The Potential Role of Angiotensin-Converting Enzyme Inhibitors and Beta-Blockers in Reducing Pneumonia Severity in Older Adults.

Background Understanding the impact of pharmacological therapy on pneumonia severity is crucial for effective clinical management. The impact of angiotensin-converting enzyme inhibitors (ACEis) and beta-blockers (BBs) on pneumonia severity remains unknown, warranting further investigation. Methodology This retrospective study examined the hospital records of inpatients (≥75 years) admitted with community-acquired pneumonia in 2021. Pneumonia severity associated with the use of pre-established ACEi and BB therapy was documented using CURB-65 (confusion, uraemia, respiratory rate, blood pressure, age ≥65 years) and pneumonia severity index (PSI) scores. Descriptive statistics and multivariable linear regression were used to analyse differences across BB therapy, ACEi therapy, their combination, or neither (control group). Results A total of 803 patient records were examined, of whom 382 (47.6%) were male and 421 (52.4%) were female. Sample sizes for each group were as follows: control (n = 492), BB only (n = 185), ACEi only (n = 68), and BB + ACEi (n = 58). Distribution of aspiration pneumonia (AP) versus non-AP for each group, respectively, was control (21.1% vs. 78.9%), BB only (9.7% vs. 90.3%), ACEi only (7.3% vs. 92.7%), and ACEi + BB (12.1% vs. 87.9%). No significant differences in PSI and CURB-65 scores were found between intervention groups even after controlling for patient characteristics and irrespective of AP or non-AP aetiology. Patients with AP had significantly higher CURB-65 (p = 0.026) and PSI scores (p = 0.044) compared to those with non-AP. Conclusions Pre-prescribed ACEi or BB therapy did not appear to be associated with differences in pneumonia severity. There were no differences in pneumonia severity scores with ACEi and BB monotherapy or combined ACEi and BB therapy.

Performance of CURB-65 and ISARIC 4C mortality scores for hospitalized patients with confirmed COVID-19 infection in Saudi Arabia.

Background: The COVID-19 pandemic continues with new waves that could persist with the arrival of new SARS-CoV-2 variants. Therefore, the availability of validated and effective triage tools is the cornerstone for proper clinical management. Thus, this study aimed to assess the validity of the ISARIC-4C score as a triage tool for hospitalized COVID-19 patients in Saudi Arabia and to compare its performance with the CURB-65 score. Material and methods: This retrospective observational cohort study was conducted between March 2020 and May 2021 at KFHU, Saudi Arabia, using 542 confirmed COVID-19 patient data on the variables relevant to the application of the ISARIC-4C mortality score and the CURB-65 score. Chi-square and t-tests were employed to study the significance of the CURB-65 score and the ISARIC-4C score variables considering the ICU requirements and the mortality of COVID-19 hospitalized patients. In addition, logistic regression was used to predict the variables related to COVID-19 mortality. In addition, the diagnostic accuracy of both scores was validated by calculating sensitivities, specificities, positive predictive value, negative predictive value, and Youden's J indices (YJI). Results: ROC analysis showed an AUC value of 0.834 [95% CI; 0.800-0.865]) for the CURB-65 score and 0.809 [95% CI; 0.773-0.841]) for the ISARIC-4C score. The sensitivity for CURB-65 and ISARIC-4C is 75% and 85.71%, respectively, while the specificity was 82.31% and 62.66%, respectively. The difference between AUCs was 0.025 (95% [CI; -0.0203-0.0704], p = 0.2795). Conclusion: Study results support external validation of the ISARIC-4C score in predicting the mortality risk of hospitalized COVID-19 patients in Saudi Arabia. In addition, the CURB-65 and ISARIC-4C scores showed comparable performance with good consistent discrimination and are suitable for clinical utility as triage tools for hospitalized COVID-19 patients.

Features of post-obstructive pneumonia in advanced lung cancer patients, a large retrospective cohort.

