Pneumonia Severity Index Class Research Articles

Oral versus intravenous antibiotic treatment of moderate-to-severe community-acquired pneumonia: a propensity score matched study

Community-acquired Pneumonia (CAP) guidelines generally recommend to admit patients with moderate-to-severe CAP and start treatment with intravenous antibiotics. This study aims to explore the clinical outcomes of oral antibiotics in patients with moderate-to-severe CAP. We performed a nested cohort study of an observational study including all adult patients presenting to the emergency department of the Haga Teaching Hospital, the Netherlands, between April 2019 and May 2020, who had a blood culture drawn. We conducted propensity score matching with logistic and linear regression analysis to compare patients with moderate-to-severe CAP (Pneumonia Severity Index class III–V) treated with oral antibiotics to patients treated with intravenous antibiotics. Outcomes were 30-day mortality, intensive care unit admission, readmission, length of stay (LOS) and length of antibiotic treatment. Of the original 314 patients, 71 orally treated patients were matched with 102 intravenously treated patients. The mean age was 73 years and 58% were male. We found no significant differences in outcomes between the oral and intravenous group, except for an increased LOS of + 2.6 days (95% confidence interval 1.2–4.0, p value < 0.001) in those treated intravenously. We conclude that oral antibiotics might be a safe and effective treatment for moderate-to-severe CAP for selected patients based on the clinical judgement of the attending physician.

Outcome of Acinetobacter baumannii Ventilator Associated Pneumonia in Upper Egypt: does the resistance profile play a role?

Abstract Background Ventilator-associated pneumonia (VAP) due to drug resistant Acinetobacter baumannii (A. baumannii) is a challenging nosocomial problem associated with increased morbidity and risk of mortality. Objective This study aimed to investigate plasmid mediated quinolone resistance genes (PMQR) as a mechanism of resistance transmission, risk factors and outcome of A. baumannii VAP. Methods This prospective cohort study included 100 VAP patients between October 2020 and December 2022. Microbiological confirmation of A. baumannii. was done and PMQR genes were exposed by polymerase chain reaction (PCR). Pneumonia severity index (PSI), risk factors for developing drug resistant A. baumannii VAP, and the outcome were studied. Results The proportions of drug sensitive (DS), multidrug (MDR), extensive drug (XDR), and pan drug (PDR) resistant A. baumannii were 14%, 35%, 50%, and 1%, respectively. Majority of PSI classes IV and V showed XDR (66%) and PDR (100%) isolates. Detection of qnrA, qepA and aac(6′)-Ib-cr genes was predominant in PSI classes IV and V. The in-hospital mortality for MDR, XDR, and PDR was 22.7%, 70.5%, and 2.3%, respectively. ICU duration, prior use of carbapenems and use more than 2 antibiotics prior to VAP were risk factors for developing MDR A. baumannii while septic shock, multilobar chest radiography (CXR) infiltration and PSI class were predictors of in-hospital mortality. Conclusions VAP caused by MDR, XDR and PDR isolates of A. baumannii which harbors qnrA, qepA and aac(6’)-Ib-cr PMQR genes showed higher PSI classes and increased in-hospital mortality. The number of PMQR genes in A. baumannii isolates, ICU days, use of more than 2 antibiotics, and use of carbapenem prior to VAP, were independent risk factors for the development of drug resistant A. baumannii VAP.

Identification rate of Legionella species in non-purulent sputum culture is comparable to that in purulent sputum culture in Legionella pneumonia.

Many Legionella pneumonia patients do not produce sputum, and it is unknown whether purulent sputum is required for the identification of Legionella species. This study aimed to evaluate the identification rate of Legionella species based on sputum quality and the factors predictive of Legionella infection. This study included Legionella pneumonia patients at Kurashiki Central Hospital from November 2000 to December 2022. Sputum quality, based on gram staining, was classified as the following: Geckler 1/2, 3/6 and 4/5. Geckler 4/5 was defined as purulent sputum. The sputa of 104 of 124 Legionella pneumonia patients were cultured. Fifty-four patients (51.9%) were identified with Legionella species, most of which were Legionella pneumophila serogroup 1 (81.5%). The identification rates of Legionella species according to sputum quality were 57.1% (16/28) in Geckler 1/2 sputum, 50.0% (34/68) in Geckler 3/6 sputum, and 50.0% (4/8) in Geckler 4/5 sputum, which were not significantly different (P = 0.86). On multivariate analysis, pre-culture treatment with anti-Legionella antimicrobials (odds ratio [OR] 0.26, 95% confidence interval [CI] 0.06-0.91), Pneumonia Severity Index class ≥IV (OR 2.57 [95% CI 1.02-6.71]), and intensive care unit admission (OR 3.08, 95% CI 1.06-10.09) correlated with the ability to identify Legionella species, but sputum quality did not (OR 0.88, 95% CI 0.17-4.41). The identification rate of Legionella species in non-purulent sputum was similar to that in purulent sputum. For the diagnosis of Legionella pneumonia, sputum should be collected before administering anti-Legionella antibiotics and cultured regardless of sputum quality.

