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Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia
EJCCM 35 5 November 2015 The Egyptian Journal of Critical Care Medicine (2015) xxx, xxx–xxx
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The Egyptian College of Critical Care Physicians
The Egyptian Journal of Critical Care Medicine http://ees.elsevier.com/ejccm www.sciencedirect.com
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ORIGINAL ARTICLE
Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia Safwat A.M. Eldaboosy a, Khalid M. Halima a, Ahmad T. Shaarawy a, Hatim M. Kanany b,*, Eman M. Elgamal c, Abdel-Aleem El-Gendi d, Mohamed O. Nour e, Usama G. Abuelhassan f, Hessa A. Alshamery g a
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Department of Chest Diseases, Al Azhar Faculty of Medicine, Egypt Department of Anesthesia and Critical Care, Al Azhar Faculty of Medicine, Egypt c Department of Internal Medicine, Al Azhar Faculty of Medicine for Girls, Egypt d Department of Clinical Pathology, Al Azhar Faculty of Medicine, Egypt e Department of Community Medicine & Occupational Medicine, Al Azhar Faculty of Medicine, Damietta Branch, Egypt f Department of Chest Diseases, Kasr Alainy Faculty of Medicine, Cairo University, Egypt g Department of Internal medicine, King Khalid Hospital, Hail, Saudi Arabia
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Received 10 May 2015; revised 6 October 2015; accepted 13 October 2015
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b
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KEYWORDS
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SIPF; CURB-65; PSI; Community-acquired pneumonia
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Abstract Objective: To compare the prognostic value of the SIPF (shock index and hypoxemia) score as the combination of shock index (heart rate/systolic blood pressure) >0.7 (1 point) plus PaO2/FiO2 < 250 (1 point), and the severity score for community-acquired pneumonia (CAP) (CURB-65) and pneumonia severity index (PSI) in predicting the need for ICU admission and mortality of patients with community-acquired pneumonia. Patients and methods: This retrospective study was conducted on patients with CAP admitted to AL-Hussein University hospital (Egypt), Muhayl general hospital and King Khalid hospital at Hail, (KSA). The information required for calculating SIPF, PSI and CURB-65 was extracted from the medical records. Results: We studied 100 patients with community-acquired pneumonia (64 men, 36 women). Thirty-four patients needed ICU admission (while 66 did not need ICU admission and admitted in observation room or general ward) and among the ICU patients 21 cases needed mechanical ventilation. Ten cases died; 9 cases in ICU and one case in observation room (ward). The ability to
* Corresponding author. Peer review under responsibility of The Egyptian College of Critical Care Physicians.
Production and hosting by Elsevier http://dx.doi.org/10.1016/j.ejccm.2015.10.001 2090-7303 Ó 2015 Production and hosting by Elsevier B.V. The Egyptian College of Critical Care Physicians. Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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S.A.M. Eldaboosy et al. predict ICU admission was higher for SIPF score compared to CURB-65 (AUC SIPF 0.88 vs. 0.83; p < 0.001) and PSI (AUC SIPF 0.88 vs. 0.79; p < 0.001). The ability to predict mortality was higher for SIPF score compared to CURB-65(AUC SIPF 0.80 vs. 0.84; p < 0.001) and PSI (AUC SIPF 0.80 vs. 0.83; p < 0.001). Conclusion: The ability of SIPF score to predict ICU admission in CAP is higher than that of CURB-65 and PSI. Simple SIPF score could be a useful tool to predict mortality in CAP.
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Ó 2015 Production and hosting by Elsevier B.V. The Egyptian College of Critical Care Physicians.
