Pneumonia Severity Scores Research Articles

Use of the ‘CURB 65’ score in hospital practice

The 'CURB 65' score is a simple well-validated tool for the assessment of severity in community acquired pneumonia (CAP). Whether it is used routinely is unknown. The aim of this study was to determine the frequency of use of the score in routine hospital practice and correlate this with clinical decision making and patient outcome. Retrospective cohort study of all patients with CAP (n=174) presenting in three winter months. Demographic and clinical outcome data were recorded and comparisons were made between those patients who had score applied on admission with those that did not. A CURB 65 score was assigned to all patients using data from the patient record, and admission decisions were compared. Only 9 (5.2%) CAP patients had the 'CURB 65' score applied at admission. The overall mortality rate was 3.4%. On applying a score to all cases retrospectively, appropriate admission decisions were made for patients with moderate or severe pneumonia and outcome was in accordance with published results. However, 23 (13%) patients age<65 with mild CAP and no comorbidities were admitted in spite of guideline recommendation for community care. These data demonstrate that clinical decision making in respect of moderate or severe CAP is the same whether or not a pneumonia severity score is applied. However, routine use of the score will identify patients with mild CAP thus potentially reducing unnecessary admission.

Comparison of clinical characteristics and performance of pneumonia severity score and CURB-65 among younger adults, elderly and very old subjects

BackgroundAge-related alterations in the clinical characteristics and performance of severity scoring systems for community-acquired pneumonia (CAP) are unknown.MethodsConsecutive patients with CAP presenting to the emergency department were prospectively studied. Patients...

Community-acquired macrolide-resistant Mycoplasma pneumoniae pneumonia in patients more than 18 years of age

A macrolide-resistant Mycoplasma pneumoniae strain was isolated from two patients with community-acquired pneumonia. The pneumonia severity score of both patients was mild, and rapid clinical improvement was seen after administration of fluoroquinolone. Clinical features of macrolide-resistant M. pneumoniae pneumonia were identical to those of macrolide-sensitive M. pneumoniae pneumonia. An A-to-G transition at position 2063 and 2064, respectively, in domain V of the 23S rRNA gene was identified. The minimum inhibitory concentration of erythromycin of these isolates was greatly elevated. In Japan, macrolide-resistant M. pneumoniae infections are common in pediatric patients but not in adults. However, physicians should pay attention to macrolide-resistant M. pneumoniae not only in children but also in adults.

Evaluation of pneumonia severity and acute physiology scores to predict ICU admission and mortality in patients hospitalized for influenza.

BackgroundThe demand for inpatient medical services increases during influenza season. A scoring system capable of identifying influenza patients at low risk death or ICU admission could help clinicians make hospital admission decisions.MethodsHospitalized patients with laboratory confirmed influenza were identified over 3 influenza seasons at 25 Ontario hospitals. Each patient was assigned a score for 6 pneumonia severity and 2 sepsis scores using the first data available following their registration in the emergency room. In-hospital mortality and ICU admission were the outcomes. Score performance was assessed using the area under the receiver operating characteristic curve (AUC) and the sensitivity and specificity for identifying low risk patients (risk of outcome <5%).ResultsThe cohort consisted of 607 adult patients. Mean age was 76 years, 12% of patients died (71/607) and 9% required ICU care (55/607). None of the scores examined demonstrated good discriminatory ability (AUC≥0.80). The Pneumonia Severity Index (AUC 0.78, 95% CI 0.72–0.83) and the Mortality in Emergency Department Sepsis score (AUC 0.77, 95% 0.71–0.83) demonstrated fair predictive ability (AUC≥0.70) for in-hospital mortality. The best predictor of ICU admission was SMART-COP (AUC 0.73, 95% CI 0.67–0.79). All other scores were poor predictors (AUC <0.70) of either outcome. If patients classified as low risk for in-hospital mortality using the PSI were discharged, 35% of admissions would have been avoided.ConclusionsNone of the scores studied were good predictors of in-hospital mortality or ICU admission. The PSI and MEDS score were fair predictors of death and if these results are validated, their use could reduce influenza admission rates significantly.

Prognostic assessment in community-acquired pneumonia by pneumonia severity scores and biomarkers

Classical biomarkers like C-reactive protein (CRP) or the leucocyte count are only inaccurate tools for predicting the severity of community-acquired pneumonia (CAP). Procalcitonin (PCT) was found to predict 28-day mortality in CAP (area under the curve (AUC) 0.8) similar to the combination of PCT and CRB65 score (AUC 0.83) [1]. Novel prognostic biomarkers, such as Pro-ET1 and MR-ProADM, were shown to correlate with CAP severity [2]. We aimed to compare the diagnostic accuracy to predict mortality and ICU admission of clinical severity scores, biomarkers and their combination.

