Effects of age, comorbidity and adherence to current antimicrobial guidelines on mortality in hospitalized elderly patients with community-acquired pneumonia

Compliance with guideline recommendations in the management of patients with hospitalized community-acquired pneumonia

Compliance with guidelines in the empirical treatment for community-acquired pneumonia (CAP) is very important to increase treatment success and reduce mortality. This study aimed to determine compliance with guideline recommendations for CAP and define the role of the clinical pharmacist (CP). Patients diagnosed with CAP were evaluated retrospectively between January 2018 and January 2020 and prospectively between February 2020 and February 2021. Compliance with guidelines was evaluated according to the local, national (Turkish Thoracic Society), and international (American Thoracic Society and Infectious Disease Society of America, European Society of Clinical Microbiology and Infectious Diseases) guidelines. A total of 751 patients (423 in the retrospective and 328 in the prospective period) were included. It was determined that the 30-day mortality and length of stay were higher in patients who were not treated according to the guidelines. The compliance for empirical treatments was 16.3%-59.1% and 7.8%-30.1% in retrospective and prospective periods, respectively. During the prospective period, a total of 603 recommendations were made by CP, and 578 (95.9%) were accepted and implemented. In the prospective period, treatment duration was shortened, inappropriate fluoroquinolone use was decreased, the switch to oral treatment was increased, and the number of potential drug-drug interactions was decreased (p < 0.001). Compliance with guidelines is essential to be improved to reduce mortality, shorten the length of stay, determine the appropriate antimicrobial duration, and reduce the use of fluoroquinolones and broad-spectrum antibiotics unless necessary. CP intervention contributes to the rational selection of antimicrobials, limiting drug-drug interactions, avoiding toxicities, and compliance with guidelines.

Prognostic factors of virus-associated pneumonia other than COVID-19 in adults

OBJECTIVE

To determine prognostic factors of virus-associated pneumonia other than coronavirus disease 2019.

METHODS

We retrospectively studied patients suffering from virus-associated community-acquired pneumonia, and who were admitted to Saitama Cardiovascular and Respiratory Center from 2002 to 2020. Prognostic factors were analyzed by univariable and multivariable regression analysis of patient demographics, laboratory data, chest imaging, severity on admission, and initial treatment.

PATIENTS

HIV-positive patients, those with non-resected lung cancer or receiving chemotherapy, and those with COVID-19 were excluded. Included were 363 patients diagnosed by nucleic acid amplification method, paired sera, and rapid diagnostic tests.

RESULTS

A CURB-65 score of ≥3 was significant by univariable analysis for 60-day mortality but was nonsignificant by multivariable analysis. The poor prognostic factors that were significant by multivariable analysis (p < 0.05) included immunosuppressive state due to systemic corticosteroid or immunosuppressant administration, acute kidney injury on admission, and corticosteroid administration initiated within 5 days or 5 days to 2 weeks from onset.

CONCLUSION

A CURB-65 score of ≥3, which is considered to indicate severe pneumonia, was of limited value for predicting mortality of virus-associated pneumonia. We showed patients' underlying diseases and complications to be independent factors of poor prognosis for 60-day mortality. Timing of the initiation of corticosteroid administration remains to be elucidated.

Erector spinae muscle-based nomogram for predicting in-hospital mortality among older patients with severe community-acquired pneumonia

BACKGROUND

No multivariable model incorporating erector spinae muscle (ESM) has been developed to predict clinical outcomes in older patients with severe community-acquired pneumonia (SCAP). This study aimed to construct a nomogram based on ESM to predict in-hospital mortality in patients with SCAP.

METHODS

Patients aged ≥ 65 years with SCAP were enrolled in this prospective observational study. Least absolute selection and shrinkage operator and multivariable logistic regression analyses were used to identify risk factors for in-hospital mortality. A nomogram prediction model was constructed. The predictive performance was evaluated using the concordance index (C-index), calibration curve, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis.

