Patients diagnosed with chronic obstructive pulmonary disease (COPD) who reported using marijuana had less risk of in-hospital mortality and pneumonia than non-users, according to a … The lack of a standardised definition for pneumonia is one limitation of the current analyses. The organisms most frequently involved were Streptococcus pneumoniae (56 cases) and Staphylococcus aureus (39 cases). Of the patients, 148 (20%) were admitted to the ICU and 83 (14%) required mechanical ventilation. See: http://creativecommons.org/licenses/by-nc/3.0/. 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. Pneumonia events occurring within 14 days were counted as one single event, if not otherwise specified. 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. AstraZeneca was a member of the study steering committee that carried overall responsibility for the study concept and design. These data confirm that COPD should be considered for inclusion as a comorbid condition for pneumonia severity of illness measures. KL is guarantor. Bacter… This is in contrast to patients either referred to hospital with COPD or diagnosed with COPD at hospitals, who are more likely to suffer from more severe COPD. Administration of antibiotics within 4 h occurred more commonly in COPD patients (35 versus 26%; p = 0.02). The steroid dose was also recalculated to equivalents of beclometasone diproprionate.23. Statistical Methods for Survival Data Analysis. Enter multiple addresses on separate lines or separate them with commas. Reducing bias in a propensity score matched-pair sample using greedy matching techniques. There were significantly more pneumonia events in patients treated with fluticasone/salmeterol than with budesonide/formoterol (table 2⇓). Data management and statistical analyses were performed with SAS version 9.2 (SAS Institute, Cary, NC, US). Univariate statistics were used to test the association of demographic and clinical characteristics with all-cause 30- and 90-day mortality. AMI, HF, Pneumonia (PN) Readmission Updates (ZIP) Chronic Obstructive Pulmonary Disease (COPD) Mortality (ZIP) Chronic Obstructive Pulmonary Disease (COPD) Readmission (ZIP) Chronic obstructive pulmonary disease patients hospitalised with community-acquired pneumonia exhibited higher 30- and 90-day mortality than patients without chronic obstructive pulmonary disease. Main outcome measures Yearly pneumonia event rates, admission to hospital related to pneumonia, and mortality. Patients with a concomitant diagnosis of asthma had a higher rate of pneumonia, and the rate ratio between fluticasone/salmeterol and budesonide/formoterol was similar to the overall result (tables 2 and 3).⇑ ⇓, Pneumonia rates in subpopulations of pairwise (1:1) propensity matched populations* treated with fluticasone/salmeterol versus budesonide/formoterol. Definitive and presumptive causes were combined for reporting purposes. We carried out an observational retrospective cohort study, matched for propensity score, linking primary care medical records to data from national mandatory Swedish registries. Diagnosis was established by a positive blood culture in 63 (8.5%) patients. As member of the study steering committee AstraZeneca took part in the interpretation of the data and the drafting of the manuscript. If you are unable to import citations, please contact 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. Community‐acquired pneumonia (CAP) is one of the most common infectious diseases worldwide and remains a major public health challenge. Furthermore, 2497 patients (25%) had at least one pneumonia event recorded during the two years before the index date; the difference between the treatment groups at index date was not significant (P=0.6). Statin use was defined as having a statin for at least 90 consecutive days after inclusion. 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⇓. Therefore, it is important to recognise COPD in patients with CAP so that they may receive appropriate antimicrobial therapy. The project aimed to search the literature in order to address the following: (i) Is COPD a risk factor for VAP development? 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 than patients treated with budesonide/formoterol. 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. The corresponding number needed to treat (NNT) to avoid one pneumonia event per year was 23 (95% confidence interval 18 to 37). BS has received honorariums for educational activities from AstraZeneca, GlaxoSmithKline, and Merck Sharp and Dohme. Community acquired pneumonia (CAP) is a common disease associated with high morbidity, mortality and inpatients care costs [1,2,3].The 2009–2014 British Thoracic Society (BTS) Audit Programme indicates that the overall 30-day inpatients mortality is 18.0% [].Chronic obstructive pulmonary disease (COPD) is a disease with persistent airflow limitation and chronic inflammatory … We do not capture any email address. The propensity score method has previously been used to reduce potential confounding caused by unbalanced covariates.19 20 The matching starts with the smallest population (2738 patients in the fluticasone/salmeterol group) and matches 1:1 to the larger treatment group. Drug prescription data from hospital care and primary care were collected from the Swedish Prescribed Drug Register. Updated 2011. The present authors believe that this difference was found by examining only patients with COPD, and excluding other pulmonary conditions, including asthma, bronchiectasis and interstitial lung disease. 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⇓). These include the decision to hospitalise the patient, the length of inpatient care if the patient is hospitalised, and the choice of antimicrobial or other types of immediate therapy. COPD is the fourth leading cause of death, while pneumonia and flu contribute to the eighth leading cause of death … Global Initiative for Chronic Obstructive Lung Disease. KHL has received speaking fees from AstraZeneca, Boehringer Ingelheim, and Merck Sharp and Dohme. There were no significant differences in the rate of oxygenation status assessment. 