Factors influencing severity of community-acquired pneumonia

Incidence and Risk Profiles for Suicide Mortality in Patients With Schizophrenia Receiving Homecare Case Management in Taiwan

Case management (CM)-based community therapy for patients with schizophrenia had little effect on reducing suicide mortality. We investigate the long-term suicide mortality outcome and associated risk factors in patients with schizophrenia receiving homecare (CM) in Taiwan. We enrolled a nationwide cohort of patients with schizophrenia who newly received homecare CM intervention (n = 13 317) between January 1, 2001, and December 31, 2015; their data were derived from Taiwan's National Health Insurance Research Database. We calculated the incidence rate of suicide methods. We examined the demographic and medical utilization profile for suicide and then performed a nested case-control study and multivariate regression to identify independent risk factors for suicide mortality. Among the 13 317 patients who received homecare CM intervention, 1766 died during the study period, of whom 213 died by suicide, which is the leading cause of unnatural death. Jumping from a high place, self-poisoning, and hanging were the top 3 suicide methods. Increased medical utilization was noted for both psychiatric and non-psychiatric services within 3 months of suicide mortality. Comorbidities of depressive disorder, nonspecific heart diseases, pneumonia, and gastrointestinal ulcers were identified as independent risk factors for suicide mortality. Suicide was the leading cause of unnatural mortality in patients with schizophrenia receiving homecare CM intervention in Taiwan. We noted the preferred suicide methods, high medical utilization, and comorbidities before suicide. Thus, we suggest that the CM team should assess lethal methods for suicide and ensure that patients adhere to psychiatry treatment for improving the current care model for this specified population.

Prevalence of atypical pathogens in patients with severe pneumonia: a systematic review and meta-analysis

OBJECTIVES

We aimed to summarise the prevalence of atypical pathogens in patients with severe pneumonia to understand the prevalence of severe pneumonia caused by atypical pathogens, improve clinical decision-making and guide antibiotic use.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, Web of Science and Cochrane Library were searched through November 2022.

ELIGIBILITY CRITERIA

English language studies enrolled consecutive cases of patients diagnosed with severe pneumonia, with complete aetiological analysis.

DATA EXTRACTION AND SYNTHESIS

We conducted literature retrieval on PubMed, Embase, Web of Science and The Cochrane Library to estimate the prevalence of Chlamydia, Mycoplasma and Legionella in patients with severe pneumonia. After double arcsine transformation of the data, a random-effects model was used for meta-analyses to calculate the pooled prevalence of each pathogen. Meta-regression analysis was also used to explore whether the region, different diagnostic method, study population, pneumonia categories or sample size were potential sources of heterogeneity.

RESULTS

We included 75 eligible studies with 18 379 cases of severe pneumonia. The overall prevalence of atypical pneumonia is 8.1% (95% CI 6.3% to 10.1%) In patients with severe pneumonia, the pooled estimated prevalence of Chlamydia, Mycoplasma and Legionella was 1.8% (95% CI 1.0% to 2.9%), 2.8% (95% CI 1.7% to 4.3%) and 4.0% (95% CI 2.8% to 5.3%), respectively. We noted significant heterogeneity in all pooled assessments. Meta-regression showed that the pneumonia category potentially influenced the prevalence rate of Chlamydia. The mean age and the diagnostic method of pathogens were likely moderators for the prevalence of Mycoplasma and Legionella, and contribute to the heterogeneity of their prevalence.

CONCLUSIONS

In severe pneumonia, atypical pathogens are notable causes, especially Legionella. The diagnostic method, regional difference, sample size and other factors contribute to the heterogeneity of prevalence. The estimated prevalence and relative heterogeneity factors can help with microbiological screening, clinical treatment and future research planning.

PROSPERO REGISTRATION NUMBER

CRD42022373950.

Prevalence, Antimicrobial Resistance, and Associated Factors of Streptococcus pneumoniae Colonization Rate among Old-Age Patients with Respiratory Tract Infection Attending Sheik Hassan Yebere Referral and Karamara General Hospitals, Jigjiga, Ethiopia

Background

Streptococcus pneumoniae is part of the normal flora of the upper respiratory tract of humans. Colonization of the upper respiratory tract (carriage of pneumococcus) by S. pneumoniae is considered a prerequisite for pneumococcal infection. It is the major cause of respiratory tract infection and frequent cause of physician visits, hospitalization, and death among old-aged patients because of their low immunity status. However, data on S. pneumoniae among old-aged patients in eastern Ethiopia are limited. This study was undertaken to determine the prevalence, antimicrobial resistance, and associated factor of S. pneumoniae colonization among old-aged patients.