RESULTS

A total of 490 patients were included, and the in-hospital mortality rate was 36.1%. The nomogram included the following independent risk factors: mean arterial pressure, peripheral capillary oxygen saturation, Glasgow Coma Scale score (GCS), lactate, lactate dehydrogenase, blood urea nitrogen levels, and ESM cross-sectional area. Incorporating ESM into the base model with other risk factors significantly improved the C-index from 0.803 (95% confidence interval [CI], 0.761-0.845) to 0.836 (95% CI, 0.798-0.873), and these improvements were confirmed by category-free NRI and IDI. The ESM-based nomogram demonstrated a high level of discrimination, good calibration, and overall net benefits for predicting in-hospital mortality compared with the combination of confusion, urea, respiratory rate, blood pressure, and age ≥ 65 years (CURB-65), Pneumonia Severity Index (PSI), Acute Physiology and Chronic Health Evaluation II (APACHEII), and Sequential Organ Failure Assessment (SOFA).

CONCLUSIONS

The proposed ESM-based nomogram for predicting in-hospital mortality among older patients with SCAP may help physicians to promptly identify patients prone to adverse outcomes.

TRIAL REGISTRATION

This study was registered at www.chictr.org.cn (registration number Chi CTR-2300070377).

Overuse of medications in low- and middle-income countries: a scoping review

Objective

To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions.

Methods

We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions.

Findings

We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives.

Conclusion

Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.

Association of Serum Albumin and Copeptin with Early Clinical Deterioration and Instability in Community-Acquired Pneumonia

Background: There is a paucity of data on biomarkers for the early deterioration and clinical instability of patients in community-acquired pneumonia (CAP), as treatment failure occurs in the first seven days in 90% of patients. Aim: To evaluate serum albumin and copeptin with CURB-65, PSI scoring and ATS/IDSA minor criteria for the prediction of early mortality or ICU-admission (7 days) and clinical instability after 72 h. Methods: In 100 consecutive hospitalized adult CAP patients, PSI-scores, CURB-65 scores, ATS/IDSA 2007 minor criteria, copeptin and albumin on admission were evaluated. Univariate and multivariate Cox regression analysis was performed to assess independent risk factors for early combined mortality or ICU admission. Predictive powers of albumin and copeptin were tested with ROC curves and ICU-free survival probability was tested using Kaplan−Meier analysis. Results: Albumin was lower and copeptin higher in patients with short-term adverse outcomes (p < 0.05). Cox regression analysis showed that albumin [HR (95% CI): 0.41 (0.18−0.94, p = 0.034)] and copeptin [HR (95% CI): 1.94 (1.03−3.67, p = 0.042)] were independent risk factors for early combined mortality or ICU admission (7 days). The Kaplan−Meier analysis observed that high copeptin (>27.12 ng/mL) and low albumin levels (<2.85 g/dL) had a lower (p < 0.001) survival probability. The diagnostic accuracy of albumin was better than copeptin. The inclusion of albumin and copeptin into ATS/IDSA minor criteria significantly improved their predictive power. Conclusions: Both biomarkers serum albumin and copeptin can predict early deterioration and clinical instability in hospitalized CAP patients and increase the prognostic power of the traditional clinical scoring systems.

Factors associated with mortality in younger and older (≥75 years) hospitalized patients with community-acquired pneumonia

BACKGROUND

Pneumonia is among the most serious infections in the elderly. The evaluation of prognosis and predicting the outcome is essential in managing the treatment of patients with pneumonia.

OBJECTIVE

Evaluate factors that might affect the mortality of elderly patients hospitalized for community-acquired pneumonia (CAP) in two age groups.

DESIGN

Medical record review.

SETTINGS

Tertiary care hospital.

PATIENTS AND METHODS

The study included CAP patients who were hospitalized during the period from January 2017 and December 2019. The CURB-65 scale was chosen to assess the severity of pneumonia on admission. Multivariate analyses were conducted separately for patients younger than 75 years and 75 years or older.

MAIN OUTCOME MEASURES

30-day mortality, factors associated with mortality.

SAMPLE SIZE AND CHARACTERISTICS

1603 patients with a median age of 74, including 918 women (57%).

