CURB-65 Performance Among Admitted and Discharged Emergency Department Patients With Community-acquired Pneumonia

Optimizing Diagnosis and Management of Community-acquired Pneumonia in the Emergency Department

Pneumonia is split into 3 diagnostic categories: community-acquired pneumonia (CAP), health care-associated pneumonia, and ventilator-associated pneumonia. This classification scheme is driven not only by the location of infection onset but also by the predominant associated causal microorganisms. Pneumonia is diagnosed in over 1.5 million US emergency department visits annually (1.2% of all visits), and most pneumonia diagnosed by emergency physicians is CAP.

Predictive model for bacterial co-infection in patients hospitalized for COVID-19: a multicenter observational cohort study

Objective

The aim of our study was to build a predictive model able to stratify the risk of bacterial co-infection at hospitalization in patients with COVID-19.

Methods

Multicenter observational study of adult patients hospitalized from February to December 2020 with confirmed COVID-19 diagnosis. Endpoint was microbiologically documented bacterial co-infection diagnosed within 72 h from hospitalization. The cohort was randomly split into derivation and validation cohort. To investigate risk factors for co-infection univariable and multivariable logistic regression analyses were performed. Predictive risk score was obtained assigning a point value corresponding to β-coefficients to the variables in the multivariable model. ROC analysis in the validation cohort was used to estimate prediction accuracy.

Results

Overall, 1733 patients were analyzed: 61.4% males, median age 69 years (IQR 57–80), median Charlson 3 (IQR 2–6). Co-infection was diagnosed in 110 (6.3%) patients. Empirical antibiotics were started in 64.2 and 59.5% of patients with and without co-infection (p = 0.35). At multivariable analysis in the derivation cohort: WBC ≥ 7.7/mm³, PCT ≥ 0.2 ng/mL, and Charlson index ≥ 5 were risk factors for bacterial co-infection. A point was assigned to each variable obtaining a predictive score ranging from 0 to 5. In the validation cohort, ROC analysis showed AUC of 0.83 (95%CI 0.75–0.90). The optimal cut-point was ≥2 with sensitivity 70.0%, specificity 75.9%, positive predictive value 16.0% and negative predictive value 97.5%. According to individual risk score, patients were classified at low (point 0), intermediate (point 1), and high risk (point ≥ 2). CURB-65 ≥ 2 was further proposed to identify patients at intermediate risk who would benefit from early antibiotic coverage.

Conclusions

Our score may be useful in stratifying bacterial co-infection risk in COVID-19 hospitalized patients, optimizing diagnostic testing and antibiotic use.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-022-01801-2.

Predicting ventilator-associated pneumonia with machine learning

Ventilator-associated pneumonia (VAP) is the most common and fatal nosocomial infection in intensive care units (ICUs). Existing methods for identifying VAP display low accuracy, and their use may delay antimicrobial therapy. VAP diagnostics derived from machine learning (ML) methods that utilize electronic health record (EHR) data have not yet been explored. The objective of this study is to compare the performance of a variety of ML models trained to predict whether VAP will be diagnosed during the patient stay.A retrospective study examined data from 6126 adult ICU encounters lasting at least 48 hours following the initiation of mechanical ventilation. The gold standard was the presence of a diagnostic code for VAP. Five different ML models were trained to predict VAP 48 hours after initiation of mechanical ventilation. Model performance was evaluated with regard to the area under the receiver operating characteristic (AUROC) curve on a 20% hold-out test set. Feature importance was measured in terms of Shapley values.The highest performing model achieved an AUROC value of 0.854. The most important features for the best-performing model were the length of time on mechanical ventilation, the presence of antibiotics, sputum test frequency, and the most recent Glasgow Coma Scale assessment.Supervised ML using patient EHR data is promising for VAP diagnosis and warrants further validation. This tool has the potential to aid the timely diagnosis of VAP.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia

This clinical policy from the American College of Emergency Physicians is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data.

Identifying patients with symptoms suspicious for COVID-19 at elevated risk of adverse events: The COVAS score

Objective

Develop and validate a risk score using variables available during an Emergency Department (ED) encounter to predict adverse events among patients with suspected COVID-19.

