Utility of community-acquired pneumonia severity scores in guiding disposition from the emergency department: Intensive care or short-stay unit?

The Battle of the Pneumonia Predictors: A Comprehensive Meta-Analysis Comparing the Pneumonia Severity Index (PSI) and the CURB-65 Score in Predicting Mortality and the Need for ICU Support

The CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥ 65 years) score and the pneumonia severity index (PSI) are widely used and recommended in predicting 30-day mortality and the need for intensive care support in community-acquired pneumonia. This study aims to compare the performance of these two severity scores in both mortality prediction and the need for intensive care support. A systematic review and meta-analysis was carried out, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) 2020 guidelines, and PubMed, Scopus, ScienceDirect, and Google Scholar were searched for articles published from 2012 to 2022. The reference lists of the included studies were also searched to retrieve possible additional studies. Twenty-five studies reporting prognostic information for CURB 65 and PSI were identified. ReviewManager (RevMan) 5.4.1 was used to produce risk ratios, and a random effects model was used to pool them. Both PSI and CURB-65 showed a high strength in identifying high-risk patients. However, CURB-65 was slightly better in early mortality prediction and had more sensitivity (96.7%) and specificity (89.3%) in predicting admission to intensive care support. Thus, CURB-65 seems to be the preferred tool in predicting mortality and the need for admission into intensive care support.

The Use of the SMART-COP Score in Predicting Severity Outcomes Among Patients With Community-Acquired Pneumonia: A Meta-Analysis

Pneumonia is a pathological process of interstitial lung tissue and distal airway and alveolar infection and infiltration. SMART-COP (systolic blood pressure, multilobar infiltrates, albumin, respiratory rate, tachycardia, confusion, oxygen, and pH) is a severity score method designed to identify individuals who require intensive respiratory or vasopressor support (IRVS) support due to pneumonia. Therefore, it is important for management decisions in pneumonia. This meta-analysis was conducted to determine the performance of the SMART-COP score in predicting the prognosis and severity of patients presenting with community-acquired pneumonia (CAP). The current meta-analysis was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search was conducted using Medline, Embase, and CINAHL to identify relevant studies assessing the validity of the SMART-COP score in predicting the severity of patients with CAP. Overall, nine studies were included in the current meta-analysis. A pooled sensitivity of the SMART-COP score to predict the use of IRVS is 89% (95% CI: 84%-92%) while its specificity is 68% (95% CI: 65%-70%). The pooled sensitivity of the SMART-COP score to predict 30-day mortality is 92% (95% CI: 89%-94%) while its specificity is 39% (95% CI: 37%-42%). To summarize, SMART-COP is a new, eight-variable instrument that appears to accurately identify patients with CAP who will require IRVS and 30-day mortality. Our findings show that SMART-COP will be a valuable tool for clinicians in accurately predicting illness severity in CAP patients as compared to other scoring systems. SMART-COP can be useful to identify patients who need urgent management.

Performance of the CORB (Confusion, Oxygenation, Respiratory Rate, and Blood Pressure) Scale for the Prediction of Clinical Outcomes in Pneumonia

