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Noguchi S, Katsurada M, Yatera K, Nakagawa N, Xu D, Fukuda Y, Shindo Y, Senda K, Tsukada H, Miki M, Mukae H. Utility of pneumonia severity assessment tools for mortality prediction in healthcare-associated pneumonia: a systematic review and meta-analysis. Sci Rep 2024; 14:12964. [PMID: 38839837 PMCID: PMC11153623 DOI: 10.1038/s41598-024-63618-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/30/2024] [Indexed: 06/07/2024] Open
Abstract
Accurate prognostic tools for mortality in patients with healthcare-associated pneumonia (HCAP) are needed to provide appropriate medical care, but the efficacy for mortality prediction of tools like PSI, A-DROP, I-ROAD, and CURB-65, widely used for predicting mortality in community-acquired and hospital-acquired pneumonia cases, remains controversial. In this study, we conducted a systematic review and meta-analysis using PubMed, Cochrane Library (trials), and Ichushi web database (accessed on August 22, 2022). We identified articles evaluating either PSI, A-DROP, I-ROAD, or CURB-65 and the mortality outcome in patients with HCAP, and calculated the pooled sensitivities, specificities, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the summary area under the curves (AUCs) for mortality prediction. Additionally, the differences in predicting prognosis among these four assessment tools were evaluated using overall AUCs pooled from AUC values reported in included studies. Eventually, 21 articles were included and these quality assessments were evaluated by QUADAS-2. Using a cut-off value of moderate in patients with HCAP, the range of pooled sensitivity, specificity, PLR, NLR, and DOR were found to be 0.91-0.97, 0.15-0.44, 1.14-1.66, 0.18-0.33, and 3.86-9.32, respectively. Upon using a cut-off value of severe in those patients, the range of pooled sensitivity, specificity, PLR, NLR, and DOR were 0.63-0.70, 0.54-0.66, 1.50-2.03, 0.47-0.58, and 2.66-4.32, respectively. Overall AUCs were 0.70 (0.68-0.72), 0.70 (0.63-0.76), 0.68 (0.64-0.73), and 0.67 (0.63-0.71), respectively, for PSI, A-DROP, I-ROAD, and CURB-65 (p = 0.66). In conclusion, these severity assessment tools do not have enough ability to predict mortality in HCAP patients. Furthermore, there are no significant differences in predictive performance among these four severity assessment tools.
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Affiliation(s)
- Shingo Noguchi
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.
- Department of Respiratory Medicine, Tobata General Hospital, Kitakyushu, Japan.
| | - Masahiro Katsurada
- Department of Respiratory Medicine, Kita-Harima Medical Center, Ono, Japan
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Natsuki Nakagawa
- Department of Respiratory Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Dongjie Xu
- Department of Pulmonary and Respiratory Medicine, Japanese Red Cross Sendai Hospital, Sendai, Japan
| | - Yosuke Fukuda
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuyoshi Senda
- Department of Pharmacy, Kinjo Gakuin University, Nagoya, Japan
| | - Hiroki Tsukada
- Department of Infection Control, The Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Makoto Miki
- Department of Pulmonary and Respiratory Medicine, Japanese Red Cross Sendai Hospital, Sendai, Japan
| | - Hiroshi Mukae
- Unit of Translational Medicine, Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Annareddy S, Ghewade B, Jadhav U, Wagh P. Unraveling the Predictive Potential of Rapid Scoring in Pleural Infection: A Critical Review. Cureus 2023; 15:e44515. [PMID: 37789994 PMCID: PMC10544591 DOI: 10.7759/cureus.44515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Pleural infection, or pleural empyema, is a severe medical condition associated with high morbidity and mortality rates. Timely and accurate prognostication is crucial for optimizing patient outcomes and resource allocation. Rapid scoring systems have emerged as promising tools in pleural infection prognostication, integrating various clinical and laboratory parameters to assess disease severity and quantitatively predict short-term and long-term outcomes. This review article critically evaluates existing rapid scoring systems, including CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥ 65 years), A-DROP (age (male >70 years, female >75 years), dehydration, respiratory failure, orientation disturbance, and low blood pressure), and APACHE II (acute physiology and chronic health evaluation II), assessing their predictive accuracy and limitations. Our analysis highlights the potential clinical implications of rapid scoring, including risk stratification, treatment tailoring, and follow-up planning. We discuss practical considerations and challenges in implementing rapid scoring such as data accessibility and potential sources of bias. Furthermore, we emphasize the importance of validation, transparency, and multidisciplinary collaboration to refine and enhance the clinical applicability of these scoring systems. The prospects for rapid scoring in pleural infection management are promising, with ongoing research and data science advances offering improvement opportunities. Ultimately, the successful integration of rapid scoring into clinical practice can potentially improve patient care and outcomes in pleural infection management.
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Affiliation(s)
- Srinivasulareddy Annareddy
- Respiratory Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Babaji Ghewade
- Respiratory Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ulhas Jadhav
- Respiratory Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pankaj Wagh
- Respiratory Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Joseph S, Mathew J, Noyal S, Biju S, Jose A. Etiological profile, prescribing pattern of antibiotics and clinical outcomes of pneumonia patients in a tertiary care hospital in South India during 5-year period. MGM JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4103/mgmj.mgmj_205_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Urea-to-Albumin Ratio and In-Hospital Mortality in Severe Pneumonia Patients. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2021; 2021:5105870. [PMID: 34721746 PMCID: PMC8556110 DOI: 10.1155/2021/5105870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/29/2021] [Indexed: 11/17/2022]
Abstract
Objective The urea-to-albumin ratio (UAR), as a new marker of the systemic inflammatory response, is associated with the mortality in pneumonia patients. However, the association between the UAR and in-hospital mortality in severe pneumonia (SP) has received little attention. Methods In this single-center retrospective cohort study, 212 SP patients in intensive care unit (ICU) from June 1, 2016, to June 1st, 2020, with baseline UAR were enrolled. The primary outcome was in-hospital mortality. The association of UAR with in-hospital mortality was assessed using a multivariable-adjusted Cox model. Results Of 212 patients, the median age was 73.0 (61.0, 82.8) years, 70.8% of patients were male, and the APACHE II score was 20.0 (16.0, 26.0). During the hospital period, 101 (47.6%) patients died. In-hospital mortality rates for the lower and higher UAR were 16 (27.6%) and 85 (55.2%), respectively (P < 0.001). Kaplan–Meier analysis revealed that survival rates were significantly different between the two groups (log rank = 13.71, P < 0.001). After adjusted for confounding factors, the higher UAR group was significantly associated with a hazard ratio (HR) for in-hospital mortality of 2.234 (95% confidence interval: 1.146–4.356, P=0.018). Besides, this pattern persisted in subgroup analyses considering sex (HR = 9.380; 95% CI: 2.248–39.138; P=0.002). Conclusions Higher UAR levels at the commencement of admission to ICU may be independently associated with increased in-hospital mortality in SP patients.
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Quah J, Liew CJY, Zou L, Koh XH, Alsuwaigh R, Narayan V, Lu TY, Ngoh C, Wang Z, Koh JZ, Ang C, Fu Z, Goh HL. Chest radiograph-based artificial intelligence predictive model for mortality in community-acquired pneumonia. BMJ Open Respir Res 2021; 8:8/1/e001045. [PMID: 34376402 PMCID: PMC8354266 DOI: 10.1136/bmjresp-2021-001045] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 07/21/2021] [Indexed: 12/15/2022] Open
Abstract
Background Chest radiograph (CXR) is a basic diagnostic test in community-acquired pneumonia (CAP) with prognostic value. We developed a CXR-based artificial intelligence (AI) model (CAP AI predictive Engine: CAPE) and prospectively evaluated its discrimination for 30-day mortality. Methods Deep-learning model using convolutional neural network (CNN) was trained with a retrospective cohort of 2235 CXRs from 1966 unique adult patients admitted for CAP from 1 January 2019 to 31 December 2019. A single-centre prospective cohort between 11 May 2020 and 15 June 2020 was analysed for model performance. CAPE mortality risk score based on CNN analysis of the first CXR performed for CAP was used to determine the area under the receiver operating characteristic curve (AUC) for 30-day mortality. Results 315 inpatient episodes for CAP occurred, with 30-day mortality of 19.4% (n=61/315). Non-survivors were older than survivors (mean (SD)age, 80.4 (10.3) vs 69.2 (18.7)); more likely to have dementia (n=27/61 vs n=58/254) and malignancies (n=16/61 vs n=18/254); demonstrate higher serum C reactive protein (mean (SD), 109 mg/L (98.6) vs 59.3 mg/L (69.7)) and serum procalcitonin (mean (SD), 11.3 (27.8) μg/L vs 1.4 (5.9) μg/L). The AUC for CAPE mortality risk score for 30-day mortality was 0.79 (95% CI 0.73 to 0.85, p<0.001); Pneumonia Severity Index (PSI) 0.80 (95% CI 0.74 to 0.86, p<0.001); Confusion of new onset, blood Urea nitrogen, Respiratory rate, Blood pressure, 65 (CURB-65) score 0.76 (95% CI 0.70 to 0.81, p<0.001), respectively. CAPE combined with CURB-65 model has an AUC of 0.83 (95% CI 0.77 to 0.88, p<0.001). The best performing model was CAPE incorporated with PSI, with an AUC of 0.84 (95% CI 0.79 to 0.89, p<0.001). Conclusion CXR-based CAPE mortality risk score was comparable to traditional pneumonia severity scores and improved its discrimination when combined.
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Affiliation(s)
- Jessica Quah
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | | | - Lin Zou
- Integrated Health Information Systems Pte Ltd, Singapore
| | - Xuan Han Koh
- Health Services Research, Changi General Hospital, Singapore
| | - Rayan Alsuwaigh
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | | | - Tian Yi Lu
- Integrated Health Information Systems Pte Ltd, Singapore
| | - Clarence Ngoh
- Integrated Health Information Systems Pte Ltd, Singapore
| | - Zhiyu Wang
- Integrated Health Information Systems Pte Ltd, Singapore
| | - Juan Zhen Koh
- Integrated Health Information Systems Pte Ltd, Singapore
| | - Christine Ang
- Integrated Health Information Systems Pte Ltd, Singapore
| | - Zhiyan Fu
- Integrated Health Information Systems Pte Ltd, Singapore
| | - Han Leong Goh
- Integrated Health Information Systems Pte Ltd, Singapore
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Mar Minn M, Aung NM, Kyaw DZ, Zaw TT, Chann PN, Khine HE, McLoughlin S, Kelleher AD, Tun NL, Oo TZC, Myint NPST, Law M, Mar Kyi M, Hanson J. The comparative ability of commonly used disease severity scores to predict death or a requirement for ICU care in patients hospitalised with possible sepsis in Yangon, Myanmar. Int J Infect Dis 2021; 104:543-550. [PMID: 33493689 DOI: 10.1016/j.ijid.2021.01.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To determine the comparative prognostic utility of commonly used disease prediction scores in adults with presumed community-acquired sepsis in a resource-limited tropical setting. METHODS This prospective, observational study was performed on the medical ward of a tertiary-referral hospital in Yangon, Myanmar. The ability of the National Early Warning Score 2 (NEWS2), quick NEWS (qNEWS), quick Sequential Organ Failure Assessment (qSOFA) score, Universal Vital Assessment (UVA) and Sequential Organ Failure Assessment (SOFA) scores to predict a complicated inpatient course (death or requirement for intensive care unit (ICU) support) in patients with two or more systemic inflammatory response syndrome criteria was determined. RESULTS Among the 509 patients, 30 (6%) were HIV-seropositive. The most commonly confirmed diagnoses were tuberculosis (30/509, 5.9%) and measles (26/509, 5.1%). Overall, 75/509 (14.7%) died or required ICU support. All the scores except the qSOFA score, which was inferior, had a similar ability to predict a complicated inpatient course. CONCLUSIONS In this resource-limited tropical setting, disease severity scores calculated at presentation using only vital signs-such as the NEWS2 score-identified high-risk sepsis patient as well as the SOFA score, which is calculated at 24 h and which also requires laboratory data. Use of these simple clinical scores can be used to facilitate recognition of the high-risk patient and to optimise the use of finite resources.
