Title

Author(s)

The characteristics of patients with previous residence in

mainland China admitted to the intensive care unit in Hong Kong
with community-acquired pneumonia
Ho, Chun-ming;

Citation

Issued Date

URL

Rights

2012

http://hdl.handle.net/10722/173739

Creative Commons: Attribution 3.0 Hong Kong License

The characteristics of patients with previous residence in Mainland China admitted to

the intensive care unit in Hong Kong with community-acquired pneumonia

By

Ho Chun Ming, Chris

MBChB

This work is submitted to

The Department of Microbiology, The University of Hong Kong
In partial fulfillment of the requirements for
The Postgraduate Diploma in Infectious Diseases (PDipID) 2010-2012

Date: 30th May 2012

Supervisor: Dr. Samson SY Wong

Declaration

I, Ho Chun Ming Chris, declare that this dissertation represents my own work and that
it has not been submitted to this or other institution in application for a degree,
diploma or any other qualifications

I, Ho Chun Ming Chris, also declare that I have read and understand the guideline on
What is plagiarism? published by The University of Hong Kong and that all parts of
this work complies with the guideline

Candidate: Ho Chun Ming Chris

Signature: __________________________
Date:

__________________________

Acknowledgement
I would like to thank my supervisor, Dr. Samson SY Wong (Assistant Professor,
Department of Microbiology, The University of Hong Kong) for his kind support and
guidance in this research project. I would also like to express my gratitude to Dr.
Wong Kwan Keung (Consultant, Department of Intensive Care, North District
Hospital), who gave me valuable advice in this research project.

Contents
Page

Chapter
Abstract
1

Introduction
1.1

Characteristics of Hong Kong people having

1-2

taken up residence in Mainland China

1.2

Importance of sepsis

2-3

1.3

Importance of community acquired pneumonia in

3-4

intensive care unit

2

Study objectives

Methods

3.1

Study design

3.2

Data collection

6-7

3.3

Inclusion and exclusion criteria

7-8

3.4

Assessment
3.4.1

Demographic Data

3.4.2

Clinical History

3.4.3

Disease Assessment

3.4.4

Outcomes

8-9

3.4.5
3.5
4

Patterns of Infection
Statistical Analysis

10
10

Results
4.1

Characteristics of Patients with Sepsis from

11-14

Mainland China
4.2

Diseases Severity

15

4.3

Outcomes

15-16

4.4

Patterns of Infection

17-18

4.5

Predictors of Mortality in Patients

19

Discussion

20-28

Conclusion

29

Reference List

30-33

The characteristics of patients with previous residence in

Mainland China admitted to the intensive care unit in Hong
Kong with community-acquired pneumonia

Abstract
Objectives: To review the characteristics, outcomes, patterns of infection, and
predictors of mortality in critically ill patients with community acquired pneumonia
from the Mainland China requiring intensive care in Hong Kong
Design: Retrospective cohort study
Setting: A regional hospital in Hong Kong
Patients: Critically ill patients who lived in the Mainland and were admitted to the
Intensive Care Unit (ICU) of North District Hospital (NDH) from September 2008 to
August 2010
Intervention: None
Measurements and Results: Fifty one patients (median age, 50 years) were analyzed.
It accounts for 4.1% of our annual ICU admission. The median APACHE II, SOFA,
and CURB-65 scores are 24.5, 10.5, and 6 respectively. Most of these patients
required mechanical ventilator support (n=42, 84%) in our unit. Pathogenic organisms
can be identified in the majority of these patients (n=33, 66%). The most common

organism was Streptococcus pneumoniae. Confusion, blood urea level greater than 7
mmol/L, and higher APACHE II / CURB-65 scores are considered as poor prognostic
factors.
Conclusions: Community acquired pneumonia is a common cause of intensive care
admission among patients living in the Mainland with a significant mortality. Better
understanding of their characteristics is important.

