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Müller-Plathe M, Osmanodja B, Barthel G, Budde K, Eckardt KU, Kolditz M, Witzenrath M. Validation of risk scores for prediction of severe pneumonia in kidney transplant recipients hospitalized with community-acquired pneumonia. Infection 2024; 52:447-459. [PMID: 37985643 PMCID: PMC10954831 DOI: 10.1007/s15010-023-02101-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/22/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE Risk scores for community-acquired pneumonia (CAP) are widely used for standardized assessment in immunocompetent patients and to identify patients at risk for severe pneumonia and death. In immunocompromised patients, the prognostic value of pneumonia-specific risk scores seems to be reduced, but evidence is limited. The value of different pneumonia risk scores in kidney transplant recipients (KTR) is not known. METHODS Therefore, we retrospectively analyzed 310 first CAP episodes after kidney transplantation in 310 KTR. We assessed clinical outcomes and validated eight different risk scores (CRB-65, CURB-65, DS-CRB-65, qSOFA, SOFA, PSI, IDSA/ATS minor criteria, NEWS-2) for the prognosis of severe pneumonia and in-hospital mortality. Risk scores were assessed up to 48 h after admission, but always before an endpoint occurred. Multiple imputation was performed to handle missing values. RESULTS In total, 16 out of 310 patients (5.2%) died, and 48 (15.5%) developed severe pneumonia. Based on ROC analysis, sequential organ failure assessment (SOFA) and national early warning score 2 (NEWS-2) performed best, predicting severe pneumonia with AUC of 0.823 (0.747-0.880) and 0.784 (0.691-0.855), respectively. CONCLUSION SOFA and NEWS-2 are best suited to identify KTR at risk for the development of severe CAP. In contrast to immunocompetent patients, CRB-65 should not be used to guide outpatient treatment in KTR, since there is a 7% risk for the development of severe pneumonia even in patients with a score of zero.
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Affiliation(s)
- Moritz Müller-Plathe
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Bilgin Osmanodja
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Georg Barthel
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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2
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Bessat C, Bingisser R, Schwendinger M, Bulaty T, Fournier Y, Della Santa V, Pfeil M, Schwab D, Leuppi JD, Geigy N, Steuer S, Roos F, Christ M, Sirova A, Espejo T, Riedel H, Atzl A, Napieralski F, Marti J, Cisco G, Foley RA, Schindler M, Hartley MA, Fayet A, Garcia E, Locatelli I, Albrich WC, Hugli O, Boillat-Blanco N. PLUS-IS-LESS project: Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments: study protocol for a pragmatic stepped-wedge cluster-randomized trial. Trials 2024; 25:86. [PMID: 38273319 PMCID: PMC10809691 DOI: 10.1186/s13063-023-07795-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/09/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Lower respiratory tract infections (LRTIs) are among the most frequent infections and a significant contributor to inappropriate antibiotic prescription. Currently, no single diagnostic tool can reliably identify bacterial pneumonia. We thus evaluate a multimodal approach based on a clinical score, lung ultrasound (LUS), and the inflammatory biomarker, procalcitonin (PCT) to guide prescription of antibiotics. LUS outperforms chest X-ray in the identification of pneumonia, while PCT is known to be elevated in bacterial and/or severe infections. We propose a trial to test their synergistic potential in reducing antibiotic prescription while preserving patient safety in emergency departments (ED). METHODS The PLUS-IS-LESS study is a pragmatic, stepped-wedge cluster-randomized, clinical trial conducted in 10 Swiss EDs. It assesses the PLUS algorithm, which combines a clinical prediction score, LUS, PCT, and a clinical severity score to guide antibiotics among adults with LRTIs, compared with usual care. The co-primary endpoints are the proportion of patients prescribed antibiotics and the proportion of patients with clinical failure by day 28. Secondary endpoints include measurement of change in quality of life, length of hospital stay, antibiotic-related side effects, barriers and facilitators to the implementation of the algorithm, cost-effectiveness of the intervention, and identification of patterns of pneumonia in LUS using machine learning. DISCUSSION The PLUS algorithm aims to optimize prescription of antibiotics through improved diagnostic performance and maximization of physician adherence, while ensuring safety. It is based on previously validated tests and does therefore not expose participants to unforeseeable risks. Cluster randomization prevents cross-contamination between study groups, as physicians are not exposed to the intervention during or before the control period. The stepped-wedge implementation of the intervention allows effect calculation from both between- and within-cluster comparisons, which enhances statistical power and allows smaller sample size than a parallel cluster design. Moreover, it enables the training of all centers for the intervention, simplifying implementation if the results prove successful. The PLUS algorithm has the potential to improve the identification of LRTIs that would benefit from antibiotics. When scaled, the expected reduction in the proportion of antibiotics prescribed has the potential to not only decrease side effects and costs but also mitigate antibiotic resistance. TRIAL REGISTRATION This study was registered on July 19, 2022, on the ClinicalTrials.gov registry using reference number: NCT05463406. TRIAL STATUS Recruitment started on December 5, 2022, and will be completed on November 3, 2024. Current protocol version is version 3.0, dated April 3, 2023.
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Affiliation(s)
- Cécile Bessat
- Infectious Diseases Service, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland.