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. 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. technical support for your product directly (links go to external sites): Thank you for your interest in spreading the word about The BMJ. Conclusions There is an intra-class difference between fixed combinations of inhaled corticosteroid/long acting β2 agonist with regard to the risk of pneumonia and pneumonia related events in the treatment of patients with COPD. English language editing and assistance with figures was provided by Anna Mett of inScience Communications, Springer Healthcare, and funded by AstraZeneca. Compared with budesonide/formoterol, rate of pneumonia and admission to hospital were higher in patients treated with fluticasone/salmeterol: rate ratio 1.73 (95% confidence interval 1.57 to 1.90; P<0.001) and 1.74 (1.56 to 1.94; P<0.001), respectively. We investigated patient characteristics and symptoms occurring before pneumonia … Project management was provided by AstraZeneca. We also assessed the effect of inhaled corticosteroids (ICS) on pneumonia mortality … 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⇓). According to the Centers for Disease Control and Prevention (CDC), an estimated … The accuracy and severity of the physician diagnoses of COPD could also not be fully verified by spirometry in all cases. 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). In total, 9893 patients had a record of treatment with a fixed combination of inhaled corticosteroid/long acting β2 agonist after a diagnosis of COPD and were eligible for matching (7155 patients received budesonide/formoterol Turbuhaler and 2738 patients received fluticasone/salmeterol Diskus at index date). Pure viral sepsis secondary to community-acquired pneumonia in adults: risk and prognostic factors. Please note: your email address is provided to the journal, which may use this information for marketing purposes. 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. All P<0.001, Poisson regression. The literature on the interaction between COPD and VAP is scarce and controversial. Other studies have found that P. aeruginosa is an important pathogen in patients with pulmonary comorbid conditions, especially those with bronchiectasis 3, 23, 24. The magnitude of the intraclass difference in pneumonia needs to be put in context with the benefits of each regimen in preventing exacerbations. Furthermore, similar to most previous randomised controlled trials, pneumonia was based on clinical diagnosis without access to severity grading, laboratory, or radiography data. Parsons LS. In addition, a presumptive diagnosis was made if qualitative valid sputum samples yielded one or more predominant bacterial pathogen. COPD makes it hard to breathe in as much air as you need. Fig 1 Cumulative number of pneumonia events and admissions to hospital because of pneumonia per patient over nine years after index date, Fig 2 Distribution of number of pneumonia events per patient by treatment (budesonide/formoterol v fluticasone/salmeterol), Pneumonia events by type for pairwise (1:1) propensity score matched populations treated with budesonide/formoterol versus fluticasone/salmeterol for COPD. These findings have implications regarding how to evaluate patients with community-acquired pneumonia and chronic obstructive pulmonary disease, and how to decide which antimicrobial agents should be used for initial empirical therapy. indicates that COPD may not be associated with increased mortality and morbidity in patients hospital-ized with CAP. Data collection was performed by Pygargus AB, Uppsala, Sweden, and funded by AstraZeneca. This rule was based on three demographic characteristics, five comorbid illnesses, five physical examination findings, and seven laboratory and radiographic findings from the time of presentation. We do not capture any email address. The mean duration of admissions related to pneumonia was similar for both groups, but mortality related to pneumonia was higher in the fluticasone/salmeterol group (97 deaths) than in the budesonide/formoterol group (52 deaths) (hazard ratio 1.76, 1.22 to 2.53; P=0.003). We found no indication of a dose related difference in the risk of a first pneumonia diagnosis in either treatment group, stratified by collected mean daily steroid dose and including disease burden in the analysis to exclude confounding by severity (hazard ratio 1.00, 95% confidence interval 0.64 to 1.57; P=0.99). 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. The statistical analysis plan was agreed on by the study steering committee, and data analysis was performed by the study database owner in collaboration with AstraZeneca. People with COPD … We replaced personal identification numbers used to identify included patients in all healthcare contacts with study identification numbers before further data processing. 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. 23 showed, in a large Spanish multicentric study, an in-hospital mortality rate of 8% in a cohort of 124 CAP patients with COPD. PSI and processes of care) 10 or a p-value of <0.10 in the univariate analyses. Patients were censored when they switched to the other fixed combination and when they left the study because of death or immigration. Methods 795 patients of the Cohort of Mortality and Inflammation in COPD (COMIC) study were divided into statin users or not. All cause mortality did not differ between the treatments (1.08, 0.93 to 1.14; P=0.59). Smoking status was similar in the two matched populations but did not constitute a matching variable (table 1).⇑. Introduction Community acquired pneumonia (CAP) is a common occurrence in patients with chronic obstructive pulmonary disease (COPD), yet controversy still remains about its affect on outcome. We included all male and female patients of any age with COPD diagnosed by a physician (ICD-10 code J44, according to the 2011 ICD-10-CM). 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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