降钙素原对老年重症社区获得性肺炎预后及病情的预测研究

目的分析血清降钙素原(PCT)水平对老年重症社区获得性肺炎(Community-acquired pneumonia,CAP)预后及病情严重程度的预测价值。方法以我院住院的老年重症CAP患者87例为研究对象,收集其临床资料,根据入院后28天生存情况分为死亡组和存活组。并按CURB、PSI评分标准分组,比较不同分组间入院第1天、第4天PCT水平(PCT1、PCT4)及其变化水平(PCT4-1)的差异。分析死亡组与存活组在PCT1、PCT4、PCT4-1、CURB≥3分、PSI≥4级5项因素方面的差异,在其中筛选死亡的独立危险因素。用受试者工作特征曲线(ROC曲线)下面积(AUC)评估各项独立危险因素单独及联合应用预测28天生存情况的效能,并对各项因素的预测效能进行比较。结果死亡组PCT4显著高于存活组。死亡组PCT4-1水平显著高于存活组,死亡组为正值,存活组为负值,即死亡组PCT4较PCT1在升高,而存活组已在下降。PCT1、PCT4水平在CURB≥3组显著高于CURB3组。PCT4、PCT4-1、CURB≥3分三项因素为死亡的独立危险因素,其预测死亡的AUC值分别为0.8768、0.7995、0.7054,PCT4、PCT4-1 AUC值无显著差异,但PCT4的AUC值显著高于CURB≥3分,三项因素合并的AUC值为0.853,显著高于CURB≥3分,其预测死亡的敏感度为81.1%,特异度为90.0%。结论动态监测血清PCT水平,对判断老年重症CAP的预后及病情严重程度有一定价值。     

我国社区获得性肺炎病情评估标准与3种国际标准效能比较研究

目的 比较我国社区获得性肺炎(CAP)病情评估标准(简称我国标准)与国外肺炎严重指数(PSI)、CURB和CURB65评估标准对CAP患者病情评估的效能.方法 选取2000年1月至2007年4月北京大学第三医院呼吸科住院的CAP患者165例作为研究对象,通过回顾性研究,将所有患者分别按PSI、CURB、CURB65评分和我国标准分组,并进一步分成低、中、高危组,比较各组病死率和重症监护病房(ICU)住院率,各评估系统预测死亡和ICU住院的敏感度、特异度、阳性预测值、阴性预测值、ROC曲线下面积(AUC).结果 PSI、CURB评分、CURB65评分3个标准均将较大一部分患者划分为低危组(分别为73.9%、61.2%、69.1%),较小部分患者划为中危组和高危组(分别为20.0%、28.5%、21.8%;6.1%、10.3%、9.1%).低危组和中危组均有死亡病例(病死率分别为1.6%、2.0%、1.8%;9.1%、6.4%、8.3%);而我国标准仅将较小部分患者划为低危组(7.3%),将较大部分患者划为中危组和高危组(44.8%、47.9%),但是低危组和中危组病死率为0,中危组ICU住院率仅为1.4%;我国标准预测死亡及入住ICU的敏感度高(100.0%、95.5%),而特异度较低(55.5%、59.4%),PSI、CURB、CURB65预测死亡及入住ICU的特异度均较高(均>90.0%),而敏感度均较低(预测死亡均为50.0%,预测入住ICU为22.7%～31.8%);根据AUC我国标准对死亡和ICU住院的总体识别力最好(AUC分别为0.777,0.774);各评估标准预测死亡及入住ICU的阳性预测值均较低(预测死亡12.7%～50.0%;预测入住ICU 26.6%～50.0%),阴性预测值均较高(预测死亡96.6%～100.0%;预测入住ICU 89.0%～98.8%).结论 在筛选低风险CAP患者、预测死亡和入住ICU方面,PSI、CURB、CURB65'评分标准和我国标准各有优势与不足,需建立更为有效的CAP评估系统.     

