Definition of hospital-acquired pneumonia and characteristics of guidelines in Japan

The evaluation of next-generation sequencing assisted pathogenic detection in immunocompromised hosts with pulmonary infection: A retrospective study

INTRODUCTION

Pulmonary infections are frequent in immunocompromised hosts (ICH), and microbial detection is difficult. As a new method, next-generation sequencing (NGS) may offer a solution.

OBJECTIVES

This study aimed to assess the impact of NGS-assisted pathogenic detection on the diagnosis, treatment, and outcomes of ICH complicated by pulmonary infection and radiographic evidence of bilateral diffuse lesions.

METHODS

This study enrolled 356 patients with ICH complicated by pulmonary infection that were admitted to Zhongshan Hospital, Fudan University, from November 17, 2017, to November 23, 2018, including 102 and 254 in the NGS and non-NGS groups, respectively. Clinical characteristics, detection time, rough positive rate, effective positive rate, impact on anti-infective treatment plan, 30-day/60-day mortality, and in-hospital mortality were compared.

RESULTS

NGS-assisted pathogenic detection reduced detection time (28.2 h [interquartile range (IQR) 25.9-29.83 h] vs. 50.50 h [IQR 47.90-90.91 h], P < 0.001), increased positive rate, rate of mixed infection detected, effective positive rate, and proportion of antibiotic treatment modification (45.28% vs. 89.22%, 4.72% vs. 51.96%, 21.65% vs. 64.71%, 16.54% vs. 46.08%, P < 0.001). The NGS group had a significantly lower 60-day mortality rate (18.63% vs. 33.07%, P = 0.007). The difference in the Kaplan-Meier survival curve was significant (P = 0.029). After multivariate logistic regression, NGS-assisted pathogenic detection remained a significant predictor of survival (OR 0.189, confidence interval [CI], 0.068-0.526).

CONCLUSION

NGS-assisted pathogenic detection may improve detection efficiency and is associated with better clinical outcomes in these patients.

Impact of a learning health system on acute care and medical complications after intracerebral hemorrhage

INTRODUCTION

Patients with stroke often experience pneumonia during the acute stage after stroke onset. Oral care may be effective in reducing the risk of stroke-associated pneumonia (SAP). We aimed to determine the changes in oral care, as well as the incidence of SAP, in patients with intracerebral hemorrhage, following implementation of a learning health system in our hospital.

METHODS

We retrospectively analyzed the data of 1716 patients with intracerebral hemorrhage who were hospitalized at a single stroke center in Japan between January 2012 and December 2018. Data were stratified on the basis of three periods of evolving oral care: period A, during which conventional, empirically driven oral care was provided (n = 725); period B, during which standardized oral care was introduced, with SAP prophylaxis based on known risk factors (n = 469); and period C, during which oral care was risk-appropriate based on learning health system data (n = 522). Logistic regression analysis was performed to evaluate associations between each of the three treatment approaches and the risk of SAP.

RESULTS

Among the included patients, the mean age was 71.3 ± 13.6 years; 52.6% of patients were men. During the course of each period, the frequency of oral care within 24 hours of admission increased (P < .001), as did the adherence rate to oral care ≥3 times per day (P < .001). After adjustment for confounding factors, a change in the risk of SAP was not observed in period B; however, the risk significantly decreased in period C (odds ratio 0.61; 95% confidence interval 0.43-0.87) compared with period A. These associations were maintained for SAP diagnosed using strict clinical criteria or after exclusion of 174 patients who underwent neurosurgical treatment.

CONCLUSIONS

Risk-appropriate care informed by the use of learning health system data could improve care and potentially reduce the risk of SAP in patients with intracerebral hemorrhage in the acute stage.

Quality of life after robot-assisted transmediastinal radical surgery for esophageal cancer

Background

The aim of this retrospective study was to assess postoperative quality of life (QOL) after robot-assisted radical transmediastinal esophagectomy, defined as a nontransthoracic esophagectomy with radical mediastinal lymphadenectomy combining a robotic transhiatal approach and a video-assisted cervical approach. The results were compared to those of transthoracic esophagectomy.

Methods

In this study, all consecutive patients who underwent robot-assisted radical transmediastinal esophagectomy or transthoracic esophagectomy for esophageal cancer at University of Tokyo between January 2010 and December 2014 were included. The European Organization for Research and Treatment of Cancer (EORTC)’s quality of life questionnaires QLQ-C30 and QLQ-OES18 were sent to all patients that were still living, had no recurrence or other malignancy, and had not undergone a reoperation because of complications after esophagectomy.

Results

We were able to survey 63 (98.4%) of 64 eligible patients. We assessed and compared the QOL scores of both groups of patients. Compared to transthoracic esophagectomy, transmediastinal esophagectomy was associated with better QOL. Global health status and the physical, role, and cognitive function scale scores were significantly superior in the transmediastinal esophagectomy group (P = 0.004, < 0.0001, 0.007, 0.002, respectively). Fatigue, nausea and vomiting, pain, appetite loss, reflux, and taste scores were significant lower (superior) in the transmediastinal esophagectomy group (P = 0.003, 0.032, 0.025, 0.018, 0.001, 0.041, respectively).

