|

Received: 13 September 2017    Accepted: 18 March 2018

DOI: 10.1111/ijcp.13085

ORIG INAL PAPER

Poverty as an independent risk factor for in-­hospital mortality

in community-­acquired pneumonia: A study in a developing
country population

Hassan Jahanihashemi1 | Mona Babaie2 | Soroush Bijani2 | Maryam Bazzazan2 | 

Behzad Bijani2

1
Department of Community Medicine, 
Qazvin University of Medical Sciences,
Qazvin, Iran
2
Clinical Microbiology Research Centre, 
Qazvin University of Medical Sciences,
Qazvin, Iran
Correspondence
Behzad Bijani, Clinical Microbiology
Research Centre, Qazvin University of
Medical Sciences, Qazvin, Iran.
Email: Dr.Bijani@gmail.com
Summary
Background: Community-­acquired pneumonia (CAP) is one of the most severe lower
respiratory tract infections with a high in-­hospital mortality. The aim of this study
was to investigate the socioeconomic and medical risk factors affecting the
prognosis of acute pneumonia. The results of this study can mention the value of
socioeconomic backgrounds like poverty and illiteracy in clinical practice, even in a
well-­known biological phenomenon (eg acute pneumonia).
Methods: In this cross-­sectional study, all admitted patients to a tertiary teaching
hospital with a diagnosis of community acquired pneumonia in a 12-­month period
were enrolled. Socioeconomic and demographic characteristics, underlying condi-
tions, clinical manifestations and para-­clinical test results at admission registered
prospectively. A logistic regression model was conducted using in-­hospital mortality
as the dependent variable.
Results: A total of 621 patients was included in this study. Among them, 47 patients
(7.6%) died during the hospitalisation period. In multiple logistic regression analysis,
pleural effusion, a higher CURB-­65 score, hyponatremia, hyperglycaemia and pov-
erty (being in the lower economic class) were identified as independent risk factors
for in-­hospital mortality in community-­acquired pneumonia.
Conclusion: Numerous factors can influence the prognosis of CAP. In addition to the
CURB-­65 score and some other medical risk factors, socioeconomic backgrounds
can also affect the early outcome in CAP. In this study, being in the lower economic
class (as an indicator of poverty) is interpreted as an independent risk factor for a
poor prognosis in CAP.

1 |  I NTRO D U C TI O N
Community-­acquired pneumonia (CAP), despite the development
and use of antibiotic therapies and intensive care management, is
still an important cause of morbidity and healthcare costs world-
wide. Among patients who discharged with a diagnosis of CAP, pa-
tient healthcare costs were not only significantly higher during the
CAP episode, but they also remained higher in the next 6 months as
well.1 In addition to morbidity and the economic issues, pneumonia
is an important cause of mortality in hospitalised patients. In popula-
tion based studies, the in-­hospital mortality of CAP is reported to be
relatively high. 2,3 Factors such as clinical or para-­clinical measures
at admission, demographic characteristics and underlying diseases
have been mentioned to affect the prognosis of CAP. Based on these
findings, many score systems are defined yet. However, as there is
no consensus about all of the factors that influence the mortality,