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Affiliation(s)
- Mar Mar Minn
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Ne Myo Aung
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - De Zin Kyaw
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Thet Tun Zaw
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Pyae Nyein Chann
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Hnin Ei Khine
- Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | | | | | - Ne Lin Tun
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Thin Zar Cho Oo
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Nan Phyu Sin Toe Myint
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Matthew Law
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mar Mar Kyi
- Insein General Hospital, Insein Township, Yangon, Myanmar; University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar; Myanmar Australia Research Collaboration for Health (MARCH), Yangon, Myanmar; The Kirby Institute, University of New South Wales, Sydney, Australia.
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7
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Angus DC, Berry S, Lewis RJ, Al-Beidh F, Arabi Y, van Bentum-Puijk W, Bhimani Z, Bonten M, Broglio K, Brunkhorst F, Cheng AC, Chiche JD, De Jong M, Detry M, Goossens H, Gordon A, Green C, Higgins AM, Hullegie SJ, Kruger P, Lamontagne F, Litton E, Marshall J, McGlothlin A, McGuinness S, Mouncey P, Murthy S, Nichol A, O’Neill GK, Parke R, Parker J, Rohde G, Rowan K, Turner A, Young P, Derde L, McArthur C, Webb SA. The REMAP-CAP (Randomized Embedded Multifactorial Adaptive Platform for Community-acquired Pneumonia) Study. Rationale and Design. Ann Am Thorac Soc 2020; 17:879-891. [PMID: 32267771 PMCID: PMC7328186 DOI: 10.1513/annalsats.202003-192sd] [Citation(s) in RCA: 229] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/08/2020] [Indexed: 12/22/2022] Open
Abstract
There is broad interest in improved methods to generate robust evidence regarding best practice, especially in settings where patient conditions are heterogenous and require multiple concomitant therapies. Here, we present the rationale and design of a large, international trial that combines features of adaptive platform trials with pragmatic point-of-care trials to determine best treatment strategies for patients admitted to an intensive care unit with severe community-acquired pneumonia. The trial uses a novel design, entitled "a randomized embedded multifactorial adaptive platform." The design has five key features: 1) randomization, allowing robust causal inference; 2) embedding of study procedures into routine care processes, facilitating enrollment, trial efficiency, and generalizability; 3) a multifactorial statistical model comparing multiple interventions across multiple patient subgroups; 4) response-adaptive randomization with preferential assignment to those interventions that appear most favorable; and 5) a platform structured to permit continuous, potentially perpetual enrollment beyond the evaluation of the initial treatments. The trial randomizes patients to multiple interventions within four treatment domains: antibiotics, antiviral therapy for influenza, host immunomodulation with extended macrolide therapy, and alternative corticosteroid regimens, representing 240 treatment regimens. The trial generates estimates of superiority, inferiority, and equivalence between regimens on the primary outcome of 90-day mortality, stratified by presence or absence of concomitant shock and proven or suspected influenza infection. The trial will also compare ventilatory and oxygenation strategies, and has capacity to address additional questions rapidly during pandemic respiratory infections. As of January 2020, REMAP-CAP (Randomized Embedded Multifactorial Adaptive Platform for Community-acquired Pneumonia) was approved and enrolling patients in 52 intensive care units in 13 countries on 3 continents. In February, it transitioned into pandemic mode with several design adaptations for coronavirus disease 2019. Lessons learned from the design and conduct of this trial should aid in dissemination of similar platform initiatives in other disease areas.Clinical trial registered with www.clinicaltrials.gov (NCT02735707).
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Affiliation(s)
- Derek C. Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Roger J. Lewis
- Berry Consultants, LLC, Austin, Texas
- Department of Emergency Medicine, Harbor–University of California Los Angeles (UCLA) Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care
- Department of Medical Microbiology, and
| | | | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Allen C. Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jean-Daniel Chiche
- Medical Intensive Care Unit, Hôpital Cochin, Paris Descartes University, Paris, France
| | - Menno De Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Anthony Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alisa M. Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - John Marshall
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit and
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, British Columbia, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent’s University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Genevieve K. O’Neill
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit and
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gernot Rohde
- Department of Respiratory Medicine, University Hospital Frankfurt, Frankfurt, Germany
- CAPNETZ Foundation, Hannover, Germany
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand; and
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Colin McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Steven A. Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St. John of God Hospital, Subiaco, Western Australia, Australia
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Min JH, Lee H, Chung SJ, Yeo Y, Park TS, Park DW, Moon JY, Kim SH, Kim TH, Sohn JW, Yoon HJ. Neutrophil Gelatinase-Associated Lipocalin for Predicting Intensive Care Unit Admission and Mortality in Patients with Pneumonia. TOHOKU J EXP MED 2020; 250:243-251. [PMID: 32307375 DOI: 10.1620/tjem.250.243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pneumonia is one of the most common causes of hospital admissions and mortality, and it is responsible for significant socioeconomic burden worldwide. Neutrophil gelatinase-associated lipocalin (NGAL) is a 25-kDa protein, which is involved in iron trafficking and has chemostatic and bacteriostatic effects. NGAL is also known as an early marker of many inflammatory diseases. However, little is known about the role of NGAL in the management of pneumonia. Thus, this study aimed to investigate whether plasma NGAL levels can predict intensive care unit (ICU) admission and in-hospital mortality in patients with pneumonia. This retrospective observational study included 241 adults hospitalized with pneumonia who underwent NGAL measurement. We compared the prognostic values of plasma NGAL with pneumonia severity index (PSI) for prediction of ICU admission and in-hospital mortality. Of 241 patients, 47 (19.5%) died during hospital admission. There was no significant difference between NGAL and PSI for predicting ICU admission (area under the receiver operating characteristic curve [AUC] of log NGAL vs. PSI, P > 0.999). Although log NGAL was useful in predicting in-hospital mortality, its ability was inferior to that of PSI (AUC of log NGAL vs. PSI, P = 0.008). Multivariable analysis revealed that log NGAL was significantly associated with ICU admission (adjusted odds ratio = 10.76, P < 0.001) and in-hospital mortality (adjusted odds ratio = 5.04, P = 0.004). These results suggest that plasma NGAL level is a useful biomarker for predicting ICU admission and mortality in hospitalized patients with pneumonia.
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Affiliation(s)
- Ji-Hee Min
- Department of Internal Medicine, Hanyang University College of Medicine
| | - Hyun Lee
- Department of Internal Medicine, Hanyang University College of Medicine
| | - Sung Jun Chung
- Department of Internal Medicine, Hanyang University College of Medicine
| | - Yoomi Yeo
- Department of Internal Medicine, Hanyang University College of Medicine
| | - Tai Sun Park
- Department of Internal Medicine, Hanyang University College of Medicine
| | - Dong Won Park
- Department of Internal Medicine, Hanyang University College of Medicine
| | - Ji-Yong Moon
- Department of Internal Medicine, Hanyang University College of Medicine
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine
| | - Tae Hyung Kim
- Department of Internal Medicine, Hanyang University College of Medicine
| | - Jang Won Sohn
- Department of Internal Medicine, Hanyang University College of Medicine
| | - Ho Joo Yoon
- Department of Internal Medicine, Hanyang University College of Medicine
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9
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Point of Care eGFR and the Prediction of Outcomes in Pneumonia. Sci Rep 2019; 9:8478. [PMID: 31186488 PMCID: PMC6559990 DOI: 10.1038/s41598-019-44945-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 05/13/2019] [Indexed: 01/27/2023] Open
Abstract
Pneumonia is a leading cause of mortality. Severity-assessment scores in pneumonia guide treatment crucially, but the ones currently in existence are limited in their use. Community-based studies demonstrated the association between pre-existing low estimated glomerular filtration rate (eGFR) and outcomes in pneumonia. However, whether a single emergency department-eGFR measurement could predict outcomes in pneumonia remains unclear. This retrospective cohort study included 1554 patients hospitalized with pneumonia. The predictor was the first eGFR measurement. Outcomes included mortality, intensive care unit (ICU) admission, durations of hospital and ICU stay, and ventilator use. Receiver operating characteristic curves was used to determine optimal cutoff values to predict mortality. Of 1554 patients, 263 had chronic kidney disease, demonstrated higher C-reactive protein and SMART-COP scores, and had more multilobar pneumonia, acute kidney injury, ICU admission, and mortality. Patients with higher pneumonia severity scores tended to have lower eGFR. For predicting in-hospital mortality, the optimal eGFR cutoff value was 56 mL/min/1.73 m2. eGFR < 56 mL/min/1.73 m2 had an odds ratio of 2.5 (95% confidence interval, 1.6–4.0) for mortality by multivariate logistic regression. In Conclusion, eGFR < 56 mL/min/1.73 m2 is an independent predictor of mortality, indicating that even mild renal impairment affects the outcome of pneumonia adversely.
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Relationship Between the Serum Level of C-Reactive Protein and Severity and Outcomes of Community-acquired Pneumonia. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2019. [DOI: 10.5812/archcid.63893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ugajin M, Matsuura Y, Matsuura K, Matsuura H. Impact of initial plasma presepsin level for clinical outcome in hospitalized patients with pneumonia. J Thorac Dis 2019; 11:1387-1396. [PMID: 31179081 DOI: 10.21037/jtd.2019.03.74] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Presepsin, the soluble CD14 subtype, is known as a sepsis biomarker. However, its clinical significance in pneumonia is unclear. We investigated the effects of plasma presepsin level on clinical outcomes in patients with pneumonia. Methods Patients over 18 years old admitted to our hospital due to pneumonia from May 2016 through November 2017 were reviewed using electronic medical records. One hundred and seventy-two patients who underwent measurement of plasma presepsin levels on admission were enrolled. Median age of enrolled patients was 81 years [interquartile range (IQR), 68-86 years]. Pneumonia severity index (PSI) class and A-DROP score on admission were calculated. The receiver operating characteristic (ROC) curve analysis was performed to assess the prognostic value of 30-day mortality and to identify the optimal cut-off value of plasma presepsin level. Correlations between plasma presepsin level and other factors were assessed using the Spearman's test. The Kaplan-Meier survival analysis and the log-rank test were performed to assess the two curves differentiated with the optimal cut-off value of plasma presepsin level. Results Seventeen patients (9.9%) died within 30 days of admission. The deceased patients had higher value of plasma presepsin on admission (539 pg/mL; IQR, 414-832 pg/mL) compared with the survivors (334 pg/mL; IQR, 223-484 pg/mL) (P=0.001). The areas under ROC curve for predicting 30-day mortality were 0.742 for plasma presepsin, 0.755 for A-DROP score, and 0.774 for PSI class. Plasma presepsin level was not associated with etiology of pneumonia. However, it was moderately correlated with serum creatinine level (rs =0.524, P<0.001). The ROC curve analysis derived 470 pg/mL of plasma presepsin level as the optimal cut-off value for predicting 30-day mortality. The Kaplan-Meier survival analysis showed that patients with plasma presepsin level ≥470 pg/mL on admission had significantly higher 30-day mortality than those with plasma presepsin level <470 pg/mL (P<0.001). Among patients with A-DROP score ≥3, those with plasma presepsin level ≥470 mg on admission had significantly higher 30-day mortality (P=0.013). Similarly, among patients with PSI class ≥4, those with plasma presepsin level ≥470 mg on admission had significantly higher 30-day mortality (P=0.005). Conclusions In hospitalized pneumonia patients, plasma presepsin level on admission could be a useful predictor of 30-day mortality and an additional prognostic biomarker on existing severity assessment scales.