The characteristics of patients with previous residence in

Mainland China admitted to the intensive care unit in Hong
Kong with community-acquired pneumonia

1
1.1

Introduction
Characteristics of Hong Kong people having taken up residence in
Mainland China
The ties between Hong Kong and Mainland China have become closer after the

handover of Hong Kong in 1997 and the improvement of Chinas socioeconomic

status and transportation system. There has been an increasing tendency for Hong
Kong people to reside in, take up jobs and acquire residential properties in the
Mainland. According to a survey conducted in May 2008 by the Planning department
of the Hong Kong Special Administrative Region (HKSAR) Government and the
Statistics Bureau of the Shenzhen Municipal Government [1], 61865 Hong Kong
people have taken up residence in Shenzhen for 3 months or more during the 6-month
period before enumeration. It accounts for 0.086% of Hong Kong population (6.99
million). 44262 persons (71.5%) did not intend to return to Hong Kong for residence
in the next five years. A total of 23156 (37.4%) Hong Kong people who took
residence in Shenzhen had used health care services in Hong Kong over the past six

months. As there is continuous growth of economy in the Mainland and increasing

sophistication of the cross-boundary transport network, the Hong Kong Government
believed that the phenomenon of Hong Kong people residing in the Mainland will
continue.
1.2

Importance of sepsis
Sepsis is a complex interaction between the infecting microorganism, the host

immunity and inflammatory responses [2]. This is a great challenge to intensive care
unit (ICU) because it is a major cause of admission with a significant mortality rate.
In the United States, more than half of the patients (51.1%) with severe sepsis
required intensive care [3]. At the same time, the incidence of sepsis in the United
States increased from 0.83 cases per 1000 population in 1979 to 2.4 cases per
population in 2000 [4]. Although there are numerous close monitoring and new
antibiotics, the ICU mortality rate in patients with sepsis was still high (35%) as
reported in Pakin et al. study [5]. It is also found that the incidence of sepsis is
increasing among elderly patients [6]. Furthermore, caring critically ill patients with
sepsis requires huge resources. For example, in England, although only 27% of all
ICU admission was accounted by patients with severe sepsis, disproportionately and
nearly 45% of all ICU bed days were used [5]. Owing to greater life expectancy and
the aging of baby boomers in Hong Kong, the proportion of those aged 65 and over is

projected to rise from 12% in 2006 to 26% in 2036 [7]. Some of these people might
end up being admitted to ICU in Hong Kong because of infection. Some of these
patients have shown mild systemic inflammatory responses. However, some can
progress to severe sepsis and even septic shock. A previous study showed that early
recognition and treatment of severe sepsis and septic shock can provide significant
benefit with respect to outcome [8]. However, those Hong Kong people living in the
Mainland often need more time for transportation to hospitals in Hong Kong. In
addition, these patients may have different pathogens after taking up residence in the
Mainland for a period of time. They may also receive different treatment modality in
the Mainland before admission. As a result, we postulate that the clinical outcomes of
these patients may be different and a deep understanding of the characteristics of these
patients is important.
1.3

Importance of community acquired pneumonia in intensive care unit

Pneumonia is the third leading cause of death in Hong Kong, which accounts for

more than 4000 deaths per year [9]. In Canada, the overall admission rate of
community acquired pneumonia (CAP) in adults is about 27 to 30 cases per 1000
persons per year [10]. According to a study by Liapikou A et al.[11], about 11 % of
patients with CAP were admitted to the ICU. The estimated cost for the treatment of
CAP in the United States is US$8.4 billion per year [12].From the Infectious Diseases

Society of America (IDSA) / American Thoracic Society (ATS) consensus guidelines

on the management of CAP in adults, direct admission to ICU is required for patients
with septic shock requiring vasopressors or with acute respiratory failure requiring
intubation and mechanical ventilator support [13]. CAP is associated with significant
morbidity and mortality, particularly in elderly patients. The 30 day mortality rate is
about 23% [14]. From the local study conducted by Man et al., the overall mortality
and ICU admission rates were 8.6% and 4.0%, respectively [15]. Given the aging
population in Hong Kong, the impact of CAP in our ICU is clearly increasing.

Study objectives
The primary objectives of the study were to identify the characteristics of the

septic patients with community acquired pneumonia living in the Mainland who
required our intensive care, and to assess their outcomes. The secondary objectives
were to assess the predictors for mortality and identify the distribution of causative
organisms.