RESULTS

The 30-day mortality rate was 6.5%. Patients with carbapenem-resistant gram-negative bacteria had lower survival rates (P<.0001). In the multivariate analysis, age, lung cancer, CURB-65, carbapenem resistance, and duration of hospital stay were associated with mortality in patients aged 75 years or older. Lung cancer, malignant disease, carbapenem resistance, duration of hospital stay and procalcitonin level were associated with mortality under the age of 75. Of 640 sputum cultures tested, P aeruginosa (42%) was the most common pathogen.

CONCLUSION

The risk factors that affected mortality differed among patients aged 75 years or older versus younger patients. Our findings are important in determining factors associated with mortality in managing the treatment and follow up of hospitalized CAP patients younger or 75 years of age or older.

LIMITATIONS

Single-center, retrospective.

CONFLICT OF INTEREST

None.

Association of Admission Blood Glucose Level with All-Cause Mortality According to Age in Patients with Community Acquired Pneumonia

Objective

To assess the impact of blood glucose levels on the prognosis of patients with community-acquired pneumonia (CAP) who were elderly or middle-aged.

Methods

From January 1, 2018, to December 31, 2020, patients with CAP (≥45 years) were retrospectively enrolled in this observational study. They were stratified by age (45-64 or ≥65 years) and blood glucose level (≥11.1 or <11.1 mmol/l). The effect of admission blood glucose on 28-day mortality was assessed with the Cox proportional hazards model, adjusted for demographic factors and comorbidity.

Results

Among 1656 patients with CAP, increased blood glucose (HR=2.08, 95% CI: 1.38-3.49; P<0.01) and advanced age (HR=2.76, 95% CI: 1.65-3.77; P<0.01) were significantly associated with a higher risk of 28-day mortality, after controlling for potential confounding factors. The strength of the association of blood glucose level with 28-day mortality decreased with age (P=0.01 for the interaction) as the adjusted HRs for death were 4.48 (95% CI: 1.40-13.65; P<0.01) for middle-age patients 45-64 years and 1.52 (95% CI: 1.09-2.17; P=0.05) for elderly patients ≥65 years.

Conclusion

The association of blood glucose level upon admission for CAP with all-cause mortality was stronger at younger ages.

Efficacy and validity of guideline-concordant treatment according to the JRS guidelines for the managements of pneumonia in adults updated in 2017 for nursing and healthcare-associated pneumonia. A propensity-matching score analysis

INTRODUCTION

Patients with nursing and healthcare-associated pneumonia (NHCAP) commonly receive empiric antibiotic therapy according to the guideline's recommendation corresponding to the patient's deteriorated conditions. However, it is unclear whether guideline-concordant treatment (GCT) could be effective or not.

PATIENTS AND METHODS

To evaluate the efficacy and validity of GCT according to the current guideline for pneumonia, we conducted this retrospective study. NHCAP patients who were admitted to our institute between 2014 and 2017 were enrolled. Based on the initial antibiotic treatment, these patients were divided into two groups, the GCT group (n = 83) and the non-GCT group (n = 146). Propensity score matching (PSM) was used to balance the baseline characteristics and potential confounders between the two groups. After PSM, patients' characteristics, microbial profiles, and clinical outcomes were evaluated.

RESULTS

Both groups were well-balanced after PSM, and 78 patients were selected from each group. There were no differences in patients' characteristics or microbial profiles between the two groups. As for outcomes, there were no differences in 30-day, in-hospital mortality rate, duration of antibiotic treatment, or admission. The severity of pneumonia was more severe in patients with the GCT group than those with the non-GCT group. Anti-pseudomonal agents as initial treatment were more frequently seen in patients with the GCT group than those in the non-GCT group.

CONCLUSION

Unlike previous studies, GCT's recommendation for management of pneumonia by the JRS in 2017 would appear to be valid and does not increase the mortality rate.

The Role of Red Blood Cell Distribution Width in the Severity and Prognosis of Community-Acquired Pneumonia

Objectives

The objective of this study is to unravel the correlation between RDW and the severity and prognosis of CAP, as well as exploring RDW with the inflammatory markers white blood cells (WBC), C-reactive protein (CRP), and procalcitonin (PCT).