Methods

A retrospective cohort study of adult visits for suspected COVID-19 between March 1 – April 30, 2020 at 15 EDs in Southern California. The primary outcomes were death or respiratory decompensation within 7-days. We used least absolute shrinkage and selection operator (LASSO) models and logistic regression to derive a risk score. We report metrics for derivation and validation cohorts, and subgroups with pneumonia or COVID-19 diagnoses.

Results

26,600 ED encounters were included and 1079 experienced an adverse event. Five categories (comorbidities, obesity/BMI ≥ 40, vital signs, age and sex) were included in the final score. The area under the curve (AUC) in the derivation cohort was 0.891 (95% CI, 0.880–0.901); similar performance was observed in the validation cohort (AUC = 0.895, 95% CI, 0.874–0.916). Sensitivity ranging from 100% (Score 0) to 41.7% (Score of ≥15) and specificity from 13.9% (score 0) to 96.8% (score ≥ 15). In the subgroups with pneumonia (n = 3252) the AUCs were 0.780 (derivation, 95% CI 0.759–0.801) and 0.832 (validation, 95% CI 0.794–0.870), while for COVID-19 diagnoses (n = 2059) the AUCs were 0.867 (95% CI 0.843–0.892) and 0.837 (95% CI 0.774–0.899) respectively.

Conclusion

Physicians evaluating ED patients with pneumonia, COVID-19, or symptoms suspicious for COVID-19 can apply the COVAS score to assist with decisions to hospitalize or discharge patients during the SARS CoV-2 pandemic.

Outcome prediction value of National Early Warning Score in septic patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study

BACKGROUND

To evaluate the accuracy of National Early Warning Score (NEWS) in predicting clinical outcomes (28-day mortality, intensive care unit [ICU] admission, and mechanical ventilation use) for septic patients with community-acquired pneumonia (CAP) compared with other commonly used severity scores (CURB65, Pneumonia Severity Index [PSI], Sequential Organ Failure Assessment [SOFA], quick SOFA [qSOFA], and Mortality in Emergency Department Sepsis [MEDS]) and admission lactate level.

METHODS

Adult patients diagnosed with CAP admitted between January 2017 and May 2019 with admission SOFA ≥2 from baseline were enrolled. Demographic characteristics were collected. The primary outcome was the 28-day mortality after admission, and the secondary outcome included ICU admission and mechanical ventilation use. Outcome prediction value of parameters above was compared using receiver operating characteristics (ROC) curves. Cox regression analyses were carried out to determine the risk factors for the 28-day mortality. Kaplan-Meier survival curves were plotted and compared using optimal cut-off values of qSOFA and NEWS.

RESULTS

Among the 340 enrolled patients, 90 patients were dead after a 28-day follow-up, 62 patients were admitted to ICU, and 84 patients underwent mechanical ventilation. Among single predictors, NEWS achieved the largest area under the receiver operating characteristic (AUROC) curve in predicting the 28-day mortality (0.861), ICU admission (0.895), and use of mechanical ventilation (0.873). NEWS+lactate, similar to MEDS+lactate, outperformed other combinations of severity score and admission lactate in predicting the 28-day mortality (AUROC 0.866) and ICU admission (AUROC 0.905), while NEWS+lactate did not outperform other combinations in predicting mechanical ventilation (AUROC 0.886). Admission lactate only improved the predicting performance of CURB65 and qSOFA in predicting the 28-day mortality and ICU admission.

CONCLUSIONS

NEWS could be a valuable predictor in septic patients with CAP in emergency departments. Admission lactate did not predict well the outcomes or improve the severity scores. A qSOFA ≥2 and a NEWS ≥9 were strongly associated with the 28-day mortality, ICU admission, and mechanical ventilation of septic patients with CAP in the emergency departments.

Derivation and validation of a prediction rule for mortality of patients with respiratory virus-related pneumonia (RV-p score)

Background:

Respiratory viruses are important etiologies of community-acquired pneumonia. However, current knowledge on the prognosis of respiratory virus-related pneumonia (RV-p) is limited. Thus, here we aimed to establish a clinical predictive model for mortality of patients with RV-p.