血清降钙素原和CURB-65评分以及APACHEⅡ评分对急诊老年社区获得性肺炎患者预后中的预测价值研究

目的 探讨PCT水平联合CURB-65评分系统以及APACHEⅡ评分系统快速评估急诊科老年重症CAP患者的严重程度。方法 选取2017年11月—2020年1月复旦大学附属华东医院急诊病房收住的101例CAP老年患者,依患者是否院内死亡分为存活组74例,死亡组27例。入院当天根据体检和实验室结果,计算患者的CURB-65评分、APACHEⅡ评分。比较2组CURB-65评分、APACHEⅡ评分及PCT之间的关系。绘制患者受试者工作特征曲线(receiver operating characteristic curve,简称ROC曲线),计算曲线下面积(area under the cure,AUC)、敏感度、特异度等指标。P<0.05为差异有统计学意义。结果 2组患者在PCT、CURB-65评分上差异无统计学意义,但死亡组患者的APACHEⅡ评分高于存活组,且P无限接近于0。使用PCT、CURB-65评分、APACHEⅡ评分绘制患者的ROC曲线,其AUC分别为0.609 (95%CI 0.481～0.738)、0.727 (95%CI 0.608～0.846)、0.997 (95%C...     

SOFA评分、qSOFA评分和SIRS评分对脓毒症患者病死率的预测价值分析

目的 探讨序贯器官衰竭评估（SOFA）评分、快速序贯器官衰竭评估（qSOFA）评分及全身炎症反应综合征（SIRS评分对脓毒症患者病死率的预测价值。方法 选择2019年1月至2020年2月杭州师范大学附属医院重症监护室（ICU）收治的急性感染患者80例,根据是否最终诊断为脓毒症分为观察组和对照组,其中观察组患者再根据预后分为存活亚组和死亡亚组。入ICU 24 h内进行SOFA评分、qSOFA评分和SIRS评分。比较SOFA评分、qSOFA评分和SIRS评分对脓毒症患者病死率的预测价值。结果 观察组患者SOFA评分、qSOFA评分和SIRS评分均高于对照组,差异均有统计学意义（均P<0.05）。存活亚组患者来源急诊比例高于死亡亚组,合并症个数、SOFA评分、qSOFA评分和SIRS评分低于死亡亚组,差异均有统计学意义（均P<0.05）。在预测脓毒症病死率上,SOFA评分的AUC、灵敏度及特异度最高,qSOFA评分次之,SIRS评分最低,差异均有统计学意义（均P<0.05）。结论 相较于qSOFA评分和SIRS评分,SOFA评分在预测ICU脓毒症病死率方面更具优势。     

NLR、PLR、APACHEⅡ评分对AECOPD患者预后的评估价值

目的探讨外周血中性粒细胞与淋巴细胞比值(NLR)、血小板淋巴细胞比值(PLR)、急性生理与慢性健康评估(APACHE)Ⅱ评分对AECOPD患者院死亡评估价值。方法收集141例患者的临床资料,包括基本信息(性别、年龄),入院24 h内中性粒细胞计数、淋巴细胞计数、血小板计数、APACHEⅡ评分等。将其分为存活组及死亡组,统计NLR、PLR、APACHEⅡ评分在两组之间有无差异,运用ROC曲线评估NLR、PLR、APACHEⅡ评分对死亡患者的预测价值。结果NLR、PLR、APACHEⅡ评分在存活组(123例)及死亡组(18例)的均值分别为7.82±9.01、205.46±165.19、16.95±3.68及34.62±20.10、547.71±481.67、29.90±6.65,两组之间存在统计学差异(P<0.05)。ROC曲线显示NLR截断值为0.849(敏感度72.22%,特异度为82.11%),PLR截断值为323.68(敏感度61.11%,特异度为87.8%),APACHEⅡ评分截断值为25.7(敏感度55.56%,特异度为90.24%),NLR、PLR、APACHEⅡ评分对AECOPD患者的死亡均具有一定的预测价值,三者联合AUC值最大,为0.892对死亡的预测价值更佳。结论NLR、PLR、APACHEⅡ评分对慢性阻塞性肺病伴有急性加重患者的预后评估具有一定价值,三者联合具有最佳预测效果,且NLR、PLR是AECOPD患者简便、有效的预后因子。     