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Affiliation(s)
- Motoi Ugajin
- Department of Respiratory Medicine, Nagoya Tokushukai General Hospital, Kasugai City, Aichi Prefecture, Japan
| | - Yu Matsuura
- Department of Internal Medicine, Nagoya Tokushukai General Hospital, Kasugai City, Aichi Prefecture, Japan
| | - Kei Matsuura
- Department of Internal Medicine, Nagoya Tokushukai General Hospital, Kasugai City, Aichi Prefecture, Japan
| | - Hiroshi Matsuura
- Department of Internal Medicine, Nagoya Tokushukai General Hospital, Kasugai City, Aichi Prefecture, Japan
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12
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An increase in mean platelet volume during admission can predict the prognoses of patients with pneumonia in the intensive care unit: A retrospective study. PLoS One 2018; 13:e0208715. [PMID: 30533065 PMCID: PMC6289458 DOI: 10.1371/journal.pone.0208715] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/22/2018] [Indexed: 02/03/2023] Open
Abstract
Platelets play an important role in hemostasis, inflammation, and immunity. Mean platelet volume (MPV), considered a marker of platelet function and activation, is associated with increased morbidity and mortality in sepsis, coronary artery disease, and chronic inflammatory disease. However, the clinical characteristics and prognostic significance of MPV changes for patients with pneumonia in the intensive care unit (ICU) have not been investigated. This retrospective study was conducted using data from an operational database of patients admitted to a medical ICU between October 2010 and October 2017. Of 235 adult patients with pneumonia admitted to the ICU, clinical characteristics and in-hospital mortality values were compared according to MPV, ΔMPVday1–2, ΔMPVday1–3, ΔMPVday1–4, and ΔMPVday1–Discharge between those who survived and those who did not. The MPV increased during the first four days for both non-survivors and survivors (P < 0.001). However, repeated measures analysis of variance revealed a significantly higher MPV rate over the first four days in non-survivors than in survivors. Additionally, the ΔMPVday1–2, ΔMPVday1–3, ΔMPVday1–4, and ΔMPVday1–Discharge values were significantly greater in non-survivors than in survivors. For in-hospital mortality, the optimal ΔMPV values were >0.9 fL, P = 0.020; >0.9 fL, P < 0.001; >0.8 fL, P < 0.001; and >1.3 fL, P < 0.001 on day 2, day 3, day 4, and at discharge, respectively. In conclusion, our findings demonstrate that ΔMPV during ICU admission may be used as a prognostic marker of mortality in ICU patients with pneumonia. Repeated MPV measurements throughout hospitalization may improve risk stratification for these patients, which could aid in improving patient outcomes.
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13
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Kobayashi D, Shindo Y, Ito R, Iwaki M, Okumura J, Sakakibara T, Yamaguchi I, Yagi T, Ogasawara T, Sugino Y, Taniguchi H, Saito H, Saka H, Kawamura T, Hasegawa Y. Validation of the prediction rules identifying drug-resistant pathogens in community-onset pneumonia. Infect Drug Resist 2018; 11:1703-1713. [PMID: 30349327 PMCID: PMC6188199 DOI: 10.2147/idr.s165669] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Appropriate initial antibiotic treatment and avoiding administration of unnecessary broad-spectrum antibiotics are important for the treatment of pneumonia. To achieve this, assessment of risk for drug-resistant pathogens (DRPs) at diagnosis is essential. Purpose The aim of this study was to validate a predictive rule for DRPs that we previously proposed (the community-acquired pneumonia drug-resistant pathogen [CAP-DRP] rule), comparing several other predictive methods. Patients and methods A prospective observational study was conducted in hospitalized patients with community-onset pneumonia at four institutions in Japan. Pathogens identified as not susceptible to ceftriaxone, ampicillin–sulbactam, macrolides, and respiratory fluoroquinolones were defined as CAP-DRPs. Results CAP-DRPs were identified in 73 (10.1%) of 721 patients analyzed. The CAP-DRP rule differentiated low vs high risk of CAP-DRP at the threshold of ≥3 points or 2 points plus any of methicillin-resistant Staphylococcus aureus specific factors with a sensitivity of 0.45, specificity of 0.87, positive predictive value of 0.47, negative predictive value of 0.87, and accuracy of 0.79. Its discrimination performance, area under the receiver operating characteristic curve, was 0.73 (95% confidence interval 0.66–0.79). Specificity of the CAP-DRP rule against CAP-DRPs was the highest among the six predictive rules tested. Conclusion The performance of the predictive rules and criteria for CAP-DRPs was limited. However, the CAP-DRP rule yielded high specificity and could specify patients who should be treated with non-broad-spectrum antibiotics, eg, a non-pseudomonal β-lactam plus a macrolide, more precisely.
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Affiliation(s)
- Daisuke Kobayashi
- Kyoto University Health Service, Kyoto, Japan.,Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,
| | - Ryota Ito
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan, .,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mai Iwaki
- Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Respiratory Medicine, Kasugai Municipal Hospital, Kasugai, Japan
| | - Junya Okumura
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan, .,Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Toshihiro Sakakibara
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan, .,Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Ikuo Yamaguchi
- Department of Central Laboratory, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Tetsuya Yagi
- Department of Infectious Diseases, Nagoya University Hospital, Nagoya, Japan
| | - Tomohiko Ogasawara
- Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yasuteru Sugino
- Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Hiroshi Saito
- Department of Respiratory Medicine, Aichi Cancer Center Aichi Hospital, Okazaki, Japan
| | - Hideo Saka
- Department of Respiratory Medicine, National Hospital Organization, Nagoya Medical Center, Nagoya, Japan
| | | | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,
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Emergency Medicine Evaluation of Community-Acquired Pneumonia: History, Examination, Imaging and Laboratory Assessment, and Risk Scores. J Emerg Med 2017; 53:642-652. [PMID: 28941558 DOI: 10.1016/j.jemermed.2017.05.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 05/07/2017] [Accepted: 05/30/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pneumonia is a common infection, accounting for approximately one million hospitalizations in the United States annually. This potentially life-threatening disease is commonly diagnosed based on history, physical examination, and chest radiograph. OBJECTIVE To investigate emergency medicine evaluation of community-acquired pneumonia including history, physical examination, imaging, and the use of risk scores in patient assessment. DISCUSSION Pneumonia is the number one cause of death from infectious disease. The condition is broken into several categories, the most common being community-acquired pneumonia. Diagnosis centers on history, physical examination, and chest radiograph. However, all are unreliable when used alone, and misdiagnosis occurs in up to one-third of patients. Chest radiograph has a sensitivity of 46-77%, and biomarkers including white blood cell count, procalcitonin, and C-reactive protein provide little benefit in diagnosis. Biomarkers may assist admitting teams, but require further study for use in the emergency department. Ultrasound has shown utility in correctly identifying pneumonia. Clinical gestalt demonstrates greater ability to diagnose pneumonia. Clinical scores including Pneumonia Severity Index (PSI); Confusion, blood Urea nitrogen, Respiratory rate, Blood pressure, age 65 score (CURB-65); and several others may be helpful for disposition, but should supplement, not replace, clinical judgment. Patient socioeconomic status must be considered in disposition decisions. CONCLUSION The diagnosis of pneumonia requires clinical gestalt using a combination of history and physical examination. Chest radiograph may be negative, particularly in patients presenting early in disease course and elderly patients. Clinical scores can supplement clinical gestalt and assist in disposition when used appropriately.
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16
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Chang PY, Tsao SM, Chang JH, Chien MH, Hung WY, Huang YW, Yang SF. Plasma levels of soluble intercellular adhesion molecule-1 as a biomarker for disease severity of patients with community-acquired pneumonia. Clin Chim Acta 2016; 463:174-180. [PMID: 27983998 DOI: 10.1016/j.cca.2016.10.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is characterized as an acute inflammation of the lung associated with the activation of macrophages and neutrophils. Intercellular adhesion molecule-1 (ICAM-1) is an essential adhesion molecule involved in immune cell recruitment in lung inflammation. We investigated whether ICAM-1 is a useful biomarker for assessing the disease severity of hospitalized adult patients with CAP. METHODS Plasma soluble ICAM-1 (sICAM-1) levels were measured in 78 patients with CAP and 69 healthy controls by using a commercial enzyme-linked immunosorbent assay. The pneumonia severity index scores were used to determine CAP severity in patients upon initial hospitalization. RESULTS The sICAM-1 and C-reactive protein (CRP) levels decreased significantly in patients with CAP after antibiotic treatment. The plasma concentration of sICAM-1 alone, but not CRP, was correlated with CAP severity according to the pneumonia severity index scores (r=0.431, p<0.001). The sICAM-1 levels in patients with CAP with high mortality risk were significantly higher than those in patients with CAP with medium or low mortality risk. Moreover, the sICAM-1 level showed a significant correlation with the length of hospital stay (r=0.488, p<0.001). Mechanistic investigations found that bacterial lipopolysaccharide induced upregulation of ICAM-1 expression through the c-Jun N-terminal kinase pathway in RAW264.7 macrophages. CONCLUSIONS Plasma sICAM-1 levels may play a role in the diagnosis and clinical assessment of CAP severity.
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Affiliation(s)
- Pin-Yu Chang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Senior Citizen Services, National Tainan Junior College of Nursing, Tainan, Taiwan
| | - Shih-Ming Tsao
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Division of Chest, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Jer-Hwa Chang
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Respiratory Therapy, College of Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ming-Hsien Chien
- Graduate Institute of Clinical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Yueh Hung
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yi-Wen Huang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Pulmonary and Critical Care Unit, Changhua Hospital, Department of Health, Changhua, Taiwan.
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan.
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17
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Liapikou A, Cillóniz C, Gabarrús A, Amaro R, De la Bellacasa JP, Mensa J, Sánchez M, Niederman M, Torres A. Multilobar bilateral and unilateral chest radiograph involvement: implications for prognosis in hospitalised community-acquired pneumonia. Eur Respir J 2016; 48:257-61. [PMID: 27103390 DOI: 10.1183/13993003.00191-2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/08/2016] [Indexed: 12/16/2022]
Affiliation(s)
| | - Catia Cillóniz
- Dept of Pneumology, Institut Clinic del Tórax, Hospital Clínic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) Barcelona, Spain
| | - Albert Gabarrús
- Dept of Pneumology, Institut Clinic del Tórax, Hospital Clínic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) Barcelona, Spain
| | - Rosanel Amaro
- Dept of Pneumology, Institut Clinic del Tórax, Hospital Clínic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) Barcelona, Spain
| | | | - Josep Mensa
- Infectious Diseases Dept, Hospital Clínic, Barcelona, Spain
| | | | - Michael Niederman
- Pulmonary and Critical Care Division, Weill Cornell Medical College, New York, NY, USA
| | - Antoni Torres
- Dept of Pneumology, Institut Clinic del Tórax, Hospital Clínic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes) Barcelona, Spain
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Risk factors for Clostridium difficile infection in hospitalized patients with community-acquired pneumonia. J Infect 2016; 73:45-53. [PMID: 27105657 DOI: 10.1016/j.jinf.2016.04.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 04/06/2016] [Accepted: 04/11/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Clostridium difficile infection (CDI) is strongly associated with anti-biotic treatment, and community-acquired pneumonia (CAP) is the leading indication for anti-biotic prescription in hospitals. This study assessed the incidence of and risk factors for CDI in a cohort of patients hospitalized with CAP. METHODS We analysed data from a prospective, observational cohort of patients with CAP in Edinburgh, UK. Patients with diarrhoea were systematically screened for CDI, and risk factors were determined through time-dependent survival analysis. RESULTS Overall, 1883 patients with CAP were included, 365 developed diarrhoea and 61 had laboratory-confirmed CDI. The risk factors for CDI were: age (hazard ratio [HR], 1.06 per year; 95% confidence interval [CI], 1.03-1.08), total number of antibiotic classes received (HR, 3.01 per class; 95% CI, 2.32-3.91), duration of antibiotic therapy (HR, 1.09 per day; 95% CI, 1.00-1.19 and hospitalization status (HR, 13.1; 95% CI, 6.0-28.7). Antibiotic class was not an independent predictor of CDI when adjusted for these risk factors (P > 0.05 by interaction testing). CONCLUSIONS These data suggest that reducing the overall antibiotic burden, duration of antibiotic treatment and duration of hospital stay may reduce the incidence of CDI in patients with CAP.
