According to the Centers for Disease Control and Prevention (CDC), an estimated … Sign In to Email Alerts with your Email Address, COPD is associated with increased mortality in patients with community-acquired pneumonia, Adherence to guidelines’ empirical antibiotic recommendations and community-acquired pneumonia outcome. 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. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. If you are unable to import citations, please contact Pneumonia events occurring within 14 days were counted as one single event, if not otherwise specified. There were no differences in mortality within 30 or 90 days for CAP patients with COPD who needed ICU admission, received mechanical ventilation or were bacteraemic (table 3⇓). This observation, combined with evidence of short-term morbidity, increased risk for new onset HF , and excess early and late mortality in adults with comorbidity consequent and following pneumonia, led us to hypothesize that in adults with underlying HF or COPD, pneumonia has an adverse impact on the pre-existing condition subsequent to the acute phase of the pneumonia … COPD is the fourth leading cause of death, while pneumonia and flu contribute to the eighth leading cause of death … The PSI is a validated prediction rule for 30-day mortality in patients with CAP 10. We aimed to determine whether patients with concomitant community‐acquired pneumonia (CAP) and chronic obstructive pulmonary disease (COPD) are at greater risk of death when compared with those with CAP or acute COPD exacerbation alone. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. After adjusting for severity of disease and processes of care, CAP patients with COPD showed significantly higher 30- and 90-day mortality than non-COPD patients. The external validity of our findings to the treatment of COPD in general practice might, therefore, be greater than for controlled clinical trials. Your struggle to properly breathe has intensified to an unparalleled degree. However, the main difference, compared with the present study, was the lack of a comparison group of CAP patients without COPD, which limited their ability to compare clinical outcomes. Variables were included in the survival analysis if they had either been previously demonstrated to be associated with CAP-related outcomes (e.g. See: http://creativecommons.org/licenses/by-nc/3.0/. These include the decision to hospitalise the patient, the length of inpatient care if the patient is hospitalised, and the choice of antimicrobial or other types of immediate therapy. 1 CAP has been consistently reported to cause significant mortality and morbidity, 2-4 representing the ninth leading cause of death… 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. 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. The pneumonia rate was 73% higher with fluticasone/salmeterol than with budesonide/formoterol (rate ratio 1.73, 95% confidence interval 1.57 to 1.90; P<0.001), with event rates of 11.0 (10.4 to 11.8) and 6.4 (6.0 to 6.9) per 100 patient years, respectively. 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). Patients were censored when they switched to the other fixed combination and when they left the study because of death or immigration. 15 22 This study aims to explore the prognostic indicators for in-hospital mortality in AECOPD patients admitted to a tertiar y care centre in Thailand, a developing country. The present data support the IDSA 14 and ATS 15 clinical practice treatment guidelines, which recommend stratifying patients based on the presence of coexisting cardiopulmonary disease (COPD and congestive heart failure) in order to select an appropriate antimicrobial agent. Similarly, admission to hospital related to pneumonia was 74% higher in the fluticasone/salmeterol treatment group than the budesonide/formoterol group (rate ratio 1.74, 1.56 to 1.94; P<0.001; NNT=34, 24 to 59), with a corresponding 82% increase in days in hospital (53 v 29 days per 100 patient years, respectively; P<0.001; table 2⇓). An aetiological diagnosis could not be obtained in 77% of the cohort. Usefulness of consecutive C-reactive protein measurements in follow-up of severe community-acquired pneumonia, Original Articles: Community-acquired pneumonia. Find out how pneumonia differs from other lung infections, and how this condition is treated. It can … Most people reach it after years of living with the disease and the lung damage it causes. Other studies have found that P. aeruginosa is an important pathogen in patients with pulmonary comorbid conditions, especially those with bronchiectasis 3, 23, 24. 