| | - Roland Bingisser
- Emergency Department, University Hospital of Basel, Basel, Switzerland
| | | | - Tim Bulaty
- Emergency Department, Cantonal Hospital of Baden, Baden, Switzerland
| | - Yvan Fournier
- Emergency Department, Intercantonal Hospital of Broye, Payerne, Switzerland
| | | | - Magali Pfeil
- Emergency Department, Hospital Riviera-Chablais, Rennaz, Switzerland
| | - Dominique Schwab
- Emergency Department, Hospital Riviera-Chablais, Rennaz, Switzerland
| | - Jörg D Leuppi
- Emergency Department and University Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Nicolas Geigy
- Emergency Department and University Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Stephan Steuer
- Emergency Department, St Claraspital, Basel, Switzerland
| | | | - Michael Christ
- Emergency Department, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Adriana Sirova
- Emergency Department, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Tanguy Espejo
- Emergency Department, University Hospital of Basel, Basel, Switzerland
| | - Henk Riedel
- Emergency Department, University Hospital of Basel, Basel, Switzerland
| | - Alexandra Atzl
- Emergency Department, Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Fabian Napieralski
- Emergency Department, Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Joachim Marti
- Health Economics and Policy Unit, Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Giulio Cisco
- Health Economics and Policy Unit, Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Rose-Anna Foley
- Qualitative research platform, social sciences sector, Department of Epidemiology and Health Services, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- School of Health Sciences HESAV, University of Applied sciences of Western Switzerland, HES-SO, Lausanne, Switzerland
| | - Melinée Schindler
- Qualitative research platform, social sciences sector, Department of Epidemiology and Health Services, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Mary-Anne Hartley
- Intelligent Global Health Research Group, Machine Learning and Optimization Laboratory, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Aurélie Fayet
- Clinical Research Center (CRC), University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Elena Garcia
- Emergency Department, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Isabella Locatelli
- Health Economics and Policy Unit, Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Werner C Albrich
- Division of Infectious Diseases & Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Noémie Boillat-Blanco
- Infectious Diseases Service, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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See KC, Lau YH. Acute management of pneumonia in adult patients. Singapore Med J 2023; 64:209-216. [PMID: 36876626 PMCID: PMC10071852 DOI: 10.4103/singaporemedj.smj-2022-050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
| | - Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
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Adams K, Tenforde MW, Chodisetty S, Lee B, Chow EJ, Self WH, Patel MM. A literature review of severity scores for adults with influenza or community-acquired pneumonia - implications for influenza vaccines and therapeutics. Hum Vaccin Immunother 2021; 17:5460-5474. [PMID: 34757894 DOI: 10.1080/21645515.2021.1990649] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Influenza vaccination and antiviral therapeutics may attenuate disease, decreasing severity of illness in vaccinated and treated persons. Standardized assessment tools, definitions of disease severity, and clinical endpoints would support characterizing the attenuating effects of influenza vaccines and antivirals. We review potential clinical parameters and endpoints that may be useful for ordinal scales evaluating attenuating effects of influenza vaccines and antivirals in hospital-based studies. In studies of influenza and community-acquired pneumonia, common physiologic parameters that predicted outcomes such as mortality, ICU admission, complications, and duration of stay included vital signs (hypotension, tachypnea, fever, hypoxia), laboratory results (blood urea nitrogen, platelets, serum sodium), and radiographic findings of infiltrates or effusions. Ordinal scales based on these parameters may be useful endpoints for evaluating attenuating effects of influenza vaccines and therapeutics. Factors such as clinical and policy relevance, reproducibility, and specificity of measurements should be considered when creating a standardized ordinal scale for assessment.
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Affiliation(s)
- Katherine Adams
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mark W Tenforde
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Shreya Chodisetty
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Benjamin Lee
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Eric J Chow
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Wesley H Self
- Department of Emergency Medicine and Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Manish M Patel
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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5
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Sterling RK, Shin D, Shin Y, French E, Stevens MP, Bajaj JS, DeWit M, Sanyal AJ. Fibrosis-4 Predicts the Need for Mechanical Ventilation in a National Multiethnic Cohort of Corona Virus Disease 2019. Hepatol Commun 2021; 5:1605-1615. [PMID: 34510829 PMCID: PMC8239534 DOI: 10.1002/hep4.1737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/11/2021] [Accepted: 04/05/2021] [Indexed: 02/04/2023] Open
Abstract
Simple tests of routine data are needed for those with severe acute respiratory syndrome coronavirus 2, which causes corona virus disease 2019 (COVID-19), to help identify those who may need mechanical ventilation (MV). In this study, we aimed to determine if fibrosis-4 (FIB-4) is associated with the need for MV in patients with COVID-19 and if there is an association to determine the optimal FIB-4 cutoff. This was a retrospective, national, multiethnic cohort study of adults seen in an ambulatory or emergency department setting who were diagnosed with COVID-19. We used the TriNetX platform for analysis. Measures included demographics, comorbid diseases, and routine laboratory tests. A total of 4,901 patients with COVID-19 were included. Patients had a mean age of 56, 48% were women, 42% were obese, 38% were white, 40% were black, 15% had cardiac disease, 39% had diabetes mellitus, 20% had liver disease, and 50% had respiratory disease. The need for MV was 6%. The optimal FIB-4 cutoff for the need for MV was 3.04 (area under the curve, 0.735), which had sensitivity, specificity, and positive and negative predictive values of 42%, 77%, 11%, and 95%, respectively, with 93% accuracy. When stratified by race, increased FIB-4 remained associated with the need for MV in both white and black patients. Conclusion: FIB-4 can be used by frontline providers to identify patients that may require MV.
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Affiliation(s)
- Richard K Sterling
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth UniversityRichmondVAUSA
| | - Dongho Shin
- Department of BiostatisticsVirginia Commonwealth UniversityRichmondVAUSA
| | - Yongyun Shin
- Department of BiostatisticsVirginia Commonwealth UniversityRichmondVAUSA
| | - Evan French
- C. Kenneth and Dianne Wright Center for Clinical and Translational ResearchVirginia Commonwealth UniversityRichmondVAUSA
| | - Michael P Stevens
- Division of Infectious Diseases Department of BiostatisticsVirginia Commonwealth UniversityRichmondVAUSA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth UniversityRichmondVAUSA
| | - Marjolein DeWit
- Division of Pulmonary Medicine and Critical CareVirginia Commonwealth UniversityRichmondVAUSA
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth UniversityRichmondVAUSA
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6
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Ewig S, Kolditz M, Pletz M, Altiner A, Albrich W, Drömann D, Flick H, Gatermann S, Krüger S, Nehls W, Panning M, Rademacher J, Rohde G, Rupp J, Schaaf B, Heppner HJ, Krause R, Ott S, Welte T, Witzenrath M. [Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. Pneumologie 2021; 75:665-729. [PMID: 34198346 DOI: 10.1055/a-1497-0693] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta-Kranken-Anstalt Bochum
| | - M Kolditz
- Universitätsklinikum Carl-Gustav Carus, Klinik für Innere Medizin 1, Bereich Pneumologie, Dresden
| | - M Pletz
- Universitätsklinikum Jena, Institut für Infektionsmedizin und Krankenhaushygiene, Jena
