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.     

社区获得性肺炎住院患者发生心血管事件的危险因素分析

目的研究社区获得性肺炎(CAP)住院患者心血管事件(CVE)的发生率、危险因素,以及CVE对患者入院后30 d死亡风险的影响。方法该研究为多中心、回顾性研究。收集2013年1月1日至2015年12月31日在北京市、山东省和云南省的5家教学医院住院的所有CAP患者的病历资料,并将入选患者按是否发生CVE分为CVE组和无CVE组。通过电子病历系统收集入选患者的年龄、性别、基础疾病、入院当天肺炎严重性指数(PSI)/CURB-65评分、血常规、生化检查和影像学资料,以及入院后30 d死亡人数。研究主要终点为住院期间发生急性CVE,次要研究终点为入院后30 d死亡。采用多因素Cox回归模型分析CAP患者发生CVE的独立危险因素。采用Kaplan-Meier生存曲线评估发生和未发生CVE的CAP患者入院后30 d的累计生存率,生存曲线之间的比较采用Log-rank检验。采用多因素Cox回归模型分析CVE对CAP患者入院后30 d死亡的影响。结果共有3561例住院CAP患者纳入该研究,其中210例(5.9%)发生了CVE(CVE组),3351例(94.1%)未发生CVE(无CVE组)。与无CVE组比较,CVE组患者年龄较大(P<0.001),合并高血压、冠心病、慢性心力衰竭(心衰)、脑血管疾病、慢性阻塞性肺病、慢性肾脏病、吸入因素、长期卧床者比例较高(P均<0.001),CURB-65评分3~5分和PSI分级Ⅳ~Ⅴ级者比例较高(P均<0.001)。与无CVE组比较,CVE组患者腋温<36℃、呼吸频率≥30次/min、意识改变、血白细胞计数>10×10^9/L、血红蛋白<100 g/L、血小板>300×10^9/L、血白蛋白<35 g/L、血尿素氮>7 mmol/L、空腹血糖>11 mmol/L、血C反应蛋白>100 mg/L、血降钙素原≥2μg/L、动脉血pH值<7.35、动脉血氧合指数≤300 mmHg(1 mmHg=0.133 kPa)以及胸部X线或CT显示多肺叶浸润和胸水者比例较高(P均<0.05),入院后30 d病死率也较高(P<0.001)。有心脑血管基础疾病的患者CVE发生率高于无心脑血管基础病的患者[13.9%(150/1079)比2.4%(60/2482),χ2=178.737,P<0.001)]。PSI分级Ⅰ/Ⅱ级的患者CVE发生率为1.7%(22/1273),Ⅲ级的患者为7.8%(40/512),Ⅳ/Ⅴ级的患者为16.9%(72/426),依次升高(χ2=228.350,P<0.001)。CURB-65评分0~1分的患者CVE发生率为3.8%(110/2924),2分的患者为17.1%(78/457),3~5分的患者为18.9%(14/74),依次升高(χ2=387.154,P<0.001)。多因素Cox回归分析结果显示,年龄(HR=1.05,95%CI 1.02~1.09,P=0.002)、基础疾病为冠心病(HR=1.88,95%CI 1.01~3.51,P=0.048)和慢性心衰(HR=4.25,95%CI 1.89~9.52,P<0.001)、PSI分级(HR=1.66,95%CI 1.50~2.62,P=0.029)以及血降钙素原≥2μg/L(HR=3.72,95%CI 1.60~8.66,P=0.002)是CAP患者发生CVE的独立危险因素。Kaplan-Meier生存曲线结果显示,发生CVE的CAP患者入院后累计30 d生存率低于未发生CVE的CAP患者(P<0.001)。校正了年龄、性别、基础疾病、CURB-65评分和PSI分级后多因素Cox回归分析结果显示,发生CVE增加CAP患者入院后30 d死亡风险(HR=6.05,95%CI 3.11~11.76,P<0.001)。结论虽然CVE在我国CAP住院患者中的发生率不高,但在重症肺炎和原有心血管基础疾病的患者中则较为常见。年龄、心血管基础疾病和PSI分级以及血降钙素原是住院CAP患者发生CVE的重要危险因素。CVE可增加CAP住院患者30 d死亡风险。     