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. It also increases the risks of pneumonia. All cause mortality did not differ between the treatments (1.08, 0.93 to 1.14; P=0.59). Patients hospitalized for COPD who carry a secondary diagnosis of pneumonia have a 30-day mortality … It is unclear whether concurrent pneumonia and chronic obstructive pulmonary disease (COPD) have a higher mortality than either condition alone. The difference remained when we included the beclometasone diproprionate equivalent dose as a covariate in the Poisson regression. The present authors believe that this difference was found by examining only patients with COPD, and excluding other pulmonary conditions, including asthma, bronchiectasis and interstitial lung disease. Patients treated with either treatment combination were matched on the following criteria during the two years before index and at index: age; sex; available lung function measurements; number of prescriptions for antibiotics, oral steroids, tiotropium, ipratropium, inhaled corticosteroids, short acting β2 agonists, long acting β2 agonists, angiotensin receptor blockers, β blockers, statins, calcium antagonists, and thiazides; diagnosis of diabetes, asthma, cancer, rheumatoid arthritis, heart failure, hypertension, and stroke; and number of previous admissions to hospital. The present study has several limitations that are important to acknowledge. Death rates declined for men but remained unchanged for women. Project management was provided by AstraZeneca. PLoS One 2014; 9: e87382.CrossRef Google Scholar PubMed. The pneumonia event rate per 100 patient years for fluticasone/salmeterol versus budesonide/formoterol was 11.0 (10.4 to 11.8) versus 6.4 (6.0 to 6.9) and the rate of admission to hospital was 7.4 (6.9 to 8.0) versus 4.3 (3.9 to 4.6). Objective To investigate the occurrence of pneumonia and pneumonia related events in patients with chronic obstructive pulmonary disease (COPD) treated with two different fixed combinations of inhaled corticosteroid/long acting β2 agonist. There were no significant differences in the rate of oxygenation status assessment. 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). It can result in serious complications. Pulmonary function data could be helpful in predicting which patients with COPD might show the highest morbidity and mortality when they develop CAP. Thank you for your interest in spreading the word on European Respiratory Society . The PSI was used to assess severity of illness on presentation. … Notwithstanding these limitations, our study also has several important strengths, not least the primary care setting used to initially identify patients with COPD, without restrictions in age, employment status, concomitant drug treatments, comorbidities, and healthcare insurance. Pneumonia is a common complication of COPD, which is associated with considerable morbidity, mortality, and health costs, Treatment with inhaled corticosteroids and long acting β2 agonists (fixed dose combinations) can increase the risk of pneumonia in these patients, though it is not known if there is a variation in risk between different combinations, This observational matched cohort study indicated that there is an intraclass difference between fixed combinations of inhaled corticosteroid/long acting β2 agonist with regard to risk of pneumonia and pneumonia related events in patients with COPD. Pneumonia is a serious complication of COPD. While neither of these conditions is necessarily fatal, when they are the main difference is speed. Categorical variables were analysed using the Chi-squared test and continuous variables using an unpaired t-test. Patients were followed from January 1999 until December 2009; the index date was defined as the date of the first prescription of fixed combination treatment after a diagnosis of COPD. Time to first pneumonia event was defined as the time from the index date to the first pneumonia event (ICD-10 codes as above). History of COPD was entered into the model as an independent dichotomised variable, and PSI score was used as the risk adjustment tool 10. 22 Cilloniz, C, Dominedo, C, Magdaleno, D, Ferrer, M, Gabarrus, A, Torres, A. When two or more microbiological causes were present, the cause was classified as polymicrobial pathogens. However, it was not possible to collect data regarding pulmonary function tests or COPD disease severity. Pneumonia is an important complication of COPD and is reported more often in patients receiving inhaled corticosteroids (ICSs). 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⇓. A large observational study identified a dose related association between inhaled corticosteroid and an increased incidence of admissions to hospital related to pneumonia and mortality in 175 906 older patients with COPD.11 In randomised controlled trials, fluticasone alone or in combination with salmeterol has been linked with increases in the incidence of pneumonia compared with alternative bronchodilator regimens.7 10 12 In the TORCH trial, the absolute risk of pneumonia with salmeterol/fluticasone also increased with GOLD stage.7 13 In a large meta-analysis in COPD, budesonide was not associated with an increased risk of pneumonia.14 With the Buscher method for indirect comparisons between clinical trials with a common placebo comparator, budesonide/formoterol was associated with significantly fewer adverse events related to pneumonia