2579. Pneumonia Severity Index and CURB-65 scoring for the evaluation of community associated pneumonia in patients with cancer at a major cancer center

Abstract Background Cancer patients with pneumonia (PNA) have 2 to 21 times higher mortality rate compared to the general population. The Pneumonia Severity Index (PSI) and CURB-65 scale have been used to predict mortality for patients with community acquired pneumonia (CAP). While these scales are well studied in the general population, there is a paucity of research on the utility of PSI and CURB-65 for predicting outcomes from CAP in patients with cancer. In this study, we assessed the relationship between PSI and CURB-65 score and 30-day mortality of CAP in cancer patients at Memorial Sloan Kettering Cancer Center (MSKCC). Methods A prospective study at MSKCC was conducted between 01/2023 and 06/2023 on patients who presented with clinical symptoms consistent with PNA and had a urine streptococcus antigen test sent for evaluation. PNA was defined as pulmonary infiltrates on chest X-ray or CT &amp;lt; 48 hours of index event and ≥ 1 clinical symptoms (fever, cough, dyspnea, increased sputum production, hypoxemia). Descriptive statistics were performed to report participant outcomes based on PSI and CURB-65 score and to identify the factors associated with CAP in this population. PSI and CURB-65 scores were derived as described in the literature, based on patient comorbidities (including neoplasia), clinical signs and laboratory values. Higher score is associated with worsening 30-day mortality. Results For 86 participants with who presented with symptoms of PNA and had a urine antigen test sent, 43 (50%) were diagnosed with CAP (Figure 1). The median age was 70 (range: 29-88), 21 (49%) were male, and 16 (37%) had hematologic malignancies (Table 1). Etiologies of CAP were identified in 8 patients (bacteria in 4 patients, virus in 3 patients, fungus in 1 patient). Of the 28 patients with 30-day outcome data available, 5 (18%) died within 30 days of CAP diagnosis. All 5 deceased participants were categorized as PSI Class IV or V (moderate to high risk); however, these participants only scored 0-2 (low to moderate risk) on the CURB-65 scale (Table 2). Conclusion We observed a 30-day overall mortality (n=28) of 18%. For cancer patients who present with CAP, PSI class provides a better means to assess mortality risk than CURB-65 score. Further study is needed to validate our findings. Disclosures Yeon Joo Lee, MD, MPH, AiCuris: institutional research support for clinical trials|Karius: institutional research support for clinical trials|Merck: Grant/Research Support|Scynexis: institutional research support for clinical trials Susan K. Seo, MD, Merck: Grant/Research Support

Etiological profile, prescribing pattern of antibiotics and clinical outcomes of pneumonia patients in a tertiary care hospital in South India during 5-year period

Background: Pneumonia is one of the most important and serious lower respiratory tract infections, which requires implacable attention. This work aimed to document the causative organisms, antibiotics used, and outcome of pneumonia patients hospitalized in a tertiary care hospital. Materials and Methods: A retrospective study was conducted in the medical departments of a tertiary care teaching hospital for 5 years. Demographic details and clinical details including pertinent laboratory values of patients diagnosed with pneumonia were documented and analyzed using a specifically designed data collection form. Results: The study was conducted on 190 patients. The average age of the study population was 56.7 ± 22.6 years and there was a male preponderance of 111(58.4%) patients. Klebsiella pneumonia was found to be the most frequently isolated pathogen in 12.5% of the sputum culture, followed by Acinetobacter baumannii in 10.22% and Pseudomonas aeruginosa in 9.09%. The most commonly prescribed empirical antibiotics were beta-lactam antibiotics mostly in combination with macrolides for synergy irrespective of Pneumonia Severity Index (PSI) classes. Definitive therapy was classified based on World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) classification of antibiotics, watch category antibiotics were prescribed according to culture report and reserve antibiotics were prescribed only in those cases where watch category antibiotics were resistant. On analyzing PSI of community-acquired pneumonia (176 patients), most of the patients in the study belong to class 4: 61 patients (34.7%) and class 5: 44 patients (25%). For the high-risk patients (PSI class 4 and 5), mortality was approximately 3.8% (4 of 105) and for low-risk patients, there was zero mortality reported within 30 days. Conclusion: Gram-negative bacteria were the major pathogens causing Pneumonia in the study site contradictory to the data from developed countries. Identifications of pathogens and appropriate antibiotic therapy based on PSI score can bring down the duration of hospital stay and mortality of patients with pneumonia.