Method

A health facility-based cross-sectional study was conducted from 1 March to 15 April 2020, at Sheik Hassan Yebere Referral and Karamara General Hospitals, Jigjiga, eastern Ethiopia. A total of 188 individuals greater than or equal to 60 years suspected of both upper and lower respiratory tract infections were included. Sociodemographic, behavioral, living conditions, and clinical data were collected by trained data collectors. Sputum samples were collected and examined for S. pneumoniae using the culture and biochemical tests as per the standard procedures. The Kirby–Bauer disk diffusion method was used for antimicrobial susceptibility testing. The data were entered on Epi-data version 3.1, and frequencies, crude odds ratio, and adjusted odds ratio were analyzed using SPSS version 20.

Results

The prevalence of S. pneumoniae colonization rate among old-aged patients was 13.8% (26/188) (95% CI: 9.6–19.1). Smoking (AOR = 3.3; 95% CI: 1.3–8.3), upper airway problems (AOR = 4.1; 95% CI: 1.1–15), and asthma disease (AOR = 3.1; 95% CI: 1.1–8.9) were the factors associated with S. pneumoniae colonization. The isolated organisms showed high antimicrobial resistance to trimethoprim-sulphamethoxazole (n = 12, 46.2%), tetracycline (n = 11, 42.3%), and ampicillin (n = 9, 34.6%).

Conclusion

This study showed that high prevalence of S. pneumoniae and antimicrobial resistance for trimethoprim-sulphamethoxazole, tetracycline, and ampicillin when compared to similar studies. Cigarette smoking, having upper airway problem, and asthma disease were factors associated with S. pneumoniae colonization. The provision of pneumococci conjugate vaccination and avoiding smoking are highly recommended for old aged in the community.

Effect of Undernutrition and Obesity on Clinical Outcomes in Adults with Community-Acquired Pneumonia

Malnutrition comprises two groups of conditions: undernutrition and overweight or obesity. It has been associated with a high risk of contracting infectious diseases and with elevated mortality rates. Community-acquired pneumonia (CAP) is one of the most common infectious diseases worldwide and its prognosis is affected by a large number of recognizable risk factors. This narrative review updates the information on the impact of malnutrition, including both undernutrition and obesity, on the risk and prognosis of adults with CAP. Studies of CAP that have evaluated undernutrition have applied a variety of definitions when assessing the nutritional status of patients. Undernutrition has been associated with unfavorable clinical outcomes, such as prolonged hospital stay, need for intensive care unit admission, and mortality; in contrast, most published studies have found that increased body mass index is significantly associated with higher survival in patients with CAP. However, some authors have presented divergent results, mainly in relation to the etiology of CAP (bacterial versus viral). Influenza infection, caused by influenza A (H1N1) pdm09, has been associated with worse prognosis in obese patients. The current data underscore the need for larger studies to examine the physiological mechanisms that explain the differential impact of malnutrition on outcomes. Achieving a better understanding may help to guide the design of new interventions to improve prognosis.

Systematic review and meta-analysis of comorbidities and associated risk factors in Indian patients of community-acquired pneumonia

Objective:

Comorbidities and risk factors have a major implication on incidence, complications, mortality, and management of community-acquired pneumonia complications and treatment outcomes. This study attempts to identify the same in the Indian population through a systematic review and meta-analysis.

Methods:

We screened observational studies (between January 1990 and February 2021) that reported potential comorbidities and other factors associated with increased risk of community-acquired pneumonia in the Indian population (⩾12 years) using PubMed, Google Scholar, and manual search. The risk of bias was identified using the Joanna Briggs Institute checklist for prevalence studies. Meta-analysis was conducted by using the random intercept logistic regression model.

Results:

Twenty-three studies were included in this analysis. The most prevalent comorbidities were chronic obstructive pulmonary disease (24.2%; 95% confidence interval: 16.4%–34.2%), hypertension (23.7%; 95% confidence interval: 13.6%–38.1%), and diabetes mellitus (16%; 95% confidence interval: 9.9%–24.7%). The prevalence of community-acquired pneumonia was high in patients with a current or previous history of smoking (51.4%; 95% confidence interval: 42.3%–61%) and advanced age ⩾50 years: (55.8%; 95% confidence interval: 48.4%–62%).

Conclusions:

Comorbid conditions like chronic obstructive pulmonary disease, hypertension, and diabetes mellitus and factors like advanced age and smoking history were common risk factors for community-acquired pneumonia in the Indian population.

Obesity survival paradox in patients hospitalized with community-acquired pneumonia. Assessing sex-differences in a population-based cohort study

AIM

To assess the effect of obesity status (no obesity/obesity/ morbid obesity) on hospital outcomes (length of hospital stay [LOHS] and in-hospital mortality [IHM]), among patients hospitalized with community-acquired pneumonia (CAP) and according to sex.