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Rello J, Perez A. Precision medicine for the treatment of severe pneumonia in intensive care. Expert Rev Respir Med 2016; 10:297-316. [PMID: 26789703 DOI: 10.1586/17476348.2016.1144477] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite advances in its management, community-acquired pneumonia (CAP) remains the most important cause of sepsis-related mortality and the reason for many ICU admissions. Severity assessment is the cornerstone of CAP patient management and the attempts to ensure the best site of care and therapy. Survival depends on a combination of host factors (genetic, age, comorbidities, defenses), pathogens (virulence, serotypes) and drugs. To reduce CAP mortality, early adequate antibiotic therapy is fundamental. The use of combination therapy with a macrolide seems to improve the clinical outcome in the subset of patients with high inflammation due to immunomodulation. Guidelines on antibiotic therapy have been associated with beneficial effects, and studies of newer adjunctive drugs have produced promising results. This paper discusses the current state of knowledge regarding of precision medicine and the treatment of severe CAP patients.
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Affiliation(s)
- Jordi Rello
- a CIBERES , Barcelona , Spain.,b School of Medicine , Universitat Autonoma de Barcelona , Barcelona , Spain
| | - Antonio Perez
- a CIBERES , Barcelona , Spain.,b School of Medicine , Universitat Autonoma de Barcelona , Barcelona , Spain
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20
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Fernandes L, Arora AS, Mesquita AM. Role of Semi-quantitative Serum Procalcitonin in Assessing Prognosis of Community Acquired Bacterial Pneumonia Compared to PORT PSI, CURB-65 and CRB-65. J Clin Diagn Res 2015; 9:OC01-4. [PMID: 26393153 DOI: 10.7860/jcdr/2015/12468.6147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 05/09/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Community Acquired Pneumonia (CAP) is one of the commonest causes of patient's visit to the Emergency Room (ER). Hospitalisation of patient depends on severity of pneumonia. Various pneumonia severity assessment scores are available to predict mortality in community acquired pneumonia but these scores are not commonly used. Procalcitonin is a biomarker which is raised in bacterial infection and is easy and quick to measure. The aim of our study was to assess the ability of baseline serum procalcitonin level to predict mortality of community acquired bacterial pneumonia compared to PSI, CURB-65 and CRB-65 and its add-on value to the simple CRB-65 score. MATERIALS AND METHODS Fifty five patients admitted with Com-munity Acquired Bacterial Pneumonia were enrolled after taking informed consent and satisfying all inclusion and exclusion criteria. PSI, CURB -65, CRB-65 and PCT scores were determined on admission. PCT was measured by semi- quantitative assay; PCT Q. Primary outcome was 30 day mortality. Sensitivity, specificity, positive and negative predictive value of PCT for assessing mortality was calculated and compared to validated pneumonia severity scores; PSI, CURB-65 and CRB-65. We also assessed the ability of the combination of PCT to each of the scores to predict 30 day pneumonia specific mortality. RESULTS In receiver operating characteristic analysis for mortality prediction, area under curve (95% CI) for PCT, PSI, CURB-65 and CRB-65 was 0.92 (0.85, 1.0), 0.88 (0.78, 0.98), 0.88 (0.76, 0.99), 0.9 (0.78, 1.0) respectively. Combination of PCT to each of the scores improved the prognostic ability to predict 30 day pneumonia specific mortality. CONCLUSION Semi-quantitative PCT level at admission is an excellent test to predict the outcome of pneumonia. It predicts patients at low risk of mortality from community acquired bacterial pneumonia.
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Affiliation(s)
- Lalita Fernandes
- Professor, Department of Pulmonary Medicine, Goa Medical College , Goa, India
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Abstract
Sepsis is the primary cause of death in the intensive care unit. The prevention of sepsis complications requires an early and accurate diagnosis as well as the appropriate mon itoring. A deep knowledge of the immunologic basis of sepsis is essential to better understand the scope of incorporating a new marker into clinical practice. Besides revising this theoretical aspect, the current available tools for bacterial iden tification have been briefly reviewed as well as a variety of new markers showing either well-recognized or potential usefulness for diagnosis and prognosis of infections in crit ically ill patients. Particular conditions such as community acquired pneumonia, pedi atric sepsis, or liver transplantation, among others, have been separately treated, since the optimal approaches and markers might be different in these special cases.
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Chalmers JD, Fleming GB, Rutherford J, Matsushita M, Kilpatrick DC, Hill AT. Serum ficolin-2 in hospitalised patients with community-acquired pneumonia. Inflammation 2014; 37:1635-41. [PMID: 24736883 DOI: 10.1007/s10753-014-9891-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mannose binding lectin (MBL) and ficolins contribute to host defence through activation of the lectin pathway of complement. In this study, serum levels of ficolin-2 and MBL were determined in 276 patients with community-acquired pneumonia (CAP). MBL deficiency and ficolin-2 insufficiency were defined using previously validated cut-offs. No differences were observed in MBL or ficolin-2 between patients and controls. MBL-deficient patients (<500 ng/ml) were not at higher risk of 30-day mortality odds ratio (OR) 0.97 (0.38-2.48,p=0.9) or a composite outcome of mortality, mechanical ventilation, vasopressor support (MV/VS) or complications OR 0.89 (0.44-1.77, p=0.9). Although no significant relationship between ficolin-2 insufficiency and outcome was observed, very low ficolin-2 levels (<1,200 ng/ml) were associated with an OR 1.23 (0.15-10.1), p=0.6 for 30-day mortality, 3.05 (0.61-15.2, p=0.2) for MV/VS and OR 2.05 (0.52-8.1, p=0.2) for the composite outcome. Low serum levels of MBL and ficolin-2 are not associated with CAP susceptibility. The high frequency of ficolin-2 insufficiency in patients with severe CAP would justify a larger investigation of ficolin-2 as a modifier of CAP severity.
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Affiliation(s)
- James D Chalmers
- Tayside Respiratory Research Group, University of Dundee, Dundee, UK,
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Ugajin M, Yamaki K, Hirasawa N, Kobayashi T, Yagi T. Prognostic value of severity indicators of nursing-home-acquired pneumonia versus community-acquired pneumonia in elderly patients. Clin Interv Aging 2014; 9:267-74. [PMID: 24611004 PMCID: PMC3929165 DOI: 10.2147/cia.s58682] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The credibility of prognostic indicators in nursing-home-acquired pneumonia (NHAP) is not clear. We previously reported a simple prognostic indicator in community-acquired pneumonia (CAP): blood urea nitrogen to serum albumin (B/A) ratio. This retrospective study investigated the prognostic value of severity indicators in NHAP versus CAP in elderly patients. METHODS Patients aged ≥65 years and hospitalized because of NHAP or CAP within the previous 3 years were enrolled. Demographics, coexisting illnesses, laboratory and microbiological findings, and severity scores (confusion, urea, respiratory rate, blood pressure, and age ≥65 [CURB-65] scale; age, dehydration, respiratory failure, orientation disturbance, and pressure [A-DROP] scale; and pneumonia severity index [PSI]) were retrieved from medical records. The primary outcome was mortality within 28 days of admission. RESULTS In total, 138 NHAP and 307 CAP patients were enrolled. Mortality was higher in NHAP (18.1%) than in CAP (4.6%) (P<0.001). Patients with NHAP were older and had lower functional status and a higher rate of do-not-resuscitate orders, heart failure, and cerebrovascular diseases. The NHAP patients more frequently had typical bacterial pathogens. Using the receiver-operating characteristics curve for predicting mortality, the area under the curve in NHAP was 0.70 for the A-DROP scale, 0.69 for the CURB-65 scale, 0.67 for the PSI class, and 0.65 for the B/A ratio. The area under the curve in CAP was 0.73 for the A-DROP scale, 0.76 for the CURB-65 scale, 0.81 for the PSI class, and 0.83 for the B/A ratio. CONCLUSION Patient mortality was greater in NHAP than in CAP. Patient characteristics, coexisting illnesses, and detected pathogens differed greatly between NHAP and CAP. The existing severity indicators had less prognostic value for NHAP than for CAP.
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Affiliation(s)
- Motoi Ugajin
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan
| | - Kenichi Yamaki
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan
| | - Natsuko Hirasawa
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan
| | - Takanori Kobayashi
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan
| | - Takeo Yagi
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan
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Yeh YH, Chang JL, Hsiao PC, Tsao SM, Lin CH, Kao SJ, Chou MC, Yang SF, Chien MH. Circulating level of lipocalin 2 as a predictor of severity in patients with community-acquired pneumonia. J Clin Lab Anal 2014; 27:253-60. [PMID: 23852780 DOI: 10.1002/jcla.21588] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 01/15/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the differential plasma levels of lipocalin 2 (LCN2) and its complex with MMP-9 (where MMP is matrix metalloproteinase) before and after antibiotic treatment in hospitalized adult patients with community-acquired pneumonia (CAP). METHOD Plasma LCN2 and LCN2/MMP-9 complex levels were measured in 61 adult patients with CAP and 60 healthy controls using commercial enzyme-linked immunosorbent assay (ELISA). RESULTS A decrease in the number of white blood cells (WBCs) and neutrophils and decreases in the levels of C-reactive protein (CRP), LCN2, and LCN2/MMP-9 complex were observed after antibiotic treatment. The plasma level of LCN2, but not that of CRP, was correlated with the severity of CAP based on the Pneumonia Severity Index (PSI; r = 0.333, P = 0.009), confusion, urea, respiratory rate and blood pressure (CURB)-65 (r = 0.288, P = 0.024), and Acute Physiology And Chronic Health Evaluation II (APACHE II) scores (r = 0.328, P = 0.010). LCN2 levels were also significantly correlated with LCN2/MMP-9 levels and the numbers of WBCs or neutrophils. CONCLUSIONS Plasma levels of LCN2 and the LCN2/MMP-9 complex can act as adjuvant diagnostic biomarkers for CAP. Plasma LCN2 might play a further role in the clinical assessment of the severity of CAP, which could potentially guide the development of future treatment strategies.
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Affiliation(s)
- Yuan-Hung Yeh
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
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Predictors of mortality in hospitalized adults with acute exacerbation of chronic obstructive pulmonary disease. Ann Am Thorac Soc 2013; 10:81-9. [PMID: 23607835 DOI: 10.1513/annalsats.201208-043oc] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
RATIONALE There is a need to identify clinically meaningful predictors of mortality following hospitalized COPD exacerbation. OBJECTIVES The aim of this study was to systematically review the literature to identify clinically important factors that predict mortality after hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD). METHODS Eligible studies considered adults admitted to hospital with COPD exacerbation. Two authors independently abstracted data. Odds ratios were then calculated by comparing the prevalence of each predictor in survivors versus nonsurvivors. For continuous variables, mean differences were pooled by the inverse of their variance, using a random effects model. MEASUREMENTS AND MAIN RESULTS There were 37 studies included (189,772 study subjects) with risk of death ranging from 3.6% for studies considering short-term mortality, 31.0% for long-term mortality (up to 2 yr after hospitalization), and 29.0% for studies that considered solely intensive care unit (ICU)-admitted study subjects. Twelve prognostic factors (age, male sex, low body mass index, cardiac failure, chronic renal failure, confusion, long-term oxygen therapy, lower limb edema, Global Initiative for Chronic Lung Disease criteria stage 4, cor pulmonale, acidemia, and elevated plasma troponin level) were significantly associated with increased short-term mortality. Nine prognostic factors (age, low body mass index, cardiac failure, diabetes mellitus, ischemic heart disease, malignancy, FEV1, long-term oxygen therapy, and PaO2 on admission) were significantly associated with long-term mortality. Three factors (age, low Glasgow Coma Scale score, and pH) were significantly associated with increased risk of mortality in ICU-admitted study subjects. CONCLUSION Different factors correlate with mortality from COPD exacerbation in the short term, long term, and after ICU admission. These parameters may be useful to develop tools for prediction of outcome in clinical practice.