Methods

3.1 Study design

This was a retrospective study of critically ill patients with sepsis admitted to the
intensive care unit (ICU) of North District Hospital (NDH) in Hong Kong. The study
period was from 1st September 2008 to 31st August 2010. It was a 13-bed mixed
medical and surgical ICU. There are about 600 admissions per year. The research
protocol was approved by the Clinical Research Ethics Committee of the New
Territories East Cluster of the Hong Kong Hospital Authority.
3.2 Data collection
By using the admission books of our intensive care unit, all patients admitted
within the aforementioned period were looked at. The patient data from case notes
and computer records were screened carefully to ensure that these patients have taking
up residence in Mainland China. All these eligible patients were screened for infection
at ICU admission. Infection was defined on the basis of clinical history, clinical
symptoms, physical examination and laboratory findings suggesting the presence of
infection that justified the use of antimicrobial agents. Sepsis and sepsis-related
conditions were diagnosed according to the criteria proposed by the American College
of Chest Physicians / Society of Critical Care Medicine (ACCP / SCCM) consensus
[16]. Systemic inflammatory response syndrome (SIRS) was defined by the presence

of abnormalities in at least 2 criteria among white cell count, body temperature, heart
rate, and respiratory rate. Sepsis was defined as systemic inflammatory response to
infection. Severe sepsis was associated with organ dysfunction, hypoperfusion
abnormality or sepsis induced hypotension in the absence of any obvious explanation
other than sepsis. Septic shock was defined as sepsis induced hypotension persisting
despite adequate fluid resuscitation along with the presence of hypoperfusion
abnormalities or organ dysfunction. Community acquired pneumonia (CAP) was
defined as an acute infection of lower respiratory tract that was associated with
symptoms of acute infection and the presence of acute infiltrate on a chest radiograph
in a patient who was not hospitalized for more than 14 days before the onset of
symptoms [17]. All eligible patients records, including the case notes and laboratory
findings, were studied in detail. In addition, by using the Clinical Management
System (CMS), the Clinical Data Analysis and Reporting System (CDARS), and the
Acute Physiology and Chronic Health Evaluation (APACHE) databases [18], all
useful information was assessed.
3.3 Inclusion and exclusion criteria
Patients were recruited if they were aged 18 or more and had a diagnosis of
sepsis upon ICU admission. If a patient was admitted more than once, only the data
from the first admission were analyzed. Patients were excluded if they had not taken

residence in Mainland China. Those patients living in the Mainland China without
sepsis and those living in Hong Kong were not studied. Patients were also not
included if they had been transferred to other hospitals or if they had stayed in our
general ward for more than 48 hours.
3.4 Assessment
3.4.1

Demographic Data
Socio-demographic data including the patients age, sex, and smoking status

were recorded.
3.4.2

Clinical History
For each patient, the co-morbidities which included the presence of chronic

obstructive pulmonary disease (COPD), chronic respiratory insufficiency with or

without pulmonary hypertension, chronic kidney disease with or without dialysis,
diabetes,

heart

failure,

liver

cirrhosis,

immunosuppression,

and

human

immunodeficiency virus (HIV) infection were recorded. On ICU admission, the data
about the intervention from the Mainland, including the history of hospitalization, the
use of antibiotics, and the use of mechanical ventilator and vasopressor during
transfer were considered. Besides, information about the intervention (mechanical
ventilator support and renal replacement therapy) in our ICU was noted. The source of
admission (medical, surgical, orthopedics, emergency departments, others) was also

studied.
3.4.3

Disease Assessment
The severity of sepsis on ICU admission was categorized according to the ACCP

/ SCCM consensus into 3 groups: sepsis, severe sepsis and septic shock [16]. The
APACHE II score [18] and the Sepsis-related Organ Failure (SOFA) score [19] were
assessed. In addition, all eligible patients were classified according to their causes for
ICU

support

into

cardiovascular,

gastrointestinal,

respiratory,

neurological,

haematological, endocrine, renal, trauma, and others. All patients had a chest
radiograph in the emergency department and in the ICU. Images were assessed by
experienced intensivists and physicians. Additional data collected for all patients
included laboratory results (complete blood count, arterial blood gas, glucose, liver
and renal function) and microbiological results (sputum, endotracheal aspirate, and
bronchoalveolar lavage).
3.4.4

Outcomes
Main outcome measures were ICU length of stay, hospital length of stay, ICU

mortality, death within 28 days and hospital mortality. Predictors for the mortality
were assessed from the collected data.

