CURB-65 Research Articles

Death in COVID-19. A Non-ICU Spanish Series: The SADDEN DEATH Study

Background: The current worldwide pandemic, coronavirus disease 2019 (COVID-19) is a novel infection with serious clinical manifestations, including death. However, autopsy reports are scarce, and little is known about the causes of death. Here we report the results of the largest series investigating exclusively deceased patients with COVID-19 in Spain. Methods: In this single-centre retrospective study, we consecutively included all deceased inpatients with laboratory-confirmed COVID-19 from Hospital Clinico San Carlos (Madrid, Spain) who had died from March 4 to April 16, 2020 for screening due to unexpected death. Demographic, clinical, treatment, and serial laboratory data, were extracted from electronic medical records and patient files and compared between unexpected and non-unexpected deaths. We used univariable and multivariable logistic regression methods to identify those factors associated with unexpected death. Findings: In total, 324 deceased patients were included. Median age, 82 years (IQR 76-87); 55.9.% males. The most common cardiovascular risk factors were hypertension (78.4%), hyperlipidemia (57.7%), and diabetes (34.3%). Other common comorbidities were chronic kidney disease (40.1%), chronic pulmonary disease (30.3%), active cancer (13%), and immunosuppression (13%). The CURB-65 score at admission was >2 in only 40.7% of patients. During hospitalization, 77.8% of patients received antivirals, 43.3% systemic corticosteroids, and 22.2% full anticoagulation. One hundred and five (32.4%) patients had an increased level of troponin I during hospitalization. The rate of any bacterial co-infection was 5.5%. The median time from initiation of therapy to death was 5 days (IQR 3.0-8.0). SARS-CoV-2 infection contributed to the patient´s death in 92.3% of patients. Progressive respiratory failure was the most frequent cause of death (92.0%). Twenty-five patients (7.7%) had an unexpected death. In 45 patients (13.9%), the death was exclusively attributed to COVID-19, and in 254 patients (78.4%) both, COVID-19 and the patient´s clinical situation before admission contributed to death. Factors independently associated with unexpected death were male sex, chronic renal failure, insulin-treated diabetes, and functional independence. Interpretation: This case series provides in-depth characterization of hospitalized non-ICU deceased patients with confirmed COVID-19 in the city of Madrid. Insulin-dependent diabetic males with chronic renal failure and independent for activities of daily living are at risk of unexpected death. Funding Statement: None. Declaration of Interests: None. Ethics Approval Statement: This study was approved by the local ethical committee and the study protocol has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki).

Clinical, Bacteriological and Radiological Study of Community Acquired Pneumonia Cases at Tertiary Medical Center in Kathmandu, Nepal

Community-acquired pneumonia (CAP) remains a common and serious illness, in spite of the availability of potent new antimicrobials and effective vaccines. Despite Nepal being one of the four developing countries accounting for 40.0% of global acute respiratory infections, studies on CAP are limited and the status of adult pneumonia in our community is unknown. This cross-sectional study reviewed the clinical, bacteriological, radiological profile of 100 cases of adult CAP and followed them during the hospital stay for the outcome. The age group with the highest incidence was 60-79 years with females (55.0%) being more affected than males (45.0%). Risk factors were present in 86.0% of cases, chronic obstructive pulmonary disease (COPD), and smoking was the most common, each present in 43.0% of cases. The most common presenting feature was cough (89.80%) followed by sputum production (78.60%), fever (67.30%), shortness of breath (63.30%), chest pain (38.80%), gastrointestinal symptoms (26.50%), altered sensorium (13.30%), and hemoptysis (13.30%). Only 48.0% of patients had leukocytosis. Klebsiella pneumoniae was the most frequent organism isolated (n=4) followed by Pseudomonas aeruginosa (n=3). Fungi were isolated in 3 cases. Lobar pneumonia was seen in 99.0% of cases with the right lower zone being the most commonly involved zone on chest x-ray. Severe pneumonia with CURB-65 (confusion, blood urea nitrogen, respiratory rate, blood pressure, age>65) Score ≥3 was seen in 15.0% of cases. The mean hospital stay was 7.55 days with 28 cases requiring ICU admission and 5 cases of mortality.

CT in relation to RT-PCR in diagnosing COVID-19 in The Netherlands: A prospective study.

