Admission lactate predicts poor prognosis independently of the CRB/CURB-65 scores in community-acquired pneumonia

Frenzen, F.; Kutschan, Ulrike; Meiswinkel, Nils; Schulte-Hubbert, B.; Ewig, Santiago; Kolditz, Martin

doi:10.1016/j.cmi.2017.07.007

Cited by 35 publications

(36 citation statements)

References 34 publications

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“…It should be noted that during the study period, all scores were being used in clinical practice, except for qSOFA, and this may have had an impact on the decision-making process when a patient was admitted to ICU. Our ICU admission rate is lower than that seen in studies performed outside the UK7 15 28; however, it is in keeping with the BTS pneumonia audit 27. This is likely to be due to inclusion of patients with treatment limitations; we choose to include patients with treatment limitations to enable application of these scores to all patients admitted.…”

Section: Discussionsupporting

confidence: 84%

“…It is associated with significant mortality2 and frequently leads to sepsis3 4 with mortality rates rising to 30% 5. Early identification of patients with severe CAP enables modification of management strategies and improves outcomes for patients 6–8…”

Section: Introductionmentioning

confidence: 99%

“…In addition, attempts have been made to refine previously well-described scores by using biomarkers such as lactate. Lactate is a strong independent predictor of mortality in both pneumonia and sepsis,13 21 and work by other groups has shown that addition of lactate ≥1.8 mmol/L improves the ability of CURB65 to predict mortality 7 13…”

Section: Introductionmentioning

confidence: 99%

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Early identification of severe community-acquired pneumonia: a retrospective observational study

et al. 2019

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BackgroundCommunity-acquired pneumonia (CAP) is a leading cause of sepsis worldwide. Prompt identification of those at high risk of adverse outcomes improves survival by enabling early escalation of care. There are multiple severity assessment tools recommended for risk stratification; however, there is no consensus as to which tool should be used for those with CAP. We sought to assess whether pneumonia-specific, generic sepsis or early warning scores were most accurate at predicting adverse outcomes.MethodsWe performed a retrospective analysis of all cases of CAP admitted to a large, adult tertiary hospital in the UK between October 2014 and January 2016. All cases of CAP were eligible for inclusion and were reviewed by a senior respiratory physician to confirm the diagnosis. The association between the CURB65, Lac-CURB-65, quick Sequential (Sepsis-related) Organ Failure Assessment tool (qSOFA) score and National Early Warning Score (NEWS) at the time of admission and outcome measures including intensive care admission, length of hospital stay, in-hospital, 30-day, 90-day and 365-day all-cause mortality was assessed.Results1545 cases were included with 30-day mortality of 19%. Increasing score was significantly associated with increased risk of poor outcomes for all four tools. Overall accuracy assessed by receiver operating characteristic curve analysis was significantly greater for the CURB65 and Lac-CURB-65 scores than qSOFA. At admission, a CURB65 ≥2, Lac-CURB-65 ≥moderate, qSOFA ≥2 and NEWS ≥medium identified 85.0%, 96.4%, 40.3% and 79.0% of those who died within 30 days, respectively. A Lac-CURB-65 ≥moderate had the highest negative predictive value: 95.6%.ConclusionAll four scoring systems can stratify according to increasing risk in CAP; however, when a confident diagnosis of pneumonia can be made, these data support the use of pneumonia-specific tools rather than generic sepsis or early warning scores.

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Section: Discussionsupporting

confidence: 84%

Section: Introductionmentioning

confidence: 99%

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Early identification of severe community-acquired pneumonia: a retrospective observational study

et al. 2019

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“…Emergency Medicine International mortality and ICU admission in pneumonia patients in ED, while results indicated that lactate is superior to CURB65 in predicting mortality, hospitalization, and intensive care unit (ICU) admission and lactate-CURB65 combination improves the predictive value of single CURB65 [10]. A similar study by Frenzen and colleagues concluded that admission lactate levels significantly improved the prognostic value (need for mechanical ventilation, vasopressors, ICU admission, or hospital mortality) of CRB/CURB65 scores in CAP patients with an optimal cutoff value of 1.8 mmol/L [23]. Song et al enrolled 443 patients with CAP in ED, and results showed that the AUROC of qSOFA and SOFA for prediction of mortality was 0.720 and 0.845, while the combination of qSOFA and lactate was not significantly different from SOFA [24].…”

Section: Discussionmentioning

confidence: 95%

Prognostic Prediction Value of qSOFA, SOFA, and Admission Lactate in Septic Patients with Community-Acquired Pneumonia in Emergency Department

