Clinical aspects and prognostic factors in elderly patients hospitalised for community-acquired pneumonia

A Novel Index in the Prediction of Pneumonia Following Acute Ischemic Stroke

BACKGROUND

The aim of our study was to search for predictive factors and to develop a model (index) for the risk of pneumonia following acute ischemic stroke.

MATERIAL AND METHODS

This study is an analysis of prospectively collected data from the neurology department of a district general hospital in Poland, comprising 1001 patients suffering from an acute ischemic stroke. Based on the medical data, the formula for the prediction of pneumonia was calculated.

RESULTS

Multivariate assessment for pneumonia occurrence was performed using the new PNEUMOINDEX. The study showed a significant increase in pneumonia risk with an increasing PNEUMOINDEX (OR non-adjusted = 2.738, p < 0.001). After accounting for age and comorbidities as confounders, the effect of the Index on pneumonia changed marginally (OR = 2.636, p < 0.001).

CONCLUSIONS

This study presents factors that show a significant association with the occurrence of pneumonia in patients with acute ischemic stroke. The calculated PNEUMOINDEX consists of data obtained at admission, namely NYHA III and IV heart failure, COPD, generalized atherosclerosis, NIHHS score on admission, and CRP/Hgb ratio, and shows high prediction accuracy in predicting hospital-acquired pneumonia in ischemic stroke patients.

Contribution of clinical severity and geriatric risk factors in predicting short-term mortality of older hospitalized pneumonia patients: the Pneumonia in Italian Acute Care for Elderly units (PIACE) study

BACKGROUND

Clinical severity of pneumonia in older persons increases the risk for short-term mortality. Comprehensive geriatric assessment (CGA) may provide further insight in prognostic stratification.

AIMS

To investigate whether CGA may improve prognostic stratification among older patients with pneumonia admitted to hospital.

METHODS

Our series consisted of 318 consecutive patients hospitalized for pneumonia in a multicenter observational study. Disease severity was assessed by Sequential Organ Failure Assessment (SOFA) and Pneumonia Severity Index (PSI). CGA included the occurrence of delirium, Basic Activities of Daily Living (BADL) disability, cognitive impairment at Short Portable Mental Status Questionnaire (SPMSQ) and overall comorbidity assessed by Cumulative Illness Rating Scale (CIRS). The outcomes were in-hospital and post-discharge 3 month mortality. Statistical analysis was carried out by Cox regression, area under receiver operating curve (AUC) and net reclassification index (NRI).

RESULTS

Overall, 53 patients died during hospitalization and 52 after discharge. Delirium, SOFA score and admission BADL disability were significant predictors of in-hospital mortality. SOFA score, CIRS, previous long-term oxygen therapy and discharge BADL dependency significantly predicted post-discharge mortality. The accuracy of SOFA in predicting in-hospital and post-discharge mortality was fair (AUC = 0.685, 95% CI = 0.610-0.761 and AUC = 0.663, 95% CI = 0.593-0.734, respectively). BADL dependency and delirium improved predictive accuracy for in-hospital mortality (ΔAUC = 0.144, 95% CI = 0.062-0.227, p < 0.001), while pre-admission oxygen therapy, CIRS and BADL dependency improved predictivity for 3 month mortality (ΔAUC = 0.177, 95% CI = 0.102-0.252, p < 0.001).

DISCUSSION

Among older pneumonia patients, prognostic stratification obtained by clinical severity indexes is significantly improved by CGA risk factors.

CONCLUSIONS

CGA provides important information for prognostic stratification and clinical management of older pneumonia patients.

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.

Pneumonia in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a frequent comorbid condition associated with increased morbidity and mortality. Pneumonia is the most common infectious disease condition. The purpose of this review is to evaluate the impact of pneumonia in patients with COPD. We will evaluate the epidemiology and factors associated with pneumonia. We are discussing the clinical characteristics of COPD that may favor the development of infections conditions such as pneumonia. Over the last 10 years, there is an increased evidence that COPD patients treated with inhaled corticosteroids are at increased risk to develp pneumonia. We will review the avaialbe information as well as the possible mechanism for this events. We also discuss the impact of influenza and pneumococcal vaccination in the prevention of pneumonia in COPD patients.

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

BACKGROUND

Limited information exists on the clinical characteristics predictive of mortality in patients aged ≥65 years in many countries. The impact of adherence to current antimicrobial guidelines on the mortality of hospitalized elderly patients with community-acquired pneumonia (CAP) has never been assessed.

METHODS

A total of 3131 patients aged ≥65 years were enrolled from a multi-center, retrospective, observational study initiated by the CAP-China network. Risk factors for death were screened with multivariable logistic regression analysis, with emphasis on the evaluation of age, comorbidities and antimicrobial treatment regimen with regard to the current Chinese CAP guidelines.