Early differentiation between emergency department (ED) patients with and without corona virus disease (COVID-19) is very important. Chest CT scan may be helpful in early diagnosing of COVID-19. We investigated the diagnostic accuracy of CT using RT-PCR for SARS-CoV-2 as reference standard and investigated reasons for discordant results between the two tests. In this prospective single centre study in the Netherlands, all adult symptomatic ED patients had both a CT scan and a RT-PCR upon arrival at the ED. CT results were compared with PCR test(s). Diagnostic accuracy was calculated. Discordant results were investigated using discharge diagnoses. Between March 13th and March 24th 2020, 193 symptomatic ED patients were included. In total, 43.0% of patients had a positive PCR and 56.5% a positive CT, resulting in a sensitivity of 89.2%, specificity 68.2%, likelihood ratio (LR)+ 2.81 and LR- 0.16. Sensitivity was higher in patients with high risk pneumonia (CURB-65 score ≥3; n = 17, 100%) and with sepsis (SOFA score ≥2; n = 137, 95.5%). Of the 35 patients (31.8%) with a suspicious CT and a negative RT-PCR, 9 had another respiratory viral pathogen, and in 7 patients, COVID-19 was considered likely. One of nine patients with a non-suspicious CT and a positive PCR had developed symptoms within 48 hours before scanning. The accuracy of chest CT in symptomatic ED patients is high, but used as a single diagnostic test, CT can not safely diagnose or exclude COVID-19. However, CT can be used as a quick tool to categorize patients into "probably positive" and "probably negative" cohorts.

Troponin I, a risk factor indicating more severe pneumonia among patients with novel coronavirus infected pneumonia.

BackgroundIn December 2019, a novel communicable disease, novel coronavirus infected pneumonia (NCIP) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) broke out. We aimed to analyze the characteristics and severity of patients with myocardial damage in NCIP.MethodsWe enrolled 215 adult patients with NCIP from January 2020 to February 2020. Outcomes were followed up until March 1st, 2020.Results28.37% of the total patients showed increased level of TnI (> 0.040 ng/ml). Patients were older and had more cardiovascular complications in increased TnI group. Higher CRP, NT-proBNP, lower immune CD3, CD4 and CD8 cell account and more involved lobes detected by CT scan in the lung were observed in increased TnI group. Patients with elevated TnI had higher CURB-65 scores and were more likely given glucocorticoid therapy and mechanical ventilation than patients in normal TnI group.ConclusionsMarkers of cardiomyocyte injury were elevated not least in elderly males with pre-existing cardiovascular disease. Patients with elevated TnI presented more severe situation, leading to multiple organ dysfunctions, which appeared as a pivotal feature of patients with NCIP that requires attention by clinicians in order to provide necessary treatment as soon as possible and improve patients' outcomes.

Utility of illness severity scores to predict mortality in patients hospitalized with respiratory deterioration of idiopathic pulmonary fibrosis.

In the context of idiopathic pulmonary fibrosis (IPF), respiratory-related admissions to hospital are associated with a high morbidity and short-term mortality with significant burden on secondary care services. It has yet to be determined how to accurately identify patients at risk of acute respiratory deterioration (ARD) or the prognosticating factors. We sought to define the characteristics of hospitalized ARD-IPF patients in a real-world cohort and investigate factors associated with worse outcomes. Specifically, we wished to determine the association between baseline CURB-65 and NEWS-2 and mortality in IPF, given illness severity scores have not previously been validated in this cohort. Single-centre retrospective observational cohort study. Of 172 first hospitalizations for ARD, 27 admissions (15.7%) were due to an acute exacerbation of IPF (AE-IPF), 28 (16.3%) secondary to cardiac failure/fluid overload and 17 due to pneumonia (9.9%). Other admissions related to lower respiratory tract infection, extra-parenchymal causes and those without a specific trigger. Baseline patient characteristics were comparable for all underlying aetiologies of ARD-IPF. Treatment pathways did not differ significantly between AE-IPF and other causes of ARD-IPF. Short-term mortality was high, with ∼22% patients dying within 30 days. Illness severity scores (NEWS-2 and CURB-65) were independent predictors of mortality in multivariable logistic regression modelling. Our findings suggest significant mortality related to hospitalization with ARD-IPF of any underlying cause. Our data support the use of CURB-65 and NEWS-2 scores as illness severity scores that can provide a simple tool to help future prognostication in IPF. Research should be aimed at refining the management of these episodes, to try to reduce mortality, where possible, or to facilitate palliative care for those with adverse prognostic characteristics.

Development and Implementation of a Clinical Pathway to Reduce Inappropriate Admissions Among Patients with Community-Acquired Pneumonia in a Private Health System in Brazil: An Observational Cohort Study and a Promising Tool for Efficiency Improvement.

