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Pneumonia In Diabetic Patients Treatment

Data Extraction And Quality Assessment

Pneumonia | Treatment and Prevention

The 2 reviewers independently extracted data in duplicate using a pilot-tested data extraction form. The following information was extracted: authors, year and location of study, study design, exposure and outcome definitions, follow-up duration, number of participants, baseline patient characteristics , study outcomes, number of events by exposure group, crude and adjusted point estimates and corresponding 95% confidence intervals , and variables included in statistical adjustment or matching.

We used an adapted version of the Risk of Bias in Nonrandomized Studies of Interventions tool to assess study quality. The predefined set of important confounders used to assess the potential level of confounding included age, sex, smoking status, alcohol use, history of asthma and history of chronic obstructive pulmonary disorder . Study quality was determined by the ROBINS-I domain with the greatest risk of bias. Quality assessment was conducted independently by 2 reviewers , with disagreements resolved by consensus or by a third reviewer .

What Is The Outlook For Pneumonia

People who are otherwise healthy often recover quickly when given prompt and proper care. However, pneumonia is a serious condition and can be life-threatening if left untreated and especially for those individuals at increased risk for pneumonia.

Even patients who have been successfully treated and have fully recovered may face long-term health issues. Children who have recovered from pneumonia have an increased risk of chronic lung diseases. Adults may experience:

  • General decline in quality of life for months or years

Selection Of Population Control Subjects

The Central Population Registry, which is updated daily, contains electronic records of all changes in vital status, including change of address, date of emigration, and date of death, for the entire Danish population since 1968. On the date of each patient’s first pneumonia-related hospital admission , we randomly selected 10 control subjects from the Central Population Registry, matched by age , sex, and residence . We used the risk set sampling technique .

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Research Design And Methods

We conducted this population-based, case-control study in the Danish counties of North Jutland and Aarhus, with a mixed rural and urban population of 1.15 million people. The Danish National Health service provides tax-supported health care for all residents, including free access to primary care and hospitals and reimbursement of a portion of the cost of most prescription drugs . Civil registration numbers, unique identifiers assigned to each Danish citizen that encode birth date and sex, allow accurate linkage among registries.

What Is The Outlook

Prevent Pneumococcal Disease in Adults

Lung cancer is the leading cause of cancer death in men and women in the United States.

More than 150,000 people are estimated to die from lung cancer each year. Infections, including pneumonia, are the second most common cause of death in people with lung cancer.

Pneumonia can be a serious lung infection. If you dont get a diagnosis and proper treatment, it can lead to serious complications and possibly even death. This type of infection is especially concerning for people with lung cancer because their lung function is already compromised.

Here are five things you can do to help prevent pneumonia:

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Inpatient Vs Outpatient Care

The costs of hospitalization and potential for nosocomial infections and thromboembolic events necessitate careful consideration of risk factors for severe CAP when considering appropriate level of care .6,20 Decision support tools such as the Pneumonia Severity Index assist in predicting the risk of 30-day mortality and severe CAP requiring ICU admission. Table 5 summarizes the more widely adopted CURB-65 and CRB-65 prediction scores,6,31 which have greater ease of use, but weaker predictive power for 30-day mortality.24,31,32 Among low-risk patients , the LR for 30-day mortality using the index is 0.08, and 0.21 using CURB-65.31 Sensitivity for predicting ICU admission was reported as 74% vs. 39% to 50% for Pneumonia Severity Index vs. CURB-65, respectively.24,32

CURB-65 and CRB-65 Mortality Prediction Tools for Patients with Community-Acquired Pneumonia

Prognostic variables


Urea nitrogen level > 20 mg per dL *

Respiratory rate 30 breaths per minute

Blood pressure

Age 65 years

30-day mortality for CURB-65


30-day observed mortality by score


LR+ = positive likelihood ratio LR = negative likelihood ratio.

*Excluded in CRB-65.

Derived from a pooled cohort of 15 studies with 1,136 events in a sample of 13,319 individuals.

