Gustavo Lopardo

Predicting mortality in hospitalized patients with 2009 H1N1 influenza pneumonia.

BACKGROUND Community-acquired pneumonia (CAP) severity scores can identify patients at low risk for mortality who may be suitable for ambulatory care. Here, we follow the clinical course of hospitalized patients with CAP due to 2009 H1N1 influenza. OBJECTIVE To evaluate the role of CAP severity scores as predictors of mortality. METHODS This was a secondary data analysis of patients hospitalized with CAP due to 2009 H1N1 influenza confirmed by reverse transcriptase polymerase chain reaction enrolled in the CAPO (Community-Acquired Pneumonia Organization) international cohort study. CAP severity scores PSI (Pneumonia Severity Index), CURB-65 (confusion, urea, respiratory rate, blood pressure, age ≥ 65 years) and CRB-65 (confusion, respiratory rate, blood pressure, age ≥ 65 years) were calculated. Actual and predicted mortality rates were compared. A total of 37 predictor variables were evaluated to define those associated with mortality. RESULTS Data from 250 patients with CAP due to 2009 H1N1 influenza were analyzed. Patients with low predicted mortality rates (0-1.5%) had actual mortality rates ranging from 2.6% to 17.5%. Obesity and wheezing were the only novel variables associated with mortality. CONCLUSIONS The decision to hospitalize a patient with CAP due to 2009 H1N1 influenza should not be based on current CAP severity scores, as they underestimate mortality rates in a significant number of patients. Patients with obesity or wheezing should be considered at an increased risk for mortality.

The effectiveness of the polysaccharide pneumococcal vaccine for the prevention of hospitalizations due to Streptococcus pneumoniae community-acquired pneumonia in the elderly differs between the sexes: Results from the Community-Acquired Pneumonia Organization (CAPO) international cohort study

BACKGROUND The effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV23) to prevent hospitalizations due to Streptococcus pneumoniae community-acquired pneumonia (SpCAP) is controversial. Recent literature suggests that vaccine effectiveness may be influenced by sex. In this study, we define the effectiveness of prior PPV23 vaccination for the prevention of hospitalizations due to SpCAP, and evaluate the impact of sex on this effectiveness. METHODS This was a nested case-control study from the CAPO international cohort study database. SpCAP was defined as CAP plus S. pneumoniae identified in blood, bronchoalveolar lavage, sputum, or urinary antigen. Vaccination with PPV23 prior to hospitalization was defined as documented in the medical record. A propensity score-weighted logistic regression model was used to calculate odds ratios. The adjusted vaccine effectiveness (aVE) was calculated as 1-adjusted odds ratio. RESULTS From a total of 2688 elderly adult hospitalized patients with CAP, SpCAP was identified in 279 (10%). The overall aVE was 37% (95% CI: 10.1-55.4%, P=0.01). For males, the aVE was 34% (95% CI:-1.0% to 57.3%, P=0.06). For females the aVE was 68% (95% CI: 40.3-83.0%, P=0.001). CONCLUSIONS PPV23 protects elderly patients from hospitalization due to SpCAP, but female sex drives the effectiveness. Future analysis of vaccine trials should consider the importance of sex as a stratification factor.

Clinical outcomes of HIV-infected patients hospitalized with bacterial community-acquired pneumonia

BACKGROUND There are limited and conflicting data on clinical outcomes of community-acquired pneumonia (CAP) among HIV-infected patients. METHODS Secondary analyses of clinical outcomes of CAP were performed for 118 patients with HIV infection and 2790 patients without HIV infection enrolled in the Community-Acquired Pneumonia Organization (CAPO) international study. After adjustment for significant confounders, the effect of HIV infection on length of stay (LOS) and time to clinical stability (TCS) were examined by survival analyses and overall mortality and CAP-related mortality by logistic regression methods. RESULTS After adjusting for significant confounders, hospitalized HIV-infected patients with CAP did not have longer times to reach clinical stability (HR 1.126; 95% CI 0.917-1.391; p=0.251) or longer stays in the hospital (HR 1.191, 95% CI 0.979-1.449; p=0.080). In addition, HIV infection did not significantly influence overall mortality rates (OR 1.205, 95% CI 0.686-2.116; p=0.517) or CAP-related mortality rates (OR 1.338; 95% CI 0.623-3.725; p=0.355). CONCLUSION The presence of HIV infection did not influence the clinical outcomes of CAP among patients assessed at CAPO centers. It is not intended that our results be extrapolated to populations receiving limited healthcare for advanced HIV disease, malnourishment and parasitic diseases.