PurposePatients with community-acquired pneumonia (CAP) at low risk of death by CURB-65 scoring system are usually unnecessarily treated as inpatients generating additional economic and clinical burden. We aimed to implement an evidence-based clinical pathway to reduce hospital admissions of low-risk CAP and investigate factors related to mortality and readmissions within 30 days.Patients and MethodsFrom November 2015 to August 2017, a clinical pathway was implemented at 20 hospitals. We included patients aged >18 years, with a diagnosis of CAP by the attendant physician. The main outcome was the monthly proportion of low-risk CURB-65 admission after the implementation of the clinical pathway. Logistic regression models were performed to assess variables associated with mortality and readmission in the admitted population within 30 days.ResultsWe included 10,909 participants with suspected CAP. The proportion of low-risk CAP admitted decreased from 22.1% to 12.8% in the period. Among participants with low risk, there has been no perceptible increase in deaths (0.80%) or readmissions (6.92%). Regression analysis identified that CURB-65 variables, presence of pleural effusion (OR= 1.74; 95%CI=1.08–2.8; p=0.02) and leucopenia (OR= 2.47; 95%CI=1.11–5.48; p=0.02) were independently associated with 30-day mortality, whereas a prolonged hospital stay (OR= 2.09; 95%CI=1.14–3.83; p=0.01) was associated with 30-day readmission in the low-risk population.ConclusionThe implementations of a clinical pathway diminished the proportion of low-risk CAP admissions with no apparent increase in clinical outcomes within 30 days. Nonetheless, additional factors influence the clinical decision about the site of care management in low-risk CAP.

A comparative study of PSI and Curb-65 scoring systems in predicting ICU admissions and mortality in cases of community-acquired pneumonia

Background:Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. Despite advanced diagnostic modalities and treatment options, CAP is the fourth leading cause of death in developing countries.Several severity scores have been proposed to guide initial decision making on hospitalization and to predict the outcome. Pneumonia Severity Index (PSI) and CURB 65 are the two most widely used scoring systems to prognosticate pneumonia. Aim: To compare the efficacy of PSI and CURB 65 scoring systems inprognosticating the ICU admission and outcome in cases of CAP. Methodology: This wasan observational study conducted at a tertiary care hospital in westernMaharashtra.A hundred patients of CAP fulfilling the inclusion criteria were enrolled in the study, classified as per CURB 65 and PSI system and their outcome compared. Result: The study subjects comprised of 100 patients (64 men and 36 women) of CAP. Twenty-four patients needed ICU admission.In both PSI and CURB-65 risk scoring systems, the need for intensive care unit (ICU) admission and mortality rates increased progressively with increasing scores.PSI class ≥IV and CURB 65 ≥III had 77.52% and 40.24% sensitivity and 88.46% and 69.48% specificity respectively in predicting ICU admissions. The PSI class ≥IV had more sensitivity and specificity in predicting ICU admission than CURB-65.CURB 65 class III and IV had sensitivity86.59% and 89.64% and specificity 89.64% and 97.54% respectivelyin predicting mortality, while PSI class IV and Vhadsensitivity68.92% and 72.58% and specificity 24.74% and 54.86% respectively. CURB 65 had more sensitivity and specificity than PSI in predicting mortality. Conclusion: The PSI is better in predicting the need for ICU admission and CURB 65 is a better predictor of mortality in cases of community-acquired pneumonia.

Sociodemographic, clinical and laboratory factors on admission associated with COVID-19 mortality in hospitalized patients: A retrospective observational study.

BackgroundTo identify and quantify associations between baseline characteristics on hospital admission and mortality in patients with COVID-19 at a tertiary hospital in Spain.Methods and findingsThis retrospective case series included 238 patients hospitalized for COVID-19 at Hospital Universitario Clínico San Cecilio (Granada, Spain) who were discharged or who died. Electronic medical records were reviewed to obtain information on sex, age, personal antecedents, clinical features, findings on physical examination, and laboratory results for each patient. Associations between mortality and baseline characteristics were estimated as hazard ratios (HR) calculated with Cox regression models.Series mortality was 25.6%. Among patients with dependence for basic activities of daily living, 78.7% died, and among patients residing in retirement homes, 80.8% died. The variables most clearly associated with a greater hazard of death were age (3% HR increase per 1-year increase in age; 95%CI 1–6), diabetes mellitus (HR 2.42, 95%CI 1.43–4.09), SatO2/FiO2 ratio (43% HR reduction per 1-point increase; 95%CI 23–57), SOFA score (19% HR increase per 1-point increase, 95%CI 5–34) and CURB-65 score (76% HR increase per 1-point increase, 95%CI 23–143).ConclusionsThe patients residing in retirement homes showed great vulnerability. The main baseline factors that were independently associated with mortality in patients hospitalized for COVID-19 were older age, diabetes mellitus, low SatO2/FiO2 ratio, and high SOFA and CURB-65 scores.

Admission C-Reactive Protein-to-Albumin Ratio Predicts the 180-Day Mortality of AIDS-Related Pneumocystis Pneumonia.

