A National Multicenter Retrospective Clinical Investigation Of Adult Community-acquired Pneumonia With Pleural Effusion

Objective: By comparing the clinical characteristics,pathogen characteristics,laboratory examination and prognosis of community acquired pneumonia(CAP)patients with and without pleural effusion,the high risk factors affecting 30-day hospital mortality of CAP patients with pleural effusion were analyzed and predicted in order to improve the ability of risk identification,reduce the use of antibiotics and hospital mortality,save medical expenses,and provide basis for the revision of guidelines for diagnosis and treatment of CAP in China.Methods: This study is a national multicenter retrospective study initiated by CAP-China network(clinical registration number NCT2489578).By analyzing the clinical data of inpatients with CAP in hospitals in 13 different regions of China(northern,central and southern China)from 2014.01.01 to 2014.12.31,the patients were divided into two groups according to imaging examination: group with pleural effusion(PE group)and group without pleural effusion(non-PE group).Integrated analysis of the two groups of patients' clinical features(symptoms,imaging features,laboratory examination),etiological characteristics,treatment and outcome and other variables.Mann-Whitney U test and Chi-square test were used to compare between groups.Univariate and multivariate analysis were used to evaluate the risk factors of 30-day hospital mortality in patients with PE,and the causes were analyzed.Results:1.4781 patients with CAP were included in the final analysis.There were 1169patients(24.5%)in the PE group and 3612 patients(75.5%)in the non-PE group.The median ages of the two groups were 70.0 and 63.0 years respectively,both of which were more male(59.6% VS 51.0%,P<0.001).2.Patients in the PE group had a higher proportion of smoking,alcoholism,inhalation factors and long-term bed rest,often characterized by dyspnea,chest pain,changes of consciousness and multiple lobar infiltration,as well as other underlying diseases such as cardiovascular disease(49.5%),diabetes(19.2%),cerebrovascular disease(19.2%),chronic kidney disease(5.7%),etc.The proportion of patients with bronchiectasis(5.3%)and bronchial asthma(3.4%)was lower(P<0.001).3.Compared with the non-PE group,the condition of the PE group was more serious,and the proportion of middle and high risk patients in CURB-65 score and PSI score was higher than that in the non-PE group(P<0.001).The levels of inflammatory indexes such as white blood cell count(WBC),neutrophils,C-reactive protein(CRP)and erythrocyte sedimentation rate(ESR)were significantly increased(P<0.001),while the levels ofhemoglobin,albumin,serum sodium and hematocrit were lower(P<0.001).There were significant differences between the two groups.4.71.7%(3680/4781)patients were examined for pathogens,including sputum,blood,bronchoalveolar lavage fluid and pleural effusion culture,urine antigen detection,serum antigen detection,antibody detection and so on,the results showed that the pathogens cultured in pleural effusion were not exactly the same as those in other specimens(such as sputum culture).The pathogen with the highest detection rate in PE group was Candida(11.8%),followed by Klebsiella pneumoniae(4.6%),Pseudomonas aeruginosa(3.4%),Staphylococcus aureus(1.9%)and so on.The pathogens detected in non-PE group were Candida(9.4%),Pseudomonas aeruginosa(4.3%),Klebsiella pneumoniae(2.5%),Acinetobacter baumannii(1.1%),Streptococcus pneumoniae,Escherichia coli(1.0%)and so on.5.The hospitalization time and ICU stay in PE group were significantly longer than those in non-PE group(P<0.001),and the ICU occupancy rate,invasive / non-invasive mechanical ventilation rate and 30-day hospital mortality were significantly increased(P<0.001).Complications such as respiratory failure,acute myocardial infarction,cardiac insufficiency and acute renal failure were easy to occur.Finally,3 cases developed empyema.6.Multivariate regression analysis showed that urea nitrogen>7mmol/L(OR 2.908,95%CI 1.089-12.439,P=0.032),long-term bed rest(OR 4.308,95%CI 1.128-16.460,P=0.033),hematocrit<30%(OR 4.704,95%CI 1.372-16.135,P=0.014),and complications such as acute renal failure(OR 5.043,95%CI 2.489-20.138,P=0.030),respiratory failure(OR 6.575,95%CI 2.632-16.427,P<0.001),acute respiratory distress syndrome(ARDS)(OR 8.003,95%CI 1.167-21.787,P=0.05)were independent risk factors affecting the 30-day mortality of PE patients.According to the above six risk factors and the scores of PSI and CURB-65,the evaluation system was established.The results showed that the number of risk factors was the best in predicting 30-day death risk,the area under the curve(AUC)was 0.836,the sensitivity was 0.732,and the specificity was 0.845.When there were 2 or more risk factors in patients with PE,the predictive accuracy was the highest,and the AUC was 0.784,the sensitivity was 0.732,and the specificity was 0.836.Conclusion:1.The hospitalization time and ICU stay of PE patients were prolonged,the risk of complications increased,and the hospital mortality increased significantly with the increase of age,complication and disease severity.2.The detection rate of fungi and Gram-negative bacteria was the highest in patients with PE.The most common pathogens in PPE were Klebsiella pneumoniae and Pseudomonas aeruginosa.Pleural effusion culture mainly included Staphylococcus aureus,Streptococcus,Enterobacter faecium,Escherichia coli and Clostridium necroticus.3.Urea nitrogen>7mmol/L,hematocrit<30%,long-term bedridden,acute renal failure,respiratory failure and ARDS are the risk factors affecting the 30-day mortality of PE patients,and the efficacy of predicting 30-day death risk is the best according to the number of 6 risk factors,which has a certain reference value for identifying and predicting PE patients with death risk.