Daily adjunctive corticosteroid dose was found to be significantly predictive of mortality outcomes in patients with rheumatic diseases complicated by Pneumocystis jirovicii pneumonia, according to study findings published in the International Journal of Infectious Diseases.
Researchers conducted a retrospective study among patients with rheumatic diseases complicated by P jirovicii pneumonia at the National Taiwan University Hospital in Japan between November 2015 and April 2021. All patients received adjunctive corticosteroid therapy in addition to first-line treatment for pneumonia. First-line treatment was either trimethoprim-sulfamethoxazole or anidulafungin. Patients were categorized into 2 groups, including survivors and nonsurvivors, and multivariable logistic regression was used to determine significant factors associated with in-hospital, 30-day, and 90-day mortality.
There were 72 patients included in the final analysis, of whom the median age was 59.5 (IQR, 44.5-66.8) years, 55.6% were women, the median duration of rheumatic disease was 23.5 (range, 3.3-104.0) months, and the median pneumonia severity index (PSI) score was 101.5 (IQR, 77.0-132.0). Of note, the majority of patients (95.8%) were receiving corticosteroid therapy prior to baseline.
Of patients who survived (n=34) and those who died (n=38), the median adjunctive corticosteroid dose was 0.44 (IQR, 0.29-0.54) and 0.85 (IQR, 0.63-1.05) mg/kg/day (P <.001), respectively. The rate of all-cause mortality among patients who died was 36.1% at 30 days and 52.8% at 90 days.
The researchers found that a median adjunctive corticosteroid dose of 0.6 mg/kg/day was the optimal cutoff point for predicting in-hospital (sensitivity, 78.9%; specificity, 82.4%), 30-day (sensitivity, 80.8%; specificity, 67.4%), and 90-day (sensitivity, 76.3%; specificity, 79.4%) mortality.
Multivariable logistic regression showed that a median adjunctive corticosteroid dose of at least 0.6 mg/kg daily (odds ratio [OR], 5.86; 95% CI, 1.36-25.33; P =.018) and a PSI score of more than 90 (OR, 11.23; 95% CI, 2.32-54.37; P =.003) were significantly associated with in-hospital mortality. A median adjunctive corticosteroid dose of at least 0.6 mg/kg daily also was significantly associated with 30-day (OR, 4.57; 95% CI, 1.27 to 16.42; P =.020) and 90-day (OR, 4.68; 95% CI, 1.22-17.94; P =.024) mortality, with similar results noted for a PSI score of more than 90 for both 30-day (OR, 5.72; 95% CI, 1.39-23.61; P =.016) and 90-day (OR, 10.86; 95% CI, 2.47-47.71; P =.002) mortality.
A sensitivity analysis was performed after the exclusion of patients who received first-line treatment with anidulafungin. Results showed that an increased risk of in-hospital mortality was significantly associated with a median adjunctive corticosteroid dose of at least 0.6 mg/kg daily (OR, 7.5; 95% CI, 1.48-37.16; P =.015), a PSI score of more than 90 (OR, 10.38; 95% CI, 1.85-58.23; P =.008), and a current bloodstream infection (OR, 9.61; 95% CI, 1.05-88.38; P =.045).
This study was limited by its retrospective design, single-center setting, and the inclusion of patients with both probable and laboratory-confirmed Pneumocystis pneumonia.
These findings “provide further evidence for the association between adjunctive corticosteroid dosage and prognosis in [P jirovicii pneumonia],” the researchers concluded.
Huang YM, Lu CH, Cheng CF, et al. Clinical features and prognostic predictors in patients with rheumatic diseases complicated by Pneumocystis pneumonia. Int J Infect Dis. Published online July 30, 2022. doi:10.1016/j.ijid.2022.07.070