Pneumonia Severity Index Score Research Articles

A deep learning-based quantitative computed tomography model for predicting the severity of COVID-19: a retrospective study of 196 patients.

BackgroundThe assessment of the severity of coronavirus disease 2019 (COVID-19) by clinical presentation has not met the urgent clinical need so far. We aimed to establish a deep learning (DL) model based on quantitative computed tomography (CT) and initial clinical features to predict the severity of COVID-19.MethodsOne hundred ninety-six hospitalized patients with confirmed COVID-19 were enrolled from January 20 to February 10, 2020 in our centre, and were divided into severe and non-severe groups. The clinico-radiological data on admission were retrospectively collected and compared between the two groups. The optimal clinico-radiological features were determined based on least absolute shrinkage and selection operator (LASSO) logistic regression analysis, and a predictive nomogram model was established by five-fold cross-validation. Receiver operating characteristic (ROC) analyses were conducted, and the areas under the receiver operating characteristic curve (AUCs) of the nomogram model, quantitative CT parameters that were significant in univariate analysis, and pneumonia severity index (PSI) were compared.ResultsIn comparison with the non-severe group (151 patients), the severe group (45 patients) had a higher PSI (P<0.001). DL-based quantitative CT indicated that the mass of infection (MOICT) and the percentage of infection (POICT) in the whole lung were higher in the severe group (both P<0.001). The nomogram model was based on MOICT and clinical features, including age, cluster of differentiation 4 (CD4)+ T cell count, serum lactate dehydrogenase (LDH), and C-reactive protein (CRP). The AUC values of the model, MOICT, POICT, and PSI scores were 0.900, 0.813, 0.805, and 0.751, respectively. The nomogram model performed significantly better than the other three parameters in predicting severity (P=0.003, P=0.001, and P<0.001, respectively).ConclusionsAlthough quantitative CT parameters and the PSI can well predict the severity of COVID-19, the DL-based quantitative CT model is more efficient.

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.

The Effectiveness of Geriatric Pneumonia Severity Index in Predicting Mortality

Background: Pneumonia severity index (PSI) estimates the risk of 30-day mortality in patients with pneumonia. In this study, we aim to develop a simplified version of the PSI (G-PSI) to estimate the risk of mortality in geriatric patients with community-acquired pneumonia (CAP). Methods: This retrospective study included 186 patients aged 65 and older with a diagnosis of CAP. PSI score and 30-day mortality rate of each patient were calculated. PSI parameters were analyzed using univariate regression analysis and the G-PSI scoring system was established to predict 30-day mortality and compared with PSI. Results: Significant effectiveness of the values of cancer (odds ratio (OR) = 3.67; 95% confidence interval (CI): 1.42-9.48), altered mental status (OR = 0.79; 95% CI: 0.68-0.92), systolic blood pressure (OR = 0.98; 95% CI: 0.97-1.00), haematocrit (Hct) (OR = 0.87; 95% CI: 0.81-0.93) and blood urea nitrogen (BUN) (OR = 1.04; 95% CI: 1.02-1.06) were observed for predicting mortality in univariate regression analysis. G-PSI scoring system, like PSI score (if cancer + 30 points, if altered mental status +20 points, if systolic blood pressure ＜ 90mmHg+ 20 points, if Hct ＜ 30% + 10 points and if BUN ≥ 30 mg/dl + 30 points) was created. The area under the receiver operating characteristic curve (AUC)was 0.762 (95% CI 0.673-0.851), revealing the excellent discriminatory ability of the G-PSI model. The AUC for the PSI score was 0.719 (95% CI 0.631-0.806).When G-PSI and PSI were compared, G-PSI had a high level of significance in predicting 30-day mortality. Conclusion: Calculated with only five parameters from standard PSI information, G-PSI accurately displays the 30-day mortality risk of geriatric patients with CAP. The applicability of the G-PSI is easier in a busy emergency service environment with similar prognostic accuracy and clinical prediction.

Correlation of serum interleukin-6 level and pneumonia severity index score in patient with community-acquired pneumonia

B iomarkers of pro-inflammatory cytokines have been widely evaluated for their efficacy in the assessment of disease severity. The pleiotropic functions of Interleukin-6 (IL-6) allow it to induce the inflammatory responses acute phase. This study aimed to evaluate the correlation between PSI scores in patients with CAP and IL-6 levels. The study was a cross-sectional study. 26 pneumonia patients who met the inclusion and exclusion criteria were included in this study. IL-6 levels and PSI scores

Endogenous Carboxyhemoglobin Concentrations in Predicting Prognosis of Patients with COVID-19 Pneumonia.