Int J Clin Pract. 2018;e13085. wileyonlinelibrary.com/journal/ijcp © 2018 John Wiley & Sons Ltd  |  1 of 8
https://doi.org/10.1111/ijcp.13085
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none of the mentioned score systems are followed strictly in clini-
cal practice.4 So far, the prognostic value of factors associated with
deprivation had not been extensively investigated in CAP. Given the
importance of this issue, this study has been performed in a year
period in a tertiary care teaching hospital in a deprived region.
2 |  M E TH O DS
2.1 | Study design and data collection
This prospective cross-­sectional study was performed in a year pe-
riod in Qazvin province, Iran. The data related to all patients over
the age of 12 with a diagnosis of CAP who were admitted at the
Avicenna hospital (the only provider of tertiary care of infectious dis-
eases covering approximately 1.5 million population) were recorded.
Patients who had lung cancer, had a history of tuberculosis or HIV
infection, had been admitted to the hospital within the last month
for any reason, as well as patients with structural damage to the res-
piratory tract were excluded from the study. An infectious diseases
specialist diagnosed CAP, according to respiratory symptoms and
signs and new infiltrates on chest radiographs. The diagnosis of CAP
was based on the criteria of the American Thoracic Society,5 which
has been approved later on by the Infectious Diseases Society of
America.6
Epidemiological data, demographic characteristics and habitual
history, such as age, gender, place of residence (urban or rural areas),
educational status (illiterate or at least primary school educated), his-
tory of smoking, alcoholism and inhalational drug abuse have been ob-
tained by interview with the patients and their companions. “Illiteracy”
is defined as lack of ability to read and write and to use other basic
means to understand, communicate, gain useful knowledge and solve
mathematical problems. “Poor availability of healthcare services” is
defined as the need for more than an hour travel to access a medi-
cal centre. Poverty is defined as “being in the lower economic class”
based on the Modified BG Prasad socioeconomic classification scale.
In this scale monthly per capita income determines five classes of eco-
nomical state and it is applicable for both families and individuals.7
The presence of underlying diseases, including cerebrovascular
(a history of cerebrovascular accident or transient ischaemic at-
tack), cardiovascular (a history of myocardial infarction or unstable
angina) and chronic lung diseases (chronic obstructive pulmonary
disease and interstitial lung disease) was determined by the previ-
ous medical records of the patients. Diagnosis of chronic renal fail-
ure had been confirmed by Para-­clinical characteristics of kidney
dysfunction (sonographic findings and raised serum creatinin) for
at least 6 months. Diabetes was diagnosed according to American
Diabetes Association criteria. 8 “Systemic steroid use” is defined as
consumption of at least 20 mg Prednisolone or equivalent dose of
other corticosteroids in the last month. Recent or active neoplastic
diseases had been considered based on the history, clinical symp-
toms and signs (severe weight loss and anorexia) and para-­clinical
findings (tumour markers and imaging). Core body temperature,
Pulse rate, respiratory rate, arterial blood pressure and confusion
What’s known
• Many factors can influence the prognosis of community
acquired pneumonia. Clinical and para-clinical predic-
tors of poor outcome are investigated widely, but the
impact of socioeconomic backgrounds are not so
obvious.
What’s new
• In the present study, some socioeconomic factors such
as residence in remote rural areas, difficult access to
medical facilities and illiteracy were not associated with
poor outcome in community acquired pneumonia, but
being in the lower economic class (as an indicator of
poverty) was shown to be an independent risk factor for
in-hospital mortality in community acquired
pneumonia.
have been determined during physical examination at the admis-
sion time. Arterial blood oxygen saturation was measured by pulse
oximetry. The radiographic signs and the presence or absence of
pleural effusion had been confirmed by chest radiography or CT
scan before admission. At admission, sputum Gram stain and cul-
ture were performed. Sputum data were evaluated when Gram
staining revealed 25 or more white blood cells and less than 10
squamous epithelial cells per low power field (100X magnification).
Serum samples were analysed for Urea and glucose on the Vitalab
Selectra E Clinical Chemistry Analyser (Vital Scientific, Dieren,
the Netherlands). Plasma sodium and potassium concentrations
were measured by flame photometry (Corning 480; Corning Ltd.,
Halstead, Essex, UK). White blood cell counts were performed on
ethylenediaminetetraacetic acid (EDTA) anticoagulated blood using
a haematology auto analyser (Sysmex KX-­21, Sysmex Corporation,
Kobe, Japan). Severity of pneumonia had been evaluated using
CURB-­65. In this criteria with a 6 point scale (0-­5) which has been
introduced by the British Thoracic Association, one score will be
given to each of the following: age over 65 years, confusion, plasma
urea >7 mmol/L, respiratory rate >30/min, and systolic blood pres-
sure <90 mm Hg or diastolic blood pressure <60 mm Hg.9
The outcome was defined as poor if the patient deceased in
hospitalisation period, and favourable if the patient discharged alive
from the hospital.
2.2 | Ethical considerations
The study was approved by the medical branch of the ethics com-
mittee of Qazvin university of medical sciences and informed con-
sent was obtained from the patients or their companions. There was
no intervention on the patients in this study and all requirements of
Helsinki protocol were considered.
JAHANIHASHEMI et al. |
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TA B L E   1   Baseline characteristics of 552 patients with

