Clinical Investigation Of Adult Community Acquired Pneumonia Combined With Chronic Obstructive Pulmonary Disease

Objective:Community-acquired pneumonia(CAP)and chronic obstructive pulmonary disease(COPD)are leading causes of morbidity and mortality worldwide.Information is contradictory on clinical characteristics predictive of mortality in CAP patients with COPD.In this study,we compared the risk factors of clinical treatment failure in 14 days by comparing the clinical characteristics,etiology and prognosis of CAP patients who were combined with and without COPD.The purpose of this study was to explore the effect of COPD on CAP disease progression.Methods:Data were derived from a multi-center,retrospectively observational study initiated by the CAP-China network(Clinicaltrial Registration No.NCT02489578).Patients admitted from 13 centers in northern,central and southern China between January 1,2014,and December 31,2014from with a discharge diagnosis of CAP were screened.14,793 patients were identified as meeting screening criteria with 5,847 meeting all pre-defined entry requirements and so werefinally enrolled.Clinical features,etiology and outcomes were compared between CAP patients with and without COPD.Single factor and multifactor analysis were used to assess the risk factors for the failure of clinical treatment within 14 days and to analyze the causes.Results:The median age of the total study population was 65.0 years old,malesaccounted for slightly more than half(53.4%).72.5%patients had at least one underlying disease.The most common underlying diseases werecardiovascular disease,diabetes mellitus,cerebrovascular diseaseand chronic pulmonary disease.831cases(13.72%)were CAP patients with COPD,and COPD patients was associated with an older(71.04±11.40vs.62.06±18.61,p<0.001)and predominantly male population(59.2%vs.52.7%,p<0.001),and severe(PSI:81.35±24.496 vs.70.33±30.882,P<0.001;CURB-65:1±0.733 vs.0.77±0.827,P<0.001)compared with CAP patients alone.Meanwhile,white blood cell count in patients with COPD was higher than that in group without COPD,especially in neutrophils.PCT in COPD group was higher(P=0.05),and there was no significant difference in other inflammatory markers between the two groups.In addition,patients with COPD are more likely to be hypoxemia,hypercapnia,and low PH.COPD patientshave a history of past or present smoking and often associated with other basic diseases.The probability of hospitalization history in the past year and past use of systemic oral/inhaled corticosteroids in CAP patients with COPD increased significantly compared with those without COPD(P<0.001).Patients without COPD were more likely to have fever and chest pain,and patients with COPD more often had cough,sputum,dyspnea and cyanosis(P<0.05).A total of 216 patients were isolated from the CAP patients with COPD,and the first two were Pseudomonas aeruginosa(62 cases,28.70%)and Klebsiella pneumoniae(29 cases,14.43%).The infection of Pseudomonas aeruginosa is closely related to the application of systemic oral/inhaled corticosteroids therapy.The hospitalization time of patients with COPD was significantly longer than that of CAP patients(13.18±9.507 days vs.12.42±9.614 days)(P=0.034),and the in-hospital mortality increased(4.3%vs.4.0%,P<0.001).There was no significant difference in the rate of clinical treatment failure within 14 days.However,the probability of noninvasive ventilation in the patients with COPD within 14 days was higher than that without COPD(P=0.001).Multivariate analysis showed cerebral vascular disease(OR 2.091,95%CI1.109-3.942,P=0.027),white blood cell is more than 10000/mm~3 or less than 4000/mm~3(OR 2.872,95%CI 1.677-4.919,P=0.001),ALB<25 g/l(OR 3.471,95%CI 1.252-9.622,P<0.001),BUN>7 mmol/l(OR 3.319,95%CI 1.922-5.731,P<0.001),PH<7.3(OR 3.728,95%CI 1.602-8.674,P<0.001),admission to ICU(OR 9.335,95%CI 5.048-17.262,P<0.001)and complications(OR 23.685,95%CI 11.418-49.130 and P<0.001)in the course of treatment,such as respiratory failure(OR 22.054,95%CI 11.847-41.055,P<0.001),heart failure(OR 10.496,95%CI 5.980-18.423,P<0.001),acute liver failure(OR 34.286,95%CI 6.505-180.701,P<0.001),acute kidney failure(OR 24.824,95%CI7.048-87.435,P=0.007),septic shock(OR 20.891,95%CI 5.725-76.277,P<0.001)and other complications were all risk factors for the failure of clinical treatment in patients with CAP combined with COPD.Previous bronchiectasis(OR 0.322,95%CI 0.144-0.719,P<0.001)was a protective predictor of failure in treatment of CAP combined with COPD.Conclusion:COPD increases the risk of infection of Pseudomonas aeruginosa in CAP patients and makes CAP patients increase in hospital mortality and prolong hospitalization time,while it has little effect on the 30 day mortality rate and the 14 day treatment failure rate.Cerebrovascular disease,white blood cell is more than 10*10^9/L or less than 4*10^9/L,ALB<25,g/l,BUN>7mmol/l and PH<7.3,and and complications during treatment including respiratory failure,heart failure,acute renal failure,septic shock were risk factors lead to the failure of clinical treatment of CAP patients with COPD.Bronchiectasis was an independent prognostic factor in CAP patients with COPD.