The coronavirus disease 2019 (COVID-19) outbreak has caused great difficulties in providing healthcare services worldwide. Accurate and useful indicators are needed for the effective use of resources. Carbon monoxide (CO) is also produced endogenously without exogenous exposure. Studies confirm that endogenous CO increases in conditions such as pneumonia, sepsis, and trauma. This study aimed to compare patients diagnosed with COVID-19 pneumonia and healthy people to reveal whether endogenous carboxyhemoglobin (COHb) levels differ. It was also to determine whether it could be a helpful indicator for the clinician in predicting disease severity in combating the COVID-19 pandemic. The study included 72 patients admitted to the hospital during the COVID-19 pandemic and diagnosed with COVID-19 pneumonia and a control group of 75 healthy people. The research data was collected retrospectively in a tertiary emergency department. The patients' demographic data, pneumonia severity index (PSI) score, CURB-65 score, 30-day mortality, hospitalization, need for mechanical ventilation (MV), and COHb levels were recorded. While the COHb level was 0.9% (min-max, 0.1 - 4.0) in patients with COVID-19 pneumonia, it was 1% (min-max, 0.1 - 2.6) in the control group. No significant difference was found between the patients and the control group in terms of COHb levels (p = 0.341). Also, there was no correlation between COHb levels and PSI and CURB-65 scores. No significant difference was detected between COHb levels and patients diagnosed with COVID-19 pneumonia in terms of mortality, need for MV, or hospitalization (p > 0.05). We concluded that COHb levels alone could not be used to diagnose COVID-19 pneumonia or predict disease severity. Besides, in COVID-19 pneumonia, the COHb level was not a useful indicator of mortality, need for MV, or hospitalization decision. Further studies are needed to find useful indicators to assist clinicians in their decision-making process in tackling the COVID-19 pandemic.

413. Association of SARS-CoV-2 Genomic Load in Nasopharyngeal Samples with Adverse COVID-19 Patient Outcomes: A Retrospective Analysis from an Academic Hospital Center in New York City

BackgroundSARS-CoV-2, the cause of COVID-19 pneumonia, is associated with heterogenous presentations ranging from asymptomatic infection to severe respiratory failure. We explored the association of SARS-CoV-2 genomic load as a risk factor for adverse patient outcomes.MethodsWe included adult patients admitted to the hospital with clinical and radiographic findings of pneumonia and a confirmatory polymerase chain reaction (PCR) test of SARS-CoV-2 within 24 hours of admission. We segregated patients into 3 genomic load status groups: low (Cycle threshold (Ct) ≥35) intermediate (25< Ct< 35) and high (Ct ≤25) using real-time PCR. The primary outcome was a composite outcome of death, intubation and/or use of extracorporeal membrane oxygenation. Secondary outcomes included severity of pneumonia on admission, as measured by the Pneumonia Severity Index (PSI). Sensitivity analyses were performed to include Acute Respiratory Distress Syndrome (ARDS) in the composite outcome and varying Ct classification breakpoints.ResultsOf 457 patients positive for SARS-CoV-2 assay from March 31st to April 10th 2020, 316 met inclusion criteria and were included in the final analysis. Included patients were followed for a median of 25 days (IQR 21–28). High genomic load at presentation was associated with higher Charlson Comorbidity Index scores (p=0.005), transplant recipient status (p< 0.001) and duration of illness less than 7 days (p=0.005). Importantly, patients with high genomic load were more likely to reach the primary endpoint (p=0.001), and had higher PSI scores on admission (p=0.03). In multivariate analysis, high genomic load remained an independent predictor of primary outcome. Results remained significant in sensitivity analyses.Flow Chart Prediction of Outcomes Based on Genomic Load Prediction of Outcomes Based on Genomic Load and Pneumonia Severity Index ConclusionHigh genomic load of SARS-CoV-2 in nasopharyngeal samples at the time of admission is independently associated with mortality and intubation. This finding should prompt further research on the role of viral load as a clinical predictor and possible modifiable risk factor for adverse outcomes as treatment strategies evolve in this global pandemic.Disclosures All Authors: No reported disclosures

