Aetiology and prognostic risk factors of mortality in patients with pneumonia receiving glucocorticoids alone or glucocorticoids and other immunosuppressants: a retrospective cohort study

Abstract

ObjectivesLong-term use of high-dose glucocorticoids can lead to severe immunosuppression and increased risk of treatment-resistant pneumonia and mortality. We investigated the aetiology and prognostic risk factors of mortality in hospitalised patients who developed pneumonia while receiving glucocorticoid therapy alone or glucocorticoid and other immunosuppressant therapies.DesignRetrospective cohort study.SettingSix secondary and tertiary academic hospitals in China.ParticipantsPatients receiving glucocorticoids who were hospitalised with pneumonia between 1 January 2013 and 31 December 2019.Main outcomesWe analysed the prevalence of comorbidities, microbiology, antibiotic susceptibility patterns, 30-day and 90-day mortality and prognostic risk factors.ResultsConclusionsA total of 716 patients were included, with pneumonia pathogens identified in 69.8% of patients. Significant morbidities occurred, including respiratory failure (50.8%), intensive care unit transfer (40.8%) and mechanical ventilation (36%), with a 90-day mortality of 26.0%. Diagnosis of pneumonia occurred within 6 months of glucocorticoid initiation for 69.7% of patients with Cytomegalovirus (CMV) pneumonia and 79.0% of patients with Pneumocystis jirovecii pneumonia (PCP). Pathogens, including Pneumocystis, CMV and multidrug-resistant bacteria, were identified more frequently in patients with persistent lymphocytopenia and high-dose glucocorticoid treatment (≥30 mg/day of prednisolone or equivalent within 30 days before admission). The 90-day mortality was significantly lower for non-CMV viral pneumonias than for PCP (p<0.05), with a similar mortality as CMV pneumonias (24.2% vs 38.1% vs 27.4%, respectively). Cox regression analysis indicated several independent negative predictors for mortality in this patient population, including septic shock, respiratory failure, persistent lymphocytopenia, interstitial lung disease and high-dose glucocorticoid use.Patients who developed pneumonia while receiving glucocorticoid therapy experienced high rates of opportunistic infections, with significant morbidity and mortality. These findings should be carefully considered when determining treatment strategies for this patient population.

Characteristics of viral pneumonia in the COVID-19 era: an update

“…CMV interstitial pneumonitis reports the highest frequency in hematopoietic stem cell transplant (HSCT) recipients and in solid organ transplant recipients, where it is associated with an increase in terms of mortality [ 36 ]. A study investigating the complications of patients undergoing bone marrow transplantation identified 16 cases of CMV pneumonia.…”

“…CMV interstitial pneumonitis reports the highest frequency in hematopoietic stem cell transplant (HSCT) recipients and in solid organ transplant recipients, where it is associated with an increase in terms of mortality [36].…”

Fatal cytomegalovirus pneumonia in a critically ill patient with COVID‐19

“…Although the dose of dexamethasone used in the RECOVERY trial (6 mg daily for up to 10 days) may not act as immunosuppressive, it may contribute to the reactivation of CMV when combined in the presence of factors such as severe lymphopenia or prolonged MV [2,11]. In fact, previous studies have reported that corticosteroid use is associated with increased risk of CMV reactivation [12–14]. The cause of the recurrent respiratory distress requiring reintubation in the present case was probably due to remnant inflammation caused by COVID‐19 pneumonia.…”

Gearing up for battle: Harnessing adaptive T cell immunity against gram-negative pneumonia

“…In mouse models, intratracheal infection of neutropenic mice with AB led to the development of severe acute lung injury and increased mortality when compared to control mice (Joly-Guillou et al, 1997). Consistent with this finding, multiple studies have demonstrated respiratory failure, neutropenic fever, and high rates of mortality in neutropenic patients diagnosed with AB pneumonia (Nunley et al, 2010;Li et al, 2020). Along with neutrophils, macrophages play a key role in the response to AB infection.…”