BACKGROUND: Post-obstructive pneumonia refers to an infection of the lung parenchyma distal to a bronchial obstruction. Previous experience-based studies reported a high prevalence of this infection among patients with a medical history of advanced lung neoplasia, up to 40-55%. OBJECTIVES: The current study was designed to investigate the features of post-obstructive pneumonia in lung cancer, including its predictors and the discriminants for 30-day mortality. METHOD: Data from medical records at the tertiary University centre, UZ Brussel, were collected retrospectively between January 2016 and January 2021. Patients affected by lung cancer stages III and IV were included. A multidisciplinary team, composed of a pulmonologist, an infectious disease specialist and a chest radiologist, identified patients affected by post-obstructive pneumonia. RESULTS: A total of 408 patients were included, of which 46 (11%) were diagnosed with post-obstructive pneumonia. Multivariable logistic regression for predictors of disease onset found significant differences for squamous cell carcinoma (OR:2.46 p-value: .014) and hilar location of the tumour (OR:2.72 p-value: .021). However, no significant differences were identified with regards to age or comorbidities. Furthermore, 30-day mortality among post-obstructive pneumonia patients was 30%. Multivariable logistic regression for prediction of 30-day mortality found significant differences in CURB-65 score (OR:73.20 p-value: .001) and smoking status (OR:0.009 p-value: .015). CONCLUSIONS: Within this cohort, the prevalence of post-obstructive pneumonia in advanced lung cancer patients was lower than previously reported. Squamous cell carcinoma and a hilar tumour location were two variables associated with disease development, independent of age and comorbidities. Furthermore, a higher CURB-65 score at post-obstructive pneumonia diagnosis was correlated with mortality.

Prognostication of COVID-19 patients using ROX index and CURB-65 score - A retrospective observational study.

Objectives: Coronavirus disease-2019 (COVID-19) disease has overwhelmed the healthcare infrastructure worldwide. The shortage of intensive care unit (ICU) beds leads to longer waiting times and higher mortality for patients. High crowding leads to an increase in mortality, length of hospital stays, and hospital costs for patients. Through an appropriate stratification of patients, rational allocation of the available hospital resources can be accomplished. Various scores for risk stratification of patients have been tried, but for a score to be useful at primary care level, it should be readily available at the bedside and be reproducible. ROX index and CURB-65 are simple bedside scores, requiring minimum equipment, and investigations to calculate. Methods: This retrospective, record-based study included adult patients who presented to the ED from May 1, 2020 to November 30, 2020 with confirmed COVID-19 infection. The patient's clinical and demographic details were obtained from the electronic medical records of the hospital. ROX index and CURB-65 score on ED arrival were calculated and correlated with the need for hospitalization and early (14-day) and late (28-day) mortality. Results: 842 patients were included in the study. The proportion of patients with mild, moderate and severe disease was 46.3%, 14.9%, and 38.8%, respectively. 55% patients required hospitalization. The 14-day mortality was 8.8% and the 28-day mortality was 20.7%. The AUROC of ROX index for predicting hospitalization was 0.924 (p < 0.001), for 14-day mortality was 0.909 (p < 0.001) and for 28-day mortality was 0.933 (p < 0.001). The AUROC of CURB-65 score for predicting hospitalization was 0.845 (p < 0.001), for 14-day mortality was 0.905 (p < 0.001) and for 28-day mortality was 0.902 (p < 0.001). The cut-off of ROX index for predicting hospitalization was ≤18.634 and for 14-day mortality was ≤14.122. Similar cut-off values for the CURB-65 score were ≥1 and ≥2, respectively. Conclusion: ROX index and CURB-65 scores are simple and inexpensive scores that can be efficiently utilised by primary care physicians for appropriate risk stratification of patients with COVID-19 infection.

Pneumonia scoring systems for severe COVID-19: which one is better.