Methods:

A total of 1431 laboratory-confirmed patients with RV-p, including 1169 and 262 patients from respective derivation and validation cohorts from five teaching hospitals in China were assessed between January 2010 and December 2019. A prediction rule was established on the basis of risk factors for 30-day mortality of patients with RV-p from the derivation cohort using a multivariate logistic regression model.

Results:

The 30-day mortality of patients with RV-p was 16.8% (241/1431). The RV-p score was composed of nine predictors (including respective points of mortality risk): (a) age ⩾65 years (1 point); (b) chronic obstructive pulmonary disease (1 point); (c) mental confusion (1 point); (d) blood urea nitrogen (1 point); (e) cardiovascular disease (2 points); (f) smoking history (2 points); (g) arterial pressure of oxygen/fraction of inspiration oxygen (P_aO₂/FiO₂) < 250 mmHg (2 points); (h) lymphocyte counts <0.8 × 10⁹/L (2 points); (i) arterial PH < 7.35 (3 points). A total of six points was used as the cut-off value for mortality risk stratification. Our model showed a sensitivity of 0.831 and a specificity of 0.783. The area under the receiver operating characteristic curve was more prominent for RV-p scoring [0.867, 95% confidence interval (CI)0.846–0.886] when compared with both pneumonia severity index risk (0.595, 95% CI 0.566–0.624, p < 0.001) and CURB-65 scoring (0.739, 95% CI 0.713–0.765, p < 0.001).

Conclusion:

RV-p scoring was able to provide a good predictive accuracy for 30-day mortality, which accounted for a more effective stratification of patients with RV-p into relevant risk categories and, consequently, help physicians to make more rational clinical decisions.

The reviews of this paper are available via the supplemental material section.

Confusion, respiratory rate, shock index (CRSI-65) score in the emergency department triage may be a new severity scoring method for community-acquired pneumonia

Objectives:

To investigate whether confusion, respiratory rate, shock index-age ≥65 years (CRSI-65) score, consisting of basic physiological parameters, can be used for severity prediction in patients with community-acquired pneumonia.

Methods:

This is a prospective cohort and single-center study conducted in Bolu Abant Izzet Baysal University Hospital, Bolu, Turkey between January 2018 and June 2018. The study investigated CRSI-65 score in predicting 4-week mortality and the need for intensive care for patients with community-acquired pneumonia.

Results:

A total of 58 patients with community-acquired pneumonia admitted to the emergency department were included in this study. Of the patients, 62.1% were males (n=36), and the mean age of the patients was 72.87 ± 12.30 years. After 4 weeks of follow-up, CURB-65 and CRSI-65 scores showed similar results in predicting mortality with respect to specificity, sensitivity, and positive and negative predictive values. Area under the receiver operating characteristic curve was 0.926 for the CURB-65 (95% confidence interval [CI] 0.853-0.999) and 0.954 for the CRSI-65 (95% CI 0.899-0.999).

Conclusion:

Similar to the CURB-65 score, the CRSI-65 score appears to be useful in predicting 4-week mortality. The evaluation of CRSI-65 score can be used in emergency department triage, primary care, and non-hospital settings.

Treatment update: Outpatient management of community-acquired pneumonia

Pneumonia is a leading cause of morbidity and mortality in the US and a primary cause of hospitalization nationwide. A recent guideline update from the American Thoracic Society and Infectious Diseases Society of America provides evidence-based recommendations for managing adults with community-acquired pneumonia in the outpatient setting.

Outpatient Antimicrobial Stewardship: Targets for Community-acquired Pneumonia

PURPOSE

Community-acquired pneumonia (CAP) is one of the leading causes of death in the United States. The primary objective of this study was to determine the prevalence of appropriate diagnosis and treatment of outpatients treated for CAP. Knowledge of problems with CAP treatment can be helpful in developing stewardship initiatives to improve care of outpatients with CAP.

METHODS

Included in this study were patients 18 years and older who received antibiotic therapy for the treatment of CAP in the outpatient setting. Outpatients were identified by International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, Tenth Revision (ICD-10) codes for CAP in the Veterans Affairs Western New York Healthcare System between January 2008 and January 2018. Appropriate treatment was evaluated using CAP guidelines. Factors associated with an inappropriate regimen were determined via multivariable analyses.

