Central Journal of Human Nutrition & Food Science

Cite this article: Takeda S, Nagata N, Akagi T, Harada T, Miyazaki H, et al. (2015) Albumin rather than Severity Assessment Scale or Procalcitonin is an Impor-tant Prognostic Factor of Pneumonia Occurring outside the Hospital Setting. J Hum Nutr Food Sci 3(4): 1069.

*Corresponding authorNobuhiko Nagata, Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Japan, 1-1-1 Zokumyoin, Chikushino-city, Fukuoka 818-8502, Tel: 81929211011; Fax: 81929283890; Email:

Submitted: 08 May 2015

Accepted: 16 June 2015

Published: 18 June 2015

ISSN: 2333-6706

Copyright© 2015 Nagata et al.

OPEN ACCESS

Research Article

Albumin rather than Severity Assessment Scale or Procalcitonin is an Important Prognostic Factor of Pneumonia Occurring outside the Hospital SettingSatoshi Takeda1, Nobuhiko Nagata1*, Takanori Akagi1, Taishi Harada1, Hiroyuki Miyazaki1, Masaru Kodama1, Shinichiro Ushijima1, Takashi Aoyama1, Masaki Fujita2 and Kentaro Watanabe2

1Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Japan2Department of Respiratory Medicine, Faculty of Medicine, Fukuoka University, Japan

Abstract

Objective: This study aimed to identify prognostic factors of pneumonia occurring outside the hospital setting by comprehensively analyzing data considered to relevant to prognosis including nutritional factors.

Methods: We retrospectively investigated the clinical charts and computed tomography images of all CAP and HCAP patients admitted to our hospital from October 2010 to April 2013. Data considered to be related to prognosis were collected. The primary outcome was 30-day mortality.

Results: Subjects were 138 CAP and 66 HCAP patients. Twenty patients died from pneumonia within 30 days from the date of admission. The numbers of patients with ADROP scores of 0/1/2/3/4/5 were 26/43/78/45/8/4, respectively. Mean (standard deviation) BMI, blood PCT, CRP, albumin, lymphocytes, TC, and number of segments involved were 20.19 (3.85) kg/m2, 5.179 (18.331) ng/mL, 12.48 (10.00) mg/dL, 3.22 (0.63) g/dL, 1090.9 (1151.0) /mm3, 147.8 (35.4) mg/dL, and 5.6 (3.9) respectively. Comorbidities included chronic obstructive pulmonary disease, dementia, central nervous system disorders, chronic heart diseases, diabetes mellitus, malignant disorders, and chronic kidney disease. The mean (standard deviation) number of segments involved was 5.6 (3.9). Logistic regression analysis revealed that BMI (p=0.007), albumin (p=0.013), the extent of pneumonia (p=0.007), dementia (p=0.017) and malignant disorders (p=0.046) were significantly related to 30-day mortality. Receiver operating characteristics curve analysis revealed that albumin is superior to BMI, PCT, ADROP score, or extent of pneumonia for prediction of 30-day mortality.

Conclusion: Albumin, rather than ADROP or PCT, is an important prognostic factor of pneumonia occurring outside the hospital setting.

Keywords•Pneumonia•Prognosis•Body mass index•Albumin•Procalcitonin•Pneumonia severity assessment scale

ABBREVIATIONSCAP: Community-Acquired Pneumonia; HCAP: Health Care-

Associated Pneumonia; ADROP: Age Dehydration Respiratory Failure Orientation Disturbance Pressure; BMI: Body Mass Index; PCT: Procalcitonin; CRP: C - reactive protein; TC: Total Cholesterol

INTRODUCTIONCommunity-acquired pneumonia (CAP) is an important

cause of morbidity and mortality throughout the world [1]. Many studies have identified prognostic factors of CAP. Although poor nutritional status is associated with a negative prognosis of

pneumonia [2-6], recent studies on prognostic factors have focused on severity assessment scales, such as the pneumonia severity index, the confusion, urea, respiratory rate, blood pressure, age>65 (CURB-65) severity score, and the age, dehydration, respiratory failure, orientation disturbance, pressure (ADROP) scoring system proposed by the Japanese Respiratory Society [7-12], as well as biomarkers such as procalcitonin (PCT) [11-18]. Severity assessment scales and PCT have been shown to impact the prognosis of CAP. In Japan, the ADROP scoring system has been widely used to evaluate pneumonia severity, and is related to the prognosis of CAP [10,11]. Moreover, several investigators have reported that PCT is positively associated with the ADROP score, and has a significant impact on the prognosis of CAP

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[11,12]. Unfortunately, most of these studies do not address nutritional status, which is likely to influence the clinical course of pneumonia. Recently, serum albumin was reported to have prognostic importance in CAP patients [19,20].