Assessment tools are necessary for the adequate stratification of patients with AIDS-related pneumocystis pneumonia (PCP). The aim of this study was to evaluate the ability of severity assessment scores and inflammation- and nutrition-based parameters for predicting the 180-day mortality of AIDS-related PCP. This was a retrospective cohort study of patients with AIDS-related PCP admitted at the Beijing Di-Tan Hospital. The CURB-65 score, Pneumonia Severity Index (PSI) score, Acute Physiology And Chronic Health Evaluation II (APACHE II) score, C-reactive protein-to-albumin ratio (CAR), procalcitonin, neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and platelet-to-lymphocyte ratio during the first 24 h of intensive care unit admission were analyzed. The prognostic values of the severity assessment scores and biomarkers for 180-day mortality were evaluated using receiver operating characteristic (ROC) curves and integrated discrimination improvement (IDI) indexes. A total of 123 patients with AIDS-related PCP were included. Fifty-five patients were dead, and 68 were still alive at 180 days after admission. CAR, CURB-65, PSI, and APACHE II were independent predictors of 180-day mortality. The optimal cutoff value of CAR was 2.0 mg/g [area under the ROC curve = 0.844, 95% credential interval (CI) = 0.776-0.913], and CAR >2.0 mg/g increased the prognostic value of all three severity assessment scores, with an IDI index of 5.1% for the CURB-65 score, 8.1% for the PSI score, and 4.1% for the APACHE II score (all p < .05). Combining CAR >2.0 mg/g enhanced the capability of CURB-65, APACHE II, and PSI in predicting the 180-day mortality of patients with AIDS-related PCP.

Clinical Impact of N-Terminal Prohormone of Brain Natriuretic Peptide on Patients Hospitalized with Community-Acquired Pneumonia

Risk stratification is important for the management of community-acquired pneumonia (CAP). The present study aimed to investigate the clinical impact of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) on prognosis and to identify clinical characteristics associated with NT-proBNP elevation in CAP patients. This retrospective study included patients hospitalized for CAP at a tertiary referral center and who underwent measurement plasma NT-proBNP levels. Based on 30-day mortality, patients (n=1,821) were divided into 2 groups, survivors (n=150) and nonsurvivors (n=1,671), and clinical and laboratory findings were compared. In multivariate analysis, blood levels of NT-proBNP (>942.5 pg/mL), albumin (<3.3 g/dL), and troponin I (>0.018 ng/mL) independently predicted 30-day mortality. Of these blood biomarkers, NT-proBNP exhibited the highest C-statistic, followed by albumin. NT-proBNP level/CURB-65 score and NT-proBNP level/pneumonia severity index (PSI) class exhibited significantly higher C-statistics than CURB-65 score and PSI class alone, respectively. The 3-test combinations of CURB-65 score/NT-proBNP level/albumin level and PSI class/NT-proBNP level/albumin level exhibited significantly higher C-statistics than the 2-test combinations. NT-proBNP elevation was associated with increased age, heart disease and chronic kidney disease and NT-proBNP levels only weakly or moderately correlated with other blood biomarkers. NT-proBNP level was a useful marker for the prediction of 30-day mortality in patients hospitalized with CAP, and provided additional prognostic value to PSI or CURB-65 alone.

The alveolar-arterial gradient, pneumonia severity scores and inflammatory markers to predict 30-day mortality in pneumonia

ObjectiveThe objective of this study was to evaluate the association of elevated alveolar-arterial oxygen (A-a O2) gradient with risk of mortality in hospitalized patients with community-acquired pneumonia (CAP). MethodsThis prospective study included 206 patients diagnosed with CAP admitted to the ED. Demographics, comorbidities, arterial blood gas, serum electrolytes, liver-renal functions, complete blood count, NLR, PLR, CRP, CAR, procalcitonin, A-a O2 gradient, expected A-a O2 and A-a O2 difference were evaluated. PSI and CURB-65 scores were classified as follow: a) PSI low risk (I-III) and moderate-high risk (IV-V) groups; b) CURB-65; low risk (0–2) and high risk (3–5) groups. ResultsThe survival rates of the PSI class (I-III) were significantly higher than the ones of the PSI class (IV-V) (92.1% vs. 62.9%, respectively). The percentage of survivors of the CURB-65 score (0–2) group (81.9%) was higher than the survivors of CURB-65 score (3–5) group (27.8%). Creatinine, BUN, uric acid, phosphorus, RDW, CRP, CAR, procalcitonin, lactate, A-a 02 gradient, expected A-a 02 and A-a 02 difference were significantly higher and basophil was lower in non-survivors. A-a O2 gradient (AUC 0.78), A-a O2 difference (AUC 0.74) and albumin (AUC 0.80) showed highest 30-day mortality prediction. NLR (AUC 0.58) and PLR (AUC 0.55) showed lowest 30-day mortality estimation. Procalcitonin (AUC 0.65), PSI class (AUC 0.81) and PSI score (AUC 0.86) indicated statistically significant higher 30-day mortality prediction. ConclusionA-a O2 gradient, A-a O2 difference and albumin are potent predictors of 30-day mortality in CAP patients in the ED.