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1. Introduction
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Community-acquired pneumonia (CAP) is a complex and evolving inflammatory disease and critical clinical deterioration can result from various processes: respiratory failure, circulatory failure, de-stabilization of a preexisting comorbidity, appropriateness of initial antibiotic therapy, or hospitalacquired illnesses. It is not surprising that no single clinical rule has sufficient operating characteristics to be useful in this wide spectrum of evolution profiles [12]. CAP represents an important therapeutic challenge to physicians, as they have to decide whether the patient is to be treated as outpatient or needs hospital admission. Therefore, it is crucial to assess the severity of the disease, as it forms a starting point in the management algorithm and helps in achieving favorable patient outcomes [13]. Several scoring systems are available to help clinicians assess the severity of the illness. While clinical judgment can vary from person to person and place to place, objective assessment based on scoring systems would probably remain the same across the board. Hence, this helps to standardize the criteria required to judge the severity of CAP [1]. The guidelines help in both severity assessment and rationale for antibiotics use. Different regions have adopted differ-
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ent guidelines for the management of CAP. The pneumonia severity index (PSI) is adopted by the American Thoracic Society and used in a wide scale in North America, which was introduced in 1997, by Fine et al. as a product of the pneumonia PORT study of ambulatory and hospitalized patients with CAP. The rule was to stratify patients into five classes of risk for death within 30 days of presentation. The lowest risk class (risk class I) comprises patients who are younger than 50 years of age, have none of the five important coexisting illnesses and have normal mental status and normal or only mildly abnormal vital signs at presentation. Assignment to the remaining risk classes depends on the presence or absence of a set of medical history, physical examination, and laboratory findings. Total point scores of 70 or less correspond to class II, 71–90 to class III, 91–130 to class IV, and more than 130 to class V. Mortality rates in risk classes I, II, and III are low (0.1– 0.4% in class I and 0.9–2.8% in class III), with correspondingly higher mortality rates in risk classes IV and V. The cumulative mortality rate of patients in risk classes I–III is less than one percent (see Diagrams 1 and 2). Pneumonia severity index (PSI):
Patient Characteristics Demographics Age (years):
Male: age Female: age Nursing home resident
Co-morbidities Neoplastic disease Liver disease Congestive heart failure Cerebrovascular disease Renal disease Examination findings Altered mental status Respiratory rate 330/minute Systolic blood pressure <90 mmHg Temperature <35 °C or 340°C Pulse 3125/minute
Diagram 1 ROC curve for different prediction scores for ICU admission in severe community-acquired pneumonia.
Laboratory findings pH <7.35 (do ABG only if hypoxic or COPD) BUN >10.7 mmol/L Sodium <130 mEq/L Glucose 313.9 mmol/L Hematocrit <0.30 PaO2 <60 mmHg or oxygen saturation <90% Pleural effusion
Points
60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 86 84 87 88 89 90
– – +10
91 92 93 94 95 96 97 98 99
+30 +20 +10 +10 +10
100 101 102 103 104 105 106 107 108 109 110 111 112
+20 +20 +20 +15 +10
113 114 115 116 117 118 119 120 121 122 123 124 125
+30 +20 +20 +10 +10 +10 +30
Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission
Diagram 2
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ROC curve for different prediction scores for mortality in severe community-acquired pneumonia.
Risk
Class
Score
Low Low Low Medium High
I II III IV V
<51 51–70 71–90 90–130 130
pressure normal:0.5–0.7 and if it is>0.7 it is considered abnormal and means presence of shock. It is identified as being atrisk for severe sepsis on initial presentation, before any laboratory testing is performed. Also the alteration of PaO2/FiO2 ratio, if less than 250 will mean presence of hypoxemia (see Tables 1–5). SIPF = {Shock Index (heart rate/systolic blood pressure) >0.7 + PaO2/FiO2 < 250}.
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Fine et al. [9]. The British Thoracic Society (BTS) in 2004 adopted CURB-65 as a guideline for managing CAP. The CURB-65 is a six-point scoring system (0–5) based on both clinical and laboratory parameters (confusion, serum urea, respiratory rate, blood pressure, and age >65 years) for assessing patients. CURB-65 score:
Confusion Blood urea >7 mmol/L at the time of admission Respiratory rate of P30/minute Systolic BP 690 mmHg or diastolic BP 660 mmHg Age P65 years A score of 1 is given for presence of each of the variables BP = blood pressure
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Man et al. [11]. Physiological score SIPF (shock index and hypoxemia) (SIPF) score: as the combination of shock index (heart rate/ systolic blood pressure) >0.7 (=1 point) plus PaO2/ FiO2 < 250 (=1 point), scoring 0–2 points. Shock index emphasizes current physiologic dynamics, rather than static criteria. Shock index is defined as heart rate/systolic blood
Heart rate/Systolic blood pressure >0.7
1 point
PaO2/FiO2 < 250
1 point 188
Sanz et al. [3,4].
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Aim of the work
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To compare the prognostic value of the two point simple SIPF (shock index and hypoxemia) score and the two other widely used severity scores for community-acquired pneumonia (CURB-65 and PSI) in predicting the need for ICU admission and prediction of mortality for community-acquired pneumonia patients (see Tables 6–10).
