Antibiotic administration longer than eight hours after triage and mortality of community-acquired pneumonia in patients with diabetes mellitus

Diabetic lung disease: fact or fiction?

Diabetes mellitus is a chronic, progressive, incompletely understood metabolic disorder whose prevalence has been increasing steadily worldwide. Even though little attention has been paid to lung disorders in the context of diabetes, its prevalence has recently been challenged by newer studies of disease development. In this review, we summarize and discuss the role of diabetes mellitus involved in the progression of pulmonary diseases, with the main focus on pulmonary fibrosis, which represents a chronic and progressive disease with high mortality and limited therapeutic options.

Evaluation of the Quality of Care among Hospitalized Adult Patients with Community-Acquired Pneumonia in Korea

Pneumonia is an important cause of morbidity and mortality. Since 2014, the Health Insurance Review and Assessment Service (HIRA) has assessed the overall quality of care among hospitalized adult patients with community-acquired pneumonia (CAP) provided by all medical institutions in Korea. A committee of the Korea Academy of Tuberculosis and Respiratory Diseases developed the hospital inpatient quality measures set for CAP consisting of eight core measures and five monitoring measures. The composite measure score was calculated. The medical records of hospitalized adult patients ages 18 years or more with CAP from October to December 2014 were evaluated. The data of 523 hospitals (42 tertiary hospitals [8.0%], 256 general hospitals [49%], and 225 hospitals [43.0%]) and 15,432 cases (tertiary hospitals, 1,673 cases [10.8%]; general hospitals, 8,803 cases [57.1%]; hospitals, 4,956 cases [32.1%]) were analyzed. We found large variations among institutions in terms of performance of care measures for CAP. For the composite measure score, the mean value was 66.7 (tertiary hospitals, 98.5; general hospitals, 79.2; hospitals, 43.8). Despite significant differences in measure scores between tertiary, general hospitals and hospitals, no significant differences were found in mortality between hospitals. Further studies are needed to determine the care measures appropriate for CAP.

Diagnosis and treatment of community-acquired pneumonia in adults: 2016 clinical practice guidelines by the Chinese Thoracic Society, Chinese Medical Association

Community‐acquired pneumonia (CAP) in adults is an infectious disease with high morbidity in China and the rest of the world. With the changing pattern in the etiological profile of CAP and advances in medical techniques in diagnosis and treatment over time, Chinese Thoracic Society of Chinese Medical Association updated its CAP guideline in 2016 to address the standard management of CAP in Chinese adults. Extensive and comprehensive literature search was made to collect the data and evidence for experts to review and evaluate the level of evidence. Corresponding recommendations are provided appropriately based on the level of evidence. This updated guideline covers comprehensive topics on CAP, including aetiology, antimicrobial resistance profile, diagnosis, empirical and targeted treatments, adjunctive and supportive therapies, as well as prophylaxis. The recommendations may help clinicians manage CAP patients more effectively and efficiently. CAP in pediatric patients and immunocompromised adults is beyond the scope of this guideline. This guideline is only applicable for the immunocompetent CAP patients aged 18 years and older. The recommendations on selection of antimicrobial agents and the dosing regimens are not mandatory. The clinicians are recommended to prescribe and adjust antimicrobial therapies primarily based on their local etiological profile and results of susceptibility testing, with reference to this guideline.

Benefit of adjunct corticosteroids for community-acquired pneumonia in diabetic patients

AIMS/HYPOTHESIS

We have recently shown that adjunct prednisone shortens the time taken to reach clinical stability (time to clinical stability, TTCS) in patients with community-acquired pneumonia (CAP). Considering the hyperglycaemic effects of prednisone, there are concerns about the efficacy and safety of this therapy for diabetic patients with CAP. Our objective was to evaluate whether diabetes and/or hyperglycaemia on admission to hospital has an influence on the effect of corticosteroids on outcome in a well-defined cohort of patients with CAP.