3.4.5

Patterns of Infection

The causative organisms were identified into gram positive (methicillin-sensitive

Staphylococcus aureus MSSA, methicillin-resistant Staphylococcus aureus MRSA,
Streptococcus pneumoniae, Enterococcus, others), gram negative (Escherichia Coli E.
Coli, Enterobacter, Proteus, Acinetobacter, Pseudomonas, Haemophilus influenzae,
Klebsiella, Moraxella catarrhalis, others), atypical (Legionella, Mycobacteria
tuberculosis, Pneumocystis), fungi and anaerobes. If the pathogens could not be
identified, the patients were labeled as only clinical diagnosis.
3.5 Statistical analyses
Statistical analysis was performed by using the Statistical Package for the Social
Sciences (SPSS, Windows version 17.0, Chicago, US). Results were expressed as
number and percentage, and median (interquartile range) where appropriate.
Comparisons of the characteristics of surviving and non-surviving septic patients were
performed using the chi-square test for the categorical variables. Continuous variables
were assessed by the 2 sample t-test. Univariate logistic regression analysis was
applied for assessing the predictors of mortality in patients with sepsis. A p value of
less than 0.05 was considered statistically significant. A multivariate logistic
regression was also applied.

Results

4.1 Characteristics of Patients with Sepsis from Mainland China

During the two-year study period, a total of 1257 patients were screened. A total
of 1086 patients (86.4%) living in Hong Kong were admitted to our ICU. On the other
hand, 171 patients were admitted to our ICU with history of residence in the Mainland.
78 patients (6.2%) were admitted for other causes; such as myocardial infarction and
cerebrovascular accidents. 93 patients (7.4%) were admitted for infection. 51 (4.1%)
patients were admitted for CAP. 1 patient was excluded because of transfer to another
hospital. The remaining 42 patients were admitted for other infections. Figure 1
showed the flow diagram of enrolled patients.

Figure 1. Flow Diagram of Enrolled Patients

Total ICU Admissions

(n=1257)

Live in Mainland
(n=171)

Infected Patients
(n=93)

Live in Hong Kong

(n=1086)

Non-Infected Patient
(n=78)

Community Acquired Pneumonia

(n=51)

Sepsis
(n=4)

Severe Sepsis
(n=17)

Other Infection
(n=42)

Septic Shock
(n=29)

Excluded
(n=1)

The median (interquartile range) age of patients with CAP was 66.5 (54.75-75)
years old. Pneumonia was more common in male admission (n=42, 84%) than in
female admission (n=8, 16%). More than half of these patients (n=30, 60%) were
chronic smokers. 24 (48%) and 26 (52%) patients were identified from the 1st and 2nd
year of study period respectively. The majority of these patients were admitted from
medical department (n=29, 58%) and emergency room (n=17, 34%). Nearly one
fourth of these patients (n=11, 22%) were admitted during the winter period. Nearly
half (n=22, 44%) of these patients had at least one co-morbidity. Diabetes (n=15, 30%)
and chronic respiratory insufficiency (n=11, 22%) were commonly found among these
patients. 4 (8%) patients had chronic kidney disease with or without renal replacement
before admission. HIV infection was known in 1 patient (2%). 6 (12%) patients
required mechanical ventilator support from the Mainland. In addition, 7 (14%)
patients required vasopressor support during the transfer. During the stay in our ICU,
the majority of patients (n=42, 84%) had mechanical ventilator support. Renal
replacement therapy support was provided for 12 patients (24%). Nearly one third of
these patients (n=16, 32%) were confused on ICU admission. 12 patients (24%) were
admitted with blood urea level greater than 7 mmol/L. Most of them (n=45, 90%)
were tachypnoeic with respiratory rate greater than 30 breaths per minute. The
characteristics of the 50 patients diagnosed with community acquired pneumonia were

shown in Table 1.
Table 1: Characteristics of Patients with Sepsis.
Total No. of Patients
Age, Median (IQR),
Years
Male (%)
Smoker (%)
Transfer from (%)
Medical Ward
Emergency Room
Surgical Ward
Orthopedic Ward
Admission During the Winter Period (%)
No. of co-morbidities (%)
None
One or More
Co-morbidities (%)
Diabetes
COPD / Chronic RespiratoryInsufficiency
Chronic Kidney Disease
Heart Failure
Immunosuppresion
Liver Cirrhosis
HIV Infection
Given Antibiotics in Mainland (%)
Requiring Mechanical Ventilator Support During Transfer (%)
Requiring Vasopressor Support During Transfer (%)
Severity of Sepsis (%)
Sepsis
Severe Sepsis
Septic Shock
APACHE II Score (IQR)
SOFA Score (IQR)
Organ Dysfunction Systems Requiring ICU Support on Admission (%)
Respiratory
Cardiovascular
Renal
Neurological
Metabolic
Hematological
Mechanical Ventilator Support in ICU Stay (%)
Renal Replacement Therapy Support in ICU Stay (%)
Confusion
Urea >/= 7 mmol/L
Respiratory Rate > / = 30 breath per minute
Diastolic Blood Pressure < / = 60 mmHg
Age > / = 65
CURB Score (IQR)

