Validity of pneumonia severity index/pneumonia outcome research trial and Curb-65 severity scoring systems in community acquired pneumonia in Indian setting
Keywords:CAP, PSI, CURB-65
Background: The symptoms of CAP begin outside the hospital or within 48 hours of admission into the hospital in patients who has not resided in a health care facility for at least 14 days before the onset of the symptoms. Pneumonia severity index (PSI) and the CURB-65 rule for CAP have been developed to identify the relevant prognostic factors might be useful for early identification of patients at high risk requiring intensive care treatment. This study was conducted to determine prognostic factors associated with mortality in and to test the validity of PSI/PORT (pneumonia outcome research trial) and CURB-65 severity scoring systems in community acquired pneumonia (CAP) in Indian setting.
Methods: Complete detailed clinical history was taken from 150 patients suspected of community acquired pneumonia patients and they were subjected to thorough physical examination, including X rays, ECG blood tests for various parameters. PSI and CURB-65 scores were taken for all the patients.
Results: Maximum no. of patients, i.e.33.33% were in the age group of 60-69. Of 150 patients, 16 died accounting for a mortality rate of 10.7%. This group included 12 (8%) patients who died in hospitals and four (2.67%) who died within 30 days of discharge. All 16 patients (100%) in death group were of PSI risk class ≥IV. Mortality in PSI class I to III was 0% in class IV 14.04% and Class V 34.78%. Mortality in CURB-65 risk class 0 to II was 0%, in risk class III it was 9.52%, 47.82% in Class IV and 50% in Class V.
Conclusions: PSI and CURB-65 have excellent sensitivity for predicting death but low specificity albeit specificity of CURB-65 was better than that of PSI. Because of its simplicity and ease of use, in addition to higher specificity, CURB-65 may be better suited than PSI as a severity scoring system in CAP in developing countries with limited resources.
Mendell LA. Pneumonia, Harrisson’s principles of internal medicine, 17th Ed, New York McGraw Hill, Vol 2, Chapt 251.
Seaton D, Anthony S. Textbook of Crofton & Doughlas respiratory diseases, 5th ed, Blackwell science, Community Acquired Pneumonia Vol 1, Chap 13. Pg 356.
R WHO (1999), Health Situation in the South-East Asia Region 1994-1997, Regional Office for SEAR, New Delhi.
Garibaldi RA. Epidemiology of community acquired respiratory tract infections in adults: incidence, etiology and impact. Am J Med. 1985;78:32-7.
Örtquist A, Hedlund J, Grillner L, Jalonen E, Kallings I, Leinonen M, et al. Aetiology, outcome and prognostic factors in patients with community acquired pneumonia requiring hospitalization. Eur Respir J. 1990;3:1105-13.
Marrie TJ, Durant H, Yates L. Community-acquired pneumonia requiring hospitalisation: 5 year prospective study. Rev Infect Dis. 1989;11:586-99.
Fang GD, Fine M, Orloff J, Arisumi D, Yu VL, Kapoor W, et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy: a prospective multicenter study of 359 cases. Medicine. 1990;69:307-16.
Schneider EL. Infectious diseases in the elderly. Ann Intern Med. 1983;98:395.
Shaun F, Gratten M, Germer S, Hazlett H, Linnemann V, Richard Payne R. Aetiology of pneumonia in Childern, Goroka Hospital, Papua New Guinea. Lancet. 1984;324(8402):537-41.
Gwatkin DR. Acute Respiratory Infections inunder-fives: 15 million deaths a year. Lancet. 1985;2(8457):699-701.
Bartlett JG, Mundy LM. Community Acquired Pneumonia. J Eng J Med. 1995;333:1618.
Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336(4):243-50.
Ewig S, De roux A, Bauer T, Garcia E, Mensa J, Niederman M, et al. Validation of predictive rules and indices of severity for community acquired pneumonia. Thorax. 2004;59(5):421-7.
Lim WS, van der Erden MM, Laing R, Boersma WG, Karalus N, Town GI, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377-82.
National Centre for Health Statistics, Health United States, 2006, with chart book on trends in the health of Americans: http://www.cdc.gov/ nchs/ data/ hus/ hus06.pdf. Accessed 17 January 2007.
Lim WS, Lewis S, Macfarlane JT. Severity prediction rules in community-acquired pneumonia: a validation study. Thorax 2000;55:219–223.
Neill AM, Martin IR, Weir R, Anderson R, Chereshsky A, Epton MJ, et al. Community-acquired pneumonia: aetiology and usefulness of severity criteria on admission. Thorax. 1996;51:1010-6.
Restrepo MI, Mortensen EM, Pugh JA, Anzueto A. COPD is associated with increased mortality in patients with community-acquired pneumonia. Eur Respir J. 2006;28:346-51.
Querol-Ribelles JM, Tenias JM, Grau E, Querol-Borras JM, Climent JL, Gomez E, et al. Plasma d-dimer levels correlate with outcomes in patients with community acquired pneumonia. Chest. 2004; 126:1087-92.
Rello J, Rodriguez A, Torres A, Roig J, Sole-Violan J, Garnacho-Montero J, et al. Implications of COPD in patients admitted to the intensive care unit by community-acquired pneumonia. Eur Respir J. 2006;27(6):1210-6.
Falguera M, Pifarre R, Martin A, Sheikh A, Moreno A, et al. Etiology and outcome of community-acquired pneumonia in Patients With Diabetes Mellitus. Chest. 2005;128(5):3233-9.
Moine P, Vercken JB, Chevret S, Chastang C, Gajdos P. Severe community acquired pneumonia. Etiology, epidemiology, and prognosis factors. french study group for community-acquired pneumonia in the intensive care unit. Chest. 1994;105:1487-95.
Díaz A, Alvarez M, Callejas C, Rosso R, Schnettler K, Saldías F. Clinical picture and prognostic factors for severe community-acquired pneumonia in adults admitted to the intensive care unit. Arch Bronconeumol. 2005;41(1):20-6.
Lim WS, Macfarlane JT. Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax. 2001;56:296-301.
Ishida T, Hashimoto T, Arita M, Ito I, Osawa M. Etiology of community acquired pneumonia in hospitalized patients. Chest. 1998;114(6):1588-93.
Buising KL1, Thursky KA, Black JF, MacGregor L, Street AC, Kennedy MP, et al. A prospective comparison of severity scores for identifying patients with severe community acquired pneumonia: reconsidering what is meant by severe pneumonia. Thorax. 2006;61(5):419-24.
Capelastegui A, Espana PP, Quintana JM, Areitio I, Gorordo I, Egurrola M, et al. Validation of a predictive rule for the management of community-acquired pneumonia. Eur Respir J. 2006;27(1):151-7.
Man SY, Nelson Lee, Margaret Ip, Antonio GE, Chau SSL, Mak P, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax. 2007;62(4):348-53.