The role of neutropenia on outcomes of cancer patients with community-acquired pneumonia

Although the presence of neutropenia may predispose cancer patients to develop community-acquired pneumonia, the role of neutropenia on their outcomes has not been investigated. The purpose of the present study was to compare clinical outcomes of cancer community-acquired pneumonia patients with and without neutropenia. Patients with cancer, identified in the Community-Acquired Pneumonia Organization database, were divided into two groups according to the type of cancer and the presence of neutropenia: patients with solid cancer without neutropenia versus those with functional or absolute neutropenia. Among the 3,106 community-acquired pneumonia patients enrolled, 135 had cancer without neutropenia and 75 had cancer with neutropenia. No significant difference was found between patients with and without neutropenia regarding mean time to clinical stability (5.4±2.7 versus 4.9±2.7 days, respectively), mean length of hospital stay (9.2±7.7 versus 9.9±9.6 days) and in-hospital mortality (18 versus 15%, respectively). Using a multiple logistic regression model, neutropenia was not associated with mortality in cancer patients when adjusting for significant covariates (odds ratio 1.30). Lack of neutropenia, during the initial evaluation of a cancer community-acquired pneumonia patient, should not be considered an indicator of better clinical outcome.

O papel da neutropenia no prognóstico do doente oncológico com pneumonia adquirida na comunidade

