Prevalence, Determinants, and Prognostic Significance of Hospital Acquired Pneumonia in Patients with Acute Heart Failure

Predictors and prognostic implications of hospital-acquired pneumonia in patients admitted for acute heart failure

Introduction

Data on predictors and prognosis of hospital acquired pneumonia (HAP) in patients admitted for acute heart failure (AHF) to intensive care units (ICU) are scarce. Better knowledge of these factors may inform management strategies. This study aimed to assess the incidence and predictors of HAP and its impact on management and outcomes in patients hospitalised for AHF in the ICU.

Methods

this was a retrospective single-centre observational study. Patient-level and outcome data were collected from an anonymized registry-based dataset. Primary outcome was in-hospital all-cause mortality and secondary outcomes included length of stay (LOS), requirement for inotropic/ventilatory support, and prescription patterns of heart failure (HF) drug classes at discharge.

Results

Of 638 patients with AHF (mean age, 71.6 ± 12.7 years, 61.9% male), HAP occurred in 137 (21.5%). In multivariable analysis, HAP was predicted by de novo AHF, higher NT proB-type natriuretic peptide levels, pleural effusion on chest x-ray, mitral regurgitation, and a history of stroke, diabetes, and chronic kidney disease. Patients with HAP had a longer LOS, and a greater likelihood of requiring inotropes (adjusted odds ratio, OR, 2.31, 95% confidence interval, CI, 2.16-2.81; p < 0.001) or ventilatory support (adjusted OR 2.11, 95%CI, 1.76-2.79, p < 0.001). After adjusting for age, sex and clinical covariates, all-cause in-hospital mortality was significantly higher in patients with HAP (hazard ratio, 2.10; 95%CI, 1.71-2.84; p < 0.001). Patients recovering from HAP were less likely to receive HF medications at discharge.

Discussion

HAP is frequent in AHF patients in the ICU setting and more prevalent in individuals with de novo AHF, mitral regurgitation, higher burden of comorbidities, and more severe congestion. HAP confers a greater risk of complications and in-hospital mortality, and a lower likelihood of receiving evidence-based HF medications at discharge.

Early treatment with a sodium-glucose co-transporter 2 inhibitor in high-risk patients with acute heart failure: Rationale for and design of the EMPA-AHF trial

AIMS

The aim of the EMPA-AHF trial is to clarify whether early initiation of a sodium-glucose co-transporter 2 inhibitor before clinical stabilization is safe and beneficial for patients with acute heart failure (AHF) who are at a high risk of adverse events.

METHODS

The EMPA-AHF trial is a randomized, double-blind, placebo-controlled, multicentre trial examining the efficacy and safety of early initiation of empagliflozin (10 mg once daily). In total, 500 patients admitted for AHF will be randomized 1:1 to either empagliflozin 10 mg daily or placebo at 47 sites in Japan. Study entry requires hospitalization for AHF with dyspnoea, signs of volume overload, elevated natriuretic peptide, and at least one of the following criteria: estimated glomerular filtration rate <60 mL/min/1.73 m²; already taking ≥40 mg of furosemide daily before hospitalization; and urine output of <300 mL within 2 hours after an adequate dose of intravenous furosemide. Patients will be randomized within 12 hours of hospital presentation, with treatment continued up to 90 days. The primary outcome is the clinical benefit of empagliflozin on the win ratio for a hierarchical composite endpoint consisting of death within 90 days, heart failure rehospitalization within 90 days, worsening heart failure during hospitalization, and urine output within 48 hours after treatment initiation.

CONCLUSION

The EMPA-AHF trial is the first to evaluate the efficacy and safety of early initiation of empagliflozin in patients with AHF considered to be at high risk under conventional treatment.

Risk Factors of Hospital-Acquired Pneumonia Among Hospitalized Patients With Cardiac Diseases

