Pneumonia Severity Index Score Research Articles

Eosinophilia is a favorable marker for pneumonia in chronic obstructive pulmonary disease.

Patients with chronic obstructive pulmonary disease (COPD) expressing eosinophilia experience slightly fewer episodes of community-acquired pneumonia (CAP) than those without eosinophilia. However, the severity and burden of hospitalized pneumonia patients with COPD concerning eosinophilia have not been assessed. We evaluated the differences in clinical characteristics between patients with CAP and COPD with or without eosinophilia by a post-hoc analysis of a prospective, multi-center, cohort study data. Of 349 CAP patients with COPD, 45 (12.9%) had eosinophilia (blood eosinophil ≥ 300 cells/µL). Patients with eosinophilia had a lower sputum culture percentile (8.1% vs. 23.4%, P < 0.05), a lower percentile of neutrophils (70.3% vs 80.2%, P<0.05), reduced C-reactive protein levels (30.6 mg/L vs 86.6 mg/L, P<0.05), and a lower pneumonia severity index score (82.5 vs. 90.0, P < 0.05) than those without eosinophilia. The duration of antibiotic treatment (8.0 days vs. 10.0 days, P < 0.05) and hospitalization (7.0 days vs. 9.0 days, P < 0.05) were shorter in eosinophilic patients. The cost of medical care per day (256.4 US$ vs. 291.0 US$, P < 0.05), cost for the medication (276.4 US$ vs. 349.9 US$, P < 0.05), and cost for examination (685.5 US$ vs 958.1 US$, P<0.05) were lower in patients with eosinophilia than those without eosinophilia. Eosinophilia serves as a favorable marker for severity of pneumonia, health-care consumption, and cost of medical care in patients with CAP and COPD.

A Comparative Study of Confusion, Urea Nitrogen, Respiratory Rate, Blood Pressure, Age ≥ 65 and Pneumonia Severity Index Scoring Systems in Patients with Pneumonia in a Tertiary Care Setting

A Comparative Study of Confusion, Urea Nitrogen, Respiratory Rate, Blood Pressure, Age ≥ 65 and Pneumonia Severity Index Scoring Systems in Patients with Pneumonia in a Tertiary Care Setting

Superinfections in COVID-19

Introduction Bacterial superinfection rates in SARS-CoV-2 (COVID-19) range from 8% to 49.6%, but the diagnosis remains a challenge. We conducted a study to determine the utility of the Pneumonia Severity Index (PSI) to predict the risk of superinfections and outcomes in COVID-19 patients. Methods A cross-sectional retrospective study was conducted on COVID-19 positive patients admitted during 2020–2022. The PSI scores were calculated at admission and at every 72-hour intervals. Data regarding clinical course, antibiotic use and overall outcome were collected. Results A total of 149 patients were included, with a mean age of 67 years. The PSI score at admission and the mean PSI score were higher for those who required antibiotics, intensive care unit (ICU) admission, or succumbed. Patients with a PSI score &gt;107 at admission had a high risk of ICU admission, &gt;113 had a high risk of antibiotic requirements, and &gt;110 had a higher risk of death. An increase in PSI score ≥25 between the day of admission and day 3 of hospitalization; or between day 3 and day 6 of hospitalization, predicted a higher chance of mortality; but had no association with the development of superinfections. Discussion The PSI score at admission can be used to predict the severity of disease requiring ICU admission, antibiotic requirement, and overall mortality, with serial monitoring of the score predicting possible clinical deterioration and increased mortality. However, it was not helpful in predicting the chances of developing superinfections and the need for antibiotic therapy. Conclusions The PSI score can be used to prognosticate the outcome in patients admitted with COVID-19, but further studies are needed to determine its utility in predicting the risk of superinfections.

The Potential Role of Angiotensin-Converting Enzyme Inhibitors and Beta-Blockers in Reducing Pneumonia Severity in Older Adults.

Background Understanding the impact of pharmacological therapy on pneumonia severity is crucial for effective clinical management. The impact of angiotensin-converting enzyme inhibitors (ACEis) and beta-blockers (BBs) on pneumonia severity remains unknown, warranting further investigation. Methodology This retrospective study examined the hospital records of inpatients (≥75 years) admitted with community-acquired pneumonia in 2021. Pneumonia severity associated with the use of pre-established ACEi and BB therapy was documented using CURB-65 (confusion, uraemia, respiratory rate, blood pressure, age ≥65 years) and pneumonia severity index (PSI) scores. Descriptive statistics and multivariable linear regression were used to analyse differences across BB therapy, ACEi therapy, their combination, or neither (control group). Results A total of 803 patient records were examined, of whom 382 (47.6%) were male and 421 (52.4%) were female. Sample sizes for each group were as follows: control (n = 492), BB only (n = 185), ACEi only (n = 68), and BB + ACEi (n = 58). Distribution of aspiration pneumonia (AP) versus non-AP for each group, respectively, was control (21.1% vs. 78.9%), BB only (9.7% vs. 90.3%), ACEi only (7.3% vs. 92.7%), and ACEi + BB (12.1% vs. 87.9%). No significant differences in PSI and CURB-65 scores were found between intervention groups even after controlling for patient characteristics and irrespective of AP or non-AP aetiology. Patients with AP had significantly higher CURB-65 (p = 0.026) and PSI scores (p = 0.044) compared to those with non-AP. Conclusions Pre-prescribed ACEi or BB therapy did not appear to be associated with differences in pneumonia severity. There were no differences in pneumonia severity scores with ACEi and BB monotherapy or combined ACEi and BB therapy.

Pneumonia Severity Index And CURB-65 Scores Are Poor Predictors For Long-Term Mortality In Hospitalized Patients With Community-Acquired Pneumonia

Introduction The Pneumonia Severity Index (PSI) and CURB-65 scores are well-defined as tools to predict short-term mortality in patients with community-acquired pneumonia (CAP). The role of these scores in predicting long-term mortality is not well-defined. The objective of this study was to evaluate the role of PSI and CURB-65 as predictors of long term mortality in patients discharged alive after an episode of CAP. Methods This was a secondary analysis of the University of Louisville Pneumonia Study (ULPS) database. The PSI and CURB-65 were calculated at the time of hospital admission. For patients discharged alive, mortality was evaluated one-year after hospital discharged. Receiver operating characteristic (ROC) analysis was performed to determine the diagnostic performance of the PSI and CURB-65 in predicting long-term mortality. Results From a total study population of 6,870 patients, 1,744 (25%) patients died within one-year post discharge, and 5,126 (75%) patients were alive one-year post-discharge. Areas under the curve (AUC) for PSI was 0.72 and for CURB-65 was 0.66. Conclusion Even though the PSI is more accurate than CURB-65, both scores are weak predictors of long-term mortality in hospitalized patients with CAP. Future research studies are necessary to improve the prediction of long-term mortality in hospitalized patients with CAP.

P/F Ratio is a Better Predictor for Non-Invasive Ventilation Failure and Length of Stay in Patients with Community-Acquired Pneumonia

Introduction: Community-acquired pneumonia (CAP) can deteriorate into respiratory failure requiring immediate ventilatory intervention. This study compared the performance of the PaO2/FiO2 (P/F) ratio, the ratio of oxygen saturation (ROX) index, and the heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) score in predicting non-invasive ventilation (NIV) failure and length of hospital stay in patients diagnosed with CAP. Methods: This study was conducted at Universitas Sebelas Maret Hospital, Surakarta, from March to September 2023. All patients diagnosed with CAP who were eligible for NIV were recruited. Each patient’s age, sex, comorbidities, vital signs, pneumonia severity index (PSI), blood urea, bilirubin, hematocrit, blood sodium, P/F ratio, ROX index, and HACOR score were measured within the first 24 hours of NIV. Subsequently, the correlations between these variables and NIV failure (intubation or mortality) and length of hospital stay were assessed. Results: The P/F ratio, ROX index, and HACOR score were not correlated with intubation or length of stay. The P/F ratio was correlated with mortality (p = 0.040), whereas the other scores were not. Higher body temperature was correlated with intubation (p = 0.032). PSI was correlated with both mortality (p = 0.033) and length of hospital stay (p = 0.009). Conclusion: The P/F ratio is superior to the ROX index and HACOR score in predicting mortality in patients with pneumonia-related respiratory failure treated with NIV. Since it is simple and accessible, measuring the P/F ratio within the first 24 hours of NIV is recommended to identify a patient’s risk of NIV failure and apply appropriate monitoring.