50
66.5

(54.75-75)

42
30

(84)
(60)

29
17
3
1

(58)
(34)
(6)
(2)

11

(22)

28
22

(56)
(44)

15
11
4
1
1
1
1
6
6
7

(30)
(22)
(8)
(2)
(2)
(2)
(2)
(12)
(12)
(14)

4
17
29
24.5
10.5

(8)
(34)
(58)
(20-32)
(7-14.5)

45
23
5
2
2
1
42
12
16
12
45
33
27
3

(90)
(46)
(10)
(4)
(4)
(2)
(84)
(24)
(32)
(24)
(90)
(65)
(54)
(2-3)

Note: IQR interquartile range, COPD Chronic Obstructive Pulmonary Disease, HIV human Immunodeficiency Virus,
APACHE II Acute Physiology And Chronic Health Evaluation II score, SOFA Sequential Organ Failure Assessment score, ICU
Intensive Care Unit

4.2 Disease Severity

These patients were categorized according to the aforementioned severity on
ICU admission. There were 4 (8%) patients with sepsis, 17 (34%) with severe sepsis,
and 29 (58%) with septic shock. The median (interquartile range) APACHE II and
SOFA scores recorded within 24 hours were 24.5 (20-32) and 10.5 (7-14.25),
respectively. The median (interquatile range) CURB-65 score was 3 (2-3). The most
common organ dysfunctions systems requiring ICU support on admission were
respiratory (90%) and cardiovascular (46%). Renal (10%) system was less common.
4.3 Outcomes
The overall hospital mortality rate was 48% (n=24). Patients with septic shock
had the highest mortality rate, which was 55.2% (n=16). The hospital mortality for
severe sepsis and sepsis were 41.2% (n=7) and 25% (n=1) respectively. The overall
28 day mortality rate was 38% (n=19). The overall ICU mortality rate was 26%
(n=13). The ICU mortality rate in patients with severe sepsis was 17.6% (n=3) and
31% (n=9) in those with septic shock. The median (interquatile range) duration of
ICU stay for screened patients was 6.5 days (3-13.5). The median (interquatile range)
hospital stay was 22 days (7.75-35.75). The outcomes of patients with previous
residence in Mainland China admitted to the intensive care unit in Hong Kong with
community-acquired pneumonia were listed in Table 2.

Table 2: Outcome of Patients with Sepsis

All

Sepsis

Severe Sepsis

Septic Shock

Died in ICU, (%)

13 (26)

1 (25)

3 (17.6)

9 (31)

Died at 28 Day, (%)

19 (38)

1 (25)

6 (35.3)

12 (41.4)

Died in Hospital, (%)

24 (48)

1 (25)

7 (41.2)

16 (55.2)

6.5 (3-13.5)

5.5 (2.75-21.75)

7 (4.5-13.5)

6 (3-15.5)

22(7.75-35.75)

18.5 (6.75-25.75)

22 (15.5-41.5)

22 (4.5-43)

Duration of ICU Stay, Days,

Median LOS Hosp, Days, (IQR)

Note: ICU Intensive Care Unit, IQR Interquartile range, LOS Length of Stay

4.4 Patterns of Infection

The majority of patients (n=33, 66%) had clinical infection with identification of
pathogens. The remaining 17 (34%) patients had clinical infection without
identification of pathogens. Most of the organisms were found in the respiratory
specimen. 2 (4%) patients had positive blood cultures. Gram positive bacteria,
including Staphylococcus aureus and Streptococcus pneumoniae, were isolated from
30.6% of specimens. Gram negative bacteria were isolated from 52.8% of specimens.
Atypical pathogens, including Legionella pneumoniae, Mycobacteria tuberculosis and
Pneumocystitis carinii, were isolated from 16.6% of specimens. Among all specimens,
the most common organism was Streptococcus pneumoniae (19.4%). The less
commonly found bacteria were Haemophilius influenzae (13.8%) and Mycobacteria
tuberculosis (11.1%). Table 3 showed the distribution of pathogens.