Background To our knowledge, no studies have been done in Saudi Arabia to determine the risk factors of hospital-acquired pneumonia (HAP) among hospitalized cardiac patients. This study aimed to assess these risk factors. Methods A retrospective study was done at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Five hundred hospitalized patients diagnosed with pre-existing cardiovascular disease (CVD) were included. A checklist was used to collect data about patients' demographic characteristics; BMI; smoking and alcohol abuse; type of cardiac disease; other chronic diseases; exposure to immunosuppressives; chemotherapy and radiotherapy in the last six months; glucocorticoid use; application of ventilator; initial, follow-up chest X-ray results; pneumonia vaccination status; nasogastric tube use; general anesthesia received; use of loop diuretics; presence of pulmonary diseases; levels of WBC, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP); results of blood and respiratory cultures; number of hospitalizations and intensive care unit (ICU) admissions in the last six months; and Richmond Agitation and Sedation Scale (RASS) score. Results The prevalence of pneumonia was 7%. Females; patients with autoimmune diseases who were exposed to immunosuppressives or glucocorticoids; those with an initial or second abnormal chest X-ray; patients who used nasogastric tube, had pulmonary disease, and had high levels of WBC, ESR, or CRP; and patients hospitalized for more than two times had a significantly higher percentage of having pneumonia. Abnormal second chest X-ray, high ESR, and more than two times of hospitalization within the last six months were the risk factors of pneumonia on multivariate logistic regression analysis. Conclusion Better prevention and intervention programs are needed to assess the risk factors of pneumonia among admitted cardiac patients.

Descriptive Epidemiology and Outcomes of Patients with Short Stay Hospitalizations for the Treatment of Congestive Heart Failure in the US

Background

Congestive heart failure (CHF) hospitalizations cost the US $35 billion annually. Two-thirds of these admissions, generally requiring </=3 days in the hospital, are solely for the purpose of diuresis, and may be avoidable.

Methods

Among patients discharged with CHF as the principal diagnosis (PD), we compared characteristics and outcomes between those with hospital length of stay (LOS) </=3 days (short, SLOS) and >3 days (long, LLOS) in a cross-sectional multicenter analysis within the 2018 National Inpatient Sample. We applied complex survey methods to calculate nationally representative results.

Results

Among 4,979,350 discharges with any CHF code, 1,177,910 (23.7%) had CHF-PD, of whom 511,555 (43.4%) had SLOS. Patients with SLOS were younger (>/=65 years: 68.3% vs 71.9%), less likely covered by Medicare (71.9% vs 75.4%), and had a lower comorbidity burden (Charlson: 3.9 [2.1] vs 4.5 [2.2) than patients with LLOS; they less frequently developed acute kidney injury (0.4% vs 2.9%) or a need for mechanical ventilation (0.7% vs 2.8%). A higher proportion with SLOS than with LLOS underwent no procedures (70.4% vs 48.4%). Mean LOS (2.2 [0.8] vs 7.7 [6.5]), direct hospital costs ($6150 [$4413]) vs $17,127 [$26,936]), and aggregate annual hospital costs $3,131,560,372 vs $11,359,002,072) were all lower with SLOS than LLOS. All comparisons reached alpha = 0.001.

Conclusion

Among patients admitted for CHF, nearly ½ have LOS </=3 days, and almost ¾ of them requires no inpatient procedures. A more aggressive outpatient heart failure management strategy may allow many patients to avoid hospitalizations and their potential complications and costs.

Telemedicine to Support Heart Failure Patients during Social Distancing: A Systematic Review

Background

Heart failure (HF) has been described as an emerging pandemic as its prevalence continues to rise with a growing and aging population. HF patients are more vulnerable to infections with higher risk of hospitalisation, morbidity, and mortality. During this COVID-19 pandemic, telemedicine has emerged as an alternative to usual out-patient care. This study aimed to systematically review available literature regarding the effect of telemedicine on mortality, health-related quality of life (HR-QoL), and hospitalisation rate of HF patients.

Method

A literature search was conducted on five databases (PubMed, Medline, EMBASE, SCOPUS and Cochrane Central Database) up to 21^st May 2022. Data from studies that fulfilled the eligibility criteria were collected and extracted. Included studies were critically appraised using suitable tools and extracted data were synthesized qualitatively.

Results

A total of 27 studies were included in the qualitative synthesis with a total of 21,006 patients and sufficient level of bias. Reduction in the mortality rate, HF-related hospitalisation rate, and improvement in the HR-QoL were shown in most of the studies, although only some were statistically significant.

Conclusions

The use of telemedicine is a promising and beneficial method for HF patients to acquire adequate health care services. Further studies in this field are needed, especially in developing countries and with standardized method, to provide better services and protections for HF patients. Telemonitoring and patient-centred partnership via interactive communication between healthcare team and patients is central to successful telemedicine implementation.

PROSPERO Registration Number

CRD42021271540.