2.3 | Statistical analysis community-­acquired pneumonia. Data are presented as median
The Kolmogrov–Smirnov test was performed to check normal dis- (interquartile range) for quantitative variables or numbers
(percentage) for dichotomous variables
tribution of quantitative data, and non-­
parametric continuous
variables were compared by the Mann–Whitney U test. Univariate Median (IQR) or
analysis of discrete variables performed by Chi-­square or Fisher’s Variable number (%)

exact test, as appropriate. Multiple logistic regression analysis using Age (y) 65.0 (47.0, 78.0)
enter method was applied to identify independent risk factors for Gender (female) 273 (44.0)
in-­hospital mortality. Factors were included if significant in the uni- Residence (rural areas) 425 (77.0)
variate analysis. The calibration and the discriminatory ability of the Education (illiterate) 71 (11.4)
model were assessed using the Hosmer-­Lemeshow goodness-­of-­fit
Poor availability of healthcare services 58 (9.3)
test and the receiver operating characteristic area under the curve
Economic class
(ROC-­AUC). All statistical analyses were performed with spss version
Upper class 11 (1.8)
16.0 software (spss Inc., Chicago, IL, USA). A P value of less than .05
Upper middle class 31 (5.0)
was considered to indicate statistical significance.
Middle class 141 (22.7)
Lower middle class 230 (37.0)
3 | R E S U LT S Lower class 208 (33.5)
Current/ex-­smoker 150 (27.2)
3.1 | Patient characteristics
Alcohol abuse 12 (2.2)
Between September 2014 and September 2015, 662 consecu- Inhalational drug abuse 56 (10.1)
tive patients with CAP were hospitalised. Forty one patients were Cerebrovascular diseases 66 (11.9)
subsequently excluded from the analysis: Four patients had lung Cardiovascular diseases 119 (21.6)
cancer; eight patients had a history of pulmonary tuberculosis; 10
Chronic lung diseases 133 (24.1)
patients had structural damage to the respiratory tract; 14 patients
Chronic renal failure 16 (2.9)
had been admitted to the hospital within the last month; and five
Systemic steroid use 18 (3.3)
patients were HIV positive. Of the 621 remaining patients, 47 (7.6%)
Diabetes 68 (12.3)
died in the admission period and 574 (92.4%) discharged alive from
Neoplastic diseases 26 (4.7)
hospital. The baseline characteristics of the study population is

TA B L E   2   Important demographic
Lower economic class Other economic
characteristics, underlying conditions,
(n = 208) classes (n = 413) P value
habits, Clinical manifestations and
Age (y) 63.5 (45.7, 78.0) 65.0 (47.0, 78.0) .586 laboratory test results in the lower
Gender (female) 97 (46.6) 176 (42.6) .341 economic class (as an indicator of poverty)
and the remaining participants. Data are
Residence (rural areas) 177 (85.1) 248 (60.0) .000
presented as median (interquartile range)
Education (illiterate) 24 (11.5) 47 (11.4) .953 for quantitative variables or numbers
Poor availability of healthcare 33 (15.9) 25 (6.1) .000 (percentage) for dichotomous variables
services
Cerebrovascular diseases 22 (10.6) 44 (10.7) .977
Chronic renal failure 8 (1.9) 8 (3.8) .156
Confusion 25 (12.0) 43 (10.4) .545
Multifocal infiltrations on chest 15 (7.2) 16 (3.9) .071
X-­ray
Pleural effusion 18 (8.7) 35 (8.5) .940
Respiratory rate (per min) 20.0 (16.0, 28.0) 20.0 (16.0, 28.0) .251
Absolute polymorphonuclear 6.7 (3.9, 9.7) 6.9 (4.6, 11.4) .060
count (1000/μL)
Serum sodium (mEq/L) 139.0 (137.0, 141.0) 139.0 (137.0, 141.0) .414
Serum urea (mmol/L) 2.3 (1.8, 3.5) 2.2 (1.7, 3.0) .052
Serum glucose (mmol/L) 6.3 (5.1, 7.8) 6.3 (5.3, 7.5) .884
CURB-­65 score 1.0 (0.0, 2.0) 1.0 (0.0, 2.0) .423
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presented in Table 1. Two hundred eight patients were in the lower TA B L E   3   Demographic characteristics, underlying conditions
economic class based on Modified BG Prasad socioeconomic clas- and habits in population study. Data are presented as median
sification scale. In Table 2 important underlying conditions, habits, (interquartile range) for quantitative variables or numbers
(percentage) for dichotomous variables
Clinical manifestations and laboratory test results of these patients
are compared with the patients belonging to the other economic Dead
classes. patients Survived patients
Variable (n = 47) (n = 574) P value