快速序贯器官功能衰竭评分联合红细胞分布宽度对老年脓毒症患者预后的预测价值

目的研究快速序贯器官功能衰竭评分(qSOFA)联合红细胞分布宽度(RDW)对老年脓毒症患者预后的预测价值。方法选取2016年6月至2019年6月在河北北方学院附属第一医院急诊科收治的老年脓毒症患者124例进行回顾性研究。根据30d的预后情况分为存活组(78例)和死亡组(46例)。主要收集患者实验室检验数据、急性生理慢性健康评分(APACHEⅡ)和qSOFA评分。采用t检验、秩和检验及χ2检验比较组间差异;采用Cox回归模型分析预后影响因素;采用Kaplan-Meier曲线分析不同qSOFA、RDW患者预后的差异;采用ROC曲线分析qSOFA、RDW对老年脓毒症患者预后的预测价值。结果与存活组相比,死亡组患者的RDW、肌酐、降钙素原、APACHEⅡ评分、qSOFA评分明显增加(P<0.05);Cox回归分析显示,RDW、APACHEⅡ、qSOFA是脓毒症患者预后的影响因素(P<0.05);Kaplan-Meier曲线分析显示,不同qSOFA、RDW患者的预后情况差异有统计学意义(P<0.05);在logistic回归模型中生成qSOFA联合RDW预测老年脓毒症患者预后的新指标(-5.728+0.505×qSOFA+0.339×RDW),并进行ROC曲线分析,结果显示合成指标对老年脓毒症患者的预后具有预测价值,最佳截断点为-0.6144,其灵敏度和特异度分别为60.87%和79.49%,优于单一指标。结论qSOFA和RDW是老年脓毒症患者预后的影响因素,qSOFA联合RDW用于预测老年脓毒症患者预后具有更高的灵敏度和特异度。     

降钙素原在重症监护患者细菌感染的预后价值

目的探讨血清降钙素原(PCT)对重症患者细菌感染性疾病预后评估和病情严重程度判断的价值。方法选取116例细菌感染性疾病患者,采用免疫色谱法检测入院后24 h内的血清PCT水平,记录患者24 h急性生理学与慢性健康状况Ⅱ(APACHEⅡ)评分。根据28 d临床结局,分为死亡组(36例)和存活组(80例),比较两组间PCT、APACHEⅡ评分的差异,分析血清PCT水平与APACHEⅡ评分的相关性,用受试者工作特征曲线(ROC)下面积(AUC)评估PCT单独应用及联合PCT和APACHEⅡ评分预测28 d生存情况的效能。对PCT和APACHEⅡ评分预测28 d生存情况的效能进行比较。结果死亡组PCT水平明显高于存活组(Z=5.598,P0.001),死亡组APACHEⅡ评分亦显著高于存活组(t=6.148,P0.01)。PCT与APACHEⅡ评分存在显著正相关(r=0.388,P0.001),PCT和APACHEⅡ评分预测重症患者细菌感染性疾病28 d生存情况的AUC分别为0.804和0.792,PCT的AUC值高于APACHEⅡ评分,但差异无统计学意义(U=0.2073,P=0.802)。联合PCT和APACHEⅡ评分预测28 d生存情况的ACU较单一指标高,为0.817,敏感度90.7%,特异度75.2%,均优于单一指标的预测效能。结论血清PCT能反映重症患者细菌感染性疾病病情严重程度及预后,是预测28 d生存情况的有效指标,联合PCT检测和APACHEⅡ评分可提高预测效能。     

红细胞分布宽度联合毛细血管渗漏指数对脓毒症并发急性呼吸窘迫综合征的预后评估价值

目的探讨红细胞分布宽度(RDW)联合毛细血管渗漏指数(CLI)对脓毒症并发急性呼吸窘迫综合征(ARDS)预后的评估价值。方法回顾性分析2017年10月～2019年12月期间我院收治的脓毒症并发ARDS患者,根据患者28天预后情况分为死亡组和存活组,收集性别、年龄、血清白蛋白、CRP、红细胞分布宽度、氧合指数值,计算APACHEⅡ评分、SOFA评分、毛细血管渗漏指数。结果存活组与死亡组比较,性别、SOFA评分差异无统计学意义(P0.05);年龄、RDW、CLI、氧合指数、APACHEⅡ评分差异有统计学意义(P=0.002;P=0.031;P=0.041;P=0.048;P=0.005)。Spearman相关分析结果显示RDW与APACHEⅡ评分呈显著正相关(rs=0.314,P0.001),RDW与氧合指数呈显著负相关(rs=-0.720,P0.001);联合变量(RDW+CLI)的AUC曲线下面积值最大,为0.651,其次是APACHEⅡ评分,为0.647,RDW的AUC值是0.646,CLI的AUC值是0.601。RDW为46.55作为临床诊断界值时,预测ARDS死亡的敏感度和特异度分别为57.8%和71%,CLI为5.87作为临床诊断界值时,预测ARDS死亡的敏感度和特异度分别为53.3%和77.4%,联合预测的敏感度和特异度分别为62.2%和67.7%。结论 RDW联合CLI对脓毒症并发ARDS患者的预后具有一定的评估价值。     

