Comparison of three predictive rules for assessing severity in elderly patients with CAP

Aim: This study compares the ability of the Pneumonia Severity Index (PSI) and the British Thoracic Society CURB‐65 and CRB‐65 rules in predicting short‐term mortality among elderly patients with community‐acquired pneumonia (CAP). Methods: It is a population‐based study including all people over 65 years old with a radiographically confirmed CAP in the region of Tarragona (Spain) between 2002 and 2008. Treatment setting and clinical variables were considered for each patient. PSI, CURB‐65 and CRB‐65 scores were calculated at the moment of diagnosis and 30‐day mortality was considered as a main dependent variable. The rules were compared based on sensitivity, specificity and area under the receiver operating characteristic curve (AUC). Results: Of the total 590 CAP cases, mortality rate was 13.6% (15.3% in hospitalised and 1.4% in outpatient cases; p = 0.001). Mortality increased with increasing PSI score (None in class II, 6,9% in class III, 14,4% in class IV and 29,5% in class V), CURB‐65 score (7.5%, 14.5%, 26.7%, 53.3% and 100% for scores 1,2,3,4 and 5 respectively) and CRB‐65 score (6.6%, 26.1%, 40.5% and 50% for scores 1,2,3 and 4 respectively). The three rules performed too similarly to predict 30‐day mortality, with a ROC area of 0.727 [95% confidence interval (CI): 0.67–0.79] for the PSI, 0.672 (95% CI: 0.61–0.74) for the CURB‐65, and 0.719 (95% CI: 0.65–0.78) for the CRB‐65. Conclusion: Our data shows that the analysed rules perform equally well among elderly people with CAP which supports the recommendation for using the simplified CRB‐65 severity score among elderly patients in primary care or emergency visits.     

Mortality prediction using serum biomarkers and various clinical risk scales in community-acquired pneumonia

We evaluated the predictive value of serum biomarkers and various clinical risk scales for the 28-day mortality of community-acquired pneumonia (CAP). Serum biomarkers including procalcitonin (PCT) and C-reactive protein (CRP) were evaluated in the emergency department. Scores for the pneumonia severity index (PSI); CURB65 (confusion, urea, respiration, blood pressure; age >65?years); Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) guidelines for severe CAP; Acute Physiology, Chronic Health Evaluation (APACHE) II; Sequential Organ Failure Assessment (SOFA); and quick SOFA (qSOFA) were calculated. Receiver-operating characteristic curves for 28-day mortality were calculated for each predictor using cut-off values, and we applied logistic regression models and area under the curve (AUC) analysis to compare the performance of predictors. Of the 125 enrolled patients, 13 died within 28?days. The AUCs of the PCT and CRP were 0.83 and 0.77, respectively. Using a PCT level >5.6?μg/L as the cut-off, the sensitivity and specificity for mortality were 76.9% and 90.2%, respectively. The three pneumonia severity scales showed an AUC of 0.86 (PSI), 0.87 (IDSA/ATS) and 0.77 (CURB65). The AUCs of the APACHE II, SOFA and qSOFA scores were 0.85, 0.83 and 0.81, respectively. The models combining CRP and/or PCT with PSI or the IDSA/ATS guidelines demonstrated superior performance to those of either PSI or the IDAS/ATS guidelines alone. In conclusion, serum PCT is a reliable single predictor for short-term mortality. Inclusion of CRP and/or PCT could significantly improve the performance of the PSI and IDAS/ATS guidelines.     

Evaluation of pneumonia severity scoring systems in nursing and healthcare-associated pneumonia for predicting prognosis: A prospective,cohort study

