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Abstract
This study was performed on patients who developed severe hospital acquired pneumonia (HAP) including ventilator associated pneumonia (VAP) admitted at Respiratory intensive care unit (RICU) at Assiut University Hospitals from March 2017 to April 2019. The ethical approval number was NCT03121690
This study was divided in two phases:
• The phase I, the cross sectional phase, aimed to assess the prognostic value of different severity scores including (PSI, CURB65, SMART COP, IDSA/ATS and SOAR) in patients with HAP which include 125 patients with median age 65 years, 45 of them were females; admitted to RICU and diagnosed HAP based on clinical criteria as suggested as (1) new or progressive radiologic pulmonary infiltrate together with (2) at least two of the following: temperature ˃38ºC, leukocytosis˃12000/mm³ or leukopenia ˂4000/ mm³ and purulent respiratory secretions, 49.6 % of them were died.
The median age of the died group 67 years, 55% of them were females while the median age of the survivors 63 years, 53% of them were males.
• The phase II, randomized control trial, aimed to evaluate the efficacy and safety of adjuvant systemic steroids in patients with severe HAP which enrolled 50 cases that diagnosed severe and very severe HAP by PSI score.
These patients were randomly divided into two groups:
1. group I, included 25 patients and received steroid therapy (steroid group) with a dosages equivalent to prednisone 40 mg/day for 7 days
2. group II, included 25 patients and didn’t receive steroid therapy (control group).
The median age of steroid group was 60 years, 13 (40%) of them were females while mean age of the control group was 67 years, 14 (44%) of them were females.
In phase I, the most frequent comorbidities found in died cases were cardiovascular diseases (71%) followed by chest and respiratory diseases (63.5%). According to clinical data and laboratory finding in died cases compared to survivors, there were significant difference in GCS; blood gases as significant alkalosis, hypercapnia and hypoxemia (↓Pao2, ↓So2 and Pao2/ Fio2); and hypoalbuminemia, CRP, ESR and creatinine level.
Platelets as a parameter of inflammation and severity of HAP, there was significant negative correlation between platelets count and the severity and outcome scores (IDSA/ ATS and SOFA) which mean more thrombocytopenia more severe HAP and positive correlation between SOFA score and MPV.
This work informed that all studied severity scores (CURB65, PSI, SMART COP, IDSA/ATS and SOAR) and outcome scores (APACHEII, SOFA and qSOFA) after diagnosis of HAP were significantly higher in died group than in survivors. All scores had discriminatory power for predicting mortality in HAP patients.
As regarding sensitivity to predict mortality observed PSI was the highest sensitive one (AUC: =0.79) followed by SMART COP and SOAR (AUC: =0.65).
All outcome scores had discriminatory power for predicting mortality in HAP patients. According to the specificity, it was found that qSOFA is the most specific one (specificity=57) in predicting mortality in the studied patients.
All the studied scores showed insignificant correlation with both the duration of mechanical ventilation and the duration of ICU stay and subsequently hospital stay.
Logestic multivariable regression analysis explained the factors significantly associated with mortality were need of mechanical ventilation (OR 20.18, 95% CI 4.89-83.25, P˂0.001), comorbidity with chest and respiratory diseases (OR 8.51, 95% CI 1.89-38.32, P.005), high PSI score (OR 1.12 95% CI 1.03-0.1.07, P˂0.001) and low GCS score (OR 0.68, 95% CI 0.63-0.94, P 0.020).
In phase II, the most frequent comorbidities were cardiovascular diseases (72% of steroid group, 80% of the control group) and endocrine 52% of both groups with no significance difference.
Between steroid and control group, GCS had significance difference while the other baseline demographic, comorbidities, clinical, gasometric and laboratory parameters with no significance difference between both groups, which had benefits for comparing as regard primary and secondary outcomes.
The steroid group had highly significant improvement of oxygenation data at the level of 3rd and 7th days which the difference of oxygenation improvement between diagnosis and 7th day had significance correlation with duration of ICU stay and time to clinical stability. On the other hand, had insignificance lower mortality rate, duration of mechanical ventilation and hospital stay than control group.
Regarding to side effects and complications of steroid therapy, in this study, there were no significance difference was observed between the steroid and control groups in term of increase sepsis and super infection; cardiac, GIT bleeding and hematological complications; neurological and hyperglycemia.
Also, in this study, we measured cortisol level before steroid administration for cases and control group, which showed insignificant difference between both groups which was in normal range and the patients were not had adrenal insufficiency.