Clinical features relating to pneumococcal colony phase variation in hospitalized adults with pneumonia.

Background. Streptococcus pneumoniae is a major causative bacteria of pneumonia and invasive pneumococcal disease (IPD); however, the mechanisms underlying its severity and invasion remain to be defined. Pneumococcal colonies exhibit opaque and transparent opacity phase variations, which have been associated with invasive infections and nasal colonization, respectively, in animal studies. This study evaluated the relationship between the opacity of pneumococcal colonies and the clinical presentation of pneumococcal pneumonia.Methods. This retrospective study included adult patients hospitalized with pneumococcal pneumonia between 2012 and 2019 at four tertiary medical institutions. Pneumococcal strains from lower respiratory tract specimens were determined for their serotypes and microscopic colony opacity, and the association between the opacity phase and the severity of pneumonia was evaluated. Serotypes 3 and 37 with mucoid colony phenotypes were excluded from the study because their colony morphologies were clearly different.Results. A total of 92 patients were included. Most patients were older adults (median age: 72 years) and males (67 %), and 59 % had community-acquired pneumonia. Of the 92 patients, 41 (45 %), 12 (13 %), and 39 (42 %) patients had opaque, transparent, and mixed variants in their pneumococcal colony, respectively. The opaque and non-opaque pneumococcal variants had no statistically significant difference in patient backgrounds. Although the pneumonia severity index score did not differ between the opaque and non-opaque groups, the rate of bacteremia was significantly higher in the opaque group than in the non-opaque group. Serotype distribution was similar between the groups.Conclusions. Opaque pneumococcal variants may cause pneumonia and invasive diseases in humans. This study could help elucidate IPD, and opacity assessment may serve as a predictor for IPD.

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

Comparison of pneumonia severity scores for COVID-19 patients with the Omicron variant

IntroductionWe demonstrated that there was a significant relationship between the severity measured using the A-DROP scoring system and the mortality rate in patients with COVID-19 community-acquired pneumonia (CAP) in the ancestral strain, Alpha variant, and Delta variant. We investigated the usefulness of the A-DROP scoring system in SARS-CoV-2 Omicron variant CAP and compared it with severity scores, the Pneumonia Severity Index (PSI) and CURB-65 score. MethodsWe analyzed a total of 547 patients with COVID-19 CAP Omicron variant; 198 cases were the BA.1 subvariant, 127 cases were the BA.2 subvariant, and 222 cases were the BA.5 subvariant, respectively. ResultsThe mortality rates in patients with COVID-19 CAP among the three Omicron subvariants were identical in each pneumonia severity group. The mortality rate in patients with the Omicron variant was 0 % in patients classified with mild disease, 0.6 % in those with moderate disease, 10.4 % in those with severe disease, and 34.8 % in those with extremely severe disease. The mortality rate in patients with COVID-19 CAP increased depending on the severity classified according to the A-DROP system in each of the Omicron subvariants (Cochran–Armitage trend test; p < 0.001). The values of the area under the curve in Receiver Operating Characteristic analysis for prediction of 30-day mortality was 0.881, 0.879, and 0.863 for A-DROP, PSI, and CURB-65, respectively. There were no significant differences in the predictive ability of each pneumonia severity score. ConclusionsOur results demonstrated that the A-DROP scoring system is useful for predicting mortality in patients with COVID-19 CAP.

The relationship between lactate dehydrogenase and Apolipoprotein A1 levels in patients with severe pneumonia.

To investigate the relationship between lactate dehydrogenase and apolipoprotein A1 levels and the condition and prognosis of patients with severe pneumonia. Data was collected from 204 patients with severe pneumonia who were hospitalized from January 1, 2019 to December 1, 2021 in Zhaotong First People's Hospital (respiratory intensive care unit (RICU)), and divided into survival group (160 patients) and death group (44 patients) according to their hospitalization outcome. The relationship between lactate dehydrogenase and apolipoprotein A1 levels and general information, disease, and treatment needs of patients with severe pneumonia was analyzed, and lactate dehydrogenase, apolipoprotein A1, neutrophil-to-lymphocyte ratio, hematocrit, C-reactive protein, calcitoninogen, D-dimer, Acute Physiology and Chronic Health Status Rating System II, and Pneumonia Severity Index scores were compared between the survival and death groups. The value of these indicators in determining the prognosis of patients was analyzed using subject operating characteristic (ROC) curves. Logistic regression was used to analyze the risk factors for death from severe pneumonia.

A nomogram based on the expression level of angiopoietin-like 4 to predict the severity of community-acquired pneumonia

BackgroundThe morbidity and mortality of community-acquired pneumonia (CAP) remain high among infectious diseases. It was reported that angiopoietin-like 4 (ANGPTL4) could be a diagnostic biomarker and a therapeutic target for pneumonia. This study aimed to develop a more objective, specific, accurate, and individualized scoring system to predict the severity of CAP.MethodsTotally, 31 non-severe community-acquired pneumonia (nsCAP) patients and 14 severe community-acquired pneumonia (sCAP) patients were enrolled in this study. The CURB-65 and pneumonia severity index (PSI) scores were calculated from the clinical data. Serum ANGPTL4 level was measured by enzyme-linked immunosorbent assay (ELISA). After screening factors by univariate analysis and receiver operating characteristic (ROC) curve analysis, multivariate logistic regression analysis of ANGPTL4 expression level and other risk factors was performed, and a nomogram was developed to predict the severity of CAP. This nomogram was further internally validated by bootstrap resampling with 1000 replications through the area under the ROC curve (AUC), the calibration curve, and the decision curve analysis (DCA). Finally, the prediction performance of the new nomogram model, CURB-65 score, and PSI score was compared by AUC, net reclassification index (NRI), and integrated discrimination improvement (IDI).ResultsA nomogram for predicting the severity of CAP was developed using three factors (C-reactive protein (CRP), procalcitonin (PCT), and ANGPTL4). According to the internal validation, the nomogram showed a great discrimination capability with an AUC of 0.910. The Hosmer–Lemeshow test and the approximately fitting calibration curve suggested a satisfactory accuracy of prediction. The results of DCA exhibited a great net benefit. The AUC values of CURB-65 score, PSI score, and the new prediction model were 0.857, 0.912, and 0.940, respectively. NRI comparing the new model with CURB-65 score was found to be statistically significant (NRI = 0.834, P < 0.05).ConclusionA robust model for predicting the severity of CAP was developed based on the serum ANGPTL4 level. This may provide new insights into accurate assessment of the severity of CAP and its targeted therapy, particularly in the early-stage of the disease.

