Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia

Aujesky, Drahomir; Auble, Thomas E.; Yealy, Donald M.; Stone, Roslyn A.; Obrosky, D. Scott; Meehan, Thomas P.; Graff, Louis; Fine, Jonathan; Fine, Michael J.

doi:10.1016/j.amjmed.2005.01.006

Cited by 325 publications

(266 citation statements)

References 24 publications

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“…Only class I of the recalibrated PSI score can therefore be used to identify patients who qualify for outpatient management. Prior validation studies have prospectively evaluated severity scores in different clinical settings and reported high mortality rates particularly in patients of PSI class III or above and CURB65 class 1 or above [10][11][12][13][14][15][16][17]. These studies, however, focused mainly on the overall discriminatory ability of the prediction rules with varying results as expressed by differences in the area under the ROC curves.…”

Section: Discussionmentioning

confidence: 99%

“…With only few exceptions [10], external validation studies of pneumonia severity scores have focused on discriminative properties, i.e. the ability of the score to distinguish patients with CAP and fatal outcome from those surviving [10][11][12][13][14][15][16][17]. Despite good discriminatory abilities, most validation studies found higher mortality rates of patients with PSI class III and CURB65 class 1 than was reported in the original studies.…”

Section: Introductionmentioning

confidence: 99%

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Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

et al. 2008

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SUMMARYIn patients with community-acquired pneumonia (CAP) prediction rules based on individual predicted mortalities are frequently used to support decision-making for in-patient vs. outpatient management. We studied the accuracy and the need for recalibration of three risk prediction scores in a tertiary-care University hospital emergency-department setting in Switzerland. We pooled data from patients with CAP enrolled in two randomized controlled trials. We compared expected mortality from the original pneumonia severity index (PSI), CURB65 and CRB65 scores against observed mortality (calibration) and recalibrated the scores by fitting the intercept a and the calibration slope b from our calibration model. Each of the original models underestimated the observed 30-day mortality of 11 %, in 371 patients admitted to the emergency department with CAP (8 . 4%, 5 . 5 % and 5 . 0% for the PSI, CURB65 and CRB65 scores, respectively). In particular, we observed a relevant mortality within the low risk classes of the original models (2 . 6%, 5 . 3%, and 3 . 7% for PSI classes I-III, CURB65 classes 0-1, and CRB65 class 0, respectively). Recalibration of the original risk models corrected the miscalibration. After recalibration, however, only PSI class I was sensitive enough to identify patients with a low risk (i.e. <1%) for mortality suitable for outpatient management. In our tertiary-care setting with mostly referred in-patients, CAP risk scores substantially underestimated observed mortalities misclassifying patients with relevant risks of death suitable for outpatient management. Prior to the implementation of CAP risk scores in the clinical setting, the need for recalibration and the accuracy of low-risk re-classification should be studied in order to adhere with discharge guidelines and guarantee patients' safety.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

et al. 2008

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“…(5) We calculated CURB-65 retrospectively using altered mental status or a new change in Glasgow Coma Scale as proxy measures for confusion. (25) Based on prior studies, we stratified procalcitonin into four tiers -tier I: < 0.1; tier II: ≥ 0.1 to < 0.25; tier III: ≥ 0.25 to < 0.5, and; tier IV: ≥ 0.5 ng/ml. (16)(17)(18) We defined a clinically significant positive culture based on published guidelines and prior literature.…”

Section: Methods Of Measurementmentioning

confidence: 99%

Risk Prediction With Procalcitonin and Clinical Rules in Community-Acquired Pneumonia

Huang

Weissfeld

Kellum

et al. 2008

Annals of Emergency Medicine

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198

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Objective-The Pneumonia Severity Index (PSI) and CURB-65 predict outcomes in community acquired pneumonia (CAP), but have limitations. Procalcitonin, a biomarker of bacterial infection, may provide prognostic information in CAP. Our objective was to describe the pattern of procalcitonin in CAP, and determine if procalcitonin provides prognostic information beyond PSI and CURB-65.Methods-We conducted a multi-center prospective cohort study in 28 community and teaching emergency departments. Patients presenting with a clinical and radiographic diagnosis of CAP were enrolled. We stratified procalcitonin levels a priori into four tiers -I: < 0.1; II: ≥ 0.1 to <0.25; III: ≥ 0.25 to < 0.5; and IV: ≥ 0.5 ng/ml. Primary outcome was 30d mortality.Results-1651 patients formed the study cohort. Procalcitonin levels were broadly spread across tiers: 32.8% (I), 21.6% (II), 10.2% (III), 35.4% (IV). Used alone, procalcitonin had modest test characteristics: specificity (35%), sensitivity (92%), positive likelihood ratio (LR) (1.41), and negative LR (0.22). Adding procalcitonin to PSI in all subjects minimally improved performance. Adding procalcitonin to low risk PSI subjects (Class I-III) provided no additional information. However, subjects in procalcitonin tier I had low 30d mortality regardless of clinical risk, including those in higher risk classes (1.5% vs. 1.6% for those in PSI Class I-III vs. Class IV/V). Among high risk PSI subjects (Class IV/V), one quarter (126/546) were in procalcitonin tier I, and the negative LR of procalcitonin tier I was 0.09. Procalcitonin tier I was also associated with lower burden of other adverse outcomes. Similar results were seen with CURB-65 stratification. Reprints not available from the authors.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conclusions-Selective use of procalcitonin as an adjunct to existing rules may offer additional prognostic information in high risk patients. NIH Public Access

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“…Drug-resistant S. pneumoniae (DSRP) has been identified in cases with increasing resistance to macrolides (7). DSRP in association with CAP, however, has not been well documented.…”

Section: Antibiotic Resistancementioning

confidence: 99%

Evaluation and Management of Community and Hospital-Acquired Pneumonia for the Primary Care Providers

Antony

2016

Int J Infect

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Context: The incidence and prevalence of both community and hospital acquired pneumonia has remained relatively constant over the last several years. This paper reviews the current treatment guidelines as well as highlight new antibiotics that have recently become available for use as well. Evidence Acquisition: We evaluated guidelines provided by the infectious diseases society of America (IDSA) for the management of community-acquired pneumonia (CAP), published in 2007, and hospital-acquired pneumonia (HAP) published in 2005. We also reviewed literature published from January 2005 to December 2015 using PubMed to evaluate how the treatment of these types of pneumonia have evolved. Results: Through our literature review, it was found that despite the advances made in the diagnosis and management of both CAP and HAP, it remains a significant challenge to diagnose and often treat. Two new IV antibiotics (tigecycline and ceftaroline) introduced for the management of CAP and telavancin was approved for HAP. Moreover, treatment of these two types of pneumonia often involves being creative with antimicrobial therapy due to the increasing multi-drug resistance. Conclusions: CAP/HAP remains one of the leading causes of morbidity and mortality in the world. Bacterial resistance is increasing and adds to the difficulty in treating these patients. Newer drugs are available but should be used judiciously and in the right setting.

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Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia

Cited by 325 publications

References 24 publications

Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

Risk Prediction With Procalcitonin and Clinical Rules in Community-Acquired Pneumonia

Evaluation and Management of Community and Hospital-Acquired Pneumonia for the Primary Care Providers

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