Serum Krebs von den Lungen-6 is associated with in-Hospital mortality of patients with severe Community-Acquired Pneumonia: A retrospective cohort study.

BACKGROUND: Currently, no ideal biomarker can accurately stratify the risk of patients with severe community-acquired pneumonia (SCAP). This study aimed to evaluate the role of serum Krebs von den Lungen-6 (sKL-6) in predicting in-hospital mortality in adults with SCAP. METHODS: In this retrospective cohort study, 249 severe pneumonia adult patients were recruited between 6 May 2021 to 30 April 2023 in Xiangya Hospital of Central South University. The sKL-6 level within 48 h of admission was measured, and the primary outcome assessed was in-hospital mortality. Multivariable logistic regression analysis was performed to calculate adjusted odds ratios (OR) with 95% confidence intervals (CI). Survival curves were plotted and subgroup analyses were conducted, stratified by relevant covariates. RESULTS: A total of 249 patients were included in the study,with 124 patients having normal sKL-6 levels, and 125 patients having abnormal sKL-6 levels. The overall in-hospital mortality rate was 28.9% (72 out of 249 patients). Univariate and multivariate logistic regression analysis revealed that the patients with abnormal sKL-6 levels had a higher risk of in-hospital mortality compared to those with normal sKL-6 levels, both in the total SCAP patient population (OR: 5.38, 95%CI: 2.41-12.01, P < 0.001) and the non-COVID-19 SCAP patients subgroup (OR: 8.12, 95%CI: 3.16-20.84, P < 0.001). Subgroup and interaction analyses confirmed the stability of the relationship between sKL-6 levels and in-hospital mortality(P for interaction > 0.05). Kaplan-Meier survival curves showed that patients with abnormal sKL-6 levels had a higher in-hospital mortality rate than those with normal sKL-6 levels (P < 0.05). However, the results of restricted cubic spline plots(RCS) analysis demonstrated a nonlinear association between sKL-6 levels (as a continuous variable) and in-hospital mortality in patients with SCAP. Similar results were observed in non-COVID-19 SCAP patients. Furthermore, the receiver operating characteristic curve (ROC) analysis revealed that sKL-6 had superior predictive performance compared to existing biomarkers (e.g., APACHE-II, SOFA, BUN/Cr, PCT, and D-dimer) for in-hospital mortality in non-COVID-19 SCAP patients. CONCLUSION: sKL-6 is a practical and useful biomarker for predicting in-hospital mortality in patients with SCAP.

Clinical outcomes and epidemiological characteristics of bacteremia in the older Japanese population.

BACKGROUND: The characteristics and clinical consequences of bacteremia in older people, who are highly susceptible to infections, need to be clarified. This study aimed to determine the epidemiological characteristics, prognosis, and predictors of 7-day mortality in patients with community-acquired (CA), healthcare-associated (HCA), and hospital-onset (HO) bacteremia in older adults aged ≥65 years. METHODS: Patients aged ≥65 years with positive blood cultures between April 1, 2015, and March 31, 2018, were divided into three groups: pre-old (65-74 years), old (75-89 years), and super-old (≥90 years). Characteristics based on medical exposure, including CA, HCA, and HO, were also compared and factors related to mortality were identified. RESULTS: Overall, 1716 episodes of bacteremia were identified in 1415 patients. Of the 1211 episodes without contamination, 32.8%, 54.3%, and 12.9% occurred in pre-old, old, and super-old patients. Central line-associated bloodstream infections were more common in pre-old patients and urinary tract infections in the old and super-old. The 7-day mortality rates in the pre-old, old, and super-old groups were 7.4%, 5.8%, and 14.2% (P = 0.002), respectively. Multivariable logistic regression showed that super-old age (adjusted odds ratio, aOR: 2.09 [1.13-3.88], P = 0.019) and HO bacteremia (aOR: 1.97 [1.18-3.28], P = 0.010) were independent risk factors for 7-day mortality. Infectious disease consultation had a protective effect on 7-day mortality (aOR: 0.59 [0.35-0.99], P = 0.047). CONCLUSIONS: The epidemiology of bacteremia differs among older people; thus, they should not be treated as a single entity. A careful approach is needed for the optimal management of bacteremia in these vulnerable patients.

Impact of macrolide treatment on long-term mortality in patients admitted to the ICU due to CAP: a targeted maximum likelihood estimation and survival analysis.

