Beyond clinical trials: real-world impact of immunotherapy on NSCLC in Jordan.

Background: This study aims to evaluate real-world (rw) outcomes of immunotherapy (IO) for advanced stage NSCLC at King Hussein Cancer Center (KHCC) in Jordan. Methods: Advanced stage NSCLC patients who received IO at KHCC between 2017 and 2022 were included. The data were retrospectively collected. PFS and OS were estimated for patients with ECOG performance status (ECOG PS) 0-1. Cox regression analyzed predictors of OS in first-line (1L) IO, regardless of performance status. Results: The total number of patients included was 244. Out of those, 160 (65%), 67 (28%), and 17 (7%) patients received IO as 1L, second-line (2L), or third-line or beyond (3L or beyond), respectively. The median age for all patients was 59 years. Male were 88%, and 77% were smokers. The median follow-up time was 12.5 months. The median PFS and OS for 1L IO were 7 [95% CI 5.8 - 10.3] and 11.8 [95% CI 8.8 - 14.4], months, respectively. In the first 3 months after starting 1L IO, 34/160 (21%) patients had died. For those who survived beyond 3 months after starting 1L IO, the median PFS and OS were 11.3 [95% CI 8.3 - 16.5] and 15.4 [95% CI 13.2 - 21] months, respectively. In the Cox regression model of 1L IO patients with any performance status, ECOG PS 2 was predictive of worse OS compared to ECOG PS 0-1 (p= 0.005). Conclusion: This real-world study of advanced-stage NSCLC patients treated with immunotherapy at KHCC reveals outcomes that fall short of those anticipated from clinical trials. The inclusion of Middle Eastern patients in lung cancer trials is essential to ensure adequate representation of various ethnicities in clinical research.

Primary Thromboprophylaxis for the Prevention of Venous Thromboembolism in Cancer Patients with Central Venous Catheters: A Literature Review.

Cancer is a known risk factor for venous thromboembolism (VTE). The wider adoption of immunotherapy and anti-angiogenic drugs in recent years have increased this risk further. Central venous catheters (CVCs) are widely used access devices utilized to deliver infusion therapy, mostly in ambulatory settings. The endothelial injury associated with the use of these catheters adds to the risk of VTE to already high-risk patients. The introduction of direct oral anticoagulants (DOACs), with its proven efficacy and safety in multiple clinical indications, have renewed the attention to VTE prophylaxis in cancer patients with CVC. Several clinical trials and meta-analyses had shown that both apixaban and rivaroxaban are effective in lowering the risk of VTE, without increasing the risk of bleeding. Several risk assessment models (RAM) have utilized patient-related, tumor-related, and treatment-related factors, in addition to widely available biomarkers, like Hemoglobin (Hb) level, white blood cell (WBC) and platelets counts to stratify patients into two or three VTE risk levels. In this manuscript, we review the published clinical trials and meta-analyses that attempted to study the efficacy and safety of anticoagulants, mostly the DOACs, in cancer patients with CVCs. We will also propose a practical risk-directed approach to enhance VTE prophylaxis rate.

Survival Outcomes after Placement of Inferior Vena Cava Filters in Cancer Patients: Insights from a Comprehensive Cancer Center's Experience.

BACKGROUND: Inferior vena cava (IVC) filters serve as a vital intervention when systemic anticoagulation proves ineffective or contraindicated, particularly in the context of cancer patients. This study aimed to provide real-world insights into the outcomes of cancer patients following IVC filter placement. PATIENTS AND METHODS: Cancer patients with IVC filters were retrospectively reviewed. The indications and survival outcomes following IVC filter insertion have been reported. RESULTS: A total of 176 cancer patients with IVC filters were included in the study. The median patient age was 56 years (range: 18-88 years). Solid tumors were the most common primary cancers (n = 125, 71.0%), and the majority (n = 99, 79.2%) had the advanced-stage disease at the time of IVC insertion. The filters were inserted because of contraindications to anticoagulation (n = 99, 56.3%) or the failure of anticoagulation (n = 56, 31.8%). The median survival (range) following filter placement was only 2 (1.45-2.55) months for patients with advanced-stage solid tumors, 5 (0.62-9.38) months for patients with brain tumors, and 44 (8.59-79.41) months for those with early-stage solid tumors, p < 0.001. CONCLUSIONS: Our findings suggest that IVC filter placement offers limited benefits to patients with advanced-stage disease. The underlying tumor, stage, and life expectancy are crucial factors in the decision-making process before IVC filter insertion.