Nutritional status, serum albumin, and body mass index (BMI) impact the clinical outcome of several respiratory disorders, including chronic obstructive pulmonary disorder [21,22], pulmonary tuberculosis [23-26], non-tuberculous mycobacterial infection [7,28), and idiopathic interstitial pneumonia [29,30]. However, recent studies on CAP do not appear to highlight the prognostic importance of nutritional status in these patients. Recently, health care-associated pneumonia (HCAP) occurring outside the hospital setting was reported to have a negative influence on prognosis [31,32]. While the extent of pneumonia influences the clinical course, its impact on prognosis has not been extensively investigated. To our knowledge, there have been no reports addressing the prognostic importance of nutritional status as it relates to the pneumonia severity assessment scale, PCT, and extent of pneumonia in hospitalized patients with pneumonia occurring outside the hospital setting.

Against this backdrop, the present study aimed to identify prognostic factors of pneumonia occurring outside the hospital setting by comprehensively analyzing the ADROP score, PCT, extent of pneumonia, and nutritional factors.

PATIENTS AND METHODSClinical charts and computed tomography images of all

CAP and HCAP patients admitted to our hospital from October 2010 to April 2013 were retrospectively reviewed. Validity of the pneumonia diagnosis was confirmed by two respiratory physicians. Exclusion criteria were: pulmonary edema, massive pleural fluid, or other non-pneumonia conditions that would influence the prognosis of pneumonia, or interfere with the assessment of the extent of pneumonia. Data on admission considered relevant to prognosis were collected, including age, sex, category of pneumonia occurring outside the hospital setting (CAP or HCAP), ADROP scale, comorbidities, blood C-reactive protein (CRP) and PCT levels, extent of pneumonic shadow, and parameters reflecting nutritional status such as body mass index (BMI), blood albumin and total cholesterol (TC) levels, and blood lymphocyte count.

The laboratory workup for microbiologic investigations included sputum samples for Gram stain and culture, two blood samples for culture, urine samples for detection of Streptococcus pneumonia and Legionella pneumophila antigens, and serum samples for serologic testing against antibodies for Mycoplasma pneumoniae and Chlamydophila pneumoniae.

The ADROP scale is similar to the CURB-65 scale and provides a five-point score based on the following parameters: confusion, blood urea nitrogen >21 mg/dL or the presence of dehydration, percutaneous oxygen desaturation (SpO2 < 90%), systolic blood pressure <90 mmHg, and age >70 years for men or >75 years for women. Each criterion receives one point, resulting in a total score ranging from 0 to 5 points [33]. The extent of pneumonic shadow is defined as the number of segments involved on CT images taken within 24 hours after admission.

Table 1: Baseline characteristics.No. patients 204

Died within 30 days 20 (9.8%)Male/female 134 (65.7%) / 70 (34.3%)Age (years) 74.8 ± 17.2CAP/HCAP 138 (67.6%) / 66 (32.4%)

ADROP score0 26 (12.7%)1 43 (21.1%)2 78 (38.2%)3 45 (21.1%)4 8 (3.9%)5 4 (2.0%)

BMI (kg/m2) 20.19 ± 3.85PCT (ng/mL) 5.18 ± 18.33CRP (mg/dL) 12.48 ± 10.00

Albumin (g/dL) 3.22 ± 0.63TC (mg/dL) 147.8 ± 35.4

Lymphocytes (/mm3) 1090.9 ± 1151.0Comorbidities

COPD 30 (14.7%)Dementia 36 (17.6%)

CNSD 62 (30.4%)CHD 47 (23.0%)

Diabetes mellitus 41(20.1%)Malignancy 12 (5.9%)

CKD 9 (4.4%)No. involved segments 5.6 ± 3.9

PathogenClassic bacteria 73

Streptococcus pneumoniae 31Escherichia coli 8

Haemophilus.influenzae 7Klebsiella pneumoniae 6Moraxella catarrhalis 5

MRSA 5Pseudomonas aeruginosa 5Legionella pneumophila 2

Others 18Atypical pathogen 18

Mycoplasma. pneumoniae 13Chlamydophila. pneumoniae 7

Mixed 6Mycoplasma. pneumoniae

+ classic bacteria 3Chlamydophila. pneumoniae

+ classic bacteria 3CAP= Community-Acquired Pneumonia; HCAP= Health Care- Associated Pneumonia; ADROP= Age Dehydration Respiratory Failure Orientation Disturbance and Pressure; BMI= Body Mass Index; PCT= Procalcitonin; CRP= C-reactive protein; TC= Total Cholesterol; COPD= Chronic Obstructive Pulmonary Disease; CHD= Chronic Heart Disease; CKD= Chronic Kidney Disease; CNSD= Central Nervous System disease; MRSA= Methicillin-Resistant Staphylococcus Aureus Data are presented as no. (%) or mean ± standard deviation.