| | - A Altiner
- Universitätsmedizin Rostock, Institut für Allgemeinmedizin, Rostock
| | - W Albrich
- Kantonsspital St. Gallen, Klinik für Infektiologie/Spitalhygiene
| | - D Drömann
- Universitätsklinikum Schleswig-Holstein, Medizinische Klinik III - Pulmologie, Lübeck
| | - H Flick
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Lungenkrankheiten, Graz
| | - S Gatermann
- Ruhr Universität Bochum, Abteilung für Medizinische Mikrobiologie, Bochum
| | - S Krüger
- Kaiserswerther Diakonie, Florence Nightingale Krankenhaus, Klinik für Pneumologie, Kardiologie und internistische Intensivmedizin, Düsseldorf
| | - W Nehls
- Helios Klinikum Erich von Behring, Klinik für Palliativmedizin und Geriatrie, Berlin
| | - M Panning
- Universitätsklinikum Freiburg, Department für Medizinische Mikrobiologie und Hygiene, Freiburg
| | - J Rademacher
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - G Rohde
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Pneumologie und Allergologie, Frankfurt/Main
| | - J Rupp
- Universitätsklinikum Schleswig-Holstein, Klinik für Infektiologie und Mikrobiologie, Lübeck
| | - B Schaaf
- Klinikum Dortmund, Klinik für Pneumologie, Infektiologie und internistische Intensivmedizin, Dortmund
| | - H-J Heppner
- Lehrstuhl Geriatrie Universität Witten/Herdecke, Helios Klinikum Schwelm, Klinik für Geriatrie, Schwelm
| | - R Krause
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Infektiologie, Graz
| | - S Ott
- St. Claraspital Basel, Pneumologie, Basel, und Universitätsklinik für Pneumologie, Universitätsspital Bern (Inselspital) und Universität Bern
| | - T Welte
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - M Witzenrath
- Charité, Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie, Berlin
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7
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Gupta RK, Harrison EM, Ho A, Docherty AB, Knight SR, van Smeden M, Abubakar I, Lipman M, Quartagno M, Pius R, Buchan I, Carson G, Drake TM, Dunning J, Fairfield CJ, Gamble C, Green CA, Halpin S, Hardwick HE, Holden KA, Horby PW, Jackson C, Mclean KA, Merson L, Nguyen-Van-Tam JS, Norman L, Olliaro PL, Pritchard MG, Russell CD, Scott-Brown J, Shaw CA, Sheikh A, Solomon T, Sudlow C, Swann OV, Turtle L, Openshaw PJM, Baillie JK, Semple MG, Noursadeghi M. Development and validation of the ISARIC 4C Deterioration model for adults hospitalised with COVID-19: a prospective cohort study. THE LANCET. RESPIRATORY MEDICINE 2021; 9:349-359. [PMID: 33444539 PMCID: PMC7832571 DOI: 10.1016/s2213-2600(20)30559-2] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/25/2020] [Accepted: 11/25/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prognostic models to predict the risk of clinical deterioration in acute COVID-19 cases are urgently required to inform clinical management decisions. METHODS We developed and validated a multivariable logistic regression model for in-hospital clinical deterioration (defined as any requirement of ventilatory support or critical care, or death) among consecutively hospitalised adults with highly suspected or confirmed COVID-19 who were prospectively recruited to the International Severe Acute Respiratory and Emerging Infections Consortium Coronavirus Clinical Characterisation Consortium (ISARIC4C) study across 260 hospitals in England, Scotland, and Wales. Candidate predictors that were specified a priori were considered for inclusion in the model on the basis of previous prognostic scores and emerging literature describing routinely measured biomarkers associated with COVID-19 prognosis. We used internal-external cross-validation to evaluate discrimination, calibration, and clinical utility across eight National Health Service (NHS) regions in the development cohort. We further validated the final model in held-out data from an additional NHS region (London). FINDINGS 74 944 participants (recruited between Feb 6 and Aug 26, 2020) were included, of whom 31 924 (43·2%) of 73 948 with available outcomes met the composite clinical deterioration outcome. In internal-external cross-validation in the development cohort of 66 705 participants, the selected model (comprising 11 predictors routinely measured at the point of hospital admission) showed consistent discrimination, calibration, and clinical utility across all eight NHS regions. In held-out data from London (n=8239), the model showed a similarly consistent performance (C-statistic 0·77 [95% CI 0·76 to 0·78]; calibration-in-the-large 0·00 [-0·05 to 0·05]); calibration slope 0·96 [0·91 to 1·01]), and greater net benefit than any other reproducible prognostic model. INTERPRETATION The 4C Deterioration model has strong potential for clinical utility and generalisability to predict clinical deterioration and inform decision making among adults hospitalised with COVID-19. FUNDING National Institute for Health Research (NIHR), UK Medical Research Council, Wellcome Trust, Department for International Development, Bill & Melinda Gates Foundation, EU Platform for European Preparedness Against (Re-)emerging Epidemics, NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, NIHR HPRU in Respiratory Infections at Imperial College London.
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Affiliation(s)
- Rishi K Gupta
- Institute for Global Health, University College London, London, UK
| | - Ewen M Harrison
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK; Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Antonia Ho
- Medical Research Council, University of Glasgow Centre for Virus Research, Glasgow, UK; Department of Infectious Diseases, Queen Elizabeth University Hospital, Glasgow, UK
| | - Annemarie B Docherty
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK; Intensive Care Unit, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Stephen R Knight
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | - Marc Lipman
- UCL Respiratory, Division of Medicine, University College London, London, UK; Royal Free Hospitals NHS Trust, London, UK
| | - Matteo Quartagno
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Riinu Pius
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Iain Buchan
- Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Gail Carson
- ISARIC Global Support Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas M Drake
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Jake Dunning
- National Infection Service, Public Health England, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Cameron J Fairfield
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Christopher A Green
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Sophie Halpin
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Hayley E Hardwick
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary, and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Karl A Holden
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary, and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Peter W Horby
- ISARIC Global Support Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Clare Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Kenneth A Mclean
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Laura Merson
- ISARIC Global Support Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jonathan S Nguyen-Van-Tam
- Division of Epidemiology and Public Health, University of Nottingham School of Medicine, Nottingham, UK
| | - Lisa Norman
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Piero L Olliaro
- ISARIC Global Support Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mark G Pritchard
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Clark D Russell
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | | | - Catherine A Shaw
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Tom Solomon
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary, and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK; Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Olivia V Swann
- Department of Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Lance Turtle
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary, and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK; Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | | | - J Kenneth Baillie
- Roslin Institute, University of Edinburgh, Edinburgh, UK; Intensive Care Unit, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Malcolm G Semple
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary, and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK; Respiratory Medicine, Alder Hey Children's Hospital, Institute in The Park, University of Liverpool, Liverpool, UK.
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, University College London, London, UK.