Validation of the Infectious Disease Society of America/American Thoracic Society 2007 guidelines for severe community-acquired pneumonia*

Validate the Infectious Disease Society of America/American Thoracic Society 2007 (IDSA/ATS 2007) criteria for predicting severe community-acquired pneumonia (SCAP) and evaluate a health-services definition for SCAP. Retrospective cohort study. LDS Hospital, an academic tertiary care facility in the western United States. Consecutive patients with International Classification of Diseases, Ninth Edition, codes and chest radiographs consistent with community-acquired pneumonia from 1996 to 2006 seen at LDS Hospital. None. We utilized the electronic medical record to examine intensive care unit admission, intensive therapies received, and predictors of severity, as well as 30-day mortality. We also developed logistic regression models of mortality and disease severity. We calculated the IDSA/ATS 2007 criteria as well as three other pneumonia severity scores. We defined SCAP as receipt of intensive therapy in the intensive care unit. In 2413 episodes of pneumonia, 1540 were admitted to the hospital, while 379 were admitted to the intensive care unit. Overall 30-day mortality was 3.7% but was 16% among intensive care patients. The IDSA/ATS 2007 minor criteria predicted SCAP with an area under the curve of 0.88 (95% confidence interval 0.85-0.90), which improved to 0.90 (95% confidence interval 0.88-0.92) with weighting. Competing models had area under the curve of 0.76 to 0.83. Using four rather than three minor criteria improved the positive predictive value from 54% to 81%, with a stable negative predictive value of 94% to 92%. The IDSA/ATS 2007 criteria predicted pneumonia severity better than other models. Using four rather than three minor criteria may be a superior cutoff, although this will depend on institutional characteristics.

Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia

oropharyngeal dysphagia is a common condition among the elderly but not systematically explored. to assess the prevalence and the prognostic significance of oropharyngeal dysphagia among elderly patients with pneumonia. a prospective cohort study. an acute geriatric unit in a general hospital. a total of 134 elderly patients (>70 years) consecutively admitted with pneumonia. clinical bedside assessment of oropharyngeal dysphagia and aspiration with the water swallow test were performed. Demographic and clinical data, Barthel Index, Mini Nutritional Assessment, Charlson Comorbidity Index, Fine's Pneumonia Severity Index and mortality at 30 days and 1 year after admission were registered. of the 134 patients, 53% were over 84 years and 55% presented clinical signs of oropharyngeal dysphagia; the mean Barthel score was 61 points indicating a frail population. Patients with dysphagia were older, showed lower functional status, higher prevalence of malnutrition and comorbidities and higher Fine's pneumonia severity scores. They had a higher mortality at 30 days (22.9% vs. 8.3%, P = 0.033) and at 1 year of follow-up (55.4% vs. 26.7%, P = 0.001). oropharyngeal dysphagia is a highly prevalent clinical finding in elderly patients with pneumonia and is an indicator of disease severity in older patients with pneumonia.

Predicting the Need for Mechanical Ventilation and/or Inotropic Support for Young Adults Admitted to the Hospital with Community‐Acquired Pneumonia

The UK Department of Health has published concerns that pneumonia severity scores determined at hospital admission may underestimate the severity of pneumonia in young adults. SMART-COP (systolic blood pressure, multilobar chest radiography involvement, albumin level, respiratory rate, tachycardia, confusion, oxygenation, and arterial pH) was superior to both the CURB65 (confusion, urea, respiratory rate, systolic or diastolic blood pressure, and age >or=65 years) score and the Pneumonia Severity Index in predicting the need for mechanical ventilation and/or inotropic support, but SMART-COP would still incorrectly stratify 15% of patients.

Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

In patients with community-acquired pneumonia (CAP) prediction rules based on individual predicted mortalities are frequently used to support decision-making for in-patient vs. outpatient management. We studied the accuracy and the need for recalibration of three risk prediction scores in a tertiary-care University hospital emergency-department setting in Switzerland. We pooled data from patients with CAP enrolled in two randomized controlled trials. We compared expected mortality from the original pneumonia severity index (PSI), CURB65 and CRB65 scores against observed mortality (calibration) and recalibrated the scores by fitting the intercept alpha and the calibration slope beta from our calibration model. Each of the original models underestimated the observed 30-day mortality of 11%, in 371 patients admitted to the emergency department with CAP (8.4%, 5.5% and 5.0% for the PSI, CURB65 and CRB65 scores, respectively). In particular, we observed a relevant mortality within the low risk classes of the original models (2.6%, 5.3%, and 3.7% for PSI classes I-III, CURB65 classes 0-1, and CRB65 class 0, respectively). Recalibration of the original risk models corrected the miscalibration. After recalibration, however, only PSI class I was sensitive enough to identify patients with a low risk (i.e. <1%) for mortality suitable for outpatient management. In our tertiary-care setting with mostly referred in-patients, CAP risk scores substantially underestimated observed mortalities misclassifying patients with relevant risks of death suitable for outpatient management. Prior to the implementation of CAP risk scores in the clinical setting, the need for recalibration and the accuracy of low-risk re-classification should be studied in order to adhere with discharge guidelines and guarantee patients' safety.

Severity of illness assessment in community-acquired pneumonia

Sir: We welcome Rello and Rodriguez’s advocacy of pulse oximetry and pneumonia severity scoring in the emergency department [1]. However, we would like to clarify their interpretation of our findings comparing a physiological–social score and CURB-65 in a community-acquired pneumonia cohort [2]. As a predictor of mortality, CURB-65 achieved an AUC of only 0.79. As a predictor of admission to hospital and to level 2 or 3 (HDU or ITU) care, it achieved an AUC of 0.88 and 0.64 respectively. In comparison, our physiological score (PMEWS) achieved an AUC of 0.94 and 0.83 as a predictor of admission to hospital and to level 2 or 3 care, respectively. We believe this highlights the limitations of a score such as CURB-65 as a track-andtrigger tool and supports the use of a physiological score such as PMEWS which incorporates co-morbid factors and pulse oximetry as suggested by Rello and Rodriguez [1].

Assessment of severity in patients with community-acquired pneumonia: reply to letter by Challen et al.

Sir: We agree with Challen et al. about the convenience of incorporating co-morbidities [1] or pulse oximetry [2, 3] in community-acquired pneumonia (CAP) severity scoring. For initial triage, the severity of CAP should be assessed by simple physiologic parameters, including oxygen saturation, blood pressure and respiratory rate. Biomarkers and lactate may help to refine prediction in specific subsets [4]. The majority of studies assessing severity in CAP patients are conducted in the emergency department (ED). Scores more frequently used in the ED, such as the Pulmonary Severity Index, usually underestimate severity, particularly in young patients, and perform poorly in predicting ICU admission. Patients who score above 90 points are classified as class V, and this is an heterogeneous group. Therefore, we believe there is a need for novel ways of stratifying CAP patients. New severity assessment tools should stratify different classes of severity of illness, because the degree of systemic response is not always predictive of outcome. An ideal severity score for CAP should be simple and easy to perform, reflect acute physiological alterations (injury-related) and consider factors such as age, co-morbidities, degree of injury and organ dysfunction. Along these lines, Rui Moreno et al. [5] recently reported a study with a new method for classifying sepsis, which includes criteria not only for infection, but also for predisposition of the patient and response of the organism to injury. We suggest that a score inspired by this concept [6] might improve our ability to assess severity and stratify risk of death in ICU patients admitted with CAP. Pulse oximetry should form part of the triage at the ED, being a simple, cheap and largely available method of identifying poor perfusion and early oxygenation assessment. References

Prognosis of community acquired pneumonia (CAP): Value of triggering receptor expressed on myeloid cells-1 (TREM-1) and other mediators of the inflammatory response

TREM-1 is an activating receptor expressed on the surface of neutrophils and mature monocytes when stimulated by bacteria or fungi, leading to amplification of the inflammatory response. Our objective is to analyze the prognostic value of serum sTREM-1 levels and other mediators of the inflammatory response, in patients hospitalized for CAP, and to compare its prognostic value with those of advanced age, pneumonia severity scores, Charlson index, nutritional status and severity of sepsis. Methods. We included 226 patients with CAP, 145 males and 81 females, median age of 74 years. The following tests were performed: arterial blood gases and chest radiography, nutritional assessment, assessment of the severity of the sepsis, Pneumonia Severity Index (PSI) and CURB-65, and mediators of inflammation: TNF alfa, IL-6, IL-10, IL-1ra, LBP, sCD14, CRP, and sTREM-1. Mortality during admittance was defined as the sole end point. Results. Twenty-eight of the two-hundred and twenty-six patients died (12.4%). On univariate analysis advanced age, dehydration, increased Na, low BMI, handgrip strength, serum albumin, prealbumin, IGF-1, lymphocyte count, conscious drowsiness, tachypnea, decreased PaO2, hypotension, creatinine, ASAT, LDH, severity of sepsis, a high PSI or CURB65, TNFα, IL-6, IL-10, IL-1ra, and sTREM-1 were related to mortality. Variables with an independent value were IGF-1, CURB-65, TREM-1, advanced age and IL-6. Conclusions. This study confirms the usefulness of TREM-1 in the diagnosis and prognosis of patients with CAP, which is independent of advanced age, other inflammation markers such as IL-6, severity index for CAP such as CURB-65 or PSI, severity of sepsis and nutritional status including IGF-1.

Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial

Objectives To compare the effectiveness of an early switch to oral antibiotics with the standard 7 day course of intravenous antibiotics in severe community acquired pneumonia. Design Multicentre randomised controlled...

Mannose-binding lectin does not act as an acute-phase reactant in adults with community-acquired pneumococcal pneumonia

The objective of this work was to study the role of mannose-binding lectin (MBL) and C-reactive protein (CRP) in pneumococcal pneumonia, to determine whether MBL acts as an acute-phase reactant and whether the severity of the disease correlates with MBL levels. The study comprised 100 patients with pneumococcal pneumonia. The pneumonia severity score was calculated and graded into a risk class of mortality (Fine scale). The MBL genotypes and the levels of MBL and CRP at the acute and recovery phases were determined. Fifty patients with the wild-type MBL genotype showed higher MBL levels in each phase (P < 0.001) and an increased risk to developing bacteraemia, odds ratio (OR) 2.74, 95% confidence interval (CI) 1.01-7.52) (P = 0.02), but this did not correlate with the pneumonia severity class. CRP levels in the acute phase, 79.53 mg/l [standard deviation (s.d.) 106.93], were higher in the subjects with positive blood cultures (P = 0.003), and remained higher [20.12 mg/l (s.d. 31.90)] in the group of patients with an underlying disease (P = 0.01). No correlation was observed between the levels of MBL and CRP in each phase, or with the pneumonia severity score. We cannot conclude that MBL acts uniformly as an acute-phase reactant in pneumococcal pneumonia. MBL levels do not correlate well with the severity of the pneumonia. The risk of developing bacteraemia could be enhanced in individuals with the wild-type MBL genotype.

Studies of Respiratory Tract Infection in Nursing Home Residents: What Are We Learning?

Studies of Respiratory Tract Infection in Nursing Home Residents: What Are We Learning?

Discharge Delay in Patients with Community‐Acquired Pneumonia Managed on a Critical Pathway

It has previously been reported that a critical pathway for community-acquired pneumonia (CAP) significantly reduces bed days per patient managed but results in no difference in average length of stay, suggesting that discharge criteria were not successfully implemented. The present study sought to identify factors in the timing of discharge not taken into account by discharge criteria. Patients admitted with CAP and placed on a pneumonia critical pathway were studied. Patients' functional and cognitive status were evaluated using the Barthel Index, Hierarchical Assessment of Balance and Mobility (HABAM) and the Mini-Mental Status Examination. Once discharge criteria were met, the patient, a family member and the treating physician were interviewed to identify other factors contributing to length of stay. Thirty-one patients were enrolled in the study; 12 were discharged when they met discharge criteria and 19 stayed in hospital longer. There were no differences between patients discharged at stability versus those with an increased length of stay in terms of demographics, pneumonia severity score, functional or cognitive status at discharge using the Barthel Index (87.3+/-11.1 versus 83.8+/-8.6, respectively; P=0.46) and MMSE (27.1+/-1.1 versus 27.3+/-1.1, respectively; P=0.64); however, there was a significant difference in HABAM score at the time clinical stability was reached (22.6+/-1.3 versus 17.4+/-3.5, respectively; P=0.03), which correlated with physician and family assessments of patients' readiness for discharge. HABAM may be a useful tool to identify patients at risk of remaining in hospital after objective discharge criteria are met. Additional resources may be targeted at these patients to reduce length of stay in CAP.