PURPOSE: To investigate the predictive significance of different pneumonia scoring systems in clinical severity and mortality risk of patients with severe novel coronavirus pneumonia. MATERIALS AND METHODS: A total of 53 cases of severe novel coronavirus pneumonia were confirmed. The APACHE II, MuLBSTA and CURB-65 scores of different treatment methods were calculated, and the predictive power of each score on clinical respiratory support treatment and mortality risk was compared. RESULTS: The APACHE II score showed the largest area under ROC curve in both noninvasive and invasive respiratory support treatment assessments, which is significantly different from that of CURB-65. Further, the MuLBSTA score had the largest area under ROC curve in terms of death risk assessment, which is also significantly different from that of CURB-65; however, no difference was noted with the APACHE II score. CONCLUSION: For patients with COVID, the APACHE II score is an effective predictor of the disease severity and mortality risk. Further, the MuLBSTA score is a good predictor only in terms of mortality risk.

High serum IL-6 values increase the risk of mortality and the severity of pneumonia in patients diagnosed with COVID-19.

The clinical presentation of COVID-19 is very heterogeneous, ranging from asymptomatic to severe, which could lead to the need for mechanical ventilation or even death.We analyzed the serum levels of IL-6 in patients with COVID-19 diagnosis and its relationship with the severity of the disease, the need for mechanical ventilation and with patient mortality. We assessed IL-6 in a cohort of 50 patients diagnosed with COVID-19 pneumonia with different degrees of disease severity, and compared it with clinical and laboratory findings. We found higher levels of IL-6 in patients with more severe pneumonia according to CURB-65 scale (p = 0.001), with ICU mechanical ventilation requirements (p = 0.02), and who subsequently died (p = 0.003). Of the clinical and analytical parameters analyzed in the current study, the serum levels of IL-6 was the most effective predictor of disease severity. From the data obtained in ROC curve analysis, we defined a cut-off point for serum IL-6 levels of 35 pg/mL above which both the risk of mortality (OR = 20.00, 95 % CI 4.214-94-912, p = 0.0001) and ICU admission (OR = 12.750, 95 % CI 2,159-75,3,3, p = 0.005) were increased. Starting from blood IL-6 levels 27 out of 50 patients, with high levels and more severe symptoms, were treated with the IL-6 receptor antagonist Tocilizumab. IL-6 serum levels appear to be a useful prognostic biomarker in patients with a diagnosis of COVID-19 pneumonia. A cut-off point of 35 pg/mL could clearly differentiate patients a with more severe disease.

Performance of Two Risk-Stratification Models in Hospitalized Patients With Coronavirus Disease.

Background: Despite an increase in the familiarity of the medical community with the epidemiological and clinical characteristics of coronavirus disease 2019 (COVID-19), there is presently a lack of rapid and effective risk stratification indicators to predict the poor clinical outcomes of COVID-19 especially in severe patients. Methods: In this retrospective single-center study, we included 117 cases confirmed with COVID-19. The clinical, laboratory, and imaging features were collected and analyzed during admission. The Multi-lobular infiltration, hypo-Lymphocytosis, Bacterial coinfection, Smoking history, hyper-Tension and Age (MuLBSTA) Score and Confusion, Urea, Respiratory rate, Blood pressure, Age 65 (CURB65) score were used to assess the death and intensive care unit (ICU) risks in all patients. Results: Among of all 117 hospitalized patients, 21 (17.9%) patients were admitted to the ICU care, and 5 (4.3%) patients were died. The median hospital stay was 12 (10-15) days. There were 18 patients with MuLBSTA score ≥ 12 points and were all of severe type. In severe type, ICU care and death patients, the proportion with MuLBSTA ≥ 12 points were greater than that of CURB65 score ≥ 3 points (severe type patients, 50 vs. 27.8%; ICU care, 61.9 vs. 19.0%; death, 100 vs. 40%). For the MuLBSTA score, the ROC curve showed good efficiency of diagnosis death (area under the curve [AUC], 0.956; cutoff value, 12; specificity, 89.5%; sensitivity, 100%) and ICU care (AUC, 0.875; cutoff value, 11; specificity, 91.7%; sensitivity, 71.4%). The K-M survival analysis showed that patients with MuLBSTA score ≥ 12 had higher risk of ICU (log-rank, P = 0.001) and high risk of death (log-rank, P = 0.000). Conclusions: The MuLBSTA score is valuable for risk stratification and could effectively screen high-risk patients at admission. The higher score at admission have higher risk of ICU care and death in patients infected with COVID.