Methods

According to the data characteristics, appropriate statistical methods were selected to analyze the relationship between RDW and the severity and prognosis of CAP patients and to determine whether RDW is associated with the inflammatory markers WBC, CRP, and PCT.

Results

The results show that with the increase of PSI and CURB-65 values, the proportion of patients with RDW ≥ 12.987% is significantly higher than that of RDW < 12.987% (P < 0.01). When RDW is combined with PSI or CURB-65 to predict the 90-day mortality of CAP patients, the area under the receiver operating characteristic (ROC) curve increased prominently, and if RDW, PSI, and CURB-65 are combined, the area under the ROC curve is maximized.

Conclusions

Our findings suggest that the higher RDW value is associated with short-term adverse outcomes in CAP patients. We also find that when RDW, PSI, and CURB-65 are combined, the best performance is achieved to predict CAP 90-day mortality risk.

The impact of comorbidities and their stacking on short- and long-term prognosis of patients over 50 with community-acquired pneumonia

BACKGROUND

The prognosis of patients hospitalized with community-acquired pneumonia (CAP) with regards to intensive care unit (ICU) admission, short- and long-term mortality is correlated with patient's comorbidities. For patients hospitalized for CAP, including P-CAP, we assessed the prognostic impact of comorbidities known as at-risk (AR) or high-risk (HR) of pneumococcal CAP (P-CAP), and of the number of combined comorbidities.

METHODS

Data on hospitalizations for CAP among the French 50+ population were extracted from the 2014 French Information Systems Medicalization Program (PMSI), an exhaustive national hospital discharge database maintained by the French Technical Agency of Information on Hospitalization (ATIH). Their admission diagnosis, comorbidities (nature, risk type and number), other characteristics, and their subsequent hospital stays within the year following their hospitalization for CAP were analyzed. Logistic regression models were used to assess the associations between ICU transfer, short- and 1-year in-hospital mortality and all covariates.

RESULTS

From 182,858 patients, 149,555 patients aged ≥ 50 years (nonagenarians 17.8%) were hospitalized for CAP in 2014, including 8270 with P-CAP. Overall, 33.8% and 90.5% had ≥ 1 HR and ≥ 1 AR comorbidity, respectively. Cardiac diseases were the most frequent AR comorbidity (all CAP: 77.4%). Transfer in ICU occurred for 5.4% of CAP patients and 19.4% for P-CAP. Short-term and 1-year in-hospital mortality rates were 10.9% and 23% of CAP patients, respectively, significantly lower for P-CAP patients: 9.2% and 19.8% (HR 0.88 [95% CI 0.84-0.93], p < .0001). Both terms of mortality increased mostly with age, and with the number of comorbidities and combination of AR and HR comorbidities, in addition of specific comorbidities.

CONCLUSIONS

Not only specific comorbidities, but also the number of combined comorbidities and the combination of AR and HR comorbidities may impact the outcome of hospitalized CAP and P-CAP patients.

Cost Effectiveness of Different Initial Antimicrobial Regimens for Elderly Community-Acquired Pneumonia Patients in General Ward

Purpose

The cost-effectiveness of different guideline-concordant antimicrobial regimens for elderly patients with community-acquired pneumonia (CAP) was rarely discussed. This study attempts to explore the most appropriate cost-effectiveness of guideline-concordant antimicrobial regimen for elderly patients with CAP in general wards.

Patients and Methods

This was a multicenter, retrospective, 4:2:1 matched study enrolling 511 elderly patients with CAP hospitalized in general wards. Two hundred ninety-two patients prescribed with β-lactam monotherapy (group A), 146 patients prescribed with fluoroquinolone monotherapy (group B) and 73 patients prescribed with β-lactam/macrolide combination therapy (group C). Clinical outcomes and medical costs were analyzed by χ² test for categorical variables or Kruskal–Wallis H-test for continuous variables.