Factors Influencing In-hospital Mortality in Community-Acquired Pneumonia: A Prospective Study of Patients Not Initially Admitted to the ICU

PurposeTo determine the factors that predict in-hospital mortality among patients who require hospitalization for the treatment of community-acquired pneumonia (CAP)Study designProspective observational study of all patients who were admitted to six hospitals in Edmonton, AL, Canada, with a diagnosis of CAP from November 15, 2000, to November 14, 2002. Pneumonia was defined as two or more respiratory symptoms and signs and an opacity on a chest radiograph as interpreted by the attending physicianResultsA total of 3,043 patients were enrolled in the study, 246 of whom died (8.1%). On multivariate analysis, increasing pneumonia severity score, increasing age, site of care, consultation with a respirologist or infectious diseases physician, and functional status at the time of admission were all independently predictive of mortality. Increasing pneumonia severity risk score, increasing age, site of hospitalization, functional status, and consultation with an infectious diseases physician or a respirologist were independently associated with both early (< 5 days) and late (≥ 5 days) mortality. In contrast, partial or complete use of the pneumonia pathway was associated with decreased early mortality, but had no effect on late mortality. A low lymphocyte count and a high serum potassium level were associated with early but not with late mortality. The type of antibiotic therapy had an effect on late but not on early mortalityConclusionsFunctional status at the time of hospital admission is a powerful predictor of mortality and should be incorporated into any scores or models that are used to predict mortality. While there are some common predictors of early and late in-hospital mortality, early mortality is not affected by the timing or type of antibiotic therapy, whereas late mortality is influenced by the type of antibiotic therapy. Hyperkalemia and lymphopenia are associated with early mortality

Factors Influencing In-hospital Mortality in Community-Acquired Pneumonia*

To determine the factors that predict in-hospital mortality among patients who require hospitalization for the treatment of community-acquired pneumonia (CAP). Prospective observational study of all patients who were admitted to six hospitals in Edmonton, AL, Canada, with a diagnosis of CAP from November 15, 2000, to November 14, 2002. Pneumonia was defined as two or more respiratory symptoms and signs and an opacity on a chest radiograph as interpreted by the attending physician. A total of 3,043 patients were enrolled in the study, 246 of whom died (8.1%). On multivariate analysis, increasing pneumonia severity score, increasing age, site of care, consultation with a respirologist or infectious diseases physician, and functional status at the time of admission were all independently predictive of mortality. Increasing pneumonia severity risk score, increasing age, site of hospitalization, functional status, and consultation with an infectious diseases physician or a respirologist were independently associated with both early (< 5 days) and late (>/= 5 days) mortality. In contrast, partial or complete use of the pneumonia pathway was associated with decreased early mortality, but had no effect on late mortality. A low lymphocyte count and a high serum potassium level were associated with early but not with late mortality. The type of antibiotic therapy had an effect on late but not on early mortality. Functional status at the time of hospital admission is a powerful predictor of mortality and should be incorporated into any scores or models that are used to predict mortality. While there are some common predictors of early and late in-hospital mortality, early mortality is not affected by the timing or type of antibiotic therapy, whereas late mortality is influenced by the type of antibiotic therapy. Hyperkalemia and lymphopenia are associated with early mortality.

Analysis of chest radiographs of culture positive Legionella pneumonia in Japan, 1980-1990. Working Party for Legionellosis, Japanese Ministry of Health and Welfare

We analyzed the initial and follow-up chest radiographs of 28 patients with culture-positive Legionella pneumonia, and developed a scoring system to quantitate the severity of radiological findings for pneumonia. Intrapulmonary shadows were observed on the initial chest radiograph in 26 patients, but pleural effusion was noted in only one. In one patient the initial chest radiograph had probably been obtained too early to reveal any pulmonary change. Alveolar shadows were noted on the initial radiograph in 21 (81%) patients, and interstitial shadows in 5 (19%). In ten (38%) patients shadows were present in both lung fields. Shadows were prominent in the middle and lower lung fields. A cavity was noted in only one patient, and pleural effusion was also noted at some time during the clinical course in 19 (70%). A large amount of pleural effusion was observed in four patients. The average pneumonia severity score was 3.3 in the 9 patients who survived, and 5.1 in the 17 who died (p > 0.05). The mortality rate was 53% in the 17 patients with pneumonia severity score of 5 or less and 89% in the 9 patients with a score of 6 or more (p > 0.05). Twelve patients died within one week after the initial chest radiograph was obtained. There were no differences among patients with community-acquired infection with or without underlying disease and those with nosocomial infection in characteristic and extension of shadow, presence of pleural effusion, or pneumonia score. The chest radiograph of Legionella pneumonia include bilateral shadow findings characteristic, pleural effusion and rapid progression of shadow, and are clinically useful for diagnosis.