红细胞分布宽度对老年社区获得性肺炎预后的评估价值

目的:探讨红细胞分布宽度(RDW)与老年社区获得性肺炎(CAP)病情危重程度的关系及对预后的评估价值。方法:回顾性分析88例社区获得性肺炎(CAP)患者的临床病历资料。根据28 d预后分为存活组52例与死亡组36例。分析RDW与肺炎严重程度评分(PSI)的关系。采用Logistic回归分析老年CAP患者预后的独立危险因素。绘制受试者工作(ROC)曲线评估RDW与生物标志物组合对老年CAP患者预后的预测价值。结果:死亡组的RDW、D-二聚体、APACHEⅡ评分及PSI评分明显高于存活组(P0.01或P0.05);RDW随着PSI评分升高而升高,两者呈正相关(r=0.49 P0.01);RDW、D-二聚体、APACHEⅡ评分及PSI评分均是老年CAP患者28 d死亡的独立预测因素;RDW、D-二聚体的曲线下面积(AUC)分别为0.81、0.76,截断值分别为12.98%,0.43 mg/L。RDW联合D-二聚体的AUC为0.86。结论:RDW对老年CAP患者的预后有一定评估价值。联合检测RDW及D-二聚体能提高老年CAP患者预后的评估价值。     

血清HMGB1联合PCT评估老年重症肺炎患者的死亡风险

目的探讨血清高迁移率族蛋白(HMG)B1联合降钙素原(PCT)评估老年重症肺炎患者死亡风险的临床意义。方法选取83例重症肺炎患者,根据入院1个月生存情况,将患者分成死亡组28例和存活组55例。比较两组血清HMGB1和PCT水平,绘制受试者工作特征(ROC)曲线比较血清HMGB1和PCT单独应用及联合检测预测重症肺炎死亡风险。结果存活组和死亡组血清HMGB1[(116.21±18.48)ng/ml vs(199.15±18.33)ng/ml]、PCT[(7.55±0.61)ng/ml vs(10.51±0.23)ng/ml],差异有统计学意义(P0.05);且存活组HMGB1和PCT水平显著低于死亡组患者,HMGB1的敏感度、特异度、Kappa值、ROC曲线下面积分别为64.3%、72.7%、0.699、0.797;PCT的敏感度、特异度、Kappa值、ROC曲线下面积分别为71.4%、74.5%、0.735、0.820。二者联合检测的敏感度、特异度、Kappa值、ROC曲线下面积分别为85.7%、70.9%、0.759、0.911。除特异性外,其余数值均高于HMGB1或PCT单项检测,且联合检测曲线下面积显著大于单独检测(均P0.05)。结论血清HMGB1和PCT对于预测重症肺炎死亡风险具有重要意义,二者联合检测可提高预测重症肺炎死亡风险的敏感度,同时还保持较高的特异性和一致性,具有极高的诊断价值。     

降钙素原与乳酸在老年社区获得性肺炎患者预后评估中的应用

目的研究降钙素原(PCT)与乳酸对老年社区获得性肺炎患者的病情和预后的评估作用。方法 118例老年社区获得性肺炎患者,入院后给予PCT、乳酸等检查,并给予肺炎严重指数(PSI)评分。分别比较重症与非重症肺炎、死亡组和存活组PCT、乳酸和PSI的区别;分析PCT、乳酸与PSI的相关性。结果重症肺炎患者乳酸、PCT和PSI评分均大于非重症患者,死亡组乳酸、PCT和PSI评分均大于存活组(P<0.05);乳酸、PCT与PSI评分呈正相关(r=0.63,0.65,P<0.05)。结论 PCT和乳酸对老年社区获得性肺炎患者的预后和病情有评估作用,PCT和乳酸升高提示患者预后差。     

