Comorbid Conditions In Patients With Cap
The frequency of comorbidities in patients diagnosed with CAP was presented in 39 studies . Study details are summarised in online supplementary table S5.
The most common comorbidities were chronic respiratory diseases , chronic heart disease or heart failure , diabetes mellitus, cerebrovascular diseases and dementia . Chronic liver and chronic renal diseases were observed in up to 20% and 27% of patients, respectively. The frequency of comorbidities was generally higher in patients aged 65years compared with those aged < 65years, and in patients with COPD, chronic renal failure or cirrhosis compared with those without such conditions .
Comorbid Conditions And Risk Of Cap
The association between comorbidities and the risk of CAP was investigated in 14 case-control studies , Germany , The Netherlands , Spain , and the UK ,,,,, .
A history of respiratory disease was associated with an increased risk of CAP. A history of pneumonia increased the risk of a subsequent episode ,,). Patients with chronic respiratory diseases, including COPD, bronchitis or asthma, had a twofold to fourfold increase in the risk of CAP to 3.92 ,,,,,,). Additional data also support this association. One study reported an adjusted OR of 2.47 for chronic respiratory disease, and another study reported adjusted RRs of 2.82 for COPD and 1.58 for asthma. Patients with at least one respiratory tract infection in the past year were also at increased risk of CAP to 4.5 ). In young adults, the risk of CAP increased in line with the number of infections over the previous 6years > 3 infections, adjusted OR 4.84 ).
Chronic cardiovascular disease increased the risk of CAP up to threefold to 3.2 ,,,,,,,). Additional studies supported an association between chronic heart disease and 1.66 ) or heart failure and 1.37 adjusted RR: 2.63 ) and the risk of CAP.
Two studies in elderly patients found a strong association between dysphagia and risk of CAP. A large database study in patients aged 65years reported a crude OR of 2.10 , whereas a small study in patients aged 70years reported a crude OR of 16.3 and an adjusted OR of 11.9 .
Factors Associated With Community Acquired Severe Pneumonia Among Under Five Children In Dhaka Bangladesh: A Case Control Analysis
Roles Conceptualization, Data curation, Formal analysis, Resources, Writing original draft
Affiliation Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
Roles Data curation, Formal analysis, Writing review & editing
Affiliation Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
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Lifestyle Factors And Risk Of Cap
The potential association between lifestyle factors and the risk of CAP was investigated in 12 case-control studies, performed in France , Germany , The Netherlands ,, Spain , and the UK .,,, Study details are summarised in online supplementary table S3.
There was consistent evidence that smoking was associated with an increased risk of CAP.,,,, Compared with non-smokers , the risk of CAP was increased in current smokers to 1.81 adjusted ORs: 0.99 to 2.00 ) and former smokers to 1.40 adjusted OR: 1.04 ).
Compared with individuals who consumed no alcohol , consumption of 40g alcohol daily appeared to protect against CAP and 0.88 )., However, the risk increased in individuals with higher consumption > 80g/day, crude OR: 2.34 ) or with a history of alcohol abuse/alcoholism and 1.62 ).
Being underweight was generally associated with an increased risk of CAP to 2.20 ,,,) compared with normal bodyweight . A reduced risk was seen in individuals classified as overweight to 0.89 ,,,, adjusted ORs: 0.6 and 0.78 ), whereas those classified as obese had either a lower risk to 0.81 ,,, adjusted ORs: 0.7 and 0.71 ) or the same risk ) as those of normal weight.
Two studies found that visiting the dentist was associated with a decreased risk of CAP in the past year, OR 0.59 ). In contrast, one study found that frequent visits to the general practitioner in the previous year were associated with a substantial increase in the risk of CAP ).