METHODS

This is a preplanned subanalysis of a prospective randomised, double-blind placebo-controlled multicentre trial. Patients aged 18 years or older with CAP were eligible and were recruited from seven tertiary care hospitals in Switzerland within 24 h of presentation. Patients were randomised (1:1 ratio) to receive either 50 mg of prednisone daily for 7 days or placebo. Allocation was concealed with a prespecified computer-generated randomisation list. Patients, treating physicians, investigators and data assessors were masked to treatment allocation. The primary endpoint was TTCS; secondary endpoints were length of stay, mortality, duration of antibiotic treatment, CAP complications and new insulin requirement at day 30. Furthermore, we analysed whether these endpoints were influenced by a glycaemic dysregulation during the study time.

RESULTS

Of 802 patients randomised (n = 402 in the prednisone, n = 400 in the placebo group), 726 patients were treated per protocol and included in this analysis (n = 362 in the prednisone, n = 364 in the placebo group). Nineteen per cent of 726 patients had diabetes mellitus (n = 66 in the prednisone group, n = 72 in the placebo group). Adjunct prednisone shortened TTCS in diabetic and non-diabetic patients (HR 1.65 [95% CI 1.16, 2.35], p = 0.007; 1.30 [95% CI 1.10, 1.53], p = 0.002) with no evidence for effect modification by diabetes in interaction analysis (p = 0.44). No difference was found in other clinically relevant endpoints. Although adjunct prednisone was associated with glycaemic dysregulation, this did not translate into worse clinical outcomes in either group, and there was no difference in secondary endpoints.

CONCLUSIONS/INTERPRETATION

The benefit of adjunct prednisone in CAP patients is also valid for those with diabetes or hyperglycaemia on admission. Hyperglycaemia in diabetic patients or due to adjunct prednisone did not have a negative effect on outcome.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00973154 FUNDING : This study was supported by a grant from the Swiss National Foundation and by the Nora van Meeuwen Häfliger Stiftung and the Gottfried Julia Bangerter-Rhyner Stiftung.

Community-Acquired Pneumonia in Patients With Diabetes Mellitus: Predictors of Complications and Length of Hospital Stay

BACKGROUND

The primary objective of the study was to determine factors associated with complications and length of hospital stay (LOS) in hospitalized adult patients with diabetes along with community-acquired pneumonia (CAP). CAP is a common infection in patients with diabetes mellitus and is associated with a significant mortality and morbidity.

MATERIALS AND METHODS

This is a retrospective cohort study of 215 adult patients with diabetes who were admitted with CAP. A multivariate logistic and Cox regression analysis were used to assess factors associated with complications and LOS of CAP, respectively.

RESULTS

During the follow-up period from admission until discharge, 94 patients (43.7%) developed complications. Respiratory failure was the most common complication (43.6%). The average LOS of study cohort was 9.47 days. In the multivariate analysis, complications of CAP were associated with time to first dose of appropriate antibiotic therapy >8 hours since triage at emergency department (ED) (odds ratio = 3.16; 95% CI: 1.58-6.32; P = 0.001) and pneumonia severity index score >90 (odds ratio = 3.52; 95% CI: 1.45-8.53; P = 0.005). In the multivariate Cox regression analysis, time to first dose of appropriate antibiotic therapy >8 hours since triage at ED (hazard ratio [HR] = 0.56, P = 0.01), pneumonia severity index score >90 (HR = 0.62, P = 0.01), presence of complications (HR = 0.53, P = 0.002), duration of antibiotics (HR = 0.90, P ≤ 0.0001) and duration of symptoms prior presentation to ED (HR = 0.96, P = 0.04) were independently determinants of LOS.

CONCLUSIONS

Delayed administration of appropriate antibiotic therapy at ED and moderate-to-severe pneumonia were associated with both increased risk of complications and prolonged LOS in hospitalized adult patients with diabetes along with CAP.