PNEUMONIA SEVERITY INDEX COMPARED TO CURB-65 IN PREDICTING THE OUTCOME OF COMMUNITY ACQUIRED PNEUMONIA -A PROSPECTIVE STUDY

Introduction: Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. 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. Objectives: Tocompare the efficacy of PSI and CURB 65 scoring systems in prognosticating the outcome in cases of CAP. Methods: This is a prospective study conducted over a period of one year on 150 patients who presented with community acquired pneumonia on the grounds of their clinical and paraclinical findings in our institution under the Department of respiratory Medicine, and fulfilling the inclusion and exclusion criteria. The patients were classified as per CURB 65 and PSI system and their outcome compared. Results: We studied 150 patients with community-acquired pneumonia (114 men, 36 women). In our study 100 % of patients in CURB 65 class 4 and 5 required ICU admission and death was 84.6% and 100% respectively. Majority of patients of PSI class 4 and 5 needed ICU admission 67% and 96% respectively and death was 16% and 58% respectively. The sensitivity and specificity of CURB-65 class ≥3 in predicting mortality were 79% and 89%, respectively (AUC 0.92). As for pneumonia severity index class ≥4, the rates were 79% and 84%, respectively (AUC 0.86). The mortality rate and need for ICU admission increased progressively with increasing scores. Conclusion: CURB-65 seems to be the preferred method to predict mortality and need for ICU admission in patients with community-acquired pneumonia.

Pneumococcal serotypes in adults hospitalized with community-acquired pneumonia in Greece using urinary antigen detection tests: the EGNATIA study, November 2017 – April 2019

ABSTRACT Greece introduced a 13-valent pneumococcal conjugate vaccine (PCV13) into the infant national immunization program in 2010 (3 + 1 schedule until June 2019). Since 2015, PCV13 has been recommended for adults aged 19–64 years with comorbidities and adults ≥65 years sequentially with 23-valent pneumococcal polysaccharide vaccine (PPSV23). We examined pneumococcal serotype distribution among Greek adults aged ≥19 years hospitalized with community-acquired pneumonia (CAP) during November 2017-April 2019. This was an interim analysis of EGNATIA, a prospective study of adult hospitalized CAP in the cities of Ioannina and Kavala. Pneumococcus was identified using cultures, BinaxNow®, serotype-specific urinary antigen detection assays (UAD-1/2). Our analysis included overall 482 hospitalized CAP patients (mean age: 70.5 years; 56.4% male). 53.53% of patients belonged to the highest pneumonia severity index (PSI) classes (IV-V). Pneumococcus was detected in 65 (13.5%) patients, with more than half (57%) of cases detected only by UAD. Approximately two-thirds of pneumococcal CAP occurred in those aged ≥65 years (n = 40, 8.3% of CAP). More than half of pneumococcal CAP (n = 35, 53.8%) was caused by PCV13 serotypes. Most frequently detected PCV13 serotypes were 3, 19A, 23F, collectively accounting for 83% of PCV13 vaccine-type (VT) CAP and 6% of all-cause CAP. Overall, 82.9% of PCV13 VT CAP occurred among persons with an indication (age/risk-based) for PCV13 vaccination. Even with a mature PCV13 childhood immunization program, a persistent burden of PCV13 VT CAP exists in Greek adults. Strategies to increase PCV13 (and higher-valency PCVs, when licensed) coverage in adults should be implemented to reduce the disease burden.

Validity of Pneumonia Severity Index and CURB-65 Severity Scoring Systems in Community Acquired Pneumonia in an Indian Setting

