Multimarker Prognostication for Hospitalized Patients with Community-acquired Pneumonia

Risk Factors for Frequent Infections in Patients With Extremely Severe Motor and Intellectual Disabilities

BACKGROUND

At our institution, patients of all ages with extremely severe motor and intellectual disabilities (ESMID) receive comprehensive management similar to intensive care for "extremely ill patients." Some patients with ESMID develop frequent infections that are difficult to manage. The purpose of this study was to identify risk factors for frequent infections in these patients.

METHODS

Thirty-seven patients with ESMID who were treated for infections at our institution between September 2018 and August 2019 were retrospectively investigated. Frequent infection was defined as three or more episodes of infection and antimicrobial treatment in one year. Infection status and potential risk factors for frequent infections (patient background factors, severity score, hematological parameters, anthropometry index, and parenteral nutritional status) were examined in univariate and multivariate analyses.

RESULTS

Frequent infections occurred in 11 of the 37 patients (29.7%) during the study period, including respiratory and urinary tract infections. Univariate and multivariate analyses suggested hypoalbuminemia (p<0.01) and hypertriglyceridemia (p<0.01) were independent risk factors for frequent infections.

CONCLUSIONS

Hypoalbuminemia and hypertriglyceridemia may be risk factors for frequent infections in patients with ESMID.

A new predictive tool consolidating CURB-65 with procalcitonin and albumin to assess short-term mortality in hospitalized elderly patients with infectious disease: A retrospective study of a patient cohort

BACKGROUND

Hospitalized elderly patients are often at risk of life-threatening infectious diseases such as pneumonia and urinary tract infection, thus diagnostic tools for bacterial infections are demanded. We developed a new predictive tool consolidating modified CURB-65, procalcitonin (PCT) and albumin (Alb).

METHOD

This is a retrospective study. Modified CURB-65 (mCURB-65) score, PCT, Alb, and various cardiovascular/respiratory/renal functions were measured. Survival analyses were conducted to assess 30-days mortality of elderly patients using mCURB-65 score, PCT and Alb. The consolidated scores were compared with the number of patients died.

RESULTS

There were 445 elderly patients included. Kaplan-Meier survival curves showed significant differences between the high and low groups of mCURB-65, PCT and Alb (log-rank test, P < .001). Cox proportional regression showed that the hazard ratios (95% confidence intervals) for high mCURB-65, high Alb, and high PCT were all significant, 1.95 (1.24-3.05), 0.50 (0.32-0.77), and 2.09 (1.32-3.31), respectively. The consolidated scores showed tendency of increase with proportion of the number of patients died.

CONCLUSIONS

The consolidated score consisted of mCURB-65, PCT and Alb can be a useful tool to predict short-term mortality of the hospitalized elderly patients with infectious disease.

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.

Prognostic factors in patients hospitalized with community-acquired aspiration pneumonia

INTRODUCTION

Patients with aspiration pneumonia (AP) exhibit higher mortality than those with non-AP. However, data regarding predictors of short-term prognosis in patients with community-acquired AP are limited.

METHODS

Patients hospitalized with community-acquired pneumonia (CAP) were retrospectively classified into aspiration pneumonia (AP) and non-AP groups. The AP patients were further divided into nonsurvivors and survivors by 30-day mortality, and various clinical variables were compared between the groups.

RESULTS

Of 1249 CAP patients, 254 (20.3%) were classified into the AP group, of whom 76 patients (29.9%) died within 30 days. CURB-65, pneumonia severity index (PSI), and Infectious Diseases Society of America/American Thoracic Society criteria for severe CAP (SCAP) showed only modest prognostic performance for the prediction of 30-day mortality (c-statistics, 0.635, 0.647, and 0.681, respectively). Along with the PSI and SCAP, Eastern Cooperative Oncology Group performance status (ECOG-PS) and blood biomarkers, including, N-terminal of prohormone brain natriuretic peptide (NT-proBNP) and albumin, were independent predictors of 30-day mortality. In models based on clinical prediction rules, including CURB-65, PSI, and SCAP, the addition of ECOG-PS further improved their c-statistics compared to the clinical prediction rules alone. In the four combinations based on SCAP, ECOG-PS, and two blood biomarkers (NT-proBNP and albumin), the c-statistics further increased to reach approximately 0.8.

CONCLUSIONS

CURB-65, PSI, and SCAP exhibited only modest discriminatory power in predicting the 30-day mortality of patients with community-acquired AP. The addition of performance status and blood biomarkers, including NT-proBNP and albumin, further increased prognostic performance, showing good predictive accuracy in the SCAP-based model.

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.

Relationship Between Clinical Features and Computed Tomographic Findings in Hospitalized Adult Patients With Community-Acquired Pneumonia

Background

Data on the relationship between the clinical and microbiological features of community-acquired pneumonia (CAP) and its computed tomography (CT) findings are limited. The aim of the present study was to investigate the clinic-microbiological features of patients with CAP presenting with ground-glass opacity (GGO) and centrilobular nodules or tree-in-bud pattern on CT images.