The usefulness of existing pneumonia severity indices for predicting mortality in nursing and healthcare-associated pneumonia (NHCAP) is unclear. This study compared the usefulness of existing pneumonia severity indices for predicting mortality in NHCAP and community-acquired pneumonia (CAP). Consecutive hospitalized pneumonia patients including NHCAP and CAP patients were prospectively enrolled between October 2010 and November 2017. Admission pneumonia severity was assessed using CURB-65, Pneumonia Severity Index (PSI), A-DROP, Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) severe pneumonia criteria, and I-ROAD. The primary outcome was 30-day mortality. The discriminatory ability of each severity index was evaluated by receiver operating characteristic curve analysis. Overall, 828 patients had NHCAP, and 1330 patients had CAP. Thirty-day mortality was 12.8% and 5.6% in NHCAP and CAP patients, respectively. The area under the curve of PSI (0.717, 95% confidence interval 0.673–0.761) was the highest among all pneumonia severity indices, with significant differences compared with CURB-65 (0.651, 95% confidence interval 0.598–0.705, P = 0.02) and IDSA/ATS severe pneumonia criteria (0.659, 95% confidence interval 0.612–0.707, P = 0.03). The predictive abilities for 30-day mortality of the pneumonia severity indices, excluding PSI and I-ROAD, were significantly inferior for NHCAP than for CAP. PSI may be the most useful pneumonia severity score for predicting mortality in NHCAP. However, the predictive ability for mortality of each pneumonia severity score was worse for NHCAP than for CAP; therefore, the prognostic factors in NHCAP need to be identified for better management of NHCAP patients.     

ICU admission and severity assessment in community-acquired pneumonia

The past 15 years have seen major advances in our understanding of severity assessment in community-acquired pneumonia (CAP). Prognostic tools have been promoted to guide all major management decisions in CAP, including admission to the critical care unit. Several recent studies, including the study by Renaud and colleagues, have challenged us to re-evaluate how we consider severe CAP, a concept for which there is still no universally accepted definition. Existing severity scores such as the Pneumonia Severity Index and the CURB65 score are designed to predict 30-day mortality. As a result, they are heavily weighted by age and co-morbidity. They perform less well when predicting other outcomes such as requirement for ICU admission and are of limited use in the critical care environment. This commentary discusses recent attempts to develop useful severity criteria to guide the use of ICU resources in patients with severe CAP.     

Cytokine responses,microbial aetiology and short‐term outcome in community‐acquired pneumonia

Background

The inflammatory response to community‐acquired pneumonia (CAP) is orchestrated through activation of cytokine networks and the complement system. We examined the association of multiple cytokines and the terminal complement complex (TCC) with microbial aetiology, disease severity and short‐term outcome.

Materials and methods

Plasma levels of 27 cytokines and TCC were analysed in blood samples obtained at hospital admission, clinical stabilization and 6‐week follow‐up from 247 hospitalized adults with CAP. Fourteen mediators were included in final analyses. Adverse short‐term outcome was defined as intensive care unit (ICU) admission and 30‐day mortality.

Results

Cytokine and TCC levels were dynamic in the clinical course of CAP, with highest levels seen at admission for most mediators. Admission levels of cytokines and TCC did not differ between groups of microbial aetiology. High admission levels of IL‐6 (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.18‐1.84, P = .001), IL‐8 (OR 1.79, 95% CI 1.26‐2.55, P = .001) and MIP‐1β (OR 2.28, 95% CI 1.36‐3.81, P = .002) were associated with a CURB‐65 severity score of ≥3, while IL‐6 (OR 1.37, 95% CI 1.07‐1.74, P = .011) and MIP‐1β (OR 1.86, 95% CI 1.03‐3.36, P = .040) were associated with a high risk of an adverse short‐term outcome.

Conclusions

In this CAP cohort, admission levels of IL‐6, IL‐8 and MIP‐1β were associated with disease severity and/or adverse short‐term outcome. Still, for most mediators, only nonsignificant variations in inflammatory responses were observed for groups of microbial aetiology, disease severity and short‐term outcome.     

Risk stratification and prediction value of procalcitonin and clinical severity scores for community-acquired pneumonia in ED

Objective

Community-acquired pneumonia (CAP) is a common presentation to the emergency department (ED) and has high mortality rates. The aim of our study is to investigate the risk stratification and prognostic prediction value of precalcitonin (PCT) and clinical severity scores on patients with CAP in ED.