Background. Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality due to misdiagnosis and inappropriate treatment approaches. Objective. To assess the performance of the CORB score in subjects with CAP for predicting in-hospital mortality, death within 30 days of admission, and requirement for invasive mechanical ventilation (IMV) and vasopressor support. Methods. A retrospective, cohort study with diagnostic test analysis of CORB and CURB-65 scores in subjects with CAP according to ATS criteria was undertaken. An alternative CORB score was estimated by replacing SpO2 ≤90% by the SpO2/FiO2 ratio. Crude and adjusted odd ratios (AOR) were calculated for each variable. The area under the receiver operating characteristics curve (AUROC) was constructed for each score, and outcomes were analyzed. AUROCs were compared with the DeLong test, considering a p value $<\mathrm{0,05}$ statistically significant. Results. From 1,811 subjects who entered the analysis, 15.1% (273/1,811) died in hospital, 8.78% required IMV (159/1,811), and 9.77% (177/1,811) needed vasopressor support. CORB had an AUROC of 0,660 (95% CI: 0,623–0,697) for in-hospital mortality; an AUROC of 0,657 (95% CI: 0,621–0,692) for 30-day mortality; an AUROC of 0,637 (CI 95%: 0,589–0,685) for IMV requirement; and an AUROC of 0,635 (95% CI: 0,589–0,681) for vasopressor support. CORB performance increases when the SpO2/FiO2 ratio <300 is used as oxygenation criterion in the prediction of requirement for IMV and vasopressor support, with AUROC of 0,700 (95% CI: 0,654–0,746; $p<0.001$ ) and AUROC of 0,702 (95% CI: 0,66–0,745; $p<0.001$ ), respectively. CURB-65 score presents an in-hospital mortality AUROC of 0,727 (95% CI: 0,695–0,759) and 30-day mortality AUROC of 0,726 (95% CI: 0,695–0,756). Conclusions. CORB score has a good performance in predicting the need for IMV and vasopressor support in CAP patients. This performance improves when the SpO2/FiO2 ratio <300 is used instead of the SpO2 ≤90% as the oxygenation parameter. CURB-65 score is superior in the prediction of mortality.

Derivation and Validation of a Novel Severity Scoring System for Pneumonia at Intensive Care Unit Admission

BACKGROUND

Severity stratification scores developed in intensive care units (ICUs) are used in interventional studies to identify the most critically ill. Studies that evaluate accuracy of these scores in ICU patients admitted with pneumonia are lacking. This study aims to determine performance of severity scores as predictors of mortality in critically ill patients admitted with pneumonia.

METHODS

Prospective cohort study in a general ICU in Brazil. ICU severity scores (Simplified Acute Physiology Score 3 [SAPS 3] and Sepsis-Related Organ Failure Assessment [qSOFA]), prognostic scores of pneumonia (CURB-65 [confusion, urea, respiratory rate, blood pressure, age] and CRB-65 [confusion, respiratory rate, blood pressure, age]), and clinical and epidemiological variables in the first 6 hours of hospitalization were analyzed.

RESULTS

Two hundred patients were included between 2015 and 2018, with a median age of 81 years (interquartile range, 67-90 years) and female predominance (52%), primarily admitted from the emergency department (65%) with community-acquired pneumonia (CAP, 80.5%). SAPS 3, CURB-65, CRB-65,and qSOFA all exhibited poor performance in predicting mortality. Multivariate regression identified variables independently associated with mortality that were used to develop a novel pneumonia-specific ICU severity score (Pneumonia Shock score) that outperformed SAPS 3, CURB-65, and CRB-65. The Shock score was validated in an external multicenter cohort of critically ill patients admitted with CAP.

CONCLUSIONS

We created a parsimonious score that accurately identifies patients with pneumonia at highest risk of ICU death. These findings are critical to accurately stratify patients with severe pneumonia in therapeutic trials that aim to reduce mortality.

Community-acquired pneumonia as an emergency condition

PURPOSE OF REVIEW

Despite the improvements in its management, community-acquired pneumonia (CAP) still exhibits high global morbidity and mortality rates, especially in elderly patients. This review focuses on the most recent findings on the epidemiology, cause, diagnosis and management of CAP.

RECENT FINDINGS

There is consistent evidence that the trend in CAP mortality has declined over time. However, the mortality of pneumococcal CAP has not changed in the last two decades, with an increase in the rate of hospitalization and more severe forms of CAP. Streptococcus pneumoniae remains the most frequent cause of CAP in all settings, age groups and regardless of comorbidities. However, the implementation of molecular diagnostic tests in the last years has identified respiratory viruses as a common cause of CAP too. The emergency of multidrug-resistance pathogens is a worldwide concern. An improvement in our ability to promptly identify the causative cause of CAP is required in order to provide pathogen-directed antibiotic therapy, improve antibiotic stewardship programs and implement appropriate vaccine strategies.

SUMMARY

It is time to apply all the knowledge generated in the last decade in order to optimize the management of CAP.