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© Borgis - Postępy Nauk Medycznych 12/2012, s. 953-957
*Mirosław Jarosz, Maria Orzeszko, Ewa Rychlik, Sylwia Gugała
Wpływ niedożywienia na ryzyko rozwoju szpitalnego zapalenia płuc
Influence of malnutrition on the risk of hospital-acquired pneumonia
Department of Nutrition and Dietetic with Clinic of Metabolic Diseases and Gastroenterology, National Food and Nutrition Institute, Warsaw
Head of Department: prof. Mirosław Jarosz, MD, PhD
Wstęp. Szpitalne zapalenie płuc (SzZP) jest groźnym, obarczonym dużym ryzykiem zgonu, powikłaniem u chorych hospitalizowanych.
Cel. W pracy zbadano, czy niedożywienie ma wpływ na zwiększenie ryzyka rozwoju SzZP.
Materiał i metody. Zbadano 2 grupy pacjentów: grupa I (kontrolna) obejmowała 166 losowo wybranych chorych (86 kobiet i 80 mężczyzn; średnia wieku: 72 lata; rozpiętość: 32-88 lat); grupa II 138 chorych (50 kobiet i 78 mężczyzn; średnia wieku: 74 lata; rozpiętość: 39-86 lat), u których rozwinęło się SzZP.
Wyniki. Na podstawie pomiarów antropometrycznych i badań biochemicznych wykazano, że niedożywienie występowało istotnie częściej (p = 0,001) w grupie II (ze SzZP) niż w grupie kontrolnej (66,7% vs 22,9%). Średni okres hospitalizacji również był istotnie dłuższy (4,5-krotnie; średnio o 22 dni) w grupie II niż w grupie kontrolnej. Odsetek zgonów w grupie chorych z SzZP był istotnie większy (p = 0,001) niż u osób z grupy kontrolnej (28,2% vs 4,2%).
Wnioski. Niedożywienie może być jednym z potencjalnych czynników ryzyka rozwoju SzZP, ryzyka zgonu, oraz może wiązać się z wydłużeniem okresu hospitalizacji. Każdy chory przyjmowany do szpitala powinien mieć wykonaną ocenę stanu odżywienia, a w przypadku rozpoznania niedożywienia – zastosowane odpowiednie leczenie żywieniowe.
Introduction. Hospital-acquired pneumonia (HAP) is a dangerous complication in hospitalized patients which involves the inherent risk of death.
Aim. The aim of this study was to check whether malnutrition has an influence on the risk of HAP.
Material and methods. Two groups of patients were examined: group I (the control group) comprised 166 randomly chosen patients (86 women and 80 men; mean age: 72; age range: 32-88 years); group II comprised 138 patients (50 women and 78 men; mean age: 74; age range: 39-86 years), suffering from hospital-acquired pneumonia.
Results. Anthropometric measurements and biochemical tests showed that malnutrition occurred definitely more often (p= 0.001) in the group II (with hospital-acquired pneumonia) than in the control group (66.7% vs 22.9%). The average length of hospital stay for patients was significantly longer (4.5 times longer; on average it was 22 days longer) in the group II than in the control group. The death rate in the group of patients with hospital-acquired pneumonia was significantly higher (p = 0.001) than in the control group (28.2% vs 4.2.%).
Conclusions. Thus, malnutrition could be one of the possible risk factor for hospital-acquired pneumonia and increased death rate, as well as could be related to longer patient’s hospital stay. Every patient admitted to hospital should have his/her nutritional status assessed and, in the case of having malnutrition diagnosed, he/she should undergo clinical medical nutrition.
Hospital-acquired pneumonia (HAP) is a dangerous complication in patients hospitalized on various hospital wards (1-3).
Hospital-acquired pneumonia is defined as pneumonia which occurs 48 hours after admitting to hospital in a patient who was not intubated at the moment of his/her admission. The incidence of pneumonia fluctuates between 5 and 15 per 1000 cases of hospitalization (4, 5). HAP is most often the result of nasopharyngeal bacterial colonization, after which the bacteria are aspired to the lower respiratory tract (4, 6, 7). Hospital-acquired pneumonia significantly worsens the prognosis for recovery and increases the cost of treating patients in hospitals, especially in the case of elderly people, over the age of 65 (5). Pneumonia causes death more often than other nosocomial infections (5, 8).
The most important pathogens causing hospital-acquired pneumonia during the first days of hospitalization are S. pneumoniae, H. influenzae, methicillin-resistant Staphylococcus aureus, and sometimes HAP is caused by Gram-negative bacteria: E. coli, K. pneumoniae, Enterobacter, Proteus, S. marcescens. From the fifth day of hospitalization, Gram-negative bacteria dominate, K. pneumoniae, Proteus, Serratia, P. aeruginosa, E. coli, Acinetobacter sp. and L. Pneumophila, as well as Gram-positive ones: P. aeruginosa, S. aureus. The source of the bacteria causing hospital-acquired pneumonia are devices used on wards, environment (the air, water, equipment, clothes). Bacteria are also transmitted from one patient to another, as well as from healthcare personnel to patients.
The development of hospital complications, including hospital-acquired pneumonia in hospitalized patients, is favoured by various diseases (diabetes, cirrhosis, chemotherapy performed earlier) which disturb immune balance or diseases in which invasive examination of respiratory system (bronchoscopy) or urinary system was performed (9). There is little data available on the influence of one’s nutritional status on the development of HAP in hospitalized patients (4, 5, 10). Pilot studies have shown that malnutrition can be a risk factor for hospital-acquired pneumonia (11). They are, however, difficult to carry out, because many factors can cause the development of this disease. Moreover, in such studies a very accurate assessment of one’s nutrition state ought to be performed, as well as patients should be appropriately selected for the study.
