Physical examination and laboratory/radiological data demonstrated that CAP patients with COPD were significantly more likely to be tachypnoeic, acidotic and hypoxaemic, but less likely to exhibit hyperglycaemia than non-COPD patients. In the Cox’s proportional-hazards model, after adjusting for potential confounders, including processes of care and severity of illness, patients with a history of COPD exhibited significantly increased 30- (hazard ratio (HR) 1.32; 95% confidence interval (CI) 1.01–1.74) and 90-day mortality (HR 1.34; 95% CI 1.02–1.76). In addition, a presumptive diagnosis was made if qualitative valid sputum samples yielded one or more predominant bacterial pathogen. Long Beach, CA, 2001. Results 9893 patients were eligible for matching (2738 in the fluticasone/salmeterol group; 7155 in the budesonide/formoterol group), yielding two matched cohorts of 2734 patients each. KL has also received unrestricted research grants from AstraZeneca, Boehringer Ingelheim, and GlaxoSmithKline. The PSI score assesses five comorbid conditions (cardiovascular, history of malignancy, cerebrovascular, renal and liver diseases), but does not include COPD as one of them 10. Setting Primary care medical records data linked to Swedish hospital, drug, and cause of death registry data for years 1999-2009. In contrast, hospital-acquired pneumonia (HAP) is seen in patients who have recently visited a hospital or who live in long-term care facilities. The end of the study was 31 December 2009 or the end of treatment with a fixed combination, emigration, or death. We found no indication of a dose related difference in the risk of a first pneumonia diagnosis in either treatment group, stratified by collected mean daily steroid dose and including disease burden in the analysis to exclude confounding by severity (hazard ratio 1.00, 95% confidence interval 0.64 to 1.57; P=0.99). This was driven mostly by increases among African American women. Ventilator-associated pneumonia (VAP) is the commonest ICU infection and results in increased morbidity/mortality and costs. BS has received honorariums for educational activities from AstraZeneca, GlaxoSmithKline, and Merck Sharp and Dohme. The higher risk of pneumonia in patients treated with fluticasone/salmeterol might be related to differences in immunosuppressant potency and pharmacokinetic and pharmacodynamic properties between budesonide and fluticasone. J Infect Dis 2019; 220: 1166 – 1171.CrossRef Google Scholar PubMed. We performed sensitivity analyses by analysing rates of pneumonia and mortality from pneumonia in the crude (unmatched) populations and by dividing the matched cohorts into quarters based on the baseline propensity score, denoted as low (first quarter), medium (second quarter), high (third quarter), and very high (fourth quarter) disease burden as a proxy for severity. In these patients, 2115 (39%) had at least one recorded episode of pneumonia during the study period, with 2746 episodes recorded during 19 170 patient years of follow up. Therefore, it is important to recognise COPD in patients with CAP so that they may receive appropriate antimicrobial therapy. Data for the crude populations showed a hazard ratio of 1.73 (1.30 to 2.29) for fluticasone/salmeterol compared with budesonide/formoterol. When comparing COPD and non-COPD patients, the proportion of patients that required hospitalisation in the ICU was higher among COPD patients, but the percentage needing mechanical ventilation was not (table 3⇓). Ventilator-associated pneumonia (VAP) is the … Introduction Community acquired pneumonia (CAP) is a common occurrence in patients with chronic obstructive pulmonary disease (COPD), yet controversy still remains about its affect on outcome. Baseline characteristics in two years before first prescription for inhaled corticosteroid/long acting β2 agonist after diagnosis of COPD according to fixed combination treatment. The number of patients with at least one event was 32% higher with fluticasone/salmeterol than budesonide/formoterol (28% v 21%, respectively), but the number of patients with multiple events during the follow-up period (for example, ≥2 and ≥3 pneumonia events) was 61% (11% v 7%) and 85% (6% v 3%) higher, respectively (fig 2)⇓). Mortality (A) and cumulative number of confirmed cases of COVID-19 since the start of the outbreak per 10 000 population (B) in Hubei and other provinces of China. The lack of a standardised definition for pneumonia is one limitation of the current analyses. PSI and processes of care) 10 or a p-value of <0.10 in the univariate analyses. 