INTRODUCTION: Patients with community-acquired pneumonia (CAP) admitted to the intensive care unit (ICU) have high mortality rates during the acute infection and up to ten years thereafter. Recommendations from international CAP guidelines include macrolide-based treatment. However, there is no data on the long-term outcomes of this recommendation. Therefore, we aimed to determine the impact of macrolide-based therapy on long-term mortality in this population. METHODS: Registered patients in the MIMIC-IV database 16 years or older and admitted to the ICU due to CAP were included. Multivariate analysis, targeted maximum likelihood estimation (TMLE) to simulate a randomised controlled trial, and survival analyses were conducted to test the effect of macrolide-based treatment on mortality six-month (6 m) and twelve-month (12 m) after hospital admission. A sensitivity analysis was performed excluding patients with Pseudomonas aeruginosa or MRSA pneumonia to control for Healthcare-Associated Pneumonia (HCAP). RESULTS: 3775 patients were included, and 1154 were treated with a macrolide-based treatment. The non-macrolide-based group had worse long-term clinical outcomes, represented by 6 m [31.5 (363/1154) vs 39.5 (1035/2621), p < 0.001] and 12 m mortality [39.0 (450/1154) vs 45.7 (1198/2621), p < 0.001]. The main risk factors associated with long-term mortality were Charlson comorbidity index, SAPS II, septic shock, and respiratory failure. Macrolide-based treatment reduced the risk of dying at 6 m [HR (95% CI) 0.69 (0.60, 0.78), p < 0.001] and 12 m [0.72 (0.64, 0.81), p < 0.001]. After TMLE, the protective effect continued with an additive effect estimate of - 0.069. CONCLUSION: Macrolide-based treatment reduced the hazard risk of long-term mortality by almost one-third. This effect remains after simulating an RCT with TMLE and the sensitivity analysis for the HCAP classification.

Hydrocortisone in Severe Community-Acquired Pneumonia.

BACKGROUND: Whether the antiinflammatory and immunomodulatory effects of glucocorticoids may decrease mortality among patients with severe community-acquired pneumonia is unclear. METHODS: In this phase 3, multicenter, double-blind, randomized, controlled trial, we assigned adults who had been admitted to the intensive care unit (ICU) for severe community-acquired pneumonia to receive intravenous hydrocortisone (200 mg daily for either 4 or 7 days as determined by clinical improvement, followed by tapering for a total of 8 or 14 days) or to receive placebo. All the patients received standard therapy, including antibiotics and supportive care. The primary outcome was death at 28 days. RESULTS: A total of 800 patients had undergone randomization when the trial was stopped after the second planned interim analysis. Data from 795 patients were analyzed. By day 28, death had occurred in 25 of 400 patients (6.2%; 95% confidence interval [CI], 3.9 to 8.6) in the hydrocortisone group and in 47 of 395 patients (11.9%; 95% CI, 8.7 to 15.1) in the placebo group (absolute difference, -5.6 percentage points; 95% CI, -9.6 to -1.7; P = 0.006). Among the patients who were not undergoing mechanical ventilation at baseline, endotracheal intubation was performed in 40 of 222 (18.0%) in the hydrocortisone group and in 65 of 220 (29.5%) in the placebo group (hazard ratio, 0.59; 95% CI, 0.40 to 0.86). Among the patients who were not receiving vasopressors at baseline, such therapy was initiated by day 28 in 55 of 359 (15.3%) of the hydrocortisone group and in 86 of 344 (25.0%) in the placebo group (hazard ratio, 0.59; 95% CI, 0.43 to 0.82). The frequencies of hospital-acquired infections and gastrointestinal bleeding were similar in the two groups; patients in the hydrocortisone group received higher daily doses of insulin during the first week of treatment. CONCLUSIONS: Among patients with severe community-acquired pneumonia being treated in the ICU, those who received hydrocortisone had a lower risk of death by day 28 than those who received placebo. (Funded by the French Ministry of Health; CAPE COD ClinicalTrials.gov number, NCT02517489.).

A Broad Learning System to Predict the 28-Day Mortality of Patients Hospitalized with Community-Acquired Pneumonia: A Case-Control Study.