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Table 2: Univariate and multivariate analysis of factors related to 30-day mortality.30-day mortality Univariate Logistic Regression Multivariate Logistic Regression

Variable No. patients n % OR 95%CI P value OR 95%CI P value

Age (years) -<70 47 2 4.3% Reference － [0.171]

70-<86 99 9 9.1% 2.249 (0.466, 10.845) 0.313

86- 58 9 15.5% 4.131 (0.847, 20.146) 0.079

Sex Female 70 5 7.1% Reference － －

Male 134 15 11.2% 1.639 (0.570, 4.712) 0.359

ADROP score 0,1 69 1 1.4% Reference － [0.002**]

2,3 123 14 11.4% 8.734 (1.123, 67.928) 0.038*

4,5 12 5 41.7% 48.571 (4.950, 476.599) <0.001***

Category of pneumonia CAP 138 12 8.7% Reference － －

HCAP 66 8 12.1% 1.449 (0.562, 3.735) 0.443

BMI (kg/m2) -<17.6 48 11 22.9% Reference － [0.001**] Reference － [0.002**]

17.6-<19.95 52 3 5.8% 0.206 (0.054, 0.791) 0.021* 0.183 (0.038,

0.879) 0.034*

19.95- 100 4 4.0% 0.140 (0.042, 0.468) 0.001** 0.143 (0.037,

0.552) 0.005**

Unknown 4 2 50.0% 3.364 (0.423, 26.718) 0.251 6.604 (0.516,

84.449) 0.147

CRP (mg/dL) -<4.30 51 1 2.0% Reference － [0.113]4.30-<19.155 102 11 10.8% 6.042 (0.758,

48.157) 0.089

19.155- 51 8 15.7% 9.299 (1.118, 77.334) 0.039*

PCT (ng/mL) -<0.39 99 5 5.1% Reference － [0.072]

0.39-<2.66 51 5 9.8% 2.043 (0.563, 7.414) 0.277

2.66- 51 9 17.6% 4.028 (1.273, 12.750) 0.018*

Unknown 3 1 33.3% 9.400 (0.724, 122.013) 0.087

Albumin (g/dL) -<2.8 44 12 27.3% Reference － [<0.001***]

2.8-<3.3 57 6 10.5% 0.314 (0.107, 0.919) 0.035*

3.3- 103 2 1.9% 0.053 (0.011, 0.249) <0.001***

Lymphocytes (/mm3) -<598.4 48 9 18.8% Reference － [0.066]598.4-<876.3 48 6 12.5% 0.619 (0.202,

1.900) 0.402

876.3- 97 4 4.1% 0.186 (0.054, 0.641) 0.008**

Unknown 11 1 9.1% 0.433 (0.049, 3.832) 0.452

Total cholesterol (mg/dL) -<124 42 9 21.4% Reference － [0.026*]

124-<147 47 6 12.8% 0.537 (0.173, 1.661) 0.280

147- 90 3 3.3% 0.126 (0.032, 0.496) 0.003**

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Unknown 25 2 8.0% 0.319 (0.063, 1.614) 0.167