23 showed, in a large Spanish multicentric study, an in-hospital mortality rate of 8% in a cohort of 124 CAP patients with COPD. But what exactly does it mean to have both COPD and pneumonia at the same time? Seventy six primary healthcare centres were included, with a catchment area covering 8% of the population. Chronic obstructive pulmonary disease patients hospitalised with community-acquired pneumonia exhibited higher 30- and 90-day mortality than patients without chronic obstructive pulmonary disease. We carried out an observational retrospective cohort study, matched for propensity score, linking primary care medical records to data from national mandatory Swedish registries. KHL has received speaking fees from AstraZeneca, Boehringer Ingelheim, and Merck Sharp and Dohme. How many … It’s a difficult, nasty disease - COPD … Community acquired pneumonia (CAP) is a common disease associated with high morbidity, mortality and inpatients care costs [1,2,3].The 2009–2014 British Thoracic Society (BTS) Audit Programme indicates that the overall 30-day inpatients mortality is 18.0% [].Chronic obstructive pulmonary disease (COPD) is a disease with persistent airflow limitation and chronic inflammatory … A diagnosis of pneumonia during the two years before the index date was not associated with an increase in the overall pneumonia rate after the index date with fluticasone/salmeterol versus budesonide/formoterol (risk ratio 1.73, 95% confidence interval 1.47 to 2.04; P<0.001); however, the pneumonia rate was higher in patients treated with fluticasone/salmeterol than with budesonide/formoterol who had no history of pneumonia in the two years before the index date (1.76, 1.57 to 1.98; P<0.001). Chronic obstructive pulmonary disease (COPD) is characterised by airflow limitation, exacerbations, and accelerated decline in lung function over time.1 The disease is an important and growing cause of morbidity and mortality worldwide,2 with pneumonia as a common complication associated with considerable health costs and mortality.3 4 5 Combination treatment with inhaled corticosteroids and long acting β2 agonists decreases the risk of exacerbation and improves quality of life in patients with severe COPD.6 7 8 9 In Sweden, two products combining an inhaled corticosteroid and a long acting β2 agonist in one dry powder inhaler are available: budesonide/formoterol (Symbicort Turbuhaler, AstraZeneca, Södertälje, Sweden) and fluticasone/salmeterol (Seretide Diskus, Glaxo Smith Kline, Middlesex, UK). There were significantly more pneumonia events in patients treated with fluticasone/salmeterol than with budesonide/formoterol (table 2⇓). However, patients with COPD are more susceptible to covid-19 infection. For both COPD and pneumonia, it is important to see a physician for an accurate diagnosis. In one study, Pneumocystis colonization was detected in 36.7% of HIV-negative patients with very severe COPD (Global Health Initiative on Obstructive Lung Disease [GOLD] Stage IV) compared with 5.3% of smokers with normal lung function or less severe COPD (GOLD … This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. mL-1 in bronchoalveolar lavage fluid). The standardised difference between the two treatment groups was calculated as the percentage of the absolute difference in population means divided by an estimate of the pooled standard deviation.21. Variables were included in the survival analysis if they had either been previously demonstrated to be associated with CAP-related outcomes (e.g. The project aimed to search the literature in order to address the following: (i) Is COPD a risk factor for VAP development? Without oxygen, cells can begin to die. The corresponding number needed to treat (NNT) to avoid one pneumonia event per year was 23 (95% confidence interval 18 to 37). A new study examines the mortality risk factors among COPD patients hospitalized with community acquired pneumonia. The overall 30- and 90-day mortality were 10 and 14%, respectively. Table 3 shows sensitivity analyses based on age, sex, duration of treatment, history of exacerbations, history of asthma, history of pneumonia, and previous treatment with bronchodilator for COPD⇓. We explored the effect of pneumonia and COPD on inpatient, 30-day and overall mortality. During follow-up, 149 matched patients (52 patients in the budesonide/formoterol cohort and 97 patients in the fluticasone/salmeterol cohort) died with pneumonia listed as one cause of death. In addition, COPD patients with CAP showed higher rates of congestive heart failure and a history of neoplastic disease. This post-hoc, pooled