Age (y) 69.0 (55.0, 64.0 (46.0, 78.0) .014

3.2 | Factors associated with in-hospital mortality 84.0)
Gender (female) 97 (46.6) 176 (42.6) .341
In univariate analysis, a higher age, illiteracy, poverty, cerebrovascu-
lar diseases, chronic renal failure, confusion, multifocal infiltrates on Residence (rural 28 (59.6) 397 (69.2) .174
areas)
chest X-­ray, pleural effusion, a higher respiratory rate, a higher abso-
Education 10 (21.3) 61 (10.6) .027
lute neutrophil count, a lower serum sodium, a higher serum urea, a
(illiterate)
higher serum glucose and a higher CURB-­65 score were associated
Poor availability 8 (17.0) 50 (8.7) .068
with in-­hospital mortality in CAP. (Tables 3 and 4).
of healthcare
All of these variables except components of CURB65 score services
(confusion, serum urea, respiratory rate and age) were entered into Poverty (being in 25 (53.2) 183 (31.9) .003
a multiple logistic regression model with in-­hospital mortality as the lower
the dependent variable. As seen in Table 5, in addition to a higher economic class)
CURB-­65 score, poverty, pleural effusion, a lower serum sodium and Current/ 16 (34.0) 134 (23.3) .099
a higher blood glucose at admission time were independent risk fac- ex-­smoker

