Incidence, Etiology, Timing, and Risk Factors for Clinical Failure in Hospitalized Patients With Community-Acquired Pneumonia

doi:10.1378/chest.08-0334

Chest

Volume 134, Issue 5, November 2008, Pages 955-962

https://doi.org/10.1378/chest.08-0334 Get rights and content

Background

The etiology of clinical failure in hospitalized patients with community-acquired pneumonia (CAP) may be related or unrelated to pulmonary infection. The objective of this study was to define the incidence, etiology, timing, and risk factors associated with clinical failures related to CAP vs those unrelated to CAP.

Methods

Observational retrospective study of consecutive CAP patients. All patients who experienced clinical failure were identified. Cases were presented to a review committee that defined, by consensus, etiology, timing, and risk factors for clinical failures related to CAP.

Results

Among 500 patients who were enrolled in the study, clinical failure was identified in 67 (13%). Clinical failure was related to CAP in 54 patients (81%). The most common etiologies for clinical failure related to CAP were severe sepsis (33%), acute myocardial infarction (28%), and progressive pneumonia (19%). All cases of severe sepsis occurred in the first 72 h of hospitalization. The most common etiology for clinical failure unrelated to CAP was the development of hospital-acquired pneumonia (45%). At the time of hospital admission, factors associated with clinical failure related to CAP were advanced age, congestive heart failure, hypotension, abnormal gas exchange, acidosis, hypothermia, thrombocytopenia, and pleural effusion.

Conclusions

The development of severe sepsis early during hospitalization is the primary etiology for clinical failure related to CAP. To achieve early treatment intervention, physicians should maintain a high index of suspicion for severe sepsis in hospitalized patients with CAP. To decrease the number of clinical failures unrelated to CAP, interventions need to be developed at the local level to improve the processes of care for patients with pneumonia.

Section snippets

Study Design and Study Patients

This was an observational, retrospective study of consecutive patients who were admitted with a diagnosis of CAP to the Veterans Affairs Medical Center of Louisville, KY, between June 2001 and March 2006. Patients enrolled in this study are part of the Community-Acquired Pneumonia Organization database.¹⁰ The study protocol and data collection form are available on the study Web site (www.caposite.com). The institutional review board of the Veterans Affairs Medical Center approved the study.

Incidence of Clinical Failure

From a total of 500 consecutive patients with CAP who were enrolled during the study period, 67 patients (13%) met at least one of the three criteria for clinical failure. The clinical failure criteria for acute pulmonary deterioration were fulfilled in 39 patients (8%), those for acute hemodynamic deterioration were fulfilled in 10 patients (2%), and those for in-hospital death were fulfilled in 36 patients (7%). Some patients met more than one criterion on the day that clinical failure was

Discussion

This study indicates that > 80% of the causes of clinical failure in hospitalized patients with CAP are directly related to pulmonary infection and its systemic inflammatory response. Clinical failures related to CAP occur primarily during the first 72 h after hospital admission, and severe sepsis is the primary etiology of clinical failure related to CAP. The independent risk factors at the time of hospital admission associated with clinical failure related to CAP found in the study population

Acknowledgment

The authors acknowledge the assistance of Raul Nakamatsu MD, Forest Arnold, MD, and Mary Elizabeth Allen, MBA (Division of Infectious Diseases, University of Louisville); and Elizabeth Smigielski, MSLS (Associate Professor, Kornhauser Health Sciences Library, University of Louisville).