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Dwyer R, Kalin M. Significance of the physician's and the patient's sex in hospitalized patients with community-acquired pneumonia. Infect Dis (Lond) 2021; 53:538-545. [PMID: 33750259 DOI: 10.1080/23744235.2021.1900906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Numerous studies have revealed that the sex of the patient or of the attending physician have impact on patient care, treatment, morbidity and mortality. Community-acquired pneumonia (CAP) is a common cause of hospitalization, antibiotic treatment and intensive care unit (ICU) admission. The purpose of this study was to examine if the patient's or the attending physicians' sex may influence the management of hospitalized patients with CAP. METHODS Our study included 826 consecutive inpatients with CAP (404 females, and 422 male patients, 429 patients initially treated by a female physician and 397 patients initially treated by a male physician). We examined if the patient's, or the initial attending physician's sex, affected treatment and outcome in patients with CAP. RESULTS Patients mean age was 69 years, 30-day mortality 9%. By use of the pneumonia severity index, male patients were found to be more severely ill at admission (p = .0008). Fewer female physicians' patients were admitted from the emergency department (ED) to the ICU when compared to male physicians' patients, 5% versus 10% (p = .006), and female physicians' patients received their first intravenous (IV) antibiotic dose later than male physicians' patients in the ED (p = .003). CONCLUSION Our study indicates that the sex of the attending physician may affect the chosen level of care and antibiotic treatment, and that admitted male patients with CAP were more seriously ill than admitted female patients with CAP.
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Affiliation(s)
- Richard Dwyer
- Department of Infectious Diseases/Venhälsan, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Mats Kalin
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Sitammagari K, Murphy S, Kowalkowski M, Chou SH, Sullivan M, Taylor S, Kearns J, Batchelor T, Rivet C, Hole C, Hinson T, McCreary P, Brown R, Dunn T, Neuwirth Z, McWilliams A. Insights From Rapid Deployment of a "Virtual Hospital" as Standard Care During the COVID-19 Pandemic. Ann Intern Med 2021; 174:192-199. [PMID: 33175567 PMCID: PMC7711652 DOI: 10.7326/m20-4076] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Pandemics disrupt traditional health care operations by overwhelming system resource capacity but also create opportunities for care innovation. OBJECTIVE To describe the development and rapid deployment of a virtual hospital program, Atrium Health hospital at home (AH-HaH), within a large health care system. DESIGN Prospective case series. SETTING Atrium Health, a large integrated health care organization in the southeastern United States. PATIENTS 1477 patients diagnosed with coronavirus disease 2019 (COVID-19) from 23 March to 7 May 2020 who received care via AH-HaH. INTERVENTION A virtual hospital model providing proactive home monitoring and hospital-level care through a virtual observation unit (VOU) and a virtual acute care unit (VACU) in the home setting for eligible patients with COVID-19. MEASUREMENTS Patient demographic characteristics, comorbid conditions, treatments administered (intravenous fluids, antibiotics, supplemental oxygen, and respiratory medications), transfer to inpatient care, and hospital outcomes (length of stay, intensive care unit [ICU] admission, mechanical ventilation, and death) were collected from electronic health record data. RESULTS 1477 patients received care in either the AH-HaH VOU or VACU or both settings, with a median length of stay of 11 days. Of these, 1293 (88%) patients received care in the VOU only, with 40 (3%) requiring inpatient hospitalization. Of these 40 patients, 16 (40%) spent time in the ICU, 7 (18%) required ventilator support, and 2 (5%) died during their hospital admission. In total, 184 (12%) patients were ever admitted to the VACU, during which 21 patients (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required respiratory inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted as an inpatient to a conventional hospital. Of these 24 patients, 10 (42%) required ICU admission, 1 (3%) required a ventilator, and none died during their hospital admission. LIMITATION Generalizability is limited to patients with a working telephone and the ability to comply with the monitoring protocols. CONCLUSION Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond. PRIMARY FUNDING SOURCE Atrium Health.
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Affiliation(s)
- Kranthi Sitammagari
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Stephanie Murphy
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina (M.K., S.C., A.M.)
| | - Shih-Hsiung Chou
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina (M.K., S.C., A.M.)
| | - Matthew Sullivan
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Stephanie Taylor
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - James Kearns
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Thomas Batchelor
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Carly Rivet
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Colleen Hole
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Tony Hinson
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Pamela McCreary
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Ryan Brown
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Todd Dunn
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Zeev Neuwirth
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina (M.K., S.C., A.M.)
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Nicolò A, Massaroni C, Schena E, Sacchetti M. The Importance of Respiratory Rate Monitoring: From Healthcare to Sport and Exercise. SENSORS (BASEL, SWITZERLAND) 2020; 20:E6396. [PMID: 33182463 PMCID: PMC7665156 DOI: 10.3390/s20216396] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/05/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022]
Abstract
Respiratory rate is a fundamental vital sign that is sensitive to different pathological conditions (e.g., adverse cardiac events, pneumonia, and clinical deterioration) and stressors, including emotional stress, cognitive load, heat, cold, physical effort, and exercise-induced fatigue. The sensitivity of respiratory rate to these conditions is superior compared to that of most of the other vital signs, and the abundance of suitable technological solutions measuring respiratory rate has important implications for healthcare, occupational settings, and sport. However, respiratory rate is still too often not routinely monitored in these fields of use. This review presents a multidisciplinary approach to respiratory monitoring, with the aim to improve the development and efficacy of respiratory monitoring services. We have identified thirteen monitoring goals where the use of the respiratory rate is invaluable, and for each of them we have described suitable sensors and techniques to monitor respiratory rate in specific measurement scenarios. We have also provided a physiological rationale corroborating the importance of respiratory rate monitoring and an original multidisciplinary framework for the development of respiratory monitoring services. This review is expected to advance the field of respiratory monitoring and favor synergies between different disciplines to accomplish this goal.
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Affiliation(s)
- Andrea Nicolò
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, 00135 Rome, Italy;
| | - Carlo Massaroni
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (C.M.); (E.S.)
| | - Emiliano Schena
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (C.M.); (E.S.)