Can we recognize severe community-acquired pneumonia without pneumonia severity index? Use of modified qSOFA with procalcitonin

ObjectiveThe aim of this study is to analyze the diagnostic value of Quick Sequential Organ Failure Assessment (qSOFA), modified qSOFA, National Early Warning Score (NEWS) and NEWS + Lactate (NEWS + L) scores in the detection of severe community-acquired pneumonia (CAP). MethodsThis research is a retrospective cohort study. Patients admitted to the Emergency Department (ED) with the diagnosis of CAP were divided into severe and mild pneumonia regarding their Pneumonia Severity Index (PSI) scores. The accuracies of lactate, procalcitonin (PCT) values, NEWS and qSOFA scores, as well as score combinations (NEWS + L and qSOFA + PCT) in predicting patients with severe CAP were analyzed. ResultsMedian qSOFA value in the severe CAP group (0 [IQR 0–1]) was found to be higher than median qSOFA value (0 [IQR 0-0]) in the mild CAP group (p < 0.001). The rate of qSOFA positivity (qSOFA ≥ 2) was significantly higher in the severe CAP group (17.1%, n = 21) compared to the mild CAP group (1.3%, n = 1) (p < 0.001). Median qSOFA + PCT for the severe CAP group (2 [IQR 1–2]) was higher than the mild CAP group (1 [IQR 0–1]) (p < 0.001). Mean NEWS score for severe CAP (4.95 ± 3.09) was found to be 1.69 (95% CI 0.92–2.46) higher than mean NEWS score of the mild CAP group (3.26 ± 2.39) (p < 0.001). The severe CAP NEWS + L score (6.97 ± 3.71) was higher than the mild CAP NEWS + L score (4.94 ± 2.48) (p < 0.001). Blood lactate level was not significant in the evaluation of severe CAP (p = 0.221). PCT (AUROC = 0.685 [95% CI 0.610–0.760]; p = 0.038), NEWS score (AUROC = 0.658 95% CI [0.582–0.733]; p < 0.001), qSOFA (AUROC = 0.686) were calculated to have adequate accuracy for the detection of severe CAP. [95% CI 0.613–0.759]; p = 0.037), NEWS + L score (AUROC = 0.665 [95% CI 0.589–0.740]; p = 0.038). The qSOFA + PCT score (AUROC = 0.758 [95% 0.691–0.825]; p = 0.034) was also found to be a highly accurate predictor of severe CAP. ConclusionIn this study, we found a combination of qSOFA and PCT to be the most reliable method of detecting severe CAP.

Clinical significance of serum S100 calcium-binding protein A12 concentrations in patients with community-acquired pneumonia.

This study aimed to investigate the clinical significance of serum S100 calcium-binding protein A12 (S100A12) concentrations in patients with community-acquired pneumonia (CAP). This was a case-control study. We selected 120 patients with CAP treated in Xichang People's Hospital from January to June 2022 as the case group. Sixty healthy adults without a history of basic diseases were selected as the control group. The patients in the case group were divided into the low S100A12 and high S100A12 subgroups. Serum S100A12, C-reactive protein (CRP), and procalcitonin (PCT) concentrations, the leukocyte count, and other study parameters were compared. Serum S100A12, CRP, and PCT concentrations and the leukocyte count were higher in the case group than in the control group. The baseline confusion, urea, respiratory rate, blood pressure, and age ≥ 65 score, baseline pneumonia severity index score, and 30-day mortality rate were higher in the high S100A12 subgroup than in the low S100A12 subgroup. Serum CRP and PCT concentrations and the leukocyte count were higher in the high S100A12 subgroup than in the low S100A12 subgroup. Patients with high serum S100A12 concentrations have more severe CAP, a more serious inflammatory reaction, and higher 30-day mortality.

Predictive value of platelet-related parameters combined with pneumonia severity index score for mortality rate of patients with severe pneumonia.

To analyse the predictive value of platelet-related parameters combined with pneumonia severity index (PSI) score for the mortality rate of patients with severe pneumonia. The clinical data of 428 severe pneumonia patients were retrospectively analysed. They were divided into survivor and death groups according to 28-day prognosis. Platelet-related parameters platelet count (PLT), mean platelet volume (MPV), platelet-large-cell ratio (P-LCR) and platelet distribution width (PDW) were measured within 24 hours after admission. The receiver operating characteristic (ROC) curves were plotted. The areas under the ROC curves (AUC) were used to describe the predictive efficiencies of platelet-related parameters, PSI score and their combination for death within 28 days. On the 28th day, there were 184 deaths and 244 survivors, and the deaths had significantly higher PLT and PSI score but lower PDW, MPV and P-LCR than those of the survivors (P<0.05). The combination of platelet-related parameters and PSI score had the highest sensitivity (96.56%) and specificity (99.34%) and the largest AUC (0.902) for predicting 28-day mortality. PLT, PDW, MPV and P-LCR are significantly abnormal in patients with severe pneumonia, and the combination of platelet-related parameters with PSI score has the highest predictive value for 28-day mortality.

Community-Acquired Pneumonia Incidence in Adults Aged 18 Years and Older in Goto City, Japan: A Prospective Population-Based Study