Panacinar emphysema complicating idiopathic pulmonary hemosiderosis: a case report.

Idiopathic pulmonary hemosiderosis (IPH) is a rare entity with no known underlying etiology. It can be complicated by lung fibrosis. Emphysema is rarely reported as a consequence of IPH. We present a case of a 30-year-old female who presented with recurrent hemoptysis and shortness of breath. Radiographs revealed advanced emphysematous changes of the lower lobes. The diagnosis of IPH was established with an open lung biopsy. She was treated with systemic steroids, underwent bullectomy and was subsequently maintained on inhaled steroids.

COMPASS-CAT versus Khorana risk assessment model for predicting venous thromboembolic events in patients with non-small cell lung cancer on active treatment with chemotherapy and/or immunotherapy, the CK-RAM study.

Cancer patients are at higher risk for venous thromboembolism (VTE). Several risk assessment models (RAM), including the Khorana and COMPASS-CAT, were developed to help predict the occurrence of VTE in cancer patients on active anti-cancer therapy. We aim to study the prevalence and predictors of VTE among patients with non-small cell lung cancer (NSCLC) and compare both RAMs in predicting VTE in patients with NSCLC were retrospectively reviewed. Variables known to increase the risk of VTE were collected and risk of VTE was assessed using both Khorana and COMPASS-CAT RAM. A total of 508 patients (mean age ± SD, 58.4 ± 12.2 years) were enrolled. Most (n = 357, 70.3%) patients had adenocarcinoma, and 333 (65.6%) patients had metastatic disease. VTE were confirmed in 76 (15.0%) patients. Rates were higher among patients with metastatic disease (19.8%, p < 0.001), adenocarcinoma (17.4%, p = 0.01) and those treated with immunotherapy (23.5%, p = 0.014). VTE rates were 21.2%, 14.1% and 13.9% among those with high (n = 66), intermediate (n = 341) and low (n = 101) Khorana risk scores, respectively (p = 0.126). On the other hand, 190 (37.4%) were classified as high risk by the COMPASS-CAT RAM; 52 (27.4%) of them had VTE compared to 24 (7.5%) of the remaining 318 (62.6%) classified as Low/Intermediate risk level, p < 0.001. In conclusion, patients with NSCLC are at high risk for VTE, especially those with adenocarcinoma, metastatic disease and when treated with immunotherapy. Compared to Khorana RAM, COMPASS-CAT RAM was better in identifying more patients in high-risk group, with higher VTE rate.

Pulmonary arterial hypertension trials put to the test: Using the fragility index to assess trials robustness.

BACKGROUND: Randomized clinical trials (RCTs) are considered the gold standard for evidence-based medicine. The Fragility Index (FI) is a tool to assess the robustness of RCT results. FI was validated for dichotomous outcomes and recent work expanded its use to continuous outcomes. Studying the robustness of RCTs in Pulmonary Arterial Hypertension (PAH) treatments is crucial due to the severity and mortality risks associated with this rare condition. OBJECTIVES: Analyze FI and Fragility quotient (FQ) of significant primary outcomes in PAH RCTs and study FI correlation with sample size and journal impact factor. METHODS: FI and FQ calculation followed by Spearman correlation to assess the correlation between FI and sample size, and FI and impact factor. RESULTS: The median sample size of the 21 trials was 202 patients (IQR 106-267), with 6 trials reporting primary outcomes as dichotomous and 15 reporting continuous primary outcomes. The median FI was 10 (IQR 3-20), and the median FQ was 0.044 (0.026-0.097). A moderate correlation was found between FI and sample size, with r = 0.56; P = 0.008 and FI and journal impact factor (r=0.50; P=0.019). The FI for continuous outcomes was similar to that for dichotomous outcomes. CONCLUSIONS: This study represents the first analysis of the FI and FQ of PAH treatment RCTs, and expands the use of FI to continuous outcomes in this context. The moderate correlation between FI and sample size suggests that increasing sample size alone is partially correlated to a higher FI. The similarity between FI for continuous and dichotomous outcomes supports the broader use of FI in PAH RCTs.

Outcomes after cardiac arrest in Medical Intensive Care Unit: A propensity score matching analysis of COVID-19 MICU vs non COVID-19 MICU cardiac arrest.