Pneumonia and Other Pulmonary Infections

Pulmonary infections span a wide spectrum, ranging from self-limited to life threatening. Pneumonia refers to infection of lung parenchyma, specifically the alveolar or gas-exchanging portions of the lung. Taken together, pneumonia and influenza rank as the sixth leading cause of death in the United States and the leading infectious cause of death in the United States and the world. Tuberculosis (TB) is a bacterial disease caused by Mycobacterium tuberculosis. TB, historically a leading cause of death worldwide, remains an enormous global public health epidemic in much of the developing world. Rates of coinfection with HIV are high, and HIV increases the morbidity and mortality associated with TB. This review details the pathophysiology, epidemiology, clinical presentation, and treatment of pulmonary infection, including pneumonia, empyema, pulmonary abscess, and tuberculosis (TB). Figures show chest radiographs of reactivation pulmonary tuberculosis, HIV-infected patients with proven culture-confirmed tuberculosis, prominent hilar adenopathy with clear lung fields, and bilateral interstitial changes; and treatment of drug-susceptible pulmonary tuberculosis. Tables list major causes of pulmonary infection, host defence mechanisms against pulmonary infection, initial empirical antibiotic therapy in patients with suspected community-acquired pneumonia, initial antibiotic therapy for community-acquired pneumonia in outpatients, initial antibiotic therapy for community-acquired pneumonia in patients who require hospitalization, antibiotic choices for aspiration pneumonia, pneumonia severity index scoring, and mortality by pneumonia severity index point score. This review contains 2 figures, 9 tables, and 87 references Key words: Pulmonary infections; Pneumonia; Tuberculosis; Lung infection; Mycobacteria; Community-acquired pneumonia; Health care-associated pneumonia; Aspiration pneumonia; Empyema; Legionnaires disease

Pneumonia and Other Pulmonary Infections

Pulmonary infections span a wide spectrum, ranging from self-limited to life threatening. Pneumonia refers to infection of lung parenchyma, specifically the alveolar or gas-exchanging portions of the lung. Taken together, pneumonia and influenza rank as the sixth leading cause of death in the United States and the leading infectious cause of death in the United States and the world. Tuberculosis (TB) is a bacterial disease caused by Mycobacterium tuberculosis. TB, historically a leading cause of death worldwide, remains an enormous global public health epidemic in much of the developing world. Rates of coinfection with HIV are high, and HIV increases the morbidity and mortality associated with TB. This review details the pathophysiology, epidemiology, clinical presentation, and treatment of pulmonary infection, including pneumonia, empyema, pulmonary abscess, and tuberculosis (TB). Figures show chest radiographs of reactivation pulmonary tuberculosis, HIV-infected patients with proven culture-confirmed tuberculosis, prominent hilar adenopathy with clear lung fields, and bilateral interstitial changes; and treatment of drug-susceptible pulmonary tuberculosis. Tables list major causes of pulmonary infection, host defence mechanisms against pulmonary infection, initial empirical antibiotic therapy in patients with suspected community-acquired pneumonia, initial antibiotic therapy for community-acquired pneumonia in outpatients, initial antibiotic therapy for community-acquired pneumonia in patients who require hospitalization, antibiotic choices for aspiration pneumonia, pneumonia severity index scoring, and mortality by pneumonia severity index point score. This review contains 2 figures, 9 tables, and 87 references Key words: Pulmonary infections; Pneumonia; Tuberculosis; Lung infection; Mycobacteria; Community-acquired pneumonia; Health care-associated pneumonia; Aspiration pneumonia; Empyema; Legionnaires disease

Performance and comparison of assessment models to predict 30-day mortality in patients with hospital-acquired pneumonia.