BackgroundFew studies have measured the burden of community-acquired pneumonia (CAP) and pneumococcal vaccine-type CAP in Japan after the introduction of the 23-valent pneumococcal polysaccharide vaccine into the adult national immunization program (NIP) for individuals ≥ 65 years of age in 2014. In this study, we estimated the incidences of CAP and Streptococcus pneumoniae CAP among Japanese adults between 2015 and 2020.Research QuestionWhat are the incidences of CAP and S pneumoniae CAP among Japanese adults? What are the common pneumococcal serotypes detected in patients with S pneumoniae CAP?Study Design and MethodsThis prospective, population-based, multicenter, active surveillance study enrolled adults ≥ 18 years of age with clinically and radiologically confirmed CAP in Goto City, Japan. S pneumoniae was detected using standard-of-care blood and sputum cultures, BinaxNOW, and serotype-specific urinary antigen detection assays.ResultsA total of 2,103 patients with CAP were enrolled; 84% were ≥ 65 years of age and 6.7% died during the study. The annual CAP, S pneumoniae CAP, 13-valent pneumococcal conjugate vaccine (PCV13) serotype CAP, and 20-valent pneumococcal conjugate vaccine (PCV20) serotype CAP incidences per 100,000 population were 1,280, 227, 63, and 110, respectively. S pneumoniae was detected in 17.8% of all patients with CAP by any detection method, with 4.9%, 5.5%, and 8.6% of cases of CAP resulting from PCV13, 15-valent pneumococcal conjugate vaccine, and PCV20 serotypes, respectively. Applying Goto’s incidence and case fatality rate to the Japanese population, assuming PCV20 has the same vaccine efficacy and duration of protection as PCV13 and if licensed in Japan for the prevention of CAP, the inclusion of PCV20 in the NIP for adults ≥ 65 years of age could prevent 29,036 cases of CAP and 2,275 CAP-related deaths per year.InterpretationGiven the substantial burden of preventable pneumococcal disease, introduction of pneumococcal conjugate vaccines in Japanese adults may be of merit. Few studies have measured the burden of community-acquired pneumonia (CAP) and pneumococcal vaccine-type CAP in Japan after the introduction of the 23-valent pneumococcal polysaccharide vaccine into the adult national immunization program (NIP) for individuals ≥ 65 years of age in 2014. In this study, we estimated the incidences of CAP and Streptococcus pneumoniae CAP among Japanese adults between 2015 and 2020. What are the incidences of CAP and S pneumoniae CAP among Japanese adults? What are the common pneumococcal serotypes detected in patients with S pneumoniae CAP? This prospective, population-based, multicenter, active surveillance study enrolled adults ≥ 18 years of age with clinically and radiologically confirmed CAP in Goto City, Japan. S pneumoniae was detected using standard-of-care blood and sputum cultures, BinaxNOW, and serotype-specific urinary antigen detection assays. A total of 2,103 patients with CAP were enrolled; 84% were ≥ 65 years of age and 6.7% died during the study. The annual CAP, S pneumoniae CAP, 13-valent pneumococcal conjugate vaccine (PCV13) serotype CAP, and 20-valent pneumococcal conjugate vaccine (PCV20) serotype CAP incidences per 100,000 population were 1,280, 227, 63, and 110, respectively. S pneumoniae was detected in 17.8% of all patients with CAP by any detection method, with 4.9%, 5.5%, and 8.6% of cases of CAP resulting from PCV13, 15-valent pneumococcal conjugate vaccine, and PCV20 serotypes, respectively. Applying Goto’s incidence and case fatality rate to the Japanese population, assuming PCV20 has the same vaccine efficacy and duration of protection as PCV13 and if licensed in Japan for the prevention of CAP, the inclusion of PCV20 in the NIP for adults ≥ 65 years of age could prevent 29,036 cases of CAP and 2,275 CAP-related deaths per year. Given the substantial burden of preventable pneumococcal disease, introduction of pneumococcal conjugate vaccines in Japanese adults may be of merit. Take-home PointsStudy Question: What are the incidences of community-acquired pneumonia (CAP) and Streptococcus pneumoniae CAP among Japanese adults?Results: The annual incidences of CAP and S pneumoniae CAP were high in Goto City (1,280 and 227 cases per 100,000 population, respectively) and increased with age.Interpretation: Given the substantial burden of preventable pneumococcal disease, introduction of pneumococcal conjugate vaccines in Japanese adults may be of merit. Study Question: What are the incidences of community-acquired pneumonia (CAP) and Streptococcus pneumoniae CAP among Japanese adults? Results: The annual incidences of CAP and S pneumoniae CAP were high in Goto City (1,280 and 227 cases per 100,000 population, respectively) and increased with age. Interpretation: Given the substantial burden of preventable pneumococcal disease, introduction of pneumococcal conjugate vaccines in Japanese adults may be of merit. Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality. Age of 65 years of older and certain medical conditions are risk factors for CAP,1Torres A. Peetermans W.E. Viegi G. Blasi F. Risk factors for community-acquired pneumonia in adults in Europe: a literature review.Thorax. 2013; 68: 1057-1065Crossref PubMed Scopus (406) Google Scholar and the incidence and mortality of CAP are highest among the elderly.2Ramirez J.A. Wiemken T.L. Peyrani P. et al.Adults hospitalized with pneumonia in the United States: incidence, epidemiology, and mortality.Clin Infect Dis. 2017; 65: 1806-1812Crossref PubMed Scopus (280) Google Scholar,3Theilacker C. Sprenger R. Leverkus F. et al.Population-based incidence and mortality of community-acquired pneumonia in Germany.PLoS One. 2021; 16e0253118Crossref Scopus (15) Google Scholar With 28.7% of the Japanese population being 65 years of age or older, pneumonia was ranked the fifth leading cause of death in 2019 (77.2 deaths per 100,000 population).4Dunne E.M. Cilloniz C. von Mollendorf C. et al.Pneumococcal vaccination in adults: what can we learn from observational studies that evaluated PCV13 and PPV23 effectiveness in the same population?.Archivos de Bronconeumología. 2023; Crossref Scopus (0) Google Scholar Because Japan has become the first super-aged society in the world,5D’Ambrogio E. Japan’s aging society. European Parliament website.https://www.europarl.europa.eu/RegData/etudes/BRIE/2020/659419/EPRS_BRI(2020)659419_EN.pdfDate accessed: September 16, 2022Google Scholar the burden of pneumonia is expected only to increase. Streptococcus pneumoniae is a leading cause of bacterial CAP. However, the use of pneumococcal conjugate vaccine (PCV) has reduced the proportion of disease attributed to S pneumoniae in children and adults.6Moore M.R. Link-Gelles R. Schaffner W. et al.Effect of use of 13-valent pneumococcal conjugate vaccine in children on invasive pneumococcal disease in children and adults in the USA: analysis of multisite, population-based surveillance.Lancet Infect Dis. 2015; 15: 301-309Abstract Full Text Full Text PDF PubMed Scopus (551) Google Scholar,7Sherwin R.L. Gray S. Alexander R. et al.Distribution of 13-valent pneumococcal conjugate vaccine Streptococcus pneumoniae serotypes in US adults aged ≥50 years with community-acquired pneumonia.J Infect Dis. 2013; 208: 1813-1820Crossref PubMed Scopus (0) Google Scholar In June 2010, a 7-valent PCV was introduced into the national immunization program (NIP) for children in Japan, replaced by a 13-valent PCV (PCV13) in 2013.8Yanagihara K. Kosai K. Mikamo H. et al.Serotype distribution and antimicrobial susceptibility of Streptococcus pneumoniae associated with invasive pneumococcal disease among adults in Japan.Int J Infect Dis. 2021; 102: 260-268Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar PCV13 coverage in Japanese children is high (> 95%), and a substantial decline (45%) in the CAP hospitalization rate has been observed among children younger than 5 years.9Takeuchi N. Naito S. Ohkusu M. et al.Epidemiology of hospitalised paediatric community-acquired pneumonia and bacterial pneumonia following the introduction of 13-valent pneumococcal conjugate vaccine in the national immunisation programme in Japan.Epidemiol Infect. 2020; 148: e91Crossref PubMed Scopus (16) Google Scholar Currently, two pneumococcal vaccines are available in Japan for adults. The 23-valent pneumococcal polysaccharide vaccine (PPSV23) was introduced into the adult NIP in October 2014 for adults ≥ 65 years of age and for adults 60 to 64 years of age with certain medical conditions.8Yanagihara K. Kosai K. Mikamo H. et al.Serotype distribution and antimicrobial susceptibility of Streptococcus pneumoniae associated with invasive pneumococcal disease among adults in Japan.Int J Infect Dis. 2021; 102: 260-268Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar The cumulative vaccination rate of PPSV23 among adults ≥ 65 years of age was 74% at the end of 2018.10Naito T. Suzuki M. Fujibayashi K. et al.The estimated impact of the 5-year national vaccination program on the trend of 23-valent pneumococcal polysaccharide vaccine vaccination rates in the elderly in Japan, 2009-2018.J Infect Chemother. 2020; 26: 407-410Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar In 2014, PCV13 was approved in adults ≥ 65 years of age in Japan, and in 2020, this approval was extended to include individuals 6 to 64 years of age with underlying medical conditions. However, PCV13 is not included in the adult NIP in Japan.11Fukusumi M. Chang B. Tanabe Y. et al.Invasive pneumococcal disease among adults in Japan, April 2013 to March 2015: disease characteristics and serotype distribution.BMC Infect Dis. 2017; 17: 2Crossref PubMed Scopus (37) Google Scholar Recently, higher-valent PCVs—15-valent PCV (including PCV13 serotypes plus serotypes 22F and 33F; Merck & Co., Inc.) and 20-valent PCV (PCV20; including PCV13 serotypes and seven additional serotypes: 8, 10A, 11A, 12F, 15B, 22F, and 33F; Pfizer, Inc.)