Scored minor criteria for severe community-acquired pneumonia predicted better

Qi Guo,Li-Hua Liang,Wei-Dong Song,Nian Liu,Yi-Ping Zhou,Hai-Yan Li,Mei Jiang,Zhong-Dong Lü,Hong-Lin Peng,Hui Liu,Ming Li,Qing-Zhou Zhao,Xia Chen,Xiao-Ke Chen,Hai-Qiong Yu

doi:10.1186/s12931-019-0991-4

Abstract

BackgroundInfectious Disease Society of America/American Thoracic Society (IDSA/ATS) minor criteria for severe community-acquired pneumonia (CAP) are of unequal weight in predicting mortality, but the major problem associated with IDSA/ATS minor criteria might be a lack of consideration of weight in prediction in clinical practice. Would awarding different points to the presences of the minor criteria improve the accuracy of the scoring system? It is warranted to explore this intriguing hypothesis.MethodsA total of 1230 CAP patients were recruited to a retrospective cohort study. This was tested against a prospective two-center cohort of 1749 adults with CAP. 2 points were assigned for the presence of PaO2/FiO2 ≤ 250 mmHg, confusion, or uremia on admission and 1 point for each of the others.ResultsThe mortality rates, and sequential organ failure assessment (SOFA) and pneumonia severity index (PSI) scores increased significantly with the numbers of IDSA/ATS minor criteria present and minor criteria scores. The correlations of the minor criteria scores with the mortality rates were higher than those of the numbers of IDSA/ATS minor criteria present. As were the correlations of the minor criteria scores with SOFA and PSI scores, compared with the numbers of IDSA/ATS minor criteria present. The pattern of sensitivity, specificity, positive predictive value, and Youden’s index of scored minor criteria of ≥2 scores or the presence of 2 or more IDSA/ATS minor criteria for prediction of mortality was the best in the retrospective cohort, and the former was better than the latter. The validation cohort confirmed a similar pattern. The area under the receiver operating characteristic curve of scored minor criteria was higher than that of IDSA/ATS minor criteria in the retrospective cohort, implying higher accuracy of scored version for predicting mortality. The validation cohort confirmed a similar paradigm.ConclusionsScored minor criteria orchestrated improvements in predicting mortality and severity in patients with CAP, and scored minor criteria of ≥2 scores or the presence of 2 or more IDSA/ATS minor criteria might be more valuable cut-off value for severe CAP, which might have implications for more accurate clinical triage decisions.

Highlights

The major problem associated with IDSA/ ATS minor criteria might be a lack of consideration of weight in prediction in clinical practice
We found that mortality among patients with severe community-acquired pneumonia (CAP) depended on combinations of IDSA/ATS minor criteria and the combination of arterial oxygen pressure/ fraction inspired oxygen (PaO2/FiO2) ≤ 250 mmHg, confusion and uremia predicted higher mortality [11]
Patients who were younger than 18 years, who had been hospitalized during the 28 days preceding the study, who had severe immunosuppression, active tuberculosis, or end-stage diseases, who had a written “do not resuscitate” order, or whose baseline consciousness was unclear, which was not derived from pneumonia, were excluded

Summary

Introduction

Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) minor criteria for severe community-acquired pneumonia (CAP) are of unequal weight in predicting mortality, but the major problem associated with IDSA/ATS minor criteria might be a lack of consideration of weight in prediction in clinical practice. Community-acquired pneumonia (CAP) is the most common cause of mortality from infectious diseases and a big burden to finite hospital and intensive care unit (ICU) resources [1]. In 2007, the Infectious Disease Society of America and the American Thoracic Society (IDSA/ATS) designed minor criteria with the aim to guide ICU admission, not to predict mortality [2]. The major problem associated with IDSA/ ATS minor criteria might be a lack of consideration of weight in prediction in clinical practice

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