Early procalcitonin determination in the emergency department and clinical outcome of community-acquired pneumonia in old and oldest old patients

We evaluated patients admitted through our ED for community-acquired pneumonia (CAP) to assess the relevance of an early procalcitonin (PCT) determination on patient's outcomes. MethodsWe reviewed all patients admitted for CAP in a 10 years period (2008-2017). Patients were stratified according to age groups: (18-65 years; 65–84 years; and ≥85 years), CURB-65 score, need for ventilation, Sepsis-3 criteria at admission, enrollment period, blood culture in ED. In-hospital mortality rate and length of hospital stay (LOS) were compared between patients that had an early PCT determination in ED vs. patients admitted without. ResultsOur study cohort consisted of 4056 CAP patients, age 76 [IQ range 64-84] years. We enrolled 1039 patients <65 years old, 2015 aged 65-84 years, and 1002 aged ≥85 years. Overall, the early PCT determination in ED was not associated to a reduced LOS (p=0.630), nor to a reduced mortality rate (p=0.134). However, in patients ≥ 85 years, the PCT determination in ED was associated with lower mortality in those with CURB-65 ≥ 2, and Charlson's score ≥ 2 (p=0.033 and p=0.002, respectively). ConclusionsAlthough an early PCT assessment in ED was not associated with better outcomes in term of LOS and mortality in patients with CAP, our findings suggest that it might be associated with reduced mortality in patients ≥ 85 years with severe CAP or high comorbidity.

FluA-p score: a novel prediction rule for mortality in influenza A-related pneumonia patients

BackgroundThe pneumonia severity index (PSI) and the CURB-65 (confusion, urea, respiratory rate, blood pressure, age ≥ 65 years) score have been shown to predict mortality in community-acquired pneumonia. Their ability to predict influenza-related pneumonia, however, is less well-established.MethodsA total of 693 laboratory-confirmed FluA-p patients diagnosed between Jan 2013 and Dec 2018 and recruited from five teaching hospitals in China were included in the study. The sample included 494 patients in the derivation cohort and 199 patients in the validation cohort. The prediction rule was established based on independent risk factors for 30-day mortality in FluA-p patients from the derivation cohort.ResultsThe 30-day mortality of FluA-p patients was 19.6% (136/693). The FluA-p score was based on a multivariate logistic regression model designed to predict mortality. Results indicated the following significant predictors (regression statistics and point contributions toward total score in parentheses): blood urea nitrogen > 7 mmol/L (OR 1.604, 95% CI 1.150–4.492, p = 0.040; 1 points), pO2/FiO2 ≤ 250 mmHg (OR 2.649, 95% CI 1.103–5.142, p = 0.022; 2 points), cardiovascular disease (OR 3.967, 95% CI 1.269–7.322, p < 0.001; 3 points), arterial PH < 7.35 (OR 3.959, 95% CI 1.393–7.332, p < 0.001; 3 points), smoking history (OR 5.176, 95% CI 2.604–11.838, p = 0.001; 4 points), lymphocytes < 0.8 × 109/L (OR 8.391, 95% CI 3.271–16.212, p < 0.001; 5 points), and early neurominidase inhibitor therapy (OR 0.567, 95% CI 0.202–0.833, p = 0.005; − 2 points). Seven points was used as the cut-off value for mortality risk stratification. The model showed a sensitivity of 0.941, a specificity of 0.762, and overall better predictive performance than the PSI risk class (AUROC = 0.908 vs 0.560, p < 0.001) and the CURB-65 score (AUROC = 0.908 vs 0.777, p < 0.001).ConclusionsOur results showed that a FluA-p score was easy to derive and that it served as a reliable prediction rule for 30-day mortality in FluA-p patients. The score could also effectively stratify FluA-p patients into relevant risk categories and thereby help treatment providers to make more rational clinical decisions.