D-二聚体、C反应蛋白、血沉与老年社区获得性肺炎严重程度的关系

目的探讨血浆D-二聚体、C反应蛋白（CRP）和血沉水平与老年社区获得性肺炎（CAP）严重程度的关系。方法收集130例老年CAP患者的临床资料,按不同的病情严重程度评分标准对患者进行分组,分别测定患者血浆D-二聚体、CRP、血沉水平,分析其在不同分组间的差异。结果不同肺炎严重度指数（PSI）分级间、不同CURB-65分组间D-二聚体、CRP水平比较差异均有统计学意义（P〈0．05）,重症肺炎组D-二聚体、CRP水平均显著高于非重症肺炎组（P〈0．01）。血沉水平在以上不同分组间比较差异均无统计学意义。血浆D-二聚体与CRP水平显著相关（r=0．368,P〈0．01）。结论血浆CRP、D-二聚体水平与CAP的严重程度有一定的相关性,可作为判断病情的指标。     

Resolution of symptoms in patients with community-acquired pneumonia treated on an ambulatory basis

OBJECTIVE: To describe the resolution of five symptoms commonly associated with community-acquired pneumonia (CAP). METHODS: Three hundred and ninety-nine patients with CAP (Fine Classes I to III) recorded the severity (from 0 to 5) of fatigue, cough, dyspnoea, sputum, and pleuritic chest pain daily from enrollment to day 14 and also on days 30 and 42. A total symptom score was obtained by multiplying an individual score by four and summing the score of the five symptom (transformed score). A total symptom score of 20 on day 14, the patients with a score > 20 (n = 122; 33%) had higher symptom scores at all time points out to 42 days. The median time to return to work was 6 days. CONCLUSION: The pneumonia symptom severity score is a useful tool for advising patients regarding the time to symptomatic resolution of pneumonia.     

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 C onfusion, U rea >7 mmol/L, R espiratory rate >30/min, low Bl ood 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.     

A teaching hospital's experience applying the Pneumonia Severity Index and antibiotic guidelines in the management of community-acquired pneumonia

BACKGROUND AND OBJECTIVES: The Pneumonia Severity Index (PSI) was developed to predict mortality in community-acquired pneumonia (CAP). It has been prospectively validated to identify patients who are at low risk of death and thereby aid in the selection of patients for outpatient management. This study assessed the compliance of medical staff at a university teaching hospital with the use of the PSI and the PSI-based local antibiotic guidelines in admitted patients. METHODS: This was a retrospective study of 137 consecutive adults admitted with a primary diagnosis of CAP between July and December 2003. Implementation of the PSI and local antibiotic guidelines occurred 4 months prior to the study period. The data collected included patient demographics, PSI parameters, patient outcomes, adherence and compliance with the PSI scoring process and local antibiotic guidelines. RESULTS: Forty per cent of all CAP admissions were patients in PSI Class I to III. The compliance with scoring the PSI was low (45 out of 137 patients; 33%), as was the accuracy of the PSI scoring (26 out of 45 patients; 58%). Compliance with the local antibiotic guidelines was 87% in patients in whom the PSI was performed. CONCLUSIONS: In admitted patients, non-adherence with the PSI admission guidelines was common. Compliance with scoring the PSI and its scoring accuracy was low. This may be due to a lack of awareness and its relative complexity. Further studies to identify potential barriers to compliance are warranted.     

Vitamin and micronutrient intake and the risk of community-acquired pneumonia in US women

Background

There are limited data regarding the role of dietary and supplemental vitamin intake and the risk of community-acquired pneumonia.

Methods

We prospectively examined, during a 10-year period, the association between dietary and supplemental vitamin intake and the risk of community-acquired pneumonia among 83,165 women in Nurses’ Health Study II who were between the ages of 27 and 44 years in 1991. We excluded women who had pneumonia before 1991, those who did not provide complete dietary information, or those with a history of cancer, cardiovascular disease, or asthma. Self-administered food frequency questionnaires were used to assess dietary and supplemental vitamin intake. Cases of pneumonia required a diagnosis by a physician and confirmation with a chest radiograph. The independent associations between specific vitamins and pneumonia risk were evaluated.

Results

There were 925 new cases of community-acquired pneumonia during 650,377 person-years of follow up. After adjusting for age, cigarette smoking, body mass index, physical activity, total energy intake, and alcohol consumption, there were no associations between dietary or total intake of any individual vitamin and risk of community-acquired pneumonia. Specifically, women in the highest quintile of vitamin A intake did not have a significantly lower risk of pneumonia than women in the lowest quintile (multivariate relative risk [RR] = 0.88; 95% confidence interval [CI], 0.70-1.09, P for trend = .16). Similarly, vitamin C (RR = 0.94; 95% CI, 0.76-1.16, P for trend = .81) and E (RR = 0.95; 95% CI, 0.76-1.17, P for trend = .74) intake did not alter risk of pneumonia.