This study was to conduct a model based on the broad learning system (BLS) for predicting the 28-day mortality of patients hospitalized with community-acquired pneumonia (CAP). A total of 1,210 eligible CAP cases from Chifeng Municipal Hospital were finally included in this retrospective case-control study. Random forest (RF) and an eXtreme Gradient Boosting (XGB) models were used to develop the prediction models. The data features extracted from BLS are utilized in RF and XGB models to predict the 28-day mortality of CAP patients, which established two integrated models BLS-RF and BLS-XGB. Our results showed the integrated model BLS-XGB as an efficient broad learning system (BLS) for predicting the death risk of patients, which not only performed better than the two basic models but also performed better than the integrated model BLS-RF and two well-known deep learning systems-deep neural network (DNN) and convolutional neural network (CNN). In conclusion, BLS-XGB may be recommended as an efficient model for predicting the 28-day mortality of CAP patients after hospital admission.

Behavior of clinical and humoral variables on admission as predictors of death in patients with community-acquired pneumonia. Comparative study between adults and older adults. / Comportamiento de variables clínicas y humorales al ingreso, como predictores de fallecimiento en pacientes con neumonía adquirida en la comunidad. Estudio comparativo entre adultos y adultos mayores

Community-acquired pneumonia is recognized as one of the main infectious health problems worldwide. The objective was to determine the condition of predictors of death for a group of selected clinical conditions, and for laboratory variables frequently used in practice. Study with descriptive design, which included 967 patients with pneumonia hospitalized between 2016 and 2019, and whose information was obtained from clinical records. Statistical treatment included bivariate and multivariate analysis (logistic regression); it was used the ratio of crossed products (odds ratio) and its 95% confidence interval. Several manifestations were significantly more frequent in older adults: dyspnea (OR 1.5[1.07,2.1]), absence of productive cough (OR 1.7 [1.3, 2.4]), neuropsychological manifestations (OR 2 [1.4,2.8]), tachypnea (OR 1.5 [1.1,2.1]), arterial hypotension (OR 2.1 [1.2,3.6]), anemia (OR 1.6[1.2,2.2]), elevated creatinine (OR 1.6[1.2,2.3]) and hypoproteinemia (OR 3.3[1.9,5.7]); showed a significant association with death: absence of productive cough, neuropsychological manifestations, temperature below 36 degrees Celsius, blood pressure below 110/70 mmHg, respiratory rate above 20 per minute, hemoglobin below 100 g/L, erythrosedimentation greater than 20 mm/L, leukopenia less than 5 x 109/L and serum creatinine above 130 micromol/L. As conclusions certain clinical and laboratory conditions present in the patient at the time of hospital admission, of routine exploration in the comprehensive assessment of the patient, were predictors of death. Additionally, the existence of evident differences in the number of conditions with a predictive nature of death between the population with pneumonia under 60 years of age and the elderly, as well as in the frequency of these conditions in both subgroups, is verified.

La neumonía adquirida en la comunidad está reconocida como uno de los principales problemas de salud de tipo infeccioso al nivel mundial. La investigación tuvo como objetivo determinar el carácter de predictores de fallecimiento de un grupo de condiciones clínicas seleccionadas, y de variables de laboratorio de uso frecuente en la práctica. Se realizó un estudio con diseño descriptivo, que incluyó a 967 pacientes con neumonía hospitalizados entre 2016 y 2019, y cuya información se obtuvo de los expedientes clínicos. El tratamiento estadístico incluyó análisis bivariante y multivariado (regresión logística); como estadígrafo se utilizó la razón de productos cruzados (odds ratio) y su intervalo de confianza de 95%. Entre los resultados se destacan los siguientes: varias manifestaciones fueron significativamente más frecuentes en los adultos mayores: disnea (OR 1,5[1,07;2,1]), ausencia de tos productiva (OR 1,7[1,3;2,4]), manifestaciones neuropsicológicas (OR 2[1,4;2,8]), taquipnea (OR 1,5[1,1;2,1]), hipotensión arterial (OR 2,1[1,2;3,6]), anemia (OR 1,6[1,2;2,2]), creatinina elevada (OR 1,6[1,2;2,3]) e hipoproteinemia (OR 3,3[1,9;5,7]); mostraron asociación significativa con el fallecimiento: ausencia de tos productiva, manifestaciones neuropsicológicas, temperatura por debajo de 36 grados Celsius, tensión arterial inferior a 110/70 mmHg, frecuencia respiratoria por encima de 20 por minuto, hemoglobina inferior a 100 g/L, velocidad de sedimentación eritrocitaria superior a 20 mm/L, leucopenia inferior a 5 x 109/L y creatinina sérica por encima de 130 micromol/L. Se concluye que ciertas condiciones clínicas y de laboratorio presentes en el paciente al momento del ingreso hospitalario, de exploración habitual en la valoración integral del enfermo, constituyeron predictores de fallecimiento. Adicionalmente, se comprueba la existencia de evidentes diferencias en el número de condiciones con carácter predictor de muerte entre la población con neumonía menor de 60 años y los adultos mayores, así como en la frecuencia de estas condiciones en ambos subgrupos.

