With that being said, bacterial pneumonia tends to be more severe than its viral cousin, especially within the context of COPD. 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). If you are unable to import citations, please contact Participants Patients with COPD diagnosed by a physician and prescriptions of either budesonide/formoterol or fluticasone/salmeterol. AstraZeneca was a member of the study steering committee that carried overall responsibility for the study concept and design. 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⇓). 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. Further, it is unknown how this interaction changes over time. Fig 3 Pneumonia event rate by treatment and by disease burden (quarters based on baseline propensity scores), with number need to treat (NNT). 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). 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. 1⇓). Methods Using Taiwan’s National Health Insurance Research Database to identify patients with incident pneumonia, we established a COPD with asthma cohort of 12,538 patients and a COPD cohort of 25,069 patients. We explored the effect of pneumonia and COPD on inpatient, 30-day and overall mortality. The PSI was used to assess severity of illness on presentation. 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. Differences in pharmacokinetic and pharmacodynamic properties related to differences in lipophilicity and hydrophilicity profiles of the respective inhaled corticosteroids have also been shown26 and proposed as an explanation for the difference in risk of pneumonia between budesonide and fluticasone.32 In patients with severe COPD, the highly lipophilic fluticasone molecule can remain in the mucosa and epithelial lining fluid of the bronchi longer than budesonide.33 It might, therefore, be speculated that suppression of local immunity is both more potent and has a longer duration of effect after intake of fluticasone than budesonide, thereby causing an increased risk of local bacterial proliferation and a pneumonia outbreak. When two or more microbiological causes were present, the cause was classified as polymicrobial pathogens. Most people reach it after years of living with the disease and the lung damage it causes. Community-acquired pneumonia (CAP) refers to pneumonia (any of several lung diseases) contracted by a person outside of the healthcare system. And without enough oxygen, you may have other problems. Chronic obstructive pulmonary disease should be evaluated for inclusion in community-acquired pneumonia … p values were from Mann-Whitney U test. In COPD your oxygen and carbon dioxide levels gradually worsen. AMI, HF, Pneumonia (PN) Readmission Updates (ZIP) Chronic Obstructive Pulmonary Disease (COPD) Mortality (ZIP) Chronic Obstructive Pulmonary Disease (COPD) Readmission (ZIP) COPD places a person at greater risk for contracting pneumonia. Ventilator-associated pneumonia (VAP) is the commonest ICU infection and results in increased morbidity/mortality and costs. PSI and processes of care) 10 or a p-value of <0.10 in the univariate analyses. One of the possible explanations for not finding a higher mortality in these specific groups is that the PSI score does not completely adjust for all of the abnormalities that are common in COPD patients. Horizontal lines represent median and IQR. 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 addition, a presumptive diagnosis was made if qualitative valid sputum samples yielded one or more predominant bacterial pathogen. The literature on the interaction between COPD and VAP is scarce and controversial. The mean PSI score was significantly higher for COPD patients than for CAP patients without COPD (105±32 versus 87±34; p = 0.05). 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). Young children, cigarette smokers, adults over 65 and people with certain medical problems including COPD are at greater risk for developing pneumonia. Pneumonia is a serious complication of COPD. The difference in pneumonia rates between the treatment groups was larger in patients with a higher disease burden. Find out how pneumonia differs from other lung infections, and how this condition is treated. … It can result in serious complications. Hoboken, NJ, Wiley, 2003. Design Observational retrospective pairwise cohort study matched (1:1) for propensity score. Variables were included in the survival analysis if they had either been previously demonstrated to be associated with CAP-related outcomes (e.g. Methods 795 patients of the Cohort of Mortality and Inflammation in COPD (COMIC) study were divided into statin users or not. 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⇓). In these patients, 2115 (39%) had at least one recorded episode of pneumonia during the study period, with 2746 episodes recorded during 19 170 patient years of follow up. 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. Definitive and presumptive causes were combined for reporting purposes. 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⇓). 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 … Along with lung cancer and pneumonia, COPD is one of the three leading contributors to respiratory mortality in developed countries such as the UK. 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. 