tors of in-­hospital mortality in CAP. Alcohol abuse 2 (4.3) 10 (1.7) .229

The model exhibited good calibration (Hosmer-­Lemeshow test Inhalational drug 6 (12.8) 50 (8.7) .422
P = .702) and discrimination (AUC: 0.953; 95% CI: 0.922-­0.984). abuse
Cerebrovascular 14 (29.8) 52 (9.1) .000
diseases
Chronic lung 15 (31.9) 118 (20.6) .068
4 |  D I S CU S S I O N
diseases
Chronic renal 5 (10.6) 11 (1.9) .005
In this study, we investigated the prognostic value of some inexpensive,
failure
easy to reach variables in acute community-­acquired pneumonia. There
Cardiovascular 13 (27.7) 106 (18.5) .124
are many score systems to predict the prognosis in CAP. The most pop- diseases
ular and easy to apply is CURB65 (and CRB-­65 in emergency situations).
Systemic steroid 3 (6.4) 15 (2.6) .149
In addition to CURB-­65, the pneumonia severity index (PSI) is utilised use
to predict the prognosis of CAP. Although these three scores perform Diabetes 8 (17.0) 60 (10.5) .166
equally well among patients with CAP to predict mortality,10 CURB-­65
Neoplastic 3 (7.6) 23 (4.0) .437
is easier to implement in clinical practice.11 In some studies CURB-­65 diseases
score was not found as a good predictor of adverse outcome12 or early
mortality13 in CAP. However, according to many other studies, patients
with a higher CURB-­65 score had a greater chance for in-­hospital mor- involved in the performance of various components of the immune
tality14 and 30-­day mortality15-17 because of pneumonia. Therefore, it system. 20 Some studies confirm that epidemiological factors related
is recommended for the patients with a higher CURB 65 score to be to deprivation such as poverty and illiteracy are associated with an
18
hospitalised to receive early parenteral antibiotic treatment. increased incidence of pneumonia in developing populations, 21 but
In the present study, in addition to the CURB-­65 score, poverty their impact on prognosis of CAP is not well-­understood and only an
(being in the lower economic class), pleural effusion, hyponatremia increase in pneumonia deaths in children under 5 years because of
and hyperglycaemia have been identified as independent risk factors malnutrition related to poverty has been claimed. 20 In the present
of in-­hospital mortality in CAP. study, residence in remote rural areas, difficult access to medical fa-
It is stated that vicious cycles of positive feedback in which in- cilities and illiteracy were not associated with poor outcome in CAP,
fectious diseases and poverty mutually reinforce each other can but being in the lower economic class (as an indicator of poverty)
produce “poverty traps.”19 Poverty-­related conditions such as malnu- was an independent risk factor for in-­hospital mortality.
trition and helminthic infections as well as lack of enough resources It should be noted that defining poverty is a critical issue. There
to access health services can aggravate the outcome of infectious are many standard scales to determine the socioeconomic situation
diseases. Malnutrition predisposes to immunosuppression through of individuals. Among them Kuppuswamy (1976) and B G Prasad
lack of many elements or oligo-­elements such as zinc and copper, (1961) scales are more popular. Modified Kuppuswamy scale uses
JAHANIHASHEMI et al. |
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TA B L E   4   Clinical manifestations and laboratory test results in the study population. Data are presented as median (interquartile range)
for non-­parametric quantitative variables or numbers (percentage) for dichotomous variables

Variable Dead patients (n = 47) Survived patients (n = 574) P value

Confusion 24 (51.1) 44 (7.7) .000

Multifocal infiltrations on chest X-­ray 6 (12.8) 25 (4.4) .023
Pleural effusion 18 (38.3) 35 (6.1) .000
Body temperature (°C) 37.6 (37.4, 38.8) 37.8 (37.1, 38.6) .690
Pulse rate (per min) 96.0 (85.0, 100.0) 88.0 (80.0, 99.0) .085
Respiratory rate (per min) 32.0 (28.0, 40.0) 19.0 (16.0, 26.0) .000
Systolic blood pressure (mm Hg) 115.0 (90.0, 130.0) 120.0 (105.0,135.5) .132
Diastolic blood pressure (mm Hg) 70.0 (55.0, 80.0) 75.0 (65.0, 80.0) .111
Arterial blood oxygen saturation (%) 92.9 (86.9, 98.2) 95.0 (89.9, 97.4) .267
Haematocrit (%) 38.8 (33.6, 43.3) 39.1 (35.7, 43.0) .918
Absolute polymorphonuclear count (number/μL) 10660.0 (7920.0, 15486.0) 6764.0 (4260.0, 10575.0) .000
Serum sodium (mEq/L) 137.0 (132.0, 139.0) 139.0 (137.0, 141.0) .000
Serum potassium (mEq/L) 4.4 (4.0, 5.1) 4.3 (3.7, 4.7) .083
Serum urea (mmol/L) 4.7 (2.8, 8.2) 2.2 (1.7, 2.9) .000
Serum glucose (mmol/L) 7.7 (6.4, 12.5) 6.2 (5.3, 7.5) .000
Sputum gram stain
Poor-­quality specimen or no sputum 18 (38.3) 269 (46.9) .257
Gram-­positive cocci in pairs and chains 9 (19.1) 76 (13.2) .257
Gram-­positive cocci in clusters 5 (10.6) 23 (4.0) .052
Small gram-­negative coccobacilli 1 (2.1) 29 (5.1) .719
Gram-­negative bacilli 3 (6.4) 18 (3.1) .207
Mixed flora 11 (23.4) 159 (27.7) .525
Sputum culture
Poor specimen or negative culture 19 (40.4) 289 (50.3) .191
Streptococcus pneumoniae 6 (12.8) 60 (10.5) .621
Staphylococcus aureus 3 (6.4) 15 (2.6) .149
Haemophilus influenzae 0 (0.0) 25 (4.4) .246
Escherichia coli 1 (2.1) 9 (1.6) .548
Pseudomonas aeruginosa 0 (0.0) 8 (1.4) 1.000
More than one micro-­organism 18 (38.3) 168 (29.3) .194
CURB-­65 score 4.0 (2.0, 4.0) 1.0 (0.0, 2.0) .000