Conclusions

Higher vitamin intake from diet and supplements is unlikely to reduce pneumonia risk in well nourished women.     

吸入性糖皮质激素增加哮喘患者肺炎风险

目的 探讨哮喘患者长期吸入激素(ICS)是否增加肺炎发生风险.方法 选择上海市杨浦区市东医院07年1月～ 07年12月哮喘患者共300例,其中使用ICS者156例(A组),未使用者144例(B组),并选择同期健康志愿者150例(C组).结果 随访6、12、18、24个月结束时,A组患者ICS使用总量分别为28.50 g、50.10 g、61.30 g、69.10 g,发生肺炎分别为10、23、37、53例次;B组发生肺炎分别为7、14、22、29例次;C组发生肺炎分别为9、16、26、33例次.B组和C组比较差异无统计学意义(P＞0.05).A组和B组、C组比较差异有统计学意义(P＜0.05).结论 长期使用ICS增加肺炎风险,随着剂量和时间增加,肺炎发病机会增高,但预后良好.     

Longitudinal associations of serum survivin with the severity and prognosis of community-acquired pneumonia patients

BackgroundSurvivin is a member of apoptosis inhibitor proteins that evokes cellular proliferation and inhibits apoptosis. However, the role of survivin in community-acquired pneumonia (CAP) patients remains to be firmly established. The aim of this cohort study was to evaluate the correlations of serum survivin with the severity and prognosis of CAP patients.MethodsThis research included 470 eligible CAP patients. Serum fasting samples were drawn from patients, and serum survivin was measured by enzyme-linked immunosorbent assay (ELISA). Meanwhile, demographic characteristics and clinical information were collected. The prognosis of CAP patients was tracked.ResultsSerum survivin gradually decreased with elevated CAP severity scores. Additionally, the correlative analysis suggested that serum survivin was associated with many clinical characteristics. Furthermore, mixed linear and logistic regression models indicated that serum survivin was negatively associated with severity. After adjusting for confounding factors, logistic regression analyses found that lower serum survivin on admission elevated the risks of mechanical ventilation, vasoactive agent usage, longer hospital stays, ICU admission, and even death during hospitalization. Serum survivin in combination with CAP severity scores elevated the predictive capacities for severity and death in CAP patients compared with a single indicator.ConclusionOn admission, there are inverse dose-response associations of serum survivin with severity and poor prognosis in CAP patients, demonstrating that serum survivin may be involved in the pathophysiology process of CAP. Serum survivin may serve as a potential biomarker for disease evaluation and prognosis in CAP patients.     

Factors associated with length of stay in hospital for suspected community-acquired pneumonia

OBJECTIVE:

To determine factors associated with the length of stay (LOS) for patients with suspected community-acquired pneumonia (CAP) who required hospitalization for treatment.

STUDY DESIGN:

The authors studied a population-based prospective cohort of 2757 adults with suspected CAP who were admitted over a two-year period. Logistic regression, multiple linear regression, and classification and regression trees were used to determine the factors associated with LOS.

SETTING:

The study was conducted in two community and tertiary care hospitals, two community and secondary care hospitals, and two community hospitals in the Capital Health Region of Edmonton, Alberta.

RESULTS:

Symptoms such as sweats, shaking chills and wheezing were associated with an LOS of seven days or shorter, whereas weight loss, functional impairment, heart, renal or neoplastic diseases and time to first dose of antibiotic were predictive of an LOS greater than seven days. Regression tree analysis indicated that rapid achievement of physiological stability was associated with a shorter LOS. The use of an indwelling urinary catheter was found to be an important determinant of LOS.

CONCLUSIONS:

The present study found several new associations with increased LOS in patients with CAP, including functional status, time to receipt of first dose of antibiotic therapy, use of certain antibiotics, presence of a urinary catheter and the importance of time to physiological stability. An intervention targeting avoidance of urinary catheters may be associated with a shorter LOS.     

