Derivation and Validation of a Clinical Prediction Rule for Nosocomial Pneumonia after Coronary Artery Bypass Graft Surgery

Kinlin, Laura M.; Kirchner, Cheryl; Zhang, Huiling; Daley, Jennifer; Fisman, David N.

doi:10.1086/649925

Cited by 42 publications

(92 citation statements)

References 48 publications

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“…1 Post-operative pneumonia is the most prevalent of all hospital-acquired infections following CAB, and is associated with increased resource utilization, morbidity and mortality. 2 Indeed, patients developing pneumonia following CAB have four-fold increased odds of mortality and three-fold increased length of stay, relative to those patients not developing pneumonia. 2 Nonetheless, accurate and reliable estimation of an individual’s risk of developing pneumonia is hampered by its low relative incidence (~3%).…”

Section: Introductionmentioning

confidence: 99%

A Preoperative Risk Model for Postoperative Pneumonia After Coronary Artery Bypass Grafting

Strobel

Liang

Zhang

et al. 2016

The Annals of Thoracic Surgery

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Background Post-operative pneumonia is the most prevalent of all hospital-acquired infections following isolated coronary artery bypass grafting (CAB). Accurate prediction of a patient’s risk of this morbid complication is hindered by its low relative incidence. In an effort to support clinical decision-making and quality improvement, we developed a pre-operative prediction model for post-operative pneumonia following CAB. Methods We undertook an observational study of 16,084 patients undergoing CAB between Q3 2011 – Q2 2014 across 33 institutions participating in the Michigan Society of Thoracic and Cardiovascular Surgeons – Quality Collaborative. Variables related to patient demographics, medical history, admission status, comorbid disease, cardiac anatomy and the institution performing the procedure were investigated. Logistic regression via forwards stepwise selection (p < 0.05 threshold) was utilized to develop a risk prediction model for estimating the occurrence of pneumonia. Traditional methods were employed to assess the model’s performance. Results Post-operative pneumonia occurred in 3.30% of patients. Multivariable analysis identified 17 pre-operative factors, including: demographics, laboratory values, comorbid disease, pulmonary and cardiac function, and operative status. The final model significantly predicted the occurrence of pneumonia, and performed well (C-statistic: 0.74). These findings were confirmed via sensitivity analyses by center and clinically important sub-groups. Conclusions We identified 17 readily obtainable pre-operative variables associated with post-operative pneumonia. This model may be used to provide individualized risk estimation and to identify opportunities to reduce a patient’s pre-operative risk of pneumonia through pre-habilitation.

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Section: Introductionmentioning

confidence: 99%

A Preoperative Risk Model for Postoperative Pneumonia After Coronary Artery Bypass Grafting

Strobel

Liang

Zhang

et al. 2016

The Annals of Thoracic Surgery

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“…In both univariable and multivariable analyses' missing data were coded as the modal value, usually as absence of the symptom. Multivariable analyses were repeated using the chained equations approach to multiple imputation: estimates and Wald P-values 15 based on 50 imputed datasets derived using Rubin's rules. 16 Prediction rules were derived in three stages.…”

Section: Discussionmentioning

confidence: 99%

Nappy pad urine samples for investigation and treatment of UTI in young children: the ‘DUTY’ prospective diagnostic cohort study

et al. 2016

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Acutely unwell children <5 years presenting to 233 UK primary care sites. MethodLogistic regression to identify independent associations of symptoms, signs, and urine dipstick test results with UTI; diagnostic utility quantified as area under the receiver operator curves (AUROC). Nappy pad rule characteristics, AUROC, and contamination, compared with findings from clean-catch samples. ResultsNappy pad samples were obtained from 3205 children (82% aged <2 years; 48% female), culture results were available for 2277 (71.0%) and 30 (1.3%) had a UTI on culture. Female sex, smelly urine, darker urine, and the absence of nappy rash were independently associated with a UTI, with an internally-validated, coefficient model AUROC of 0.81 (0.87 for clean-catch), which increased to 0.87 (0.90 for clean-catch) with the addition of dipstick results. GPs' 'working diagnosis' had an AUROC 0.63 (95% confidence intervals [CI] = 0.53 to 0.72). A total of 12.2% of nappy pad and 1.8% of cleancatch samples were 'frankly contaminated' (risk ratio 6.66; 95% CI = 4.95 to 8.96; P<0.001). ConclusionNappy pad urine culture results, with features that can be reported by parents and dipstick tests, can be clinically useful, but are less accurate and more often contaminated compared with clean-catch urine culture.