—have been licensed by the US Food and Drug Administration and European Medicines Agency for use in adults ≥ 18 years of age12Committee for Medicinal Products for Human Use, European Medicines AgencySummary of opinion (initial authorisation): Apexxnar. European Medicines Agency website.https://www.ema.europa.eu/en/documents/smop-initial/chmp-summary-positive-opinion-apexxnar_en.pdfDate accessed: September 16, 2022Google Scholar, 13Committee for Medicinal Products for Human Use, European Medicines AgencySummary of opinion (initial authorisation): Vaxneuvance. European Medicines Agency website.https://www.ema.europa.eu/en/documents/smop-initial/chmp-summary-positive-opinion-vaxneuvance_en.pdfDate accessed: September 16, 2022Google Scholar, 14Kobayashi M. Farrar J.L. Gierke R. et al.Use of 15-valent pneumococcal conjugate vaccine and 20-valent pneumococcal conjugate vaccine among U.S. adults: updated recommendations of the Advisory Committee on Immunization Practices - United States, 2022.MMWR Morb Mortal Wkly Rep. 2022; 71: 109-117Crossref PubMed Scopus (87) Google Scholar and are undergoing clinical evaluations in Japan. In an aging society like Japan, it is important to understand the burden of CAP in adults and the degree to which CAP may be prevented with the current and next-generation pneumococcal vaccines. However, while studies have been conducted measuring the burden of CAP and vaccine-type (VT) CAP in Japan, the most comprehensive data were obtained between 2011 and 2013,15Morimoto K. Suzuki M. Ishifuji T. et al.The burden and etiology of community-onset pneumonia in the aging Japanese population: a multicenter prospective study.PLoS One. 2015; 10e0122247Crossref Scopus (128) Google Scholar which was before PPSV23 introduction into the NIP for older adults in 2014. Herein, we present the results from a population-based CAP incidence study among adults in Goto City, Japan, between 2015 and 2020. Although the population aging rate (≥ 65 years) in Goto City (36.8% in 2015) was higher than that in Japan as a whole (29.1% in 2021),16Statistics Bureau of JapanPopulation estimates. Statistics Bureau of Japan website.https://www.stat.go.jp/english/index.htmlDate accessed: January 18, 2023Google Scholar Goto City is epidemiologically similar to Japan as whole. Therefore, the findings in this study are generalizable to Japan. This was a prospective, multicenter, active-surveillance, population-based incidence study. Residents ≥ 18 years of age in Goto City, Japan, with suspected CAP were screened at all hospitals and outpatient clinics. Goto City is located in the southwest part of Japan, encompassing 11 inhabited islands. Of the 39,808 inhabitants, 85% are ≥ 18 years of age.17Glick H.A. Miyazaki T. Hirano K. et al.One-year quality of life post-pneumonia diagnosis in Japanese adults.Clin Infect Dis. 2021; 73: 283-290Crossref Scopus (11) Google Scholar Study participants were recruited between December 2015 and November 2020. All health-care facilities in Goto City, including four hospitals and 25 outpatient clinics, were include in the study. The study was approved by the ethics review committees and was registered in the University Hospital Medical Information Network (registration ID: [removed]). Patients signed the written informed consent before enrollment. All patients who sought treatment at the participating health-care facilities and demonstrated signs, symptoms, and radiographic evidence of pneumonia were screened for inclusion. To be included, patients: (1) had to be ≥ 18 years of age; (2) had to be a resident of Goto City; (3) had to have a diagnosis of pneumonia based on the presence of two or more of the signs and symptoms of cough; purulent sputum; fever (axillary temperature ≥ 37° C); dyspnea, tachypnea, or both; WBC count of > 10,000/mm3 or > 15% bands or WBC count of < 4,500/mm3; elevated C-reactive protein (CRP) level; hypoxemia; or abnormal auscultatory findings suggestive of pneumonia; (4) had to show a pneumonia pattern (eg, alveolar infiltrative shadow associated with air bronchogram) on chest radiography or chest CT scan imaging; and (5) had to be willing and able to provide a urine sample. Patients were excluded if: (1) they were transferred to a participating health-care facility after having been hospitalized for ≥ 48 h at another hospital. (2) they had hospital-acquired pneumonia (ie, pneumonia developed ≥ 48 h after hospitalization), (3) they had received PPSV23 or PCV13 within the past 30 days (because vaccine receipt may cause false-positive urinary antigen detection [UAD] results), or (4) they had been enrolled previously in the study within the past 30 days. For patients who were eligible for the study, demographics, medical history, pneumococcal vaccination history within the last 5 years, pneumonia severity on admission, and clinical outcomes were collected. Patients were followed for up to 30 days after enrollment. The pneumococcal vaccination history was confined to 5 years because PPSV23 was introduced into the adult NIP in 2014 and the study participants were recruited between 2015 and 2020. Further, only a small proportion of participants had received PCV13. Therefore, confining pneumococcal vaccination history to the previous 5 years should have provided a reasonable coverage estimate. The risk status of participants (high risk, at risk, and low risk) was determined based on the presence of certain medical conditions (based on Shea et al18Shea K.M. Edelsberg J. Weycker D. Farkouh R.A. Strutton D.R. Pelton S.I. Rates of pneumococcal disease in adults with chronic medical conditions.Open Forum Infect Dis. 2014; 1: ofu024Crossref PubMed Google Scholar and on the US Advisory Committee on Immunization Practices guidelines) (e-Table 1). Sputum and specimens from normally sterile sites were collected as part of standard-of-care practice and underwent culture at Goto Central Hospital Laboratory. S pneumoniae isolates then were sent to the German National Reference Center for Streptococci for confirmatory testing and serotyping using the Quellung reaction. Urine samples were collected as a study-related procedure for BinaxNOW S pneumoniae antigen card, and UAD assays were performed at Pfizer’s Vaccines Research and Development Laboratory. The UAD assays are multiplex immunoassays based on the Luminex technology. By capturing serotype-specific S pneumoniae polysaccharides secreted in human urine, the UAD assays simultaneously can detect multiple S pneumoniae serotypes.19Kalina W.V. Souza V. Wu K. et al.Qualification and clinical validation of an immunodiagnostic assay for detecting 11 additional Streptococcus pneumoniae serotype-specific polysaccharides in human urine.Clin Infect Dis. 2020; 71: e430-e438Google Scholar,20Pride M.W. Huijts S.M. Wu K. et al.Validation of an immunodiagnostic assay for detection of 13 Streptococcus pneumoniae serotype-specific polysaccharides in human urine.Clin Vaccine Immunol. 2012; 19: 1131-1141Crossref PubMed Scopus (87) Google Scholar The UAD 1 assay detects all 13 serotypes contained in PCV13 (1, 3, 4, 5, 6A/C, 6B, 7F/A, 9V/A, 14, 18C/A/B/F, 19A, 19F, and 23F), and the UAD 2 assay detects 11 additional serotypes (2, 8, 9N, 10A/39, 11A/D/F, 12F, 15B/C, 17F/A, 20A/B, 22F/A, and 33F/A). The UAD 1 and 2 assays and corresponding positivity cutoff values were validated clinically, demonstrating high sensitivity and specificity against urine specimens obtained from patients with radiography-confirmed bacteremic CAP.19Kalina W.V. Souza V. Wu K. et al.Qualification and clinical validation of an immunodiagnostic assay for detecting 11 additional Streptococcus pneumoniae serotype-specific polysaccharides in human urine.Clin Infect Dis. 2020; 71: e430-e438Google Scholar,20Pride M.W. Huijts S.M. Wu K. et al.Validation of an immunodiagnostic assay for detection of 13 Streptococcus pneumoniae serotype-specific polysaccharides in human urine.Clin Vaccine Immunol. 2012; 19: 1131-1141Crossref PubMed Scopus (87) Google Scholar However, the sensitivity and specificity for nonbacteremic CAP have not been determined because of a lack of a reference standard for this outcome. A patient was defined as having CAP if the patient met all the eligibility criteria described previously, was defined as having pneumococcal CAP if the patient had CAP and showed positive culture results for S pneumoniae (including sputum) or BinaxNOW or UAD assay test positive results and was defined as having PCV13 VT CAP or PCV20 VT CAP if the patient had pneumococcal CAP with one of the PCV13 serotypes or PCV20 serotypes detected by culture (including sputum) or the UAD assays. Descriptive statistical analysis was performed. Continuous variables were summarized as mean ± SD, medians, and minimum and maximum values, and a difference in two means and its CI were evaluated by the two-sample t test. Categorical variables were described as frequencies and percentages, and a difference in two proportions and its CI were evaluated by z test based on the binomial theory. Incidences of CAP, pneumococcal CAP, PCV13 VT CAP, and PCV20 VT CAP were calculated with the numerators based on the number of cases and denominators using age-specific population data of Goto City.21McLaughlin J.M. Jiang Q. Gessner B.D. et al.Pneumococcal conjugate vaccine against serotype 3 pneumococcal pneumonia in adults: a systematic review and pooled analysis.Vaccine. 2019; 37: 6310-6316Crossref Scopus (31) Google Scholar Incidence per 100,000 population was shown by age group (18-64 years, 65-79 years, and ≥ 80 years) and by study year (2015 through 2020). For estimating the effect of introducing PCV20 into the adult NIP in Japan, we assumed PCV20 vaccine efficacy (VE) to be the same as that of PCV13 VE, which is 45.56% for the prevention of first episodes of vaccine-type CAP in adults ≥ 65 years of age, as demonstrated in the CAPiTA study.22Bonten M.J. Huijts S.M. Bolkenbaas M. et al.Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults.N Engl J Med. 2015; 372: 1114-1125Crossref PubMed Scopus (836) Google Scholar This assumption was made because PCV20 is built on the manufacturing platform successfully established by PCV13 and the immune responses to PCV20 in adults have been noninferior to PCV13.23Essink B. Sabharwal C. Cannon K. et al.Pivotal phase 3 randomized clinical trial of the safety, tolerability, and immunogenicity of 20-valent pneumococcal conjugate vaccine in adults aged ≥18 years.Clin Infect Dis. 2022; 75: 390-398Crossref PubMed Scopus (0) Google Scholar To calculate CAP cases preventable by PCV20, the PCV20 VT CAP annual incidence rate from Goto City was multiplied by Japan’s population to obtain annual PCV20 VT CAP cases among adults ≥ 65 years of age. Then the annual PCV20 VT CAP cases were multiplied by PCV20 VE of 45.56% to arrive at the number of cases per year preventable by PCV20. To calculate CAP-related deaths preventable by PCV20, the annual all-cause CAP death rate from Goto City was multiplied by Japan’s population to obtain annual all-cause CAP deaths among adults ≥ 65 years of age. Then, the annual all-cause CAP deaths were multiplied by the proportion of CAP cases caused by PCV20 serotypes and PCV20 VE of 45.56% to arrive at CAP-related deaths per year preventable by PCV20. In Japan, the use of PCV13 in adults ≥ 65 years of age is extremely low, and recent evidence supports limited protection against nonbacteremic pneumonia (which makes up by far most cases of pneumococcal pneumonia) in adults vaccinated with PPSV23.4Dunne E.M. Cilloniz C. von Mollendorf C. et al.Pneumococcal vaccination in adults: what can we learn from observational studies that evaluated PCV13 and PPV23 effectiveness in the same population?.Archivos de Bronconeumología. 2023; Crossref Scopus (0) Google Scholar,10Naito T. Suzuki M. Fujibayashi K. et al.The estimated impact of the 5-year national vaccination program on the trend of 23-valent pneumococcal polysaccharide vaccine vaccination rates in the elderly in Japan, 2009-2018.J Infect Chemother. 2020; 26: 407-410Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Therefore, we expect prior vaccination with either PCV13 or PPSV23 to have little or no effect on the calculations of the potential benefit of PCV20 against pneumonia. Of 2,105 patients screened, 2,103 patients were eligible and included in the analysis population (Table 1). Two screened patients were not included in the analysis because the radiographic findings were not compatible with CAP. The mean age at consent was 77.6 years, 1,765 patients (83.9%) were ≥ 65 years of age, and 53.9% were female. The mean pneumonia severity index (PSI) score on admission was 108.9, with 39.0% and 28.6% of patients having class IV or V PSI scores, respectively. The mean CURB-65 score was 1.7 and 20.7% of patients had a CURB-65 score of 3 to 5. Pneumococcal vaccination within the previous 5 years was reported for 414 of 2,103 patients (19.7%), with 6.8% in adults 18 to 64 years of age and 22.2% in adults ≥ 65 years of age. In total, 70.7% of all patients were hospitalized; the mean hospital stay duration was 14.1 days. Mortality during the study was 6.7% (141/2,103), and in-hospital mortality was 6.2% (130/2,103). Among patients who died, 94.3% (133/141) were ≥ 65 years of age and 5.7% (8/141) were 18 to 64 years of age. Among patients ≥ 18 years of age, 18 to 64 years of age, and ≥ 65 years of age, 69.5%, 64.5%, and 70.4% were at risk or high risk, respectively (Table 2).Table 1Demographics and Clinical Characteristics of Patients With CAPVariableAge Group, y18-64 (n = 338)≥ 65 (n = 1,765)≥ 18 (n = 2,103)Age at consent, y No.3381,7652,103 Mean ± SD51.1 ± 12.182.6 ± 8.677.6 ± 14.8 Median56.084.082.0 Interquartile range19-6465-10319-103Sex Female186 (55.0)948 (53.7)1,134 (53.9) Male152 (45.0)817 (46.3)969 (46.1)Pneumonia severity index No.3381,7642,102 Mean ± SD64.6 ± 32.3117.4 ± 34.0108.9 ± 38.9 Median57.0115.0109.0 Interquartile range13-19455-27513-275 GradeI139 (41.1)102 (5.8)241 (11.5)II82 (24.3)46 (2.6)128 (6.1)III43 (12.7)267 (15.1)310 (14.7)IV59 (17.5)762 (43.2)821 (39.0)V14 (4.1)587 (33.3)601 (28.6)Missing1 (0.3)1 (0.1)2 (0.1)CURB-65 score No.3381,7652,103 Mean ± SD0.3 ± 0.61.9 ± 0.91.7 ± 1.0 Median0.02.02.0 Interquartile range0-41-50-5 0254 (75.1)0 (0.0)254 (12.1) 160 (17.8)708 (40.1)768 (36.5) 222 (6.5)624 (35.4)646 (30.7) 31 (0.3)328 (18.6)329 (15.6) 41 (0.3)102 (5.8)103 (4.9) 50 (0.0)3 (0.2)3 (0.1)Prior vaccine Pneumococcal vaccine within 5 y23 (6.8)391 (22.2)414 (19.7) Prior PPSV23 use9 (2.7)376 (21.3)385 (18.3) Prior PCV13 use15 (4.4)14 (0.8)29 (1.4)Hospitalized Yes145 (42.9)1,342 (76.0)1,487 (70.7) No193 (57.1)423 (24.0)616 (29.3)Hospitalization durationaOnly participants with hospital admission date and discharge date were included in the analysis. No.1239871,110 Mean ± SD13.2 ± 7.714.2 ± 6.914.1 ± 7.0 Median12.013.013.0 Interquartile range1-401-351-40Hospitalization duration ≥ 30 dbPatients with ongoing hospitalization status and with study end date 30 d after hospital admission date were included, in addition to patients with actual stays of ≥ 30 d.27 (8.0)373 (21.1)400 (19.0)Death8 (2.4)133 (7.5)141 (6.7) Death caused by pneumonia5 (1.5)100 (5.7)105 (5.0)Time from hospitalization to death No.8130138 Mean ± SD12.5 ± 9.012.4 ± 8.612.4 ± 8.6 Median11.010.510.5 Interquartile range3-281-311-31Death in hospital7 (2.1)123 (7.0)130 (6.2)Death after hospital discharge1 (0.3)7 (0.4)8 (0.4)Data are presented as No. (%), unless otherwise indicated. CAP = community-acquired pneumonia; PCV13 = 13-valent pneumococcal conjugate vaccine; PPSV23 = 23-valent pneumococcal polysaccharide vaccine.a Only participants with hospital admission date and discharge date were included in the analysis.b Patients with ongoing hospitalization status and with study end date 30 d after hospital admission date were included, in addition to patients with actual stays of ≥ 30 d. Open table in a new tab Table 2Baseline Medical Characteristics of Patients With CAPVariableAge Group, y18-64 (n = 338)≥ 65 (n = 1,765)≥ 18 (n = 2,103)Risk level High86 (25.4)593 (33.6)679 (32.3) At risk132 (39.1)650 (36.8)782 (37.2) Low120 (35.5)522 (29.6)642 (30.5)High risk Chronic renal failure19 (5.6)189 (10.7)208 (9.9) Immunosuppressive therapy41 (12.1)205 (11.6)246 (11.7) Immunodeficiency0 (0.0)0 (0.0)0 (0.0) AIDS0 (0.0)0 (0.0)0 (0.0) HIV infection0 (0.0)0 (0.0)0 (0.0) Hematologic cancer3 (0.9)41 (2.3)44 (2.1) Cancer (solid tumor)43 (12.7)276 (15.6)319 (15.2) Organ transplantation1 (0.3)0 (0.0)1 (0.0) Biologic agent2 (0.6)8 (0.5)10 (0.5) Splenectomy2 (0.6)9 (0.5)11 (0.5) No. of high-risk conditions162 (18.3)473 (26.8)535 (25.4)223 (6.8)106 (6.0)129 (6.1)31 (0.3)13 (0.7)14 (0.7)≥ 40 (0.0)1 (0.1)1 (0.0)1 with ≥ 1 at-risk condition38 (11.2)313 (17.7)351 (16.7)≥ 2 with ≥ 1 at-risk condition10 (3.0)84 (4.8)94 (4.5)At risk COPD20 (5.9)331 (18.8)351 (16.7) Asthma44 (13.0)167 (9.5)211 (10.0) Congestive heart failure10 (3.0)339 (19.2)349 (16.6) Diabetes mellitus38 (11.2)404 (22.9)442 (21.0) Liver disease38 (11.2)220 (12.5)258 (12.3) Smoke100 (29.6)93 (5.3)193 (9.2) No. of at-risk conditions197 (28.7)435 (24.6)532 (25.3)228 (8.3)173 (9.8)201 (9.6)36 (1.8)34 (1.9)40 (1.9)≥ 41 (0.3)8 (0.5)9 (0.4)Other risk factors Used antibiotics in the past 90 d72 (21.3)545 (30.9)617 (29.3) Living with children88 (26.0)19 (1.1)107 (5.1)Data are presented as No. (%). CAP = community-acquired pneumonia. Open table in a new tab Data are presented as No. (%), unless otherwise indicated. CAP = community-acquired pneumonia; PCV13 = 13-valent pneumococcal conjugate vaccine; PPSV23 = 23-valent pneumococcal polysaccharide vaccine. Data are presented as No. (%). CAP = community-acquired pneumonia. Among all patients, the annual incidence of CAP was 1,280 cases per 100,000 population. CAP incidence increased with age, and the incidence among adults ≥ 80 years of age was 11.8 times the incidence among adults 18 to 64 years of age (4,288 per 100,000 population vs 362 per 100,000 population) and 3.2 times the incidence among those 65 to 79 years of age (4,288 per 100,000 population vs 1,352 per 100,000 population) (Fig 1). A similar relationship between incidence and age was observed for pneumococcal CAP, PCV13 VT CAP, and PCV20 VT CAP. In all adults 18 to 64 years of age, those 65 to 79 years of age, and those ≥ 80 years of age, annual incidences per 100,000 population were 227, 89, 260, and 645, respectively, for pneumococcal CAP; 63, 23, 80, and 171, respectively, for PCV13 VT CAP; and 110, 47, 159, and 244, respectively, for PCV20 VT CAP. Extrapolating the CAP incidence and the case fatality rate to Japan’s population and assuming PCV20 has the same VE and duration of protection as PCV13,22Bonten M.J. Huijts S.M. Bolkenbaas M. et al.Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults.N Engl J Med. 2015; 372: 1114-1125Crossref PubMed Scopus (836) Google Scholar if licensed, PCV20 immunization in Japanese adults ≥ 65 years of age could prevent 29,036 CAP cases and 2,275 CAP-related deaths per year. Between 2015 and 2020, CAP incidence and pneumococcal CAP incidence generally remained stable, except for year 5 (December 2019-November 2020) during which the incidences were lower compared with other study years (Fig 2). Urine samples were not collected in 68 of 2,103 patients (3.2%); however, S pneumoniae was detected by culture in 5 of 68 patients (7.3%) from whom a urine sample was not collected. Among 2,099 patients who had diagnostic results available, S pneumoniae was detected in 373 patients (17.8%) by UAD assays, BinaxNOW, or culture (Table 3). S pneumoniae was detected by UAD alone in 78 of 2,099 patients (3.7%; 78/373 patients [20.9%] with pneumococcal CAP), by BinaxNOW alone in 125 of 2,099 patien