AIM: To assess whether there were differences in resuscitation efforts and outcomes for medical intensive care unit (MICU) in-hospital cardiac arrest (IHCA) during the COVID-19 pandemic when compared to pre-pandemic. METHODS: Comparing COVID-19 MICU-IHCA patients (03/2020 to 10/2020) to non-COVID-19 MICU IHCA (01/2014 to 12/2018) at Clevleand Clinic Health System (CCHS) of NE Ohio. Propensity score matching analysis (PSMA) was used to create comparable groups. RESULTS: There were a total of 516 patients, 51 in COVID-19 MICU IHCA cohort and 465 in the non-COVID-19 MICU IHCA cohort. The mean (SD) age of the study population was 60.9 (16) years and 56% were males. In 92.1% (n = 475) patients, initial arrest rhythm was non-shockable. At the time of ICU admission, compared to the non-COVID-19 MICU-IHCA cohort, the COVID-19 MICU IHCA cohort had a lower mean APACHE III score (70 [32.9] vs 101.3 [39.6], P = <0.01). The COVID-19 cohort had a higher rate of survival to hospital discharge (12 [23.5%] vs 59 [12.7%], P = 0.03). Upon PSMA, the algorithm selected 40 COVID-19 patients and 200 non-COVID-19 patients. Imbalances in baseline characteristics, comorbidities, and APACHE III were well-balanced after matching. Survival rate after matching became non-significant; (10 [25%] vs 42 [21%], P = 0.67). Further, there were no significant differences in ICU or hospital length-of-stay or neurological outcomes at discharge for survivors in the two matched cohorts. CONCLUSION: It is imperative that COVID-19 patients receive unbiased and unrestricted resuscitation measures, without any discouragement.

Incorporating Early Palliative Medicine Consultation Into Daily Morning Huddle in the ICU.

OBJECTIVES: Early palliative medicine consult in the ICU can significantly improve outcomes in high-risk patients. We describe a pilot study of including a recommendation for palliative medicine consult in the ICU morning huddle. DESIGN: A prospective, observational, quality improvement study. PATIENTS AND SETTING: Adult patients (age above 18 yr) admitted with cardiac arrest, stage IV cancer, admission from a long-term acute care facility, and circulatory shock on mechanical ventilation to the medical ICU. INTERVENTIONS: We aim to assess the effect of an early palliative medicine consultation in selected high-risk patients on change in code status, referral to hospice, tracheostomy, and or percutaneous gastrostomy tube placement. MEASUREMENTS AND MAIN RESULTS: There were 83 patients who triggered an early palliative medicine consult. Palliative medicine consultation occurred in 44 patients (53%); 23 patients (28%) had a palliative medicine consult within the first 48 hours, 21 (25%) had a palliative medicine consult afterwards. There was a significantly higher number of patients who de-escalated their code status in the palliative medicine consult group compared with the no palliative medicine consult group (63.6% vs 7.7%); however, the number was higher in the late palliative medicine consult group (71.4% vs 56.5%). There were more patients referred to hospice in the palliative medicine consult group. No difference in length of stay was observed. CONCLUSIONS: Early palliative medicine consultation in the daily ICU morning huddle is achievable, can produce a palliative medicine consultation in most cases, and results in a significant change in code status toward less aggressive measures.

Does inpatient hyperglycemia predict a worse outcome in COVID-19 intensive care unit patients?

BACKGROUND: We undertook this study to evaluate the association between hyperglycemia and outcomes in patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU). METHODS: We conducted a multicenter retrospective study involving all adults with COVID-19 admitted to the ICU between March and May 2020. Patients were divided into normoglycemic (average blood glucose <140 mg/dL) and hyperglycemic (average blood glucose ≥140 mg/dL) groups. Outcomes such as mortality, need and duration of mechanical ventilation, and length of hospital and ICU stays were measured. RESULTS: Among 495 patients, 58.4% were male with a median age of 68 years (interquartile range [IQR]: 58.00-77.00), and baseline average blood glucose was 186.6 (SD ± 130.8). Preexisting diabetes was present in 35.8% of the studied cohort. Combined ICU and hospital mortality rates were 23.8%; mortality and mechanical ventilation rates were significantly higher in the hyperglycemic group with 31.4% vs 16.6% (P = .001) and 50.0% vs 37.2% (P = .004), respectively. Age above 60 years (hazard ratio [HR] 3.21; 95% CI 1.78, 5.78) and hyperglycemia (HR 1.79; 95% CI 1.14, 2.82) were the only significant predictors of in-hospital mortality. Increased risk for hyperglycemia was found in patients with steroid use (odds ratio [OR] 1.521; 95% CI 1.054, 2.194), triglycerides ≥150 mg/dL (OR 1.62; 95% CI 1.109, 2.379), and African American race (OR 0.79; 95% CI 0.65, 0.95). CONCLUSIONS: Hyperglycemia in patients with COVID-19 is significantly associated with a prolonged ICU length of stay, higher need of mechanical ventilation, and increased risk of mortality in the critical care setting. Tighter blood glucose control (≤140 mg/dL) might improve outcomes in COVID-19 critically ill patients; evidence from ongoing clinical trials is needed.