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Kwok CS, Loke YK, Woo K, Myint PK. Risk prediction models for mortality in community-acquired pneumonia: a systematic review. BIOMED RESEARCH INTERNATIONAL 2013; 2013:504136. [PMID: 24228253 PMCID: PMC3817804 DOI: 10.1155/2013/504136] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 08/07/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several models have been developed to predict the risk of mortality in community-acquired pneumonia (CAP). This study aims to systematically identify and evaluate the performance of published risk prediction models for CAP. METHODS We searched MEDLINE, EMBASE, and Cochrane library in November 2011 for initial derivation and validation studies for models which predict pneumonia mortality. We aimed to present the comparative usefulness of their mortality prediction. RESULTS We identified 20 different published risk prediction models for mortality in CAP. Four models relied on clinical variables that could be assessed in community settings, with the two validated models BTS1 and CRB-65 showing fairly similar balanced accuracy levels (0.77 and 0.72, resp.), while CRB-65 had AUROC of 0.78. Nine models required laboratory tests in addition to clinical variables, and the best performance levels amongst the validated models were those of CURB and CURB-65 (balanced accuracy 0.73 and 0.71, resp.), with CURB-65 having an AUROC of 0.79. The PSI (AUROC 0.82) was the only validated model with good discriminative ability among the four that relied on clinical, laboratorial, and radiological variables. CONCLUSIONS There is no convincing evidence that other risk prediction models improve upon the well-established CURB-65 and PSI models.
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Affiliation(s)
- Chun Shing Kwok
- Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
| | - Yoon K. Loke
- Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Kenneth Woo
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Phyo Kyaw Myint
- School of Medicine & Dentistry, Division of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
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Kao SJ, Chuang CY, Tang CH, Lin CH, Bien MY, Yu MC, Bai KJ, Yang SF, Chien MH. Plasma endothelial cell-specific molecule-1 (ESM-1) in management of community-acquired pneumonia. ACTA ACUST UNITED AC 2013; 52:445-51. [DOI: 10.1515/cclm-2013-0638] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 08/28/2013] [Indexed: 01/09/2023]
Abstract
Abstract
Background: Endothelial cell-specific molecule (ESM)-1 is a soluble proteoglycan expressed by the vascular endothelium and which also circulates in the bloodstream. Inflammatory cytokines and proangiogenic growth factors increase its expression, and increased serum levels are found in immunocompetent patients with sepsis. The aim of this study was to investigate differential changes in plasma levels of ESM-1 before and after antibiotic treatment in hospitalized adult patients with community-acquired pneumonia (CAP).
Methods: Plasma ESM-1 levels were measured in 82 adult patients with CAP and 82 healthy controls using a commercial enzyme-linked immunosorbent assay (ELISA). Upon initial hospitalization, Acute Physiology and Chronic Health Evaluation II (APACHE II), CURB-65, and Pneumonia Severity Index (PSI) scores were determined to assess CAP severity in these patients.
Results: Results showed a decline in the number of white blood cells (WBCs) and neutrophils, and decreases in the concentrations of C-reactive protein (CRP) and ESM-1 after antibiotic treatment. The plasma concentration of ESM-1, but not CRP or the WBC count, was correlated with the severity of CAP based on the PSI (r=0.554, p<0.001), CURB-65 (r=0.510, p<0.001), and APACHE II scores (r=0.447, p<0.001).
Conclusions: Plasma levels of ESM-1 may be able to play a role in the diagnosis and clinical assessment of the severity of CAP, which could potentially guide the development of treatment strategies.
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Affiliation(s)
- Shang-Jyh Kao
- Department of Chest Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- School of Respiratory Therapy, Taipei Medical University, Taipei, Taiwan
| | - Chun-Yi Chuang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Otolaryngology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsin Tang
- Graduate Institute of Basic Medical Science, China Medical University, Taichung, Taiwan
- Department of Biotechnology, College of Health Science, Asia University, Taichung, Taiwan
| | - Chien-Huang Lin
- Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan
| | - Mauo-Ying Bien
- School of Respiratory Therapy, Taipei Medical University, Taipei, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University-Wan Fan Hospital, Taipei, Taiwan
| | - Ming-Chih Yu
- School of Respiratory Therapy, Taipei Medical University, Taipei, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University-Wan Fan Hospital, Taipei, Taiwan
| | - Kuan-Jen Bai
- School of Respiratory Therapy, Taipei Medical University, Taipei, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University-Wan Fan Hospital, Taipei, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Clinical Medicine, Taipei Medical University, 250 Wu-Hsing Street, Taipei 110, Taiwan
| | - Ming-Hsien Chien
- Department of Chest Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
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Severity assessment scores to guide empirical use of antibiotics in community acquired pneumonia. THE LANCET RESPIRATORY MEDICINE 2013; 1:653-662. [DOI: 10.1016/s2213-2600(13)70084-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Kao SJ, Yang HW, Tsao SM, Cheng CW, Bien MY, Yu MC, Bai KJ, Yang SF, Chien MH. Plasma long pentraxin 3 (PTX3) concentration is a novel marker of disease activity in patients with community-acquired pneumonia. Clin Chem Lab Med 2013; 51:907-13. [PMID: 23152412 DOI: 10.1515/cclm-2012-0459] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 10/07/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND Long pentraxin 3 (PTX3) is an acute-phase protein secreted by various cells, including leukocytes and endothelial cells. Like C-reactive protein (CRP), it belongs to the pentraxin superfamily. The aim of this study was to investigate the differential changes in plasma levels of PTX3 between before and after antibiotic treatment in hospitalized adult patients with community-acquired pneumonia (CAP). METHODS Plasma PTX3 levels were measured in 61 adult patients with CAP and 60 healthy controls using a commercial enzyme-linked immunosorbent assay (ELISA). Upon initial hospitalization, APACHE II, CURB-65, and pneumonia severity index (PSI) scores were determined to assess CAP severity in patients. RESULTS The results showed a decline in the number of white blood cells (WBCs) and neutrophils, and decreases in the concentrations of CRP and PTX3 observed after antibiotic treatment. The plasma concentration of PTX3, but not CRP, was correlated with the severity of CAP based on the PSI (r=0.290, p=0.023), CURB-65 (r=0.312, p=0.015), and APACHE II scores (r=0.427, p=0.001). The PTX3 level also exhibited a significant correlation with the length of hospital stay (r=0.500, p<0.0001). CONCLUSIONS PTX3 may be able to play a role in the diagnosis and clinical assessment of the severity of CAP, which could potentially guide the development of treatment strategies.
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Affiliation(s)
- Shang-Jyh Kao
- Department of Chest Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, and School of Respiratory Therapy, Taipei Medical University, Taipei, Taiwan
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Chiang TY, Yu YL, Lin CW, Tsao SM, Yang SF, Yeh CB. The circulating level of MMP-9 and its ratio to TIMP-1 as a predictor of severity in patients with community-acquired pneumonia. Clin Chim Acta 2013; 424:261-6. [DOI: 10.1016/j.cca.2013.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 06/10/2013] [Accepted: 06/11/2013] [Indexed: 01/06/2023]
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Serisier DJ, Williams S, Bowler SD. Australasian respiratory and emergency physicians do not use the pneumonia severity index in community-acquired pneumonia. Respirology 2013; 18:291-6. [PMID: 23036136 DOI: 10.1111/j.1440-1843.2012.02275.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE The value of community-acquired pneumonia (CAP) severity scoring tools is almost exclusively reliant upon regular and accurate application in clinical practice. Until recently, the Australasian Therapeutic Guidelines has recommended the use of the Pneumonia Severity Index (PSI) in spite of poor user-friendliness. METHODS Electronic and postal survey of respiratory and emergency medicine physician and specialist registrar members of the Royal Australasian College was undertaken to assess the use of the PSI and the accuracy of its application to hypothetical clinical CAP scenarios. The confusion, urea, respiratory rate, blood pressure, age 65 or older (CURB-65) score was also assessed as a simpler alternative. RESULTS Five hundred thirty-six (228 respiratory, 308 emergency) responses were received. Only 12% of respiratory and 35% of emergency physicians reported using the PSI always or frequently. The majority were unable to accurately approximate PSI scores, with significantly fewer respiratory than emergency physicians recording accurate severity classes (11.8% vs 21%, OR 0.50, 95% CI: 0.37-0.68, P < 0.0001). In contrast, significantly more respiratory physicians were able to accurately calculate the CURB-65 score (20.4% vs 15%, OR 1.45, 95% CI: 1.10-1.91, P = 0.006). CONCLUSIONS Australasian specialist physicians primarily responsible for the acute management of CAP report infrequent use of the PSI and are unable to accurately apply its use to hypothetical scenarios. Furthermore, respiratory and emergency physicians contrasted distinctly in their use and application of the two commonest severity scoring systems--the recent recommendation of two further alternative scoring tools by Australian guidelines may add to this confusion. A simple, coordinated approach to pneumonia severity assessment across specialties in Australasia is needed.
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Affiliation(s)
- David J Serisier
- Department of Respiratory Medicine, Mater Adult Hospital, Auchenflower, Queensland, Australia.
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The usefulness of confusion, urea, respiratory rate, and shock index or adjusted shock index criteria in predicting combined mortality and/or ICU admission compared to CURB-65 in community-acquired pneumonia. BIOMED RESEARCH INTERNATIONAL 2013; 2013:590407. [PMID: 24024203 PMCID: PMC3762190 DOI: 10.1155/2013/590407] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 07/16/2013] [Indexed: 11/24/2022]
Abstract
Background and Objectives. The study aims to assess the usefulness of age-independent criteria CURSI and temperature adjusted CURSI (CURASI) compared to CURB-65 in predicting community-acquired pneumonia (CAP) mortality. The criteria, CRSI and CRASI, were adapted for use in primary care and compared to CRB-65. Methods. A retrospective analysis of a prospectively identified cohort of community-acquired pneumonia inpatients was conducted. Outcomes were (1) mortality and (2) mortality and/or ICU admission within six weeks. Results. 95 patients (median age = 61 years) were included. All three criteria had similar sensitivity in predicting mortality alone, with CURB-65 having slightly higher specificity. When predicting mortality and/or intensive care admission, CURSI/CURASI showed higher sensitivity and slightly lower specificity. CRSI and CRASI had higher sensitivity and lower specificity when compared with CRB-65 for predicting both primary and secondary outcomes. Results for both analyses had P values >0.05. Conclusions. In a cohort of younger patients CURSI and adjusted CURSI perform at least as well as CURB-65, with a similar trend for CRSI and adjusted CRSI compared to CRB-65. Further studies are needed in different age groups and in primary and secondary care settings.
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Ribeiro C, Ladeira I, Gaio AR, Brito MC. Pneumococcal pneumonia - Are the new severity scores more accurate in predicting adverse outcomes? REVISTA PORTUGUESA DE PNEUMOLOGIA 2013; 19:252-9. [PMID: 23850193 DOI: 10.1016/j.rppneu.2012.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 09/13/2012] [Accepted: 09/13/2012] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The site-of-care decision is one of the most important factors in the management of patients with community-acquired pneumonia. The severity scores are validated prognostic tools for community-acquired pneumonia mortality and treatment site decision. The aim of this paper was to compare the discriminatory power of four scores - the classic PSI and CURB65 ant the most recent SCAP and SMART-COP - in predicting major adverse events: death, ICU admission, need for invasive mechanical ventilation or vasopressor support in patients admitted with pneumococcal pneumonia. METHODS A five year retrospective study of patients admitted for pneumococcal pneumonia. Patients were stratified based on admission data and assigned to low-, intermediate-, and high-risk classes for each score. Results were obtained comparing low versus non-low risk classes. RESULTS We studied 142 episodes of hospitalization with 2 deaths and 10 patients needing mechanical ventilation and vasopressor support. The majority of patients were classified as low risk by all scores - we found high negative predictive values for all adverse events studied, the most negative value corresponding to the SCAP score. The more recent scores showed better accuracy for predicting ICU admission and need for ventilation or vasopressor support (mostly for the SCAP score with higher AUC values for all adverse events). CONCLUSIONS The rate of all adverse outcomes increased directly with increasing risk class in all scores. The new gravity scores appear to have a higher discriminatory power in all adverse events in our study, particularly, the SCAP score.