BackgroundHospital-acquired pneumonia (HAP) is the most common hospital-acquired infection in China with substantial morbidity and mortality. But no specific risk assessment model has been well validated in patients with HAP. The aim of this study was to investigate the published risk assessment models that could potentially be used to predict 30-day mortality in HAP patients in non-surgical departments.MethodsThis study was a single-center, retrospective study. In total, 223 patients diagnosed with HAP from 2012 to 2017 were included in this study. Clinical and laboratory data during the initial 24 hours after HAP diagnosis were collected to calculate the pneumonia severity index (PSI); consciousness, urea nitrogen, respiratory rate, blood pressure, and age ≥65 years (CURB-65); Acute Physiology and Chronic Health Evaluation II (APACHE II); Sequential Organ Failure Assessment (SOFA); and Quick Sequential Organ Failure Assessment (qSOFA) scores. The discriminatory power was tested by constructing receiver operating characteristic (ROC) curves, and the areas under the curve (AUCs) were calculated.ResultsThe all-cause 30-day mortality rate was 18.4% (41/223). The PSI, CURB-65, SOFA, APACHE II, and qSOFA scores were significantly higher in non-survivors than in survivors (all P < 0.001). The discriminatory abilities of the APACHE II and SOFA scores were better than those of the CURB-65 and qSOFA scores (ROC AUC: APACHE II vs. CURB-65, 0.863 vs. 0.744, Z = 3.055, P = 0.002; APACHE II vs. qSOFA, 0.863 vs. 0.767, Z = 3.017, P = 0.003; SOFA vs. CURB-65, 0.856 vs. 0.744, Z = 2.589, P = 0.010; SOFA vs. qSOFA, 0.856 vs. 0.767, Z = 2.170, P = 0.030). The cut-off values we defined for the SOFA, APACHE II, and qSOFA scores were 4, 14, and 1.ConclusionsThese results suggest that the APACHE II and SOFA scores determined during the initial 24 h after HAP diagnosis may be useful for the prediction of 30-day mortality in HAP patients in non-surgical departments. The qSOFA score may be a simple tool that can be used to quickly identify severe infections.

Pneumonia Severity Index and CURB-65 score as a Predictor of In-Hospital Mortality in Acute Exacerbation of COPD

Pneumonia Severity Index and CURB-65 score as a Predictor of In-Hospital Mortality in Acute Exacerbation of COPD

ROLE OF PNEUMONIA SEVERITY INDEX AND CURB-65 SCORE IN PATIENTS WITH ACUTE EXACERBATION OF COPD WITH REFERENCE TO THEIR DURATION OF HOSPITAL STAY

Aim and Objective: To investigate the role of Pneumonia Severity Index and CURB-65 score in patients with acute exacerbation of COPD with reference to Duration of hospital stay. Methods:In our study a total of 100 patients of COPD with acute exacerbation were included in the study from the tertiary care Centre, Kolkata for a period of 12 months from December 2015 to November 2016. Results: The relationship between Respiratory rate, Arterial pH, Urea and BUN levels, Blood glucose, Hematocrit level, pO2 as well as PSI and CURB-65 score in reference with duration of hospital was found to be significant. Our study revealed that PSI and CURB-65 score have good predictive capacity for in hospital deaths as well as duration of hospital stay. Conclusion: PSI and CURB -65 can predict the duration of hospital stay, with a good prognostic capacity. The role of PSI and CURB-65 in defining duration of hospital stay needs to be assessed by further studies on larger samples using Indian data for reference value. The present study is a stimulus to future research on role of PSI, CURB-65 as well as comorbidities in defining the outcome of acute exacerbations in COPD, one of the most dreaded respiratory diseases.

Risk factors for mortality among patients with SARS-CoV-2 infection: A longitudinal observational study.

Recent literature suggests that approximately 5%–18% of patients diagnosed with severe acute respiratory syndrome coronavirus 2 may progress rapidly to a severe form of the illness and subsequent death. We examined the relationship between sociodemographic, clinical, and laboratory findings with mortality among patients. In this study, 112 patients were evaluated from February to May 2020 and 80 patients met the inclusion criteria. Tocilizumab was administered, followed by methylprednisolone to patients with pneumonia severity index score ≤130 and computerized tomography scan changes. Demographic data and clinical outcomes were collected. Laboratory biomarkers were monitored during hospitalization. Statistical analyses were performed with significance p ≤ .05. A total of 80 patients: 45 males (56.25%) and 35 females (43.75%) met the study inclusion criteria. A total of 7 patients (8.75%) were deceased. An increase in mortality outcome was statistically significantly associated with higher average levels of interleukin‐6 (IL‐6) with p value (.050), and d‐dimer with p value (.024). Bivariate logistics regression demonstrated a significant increased odds for mortality for patients with bacterial lung infections (odds ratio [OR]: 10.83; 95% confidence interval [CI]: 2.05–57.40; p = .005) and multiorgan damage (OR: 103.50; 95% CI: 9.92–1079.55; p = .001). Multivariate logistics regression showed a statistically significant association for multiorgan damage (adjusted odds ratio [AOR]: 94.17; 95% CI: 7.39–1200.78; p = .001). We identified three main predictors for high mortality. These include IL‐6, d‐dimer, and multiorgan damage. The latter was the highest potential risk for in‐hospital deaths. This warrants aggressive health measures for early recognition of the problem and initiation of treatment to reverse injuries.