analysis included studies of COPD patients treated with inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA) combinations and comparator arms of ICS, LABA, and/or placebo. Furthermore, 2497 patients (25%) had at least one pneumonia event recorded during the two years before the index date; the difference between the treatment groups at index date was not significant (P=0.6). The mean collected budesonide dose over time in the study was 568 (SD 235) µg/day (matched patients treated with budesonide/formoterol) and the mean fluticasone dose was 783 (SD 338) µg/day (matched patients treated with fluticasone/salmeterol). The differential risk of pneumonia among inhaled corticosteroid (ICS) use in patients with COPD requires more investigation, especially regarding beclomethasone-containing inhalers. In the present study, it was found that COPD patients hospitalised with CAP, compared to patients without COPD, show significantly higher 30- and 90-day mortality. Introduction. It is unclear whether concurrent pneumonia and chronic obstructive pulmonary disease (COPD) have a higher mortality than either condition alone. Four patients in the fluticasone/salmeterol treated group could not be matched, and, together with the remaining 4421 patients in the budesonide/formoterol treated group, were excluded from the matched analysis. Along with lung cancer and pneumonia, COPD is one of the three leading contributors to respiratory mortality in developed countries such as the UK. First, it was a retrospective cohort study, and inherent problems related to this design include ascertainment and selection bias. Recent study showed there was no significant difference in the survival rate of AECOPD patients between with pneumonia and without pneumonia 14 and others noted that mortality was higher in COPD patients combined pneumonia. All of these variables are also included in the PSI score, the severity of illness predictor used in the present study 10. European Respiratory Society442 Glossop RoadSheffield S10 2PXUnited KingdomTel: +44 114 2672860Email: journals@ersnet.org, Print ISSN:  0903-1936 The longer either condition is left untreated, the worse the prognosis, and the shorter a person’s life expectancy may become. The magnitude of the intraclass difference in pneumonia needs to be put in context with the benefits of each regimen in preventing exacerbations. GS, HG, and LJ are fulltime employees of AstraZeneca Nordic. In addition, CAP patients with COPD receiving any form of corticosteroids, whether inhaled or systemic, did not show any significant differences in 30- or 90-day mortality compared with non-COPD patients (table 3⇓). In total, 9893 patients had a record of treatment with a fixed combination of inhaled corticosteroid/long acting β2 agonist after a diagnosis of COPD and were eligible for matching (7155 patients received budesonide/formoterol Turbuhaler and 2738 patients received fluticasone/salmeterol Diskus at index date). Purpose To evaluate the association among chronic obstructive pulmonary disease (COPD) with asthma, steroid use, and pneumonia in the general population. All P<0.001, Poisson regression. While neither of these conditions is necessarily fatal, when they are the main difference is speed. Usefulness of consecutive C-reactive protein measurements in follow-up of severe community-acquired pneumonia, Original Articles: Community-acquired pneumonia. Compared with budesonide/formoterol, rate of pneumonia and admission to hospital were higher in patients treated with fluticasone/salmeterol: rate ratio 1.73 (95% confidence interval 1.57 to 1.90; P<0.001) and 1.74 (1.56 to 1.94; P<0.001), respectively. 22 Cilloniz, C, Dominedo, C, Magdaleno, D, Ferrer, M, Gabarrus, A, Torres, A. Most diagnoses, however, were recorded at hospitals where radiography is a standard procedure.24 A subanalysis of these patients showed that the increased risk of pneumonia with fluticasone/salmeterol versus budesonide/formoterol was unchanged. Death rates declined for men but remained unchanged for women. The PSI was used to assess severity of illness on presentation. Further, COPD is one of the most frequent co-morbid conditions associated with the development of community-acquired pneumonia (CAP) ; COPD is the most common underlying disease in patients with CAP who require hospitalization , and such patients have increased mortality [8, 9]. Proceedings of the Twenty-Sixth Annual SAS Users Group International Conference. We used pairwise 1:1 propensity score matching (greedy 5-to-1 digit matching without replacement),18 including logistic