Accepted Manuscript Risk Factors for Slowly Resolving Pneumonia in the Intensive Care Unit Meiling Li , MD, Jialin Liu , MD PhD, Ruoming Tan , MD, Zhaojun Liu , MD, Jianyong Yin , MD, Hongping Qu , MD PII:
S1684-1182(14)00235-7
DOI:
10.1016/j.jmii.2014.11.005
Reference:
JMII 571
To appear in:
Journal of Microbiology, Immunology and Infection
Received Date: 18 September 2013 Revised Date:
2 June 2014
Accepted Date: 6 November 2014
Please cite this article as: Li M, Liu J, Tan R, Liu Z, Yin J, Qu H, Risk Factors for Slowly Resolving Pneumonia in the Intensive Care Unit, Journal of Microbiology, Immunology and Infection (2014), doi: 10.1016/j.jmii.2014.11.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title page
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Title: Risk Factors for Slowly Resolving Pneumonia in the Intensive Care Unit
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Running title: a retrospective and cohort-based study among ICU in a
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university-affiliated hospital in Shanghai
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Meiling Li1†,MD; Jialin Liu2,MD, PhD; Ruoming Tan1,MD; Zhaojun Liu1,MD;
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Jianyong Yin1, MD Hongping Qu1†*,MD;
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1 Department of Critical Care Medicine and Respiratory intensive care unit, Ruijin
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Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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2 Department of Pulmonary Medicine, Ruijin Hospital, Shanghai Jiao Tong
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University School of Medicine, Shanghai, China
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† Co-authers, these authors contributed equally to this work
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Email address (Meiling Li):
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Name: Hongping Qu
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Institution: Department of Critical Care Medicine and Respiratory intensive care unit
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Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Address: 197 Rui-Jin Er Rd., Bld. 36, Shanghai 200025, China
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E-mail:
[email protected] 21
Tel: 86-021-64370045 Ext. 680901
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Fax: 86-021-64674301
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Corresponding author
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Statement
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All authors declare that they have no financial or other potential conflicts of interest
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and never submitted the manuscript, in whole or in part, to other journals.
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Abstract
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Background: Slowly resolving pneumonia poses early identified challenges and
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medical costs abandon for clinicians with few literatures among ICU.
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Methods: This was a retrospective and cohort-based study among ICU in a
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university-affiliated hospital in Shanghai. Medical records of pneumonia patients in
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ICU between April 2008 and February 2011were reviewed retrospectively to evaluate
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the risk factors for slowly resolving pneumonia.
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Results: In all, 106 pneumonia patients among ICU were identified as
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immune-competent bacteritic pneumonia. There were 62
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showed slowly resolving pneumonia and their radiographic infiltrations were
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completely resolved from five to eight weeks. The multivariate logistic regression
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analysis demonstrated that initial treatment with an inappropriate antibiotic use,
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multi-lobar infiltration and a high CURB-65 score were independent risk factors for
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slowly resolving pneumonia, with OR values of 8.338 (95% CI 2.117-32.848), 11.184
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(95% CI 2.526-49.514) and 2.329 (95% CI 1.172-4.626), respectively. The length of
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the ICU stay in the slowly resolving pneumonia group was twice longer than in the
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normally resolving pneumonia group (62.27±73.73 vs. 32.25±23, p=0.002). The
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28-day and 60-day mortality rates in the slowly resolving pneumonia group were
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17.74% and 25.81%, respectively. In addition, the 60-day mortality rate was
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significantly higher in the SRP group than the NRP group (25.81% vs. 6.82%,
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respectively; p=0.012).Moreover, slowly resolving pneumonia was an independent
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risk factor for 60-day mortality (OR 5.687, 95% CI 1.334-24.240).
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58.49% patients who
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Conclusions: Treatment with an inappropriate antibiotic, multi-lobar infiltration and a
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high CURB-65 score were independent risk factors for slowly resolving pneumonia.