RESULTS

The mean age of the study population was 77.4 ± 7.4 years. Overall in-hospital and 60-day mortality were 5.7% and 7.6%, respectively; these rates were three-fold higher in those aged ≥85 years than in the 65-74 group (11.9% versus 3.2% for in-hospital mortality and 14.1% versus 4.7% for 60-day mortality, respectively). The mortality was significantly higher among patients with comorbidities compared with those who were otherwise healthy. According to the 2016 Chinese CAP guidelines, 62.1% of patients (1907/3073) received non-adherent treatment. For general-ward patients without risk factors for Pseudomonas aeruginosa (PA) infection (n = 2258), 52.3% (1094/2090) were over-treated, characterized by monotherapy with an anti-pseudomonal β-lactam or combination with fluoroquinolone + β-lactam; while 71.4% of intensive care unit (ICU) patients (120/168) were undertreated, without coverage of atypical bacteria. Among patients with risk factors for PA infection (n = 815), 22.9% (165/722) of those in the general ward and 74.2% of those in the ICU (69/93) were undertreated, using regimens without anti-pseudomonal activity. The independent predictors of 60-day mortality were age, long-term bedridden status, congestive heart failure, CURB-65, glucose, heart rate, arterial oxygen saturation (SaO2) and albumin levels.

CONCLUSIONS

Overtreatment in general-ward patients and undertreatment in ICU patients were critical problems. Compliance with Chinese guidelines will require fundamental changes in standard-of-care treatment patterns. The data included herein may facilitate early identification of patients at increased risk of mortality.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov ( NCT02489578 ).

Pharmacotherapy for community-acquired pneumonia in the elderly

INTRODUCTION

Community-acquired pneumonia (CAP) is an increasing problem in the elderly that is associated with elevated morbidity and mortality. Given the expected increased life expectancy, this problem is only likely to worsen, so it has been considered that treatment effects must be examined separately in elderly adults with CAP. Areas covered: In this narrative review, we give an update of the available data of antibiotics for elderly patients with CAP. Clinical features, drug pharmacokinetics and pharmacodynamics, adverse effects, and outcomes differ in CAP depending on patient age. Older age, for example, can affect the effect of specific antibiotic regimens on important CAP clinical outcomes. Current guidelines do not offer specific recommendations for the management of CAP in elderly patients. Expert opinion: Most of our knowledge about the treatment of CAP in elderly patients has been gained from studies in young populations. However, elderly patients with CAP deserve special attention because there are several factors in this population that could influence their response to antibiotic regimens in CAP.

The prognostic significance of respiratory rate in patients with pneumonia: a retrospective analysis of data from 705,928 hospitalized patients in Germany from 2010-2012

BACKGROUND

Measurement of the respiratory rate is an important instrument for assessing the severity of acute disease. The respiratory rate is often not measured in routine practice because its clinical utility is inadequately appreciated. In Germany, documentation of the respiratory rate is obligatory when a patient with pneumonia is hospitalized. This fact has enabled us to study the prognostic significance of the respiratory rate in reference to a large medical database.

METHOD

We retrospectively analyzed data from the external quality-assurance program for community-acquired pneumonia for the years 2010-2012. All patients aged 18 years or older who were not mechanically ventilated on admission were included in the analysis. Logistic regression was used to determine the significance of the respiratory rate as a risk factor for in-hospital mortality.

RESULTS

705,928 patients were admitted to the hospital with community-acquired pneumonia (incidence: 3.5 cases per 1000 adults per year). The in-hospital mortality of these patients was 13.1% (92 227 persons). The plot of mortality as a function of respiratory rate on admission was U-shaped and slanted to the right, with the lowest mortality at a respiratory rate of 20/min on admission. If patients with a respiratory rate of 12-20/min are used as a baseline for comparison, patients with a respiratory rate of 27-33/min had an odds ratio (OR) of 1.72 for in-hospital death, and those with a respiratory rate above 33/min had an OR of 2.55. Further independent risk factors for in-hospital death were age, admission from a nursing home, hospital, or rehabilitation facility, chronic bedridden state, disorientation, systolic blood pressure, and pulse pressure.

CONCLUSION

Respiratory rate is an independent risk marker for in-hospital mortality in community-acquired pneumonia. It should be measured when patients are admitted to the hospital with pneumonia and other acute conditions.

Management of community-acquired pneumonia in older adults

Community-acquired pneumonia (CAP) is an increasing problem among the elderly. Multiple factors related to ageing, such as comorbidities, nutritional status and swallowing dysfunction have been implicated in the increased incidence of CAP in the older population. Moreover, mortality in patients with CAP rises dramatically with increasing age. Streptococcus pneumoniae is still the most common pathogen among the elderly, although CAP may also be caused by drug-resistant microorganisms and aspiration pneumonia. Furthermore, in the elderly CAP has a different clinical presentation, often lacking the typical acute symptoms observed in younger adults, due to the lower local and systemic inflammatory response. Several independent prognostic factors for mortality in the elderly have been identified, including factors related to pneumonia severity, inadequate response to infection, and low functional status. CAP scores and biomarkers have lower prognostic value in the elderly, and so there is a need to find new scales or to set new cut-off points for current scores in this population. Adherence to the current guidelines for CAP has a significant beneficial impact on clinical outcomes in elderly patients. Particular attention should also be paid to nutritional status, fluid administration, functional status, and comorbidity stabilizing therapy in this group of frail patients. This article presents an up-to-date review of the main aspects of CAP in elderly patients, including epidemiology, causative organisms, clinical features, and prognosis, and assesses key points for best practices for the management of the disease.

