Pneumonia Severity Index Class V Patients With Community-Acquired Pneumonia: Characteristics, Outcomes, and Value of Severity Scores

doi:10.1378/chest.07-0306

Chest

Volume 132, Issue 2, August 2007, Pages 515-522

https://doi.org/10.1378/chest.07-0306 Get rights and content

Background

Community-acquired pneumonia (CAP) with a pneumonia severity index (PSI) score in risk class V (PSI-V) is a potentially life-threatening condition, yet the majority of patients are not admitted to the ICU. The aim of this study was to characterize CAP patients in PSI-V to determine the risk factors for ICU admission and mortality, and to assess the performance of CAP severity scores in this population.

Methods

Prospective observational study including hospitalized adults with CAP in PSI-V from 1996 to 2003. Clinical and laboratory data, microbiological findings, and outcomes were recorded. The PSI score; modified American Thoracic Society (ATS) score; the confusion, urea, respiratory rate, low BP (CURB) score, and CURB plus age of ≥ 65 years score were calculated. A reduced score based on the acute illness variables contained in the PSI was also obtained.

Results

A total of 457 patients were included in the study (mean [± SD] age, 79 ± 11 years), of whom 92 (20%) were admitted to the ICU. Patients in the ward were older (mean age, 82 ± 10 vs 70 ± 10 years, respectively) and had more comorbidities. ICU patients experienced significantly more acute organ failures. The mortality rate was higher in ICU patients, but also was high for non-ICU patients (37% vs 20%, respectively; p = 0,003). A low level of consciousness (odds ratio [OR], 3.95; 95% confidence interval [CI], 2 to 5) and shock (OR, 24.7; 95% CI, 14 to 44) were associated with a higher risk of death. The modified ATS severity rule had the best accuracy in predicting ICU admission and mortality.

Conclusions

Most CAP patients PSI-V were treated on a hospital ward. Those admitted to the ICU were younger and had findings of more acute illness. The PSI performed well as a mortality prediction tool but was less appropriate for guiding site-of-care decisions.

Section snippets

Study Subjects

The study was conducted in a 700-bed, tertiary care university hospital. All patients with CAP were prospectively followed from January 1996 to June 2003. CAP was defined as symptoms of lower respiratory tract infection plus new infiltrates seen on a chest radiograph and the absence of an alternative diagnosis. We included consecutively all patients classified on hospital admission as being in PSI-V (PSI index score, ≥ 130).⁴ Patients with a hospital admission in the previous month or those who

Baseline Characteristics

During the study period, CAP was diagnosed in 2,029 patients. Of these, 457 patients were classified as being in PSI-V with a mean (± SD) PSI of 154 ± 20 points (range, 131 to 234) points. The mean age was 79 ± 11 years (range, 33 to 102 years), and 70% of patients were men. Considering comorbidity, 277 patients (60%) had a previous diagnosis pulmonary disease, 166 patients (36%) had heart disease, 133 patients (29%) had a neurologic disorder, 115 patients (25%) had chronic renal disease, and

Discussion

This study has evaluated the profile and outcomes of patients with CAP and PSI-V in detail. Our results show that, despite a high mortality rate, only 20% of patients were admitted to the ICU. The patients treated in the ICU were younger and had less comorbidity. Mortality was high in ICU patients but was also relatively high in patients on the ward. The modified ATS severity rule had the best accuracy in predicting ICU admission and death. Finally, for the whole group of PSI-V CAP patients,

References (27)