education and occupation of the head of the family and monthly
family income to calculate the socioeconomic scale. It determines
socioeconomic class, but is applicable only in urban and peri-­urban
areas. Furthermore, it is only applicable to families and not individu-
als. Modified BG Prasad scale uses only monthly per capita income
to determine economical class of the person or his or her family.
22
Also, it is applicable to both urban and rural areas, so in our study
population, which was consisted of urban and rural residents, the
modified BG Prasad scale was more applicable.
In some other studies, other factors besides components of
CURB-­
65 and socioeconomic backgrounds have been identified
as independent predictors of poor prognosis in CAP. Renaud et al
(2009) and McGregor et al (2006) reported male gender as an in-
dependent risk factor for poor prognosis in CAP. 23,24 In our study,
there was no significant association between gender and prognosis
of the disease.
In a study in Japan, including 1544 patients hospitalized with
CAP, polybacterial aetiology was an independent predictor of 30-
day mortality. 25 In our study a significant association between the
results of sputum culture and in-­hospital mortality was not observed.
In a retrospective study in the United States, a history of diabe-
tes was associated with increased mortality in a year period after the
onset of CAP. 26 Also, in another retrospective cohort study in two
tertiary teaching hospitals in Texas, USA, hypoglycaemia was intro-
duced as a risk factor for 30-­day mortality in pneumonia. 27 In the
present study, being a known case of diabetes mellitus was not asso-
ciated with higher mortality in CAP, but higher blood glucose at ad-
mission time was an independent predictor of in-­hospital mortality.
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6 of 8       JAHANIHASHEMI et al.

TA B L E   5   Multivariate analyses of factors associated with introduced as an independent risk factor for increased 28 day mor-
in-­hospital mortality in patients with community-­acquired tality in community-­acquired pneumonia.31
pneumonia In addition to the above mentioned variables, the presence of pleu-
Odds ratio (confi- ral effusion is associated with poor prognosis in bacterial pneumonia
Variable dence interval) P value in many studies. In a study conducted on 253 patients with pneumo-
Education (illiterate) 2.02 (0.53-­7.54) .305 nia in Spain, higher levels of interleukin-­6 and pleural effusion have