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Affiliation(s)
- C Ribeiro
- Serviço de Pneumologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal.
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Brown SM, Jones JP, Aronsky D, Jones BE, Lanspa MJ, Dean NC. Relationships among initial hospital triage, disease progression and mortality in community-acquired pneumonia. Respirology 2013; 17:1207-13. [PMID: 22805170 DOI: 10.1111/j.1440-1843.2012.02225.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Appropriate triage of patients with community-acquired pneumonia (CAP) may improve morbidity, mortality and use of hospital resources. Worse outcomes from delayed intensive care unit (ICU) admission have long been suspected but have not been verified. METHODS In a retrospective study of consecutive patients with CAP admitted from 1996-2006 to the ICUs of a tertiary care hospital, we measured serial severity scores, intensive therapies received, ICU-free days, and 30-day mortality. Primary outcome was mortality. We developed a regression model of mortality with ward triage (and subsequent ICU transfer within 72 h) as the predictor, controlled by propensity for ward triage and radiographic progression. RESULTS Of 1059 hospital-admitted patients, 269 (25%) were admitted to the ICU during hospitalization. Of those, 167 were directly admitted to the ICU without current requirement for life support, while 61 (23%) were initially admitted to the hospital ward, 50 of those undergoing ICU transfer within 72 h. Ward triage was associated with increased mortality (OR 2.6, P = 0.056) after propensity adjustment. The effect was less (OR 2.2, P = 0.12) after controlling for radiographic progression. The effect probably increased (OR 4.1, P = 0.07) among patients with ≥ 3 severity predictors at admission. CONCLUSIONS Initial ward triage among patients transferred to the ICU is associated with twofold higher 30-day mortality. This effect is most apparent among patients with ≥ 3 severity predictors at admission and is attenuated by controlling for radiographic progression. Intensive monitoring of ward-admitted patients with CAP seems warranted. Further research is needed to optimize triage in CAP.
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Affiliation(s)
- Samuel M Brown
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
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Viasus D, Di Yacovo S, Garcia-Vidal C, Verdaguer R, Manresa F, Dorca J, Gudiol F, Carratalà J. Community-acquired Legionella pneumophila pneumonia: a single-center experience with 214 hospitalized sporadic cases over 15 years. Medicine (Baltimore) 2013; 92:51-60. [PMID: 23266795 PMCID: PMC5348137 DOI: 10.1097/md.0b013e31827f6104] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Legionella pneumophila has been increasingly recognized as a cause of community-acquired pneumonia (CAP) and an important public health problem worldwide. We conducted the present study to assess trends in epidemiology, diagnosis, clinical features, treatment, and outcomes of sporadic community-acquired L. pneumophila pneumonia requiring hospitalization at a university hospital over a 15-year period (1995-2010). Among 3934 nonimmunosuppressed hospitalized patients with CAP, 214 (5.4%) had L. pneumophila pneumonia (16 cases were categorized as travel-associated pneumonia, and 21 were part of small clusters). Since the introduction of the urinary antigen test, the diagnosis of L. pneumophila using this method remained stable over the years (p = 0.42); however, diagnosis by means of seroconversion and culture decreased (p < 0.001 and p = 0.001, respectively). The median age of patients with L. pneumophila pneumonia was 58.2 years (SD 13.8), and 76.4% were male. At least 1 comorbid condition was present in 119 (55.6%) patients with L. pneumophila pneumonia, mainly chronic heart disease, diabetes mellitus, and chronic pulmonary disease. The frequency of older patients (aged >65 yr) and comorbidities among patients with L. pneumophila pneumonia increased over the years (p = 0.06 and p = 0.02, respectively). In addition, 100 (46.9%) patients were classified into high-risk classes according to the Pneumonia Severity Index (groups IV-V). Twenty-four (11.2%) patients with L. pneumophila pneumonia received inappropriate empirical antibiotic therapy at hospital admission. Compared with patients who received appropriate empirical antibiotic, patients who received inappropriate therapy more frequently had acute onset of illness (p = 0.004), pleuritic chest pain (p = 0.03), and pleural effusion (p = 0.05). The number of patients who received macrolides decreased over the study period (p < 0.001), whereas the number of patients who received levofloxacin increased (p < 0.001). No significant difference was found in the outcomes between patients who received erythromycin and clarithromycin. However, compared with macrolide use during hospital admission, levofloxacin therapy was associated with a trend toward a shorter time to reach clinical stability (median, 3 vs. 5 d; p = 0.09) and a shorter length of hospital stay (median, 7 vs. 10 d; p < 0.001). Regarding outcomes, 38 (17.8%) patients required intensive care unit (ICU) admission, and the inhospital case-fatality rate was 6.1% (13 of 214 patients). The frequency of ICU admission (p = 0.34) and the need for mechanical ventilation (p = 0.57) remained stable over the study period, but the inhospital case-fatality rate decreased (p = 0.04). In the logistic regression analysis, independent factors associated with severe disease (ICU admission and death) were current/former smoker (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.01-8.62), macrolide use (OR, 2.40; 95% CI, 1.03-5.56), initial inappropriate therapy (OR, 2.97; 95% CI, 1.01-8.74), and high-risk Pneumonia Severity Index classes (OR, 9.1; 95% CI, 3.52-23.4). In conclusion, L. pneumophila is a relatively frequent causative pathogen among hospitalized patients with CAP and is associated with high morbidity. The annual number of L. pneumophila cases remained stable over the study period. In recent years, there have been significant changes in diagnosis and treatment, and the inhospital case-fatality rate of L. pneumophila pneumonia has decreased.
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Affiliation(s)
- Diego Viasus
- From the Departments of Infectious Diseases (DV, SDY, CGV, FG, JC), Microbiology (RV), and Respiratory Medicine (FM, JD), Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona; and Department of Clinical Science (FM, JD, FG, JC), University of Barcelona, Barcelona, Spain
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Courtais C, Kuster N, Dupuy AM, Folschveiller M, Jreige R, Bargnoux AS, Guiot J, Lefebvre S, Cristol JP, Sebbane M. Proadrenomedullin, a useful tool for risk stratification in high Pneumonia Severity Index score community acquired pneumonia. Am J Emerg Med 2012; 31:215-21. [PMID: 23000327 DOI: 10.1016/j.ajem.2012.07.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 07/13/2012] [Accepted: 07/14/2012] [Indexed: 02/06/2023] Open
Abstract
The aim of the present study was, first, to evaluate the prognostic value of mid-regional proadrenomedullin (proADM) in emergency department (ED) patients with a diagnosis of community acquired pneumonia (CAP) and, second, to analyze the added value of proADM as a risk stratification tool in comparison with other biomarkers and clinical severity scores. We evaluated proADM, C-reactive protein and procalcitonin, along with the Pneumonia Severity Index (PSI) score in consecutive CAP patients. Ability to predict 30-day mortality was assessed using receiver operating characteristic curve analysis, logistic regression, and reclassification metrics for all patients and for patients with high PSI scores. Primary outcome was death within 30 days after ED admission. One hundred nine patients were included (median age [interquartile range] 71 [27] years). Nine patients died within 30 days. A significant correlation between proADM and PSI was found (ρ = 0.584, P < .001). PSI and proADM levels were significantly predictive of risk of death. In patients with PSI class IV and V (score >90), proADM levels significantly predicted risk of death (OR [95% CI], 4.681 (1.661-20.221), P = .012) whereas PSI score did not (P = .122). ROC(AUC) (area under the receiver operating characteristic curve) was higher for proADM than for PSI score (ROC(AUC) [95% CI], 0.810 [0.654-0.965] and 0.669 [0.445-0.893] respectively). Reclassification analysis revealed that combination of PSI and proADM allows a better risk assessment than PSI alone (P = .001). MR-proADM may be helpful in individual risk stratification of CAP patients with a high PSI score in the ED, allowing to a better identification of patients at risk of death.
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Affiliation(s)
- Caroline Courtais
- Department of Biochemistry, Lapeyronie Hospital, 191 Avenue du Doyen Gaston Giraud, 34295 Montpellier cedex 5, France
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Ugajin M, Yamaki K, Iwamura N, Yagi T, Asano T. Blood urea nitrogen to serum albumin ratio independently predicts mortality and severity of community-acquired pneumonia. Int J Gen Med 2012; 5:583-9. [PMID: 22866010 PMCID: PMC3410717 DOI: 10.2147/ijgm.s33628] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Early studies of community-acquired pneumonia showed that nonsurvivors had higher blood urea nitrogen levels and lower serum albumin levels than survivors. Therefore, elevation of the blood urea nitrogen to serum albumin (B/A) ratio may identify patients with community-acquired pneumonia who are becoming critically ill. This study investigated the correlation between commonly used laboratory markers, in particular the B/A ratio, and clinical outcomes of community-acquired pneumonia. Methods This observational study was performed in consecutive patients with community-acquired pneumonia admitted to our hospital over a period of one year. Blood counts, commonly used laboratory markers, microbiological tests, and calculation of Pneumonia Severity Index (PSI) and CURB-65 were done on admission. The endpoints were mortality within 28 days of admission and requirement for intensive care. Results One hundred and seventy-five patients with community-acquired pneumonia were enrolled. Nineteen patients died within 28 days of admission and 29 patients required intensive care. Using multivariate analysis, independent factors associated with mortality were the requirement for intensive care (odds ratio [OR] 14.96, 95% confidence interval [CI] 3.73–60.03, P < 0.001), PSI class (OR 3.55, 95% CI 1.08–11.66, P = 0.037), and B/A ratio (OR 1.10, 95% CI 1.01–1.20, P = 0.037). Similarly, independent factors associated with need for intensive care were PSI class (OR 5.35, 95% CI 1.90–15.06, P = 0.002), CURB-65 (OR 2.37, 95% CI 1.26–4.45, P = 0.007), and B/A ratio (OR 1.27, 95% CI 1.09–1.47, P = 0.002). Conclusion The B/A ratio is a simple but independent predictor of mortality and severity of community-acquired pneumonia.
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Affiliation(s)
- Motoi Ugajin
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Aichi Prefecture, Japan
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Chalmers JD, Rutherford J. Can we use severity assessment tools to increase outpatient management of community-acquired pneumonia? Eur J Intern Med 2012; 23:398-406. [PMID: 22726367 DOI: 10.1016/j.ejim.2011.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 10/02/2011] [Accepted: 10/03/2011] [Indexed: 02/08/2023]
Abstract
Outpatient management of community-acquired pneumonia (CAP) has several potential advantages, including significant cost-savings, a reduction in hospital-acquired infections and increased patient satisfaction. Despite the benefits, it is often difficult to identify which patients may be managed in the community without compromising patient safety. CAP severity scores, such as the pneumonia severity index (PSI) and the British Thoracic Society CURB65/CRB65 scores are designed to identify groups of patients at low risk of mortality who may be suitable for outpatient care. This review discusses the strengths and weaknesses of severity scores for use in determining site of care for patients with pneumonia. Use of the PSI in emergency departments has been shown to increase the proportion of patients treated in the community without increasing patient mortality or hospital readmissions. The CURB65 and CRB65 scores are less complex alternatives to the PSI that have been shown to perform similarly for prediction of 30-day mortality. All 3 scores identify populations at low risk of mortality who may be eligible for outpatient care. Nevertheless, a number of factors not included in severity scores may prevent discharge of these patients, including social factors, co-morbidities and severity markers not captured by severity scores. The limitations of severity scores are discussed along with recent attempts to improve predictive tools, with the development of new biomarkers and alternative scoring systems.
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Affiliation(s)
- James D Chalmers
- MRC Centre for Inflammation Research, Queens Medical Research Centre, University of Edinburgh, Edinburgh, UK.