Methods

Patients with CAP who underwent a CT scan at presentation were retrospectively classified using CT findings into consolidation, GGO and bronchiolitis groups. These 3 groups were compared in terms of clinical parameters and microbiological data.

Results

A total of 40 patients (2.4%) were allocated to the bronchiolitis group and 46 (2.8%) to the GGO group. The most common pathogen in the bronchiolitis group was Mycoplasma pneumoniae, which was significantly more frequently isolated in this group. The bronchiolitis group was characterized by a higher percentage of cough, a lower percentage of chest pain and lower blood levels of inflammatory markers. Common pathogens in the GGO group were not significantly different from those in the other 2 groups. Unlike that observed in the consolidation group, complicated parapneumonic effusion or empyema was not observed in the bronchiolitis or GGO group. Outcome variables were similar in the 3 groups.

Conclusions

The bronchiolitis group was characterized by a higher frequency of M. pneumoniae and a less severe form of CAP. The GGO and consolidation groups was similar with respect to causative microorganisms and the clinical features of CAP. No patient in the bronchiolitis or GGO group exhibited complicated parapneumonic effusion or empyema.

A Composite of Functional Status and Pneumonia Severity Index Improves the Prediction of Pneumonia Mortality in Older Patients

BACKGROUND

The baseline health status may be a determinant of interest in the evolution of pneumonia.

OBJECTIVE

Our objective was to assess the predictive ability of community-acquired pneumonia (CAP) mortality by combining the Barthel Index (BI) and Pneumonia Severity Index (PSI) in patients aged ≥ 65 years.

DESIGN, PATIENTS AND MAIN MEASURES

In this prospective, observational, multicenter analysis of comorbidities, the clinical data, additional examinations and severity of CAP were measured by the PSI and functional status by the BI. Two multivariable models were generated: Model 1 including the PSI and BI and model 2 with PSI plus BI stratified categorically.

KEY RESULTS

The total population was 1919 patients, of whom 61% had severe pneumonia (PSI IV-V) and 40.4% had some degree of dependence (BI ≤ 90 points). Mortality in the PSI V-IV group was 12.5%. Some degree of dependence was associated with increased mortality in both the mild (7.2% vs. 3.2%; p = 0.016) and severe (14% vs. 3.3%; p < 0.001) pneumonia groups. The combination of PSI IV-V and BI ≤ 90 was the greatest risk factor for mortality (aOR 4.17; 95% CI 2.48 to 7.02) in our series.

CONCLUSIONS

The use of a bimodal model to assess CAP mortality (PSI + BI) provides more accurate prognostic information than the use of each index separately.

Hypoalbuminemia Predicts Perioperative Morbidity and Mortality after Infrainguinal Lower Extremity Bypass for Critical Limb Ischemia

BACKGROUND

Poor nutritional status has been associated with a higher risk of morbidity and mortality in general surgery patients; however, outcomes in vascular surgery patients are unclear. Our goal was to determine the effect of poor nutritional status on perioperative morbidity and mortality after lower extremity bypass (LEB).

METHODS

The 2005-2012 National Surgical Quality Improvement Program was analyzed to determine associated complications, mortality, length of stay (LOS), and readmissions for patients with hypoalbuminemia (serum albumin <3.5 g/dL and <2.8 g/dL) undergoing infrainguinal lower extremity bypass for critical limb ischemia. Multivariable analyses were performed to assess associated risk factors while adjusting for possible confounders.

RESULTS

There were 5,110 LEB identified with an albumin level recorded. There were 2,327 (45.5%) patients with a low preoperative albumin. Patients with a low albumin were more likely to have diabetes, chronic obstructive pulmonary disease, congestive heart failure, previous myocardial infarction, renal failure, dialysis dependence, hypertension, history of transient ischemic attack or stroke, steroid use, impaired functional status, dyspnea at rest, anemia, prior operations within 30 days, preoperative wounds or infections, and a tibial target (P < 0.05). Multivariable analyses showed that low albumin was independently associated with increased mortality (odds ratio [OR]: 1.8, 95% confidence interval [95% CI]: 1.3-2.6, P = 0.001), return to the operating room (OR: 1.4, 95% CI: 1.2-1.6, P < 0.001), and increased LOS (MR: 1.2, 95% CI: 1.1-1.2, P < 0.001). When compared with patients with normal albumin, patients with more severe hypoalbuminemia, less than 2.8 g/dL, showed further increased risk of mortality (OR: 2.5, 95% CI: 1.6-3.8), return to the operating room (OR: 1.6, 95% CI: 1.3-2.0), and prolonged LOS (MR: 1.2, 95% CI: 1.2-1.3).

CONCLUSIONS

Poor preoperative hypoalbuminemia is associated with morbidity and mortality after infrainguinal lower extremity bypass for critical limb ischemia. Evaluation and optimization of nutritional status should be performed preoperatively in this high risk population.