社区获得性肺炎患者呼出气冷凝液和血清中8-异前列腺素检测的临床意义

目的探讨社区获得性肺炎(CAP)患者呼出气冷凝液(EBC)和血清中8-异前列腺素(8-isoPG)对病情评估及疗效评价中的价值。方法选择CAP患者71例(CAP组),给予正规治疗,分别收集患者入院第1、3、7天EBC及血清标本,并记录患者入院时白细胞计数、红细胞沉降率、CURB-65评分。选择健康体检者46例(健康对照组),收集其EBC及血清标本。以酶免疫法测定EBC和血清中8-isoPG浓度。结果 CAP患者EBC和血清中8-isoPG浓度均高于健康对照组,差异有统计学意义(P0.05)。与入院第1天比较,CAP患者入院第3、7天EBC和血清中8-isoPG浓度均下降,差异有统计学意义(P0.05)。CAP患者EBC和血清中8-isoPG浓度与CURB-65评分呈正相关(r分别为0.774、0.655,P0.05)。结论 CAP患者体内存在不同程度的炎性反应和氧化应激,EBC和血清中的8-isoPG浓度对CAP的病情评估和疗效评价具有价值。     

重症肺炎患者血清磷水平与30d病死率的相关性研究

目的探讨重症肺炎患者血清磷水平与30d病死率的相关性。方法将2014年1月至2015年10月于该院呼吸科住院治疗的80例重症肺炎患者纳入本研究,根据30d死亡事件,分为死亡组(n=30)和存活组(n=50)。比较血清磷,急性生理学与慢性健康状况评价系统(APACHEⅡ)评分,肺部感染(CPIS)评分,英国胸科协会改良肺炎评分(CURB-65评分),感染相关器官衰竭评估(SOFA)评分以及肺炎严重指数(PSI)评分水平差异。结果死亡组患者血清磷水平低于存活组患者(P0.05)。ROC曲线分析提示血清磷、APACHEⅡ评分和CURB-65评分的预测30d死亡事件的AUC分别为0.732、0.664和0.682。相关性分析提示血清磷水平与30d死亡事件呈负相关(r=-0.566,P0.05)、CURB-65评分(r=-0.392,P0.05)和PSI评分(r=-0.235,P0.05)呈负相关。Logistics回归分析提示血清磷小于0.030 mmol/L(OR=1.56)和CURB-65评分大于3.9(OR=1.15)为MACE发生的独立危险因素。结论重症肺炎患者入院时血清磷水平与30d病死率密切相关。     

Performance of Severity of Illness Scoring Systems in Emergency Department Patients with Infection

Objectives To validate the Mortality in Emergency Department Sepsis (MEDS) score, the Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older (CURB‐65) score, and a modified Rapid Emergency Medicine Score (mREMS) in patients with suspected infection. Methods This was a prospective cohort study. Adult patients with clinically suspected infection admitted from December 10, 2003, to September 30, 2004, in an urban emergency department with approximately 50,000 annual visits were eligible. The MEDS and CURB‐65 scores were calculated as originally described, but REMS was modified in neurologic scoring because a full Glasgow Coma Scale score was not uniformly available. Discrimination of each score was assessed with the area under the receiver operating characteristics curve (AUC). Results Of 2,132 patients, 3.9% (95% confidence interval [CI] = 3.1% to 4.7%) died. Mortality stratified by the MEDS score was as follows: 0–4 points, 0.4% (95% CI = 0.0 to 0.7%); 5–7 points, 3.3% (95% CI = 1.7% to 4.9%); 8–12 points, 6.6% (95% CI = 4.4% to 8.8%); and ≥13 points, 31.6% (95% CI = 22.4% to 40.8%). Mortality stratified by CURB‐65 was as follows: 0 points, 0% (0 of 457 patients); 1 point, 1.6% (95% CI = 0.6% to 2.6%); 2 points, 4.1% (95% CI = 2.3% to 6.0%); 3 points, 4.9% (95% CI = 2.8% to 6.9%); 4 points, 18.1% (95% CI = 11.9% to 24.3%); and 5 points, 28.0% (95% CI = 10.4% to 45.6%). Mortality stratified by the mREMS was as follows: 0–2 points, 0.6% (95% CI = 0 to 1.2%); 3–5 points, 2.0% (95% CI = 0.8% to 3.1%); 6–8 points, 2.3% (95% CI = 1.1% to 3.5%); 9–11 points, 7.1% (95% CI = 4.2% to 10.1%); 12–14 points, 20.0% (95% CI = 12.5% to 27.5%); and ≥15 points, 40.0% (95% CI = 22.5% to 57.5%). The AUCs were 0.85, 0.80, and 0.79 for MEDS, mREMS, and CURB‐65, respectively. Conclusions In this large cohort of patients with clinically suspected infection, MEDS, mREMS, and CURB‐65 all correlated well with 28‐day in‐hospital mortality.     