Little information is available from India regarding prognostic factors in patients with community acquired pneumonia (CAP). Hospital-based prospective study to test the validity of pneumonia severity index (PSI) and the confusion, urea, respiratory rate, blood pressure, age over 65 years (CURB-65) risk scoring systems in patients with CAP (n=150). Although both CURB-65 class > or = III and PSI class > or = IV were 100% sensitive in predicting death, CURB-65 class > or = III had a higher specificity (74.6%) than PSI class > or = IV (52.2%) when used to predict death. In both PSI and CURB-65 risk scoring systems, mortality rate, need for intensive care unit (ICU) admission, prolonged need for intravenous (I.V.) antibiotics, prolonged duration of hospital stay and need for admission to ICU increased progressively with increasing scores. The PSI class > or = IV was more sensitive in predicting ICU admission than CURB-65. The duration of hospital stay was found to have a weak but significant correlation with PSI and CURB-65 criteria. Defervescence time also had a very weak but significant correlation with PSI and CURB-65 criteria. Duration of I.V. antibiotics had a moderately strong correlation with CURB-65 criteria but a weak correlation with PSI criteria. Both PSI and CURB-65 were found to have equal sensitivity to predict death from CAP. Specificity of CURB-65 was higher than that of PSI. However, PSI was more sensitive in predicting ICU admission than CURB-65.

Age, Pulse, Urea, and Albumin Score: A Tool for Predicting the Short-Term and Long-Term Outcomes of Community-Acquired Pneumonia Patients With Diabetes

ObjectiveThe predictive performances of CURB-65 and pneumonia severity index (PSI) were poor in patients with diabetes. This study aimed to develop a tool for predicting the short-term and long-term outcomes of CAP in patients with diabetes.MethodsA retrospective study was conducted on 531 CAP patients with type 2 diabetes. The short-term outcome was in-hospital mortality. The long-term outcome was 24-month all-cause death. The APUA score was calculated according to the levels of Age (0-2 points), Pulse (0-2 points), Urea (0-2 points), and Albumin (0-4 points). The area under curves (AUCs) were used to evaluate the abilities of the APUA score for predicting short-term outcomes. Cox regression models were used for modeling relationships between the APUA score and 24-month mortality.ResultsThe AUC of the APUA score for predicting in-hospital mortality was 0.807 in patients with type 2 diabetes (P<0.001). The AUC of the APUA score was higher than the AUCs of CURB-65 and PSI class (P<0.05). The long-term mortality increased with the risk stratification of the APUA score (low-risk group (0-1 points) 11.5%, intermediate risk group (2-4 points) 16.9%, high risk group (≥5 points) 28.8%, P<0.05). Compared with patients in the low-risk group, patients in the high-risk group had significantly increased risk of long-term death, HR (95%CI) was 2.093 (1.041~4.208, P=0.038).ConclusionThe APUA score is a simple and accurate tool for predicting short-term and long-term outcomes of CAP patients with diabetes.

Neutrophil-lymphocyte ratio as a predictor of adverse outcome in patients with community-acquired pneumonia: A systematic review.

BackgroundCommunity‐acquired pneumonia (CAP) is the acute infection of lung tissue in an immunocompetent who acquired it from the community. Its incidence and mortality are significant and require a marker to predict the severity and mortality in these patients. Neutrophil–lymphocyte ratio (NLR) is a simple, cheap, and easy‐to‐use marker and this study describes its role in predicting the adverse outcome in patients with CAP.MethodsPubMed, EMBASE, and Google Scholar were used to search for related studies on February 8, 2021. A total of 186 articles were retrieved upon detailed searching in the databases and search engines. After a series of removing duplicate articles, title and abstract screening, and full‐text review; nine articles were found eligible and included in the study. The data from each article were collected in MS Excel and the findings were summarized in this manuscript.ResultsThe total number of patients analyzed in this systematic review is 3340. The mean age of the patient in the included studies ranged from 61 to 90.4 years. All studies had adverse outcomes as the endpoint of the study, which included in‐hospital mortality or intensive care unit (ICU) admission or deterioration from medium and low risk to high risk or 30 days' mortality. The prevalence of endpoint ranged from 5.8% to 44.8%. NLR with a cutoff value of more than 10 was shown to predict mortality compared to C‐reactive protein levels, white blood cell count, neutrophil count, lymphocyte level, Pneumonia Severity Index (PSI) level, PSI class, procalcitonin, and CURB‐65 (Confusion, Respiratory rate, Blood pressure, 65 years of age and older) in most of the studies.ConclusionNLR is a simple, easily measured yet promising marker for predicting outcomes in patients with CAP.

The Impact of Principal Diagnosis on Readmission Risk among Patients Hospitalized for Community-Acquired Pneumonia.