COPD Overdiagnosis and Its Effect on 30-Day Hospital Readmission Rates.

BACKGROUND: Although specific guidelines exist for diagnosing COPD on the basis of spirometry testing data (FEV1/FVC < 0.70 or above the lower limit of normal), the literature suggests that overdiagnosis is common. Whether overdiagnosis increases 30-d readmission rates has not yet been explored. The objective of this study was to determine the prevalence of COPD overdiagnosis and its effect on 30-d hospital readmission rates in our institution. METHODS: We retrospectively identified all subjects who were coded with a COPD hospital discharge in 2018 at Cleveland Clinic main campus and had spirometry data available, including FEV1 and FVC. FEV1/FVC was calculated and compared with the predicted lower limit of normal values. Hospital discharge diagnosis and 30-d hospital readmission data were captured along with comorbidities and other demographics. RESULTS: In 2018, there were 424 hospital discharges with a COPD diagnosis with spirometry testing available. Of these subjects, 124 (29%) were overdiagnosed in the lower limit of normal group and 99 (23.3%) were in the ≥ 0.70 group. One hundred subjects (23.6%) had a 30-d hospital readmission. Of these subjects, 35 had FEV1/FVC that was greater than their predicted lower limit of normal on spirometry. Of the 324 subjects who were not readmitted within 30 d, 89 (27.5%) had FEV1/FVC greater than the lower limit of normal. If the 35 readmitted subjects had not been coded with COPD, the 30-d readmission rate would have decreased significantly from 23.6% to 16.7% (100 of 424 vs 65 of 389, P = .01). Even if all of the 124 subjects who had pulmonary function test data greater than the lower limit of normal had not been counted, the readmission rate would still have decreased from 23.6% to 21.7%, but this was not significant (from 100 of 424 to 65 of 300, P = .3). CONCLUSIONS: COPD was overdiagnosed in our cohort of subjects; this was true whether the FEV1/FVC < 0.70 standard or the lower limit of normal standard was used. Furthermore, this overdiagnosis artificially inflated the 30-d readmission rate. These results illustrate the caution providers should use when making a COPD diagnosis.

Transaminases are Potential Biomarkers of Disease Severity in COVID-19 Patients: A Single-Center Experience.

BACKGROUND: Considering the rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), the clinical implications of gastrointestinal (GI) and hepatic manifestations of coronavirus disease 2019 (COVID-19) in the U.S. population require analysis. METHODS: We retrospectively reviewed all adult patients with COVID-19 admitted to our facility. Patients were divided into two groups based on the presence of GI symptoms and transaminitis at presentation. Univariable analysis was performed to assess the differences between study groups. Kruskal-Wallis and Pearson's chi-square tests were used to compare the median of continuous and categorical variables, respectively. Multivariate logistic regression analysis was performed to identify predictors of mechanical ventilation, cytokine release syndrome (CRS), and mortality after adjusting for baseline variables. RESULTS: A total of 84 patients were analyzed. After adjusting for baseline comorbidities, presence of GI symptoms (aOR, adjusted odds ratio 4.2, 95% CI, 1.17-15.60, p=0.03) and transaminitis on admission (aOR 5.69, 95% CI, 1.47-21.99, p=0.01) were associated with CRS. Transaminitis on admission and elevated total bilirubin during hospitalization were associated with an increased need for mechanical ventilation (aOR 6.17, 95% CI, 1.49-25.44, p=0.02 and aOR 7.29, 95% CI, 1.73-30.75, p=0.007, respectively). An elevated aspartate aminotransferase (AST) on admission (aOR 13.41, 95% CI, 1.08-165.69, p=0.04) and elevated total bilirubin during hospitalization (aOR 82.68, 95% CI, 1.67-4074.8, p=0.02) were independently associated with an increased risk of mortality in COVID-19 patients. CONCLUSION: COVID-19 patients with transaminitis on admission had a higher risk of requiring mechanical ventilation and developing CRS. Patients with elevated AST on admission and elevated total bilirubin had higher mortality. Patients with GI symptoms did not have worse outcomes.