Resumo A doenca infecciosa contribui para uma elevada morbilidade e mortalidade no doente oncologico, representando a pneumonia adquirida na comunidade a mais frequente. O desenvolvimento de PAC no doente neoplasico parece advir da modificacao de mecanismos de defesa imunitaria resultante, quer da patologia maligna, quer do tratamento oncologico. O risco de infeccao relacionada com o tipo de neoplasia pode associar-se ao defice de imunidade humoral, celular ou do numero de neutrofilos. As doencas hematologicas malignas podem predispor o doente as infeccoes devido a substituicao da medula por celulas neoplasicas. Consequentemente, estes doentes tem neutropenia funcional, apesar de apresentarem, muitas vezes, um numero normal ou aumentado de neutrofilos. Por outro lado, estes doentes podem ter neutropenia como efeito secundario da quimioterapia e/ou radioterapia (neutropenia absoluta). A gravidade da neutropenia foi considerada como principal factor de risco isolado no doente neoplasico, com particular relevância se o numero de neutrofilos ≤500cel/mm3. A mortalidade global atribuida a neutropenia febril no doente neoplasico e de 30–50%. Nas ultimas decadas, o tratamento das infeccoes na populacao oncologica foi direccionado, primariamente, para o manuseamento da neutropenia febril, devido ao facto de o local da infeccao nao ser determinado em 50–80% dos casos. As guidelines da American Thoracic Society de 2001 utilizavam a neutropenia para identificar os quadros mais graves de PAC nos doentes oncologicos. Os doen tes com patologia hematologica e neutropenia funcional ou individuos com qualquer tipo de neoplasia e neutropenia absoluta foram excluidos das referidas guidelines. A decisao de incluir doentes com tumores solidos nao neutropenicos foi baseada, apenas, na opiniao de especialistas. Assim, os clinicos podiam sentir-se confiantes e tratar a PAC no doente oncologico nao neutropenico como na populacao geral. No entanto, o papel da neutropenia no prognostico de doentes neoplasicos hospitalizados com PAC nao tinha, ainda, sido investigado O objectivo do presente estudo foi comparar o prognostico de doentes neoplasicos e doentes imunocompetentes com PAC, bem como o prognostico de individuos com patologia maligna e neutropenia absoluta ou funcional e sem neutropenia. Foi efectuada uma analise retrospectiva envolvendo 43 hospitais em 12 paises no periodo compreendido entre Junho de 2001 e Janeiro de 2006. Foram incluidos os individuos com idade ≥ 18 anos com criterios de PAC, tendo sido eliminados os portadores de infeccao VIH. A PAC foi definida pela presenca de infiltrado pulmonar “de novo” na radiografia do torax na altura do internamento, associado a, pelo menos, um dos seguintes parâmetros: tosse ou aumento da intensidade desta; tax 37,8°C; numero de leucocitos no sangue periferico (leucocitose, desvio esquerdo ou leucopenia). Neoplasia foi definida como qualquer tipo de malignidade diagnosticada nos 12 meses anteriores ou neoplasia activa. Considerou-se que esta estaria presente em doentes sob quimioterapia e/ou radioterapia nos 12 meses precedentes ou com sinais ou sintomas de neoplasia ao longo do ultimo ano. Doentes com neoplasia de celulas escamosas ou basais da pele foram consideradas imunocompetentes. A neutropenia foi classificada como funcional ou absoluta. A primeira estava presente em doentes com doenca hematologica maligna. A neutropenia absoluta correspondeu a um numero de neutrofilos Os doentes com PAC foram divididos em dois grupos: doentes nao oncologicos – Grupo I, e doentes com neoplasia – Grupo II. Este ultimo foi, por seu turno, subdividido em dois subgrupos, de acordo com o tipo de neoplasia e o numero de neutrofilos – doentes com tumor solido sem neutropenia (Grupo IIa) e doentes com neutropenia (Grupo IIb). Foram avaliados a mortalidade, a duracao do internamento e o tempo de estabilizacao clinica. Foram estudados 3106 individuos com PAC dos quais 135 eram doentes neoplasicos sem neutropenia e 75 tinham neoplasia e neutropenia. A taxa de mortalidade foi significativamente superior nos doentes oncologicos em comparacao com os doen tes nao neoplasicos (14% versus 8%). Nestes ultimos, a morte foi atribuida a PAC em 30% dos casos. A presenca de neoplasia na populacao estudada teve impacto significativo na mortalidade quando ajustado para as covariaveis. Os doentes com neoplasia tambem tiveram um tempo de estabilizacao clinica significativamente superior (5,1±2,6 dias versus 4,6±2,5 dias) e um tempo de internamento mais prolongado (9,3±4,8 dias versus 8,4±4,7 dias). Nos doentes neoplasicos com ou sem neutropenia, o tempo de estabilizacao clinica foi semelhante nos dois subgrupos (5,7±2,7 versus 4,9±2,7 dias, respectivamente), bem como o tempo medio de internamento (9,2±7,7 versus 9,9±9,6 dias, respectivamente). Nao se verificou uma diferenca estatisticamente significativa na taxa de mortalidade dos doentes oncologicos com ou sem neutropenia (18% versus 15%), mas esta diferenca ja foi significativa quando comparados individuos nao neoplasicos com os doentes neo plasicos sem neutropenia (8% versus 15%) e com neutropenia (8% versus 18%).

The role of neutropenia on outcomes of cancer patients with community-acquired pneumonia.

Although the presence of neutropenia may predispose cancer patients to develop community-acquired pneumonia, the role of neutropenia on their outcomes has not been investigated. The purpose of the present study was to compare clinical outcomes of cancer community-acquired pneumonia patients with and without neutropenia. Patients with cancer, identified in the Community-Acquired Pneumonia Organization database, were divided into two groups according to the type of cancer and the presence of neutropenia: patients with solid cancer without neutropenia versus those with functional or absolute neutropenia. Among the 3,106 community-acquired pneumonia patients enrolled, 135 had cancer without neutropenia and 75 had cancer with neutropenia. No significant difference was found between patients with and without neutropenia regarding mean time to clinical stability (5.4¡2.7 versus 4.9¡2.7 days, respectively), mean length of hospital stay (9.2¡7.7 versus 9.9¡9.6 days) and in-hospital mortality (18 versus 15%, respectively). Using a multiple logistic regression model, neutropenia was not associated with mortality in cancer patients when adjusting for significant covariates (odds ratio 1.30). Lack of neutropenia, during the initial evaluation of a cancer community-acquired pneumonia patient, should not be considered an indicator of better clinical outcome.