The usefulness of confusion, urea, respiratory rate, and shock index or adjusted shock index criteria in predicting combined mortality and/or ICU admission compared to CURB-65 in community-acquired pneumonia

Background and Objectives. The study aims to assess the usefulness of age-independent criteria CURSI and temperature adjusted CURSI (CURASI) compared to CURB-65 in predicting community-acquired pneumonia (CAP) mortality. The criteria, CRSI and CRASI, were adapted for use in primary care and compared to CRB-65. Methods. A retrospective analysis of a prospectively identified cohort of community-acquired pneumonia inpatients was conducted. Outcomes were (1) mortality and (2) mortality and/or ICU admission within six weeks. Results. 95 patients (median age = 61 years) were included. All three criteria had similar sensitivity in predicting mortality alone, with CURB-65 having slightly higher specificity. When predicting mortality and/or intensive care admission, CURSI/CURASI showed higher sensitivity and slightly lower specificity. CRSI and CRASI had higher sensitivity and lower specificity when compared with CRB-65 for predicting both primary and secondary outcomes. Results for both analyses had P values >0.05. Conclusions. In a cohort of younger patients CURSI and adjusted CURSI perform at least as well as CURB-65, with a similar trend for CRSI and adjusted CRSI compared to CRB-65. Further studies are needed in different age groups and in primary and secondary care settings.

Predicting mortality among older adults hospitalized for community-acquired pneumonia: an enhanced confusion, urea, respiratory rate and blood pressure score compared with pneumonia severity index

BACKGROUND AND OBJECTIVE

Pneumonia Severity Index (PSI) predicts mortality better than Confusion, Urea >7 mmol/L, Respiratory rate >30/min, low Blood pressure: diastolic blood pressure <60 mm Hg or systolic blood pressure <90 mm Hg, and age >65 years (CURB-65) for community-acquired pneumonia (CAP) but is more cumbersome. The objective was to determine whether CURB enhanced with a small number of additional variables can predict mortality with at least the same accuracy as PSI.

METHODS

Retrospective review of medical records and administrative data of adults aged 55 years or older hospitalized for CAP over 1 year from three hospitals.

RESULTS

For 1052 hospital admissions of unique patients, 30-day mortality was 17.2%. PSI class and CURB-65 predicted 30-day mortality with area under curve (AUC) of 0.77 (95% confidence interval (CI): 0.73-0.80) and 0.70 (95% CI: 0.66-0.74) respectively. When age and three co-morbid conditions (metastatic cancer, solid tumours without metastases and stroke) were added to CURB, the AUC improved to 0.80 (95% CI: 0.77-0.83). Bootstrap validation obtained an AUC estimate of 0.78, indicating negligible overfitting of the model. Based on this model, a clinical score (enhanced CURB score) was developed that had possible values from 5 to 25. Its AUC was 0.79 (95% CI: 0.76-0.83) and remained similar to that of PSI class.

CONCLUSIONS

An enhanced CURB score predicted 30-day mortality with at least the same accuracy as PSI class did among older adults hospitalized for CAP. External validation of this score in other populations is the next step to determine whether it can be used more widely.

Diagnostic challenges and opportunities in older adults with infectious diseases

Infections remain a major threat to the well-being of our growing aged population. The correct and timely diagnosis of infections in older adults is increasingly important in the current age of antimicrobial resistance. Urinary tract infection, pneumonia, and bacteremia present particular challenges. In older patients with bacteremia, blood cultures have comparable yield as compared with younger patients. However, the routine triggers for ordering blood cultures may not be appropriate in older adults. In addition, resistance patterns of isolated pathogens may change with age. The main difficulties in diagnosing urinary tract infections in older adults are caused by an increased prevalence of asymptomatic bacteriuria and frequent use of urinary catheters. However, a combined noninvasive approach that includes history, physical examination, urinary dipstick testing, urine cultures, and simple blood tests can provide direction. In addition, specific guidelines for specific populations are available. In older patients suspected of bacterial pneumonia, bedside pulse oximetry and urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila provide direction for the clinician. Although infected older adults pose specific and unique diagnostic challenges, a thorough history and physical examination combined with minimally invasive testing will lead to the correct diagnosis in most older adults with infectious diseases, limiting the need for empiric antibiotics in this age group.

