital mortality increased with the risk stratification defined as CURB-65 and PSI class in both non-diabetes and T2DM patients (P<0.05). The AUCs for predicting in-hospital mortality were 0.728～0.798 in patients without T2DM (CRB-65: 0.728, CURB-65: 0.757 and PSI class: 0.798) and 0.641～0.716 in patients with T2DM (CRB-65: 0.641, CURB-65: 0.677 and PSI class: 0.716)(P<0.001). The AUC of the PSI class was lower in patients with T2DM than in patients without T2DM (P<0.05).

CONCLUSION

CURB-65 and PSI class are correlated with in-hospital mortality of CAP in patients with and without T2DM. Compared with non-diabetes patients, the predictive performance of CURB-65 and PSI class decreased in patients with T2DM. A prediction model for evaluating the CAP severity in the T2DM population should be developed by future studies.

Effects of Early Dysphagia Rehabilitation by Speech-language-hearing Therapists on Patients with Severe Aspiration Pneumonia

Objective:

To clarify the effect of early dysphagia rehabilitation, early rehabilitation was started within 2 days of admission by speech-language-hearing therapists in patients with severe aspiration pneumonia.

Methods:

The subjects were inpatients with severe aspiration pneumonia (A-DROP≥3) admitted to our hospital between April 2014 and March 2019. We retrospectively investigated patient age, sex, A-DROP score, community-acquired or nursing- and healthcare-associated pneumonia, invasive and noninvasive ventilation, comorbidities, nutritional risk, admission from nursing home, discharge to nursing home, walking ability before admission and at discharge, Food Intake LEVEL Scale (FILS) score at the start of rehabilitation and at discharge, the achievement of oral intake, alternative nutrition in use at discharge, number of days from admission to the start of rehabilitation, and number of days from admission to oral intake. We compared the patient characteristics and rehabilitation outcomes between 159 patients who underwent early dysphagia rehabilitation and 67 patients who underwent later dysphagia rehabilitation. To assess the association between alternative nutrition at discharge and early dysphagia rehabilitation, binominal logistic regression analysis was performed.

Results:

Early dysphagia rehabilitation was significantly associated with shorter hospital stays, fewer discharges to nursing homes, higher likelihood of oral intake, the removal of alternative nutrition at discharge, fewer days from admission to oral intake, and higher FILS scores at discharge. Early dysphagia rehabilitation was significantly associated with no alternative nutrition at discharge in binominal logistic regression analysis (odds ratio 3.26; P <0.01).

Conclusions:

This study suggested that early dysphagia rehabilitation was effective in improving outcomes of severe aspiration pneumonia including the removal of alternative nutrition at discharge.

Prognostic factors in nursing and healthcare-associated pneumonia

BACKGROUND AND OBJECTIVE

Nursing and healthcare-associated pneumonia (NHCAP) is a category of healthcare-associated pneumonia modified for the healthcare system in Japan. To date, only a few studies have examined the prognostic factors of NHCAP in a prospective cohort. This study aimed to investigate the prognostic factors related to 30-day mortality in patients with NHCAP by analyzing prospective data.

METHODS

We analyzed patients hospitalized for NHCAP who were enrolled between October 2010 and February 2017. Age, sex, comorbidities, vital signs and laboratory findings were used as prognostic variables. The primary outcome was 30-day mortality.

RESULTS

Of 817 NHCAP patients identified, the mean age was 78.0 ± 11.1 years, 580 (71.0%) were men and 30-day mortality was 13.1% (107/817). On multivariate analysis, male sex (odds ratio [OR]: 2.07, 95% confidence interval [CI]: 1.18-3.63), malignancy (OR: 2.35, 95%CI: 1.38-4.01), performance status (PS) (OR: 1.55, 95%CI: 1.23-1.96), body temperature (OR: 0.77, 95%CI: 0.61-0.97), heart rate (OR: 1.02, 95%CI: 1.01-1.03), respiratory rate (OR: 1.04, 95%CI: 1.01-1.08), serum albumin (Alb) (OR: 0.45, 95%CI: 0.30-0.66) and blood urea nitrogen (BUN) (OR: 1.02, 95%CI: 1.01-1.03) were significantly related to 30-day mortality. On the other hand, the risk factors for involvement by drug-resistant pathogens predicted a better prognosis (OR: 0.39, 95%CI: 0.19-0.82).

CONCLUSIONS

Male sex, malignancy, poor PS, hypothermia, tachycardia, tachypnea, low serum Alb and high BUN are worse prognostic factors. Thus, the risk of drug-resistant pathogens is not necessarily related to poor prognosis.