Updating cut-off values of severity scoring systems for community-acquired pneumonia to orchestrate more predictive accuracy

Background: The assessment of severity is crucial in the management of community-acquired pneumonia (CAP). It remains unknown whether updating cut-off values of severity scoring systems orchestrate improvement in predictive accuracy. Methods: 3,212 patients with CAP were recruited to two observational prospective cohort studies. Three bettered scoring systems were derived from the corresponding well-established and extensively used pneumonia-specific severity scoring systems, i.e. pneumonia severity index, minor criteria and CURB-65 (confusion, urea >7 mmol/L, respiratory rate ≥30/min, low blood pressure, and age ≥65 years) score, with the updating cut-off values for tachypnea and low blood pressure. Cronbach α was employed to determine construct validity. Discrimination was valued by calculating the area under the receiver operating characteristic curve (AUROC) and net reclassification improvement (NRI). Results: Respiratory rate ≥22/min and systolic blood pressure ≤100 mm Hg were performed better than respiratory rate ≥30/min and hypotension for predicting mortality in the derivation cohort, respectively (AUROC, 0.823 vs 0.519, 0.688 vs 0.622; NRI, 0.61, 0.13). Bettered scoring systems orchestrated higher convergences, indicated by greater Cronbach α and more decrease in Cronbach α if the updating cut-off values were deleted. The six scoring systems agreed well with one another. Bettered- pneumonia severity index, minor criteria and CURB-65 score showed higher associations with severity and mortality rates and demonstrated greater predictive accuracies for mortality compared with the corresponding original systems (AUROC, 0.939 vs 0.883, 0.909 vs 0.871, 0.913 vs 0.859; NRI, 0.113, 0.076, 0.108; respectively). The validation cohort confirmed a similar pattern. Conclusions: Updating cut-off values of severity scoring systems for CAP orchestrate improvement in predictive accuracy, suggesting that it may facilitate the rationalization of clinical triage decision-making and further reduce mortality. The current studies provide the first known prospective evidence of potential benefit of the updating cut-off values of severity scoring systems for CAP in predictive accuracy. Key messages Updating cut-off values were performed better for predicting mortality. Bettered scoring systems orchestrated higher convergences. Bettered scoring systems demonstrated greater predictive accuracies for mortality.

