Community-acquired pneumonia in patients with decompensated chronic heart failure


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Introduction. A distinctive feature of the Russian population of patients hospitalized with decompensated chronic heart failure (CHF) is the large number of pneumonia identified at the time of admission. Combination of CHF and pneumonia has a significant negative impact on the prognosis of patients, as well as makes difficult of diagnosis and management of patients. Purpose. Evaluation of long-term prognosis of patients with decompensated CHF and pneumonia depending on the clinical characteristics of the patients and the causative agent of pneumonia. Materials and methods. The prospective study included 284 patients with pneumonia against the background of CHF decompensation. All patients had CHF of ischemic etiology, decompensation was confirmed by several symptoms, pneumonia in all patients was verified by chest X-ray, as well as by the presence of clinical signs of lower respiratory tract infection. The mean age of the patients was 72.1±10.1 years; duration of CHF over 5 years - 84.3%, more than 10 years - 15.7%. Clinical, laboratory, and instrumental parameters were assessed; sputum culture for sterility and determination of antibiotic susceptibility was performed; body composition (deficit of lean body mass - LBM)) was assessed; medical history (number of hospitalizations in the previous year, COPD with daily administration of inhaled medications) was registered; and CURB-65, PSI and Charlson comorbidity indices were calculated. Results. The most frequent result of the sputum culture for sterility - revealing the mixed flora (30.3%), with Streptococcus pneumoniae detected only in 22.7% of cases, and there was no microflora in 41.3% of the cases after three times daily sputum collection and culture. Comparison of the clinical characteristics of patients with a 44 variety of results of sputum culture has shown that the patients who had the most severe clinical manifestations referred to the group of mixed infection, the Proteus and Staph. Aureus. Statistically significant (p<0.05) differences among all groups identified in terms of the number of patients with COPD, the LBM deficit. In-hospital mortality was 20.4% (in patients with mixed infection - 40%, with Str. pneumonia - 9,1%); during the six months after hospitalization it reached 50.4%, and 12 months after hospitalization - 62.3% (90.67% - in patients with mixed infection, and only 34.6% in the group Str. pneumonia). Differences in survival in the groups were statistically significant (p<0.05). LBM deficit of more than 10% was detected in 16.2% of patients, LBM deficit of 5-10% - in 25.4% of patients, LBM deficit of less than 5% was detected in 51.1% of patients. In-hospital mortality in patients with LBM deficit of more than 10% was 56.5%, one-year mortality - 100%; in patients without LMB deficit there were no deaths during index hospitalization, one-year mortality was 19.0%. Based on the clinical parameters most significant for the prediction, clinical phenotypes have been proposed, and their prognostic role was evaluated. Combination of mixed infection and LBM deficit more than 5% was revealed in 29.9% of patients; combination of COPD and mixed infection - in 6% of patients; combination of mixed infection, LBM deficit more than 5% and COPD - in 6.3% of patients, of these 2.8% had decreased glomerular filtration rate below 60 mL/min and frequent hospitalization history (more than 2 in the previous year). Various combinations of clinical phenotypes with other results of sputum cultutre were detected less than in 5% of cases. Conclusion. The most poor prognosis for patients with decompensated CHF and pneumonia is associated with the identification of mixed infection in the sputum. Patients in the group with verified mixed infection in the sputum are also characterized by the most severe clinical phenotypes, including frequent hospitalizations, a decrease in LBM more than 5%, and high comorbidity (COPD, decreased GFR less than 60 mL/min).

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Anna Simbirtseva

N.I. Pirogov Russian national research medical university

assistant of the Department of propedeutics of internal diseases, general physiotherapy and radiodiagnosis of pediatric faculty

参考

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