FINDINGS

This study included 518 outpatients, of whom 66% were appropriately diagnosed with CAP. Of the 341 appropriately diagnosed patients, only 31% received an antibiotic regimen consistent with guidelines. Regarding inappropriate regimens, 76.7% contained an incorrect drug based on patient comorbidities, and 39.4% consisted of an inappropriate duration, which was most often attributable to prolonged length of therapy >7 days. The odds of being prescribed an inappropriate regimen if a patient was considered to be at risk for drug-resistant Streptococcus pneumoniae (DRSP) was 4.2 (95% CI, 2.4-7.4). The population at risk for DRSP was more likely to present to the health care system again within 30 days compared with low-risk patients (19.4% vs 8.7%, P = 0.005).

IMPLICATIONS

Improvement in prescribing is needed for CAP. An outpatient stewardship program that targets patients with risk factors for DRSP would improve adherence to guidelines.

Prescribing trends and revisit rates following a pharmacist-driven protocol change for community-acquired pneumonia in an emergency department

OBJECTIVE

To compare pharmacist-led prescribing changes and associated 30-day revisit rates across different regimens for patients discharged from an emergency department (ED) with a diagnosis of community-acquired pneumonia (CAP).

METHODS

An observational, retrospective cohort analysis was conducted of patients who were discharged from an ED over a 4-year period with a diagnosis of CAP. Patient demographics, clinical characteristics, antibiotic selection and comorbidity and condition severity scores were collected for two cohorts: 2012-13 (before protocol change) and 2014-15 (post-protocol change). During January 2014, a pharmacist-led protocol change with prescriber education was implemented to better align ED treatment practices with clinical practice guidelines. The primary endpoint was the change in prescribing practices across the two cohorts.

KEY FINDINGS

A total of 741 patients with CAP were identified, including 411 (55.5%) patients in 2012-13 and 330 (44.5%) in 2014-15. Prescribing of macrolide monotherapy regimens decreased significantly following protocol change (70.1% versus 42.7%; difference: 27.4%, 95% CI: 23.8-31.0%) with a reciprocal increase in macrolide/β-lactam combination prescribing (6.3-21.8%; difference: 15.5%, 95% CI: 12.9-18.1%). A total of 12.2% of patients who received macrolide/β-lactam combination treatment revisited a network ED within 30 days due to worsening pneumonia, compared to 8.6% of patients who received macrolide monotherapy treatment (P = NS).

CONCLUSIONS

The current study showed a significant increase in antibiotic prescribing compliance following a pharmacist-driven protocol change and education, but no statistical difference in rates of return for macrolide monotherapy versus other regimens.

Performance of the CURB-65 Score in Predicting Critical Care Interventions in Patients Admitted With Community-Acquired Pneumonia

STUDY OBJECTIVE

Confusion, uremia, elevated respiratory rate, hypotension, and aged 65 years or older (CURB-65) is a clinical prediction rule intended to stratify patients with pneumonia by expected mortality. We assess the predictive performance of CURB-65 for the proximal endpoint of receipt of critical care intervention in emergency department (ED) patients admitted with community-acquired pneumonia.

METHODS

We performed a retrospective analysis of electronic health records from a single tertiary center for ED patients admitted as inpatients with a primary diagnosis of pneumonia from 2010 to 2014. Patients with a history of malignancy, tuberculosis, bronchiectasis, HIV, or readmission within 14 days were excluded. We assessed the predictive accuracy of CURB-65 for receipt of critical care interventions (ie, vasopressors, large-volume intravenous fluids, invasive catheters, assisted ventilation, insulin infusions, or renal replacement therapy) and inhospital mortality. Logistic regression was performed to assess the increase in odds of critical care intervention or inhospital mortality by increasing CURB-65 score.