The problem is quite serious, because many studies have shown that from 30% to 70% hospitalized patients suffer from protein-energy malnutrition, as well as vitamin or mineral malnutrition (8, 12-15). Studies carried out in Poland have shown that the symptoms of malnutrition can be observed in almost half of hospitalized patients (16, 17). The most serious causes of hospital malnutrition are: disease, hospital diet – especially low-protein – and low-energy diet, a lack of appropriate interest of doctors and nurses in this problem, as well as the fact that hospital dietitians cannot influence feeding arrangements in hospital (18-20). Moreover, hospitalized patients very often suffer nutrients loss as a result of hyper-catabolism (21, 22).
MaTerial and methods
Patients selected to participate in the study were hospitalized in the Clinic of Metabolic Diseases and Gastroenterology in the Mazowiecki Bródnowski Hospital. They suffered from: ischemic heart disease, myocardial infarction, hypertension, cardiac dysrhythmia, atherosclerotic psychoorganic syndrome, gallstone, functional bowel disorders, chronic and acute pancreatitis, peptic ulcer, gastroesophageal reflux disease and neoplasm (patients who had not undergone chemotherapy).
The patients who were not selected for this study were admitted to hospital for bacterial infections and other illnesses which could become a risk factor of nosocomial infections, as well as patients who had undergone invasive examinations of respiratory system. The reasons for excluding patients from the study were as follows: the patient’s hospital stay shorter than 2 days or longer than 14 days, non-HAP, chronic obstructive pulmonary disease, urinary tract infections, cholecystitis, ascending cholangitis, diabetes, cirrhosis, gastrointestinal bleeding, AIDS, coma, stroke, tracheal intubation, invasive examination of respiratory system (e.g. bronchoscopy), ear, nose and throat examination.
The (control) group I comprised randomly selected patients, who were admitted to the Clinic and who fulfilled all requirements. There were 166 people in this group (86 women and 80 men), mean age: 72 (age range: 32-88 years). The group II comprised patients who within 14 days of their hospital stay developed so called hospital-acquired pneumonia that is at least after 48 hours of their stay in hospital there were clinical and radiological symptoms of pneumonia observed. The following criteria for the detection of HAP were applied: new pulmonary infiltrates and worsening of exisiting infiltrates; 2 or 3 clinical symptoms present – body temperature ≥ 38°C, leukocytosis or leukopenia, pus in bronchi (23). Blood and/or sputum culture was done in order to identify bacteria that caused pneumonia (1). Group II comprised 138 patients (50 women and 78 men); mean age: 74 (age range: 39-86 years).
The assessment of nutritional status in all patients selected for the study was performed. The assessment covered: anthropometric measurements (BMI – Body Mass Index) (21, 24) as well as laboratory analyses (RBC count, haemoglobin concentration, peripheral blood lymphocyte count and serum albumin) (21, 22, 25). The following criteria to detect malnutrition were applied: BMI < 18.5 kg/m2, haemoglobin concentration (g/dl) in men < 14 g/dl, in women < 12 g/dl, peripheral blood lymphocyte count < 1500/mm3, serum albumin < 3.5 g/dl (21, 24, 25). The statistical analysis was performed with the use of chi-square test.
The analysis of results showed that when the symptoms of hospital-acquired pneumonia occurred, most patients had abnormalities of nutritional status of various stages (anthropometric and biochemical abnormalities) suggesting malnutrition (tab. 1). The abnormalities were observed in 92 out of 138 patients (66.7%) with HAP (group II), whereas in the control group (group I) malnutrition symptoms were observed in 38 out of 166 patients (22.9%). Worth noticing is the fact that in the group II in other 46 patients (33.3%) with hospital-acquired pneumonia overweight and obesity was observed. This proves that the development of HAP may be caused not only by malnutrition but also by overweight and obesity.
Table 1. Abnormalities of nutritional status (anthropometric and biochemical) suggesting malnutrition in the groups: group I (controls, n = 166) and group II (with HAP, n = 138).
Parameter studied Group I, control group
n = 166
% Group II
n = 138
Anthropometric data
Underweight (malnutrition risk) BMI< 18.5 kg/m23822.992*66.7*
Normal BMI18.5-24.9 kg/m23219.3
Overweight and obesity BMI> 25.0 kg/m29657.846*33.3
Laboratory analysis
RBC count K K (F) < 4 200 000 M (M) < 4 600 0002615.758*42
Haemoglobin concentration K (F) < 12 g/dl M (M) < 14 g/dl3822.989*64.5
Peripheral blood lymphocyts count< 1500/mm33420.572*52.2
Serum albumin< 3.5 g/dl3420.590*65.2
Malnutrition markers
Anthropometric and/or biochemical3822.9*92*66.7*
*Chi-square test p = 0.001 (vs group I)

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otrzymano: 2012-09-26
zaakceptowano do druku: 2012-10-31

Adres do korespondencji:
*Mirosław Jarosz
Department of Nutrition and Dietetic with Clinic of Metabolic Diseases and Gastroenterology National Food and Nutrition Institute
ul. Powsińska 61/63, 02-903 Warszawa
tel.: +48 (22) 550-96-77
e-mail: jarosz.zaklad@izz.waw.pl

Postępy Nauk Medycznych 12/2012
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