Conclusions

This study indicates that robot-assisted radical transmediastinal esophagectomy is associated with better postoperative QOL compared to transthoracic esophagectomy. A larger study and prospective analyses are needed to confirm the current results.

Factors Associated with Pneumonia-caused Death in Older Adults with Autopsy-confirmed Dementia

Objective A better understanding of risk factors for pneumonia-caused death may help to improve the clinical management of dementia. Methods A retrospective observational study was conducted by reviewing the medical charts and autopsy reports of 204 patients who were admitted to hospital, underwent a post-mortem examination, and who were neuropathologically diagnosed with dementia. The risk factors for pneumonia-caused death were examined both as underlying and immediate causes of death using logistic regression models. Results A high frequency of pneumonia-caused death was observed both in underlying- (37.3%) and immediate- (44.1%) cause of death, but varied according to the subtypes of dementia. The factors related to pneumonia-caused death (underlying) were subtypes of dementia; Alzheimer's disease (odds ratio [OR], 2.891; 95% confidence interval [CI], 1.459-5.730); argyrophilic grain disease (OR, 3.148; 95% CI, 0.937-10.577); and progressive supranuclear palsy (OR, 34.921; 95% CI, 3.826-318.775), dysphagia (OR, 2.045; 95% CI, 1.047-3.994), diabetes mellitus (OR, 3.084; 95% CI, 1.180-8.061) and conversely related with heart failure (OR, 0.149; 95% CI, 0.026-0.861). Factors relating to pneumonia-caused death (immediate) were incidence of pneumonia during hospitalizations (OR, 32.579; 95%CI, 4.308-246.370), gender-male (OR, 2.060; 95% CI, 1.098-3.864), and conversely related with malignant neoplasm (OR, 0.220; 95% CI, 0.058-0.840). Conclusion The different factors relating to the pneumonia-caused death were evaluated depending on whether pneumonia was the underlying- or immediate-cause of death. Strengthening clinical management on dysphagia and diabetes mellitus, and preventing incidence of pneumonia during hospitalization appear to be the important for the terminal stage of hospitalized patients with dementia.

Prognostic Factors Related to Dementia with Lewy Bodies Complicated with Pneumonia: An Autopsy Study

Objective In patients demonstrating dementia with Lewy bodies (DLB), pneumonia is a common complication. However, the prognostic factors for the survival time in DLB with pneumonia have not been investigated by autopsy in patients with neuropathologically confirmed DLB. Methods We conducted a retrospective study of the medical and autopsy reports of 42 patients admitted to a Japanese hospital between 2005 and 2014. The patients were neuropathologically diagnosed as having DLB by post-mortem examinations. We analyzed the effects of various factors on the time from DLB onset to death. Results Thirty-nine of the 42 patients with DLB (92.9%) developed pneumonia during hospitalization. The median age at DLB onset was 78 years and the median time from DLB onset to death was 8 years. The Cox proportional hazard model demonstrated cerebral infarction [Hazard Ratio (HR), 2.36 (95% CI 1.12-4.96), p=0.023], muscle weakness [HR, 2.04 (0.95-4.39), p=0.067], male sex [HR, 2.84 (1.24-6.50), p=0.014], and age at onset (≥78 years.) [HR, 4.71 (1.82-12.18), p=0.001] to be prognostic factors for a shorter time from DLB onset to death. Conclusion Careful treatment of cerebral infarction and muscle weakness of the lower extremities is crucial for DLB patients with pneumonia, especially for those over 78 years of age, in order to maximize the patients' life expectancies.

Update on the pathogenesis and management of pneumonia in the elderly-roles of aspiration pneumonia

Pneumonia in the elderly results in the highest mortality among cases of community-acquired pneumonia (CAP). The pathophysiology of pneumonia in the elderly is primarily due to aspiration pneumonia (ASP). ASP comprises two pathological conditions: airspace infiltration with bacterial pathogens and dysphagia-associated miss-swallowing. The first-line therapy for the treatment of bacterial pneumonia in the elderly is a narrow spectrum of antibiotics, including sulbactam/ampicillin, which are effective against major lower respiratory infection pathogens and anaerobes. The bacterial pathogens of ASP cases of pneumonia in the elderly are similar to those associated with adult CAP. In addition to an appropriate course of antibiotics, pharmacologic and non-pharmacologic approaches for dysphagia and upper airway management are necessary for the treatment and prevention of pneumonia. Swallowing rehabilitation, oral health care, pneumococcal vaccination, gastroesophageal reflux management, and a head-up position during the night are necessary for the treatment and prevention of repeated episodes of pneumonia in elderly patients. In addition, tuberculosis should always be considered for the differential diagnosis of pneumonia in this patient population.