and serious adverse events than fluticasone/salmeterol.15 While these data suggest intraclass differences in combination treatments with pneumonia as an adverse event, definitive conclusions are limited by the lack of long term head to head trials in patients with COPD.15. Hospitalised CAP patients with COPD showed more infections attributable to Pseudomonas aeruginosa, a trend of higher rates of Haemophilus influenzae, but less S. aureus than patients without COPD (table 2⇓). Unmatched and pairwise (1:1) propensity matched populations are shown. There were no significant differences among the LAMA/LABA combinations in terms of the number of moderate to severe exacerbations, all-cause mortality, major adverse cardiovascular events, or pneumonia. All P<0.001, Poisson regression. 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)⇓). Patients eligible for matching were receiving fixed combinations of inhaled corticosteroid/long acting β2 agonist (budesonide/formoterol Turbuhaler or fluticasone/salmeterol Diskus). Smoking status was similar in the two matched populations but did not constitute a matching variable (table 1).⇑. 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. 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. In addition, COPD patients with CAP showed higher rates of congestive heart failure and a history of neoplastic disease. The present data show that P. aeruginosa was the second-most-common organism in patients with COPD; therefore, appropriate anti-pseudomonal coverage should be considered in patients with COPD, whether or not bronchiectasis is present. (See "Nonresolving pneumonia".) This corresponded to a 76% increase in risk of mortality related to pneumonia with fluticasone/salmeterol versus budesonide/formoterol (hazard ratio 1.76, 95% confidence interval 1.22 to 2.53; P=0.003; fig 4⇓). One or more concomitant comorbid medical conditions were present in 635 (85%) patients. 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. These results are based on retrospective observational data and, although the included patients were matched pairwise with respect to several variables, there could still be possible unknown confounding factors. In COPD your oxygen and carbon dioxide levels gradually worsen. 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. 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. A considerable proportion of patients with stable COPD show a spectrum of pathogens colonising the lower airways.34 This bacterial load increases during exacerbations compared with the stable state35; consequently, COPD exacerbations might be associated with pneumonia in patients treated with inhaled fluticasone to a greater extent than budesonide. Fortunately, there are simple things you can do. 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). People with COPD … For this study cohort, the median length of stay was longer by 2 days in COPD versus non-COPD patients (7±8 versus 9±25 days; p = 0.05). 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. It is unclear whether concurrent pneumonia and chronic obstructive pulmonary disease (COPD) have a higher mortality than either condition alone. Diabetes, obesity, COPD, and tobacco smoking are not associated with an increased risk of dying from pneumonia. Statistical Methods for Survival Data Analysis. In addition, COPD patients with CAP were more tachypnoeic, acidotic and hypoxaemic. Mortality — Although the majority of patient with CAP recover without complications, CAP is a severe illness and among the leading causes of mortality worldwide. KHL has received speaking fees from AstraZeneca, Boehringer Ingelheim, and Merck Sharp and Dohme. We used the latest time point alive to censor patients without an event. Introduction. The mean duration of admission for pneumonia was similar in both groups (fluticasone/salmeterol 6.5 (SD 6.6) v budesonide/formoterol 7.1 (SD 7.2) days; P=0.12). Relevant anonymised patient level data are available on reasonable request from the authors. A new study examines the mortality risk factors among COPD patients hospitalized with community acquired pneumonia. mL-1 in bronchoalveolar lavage fluid). The accuracy and severity of the physician diagnoses of COPD could also not be fully verified by spirometry in all cases. The propensity score method has previously been used to reduce potential confounding caused by unbalanced covariates.19 20 The matching starts with the smallest population (2738 patients in the fluticasone/salmeterol group) and matches 1:1 to the larger treatment group. We also assessed the effect of inhaled corticosteroids (ICS) on pneumonia mortality … We do not capture any email address. The literature on the interaction between COPD and VAP is scarce and controversial. Baseline characteristics in two years before first prescription for inhaled corticosteroid/long acting β2 agonist after diagnosis of COPD according to fixed combination treatment. 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. Can CAP guideline adherence improve patient outcome in internal medicine departments? 