Rebounds after discharge from the emergency department for community-acquired pneumonia: focus on the usefulness of severity scoring systems.

BACKGROUND: Community-acquired pneumonia (CAP) is common cause of hospital admission and leading cause of morbidity and mortality. Severity scoring systems are used to predict risk profile, outcome and mortality, and to help decisions about management strategies. Aim of the work and Methods: To critically analyze pneumonia "rebound" cases, once discharged from the emergency department (ED) and afterwards admitted. We conducted an observational clinical study in the acute setting of a university teaching hospital, prospectively analyzing, in a 1 year period, demographic, medical, clinical and laboratory data, and the outcome. RESULTS: 249 patients were discharged home with diagnosis of CAP; 80 cases (32.1%) resulted in the high-intermediate risk class according to CURB-65 or CRB-65. Twelve patients (4.8%) presented to the ED twice and were then admitted. At their first visit 5 were in the high-intermediate risk group; just 4 of them were in the non-low risk group at the time of their admission. The rebound cohort showed some peculiar abnormalities in laboratory parameters (coagulation and renal function) and severe chest X-rays characteristics. None died in 30 days. CONCLUSIONS: The power of CURB-65 to correctly predict mortality for CAP patients discharged home from the ED is not confirmed by our results; careful clinical judgement seems to be irreplaceable in the management process. Many patients with a high-intermediate risk according to CURB-65 can be safely treated as outpatients, according to adequate welfare conditions; we identified a subgroup of cases that should worth a special attention and, therefore, a brief observation period in the ED before the final decision to safely discharge or admit.

Performance of CURB-65 in predicting mortality of patients with community-acquired pneumonia in Saudi Arabia.

INTRODUCTION: Various objective scoring systems were developed to standardize the approach to the designation of severity of community-acquired pneumonia (CAP). There is limited data on the use of CURB-65 among admitted CAP patients in Saudi Arabia.  METHODOLOGY: The retrospective study included CAP patients, admitted to a general hospital in Eastern Saudi Arabia. The CURB-65 was extracted from the available medical records. RESULTS: During the study period, from 2013 to 2016, a total of 1786 adults were admitted with a mean age of 63.9 ± 21.7 (range 14-108 years). The majority of the patients (51.7%) had CURB-65 score 0 or 1 followed by the score 2, 3 and 4/5 (29%, 15.2%, and 4.1%, respectively).  The mean CURB-65 was 1.4 ± 1.12 for those who survived and 2.27 ± 1.03 for those who died (p < 0.001). The mean age was 63.01± 21.9 years for survived patients and 75.1 ± 15.58 years for fatal cases (p < 0.001). The overall 30-day crude mortality rate was 7.6%. The mortality rates for CURB-65 scores 0, 1, 2, 3, and 4/5 were 1.8%, 4.3%, 10.2%, 14%, and 21.9%, respectively. CONCLUSIONS: The mortality rates of admitted patients with CAP did not differ from those reported in the literature. However, the utilization of CURB-65 score was low and there is a need for wider implementation of pneumonia severity index for patients presenting with CAP.

Hyponatremia in Patients with Community Acquired Pneumonia.