Prognostic Value of Histidine-Rich Glycoprotein for Community-Acquired Pneumonia.

PURPOSE: Histidine-rich glycoprotein (HRG) is abundant in serum and has been implicated in several processes including blood coagulation and immune response. This prospective study is aimed at exploring HRG as a biomarker in patients hospitalized for community-acquired pneumonia (CAP). METHODS: A total of 160 patients (73 severe CAP, 57 nonsevere CAP), and 30 healthy controls were enrolled in 2019. Demographic and clinical data were recorded for all patients. Serum HRG concentration was measured upon admission using ELISA. RESULTS: HRG levels were significantly lower in severe CAP patients compared with other groups, regardless of etiology, and were negatively correlated with serum interleukin-6 and disease severity index scores. Combination of CURB-65, PSI, and APACHE II scores with HRG values significantly improved the accuracy of predicting 30-day mortality in these patients. Cox regression analysis showed that HRG could serve as an independent risk factor for 30-day mortality. Notably, patients with HRG ≤ 16.92 µg/mL had significantly lower cumulative survival than those with HRG > 16.92 µg/mL. CONCLUSION: Serum HRG levels are lower in patients with severe CAP and are negatively correlated with disease severity scores. Measurement of HRG upon admission can provide valuable prognostic information for patients with CAP.

Value of D-dimer in predicting various clinical outcomes following community-acquired pneumonia: A network meta-analysis.

BACKGROUND: Whether high D-dimer level before treatment has any impact on poor outcomes in patients with community-associated pneumonia (CAP) remains unclear. Therefore, we conducted the first meta-analysis focusing specifically on prognostic value of high D-dimer level before treatment in CAP patients. METHODS: Pubmed, Embase, the Cochrane Central Register of Controlled Trials and World Health Organization clinical trials registry center were searched up to the end of March 2021. Randomized clinical trials (RCT) and observational studies were included to demonstrate the association between the level of D-dimer and clinical outcomes. Data were extracted using an adaptation of the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies (CHARMS-PF). When feasible, meta-analysis using random-effects models was performed. Risk of bias and level of evidence were assessed with the Quality in Prognosis Studies tool and an adaptation of Grading of Recommendations Assessment, Development, and Evaluation. Data were analyzed using STATA 14.0 to complete meta and network analysis. MAIN OUTCOMES AND MEASURES: Besides d-dimer levels in CAP patients with poor outcomes, we also analyzed proportion of patients with or without poor outcomes correctly classified by the d-dimer levels as being at high or low risk. The poor outcome includes severe CAP, death, pulmonary embolism (PE) and invasive mechanical ventilators. RESULTS: 32 studies with a total of 9,593 patients were eventually included. Pooled effect size (ES) suggested that d-dimer level was significantly higher in severe CAP patients than non-severe CAP patients with great heterogeneity (SMD = 1.21 95%CI 0.87-1.56, I2 = 86.8% p = 0.000). D-dimer level was significantly elevated in non-survivors compared to survivors with CAP (SMD = 1.22 95%CI 0.67-1.77, I2 = 85.1% p = 0.000). Prognostic value of d-dimer for pulmonary embolism (PE) was proved by hierarchical summary receiver operating characteristic curve (HSROC) with good summary sensitivity (0.74, 95%CI, 0.50-0.89) and summary specificity (0.82, 95%CI, 0.41-0.97). Network meta-analysis suggested that there was a significant elevation of d-dimer levels in CAP patients with poor outcome than general CAP patients but d-dimer levels weren't significantly different among poor outcomes. CONCLUSION: The prognostic ability of d-dimer among patients with CAP appeared to be good at correctly identifying high-risk populations of poor outcomes, suggesting potential for clinical utility in patients with CAP.

Longer than 2 hours to antibiotics is associated with doubling of mortality in a multinational community-acquired bacterial meningitis cohort.