Prediction of adverse clinical outcomes in patients with coronavirus disease 2019.

ObjectiveThis study aims to investigate blood and biochemical laboratory findings in patients with coronavirus disease (COVID‐19) and analyze the potential predictors of poor outcome in patients with COVID‐19.MethodsThe clinical, laboratory, and outcome data of 87 patients with COVID‐19 were collected and retrospectively analyzed. Only data collected at the time of admission were used in the analysis for predictors of poor outcome. These patients were divided into two groups: the adverse prognosis group (36 patients) and the non‐adverse prognosis group (51 patients). The adverse prognosis of COVID‐19 patients was defined as admission to the intensive care unit or death.ResultsOn the univariate analysis, age, white blood cell (WBC) count, neutrophil counts, lymphocytes count, neutrophils‐to‐lymphocytes ratio (NLR), interleukin‐6, albumin‐to‐globulin ratio (AGR), albumin, lactate dehydrogenase, glutamyl transpeptidase, and blood glucose were found to be the significant predictors. On the multivariate analysis, the predictors of poor outcome of patients with COVID‐19 were NLR (OR = 2.741, [95% CI = 1.02 ~ 7.35], P = .045) and IL‐6 (OR = 1.405, [95% CI = 1.04 ~ 1.89, P = .025]). The receiver operating characteristic (ROC) curve revealed that the AUC of NLR, interleukin‐6, pneumonia severity index (PSI) score, and Confusion‐Urea‐Respiratory Rate‐Blood pressure‐65 (CURB‐65) score were 0.883, 0.852, 0.824, and 0.782, respectively.ConclusionHigh interleukin‐6 (6 pg/mL, cuff value) and NLR (4.48, cuff value) can be used to predict poor outcomes in patients with COVID‐19 on admission, thus can serve as a beneficial tool for timely identifying COVID‐19 patients prone to poor outcome and reduce patient mortality through early intervention.

Timing of invasive mechanic ventilation in critically ill patients with coronavirus disease 2019

Invasive mechanical ventilation (IMV) is a lifesaving strategy for critically ill patients with coronavirus disease 2019 (COVID-19). We aim to report the case series of critical patients receiving IMV in Wuhan and to discuss the timing of IMV in these patients. Data of 657 patients admitted to emergency intensive care unit of Zhongnan Hospital and isolated isolation wards of Wuhan Union Hospital from January 1 to March 10, 2020, were retrospectively reviewed. All medical records of 40 COVID-19 patients who required IMV were collected at different time points, including baseline (at admission), before receiving IMV, and before death or hospital discharge. Among 40 COVID-19 patients with IMV, 31 died, and 9 survived and was discharged. The median age was 70 years (interquartile range [IQR], 62-76 years), and nonsurvivors were older than survivors. The median period from the noninvasive mechanic ventilation (NIV) or high-flow nasal cannula oxygen therapy (HFNC) to intubation was 7 hours (IQR, 2-42 hours) in IMV survivors and 54 hours (IQR, 28-143 hours) in IMV nonsurvivors. We observed that, when the time interval from NIV/HFNC to intubation was less than 50 hours (about 2 calendar days), together with Acute Physiology and Chronic Health Evaluation II (APACHE II) score of less than 10 or pneumonia severity index (PSI) score of less than 100, mortality can be reduced to 60% or less. Prolonged interval from NIV/HFNC to intubation and high levels of APACHE II and PSI before intubation were associated with higher mortality in critically ill patients. Multiple organ damage was common among these nonsurvivors in the course of treatment. Early initial intubation after NIV/HFNC might have a beneficial effect in reducing mortality for critically ill patients meeting IMV indication. Considering APACHE II and PSI scores might help physicians in decision making about timing of intubation for curbing subsequent mortality. Therapeutic, level V.

