Viral prevalence, clinical profiles and comparison of severity scores for predicting the mortality of adults with severe acute respiratory infections

Characterizing deaths among adult patients with severe acute respiratory infection: during the pre- and COVID-19 pandemic periods in Bangladesh, 2018-2022

BACKGROUND

Severe acute respiratory infection (SARI) is a leading cause of mortality globally, peaking during the COVID-19 pandemic. We analyzed SARI-associated deaths during the pre-and-pandemic periods in Bangladesh to identify the contributing factors.

METHODS

We analyzed data from hospital-based influenza surveillance at nine tertiary-level hospitals in Bangladesh. We considered March 2018-February 2020 as the pre-pandemic period and March 2020-February 2022 as the pandemic period and included adult (≥ 18 years) participants in our study. Surveillance physicians identified WHO-SARI case definition meeting inpatients and collected demographics, clinical characteristics, and outcomes at hospital discharge and 30 days post-discharge. We performed rRT-PCR for influenza and SARS-CoV-2 viruses on collected nasopharyngeal and oropharyngeal swabs. We used multivariable Cox's regression models to calculate the hazard ratio (HR) for factors associated with SARI deaths in these adult patients.

RESULTS

We enrolled 4392 SARI patients during the pre-pandemic and 3824 SARI patients during the pandemic period. Case fatality ratio was higher during the pandemic: 13.62% (521) [in-hospital: 6.45% (247); post-discharge: 7.17% (274)] compared to pre-pandemic, 6.01% (264) [in-hospital: 2.01% (89), post-discharge: 4% (175)] (p < 0.001). Pre-pandemic, influenza was detected in 14% (37/264) of SARI deaths. Influenza was detected during the pandemic in 2.3% (12/521), SARS-CoV-2 in 41.8% (218/521), and both viruses in only one SARI death. History of smoking and the presence of 1 or more co-morbid conditions independently attributed to SARI deaths in adults in the pre-pandemic period. SARI deaths in such patients were also associated with respiratory difficulties on admission in both pre-pandemic (aHR 2.36; 95% CI:1.65-3.36) and pandemic period (aHR 2.30; 95% CI: 1.57-3.35) after accounting for age, sex, smoking status, presence of 1 or more co-morbid conditions, and detection of influenza and SARS-CoV-2 viruses.

CONCLUSIONS

During the pandemic, SARI mortality increased; influenza-associated mortality declined, and SARS-CoV-2 caused over a third of SARI deaths. Post-discharge mortality was higher than in-hospital mortality during both periods. Limiting premature discharge and strengthening post-discharge monitoring and nursing services could reduce unexpected deaths. Formative research to better understand post-discharge mortality is essential to reduce SARI deaths.

The prognostic value of rapid risk scores among patients with community-acquired pneumonia : A retrospective cohort study

BACKGROUND

Community-acquired pneumonia (CAP) is a frequent reason for emergency department (ED) presentations. Various risk scores have been validated in the management of CAP and are recommended for daily practice.

OBJECTIVE

The aim of the study was to evaluate the performance of the rapid risk scores (the rapid acute physiology score (RAPS), the rapid emergency medicine score (REMS), the Worthing physiological scoring system (WPS), CURB-65 and CRB-65) among patients with CAP.

METHODS

This retrospective cohort study was conducted in the ED of a tertiary hospital between 1 January 2019 and 31 December 2019. Patients aged ≥ 18 years and diagnosed with CAP were included. Patients who were transferred from another center or with missing records were excluded. Demographic information, vital signs, level of consciousness, laboratory results, and outcomes were recorded.

RESULTS

A total of 2057 patients were included in the final analysis. The 30-day mortality of the patients was 15.2% (n = 312). The WPS achieved the most successful results for all three outcomes, 30-day mortality, intensive care unit (ICU) admission and mechanical ventilation (MV) needs (area under the curve, AUC 0.810, 0.918, and 0.910, respectively; p < 0.001). In the prediction of mortality, RAPS, REMS, CURB-65, and CRB-65 had a moderate overall performance (AUC 0.648, 0.752, 0.778, and 0.739, respectively). In the prediction of ICU admission and MV needs, RAPS, REMS, CURB-65, and CRB-65 had moderate to good overall performance (AUC at ICU admission 0.793, 0.873, 0.829, and 0.810; AUC for MV needs 0.759, 0.892, 0.754, and 0.738, respectively). Advanced age, lower levels of mean arterial pressure and peripheral oxygen saturation, presence of active malignancy and cerebrovascular disease, and ICU admission were associated with mortality (p < 0.05).

CONCLUSION

The WPS outperformed other risk scores in patients with CAP and can be used safely. The CRB-65 can be used to discriminate critically ill patients with CAP due to its high specificity. The overall performances of the scores were satisfactory for all three outcomes.

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

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