Effect of parenteral energy or amino acid doses on in-hospital mortality, among patients with aspiration pneumonia: a cohort medical claims database study

Comprehensive management of pneumonia in older patients

Pneumonia is a leading cause of death and functional decline in the older population. Diagnosis of pneumonia conventionally includes the presence of respiratory signs and symptoms, systemic signs of infection and a radiographic demonstration of lung involvement. Pneumonia diagnosis in the very old patient is compromised by atypical and unspecific presentation, resulting in a high proportion of false positive diagnosis. Chest radiograph is frequently of low quality and inconclusive in older patients. Computed tomography scan and chest ultrasound may provide valuable diagnostic confirmation in uncertain cases. Bacterial pneumonia has been mainly studied, but viruses, among which influenza, SARS-CoV-2, and respiratory syncytial virus, are increasingly recognized as major players. The decision to treat pneumonia is usually based on a triple assessment of diagnostic probability, disease severity and the general assessment of the patient (frailty, comorbidities, place of living, and goals of care). Antimicrobial treatment is probabilistic, targeting common pathogens. The optimal antibiotic treatment depends on epidemiological data, setting of acquisition, comorbidities, risk factors for methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, or aspiration pneumonia, and severity. Recent controlled trials have demonstrated the non-inferiority of short regimen in non-severe community acquired pneumonia, even in older individuals and a five-day antibiotic treatment is recommended in case of clinical improvement. Pneumonia management in older patients requires a comprehensive approach, including control of comorbidities (particularly cardiovascular), nutritional support, rehabilitation, and prevention of aspiration. Finally, pneumonia may be a pre-terminal event in many patients, requiring advanced-care planning and prompt instauration of palliative management.

Parenterally administered amino acids decrease acute mortality in fasting patients with aspiration pneumonia: A retrospective study

BACKGROUND & AIMS

To prevent food aspiration, numerous patients with aspiration pneumonia are restricted from eating early during their hospital stay. Although they receive parenteral nutrition (PN) on a fasting regimen, the optimal dose and composition remain unknown. The current study aimed to investigate whether PN with amino acids (AA) affects 30-day mortality of patients with aspiration pneumonia.

METHODS

This retrospective study included 115 patients with aspiration pneumonia who were admitted to our hospital between November 2019 and November 2023. All patients followed the clinical pathway for aspiration pneumonia, had been fasting for >5 days, and received PN alone on admission. Given that treating physicians could modify the standard PN regimen by including AA, some patients received maintenance infusion without AA. The patients were divided in those who received PN with AA (>15 g/day, AA group) and those who did not (0-15 g/day, non-amino acid [NAA] group). The primary endpoint was 30-day in-hospital mortality.

RESULTS

Among the 115 patients, 65 (57 %) received PN with AA from days 2-5. No significant differences in background characteristics and severity of pneumonia were observed, except for heart failure. Serum albumin levels were significantly lower in the AA group than in the NAA group (median, 2.9 vs. 3.2 g/dL; P = 0.003). Median energy intake on days 2 and 5 were significantly higher in the AA group than in the NAA group (day 2: 10.7 vs. 3.7 kcal/kg/day; day 5: 10.6 vs. 4.2 kcal/kg/day, respectively). The AA group had a median protein dose of 0.76 and 0.74 g/kg/day on days 2 and 5, respectively, whereas the NAA group had a median protein dose of 0.00 g/kg/day on both days. After adjusting for age, sex, body mass index, albumin, and pneumonia severity, 30-day in-hospital mortality was lower in the AA group than in the NAA group (hazard ratio, 0.31; 95 % confidence interval, 0.10-0.99).

CONCLUSIONS

Early PN with AA may play an important role in improving 30-day in-hospital mortality among fasting patients with aspiration pneumonia after hospital admission.

Long-Term Survival After Aspiration Pneumonia in Older Inpatients: A Comparative Study

OBJECTIVES

Aspiration pneumonia (AsP), a leading cause of death in older people, remains poorly studied. We aimed to evaluate short- and long-term prognosis after AsP in older inpatients.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

All consecutive patients aged ≥75 years hospitalized in a 62-bed acute geriatric unit during a 1-year period.

METHODS

We compared clinical characteristics and overall 2-year survival between patients with a main diagnosis of AsP, patients with other types of acute pneumonia (non-AsP), and patients hospitalized for another cause.

RESULTS

Among the 1774 patients hospitalized over 1 year (median age: 87 years, 41% female), 125 (7%) had a primary diagnosis of acute pneumonia, of whom 39 (31%) had AsP and 86 (69%) non-AsP. Patients with AsP were more frequently male, lived more frequently in a nursing home, and had a more frequent history of stroke or neurocognitive disorders. Mortality rates were much higher after AsP, reaching 31% at 30 days (vs 15% after Non-AsP and 11% in the rest of the cohort, P < .001), and 69% 2 years after admission (vs 56% and 49%, P < .001). After adjustment for confounders, AsP was significantly associated with mortality but non-AsP was not [adjusted hazard ratio (95% CI): 3.09 (1.72-5.57) at 30 days and 1.67 (1.13-2.45) at 2 years for AsP; 1.36 (0.77-2.39) and 1.14 (0.85-1.52) for non-AsP]. However, among patients who survived at 30 days, mortality did not significantly differ between the 3 groups (P = .1).

CONCLUSIONS AND IMPLICATIONS

In an unselected cohort of patients hospitalized in an acute geriatric unit, a third of AsP patients died within the first month after admission. However, among those surviving at 30 days, long-term mortality did not significantly differ from the rest of the cohort. These findings underline the importance of optimizing the early management of AsP.

Dose-Dependent Effects of Amino Acids on Clinical Outcomes in Adult Medical Inpatients Receiving Only Parenteral Nutrition: A Retrospective Cohort Study Using a Japanese Medical Claims Database

The majority of inpatients requiring parenteral nutrition (PN) do not receive adequate amino acid, which may negatively impact clinical outcomes. We investigated the influence of amino acid doses on clinical outcomes in medical adult inpatients fasting >10 days and receiving only PN, using Japanese medical claims database. The primary endpoint was in-hospital mortality, and the secondary endpoints included deterioration of activities of daily living (ADL), intravenous catheter infection, hospital readmission, hospital length of stay (LOS), and total medical costs. Patients were divided into four groups according to their mean prescribed daily amino acid doses from Days 4 to 10 of fasting: Adequate (≥0.8 g/kg/day), Moderate (≥0.6−<0.8 g/kg/day), Low (≥0.4−<0.6 g/kg/day), and Very low (<0.4 g/kg/day). Multivariate logistic or multiple regression analyses were performed with adjustments for patient characteristics (total n = 86,702). The Adequate group was used as the reference in all analyses. For the Moderate, Low, and Very low groups, adjusted ORs (95% CI) of in-hospital mortality were 1.20 (1.14−1.26), 1.43 (1.36−1.51), and 1.72 (1.62−1.82), respectively, and for deterioration of ADL were 1.21 (1.11−1.32), 1.34 (1.22−1.47), and 1.22 (1.09−1.37), respectively. Adjusted regression coefficients (95% CI) of hospital LOS were 1.2 (0.4−2.1), 1.5 (0.6−2.4), and 2.9 (1.8−4.1), respectively. Lower prescribed doses of amino acids were associated with worse clinical outcomes including higher in-hospital mortality.