Validation of sputum Gram stain for treatment of community-acquired pneumonia and healthcare-associated pneumonia: a prospective observational study

BACKGROUND

The usefulness of sputum Gram stain in patients with community-acquired pneumonia (CAP) is controversial. There has been no study to evaluate the diagnostic value of this method in patients with healthcare-associated pneumonia (HCAP). The purpose of this study was to evaluate the usefulness of sputum Gram stain in etiological diagnosis and pathogen-targeted antibiotic treatment of CAP and HCAP.

METHODS

We conducted a prospective observational study on hospitalized patients with pneumonia admitted to our hospital from August 2010 to July 2012. Before administering antibiotics on admission, Gram stain was performed and examined by trained physicians immediately after sputum samples were obtained. We analyzed the quality of sputum samples and the diagnostic performance of Gram stain. We also compared pathogen-targeted antibiotic treatment guided by sputum Gram stain with empirical treatment.

RESULTS

Of 670 patients with pneumonia, 328 were CAP and 342 were HCAP. Sputum samples were obtained from 591 patients, of these 478 samples were good quality. The sensitivity and specificity of sputum Gram stain were 62.5% and 91.5% for Streptococcus pneumoniae, 60.9% and 95.1% for Haemophilus influenzae, 68.2% and 96.1% for Moraxella catarrhalis, 39.5% and 98.2% for Klebsiella pneumoniae, 22.2% and 99.8% for Pseudomonas aeruginosa, 9.1% and 100% for Staphylococcus aureus. The diagnostic yield decreased in patients who had received antibiotics or patients with suspected aspiration pneumonia. Pathogen-targeted treatment provided similar efficacy with a decrease in adverse events compared to empirical treatment.

CONCLUSIONS

Sputum Gram stain is highly specific for the etiologic diagnosis and useful in guiding pathogen-targeted antibiotic treatment of CAP and HCAP.

Clinical features and the role of atypical pathogens in nursing and healthcare-associated pneumonia (NHCAP): differences between a teaching university hospital and a community hospital

OBJECTIVE

The Japan Respiratory Society documented a new category of guidelines for nursing and healthcare-associated pneumonia (NHCAP), which is distinct from community acquired pneumonia (CAP). The objective of this study was to determine the epidemiological differences between NHCAP patients in a teaching university hospital and a community hospital. In addition, to clarify the strategy for treatment of NHCAP, we investigated the role of atypical pathogens.

METHODS

We analyzed 250 NHCAP and 421 CAP cases in a university hospital and 349 NHCAP and 374 CAP cases in a community hospital.

RESULTS

Patient age and the incidences of poor general condition were significantly higher in the community hospital compared with those in the university hospital. The distribution and frequency of pathogens, especially multidrug-resistant (MDR) pathogens, were significantly different between the two hospitals. Central nervous system disorders, dementia and poor performance status, which was possibility related to aspiration pneumonia, were significantly more frequent in patients with NHCAP compared with those with CAP in both hospitals. Atypical pathogens were detected in a few cases in patients with NHCAP.

CONCLUSION

There were many differences in the clinical characteristics between NHCAP patients in a university hospital and a community hospital even for hospitals located in the same area. Aspiration pneumonia was thought to be the main characteristic of NHCAP in both hospitals. Thus, all NHCAP patients did not need the same empiric therapy with a multidrug regimen directed against MDR pathogens. In addition, physicians rarely need to consider atypical pathogens in NHCAP treatment.

Evaluation of an assessment system for the JRS 2005: A-DROP for the management of CAP in adults

OBJECTIVE

The Japanese Respiratory Society (JRS) last revised the guidelines for community-acquired pneumonia (CAP) in adults in 2005. These guidelines proposed new criteria (A-DROP) to assess the severity of pneumonia and to differentiate between typical bacterial pneumonia and atypical pneumonia. The goal of the present study was to evaluate the utility of the A-DROP criteria for these described purposes.

METHODS

An observational survey was conducted between July 2006 and March 2007, and patients with CAP were prospectively surveyed using consecutive enrollment methods.

PATIENTS

In total, 1,875 patients from 200 medical facilities throughout Japan were analyzed.

RESULTS

The JRS 2005 A-DROP system was a good indicator of mortality in the patient population, and these results were significantly correlated with the Pneumonia Severity Index (PSI) of the Infectious Disease Society of America (IDSA). Among the various factors characterized, 'SpO(2) of 90% or less (PaO(2) of 60 Torr or less)' was the strongest predictor of mortality. In terms of the differential diagnosis between typical bacterial and atypical pneumonia, five of six JRS 2005 items were strongly and significantly correlated with a diagnosis of atypical pneumonia.

CONCLUSION

The JRS 2005 A-DROP system was accurate and clinically useful for the assessment of the severity of pneumonia and for the differentiation between typical bacterial pneumonia and atypical pneumonia.