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Patients and methods
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In this study, medical records of 100 patients diagnosed as having community acquired pneumonia (CAP) were reviewed. They were selected from the departments of chest diseases, AL-Hussein University hospital- (Egypt), Muhayl general hospital and King Khalid hospital at Hail (Kingdom of Saudi Arabia) in the period between June 2013 and December
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Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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S.A.M. Eldaboosy et al. Table 1 Descriptive statistics of the studied patients at admission.
Table 3
Relation between comorbidities and PSI score.
PSI score
Comorbidities
p-value
Variables
ICU admitted group (N = 34)
Non ICU admitted group (N = 66)
Age (yrs)1 Gender2
56.0 ± 25.2 22 (64.7%) 12 (35.3%) 9 (26.5%) 25 (73.5%)
48.8 ± 17.5 39 (59.1%) 27 (40.9%) 22 (33.3%) 44 (66.7%)
13.6 ± 1.7 117.1 ± 21.8 37.7 ± 5.1 111.6 ± 21.8
14.9 ± 0.4 101.0 ± 15.1 27.0 ± 6.1 133.0 ± 21.2
<0.001 <0.001 <0.001 <0.001
64.4 ± 8.4
73.7 ± 12.2
<0.001
Table 4 Comparison between ICU and non ICU admitted groups regarding PSI class.
29 (85.3%) 5 (14.7%) 14.4 ± 5.4 11.7 ± 2.4 212.0 ± 86.3 1.9 ± 1.0 56.0 ± 29.8 3.6 ± 0.7 7.35 ± 0.05 37.5 ± 12.3 50.2 ± 7.5 230.6 ± 44.8 21.1 ± 4.0 32 (94.1%)
10 (15.2%) 56 (84.8%) 13.5 ± 4.5 12.7 ± 2.1 247.3 ± 107.7 1.4 ± 0.9 38.0 ± 17.6 4.3 ± 0.6 7.37 ± 0.03 35.6 ± 5.1 64.8 ± 8.3 307.2 ± 39.1 22.9 ± 2.5 29 (43.9%)
<0.001
PSI score
2 (5.9%)
37 (56.1%)
Smoking habit 2
Males Females Smoker Nonsmoker
GCS Pulse (beats/min) RR (breaths/min) Systolic Bl. P (mmHg) Diastolic Bl. P (mmHg) Cyanosis Present Absent WBCs (cells/mm3) HB (gm/dl) Platelets (cells/mm3) Creatinine (mg/dl) Urea (mg/dl) Albumin (mg/dl) PH PaCO2 (mmHg) PaO2 (mmHg) PaO2%FiO2 HCO3 (mEq/L) Multi-lobar pneumonia Lobar pneumonia
p-value
0.099 0.668 0.649
0.373 0.035 0.101 0.012 <0.001 <0.001 0.036 0.287 <0.001 <0.001 0.008 <0.001
I II III IV V
Present (n = 70) Mean ± SD
Absent (n = 30) Mean ± SD
36.4 ± 10.6 63.8 ± 6.5 85.7 ± 11.3 112.7 ± 13.1 168.3 ± 26.9
37.8 ± 9.0 63.7 ± 6.4 75.0 – 190.0
0.840 0.969 0.221 0.098
Values presented as mean ± SD and analyzed by Mann–Whitney U test.
I II III IV V Mean ± SD
ICU admission
p-value
Yes (n = 34)
No (n = 66)
No.
No.
%
3 8.8 4 11.8 4 11.8 12 35.3 11 32.4 119.88 ± 50.3
%
30 45.4 16 24.2 9 13.6 5 7.6 6 9.1 65.95 ± 37.8
<0.0011
<0.0012
1 Values presented as number & % and analyzed by Chi-square test. 2 Values presented as mean ± SD and analyzed by Independent samples t test.
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Values presented as mean ± SD and analyzed by Independent samples t test. 2 Values presented as number and % and analyzed by Fisher’s exact test.
Table 5 Comparison between ICU and non ICU admitted groups regarding PSI score. PSI score
Table 2 Distribution of comorbidities between ICU and non ICU admitted cases. Comorbidities
ICU admission Yes (n = 34)
Present Absent
p-value No (n = 66)
No.