The usefulness of serum procalcitonin,C-reactive protein,soluble triggering receptor expressed on myeloid cells 1 and Clinical Pulmonary Infection Score for evaluation of severity and prognosis of community-acquired pneumonia in elderly patients

AimsTo comparatively analyze the usefulness of serum procalcitonin (PCT), C-reactive protein (CRP), soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) and Clinical Pulmonary Infection Score (CPIS) for assessing the severity and prognosis of community-acquired pneumonia (CAP) in the elderly.MethodsA total of 214 elderly patients with CAP and 106 healthy persons were enrolled in this prospective study. On the admission day, serum inflammatory markers, including CRP, PCT, sTREM-1, and CPIS were analyzed. By severity, the CAP patients were subdivided into non-severe CAP group and severe CAP group. By outcome, the patients were classified into survival group and death group. The efficiency of three inflammatory markers and CPIS on predicting prognosis of pneumonia patients was then analyzed.ResultsThe serum inflammatory markers and CPIS were significantly higher in CAP patients than in healthy controls. These biomarkers and CPIS were significantly higher in patients with severe CAP than in patients with non-severe CAP. Compared with patients who would survive, these markers and CPIS were significantly higher in patients who would die. Receiver operating characteristic curve analysis showed that the area under the curve and sensitivity were higher for serum sTREM-1 than for other indicators, while the specificity of serum PCT was the highest.ConclusionsSerum CRP, PCT, and sTREM-1 and CPIS determined on the admission day are effective indicators to evaluate the severity and prognosis of CAP in the elderly. The prognostic value of PCT and sTREM-1 is better than that of CRP and CPIS.     

Plasma d-dimer levels increase with the severity of community acquired pneumonia

The aim of this study is to investigate the relationship of the plasma D-Dimer (D-d) level and the severity of the pneumonia in patients who have not any disease that may increase the D-d level, but pneumonia. This is prospective controlled study. Using the ATS 2001 Community Acquired Pneumonia (CAP) Guideline we divided the patients into two groups [severe (n= 14) and non-severe (n= 37) CAP] and looked for any significant difference in D-d levels with ELISA method among the patients groups and control group. Plasma D-d levels were 2438 +/- 2158 ng/mL in severe CAP group, 912.6 +/- 512.6 ng/mL in non-severe CAP group and 387 +/- 99.56 ng/mL in the control group. Patients with non-severe CAP and those with severe CAP group both showed an increase in plasma levels of D-d compared to control group (p< 0.05, p< 0.001, respectively). We also found that the severe CAP group had increased in plasma levels of D-d compared to the non-severe CAP group (p< 0.001). Plasma D-d level increases significantly in patients with CAP compared to control group. Plasma D-d levels increases significantly with the severity of the CAP.     

Severe community-acquired pneumonia: what's in a name?

PURPOSE OF REVIEW: Formerly, patients with community-acquired pneumonia admitted to an intensive care unit were considered as having the severe form of the disease. Recently, guidelines have distinguished severe and non-severe community-acquired pneumonia based on clinical definitions. In this review, we describe the different definitions of severe community-acquired pneumonia, and whether a differentiation based on these definitions reflects variation in etiology, risk factors, diagnostic approaches and treatment. RECENT FINDINGS: New definitions do not seem to accurately identify patients with high risks of mortality; patients not admitted to an intensive care unit could also be diagnosed as having severe community-acquired pneumonia. Host-factors, such as genetic factors and underlying diseases, can influence severity of presentation of community-acquired pneumonia. Distribution of pathogens in severe and non-severe disease forms is comparable. Initial antibiotic therapy in patients with severe disease should provide coverage of Streptococcus pneumoniae and Legionella pneumophila, as delay is associated with worse outcomes. However, recent studies also suggested an additional benefit of atypical coverage in non-severe disease. As a result, initial therapy with a beta-lactam plus a macrolide or an anti-pneumococcal fluoroquinolone is recommended for all patients with community-acquired pneumonia. Furthermore, the value of vaccination against pneumococci to prevent episodes of severe disease is yet unknown. SUMMARY: As current guidelines do not adequately identify patients with high risk of mortality and intensive care unit admittance, clinical judgment remains important. Based on distribution of pathogens, investigational procedures and therapy recommended in recent guidelines, differentiation between severe and non-severe community-acquired pneumonia does not seem useful. Whether atypical coverage indeed has additional value in non-severe or pneumococcal CAP, however, remains to be determined. In addition, the preventive benefit of influenza and pneumococcal vaccination for development of SCAP awaits further evidence.     

