Compared with non-users, new users of higher-dose cannabinoids had a 178% relative increase in hospitalisation for COPD or pneumonia and a 231% relative increase in all-cause mortality. European Respiratory Society442 Glossop RoadSheffield S10 2PXUnited KingdomTel: +44 114 2672860Email: journals@ersnet.org, Print ISSN:  0903-1936 The organisms most frequently involved were Streptococcus pneumoniae (56 cases) and Staphylococcus aureus (39 cases). With that being said, bacterial pneumonia tends to be more severe than its viral cousin, especially within the context of COPD. Bacterial respiratory infections are generally more aggressive than viral. Baseline characteristics in two years before first prescription for inhaled corticosteroid/long acting β2 agonist after diagnosis of COPD according to fixed combination treatment. Online ISSN: 1399-3003, Copyright © 2021 by the European Respiratory Society, Lee ET, Wang JW. Pneumonia is a serious complication of COPD. Relevant anonymised patient level data are available on reasonable request from the authors. COPD patients used inhaled corticosteroids more frequently; however, they used similar amounts of systemic steroids to patients without COPD (table 1⇑). In addition, COPD patients with CAP were more tachypnoeic, acidotic and hypoxaemic. The outcomes were pneumonia (ICD-9-CM codes 480–486, and 507), pneumonia requiring invasive and non-invasive mechanical ventilation (MV) (as presentation for severe pneumonia), and all-cause mortality. Pneumonia is an important complication of COPD and is reported more often in patients receiving inhaled corticosteroids (ICSs). The mean PSI score was significantly higher for COPD patients than for CAP patients without COPD (105±32 versus 87±34; p = 0.05). 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. Long term randomised controlled trials comparing fixed combinations of inhaled corticosteroid/long acting β2 agonist in COPD with respect to occurrence of pneumonia and exacerbations are, therefore, warranted. 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⇓). 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. In addition, the ability to accurately predict medical outcomes in CAP influences patient management decisions made by physicians. History of COPD was entered into the model as an independent dichotomised variable, and PSI score was used as the risk adjustment tool 10. KL has served in an advisory board and/or served as a speaker and/or participated in education arranged by AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Meda, MSD, Nycomed, Novartis, and Pfizer. See: http://creativecommons.org/licenses/by-nc/3.0/. Pure viral sepsis secondary to community-acquired pneumonia in adults: risk and prognostic factors. 22 Cilloniz, C, Dominedo, C, Magdaleno, D, Ferrer, M, Gabarrus, A, Torres, A. Main outcome measures Yearly pneumonia event rates, admission to hospital related to pneumonia, and mortality. Comorbid COPD has been shown to be associated with morbidity and mortality after open-chest heart surgery, and COPD can often contribute to a … Data sharing: The dataset is still subject to further analyses, but will continue to be held and managed by the Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden. Pneumonia can be treated. Finally, the follow-up time and patient years covered were substantial (over three years on average) for both drugs, without the potential for increased and differential drop-out rates with either treatment, which often confounds results of longer term placebo controlled studies.25 The present dataset adds robustness to the increased association between pneumonia and fluticasone found by others in placebo controlled trials.10 15, Fluticasone/salmeterol has been associated with a higher incidence of pneumonia than placebo, salmeterol alone,7 26 or tiotropium.3 12 In the three year TORCH study, a significant 64% increase in the occurrence of non-fatal pneumonia was reported in patients treated with fluticasone/salmeterol versus placebo.26 Likewise, the risk of pneumonia was 94% higher with fluticasone/salmeterol than tiotropium in the two year INSPIRE study.3 These findings support those from a Cochrane systematic review of seven randomised controlled trials that highlighted that fluticasone/salmeterol increased the risk of pneumonia 1.8-fold compared with placebo.10 No increased risk was found in a meta-analysis of budesonide studies of at least three years’ duration, in which treatment with budesonide and budesonide/formoterol was pooled and compared with treatments that did not contain inhaled corticosteroid.14 Our findings also support those of Halpin and colleagues, who found a twofold increase in the risk of adverse events related to pneumonia and serious adverse events with fluticasone/salmeterol versus budesonide/formoterol in eight fluticasone/salmeterol placebo controlled trials and four budesonide/formoterol placebo controlled trials in COPD with the Bucher adjusted indirect method of comparisons between studies.15, The risk of pneumonia, particularly admission to hospital and mortality, associated with the use of inhaled corticosteroid has been suggested to be dose related,11 but lower doses of fluticasone/salmeterol (500 µg/day) have been reported to carry a similarly increased risk.27. 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. It was expected that COPD patients hospitalised with CAP, who had higher PSI scores, rates of ICU admission and a longer length of stay in the hospital, would also show a higher mortality. In conclusion, the present study demonstrates significantly higher 30- and 90-day mortality, and increased length of stay and intensive care unit admission in chronic obstructive pulmonary disease patients hospitalised for community-acquired pneumonia compared with patients without chronic obstructive pulmonary disease. The PSI was used to assess severity of illness on presentation. PSI and processes of care) 10 or a p-value of <0.10 in the univariate analyses. Pneumonia is an important complication of COPD and is reported more often in patients receiving inhaled corticosteroids (ICSs). Medical records data (such as date of birth, sex, diagnoses by ICD-10-CM (international classification of diseases, 10th revision, clinical modification) codes, number of healthcare contacts, lung function assessments, and drug dispensations) were extracted with an established software system (Pygargus Customized eXtraction Program, CXP, Stockholm, Sweden).17 We collected national registry morbidity and mortality data from the National Patient Register, data on inpatient hospital care (admission and discharge dates, main and secondary diagnoses) and outpatient hospital care (number of contacts, diagnoses as specified by ICD-10-CM codes), and data from the cause of death register (date and cause(s) of death). Their mean±sd age was 61±16 yrs (range 18–105 yrs). 