MS Niederman et al.
Community-acquired pneumonia in elderly patients
Clin Geriatr Med
(2003)
J Almirall et al.
Prognostic factors of pneumonia requiring admission to the intensive care unit
Chest
(1995)
J Almirall et al.
Epidemiology of community-acquired pneumonia in adults: a population based study
Eur Respir J
(2000)
BG Feagan et al.
Treatment and outcomes of community-acquired pneumonia at Canadian hospitals
Can Med Assoc J
(2000)
JF Guest et al.
Community-acquired pneumonia: the annual cost to the national health service in the UK
Eur Respir J
(1997)
MJ Fine et al.
Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patients Outcomes Research Team (PORT) cohort study
Arch Intern Med
(1999)
MJ Fine et al.
A prediction rule to identify low-risk patients with community-acquired pneumonia
N Engl J Med
(1997)
DC Angus et al.
Severe community-acquired pneumonia: use of intensive care services and evaluation of American and British Thoracic Society Diagnostic criteria
Am J Respir Crit Care Med
(2002)
MS Niederman et al.
Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention
Am J Respir Crit Care Med
(2001)
S Ewig et al.
Validation of predictive rules and indices of severity for community-acquired pneumonia
Thorax
(2004)

S Ewig et al.

Severe community-acquired pneumonia: assessment of severity criteria

Am J Respir Crit Care Med

(1998)

S Ewig et al.

Comparative validation of prognostic rules for community-acquired pneumonia in an elderly population

Eur Respir J

(1999)

British Thoracic Society

BTS guidelines for the management of community acquired pneumonia in adults

Thorax

(2001)

Cited by (102)