Characteristics, Management, and Outcomes of Community-Acquired Pneumonia due to Respiratory Syncytial Virus: A Retrospective Study.

Respiratory syncytial virus (RSV), a well-known cause of bronchiolitis in children, can cause community-acquired pneumonia (CAP) in adults, but this condition is not well studied. Hence, we described the characteristics and outcomes of patients hospitalized for CAP due to RSV. This was a retrospective study of patients admitted to a tertiary-care hospital between 2016 and 2019 with CAP due to RSV diagnosed by a respiratory multiplex PCR within 48 hours of admission. We compared patients who required ICU admission to those who did not. Eighty adult patients were hospitalized with CAP due to RSV (median age 69.0 years, hypertension 65.0%, diabetes 58.8%, chronic respiratory disease 52.5%, and immunosuppression 17.5%); 19 (23.8%) patients required ICU admission. The median pneumonia severity index score was 120.5 (140.0 for ICU and 102.0 for non-ICU patients; p = 0.09). Bacterial coinfection was rare (10.0%). Patients who required ICU admission had more hypotension (systolic blood pressure < 90 mmHg) and a higher prevalence of bilateral infiltrates on chest X-ray (CXR) (89.5% versus 32.7%; p < 0.001). Systemic corticosteroids were used in 57.3% of patients (median initial dose was 40 mg of prednisone equivalent) with ICU patients receiving a higher dose compared to non-ICU patients (p = 0.02). Most (68.4%) ICU patients received mechanical ventilation (median duration of 4 days). The overall hospital mortality was 8.8% (higher for ICU patients: 31.6% versus 1.6%, p < 0.001). Most patients with CAP due to RSV were elderly and had significant comorbidities. ICU admission was required in almost one in four patients and was associated with higher mortality.

Platelet Count as a Predictor for Community-Acquired Pneumonia Severity Using PSI Score

Community-Acquired pneumonia (CAP) refers to the inflammation of the lung parenchyma that is contracted outside of a hospital setting. In addition, in developing countries, it is among the top three causes of death worldwide. Pneumonia severity is often assessed using various instruments, including Pneumonia Severity Index (PSI). Furthermore, the platelet play a crucial role in both hemostasis and the defense of the body against infectious agents. A relatively inexpensive and routinely conducted test, namely the platelet count serves as a supporting examination. Therefore, this study aimed to determine the potential correlation between the platelet count and CAP severity. Aims: The objective of this study was to investigate the potential role of platelet count as a predictive factor for evaluating the severity of CAP patients using PSI scores. Methodology: An analytical observational study with a retrospective cross-sectional design was conducted on patients diagnosed with CAP at Dr. Moewardi General Hospital Surakarta from October 2022 to May 2023. Patients data were extracted from medical records. The correlation between the platelet count and CAP severity was analysed using the Spearman correlation test. The platelet count cut-off value was determined using Receiver Operating Characteristic (ROC) curve. Results: In this study, there were 183 subjects with an average age of 56.90 and a platelet count of 272,688.52 (SD ± 157,524.87). The CAP severity was dominated by the moderate-severe category (52.5%). The platelet count was negatively correlated with severity based on PSI score with p=0.029 (p&lt;0.05) and r=0.162 (low correlation value). Based on ROC curve, AUC value = 0.594 (very weak predictor) and the platelet count cut-off value was 152,000 (sensitivity = 0.322, specificity = 0.91). Scientific Novelty: There is a correlation between the platelet count and the severity of CAP based on the PSI score. Conclusion: A significant correlation was found between the platelet count and CAP severity based on PSI score. However, the platelet count could not be used as a reliable predictor of CAP severity.

Development and validation of a survival prediction model in elder patients with community-acquired pneumonia: a MIMIC-population-based study

BackgroundTo develop a prediction model predicting in-hospital mortality of elder patients with community-acquired pneumonia (CAP) admitted to the intensive care unit (ICU).MethodsIn this cohort study, data of 619 patients with CAP aged ≥ 65 years were obtained from the Medical Information Mart for Intensive Care III (MIMIC III) 2001–2012 database. To establish the robustness of predictor variables, the sample dataset was randomly partitioned into a training set group and a testing set group (ratio: 6.5:3.5). The predictive factors were evaluated using multivariable logistic regression, and then a prediction model was constructed. The prediction model was compared with the widely used assessments: Sequential Organ Failure Assessment (SOFA), Pneumonia Severity Index (PSI), systolic blood pressure, oxygenation, age and respiratory rate (SOAR), CURB-65 scores using positive predictive value (PPV), negative predictive value (NPV), accuracy (ACC), area under the curve (AUC) and 95% confidence interval (CI). The decision curve analysis (DCA) was used to assess the net benefit of the prediction model. Subgroup analysis based on the pathogen was developed.ResultsAmong 402 patients in the training set, 90 (24.63%) elderly CAP patients suffered from 30-day in-hospital mortality, with the median follow-up being 8 days. Hemoglobin/platelets ratio, age, respiratory rate, international normalized ratio, ventilation use, vasopressor use, red cell distribution width/blood urea nitrogen ratio, and Glasgow coma scales were identified as the predictive factors that affect the 30-day in-hospital mortality. The AUC values of the prediction model, the SOFA, SOAR, PSI and CURB-65 scores, were 0.751 (95% CI 0.749–0.752), 0.672 (95% CI 0.670–0.674), 0.607 (95% CI 0.605–0.609), 0.538 (95% CI 0.536–0.540), and 0.645 (95% CI 0.643–0.646), respectively. DCA result demonstrated that the prediction model could provide greater clinical net benefits to CAP patients admitted to the ICU. Concerning the pathogen, the prediction model also reported better predictive performance.ConclusionOur prediction model could predict the 30-day hospital mortality in elder patients with CAP and guide clinicians to identify the high-risk population.

Effect Of Eight Hours Per Day Of Intermittent Self Prone Positioning For Seven Days On The Severity Of Covid-19 Pneumonia/ Acute Respiratory Distress Syndrome.

Prone positioning improves ventilation-perfusion mismatch, distribution of gravitational gradient in pleural pressure, and oxygen saturation significantly in patients with Covid pneumonia. We aimed to find out the efficacy of eight hours per day of intermittent selfprone positioning for seven days in patients affected with COVID-19 pneumonia/ ARDS. This Randomized Clinical Trial was conducted in the Covid isolation wards of Ayub Teaching Hospital, Abbottabad. Patients suffering from COVID-19 pneumonia/ ARDS were enrolled with permuted block randomization into a control and an experimental group each consisting of 36 patients. Parameters of Pneumonia Severity Index (PSI) score along with other sociodemographic data was noted on a preformed structured questionnaire. Death was confirmed by requesting the death certificate of patients on the 90th day of enrolment. Data Analysis was done with SPSS Version 25. Tests of significance were applied to calculate the difference in the patients of the two groups with respect to respiratory physiology and survival. The mean age of the patients was 63.79±15.26 years. A total of 25 (32.9%) male and 47 (61.8%) female patients were enrolled. Statistically significant improvement was found in the respiratory physiology of the patients at 7th and 14th DOA between the groups. Pearson Chi-Square test of significance showed a difference in mortality between the two groups at 14th DOA (pvalue=0.011) but not at 90th DOA (p-value=0.478). Log Rank (Mantel-Cox) test of significance, applied on the Kaplan Meier curve and showed no statistically significant difference among the groups based on the survival of the patients. (p-value=0.349). Early transient improvement in respiratory physiology and mortality does occur with 8 hours of self-prone positioning for seven days but there is no effect on the 90-day survival of the patients. Thus, the impact of the manoeuvre on improving survival needs to be explored with studies having an application of the manoeuvre for a longer duration and period.