Poverty 2.92 (1.16-­7.38) .023
Cerebrovascular diseases 1.45 (.50-­4.21) .496
Chronic renal failure 2.48 (0.52-­11.81) .256
Multifocal infiltrations on chest 2.05 (0.26-­16.01) .494
X-­ray
Pleural effusion 10.06 (3.24-­31.25) .000
Absolute polymorphonuclear 1.08 (0.99-­1.17) .098
count
Serum sodium 0.86 (0.78-­0.96) .006
Serum glucose 1.16 (1.06-­1.28) .001
CURB-­65 score 6.46 (3.81-­10.96) .000
In some studies, tachycardia and leucocytosis are introduced
as risk factors for poor prognosis in CAP. For instance, in the study
of Renaud et al. The pulse rate higher than 125 per minute at the
point of admission was a risk factor for early onset ICU admission in
CAP. In the mentioned study, WBC <3000/μL or >20000/μL were
associated with a poor prognosis in CAP. 23 Meanwhile, in a 4 year
study on 391 elderly patients with CAP, the white blood cell count
was not associated with 30-­day mortality.17 In our study a signifi-
cant association between pulse rate or peripheral leukocyte count
and in-­hospital mortality is not obtained. The disagreement in the
results of various studies shows that the assertion of an association
between pulse rate or peripheral blood leukocyte count and progno-
sis of pneumonia requires more studies.
Hyponatremia is a laboratory abnormality that can be a predictor
of adverse outcome in pneumonia, but it is not a component of CURB-­
65 score. In a case–control study performed in a 900 bed teaching
hospital, regardless of the reason for hospitalisation, plasma sodium
lower than 128 mmol/L was an independent predictor of mortal-
ity. 28 This also had been studied in patients with pneumonia. In a
historical cohort study including 5916 patients with pneumonia in
27 hospitals in the USA, the length of hospital stay, need for assisted
ventilation, admission to intensive care units and finally the overall
costs of hospitalisation had been significantly higher in patients with
hyponatremia compared with other patients. 29 In a population based
study from 2001 to 2011 in Sweden, patient outcomes and health-
care resources related to hospital stay were compared between hy-
ponatremic and control patients. In 5270 patients admitted with a
diagnosis of pneumonia, hyponatremic patients had a higher hospi-
tal re-­admission and a longer hospital stay. In this study, the median
time to first readmission was 14 days shorter for the hyponatremic
patients.30 In another study based on the data obtained from the
German competence network for the study of community-­acquired
pneumonia (CAPNETZ), in 2138 new cases, hyponatremia had been
been identified as independent predictors of treatment failures in
pneumonia.32 In our patients measuring of interleukin-­6 had not been
performed, but the role of pleural effusion in prognosis had been con-
firmed. It should be noted that in another study, pleural effusion was
not identified as an independent risk factor for in-­hospital mortality in
influenza pneumonia.33 It is possible that pleural effusion be consid-
ered as a risk factor of in-­hospital mortality in cases of community-­
acquired pneumonia suspected to have a bacterial aetiology.
In developed countries, numerous novel laboratory tests are
available to help clinicians to predict the prognosis of pneumonia
more accurately, 34 but generally these biomarkers are unavail-
able in the most of remote hospitals in the developing countries.
In other words, the higher price and inaccessible advanced labo-
ratory facilities limit the application of some valuable tests such
as procalcitonin in the majority of hospitals in low income devel-
oping countries, so in the present study, the emphasis was on the
implementation of clinical signs and accessible inexpensive labora-
tory tests to determine the predictors of acute pneumonia in low-­
income populations.
Our study has some limitations. In this study, we had no re-
sources to apply expensive para-­clinical tests such as quantitative
CRP or procalcitonin. In most hospitals in developing countries
expensive laboratory tests are not accessible because of financial
problems. Another limitation of this study is the reliance on in-
terview and previous medical records of the patients for deter-
mination of epidemiological data and underlying conditions. If it
is financially possible, utilisation of more accurate methods for
determination of underlying diseases is proposed for the future
studies. At last, our study is conducted in a deprived community
with a high prevalence of poverty. It is proposed to perform sim-
ilar studies in developed countries to determine the prognostic
value of this socioeconomic factor in populations with a lower fre-
quency of poverty.
5 | CO N C LU S I O N
Because of the wide heterogeneity in the prognosis of pneumonia,
the identification of affordable and practically accessible predictors
of poor outcome may help the physicians to treat the critical patients
more aggressively, and on the other hand avoid to impose additional
costs for benign cases. It can make the limited resources available to
patients who really need them.
The results of this study emphasise the influence of socioeco-
nomic backgrounds (eg, poverty) on the prognosis of a medical ill-
ness, ie acute pneumonia.
JAHANIHASHEMI et al.
D I S C LO S U R E S
The authors report no conflicts of interest.
AU T H O R C O N T R I B U T I O N S
H. Jahanihashemi participated in the study design, drafted the ar-
ticle and conducted the statistical analysis. M. Babaie collected the
data and participated in the study design and reviewed clinical data.
S. Bijani participated in the study design, co-­ordinated the labora-
tory studies and drafted the article. M. Bazzazan participated in
the study design and co-­ordinated the laboratory studies. B. Bijani
designed and co-­ordinated the study and drafted the article. All
authors had access to the study data and read and approved the
manuscript.
ORCID
Behzad Bijani  http://orcid.org/0000-0003-1789-3055
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