Table 3: Positive Microbiological Cultures where Pathogens Identified

Organisms

Number

Percentage (%)

MSSA

11.1

Streptococcus Pneumonia

19.4

Enterococcus

Others

MRSA

E. Coli

2.8

Klebsiella

8.3

Pseudomonas

2.8

Enterobacter

5.6

ESBL E. Coli

2.8

Haemophilius Influenza

13.8

ESBL Klebsiella

5.6

Acinetobacter

5.6

Moraxella Catarrhalis

5.6

Mycobacterium Tuberculosis

11.1

Legionella

2.8

Pneumocystis

2.8

Gram-Positive Bacteria

Gram-Negative Bacteria

Atypical Organisms

Note: MSSA Methicillin-Sensitive Staphylococcus Aureus, MRSA Methicillin-Resistant Staphylococcus Aureus, E. Coli
Escherichia Coli, ESBL Extended-Spectrum Beta-Lactamase
Percentages are calculated on the number of microbiologically documented infections

4.5 Predictors of Mortality in Patients

From univariate logistic regression analysis, some factors were found as poor
prognostic factors. Confusion (OR 9.061; 95% CI, 2.691-30.503; p < 0.005) and the
blood urea level greater than 7 mmol/L (OR 8.571; 95% CI, 2.415-13.042; p < 0.005)
are associated with poor prognosis.
Some factors are marginally significant as predictors of mortality. These include
the use of vasopressor in China during transfer (OR 8.333; 95% CI, 1.313-52.891; p =
0.059) and mechanical ventilator support in our ICU (OR 8.474; 95% CI, 1.358-52.87;
p = 0.055).
Our analyses also confirmed that the APACHE II (p < 0.005) and CURB-65 (p <
0.005) scores were independent predictors for hospital death[20-22]. On the other
hand, the SOFA score (p = 0.056) was marginally significant risk factor of hospital
death.
Although more male patients were admitted when compared with female patients,
gender (47.6% vs 50%, p = 0.902) was not poor prognostic factor for mortality.
All the preceding variables from the univariate analysis were modeled in the
multivariate analysis. Factors associated with increased mortality in our patients
included APACHE II and CURB-65 scores.

Discussion
The overall incidence rate of CAP varies from 1.62 cases to 6.11 cases per 1000

persons per year in different studies. The incidence rate increases by age and is higher
in males than in females. It was also more commonly found in winter season. The rate
of hospital admission was 61.4% [10,23]. In our study, among 171 patients with
previous residence in Mainland, 93 of them were admitted to our ICU for infections.
More than half of these patients (n=51, 54.8%) are due to community acquired
pneumonia. Hospital acquired infections (n=18, 19.3%) and intra-abdominal
infections (n=14, 15.1%) are also common. There are multiple reasons for the high
proportion of patients admitted for infections. Firstly, few Mainland patients were
admitted for reasons other than sepsis, such as scheduled post operative ICU care.
Secondly, nosocomial infections are commonly found in these patients. These
infections can occur in patients during the hospital stay in the Mainland. Nosocomial
infections usually prolong hospital stay and consequently make patients transfer back
to ICU in Hong Kong. Their choice of transfer involves financial consideration,
family ties in Hong Kong and a lack of confidence in the Mainland medical services.
Many studies concluded that the incidence of CAP requiring ICU care is
increasing annually [10,24]. In our study, the number of patients was also found to be
increasing annually (n=23 vs n=27). The reasons for increasing incidence included the

increasing number of Hong Kong people residing in Shenzhen, aging of people and
increasing number of immunocompromised patients. However, the accuracy of our
result may be limited by our short period of study.
Age is always an important factor in determining the risk of sepsis and mortality
rate. A previous study carried out in the United States showed that the elderly have
both an increased incidence of pneumonia and an increased mortality, compared with
the younger population [25]. The mortality of CAP was 4.5% in those aged 18 to 44
years. However, the mortality rate increased to 12.5% in those over age 65 [26].
Higher mortality was related to co-morbid illness and impaired immunologic response
to infection [27].Our results showed that the median age of patients was 66.5 years
old. However, the trend of increasing mortality among the elderly was not obvious in
our study. The reasons included earlier death of elderly patients before transfer, and
limitation of intensive care for the elderly either imposed by the patient or the
physician. With an aging population and greater life expectancy, it is likely that there
will be an increasing incidence of CAP with a previous residence in the Mainland.
A previous study showed that increased risk of CAP was associated with
smoking, previous respiratory infection and chronic bronchitis [28].In patients with
chronic illnesses such as COPD, diabetes, and alcoholism, Klebsiella pneumoniae has
a significant mortality [29].In our study, although there were more smokers than

non-smokers, smoking was not associated with increased mortality.