Comparison of three predictive rules for assessing severity in elderly patients with CAP

AIM

This study compares the ability of the Pneumonia Severity Index (PSI) and the British Thoracic Society CURB-65 and CRB-65 rules in predicting short-term mortality among elderly patients with community-acquired pneumonia (CAP).

METHODS

It is a population-based study including all people over 65 years old with a radiographically confirmed CAP in the region of Tarragona (Spain) between 2002 and 2008. Treatment setting and clinical variables were considered for each patient. PSI, CURB-65 and CRB-65 scores were calculated at the moment of diagnosis and 30-day mortality was considered as a main dependent variable. The rules were compared based on sensitivity, specificity and area under the receiver operating characteristic curve (AUC).

RESULTS

Of the total 590 CAP cases, mortality rate was 13.6% (15.3% in hospitalised and 1.4% in outpatient cases; p = 0.001). Mortality increased with increasing PSI score (None in class II, 6,9% in class III, 14,4% in class IV and 29,5% in class V), CURB-65 score (7.5%, 14.5%, 26.7%, 53.3% and 100% for scores 1,2,3,4 and 5 respectively) and CRB-65 score (6.6%, 26.1%, 40.5% and 50% for scores 1,2,3 and 4 respectively). The three rules performed too similarly to predict 30-day mortality, with a ROC area of 0.727 [95% confidence interval (CI): 0.67-0.79] for the PSI, 0.672 (95% CI: 0.61-0.74) for the CURB-65, and 0.719 (95% CI: 0.65-0.78) for the CRB-65.

CONCLUSION

Our data shows that the analysed rules perform equally well among elderly people with CAP which supports the recommendation for using the simplified CRB-65 severity score among elderly patients in primary care or emergency visits.

[Usefulness of the CRB-65 scale for prognosis assessment of patients 65 years or older with community-acquired pneumonia]

BACKGROUND AND OBJECTIVE

The assessment of severity may be important to decide hospitalisation and type of treatment in community-acquired pneumonia (CAP) cases. This study evaluated the ability of the severity rule CRB-65 for the management of older adults with CAP.

PATIENTS AND METHODS

Population-based study including 473 patients 65 years or older with a radiographically confirmed CAP in the region of Tarragona (Spain). Treatment setting and clinical variables were considered for each patient, CRB-65 score (confusion, respiratory rate>or=30, systolic blood pressure<90 mmHg or diastolic<or=60 mmHg, age>or=65 years) was calculated at the time of diagnosis, and 30-day mortality was considered as a main dependent variable.

RESULTS

Overall mortality rate was 12.7% (15.5% among hospitalised and 1.7% in outpatient cases). Mortality was directly associated with the CRB-65 score, being 6.8% in score 1 (2.4% among patients 65-74 years and 10.1% in patients 75 years or older; P=.005), 26.1% in score 2, 41.7% in score 3 and 66.7% in score 4. For a breakpoint of CRB-65 score>or=2, sensitivity was 60% (95% CI: 42-78) and specificity was 80% (95% CI: 76-84).

CONCLUSIONS

The CRB-65 has an acceptable ability to classify mortality risk in elderly patients with CAP. Patients with CRB-65=1 have a relatively small mortality rate, which suggests that they could be managed as outpatients.

Prognosis of primary care patients aged 80 years and older with lower respiratory tract infection

BACKGROUND

Predictors for a complicated course of a lower respiratory tract infection (LRTI) episode among patients aged > or =80 years are unknown.

AIM

To determine prognostic factors for hospital admission or death within 30 days after first onset of LRTI among primary care patients aged > or =80 years.

DESIGN OF STUDY

Retrospective cohort study.

SETTING

Utrecht General Practitioner Research Network.

METHOD

Data were obtained using the computerised database of the research network over the years 1997 to 2003. Multivariable logistic regression analysis was applied to estimate the independent association of predictors with 30-day hospitalisation or death.

RESULTS

In all, 860 episodes of LRTI were observed in 509 patients; 13% of patients were hospitalised or died within 30 days. Type of LRTI, diabetes, use of oral glucocorticoids, use of antibiotics in the previous month, and hospitalisation in the previous 12 months were independently associated with the combined outcome. Patients with insulin-dependent diabetes mellitus had a greater risk of 30-day hospitalisation or death compared with patients with non-insulin-dependent diabetes.

CONCLUSION

Independent of age, serious comorbidity - notably the presence of insulin-dependent diabetes or exacerbation of chronic obstructive pulmonary disease requiring oral glucocorticoids - increases the risk for complications, including hospital admissions, in patients aged > or =80 years with an LRTI.