%
No.
%
30 4
88.2 11.8
40 26
60.6 39.4
0.003
I II III IV V
ICU admission
p-value
Yes (n = 34) Mean ± SD
No (n = 66) Mean ± SD
38.0 ± 13.1 65.0 ± 6.4 92.5 ± 16.6 112.2 ± 11.8 180.4 ± 21.1
37.2 ± 9.4 63.5 ± 6.5 81.4 ± 6.5 113.8 ± 17.3 153.3 ± 27.1
0.975 0.737 0.182 0.833 0.037
Values presented as mean ± SD and analyzed by Mann–Whitney U test.
Values presented as number & % and analyzed by Fisher’s exact test.
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2014. Community acquired pneumonia was defined as the presence of new shadowing on admission chest X-ray and clinical features consistent with pneumonia (e.g., cough, sputum expectoration, shortness of breath, and pleuritic chest pain with or without fever). Only patients in whom CAP was the main reason for admission were included. The following data were obtained from medical records: complete medical history and physical examination, plain chest x ray (postero-anterior and lateral views), CT scanning of the chest, blood count, erythrocyte sedimentation rate (ESR), liver function tests, renal function tests, bleeding profile
(prothrombin time and concentration), and arterial blood gases (ABG). Data from routine sputum smears examination for Grams stain and culture and PCR for viral detection in selected cases were also obtained from medical records.
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Study protocol
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Based on clinical judgment of the attending physician, all cases were admitted in the hospital either in wards (observation rooms) or in ICU. Five cases were admitted first to the observation room in the ward but within 48 h they were shifted to
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Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission Table 6
Comparison between the two groups regarding CURB-65 score. ICU group (n = 34)
Ward group (n = 66)
p-value
CURB-65
2.5 ± 1.4 [(MV = 21) 2.67 ± 1.46]
0.9 ± 1.0
<0.0011
Ward 30 (45.5%) 23 (34.8%) 9 (13.6%) 2 (3.0%) 1 (1.5%) 1 (1.5%)
<0.0012
Score Score Score Score Score Score
ICU 1 (2.9%) 10 (29.4%) 6 (17.6%) 8 (23.5%) 6 (17.6%) 3 (8.8%)
1 2
(0) (1) (2) (3) (4) (5)
[MV(n = 21)] 1 (4.8%) 5 (23.8%) 3 (14.3%) 5 (23.8%) 5 (23.8%) 2 (9.5%)
Values presented as mean ± SD and analyzed by Independent samples t test. Values presented as number & % and analyzed by Chi-square t test.
Table 7
Comparison between both groups regarding SIPF score. ICU Group (n = 34)
SIPF Score (0) Score (1) Score (2) 1 2
ICU
MV (n = 21)
1.7 ± 0.5 1 (2.9%) 8 (23.5%) 25 (73.5%)
1.81 ± 0.40 0 (0%) 4 (19%) 17 (81%)
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Statistical analysis
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Statistical analysis was carried out using the SPSS computer package version 17.0 (SPSS Inc., Chicago, IL, USA). The mean ± SD were used for quantitative variables while number and% were used for qualitative variables. In order to assess the differences in frequency of qualitative variables Chi-square test (v2) or Fisher’s exact test (FET) was applied when appropriate. In order to assess differences in means of quantitative variables Independent samples t-test was applied while Mann–Whitney test was used for non-parametric statistics. To determine the ability of different scores to predict ICU admission or mortality, ROC curve was generated. The statistical methods were verified, assuming a significance level of p < 0.05 and a highly significance level of p < 0.001.
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Results
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From one hundred patients with CAP included in this study, 34 patients were admitted to ICU and 66 patients were admitted to the ward according to clinical judgment of the attending physician. Only 5 patients were admitted first to the observation room but within the next 48 h were shifted to the ICU. Twenty-one patients needed mechanical ventilation and 9 (9%) patients died (8 in ICU and one in the observation room
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Non-ICU group (n = 66)
p-value
0.7 ± 0.5 22 (33.3%) 41 (62.1%) 3 (4.5%)
<0.0011 <0.0012
Values presented as mean ± SD and analyzed by independent samples t test. Values presented as number & % and analyzed by Chi-square test.