血清降钙素原在肺炎诊断及严重程度判断中的研究

目的:评价血清降钙素原(PCT)对肺炎诊断及严重程度评估中的应用价值。方法:本研究为前瞻性,收集肺炎患者51例,检测患者的血清PCT、C-反应蛋白(CRP)、内毒素(LPS)、白细胞(WBC)计数及白细胞介素-6(IL-6)。结果:1.痰细菌培养阳性肺炎组PCT水平较支原体肺炎或衣原体肺炎组高,差异有统计学意义(P<0.01),较病原学检测阴性肺炎组高,差异有统计学意义(P<0.01),病原学检测阴性肺炎组PCT水平较支原体肺炎或衣原体肺炎组高,差异无统计学意义(P>0.05)。2.有并发症组的PCT水平较无并发症组高,差异有统计学意义(P<0.05)。PCT水平在中高危组较低危组高,差异有统计学意义(P<0.05);PCT阳性率在中高危组较低危组高,差异有统计学意义(P<0.05)结论:血清PCT水平对肺炎的病原学诊断有一定的预测价值,而CRP、内毒素、WBC计数及IL-6组间,差异无统计学意义;血清PCT作为肺炎患者严重程度的一项评价指标可能具有一定意义。     

中国城市成人社区获得性肺炎665例病原学多中心调查

目的 研究引起社区获得性肺炎（CAP）的病原体分布及患者入选前是否应用抗生素、肺炎患者预后研究组（PORT）分级等的情况，同时检测常见病原菌的耐药性。方法 入选2003年12月至2004年11月中国7个城市12个中心的665例CAP患者并进行病原体检测。病原体确定诊断的阳性判断标准为：（1）合格痰标本培养出1株或多株细菌；（2）血培养检出病原体；（3）间隔2～4周采集的2次标本的血清肺炎支原体、肺炎衣原体或嗜肺军团菌抗体滴度呈现4倍或4倍以上增高或降低。应用琼脂稀释法对常见病原菌进行最低抑菌浓度（MIC）检测。结果 在610例同时进行了细菌培养和血清学检测的患者中，肺炎支原体是最常见的病原体，阳性率为20．7％（126例），其后依次为肺炎链球菌10．3％（63例）、流感嗜血杆菌9．2％（56例）、肺炎衣原体6，6％（40例）、肺炎克雷伯杆菌6.1％（37例）、嗜肺军团菌5.1％（31例）、金黄色葡萄球菌3．8％（23例）、大肠杆菌1．6％（10例）、卡他莫拉菌1.3％（8例）、铜绿假单胞菌1．0％（6例）。在195例细菌培养阳性患者中，共有10．2％（62例）合并非典型病原体感染。69株肺炎链球菌，对青霉素、阿奇霉素和莫西沙星的不敏感率分别为20．3％、75．4％和4．3％。结论 非典型病原体尤其是肺炎支原体感染在CAP中占据重要地位；细菌合并非典型病原体的混合感染占10．2％。肺炎链球菌、流感嗜血杆菌仍为常见的致病细菌，我国致CAP肺炎链球菌对大环内酯类抗生素的耐药率高达75．0％以上，对青霉素的不敏感率为20，3％．     

Clinical policy for the management and risk stratification of community-acquired pneumonia in adults in the emergency department

This clinical policy represents an approach that emphasizes key clinical information to determine the severity of CAP. By using this approach, a determination of whether the patient can be treated as an outpatient or inpatient may be made. Recommendations about the utility of ancillary studies and the use of antibiotics are also given. As more of the questions are answered through controlled studies, an evidence-based approach to this problem will become increasingly important in improving the outcome of patients with CAP.     

无创正压通气对老年社区获得性肺炎所致呼吸衰竭的疗效分析

目的 评价无创正压通气(NPPV)对老年社区获得性肺炎呼吸衰竭的疗效. 方法 将321例无心肺复苏、呼吸停止、严重血流动力学不稳定等需紧急气管插管,平均年龄(75.6±12.2)岁伴呼吸衰竭的社区获得性肺炎患者,随机分配给予NPPV(162例)或标准氧疗(159例)作为呼吸衰竭救治方法,比较其插管率、呼吸衰竭控制率及病死率,筛选影响因素. 结果 全部患者中,90％为Ⅰ型呼吸衰竭,NPPV组治疗失败插管率低于标准氧疗组(46.9％比64.2％,x2=9.652,P＜0.01),但两组呼吸衰竭控制率无差别(77.9％比72.3％,x2=1.274,P＞0.05),30 d病死率及90 d累积生存率亦无差别.NPPV治疗失败者病死率高于成功者(48.7％比11.6％,x2=26.900,P＜0.01).NPPV治疗失败、简易急性生理评分和年龄高、多肺叶病变是死亡的独立危险因素. 结论 NPPV 可降低老年社区获得性肺炎Ⅰ型呼吸衰竭的插管率,但总体疗效并不突出,应用时需警惕延误插管.     