Hospital Admission Patterns in Adult Patients with Community-Acquired Pneumonia Who Received Ceftriaxone and a Macrolide by Disease Severity across United States Hospitals

(1) Objective: There are limited data regarding community-acquired pneumonia (CAP) admissions patterns in US hospitals. Current expert CAP guidelines advocate for outpatient treatment or an abbreviated hospital stay for CAP patients in pneumonia severity index (PSI) risk classes I–III (low risk); however, the extent of compliance with this recommendation is unclear. This study sought to estimate the proportion of admissions among CAP patients who received ceftriaxone and macrolide therapy, one of the most commonly prescribed guideline-concordant CAP regimens, by PSI risk class and Charlson comorbidity index (CCI) score. (2) Methods: A retrospective cross-sectional study of patients in the Vizient® (MedAssets, Irving, Texas) database between 2012 and 2015 was performed. Patients were included if they were aged ≥ 18 years, had a primary diagnosis for CAP, and received ceftriaxone and a macrolide on hospital day 1 or 2. Baseline demographics and admitting diagnoses were used to calculate the PSI score. Patients in the final study population were grouped into categories by their PSI risk class and CCI score. Hospital length of stay, 30-day mortality rates, and 30-day CAP-related readmissions were calculated across resulting PSI–CCI strata. (3) Results: Overall, 32,917 patients met the study criteria. Approximately 70% patients were in PSI risk classes I–III and length of stay ranged between 4.9 and 6.2 days, based on CCI score. The 30-day mortality rate was <0.5% and <1.4% in patients with PSI risk classes I and II, respectively. (4) Conclusions: Over two-thirds of hospitalized patients with CAP who received ceftriaxone and a macrolide were in PSI risk classes I–III. Although the findings should be interpreted with caution, they suggest that there is a potential opportunity to improve the efficiency of healthcare delivery for CAP patients by shifting inpatient care to the outpatient setting in appropriate patients.

Managing Bacterial Infections in the Era of COVID-19

Managing Bacterial Infections in the Era of COVID-19

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.

Clinical features and prognostic factors of parainfluenza virus infections in adult patients

Objective: To explore the clinical features and prognostic factors of parainfluenza viral lower respiratory tract infections in adults. Methods: A total of 70 patients withpositive nucleic acid of parainfluenza virus (PIV) admitted to China-Japan Friendship Hospital between August 2016 and November 2019 were enrolled. Multiplex real-time polymerase chain reaction (RT-PCR) assays for viral detection were implemented to specimens (nasopharynx swab, sputum or bronchoalveolar lavage) obtained from all the patients, which was consistent with the diagnosis of lower respiratory tract infection. Patients were divided into two groups depending on the status of immune function (immunocompromised group, n=26; immunocompetent group, n=44), and patients were divided into PIV infection group (n=43) and mixed infection group (n=27) according to whether there was mixed infection. Characteristics including age, gender, underlying diseases, symptoms, disease severity, imaging manifestations, etiology, respiratory failure, mechanical ventilation, vasoactive drug, antimicrobial drug and 30-day mortality between the groups were compared, and the prognostic factors of PIV infections were investigated using Cox regression. Results: The peak incidence of PIV infection time was in May, August, September and December, accounting for 58.6% of all cases. The enrolled 70 cases included 43 cases with pneumonia, 16 cases with interstitial lung disease and infection, 7 cases with bronchiectasis and infection, and 4 cases with acute exacerbation of chronic obstructive pulmonary disease. Eight patients (11.4%) had no underlying diseases, 21 patients (30.0%) had respiratory failure, 18 patients (25.7%) were treated with mechanical ventilation, 15 patients (21.4%) died within 30 days after admission. The pneumonia severity index score, percentage of patients with ground-glass opacity according CT scan, with honeycomb or reticular pattern, with mechanical ventilation, with respiratory failure, with ICU admission, and 30-day mortality in immunocompromised group were higher than those of immunocompetent group [(91.5 vs 84.0), (60.0% vs 34.1%), (44.0% vs 11.4%), (42.3% vs 15.9%), (50.0% vs 18.2%), (38.5% vs 22.7%), (34.6% vs 13.6%)] (all P<0.05). There were 27 cases (38.6%) with mixed infection, including 17 viruses (24.3%), 19 bacteria (27.1%), 14 (20.0%) fungi (PCP, aspergillus) and 1 (1.4%) Mycobacterium intracellulare. Sixteen patients (59.3%) in the mixed infection group were immunocompromised patients and 21 patients (77.8%) had chronic lung disease. Cox regression analysis showed that mechanical ventilation and interstitial lung disease were independent predictors of prognosis in all patients, and mechanical ventilation was an independent predictor of prognosis in PIV infection group. Conclusions: Most of the patients with PIV lower respiratory tract infection in adults are complicated with underlying diseases and mixed infection, with a high 30-day mortality. Interstitial lung disease and mechanical ventilation indicate poor prognosis in these patients.