ICU because there was no available ICU bed at time of admission. A questionnaire including the demographic data, clinical, para-clinical and imaging findings of the patients was completed for each patient. SIPF, PSI and CURB-65 scores were calculated for each patient. The prediction of mortality and the need for ICU stay were compared according to the calculated SIPF, PSI and CURB-65.
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in the ward). The mean age in the ICU group was 56.0 ± 25.2 years and 48.8 ± 17.5 years in the ward group, with a statistically significant difference between the two groups. As regards gender, the ICU group comprised 22 (64.7%) males and 12 (35.3%) females while in the ward group 39 (59.1%) were males and 27 (40.9%) were females, with no statistically significant difference between the two groups. As regards clinical parameters on admission there was a statistically significant difference between the two groups in all the parameters, GCS, heart rate, respiratory, systolic and diastolic blood pressures. As regards laboratory parameters on admission there was a statistically significant difference between the two groups except in WBC count and Paco2. As regards CXR findings, recorded as lobar or multi-lobar consolidation there was a statistically significant difference between the two groups. As regards comorbidities in the form of old age, diabetes mellitus, old cerebral insult, renal impairment and/or heart failure there was a statistically significant difference between the two groups. As regards comorbidities in relation to PSI score there was no statistically significant difference within each class. As regard PSI class there was a statistically significant difference between the two groups as PSI class was higher in the ICU admitted group than the non-ICU admitted group. Most cases admitted to ICU were in the classes IV and V 23/34 (67%), and most cases admitted to the ward were in the classes I and II 46/66 (69%). As regards PSI score in relation to ICU admission there was a statistically significant difference between the two groups only in class V which was higher in the ICU admitted group (mean 180.4 ± 21.1) than in the non-ICU admitted group (mean 153.3 ± 27.1).
Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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S.A.M. Eldaboosy et al. Table 8
Comparison between survivors and non-survivors as regards other parameters. FET#/t
Non-survivor (n = 10)
Survivor (n = 90)
Gender Male Female Age [Mean ± SD]
5 (55.6%) 5(55.6%) 60.4 ± 27.5
55 (61.1%) 35 (38.9%) 50.4 ± 19.9
0.106#
0.745
1.397
0.166
Comorbidity Present Absent PH. [Mean ± SD] PaO2 [Mean ± SD] (mmHg) Pulse [Mean ± SD] (beats/min) GCS [Mean ± SD] Systolic blood pressure [Mean ± SD] (mmHg) Diastolic blood pressure [Mean ± SD] (mmHg) Urea [Mean ± SD] (mg/dl) RR [Mean ± SD] (breaths/m) Hb. [Mean ± SD] (gm/dl) PSI [Mean ± SD] SIPF CURB-65
9 (90%) 1 (10%) 7.4 ± 0.1 45.4 ± 4.7 112.2 ± 24.9 13.0 ± 2.1 110.0 ± 25.0 62.2 ± 9.4 58.3 ± 15.6 39.6 ± 3.7 10.9 ± 1.8 4.3 ± 0.7 1.78 ± 0.44 3.11 ± 1.27
61 (67.8%) 29 (32.2%) 7.4 ± 0.0 61.2 ± 9.9 105.9 ± 18.7 14.6 ± 1.0 126.9 ± 22.9 71.0 ± 11.5 42.9 ± 24.3 29.9 ± 7.3 12.5 ± 2.3 2.5 ± 1.5 1.83 ± 0.39 2.33 ± 1.56
1.727#
0.189
#
0.105 4.686 0.938 4.189 2.101 2.227 1.869 3.862 2.080 3.703 0.306 1.222
p-value
0.917 <0.001 0.350 <0.001 0.038 0.028 0.065 <0.001 0.040 <0.001 0.763 0.236
FET: Fisher exact test; t-independent sample t-test. p-Value <0.05 S; p-value <0.001 HS.
Table 9
Different prediction scores for ICU admission in severe community-acquired pneumonia.
Scores
Cutoff values
Sensitivity (%)
Specificity (%)
ROC (AUC) (95% CI)
p-value
CURB-65 SIPF PSI
>0.5 >0.5 >1.5
97.1 97.1 91.2
45.5 33.3 45.5
0.83 (0.75–0.91) 0.88 (0.80–0.95) 0.79 (0.70–0.89)
<0.001 <0.001 <0.001
Table 10
Different prediction scores for mortality in severe community-acquired pneumonia.