Coding variation distorts performance/outcome statistics not eliminated by risk adjustment. Among 1596 community-acquired pneumonia patients hospitalized from 1998 to 2012 identified using an evidence-based algorithm, the authors measured the association of principal diagnosis (PD) with 30-day readmission, stratified by Pneumonia Severity Index risk class. The 152 readmitted patients were more ill (Pneumonia Severity Index class V 38.8% versus 25.8%) and less likely to have a pneumonia PD (52.6% versus 69.9%). Among patients with PDs of pneumonia, respiratory failure, sepsis, and aspiration, mortality/readmission rates were 3.9/8.5%, 28.8/14.0%, 24.7/19.6%, and 9.0/15.0%, respectively. The nonpneumonia PDs were associated with a greater risk of adjusted 30-day readmission: respiratory failure odds ratio (OR) 1.89 (95% confidence interval [CI], 1.13-3.15), sepsis OR 2.54 (95% CI, 1.52-4.26), and possibly aspiration OR 1.73 (95% CI, 0.88-3.41). With increasing use of alternative PDs among pneumonia patients, quality reporting must account for variations in condition coding practices. Rigorous risk adjustment does not eliminate the need for accurate, consistent case definition in producing valid quality measures.

Role of Chest Computed Tomography in Patients Hospitalized with Community-Acquired Complicated Parapneumonic Effusion or Empyema

BackgroundData regarding predictors of the outcome in patients with community-acquired complicated parapneumonic effusion (CPPE) or empyema are insufficient. The aim of the present study was to investigate the prognostic factors in these patients. MethodsPatients with community-acquired pneumonia (CAP) were classified into a CPPE or empyema group and a control group. The patients with CPPE or empyema were further divided into longer and shorter length of stay (LOS) groups, and clinical variables and computed tomographic (CT) findings were compared between the 2 groups. ResultsOf outcome variables, LOS was significantly longer in the CPPE or empyema group than in the control group (13 days [interquartile range, 10‒17 days] versus 8 days [6‒12 days], p < 0.001), whereas 30-day mortality and in-hospital mortality were not significantly different between the 2 groups. Patients with CPPE or empyema were divided into shorter LOS (<14 days) and longer LOS (≥14 days) groups. Pneumonia severity index (PSI) class IV‒V (odds ratio [OR], 2.79; 95% confidence interval [CI]: 1.35, 5.76; p = 0.006), increased attenuation of extrapleural fat (OR, 2.26; 95% CI: 1.06, 4.80; p = 0.034), and pleural microbubbles (OR 3.93; 95% CI: 1.03, 14.98; p = 0.045) were independent predictors for prolonged LOS in CAP patients with CPPE or empyema. ConclusionsIncreased attenuation of extrapleural fat and pleural microbubbles assessed with CT and PSI class IV‒V independently predicted prolonged LOS in CAP patients with CPPE or empyema. These findings may be helpful to identify patients who need more intensive evaluation and intervention.

Accuracy Between CURB-65 Score and PSI in Determining The Prognosis of Community-Acquired Pneumonia Patients at H. Adam Malik General Hospital, Medan

Background: Community-Acquired Pneumonia (CAP) is an important problem associated with morbidity and mortality. An accurate initial assessment is required before starting management of a CAP patient to determine the prognosis of the patient as early as possible. The CURB-65 score and PSI (Pneumonia Severity Index) are initial assessment scores that can be used. This study aimed to compare the accuracy between the CURB-65 score and the PSI in determining the prognosis in CAP patients at H. Adam Malik General Hospital Medan. Method: A descriptive study was conducted on 76 patients diagnosed with CAP. Each patient was assessed for their CURB-65 score, PSI class and mortality within 30 days of admission. Data were collected through patient medical records diagnosed CAP in 2018 and performed statistical analysis using 2x2 tables. Results: The CURB-65 ≥3 score showed accuracy (71.0%), sensitivity (53.8%), and specificity (89,2%). The CURB-65 ≥ 2 score showed accuracy (75.0%), sensitivity (82.1%), and specificity (67.6%). Meanwhile, the Class IV-V PSI showed accuracy (77.6%), sensitivity (87.2%) and specificity (67.6%). Conclusion: The accuracy of the PSI is higher when compared to the CURB-65 score in determining the prognosis of CAP patients at H. Adam Malik General Hospital Medan. Although PSI is more accurate, CURB-65 is simpler, easier and less expensive to use

Clinical Features of the 60 Years and Older Patients Infected with 2019 Novel Coronavirus: Can We Predict Mortality Earlier?