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Citation Excerpt :
The length of stay (LOS) was defined in days and calculated for each patient as the day of discharge minus the day of admission. LOS was truncated at 14 days in an effort to capture only CAP-related LOS.12 Patients who died in the hospital within 14 days of hospitalization had the longest LOS possible assigned (14 days).
After hospitalization for community-acquired pneumonia (CAP), patients’ clinical course may progress to clinical improvement, clinical failure, or nonresolving pneumonia. The epidemiology and outcomes of patients with CAP according to clinical course has not been well studied. The objective of this study was to characterize the incidence and outcomes for each clinical course of hospitalized patients with CAP.
This was a secondary data analysis of the University of Louisville Pneumonia Study. Clinical course was classified as improvement, failure, and nonresolving. Objective criteria were used to define improvement and failure during the first week of hospitalization. If neither group of criteria were met, the course was classified as nonresolving. Incidence for each clinical course was calculated. Mortality was evaluated at different time points through the first year. P < .05 was considered statistically significant.
A total of 7,449 patients were hospitalized with CAP during the study period. Improvement was documented in 5,732 patients (77%), failure was documented in 1,458 patients (20%), and nonresolving CAP was documented in 259 patients (3%). Mortality at 30 days was 6% for those who improved, 34% for those who failed, and 34% for those with nonresolving pneumonia. Mortality at 1 year was 23%, 52%, and 51%, respectively.
This study shows that > 75% of hospitalized patients with CAP will reach clinical improvement. One of two patients with clinical failure or nonresolving CAP may die 1 year after hospitalization. Understanding the pathogenesis of long-term mortality is critical to developing interventions.
Initial empiric antibiotic therapy for community-acquired pneumonia in Chinese hospitals
2018, Clinical Microbiology and Infection
Studies on treatment of community-acquired pneumonia (CAP) in China are scarce. We performed a study to investigate empiric antibiotic practices for patients hospitalized with CAP in China and the risk factors for treatment failure.
Data were collected from a national Chinese hospitalization database. Adult patients who were diagnosed with CAP between 1 October 2014 and 30 September 2015 were identified. We studied initial empiric antibiotic regimens, microbiologic sampling, treatment failure, in-hospital mortality and length of hospital stay.
We included 18 043 adult patients from 185 hospitals who met all the study inclusion criteria. The most common initial antibiotic regimen for CAP was monotherapy with a fluoroquinolone (14.8%, 2671/18 043). The most common initial antibiotic (used alone or in combination with other antibiotics) was levofloxacin (15.7%, 4597/29 278 (this denominator represents the total number of initial antibiotics)). The microbiologic sampling rate was 26.9% (4851/18 043). A total of 4050 (22.4%) of 18 043 patients experienced treatment failure. Multivariate logistic regression demonstrated that older age, male sex, coexisting lung cancer and use of regimens not covering atypical pathogens were risk factors for treatment failure. In-hospital mortality was 2.1% (380/18 043). The median hospital length of stay was 11 days (interquartile range, 8–15 days).
Patients receiving Chinese guideline-adherent regimens had better outcomes, and atypical pathogen active regimens were associated with a lower treatment failure rate and shorter length of hospital stay.
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The use of noninvasive ventilation (NIV) in non-COPD patients with pneumonia is controversial due to its high rate of failure and the potentially harmful effects when NIV fails. The purpose of the study was to evaluate outcomes of the first ventilatory treatment applied, NIV or invasive mechanical ventilation (MV), and to identify predictors of NIV failure.
Historical cohort study of 159 non-COPD patients with pneumonia admitted to the ICU with ventilatory support. Subjects were divided into 2 groups: invasive MV or NIV. Univariate and multivariate analyses with demographic and clinical data were performed. Analysis of mortality was adjusted for the propensity of receiving first-line invasive MV.
One hundred and thirteen subjects received first-line invasive MV and 46 received first-line NIV, of which 27 needed intubation. Hospital mortality was 35%, 37% and 56%, respectively, with no significant differences among groups. In the propensity-adjusted analysis (expressed as OR [95% CI]), hospital mortality was associated with age (1.05 [1.02–1.08]), SAPS3 (1.03 [1.00–1.07]), immunosuppression (2.52 [1.02–6.27]) and NIV failure compared to first-line invasive MV (4.3 [1.33–13.94]). Compared with invasive MV, NIV failure delayed intubation (P=.004), and prolonged the length of invasive MV (P=.007) and ICU stay (P=.001). NIV failure was associated with need for vasoactive drugs (OR 7.8 [95% CI, 1.8–33.2], P=.006).
In non-COPD subjects with pneumonia, first-line NIV was not associated with better outcome compared with first-line invasive MV. NIV failure was associated with longer duration of MV and hospital stay, and with increased hospital mortality. The use of vasoactive drugs predicted NIV failure.
El uso de ventilación no invasiva (VNI) en pacientes sin EPOC con neumonía es motivo de controversia, debido a la elevada tasa de fracasos y a los efectos potencialmente nocivos de dicho fracaso. La finalidad de este estudio fue evaluar la evolución de los pacientes en función de cuál había sido el primer tipo de soporte ventilatorio aplicado, VNI o ventilación mecánica (VM) invasiva, e identificar factores de predicción del fracaso de la VNI.
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International experts suggest tailoring antibiotic duration in community-acquired pneumonia (CAP) according to patients' characteristics. We aimed to assess the effectiveness of an individualized approach to antibiotic duration based on time in which CAP patients reach clinical stability during hospitalization. In a multicenter, non-inferiority, randomized, controlled trial hospitalized adult patients with CAP reaching clinical stability within 5 days after hospitalization were randomized to a standard vs. individualized antibiotic duration. In the Individualized group, antibiotics were discontinued 48 h after the patient reached clinical stability, with at least five days of total antibiotic treatment. Early failure within 30 days was the primary composite outcome. 135 patients were randomized to the Standard group and 125 to the Individualized group. The trial was interrupted by the safety committee because of an apparent inferiority of the Individualized group over the Standard treatment: 14 (11.2%) patients in the Individualized group experienced early failure vs. 10 (7.4%) patients in the Standard group, p = 0.200, at the intention-to-treat analysis. 30-day mortality rate was four-time higher in the Individualized group than the Standard group. Shortening antibiotic duration according to patients' characteristics still remains an open question.
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The work was performed in the Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY.

This work was accepted as oral communication at the European Respiratory Society Annual Congress 2007.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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Chest

Original ResearchPneumoniaIncidence, Etiology, Timing, and Risk Factors for Clinical Failure in Hospitalized Patients With Community-Acquired Pneumonia

Background

Methods

Results

Conclusions

Section snippets

Study Design and Study Patients

Incidence of Clinical Failure

Discussion

Acknowledgment

Clin Microbiol Infect

Clin Microbiol Infect

Chest

Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention

Am J Respir Crit Care Med

Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults

Clin Infect Dis

Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome

Thorax

Causes and factors associated with early failure in hospitalized patients with community-acquired pneumonia

Arch Intern Med

Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications

Am J Respir Crit Care Med

Analysis of factors that contribute to treatment failure in patients with community-acquired pneumonia

Eur J Clin Microbiol Infect Dis

Causes of death for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study

Arch Intern Med

Original Research
Pneumonia
Incidence, Etiology, Timing, and Risk Factors for Clinical Failure in Hospitalized Patients With Community-Acquired Pneumonia