Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Road, Chao-yang District, Beijing, China.
Department of Respiratory Medicine, Qingdao Municipal Hospital Group, Jiaozhou Road, Qingdao City, Shandong Province, China.
BMC Infect Dis. 2018 Apr 24;18(1):192. doi: 10.1186/s12879-018-3098-5.
Limited information exists on the clinical characteristics predictive of mortality in patients aged ≥65 years in many countries. The impact of adherence to current antimicrobial guidelines on the mortality of hospitalized elderly patients with community-acquired pneumonia (CAP) has never been assessed.
A total of 3131 patients aged ≥65 years were enrolled from a multi-center, retrospective, observational study initiated by the CAP-China network. Risk factors for death were screened with multivariable logistic regression analysis, with emphasis on the evaluation of age, comorbidities and antimicrobial treatment regimen with regard to the current Chinese CAP guidelines.
The mean age of the study population was 77.4 ± 7.4 years. Overall in-hospital and 60-day mortality were 5.7% and 7.6%, respectively; these rates were three-fold higher in those aged ≥85 years than in the 65-74 group (11.9% versus 3.2% for in-hospital mortality and 14.1% versus 4.7% for 60-day mortality, respectively). The mortality was significantly higher among patients with comorbidities compared with those who were otherwise healthy. According to the 2016 Chinese CAP guidelines, 62.1% of patients (1907/3073) received non-adherent treatment. For general-ward patients without risk factors for Pseudomonas aeruginosa (PA) infection (n = 2258), 52.3% (1094/2090) were over-treated, characterized by monotherapy with an anti-pseudomonal β-lactam or combination with fluoroquinolone + β-lactam; while 71.4% of intensive care unit (ICU) patients (120/168) were undertreated, without coverage of atypical bacteria. Among patients with risk factors for PA infection (n = 815), 22.9% (165/722) of those in the general ward and 74.2% of those in the ICU (69/93) were undertreated, using regimens without anti-pseudomonal activity. The independent predictors of 60-day mortality were age, long-term bedridden status, congestive heart failure, CURB-65, glucose, heart rate, arterial oxygen saturation (SaO) and albumin levels.
Overtreatment in general-ward patients and undertreatment in ICU patients were critical problems. Compliance with Chinese guidelines will require fundamental changes in standard-of-care treatment patterns. The data included herein may facilitate early identification of patients at increased risk of mortality.
The study was registered at ClinicalTrials.gov ( NCT02489578 ).
在许多国家，年龄≥65 岁的患者的临床特征与死亡率相关的信息有限。目前还没有评估符合当前抗菌药物指南的情况下，住院老年社区获得性肺炎（CAP）患者的死亡率。
这项多中心、回顾性、观察性研究共纳入了 3131 名年龄≥65 岁的患者，该研究由 CAP-China 网络发起。采用多变量逻辑回归分析筛选死亡的危险因素，重点评估年龄、合并症以及抗菌药物治疗方案与当前中国 CAP 指南的一致性。
研究人群的平均年龄为 77.4±7.4 岁。总的住院死亡率和 60 天死亡率分别为 5.7%和 7.6%；≥85 岁组的住院死亡率和 60 天死亡率分别是 65-74 岁组的 3 倍（11.9%对 3.2%，14.1%对 4.7%）。与无合并症的患者相比，有合并症的患者死亡率显著升高。根据 2016 年中国 CAP 指南，62.1%（1907/3073）的患者接受了不规范治疗。对于无铜绿假单胞菌（PA）感染危险因素的普通病房患者（n=2258），52.3%（1094/2090）接受了过度治疗，表现为使用抗假单胞菌β-内酰胺类药物单药治疗或联合使用氟喹诺酮类药物+β-内酰胺类药物；而重症监护病房（ICU）患者（n=120）接受了不充分治疗，未覆盖非典型病原体，比例为 71.4%（71.4%）。在有 PA 感染危险因素的患者（n=815）中，普通病房患者中有 22.9%（165/722）和 ICU 患者中有 74.2%（69/93）接受了不规范治疗，使用的治疗方案无抗假单胞菌活性。60 天死亡率的独立预测因素为年龄、长期卧床、充血性心力衰竭、CURB-65、血糖、心率、动脉血氧饱和度（SaO2）和白蛋白水平。
普通病房患者过度治疗和 ICU 患者治疗不足是关键问题。要符合中国指南的要求，就必须对标准治疗模式进行根本改变。本文中的数据可能有助于早期识别死亡率增加的患者。
本研究在 ClinicalTrials.gov 注册（NCT02489578）。