To optimally define the association between time to effective antibiotic therapy and clinical outcomes in adult community-acquired bacterial meningitis. A systematic review of the literature describing the association between time to antibiotics and death or neurological impairment due to adult community-acquired bacterial meningitis was performed. A retrospective cohort, multivariable and propensity-score based analyses were performed using individual patient clinical data from Australian, Danish and United Kingdom studies. Heterogeneity of published observational study designs precluded meta-analysis of aggregate data (I2 = 90.1%, 95% CI 71.9-98.3%). Individual patient data on 659 subjects were made available for analysis. Multivariable analysis was performed on 180-362 propensity-score matched data. The risk of death (adjusted odds ratio, aOR) associated with treatment after two hours was 2.29 (95% CI 1.28-4.09) and increased substantially thereafter. Similarly, time to antibiotics of greater than three hours was associated with an increase in the occurrence of neurological impairment (aOR 1.79, 95% CI 1.03-3.14). Among patients with community-acquired bacterial meningitis, odds of mortality increase markedly when antibiotics are given later than two hours after presentation to the hospital.

Comparison of Thrombotic Events and Mortality in Patients with Community-Acquired Pneumonia and COVID-19: A Multicenter Observational Study.

BACKGROUND: It is still unclear if patients with community-acquired pneumonia (CAP) and coronavirus disease 2019 (COVID-19) have different rate, typology, and impact of thrombosis on survival. METHODS: In this multicenter observational cohort study, 1,138 patients, hospitalized for CAP (n = 559) or COVID-19 (n = 579) from seven clinical centers in Italy, were included in the study. Consecutive adult patients (age ≥ 18 years) with confirmed COVID-19-related pneumonia, with or without mechanical ventilation, hospitalized from March 1, 2020 to April 30, 2020, were enrolled. COVID-19 was diagnosed based on the World Health Organization interim guidance. Patients were followed-up until discharge or in-hospital death, registering the occurrence of thrombotic events including ischemic/embolic events. RESULTS: During the in-hospital stay, 11.4% of CAP and 15.5% of COVID-19 patients experienced thrombotic events (p = 0.046). In CAP patients all the events were arterial thromboses, while in COVID-19 patients 8.3% were venous and 7.2% arterial thromboses.During the in-hospital follow-up, 3% of CAP patients and 17% of COVID-19 patients died (p < 0.001). The highest mortality rate was found among COVID-19 patients with thrombotic events (47.6 vs. 13.4% in thrombotic-event-free patients; p < 0.001). In CAP, 13.8% of patients experiencing thrombotic events died versus 1.8% of thrombotic event-free ones (p < 0.001). A multivariable Cox-regression analysis confirmed a higher risk of death in COVID-19 patients with thrombotic events (hazard ratio: 2.1; 95% confidence interval: 1.4-3.3; p < 0.001). CONCLUSION: Compared with CAP, COVID-19 is characterized by a higher burden of thrombotic events, different thrombosis typology and higher risk of thrombosis-related in-hospital mortality.

Treatment and outcomes among patients ≥85 years hospitalized with community-acquired pneumonia.

Our objective was to describe community-acquired pneumonia (CAP) among patients ≥85 years and compare them to patients aged 65-74. This was a retrospective cohort study. The study setting included 638 hospitals in the USA participating in the Premier database from 2010 to 2015. The study participants were 488,382 adults aged ≥65 years hospitalized with CAP. Patients ≥85 years were more likely to be white (79.8% vs 76.2%), female (58.1% vs 48.3%), and admitted with aspiration pneumonia (17.1% vs 7.0%) as compared with those aged 65-75 years. They had higher rates of dementia (30.4% vs 7.8%), but lower rates of diabetes (11.2% vs 17.6%) and chronic obstructive pulmonary disease (25.5% vs 54.7%). While Staphylococcus aureus (33.4%) was the most common pathogen across all age groups, patients aged ≥85 were more likely to have Escherichia coli pneumonia (16.1% vs 10.7%) compared with those aged 65-74. In adjusted models, patients aged ≥85 had greater in-hospital mortality (OR 1.14, 95% CI 1.11 to 1.18), but were less likely to be admitted to the intensive care unit (OR 0.54, 95% CI 0.53 to 0.55) and receive mechanical ventilation (OR 0.47, 95% CI 0.46 to 0.48). They also had lower rates of acute kidney injury (OR 0.95, 95% CI 0.91 to 1.00) and Clostridium difficile infection (OR 0.91, 95% CI 0.85 to 0.99), shorter lengths of stay (mean multiplier 0.93, 95% CI 0.92 to 0.93) and lower cost (mean multiplier 0.81, 95% CI 0.80 to 0.81), and were more likely to be discharged to a skilled nursing facility (OR 2.19, 95% CI 2.15 to 2.24) or hospice (OR 2.19, 95% CI 2.11 to 2.27). In conclusion, patients aged ≥85 have different comorbidities and etiologies of CAP, receive less intense treatment, and have greater mortality than patients between 65 and 75 years.