Improving outcomes of elderly patients with community-acquired pneumonia

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in elderly patients. Therefore, efforts to optimize the healthcare process for patients with CAP are warranted. An organized approach to management is likely to improve clinical results. Assessing the severity of CAP is crucial to predicting outcome, deciding the site of care, and selecting appropriate empirical therapy. Unfortunately, current prognostic scoring systems for CAP such as CURB-65 (confusion, uraemia, respiratory rate, low blood pressure and 65 years of age) or the Pneumonia Severity Index have not been validated specifically in older adults, in whom assessment of mortality risk alone might not be adequate for predicting outcomes. Obtaining a microbial diagnosis remains problematic and may be particularly challenging in frail elderly persons, who may have greater difficulties producing sputum. Effective empirical treatment involves selection of a regimen with a spectrum of activity that includes the causative pathogen. Although most cases of CAP are probably caused by a single pathogen, dual and multiple infections are increasingly being reported. Streptococcus pneumoniae remains the overriding aetiological agent, particularly in very elderly people. However, respiratory viruses and 'atypical' organisms such as Chlamydia pneumoniae are being described with increasing frequency in old patients, and aspiration pneumonia should also be taken into consideration, particularly in very elderly subjects and those with dementia. Age >65 years is a well established risk factor for infection with drug-resistant S. pneumoniae. Clinicians should be aware of additional risk factors for acquiring less common pathogens or antibacterial-resistant organisms that may suggest that additions or modifications to the basic empirical regimen are warranted. In addition to administration of antibacterials, appropriate supportive therapy, covering management of severe sepsis and septic shock, respiratory failure, as well as management of any decompensated underlying disease, may be critical to improving outcomes in elderly patients with CAP. Immunization with pneumococcal and influenza vaccines has also been demonstrated to be beneficial in numerous large studies. There is good evidence that implementation of guidelines leads to improvement in clinical outcomes in elderly patients with CAP, including a reduction in mortality. Protocols should address a comprehensive set of elements in the process of care and should periodically be evaluated to measure their effects on clinically relevant outcomes. Assessment of functional clinical outcome variables, in addition to survival, is strongly recommended for this population.

Free and Total Cortisol Levels as Predictors of Severity and Outcome in Community-acquired Pneumonia

RATIONALE

High cortisol levels are of prognostic value in sepsis. The predictive value of cortisol in pneumonia is unknown. Routinely available assays measure serum total cortisol (TC) and not free cortisol (FC). Whether FC concentrations better reflect outcome is uncertain.

OBJECTIVES

To investigate the predictive value of TC and FC in community-acquired pneumonia (CAP).

METHODS

Preplanned subanalysis of a prospective intervention study in 278 patients presenting to the emergency department with CAP.

MEASUREMENTS AND MAIN RESULTS

TC, FC, procalcitonin, C-reactive protein, leukocytes, clinical variables, and the pneumonia severity index (PSI) were measured. The major outcome measures were PSI and survival. TC and FC, but not C-reactive protein or leukocytes, increased with increasing severity of CAP according to the PSI (P < 0.001). TC and FC levels on presentation in patients who died during follow-up were significantly higher as compared with levels in survivors. In a receiver operating characteristic analysis to predict survival, the area under the receiver operating characteristic curve (AUC) was 0.76 (95% confidence interval, 0.70-0.81) for TC and 0.69 (0.63-0.74) for FC. This was similar to the AUC of the PSI (0.76 [0.70-0.81]), and better as compared with C-reactive protein, procalcitonin, or leukocytes. In univariate analysis, only TC, FC, and the PSI were predictors of death. In multivariate analysis, the predictive potential of TC equaled the prognostic power of PSI points.

CONCLUSIONS

Cortisol levels are predictors of severity and outcome in CAP to a similar extent to the PSI, and are better than routinely measured laboratory parameters. In CAP, the prognostic accuracy of FC is not superior to TC. Clinical trial registered with www.controlled-trials.com (ISRCTN04176397).

Community-Acquired Respiratory Complications in the Intensive Care Unit: Pneumonia and Acute Exacerbations of COPD

This chapter will review the two most common lower respiratory tract infections in the intensive care unit (ICU), community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In addition we will provide an overview of the topics including recommendations for the diagnosis and treatment.

Circulating levels of pro-atrial natriuretic peptide in lower respiratory tract infections

OBJECTIVE

To analyse the mid region of plasma N-terminal pro-atrial natriuretic peptide (MR-proANP) levels in patients with lower respiratory tract infections to evaluate its prognostic use for the severity of disease and outcome.

DESIGN

Prospective observational study. Setting. Emergency department of a university hospital.

SUBJECTS

A total of 545 consecutive patients with lower respiratory tract infections and 50 healthy controls. Interventions. MR-proANP was measured in serum from all patients using a new sandwich immunoassay.