INTRODUCTION: Community acquired pneumonia is one the frequent cause of hospital admissions. Whereas, hyponatremia is a common electrolyte abnormality in hospitalized patients and has been shown to be associated with considerable morbidity and mortality. We aim to studyt the association of hyponatremia with community acquired pneumonia in terms of morbidity and mortality. METHODS: A prospective observational hospital based study was conducted in a hospital for a year. All patients with a diagnosis of community acquired pneumonia and admitted in medicine ward, were included. Patients with diarrhea, known Chronic Kidney Disease, Heart Failure, Cirrhosis of Liver, Malignancy, taking diuretics, chemical pneumonitis, interstitial pneumonias and other debilitating disease were excluded. RESULTS: Among the 72 cases of CAP, 61% were females and 39% were males. The mean age of patients was 51.3 years, 22 (30.55%) patients had severe CAP. A total of 7 cases expired with an overall mortality of 13.7%. The mortality risk increased with increasing CURB-65 score; CURB-65 score 0, 0%; CURB-65 score 1, 0%; CURB-65 score 2, 0%; CURB-65 score 3, 10%; CURB-65 score 4, 33%; CURB-65 score 5, 100%. i.e higher the CURB-65 score, higher the death rate of CAP patients (p<0.05). Hyponatremia was a common occurrence at hospital admission with an incidence of 36.11%. Hyponatremia at hospital admission was also associated with a longer length of hospital stay in cured CAP patients. The mean length of hospital stay was 4.3 days. CONCLUSIONS: High CURB-65 scores and lower values of serum sodium at admission in patients of CAP are associated with adverse outcomes both in terms of mortality and longer length of hospital stay. CURB-65 score should be incorporated into assessment of CAP and sodium of the patients during admission.

Community-acquired Haemophilus influenzae pneumonia--New insights from the CAPNETZ study.

OBJECTIVES: We aimed to identify clinical characteristics and to assess effectiveness of different initial antibiotic regimens in adult patients with community-acquired pneumonia (CAP) caused by Haemophilus influenzae. METHODS: Characteristics were compared between patients with H. influenzae monoinfection versus CAP of other and unknown aetiology enrolled by the German prospective cohort study CAPNETZ. Impact of initial antibiotic treatment on "early clinical response" according to FDA criteria and overall clinical cure were analysed. RESULTS: H. influenzae was found in 176 out of 2790 patients with pathogen detection (6.3%). Characteristics significantly associated with a H. influenzae CAP (p < 0.017) included purulent sputum, prior pneumococcal vaccination and respiratory co-morbidities. Early clinical response rates on day 4 did not differ between patients receiving any mono- versus combination therapy (85.9% versus 88%), but were numerically higher for regimens including any fluoroquinolone (96.7%) and lower under macrolide monotherapy (70%). Initial CURB-65 score and chronic liver disease were identified as negative predictors for "early clinical response". At day 14, overall clinical cure was 91.9%. CONCLUSIONS: H. influenzae was a common CAP pathogen, particularly in patients with previous pneumococcal vaccination and respiratory co-morbidities. Severity of illness and chronic liver disease were associated with a lower rate of "early clinical response".

CURB-65 and other markers of illness severity in community-acquired pneumonia among HIV-positive patients.