Introduction: The novel coronavirus (COVID-19), which has affected over 100 countries in a short while, progresses more mortally in elderly patients with comorbidities. In this study, we examined the epidemiological, clinical, and laboratory characteristics of the patients aged 60 and over who had been infected with COVID-19. Methods: The data of the patients admitted to the hospital within 1 month from May 8, 2020 onwards and hospitalized for COVID-19 pneumonia were obtained from the hospital medical records, and the epidemiological, clinical, and laboratory parameters of the patients during the admission to the emergency department were examined. Patients were divided into 2 groups regarding the criteria of having in-hospital mortality (mortality group) and being discharged with full recovery (survivor group). The factors, which could have an impact on the mortality, were investigated using a univariate and multivariate logistic regression analysis. Results: This retrospective study included 113 patients aged 60 years and older, with a confirmed diagnosis of COVID-19 pneumonia. The mean age of the patients was 70.7 ± 7.9, and 64.6% (n = 73) of them were male. The mortality rate was 19.4% (n = 22). Among the comorbid illnesses, only renal failure was significant in the mortality group (p = 0.04). A CURB-65score ≥3 or pneumonia severity index (PSI) class ≥4 manifested a remarkable discrimination ability to predict 30-day mortality (p < 0.001). When the laboratory parameters were considered, the value of neutrophil to lymphocyte ratio (NLR) was significant in predicting mortality in univariate and multivariate analysis (odds ratio [OR] = 1.11; 95% confidence interval [95% CI], 1.03–1.21; p = 0.006, and OR = 1.51; 95% CI, 1.11–2.39; p = 0.044, respectively). Conclusion: In our study, NLR was determined to be an independent marker to predict in-hospital mortality among patients with COVID-19. PSI and CURB-65 revealed a considerably precise prognostic accuracy for the patients with COVID-19 in our study as well. Moreover, thanks to that NLR results in a very short time, it can enable the clinician to predict mortality before the scoring systems are calculated and hasten the management of the patients in the chaotic environment of the emergency room.

The Performance of CURB-65 and PSI for Predicting In-Hospital Mortality of Community-Acquired Pneumonia in Patients with Type 2 Diabetes Compared with the Non-Diabetic Population.

ObjectiveTo compare the performance of CURB-65 and Pneumonia Severity Index (PSI) for predicting in-hospital mortality of community-acquired pneumonia (CAP) between patients with and without type 2 diabetes (T2DM).MethodsA retrospective study was conducted on 2365 CAP patients in The First Hospital of Qinhuangdao, China. The primary outcome was in-hospital mortality. The area under curves (AUCs) was used to evaluate the abilities of CRB-65, CURB-65, and PSI class for predicting in-hospital mortality in patients with CAP.ResultsAmong CAP patients, 127 patients (5.4%) died, 80 patients were without diabetes, and 47 patients had T2DM. In-hospital mortality increased with the risk stratification defined as CURB-65 and PSI class in both non-diabetes and T2DM patients (P<0.05). The AUCs for predicting in-hospital mortality were 0.728～0.798 in patients without T2DM (CRB-65: 0.728, CURB-65: 0.757 and PSI class: 0.798) and 0.641～0.716 in patients with T2DM (CRB-65: 0.641, CURB-65: 0.677 and PSI class: 0.716)(P<0.001). The AUC of the PSI class was lower in patients with T2DM than in patients without T2DM (P<0.05).ConclusionCURB-65 and PSI class are correlated with in-hospital mortality of CAP in patients with and without T2DM. Compared with non-diabetes patients, the predictive performance of CURB-65 and PSI class decreased in patients with T2DM. A prediction model for evaluating the CAP severity in the T2DM population should be developed by future studies.

Adjunctive treatment with oral dexamethasone in non-ICU patients hospitalised with community-acquired pneumonia: a randomised clinical trial.

Adjunctive intravenous corticosteroid treatment has been shown to reduce length of stay (LOS) in adults hospitalised with community-acquired pneumonia (CAP). We aimed to assess the effect of oral dexamethasone on LOS and whether this effect is disease severity dependent. In this multicentre, stratified randomised, double-blind, placebo-controlled trial, immunocompetent adults with CAP were randomly assigned (1:1 ratio) to receive oral dexamethasone (6 mg once daily) or placebo for 4 days in four teaching hospitals in the Netherlands. Randomisation (blocks of four) was stratified by CAP severity (pneumonia severity index class I-III and IV-V). The primary outcome was LOS. Between December 2012 and November 2018, 401 patients were randomised to receive dexamethasone (n=203) or placebo (n=198). Median LOS was shorter in the dexamethasone group (4.5 days, 95% CI 4.0-5.0 days) than in the placebo group (5.0 days, 95% CI 4.6-5.4 days; p=0.033). Within both CAP severity subgroups, differences in LOS between treatment groups were not statistically significant. The secondary ICU admission rate was lower in the dexamethasone arm (5 (3%) versus 14 (7%); p=0.030); 30-day mortality did not differ between groups. In the dexamethasone group the rate of hospital readmission tended to be higher (20 (10%) versus 9 (5%); p=0.051) and hyperglycaemia (14 (7%) versus 1 (1%); p=0.001) was more prevalent. Oral dexamethasone reduced LOS and ICU admission rate in adults hospitalised with CAP. It remains unclear for which patients the risk-benefit ratio is optimal.