COPD Absent 174 17 9.8% Reference － －

Present 30 3 10.0% 1.026 (0.282, 3.741) 0.969

Dementia Absent 168 12 7.1% Reference － － Reference － －

Present 36 8 22.2% 3.714 (1.393, 9.905) 0.009** 4.200 (1.213,

14.540) 0.024*

CNSD Absent 142 10 7.0% Reference － －

Present 62 10 16.1% 2.538 (0.998, 6.456) 0.050

CHD Absent 157 16 10.2% Reference － －

Present 47 4 8.5% 0.820 (0.260, 2.583) 0.734

Diabetes mellitus Absent 163 16 9.8% Reference － －

Present 41 4 9.8% 0.993 (0.313, 3.148) 0.991

Malignancy Absent 192 16 8.3% Reference － － Reference － －

Present 12 4 33.3% 5.500 (1.492, 20.279) 0.010 * 11.331 (1.981,

64.805) 0.006**

CKD Absent 195 19 9.7% Reference － －

Present 9 1 11.1% 1.158 (0.137, 9.764) 0.893

No. involved segments -<7 128 5 3.9% Reference － － Reference － －

7- 68 14 20.6% 6.378 (2.187, 18.595) <0.001 *** 8.307 (2.388,

28.900)<0.001 ***

Unknown 8 1 12.5% 3.514 (0.360, 34.293) 0.280 3.039 (0.169,

54.707) 0.451

OR=Odds Ratio; CI=Confidence Interval; ADROP=Age Dehydration Respiratory Failure Orientation Disturbance and Pressure; CAP=Community-Acquired Pneumonia; HCAP=Health Care-Associated Pneumonia; BMI=Body Mass Index; CRP=C-reactive protein; PCT=Procalcitonin; COPD=Chronic Obstructive Pulmonary Disease; CNSD=Central Nervous System Disease; CHD=Chronic Heart Disease; CKD=Chronic Kidney Disease ***P < 0.001, **P < 0.01, *P < 0.05. P values in parentheses are in relation to the corresponding variable. P values without parentheses are in relation to the reference category.

The primary outcome was death within 30 days from the date of admission. We analyzed factors related to 30-day mortality using logistic regression and receiver operating characteristic (ROC) curve analyses, which were performed with statistical software (SAS version 9.2, SAS Institute Inc., Cary, NC, USA). P <0.05 was considered significant. This study was approved by the institutional review board of Fukuoka University Chikushi Hospital.

RESULTSStudy population

Clinical features of patients included in the study are summarized in Table 1. The study population consisted of 204 patients (138 CAP and 66 HCAP patients; 119 men (64.7%)). Numbers of patients with ADROP scores of 0, 1, 2, 3, 4, and 5 were 26, 43, 78, 45, 8, and 4, respectively. Mean (standard deviation) BMI, blood PCT, CRP, albumin, lymphocytes, and TC were 20.19 (3.85) kg/m2, 5.179 (18.331) ng/mL, 12.48 (10.00) mg/dL, 3.22 (0.63) g/dL, 1090.9 (1151.0) /mm3, and 147.8 (35.4) mg/dL, respectively. Comorbidities included 30 patients with chronic obstructive pulmonary disease, 36 with dementia, 62 with central nervous system disorders, 47 with chronic heart disease, 41 with diabetes mellitus, 12 with malignant disorders, and nine with

chronic kidney disease. The mean (standard deviation) number of segments involved was 5.6 (3.9). The causative pathogen was identified in 97 of the 204 patients (47.5%), as follows: classic bacterial pathogens (n=73), atypical pathogens (n=18), and mixed classic bacterial and atypical pathogens (n=6). Among the classic bacterial pathogens, Streptococcus pneumoniae was the leading pathogen (n=31), followed by E. coli (n=8), Haemophilus influenzae (n=7), Klebsiella pneumoniae (n=6), Moraxella catarrhalis (n=5), MRSA (n=5), and Pseudomonas aeruginosa (n=5). Atypical pathogens included Mycoplasma pneumonia (n=14), Chlamydophila pneumoniae (n=8), and co-infection by Mycoplasma pneumoniae and Chlamydophila pneumoniae (n=2). Twenty patients (9.8%; 12 CAP and 8 HCAP) died from pneumonia within 30 days from the date of admission; all died from pneumonia.

Factors related to 30-day mortality

Univariate analysis revealed that ADROP score (p<0.001), BMI (p=0.001), albumin (p<0.001), TC (p=0.026), dementia (p=0.009), malignant disease (p=0.01), and the extent of pneumonia (p<0.001) were significantly related to 30-day mortality. Multivariate analysis revealed that BMI (p=0.002), dementia (p=0.024), malignant disease (p=0.006), and the extent of pneumonia (p<0.001) remained significant as factors

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related to 30-day mortality (Table 2). We also examined a model in which BMI was excluded. In this model, albumin (p<0.001), dementia (p=0.017), malignant disease (p=0.046), and the extent of pneumonia (p=0.007) were significantly associated with 30-day mortality (Table 3).

ROC curve analysis revealed that albumin (AUC 0.832) is superior to BMI (AUC 0.768), PCT (AUC 0.685), ADROP score (AUC 0.761), or extent of pneumonia (AUC 0.742) for prediction of 30-day mortality or survival beyond 30 days (Figure1).