As the relative burden of community-acquired bacterial pneumonia among HIV-positive patients increases, adequate prediction of case severity on presentation is crucial. We sought to determine what characteristics measurable on presentation are predictive of worse outcomes. We studied all admissions for community-acquired bacterial pneumonia over one year at a tertiary centre. Patient demographics, comorbidities, HIV-specific markers and CURB-65 scores on Emergency Department presentation were reviewed. Outcomes of interest included mortality, bacteraemia, intensive care unit admission and orotracheal intubation. A total of 396 patients were included: 49 HIV-positive and 347 HIV-negative. Mean CURB-65 score was 1.3 for HIV-positive and 2.2 for HIV-negative patients (p < 0.0001), its predictive value for mortality being maintained in both groups (p = 0.03 and p < 0.001, respectively). Adjusting for CURB-65 scores, HIV infection by itself was only associated with bacteraemia (adjusted odds ratio [AOR] 7.1, 95% CI [2.6-19.5]). Patients with < 200 CD4 cells/µL presented similar CURB-65 adjusted mortality (aOR 1.7, 95% CI [0.2-15.2]), but higher risk of intensive care unit admission (aOR 5.7, 95% CI [1.5-22.0]) and orotracheal intubation (aOR 9.1, 95% CI [2.2-37.1]), compared to HIV-negative patients. These two associations were not observed in the > 200 CD4 cells/µL subgroup (aOR 2.2, 95% CI [0.7-7.6] and aOR 0.8, 95% CI [0.1-6.5], respectively). Antiretroviral therapy and viral load suppression were not associated with different outcomes (p > 0.05). High CURB-65 scores and CD4 counts < 200 cells/µL were both associated with worse outcomes. Severity assessment scales and CD4 counts may both be helpful in predicting severity in HIV-positive patients presenting with community-acquired bacterial pneumonia.

Serum iron and A(2)DS(2) score in stroke-associated pneumonia.

To evaluate the efficacy of serum biomarkers such as iron, procalcitonin (PCT), C-reactive protein (CRP) and A(2)DS(2) scores at hospital admission to predict the onset and severity of stroke-associated pneumonia (SAP), 101 patients with acute stroke were selected and divided into the control and SAP group. Compared with control group, no significant differences were discovered in age, sex, vascular risk factors including hypertension, diabetes and hyperlipidemia, chronic lung disease of SAP group, while a significantly higher level was found in incidence of dysphagia, NIHSS score, A(2)DS(2) score, CURB-65 score, serum iron, serum ferritin, PCT and CRP (P < 0.01). The receiver operating characteristic curve showed that serum iron, serum ferritin, PCT, CRP, A(2)DS(2) score and CURB-65 score had relatively high values in the SAP prediction (all P < 0.01, all AUC > 0.5). When combined ferritin, PCT, and A(2)DS(2) scores and other indicators with CRP for SAP prediction, the model had a larger area under the curve (AUC) and higher specificity than individual prediction models. Spearman regression analysis presented that serum iron, serum ferritin and A(2)DS(2) score were highly correlated with CURB-65 score (P < 0.01). It was suggested that Serum iron and A(2)DS(2) score measured at admission were effective indicators in SAP prediction which could be used for SAP screening and severity prediction. Besides, the specificity in SAP prediction could be improved when Serum iron and A(2)DS(2) score combined with CRP.

Performance of severity scores for home care-based patients suffering from pneumonia.

AIM: The Pneumonia Severity Index (PSI) is used to determine the prognosis of community-acquired pneumonia (CAP). The concept of nursing- and healthcare-associated pneumonia (NHCAP) has recently been established in Japan. The present study aims to examine whether the PSI can predict the prognosis of home care-based patients diagnosed with NHCAP. METHODS: We retrospectively sampled 97 home care-based patients diagnosed with pneumonia in 2011 at Aozora Clinic in Kamihongo. Each case was scored using the PSI, the A-DROP and the CURB-65, and the severity of each case was evaluated. We also modified the PSI to obtain the score on the site of the home visits by omitting the scores related to the radiographic and laboratory findings. We call this new score the modified PSI for home care-based patients (PSI-HC). We assessed how well each score predicted mortality. RESULTS: The correlation efficiency of the PSI and the PSI-HC before categorization was 0.89. All the four scores well predicted the mortality, with the area under the curve of the receiver operating characteristic curves of the PSI, the PSI-HC, the A-DROP and the CURB-65 being 0.859, 0.856, 0.778, and 0.806, respectively. These scores also predicted the hospitalization rate, but more than two-thirds of high-scoring patients received therapy at home contrary to the recommendations of guidelines. CONCLUSIONS: All four scores for CAP well predicted the prognosis of pneumonia of the home care-based patients, which was categorized in NHCAP. The decision of hospitalization was made not only by considering the severity of the pneumonia.