Derived from a pooled cohort of nine studies with 55,302 events in a sample of 395,802 individuals.

Information from references 6 and 31.

Prognostic variables

*Excluded in CRB-65.

Information from references 6 and 31.

How Do The Lungs Work

Your lungs main job is to get oxygen into your blood and remove carbon dioxide. This happens during breathing. You breathe 12 to 20 times per minute when you are not sick. When you breathe in, air travels down the back of your throat and passes through your voice box and into your windpipe . Your trachea splits into two air passages . One bronchial tube leads to the left lung, the other to the right lung. For the lungs to perform their best, the airways need to be open as you breathe in and out. Swelling and mucus can make it harder to move air through the airways, making it harder to breathe. This leads to shortness of breath, difficulty breathing and feeling more tired than normal.

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Setting And Study Population

We conducted this population-based cohort study in the Danish counties of North Jutland and Aarhus, with a mixed rural/urban population of 1.15 million. The cohort consisted of all adult patients with a first-time hospital discharge diagnosis of pneumonia recorded in population-based medical databases between 1 January 1997 and 31 December 2004. The Danish National Health Service provides universal tax-supported health care, including free access to primary and hospital care and reimbursement of most prescription medication costs . Since 1968, all Danish residents carry a unique civil registration number, encoding sex and birth date, which is used in all health databases and permits unambiguous record linkage among them.

Risk Prediction Of In

Pneumonia Treatment, Nursing Interventions, Antibiotics Medication | NCLEX Respiratory Part 2

Sijun Cheng1^, Guangjian Hou2, Zhipeng Liu2, Ye Lu1, Sicong Liang1, Lin Cang3, Xinyue Zhang3, Cunlu Zou2,4, Jian Kang3, Yu Chen1^

1Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University , 2Neusoft Research of Intelligent Healthcare Technology, Co. Ltd. The First Hospital of China Medical University , , China

Contributions: Conception and design: Y Chen, J Kang, C Zou Administrative support: Y Chen, J Kang, C Zou Provision of study materials or patients: Y Chen, J Kang Collection and assembly of data: S Cheng, Y Lu, S Liang, L Cang, X Zhang Data analysis and interpretation: S Cheng, G Hou, Z Liu, Y Chen, J Kang, C Zou Manuscript writing: All authors Final approval of manuscript: All authors.

^Sijun Cheng, ORCID: 0000-0002-3669-3641 Yu Chen, ORCID: 0000-0001-9767-4797.

Correspondence to:

Background: The aim of the present study was to investigate the risk factors for in-hospital mortality among patients with type 2 diabetes mellitus and concomitant community-acquired pneumonia and establish a risk prediction score.

Keywords: Community-acquired pneumonia type 2 diabetes mellitus mortality prediction risk prediction score clinical features

Submitted Jun 30, 2020. Accepted for publication Aug 27, 2020.

doi: 10.21037/apm-20-1489

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History And Physical Examination

Most patients with CAP present with a combination of cough, dyspnea, pleuritic pain, fever or chills, and malaise. Risk and severity of CAP, including infection with less common pathogens , increase with older age, cardiopulmonary disease, poor baseline functional status, low socioeconomic status, and recent weight loss or underweight status.4,9 Although a thorough history is an essential component in the diagnosis of CAP, no individual symptom can adequately predict its presence. Across four studies, the most predictive findings were fever greater than 100°F and egophony .13 Clinical prediction rules that combine symptoms and examination findings can be helpful in generating a likelihood ratio that can be applied to patients with different prior probabilities of CAP and aid in diagnosis and management.14

Prediction Rule for Community-Acquired Pneumonia Diagnosis

Add points when present

Respiratory rate > 25 breaths per minute

Temperature 100°F

Scoring and likelihood ratios of pneumonia

Total points

LR+ = positive likelihood ratio LR = negative likelihood ratio.

Information from reference 14.

Prediction Rule for Community-Acquired Pneumonia Diagnosis

Add points when present

Respiratory rate > 25 breaths per minute

Temperature 100°F

Scoring and likelihood ratios of pneumonia

Total points

LR+ = positive likelihood ratio LR = negative likelihood ratio.