Paediatric pneumonia in high-income countries: Defining and recognising cases at increased risk of severe disease
2021, Paediatric Respiratory Reviews
Citation Excerpt :
The performance of these tests to predict ICU admission is shown in Table 2 [99]. Severity scores have been useful in recognising low risk patients safe to be managed with outpatient treatment [100] and predicting the need for ICU admission [101]. Their use has been associated with improved concordance with empiric antibiotic prescription guidelines, yet it is not clear that severity scores are helpful in guiding antibiotic choices [102].
World Health Organisation definitions of pneumonia severity are routinely used in research. In high income health care settings with high rates of pneumococcal vaccination and low rates of mortality, malnutrition and HIV infection, these definitions are less applicable. National guidelines from leading thoracic and infectious disease societies describe ‘severe pneumonia’ according to criteria derived from expert consensus rather than a robust evidence base. Contemporary cohort studies have used clinical outcomes such as intensive care therapy or invasive procedures for complicated pneumonia, to define severe disease. Describing severe pneumonia in such clinically relevant terms facilitates the identification of risk factors associated with worsened disease and the subsequently increased morbidity, and need for tertiary level care. The early recognition of children at higher risk of severe pneumonia informs site of care decisions, antibiotic treatment decisions as well as guiding appropriate investigations. Younger age, malnutrition, comorbidities, tachypnoea, and hypoxia have been identified as important associations with ‘severe pneumonia’ by WHO definition. Most studies have been performed in low-middle income countries and whilst they provide some insight into those at risk of mortality or treatment failure, their generalisability to the high-income setting is limited. There is a need to determine more precise definitions and criteria for severe disease in well-resourced settings and to validate factors associated with intensive care admission or invasive procedures to enhance the early recognition of those at risk.
Hypernatremia and moderate-to-severe hyponatremia are independent predictors of mortality in septic patients at emergency department presentation: A sub-group analysis of the need-speed trial
2021, European Journal of Internal Medicine
Early risk stratification of septic patients presenting to the emergency department (ED) is challenging. The aim of the study was to evaluate the prognostic role of plasmatic sodium level (_PNa⁺) derangements at ED presentation in septic patients.
According to _PNa⁺ at ED presentation patients were divided in eunatremic (136–145 mEq/L), hypernatremic (>145 mEq/L) and hyponatremic (<136 mEq/L). Hyponatremic patients were subsequently divided in mild (130–135 mEq/L), moderate (125–129 mEq/L) and severe (<125 mEq/L). 7 and 30-day mortality was evaluated according to _PNa⁺ derangements and the degree of hyponatremia. The same analysis was then performed only in respiratory tract infection-related (RTI-r) sepsis patients.
879 septic patients were included in this analysis, 40.3% had hyponatremia, 5.7% hypernatremia. Hypernatremia showed higher mortality rates at both endpoints compared to eunatremia and hyponatremia (p<0.0001 for both). Eunatremia and mild hyponatremia were compared vs. moderate-to-severe hyponatremia showing a significant difference in terms of 7 and 30-day survival (p = 0.004 and p = 0.007, respectively). The Cox proportional model identified as independent predictors of 7 and 30-day mortality moderate-to-severe hyponatremia (HR 4.89[2.38–10.03] and 1.79[1.07–3.01], respectively) and hypernatremia (HR 3.52[1.58–7.82] and 2.14[1.17–3.92], respectively). The same analysis was performed in patients with respiratory tract infection-related sepsis (n = 549), with similar results.
Both hypernatremia and moderate-to-severe hyponatremia at ED presentation independently predict mortality in septic patients, allowing early risk stratification and suggesting more aggressive therapeutic strategies.
Antibiotic therapy prior to hospital admission is associated with reduced septic shock and need for mechanical ventilation in patients with community-acquired pneumonia
2017, Journal of Infection
A subgroup of patients admitted to the hospital with a diagnosis of community-acquired pneumonia (CAP) have received antibiotic therapy prior to admission for the current episode of pneumonia. The objective of this study was to assess the clinical course of patients receiving antibiotics prior to admission, compared to patients not previously treated. An observational cohort of 3364 CAP patients consecutively admitted to our hospital, and prospectively included, were studied. We collected clinical, microbiological and biochemical parameters, focusing on recent antibiotics received prior to admission. 610 (18%) patients received antibiotics prior to hospital admission for the current CAP episode. Patients with previous antibiotic use developed septic shock less frequently (4% vs. 7%, p = 0.007) and required invasive ventilation less often (3% vs. 6%, p = 0.002). After adjustment by different covariate factors and propensity score, antibiotic therapy was still independently associated with a lower incidence of septic shock at admission (OR 0.54 [95% CI 0.31–0.95], p = 0.03) and less need for invasive ventilation (OR 0.38 [95% CI 0.16–0.91], p = 0.03). In this cohort, recent use of antibiotics before hospital admission in CAP seems to be associated with a lower incidence of septic shock on admission and a lower need for invasive ventilation.
Guidelines-concordant empiric antimicrobial therapy and mortality in patients with severe community-acquired pneumonia requiring mechanical ventilation
2017, Respiratory Investigation
Citation Excerpt :
After adjustment for patient backgrounds, the use of guidelines-concordant empirical combined antimicrobial therapy was independently associated with 7-day mortality. Severe CAP is well known to have poor prognosis; in-hospital mortality of patients with severe CAP admitted to the ICU has been reported to be 18–37% [9–11]. In-hospital mortality in this study was 54.6%, which is higher than that previously reported; this is because the patients included in the present study had very severe pneumonia that required mechanical ventilation at admission.
Community-acquired pneumonia (CAP) has high morbidity and mortality among adults. Several clinical guidelines recommend prompt administration of combined antimicrobial therapy. However, the association between guidelines concordance and mortality in patients with severe pneumonia remains unclear. The present study aimed to examine the impact of guidelines-concordant empiric antimicrobial therapy on 7-day mortality in patients with extremely severe pneumonia who required mechanical ventilation at admission, using a nationwide inpatient database in Japan.
Data of CAP patients aged over 20 years who required mechanical ventilation at admission between April 2012 and March 2014 were retrospectively analyzed. Multivariable logistic regression analysis was performed to examine the association between guidelines-concordant empiric antimicrobial therapy and all-cause 7-day mortality, with adjustment for patient backgrounds and pneumonia severity.
There were a total of 3719 eligible patients, 836 (22.5%) of whom received guidelines-concordant combination therapy. Overall, 7-day mortality was 29.5%. Higher 7-day mortality was associated with advanced age, confusion, lower systolic blood pressure, malignant tumor or immunocompromised state, and C-reactive protein ≥20 mg/dl or infiltration occupying two-thirds of one lung on chest radiography. After adjustment for these variables, guidelines-concordant combined antimicrobial therapy was associated with significantly lower 7-day mortality (odds ratio: 0.78; 95% confidence interval: 0.65–0.95; P=0.013).
Adherence to initial empiric treatment as recommended by the guidelines was associated with better short-term prognosis in patients with extremely severe pneumonia who required mechanical ventilation on hospital admission.
The impact of multimorbidity on short-term events in patients with community-acquired pneumonia: Prospective cohort study
2015, Clinical Microbiology and Infection
The impact of multimorbidity on patients with community-acquired pneumonia has not been well characterised. Thus, our aim was to explore the relationship between multimorbidity and adverse events within 90 days of discharge. Data were prospectively collected for a population-based cohort of all adults discharged from any of the seven emergency departments (ED) or six hospitals in Edmonton (Alberta, Canada) with community-acquired pneumonia. Multivariable Cox regression models were used to examine the independent association between multimorbidity (defined as two or more chronic conditions) and subsequent 90-day mortality, hospitalisation, or ED visits after treatment of pneumonia. The cohort included 5565 patients, mean age was 57 years (SD 20), 54% were male, and 59% were treated as outpatients; 1602 (29%) patients had multimorbidity. Within 90 days, 255 (5%) patients died, 1205 (22%) were hospitalised, 1280 (23%) died or were hospitalised, and 2049 (37%) were admitted to the ED. The presence of multimorbidity was independently associated with an increased risk of death or hospitalisation within 90 days (37% vs. 17% for those without multimorbidity, adjusted hazard ratio: 1.43, 95% confidence interval: 1.26 to 1.62) as well as ED visits (45% vs. 34%, adjusted hazard ratio: 1.40, 95% confidence interval: 1.26 to 1.56). Multimorbidity was present in one-third of all patients with pneumonia in our study, and it was independently associated with death, hospitalisation, or return to ED within 90 days of discharge. Our findings suggest that multimorbidity is strongly related to prognosis and should be considered when making site-of-care decisions in the ED or deciding upon readiness for discharge.
Illness severity scores in veterinary medicine
2014, Small Animal Critical Care Medicine, Second Edition