Clinical Characteristics of COVID-19 Patients at Different Epidemic Stages in Zhejiang, China

Background: At present, COVID-19 is the most serious threat to global public health. It is important to understand COVID-19 from different perspectives. Evidence is needed to determine whether there are differences in the clinical characteristics of COVID-19 patients as the SARS-CoV-2 virus continues to circulate in the population. Methods: This is a retrospective, multi-center cohort study. All adult cases with laboratory-confirmed COVID-19 from four hospitals in Zhejiang, China were enrolled in this study. Based on epidemiological history, patients were clustered into 3 groups. They included first-generation patients who had a clear travel history to Hubei within 14 days before disease onset; second generation patients who had a clear contact history with first-generation patients; third-generation patients who had a clear contact history with second-generation patients. Demographic, clinical characteristics, radiological features, laboratory data, clinical outcomes, and duration of viral shedding were then analyzed. Findings: Total of 171 patients with COVID-19 (aged 50.5±15.2 years, 92 males (53.8)) were enrolled. Third generation patients were older ( P <0.001), had more coexisting conditions ( P =0.013), a higher level of urea nitrogen ( P <0.05) and significantly higher CURB-65 scores ( P =0.004) compared to the other two groups. At 7±1 days from illness onset, white blood cell counts decreased in 26.9% of patients, lymphocyte counts decreased in 50.3% of patients, and platelet counts decreased in 11.4% of patients. Lung CT scans indicated that 66.1% of patients had a wide range of lesions that involved 4-5 pulmonary lobes. Third generation patients had lower lymphocyte and platelet levels ( P =0.007), higher C-reactive protein ( P =0.007) and D-dimer levels ( P =0.002), and more lesions involving the pulmonary lobes as determined by lung CT scans ( P <0.001). The proportion of third-generation patients who developed severe illness ( P <0.001), critical illness ( P <0.001) and received endotracheal intubation ( P =0.002) were significantly higher compared to the other two groups. No significant differences were observed between the three groups for the mean time from onset to severe or critical illness, distribution of endotracheal intubation and ECMO treatment, SARS-CoV-2 RNA negative conversion in the respiratory tract. Interpretation: Third generation patients were older, had more underlying comorbidities and had a higher proportion of severe or critical illness compared to first and second-generation patients. Baseline characteristics and clinical procedures in first- and second-generation patients were similar. We did not observe evidence of decreased virulence after the SARS-CoV-2 virus had passed through the population in Zhejiang, China. Funding Statement: This work was supported by a grant for COVID-19 from Jiaxing Science and Technology Bureau (2020GZ30001) and a grant from the National Natural Science Foundation of China (81971897). The research funding was provided to Dr. Hua Zhou. Declaration of Interests: All authors declare no conflicts of interest. Ethics Approval Statement: The study was approved by the Research Ethics Commission of The First Affiliated Hospital, School of Medicine, Zhejiang University (IIT20200129A), and supported by the Research Ethics Commissions of the other three hospitals. Due to the urgency to collect data on this emerging pathogen, the requirement for informed consent was waived by the Ethics Commission.

Management of community-acquired pneumonia: essential tips for the physician on call.

Community-acquired pneumonia is a common clinical problem requiring admission to hospital, with a particularly high incidence in the elderly population and those with significant comorbidities. Diagnosis is made on the combination of a short history of respiratory symptoms and systemic ill-health with new examination and/or radiological features of consolidation. Multiple other infective and non-infective conditions can mimic community-acquired pneumonia, leading to misdiagnosis in 5-17% of cases. The CURB-65 score can identify patients with community-acquired pneumonia with a higher risk of mortality, but is insensitive at identifying patients requiring intensive care support and needs to be combined with clinical markers of potential severity. Both high admission levels of C-reactive protein and the failure of levels of C-reactive protein to decline by >50% by day 4 after admission are associated with higher risk of complications, need for ventilation or inotropic support, and mortality. Empirical antibiotic therapy for most patients admitted to hospital is combination of a ß-lactam and a macrolide. Short courses of antibiotics do not result in significantly different outcomes to longer courses unless the patient has developed complications such as a complex parapneumonic effusion. Implementation of a community-acquired pneumonia care bundle into clinical practice reduces mortality, and should be a high priority for all acute hospitals.

Prognostic value of albumin-red cell distribution width score in patients with severe community-acquired pneumonia.