血清血管生成素-2与老年人社区获得性肺炎严重程度的相关性研究

目的:探讨血清血管生成素-2(Ang-2)在老年社区获得性肺炎(CAP)患者中的表达,并评估其与CAP严重程度的相关性。方法:采用病例对照研究,选取老年CAP住院患者共118例,根据病情严重程度将所有患者分为普通肺炎组(67例)和重症肺炎组(51例),同时选取40例老年无肺炎健康体检者作为对照组。检测血清Ang-2、白...     

Addition of macrolide in treating adult hospitalized community-acquired pneumonia

OBJECTIVES: Current clinical practice guidelines, including those in south Asia, recommend the addition of a macrolide to a broad-spectrum antibiotic for the treatment of severe hospitalized community-acquired pneumonia (CAP). The aim of this study was to observe the influence of macrolide addition on clinical outcomes of hospitalized adult patients with CAP. METHODOLOGY: Over a 16-month period between 2002 and 2004, 141 eligible patients were prospectively recruited from an urban-based teaching hospital in Malaysia. RESULTS: Of the 141 patients, 63 (44.7%) patients (age (standard deviation (SD)) 56 (20.0) years; 50.8% male) received a macrolide-containing antibiotic regimen, while 78 (55.3%; age (SD) 57 (20.2) years; 52.6% male) were on a single broad-spectrum antibiotic only. In total, 39 (27.7%) and 102 (72.3%) patients had severe and 'non-severe' pneumonia, respectively. Irrespective of whether they had severe or non-severe pneumonia, there were no significant differences in mortality (non-severe pneumonia, 6.5% vs. 5.4%, P = 0.804; severe pneumonia, 17.6% vs. 18.2%, P = 0.966), need of ventilation (non-severe pneumonia, 8.7% vs. 3.6%, P = 0.274; severe pneumonia, 23.5% vs. 13.6%, P = 0.425) or median length of hospital stay (non-severe pneumonia, 5.5 vs. 5 days, P = 0.954; severe pneumonia, 7 vs. 6 days, P = 0.401) between the two treatment regimens. CONCLUSION: This observational, non-randomized study suggests that addition of a macrolide may not convey any extra clinical benefits in adult hospitalized patients with CAP.     

Limited prognostic accuracy of the CRB-65 and qSOFA in patients presenting with pneumonia and immunosuppression

BackgroundScores for risk prediction used in immunocompetent patients with sepsis or pneumonia are poorly evaluated in immunocompromised patients. Therefore, we evaluated the prognostic value of the qSOFA- and CRB-65-criteria in immunocompromised patients presenting with pneumonia.MethodsRetrospective cohort study including consecutive patients hospitalized with pneumonia and immunosuppression without treatment restrictions. The qSOFA and CRB-65 criteria were documented in the emergency department. Outcome was defined as need of mechanical ventilation (MV) or vasopressor support (VS) and/or hospital-mortality.Results41 of 198 (21%) patients reached the outcome and 10% died. Both, the CRB-65 and qSOFA- were independently associated with the outcome (all p<0.01), but age was not predictive. ROC curve analysis showed moderate predictive potential for both scores (CRB-65: AUC 0.63 and qSOFA: 0.69). With scores of 0, the negative predictive values were below 90% (CRB-65: 9/60 and qSOFA: 12/105 missed patients). With scores > 1, the positive predictive values were 36% (CRB-65) and 58% (qSOFA), respectively.ConclusionsBoth, the qSOFA and the CRB-65 only showed moderate prognostic value, and negative predictive values were inadequate to exclude organ failure or death in patients with immunosuppression. In this population, age was not a predictive parameter. Patients with > 1 positive vital sign criterion measured by both scores should be assessed for organ failure.     

