A recalibrated prediction model can identify level-1 trauma patients at risk of nosocomial pneumonia

Abstract

IntroductionNosocomial pneumonia has poor prognosis in hospitalized trauma patients. Croce et al. published a model to predict post-traumatic ventilator-associated pneumonia, which achieved high discrimination and reasonable sensitivity. We aimed to externally validate Croce’s model to predict nosocomial pneumonia in patients admitted to a Dutch level-1 trauma center.Materials and methodsThis retrospective study included all trauma patients (≥ 16y) admitted for > 24 h to our level-1 trauma center in 2017. Exclusion criteria were pneumonia or antibiotic treatment upon hospital admission, treatment elsewhere > 24 h, or death < 48 h. Croce’s model used eight clinical variables—on trauma severity and treatment, available in the emergency department—to predict nosocomial pneumonia risk. The model’s predictive performance was assessed through discrimination and calibration before and after re-estimating the model’s coefficients. In sensitivity analysis, the model was updated using Ridge regression.Results809 Patients were included (median age 51y, 67% male, 97% blunt trauma), of whom 86 (11%) developed nosocomial pneumonia. Pneumonia patients were older, more severely injured, and underwent more emergent interventions. Croce’s model showed good discrimination (AUC 0.83, 95% CI 0.79–0.87), yet predicted probabilities were too low (mean predicted risk 6.4%), and calibration was suboptimal (calibration slope 0.63). After full model recalibration, discrimination (AUC 0.84, 95% CI 0.80–0.88) and calibration improved. Adding age to the model increased the AUC to 0.87 (95% CI 0.84–0.91). Prediction parameters were similar after the models were updated using Ridge regression.ConclusionThe externally validated and intercept-recalibrated models show good discrimination and have the potential to predict nosocomial pneumonia. At this time, clinicians could apply these models to identify high-risk patients, increase patient monitoring, and initiate preventative measures. Recalibration of Croce’s model improved the predictive performance (discrimination and calibration). The recalibrated model provides a further basis for nosocomial pneumonia prediction in level-1 trauma patients. Several models are accessible via an online tool.Level of evidenceLevel III, Prognostic/Epidemiological Study.