| | - Massimo Sacchetti
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, 00135 Rome, Italy;
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11
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Knight SR, Ho A, Pius R, Buchan I, Carson G, Drake TM, Dunning J, Fairfield CJ, Gamble C, Green CA, Gupta R, Halpin S, Hardwick HE, Holden KA, Horby PW, Jackson C, Mclean KA, Merson L, Nguyen-Van-Tam JS, Norman L, Noursadeghi M, Olliaro PL, Pritchard MG, Russell CD, Shaw CA, Sheikh A, Solomon T, Sudlow C, Swann OV, Turtle LC, Openshaw PJ, Baillie JK, Semple MG, Docherty AB, Harrison EM. Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score. BMJ 2020; 370:m3339. [PMID: 32907855 PMCID: PMC7116472 DOI: 10.1136/bmj.m3339] [Citation(s) in RCA: 604] [Impact Index Per Article: 151.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To develop and validate a pragmatic risk score to predict mortality in patients admitted to hospital with coronavirus disease 2019 (covid-19). DESIGN Prospective observational cohort study. SETTING International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) World Health Organization (WHO) Clinical Characterisation Protocol UK (CCP-UK) study (performed by the ISARIC Coronavirus Clinical Characterisation Consortium-ISARIC-4C) in 260 hospitals across England, Scotland, and Wales. Model training was performed on a cohort of patients recruited between 6 February and 20 May 2020, with validation conducted on a second cohort of patients recruited after model development between 21 May and 29 June 2020. PARTICIPANTS: Adults (age ≥18 years) admitted to hospital with covid-19 at least four weeks before final data extraction. MAIN OUTCOME MEASURE In-hospital mortality. RESULTS 35 463 patients were included in the derivation dataset (mortality rate 32.2%) and 22 361 in the validation dataset (mortality rate 30.1%). The final 4C Mortality Score included eight variables readily available at initial hospital assessment: age, sex, number of comorbidities, respiratory rate, peripheral oxygen saturation, level of consciousness, urea level, and C reactive protein (score range 0-21 points). The 4C Score showed high discrimination for mortality (derivation cohort: area under the receiver operating characteristic curve 0.79, 95% confidence interval 0.78 to 0.79; validation cohort: 0.77, 0.76 to 0.77) with excellent calibration (validation: calibration-in-the-large=0, slope=1.0). Patients with a score of at least 15 (n=4158, 19%) had a 62% mortality (positive predictive value 62%) compared with 1% mortality for those with a score of 3 or less (n=1650, 7%; negative predictive value 99%). Discriminatory performance was higher than 15 pre-existing risk stratification scores (area under the receiver operating characteristic curve range 0.61-0.76), with scores developed in other covid-19 cohorts often performing poorly (range 0.63-0.73). CONCLUSIONS An easy-to-use risk stratification score has been developed and validated based on commonly available parameters at hospital presentation. The 4C Mortality Score outperformed existing scores, showed utility to directly inform clinical decision making, and can be used to stratify patients admitted to hospital with covid-19 into different management groups. The score should be further validated to determine its applicability in other populations. STUDY REGISTRATION ISRCTN66726260.
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Affiliation(s)
- Stephen R Knight
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Antonia Ho
- Medical Research Council, University of Glasgow Centre for Virus Research, Glasgow, UK
- Department of Infectious Diseases, Queen Elizabeth University Hospital, Glasgow, UK
| | - Riinu Pius
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Iain Buchan
- Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Gail Carson
- ISARIC Global Support Centre, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas M Drake
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Jake Dunning
- National Infection Service, Public Health England, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Cameron J Fairfield
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Christopher A Green
- Institute of Microbiology & Infection, University of Birmingham, Birmingham, UK
| | - Rishi Gupta
- Institute of Global Health, University College London, London, UK
| | - Sophie Halpin
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Hayley E Hardwick
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Karl A Holden
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Peter W Horby
- ISARIC Global Support Centre, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Clare Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Kenneth A Mclean
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Laura Merson
- ISARIC Global Support Centre, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jonathan S Nguyen-Van-Tam
- Division of Epidemiology and Public Health, University of Nottingham School of Medicine, Nottingham, UK
| | - Lisa Norman
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, University College London, London, UK
| | - Piero L Olliaro
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mark G Pritchard
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Clark D Russell
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Catherine A Shaw
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Tom Solomon
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Olivia V Swann
- Department of Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Lance Cw Turtle
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Tropical & Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Peter Jm Openshaw
- National Heart and Lung Institute, Imperial College London, London, UK
| | - J Kenneth Baillie
- Roslin Institute, University of Edinburgh, Edinburgh, UK
- Intensive Care Unit, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Malcolm G Semple
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Respiratory Medicine, Alder Hey Children's Hospital, Institute in The Park, University of Liverpool, Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - Annemarie B Docherty
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
- Intensive Care Unit, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Ewen M Harrison
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
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12
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Høgli JU, Garcia BH, Svendsen K, Skogen V, Småbrekke L. Empirical prescribing of penicillin G/V reduces risk of readmission of hospitalized patients with community-acquired pneumonia in Norway: a retrospective observational study. BMC Pulm Med 2020; 20:169. [PMID: 32539706 PMCID: PMC7294665 DOI: 10.1186/s12890-020-01188-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 05/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Norwegian guideline recommendations on first-line empirical antibiotic prescribing in hospitalised patients with community-acquired pneumonia (CAP) are penicillin G/V in monotherapy, or penicillin G in combination with gentamicin (or cefotaxime) in severely ill patients. The aim of this study was to explore how different empirical antibiotic treatments impact on length of hospital stay (LOS) and 30-day hospital readmission. A secondary aim was to describe median intravenous- and total treatment duration. METHODS We included CAP patients (≥18 years age) hospitalised in North Norway during 2010 and 2012 in a retrospective study. Patients with negative chest x-ray, malignancies or immunosuppression or frequent readmissions were excluded. We collected data on patient characteristics, empirical antibiotic prescribing, treatment duration and clinical outcomes from electronic patient records and the hospital administrative system. We used directed acyclic graphs for statistical model selection, and analysed data with mulitvariable logistic and linear regression. RESULTS We included 651 patients. Median age was 77 years [IQR; 64-84] and 46.5% were female. Median LOS was 4 days [IQR; 3-6], 30-day readmission rate was 14.4% and 30-day mortality rate was 6.9%. Penicillin G/V were empirically prescribed in monotherapy in 51.5% of patients, penicillin G and gentamicin in combination in 22.9% and other antibiotics in 25.6% of patients. Prescribing other antibiotics than penicillin G/V monotherapy was associated with increased risk of readmission [OR 1.9, 95% CI; 1.08-3.42]. Empirical antibiotic prescribing was not associated with LOS. Median intravenous- and total treatment duration was 3.0 [IQR; 2-5] and 11.0 [IQR; 9.8-13] days. CONCLUSIONS Our findings show that empirical prescribing with penicillin G/V in monotherapy in hospitalised non-severe CAP-patients, without complicating factors such as malignancy, immunosuppression and frequent readmission, is associated with lower risk of 30-day readmission compared to other antibiotic treatments. Median total treatment duration exceeds treatment recommendations.
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Affiliation(s)
- June Utnes Høgli
- Regional Centre for Infection Control, University Hospital of North Norway, N-9038, Tromsø, Norway.,Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, N-9037, Tromsø, Norway
| | - Beate Hennie Garcia
- Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, N-9037, Tromsø, Norway
| | - Kristian Svendsen
- Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, N-9037, Tromsø, Norway.,Hospital Pharmacy of North Norway Trust, N-9291, Tromsø, Norway
| | - Vegard Skogen
- Department of Infectious Diseases, Division of Internal Medicine, University Hospital of North Norway, N-9038, Tromsø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, N-9037, Tromsø, Norway.,Infectious Diseases Unit, LaFe University Hospital, Valencia, Spain
| | - Lars Småbrekke
- Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, N-9037, Tromsø, Norway.