Sex Differences in Hospital-Acquired Pneumonia among Patients with Type 2 Diabetes Mellitus Patients: Retrospective Cohort Study using Hospital Discharge Data in Spain (2016-2019)

(1) Background: To analyze the incidence, clinical characteristics, use of procedures, and in-hospital outcomes in patients who developed pneumonia during their hospital admission according to sex and to the presence of type 2 diabetes mellitus (T2DM). (2) Methods: Retrospective cohort study using data from the Spanish National Hospital Discharge Database. Hospital-acquired pneumonia (HAP) was classed as non-ventilator HAP and ventilator-associated pneumonia (VAP). Separate analyses were performed for men and women with and without T2DM. Population subgroups were compared using propensity score matching. (3) Results: HAP was identified in 38,814 patients (24.07% with T2DM). The adjusted incidence of HAP was higher in patients with T2DM (both sexes) (IRR 1.28; 95% CI 1.25–1.31). The incidence of HAP was higher in men with T2DM than in women with T2DM (adjusted-IR 1.47; 95% CI 1.41–1.53). The incidence of HAP among T2DM patients increased over time. In-hospital mortality (IHM) was around 28% irrespective of T2DM status and sex. After adjusting for confounders and sex, VAP was associated to higher IHM among patients with T2DM (OR 2.09; 95% CI 1.7–2.57). (4) Conclusions: T2DM is associated with a higher risk of HAP, whose incidence increased over time. Men with T2DM have an almost 50% higher risk of HAP than women with T2DM. The probability of dying in the hospital was not associated with sex or T2DM.

Assessing the Impact of Gender and COPD on the Incidence and Mortality of Hospital-Acquired Pneumonia. A Retrospective Cohort Study Using the Spanish National Discharge Database (2016-2019)

BACKGROUND

We aim to analyze incidence and outcomes of patients hospitalized with hospital-acquired pneumonia (HAP) according to chronic obstructive pulmonary disease (COPD) status and sex in Spain (2016-2019).

METHODS

We conducted a retrospective cohort study using national hospital discharge data of patients ≥40 years with a primary diagnosis of HAP, using the specific diagnostics of non-ventilator (NV)-HAP and ventilator-associated pneumonia (VAP).

RESULTS

We identified 37,029 patients with HAP ((NV)-HAP 87.28%, VAP 12.72%), 13.40% with COPD. HAP incidence increased over time, but only in subjects without COPD (p < 0.001). In women, incidence of HAP and (NV)-HAP was similar regardless of COPD status, but VAP incidence was lower in COPD women (p = 0.007). In men, the incidence of (NV)-HAP was significantly higher in those with COPD, while VAP incidence was lower in COPD men (p < 0.001). The in-hospital mortality (IHM) was similar in men and women with and without COPD. The risk of dying in hospital increased with age, congestive heart failure, cancer, and dialysis among men and women with COPD. Men that underwent surgery had a lower risk of IHM. VAP increased 2.58-times the probability of dying in men and women. Finally, sex was not associated with IHM among COPD patients.

CONCLUSIONS

Incidence of HAP was significantly higher in COPD patients than in those without COPD, at the expense of (NV)-HAP but not of VAP. When stratifying by sex, we found that the difference was caused by men. IHM was similar in COPD and non-COPD patients, with no significant change overtime. In addition, sex was not associated with IHM.

Early Initiation of Feeding and In-Hospital Outcomes in Patients Hospitalized for Acute Heart Failure

Extensive data on early nutrition support for patients requiring critical care are available. However, whether early initiation of feeding could be beneficial for patients hospitalized for acute heart failure (HF) remains unclear. We sought to compare outcomes of early and delayed initiation of feeding for hospitalized patients with acute HF using a nationwide inpatient database. We retrospectively analyzed data from the Diagnosis Procedure Combination database. We included patients hospitalized for HF between January 2010 and March 2018. We excluded patients with length of hospital stay ≤2 days, those patients who underwent major procedures under general anesthesia, and those requiring advanced mechanical supports within 2 days after admission including intubation, intra-aortic balloon pumping, and extracorporeal membrane oxygenation. Propensity score matching and instrumental variable analyses were conducted to compare in-hospital mortality, complications and length of stay between the early and delayed feeding groups. Among 432,620 eligible patients, 403,442 patients (93%) received early initiation of feeding (within 2 days after admission) and 29,178 patients (7%) received delayed initiation of feeding. Propensity score matching created 29,153 pairs and delayed initiation of feeding was associated with higher in-hospital mortality (odds ratio 1.32; 95% confidence interval 1.26 to 1.39), longer hospital stay and higher incidence of pneumonia and sepsis. The instrumental variable analysis also showed patients with delayed initiation of feeding had higher in-hospital mortality (odds ratio 1.34; 95% confidence interval 1.28 to 1.40). In conclusion, our analysis suggested a potential benefit of early initiation of feeding for in-hospital outcomes in hospitalized patients hospitalized for acute HF. Further investigations are required to confirm our results and to clarify the underlying mechanisms.