Impact on in-hospital mortality of ceftaroline versus standard of care in community-acquired pneumonia: a propensity-matched analysis.

The purpose of this study is to evaluate the in-hospital mortality of community-acquired pneumonia (CAP) treated with ceftaroline in comparison with standard therapy. This was a retrospective observational study in two centers. Hospitalized patients with CAP were grouped according to the empiric regimen (ceftaroline versus standard therapy) and analyzed using a propensity score matching (PSM) method to reduce confounding factors. Out of the 6981 patients enrolled, 5640 met the inclusion criteria, and 89 of these received ceftaroline. After PSM, 78 patients were considered in the ceftaroline group (cases) and 78 in the standard group (controls). Ceftaroline was mainly prescribed in cases with severe pneumonia (67% vs. 56%, p = 0.215) with high suspicion of Staphylococcus aureus infection (9% vs. 0%, p = 0.026). Cases had a longer length of hospital stay (13 days vs. 10 days, p = 0.007), while an increased risk of in-hospital mortality was observed in the control group compared to the case group (13% vs. 21%, HR 0.41; 95% CI 0.18 to 0.62, p = 0.003). The empiric use of ceftaroline in hospitalized patients with severe CAP was associated with a decreased risk of in-hospital mortality.

qSOFA predicted pneumonia mortality better than minor criteria and worse than CURB-65 with robust elements and higher convergence.

BACKGROUND: Limited data are available on the discriminatory capacity of quick sequential [sepsis-related] organ failure assessment (qSOFA) versus IDSA/ATS minor criteria for predicting mortality in patients with community-acquired pneumonia (CAP). METHODS: An observational prospective cohort study of 2116 patients with CAP was performed. Construct validity was determined using Cronbach α. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC) and net reclassification improvement (NRI). RESULTS: Overall in-hospital mortality was 6.43%. Mortality was 25.96% for patients with a qSOFA score of 2 or higher versus 3.05% for those with a qSOFA score less than 2 (odds ratio for mortality 6.57, P < 0.0001), and 13.85% for patients with at least 3 minor criteria versus 2.03% for those with 2 or fewer minor criteria (odds ratio for mortality 2.27, P < 0.0001). qSOFA had a higher correlation with mortality than minor criteria, as well as higher internal consistency (Cronbach alpha 0.43 versus 0.14) and diagnostic values of individual elements (larger AUROCs and higher Youden's indices). qSOFA ≥2 was less sensitive but more specific for predicting mortality than ≥3 minor criteria (qSOFA sensitivity 59.6%, specificity 88.3% and positive likelihood ratio 5.11 versus ≥3 minor criteria sensitivity 80.1%, specificity 65.8% and positive likelihood ratio 2.34). The predictive validity of qSOFA was good for mortality (AUROC = 0.868), was statistically greater than minor criteria, was equal to pneumonia severity index, and was inferior compared with CURB-65 (AUROC, 0.824, 0.902, 0.919; NRI, 0.088, -0.068, -0.103; respectively). CONCLUSIONS: The qSOFA predicted mortality in CAP better than IDSA/ATS minor criteria and worse than CURB-65 with robust elements and higher convergence. qSOFA as a bedside prompt might be positioned as a proxy for minor criteria and increase the recognition and thus merit more appropriate management of CAP patients likely to fare poorly, which might have implications for more accurate clinical triage decisions.

Anastomotic Leak is Increased With Clostridium difficile Infection After Colectomy: Machine Learning-Augmented Propensity Score Modified Analysis of 46 735 Patients.