Comparative Study Of Pneumonia Severity Index (psi) &amp; Curb-65 Score In Assessing Severity Of Community Acquired Pneumonia

INTRODUCTION:Community acquired pneumonia (CAP) is a common disorder with an incidence of about 20% to 30% in developing countries compared to an incidence of 3% to 4 % in developed countries. It is very difficult to find causative organism of community acquired pneumonia in every patient despite aggressive laboratory investigation and blood or sputum culture and it takes few days for it. It is believed that definite prognostic score will be very useful for stratifying patients at high risk and require critical care unit treatment. Pneumonia severity index (PSI) score and CURB-65 Score are two prognostic scoring systems that can stratify patients requiring intensive care unit treatment. Each prognostic score has individual pros and cons and both can be used supplementary to each other. So here we want to study the reliability and validity of PSI and CURB 65 score in Indian population with pneumonia.MATERIAL & METHOD:A hospital based comparative observational study included total 50 patients with pneumonia based on inclusion and exclusion criteria. Complete clinical history and physical examination done. At the time of initial evaluation, chest radiograph was done and repeated after 48 hours. ECG, ABGA, serum electrolyte measurement, sputum for gram staining and culture, blood cultures (in selected patients), complete blood counts, blood urea nitrogen and serum creatinine and fasting blood glucose were measured in every patient. Analysis was done with help of SPSS software and using Microsoft Excel 2012.RESULTS:In our study, total 50 patients were enrolled among them 34 patients were male while 16 patients were female. Most common organism cultured was klebsiella species that was in 18 (36%) patients while 18 patients had no organisms seen in sputum culture. In our study, 8(16%) patients were died out of 50 patients admitted. PSI class 4 showed highest sensitivity in predicting mortality 50%, while specificity was highest for class 2 with 90.4%, followed by class 5 with 73.8%. The PPV was highest for class 4 22%, and NPV was highest for class 4 87.5%. Among CURB 65 score, class 4 showed highest sensitivity in predicting mortality 50%, while specificity was highest for class 4 with 92.8%, followed by class 3 with 85.7%. The PPV was highest for class 4= 57.1%, and NPV was highest for class 4= 90.6%.CONCLUSION:It is observed that PSI has better specificity and negative predictive value (NPV) but less sensitivity and positive predictive value (PPV). This is because impact of age is observed in PSI which leads to lower estimation of severity of CAP mostly in young patients who have no other comorbidities. The two scoring CURB-65 and PSI approaches have to be viewed at the most as being complementary as each has different strengths and weaknesses. With help of CURB-65 and PSI Score, we can better understand the prognosis and classify patients on basis of severity and adequate utilization of resources and proper treatment to improve outcome in developing countries like India.

1464. Adjuvant Systemic Steroid Therapy and Length of Hospital Stay in Pneumonia Patients: A Retrospective Cohort Study in a Community Hospital

BackgroundPneumonia is a leading cause of morbidity and mortality worldwide resulting in a substantial healthcare expenditure. Antimicrobial agents are the main treatment. Recent studies showed the benefits of steroid therapy as an adjuvant therapy for patients with pneumonia; however, the overall evidence is still controversial.MethodsElectronic medical records of hospitalized patients (age >18) at a community hospital in a rural Maine with the discharge diagnosis of pneumonia in 2015 and 2016 were reviewed. Demographics, comorbidities, physical examination, initial laboratory, and Pneumonia Severity Index (PSI) were collected for each patient. The exposure was a systemic steroid administered by either oral or intravenous. The outcomes included length of hospital stay (LOS), inpatient mortality, and transfer to tertiary care center. Competing-risks regression was utilized to examine the association between steroid and LOS. Multivariable logistic regression analysis adjusted for propensity score was used for other outcomes.ResultsA total of 414 patients were included. 277(63%) patients received systemic steroids. Overall, steroid use was significantly associated with shorter LOS (HR 1.26, 95%CI 1.03-1.54, p=0.02) and decrease inpatient mortality (OR 0.11, 95%CI 0.03-0.45, p< 0.01). In subgroup analysis, steroid associated with shorter LOS only in patients with PSI class IV (HR 1.38, 95%CI 1.02-1.89, p=0.04) and PSI class V (HR 2.04, 95%CI 1.11-3.74, p=0.02). There was an association of steroid and shorter LOS in subgroup of COPD patients (HR 1.42, 95%CI 1.02-1.97, p=0.03).Table 1: The baseline characteristics of hospitalized patients with a diagnosis of pneumonia who received steroid vs non-steroid Figure 1: Subgroup analysis the effect of steroid and lenght of hospital stay (LOS) ConclusionOur study concluded that adjuvant steroid therapy associated with a decrease in length of hospital stay and improved inpatient mortality in hospitalized pneumonia patients. Steroid was most beneficial to those with severe pneumonia (PSI class IV-V) and COPD patients.Disclosures All Authors: No reported disclosures