RESULTS

MR-proANP levels (median [IQR], in pmol L(-1)) were significantly higher in patients with lower respiratory tract infections when compared with controls (138.0 [74.1-279.0] vs. 72.7 [62.5-89.5], P < 0.001), with highest levels in patients with community-acquired pneumonia (CAP). MR-proANP, but not C-reactive protein (CRP) levels, gradually increased with increasing severity of CAP, classified according to the pneumonia severity index (PSI) score (P < 0.001). On admission, MR-proANP levels were significantly higher in nonsurvivors when compared with survivors (293.0 [154.0-633.0] vs. 129.0 [71.4-255.0], P < 0.001). In a receiver operating characteristic (ROC) analysis for the prediction of survival of patients with CAP the area under the ROC curve (AUC) for MR-proANP was 0.69, similar when compared with the PSI (AUC 0.74, P = 0.31), and better when compared with other biomarkers, i.e. procalcitonin (AUC 0.57, P = 0.08), CRP (AUC 0.52, P = 0.02), and leucocyte count (AUC 0.56, P = 0.07).

CONCLUSIONS

MR-proANP levels are increased in lower respiratory tract infections, especially in CAP. Together with other clinical, radiographic and laboratory findings, MR-proANP levels might be helpful for the risk stratification in CAP.

A Validation and Potential Modification of the Pneumonia Severity Index in Elderly Patients with Community-Acquired Pneumonia

OBJECTIVES

To evaluate the discriminatory power of the Pneumonia Severity Index (PSI) in elderly patients with community-acquired pneumonia (CAP) and to improve its performance.

DESIGN

Retrospective review of 193 patients from 1999 to 2001 to derive prognostic rules. The rules were prospectively validated in 144 patients from 2002 to 2003.

SETTING

Iwata City Hospital, a 400-bed general hospital.

PARTICIPANTS

Patients aged 80 and older who had CAP and were admitted to the hospital.

MEASUREMENTS

Predictors of 30-day mortality were identified using logistic regression analysis, and several rules were constructed by combining the PSI and the independent predictors.

RESULTS

The original PSI, which defines PSI Class IV and V as a high-risk group, did not perform well in discriminating survivors from nonsurvivors (sensitivity 100%, specificity 15%), whereas a modified PSI, which defines only PSI Class V as a high-risk group, performed better (sensitivity 86%, specificity 63%). Three predictors for mortality were identified independent from the modified PSI: performance status (PS) Grade 3 or higher, anorexia, and partial pressure of carbon dioxide of 50 mmHg or greater. By combining the modified PSI and PS, the performance could be further improved (sensitivity 79%, specificity 80%).

CONCLUSION

The modified PSI could identify low-risk patients more accurately than the original PSI. In addition, by combining the modified PSI with PS, higher performance was obtained. Such information would aid physicians in clinical decision-making without overestimating the risk for elderly patients with CAP.

Mortality and serum urea and electrolytes on admission for hip fracture patients

OBJECTIVE

To assess the relationship between pre-operative serum urea and electrolyte concentrations and mortality in patients with hip fractures requiring surgery.

METHODS

A prospective observational study of 2963 consecutive patients admitted to a single trauma unit with a hip fracture, treated operatively.

RESULTS

The 30-day mortality for patients with low and normal urea concentrations was 6.9%. The 30-day mortality for patients with raised urea concentrations was almost double (11.5%). A raised admission serum urea concentration was an independent predictor for mortality at 30 days, 90 days, 1 year and 2 years. Mortality was significantly increased in patients admitted with: raised or low serum sodium, raised serum potassium and raised serum creatinine.

CONCLUSION

Mortality is high following hip fracture. Patients admitted with a raised serum urea are at increased risk of death at all time intervals analysed up to and including 2 years. This group of patients may require a separate care pathway that provides more intensive management of fluid and electrolyte balance.

Factores pronósticos de la neumonía adquirida en la comunidad en ancianos

BACKGROUND AND OBJECTIVE

To determine whether there are differences between the prognostic factors associated with 30-days mortality in patients 65-84 year-old and patients over 84 years hospitalized for community-acquired pneumonia (CAP).

PATIENTS AND METHOD

An observational study with retrospective data collection was carried out in a representative sample of all CAP in-patients of 27 general hospitals. Data regarding comorbidities, signs and symptoms on admission, radiological and laboratory examinations, and complications during hospitalization were recorded.

RESULTS

1,191 CAP patients were studied, 80.1% in the 65-84 age group and 19.9% in the over 84 age group. Mortality during the first 30 days was 11.9% in the younger group and 20.7% in the older (p < 0.001). In the younger group, the multivariate analysis showed the following independent prognostic factors: general discomfort (odds ratio [OR] = 3.93), respiratory rate > 30/min (OR = 5.02), atrial fibrillation (OR = 3.57), dementia (OR = 9.18), and hospitalization during the previous year (OR = 3.74). In the older group, independent prognostic factors were cancer (OR = 8.4) and renal failure (3.32). Age significantly modified the effect of altered mental state, tachypnea, tachycardia, hyperglycemia, and dementia on mortality.

CONCLUSIONS

In people over 84 years, except cancer and renal failure, classic CAP prognostic factors used in severity indexes do not distinguish those who will die from those who will not. Therefore, these factors must be interpreted with caution.

