Risk factors for severe outcomes among members of the United States military hospitalized with pneumonia and influenza, 2000–2012

BackgroundThe progression from hospitalization for a respiratory infection to requiring substantial supportive therapy is a key stage of the influenza severity pyramid. Respiratory infections are responsible for 300,000–400,000 medical encounters each year among US military personnel, some of which progress to severe acute respiratory infections.MethodsWe obtained data on 11,086 hospitalizations for pneumonia and influenza (P&I) among non-recruit US military service members during the period of 1 January 2000 through 31 December 2012. From these, we identified 512 P&I hospitalizations that progressed to severe episodes using standard case definitions. We evaluated the effect of demographic and occupational characteristics, co-morbid conditions, and history of influenza vaccination on the risk of a hospitalized P&I case becoming a severe case. We also evaluated the risk of a severe outcome and the length of time since influenza vaccination (within 180, 60, and 30 days).ResultsThe median age of subjects at the time of the P&I episode was 32 years (range, 28–40) and subjects were predominantly male (89.5%). In a univariate analysis, demographic risk factors for a severe episode included service in the US Air Force (RR = 1.6 relative to US Army, 95%CI 1.3–2.1), US Coast Guard (RR = 2.1, 1.2–3.7) or US Navy (RR = 1.4, 1.1–1.8). Being born in the US and recent influenza vaccination (within 180 days of episode) were protective against developing severe disease. Among co-morbid conditions, univariate risk factors for severe disease included chronic renal or liver disease (RR = 4.98, 95%CI 4.1–6.1), diseases of the circulatory system (RR = 3.1, 95%CI 2.6–3.7), diabetes mellitus (RR = 2.3, 95%CI 1.5–3.6), obesity (RR = 1.6, 95%CI 1.2–2.1), cancer (RR = 1.6, 95%CI 1.3–2.0), and chronic obstructive pulmonary disease (RR = 1.4, 95%CI 1.1–1.7). Although many of the risk factors found to be significant in univariate analysis were no longer significant under a multivariate analysis, receipt of any influenza vaccine within 180 days of episode remained protective (RR = 0.81, 95%CI 0.67–0.99), while serving in the US Coast Guard (RR = 1.9, 95%CI 1.1–3.4) or US Air Force (RR = 1. 5, 95%CI 1.2–2.0), presence of renal or liver disease (RR = 3.6, 95%CI 2.9–4.6), and diseases of the circulatory system (RR = 2.2, 95%CI 1.8–2.8), remained significantly associated with a higher risk of developing severe disease.ConclusionsIn a large cohort, after adjusting for many possible risk factors, influenza vaccination was protective against severe episodes among P&I hospitalizations. The service-specific (US Coast Guard or US Air Force) increased risk may represent some differences in data (e.g., coding or reporting practices) as opposed to genuine differences in physiological outcome. Our findings suggest that renal and liver disease as well as diseases of the circulatory system may contribute to influenza severity in this population independently of age and other potential comorbidities. These findings provide additional evidence for the prioritization of specific risk groups within the US military for influenza vaccination     

定喘汤对合胞病毒感染型肺炎患者免疫、炎症因子的影响

目的:探讨定喘汤对合胞病毒(RSV)感染型肺炎患者免疫、炎症因子的影响。方法:纳入2015年3月~2017年3月我院收治的RSV感染型肺炎患者96例,随机分为对照组和观察组,各48例。对照组予以静脉滴注利巴韦林治疗,观察组在对照组的基础上给予定喘汤口服治疗。两组均于治疗前和治疗后,分别采用流式细胞仪对外周血T细胞亚群(CD3+、CD8+、CD4+/CD8+)及自然杀伤细胞(NK)活性进行测定,采用酶联免疫吸附测定法对血清IL-4、IL-6、IL-8和INF-γ水平进行检测。另选取同期体检健康人员48例为正常组。比较各组上述指标水平。结果:治疗前,观察组和对照组CD3+、CD8+、NK、INF-γ水平均低于正常组,CD4+/CD8+、IL-4、IL-6、IL-8水平均高于正常组,差异有统计学意义(P0.05)。治疗后,观察组和对照组CD3+、CD8+、NK、INF-γ水平较治疗前均明显上升,CD4+/CD8+、IL-4、IL-6、IL-8水平较治疗前均明显降低,差异有统计学意义(P0.05);治疗后观察组CD3+、CD8+、NK、INF-γ水平均高于对照组,CD4+/CD8+、IL-4、IL-6、IL-8水平均低于对照组,差异有统计学意义(P0.05)。结论 :定喘汤能有效调节炎症免疫反应,对RSV感染型肺炎患者具有良好的治疗作用。     

The bacterial pneumonias: a new treatment paradigm

Pneumonia is a common disease that carries a high mortality. Traditionally, pneumonia has been classified and treated according to the setting where the pneumonia develops, namely community-acquired pneumonia, health-care–associated pneumonia, and hospital-acquired pneumonia. This classification was based on the risk of a patient being infected with a hospital-acquired drug-resistant pathogen. A new treatment paradigm has been proposed based on the risk of the patient being infected with a community-acquired drug-resistant pathogen. The risk factors for infection with a community-acquired drug-resistant pathogen include (1) hospitalization for > 2 days during the previous 90 days, (2) antibiotic use during the previous 90 days, (3) nonambulatory status, (4) tube feeds, (5) immunocompromised status, (6) use of acid-suppressive therapy, (7) chronic hemodialysis during the preceding 30 days, (8) positive methicillin-resistant Staphylococcus aureus history within the previous 90 days, and (9) present hospitalization > 2 days. This article reviews this new treatment paradigm and other issues relevant to the diagnosis and management of pneumonia based on information from MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials.     

