Pneumonia severity scores in resource poor settings

The relevance of chest X-ray radiologic severity index and CURB-65 score with the death event in hospitalized patient with COVID-19 pneumonia

Background

The global pandemic respiratory infection COVID-19 has had a high mortality rate since early 2020 with a broad spectrum of symptoms and giving a high burden. This study used the chest X-ray radiologic severity index method to radiologically assess the degree of lung lesions and the CURB-65 score to clinically assess COVID-19 pneumonia patients associated with the incidence of death in hospitalized patients.

Results

The research data were carried out from March 2020 to April 2021 based on patient medical records and chest X-rays at Doctor Kariadi General Hospital Semarang Indonesia. One hundred and five subjects were collected that fulfilled the inclusion and exclusion criteria. The CURB-65 score ≥ 2 had a significant relationship to the death event with a prevalence interval of 2.98 (95% CI, p = 0.000). The radiologic severity index ≥ 22.5 in initial chest X-ray signified a prevalence ratio of 2.24 (CI 95%, p = 0.004) and the radiologic severity index ≥ 29.5 in the second chest X-ray signified a prevalence ratio of 4.53 for the incidence of death (95% CI, p = 0.000). The combination of CURB-65 and the first chest X-ray radiologic severity index resulted in a prevalence ratio of 27.44, and the combination of CURB-65 and the second chest X-ray radiologic severity index resulted in a prevalence ratio of 60.2 which were significant for the mortality of hospitalized COVID-19 pneumonia patients.

Conclusions

Chest X-ray radiologic severity index and CURB-65 score have a significant relevance with the death event in hospitalized patients with COVID-19 pneumonia and can thus be used as a predictor of mortality.

Comparison of Frailty Index to Pneumonia Severity Measures in Older Patients With Pneumonia

OBJECTIVES

Risk stratification tools are useful to provide appropriate clinical care for older patients with pneumonia. This study aimed to compare a Frailty Index (FI) with pneumonia severity measures, CURB-65, and the Pneumonia Severity Index (PSI), for predicting mortality and persistent disability after pneumonia.

DESIGN

Single-center prospective cohort study.

SETTING AND PARTICIPANTS

The study included 190 patients aged ≥65 years who were hospitalized with pneumonia at a university hospital in Korea between October 2019 and September 2020.

METHODS

At admission, a 50-item deficit-accumulation FI (range: 0-1), CURB-65 (range: 0-5), and PSI (range: 0-395) scores were calculated. The outcomes were death and a composite outcome of death or decline in ability to perform daily activities and physical task 6 months later.

RESULTS

The median age was 79 years (interquartile range: 74-85), and 70 (36.8%) patients were women. The patients who died (n = 53) had higher FI (median, 0.46 vs 0.20; P < .011), CURB-65 score (median, 3 vs 2; P = .001), and PSI score (median, 149 vs 116; P < .001) than those who did not. The C-statistics (95% confidence intervals) for 6-month mortality were 0.69 (0.61-0.77) for the FI, 0.62 (0.53-0.71) for CURB-65, and 0.71 (0.62-0.79) for the PSI (P = .019). The C-statistics for the 6-month composite outcome were 0.73 (0.65-0.81) for the FI, 0.64 (0.55-0.73) for CURB-65, and 0.69 (0.60-0.77) for the PSI (P = .096). The C-statistics improved when the FI was added to CURB-65 (from 0.64 to 0.74; P = .003) and to the PSI (from 0.69 to 0.75; P = .044) for the composite outcome.

CONCLUSIONS AND IMPLICATIONS

Measuring frailty provides additive value to widely used pneumonia severity measures in predicting death or persistent hospitalization-associated disability in older adults after pneumonia hospitalization. Early recognition of frailty may be useful to identify those who require in-hospital and post-acute care interventions for functional recovery.

Validating a novel index (SWAT-Bp) to predict mortality risk of community-acquired pneumonia in Malawi

BACKGROUND

Community-acquired pneumonia is a major cause of mortality worldwide. Early assessment and initiation of management improves outcomes. In higher-income countries, scores assist in predicting mortality from pneumonia. These have not been validated for use in most lower-income countries.

AIM

To validate a new score, the SWAT-Bp score, in predicting mortality risk of clinical community-acquired pneumonia amongst hospital admissions at Queen Elizabeth Central Hospital, Blantyre, Malawi.

METHODS

The five variables constituting the SWAT-Bp score (male [S]ex, muscle [W]asting, non-[A]mbulatory, [T]emperature (>38°C or <35°C) and [B]lood [p]ressure (systolic<100 and/or diastolic<60)) were recorded for all patients with clinical presentation of a lower respiratory tract infection, presumed to be pneumonia, over four months (N=216). The sensitivity and specificity of the score were calculated to determine accuracy of predicting mortality risk.

RESULTS

Median age was 35 years, HIV prevalence was 84.2% amongst known statuses, and mortality rate was 12.5%. Mortality for scores 0-5 was 0%, 8.5%, 12.7%, 19.0%, 28.6%, 100% respectively. Patients were stratified into three mortality risk groups dependent on their score. SWAT-Bp had moderate discriminatory power overall (AUROC 0.744). A SWAT-Bp score of ≥2 was 82% sensitive and 51% specific for predicting mortality, thereby assisting in identifying individuals with a lower mortality risk.

CONCLUSION

In this validation cohort, the SWAT-Bp score has not performed as well as in the derivation cohort. However, it could potentially assist clinicians identifying low-risk patients, enabling rapid prioritisation of treatment in a low-resource setting, as it helps contribute towards individual patient risk stratification.

The definition and classification of pneumonia

Following the publication of a volume of Pneumonia focused on diagnosis, the journal's Editorial Board members debated the definition and classification of pneumonia and came to a consensus on the need to revise both of these. The problem with our current approach to the classification of pneumonia is twofold: (i) it results in widespread empirical, and often unnecessary, use of antimicrobials that contributes to pathogen resistance; and (ii) it contributes to heterogeneity among the groups of subjects compared in research, causing misclassification bias and mixtures of effects that threaten internal validity. After outlining the problem of classification, this commentary describes the strengths and weaknesses of a range of systems for the classification of pneumonia. The commentary then calls for debate to generate consensus classifications in the field, proposing a working definition and way forward focusing on the following three points: (i) pneumonia should be defined as an acute infection of the lung parenchyma by various pathogens, excluding the condition of bronchiolitis; (ii) defining pneumonia as a group of specific (co)infections with different characteristics is an ideal that currently has limited use, because the identification of aetiologic organisms in individuals is often not possible (however, the benefits of classifying pneumonia into specific, more homogenous phenotypes should be carefully considered when designing research studies); and (iii) investigation of more homogenous pneumonia groupings is achievable and is likely to yield more rapid advances in the field.