Scores
Cutoff values
Sensitivity (%)
Specificity (%)
ROC (AUC) (95% CI)
p-value
CURB-65 SIPF PSI
>1.5 >1.5 >2.5
90.0 90.0 90.0
70.0 79.9 58.8
0.81 (0.66–0.96) 0.86 (0.76–0.95) 0.80 (0.65–0.95)
0.001 <0.001 0.002
The ability to predict mortality was higher for SIPF score at cutoff value of >1.5 compared to PSI (AUC SIPF 0.86 vs. PSI 0.80; p < 0.001) and CURB-65 (AUC SIPF 0.86 vs. 0.81; p < 0.001).
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There was a statistically significant difference between the two groups regarding CURB-65 score which was higher for the ICU group with a mean of 2.5 + 1.4 while it was lower in the ward group with a mean of 0.9 + 1.0. As 70% (24/34) of cases admitted to ICU were in the classes 1–3, 80% (53/66) of cases admitted to the ward were in the classes 0–1. SIPF score was higher in the ICU admitted group (mean 1.7 ± 0.5) than in the non-ICU group (mean 0.7 ± 0.5). Most cases admitted to ICU had a SIPF score of (2) 25/34 (73.5%). Most cases admitted to the ward had a SIPF score of (0 or 1) 63/66 (95.4%). Also within the ICU admitted group those who were mechanically ventilated (n = 21) had a higher SIPF score with a high statistically significant difference. This table shows a statistically significant difference between groups as regards PaO2, GCS, systolic blood pressure, diastolic blood pressure, RR, Hb. and PSI. PSI was higher in non-survived patients (4.3 ± 0.7) than survived (2.5 ± 1.5)
with p-value (<0.001) but no significant difference between the two groups as regards CURB-65 and SIPF was found. Definition of abbreviations: CURB-65 = confusion, BUN > 7 mmol/l, respiratory rate > 30, systolic blood pressure < 90 mmHg and age > 65; SIPF = shock index (heart rate/systolic blood pressure) > 0.7 plus PaO2/ FiO2 < 250; PSI = pneumonia severity index; ROC = receiver operator characteristic; AUC = area under the curve; CI = confidence interval. The ability to predict ICU admission was higher for SIPF score at cutoff value of >0.5 compared to PSI (AUC SIPF 0.88 vs. PSI 0.79; p < 0.001) and CURB-65 (AUC SIPF 0.88 vs. 0.83; p < 0.001).
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Discussion
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The majority of admissions in cases of CAP to the ICU occur within the first 24 h of admission in the hospital. Delayed
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transfer to the ICU is associated with increased mortality, and therefore early recognition of these patients is important. PSI and CURB-65 don’t have sufficient operating characteristics to be useful for making ICU triage decisions in severe CAP [6]. In this study 100 CAP patients were recruited from 3 different tertiary hospitals in 2 countries, 34% of patients were admitted to ICU and 66% were admitted to the ward. This is in agreement with [14] who found that about 36% of CAP patients necessitated ICU care. Comorbidities in the form of old age, high blood sugar, old cerebral insult, renal impairment and heart failure were present in 88.2% in the ICU group and in 60.6% in the ward group. The BTS guidelines illustrated the importance of pre-existing comorbidities, including chronic obstructive pulmonary diseases (COPD; 32%), asthma (13%), and cardiac disease (15%). Other significant conditions include diabetes, chronic liver diseases, chronic renal failure, immunosuppression, and alcoholism. The incidence of severe CAP and adverse events increases with age. For example, 90% of pneumonia deaths occurred in patients over the age of 70. Marti and coworkers, 2012 in a meta-analysis found 10–20% of CAP is admitted to the intensive care unit. In this study ICU admitted patients had lower GCS, higher heart rate, higher respiratory rate, lower systolic and diastolic blood pressures, higher levels of serum creatinine and urea, lower PaO2 and PaO2%FiO2 and multilobar radiographic appearances than ward patients. [15] reported older age, respiratory rate >20bpm, nursing home residence, chronic pulmonary disease, diabetes, and multilobar CAP were independently associated with longer stay in ICU. Liapikou and coworkers [10] found the patients who were admitted to the ICU were younger; more likely to have a smoking history, had worse oxygenation; had higher PSI and CURB-65 risk classes compared with patients who were not admitted to the ICU. In this study CURB-65 was higher in the ICU admitted