BACKGROUND: Clostridium difficile infection (CDI) is now the most common cause of healthcare-associated infections, with increasing prevalence, severity, and mortality of nosocomial and community-acquired CDI which makes up approximately one third of all CDI. There are also increased rates of asymptomatic colonization particularly in high-risk patients. C difficile is a known collagenase-producing bacteria which may contribute to anastomotic leak (AL). METHODS: Machine learning-augmented multivariable regression and propensity score (PS)-modified analysis was performed in this nationally representative case-control study of CDI and anastomotic leak, mortality, and length of stay for colectomy patients using the ACS-NSQIP database. RESULTS: Among 46 735 colectomy patients meeting study criteria, mean age was 61.7 years (SD 14.38), 52.2% were woman, 72.5% were Caucasian, 1.5% developed CDI, 3.1% developed anastomotic leak, and 1.6% died. In machine learning (backward propagation neural network)-augmented multivariable regression, CDI significantly increases anastomotic leak (OR 2.39, 95% CI 1.70-3.36; P < .001), which is similar to the neural network results. Having CDI increased the independent likelihood of anastomotic leak by 3.8% to 6.8% overall, and in dose-dependent fashion with increasing ASA class to 4.3%, 5.7%, 7.6%, and 10.0%, respectively, for ASA class I to IV. In doubly robust augmented inverse probability weighted PS analysis, CDI significantly increases the likelihood of AL by 4.58% (95% CI 2.10-7.06; P < .001). CONCLUSIONS: This is the first known nationally representative study on CDI and AL, mortality, and length of stay among colectomy patients. Using advanced machine learning and PS analysis, we provide evidence that suggests CDI increases AL in a dose-dependent manner with increasing ASA Class.

Mortality and evolution between community and hospital-acquired COVID-AKI.

BACKGROUND: Acute kidney injury (AKI) is associated with poor outcomes in COVID patients. Differences between hospital-acquired (HA-AKI) and community-acquired AKI (CA-AKI) are not well established. METHODS: Prospective, observational cohort study. We included 877 patients hospitalized with COVID diagnosis at two third-level hospitals in Mexico. Primary outcome was all-cause mortality at 28 days compared between COVID patients with CA-AKI and HA-AKI. Secondary outcomes included the need for KRT, and risk factors associated with the development of CA-AKI and HA-AKI. RESULTS: A total of 377 patients (33.7%) developed AKI. CA-AKI occurred in 202 patients (59.9%) and HA-AKI occurred in 135 (40.1%). Patients with CA-AKI had more significant comorbidities, including diabetes (52.4% vs 38.5%), hypertension (58.4% vs 39.2%), CKD (30.1% vs 14.8%), and COPD (5.9% vs 1.4%), than those with HA-AKI. Patients' survival without AKI was 87.1%, with CA-AKI it was 75.4%, and with HA-AKI it was 69.6%, log-rank test p < 0.001. Only age > 60 years (OR 1.12, 95% CI 1.06-1.18, p <0.001), COVID severity (OR 1.09, 95% CI 1.03-1.16, p = 0.002), the need in mechanical lung ventilation (OR 1.67, 95% CI 1.56-1.78, p <0.001), and HA-AKI stage 3 (OR 1.16, 95% CI 1.05-1.29, p = 0.003) had a significant increase in mortality. The presence of CKD (OR 1.48, 95% CI 1.391.56, p < 0.001), serum lymphocytes < 1000 µL (OR 1.03, 95% CI 1.00-1.07, p = 0.03), the need in mechanical lung ventilation (OR 1.06, 95% CI 1.02-1.11, p = 0.003), and CA-AKI stage 3 (OR 1.37, 95% CI 1.29-1.46, p < 0.001) were the only variables associated with a KRT start. CONCLUSIONS: We found that COVID patients who are complicated by CA-AKI have more comorbidities and worse biochemical parameters at the time of hospitalization than HA-AKI patients, but despite these differences, their probability of dying is similar.

In-hospital mortality associated with community-acquired pneumonia due to methicillin-resistant Staphylococcus aureus: a matched-pair cohort study.