Results

There were no statistical differences in imaging features, etiology and complications during hospitalization among these three groups. The rates of clinical failure occurrence, in-hospital mortality, 30-day mortality and 60-day mortality also had no significant differences among group A, B and C patients; however, the median length of stay (LOS) in group A patients was 12.0 days, which was significantly higher than that in group B and C patients (both 10.0 days, p<0.02). The median total, drug, and antibiotic costs for one elderly CAP episode in group B patients were RMB 10368.4, RMB 3874.8, and RMB 1796.3, respectively, which were significantly lower than those in group A and C patients (p<0.01).

Conclusion

Non-inferiority of clinical failure occurrence and short-term mortality was observed in different guideline-concordant antimicrobial regimens for elderly patients with CAP in general wards; however, the median LOS and hospitalization-associated costs for one elderly CAP episode with fluoroquinolone monotherapy were significantly lowest, and this strategy was considered to be the most cost-effective strategy in general wards.

The Associations of Serum IL-37 With the Severity and Prognosis in Patients With Community-Acquired Pneumonia: A Retrospective Cohort Study

Background

Recent evidences suggested that IL-37 may participate in the pathophysiology of community-acquired pneumonia (CAP). Nevertheless, its exact biological role was unknown. The objective of this study was to determine the associations of serum IL-37 with the severity and prognosis in CAP patients based on a retrospective cohort study.

Methods

The whole of 120 healthy subjects and 240 CAP patients were summoned. Peripheral blood was collected and IL-37 was detected using ELISA.

Results

Serum IL-37 was obviously decreased in CAP patients on admission. In addition, serum IL-37 was gradually decreased in parallel with CAP severity scores. Correlative analysis revealed that serum IL-37 was negatively associated with CAP severity scores and inflammatory cytokines. Further logistical regression found that reduction of serum IL-37 augmented the severity of CAP patients. Moreover, the follow-up research was performed in CAP patients. Serum lower IL-37 on admission prolonged the hospital stay in CAP patients. Serum IL-37 combination with PSI and CURB-65 had a stronger predictive capacity for death than IL-37 and CAP severity score alone in CAP patients.

Conclusion

There are remarkably negative correlations between serum IL-37 with the severity and prognosis in CAP patients. Serum IL-37 on admission prolongs the hospital stay, demonstrating that IL-37 may involve in the process of CAP. Serum IL-37 may be regarded as a biomarker for diagnosis and prognosis for CAP patients.

Combined Neutrophil-to-Lymphocyte Ratio and CURB-65 Score as an Accurate Predictor of Mortality for Community-Acquired Pneumonia in the Elderly

Purpose

Community-acquired pneumonia (CAP) is common among the elderly; it typically has a poor prognosis and high mortality. This study evaluated the factors predicting CAP-related in-hospital mortality in the elderly to identify a simpler and more accurate predictor.

Patients and Methods

This was a single-center, retrospective study. The data used in this study was collected from all older patients (≥65) with CAP admitted to our hospital between January 2012 and April 2020.

Results

A total of 2028 older patients with CAP were included; 121 (5.97%) died in hospital. Of the patients in the study, 1267 (62.5%) were men and 261 (12.9%) had a history of malignant tumors. After performing univariate and multivariate Cox regression analyses, sex, history of malignant tumor, CURB-65 score, neutrophil-to-lymphocyte ratio (NLR), hemoglobin level, and NLR*CURB-65 levels were associated with CAP mortality. By comparing the area under the receiver operating characteristic (ROC) curves of the predicted factors, the NLR*CURB-65 level used to predict CAP mortality in the elderly was 0.755, and was superior to other measurements. All included patients were then dichotomized into two groups based on NLR*CURB-65 level (≤9.06 and >9.06) according to the ROC analysis. Patients with a high NLR*CURB-65 level had higher in-hospital mortality than those with a low NLR*CURB-65 level. The two divided groups showed significant differences in age, sex, smoking history, comorbidity, and laboratory findings. This indicates that NLR*CURB-65 is a predictive index that could reflect the comprehensive condition of older patients with CAP.

Conclusion

NLR*CURB-65 is a simpler and more accurate predictor of CAP-related in-hospital mortality in the elderly.