Information from reference 14.

Age And Sex Analysis In Diabetic Patients

A total of 86.1% of the diabetic patients with CAP were 60years of age and some comorbidities were more prevalent in this age group : heart disease , dementia , COPD , arthrosis , CVA , anaemia , Parkinsons disease and renal disease and arthritis .

Fig. 1

Differences between diabetic and no diabetic by sex and age. In this figure you can see the proportion of subjects who had every risk factor in each group: diabetic and no diabetic by sex and age

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Outpatient Vs Inpatient Treatment

Choosing between outpatient and inpatient treatment is a crucial decision because of the possible risk of death.9,15,16 This decision not only influences diagnostic testing and medication choices, it can have a psychological impact on patients and their families. On average, the estimated cost for inpatient care of patients with CAP is $7,500. Outpatient care can cost as little as $150 to $350.1719 Hospitalization of a patient should depend on patient age, comorbidities, and the severity of the presenting disease.9,20

Physicians tend to overestimate a patients risk of death14 therefore, many low-risk patients who could be safely treated as out-patients are admitted for more costly inpatient care. The Pneumonia Severity Index was developed to assist physicians in identifying patients at a higher risk of complications and who are more likely to benefit from hospitalization.9,15,16 Investigators developed a risk model based on a prospective cohort study16 of 2,287 patients with CAP in Pittsburgh, Boston, and Halifax, Nova Scotia. By using the model, the authors found that 26 to 31 percent of the hospitalized patients were good outpatient candidates, and an additional 13 to 19 percent only needed brief hospital observation. They validated this model using data17 from more than 50,000 patients with CAP in 275 U.S. and Canadian hospitals.1517,21,22


Information from reference 15.

Patients With Diabetes Mellitus Have Worse Pneumonia Outcomes

Pneumonia: Symptoms, causes, and treatments

Results from a retrospective, nationwide analysis of more than 157,000 Portuguese patients hospitalized for community-acquired pneumonia showed that those with diabetes were more likely to be hospitalized, had longer hospital stays, and had higher mortality than adults who did not have diabetes.

Carlos Penha-Gonçalves, PhD, of Instituto Gulbenkian de Ciência in Lisbon, Portugal and other researchers reviewed data collected by the Central Administration of the Health System of the Portuguese Ministry of Health on all patients hospitalized for community-acquired pneumonia from 2009 to 2012. After applying the exclusion criteria and selecting the target age range of 20 to 79, the researchers analyzed data on 74,175 CAP hospitalizations.

The percentage of patients with diabetes mellitus admitted for CAP was more than double the estimated population of people with diabetes in Portugal. Roughly 26% of those hospitalized for CAP had diabetes.

The proportion of patients with diabetes hospitalized for CAP increased from 23.7% in 2009 to 28.1% in 2012. Researchers noted that the increase could be due in part to an aging patient population the percentage of patients aged 60 to 79 increased from 67.5% in 2009 to 75.4% in 2012.

Patients with diabetes had consistently longer hospital stays, staying an additional 0.8 to 1.0 days. The researchers explained that added up to an extra 15,370 days of stay attributable to diabetes in more than 19,000 incidents.

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How Is Pneumonia Treated

When you get a pneumonia diagnosis, your doctor will work with you to develop a treatment plan. Treatment for pneumonia depends on the type of pneumonia you have, how sick you are feeling, your age, and whether you have other health conditions. The goals of treatment are to cure the infection and prevent complications. It is important to follow your treatment plan carefully until you are fully recovered.

Take any medications as prescribed by your doctor. If your pneumonia is caused by bacteria, you will be given an antibiotic. It is important to take all the antibiotic until it is gone, even though you will probably start to feel better in a couple of days. If you stop, you risk having the infection come back, and you increase the chances that the germs will be resistant to treatment in the future.

Typical antibiotics do not work against viruses. If you have viral pneumonia, your doctor may prescribe an antiviral medication to treat it. Sometimes, though, symptom management and rest are all that is needed.