RESULTS

There were 2,322 patients admitted with community-acquired pneumonia in the study cohort; 630 (27.1%) were admitted to the ICU within 48 hours of ED triage and 343 (14.8%) received a critical care intervention. Of patients with a CURB-65 score of 0 to 1, 181 (15.6%) were admitted to the ICU, 74 (6.4%) received a critical care intervention, and 7 (0.6%) died. Of patients with a CURB-65 score of 2, 223 (27.0%) were admitted to the ICU, 127 (15.4%) received a critical care intervention, and 47 (5.7%) died. Among patients with CURB-65 score greater than or equal to 3, 226 (67.0%) were admitted to the ICU, 142 (42.1%) received a critical care intervention, and 43 (12.8%) died. The areas under the receiver operating characteristic for CURB-65 as a predictor of critical care intervention and mortality were 0.73 and 0.77, whereas sensitivity of CURB-65 score greater than or equal to 2 in predicting critical care intervention was 78.4%; for mortality, 92.8%.

CONCLUSION

Patients with CURB-65 score less than or equal to 2 were often admitted to the ICU and received critical care interventions. Given this finding and the relatively low sensitivity of CURB-65 for critical care intervention, clinicians should exercise caution when using CURB-65 to guide disposition. Future ED-based clinical prediction rules may benefit from calibration to proximal endpoints.

Rebounds after discharge from the emergency department for community-acquired pneumonia: focus on the usefulness of severity scoring systems

Background:

Community-acquired pneumonia (CAP) is common cause of hospital admission and leading cause of morbidity and mortality. Severity scoring systems are used to predict risk profile, outcome and mortality, and to help decisions about management strategies.

Aim of the work and Methods:

To critically analyze pneumonia “rebound” cases, once discharged from the emergency department (ED) and afterwards admitted. We conducted an observational clinical study in the acute setting of a university teaching hospital, prospectively analyzing, in a 1 year period, demographic, medical, clinical and laboratory data, and the outcome.

Results:

249 patients were discharged home with diagnosis of CAP; 80 cases (32.1%) resulted in the high-intermediate risk class according to CURB-65 or CRB-65. Twelve patients (4.8%) presented to the ED twice and were then admitted. At their first visit 5 were in the high-intermediate risk group; just 4 of them were in the non-low risk group at the time of their admission. The rebound cohort showed some peculiar abnormalities in laboratory parameters (coagulation and renal function) and severe chest X-rays characteristics. None died in 30 days.

Conclusions:

The power of CURB-65 to correctly predict mortality for CAP patients discharged home from the ED is not confirmed by our results; careful clinical judgement seems to be irreplaceable in the management process. Many patients with a high-intermediate risk according to CURB-65 can be safely treated as outpatients, according to adequate welfare conditions; we identified a subgroup of cases that should worth a special attention and, therefore, a brief observation period in the ED before the final decision to safely discharge or admit. (www.actabiomedica.it)

Presepsin as a novel diagnostic biomarker for differentiating active pulmonary tuberculosis from bacterial community acquired pneumonia

BACKGROUND

The expression of presepsin in active pulmonary tuberculosis (APTB) is unknown. We observed the expression of presepsin in APTB, and to evaluate the value for discriminating between APTB and bacterial community acquired pneumonia (BCAP).

METHODS

Consecutive APTB patients who were accurately diagnosed by sputum culture and BCAP patients were enrolled from August 2013 to July 2015. Clinical data were collected, and plasma presepsin concentrations were tested. Receiver operating characteristic (ROC) curves were performed for diagnostic analysis.

RESULTS

In all, 133 healthy individuals, 103 APTB and 202 BCAP patients were enrolled. Presepsin concentrations in APTB group (218.0 [146.0, 368.0] pg/ml) were higher than those in the healthy control group (128.0 [101.5, 176.5] pg/ml, P<0.001), and lower than the concentrations measured in the BCAP group (532.0 [364.0, 852.3] pg/ml, P<0.001). Simple APTB and miliary tuberculosis patients showed no significant differences in presepsin concentrations. Compared with both Gram-positive and negative bacteria, Mycobacterium tuberculosis caused a limited increase of presepsin. With the cut-off value set at 401pg/ml, presepsin demonstrated high positive predictive value, allowing initial discriminating between APTB and BCAP. Presepsin combined with CURB-65 score could significantly improve the discrimination ability.

CONCLUSIONS

Presepsin concentrations in APTB patients were slightly increased, and may be helpful for initial discrimination between APTB and BCAP.