regression, to reduce concerns related to non-random assignment of patients to treatments. COPD patients used inhaled corticosteroids more frequently; however, they used similar amounts of systemic steroids to patients without COPD (table 1⇑). Our data suggest that statin-related reduction in influenza/pneumonia mortality is not explained by reduction of COPD-related mortality risks. Univariate statistics were used to test the association of demographic and clinical characteristics with all-cause 30- and 90-day mortality. The cohort consisted of 582 (78%) males and 162 (22%) females. Previous studies indicate that the two inhaled corticosteroid/long acting β2 agonist treatments investigated in our present study are equally effective at decreasing exacerbations and improving quality of life in patients with COPD,10 although in a separate analysis of the present study population, budesonide/formoterol was associated with fewer exacerbations than fluticasone/salmeterol.29 This difference was, however, smaller than the difference in the incidence of pneumonia between the two treatment alternatives. The authors appreciate the assistance of A. Torres in preparing the manuscript and editorial support. This rule was based on three demographic characteristics, five comorbid illnesses, five physical examination findings, and seven laboratory and radiographic findings from the time of presentation. People with chronic obstructive pulmonary disease (COPD) who … Bacter… AMI, HF, Pneumonia (PN) Readmission Updates (ZIP) Chronic Obstructive Pulmonary Disease (COPD) Mortality (ZIP) Chronic Obstructive Pulmonary Disease (COPD) Readmission (ZIP) The COPD group had a higher mean pneumonia severity index score (105+/-32 versus 87+/-34) and were admitted to the intensive care unit more frequently (25 versus 18%). UK deaths from COPD compared with other lung diseases, 2012 . Key words: chronic obstructive pulmonary disease, meta-analysis, morbidity, mortality, pneumonia. Data management and statistical analyses were performed with SAS version 9.2 (SAS Institute, Cary, NC, US). We included all male and female patients of any age with COPD diagnosed by a physician (ICD-10 code J44, according to the 2011 ICD-10-CM). Pneumonia is dangerous, because it reduces the amount of oxygen in the body. All authors analysed and interpreted the data, revised the manuscript, had access to complete study data, and had authority over manuscript preparation, approval of final version and the decision to submit for publication. 32 Therefore, an increase in pneumonia associated with inhaled corticosteroids would be expected to result in increased mortality. The choice of appropriate empirical antibiotic regimens depends on several factors, including the aetiology of CAP. Categorical variables were analysed using the Chi-squared test and continuous variables using an unpaired t-test. Community-acquired pneumonia (CAP) refers to pneumonia (any of several lung diseases) contracted by a person outside of the healthcare system. The accuracy and severity of the physician diagnoses of COPD could also not be fully verified by spirometry in all cases. The present NMA including all available RCTs provided that there is no strong evidence suggesting different benefits among LAMA/LABAs in patients with stable COPD who have been … All cause mortality did not differ between the treatments (1.08, 0.93 to 1.14; P=0.59). Further, it is unknown how this interaction changes over time. Trial registration Clinical Trials.gov NCT01146392. However, there were no other significant differences between other pathogens in either group. Our findings showed no dose-response relation with regard to increased risk of pneumonia with the two treatments—that is, any excess risk was linked with the choice of inhaled corticosteroid/long acting β2 agonist and not the dose prescribed and collected by the patient. Administration of antibiotics within 4 h occurred more commonly in COPD patients (35 versus 26%; p = 0.02). Data collection was performed by Pygargus AB, Uppsala, Sweden, and funded by AstraZeneca. Main outcome measures Yearly pneumonia event rates, admission to hospital related to pneumonia, and mortality. Fig 1 Cumulative number of pneumonia events and admissions to hospital because of pneumonia per patient over nine years after index date, Fig 2 Distribution of number of pneumonia events per patient by treatment (budesonide/formoterol v fluticasone/salmeterol), Pneumonia events by type for pairwise (1:1) propensity score matched populations treated with budesonide/formoterol versus fluticasone/salmeterol for