Macrophage-derived cytokines in pneumonia: Linking cellular immunology and genetics

Macrophages represent the first line of anti-pathogen defense - they encounter invading pathogens to perform the phagocytic activity, to deliver the plethora of pro- and anti-inflammatory cytokines, and to shape the tissue microenvironment. Throughout pneumonia course, alveolar macrophages and infiltrated blood monocytes produce increasing cytokine amounts, which activates the antiviral/antibacterial immunity but can also provoke the risk of the so-called cytokine “storm” and normal tissue damage. Subsequently, the question of how the cytokine spectrum is shaped and balanced in the pneumonia context remains a hot topic in medical immunology, particularly in the COVID19 pandemic era. The diversity in cytokine profiles, involved in pneumonia pathogenesis, is determined by the variations in cytokine-receptor interactions, which may lead to severe cytokine storm and functional decline of particular tissues and organs, for example, cardiovascular and respiratory systems. Cytokines and their receptors form unique profiles in individual patients, depending on the (a) microenvironmental context (comorbidities and associated treatment), (b) lung monocyte heterogeneity, and (c) genetic variations. These multidisciplinary strategies can be proactively considered beforehand and during the pneumonia course and potentially allow the new age of personalized immunotherapy.

Disease burden and prognostic factors for clinical failure in elderly community acquired pneumonia patients

Background

The study was to evaluate initial antimicrobial regimen and clinical outcomes and to explore risk factors for clinical failure (CF) in elderly patients with community-acquired pneumonia (CAP).

Methods

3011 hospitalized elderly patients were enrolled from 13 national teaching hospitals between January 1, 2014 and December 31, 2014 initiated by the CAP-China network. Risk factors for CF were screened by multivariable logistic regression analysis.

Results

The incidence of CF in elderly CAP patients was 13.1%. CF patients were older, longer hospital stays and higher treatment costs than clinical success (CS) patients. The CF patients were more prone to present hyperglycemia, hyponatremia, hypoproteinemia, pleural effusion, respiratory failure and cardiovascular events. Inappropriate initial antimicrobial regimens in CF group were significantly higher than CS group. Undertreatment, CURB-65, PH < 7.3, PaO₂/FiO₂ < 200 mmHg, sodium < 130 mmol/L, healthcare-associated pneumonia, white blood cells > 10,000/mm³, pleural effusion and congestive heart failure were independent risk factors for CF in multivariable logistic regression analysis. Male and bronchiectasis were protective factors.

Conclusions

Discordant therapy was a cause of CF. Early accurate detection and management of prevention to potential causes is likely to improve clinical outcomes in elderly patients CAP.

Trial registration

A Retrospective Study on Hospitalized Patients With Community-acquired Pneumonia in China (CAP-China) (RSCAP-China), NCT02489578. Registered 16 March 2015, https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0005E5S&selectaction=Edit&uid=U0000GWC&ts=2&cx=1bnotb

Community-acquired pneumonia in critically ill very old patients: a growing problem

Very old (aged ≥80 years) adults constitute an increasing proportion of the global population. Currently, this subgroup of patients represents an important percentage of patients admitted to the intensive care unit. Community-acquired pneumonia (CAP) frequently affects very old adults. However, there are no specific recommendations for the management of critically ill very old CAP patients. Multiple morbidities, polypharmacy, immunosenescence and frailty contribute to an increased risk of pneumonia in this population. CAP in critically ill very old patients is associated with higher short- and long-term mortality; however, because of its uncommon presentation, diagnosis can be very difficult. Management of critically ill very old CAP patients should be guided by their baseline characteristics, clinical presentation and risk factors for multidrug-resistant pathogens. Hospitalisation in intermediate care may be a good option for critical ill very old CAP patients who do not require invasive procedures and for whom intensive care is questionable in terms of benefit.

There is currently no international recommendation for the management of critically ill older patients over 80 years of age with CAP. We report and discuss recent literature in order to help physicians in the decision-making process of these patients.http://bit.ly/2ql0mIz

Age, Pulse, Urea and Albumin (APUA) Model: A Tool for Predicting in-Hospital Mortality of Community-Acquired Pneumonia Adapted for Patients with Type 2 Diabetes

OBJECTIVE

The aim of this study was to develop a tool for predicting in-hospital mortality of community-acquired pneumonia (CAP) in patients with type 2 diabetes (T2DM).