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

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

CCERW:一种预测中老年人社区获得性肺炎临床无效结局的工具

目的 建立一种预测中国中老年人社区获得性肺炎(CAP)临床无效结局的工具,并与其他工具进行对比.方法 前瞻性收集2006年12月17日至2008年12月22日3所高校教学医院呼吸内科住院部收治的年龄≥45岁并确诊为CAP患者的数据,按随机数字表法将其中75%的患者数据用于工具的建立(推导组),25%的患者数据用于工具内部真实性的检验(内部组).同期收集另外一所高校教学医院的患者数据用于工具外部真实性的检验(外部组).结局定义为患者入院14 d或未满14 d出院时的临床无效状态.观测指标包括社会人口学特征、基础疾病和既往情况、并发症、症状、体征、辅助检查结果共6个方面58个因素.采用单因素分析、多因素分析和受试者工作特征曲线(ROC曲线)分析结合的方法进行工具的建立和评价,并与肺炎严重度指数(PSI)、英国胸科协会评估标准(CURB65)及其修订版(CRB65)等预测工具对临床结局的判断能力进行比较.结果 3个中心共纳入539例CAP患者的资料用于数据分析,其中推导组400例,内部组139例;外部组159例.以推导组400例数据进行单因素分析显示,共6个方面33个变量在痊愈和临床无效两组间差异有统计学意义;并以此进行多因素分析显示,精神混乱(C)、肌酐(Cr)＜60 μmol/L、电解质紊乱(E)、呼吸衰竭(R)、白细胞计数(WBC)＞7.5×109/L 5个因素差异有统计学意义.以此5个变量建立预后工具,即CCERW,将患者分为3个危险级别:得0～1分者无效率为5.5%～9.1%,得2分者无效率为12.8%～20.0%,得3～6分者无效率为31.0%～40.5%.ROC曲线分析显示,CCERW对推导组、内部组和外部组临床无效结局的预测能力分别为0.709[95%可信区间(95%CI)0.638～0.780]、0.725(95%CI 0.613～0.838)、0.686(95%CI 0.590～0.782).CCERW对全部698例患者的临床结局判断能力为0.710(95%CI 0.659～0.761),而PSI、CURB65、CRB65的判断能力分别为0.667(95%CI 0.614～0.719)、0.648(95%CI 0.592～0.705)和0.584(95%CI 0.530～0.638).结论 CCERW可帮助临床医师快速区分出中国中老年CAP患者的临床无效结局,且其对临床结局的判断能力优于PSI、CURB65、CRB65等预测工具,谨慎推荐将其在中国大陆地区汉族中老年CAP患者中使用.