Measurement And Data Collection
From the medical records, the following details were extracted: age, sex, caregiver, smoking history, Barthel index scores, seasonal influenza vaccination history, and use of nasogastric or tracheostomy tube. We calculated mean body mass index, mean hemoglobin value, and mean serum albumin level during the study period as markers of nutritional status . Body mass index was calculated based on estimated body weight and height using the formula for Chinese adults . Anemia was defined as hemoglobin level< 12 g/dL and 13 g/dL in women and men, respectively, according to World Health Organization criteria. Hypoalbuminemia was defined as serum albumin level< 3.5 g/dL.
Comorbidities were documented based on the International Classification of Diseases, Tenth Revision, Clinical Modification codes used during the pneumonia hospitalization and in medical records prior to admission. Comorbidities included stroke, dementia, Parkinsons disease, diabetes, heart failure, chronic respiratory disease , chronic kidney disease, chronic liver disease , and malignancy. We also recorded the amount of prescribed medications for chronic diseases. Excessive polypharmacy was defined as the prescription of 10 daily drugs .
Patients diagnosed with hospital-acquired pneumonia were excluded. For patients with repeated episodes of pneumonia requiring admission in the study period, we included only the first episode for the analysis.
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Risk Factors Of Community
To the Editors:
In a recent issue of the European Respiratory Journal, Teepe et al. published their interesting observations of determinants of community-acquired pneumonia in children in primary care. The authors included 107 children with either radiologically or clinically diagnosed CAP treated as outpatients in four Dutch healthcare centres in 19992008, and compared the potential determinants of CAP between the cases and 321 controls from the same area with no CAP during the study period. In adjusted analyses, lower age , asthma history and the number of previous visits for upper respiratory tract infections were independently associated with CAP. The authors concluded that the association between CAP and the number of URTIs can be explained by infection susceptibility of the individuals .
In the discussion, the authors mentioned that their study was the first to explore the determinants of CAP in children in primary care. Actually, their study was the second one.
To evaluate the possible risk factors for paediatric CAP, identical standardised questionnaires were sent to the parents of the 201 children with CAP and to 250 controls from the same four municipalities. In all, 176 cases and 233 controls answered.
Ethics Approval And Consent To Participate
The information contained in BIFAP is completely anonymous and includes no data that could identify patients, doctors or centers, ensuring full confidentiality. The Data Protection Agency considers that BIFAP meets the requirements of Law 14/2007 on Biomedical Research regarding the protection of personal data and privacy. The Galician Research Ethics Committee granted permission for the study .
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Data Synthesis And Analysis
The quality and concordance of the evidence was used to develop standardized statements for each risk factor. For each analysis in each individual study, the resulting effect of the risk factors was categorized as significant risk factor, significant protective factor, or nonsignificant risk factor. Only the results of multivariate adjusted models were taken into account. If a given category was present in > 66% of the studies and the other categories in 34% of the studies, and the given category had no clearly lower methodological quality, then standardized statements of clear risk factor, clear protective factor, or no effect were established otherwise, a statement of no definitive conclusion was considered . No clearly lower methodological quality was considered if the difference in median NOS scores between categories was < 1 point.
Standardized definitions of the confidence of the predictive effect of risk factors for CAP
Enhancing Healthcare Team Outcomes
Patients with community pneumonia may present to the primary care provider or the emergency department. Hence these professionals should be aware of the signs and symptoms. The health care team can improve outcomes. The team can include primary care, emergency department personnel, specialists, nurses, and pharmacists. If the diagnosis is not clear cut, then an infectious disease or pulmonology consult is recommended. Most patients do respond to outpatient antibiotic therapy for 5-7 days. Patients who are short of breath, febrile, and in respiratory distress need to be admitted. Some patients may present with a parapneumonic effusion, which may require drainage. Nurses monitor the patients and report current status and updates to the rest of the team. Pharmacists evaluate medication choice, check for allergies and interactions, and educate patients about side effects and the importance of compliance. The providers should encourage all patients to get the annual influenza vaccine. In addition, all adults 65 years and older and those considered at risk for pneumonia must receive the pneumococcal vaccination. The outcomes in most patients with community-acquired pneumonia are excellent.