DISCUSSIONThe nutritional status of the host affects the clinical features

of respiratory infectious diseases such as tuberculosis [23-26] and non-tuberculous mycobacterial infection [7, 28]. We previously reported that poor nutritional status, especially hypoalbuminemia, affects CT findings as well as in-hospital mortality of tuberculosis patients [25,26], and identified the relationship between nutritional status, especially BMI, and

disease spread of non-tuberculous mycobacterial infections [28]. With respect to pneumonia, previous studies have highlighted the importance of nutritional status as a prognostic factor [2-6]. However, recent studies have emphasized the pneumonia severity assessment scale as a prognostic factor of CAP [7-12]. PCT is also a prognostic factor of CAP [13-18]. Given that these recent studies did not analyze nutritional status, it is not clear which of these factors best predicts prognosis of CAP. Some studies have reported that HCAP occurring outside the hospital setting is a negative prognostic factor [31,32]. To clarify which factors are the best prognostic factors for pneumonia occurring outside the hospital setting, the present study aimed to comprehensively analyze previously reported factors.

To our knowledge, this is the first study to examine prognostic factors of pneumonia occurring outside the hospital setting by comprehensively analyzing the ADROP score, PCT, extent of pneumonia, and nutritional factors. We found that albumin was the best prognostic factors, although both ADROP score and PCT

Table 3: Univariate and multivariate analysis of factors (excluding BMI) related to 30-day mortality.30-day mortality Univariate Logistic Regression Multivariate Logistic Regression

Variable No. patients n % OR 95%CI P value OR 95%CI P value

Age (years) -<70 47 2 4.3% Reference － [0.171]

70-<86 99 9 9.1% 2.249 (0.466, 10.845) 0.313

86- 58 9 15.5% 4.131 (0.847, 20.146) 0.079

Sex Female 70 5 7.1% Reference － －

Male 134 15 11.2% 1.639 (0.570, 4.712) 0.359

ADROP score 0,1 69 1 1.4% Reference － [0.002**]

2,3 123 14 11.4% 8.734 (1.123, 67.928) 0.038*

4,5 12 5 41.7% 48.571 (4.950, 476.599) <0.001***

Category of pneumonia CAP 138 12 8.7% Reference － －

HCAP 66 8 12.1% 1.449 (0.562, 3.735) 0.443

CRP (mg/dL) -<4.30 51 1 2.0% Reference － [0.113]4.30-<19.155 102 11 10.8% 6.042 (0.758,

48.157) 0.089

19.155- 51 8 15.7% 9.299 (1.118, 77.334) 0.039*

PCT (ng/ml) -<0.39 99 5 5.1% Reference － [0.072]

0.39-<2.66 51 5 9.8% 2.043 (0.563, 7.414) 0.277

2.66- 51 9 17.6% 4.028 (1.273, 12.750) 0.018*

unknown 3 1 33.3% 9.400 (0.724, 122.013) 0.087

Albumin (g/dL) -<2.8 44 12 27.3% Reference － [<0.001***] Reference － [0.013*]

2.8-<3.3 57 6 10.5% 0.314 (0.107, 0.919) 0.035* 0.360 (0.112, 1.159) 0.087

3.3- 103 2 1.9% 0.053 (0.011, 0.249) <0.001*** 0.096 (0.018, 0.497) 0.005**Lymphocytes (/mm3) -<598.4 48 9 18.8% Reference － [0.066]

598.4-<876.3 48 6 12.5% 0.619 (0.202, 1.900) 0.402

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876.3- 97 4 4.1% 0.186 (0.054, 0.641) 0.008**

unknown 11 1 9.1% 0.433 (0.049, 3.832) 0.452Total cholesterol (mg/dL) -<124 42 9 21.4% Reference － [0.026*]