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. These data confirm that COPD should be considered for inclusion as a comorbid condition for pneumonia severity of illness measures. Fourthly, patients were identified as having COPD by medical history, which has been demonstrated in past studies to be the same method as that used to identify other comorbid conditions included to create the PSI score 6, 10, 23, 25, 26. We do not capture any email address. 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⇓. All P<0.001, Poisson regression. Developing an illness as serious as pneumonia can be quite frightening, and even more so when you suffer from a debilitating lung disease such as chronic obstructive pulmonary disease (COPD). 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. The literature on the interaction between COPD and VAP is scarce and controversial. 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. Therefore, it is important to recognise COPD in patients with CAP so that they may receive appropriate antimicrobial therapy. 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. It can … 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⇓). 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). Of the patients, 83% were admitted via the emergency department from their own home and 7% from a nursing home; 128 (17%) had received outpatient antibiotic therapy prior to admission (table 1⇓). In COPD your oxygen and carbon dioxide levels gradually worsen. Ventilator-associated pneumonia (VAP) is the … Explanations for the difference in risk of pneumonia between COPD patients treated with inhaled corticosteroid/long acting β2 agonist combinations containing budesonide or fluticasone could be related to differences in the intrinsic properties of the two inhaled corticosteroids. A microbiological diagnosis was assigned in 172 (23%) patients with microorganisms identified from cultures of blood and/or sputum. Updated 2011. The difference observed between budesonide/formoterol and fluticasone/salmeterol with regard to pneumonia diagnosis was independent of where the diagnosis was recorded, in primary care or at hospital (67% of all diagnoses; table 2⇓). 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. According to the Centers for Disease Control and Prevention (CDC), an estimated … This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. KL has also received unrestricted research grants from AstraZeneca, Boehringer Ingelheim, and GlaxoSmithKline. Furthermore, similar to most previous randomised controlled trials, pneumonia was based on clinical diagnosis without access to severity grading, laboratory, or radiography data. pneumonia who previously would have been counted in the pneumonia measure (Figure 1). Pneumonia is dangerous, because it reduces the amount of oxygen in the body. It is unclear whether concurrent pneumonia and chronic obstructive pulmonary disease (COPD) have a higher mortality than either condition alone. In addition, COPD patients with CAP showed higher rates of congestive heart failure and a history of neoplastic disease. The linked database was held and managed by the Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden. mL-1 in bronchoalveolar lavage fluid). Horizontal lines represent median and IQR. The yearly pneumonia event rate (diagnoses and admissions to hospital) observed with each inhaled corticosteroid/long acting β2 agonist regimen and comparisons between groups were analysed with Poisson regression, with events as the dependent variable and time on specific fixed combination treatment as an offset variable. We do not capture any email address. The difference in pneumonia rates between the treatment groups was larger in patients with a higher disease burden. Using highly detailed administrative data to predict pneumonia mortality. Unmatched and pairwise (1:1) propensity matched populations are shown. Introduction. Funding: This study was funded by AstraZeneca. English language editing and assistance with figures was provided by Anna Mett of inScience Communications, Springer Healthcare, and funded by AstraZeneca. First, it was a retrospective cohort study, and inherent problems related to this design include ascertainment and selection bias. End-stage, or stage 4, COPD is the final stage of chronic obstructive pulmonary disease. Therefore, it was possible to examine the impact of COPD without dealing with other potential confounding pulmonary conditions. 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⇓). Compared to former and never smokers, current smokers were at greater risk of severe complications and higher mortality … This alteration in the composition of the COPD cohort is critical to interpreting changes in COPD mortality. Little is known about the clinical course and factors predisposing to pneumonia in patients with COPD. However, there were no other significant differences between other pathogens in either group. 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. The magnitude of the intraclass difference in pneumonia needs to be put in context with the benefits of each regimen in preventing exacerbations. Seventy six primary healthcare centres were included, with a catchment area covering 8% of the population. (ii) Does COPD impact the outcome of patients with VAP? 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. 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. How old were the people who died from COPD in 2012? However, COPD patients received other processes of care less commonly, including collection of appropriate blood cultures prior to antibiotics and within the first 24 h (70 versus 77%; p = 0.04), and tended to have received antimicrobial therapy not concordant with the recommendation from national guidelines (74 versus 80%; p = 0.05). 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