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Sinha S, Sardesai I, Galwankar SC, Nanayakkara P, Narasimhan DR, Grover J, Anderson HL, Paladino L, Gaieski DF, Somma SD, Stawicki SP. Optimizing respiratory care in coronavirus disease-2019: A comprehensive, protocolized, evidence-based, algorithmic approach. Int J Crit Illn Inj Sci 2020; 10:56-63. [PMID: 32904508 PMCID: PMC7456282 DOI: 10.4103/ijciis.ijciis_69_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/17/2020] [Accepted: 05/21/2020] [Indexed: 12/17/2022] Open
Affiliation(s)
- Sagar Sinha
- Department of Critical Care and Emergency Medicine, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India
| | - Indrani Sardesai
- Department of Accident and Emergency Medicine, Queen Elizabeth Hospital, Gateshead, United Kingdom
| | - Sagar C. Galwankar
- Department of Emergency Medicine, Sarasota Memorial Hospital, Florida State University, Sarasota, Florida, USA
| | - P.W.B. Nanayakkara
- Section General and Acute Internal Medicine, Amsterdam UMC, Location VU University Medical Center, Amsterdam, the, Netherlands
| | | | - Joydeep Grover
- Department of Emergency Medicine, Southmead Hospital, Bristol, England, United Kingdom
| | - Harry L. Anderson
- Department of Surgery, St. Joseph Mercy Ann Arbor, Ann Arbor, Michigan
| | - Lorenzo Paladino
- Department of Emergency Medicine, SUNY Downstate and Kings County Hospital Medical Center, New York, USA
| | - David F. Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Salvatore Di Somma
- Department of Medical-Surgical Sciences and Translational Medicine, University of Rome “Sapienza”, Rome, Italy
| | - Stanislaw P. Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
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14
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Predictors of Mortality Among Hospitalized Patients With Lower Respiratory Tract Infections in a High HIV Burden Setting. J Acquir Immune Defic Syndr 2019; 79:624-630. [PMID: 30222660 DOI: 10.1097/qai.0000000000001855] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Lower respiratory tract infections (LRTIs) are a leading cause of mortality in sub-Saharan Africa. Triaging identifies patients at high risk of death, but laboratory tests proposed for use in severity-of-illness scores are not readily available, limiting their clinical use. Our objective was to determine whether baseline characteristics in hospitalized participants with LRTI predicted increased risk of death. METHODS This was a secondary analysis from the Mulago Inpatient Non-invasive Diagnosis-International HIV-associated Opportunistic Pneumonias (MIND-IHOP) cohort of adults hospitalized with LRTI who underwent standardized investigations and treatment. The primary outcome was all-cause mortality at 2 months. Predictors of mortality were determined using multiple logistic regression. RESULTS Of 1887 hospitalized participants with LRTI, 372 (19.7%) died. The median participant age was 34.3 years (interquartile range, 28.0-43.3 years), 978 (51.8%) were men, and 1192 (63.2%) were HIV-positive with median CD4 counts of 81 cells/µL (interquartile range, 21-226 cells/µL). Seven hundred eleven (37.7%) participants had a microbiologically confirmed diagnosis. Temperature <35.5°C [adjusted odds ratio (aOR) = 1.77, 95% confidence intervals (CI): 1.20 to 2.60; P = 0.004], heart rate >120/min (aOR = 1.82, 95% CI: 1.37 to 2.43; P < 0.0001), oxygen saturation <90% (aOR = 2.74, 95% CI: 1.97 to 3.81; P < 0.0001), being bed-bound (aOR = 1.88, 95% CI: 1.47 to 2.41; P < 0.0001), and being HIV-positive (aOR = 1.49, 95% CI: 1.14 to 1.94; P = 0.003) were independently associated with mortality at 2 months. CONCLUSIONS Having temperature <35.5°C, heart rate >120/min, hypoxia, being HIV-positive, and bed-bound independently predicts mortality in participants hospitalized with LRTI. These readily available characteristics could be used to triage patients with LRTI in low-income settings. Providing adequate oxygen, adequate intravenous fluids, and early antiretroviral therapy (in people living with HIV/AIDS) may be life-saving in hospitalized patients with LRTI.
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Kim B, Kim J, Jo YH, Lee JH, Hwang JE. The change in age distribution of CAP population in Korea with an estimation of clinical implications of increasing age threshold of current CURB65 and CRB65 scoring system. PLoS One 2019; 14:e0219367. [PMID: 31415581 PMCID: PMC6695142 DOI: 10.1371/journal.pone.0219367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 06/21/2019] [Indexed: 01/26/2023] Open
Abstract
Background CURB65 and CRB65 score are simple and popular methods to estimate the mortality in patients with community-acquired pneumonia (CAP). Although there has been a global increase in life expectancy and population ageing, we are still using the same age threshold derived from patients in late 1990s to calculate the scores. We sought to assess the implication of using higher age threshold using Korean population data and a single center hospital records. Methods Using Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC), we analyzed annual age distribution of CAP patients in Korea from 2005 to 2013 and report how patients aged >65 years increased over time. We also assessed annual change in test characteristics of various age threshold in Korean CAP population. Using a single center hospital registry of CAP patients (2008–2017), we analyzed test characteristics of CURB65 and CRB65 scores with various age thresholds. Results 116,481 CAP cases were identified from NHIS-NSC dataset. The proportion of patients aged >65 increased by 1.01% (95% CI, 0.70%-1.33%, P<0.001) every year. In the sample Korean population dataset, age threshold showed its peak AUROC (0.829) at 70. In the hospital dataset, 7,197 cases were included for analysis. The AUROC of both CRB65 and CURB65 was maximized at 71. When CRB71 was applied instead of CRB65 for hospital referral using score <1 to define a low-risk case, the potential hospital referral was significantly decreased (72.9% to 64.6%, P<0.001) without any significant increase in 1-month mortality in the low risk group (0.6% to 0.7%, P = 0.690). Conclusion There was a significant age shift in CAP population in Korea. Increasing the current age threshold of CURB65 (or CRB65) could be a viable option to reduce ever-increasing hospital referrals and admissions of CAP patients.
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Affiliation(s)
- Byunghyun Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
- * E-mail:
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Ji Eun Hwang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
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16
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Ebell MH, Walsh ME, Fahey T, Kearney M, Marchello C. Meta-analysis of Calibration, Discrimination, and Stratum-Specific Likelihood Ratios for the CRB-65 Score. J Gen Intern Med 2019; 34:1304-1313. [PMID: 30993633 PMCID: PMC6614215 DOI: 10.1007/s11606-019-04869-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/19/2018] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients. OBJECTIVE To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios. DESIGN Meta-analysis of accuracy, discrimination, and calibration. METHODS We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported. KEY RESULTS Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95% CI 0.71-0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95% CI 0.91-1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70-0.81) and 0.88 (0.69-1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients. CONCLUSIONS The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4% overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5%.