Most people can manage their symptoms such as fever and cough at home by following these steps:

If your pneumonia is so severe that you are treated in the hospital, you may be given intravenous fluids and antibiotics, as well as oxygen therapy, and possibly other breathing treatments.

Study Design And Population

This retrospective case-control study was conducted in a population of 142 175 patients with diabetes recorded in the GPRD from 1 June 1987 to 21 January 2001 . This population has been used for previous studies on other topics not related to the present research study.

Cases were defined as patients aged 18 years and older with a first medical attendance for an episode of community acquired pneumonia . The date of pneumonia diagnosis was recorded as the index date. For each case up to four controls were matched for sex, age , general practice, and index date of the case. Controls were randomly selected from the baseline cohort of diabetic patients without a record of pneumonia. To be able to control for potential prognostic differences between comparison groups, both cases and controls were eligible for inclusion in the study if they had a medical history in the database for at least 365 days before the index date.

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Q: What Are The Possible Diagnoses And How Would You Investigate This Patient

The diagnosis is diabetic ketoacidosis in type 1 diabetes mellitus, which was precipitated by fulminant chest infection and omission of insulin. He survived four days without insulin so there was possibly some endogenous insulin production. At presentation, he had metabolic acidosis with high anion gap . In addition he had respiratory alkalosis caused by compensatory mechanisms and lung infection. He recovered from the diabetic ketoacidosis but pulmonary infection worsened leading to ARDS . Preterminally, he had a stress induced upper gastrointestinal bleed.

Hyperglycemia At Admission And Mortality

Doctor explains how pneumonia can be fatal

Ninety percent of diabetic and 71% of nondiabetic patients in the North Jutland subcohort had blood glucose values measured at admission or on the following day. Among patients without diabetes, the 30-day mortality increased from 13.9% at glucose values 6 mmol/l to 26.1% at glucose values 14 mmol/l . Hyperglycemia was also associated with increased mortality in patients with diabetes, but the association was restricted to those with admission glucose values of > 11 mmol/l. In the adjusted analyses, a high glucose level at admission remained a strong predictor of death among patients with diabetes but more so among those without diagnosed diabetes: adjusted 30-day MRRs for glucose levels 14 mmol/l were 1.46 and 1.91 , respectively. When we included admission glucose values as a continuous variable, each 1-mmol/l increase augmented the mortality rate among all patients by 3.3% after 30 days and by 2.1% after 90 days. For the diabetic patients, the respective increases were 3.2 and 1.8% and for other patients were 4.1 and 3.0%. However, the linear model did not fit the data well, with both very low and high glucose levels associated with increased mortality.

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When Would I Need To Be Hospitalized For Pneumonia

If your case of pneumonia is more severe, you may need tostay in the hospital for treatment. Hospital treatments may include:

  • Oxygen
  • Fluids, antibiotics and other medicines given through an IV
  • Breathing treatments and exercises to help loosen mucus

People most likely to be hospitalized are those who are most frail and/or at increased risk, including:

  • Babies and young children
  • People with weakened immune systems
  • People with health conditions that affect the heart and lungs

It may take six to eight weeks to return to a normal level of functioning and well-being if youve been hospitalized with pneumonia.

Validation And Performance Of Nomogram

For the total study population , the C-statistics value for the nomogram was 0.811 . The sensitivity and specificity of this model were 0.717 and 0.780 under cut-off of 125 score. The AUROC of the training set was 0.821 , while that of the testing set was 0.771 , respectively. The HosmerLemeshow type 2 statistics value was 13.637 , indicating a good fit for the model. The calibration curve of the score using 5,000 bootstrapped dataset is shown in Figure 4, confirming a satisfactory accuracy. The validation was also performed using 10-fold cross-validation in the derivation cohort, which revealed an accuracy of 0.7788 .

Figure 4 Calibration plot of the actual risk probability over the predicted risk probability based on the nomogram of PDPI in Figure 3.

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