Age, Pulse, Urea and Albumin (APUA) Model: A Tool for Predicting in-Hospital Mortality of Community-Acquired Pneumonia Adapted for Patients with Type 2 Diabetes.

ObjectiveThe aim of this study was to develop a tool for predicting in-hospital mortality of community-acquired pneumonia (CAP) in patients with type 2 diabetes (T2DM).MethodsA retrospective study was conducted on 531 CAP patients with T2DM at The First Hospital of Qinhuangdao. The primary outcome was in-hospital mortality. Variables to develop the nomogram were selected using multiple logistic regression analysis. Discrimination was evaluated using receiver operating characteristic (ROC) curve. Calibration was evaluated using the Hosmer–Lemeshow test and calibration plot.ResultsMultiple logistic regression analysis showed that age, pulse, urea and albumin (APUA) were independent risk predictors. Based on these results, we developed a nomogram (APUA model) for predicting in-hospital mortality of CAP in T2DM patients. In the training set, the area under the curve (AUC) of the APUA model was 0.814 (95% CI: 0.770–0.853), which was higher than the AUCs of albumin alone, CURB-65 and Pneumonia Severity Index (PSI) class (p<0.05). The Hosmer–Lemeshow test (χ2=5.298, p=0.808) and calibration plot (p=0.802) showed excellent agreement between the predicted possibility and the actual observation in the APUA model. The results of the validation set were similar to those of the training set.ConclusionThe APUA model is a simple and accurate tool for predicting in-hospital mortality of CAP, adapted for patients with T2DM. The predictive performance of the APUA model was better than CURB-65 and PSI class.

Long‐term prognosis of adolescent and middle‐aged Chinese patients with low‐medium risk community‐acquired pneumonia: A cohort study

The long-term mortality rate in adolescent and middle-aged patients with low-medium risk community-acquired pneumonia (CAP) remains unelucidated. Understanding the long-term mortality rate in adolescent and middle-aged patients with low-medium risk CAP in Beijing, China, to provide a basis for the long-term management of CAP patient. A follow-up survey was conducted telephonically from December 2017 to January 2018 to assess the survival status among 808 patients from a CAP-China cohort enrolled from 10 general hospitals in Beijing between November 2010 and April 2012. The all-cause mortality rate was determined and Cox's proportional hazard model was performed to identify potential factors predicting mortality. Among the 808 patients, the mean age (SD) was 45.4 (19.6) year-old and the median (IQR) pneumonia severity index (PSI) score was 42.0 (35.8). Survival status for a total of 426 (52.7%) were determined during the follow-up and the non-follow-up patients were with slightly larger PSI score. The mean age (SD) for the follow-up patients were 44.6 (18.7) year-old and the median (IQR) PSI score was 42.0 (33.3). Over a median of 7 years, 32 participants died and the cumulative 1-, 3-, 5- and 7-year all-cause mortality rates were 1.6%, 4.2%, 5.9% and 7.5%, respectively. The average annual standardized mortality rate among the study participants was 9.79‰, which was significantly higher than the mortality rate of 5.20‰ among Beijing residents in 2016. Multivariable Cox proportional hazards analyses revealed that age, comorbidity and PSI were independent prognostic factors associated with long-term mortality, with hazard ratios of 4.953 (95% confidence interval [CI]3.270-7.502), 2.393 (95% CI 1.148-4.985) and 3.553 (95% CI 2.607-4.843), respectively. [Correction added on 20 August 2020, after first online publication: "9.79%" has been corrected to "9.79‰".] CONCLUSION: The long-term mortality rate is higher among patients with CAP compared with the age-adjusted general population in the same city. Age, comorbidity and initial PSI class are independently prognostic factors for the long-term mortality rate.