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Affiliation(s)
- Mark H Ebell
- Department of Epidemiology and Biostatistics, College of Public Health , University of Georgia, Athens, GA, USA.
| | - Mary E Walsh
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Maggie Kearney
- Department of Epidemiology and Biostatistics, College of Public Health , University of Georgia, Athens, GA, USA
| | - Christian Marchello
- Department of Epidemiology and Biostatistics, College of Public Health , University of Georgia, Athens, GA, USA
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17
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Kim B, Kim J, Jo YH, Lee JH, Hwang JE, Park MJ, Lee S. Prognostic value of pneumococcal urinary antigen test in community-acquired pneumonia. PLoS One 2018; 13:e0200620. [PMID: 30028834 PMCID: PMC6054390 DOI: 10.1371/journal.pone.0200620] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 06/29/2018] [Indexed: 12/18/2022] Open
Abstract
Background The pneumococcal urinary antigen test (UAT) has been known to improve sensitivity and specificity for the diagnosis of pneumococcal pneumonia. Associations of UAT results with prognosis in community acquired pneumonia (CAP) are not known. We hypothesized that positive UAT is associated with a good prognosis, and incorporation of UAT into CRB65 would improve its prognostic performance. Methods In this registry-based retrospective study, we analyzed CAP patients over a 10-year period beginning in April 2008. Patients who had UAT results were included in multivariable extended Cox-regression analyses to determine the association between UAT positivity and 30-day mortality. UAT results were incorporated for patients with a CRB65 score of 1 by subtracting 1 from the scoring system if the test was positive. The performance of the modified scoring systems was assessed with area under the receiver operating characteristic (AUROC) curves. Results Among 5145 CAP patients, total 2280 patients had UAT results and were included in analyses. A positive UAT result was associated with a good prognosis after a week of hospitalization (aHR, 0.14; p = 0.007). After modification of CRB65 using UAT results, positive and negative predictive values for 30-day mortality were increased from 7.7 to 8.3 (p<0.001) and 98.9 to 99.1 (p = 0.010). The AUROC increased from 0.73 to 0.75 (p<0.001). Conclusions Positive results on UAT could be considered as a good prognostic factor in CAP. UAT could be used as a useful tool in deciding whether to refer patients to the hospital, especially in moderate CAP with a CRB score of 1.
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Affiliation(s)
- Byunghyun Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
- * E-mail:
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Ji Eun Hwang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Min Ji Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Sihyung Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
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18
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Jeon K, Yoo H, Jeong BH, Park HY, Koh WJ, Suh GY, Guallar E. Functional status and mortality prediction in community-acquired pneumonia. Respirology 2017; 22:1400-1406. [PMID: 28513919 DOI: 10.1111/resp.13072] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/07/2017] [Accepted: 03/24/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVE Poor functional status (FS) has been suggested as a poor prognostic factor in both pneumonia and severe pneumonia in elderly patients. However, it is still unclear whether FS is associated with outcomes and improves survival prediction in community-acquired pneumonia (CAP) in the general population. METHODS Data on hospitalized patients with CAP and FS, assessed by the Eastern Cooperative Oncology Group (ECOG) scale were prospectively collected between January 2008 and December 2012. The independent association of FS with 30-day mortality in CAP patients was evaluated using multivariable logistic regression. Improvement in mortality prediction when FS was added to the CRB-65 (confusion, respiratory rate, blood pressure and age 65) score was evaluated for discrimination, reclassification and calibration. RESULTS The 30-day mortality of study participants (n = 1526) was 10%. Mortality significantly increased with higher ECOG score (P for trend <0.001). In multivariable analysis, ECOG ≥3 was strongly associated with 30-day mortality (adjusted OR: 5.70; 95% CI: 3.82-8.50). Adding ECOG ≥3 significantly improved the discriminatory power of CRB-65. Reclassification indices also confirmed the improvement in discrimination ability when FS was combined with the CRB-65, with a categorized net reclassification index (NRI) of 0.561 (0.437-0.686), a continuous NRI of 0.858 (0.696-1.019) and a relative integrated discrimination improvement in the discrimination slope of 139.8 % (110.8-154.6). CONCLUSION FS predicted 30-day mortality and improved discrimination and reclassification in consecutive CAP patients. Assessment of premorbid FS should be considered in mortality prediction in patients with CAP.
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Affiliation(s)
- Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hongseok Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won-Jung Koh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gee Young Suh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eliseo Guallar
- Departments of Epidemiology and Medicine, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Abstract
PURPOSE OF REVIEW Community-acquired pneumonia (CAP) is a pervasive disease that is encountered in outpatient and inpatient settings. CAP is the leading cause of death from an infectious disease and accounts for significant worldwide morbidity and mortality. This update reviews current advances that can be used to promote improved outcomes in CAP. RECENT FINDINGS Early recognition of CAP and its severe presentations, with appropriate site of care decisions, leads to reduced patient mortality. In addition to traditional prognostic tools, certain serum biomarkers can assist in defining disease severity and guide treatment and management strategies. The use of macrolides as part of combination antibiotic therapy has shown beneficial mortality effects across the CAP disease spectrum, especially for those with severe illness. When treating community-associated, methicillin-resistant Staphylococcus aureus pneumonia, use of an antitoxin antibiotic is likely to be valuable. Adjunctive therapy with corticosteroids may prevent delayed clinical resolution in selected patients with severe CAP. Recent data expand on the interaction of CAP with comorbid disease, particularly cardiovascular disease, and its impact on mortality in CAP patients. SUMMARY Improved diagnostic tools, optimized treatment regimens, and enhanced understanding of CAP-induced perturbations in comorbid disease states hold promise to improve patient outcomes.
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20
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Anderson I. A proposed Primary Health Early Warning Score (PHEWS) with emphasis on early detection of sepsis in the elderly. J Prim Health Care 2016; 8:5-8. [PMID: 27477368 DOI: 10.1071/hc15044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
There are several secondary care early warning scores which alert for severe illness including sepsis. None are specifically adjusted for primary care. A Primary Health Early Warning Score (PHEWS) is proposed which incorporates practical parameters from both secondary and primary care.
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Affiliation(s)
- Ian Anderson
- Waiuku Medical Centre, 30 Constable Rd, Waiuku 2123, New Zealand.