1⇓). In 2004, the COPD death rate was 72.9 per 100,000 people, declining to 67.4 by 2018. The overall 30- and 90-day mortality were 10 and 14%, respectively. Chronic obstructive pulmonary disease should be evaluated for inclusion in community-acquired pneumonia … There were significantly more pneumonia events in patients treated with fluticasone/salmeterol than with budesonide/formoterol (table 2⇓). pneumonia who previously would have been counted in the pneumonia measure (Figure 1). What happens when you die of copd or pneumonia? Updated 2011. The incidence of pneumonia increased in both treatment groups with increasing disease burden, evidenced by the analysis of pneumonia rate by quarter of baseline propensity score (fig 3⇓). The difference in pneumonia rates between the treatment groups was larger in patients with a higher disease burden. The unadjusted mortality was lower for non-COPD patients than COPD patients: 30 day, 8.7 versus 10.6% (p = 0.4); 90 day, 11.7 versus 18.6% (p = 0.013). Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: CJ has received honorariums for educational activities from AstraZeneca, GlaxoSmithKline, and Merck Sharp and Dohme. Secondly, the present sample was predominantly male since one of the sites was a Veterans Administration hospital and so it was not possible to examine whether or not females with COPD and CAP may exhibit a different clinical course, or outcomes, compared with males. 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 … NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. 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⇓). Main outcome measures Yearly pneumonia event rates, admission to hospital related to pneumonia, and mortality. COPD makes it hard to breathe in as much air as you need. Figures are means (SD) unless specified otherwise, Pairwise matching (1:1) of the budesonide/formoterol and fluticasone/salmeterol populations resulted in two similar cohorts of 2734 patients each (table 1⇑). In contrast, hospital-acquired pneumonia (HAP) is seen in patients who have recently visited a hospital or who live in long-term care facilities. Pure viral sepsis secondary to community-acquired pneumonia in adults: risk and prognostic factors. Bacterial respiratory infections are generally more aggressive than viral. Whether other unknown risks of pneumonia that were not adequately controlled for in this matched cohort study contributed to our findings remains uncertain. How many … 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. AstraZeneca was a member of the study steering committee that carried overall responsibility for the study concept and design. Enter multiple addresses on separate lines or separate them with commas. COPD is considered a risk factor for the development of CAP, and previous studies of CAP including outpatient, inpatient and ICU cohorts have shown that COPD is a frequently reported comorbid condition 3, 4, 9, 17–22. Proceedings of the Twenty-Sixth Annual SAS Users Group International Conference. The corresponding number needed to treat (NNT) to avoid one pneumonia event per year was 23 (95% confidence interval 18 to 37). All P<0.001, Poisson regression. Although COPD prevalence in COVID-19 cases was low in current reports, COVID-19 infection was associated with substantial severity and mortality rates in COPD. GS, HG, and LJ are fulltime employees of AstraZeneca Nordic. The present study showed that hospitalised CAP patients with COPD show higher mortality at 30- and 90-days compared to patients without CAP. Aortic stenosis is a common heart-related comorbidity associated with COPD. Young children, cigarette smokers, adults over 65 and people with certain medical problems including COPD are at greater risk for developing pneumonia. The magnitude of the intraclass difference in pneumonia needs to be put in context with the benefits of each regimen in preventing exacerbations. Ventilator-associated pneumonia (VAP) is the … Diabetes, COPD, and chronic renal disease (CRD) were present in 5892 (16.3%), 4337 (12%), and 4106 (11.4%) of the patients, respectively . 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 … Statin use was defined as having a statin for at least 90 consecutive days after inclusion. 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. Community-acquired pneumonia (CAP) is one of the most frequent medical causes of hospital admission and still carries a high morbidity and mortality. 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. Matched cohort studies of this type are not without limitations. 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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And severity of illness measures CAP guideline adherence improve patient outcome in internal medicine?. Little is known about the clinical course and factors predisposing to pneumonia, Merck... On separate lines or separate them with commas most common infectious diseases worldwide and remains a major public challenge!