Clinical Outcomes in the Hospitalized Patients with ...

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Clinical Outcomes in the Hospitalized Patients with Community-Acquired Pneumonia in Louisville, KY: Results from the University of Louisville Study. Shashvin ...
Clinical Outcomes in the Hospitalized Patients with Community-Acquired Pneumonia in Louisville, KY: Results from the University of Louisville Study Shashvin Singh, Rajashekar Reddy Yeruva, Eman Abbas, Kuldeep Ghosh, Sarah Van Heidan, Thomas Chandler, Kimberly Buckner, Paula Peyrani Division of Infectious Diseases ABSTRACT

METHODS

RESULTS

Introduction Pneumonia is the eighth leading cause of death in the United States and the primary cause of infectious-related deaths. Several studies have studied the clinical course, length of stay and mortality in hospitalized patients with community-acquired pneumonia (CAP). However, these studies were mostly done in Europe and within different populations. Objective The objective of this study was to evaluate the clinical outcomes of hospitalized patients with CAP in Louisville, KY. Methods This was a secondary data analysis of the University of Louisville Pneumonia study. Study outcomes were clinical stability (CS), clinical failure (CF), nonresolving pneumonia (NRP), length of stay (LOS), and in-hospital mortality. CS, CF, and NRP were evaluated during the first week of the hospitalization. Dichotomous variables are presented as number (%) and continuous variables as median (IQR). Results A total of 8,269 patients were hospitalized with CAP during the study period. A total of 6,326 (86%) patients reached CS, 1,502 (9%) patients developed clinical failure, and 441 (5%) NRP. In-hospital mortality was 6%. Conclusions This study shows that the majority of patients hospitalized with CAP reach clinical stability within the first week. Further research is needed in order to identify characteristics to predict the clinical course of hospitalized patients with CAP and improve the management of those patients who will not improve.

Study design and population: This was a secondary data analysis of the University of Louisville Pneumonia study, a prospective population-based cohort study of all hospitalized adults with CAP who were residents in the city of Louisville, Kentucky, from June 1st 2014 to May 31st 2016. Institutional Review Board approval was obtained. Study outcomes were clinical stability (CS), clinical failure (CF), non-resolving pneumonia (NRP), length of stay (LOS), and in-hospital mortality. CS, CF, and NRP were evaluated during the first week of the hospitalization. Inclusion criteria: CAP: Diagnosis of CAP required the presence of criterion A, B, and C: A. New pulmonary infiltrate on imaging (CT scan or chest x-ray) at the time of admission to the hospital. B. Signs and Symptoms of CAP (at least one of the following): - New or increased cough - Fever >37.8°C (100.0°F) or hypothermia 11,000 cells/mm3, left shift > 10% band forms/microliter, or leukopenia < 4,000 cells/mm3 C. Working diagnosis of CAP at the time of hospital admission with antimicrobial therapy given within 24 hours of admission.

• A total of 8,269 patients hospitalized with CAP were included in the study. • Patients’ characteristics are shown in table 1. • The clinical course of the study population is shown in figure 1. Median TCS was 2 (3) days and LOS was 5 (5) days • Mortality rates are sown in Figure 2.

INTRODUCTION Community-acquired pneumonia (CAP) is the leading cause of mortality of infectious diseases. In the USA, pneumonia was the eighth leading cause of death in 2004 and caused 1.3 million hospitalizations in 2005 (1). The outcomes of CAP depends on many factors starting from age, socio-economic status, primordial diseases, host immune system, pathogenicity of the microbe and response to treatment. Recent literature showed that the time in which patients with CAP reach clinical stability during the hospital course could impact outcomes after hospital discharge. Patients with a time to clinical stability (TCS) more than 3 days showed a significantly higher rate of adverse outcomes after discharge compared with those with a TCS equal to or less than 3 days(2). Patients with early clinical stability had lower 90-day mortality rate and fewer admissions to ICU and shorter length of stay in the hospital (3). Identifying the clinical outcomes clinical stability versus clinical failure early in the course of illness could help in improving the patient care by changing the clinical strategies. Once the antibiotics are started the outcomes of CAP patients can be divided into clinical improvement, clinical deterioration and non-resolving pneumonia.

In the past studies it is known that CAP is associated with short term mortality (4) but from recent studies it is clear that CAP is associated with long term mortality ranging from 13% to 53% at 3 and 7 years respectively(5-7). Most of the above studies were done in Europe evaluating the clinical outcomes separately and non of them were done in same population.

Objective The objective of this study was to evaluate the clinical outcomes of hospitalized patients with CAP in Louisville, KY.