METHODS

A retrospective study was conducted on 531 CAP patients with T2DM at The First Hospital of Qinhuangdao. The primary outcome was in-hospital mortality. Variables to develop the nomogram were selected using multiple logistic regression analysis. Discrimination was evaluated using receiver operating characteristic (ROC) curve. Calibration was evaluated using the Hosmer-Lemeshow test and calibration plot.

RESULTS

Multiple logistic regression analysis showed that age, pulse, urea and albumin (APUA) were independent risk predictors. Based on these results, we developed a nomogram (APUA model) for predicting in-hospital mortality of CAP in T2DM patients. In the training set, the area under the curve (AUC) of the APUA model was 0.814 (95% CI: 0.770-0.853), which was higher than the AUCs of albumin alone, CURB-65 and Pneumonia Severity Index (PSI) class (p<0.05). The Hosmer-Lemeshow test (χ ²=5.298, p=0.808) and calibration plot (p=0.802) showed excellent agreement between the predicted possibility and the actual observation in the APUA model. The results of the validation set were similar to those of the training set.

CONCLUSION

The APUA model is a simple and accurate tool for predicting in-hospital mortality of CAP, adapted for patients with T2DM. The predictive performance of the APUA model was better than CURB-65 and PSI class.

Knowledge and Expectations on Antibiotic Use among Older Adults in Malaysia: A Cross-Sectional Survey

Antibiotics are commonly prescribed among older adults, and inappropriate use of antibiotics has been noted. However, there is limited information about their knowledge and expectations for antibiotics. This study aimed to assess older adults' knowledge of antibiotic use and resistance, their expectations for antibiotics and the relationship between knowledge, expectation and inappropriate practices related to antibiotic use. A cross-sectional survey involving respondents aged 60 years and above was conducted, using a validated questionnaire. A lack of knowledge about the role of antibiotics was observed, whereby more than half of the respondents incorrectly believed that antibiotics can treat viral infections (53.5%) and colds and coughs (53.7%). Also, 67.9% of respondents incorrectly believed that antibiotic resistance occurs when the body becomes resistant to antibiotics. Almost half of the respondents would expect antibiotics for symptoms of self-limiting viral infections. Respondents who answered correctly for the role of antibiotics in viral infections were more likely not to expect antibiotics for cold, flu and cough (p < 0.001). Respondents who answered correctly regarding the need to adhere to antibiotics were more likely to have completed their antibiotic course (p < 0.001). Future educational initiatives should provide key information on the role of antibiotics and the importance of complying with antibiotics in this population.

Association Between Medication Adherence and 1-Year Major Cardiovascular Adverse Events After Acute Myocardial Infarction in China

Background Secondary prevention after acute myocardial infarction ( AMI ) requires long-term guideline-directed medical therapy. However, the level of medication adherence, factors associated with poor adherence, and extent to which good adherence can reduce adverse events after AMI in China remain uncertain. Methods and Results In 2013 to 2014, 4001 AMI patients aged ≥18 years were discharged alive from 53 hospitals across China (mean age 60.5±11.7 years; 22.7% female). Good adherence was defined as taking medications (aspirin, β-blockers, statins, clopidogrel, or angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers) ≥90% of the time as prescribed. Cox models assessed the association between good adherence (a time-varying covariate) and 1-year cardiovascular events after AMI . The most common medications were aspirin (82.2%) and statins (80.5%). There were 243 patients who were not prescribed any medications during follow-up; 1-year event rates were higher for these patients (25.1%, 95% CI 19.7-30.6%) versus those taking ≥1 medications (6.6%, 95% CI 5.76-7.34%). The overall rate of good adherence was 52.9%. Good adherence was associated with lower risk of 1-year events (adjusted hazard ratio 0.61, 95% CI 0.49-0.77). The most common reason for poor adherence was belief that one's condition had improved/no longer required medication. More comorbidities and lower education level were associated with poor adherence. Conclusions Good adherence reduced 1-year cardiovascular event risk after AMI . About half of our cohort did not have good adherence. National efforts to improve AMI outcomes in China should focus on medication adherence and educating patients on the importance of cardiovascular medications for reducing risk of recurrent events. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT01624909.