Abstract：

Objective To develop and validate a clinical rule to predict treatment failure in middleaged and elderly patients suffering from community-acquired pneumonia (CAP) in China, and to compare it with other prognostic rules. Methods Data of 58 variables affiliated to 6 aspects, including demographics,underlaying diseases, previous status, complications, symptoms, signs and laboratory examination results from the CAP patients aged ≥ 45 years admitted to the respiratory departments in three university affiliated hospitals between December 17, 2006 and December 22, 2008 were enrolled prospectively and then validated in two groups to create a derivation cohort with 75% of the patients for rule development and an internal validation cohort with the other 25% for internal test. An external validation cohort was formed at the same time with patients admitted to the other university affiliated hospital for external test. The single outcome was treatment failure at the time of 14 days after admitted or at discharge from hospital. Univariate analysis, multivariate analysis and receiver operating characteristics (ROC) curve were used for the rule establishment, assessment and comparison among the pneumonia severity index (PSI), CURB65 [confusion,blood urea nitrogen＞6.8 mmol/L, respiratory rate (RR)≥30 breaths per minute, systolic blood pressure (SBP)＜90 mm Hg (1 mm Hg=0. 133 kPa) or diastolic blood pressure (DBP)≤60 mm Hg, age≥65 years]and CRB65 (confusion, RR ≥ 30 breaths per minute, SBP ＜ 90 mm Hg or DBP ≤ 60 mm Hg,age≥65 years). Results The data of a total of 539 patients in three hospitals were enrolled for analysis. Ofthose, 400 and 139 patients were randomly allocated into the derivation cohort or internal validation cohort respectively. Meanwhile, 159 patients were enrolled in the external validation cohort. Analyzing the data from 400 patients in the derivation cohort, 33 variables of 6 aspects had significant difference between cure and treatment failure outcome in the univariate analysis. Then, in the multivariate analyses, five independent predictive factors showed significant difference, including confusion (C), creatinine ＜60 μmol/L, electrolyte disturbances (E), respiratory failure (R), white blood cell (WBC)＞7.5× 109/L. A clinical prediction rule CCERW based on these variables showed that the treatment failure outcome increased directly with increasing scores : 5.5%- 9. 1 %, 12.8 %- 20. 0% and 31.0 %- 40. 5% for scores of 0 - 1, 2 and 3 - 6, respectively. ROC curve analysis yielded an area under the curve (AUC) for CCERW of 0. 709 [95% confidence intervals (95%CI) 0.638 - 0.780], 0.725 (95%CI 0.613 - 0.838) and 0.686 (95%CI 0.590 - 0.782) in the derivation, internal and external validation cohorts respectively; and in the same manner, of 0.710(95%CI 0. 659 - 0. 761) for total 698 patients, which was better than PSI, CURB65 and CRB65, at 0. 667(95%CI 0. 614 - 0. 719), 0. 648 (95%CI0. 592 - 0. 705), and 0. 584 (95%CI 0.530 - 0.638), respectively.Conclusion CCERW can help physicians to distinguish high and low risk leading to treatment failure in middle-aged and elder patients with CAP, and has better predictable capability than PSI, CURB65 and CRB65. We prudent recommend the simple rule can be used in the middle-aged and elder patients with CAP of Han race people in China.     

Assessment of the pneumonia severity score in community-acquired and nursing and healthcare-associated pneumonia due to COVID-19

IntroductionThe Japanese Respiratory Society (JRS) pneumonia guidelines recommend simple predictive rules, the A-DROP scoring system, for assessment of the severity of community-acquired pneumonia (CAP) and nursing and healthcare-associated pneumonia (NHCAP). We evaluated whether the A-DROP system can be adapted for assessment of the severity of coronavirus disease 2019 (COVID-19) pneumonia.MethodsData from 1141 patients with COVID-19 pneumonia were analyzed, comprising 502 patients observed in the 1st to 3rd wave period, 338 patients in the 4th wave and 301 patients in the 5th wave in Japan.ResultsThe mortality rate and mechanical ventilation rate were 0% and 1.4% in patients classified with mild disease (A-DROP score, 0 point), 3.2% and 46.7% in those with moderate disease (1 or 2 points), 20.8% and 78.3% with severe disease (3 points), and 55.0% and 100% with extremely severe disease (4 or 5 points), indicating an increase in the mortality and mechanical ventilation rates in accordance with severity (Cochran–Armitage trend test; p = <0.001). This significant relationship between the severity in the A-DROP scoring system and either the mortality rate or mechanical ventilation rate was observed in patients with COVID-19 CAP and NHCAP. In each of the five COVID-19 waves, the same significant relationship was observed.ConclusionsThe mortality rate and mechanical ventilation rate in patients with COVID-19 pneumonia increased depending on severity classified according to the A-DROP scoring system. Our results suggest that the A-DROP scoring system can be adapted for the assessment of severity of COVID-19 CAP and NHCAP.     