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Pereira JM, Paiva JA, Rello J. Severe sepsis in community-acquired pneumonia--early recognition and treatment. Eur J Intern Med 2012; 23:412-9. [PMID: 22726369 DOI: 10.1016/j.ejim.2012.04.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Revised: 04/29/2012] [Accepted: 04/30/2012] [Indexed: 01/17/2023]
Abstract
Despite remarkable advances in its management, community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality leading to significant consumption of health, social and economic resources. The assessment of CAP severity is a cornerstone in its management, facilitating selection of the most appropriate site of care and empirical antibiotic therapy. Several clinical scoring systems based on 30-day mortality have been developed to identify those patients with the highest risk of death. Although well validated in appropriate patient groups, each system has its own limitations and each exhibits different sensitivity and specificity values. These problems have increased interest in the use of biomarkers to predict CAP severity. Although so far no ideal solution has been identified, recent advances in bacterial genomic load quantification have made this tool very attractive. Early antibiotic therapy is essential to the reduction of CAP mortality and the selection of antibiotic treatment according to clinical guidelines is also associated with an improved outcome. In addition, the addition of a macrolide to standard empirical therapy seems to improve outcome in severe CAP although the mechanism of this is unclear. Finally, the role of adjuvant therapy has not yet been satisfactorily established. In this review we will present our opinion on current best practice in the assessment of severity and treatment of severe CAP.
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Affiliation(s)
- Jose Manuel Pereira
- Emergency and Intensive Care Department, Centro Hospitalar S. João EPE, Grupo de Infecção e Sepsis, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
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Narvaez-Rivera RM, Rendon A, Salinas-Carmona MC, Rosas-Taraco AG. Soluble RAGE as a severity marker in community acquired pneumonia associated sepsis. BMC Infect Dis 2012; 12:15. [PMID: 22264245 PMCID: PMC3274434 DOI: 10.1186/1471-2334-12-15] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 01/20/2012] [Indexed: 11/10/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is considered the most important cause of death from infectious disease in developed countries. Severity assessment scores partially address the difficulties in identifying high-risk patients. A lack of specific and valid pathophysiologic severity markers affect early and effective sepsis therapy. HMGB-1, sRAGE and RAGE have been involved in sepsis and their potential as severity markers has been proposed. The aim of this study was to evaluate HMGB-1, RAGE and sRAGE levels in patients with CAP-associated sepsis and determine their possible association with clinical outcome. Method We evaluated 33 patients with CAP-associated sepsis admitted to the emergency room and followed in the medical wards. Severity assessment scores (CURB-65, PSI, APACHE II, SOFA) and serologic markers (HMGB-1, RAGE, sRAGE) were evaluated on admission. Results Thirty patients with a diagnosis of CAP-associated sepsis were enrolled in the study within 24 hours after admission. Fourteen (46.6%) had pandemic (H1N1) influenza A virus, 2 (6.6%) had seasonal influenza A and 14 other diagnoses. Of the patients in the study group, 16 (53.3%) had a fatal outcome. ARDS was observed in 17 (56.6%) and a total of 22 patients had severe sepsis on admission (73%). The SOFA score showed the greatest difference between surviving and non-surviving groups (P = .003) with similar results in ARDS patients (P = .005). sRAGE levels tended to be higher in non-surviving (P = .058) and ARDS patients (P = .058). Logistic regression modeling demonstrated that SOFA (P = .013) and sRAGE (P = .05) were the only variables that modified the probability of a fatal outcome. Conclusion The association of elevated sRAGE with a fatal outcome suggests that it may have an independent causal effect in CAP. SOFA scores were the only clinical factor with the ability to identify surviving and ARDS patients.
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Affiliation(s)
- Rodrigo M Narvaez-Rivera
- Department of Immunology, Universidad Autonoma de Nuevo Leon, UANL, School of Medicine and University Hospital, Monterrey Nuevo Leon, Mexico
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Myint PK, Kwok CS, Majumdar SR, Eurich DT, Clark AB, España PP, Man SY, Huang DT, Yealy DM, Angus DC, Capelastegui A, Rainer TH, Marrie TJ, Fine MJ, Loke YK. The International Community-Acquired Pneumonia (CAP) Collaboration Cohort (ICCC) study: rationale, design and description of study cohorts and patients. BMJ Open 2012; 2:bmjopen-2012-001030. [PMID: 22614174 PMCID: PMC3358618 DOI: 10.1136/bmjopen-2012-001030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To improve the understanding of the determinants of prognosis and accurate risk stratification in community-acquired pneumonia (CAP). DESIGN Multicentre collaboration of prospective cohorts. SETTING 6 cohorts from the USA, Canada, Hong Kong and Spain. PARTICIPANTS From a published meta-analysis of risk stratification studies in CAP, the authors identified and pooled individual patient-level data from six prospective cohort studies of CAP (three from the USA, one each from Canada, Hong Kong and Spain) to create the International CAP Collaboration Cohort. Initial essential inclusion criteria of meta-analysis were (1) prospective design, (2) in English language, (3) reported 30-day mortality and transfer to an intensive or high dependency care and (4) minimum 1000 participants. Common baseline patient characteristics included demographics, history and physical examination findings, comorbidities and laboratory and radiographic findings. PRIMARY AND SECONDARY OUTCOME MEASURES This paper reports the rationale, hypotheses and analytical framework and also describes study cohorts and patients. The authors aim to (1) compare the prognostic accuracy of existing CAP risk stratification tools, (2) assess patient-level determinants of prognosis, (3) improve risk stratification by combined use of scoring systems and (4) understand prognostic factors for specific patient groups. RESULTS The six cohorts assembled from 1991 to 2007 included 13 784 patients (median age 71 years, 54% men). Aside from one randomised controlled study, the remaining five were cohort studies, but all had similar inclusion criteria. Overall, there was 0%-6% missing data. A total of 6159 (44%) had severe pneumonia by Pneumonia Severity Index class IV/V. Mortality at 30 days was 8% (1036). Admission to intensive care or high dependency unit was also 8% (1059). CONCLUSIONS International CAP Collaboration Cohort provides a pooled multicentre data set of patients with CAP, which will help us to better understand the prognosis of CAP.
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Affiliation(s)
- Phyo Kyaw Myint
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Chun Shing Kwok
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Sumit R Majumdar
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Allan B Clark
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Pedro P España
- Servicio de Neumología, Hospital de Galdakao, Galdakao, Bizkaia, Spain
| | - Shin Yan Man
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR
| | - David T Huang
- Department of Emergency Medicine at the University of Pittsburgh School of Medicine and The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Donald M Yealy
- VA Pittsburgh Healthcare System and Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek C Angus
- Department of Emergency Medicine at the University of Pittsburgh School of Medicine and The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Timothy H Rainer
- Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR
| | | | - Michael J Fine
- VA Pittsburgh Healthcare System and Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yoon K Loke
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
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Lee YT, Chen SC, Shyu LY, Lee MC, Wu TC, Tsao SM, Yang SF. Significant elevation of plasma cathepsin B and cystatin C in patients with community-acquired pneumonia. Clin Chim Acta 2011; 413:630-5. [PMID: 22209964 DOI: 10.1016/j.cca.2011.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/07/2011] [Accepted: 12/12/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND We identified the relationship between plasma level changes of cathepsin B and cystatin C before and after antibiotic treatment in hospitalized adult patients with community-acquired pneumonia (CAP). METHODS We collected blood specimens from 61 adult patients with CAP before and after antibiotic treatment and from 60 healthy controls and measured the plasma concentrations of cathepsin B and cystatin C expression using the enzyme-linked immunosorbent assay (ELISA). The APACHE II, CURB-65, and Pneumonia Severity Index (PSI) scores were determined to assess CAP severity in patients upon initial hospitalization. RESULTS The results showed a decline in the number of WBCs and neutrophils, with decreases in the concentrations of CRP, cathepsin B, cystatin C, and the cathepsin B/cystatin C ratio being observed after antibiotic treatment. The plasma concentration of cathepsin B correlated with severity of CAP with the PSI score (r=0.290, p=0.025) and the CURB-65 score (r=0.258, p=0.047), respectively. The plasma concentration of cystatin C correlated with the APACHE II score (r=0.523, p<0.001), severity of CAP in the PSI score (r=0.721, p<0.001) and the CURB-65 score (r=0.609, p<0.001), respectively. CONCLUSIONS Cathepsin B and cystatin C may play a role in the diagnosis and clinical assessment of the severity of CAP, which could potentially guide the development of treatment strategies.
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Affiliation(s)
- Yuan-Ti Lee
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
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Singanayagam A, Singanayagam A, Wood V, Chalmers JD. Factors associated with severe illness in pandemic 2009 influenza a (H1N1) infection: implications for triage in primary and secondary care. J Infect 2011; 63:243-51. [PMID: 21839111 DOI: 10.1016/j.jinf.2011.07.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 07/29/2011] [Accepted: 07/29/2011] [Indexed: 10/17/2022]
Abstract
Pandemic (H1N1) 2009 influenza virus (pH1N1/09) infection spread rapidly around the globe, leading to a phase 6 pandemic level of alert declared in June 2009. The WHO declared the end of the pandemic in August 2010. Although for the majority of infected patients, it manifest as a mild, self-limiting illness, a proportion appeared to follow an adverse clinical course, requiring higher level care and aggressive management strategies. Experience with previous pandemics suggests that H1N1 will continue to circulate for many years. The aim of this review is to evaluate data from published case series reporting patients with pH1N1/09 influenza to identify clinical markers of severe disease. Comorbid illnesses including chronic lung disease, obesity and pregnancy have been shown to confer increased risk of severe infection. Admission vital signs, laboratory investigations and chest radiographic features can guide admitting clinicians to stratify patients' risk of severe disease, however, the currently available severity scoring tools have only a limited role in risk assessment. Knowledge of high risk parameters remains important for clinicians triaging patients with suspected pH1N1/09 influenza and to inform strategies for future pandemics.
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Affiliation(s)
- Anika Singanayagam
- Department of Respiratory Medicine, Barnet and Chase Farm Hospitals NHS Trust, London EN28JL, United Kingdom.
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Abstract
Pneumonia is an important clinical and public health problem. Identification and prediction of severe pneumonia are significant concerns. Attempts to define severe pneumonia should recognize that different purposes are served by different definitions; no single definition meets all needs. At present, several prediction models have been proposed or validated. Biomarkers are not yet ready for routine use. The authors recommend careful consideration of the implications of any given definition of pneumonia severity. Outcome studies are needed to integrate human and health care system factors with the application of pneumonia severity definitions.
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Affiliation(s)
- Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.
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Chalmers JD, Mandal P, Singanayagam A, Akram AR, Choudhury G, Short PM, Hill AT. Severity assessment tools to guide ICU admission in community-acquired pneumonia: systematic review and meta-analysis. Intensive Care Med 2011; 37:1409-20. [PMID: 21660535 DOI: 10.1007/s00134-011-2261-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 03/29/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of this meta-analysis was to determine if severity assessment tools can be used to guide decisions regarding intensive care unit (ICU) admission of patients with community-acquired pneumonia. METHODS A search of PUBMED and EMBASE (1980-2009) was conducted to identify studies reporting pneumonia severity scores and prediction of ICU admission. Two reviewers independently collected data and assessed study quality. Performance characteristics were pooled using a random-effects model. RESULTS Sufficient data were collected to perform a meta-analysis on five current scoring systems: the Pneumonia Severity Index (PSI), the CURB65 score, the CRB65 score, the American Thoracic Society (ATS) 2001 criteria and the Infectious Disease Society of America/ATS (IDSA/ATS) 2007 criteria. The analysis was limited due to large variations in the ICU admission criteria, ICU admission rates and patient characteristics between different studies and different healthcare systems. In the pooled analysis, PSI, CURB65 and CRB65 performed similarly in terms of sensitivity and specificity across a range of cut-offs. Patients in CURB65 group 0 were at lowest risk of ICU admission (negative likelihood ratio 0.14; 95% confidence interval 0.06-0.34) while the ATS 2001 criteria had the highest positive likelihood ratio (7.05; 95% confidence interval 4.39-11.3). CONCLUSION Large variations exist in the use of ICU resources between different studies and different healthcare systems. Scoring systems designed to predict 30-day mortality perform less well when ICU admission is taken into account. Further studies of dedicated ICU admission scores are required.