Pro-adrenomedullin to predict severity and outcome in community-acquired pneumonia [ISRCTN04176397]

Introduction

Pro-adrenomedullin (proADM) is helpful for individual risk assessment and outcome prediction in sepsis. A major cause of sepsis is community-acquired pneumonia (CAP). The aim of this study was to investigate the value of proADM levels for severity assessment and outcome prediction in CAP.

Methods

Data from 302 patients admitted to the emergency department with CAP were included in a prospective observational study. Procalcitonin, C-reactive protein levels, leukocyte count, clinical variables and the pneumonia severity index (PSI) were measured. ProADM levels were measured with a new sandwich immunoassay for mid regional ProADM (MR-proADM, Brahms AG, Hennigsdorf/Berlin, Germany).

Results

ProADM levels, in contrast to C-reactive protein and leukocyte count, increased with increasing severity of CAP, classified according to the PSI score (ANOVA, p < 0.001). In patients who died during follow-up, proADM levels on admission were significantly higher compared to levels in survivors (2.1 (1.5 to 3.0) versus 1.0 (0.6 to 1.6) nmol/l, p < 0.001). In a receiver operating characteristic (ROC) analysis for survival, the area under the ROC curve (AUC) for proADM was 0.76 (95% confidence interval (CI) 0.71–0.81), which was significantly higher compared to procalcitonin (p = 0.004), C-reactive protein (p < 0.001) and total leukocyte count (p = 0.001) and similar to the AUC of the PSI (0.73, p = 0.54). A clinical model including the PSI and proADM increased the prognostic accuracy to predict failure compared to a model relying on the PSI alone (AUC, 0.77 (0.70 to 0.84), p = 0.03).

Conclusion

ProADM, as a novel biomarker, is a useful tool for the risk stratification of patients with CAP.

Prognostic factors for serious morbidity and mortality from community-acquired lower respiratory tract infections among the elderly in primary care

BACKGROUND

Uncertainty about the prognosis of lower respiratory tract infections (LRTI) hinders optimal management in primary care.

OBJECTIVE

We determined prognostic factors for a severe complicated course of LRTI among elderly patients in primary care.

METHODS

In a retrospective clinical database study we examined 455 patients with a first LRTI episode; 226 with physician-diagnosed acute bronchitis or lung exacerbations and 229 with pneumonia. Multivariate logistic regression analysis was used to assess independent associations of the potential predictors with the endpoint.

RESULTS

Occurrence of the combined endpoint 30-day home-treated complications from LRTI (4.4%) or hospitalisation (4.6%), or all-cause mortality (5.3%) was 14.3%. In a logistic regression model, increasing age [odds ratio (OR) 1.04; 95% confidence interval (95% CI) 1.00-1.08], male sex (OR 3.12; 95% CI 1.66-5.87), heart failure (OR 5.14; 95% CI 2.33-11.34), stroke or dementia (OR 3.36; 95% CI 1.18-9.58), use of antidepressants or benzodiazepines (OR 1.89; 95% CI 1.02-3.52) and a diagnosis of pneumonia (OR 4.24; 95% CI 2.17-8.28) were independent predictors.

CONCLUSION

GPs need to be aware of readily available prognostic factors that can be used in primary care to complement physical examination and laboratory data in LRTI to guide preventive and therapeutic management decisions.

Antimicrobial treatment of community-acquired pneumonia

Community-acquired pneumonia (CAP) is a clinical diagnosis that has a significant impact on health care management around the world. Early clinical suspicion and prompt empiric antimicrobial therapies are mandatory in patients with CAP. This article provides a review of recent studies and guidelines addressing antimicrobial therapy for hospitalized patients with CAP.

Ambulant erworbene Pneumonie

Eine rationale Diagnostik der ambulant erworbenen Pneumonie soll dem Arzt helfen, eine definitive Diagnose zu stellen, den verantwortlichen Erreger zu bestimmen und eine Aussage über die Prognose zu treffen. „Gold-Standard“ in der Diagnosestellung ist neben anamnestischen und klinischen Befunden weiterhin die Röntgenaufnahme der Thoraxorgane. Moderne Entzündungsmarker wie das C-reaktive Protein und in Zukunft möglicherweise das Prokalzitonin sind wichtig für die Differenzialdiagnose und Verlaufsuntersuchung. Die mögliche Erregerdiagnostik umfasst neben der klassischen Kultur neuere Urinantigentests gegen Streptococcus pneumoniae und Legionella pneumophila. Ein einfacher klinischer Prognosescore hilft dem Arzt bei der Entscheidung, welcher Patient ins Krankenhaus eingewiesen werden sollte.