降钙素原测定指导老年人呼吸机相关性肺炎抗生素治疗的使用价值

目的 探讨在老年人呼吸机相关性肺炎(VAP)治疗中用降钙素原(PCT)水平来指导临床抗生素使用的价值.方法 50例老年VAP患者分为常规治疗组与PCT指导治疗组.常规治疗组按常规治疗方法使用抗生素进行治疗,PCT组通过检测血清PCT浓度来指导抗生素使用.比较两组抗生素使用时间、使用率以及抗生素治疗结束后两组患者炎性指标[白细胞、中性粒细胞、C-反应蛋白(CRP)]和临床肺部感染积分(CPIS)之间的差异.结果 两组经治疗后,PCT组患者白细胞、中性粒细胞、CRP[(8.9±3.5)×109/L、0.62±0.04、(18.7±8.5)mg/L]与常规组[(9.4±3.7)×109/L、0.60±0.04、(21.6±6.0)mg/L]差异无统计学意义(t值分别为0.47、1.84、1.37,均P>0.05),但是PCT组CPIS[(4.0±1.4)分]明显低于常规治疗组[(4.7±1.0)分],差异有统计学意义(t=2.18,P<0.05).两组在治疗前后,各炎性指标中除白细胞计数外,中性粒细胞、CRP及CPIS均较治疗前明显降低;PCT组PCT值也较治疗前降低[(1.7±0.7)mg/L至(0.5±0.9)mg/L].同时,在抗生素使用时间上,常规组[(8.72±1.32)d]与PCT组[(5.17±0.72)d]相比,差异有统计学意义(t=11.96,P<0.01);抗生素使用率分别为95.2%和55.2%,差异有统计学意义(χ2=12.41,P<0.01),PCT组抗生素使用率明显低于常规组.结论 在老年VAP患者治疗中参考PCT水平用药,可以在达到更好治疗效果的同时减少抗生素的使用.     

Recurrent Community-acquired Pneumonia in Patients Starting Acid-suppressing Drugs

Background

Several studies suggest that proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H2s) increase risk of community-acquired pneumonia. To test this hypothesis, we examined a prospective population-based cohort predisposed to pneumonia: elderly patients (≥65 years) who had survived hospitalization for pneumonia.

Methods

This study featured a nested case-control design where cases were patients hospitalized for recurrent pneumonia (≥30 days after initial episode) and controls were age, sex, and incidence-density sampling matched but never had recurrent pneumonia. PPI/H2 exposure was classified as never, past, or current use before recurrent pneumonia. The association between PPI/H2s and pneumonia was assessed using multivariable conditional logistic regression.

Results

During 5.4 years of follow-up, 248 recurrent pneumonia cases were matched with 2476 controls. Overall, 71 of 608 (12%) current PPI/H2 users had recurrent pneumonia, compared with 130 of 1487 (8%) nonusers (adjusted odds ratio [aOR] 1.5; 95% confidence interval [CI], 1.1-2.1). Stratifying the 608 current users according to timing of PPI/H2 initiation revealed incident current-users (initiated PPI/H2 after initial pneumonia hospitalization, n = 303) bore the entire increased risk of recurrent community-acquired pneumonia (15% vs 8% among nonusers, aOR 2.1; 95% CI, 1.4-3.0). The 305 prevalent current-users (PPI/H2 exposure before and after initial community-acquired pneumonia hospitalization) were equally likely to develop recurrent pneumonia as nonusers (aOR 0.99; 95% CI, 0.63-1.57).

Conclusion

Acid-suppressing drug use substantially increased the likelihood of recurrent pneumonia in high-risk elderly patients. The association was confined to patients initiating PPI/H2s after hospital discharge. Our findings should be considered when deciding to prescribe these drugs in patients with a recent history of pneumonia.     

Diagnostic Value of Chest Radiographs in Bedridden Patients Suspected of Having Pneumonia

Objectives

To assess the diagnostic value of the chest radiograph for the diagnosis of pneumonia in bedridden patients, using non-contrast-enhanced high-resolution chest computed tomography (CT) as the gold standard.

Methods

We prospectively evaluated bedridden patients hospitalized with moderate to high clinical probability of pneumonia. Chest radiographs were interpreted in a blinded fashion by 3 observers and classified as definite, normal, or uncertain for pneumonia. Chest CT was obtained within 12 hours of chest radiograph. We applied Bayesian analysis to assess the accuracy of chest radiograph in the diagnosis of pneumonia.