Prediction of severe community-acquired pneumonia: a systematic review and meta-analysis

ABSTRACT: INTRODUCTION: Severity assessment and site-of-care decisions for patients with community-acquired pneumonia (CAP) are pivotal for patients' safety and adequate allocation of resources. Late admission to the intensive care unit (ICU) has been associated with increased mortality in CAP. We aimed to review and meta-analyze systematically the performance of clinical prediction rules to identify CAP patients requiring ICU admission or intensive treatment. METHODS: We systematically searched Medline, Embase, and the Cochrane Controlled Trials registry for clinical trials evaluating the performance of prognostic rules to predict the need for ICU admission, intensive treatment, or the occurrence of early mortality in patients with CAP. RESULTS: Sufficient data were available to perform a meta-analysis on eight scores: PSI, CURB-65, CRB-65, CURB, ATS 2001, ATS/IDSA 2007, SCAP score, and SMART-COP. The estimated AUC of PSI and CURB-65 scores to predict ICU admission was 0.69. Among scores proposed for prediction of ICU admission, ATS-2001 and ATS/IDSA 2007 scores had better operative characteristics, with a sensitivity of 70% (CI, 61 to 77) and 84% (48 to 97) and a specificity of 90% (CI, 82 to 95) and 78% (46 to 93), but their clinical utility is limited by the use of major criteria.ATS/IDSA 2007 minor criteria have good specificity (91% CI, 84 to 95) and moderate sensitivity (57% CI, 46 to 68). SMART-COP and SCAP score have good sensitivity (79% CI, 69 to 97, and 94% CI, 88 to 97) and moderate specificity (64% CI, 30 to 66, and 46% CI, 27 to 66). Major differences in populations, prognostic factor measurement, and outcome definition limit comparison. Our analysis also highlights a high degree of heterogeneity among the studies. CONCLUSIONS: New severity scores for predicting the need for ICU or intensive treatment in patients with CAP, such as ATS/IDSA 2007 minor criteria, SCAP score, and SMART-COP, have better discriminative performances compared with PSI and CURB-65. High negative predictive value is the most consistent finding among the different prediction rules. These rules should be considered an aid to clinical judgment to guide ICU admission in CAP patients.     

Prognostic factors in patients hospitalized with community-acquired aspiration pneumonia

IntroductionPatients with aspiration pneumonia (AP) exhibit higher mortality than those with non-AP. However, data regarding predictors of short-term prognosis in patients with community-acquired AP are limited.MethodsPatients hospitalized with community-acquired pneumonia (CAP) were retrospectively classified into aspiration pneumonia (AP) and non-AP groups. The AP patients were further divided into nonsurvivors and survivors by 30-day mortality, and various clinical variables were compared between the groups.ResultsOf 1249 CAP patients, 254 (20.3%) were classified into the AP group, of whom 76 patients (29.9%) died within 30 days. CURB-65, pneumonia severity index (PSI), and Infectious Diseases Society of America/American Thoracic Society criteria for severe CAP (SCAP) showed only modest prognostic performance for the prediction of 30-day mortality (c-statistics, 0.635, 0.647, and 0.681, respectively). Along with the PSI and SCAP, Eastern Cooperative Oncology Group performance status (ECOG-PS) and blood biomarkers, including, N-terminal of prohormone brain natriuretic peptide (NT-proBNP) and albumin, were independent predictors of 30-day mortality. In models based on clinical prediction rules, including CURB-65, PSI, and SCAP, the addition of ECOG-PS further improved their c-statistics compared to the clinical prediction rules alone. In the four combinations based on SCAP, ECOG-PS, and two blood biomarkers (NT-proBNP and albumin), the c-statistics further increased to reach approximately 0.8.ConclusionsCURB-65, PSI, and SCAP exhibited only modest discriminatory power in predicting the 30-day mortality of patients with community-acquired AP. The addition of performance status and blood biomarkers, including NT-proBNP and albumin, further increased prognostic performance, showing good predictive accuracy in the SCAP-based model.     

