Li Lijuan, Hsu Steven H, Gu Xiaoying, Jiang Shan, Shang Lianhan, Sun Guolei, Sun Lingxiao, Zhang Li, Wang Chuan, Ren Yali, Wang Jinxiang, Pan Jianliang, Liu Jiangbo, Bin Cao
Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China.
Department of Medical Intensive Care Unit, Houston Methodist Hospital, Houston, Texas, USA.
BMJ Open. 2020 Oct 27;10(10):e037419. doi: 10.1136/bmjopen-2020-037419.
Long-term use of high-dose glucocorticoids can lead to severe immunosuppression and increased risk of treatment-resistant pneumonia and mortality. We investigated the aetiology and prognostic risk factors of mortality in hospitalised patients who developed pneumonia while receiving glucocorticoid therapy alone or glucocorticoid and other immunosuppressant therapies.
Retrospective cohort study.
Six secondary and tertiary academic hospitals in China.
Patients receiving glucocorticoids who were hospitalised with pneumonia between 1 January 2013 and 31 December 2019.
We analysed the prevalence of comorbidities, microbiology, antibiotic susceptibility patterns, 30-day and 90-day mortality and prognostic risk factors.
CONCLUSIONS: A total of 716 patients were included, with pneumonia pathogens identified in 69.8% of patients. Significant morbidities occurred, including respiratory failure (50.8%), intensive care unit transfer (40.8%) and mechanical ventilation (36%), with a 90-day mortality of 26.0%. Diagnosis of pneumonia occurred within 6 months of glucocorticoid initiation for 69.7% of patients with (CMV) pneumonia and 79.0% of patients with pneumonia (PCP). Pathogens, including , CMV and multidrug-resistant bacteria, were identified more frequently in patients with persistent lymphocytopenia and high-dose glucocorticoid treatment (≥30 mg/day of prednisolone or equivalent within 30 days before admission). The 90-day mortality was significantly lower for non-CMV viral pneumonias than for PCP (p<0.05), with a similar mortality as CMV pneumonias (24.2% vs 38.1% vs 27.4%, respectively). Cox regression analysis indicated several independent negative predictors for mortality in this patient population, including septic shock, respiratory failure, persistent lymphocytopenia, interstitial lung disease and high-dose glucocorticoid use.Patients who developed pneumonia while receiving glucocorticoid therapy experienced high rates of opportunistic infections, with significant morbidity and mortality. These findings should be carefully considered when determining treatment strategies for this patient population.
长期使用高剂量糖皮质激素可导致严重免疫抑制，并增加治疗抵抗性肺炎和死亡风险。我们调查了单独接受糖皮质激素治疗或接受糖皮质激素与其他免疫抑制剂联合治疗的住院患者发生肺炎时的死亡病因和预后风险因素。
回顾性队列研究。
中国的6家二级和三级学术医院。
2013年1月1日至2019年12月31日期间因肺炎住院且接受糖皮质激素治疗的患者。
我们分析了合并症的患病率、微生物学、抗生素敏感性模式、30天和90天死亡率以及预后风险因素。
结论：共纳入716例患者，69.8%的患者鉴定出肺炎病原体。出现了显著的合并症，包括呼吸衰竭（50.8%）、转入重症监护病房（40.8%）和机械通气（36%），90天死亡率为26.0%。69.7%的巨细胞病毒（CMV）肺炎患者和79.0%的肺孢子菌肺炎（PCP）患者在开始使用糖皮质激素后6个月内诊断出肺炎。在持续性淋巴细胞减少和接受高剂量糖皮质激素治疗（入院前30天内泼尼松龙或等效药物≥30mg/天）的患者中，更频繁地鉴定出病原体，包括肺孢子菌、CMV和多重耐药菌。非CMV病毒性肺炎的90天死亡率显著低于PCP（p<0.05），与CMV肺炎的死亡率相似（分别为24.2%、38.1%和27.4%）。Cox回归分析表明，该患者群体中几个独立的死亡负性预测因素包括感染性休克、呼吸衰竭、持续性淋巴细胞减少、间质性肺疾病和高剂量糖皮质激素的使用。接受糖皮质激素治疗时发生肺炎的患者机会性感染率高，发病率和死亡率显著。在确定该患者群体的治疗策略时，应仔细考虑这些发现。