入院时血乳酸水平联合重症评分对社区获得性肺炎患者预后的评估价值

目的:探讨入院时血乳酸水平联合快速脓毒症相关器官衰竭评分(qSOFA)、CRB/CURB-65评分对社区获得性肺炎(CAP)患者预后的评估价值。方法:回顾性收集入院8 h内有测定乳酸的512例CAP患者,均计算每例患者qSOFA、CRB/CURB-65评分,用受试者操作特性曲线(ROC曲线)评估各指标对不良预后(气管插管机械通气或需要血管加压素及住院期间死亡)的预测价值,并确定最佳截断值,行logistic回归确定不良预后的独立危险因素。结果:3个评分系统均显示得分越高,发生不良预后的几率越高:qSOFA(19.4%、45.5%、50%),CRB-65(10.7%、45.2%、66.7%),CURB-65(11.1%、23.5%、47.6%、100%),其中CURB-65(0.791、95%CI 0.707～0.876)对CAP患者不良预后具有最高的预测价值,联合血乳酸水平后CRB-65(0.761～0.795)、CURB-65(0.791～0.835)和qSOFA(0.770～0.837)评分的预测效能提高,qSOFA评分提高最明显。结论:单独CURB-65评分对住院CAP患者短期不良结局的预测价值优于qSOFA和CRB-65评分,但联合血乳酸水平后qSOFA评分具有更大的效力,对重症患者的检出可能更有利。     

Etiology and outcome of community-acquired pneumonia in relation to age and severity in hospitalized adult patients]

The aim of this study was to determine the etiology and outcome of community-acquired pneumonia (CAP) in relation to age and severity in hospitalized patients. Overall, 652 consecutive patients with CAP were studied retrospectively during a 4-year period from 2002. Severity of pneumonia was classified according to the guidelines of the Japanese Respiratory Society (JRS 2005) and American Thoracic Society (ATS 2001). The etiology was identified in 401 of 652 (61.5%) cases. The four most frequent pathogens were Streptococcus pneumoniae (26.2%), influenza virus (12.4%), Mycoplasma pneumoniae (10.9%), and Haemophilus influenzae (5.9%). The most common pathogen in the younger (15-44 years) group and very severe patients (JRS) was Mycoplasma pneumoniae (38.4%) and influenza virus (28.6%), respectively. The three most frequent pathogens in severe CAP patients (ATS) were Streptococcus pneumoniae (29.0%), influenza virus (17.4%), and Legionella species (13.0%). The overall mortality was 6.4%. The mortality of CAP patients among aged 1544, 45-64, 65-74, and 75 years or older was 1.4%, 3.3%, 6.9% and 9.3%, respectively. The mortality of mild, moderate, severe, and very severe patients (RS) was 0%, 4.1%, 15.5%, and 53.6%, respectively. The mortality of non-severe and severe patients (ATS) was 1.8% and 23.9%, respectively. Age and severity had influence on the prevalence of the main microbial pathogens. Streptococcus pneumoniae remained the most important pathogen that needs consideration in initial antibiotic therapy in patients with CAP of all ages and severities. Pathogens identified in patients with severe CAP in Japan were similar to those of Western countries, except for the high incidence of the influenza virus.     

Performance of PSI, CURB-65, and SCAP scores in predicting the outcome of patients with community-acquired and healthcare-associated pneumonia

The objective was to compare three score systems, pneumonia severity index (PSI), the Confusion-Urea-Respiratory Rate-Blood pressure-65 (CURB-65), and severe community-acquired pneumonia (SCAP), for prediction of the outcomes in a cohort of patients with community-acquired (CAP) and healthcare-associated pneumonia (HCAP). Large multi-center, prospective, observational study was conducted in 55 hospitals. HCAP patients were included in the high classes of CURB-65, PSI and SCAP scores have a mortality rate higher than that of CAP patients. HCAP patients included in the low class of the three severity rules have a significantly higher incidence of adverse events, including development of septic shock, transfer into an ICU, and death (p < 0.01). At multivariate Cox regression analysis, inclusion in the severe classes of PSI, CURB-65, or SCAP scores and receipt of an empirical therapy not adherent to international guidelines prove to be risk factors independently associated with poor outcome. PSI, CURB-65, and SCAP score have a good performance in patients with CAP but are less useful in patients with HCAP, especially in patients classified in the low-risk classes.