Severity assessment tools in ICU patients with 2009 Influenza A (H1N1) pneumonia

Clin Microbiol Infect 2012; 18: 1040-1048 ABSTRACT: The aim of this study was to determine if severity assessment tools (general severity of illness and community-acquired pneumonia specific scores) can be used to guide decisions for patients admitted to the intensive care unit (ICU) due to pandemic influenza A pneumonia. A prospective, observational, multicentre study included 265 patients with a mean age of 42 (±16.1)?years and an ICU mortality of 31.7%. On admission to the ICU, the mean pneumonia severity index (PSI) score was 103.2?±?43.2 points, the CURB-65 score was 1.7?±?1.1 points and the PIRO-CAP score was 3.2?±?1.5 points. None of the scores had a good predictive ability: area under the ROC for PSI, 0.72 (95% CI, 0.65-0.78); CURB-65, 0.67 (95% CI, 0.59-0.74); and PIRO-CAP, 0.64 (95% CI, 0.56-0.71). The PSI score (OR, 1.022 (1.009-1.034), p 0.001) was independently associated with ICU mortality; however, none of the three scores, when used at ICU admission, were able to reliably detect a low-risk group of patients. Low risk for mortality was identified in 27.5% of patients using PIRO-CAP, but above 40% when using PSI (I-III) or CURB65 (<2). Observed mortality was 13.7%, 13.5% and 19.4%, respectively. Pneumonia-specific scores undervalued severity and should not be used as instruments to guide decisions in the ICU.     

Pacemaker and Defibrillator Lead Extraction: Predictors of Mortality during Follow‐Up

Background: Extraction of cardiac implantable electric devices is an accepted procedure when systems become infected or malfunction. However, there is an associated morbidity and mortality. We report our 5‐year experience and identify predictors of mortality, and long‐term follow‐up. Methods: We analyzed extraction data from January 2003 to November 2007. Extraction methods used were: locking stylets, telescoping sheaths ± laser, and femoral work stations. Results: One hundred and eighty‐three cases were referred, aged 65 ± 16 years (range 28–83); 76% were males. Mean implant time was 75 months (range 4–312 months) and indications were: pocket infection (48%), nonfunctioning lead (22%), erosion through skin (18%), endocarditis/septicemia (11%), bilateral superior vena cava thrombosis (0.5%), and painful lead (0.5%). The number of leads extracted were 369, with complete removal in 90.7% and partial in 7.6%. There were no intraoperative deaths but five (2.7%) died within the same admission as their extraction from overwhelming sepsis. Twelve deaths (6.6%) occurred during an average follow‐up of 965 days (range 40–1670). Multivariate logistic regression demonstrated that C‐reactive protein preprocedure was predictive of acute in‐hospital mortality. Conclusions: Intravascular lead extraction is a safe and efficient method of removing leads. However, there is a subgroup of patients with systemic sepsis with raised inflammatory markers who are at high risk of in‐hospital mortality. Long‐term follow‐up demonstrates mortality which is a marker of the underlying etiology for device implantation, with heart failure patients particularly at risk. (PACE 2010; 33:209–216)     

心血管事件对老年重症社区获得性肺炎30 d病死率的影响

目的探讨心血管事件（CVE）对老年重症社区获得性肺炎（CAP）患者30 d病死率的影响。 方法将2012年1月至2014年6月期间符合老年重症CAP诊断标准并入院接受治疗的167例患者纳入研究,按照CAP指南进行规范化治疗。记录患者住院期间CVE发生情况及30 d病死率,采用Kaplan-Meier生存曲线分析合并CVE患者与未合并CVE患者的病死率情况,并采用Logistic多因素回归分析CVE对CAP患者30 d病死率的影响。 结果167例符合标准的重症CAP患者中,30 d病死率为28.7%（48/167）,86例发生CVE（51.5%）,合并CVE的CAP患者30 d病死率为39.5%（34/86）,未合并CVE的CAP患者病死率为17.3%（14/81）,两者比较差异有明显统计学意义（Log-rank检验,χ²=10.065,P=0.002）。Logistic多因素回归分析表明,并发CVE是老年重症CAP患者30 d死亡的独立危险因素（OR=1.997,P<0.05）。 结论合并CVE的老年重症CAP患者有更高的30 d死亡风险。     

Severe community-acquired pneumonia as a cause of severe sepsis: data from the PROWESS study