COPD. A patient was considered to have CAP of unknown cause if no diagnostic tests were performed, or tests were performed but test results did not meet criteria for assigning a microbiological cause (including a contaminant pathogen). Relevant anonymised patient level data are available on reasonable request from the authors. These data confirm that COPD should be considered for inclusion as a comorbid condition for pneumonia severity of illness measures. The present study showed that hospitalised CAP patients with COPD show higher mortality at 30- and 90-days compared to patients without CAP. The present study has several limitations that are important to acknowledge. The Swedish National Board of Health and Welfare performed the data linkage. Comparative effectiveness data from observational databases of propensity matched cohorts provide an alternative means to balance study groups to minimise bias when randomisation is not possible.16 In this long term observational cohort study matched for propensity score we investigated the incidence of pneumonia and events related to pneumonia, including mortality, in a population with COPD treated with fixed combinations of inhaled corticosteroid/long acting β2 agonist (fluticasone/salmeterol or budesonide/formoterol) using data based on linkage of electronic primary care medical records with national Swedish healthcare registers. The mean age in the respective quarters, from low to very high burden, was 65.4, 66.2, 68.1, and 70.9, and the number of previous pneumonia events/year was 0.06, 0.10, 0.15, and 0.24. In addition, COPD patients with CAP were more tachypnoeic, acidotic and hypoxaemic. The cumulative number of pneumonia events showed a uniform pattern over time (fig 1⇓) and was independent of time after index date. Chronic obstructive pulmonary disease patients hospitalised with community-acquired pneumonia exhibited higher 30- and 90-day mortality than patients without chronic obstructive pulmonary disease. AstraZeneca was a member of the study steering committee that carried overall responsibility for the study concept and design. This is in contrast to patients either referred to hospital with COPD or diagnosed with COPD at hospitals, who are more likely to suffer from more severe COPD. Time to first pneumonia event and death related to pneumonia was compared between treatments with Cox regression after tests for constant hazard ratio versus time, with time calculated as the difference between index date and event date for patients on the same fixed combination treatment as at index date. Corticosteroid inhalation yields high local concentrations of the drug in the lungs and could increase the risk pneumonia because of their immunosuppressive effects.30 As the immunosuppressant potency of fluticasone is reported to be up to 10-fold higher than that of budesonide with regard to ex vivo inhibition of human alveolar macrophage innate immune response to bacterial triggers,31 this factor alone could explain our findings. Furthermore, our analysis shows no association between the length of admissions related to pneumonia or all cause mortality based on inhaled corticosteroid use or type, suggesting that any increased risk of mortality associated with pneumonia was probably related to the initial diagnosis of pneumonia and not the ability to successfully manage these events, which is in keeping with the findings of Ernst and colleagues.11 12 Other COPD registry studies, which did not find an association between inhaled corticosteroid use and mortality related to pneumonia, have followed patients only after arrival at hospital.28 In the INSPIRE study, a significant excess of antibiotic driven exacerbations of COPD and a significant increase in pneumonia events was observed in patients treated with fluticasone/salmeterol compared with those treated with tiotropium.12 These excess pneumonia events observed during fluticasone/salmeterol treatment were not related to de novo events without associated exacerbations but were apparent only after unresolved exacerbations.3 In our study, the incidence of pneumonia was also clustered to a greater degree with previous events in the fluticasone/salmeterol group, so while the risk of a first pneumonia was 25% greater with fluticasone/salmeterol versus budesonide/formoterol, the difference in overall event rate was about 75% higher. 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Can CAP guideline adherence improve patient outcome in internal medicine departments depends on several factors, the.

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