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Key words
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Pneumonia; resolution; antibiotic therapy; radiographic infiltrations; critically ill; risk
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factors
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Introduction
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The unapparent resolution of pulmonary infiltrates includes both non-resolving
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and slowly resolving pneumonia (SRP) poses diagnostic and treatment challenges for
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clinicians as a common consultation problem.1,2 Non-resolving pneumonia often
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represents a noninfectious process that mimics an infectious process.3,4 Slowly
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resolving pneumonia is usually associated with host- or treatment-related factors.5,6
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Advances in the procedures used to diagnose pneumonia have led to a declining
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incidence of non-resolving pneumonia, while the incidence of slowly resolving
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pneumonia is definitely rising with multiple supporting methods.7,8 Kirtland and
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Winterbauer first proposed a definition of slowly resolving pneumonia that referred to
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immune-competent patients who exhibited improved clinical symptoms with
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antibiotic therapy and chest radiographs with less than 50% clearing by 2 weeks or
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less than complete clearing at 4 weeks.9,10 To date, the literature concerning slowly
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resolving pneumonia was too limited to evaluate or treat slowly resolving pneumonia.
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Although the precise incidence of slowly resolving pneumonia is not well established,
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early studies reported that 25-67% of the pulmonary infiltration of pneumonia patients
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showed delayed resolution along with high mortality,11 prolonged hospital stays and
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high treatment costs.8 Some studies on critically ill patients found that as many as
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47% of pneumonia cases showed delayed resolution.12 Due to its high incidence and
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poor outcome, the recognition and resolution of slowly resolving pneumonia in the
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ICU deserve more attention from clinicians.
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The objective of this study was to investigate the incidence, length of ICU stay, 5
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outcome and risk factors associated with slowly resolving pneumonia in critically ill
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patients to promote the identification of high-risk patients.
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Materials and Methods
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Ethical Statements
We did no harm to participants and just evaluated radiographic resolution and
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clinical features of participants. We promised to hold all the information of
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participants as a confidential manner. The study protocol and consent procedure with
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waiver of written consent was approved by the Shanghai Jiao Tong University School
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of Medicine affiliated Ruijin Hospital Ethics Committee.
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Study Population
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The study group was sampled from patients who were admitted to the intensive
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care unit in a 1,300-bed university-affiliated hospital with a diagnosis of pneumoniaa
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between April 2008 and February 2011. The inclusion criteria included pneumonia
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patients who reached clinical stabilityb due to treatment in ICU with a complete
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resolution or resolution of infiltrate differentiated from chronic changes. The
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exclusion criteria included patients with immunodepressionc, interstitial pneumonia,
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pulmonary tumor, pulmonary tuberculosis, H1N1 and other respiratory tract virus
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legionnaires pneumonia, mycoplasma pneumonia, chlamydia pneumonia and acute
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respiratory distress syndrome.
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a
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Pneumonia was defined as a new or progressive infiltrate as seen on a chest 6
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radiograph or CT scan along with a high clinical suspicious of pneumonia, defined
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with at least one of the following: fever (>38
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leukocytosis (>12000 WBC/mm3), altered mental status with no other recognized
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cause (for adults older than 70 years),and at least two of the following: (a) new onset
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of purulent sputum, or change in character of sputum, or increased respiratory
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secretions, or increased suctioning requirements,(b) new onset or worsening cough, or
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dyspnea, or increased ventilation demand.
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b
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a respiratory rate ≤24 breaths/min, systolic blood pressure ≥90 mmHg, arterial oxygen
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saturation ≥90% or PaO2 ≥ 60mmHg in room air, the ability to maintain oral intake
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and a normal mental status.10
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c
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neutrophils/L for 110 days); the receipt of an allogeneic stem cell transplant; the
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prolonged use of corticosteroids (a mean minimum dose of 0.3 mg of prednisone
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equivalent/kg/day for 13 weeks); treatment with another recognized T cell suppressant
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such as cyclosporine, TNF-a blockers, specific monoclonal antibodies, or nucleoside
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analogs during the past 90 days; or inherited severe immunodeficiency (such as
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chronic granulomatous disease or severe combined immunodeficiency). 13
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, a heart rate ≤100 beats/min,
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Clinical stability was defined as a temperature ≤37.8
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Immunodepression was defined as a recent history of neutropenia (