METHODS

We conducted a retrospective cohort study based on national hospital discharge data of all subjects aged≥ 18 years hospitalized with CAP in Spain from 2016 to 2019.

RESULTS

We identified 519,750 hospital discharges with CAP. The prevalence of obesity was 6.38% and 1.78%. for morbid obesity. The mean age was higher for patients without obesity followed by those with obesity and morbid obesity (74.61, 72.5 and 70.2 years respectively; p<0.001). The mean number of comorbidities was similar for patients with obesity and morbid obesity (2.30 and 2.29) and significantly higher than for non-obese individuals (2.10). The crude IHM was higher among the non-obese patients (12.71%) followed by those with morbid obesity (8.56%) and obesity (7.72%), without finding differences between men and women. Among men, after multivariable logistic regression analysis, the probability of dying in the hospital was significantly lower for those with obesity (Adjusted-OR 0.59;95%CI 0.55-0.63) and morbid obesity (Adjusted-OR 0.62;95%CI 0.54-0.71) compared with non-obese. The protective effect of obesity (Adjusted-OR 0.71;95%CI 0.67-0.75) and morbid obesity (Adjusted OR 0.73;95%CI 0.66-0.8) was also observed among women.

CONCLUSIONS

Obese and obesity morbid patients with CAP have a lower risk of IHM than non-obese patients, without sex differences in this association. These data confirm the existence of the obesity paradox in this patient population.

A literature review of severity scores for adults with influenza or community-acquired pneumonia - implications for influenza vaccines and therapeutics

Influenza vaccination and antiviral therapeutics may attenuate disease, decreasing severity of illness in vaccinated and treated persons. Standardized assessment tools, definitions of disease severity, and clinical endpoints would support characterizing the attenuating effects of influenza vaccines and antivirals. We review potential clinical parameters and endpoints that may be useful for ordinal scales evaluating attenuating effects of influenza vaccines and antivirals in hospital-based studies. In studies of influenza and community-acquired pneumonia, common physiologic parameters that predicted outcomes such as mortality, ICU admission, complications, and duration of stay included vital signs (hypotension, tachypnea, fever, hypoxia), laboratory results (blood urea nitrogen, platelets, serum sodium), and radiographic findings of infiltrates or effusions. Ordinal scales based on these parameters may be useful endpoints for evaluating attenuating effects of influenza vaccines and therapeutics. Factors such as clinical and policy relevance, reproducibility, and specificity of measurements should be considered when creating a standardized ordinal scale for assessment.

Etiology, Clinical Course, and Outcomes of Pneumonia in the Elderly: A Retrospective and Prospective Cohort Study in Thailand

Pneumonia is a leading cause of hospitalization and death among elderly adults. We performed a retrospective and prospective observational study to describe the etiology, clinical course, and outcomes of pneumonia for patients 60 years and older in Thailand. We enrolled 490 patients; 440 patients were included in the retrospective study and 50 patients were included in the prospective study. The CURB-65 score and a modified SMART-COP score (SMART-CO score) were used to assess disease severity. The median patient age was 80 years (interquartile range, 70-87 years); 51.2% were men. Klebsiella pneumoniae (20.4%) and Pseudomonas aeruginosa (15.5%) were the most common causative agents of pneumonia. A significant minority (23%) of patients were admitted to the intensive care unit (ICU), and mortality among this subset of patients was 45%. Most patients (80.8%) survived and were discharged from the hospital. The median duration of hospitalization was 8 days (interquartile range, 4-16 days). In contrast, 17.6% of patients died while undergoing care and 30-day mortality was 14%. Factors significantly associated with mortality were advanced age (P = 0.004), male sex (P = 0.005), multiple bacterial infections (P = 0.007; relative risk [RR], 1.88; 95% confidence interval [CI], 1.19-2.79), infection with multi-drug-resistant/extended-spectrum B-lactamase-producing organisms (P < 0.001; RR, 2.82; 95% CI, 1.83-4.85), ICU admission (P < 0.001; RR, 1.8; 95% CI, 1.4-2.3), and complications of pneumonia (P < 0.001; RR, 2.5; 95% CI, 1.8-3.4). Patients with higher SMART-CO and CURB-65 scores had higher rates of ICU admission and higher 30-day mortality rates (P < 0.001). These results emphasize the importance of Gram-negative bacteria, particularly K. pneumoniae and P. aeruginosa, as major causes of pneumonia among the elderly. Streptococcus pneumoniae is a common cause of pneumonia among elderly individuals worldwide. The SMART-COP and CURB-65 scores were developed to assess pneumonia severity and predict mortality of young adults with pneumonia. Few studies have examined the appropriateness of these scores for elderly patients with multiple comorbidities. A limited number of studies have used modified versions of these scores among elderly individuals. We found that Gram-negative bacteria has a major role in the etiology of pneumonia among elderly individuals in Southeast Asia. A significant proportion of elderly individuals with low CURB-65 scores were admitted to the hospital, indicating that hospital admission may reflect fragility among elderly individuals with low CURB-65 scores. The modified SMART-COP score (SMART-CO score) sufficiently predicted intensive care unit admission and the need for intensive vasopressor or respiratory support. A SMART-CO score ≥ 7 accurately predicted 30-day mortality.