It has been recently reported that albumin (ALB) and red cell distribution width (RDW) are correlated with the prognosis of community-acquired pneumonia, while their role in severe communityacquired pneumonia (sCAP) is unknown. This study aimed to investigate the correlation between the ALBRDW score and 90-day mortality of sCAP patients. A total of 179 sCAP patients admitted to our hospital between January 1, 2014 and June 30, 2019 were enrolled in this study. Data of patient characteristics and laboratory data were obtained and CURB-65 was calculated. The ALB-RDW score was calculated based on serum ALB and RDW. Receiver operating characteristic (ROC) curve and the value of area under the curve (AUC) were used to evaluate the association between ALB-RDW score and 90-day mortality of sCAP patients. Compared with survivors, age, white blood cell counts, neutrophil counts, RDW, D-dimer, serum creatinine, lactic dehydrogenase, CURB-65 score, ALB-RDW high score ratio, invasive ventilation and septic shock were higher in non-survivors, while ALB and hemoglobin (HB) were lower. Multivariate logistic regression analysis identified that high age, serum creatinine, ALB-RDW score and invasive ventilation were the independent risk factors of 90-day mortality (P<0.05). Moreover, the AUC of ALB-RDW score was 0.742 [95% confidence interval (CI): 0.667-0.817], which was superior to CURB-65 score 0.725 (95% CI: 0.651-0.798). The AUC increased to 0.798 (95% CI: 0.733-0.862) when combined with CURB-65 score. High age, serum creatinine, ALB-RDW score and invasive ventilation were the independent risk factors of 90-day mortality of sCAP patients. In addition, the correlation between ALB-RDW and 90-day mortality was even stronger when combined with CURB-65 score.

Acute Physiology and Chronic Health Evaluation II Score as a Predictor of Hospital Mortality in Patients of Coronavirus Disease 2019.

Coronavirus disease 2019 has emerged as a major global health threat with a great number of deaths in China. We aimed to assess the association between Acute Physiology and Chronic Health Evaluation II score and hospital mortality in patients with coronavirus disease 2019, and to compare the predictive ability of Acute Physiology and Chronic Health Evaluation II score, with Sequential Organ Failure Assessment score and Confusion, Urea, Respiratory rate, Blood pressure, Age 65 (CURB65) score. Retrospective observational cohort. Tongji Hospital in Wuhan, China. Confirmed patients with coronavirus disease 2019 hospitalized in the ICU of Tongji hospital from January 10, 2020, to February 10, 2020. None. Of 178 potentially eligible patients with symptoms of coronavirus disease 2019, 23 patients (12.92%) were diagnosed as suspected cases, and one patient (0.56%) suffered from cardiac arrest immediately after admission. Ultimately, 154 patients were enrolled in the analysis and 52 patients (33.77%) died. Mean Acute Physiology and Chronic Health Evaluation II score (23.23 ± 6.05) was much higher in deaths compared with the mean Acute Physiology and Chronic Health Evaluation II score of 10.87 ± 4.40 in survivors (p < 0.001). Acute Physiology and Chronic Health Evaluation II score was independently associated with hospital mortality (adjusted hazard ratio, 1.07; 95% CI, 1.01-1.13). In predicting hospital mortality, Acute Physiology and Chronic Health Evaluation II score demonstrated better discriminative ability (area under the curve, 0.966; 95% CI, 0.942-0.990) than Sequential Organ Failure Assessment score (area under the curve, 0.867; 95% CI, 0.808-0.926) and CURB65 score (area under the curve, 0.844; 95% CI, 0.784-0.905). Based on the cut-off value of 17, Acute Physiology and Chronic Health Evaluation II score could predict the death of patients with coronavirus disease 2019 with a sensitivity of 96.15% and a specificity of 86.27%. Kaplan-Meier analysis showed that the survivor probability of patients with coronavirus disease 2019 with Acute Physiology and Chronic Health Evaluation II score less than 17 was notably higher than that of patients with Acute Physiology and Chronic Health Evaluation II score greater than or equal to 17 (p < 0.001). Acute Physiology and Chronic Health Evaluation II score was an effective clinical tool to predict hospital mortality in patients with coronavirus disease 2019 compared with Sequential Organ Failure Assessment score and CURB65 score. Acute Physiology and Chronic Health Evaluation II score greater than or equal to 17 serves as an early warning indicator of death and may provide guidance to make further clinical decisions.

Confusion, respiratory rate, shock index (CRSI-65) score in the emergency department triage may be a new severity scoring method for community-acquired pneumonia.

Objectives:To investigate whether confusion, respiratory rate, shock index-age ≥65 years (CRSI-65) score, consisting of basic physiological parameters, can be used for severity prediction in patients with community-acquired pneumonia.Methods:This is a prospective cohort and single-center study conducted in Bolu Abant Izzet Baysal University Hospital, Bolu, Turkey between January 2018 and June 2018. The study investigated CRSI-65 score in predicting 4-week mortality and the need for intensive care for patients with community-acquired pneumonia.Results:A total of 58 patients with community-acquired pneumonia admitted to the emergency department were included in this study. Of the patients, 62.1% were males (n=36), and the mean age of the patients was 72.87 ± 12.30 years. After 4 weeks of follow-up, CURB-65 and CRSI-65 scores showed similar results in predicting mortality with respect to specificity, sensitivity, and positive and negative predictive values. Area under the receiver operating characteristic curve was 0.926 for the CURB-65 (95% confidence interval [CI] 0.853-0.999) and 0.954 for the CRSI-65 (95% CI 0.899-0.999).Conclusion:Similar to the CURB-65 score, the CRSI-65 score appears to be useful in predicting 4-week mortality. The evaluation of CRSI-65 score can be used in emergency department triage, primary care, and non-hospital settings.