Causes and risk factors for rehospitalization of patients hospitalized with community-acquired pneumonia.

BACKGROUND: Rehospitalization after inpatient treatment of community-acquired pneumonia occurs in one-tenth of all hospitalizations, but the clinical circumstances surrounding readmission to the hospital have not been well studied. The objective of this study was to identify the causes and risk factors for rehospitalization of inpatients with community-acquired pneumonia. METHODS: This project was performed as part of a randomized, multicenter, controlled trial of the implementation of practice guidelines to reduce the duration of intravenous antibiotic therapy and duration of hospitalization for patients who have received a clinical and radiographic diagnosis of pneumonia. The trial was conducted at 7 hospitals in Pittsburgh, Pennsylvania, from February 1998 through March 1999. The primary outcome for these analyses was rehospitalization within 30 days after the index hospitalization. Two physicians independently assigned the cause of rehospitalization as pneumonia related, comorbidity related, or both; consensus was reached for all assignments. Patient demographic characteristics and clinical factors independently associated with rehospitalization were identified using multiple logistic regression analysis. RESULTS: Of the 577 patients discharged after hospitalization for community-acquired pneumonia, 70 (12%) were rehospitalized within 30 days. The median time to rehospitalization was 8 days (interquartile range, 4-13 days). Overall, 52 rehospitalizations (74%) were comorbidity related, and 14 (20%) were pneumonia related. The most frequent comorbid conditions responsible for rehospitalization were cardiovascular (n = 19), pulmonary (n = 6) and neurological (n = 6) in origin. Less than a high school education (odds ratio, 2.0; 95% confidence interval, 1.1-3.4), unemployment (odds ratio, 3.7; 95% confidence interval, 1.1-12.3), coronary artery disease (odds ratio, 2.7; 95% confidence interval, 1.5-4.7), and chronic obstructive pulmonary disease (odds ratio, 2.3; 95% confidence interval, 1.3-4.1) were independently associated with rehospitalization. CONCLUSIONS: The majority of rehospitalizations following pneumonia are comorbidity related and are the result of underlying cardiopulmonary and/or neurologic diseases. Careful attention to the clinical stability of patients with these coexisting conditions at and following hospital discharge may decrease the frequency of rehospitalization of patients with community-acquired pneumonia.     

老年心力衰竭患者的社区获得性肺炎病原菌分布及危险因素分析

目的探讨老年心力衰竭患者的社区获得性肺炎(CAP)病原菌分布及危险因素分析。方法入选2015年1月至2016年5月就诊于合肥市妇幼保健院的老年心力衰竭患者60例作为研究组。另选取同期就诊的由其他非感染诱因导致心力衰竭恶化的患者43例作为对照组。收集所有患者的临床资料及SF-36健康调查量表评分。采集研究组患者的痰液标本,分离培养检定病原菌并进行药敏试验。采用SPSS 23.0软件进行数据处理。依据数据类型,组间比较分别采用t检验或χ~2检验。使用logistic回归分析影响CAP发生的危险因素。结果 60例CAP患者中,共培养出病原体71株,其中革兰阴性菌43株(60.6%),革兰阳性菌21株(29.6%),真菌7株(9.9%)。革兰阴性菌对喹诺酮类、第三代头孢菌素的耐药性较高,对亚胺培南的敏感性较高。革兰阳性菌对青霉素、克林霉素普遍耐药,对万古霉素的敏感性较高。logistic回归分析提示,吸烟史(OR=2.91,95%CI 1.13~7.44,P=0.026)和SF-36健康调查量表总评分(OR=0.98,95%CI 0.97~0.99,P0.001)低是老年心力衰竭患者发生CAP的危险因素(P0.05)。结论老年心力衰竭患者的CAP病原菌分布以革兰阴性菌为主,且对头孢菌素和喹诺酮类耐药性较高。吸烟、基础生活质量差是老年心力衰竭患者发生CAP的危险因素。     

肺炎合并低氧血症患者进展为ARDS危险因素分析

目的 探究肺炎合并低氧血症患者进展为ARDS的早期危险因素.方法 回顾性病例对照研究,选取2016年1月1日至2019年12月30日陆军军医大学新桥医院收治的64例肺炎合并低氧血症患者作为研究对象,根据患者是否发展为ARDS分为ARDS病例组32例和对照组32例.收集两组患者发生肺炎合并低氧血症时的性别、年龄、合并症、...