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“…In recent years various attempts have been made to find markers and risk factors to predict the development of nosocomial pneumonia after cardiac surgery. A large cohort study in the USA in 17,145 patients undergoing cardiac surgery was performed to clarify the derivation and validation of postoperative pneumonia [27]. In this study only 361 patients (2%) developed pneumonia.…”

Section: Discussionmentioning

confidence: 99%

“…They were able to identify thirteen independent predictors for postoperative pneumonia, for example body mass index <18.5, smoking history, creatinine level over 1.2 mg/dl, blood transfusion, mechanical ventilation time >24 hours, cancer history and emergency status. The authors concluded that it may be useful to prove the concept of preventive interventions [27]. However, specificity of this risk model seems to be poor and prevents implementation of preventive strategies.…”

Section: Discussionmentioning

confidence: 99%

Dysfunction of alveolar macrophages after 3 cardiac surgery and postoperative pneumonia? – an 5 observational study

et al. 2013

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IntroductionPatients undergoing cardiac surgery have an increased risk of postoperative pneumonia. Pulmonary immune dysfunction might be a contributing factor. We therefore determined changes of the surface molecules on alveolar macrophages (AMs). To characterize modulation in patients with pneumonia we correlated these changes to the development of postoperative pneumonia.MethodsAfter ethical approval and written informed consent, 33 patients undergoing elective coronary bypass grafting surgery were included in this observational study. Peripheral blood cells and alveolar lavage fluid were collected directly after induction of anesthesia and two hours after separation from cardiopulmonary bypass (CPB). Human leukocyte antigen-DR (HLA-DR) and toll-like receptors (TLR) 2/4 expression on monocytes and AM were assessed by flow cytometry. A total of three patients developed postoperative pneumonia determined according to the criteria of the Center of Disease Control. Statistical analysis was performed with the Mann–Whitney-U test and Wilcoxon test.ResultsWe found significant changes of phenotypic and functional immune markers on AMs after cardiac surgery. HLA-DR expression on peripheral blood monocytes and AMs was significantly reduced compared to baseline in all patients (each approximately 30%). After surgery patients who developed postoperative pneumonia revealed a trend of stronger reduction of HLA-DR expression (83.7% versus 27.1%) and TLR4 expression on AMs (46.1% versus 9.9%) compared to patients without pneumonia. Already before surgery, the baseline of TLR2 expression on AM was significantly lower (27.7%) in patients who developed postoperative pneumonia.ConclusionsAs far as we know this is the first study that shows an early impairment of lung cellular immune response after cardiac surgery. These findings can help to understand the role of cell-mediated immunosuppression and its association to the development of postoperative pneumonia.

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Derivation and Validation of a Clinical Prediction Rule for Nosocomial Pneumonia after Coronary Artery Bypass Graft Surgery

Abstract: Using a large cohort of patients treated at community and teaching hospitals, we derived and validated a prediction rule for pneumonia after CABG. This index may prove to be useful in prioritizing receipt of preventive interventions.

Cited by 42 publications

References 48 publications

A Preoperative Risk Model for Postoperative Pneumonia After Coronary Artery Bypass Grafting

A Preoperative Risk Model for Postoperative Pneumonia After Coronary Artery Bypass Grafting

Nappy pad urine samples for investigation and treatment of UTI in young children: the ‘DUTY’ prospective diagnostic cohort study

Dysfunction of alveolar macrophages after 3 cardiac surgery and postoperative pneumonia? – an 5 observational study

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