Prognostic Scoring Systems for Infectious Diseases: Their Applicability to the Care of Older Adults

Physicians often make clinical predictions about individual patients. For many infectious diseases, published prognostic scoring systems (PSSs) can help predict relevant outcomes. Validated PSSs exist for the general adult population for diseases such as pneumonia, endocarditis, meningitis, and bloodstream infection. Although these PSSs have been rigorously derived and validated, they have limited value in the care of older adults, because most studies have involved a heterogeneous adult population with mortality as the primary end point. In the United States, the number of patients who are > or =65 years old is growing, and their health care costs are increasing. Assessment of clinical outcomes other than merely survival (i.e., physical functional ability, cognitive ability, need for nursing home care, and overall quality of life) is required for this population. Some pioneering work has been done to develop PSSs that specifically address the health care needs of older adults. This review will describe existing PSSs and explore areas of further investigation.

Community-acquired pneumonia in the emergency department: a practical approach to diagnosis and management

Pneumonia is one of the most common conditions for which patients seek emergency care. It is a challenging infection in that the spectrum of illness ranges from the nontoxic patient appropriate for outpatient antibiotics to the critically ill patient requiring intensive care hospitalization. Current data and diagnostic technology provide the emergency physician with the tools for an appropriately rapid evaluation and consideration of the differential diagnosis. Key critical thinking and application of published findings allow for intelligent empirical antibiotic treatment and risk stratification for the best disposition. Although antibiotic-resistant organisms increasingly are being identified, patients continue to benefit from early institution of standard ED treatment. Coverage for atypical organisms improves patient response and outcome. Finally, identification and treatment of the complications of pneumonia and accompanying sepsis must be considered by the ED physician when evaluating critically ill patients.

Community-acquired pneumonia in very elderly patients: causative organisms, clinical characteristics, and outcomes

We performed an observational analysis of prospectively collected data on 1,474 adult patients who were hospitalized for community-acquired pneumonia; 1,169 patients were under 80 years of age and 305 (21%) patients were over 80 years ("very elderly"). Mean patient ages were 60 years in the former group and 85 years in the latter group. Severely immunosuppressed patients and nursing-home residents were not included. Comorbidities significantly associated with older age were chronic obstructive pulmonary disease, chronic heart disease, and dementia. The most common causative organism was Streptococcus pneumoniae (23% in both groups). Aspiration pneumonia was more frequent in the very elderly (5% in younger patients versus 10% in the very elderly); Legionella pneumophila (8% in younger patients versus 1% in the very elderly) and atypical agents (7% in younger patients versus 1% in the very elderly) were rarely recorded in the very elderly. While very elderly patients complained less frequently of pleuritic chest pain, headache, and myalgias, they were more likely to have absence of fever and altered mental status on admission. No significant differences were observed between groups as regards incidence of classic bacterial pneumonia syndrome (60% versus 59%) in 343 patients with pneumococcal pneumonia. The development of inhospital complications (26% in younger versus 32% in very elderly patients) as well as early mortality (2% in younger versus 7% in very elderly patients) and overall mortality (6% in younger versus 15% very elderly patients) were significantly higher in very elderly patients. Acute respiratory failure and shock/multiorgan failure were the most frequent causes of death, especially of early mortality. Factors independently associated with 30-day mortality in the very elderly were altered mental status on admission (odds ratio, 3.69), shock (odds ratio, 10.69), respiratory failure (odds ratio, 3.50), renal insufficiency (odds ratio, 5.83), and Gram-negative pneumonia (odds ratio, 20.27).

Factors associated with death among adults <55 years of age hospitalized for community-acquired pneumonia

An administrative database was used to study death occurring among adults aged 18-55 years who were hospitalized during the period from 1 April 1994 through 31 March 1999 for treatment of community-acquired pneumonia. In-hospital case-fatality rates for the first 10 days of hospitalization and overall were 2.1% and 3.2%, respectively, for 11,684 patient hospitalizations. Patient factors (age, sex, and comorbidity) were the most important associations with death. Aspiration provided the largest explanation of variance in deaths occurring during the first 10 days of hospitalization (odds ratio, 5.0; 95% confidence interval, 3.7-6.8). Busy hospitals (higher occupancy and higher number of daily admissions) were not associated with higher case-fatality rates. Bigger hospitals (metropolitan hospitals) had higher case-fatality rates, but this was more likely related to greater comorbidity and severity of pneumonia. Death due to community-acquired pneumonia among young and middle-aged adults is infrequent and is more related to the severity of pneumonia and to such risk factors as aspiration than to the manner in which the provision of care is organized.

Severe community-acquired pneumonia: current outcomes, epidemiology, etiology, and therapy

Severe community-acquired pneumonia is a clinical diagnosis with a significant impact on healthcare management around the world, with the highest morbidity and mortality of all of the forms of community-acquired pneumonia. Patients with severe pneumonia usually require intensive care unit management, including vasopressors or mechanical ventilation. Early clinical suspicion and prompt empiric antimicrobial therapies are mandatory in patients with severe pneumonia. A number of recent studies and guidelines addressing these issues have been published, and they will be reviewed in this article.