ObjectiveTo assess the validity of CRB-65 (Confusion, Respiratory rate >30 breaths/min, BP<90/60 mmHg, age >65 years) as a pneumonia severity index in a Malawian hospital population, and determine whether an alternative score has greater accuracy in this setting.DesignForty three variables were prospectively recorded during the first 48 hours of admission in all patients admitted to Queen Elizabeth Central Hospital, Malawi, for management of lower respiratory tract infection over a two month period (N = 240). Calculation of sensitivity and specificity for CRB-65 in predicting mortality was followed by multivariate modeling to create a score with superior performance in this population.ResultsMedian age 37, HIV prevalence 79.9%, overall mortality 18.3%. CRB-65 predicted mortality poorly, indicated by the area under the ROC curve of 0.649. Independent predictors of death were: Male sex, “S” (AOR 2.6); Wasting, “W” (AOR 6.6); non-ambulatory, “A” (AOR 2.5); Temp >38°C or <35°C, “T” (AOR 3.2); BP<100/60, “Bp” (AOR 3.7). Combining these factors to form a severity index (SWAT-Bp) predicted mortality with high sensitivity and specificity (AUC: 0.867). Mortality for scores 0–5 was 0%, 3.3%, 7.4%, 29.2%, 61.5% and 87.5% respectively. A score ≥3 was 84% sensitive and 77% specific for mortality prediction, with a negative predictive value of 95.8%.ConclusionCRB-65 performs poorly in this population. The SWAT-Bp score can accurately stratify patients; ≤2 indicates non-severe infection (mortality 4.4%) and ≥3 severe illness (mortality 45%).

Background Optimising the diagnosis of bacteraemia has clinical, infection control and antimicrobial stewardship benefits. It's well documented that volume of blood received in blood culture bottles affects test sensitivity. The ability of blood cultures to detect bacteraemia is proportional to the volume of blood cultured. We undertook a period of baseline measurement and established that mean blood culture fill volume was inadequate. Aim The primary aim was to increase the percentage of adequately filled blood cultures (≥5ml) by 20% and increase the percentage of optimally filled bottles (8–10ml) by 10% in six months (by 1st August 2018). Our secondary aim was to increase the mean volume in blood culture bottles to 8ml (by 1 st August 2018). We measured the clinical impact of this on test sensitivity by comparing blood culture positivity rate between adequately and inadequately filled bottles. Methods Following a period of baseline measurement we implemented three phases of plan/do/study/act (PDSA) intervention cycles (including a small test pilot cycle). Interventions were focused around user education/engagement, real time user feedback and laboratory reporting. User questionnaires were administered to investigate knowledge and practice; further informing the interventions. Results & Conclusion Between 1 st March - 1 st August 2018 the mean volume of blood inoculated into culture bottles rose from 5ml (95% CI 4.1–6.0ml) to 7.5ml (95% CI 6.4–8.5ml). The percentage of adequately-filled (≥5ml) blood culture bottles increased from 47% to 61% (absolute increase of 14%) and the percentage of optimally-filled (≥8ml) bottles increased from 16% to 29% (absolute increase of 13%). Although our project didn't fully meet its aims, we observed a significant and sustained improvement in filling of blood culture bottles.

BackgroundCommunity-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.AimTo 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.MethodsThe 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.ResultsMedian 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.ConclusionIn 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.