BackgroundGuidelines recommend maximal efforts to obtain blood and sputum cultures in patients with COVID-19, as bacterial coinfection is associated with worse outcomes. The aim of this study was to evaluate the yield of bacteriological tests, including blood and sputum cultures, and the association of multiple biomarkers and the Pneumonia Severity Index (PSI) with clinical and microbiological outcomes in patients with COVID-19 presenting to the emergency department (ED).MethodsThis is a substudy of a large observational cohort study (PredictED study). The PredictED included adult patients from whom a blood culture was drawn at the ED of Haga Teaching Hospital, The Netherlands. For this substudy, all patients who tested positive for SARS-CoV-2 by PCR in March and April 2020 were included. The primary outcome was the incidence of bacterial coinfection. We used logistic regression analysis for associations of procalcitonin, C reactive protein (CRP), ferritin, lymphocyte count and PSI score with a severe disease course, defined as intensive care unit admission and/or 30-day mortality. The area under the receiver operating characteristics curve (AUC) quantified the discriminatory performance.ResultsWe included 142 SARS-CoV-2 positive patients. On presentation, the median duration of symptoms was 8 days. 41 (29%) patients had a severe disease course and 24 (17%) died within 30 days. The incidence of bacterial coinfection was 2/142 (1.4%). None of the blood cultures showed pathogen growth while 6.3% was contaminated. The AUCs for predicting severe disease were 0.76 (95% CI 0.68 to 0.84), 0.70 (0.61 to 0.79), 0.62 (0.51 to 0.74), 0.62 (0.51 to 0.72) and 0.72 (0.63 to 0.81) for procalcitonin, CRP, ferritin, lymphocyte count and PSI score, respectively.ConclusionBlood cultures appear to have limited value while procalcitonin and the PSI appear to be promising tools in helping physicians identify patients at risk for severe disease course in COVID-19 at presentation to the ED.

IMPORTANCE Misdiagnosis of infection is among the most commonly made diagnostic errors and is associated with increased morbidity and mortality. Little is known about how often misdiagnosed site of infection occurs and its association with clinical outcomes. OBJECTIVES To evaluate the discrepancy between admission and discharge site of infectiondiagnoses among patients with suspected bacteremia, to explore factors associated with discrepant diagnoses, and to evaluate the association with clinical outcomes.

BackgroundThe Pneumonia Severity Index (PSI) and the CURB-65 score assess disease severity in patients with community acquired pneumonia (CAP). We compared the clinical performance of both prognostic scores according to clinical outcomes and admission rates.MethodsA nationwide retrospective cohort study was conducted using claims data from adult CAP patients presenting to the emergency department (ED) in 2018 and 2019. Dutch hospitals were divided into three categories: “CURB-65 hospitals” (n=25), “PSI hospitals” (n=19) and hospitals using both (“no-consensus hospitals”, n=15). Main outcomes were hospital admission rates, intensive care unit admissions, length of hospital stay, delayed admissions, readmissions and all-cause 30-day mortality. Multilevel logistic and Poisson regression analysis were used to adjust for potential confounders.FindingsOf 50.984 included CAP patients, 21.157 were treated in CURB-65 hospitals, 17.279 in PSI hospitals and 12.548 in no-consensus hospitals. The 30-day mortality was significantly lower in CURB-65 hospitalsversusPSI hospitals (8·6% and 9·7%, adjusted odds ratio (aOR) 0·89, 95% CI: 0·83–0·96, p=0·003). Other clinical outcomes were similar between CURB-65 hospitals and PSI hospitals. No-consensus hospitals had higher admission rates compared to the CURB-65 and PSI hospitals combined (78·4% and 81·5%, aOR 0·78, 95% CI: 0·62–0·99).InterpretationIn this study, using the CURB-65 in CAP patients at the ED is associated with similar and possibly even better clinical outcomes compared to using the PSI. After confirmation in prospective studies, the CURB-65 may be recommended over the use of the PSI since it is associated with lower 30-day mortality and more user-friendly.

Background The Pneumonia Severity Index (PSI) and the Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older (CURB-65) score can assess the severity in patients with community acquired pneumonia (CAP). We compared the clinical performance of both prognostic scores according to clinical outcome and admission rates. Methods A nationwide observational cohort study was conducted using claims data from adult patients presenting to the emergency department (ED) with CAP in 2018 and 2019. Dutch hospitals were divided into three categories: ‘CURB-65 hospitals’ (n=25), ‘PSI hospitals’ (n=19) and hospitals using both (‘no-consensus hospitals’, n=15). Main outcomes were number of hospital admissions, intensive care unit (ICU) admissions, length of hospital stay, and all-cause 30-day mortality. Multilevel logistic and Poisson regression analysis were used to adjust for potential confounders, including age, gender, comorbidities, medical specialism, and type of hospital. Results Of the 51.241 included patients with CAP at the ED, 21.233 were treated in CURB-65 hospitals, 17.389 in PSI hospitals and 12.619 in no-consensus hospitals. The 30-day mortality rate was 8·6% in CURB-65 hospitals versus 9·7% in PSI hospitals. Adjusted odds ratios (aORs) for 30-day mortality were lower in CURB-65 hospitals than in PSI hospitals (aOR 0·88, 95% confidence interval (CI): 0·82-0·95, p = 0·002). The admission rates in CURB-65 and PSI hospitals were similar (77·2% and 79·9%, aOR 0·81, 95% CI: 0·64-1·02). No-consensus hospitals had slightly higher admission rates on average compared to the CURB-65 and PSI hospitals combined (78·4% and 81·5%, aOR 0·79, 95% CI: 0·62-1·0). Conclusion The routine use of CURB-65 for risk assessment in CAP patients presenting to the ED in the Netherlands is associated with lower 30-day mortality. After further confirmation, the CURB-65 may be recommended over the use of the PSI. Disclosures W. Joost Wiersinga, PhD, AstraZeneca: Honoraria|GSK (DSMB): Honoraria|Pfizer: Honoraria|Sobi: Honoraria.