According to a worldwide observational study [30], renal failure is commonly
found in patients with CAP who needed ICU treatment. It was also associated with
greater risk for death. In our study, nearly one fourth of patients (n=12, 24%) received
renal replacement therapy support. We found that their renal failure might be a result
of sepsis. Although there was no significant difference in the mortality of patients, use
of renal replacement therapy was associated with higher chance of death.
The SOFA score characterized the degree of dysfunction or failure by organ
system [19].The median SOFA core in our study was 10.5.Similarly, APACHE II
scoring system is widely used and accepted in predicting ICU outcomes [31]. The
median APACHE II score in our study was 24.5. In addition, the median CURB-65
score in our study was 3. A previous study showed that both APACHE II and
CURB-65 scores perform similarly in predicting 28 day and in hospital mortality of
CAP patients [32].Our study confirmed that higher values of these organ dysfunction
scores (APACHE II, p < 0.005; CURB-65, p < 0.005) remained as a strong
independent risk factor of mortality in critically ill patients. Therefore, these scores
should be used for stratification of patients with CAP from the Mainland. Furthermore,
CURB-65 is simpler, and thus, may provide more efficient assessment in these
patients.

Although there was numerous close monitoring, new antibiotics and international
guidelines

for

the

management

of

CAP,

the

mortality

was

still

high

[17].Approximately 10% to 36% of patients with CAP who need hospitalization

require ICU treatment [33].The reported mortality of CAP varied from less than 5%
among outpatients to about 12% among all hospitalized CAP patients, and even over
30% among those admitted to the ICU.[10,24]. In our study, a positive correlation
between mortality and sepsis severity was shown. The ICU mortality rate of our
studied patients was 26%, which was similar to previous study[24]. Besides, our
median length of ICU stay was 6.5 days, which was also similar to the previous study
[34].The difference between ICU mortality rate (26%) and hospital mortality rate
(48%) was obvious. 30% of discharged patients from ICU died before discharge from
hospital. These differences could be explained by discharge from ICU for palliative
care or premature discharge to general ward. As a result, patients with previous
residence in the Mainland admitted for CAP may have greater benefit if longer ICU
stay could be provided.
Positive microbiological detection rate in CAP ranges between 2.1% and 75%.
The reasons for these differences include the use of diagnostic tests and the
widespread use of antibiotics in private practice [35-37].In our study, the rate of
documented infection was 66% (n=33) among our patients, a figure comparable as

reported in other studies [38].This result may be explained by early and adequate
sampling of cultures before the use of antibiotics.
In Hong Kong, the aetiologic diagnosis of CAP was made in 41% cases [39]. In
Japan, 61% of pathogens were found in patients with CAP. The most commonly
identified pathogens included Streptococcus pneumoniae (23%), Haemophilus
influenza (7%), and Mycoplasma pneumonia (5%) [40].However, the identification of
pathogens is different among patients receiving treatment in outpatient, general ward
and ICU. In European ICUs (outside of the United Kingdom), the identification of
Legionella was lower. On the other hand, the identification of gram negative bacilli
was higher (9%) although Streptococcus pneumoniae was still most commonly
found[17].In the United States, for CAP patients with septic shock, the most
commonly

identified

pathogens

were

Streptococcus

pneumoniae

(19%),

Staphylococcus aureus (18%), Haemophilus influenzae (14%), Klebsiella pneumoniae

(11%), and Pseudomonas aeruginosa (7%) [41].In Hong Kong, Streptococcus
pneumoniae remains the most common pathogen in CAP [42].Similarly, our study
showed that Streptococcus pneumoniae is the most commonly found organism.
Reduced susceptibility of Streptococcus pneumoniae to penicillin and resistance to
fluoroquinolone have been increasingly seen in our community. The prevalence of
resistance was higher in elderly patients and patients with COPD [43,44]. Surprisingly,