Clinical Value of Neutrophil-to-Lymphocyte Ratio in Primary Intraventricular Hemorrhage

OBJECTIVES

The neutrophil-to-lymphocyte ratio (NLR) reflects the balance between innate and adaptive inflammatory responses. This study intended to evaluate parameters associated with admission high NLR and its impact on clinical outcome in patients with primary intraventricular hemorrhage (PIVH).

METHODS

This study retrospectively analyzed consecutive patients with PIVH without a history of head trauma or parenchymal/subarachnoid hemorrhage on computed tomography scan between 2010 and 2016 in a single center. Clinical outcomes at discharge and 90 days were assessed with the modified Rankin Score (mRS) and dichotomized as good (mRS 0-2) and poor (mRS 3-6) outcomes. Associations were estimated using multivariable logistic regression.

RESULTS

We had 171 patients with PIVH included in the present study. There were 94 male (55.0%) and 77 female (45.0%) patients, with an average age of 46.1 ± 17.2 years. Multivariable logistic analyses revealed independent associations of high NLR (≥8.25) with higher Graeb score, Moyamoya disease, higher admission blood glucose level, and lower platelet count. The patients with high NLR had poorer outcome at discharge and 90 days. After adjustment, the patients with high NLR tended to be associated with poor outcome both at discharge and 90 days. In addition, NLR exhibited a superior predictive power of pneumonia in PIVH than absolute neutrophil count and white blood cell count.

CONCLUSIONS

NLR tended to be associated with 90-day clinical outcomes of patients with PIVH and exhibited independent predictive power for pneumonia in PIVH.

Diagnostic value of blood parameters for community-acquired pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) has a high rate of morbidity and mortality. Blood parameters, including neutrophil, platelet, lymphocyte, monocyte, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and monocyte to lymphocyte ratio (MLR), have been proposed as indicators of systemic inflammation and infection. However, few studies have focused on the diagnostic value of blood parameters for CAP.

OBJECTIVE

The study aims to determine the diagnostic value of blood parameters for CAP and to investigate their relationship with disease severity.

METHODS

CAP patients who fulfilled the inclusion criteria were enrolled in this study. Healthy age- and gender-matched subjects were also enrolled as a control group. Blood parameters, blood biochemistry, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT), days in hospital, body temperature, pneumonia severity index (PSI), and CURB-65 were recorded. The area under the curve (AUC) values was determined using the receiver-operating characteristic (ROC) curve. The correlation between the variables was tested with Pearson correlation analysis.

RESULTS

The study included 80 CAP patients and 49 healthy subjects. White blood cell (WBC), neutrophil, monocyte, MLR, PLR, and NLR levels in the CAP group were higher than that of control group, while lymphocyte and hemoglobin (HGB) levels were lower (P < 0.05). The ROC curve result showed that NLR and MLR yielded higher AUC values than other variables. Monocyte was positively correlated with ESR and negatively with body temperature, aspartate aminotransferase (AST), and creatinine (CREA). NLR was positively correlated with CRP, PCT, days in hospital, alanine aminotransferase (ALT), AST, and PSI. MLR was positively correlated with CRP, PCT, and body temperature. An increase in ALT or AST of >2 times of normal was defined as liver injury, and CAP patients were divided into the liver normal group and liver injury group. Sixty-nine patients belonged to the liver normal group, and 11 patients belonged to the liver injury group. Blood parameters, ESR, CRP, PCT, PSI, and CURB-65 were compared between the two groups. The results demonstrated that the monocyte level in the liver injury group was lower than that of the liver normal group (P < 0.05). The ROC curve result showed that the AUC value of monocyte for liver injury was 0.838 (95% confidence interval: 0.733-0.943), which was higher than other variables.

CONCLUSIONS

NLR and MLR were elevated in CAP patients, resulting in a higher diagnostic value for CAP. NLR showed a significant correlation to PSI, indicating the disease severity of CAP. Monocyte had a higher diagnostic value for liver injury in CAP patients.