Efficacy of the quick sequential organ failure assessment for predicting clinical outcomes among community-acquired pneumonia patients presenting in the emergency department

BackgroundThe study aimed to investigate the predictive value of the quick sequential organ failure assessment (qSOFA) for clinical outcomes in emergency patients with community-acquired pneumonia (CAP).MethodsA total of 742 CAP cases from the emergency department (ED) were enrolled in this study. The scoring systems including the qSOFA, SOFA and CURB-65 (confusion, urea, respiratory rate, blood pressure and age) were used to predict the prognostic outcomes of CAP in ICU-admission, acute respiratory distress syndrome (ARDS) and 28-day mortality. According to the area under the curve (AUC) of the receiver operating characteristic (ROC) curves, the accuracies of prediction of the scoring systems were analyzed among CAP patients.ResultsThe AUC values of the qSOFA, SOFA and CURB-65 scores for ICU-admission among CAP patients were 0.712 (95%CI: 0.678–0.745, P < 0.001), 0.744 (95%CI: 0.711–0.775, P < 0.001) and 0.705 (95%CI: 0.671–0.738, P < 0.001), respectively. For ARDS, the AUC values of the qSOFA, SOFA and CURB-65 scores were 0.730 (95%CI: 0.697–0.762, P < 0.001), 0.724 (95%CI: 0.690–0.756, P < 0.001) and 0.749 (95%CI: 0.716–0.780, P < 0.001), respectively. After 28 days of follow-up, the AUC values of the qSOFA, SOFA and CURB-65 scores for 28-day mortality were 0.602 (95%CI: 0.566–0.638, P < 0.001), 0.587 (95%CI: 0.551–0.623, P < 0.001) and 0.614 (95%CI: 0.577–0.649, P < 0.001) in turn. There were no statistical differences between qSOFA and SOFA scores for predicting ICU-admission (Z = 1.482, P = 0.138), ARDS (Z = 0.321, P = 0.748) and 28-day mortality (Z = 0.573, P = 0.567). Moreover, we found no differences to predict the ICU-admission (Z = 0.370, P = 0.712), ARDS (Z = 0.900, P = 0.368) and 28-day mortality (Z = 0.768, P = 0.442) using qSOFA or CURB-65 scores.ConclusionqSOFA was not inferior to SOFA or CURB-65 scores in predicting the ICU-admission, ARDS and 28-day mortality of patients presenting in the ED with CAP.

Adherence to Treatment Guideline Improves Patient Outcomes in a Prospective Cohort of Adults Hospitalized for Community-Acquired Pneumonia.

BackgroundUnderstanding local epidemiology and etiologies of community-acquired pneumonia in hospitalized patients is crucial for determining the appropriateness of treatment guidelines. We aim to determine the etiologies, severity, and outcomes in adults hospitalized for community-acquired pneumonia and to study the impact of empirical antibiotic therapy on patient outcomes.MethodsWe performed a prospective observational cohort study involving adults hospitalized for community-acquired pneumonia in Hong Kong. Sputum, nasopharyngeal aspirate, blood, and urine were collected for bacterial culture, molecular tests for detection of viruses and atypical pathogens, and antigen tests. Multivariable logistic regression model and Cox proportional hazard models were performed to determine independent factors associated with prolonged hospitalization and mortality.ResultsFrom February 2017 to July 2018, 258 patients were enrolled. The median age was 73 (interquartile range, 61–80) years, 66% were male, 57% had underlying chronic illnesses, 13% had CURB-65 score ≥3, and 10% had higher 1-year mortality. Pathogens were identified in 45% of patients; 20% had viral, 15% had bacterial, and 9% had polymicrobial pneumonia. Streptococcus pneumoniae (12%), influenza virus (12%), and Mycoplasma pneumoniae (1.2%) were the most common bacterial, viral, and atypical pathogens, respectively. Nonadherence to local empirical antibiotic treatment guidelines (primarily recommending beta-lactam and doxycycline) was observed in 25% and was independently associated with prolonged hospitalization (≥7 days) and higher mortality, after adjustment for age, underlying chronic illness, and disease severity.ConclusionsAdherence to treatment guidelines was associated with shorter hospitalization and improved survival. We provided evidence for the use of doxycycline for coverage of atypical pathogens in nonsevere pneumonia.