all of them had penicillin susceptible strains. The result may be explained by small
sample size.
Falguera M [45] reported that the overall rates of bacteremia were between 12%
and 16% in their cohort study. However, in our study, only 2 patients (4%) had
positive blood cultures. Because our study was retrospective, one possible reason for
lower percentage of positive blood cultures could be related to the use of antibiotics in
the Mainland even without hospitalization. Streptococcus pneumoniae remained the
most common causative pathogens which can be found in the blood culture [46].In
our cases, both patients had positive blood cultures for Streptococcus pneumoniae.
The tuberculosis may masquerade as CAP in about 12% of patients in Hong
Kong [39]. Ryu et al. [47] reported that patients with respiratory failure caused by
pulmonary tuberculosis necessitating mechanical ventilation had a high mortality rate
(59%) and poor prognosis. In our study, Mycobacteria tuberculosis was also an
important cause of CAP. They all required mechanical ventilator support owing to
respiratory failure. 3 patients (75%) were dead. Therefore, pulmonary tuberculosis
should also be considered in the diagnosis, and respiratory specimens should be
examined routinely for acid fast bacilli in those patients living in the Mainland.
In Germany, Von Baum H [48] reported that Legionella pneumonia was
diagnosed in about 3.8% of patients. In Hong Kong, there were 19 cases of

Legionnaires disease from 1994 to 2002 [49]. All of these patients had symptoms of
pneumonia. More than half of them had positive urine antigen test (50%-75%). 58%
of cases required intensive care during hospitalization. In addition, the number is
increasing in these few years. There were 38 reportable cases from 2005 to 2007. In
our study, the only patient with Legionella pneumonia had history of going wet sauna
in Shenzhen. Thus, a high index of suspicion is important for all patients.
Staphylococcus aureus pneumonia (19%), following Streptococcus pneumonia
(48%), is commonly seen in elderly patients and in patients after influenza infection
[50]. Patients with Community Acquired Methicillin Resistant Staphylococcus Aureus
(CA-MRSA) infection usually present with skin and soft tissue infections. Outbreak
of CA-MRSA pneumonia was reported in overseas [51].In our study, all patients with
Staphylococcus aureus pneumonia were methicillin sensitive.
On the other hand, the rate of extended-spectrum beta-lactamases (ESBL)
producing strains among E. coli and Klebsiella pneumoniae was 42.8% in our study.
In the Mainland, the rate of ESBL producing E. coli in ICU ranged between 28.6%
and 45.7% [52,53]. There are several reasons contributing to the high incidence of
ESBL producing organisms among these Mainland patients who required our ICU
care. Firstly, an increasing and unnecessary exposure to antibiotics in the Mainland,
especially third generation cephalosporin, is an important cause. In the Mainland,

more than 100 domestic manufactures produced cefotaxime and ceftriaxone at a very
cheap price, causing a widespread use [53].Although there are new prescription
guidelines were issued by the Chinese Ministry of Health in 2004 to restrict the use of
antibiotics, the guidelines are not being followed effectively, according to the head of
Chinas National Antibiotics Resistance Investigation Network [54].Secondly,
vulnerability to infection from immunocompromised status is another cause.
Furthermore, high prevalence of carriage of ESBL producing organisms in the
Mainland community can increase the incidence of resistant infection. Close contact
with poor hygiene practice in household settings might contribute to ESBL
dissemination in the Mainland community. A recently published study by Ho et al. [55]
showed that history of prolonged residence in the Mainland was significantly
associated with carriage of ESBL producing organisms. Thus, the problem of
emerging resistance bacteria raised our concerns in treating patients who live in the
Mainland. Our findings also have implications for the choice of empirical therapy in
enterobacteriaceae infection.
There are several limitations to our study. Despite many Mainland patients being
admitted into our intensive care unit, this study was on a single-centre basis, and thus
the results may not be generalized to other centres in Hong Kong. Besides, no data on
long term follow up was available beyond hospital discharge. We could not assess

whether the patients had a reduction of life expectancy or not. Furthermore, only
patients treated in ICU was focused in our study. The characteristics of patients with
CAP treated in general ward were not assessed. Finally, use of antibiotics was not
measured in our study, and thus the effectiveness of antibiotics could not be assessed.

Conclusion
In conclusion, despite the aforementioned limitations, our findings emphasize the

importance of early care for those critically ill patients with a previous residence in
Mainland China requiring intensive care for community acquired pneumonia. Also,
we observe that APACHE II and CURB-65 scores are good severity assessment tools
to stratify patients from the Mainland. Furthermore, an increase in the number of
patients residing the Mainland is expected in the near future. In view of this, better
understandings of the characteristics of these patients are required, and continued
research efforts are mandatory in order to optimize patient-centered outcomes.

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