View all citing articles on Scopus

This research was supported by Fondo de Investigaciones Sanitarias grant 02/0632, and Institut de Investigacions Biomédiques August Pi i Sunyer grant 2005 SGRQ/00822, and Centro de Investigacion Biomedica en Red-Enfermedades Respiratorias CB 06/06/0028. Dr. Mauricio Valencia received a research fellowship grant in 2002 funded by the European Respiratory Society.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

View full text

Chest

Original ResearchChest InfectionsPneumonia Severity Index Class V Patients With Community-Acquired Pneumonia: Characteristics, Outcomes, and Value of Severity Scores

Background

Methods

Results

Conclusions

Section snippets

Study Subjects

Baseline Characteristics

Discussion

Clin Geriatr Med

Chest

Epidemiology of community-acquired pneumonia in adults: a population based study

Eur Respir J

Treatment and outcomes of community-acquired pneumonia at Canadian hospitals

Can Med Assoc J

Community-acquired pneumonia: the annual cost to the national health service in the UK

Eur Respir J

Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patients Outcomes Research Team (PORT) cohort study

Arch Intern Med

A prediction rule to identify low-risk patients with community-acquired pneumonia

N Engl J Med

Severe community-acquired pneumonia: use of intensive care services and evaluation of American and British Thoracic Society Diagnostic criteria

Am J Respir Crit Care Med

Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention

Am J Respir Crit Care Med

Validation of predictive rules and indices of severity for community-acquired pneumonia

Thorax

Severe community-acquired pneumonia: assessment of severity criteria

Am J Respir Crit Care Med

Comparative validation of prognostic rules for community-acquired pneumonia in an elderly population

Eur Respir J

BTS guidelines for the management of community acquired pneumonia in adults

Thorax

Original Research
Chest Infections
Pneumonia Severity Index Class V Patients With Community-Acquired Pneumonia: Characteristics, Outcomes, and Value of Severity Scores