Study variables: The following variables were collected from the medical record if available: - Demographics: age, sex and race. - Risk factors: Alcohol abuse/dependence, Congestive Heart Failure, COPD, Cerebrovascular Disease, Diabetes, HIV, Liver Disease, Neoplastic Disease, Renal Disease and Renal Failure. - Vitals on admission: Height, Weight, Temperature, Heart Rate, Systolic and Diastolic Blood Pressures, Respiratory Rate, O2 saturation and FiO2. - Severity of Disease: Requirement of ventilatory support, requirement of vasopressors, altered mental status, and Pneumonia Severity Index (PSI). Study outcomes: - Time to Clinical Stability (TCS): TCS is evaluated during the first week of hospitalization. A patient was defined as clinically stable the day that the following four criteria were met: (a) improved cough and shortness of breath; (b) lack of fever for at least 8 hours; (c) improving leukocytosis (decreased at least 10% from the previous day); and (d) tolerating oral intake with adequate gastrointestinal absorption. Patients were evaluated daily within the first 7 days of hospitalization to determine the day when clinical stability was reached. Early clinical improvement or deterioration is evaluated in ≤3 days and late clinical improvement or deterioration is evaluated during 4-7 days. - Length of stay (LOS): defined in days and calculated for each patient as the day of discharge minus the day of admission. Patients hospitalized for more than 14 days were censored at 14 days in an effort to capture LOS data related only to bacterial CAP. - Clinical failure(CF): CF is evaluated during the first 14days of hospitalization. For a patient to develop clinical failure, the pulmonary function and hemodynamic status are compared to the baseline values (worst values collected on day 0). The following criteria should be evaluated daily from day 1 until the patient is discharged from the hospital, or up to day 14 if the patient is still hospitalized. 1. Acute pulmonary deterioration with the need of mechanical ventilation 2. Acute hemodynamic deterioration with the need of vasopressors 3. Death - Non-resolving pneumonia: defined as not meeting criteria for clinical stability of failure in the first week of hospitalization. - In-hospital mortality: It is defined as death by any cause during hospitalization.

RESULTS(continue..)

Table 1: Patient characteristics Demographics Age, Median (IQR) Sex: Male, n (%) Race: Black, n (%) Nursing home resident n(%) Social and medical history Alcohol use, n(%) Obesity (BMI > 30), n(%) Congestive heart failure , n(%) COPD, n(%) Cerebrovascular disease, n(%) Diabetes, n(%) HIV, n(%) Liver disease, n(%) Neoplastic disease, n(%) Renal disease, n(%) Chronic renal failure, n(%) Vital signs on admission Altered mental status on admission, n(%) Heart rate (Beats/Minute), Median(IQR) Respiratory rate (Breaths/Minute), Median(IQR) Temperature (Degrees Celsius), Median(IQR) Hypotension (SBP < 90), n(%) Severity of the disease Vasopressors on day 0, n(%) Ventilatory support on day 0, n(%) Pneumonia Severity Index (PSI), Median(IQR) PSI Class IV or V, n(%)

6%

70%

68 (24) 3819 (46.2) 1648 (19.9) 1125 (13.6)

CONCLUSIONS 452 (5.5) 2859 (34.6) 2512 (30.4) 4041 (48.9) 1116 (13.5) 2727 (33) 136 (1.6) 599 (7.2) 1133 (13.7) 2488 (30.1) 685 (8.3) 1591 (19.2) 105 (28) 22 (7) 37.2 (1.1) 1023 (12.4) 241 (2.9) 1148 (13.9) 103 (57) 5072 (61.3)

3%

16%

Figure 2: Mortality rates for study population during the first year

5%

Statistic Analysis: Descriptive statistics were performed. Baseline categorical explanatory variables were summarized as frequencies and percentages and Continuous variables were summarized as frequencies and interquartile range.

Figure 1: Clinical course for hospitalized patients with CAP

• This study shows that the majority of patients hospitalized with CAP reach clinical stability within the first week. This is the first study to evaluate the full clinical course of hospitalized patients with CAP in the same population • More than one-fourth of patients die within a year after being hospitalized for CAP. • Primordial diseases like COPD, CHF and Diabetes have significant effect on clinical outcome of the patients. • Further research is needed in order to identify characteristics to predict the clinical course of hospitalized patients with CAP and improve the management of those patients who have poor outcomes.

REFERENCES 1. Niederman MS. Community-acquired pneumonia: the U.S. perspective. Semin Respir Crit Care Med. 2009;30(2):179-88. 2. Aliberti S, Blasi F. Clinical stability versus clinical failure in patients with community-acquired pneumonia. Semin Respir Crit Care Med. 2012;33(3):284-91. 3. Garin N, Felix G, Chuard C, Genne D, Carballo S, Hugli O, et al. Predictors and Implications of Early Clinical Stability in Patients Hospitalized for Moderately Severe Community-Acquired Pneumonia. PloS one. 2016;11(6):e0157350. 4. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. The New England journal of medicine. 1997;336(4):243-50. 5. Mortensen EM, Metersky ML. Long-Term Mortality after Pneumonia. Semin Respir Crit Care Med. 2012;33(03):319-24. 6. Adamuz J, Viasus D, Jimenez-Martinez E, Isla P, Garcia-Vidal C, Dorca J, et al. Incidence, timing and risk factors associated with 1-year mortality after hospitalization for community-acquired pneumonia. The Journal of infection. 2014;68(6):534-41. 7. Holter JC, Ueland T, Jenum PA, Muller F, Brunborg C, Froland SS, et al. Risk Factors for Long-Term Mortality after Hospitalization for Community-Acquired Pneumonia: A 5-Year Prospective Follow-Up Study. PloS one. 2016;11(2):e0148741.