OBJECTIVE: To investigate community-acquired pneumonia (CAP) as a cause of severe sepsis in the PROWESS (Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis) trial and to evaluate the effect of drotrecogin alfa (activated) (DrotAA) in this subgroup. DESIGN: Retrospective analysis of the severe CAP subgroup in the PROWESS trial. SETTING: Tertiary care institutions in 11 countries. INTERVENTIONS: DrotAA (n = 850), 24 microg.kg.hr for 96 hrs, or placebo (n = 840). PARTICIPANTS: The 1,690 patients with severe sepsis enrolled in the PROWESS trial. MEASUREMENTS AND MAIN RESULTS: Patients were classified as having CAP if lung was the primary site of infection and if they were enrolled directly from home (private residence) with /=25, Pneumonia Severity Index score of >/=4, or CURB-65 (confusion, urea, respiratory rate, blood pressure, age) score of >/=3. CONCLUSIONS: CAP associated with a high Pneumonia Severity Index score, bacteremia, or an intense coagulation and inflammatory response requiring intensive care unit care were indicators of a high risk of death from severe sepsis. In patients with severe sepsis resulting from CAP, a readily identifiable disease, DrotAA, improved survival compared with placebo.     

老年重症社会获得性肺炎与健康护理相关性肺炎的病原学特点

:　目的　探讨老年重症社会获得性肺炎与医疗机构获得性肺炎的预后、病原学分布及药敏特点。方法　对43例老年重症肺炎入院时的下呼吸道分泌物,行定量培养、药敏与ESBLs检测,并观察住院28天死亡率。结果　本组老年重症肺炎患者的总死亡率为46.5%,其中,16例老年重症CAP患者死亡率为31%,而HCAP患者的死亡率高达55.5%。本组老年院外获得性肺炎的致病病原以G-杆菌为主（占70%）和较高的ESBLs分离率（为30%）。其中,老年HCAP患者之铜绿假单胞菌、肺炎克雷伯杆菌比例和混合感染率增加尤其显著;老年HCAP与CAP的G-杆菌ESBLs分离率分别为14%与33%。对常用抗生素的药敏试验：与非产ESBLs酶菌株组相比,产酶菌株除对亚胺培南外,对其他常用抗生素的耐药率非常显著。 结论　老年CAP患者存在较高的死亡率,其致病病原以G-杆菌为主和较高的ESBLs分离率;老年HCAP患者的死亡率、致病病原中的耐药菌株比例与ESBLs分离率更高。在抗感染治疗及抗生素选用时应充分考虑病原学的以上特点。     

Epidemiology and outcome of severe pneumococcal pneumonia admitted to intensive care unit: a multicenter study

ABSTRACT: INTRODUCTION: Community-acquired pneumonia (CAP) account for a high proportion of ICU admissions, with Streptococcus pneumoniae being the main pathogen responsible for these infections. However, little is known on the clinical features and outcomes of ICU patients with pneumococcal pneumonia. The aims of this study were to provide epidemiological data and to determine risk factors of mortality in patients admitted to ICU for severe S. pneumoniae CAP. METHODS: We performed a retrospective review of two prospectively-acquired multicentre ICU databases (2001-2008). Patients admitted for management of severe pneumococcal CAP were enrolled if they met the 2001 American Thoracic Society criteria for severe pneumonia, had life-threatening organ failure and had a positive microbiological sample for S. pneumoniae. Patients with bronchitis, aspiration pneumonia or with non-pulmonary pneumococcal infections were excluded. RESULTS: Two hundred and twenty two patients were included, with a median SAPS 2 score reaching 47 [36-64]. Acute respiratory failure (n=154) and septic shock (n=54) were their most frequent causes of ICU admission. Septic shock occurred in 170 patients (77%) and mechanical ventilation was required in 186 patients (84%); renal replacement therapy was initiated in 70 patients (32%). Bacteremia was diagnosed in 101 patients. The prevalence of S. pneumoniae strains with decreased susceptibility to penicillin was 39.7%. Although antibiotherapy was adequate in 92.3% of cases, hospital mortality reached 28.8%. In multivariate analysis, independent risk factors for mortality were age [OR 1.05 (95% CI: 1.02-1.08)], male sex [OR 2.83 (95% CI: 1.16-6.91)] and renal replacement therapy [OR 3.78 (95% CI: 1.71-8.36)]. Co-morbidities, macrolide administration, concomitant bacteremia or penicillin susceptibility did not influence outcome. CONCLUSIONS: In ICU, mortality of pneumococcal CAP remains high despite adequate antimicrobial treatment. Baseline demographic data and renal replacement therapy have a major impact on adverse outcome.