Cold-inducible RNA-binding protein might determine the severity and the presences of major/minor criteria for severe community-acquired pneumonia and best predicted mortality

BackgroundSeverity of community-acquired pneumonia (CAP) depends on microbial pathogenicity, load and virulence, and immune responses. The Infectious Disease Society of America and the American Thoracic Society (IDSA/ATS) minor criteria responsible for clinical triage of patients with CAP are of unequal weight in predicting mortality. It is unclear whether the IDSA/ATS major/minor criteria might be strongly and positively associated with the immune responses. It is warranted to explore this intriguing hypothesis.MethodsA prospective cohort study of 404 CAP patients was performed. Cold-inducible RNA-binding protein (CIRP) levels were measured using a sandwich-based enzyme-linked immunosorbent assay. The receiver operating characteristic curves were created and the areas under the curves were calculated to illustrate and compare the accuracy of the indices.ResultsSevere CAP patients meeting the major criteria had the highest plasma concentrations of CIRP. The more the number of most predictive minor criteria strongly associated to mortality, i.e. arterial oxygen pressure/fraction inspired oxygen ≤ 250 mmHg, confusion, and uremia, present, the higher the CIRP level. Interestingly, the patients with non-severe CAP meeting the most predictive minor criteria demonstrated unexpectedly higher CIRP level compared with the patients with severe CAP not fulfilling the criteria. Procalcitonin (PCT), interleukin-6 (IL-6), C-reactive protein (CRP), sequential organ failure assessment (SOFA) and pneumonia severity index (PSI) scores, and mortality confirmed similar intriguing patterns. CIRP was strongly linked to PCT, IL-6, CRP, minor criteria, SOFA and PSI scores, and mortality (increased odds ratio 3.433). The pattern of sensitivity, specificity, positive predictive value, and Youden’s index of CIRP ≥ 3.50 ng/mL for predicting mortality was the optimal. The area under the receiver operating characteristic curve of CIRP was the highest among the indices.ConclusionsCIRP levels were strongly correlated with the IDSA/ATS major/minor criteria. CIRP might determine the severity and the presences of major/minor criteria and best predicted mortality, and a CIRP of ≥ 3.50 ng/mL might be more valuable cut-off value for severe CAP, suggesting that CIRP might be a novel and intriguing biomarker for pneumonia to monitor host response and predict mortality, which might have implications for more accurate clinical triage decisions.

Early use of tocilizumab in the prevention of adult respiratory failure in SARS-CoV-2 infections and the utilization of interleukin-6 levels in the management.

Respiratory failure in severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection appears related to cytokine release syndrome that often results in mechanical ventilation (MV). We investigated the role of tocilizumab (TCZ) on interleukin‐6 (IL‐6) trends and MV in patients with SARS‐CoV‐2. In this longitudinal observational study, 112 patients were evaluated from 1 February to 31 May 2020. TCZ was administered followed by methylprednisolone to patients with >3L oxygen requirement and pneumonia severity index score ≤130 with computed tomography scan changes. IL‐6, C‐reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), D‐dimer, and procalcitonin were monitored on days 0, 3, and 6 of therapy. Statistical analyses were performed with significance ≤0.05. Eighty out of 112 SARS‐CoV‐2‐positive patients (45 males, 56.96%; 34 females, 43.04%) were included in this study. Seven patients expired (8.75%) and nine patients required MV (11.25%). Median IL‐6 levels pre‐administration of TCZ was 342.50 (78.25‐666.25) pg/mL compared with post‐administration on day 3 (563; 162‐783) pg/mL (P < .00001). On day 6, the median dropped to 545 (333.50‐678.50) pg/mL compared with day 3 (P = .709). CRP, ferritin, LDH, and D‐dimer levels were reduced after TCZ therapy. Early use of TCZ may reduce the need for MV and decrease CRP, ferritin, LDH, and D‐dimer levels. The sequential use of methylprednisolone for 72 hours seems to potentiate the effect and prolong the suppression of the cytokine storm. IL‐6 levels may be helpful as a prognostic tool.