Causes of diabetic ketoacidosis among adults with type 1 diabetes mellitus: insulin pump users and non-users.

INTRODUCTION: Insulin pumps are increasingly being used as a method of insulin delivery in patients with type 1 diabetes mellitus (T1DM). Diabetic ketoacidosis (DKA) is a serious complication of T1DM. This study aims to identify the causes of DKA in patients with T1DM on continuous subcutaneous insulin infusion (CSII) and to compare these with patients with T1DM on multiple daily insulin injections (MDIIs). RESEARCH DESIGN AND METHODS: This is a prospective observational study between January and June 2019 at the Cleveland Clinic Fairview Hospital. Demographic, clinical, and biochemical data were obtained from chart review. A questionnaire to explore additional clinical data relating to DKA was administered, with additional items for patients on the insulin pump. RESULTS: Seventy-four patients were admitted with a diagnosis of DKA between the period of January and June 2019. Of these, 45 met the inclusion criteria and 43 consented. These were divided into two groups: group 1 included patients on MDII and group 2 included CSII. Overall, the most common precipitating factor for developing DKA was insulin non-adherence, seen in 51.2% of the cases. The most common cause of DKA in group 2 was pump/tubing related to 55% of the cases. CONCLUSION: Despite non-adherence being common in both CSII and MDII, a combination of social factors, education and insulin pump malfunction, such as pump/tubing problems, might be playing a pivotal role in DKA etiology in young adults with T1DM, especially in CSII users. Continued education on pump use may reduce the rate of DKA in pump users.

Lower lobe lung volume reduction surgery: a case report.

Lung volume reduction surgery (LVRS) is an option for select patients with advanced chronic obstructive pulmonary disease (COPD). Current guidelines recommend LVRS for patients with appropriate physiology and heterogeneous distribution of emphysema predominately involving upper lobes. We present an unusual case of a 72-year-old male with an advanced COPD who suffered with recurrent exacerbations despite optimal medical management. He underwent a two-stage bilateral lower lobe LVRS for heterogeneous lower lobe emphysema via video-assisted thoracoscopic (VATS) approach. This resulted in a significant subjective as well as objective improvement in his pulmonary functions, 6-min walk distance and subsequent discontinuation of supplemental oxygen.

Tocilizumab for treatment of patients with severe COVID-19: A retrospective cohort study.

BACKGROUND: Tocilizumab was approved for chimeric antigen receptor T-cell therapy induced cytokine release syndrome and it may provide clinical benefit for selected COVID-19 patients. METHODS: In this retrospective cohort study, we analyzed hypoxic COVID-19 patients who were consecutively admitted between March 13, 2020 and April 19, 2020. Patients with lung infiltrates and elevated inflammatory markers received a single dose of tocilizumab if no contraindication was present. Systemic steroid, hydroxychloroquine, and azithromycin were concomitantly used for majority of the patients. FINDINGS: Of the 51 patients included for analysis, 28 (55%) received tocilizumab and 23 (45%) did not receive tocilizumab. Tocilizumab cohort required more invasive ventilation (68% vs. 22%) at baseline and during entire hospitalization (75% vs. 48%). The median time to clinical improvement in tocilizumab vs. no tocilizumab cohorts was 8 days (Interquartile range [IQR]: 6·25 - 9·75 days) vs. 13 days (IQR: 9·75 - 15·25 days) among patients who required mechanical ventilation at any time (Hazard ratio for clinical improvement: 1·83, 95% confidence interval [CI]: 0·57 - 5·84) and 6·5 days vs. 7 days among all patients (Hazard ratio for clinical improvement: 1·14, 95% CI: 0·55 - 2·38), respectively. The median duration of vasopressor support and invasive mechanical ventilation were 2 days (IQR: 1·75 - 4·25 days) vs. 5 days (IQR: 4 - 8 days), p = 0.039, and 7 days (IQR: 4 - 14 days) vs. 10 days (IQR: 5 - 15 days) in tocilizumab vs. no tocilizumab cohorts, p = 0.11, respectively. Similar rates of hospital-acquired infections occurred in both cohorts (18% in tocilizumab and 22% in no tocilizumab cohort). INTERPRETATION: In patients with severe COVID-19, tocilizumab was associated with significantly shorter duration of vasopressor support. Although not statistically significant, tocilizumab also resulted in shorter median time to clinical improvement and shorter duration of invasive ventilation. These findings require validation from ongoing clinical trials of Tocilizumab in COVID-19 patients.