124-<147 47 6 12.8% 0.537 (0.173, 1.661) 0.280

147- 90 3 3.3% 0.126 (0.032, 0.496) 0.003**

unknown 25 2 8.0% 0.319 (0.063, 1.614) 0.167

COPD absent 174 17 9.8% Reference － －

present 30 3 10.0% 1.026 (0.282, 3.741) 0.969

Dementia absent 168 12 7.1% Reference － － Reference － －

present 36 8 22.2% 3.714 (1.393, 9.905) 0.009** 4.174 (1.285, 13.558) 0.017*

CNSD absent 142 10 7.0% Reference － －

present 62 10 16.1% 2.538 (0.998, 6.456) 0.050

CHD absent 157 16 10.2% Reference － －

present 47 4 8.5% 0.820 (0.260, 2.583) 0.734

Diabetes mellitus absent 163 16 9.8% Reference － －

present 41 4 9.8% 0.993 (0.313, 3.148) 0.991

Malignancy absent 192 16 8.3% Reference － － Reference － －

present 12 4 33.3% 5.500 (1.492, 20.279) 0.010* 5.070 (1.028,

25.000) 0.046*

CKD absent 195 19 9.7% Reference － －

present 9 1 11.1% 1.158 (0.137, 9.764) 0.893No. involved segments -<7 128 5 3.9% Reference － － Reference － －

7- 68 14 20.6% 6.378 (2.187, 18.595) <0.001*** 5.033 (1.560,

16.236) 0.007**

unknown 8 1 12.5% 3.514 (0.360, 34.293) 0.280 5.641 (0.312,

102.044) 0.242

OR=Odds Ratio; CI=Confidence Interval; ADROP=Age Dehydration Respiratory Failure Orientation Disturbance and Pressure; CAP=Community-acquired pneumonia; HCAP=Health Care-associated pneumonia; CRP=C-reactive protein; PCT=Procalcitonin; COPD=Chronic Obstructive Pulmonary Disease; CNSD=Central Nervous System Disease; CHD=Chronic Heart Disease; CKD=Chronic Kidney Disease **P < 0.01, *P < 0.05. P values in parentheses are in relation to the corresponding variable. P values without parentheses are in relation to the reference category.

Figure 1 Receiver operating characteristics curve of albumin, body mass index (BMI), extent of pneumonia (that is, number of segments involved), procalcitonin (PCT), and ADROP score for prediction of 30-day mortality (extent of pneumonia, PCT, and ADROP score), or survival beyond 30 days (albumin, and BMI).

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were included in the analysis. Though several investigators have reported that PCT is positively associated with the ADROP score, and has a significant impact on the prognosis of CAP [11,12], PCT did not have significant impact on the death within 30 days in the present study. PCT is not reported to increase in sera of the patients with autoinflammatory or autoimmune diseases, and elderly patients [34-36]. These findings may explain why PCT did not relate to 30-d mortality, because many elderly patients were included in our study.

The prognosis of HCAP is reported to be worse than that of CAP [31,32]. In the present study, the 30-day mortality of HCAP patients was lower than those reported previously, although the 30-day mortality of CAP was similar. This may explain why HCAP did not remain significant as a prognostic factor. It is unclear why the prognosis of HCAP patients was relatively good in the present study.

Aspiration was recently found to negatively influence the prognosis of pneumonia [37]. Although we did not evaluate swallowing function, many dementia patients are known to suffer from swallowing disorders and have a history of aspiration. Thus, aspiration may be one explanation for why dementia remained a significant prognostic factor.

It is noteworthy that the extent of pneumonia as assessed by CT significantly influenced the prognosis of pneumonia. It is clear that the more widespread the pneumonia, the worse the prognosis. However, it is not standard clinical practice to evaluate CT images in patients with pneumonia. Thus, in the future, it will be necessary to examine the relationship between the extent of pneumonia as assessed by chest roentgenogram and the prognosis of pneumonia.

There are several limitations to this study worth noting. First, the study was retrospective in nature, and thus data were missing for a few patients. A prospective study will be needed to confirm our results. Second, we did not determine whether antibiotics were properly used. However, because antibiotics are chosen based on guidelines set forth by the Japan Respiratory Society, it is likely that antibiotics were properly used in most patients.

CONCLUSIONAlbumin appears to be better than ADROP scores or PCT for

predicting 30-day mortality in pneumonia occurring outside the hospital setting. Moreover, the extent of pneumonia as assessed by CT images is also an important prognostic factor.

AUTHOR CONTRIBUTIONSST and NN contributed to the planning of the study, data

analysis, and preparation, review, and submission of the manuscript. TA, TH, HM, SU and SA contributed to data collection, data analysis, and review and submission of the manuscript. MF and KW contributed to data analysis and review and submission of the manuscript.

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Takeda S, Nagata N, Akagi T, Harada T, Miyazaki H, et al. (2015) Albumin rather than Severity Assessment Scale or Procalcitonin is an Important Prognostic Factor of Pneumonia Occurring outside the Hospital Setting. J Hum Nutr Food Sci 3(4): 1069.

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