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When To Contact A Medical Professional
- Cough that brings up bloody or rust-colored mucus
- Breathing symptoms that get worse
- Chest pain that gets worse when you cough or breathe in
- Fast or painful breathing
- Night sweats or unexplained weight loss
- Shortness of breath, shaking chills, or persistent fevers
- Signs of pneumonia and a weak immune system
- Worsening of symptoms after initial improvement
Availability Of Data And Materials
Most of the data generated or analysed during this study are included in this published article , although restrictions apply to the availability of some data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of BIFAP database.
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Triage: Who Needs Icu
No criteria apply perfectly for every patient. However, the IDSA/ATS criteria may provide a useful conceptual framework for borderline situations.
classic errors in pneumonia triage
- Triage solely based on the amount of oxygen the patient requires:
- A common myth is that if the patient can saturate adequately on nasal cannula then it’s OK for them to go to the ward. This is completely and utterly wrong.
IDSA/ATS criteria for severe pneumonia
- These criteria have been validated for use in ICU triage . Severe pneumonia is defined by either having at least one major criteria, or at least three minor criteria.
- Major criteria :
- Respiratory distress requiring mechanical ventilation. These criteria were created prior to the common use of high-flow nasal cannula. A patient with substantial work of breathing or tachypnea who requires high-flow nasal cannula should be considered for ICU admission.
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Pearls And Other Issues
All adults 65 years and older and those considered at risk for pneumonia must receive the pneumococcal vaccination. There are two vaccines available: PPSV 23 and PCV 13.
Current ACIP recommendations for unvaccinated non-immune-compromised individuals aged 19 to 64 years old and at risk for pneumonia, first should receive PPSV 23. After age 65, a dose of PCV 13 can be given , followed by the second dose of PPSV 23 spaced at least one year from PCV 13 and 5 years from the first dose of PPSV 23. For patients who are immune-compromised or asplenic and 19 to 64 years old, first give PCV 13, followed by the first dose of PPSV 23 8 weeks or later and second dose PPSV 23 after five years. A booster PPSV 23 can be given for a patient 65 years or older after at least five years or longer from the second dose of PPSV 23.
For all unvaccinated adults 65 years or older, first vaccinate with PCV 13, followed by PPSV 23 at least a year later for immune-competent patients and at least eight weeks or more apart for patients who are immune-compromised or asplenic.
Influenza vaccination is recommended for all adult patients at risk for complications from influenza. Inactivated flu shots are usually recommended for adults. Live attenuated intranasal vaccine can be given to healthy, nonpregnant adults who are less than 49 years old. It is contraindicated in pregnancy, the immune-suppressed or health care workers caring for them, and in those with comorbidities.
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Characteristics Of The Studies
Twenty studies had a case-control design, 8 had a cohort design, and 1 had a cross-sectional design . The case-control and cross-sectional studies included 29,018 participants. The cohort studies were prospective in 6 cases and retrospective in 2, and overall they included more than 140,000 participants. The cohort studies were published between 1994 and 2015, with the longest follow-up being 16 years and 11 months. Most studies focused on elderly subjects 65 years of age or mixed populations where the participants’ age was > 14 years , and a few studies considered only the age range between 18 and 60 years. The definitions used for cases and controls, as well as exposed and nonexposed subjects, in each of the included studies are detailed in online supplementary Table 2.
General characteristics of the 29 studies included in the systematic review of risk factors for CAP
Limitations Of The Study:
A small sample size, the lack of biochemical infection indicators , and the lack of quantitative culture techniques for pneumonia diagnoses are all noteworthy shortcomings of this study. The primary physicians discretion was used to conduct the majority of the investigations. Sputum culture was not ordered in all cases. Moreover, data was not available regarding the class, duration and number of antibiotics taken in the community before hospital admission. Since this study was performed in a single hospital, extrapolating the results to other settings should be done with caution.
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