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⇓). It is unclear whether concurrent pneumonia and chronic obstructive pulmonary disease (COPD) have a higher mortality than either condition alone. 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⇓). Pneumonia is an important complication of COPD and is reported more often in patients receiving inhaled corticosteroids (ICSs). How old were the people who died from COPD in 2012? Data management and statistical analyses were performed with SAS version 9.2 (SAS Institute, Cary, NC, US). Main outcome measures Yearly pneumonia event rates, admission to hospital related to pneumonia, and mortality. In addition, processes of care measures (initial antibiotics within 4 h, obtention of blood cultures prior to initial dose of antibiotics, and whether antimicrobial therapy was guideline-concordant) were used as potential confounding variables. 22 Cilloniz, C, Dominedo, C, Magdaleno, D, Ferrer, M, Gabarrus, A, Torres, A. 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⇓). 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. The steroid dose was also recalculated to equivalents of beclometasone diproprionate.23. Further, COPD is one of the most frequent co-morbid conditions associated with the development of community-acquired pneumonia (CAP) ; COPD is the most common underlying disease in patients with CAP who require hospitalization , and such patients have increased mortality [8, 9]. A diagnosis of pneumonia during the two years before the index date was not associated with an increase in the overall pneumonia rate after the index date with fluticasone/salmeterol versus budesonide/formoterol (risk ratio 1.73, 95% confidence interval 1.47 to 2.04; P<0.001); however, the pneumonia rate was higher in patients treated with fluticasone/salmeterol than with budesonide/formoterol who had no history of pneumonia in the two years before the index date (1.76, 1.57 to 1.98; P<0.001). Global Initiative for Chronic Obstructive Lung Disease. English language editing and assistance with figures was provided by Anna Mett of inScience Communications, Springer Healthcare, and funded by AstraZeneca. Comorbid COPD has been shown to be associated with morbidity and mortality after open-chest heart surgery, and COPD can often contribute to a … The differential risk of pneumonia among inhaled corticosteroid (ICS) use in patients with COPD requires more investigation, especially regarding beclomethasone-containing inhalers. Corticosteroid inhalation yields high local concentrations of the drug in the lungs and could increase the risk pneumonia because of their immunosuppressive effects.30 As the immunosuppressant potency of fluticasone is reported to be up to 10-fold higher than that of budesonide with regard to ex vivo inhibition of human alveolar macrophage innate immune response to bacterial triggers,31 this factor alone could explain our findings. This observational matched cohort study indicated that there is an intraclass difference between inhaled corticosteroid/long acting β2 agonist regarding the risk of pneumonia and pneumonia related mortality in the treatment of patients with COPD. Therefore, it was possible to examine the impact of COPD without dealing with other potential confounding pulmonary conditions. Fortunately, there are simple things you can do. Thirdly, unfortunately, no serological information was available, including Legionella urinary antigen. The authors appreciate the assistance of A. Torres in preparing the manuscript and editorial support. The lack of a standardised definition for pneumonia is one limitation of the current analyses. However, COPD has not been previously identified as being a risk factor for mortality in CAP patients 6–9. Please note: your email address is provided to the journal, which may use this information for marketing purposes. The higher risk of pneumonia with fluticasone/salmeterol was independent of whether or not patients had a recorded episode of pneumonia before the index date. Long Beach, CA, 2001. and pneumonia.8 13 20 However, the effect and significance of each predictor on mortality varied across different studies. Pneumonia is an important complication of COPD and is reported more often in patients receiving inhaled corticosteroids (ICSs). A microbiological diagnosis was assigned in 172 (23%) patients with microorganisms identified from cultures of blood and/or sputum. 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). We replaced personal identification numbers used to identify included patients in all healthcare contacts with study identification numbers before further data processing. While neither of these conditions is necessarily fatal, when they are the main difference is speed. In this observational retrospective matched cohort study patients with chronic obstructive pulmonary disease (COPD) who were treated with fluticasone/salmeterol were significantly more likely to experience pneumonia and had a higher mortality related to pneumonia … Without oxygen, cells can begin to die. 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. 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. 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. How many … See: http://creativecommons.org/licenses/by-nc/3.0/. Chronic obstructive pulmonary disease patients hospitalised with community-acquired pneumonia exhibited higher 30- and 90-day mortality than patients without chronic obstructive pulmonary disease. 