The role of a radiology electronic notification system in the emergency department setting and its impact on patient care

Background

To determine the impact of a radiology electronic notification system (ENS) on emergency department (ED) patient care.

Materials and Methods

A retrospective review of de-identified patient data for a 2-year period (1 year prior to and 1 year following ENS implementation) was approved by the hospital’s institutional review board. The effect of a radiology ENS on ED patient care was investigated by analyzing the intervals between completion of a chest radiograph and the times antibiotics were ordered/administered on patients presenting with symptoms of community acquired pneumonia (CAP). The square root transformation of the means was analyzed with an ANOVA model to determine statistical significance.

Results

During the 24-month study protocol, 1,341 patients who were evaluated in the ED met the study eligibility criteria. The least square estimates of the mean times from when the chest radiograph was completed to when antibiotics were ordered prior to and after the implementation of the ENS were 89 and 107 minutes, respectively (P < 0.01). The least square estimates of the mean times from when the chest radiograph was completed to when antibiotics were administered prior to and after the implementation of the ENS were 115 and 132 minutes, respectively (P = 0.02).

Conclusion

The implementation of a radiology ENS does have advantages for the radiologist in streamlining the communication and documentation processes but may negatively impact time to treatment and thus patient care.

Community-acquired pneumonia

PURPOSE OF REVIEW

Community-acquired pneumonia (CAP) contributes significantly to morbidity and mortality, especially in the elderly. Recent advances aimed at improving outcomes and reducing CAP disease burden are summarized.

RECENT FINDINGS

Emerging data suggests that newer CAP risk stratification indices based on disease severity hold promise in predicting intensive care need. Additional evidence supports a role of procalcitonin and pro-adrenomedullin as biomarkers of disease severity and for guiding antimicrobial therapy. New diagnostic tools have greatly contributed to early diagnosis and better-targeted therapy. There is increasing recognition of the role of coinfections in CAP. In patients with severe disease, therefore, current guidelines advise against monotherapy. Although inclusion of coverage for atypical pathogens in nonsevere CAP has been challenged, evidence suggests that such coverage is beneficial in patients with severe disease. Use of steroids as adjunctive therapy for CAP, however, is associated with complications and prolonged hospitalization. Updated prevention strategies include approval of pneumococcal conjugate vaccine (PCV13) for adults at risk.

SUMMARY

Despite these developments research aimed at further reducing CAP-related morbidity and mortality is required. Increasing global life expectancy is likely to expand the at-risk population; therefore, research directed at CAP prevention in view of changing demography is essential.

Clinical features, etiology, and outcomes of community-acquired pneumonia in patients with diabetes mellitus

We performed an observational analysis of a prospective cohort of immunocompetent hospitalized adults with community-acquired pneumonia (CAP) to determine the epidemiology, clinical features, and outcomes of pneumonia in patients with diabetes mellitus (DM). We also analyzed the risk factors for mortality and the impact of statins and other cardiovascular drugs on outcomes. Of 2407 CAP episodes, 516 (21.4%) occurred in patients with DM; 483 (97%) had type 2 diabetes, 197 (40%) were on insulin treatment, and 119 (23.9%) had end-organ damage related to DM. Patients with DM had different clinical features compared to the other patients. They were less likely to have acute onset, cough, purulent sputum, and pleural chest pain. No differences in etiology were found between study groups. Patients with DM had more inhospital acute metabolic complications, although the case-fatality rate was similar between the groups. Independent risk factors for mortality in patients with DM were advanced age, bacteremia, septic shock, and gram-negative pneumonia. Patients with end-organ damage related to DM had more inhospital cardiac events and a higher early case-fatality rate than did the overall population. The use of statins and other cardiovascular drugs was not associated with better CAP outcomes in patients with DM. In conclusion, CAP in patients with DM presents different clinical features compared to the features of patients without DM.