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21
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Chen YX, Wang JY, Guo SB. Use of CRB-65 and quick Sepsis-related Organ Failure Assessment to predict site of care and mortality in pneumonia patients in the emergency department: a retrospective study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:167. [PMID: 27250351 PMCID: PMC4888495 DOI: 10.1186/s13054-016-1351-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 05/13/2016] [Indexed: 01/19/2023]
Abstract
Background The quick Sepsis-related Organ Failure Assessment (qSOFA) is a new screening system for sepsis that has prognostic performance equal to the full SOFA for patients with suspected infection outside the intensive care unit (ICU). The predictive value of qSOFA for mortality and site of care in patients with pneumonia is not clear. The present study was designed to investigate the predictive performance of qSOFA, CRB-65 (confusion, respiratory rate ≥30/minute, systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg, age ≥65 years) and CRB (confusion, respiratory rate ≥30/minute, systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg) for mortality, hospitalisation and ICU admission in patients with pneumonia in the emergency department (ED). Methods Retrospective analyses of published data on adult patients with pneumonia presenting between January 2012 and May 2014 were undertaken. The prevalence of 28-day mortality, hospitalisation and ICU admission were compared with regard to qSOFA, CRB and CRB-65 scores. The performance of these three systems for predicting outcomes was compared. Results Of 1641 patients, 861 (53 %) were hospitalised (38 % in a general ward, 15 % in the ICU), and the remaining 780 (47 %) were treated as outpatients or were observed in the ED. Within 28 days, 547 (33 %) of 1641 patients died. CRB-65, CRB and qSOFA scores of patients who died, were hospitalised and admitted to the ICU than those who survived and were not hospitalised or admitted to the ICU (P < 0.001). AUC values of qSOFA for prediction of 28-day mortality, hospitalisation and ICU admission were similar to those for CRB-65 and CRB. Patients with qSOFA scores of 0, 1, 2 and 3 were associated with, respectively, mortality of 16.3 %, 24.4 %, 48.2 % and 68.4 %; prevalence of hospitalisation of 37.2 %, 47.4 %, 61.6 % and 73.7 %; and prevalence of ICU admission of 9.3 %, 9.1 %, 22.4 % and 45.3 %. Patients with qSOFA scores of 2 and 3 had a significantly higher prevalence of mortality and ICU admission than patients with identical CRB-65 scores. Conclusions qSOFA is better than CRB-65 for identification of a high risk of mortality and requirement of ICU admission.
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Affiliation(s)
- Yun-Xia Chen
- Emergency Department, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, Chaoyang District, Beijing, 100020, China
| | - Jun-Yu Wang
- Emergency Department, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, Chaoyang District, Beijing, 100020, China
| | - Shu-Bin Guo
- Emergency Department, Beijing Chao-Yang Hospital Affiliated to Capital Medical University, Chaoyang District, Beijing, 100020, China. .,, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing, 100020, China.
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22
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Pletz MW, Rohde GG, Welte T, Kolditz M, Ott S. Advances in the prevention, management, and treatment of community-acquired pneumonia. F1000Res 2016; 5. [PMID: 26998243 PMCID: PMC4786904 DOI: 10.12688/f1000research.7657.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2016] [Indexed: 01/06/2023] Open
Abstract
Community-acquired pneumonia (CAP) is the infectious disease with the highest number of deaths worldwide. Nevertheless, its importance is often underestimated. Large cohorts of patients with CAP have been established worldwide and improved our knowledge about CAP by far. Therefore, current guidelines are much more evidence-based than ever before. This article discusses recent major studies and concepts on CAP such as the role of biomarkers, appropriate risk stratification to identify patients in need of hospitalisation or intensive care, appropriate empiric antibiotic therapy (including the impact of macrolide combination therapy and antibiotic stewardship), and CAP prevention with novel influenza and pneumococcal vaccines.
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Affiliation(s)
- Mathias W Pletz
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Gernot G Rohde
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Martin Kolditz
- Division of Pulmonology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Sebastian Ott
- Department of Pulmonary Medicine, Inselspital, University Hospital, Bern, Switzerland
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23
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Kolditz M, Ewig S, Schütte H, Suttorp N, Welte T, Rohde G. Assessment of oxygenation and comorbidities improves outcome prediction in patients with community-acquired pneumonia with a low CRB-65 score. J Intern Med 2015; 278:193-202. [PMID: 25597400 DOI: 10.1111/joim.12349] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Addition of assessment of comorbid diseases ('D') and oxygen saturation ('S') to the CRB-65 score has been recommended to improve its accuracy for risk stratification in community-acquired pneumonia (CAP). The aim of this study was to validate the resulting DS-CRB-65 score in a large cohort of patients with CAP. METHODS A total of 4432 patients prospectively enrolled in the CAPNETZ cohort were included in this study. Predefined end points were 28-day mortality, requirement for mechanical ventilation or vasopressors (MV/VS) and requirement for MV/VS or intensive care unit admission (MV/VS/ICU). Receiver operating characteristic curve analysis was used to determine the accuracy of the CRB-65 score and the addition of D (extra-pulmonary comorbidities) and S (oxygen saturation <90% or partial pressure of oxygen <8 kPa). Binary logistic regression and the method of Hanley and McNeil were used to compare the criteria. RESULTS The mortality rate was 4.0%, and 4.2% of patients required MV/VS and 6.6% required MV/VS/ICU. After multivariate analysis, D and S independently were added to the CRB-65 criteria for mortality prediction, but only S improved prediction of MV/VS and MV/VS/ICU (P < 0.001 for all). The area under the curve of the CRB-65 score was significantly improved by adding D and S for all end points (P < 0.02). Amongst patients who died or required MV/VS despite a CRB-65 score of 0, 64-80% would have been identified by the DS-CRB-65 score. CONCLUSIONS The addition of assessment of oxygenation and comorbidities significantly improved the prognostic accuracy of the CRB-65 score. Consequently, the DS-CRB-65 score may have a useful role in risk stratification algorithms for CAP.
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Affiliation(s)
- M Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technical University, Dresden, Germany
| | - S Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, EVK Herne and Augusta-Kranken-Anstalt, Bochum, Germany
| | - H Schütte
- Department of Pulmonology, Klinikum Ernst von Bergmann, Potsdam, Germany.,Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,CAPNETZ STIFTUNG, Hannover, Germany
| | - N Suttorp
- Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,CAPNETZ STIFTUNG, Hannover, Germany
| | - T Welte
- CAPNETZ STIFTUNG, Hannover, Germany.,Department of Respiratory Medicine, Medizinische Hochschule, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), The German Center for Lung Research (DZL), Hannover, Germany
| | - G Rohde
- CAPNETZ STIFTUNG, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), The German Center for Lung Research (DZL), Hannover, Germany.,Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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