BACKGROUND: It remains unclear whether methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is associated with higher mortality compared with non-MRSA pneumonia. This study's objective was to compare outcomes including in-hospital mortality and healthcare costs during hospitalisation between patients with MRSA pneumonia and those with non-MRSA pneumonia. METHODS: Using a national inpatient database in Japan, we conducted a 1:4 matched-pair cohort study of inpatients with community-acquired pneumonia from 1 April 2012 to 31 March 2014. In-hospital outcomes (mortality, length of stay and healthcare costs during hospitalisation) were compared between patients with and without MRSA infection. We performed multiple imputation using chained equations followed by multivariable regression analyses fitted with generalised estimating equations to account for clustering within matched pairs. All-cause in-hospital mortality and healthcare costs during hospitalisation were compared for pneumonia patients with and without MRSA infection. RESULTS: Of 450,317 inpatients with community-acquired pneumonia, 3102 patients with MRSA pneumonia were matched with 12,320 patients with non-MRSA pneumonia. The MRSA pneumonia patients had higher mortality, longer hospital stays and higher costs. Multivariable logistic regression analysis revealed that MRSA pneumonia was significantly associated with higher in-hospital mortality compared with non-MRSA pneumonia (adjusted odds ratio = 1.94; 95% confidence interval: 1.72-2.18; p < 0.001). Healthcare costs during hospitalisation were significantly higher for patients with MRSA pneumonia than for those with non-MRSA pneumonia (difference = USD 8502; 95% confidence interval: USD 7959-9045; p < 0.001). CONCLUSIONS: MRSA infection was associated with higher in-hospital mortality and higher healthcare costs during hospitalisation, suggesting that preventing MRSA pneumonia is essential.

Comparative clinical characteristics and outcomes of patients with community acquired bacteremia caused by Escherichia coli, Burkholderia pseudomallei and Staphylococcus aureus: A prospective observational study (Ubon-sepsis).

BACKGROUND: Community acquired bacteremia (CAB) is a common cause of sepsis in low and middle-income countries (LMICs). However, knowledge about factors associated with outcomes of CAB in LMICs is limited. METHODOLOGY/PRINCIPAL FINDINGS: A prospective observational study (Ubon-sepsis) of adults admitted to a referral hospital with community-acquired infection in Northeastern Thailand was conducted between March 1, 2013 and February 1, 2017. In the present analysis, patients with a blood culture collected within 24 hours of admission that was positive for one of the three most common pathogens were studied. Clinical features, management, and outcomes of patients with each cause of CAB were compared. Of 3,806 patients presenting with community-acquired sepsis, 155, 131 and 37 patients had a blood culture positive for Escherichia coli, Burkholderia pseudomallei and Staphylococcus aureus, respectively. Of these 323 CAB patients, 284 (89%) were transferred from other hospitals. 28-day mortality was highest in patients with B. pseudomallei bactaeremia (66%), followed by those with S. aureus bacteraemia (43%) and E. coli (19%) bacteraemia. In the multivariable Cox proportional hazards model adjusted for age, sex, transfer from another hospital, empirical antibiotics prior to or during the transfer, and presence of organ dysfunction on admission, B. pseudomallei (aHR 3.78; 95%CI 2.31-6.21) and S. aureus (aHR 2.72; 95%CI 1.40-5.28) bacteraemias were associated with higher mortality compared to E. coli bacteraemia. Receiving empirical antibiotics recommended for CAB caused by the etiologic organism prior to or during transfer was associated with survival (aHR 0.58; 95%CI 0.38-0.88). CONCLUSIONS/SIGNIFICANCE: Mortality of patients with CAB caused by B. pseudomallei was higher than those caused by S. aureus and E. coli, even after adjusting for presence of organ dysfunction on admission and effectiveness of empirical antibiotics received. Improving algorithms or rapid diagnostic tests to guide early empirical antibiotic may be key to improving CAB outcomes in LMICs.

The Role of Red Blood Cell Distribution Width in the Severity and Prognosis of Community-Acquired Pneumonia.

Objectives: The objective of this study is to unravel the correlation between RDW and the severity and prognosis of CAP, as well as exploring RDW with the inflammatory markers white blood cells (WBC), C-reactive protein (CRP), and procalcitonin (PCT). Methods: According to the data characteristics, appropriate statistical methods were selected to analyze the relationship between RDW and the severity and prognosis of CAP patients and to determine whether RDW is associated with the inflammatory markers WBC, CRP, and PCT. Results: The results show that with the increase of PSI and CURB-65 values, the proportion of patients with RDW ≥ 12.987% is significantly higher than that of RDW < 12.987% (P < 0.01). When RDW is combined with PSI or CURB-65 to predict the 90-day mortality of CAP patients, the area under the receiver operating characteristic (ROC) curve increased prominently, and if RDW, PSI, and CURB-65 are combined, the area under the ROC curve is maximized. Conclusions: Our findings suggest that the higher RDW value is associated with short-term adverse outcomes in CAP patients. We also find that when RDW, PSI, and CURB-65 are combined, the best performance is achieved to predict CAP 90-day mortality risk.