Multiresistant Bacterial Pathogens Causing Bacterial Pneumonia and Analyses of Potential Risk Factors from Northeast Ethiopia

BACKGROUND

Pneumonia is the most common cause of morbidity and mortality in developing countries, mostly caused by different species of bacterial pathogens. Hence, patient management needs awareness of the pathogens and antimicrobial susceptibility testing (AST). This study was aimed to assess the type of bacterial isolates and their antimicrobial susceptibility patterns among pneumonia suspected patients at Dessie Referral Hospital, Northeast Ethiopia. Potential risk factors were also assessed to apply preventive measures accordingly.

MATERIALS AND METHODS

A cross-sectional study design was employed among pneumonia suspected patients from February to April 2020 at Dessie Referral Hospital. Sociodemographic characteristics and associated risk factors were collected using a pretested questionnaire, and clinical data were extracted by reviewing medical records. Sputum specimens were collected and inoculated into chocolate agar, blood agar, mannitol salt agar, and MacConkey agar which are then incubated at 35°C or 37°C for 24-48 hours. Bacterial species were identified based on Gram stain, colony characteristics, and biochemical techniques. The data were entered in to Epi-Info version 7.1.5 and analyzed with SPSS software version 20. p value <0.05 at 95% CI was considered as statistically significant.

RESULTS

A total of 406 sputum specimens were collected and cultured, among which 157 (38.7%) were positive for different bacterial pathogens. The predominant pathogens were Klebsiella pneumoniae (28.0%), Streptococcus pneumoniae (24.8%), Staphylococcus aureus (18.5%), and Pseudomonas aeruginosa (14.0%). Majority of the isolates exhibited resistance to ampicillin with 81.5% followed by penicillin with 75.9% and amoxicillin-clavulanate with 61.2%. Multivariable logistic regression showed a significant association of culture positivity with older age (AOR = 2.43, CI: 1.12-5.28, p value = 0.025), cigarette smoking (AOR = 4.67, CI: 2.39-9.20, p value <0.001), and alcohol use (AOR = 5.58, CI: 3.14-9.92, p value <0.001). Resistance to ampicillin and penicillin was associated with repeated prescription and use.

CONCLUSIONS

This study found high prevalence of bacterial pneumonia in the study area, and high rate of bacterial resistance was observed in ampicillin, penicillin, and amoxicillin-clavulanate. Repeated prescriptions and use of antimicrobials were significantly independent factors of bacterial resistance. Therefore, patient management needs identification of bacteria by routine culture with antimicrobial susceptibility testing.

Prognostic factors in elderly patients admitted to the intensive care unit with community-acquired pneumonia

OBJECTIVE

We aimed to determine the clinical, radiological and laboratory findings that may indicate poor prognosis in severe community acquired pneumonia (CAP) requiring intensified care to reduce the risk of death.

METHODS

The medical histories, demographic characteristics and laboratory values of over 65 years old patients admitted to the intensive care unit (ICU) and diagnosed with CAP were recorded.

RESULTS

Total of 86 patients were included in the study. Among those patients 39 were discharged from the ICU with health but 47 were expired. Diastolic blood pressure was significantly lower in expired patients (p = 0.044). In multivariate analysis, older age (>78 years) (p = 0.004), at admission elevated blood glucose (>108 mg/dL) levels (p = 0.048), decreased serum albumin (<3.5 g/dL) levels (p = 0.043), elevated serum procalcitonin levels (>0.63 μg/L) (p = 0.034) and in blood gas analysis decreased pH (<7.35) (p = 0.042)and increased lactate (>2mmol/L) (p = 0.001) were the significant risk factors for in-ICU mortality.

CONCLUSIONS

At old age, blood glucose and procalcitonin levels increased at the time of admission, serum albumin levels decreased, pH decreased in blood gas analysis and lactate levels increased, and significant mortality determinants in CAP patients over 65 years of age who applied to the intensive care unit.