Use of Antibiotics in Chronic Obstructive Pulmonary Disease: What is Their Current Role in Older Patients?

Chronic obstructive pulmonary disease (COPD) has considerable morbidity and mortality in the older adult population. The role of antibiotics in the management of acute exacerbations of COPD (AECOPD) is currently evolving. Despite only mild benefits, most patients with AECOPD in ambulatory settings receive antibiotics based on clinical criteria. Utilization of point-of-care C-reactive protein (CRP) has reduced antibiotic prescriptions by 20% without compromising clinical outcomes. A strict protocol allowing antibiotic use only in patients with clinical criteria and CRP ≥ 20 mg/L has the potential to reduce antibiotic prescriptions for AECOPD in ambulatory settings by nearly 50%. Amoxicillin and doxycycline are commonly prescribed for AECOPD based on a favorable benefit-to-risk ratio. Prophylactic antibiotics have also been used in selected patients with severe COPD and frequent exacerbations. The use of continuous or intermittent azithromycin has demonstrated efficacy in reducing the frequency of AECOPD in this population; however, this approach has potential for the development of antibiotic resistance and adverse effects. The use of azithromycin prophylaxis in older patients with frequent AECOPD should be determined on a case-by-case basis after careful review, discussion, and counseling of the potential benefits and risks. The role of continuous doxycycline and pulsed moxifloxacin prophylaxis for frequent AECOPD remains controversial.

A Rare Case of ST-elevation Myocardial Infarction After Blunt Chest Trauma.

Myocardial infarction (MI) after blunt chest trauma (BCT) is a rare but potentially life-threatening situation that should be addressed immediately in a patient who presents to the ED. Early management is directly related to favorable outcomes. Here we describe a case of ST-elevation MI after BCT.

Hyperglycemia management in hospitalized patients with COVID-19.

It has been well established that patients with diabetes who have COVID-19 have a more severe disease course and higher mortality. Providing adequate care for these patients has required hospitals to adapt protocols for monitoring blood glucose and administering therapy to protect both patient and caregiver safety. Inpatient use of continuous glucose monitoring systems or home-use glucose monitoring systems has provided options for reduced contact glucose monitoring. For therapy, protocols for managing hyperglycemia and diabetes ketoacidosis have been designed with less frequent monitoring and medication administration. Finally, telemedicine has allowed for consultative care in a manner not requiring physical proximity.

Risk factors for pneumonia due to beta-lactam-susceptible and beta-lactam-resistant Pseudomonas aeruginosa: a case-case-control study.

PURPOSE: This case-case-control study aims to identify clinical predictors for pneumonia due to Pseudomonas aeruginosa (PA) which is (1) susceptible to all routinely tested antipseudomonal beta-lactams (APBL-S) and (2) resistant to at least one antipseudomonal beta-lactam (APBL-R). METHODS: Hospitalized adults with acute bacterial pneumonia at Palmetto Health hospitals in Columbia, SC, USA from January 1, 2012 to April 15, 2014 were identified. Multivariate logistic regression was used to determine risk factors for pneumonia due to APBL-S PA and APBL-R PA. RESULTS: Among 326 unique patients, 119 had pneumonia due to APBL-S PA (cases), 44 due to APBL-R PA (cases) and 163 due to ceftriaxone-susceptible bacteria (controls). Bronchiectasis [odds ratio (OR) 5.7, 95% confidence intervals (CI) 1.3-39.2], interstitial lung disease (OR 6.2, 95% CI 1.5-42.6), prior airway colonization with APBL-S PA (OR 7.2, 95% CI 1.1-139.4) and recent exposure to both antipseudomonal beta-lactam (APBL; OR 2.2, 95% CI 1.1-4.5) and nonpseudomonal beta-lactams (OR 2.6, 95% CI 1.0-6.8) were independently associated with increased risk of APBL-S PA pneumonia. Bronchiectasis (OR 8.3, 95% CI 1.7-46.6), prior airway colonization with APBL-R PA (OR 14.9, 95% CI 2.0-312.9) and recent use of only APBL (OR 7.7, 95% CI 3.4-17.9) were predictors for APBL-R PA pneumonia. CONCLUSIONS: Stratification of hospitalized patients with pneumonia based on structural lung disease, prior airway colonization and recent antimicrobial exposure may improve empirical antimicrobial selection. Expansion of antimicrobial regimen from ceftriaxone to APBL or combination therapy is suggested in patients with risk factors for APBL-S or APBL-R PA, respectively.