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Viasus D, Garcia-Vidal C, Castellote J, Adamuz J, Verdaguer R, Dorca J, Manresa F, Gudiol F, Carratalà J. Community-acquired pneumonia in patients with liver cirrhosis: clinical features, outcomes, and usefulness of severity scores. Medicine (Baltimore) 2011; 90:110-118. [PMID: 21358441 DOI: 10.1097/md.0b013e318210504c] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We performed an observational analysis of a prospective cohort of nonimmunocompromised hospitalized adults with community-acquired pneumonia (CAP) to determine the epidemiology, clinical features, and outcomes of patients with liver cirrhosis. We also analyzed the prognostic value of several severity scores. Of 3420 CAP episodes, 90 occurred in patients with liver cirrhosis. The median value of the Model for End-Stage Liver Disease (MELD) was 14 (range, 6-36). On the Child-Pugh (CP) score, 56% of patients were defined as grade B and 22% as grade C. Patients with liver cirrhosis were younger (61.8 vs. 66.8 yr; p = 0.001) than patients without cirrhosis, more frequently presented impaired consciousness at admission (33% vs. 14%; p < 0.001) and septic shock (13% vs. 6%; p = 0.011), and were more commonly classified in high-risk Pneumonia Severity Index (PSI) classes (classes IV-V) (74% vs. 58%; p = 0.002). Streptococcus pneumoniae (47% vs. 33%; p = 0.009) and Pseudomonas aeruginosa (4.4% vs. 0.9%; p = 0.001) were more frequently documented in patients with cirrhosis. Bacteremia was also more common in these patients (22% vs. 13%; p = 0.023). Areas under the curve (AUCs) from disease-specific scores (MELD, CP, PSI, and CURB-65 [confusion, urea, respiratory rate, blood pressure, and age ≥65 yr]) were comparable in predicting severe disease (30-d mortality and intensive care unit [ICU] admission). A new score based on MELD, multilobar pneumonia, and septic shock at admission (MELD-CAP) had an AUC of 0.945 (95% confidence interval [CI], 0.872-0.983) for predicting severe disease and was significantly different from other scores. Early (5.6% vs. 2.1%; p = 0.048) and overall (14.4% vs. 7.4%; p < 0.024) mortality rates were higher in cirrhotic patients than in patients without cirrhosis. Factors associated with mortality were impaired consciousness, multilobar pneumonia, ascites, acute renal failure, bacteremia, ICU admission, and MELD score. Among the severity scores, MELD-CAP was the only score associated with severe disease (odds ratio [OR], 1.33; 95% CI, 1.09-1.52) and mortality (OR, 1.21; 95% CI, 1.03-1.42). In conclusion, CAP in patients with liver cirrhosis presents a distinctive clinical picture and is associated with higher mortality than is found in patients without cirrhosis. The severity of hepatic dysfunction plays an important role in the development of adverse events. Cirrhosis-specific scores may be useful for predicting and stratifying cirrhotic patients with CAP who have a high risk of severe disease.
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Affiliation(s)
- Diego Viasus
- From Departments of Infectious Diseases (DV, CG, JA, FG, J. Carratalà), Hepatology and Liver Transplant (J. Castellote), Microbiology (RV), and Respiratory Medicine (JD, FM), Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona. L'Hospitalet de Llobregat, Barcelona, Spain
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Validity of British Thoracic Society guidance (the CRB-65 rule) for predicting the severity of pneumonia in general practice: systematic review and meta-analysis. Br J Gen Pract 2010; 60:e423-33. [PMID: 20883616 DOI: 10.3399/bjgp10x532422] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The CRB-65 score is a clinical prediction rule that grades the severity of community-acquired pneumonia in terms of 30-day mortality. AIM The study sought to validate CRB-65 and assess its clinical value in community and hospital settings. DESIGN OF STUDY Systematic review and meta-analysis of validation studies of CRB-65. METHOD Medline (1966 to June 2009), Embase (1988 to November 2008), British Nursing Index (BNI) and PsychINFO were searched, using a diagnostic accuracy search filter combined with subject-specific terms. The derived (index) rule was used as a predictive model and applied to all validation studies. Comparison was made between the observed and predicted number of deaths stratified by risk group (low, intermediate, and high) and setting of care (community or hospital). Pooled results are presented as risk ratios (RRs) in terms of over-prediction (RR>1) or under-prediction (RR<1) of 30-day mortality. RESULTS Fourteen validation studies totalling 397 875 patients are included. CRB-65 performs well in hospitalised patients, particularly in those classified as intermediate (RR 0.91, 95% confidence interval [CI] = 0.71 to 1.17) or high risk (RR 1.01, 95% CI = 0.87 to 1.16). In community settings, CRB-65 over-predicts the probability of 30-day mortality across all strata of predicted risk, low (RR 9.41, 95% CI = 1.75 to 50.66), intermediate (RR 4.84, 95% CI = 2.61 to 8.69), and high (RR 1.58, 95% CI = 0.59 to 4.19). CONCLUSION CRB-65 performs well in stratifying severity of pneumonia and resultant 30-day mortality in hospital settings. In community settings, CRB-65 appears to over-predict the probability of 30-day mortality across all strata of predicted risk. Caution is needed when applying CRB-65 to patients in general practice.
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Chalmers JD, Singanayagam A, Akram AR, Choudhury G, Mandal P, Hill AT. Safety and efficacy of CURB65-guided antibiotic therapy in community-acquired pneumonia. J Antimicrob Chemother 2010; 66:416-23. [DOI: 10.1093/jac/dkq426] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Myint PK, Musonda P, Sankaran P, Subramanian DN, Ruffell H, Smith AC, Prentice P, Tariq SM, Kamath AV. Confusion, Urea, Respiratory Rate and Shock Index or Adjusted Shock Index (CURSI or CURASI) criteria predict mortality in community-acquired pneumonia. Eur J Intern Med 2010; 21:429-33. [PMID: 20816599 DOI: 10.1016/j.ejim.2010.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 04/15/2010] [Accepted: 07/08/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is common and associated with a significant mortality. Shock index, heart rate divided by systolic blood pressure, has been shown to be associated with outcome in sepsis. OBJECTIVE To examine the usefulness of two new criteria CURSI (confusion, urea, respiratory rate and shock index), and CURASI where shock index is replaced by temperature adjusted shock index in mortality assessment of CAP. METHODS A prospective study was conducted in Norfolk and Suffolk, UK. We explored the usefulness of CURSI and CURASI which we derived and performed mapping exercise using a different cohort. In this study we compared these new indices with the CURB-65 criteria in correctly predicting mortality in CAP. RESULTS A total of 190 patients were included (males=53%). The age range was 18-101 years (median=76 years). There were a total of 54 deaths during a six-week follow-up. All died within 30-days. Sixty-five (34%) had severe pneumonia by CURB-65. Using CURSI and CURASI, 71(37%) and 69(36%) had severe pneumonia, respectively. The sensitivity, specificity, positive and negative predictive values in predicting death during six-week follow-up were comparable among three indices examined. The Receiver Operating Characteristic curve values (95%CI) for the criteria were 0.67(0.60-0.75) for CURB-65, 0.67(0.59-0.74) for CURSI and 0.66(0.58-0.74) for CURASI (p>0.05). There were strong agreements between these three indices (Kappa values > or =0.75 for all). Repeating analyses in those who were aged 65years and over (n=135) did not alter the results. CONCLUSIONS Both CURSI and CURASI are similarly useful to CURB-65 in predicting deaths associated with CAP including older patients.
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Affiliation(s)
- Phyo K Myint
- School of Medicine, Health Policy and Practice, Health and Social Sciences Research Institute, Faculty of Health, University of East Anglia, Norwich, Norfolk, UK
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Rodriguez-Noriega E, Gonzalez-Diaz E, Morfin-Otero R, Gomez-Abundis GF, Briseño-Ramirez J, Perez-Gomez HR, Lopez-Gatell H, Alpuche-Aranda CM, Ramírez E, López I, Iguala M, Chapela IB, Zavala EP, Hernández M, Stuart TL, Villarino ME, Widdowson MA, Waterman S, Uyeki T, Azziz-Baumgartner E. Hospital triage system for adult patients using an influenza-like illness scoring system during the 2009 pandemic--Mexico. PLoS One 2010; 5:e10658. [PMID: 20498718 PMCID: PMC2871038 DOI: 10.1371/journal.pone.0010658] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 04/12/2010] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pandemic influenza A (H1N1) virus emerged during 2009. To help clinicians triage adults with acute respiratory illness, a scoring system for influenza-like illness (ILI) was implemented at Hospital Civil de Guadalajara, Mexico. METHODS A medical history, laboratory and radiology results were collected on emergency room (ER) patients with acute respiratory illness to calculate an ILI-score. Patients were evaluated for admission by their ILI-score and clinicians' assessment of risk for developing complications. Nasal and throat swabs were collected from intermediate and high-risk patients for influenza testing by RT-PCR. The disposition and ILI-score of those oseltamivir-treated versus untreated, clinical characteristics of 2009 pandemic influenza A (H1N1) patients versus test-negative patients were compared by Pearson's Chi(2), Fisher's Exact, and Wilcoxon rank-sum tests. RESULTS Of 1840 ER patients, 230 were initially hospitalized (mean ILI-score = 15), and the rest were discharged, including 286 ambulatory patients given oseltamivir (median ILI-score = 11), and 1324 untreated (median ILI-score = 5). Fourteen (1%) untreated patients returned, and 3 were hospitalized on oseltamivir (median ILI-score = 19). Of 371 patients tested by RT-PCR, 104 (28%) had pandemic influenza and 42 (11%) had seasonal influenza A detected. Twenty (91%) of 22 imaged hospitalized pandemic influenza patients had bilateral infiltrates compared to 23 (38%) of 61 imaged hospital test-negative patients (p<0.001). One patient with confirmed pandemic influenza presented 6 days after symptom onset, required mechanical ventilation, and died. CONCLUSIONS The triaging system that used an ILI-score complimented clinicians' judgment of who needed oseltamivir and inpatient care and helped hospital staff manage a surge in demand for services.
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Affiliation(s)
- Eduardo Rodriguez-Noriega
- Hospital Civil de Guadalajara, Fray Antonio Alcalde, Guadalajara, Jalisco, México
- Instituto de Patología Infecciosa y Experimental, Centro Universitario Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, México
| | | | - Rayo Morfin-Otero
- Hospital Civil de Guadalajara, Fray Antonio Alcalde, Guadalajara, Jalisco, México
- Instituto de Patología Infecciosa y Experimental, Centro Universitario Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, México
| | - Gerardo F. Gomez-Abundis
- Instituto de Patología Infecciosa y Experimental, Centro Universitario Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, México
| | - Jaime Briseño-Ramirez
- Hospital Civil de Guadalajara, Fray Antonio Alcalde, Guadalajara, Jalisco, México
- Instituto de Patología Infecciosa y Experimental, Centro Universitario Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, México
| | - Hector Raul Perez-Gomez
- Hospital Civil de Guadalajara, Fray Antonio Alcalde, Guadalajara, Jalisco, México
- Instituto de Patología Infecciosa y Experimental, Centro Universitario Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, México
| | - Hugo Lopez-Gatell
- Dirección General de Epidemiología, México Ministry of Health, México City, Distrito Federal, México
| | | | - Ernesto Ramírez
- National Public Health Laboratory, México City, Distrito Federal, México
| | - Irma López
- National Public Health Laboratory, México City, Distrito Federal, México
| | - Miguel Iguala
- National Public Health Laboratory, México City, Distrito Federal, México
| | - Ietza Bojórquez Chapela
- Dirección General de Epidemiología, México Ministry of Health, México City, Distrito Federal, México
| | - Ethel Palacios Zavala
- Dirección General de Epidemiología, México Ministry of Health, México City, Distrito Federal, México
| | - Mauricio Hernández
- Dirección General de Epidemiología, México Ministry of Health, México City, Distrito Federal, México
| | | | - Margarita Elsa Villarino
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Marc-Alain Widdowson
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Steve Waterman
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Timothy Uyeki
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Eduardo Azziz-Baumgartner
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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