Results

In a 5-month period, 58 patients were evaluated, 31 (53%) were female. Their chest radiographs were interpreted as negative, uncertain, or positive for pneumonia in 31 (53%), 15 (26%), and 12 (21%) patients, respectively, while CT confirmed pneumonia in 11 (35%), 10 (67%), and in 10 (83%). The sensitivity of the chest radiograph to diagnose pneumonia was 65%, the specificity was 93%, the positive and negative predictive values were, respectively, 83% and 65%, while the overall accuracy was 69% (95% confidence interval, 50%-79%).

Conclusions

In bedridden patients with suspected pneumonia, a normal chest radiograph does not rule out the diagnosis, hence, a chest CT scan might provide valuable diagnostic information.     

双黄连注射剂辅助治疗肺炎随机对照试验的系统评价

目的:评价双黄连注射剂辅助治疗肺炎的疗效和安全性。方法:检索中文期刊全文数据库(CNKI)、万方数据库、中文科技期刊数据库(VIP)、中国生物医学文献数据库(CBM)、PubMed、Cochrane临床试验数据库。纳入1990年—2010年公开发表在国内外关于双黄连注射剂治疗肺炎随机对照试验的文献,根据纳入标准及排除标准选择相关文献,并根据文献的不同干预措施进行分层分析:双黄连组(双黄连+西医常规治疗)与单纯西医常规治疗组比较、双黄连组(双黄连+西医常规治疗)与痰热清组(痰热清+西医常规治疗)比较。采用CochraneRev Man 5.0软件进行荟萃分析(Meta分析)。结果:符合纳入标准的论文共有8篇。Meta分析结果显示,双黄连组与单纯西医组相比(共6篇),有效率优势比(OR)为3.97,95%可信区间(95%CI)为[2.02,7.81];痊愈率OR为3.78,95%CI为[2.09,6.83];肺部湿啰音消失时间权重均数差(WMD)为-1.37,95%CI为[-1.76,-0.98];X线恢复正常时间WMD为-1.40,95%CI为[-2.73,-0.08],两组上述各指标比较,差异均有统计学意义。双黄连组优于单纯西医组(P<0.05,P<0.01)。双黄连组与痰热清组比较(共2篇),有效率OR为0.43,95%CI为[0.19,0.96],痰热清组优于双黄连组(P<0.05)。未见报道与双黄连临床应用相关严重不良反应。结论:辅以双黄连注射剂治疗肺炎在综合疗效、肺部湿啰音消失时间、X线恢复正常时间方面优于单纯西医常规治疗。由于本次系统评价纳入研究质量所限,尚需开展高质量的研究进一步分析。     

Methicillin-resistant staphylococcus aureus screening and eradication in the surgical intensive care unit: Is it worth it?

Background

The problem of intensive care unit methicillin-resistant Staphylococcus aureus (MRSA) infections has led to routine surveillance and eradication strategies.

Methods

Our surgical intensive care unit (SICU) admissions receive MRSA nares cultures and if positive are isolated followed by eradication treatment. This strategy was retrospectively reviewed.

Results

Our nares-positive culture rate was 21% (30/145), and the sputum positive (sputum+) rate was 18% (26/145). Positive nares culture (Nares+) was eradicated in 63%. The rate of sputum+ in Nares+ patients was 36% (9/25). The rate of sputum+ in Nares− was 10% (12/115; P = .003). The sputum+ SICU length of stay (LOS) (18 ± 12 days in 23 S+ patients) is longer than in sputum− (10 ± 9 days in 69 S-patients, P = .0002).

Conclusions

This SICU has high rates of both nares and sputum MRSA cultures. Our data suggest eradicating nares colonization may prevent pneumonia and might decrease SICU LOS.     

甲型H1N1流感并发肺部感染七例临床分析

甲型H_1N_1流感是一种新型流感病毒引起的急性呼吸道传染病.病毒表面有2种蛋白质：红细胞凝集素（H）和神经氨酸酶（N）.研究发现该病毒含有猪流感、禽流感和人流感3种流感病毒的核糖核酸基因片段~（[1]）.此病毒传染性大,毒力强,人群普遍易感.2009年3月墨西哥、美国相继暴发甲型H_1N_1流感,疫情在全球迅速蔓延.     

重症医学科呼吸机相关肺炎59例临床分析

目的分析重症医学科（ICU）呼吸机相关性肺炎（VAP）的病原学感染因素,探讨有效控制VAP发生率的措施。方法以该院于2009年10月—2013年1月收治的重症医学科机械通气患者126例为监测对象,其中发生VAP例数为59例。结果该组患者呼吸机相关性肺炎发生率为46.83%。共检出93株病原菌,G-杆菌72.04%、G＋菌10.76%、真菌17.20%。结论重症医学科呼吸机相关肺炎的病原学感染因素主要为革兰阴性菌,临床上我们应该针对不同的病原菌合理的使用抗生素,避免病原菌耐药性的增加,有效控制VAP的发生与恶化。