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. Subject demographic and clinical characteristics by chronic obstructive pulmonary disease(COPD) diagnosis. A new study examines the mortality risk factors among COPD patients hospitalized with community acquired pneumonia. 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⇓). 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). Fig 4 Fraction of patients with mortality related to pneumonia by treatment (budesonide/formoterol v fluticasone/salmeterol), Fig 5 Number of patients with mortality related to pneumonia (52 patients in budesonide/formoterol cohort; 97 patients in fluticasone/salmeterol cohort) by disease burden (quarters based on propensity scores at baseline). ... Background Chronic obstructive pulmonary disease (COPD) is one … Statin use was defined as having a statin for at least 90 consecutive days after inclusion. Bacter… KL has also received unrestricted research grants from AstraZeneca, Boehringer Ingelheim, and GlaxoSmithKline. Patients with chronic obstructive pulmonary disease (COPD) are at risk of exacerbations and pneumonia; how the risk factors interact is unclear. Patients eligible for matching were receiving fixed combinations of inhaled corticosteroid/long acting β2 agonist (budesonide/formoterol Turbuhaler or fluticasone/salmeterol Diskus). All P<0.001, Poisson regression. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. However, patients with COPD are more susceptible to covid-19 infection. 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. technical support for your product directly (links go to external sites): Thank you for your interest in spreading the word about The BMJ. These data confirm that COPD should be considered for inclusion as a comorbid condition for pneumonia severity of illness measures. But what exactly does it mean to have both COPD and pneumonia at the same time? We also assessed the effect of inhaled corticosteroids (ICS) on pneumonia mortality … Furthermore, it was possible to verify that all of the patients had a radiological diagnosis of CAP. It is unclear whether concurrent pneumonia and chronic obstructive pulmonary disease (COPD) have a higher mortality than either condition alone. Life-threatening complications can develop in people with COPD. Yearly data for the pneumonia event rate for the unmatched populations showed a rate ratio of 1.76 (1.63 to 1.89) in patients treated with fluticasone/salmeterol versus budesonide/formoterol. In 2004, the COPD death rate was 72.9 per 100,000 people, declining to 67.4 by 2018. Copyright © 2021 BMJ Publishing Group Ltd 京ICP备15042040号-3, Pneumonia and pneumonia related mortality in patients with COPD treated with fixed combinations of inhaled corticosteroid and long acting β, Pneumonia and pneumonia related mortality in patients with COPD treated with fixed combinations of inhaled corticosteroid and long acting β2 agonist: observational matched cohort study (PATHOS) - June 20, 2013, http://creativecommons.org/licenses/by-nc/3.0/, Pneumonia and pneumonia related mortality in patients with COPD treated with fixed combinations of inhaled corticosteroid and long acting β2 agonist: observational matched cohort study (PATHOS), Kent and Medway NHS & Social Care Partnership Trust: Consultant Psychiatrist - Britton House, Kent and Medway NHS & Social Care Partnership Trust: Consultant Psychiatrist in MHLD, Kent and Medway NHS & Social Care Partnership Trust: Consultant Psychiatrist - Pinewood Ward, Women’s, children’s & adolescents’ health. The linked database was held and managed by the Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden. The choice of appropriate empirical antibiotic regimens depends on several factors, including the aetiology of CAP. 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. Bacterial respiratory infections are generally more aggressive than viral. Key words: chronic obstructive pulmonary disease, meta-analysis, morbidity, mortality, pneumonia. 23 showed, in a large Spanish multicentric study, an in-hospital mortality rate of 8% in a cohort of 124 CAP patients with COPD. This non-biased data extraction from electronic primary healthcare medical records linked with mandatory national healthcare registers with high coverage and quality, together with the opportunity to follow a patient through their treatment by using personal identification numbers, provides solid and unique data. Trial registration Clinical Trials.gov NCT01146392. COPD makes it hard to breathe in as much air as you need. For both COPD and pneumonia, it is important to see a physician for an accurate diagnosis. 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. 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⇓). 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. GS, HG, and LJ are fulltime employees of AstraZeneca Nordic. Mortality (A) and cumulative number of confirmed cases of COVID-19 since the start of the outbreak per 10 000 population (B) in Hubei and other provinces of China. (C) Correlation between mortality and number of cases per 10 000 population (Spearman method). Recent data from the European … 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. 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