Zhou

Lan

Guo

2020

Emergency Medicine International

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Background. Community-acquired pneumonia (CAP) is a leading cause of sepsis and common presentation to emergency department (ED) with a high mortality rate. The prognostic prediction value of sequential organ failure assessment (SOFA) and quick SOFA (qSOFA) scores in CAP in ED has not been validated in detail. The aim of this research is to investigate the prognostic prediction value of SOFA, qSOFA, and admission lactate compared with that of other commonly used severity scores (CURB65, CRB65, and PSI) in septic patients with CAP in ED. Methods. Adult septic patients with CAP admitted between Jan. 2017 and Jan. 2019 with increased admission SOFA ≥ 2 from baseline were enrolled. The primary outcome was 28-day mortality. The secondary outcome included intensive care unit (ICU) admission, mechanical ventilation, and vasopressor use. Prognostic prediction performance of the parameters above was compared using receiver operating characteristic (ROC) curves. Kaplan–Meier survival curves were compared using optimal cutoff values of qSOFA and admission lactate. Results. Among the 336 enrolled septic patients with CAP, 89 patients died and 247 patients survived after 28-day follow-up. The CURB65, CRB65, PSI, SOFA, qSOFA, and admission lactate levels were statistically significantly higher in the death group (P<0.001). qSOFA and SOFA were superior and the combination of qSOFA + lactate and SOFA + lactate outperformed other combinations of severity score and admission lactate in predicting both primary and secondary outcomes. Patients with admission qSOFA < 2 or lactate ≤ 2 mmol/L showed significantly prolonged survival than those patients with qSOFA ≥ 2 or lactate > 2 mmol/L (log-rank χ2 = 59.825, P<0.001). The prognostic prediction performance of the combination of qSOFA and admission lactate was comparable to the full version of SOFA (AUROC 0.833 vs. 0.795, Z = 1.378, P=0.168 in predicting 28-day mortality; AUROC 0.868 vs. 0.895, Z = 1.022, P=0.307 in predicting ICU admission; AUROC 0.868 vs. 0.845, Z = 0.921, P=0.357 in predicting mechanical ventilation; AUROC 0.875 vs. 0.821, Z = 2.12, P=0.034 in predicting vasopressor use). Conclusion. qSOFA and SOFA were superior to CURB65, CRB65, and PSI in predicting 28-day mortality, ICU admission, mechanical ventilation, and vasopressor use for septic patients with CAP in ED. Admission qSOFA with lactate is a convenient and useful predictor. Admission qSOFA ≥ 2 or lactate > 2 mmol/L would be very helpful in discriminating high-risk patients with a higher mortality rate.

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“…Hyperlactataemia is an independent predictor of mortality in both pneumonia and sepsis 71. Much evidence now supports the view that hyperlactataemia is not only due to tissue hypoxia or anaerobic glycolysis but also due to increased aerobic glycolysis (the conversion of pyruvate to lactate to generate ATP in the presence of oxygen).…”

Section: Host Immune System At the Extremes Of Agementioning

confidence: 95%

Neutrophils in community-acquired pneumonia: parallels in dysfunction at the extremes of age

Grudzinska

Brodlie

Scholefield

et al. 2019

Thorax

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"Science means constantly walking a tight rope" Heinrich Rohrer, physicist, 1933. Community-acquired pneumonia (CAP) is the leading cause of death from infectious disease worldwide and disproportionately affects older adults and children. In high-income countries, pneumonia is one of the most common reasons for hospitalisation and (when recurrent) is associated with a risk of developing chronic pulmonary conditions in adulthood. Pneumococcal pneumonia is particularly prevalent in older adults, and here, pneumonia is still associated with significant mortality despite the widespread use of pneumococcal vaccination in middleand high-income countries and a low prevalence of resistant organisms. In older adults, 11% of pneumonia survivors are readmitted within months of discharge, often with a further pneumonia episode and with worse outcomes. In children, recurrent pneumonia occurs in approximately 10% of survivors and therefore is a significant cause of healthcare use. Current antibiotic trials focus on short-term outcomes and increasingly shorter courses of antibiotic therapy. However, the high requirement for further treatment for recurrent pneumonia questions the effectiveness of current strategies, and there is increasing global concern about our reliance on antibiotics to treat infections. Novel therapeutic targets and approaches are needed to improve outcomes. Neutrophils are the most abundant immune cell and among the first responders to infection. Appropriate neutrophil responses are crucial to host defence, as evidenced by the poor outcomes seen in neutropenia. Neutrophils from older adults appear to be dysfunctional, displaying a reduced ability to target infected or inflamed tissue, poor phagocytic responses and a reduced capacity to release neutrophil extracellular traps (NETs); this occurs in health, but responses are further diminished during infection and particularly during sepsis, where a reduced response to granulocyte colony-stimulating factor (G-CSF) inhibits the release of immature neutrophils from the bone marrow. Of note, neutrophil responses are similar in preterm infants. Here, the storage pool is decreased, neutrophils are less able to degranulate, have a reduced migratory capacity and are less able to release NETs. Less is known about neutrophil function from older children, but theoretically, impaired functions might increase susceptibility to infections. Targeting these blunted responses may offer a new paradigm for treating CAP, but modifying neutrophil behaviour is challenging; reducing their numbers or inhibiting their function is associated with poor clinical outcomes from infection. Uncontrolled activation and degranulation can cause significant host tissue damage. Any neutrophil-based intervention must walk the tightrope described by Heinrich Rohrer, facilitating necessary phagocytic functions while preventing bystander host damage, and this is a significant challenge which this review will explore.

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Admission lactate predicts poor prognosis independently of the CRB/CURB-65 scores in community-acquired pneumonia

Abstract: Admission lactate levels significantly improved the prognostic value of the CRB/CURB-65 scores in CAP patients. Lactate may therefore be considered a rapid, cheap and broadly available additional criterion for the assessment of risk in patients with CAP.

Cited by 35 publications

References 34 publications

Early identification of severe community-acquired pneumonia: a retrospective observational study

Early identification of severe community-acquired pneumonia: a retrospective observational study

Prognostic Prediction Value of qSOFA, SOFA, and Admission Lactate in Septic Patients with Community-Acquired Pneumonia in Emergency Department

Neutrophils in community-acquired pneumonia: parallels in dysfunction at the extremes of age

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