group (mean 2.5 ± 1.4) than in the ward group (mean 0.9 ± 1.0) with 97% sensitivity, 45.5% specificity and AUC 0.83. In the meta-analysis done by Marti and coworkers 2012, patients with CURB-65 of 3 or more were admitted to ICU, with a pooled sensitivity of 56%, and specificity, of 74% while Mene´ndez and coworkers [2] reported that CAP patients with CURB-65 more than or equal 2 or if there were multilobar and/or bilateral radiographic involvement or a SpO2 < 92% would also be criteria to send the patient to the hospital and need for ICU admission. In this study, PSI total sensitivity was 91.5% and specificity was 45.5% and AUC 0.79. Mbata and coworkers [13] found the global performance of PSI to predict ICU admission was modest, with an AUC of 0.69 with a pooled sensitivity of 92.4% (CI, 89–95) and specificity of 56.2% (CI, 43–69) in four cohorts including 3,195 patients and significant heterogeneity was present. Sanz and co-workers [3] modified shock index if heart rate/ systolic BP more than 0.7 = 1 score. In this study the ability to predict ICU admission was higher for SIPF score compared to PSI (AUC SIPF 0.88 vs. PSI 0.79) and CURB-65 (AUC SIPF 0.88 vs. 0.83). Sanz and co-workers [3] analyzed 1090 CAP patients from whom 54% (589 cases) showed PSI score IV-V, 462 (42.4%) with CURB-65 score equal to or more than 2, 149 (13.7%) scored 3 or more of the American Thoracic society and Infectious diseases society of America (ATS/IDSA) minor criteria, and 16.9% (184) rated 2 points in SIPF score. The ability to predict
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ICU admission was higher for SIPF score compared to PSI (AUC SIPF 0.735 vs. PSI 0.618) and CURB-65 (AUC SIPF 0.735 vs. 0.573) and similar to ATS/IDSA minor criteria (AUC SIPF 0.735 vs. 0.720; 0.636). Other studies have evaluated PSI and CURB-65 for their predictive accuracy for the major ATS criteria of need for mechanical ventilation, or presence of septic shock with need for vasopressors. These outcomes appear to be more robust measures. One disadvantage of both PSI and CURB65 was their reliance on laboratory investigations for calculation which limits their use by health care professionals in the community [5]. The mortality rate in this study was 10% and mortality was higher in the elderly and patients with comorbidities. Those patients who died had lower PaO2, GCS, systolic blood pressure, and diastolic blood pressure, RR, Hb and PSI. PSI was higher in non-survived patients (4.3 ± 0.7) than survived (2.5 ± 1.5). The ability to predict mortality was higher for SIPF score at cutoff value of >1.5 compared to PSI (AUC SIPF 0.86 vs. PSI 0.80) and CURB-65 (AUC SIPF 0.86 vs. 0.81). Mbata et al. [13] found mortality rate was 15% and found both CURB-65 and CRB-65 can be applied in the community setting to augment clinical judgment regarding the need for hospital admission but did not appear to be useful for identifying patients requiring ICU care because of their low specificities and low positive predictive values due to disease severity is not the only factor to consider; premorbid status, age of patient, and availability of the resources are all considered by ICU physicians before admitting a patient into ICU. Alavi-Moghaddam et al. [1] found that CURB-65 had better accuracy in predicting mortality and the need for ICU admission among patients with CAP. While CURB-65 had a high sensitivity in predicting mortality and need for ICU admission, PSI was shown to have a high specificity in this regard. Alavi-Moghaddam et al. [1] reported also mortality increased with age, presence of underlying heart failure, high blood levels of urea, pH lower than 7.35, and decreased consciousness level. Man et al. [11] used the ROC curves to assess 30 day mortality for each prediction scoring method PSI, CRB-65, and CURB-65. They found no significant difference in the area under the ROC curves for each of the PSI 0.728 (95% CI 0.662–0.793), CURB-65 0.713 (95% CI 0.639–0.788) and CRB-65 0.654 (95% CI 0.572–0.736) and no significant differences were found between PSI, CURB65 and CRB65 in predicting 30 day mortality. Marti et al. [12] in a systematic review of clinical prediction rules to predict severe CAP, PSI and CURB-65 found similar performances to identify patients requiring ICU admission. A PSI class of IV or more is more sensitive (75% vs. 56%) but less specific (47% vs. 74%) than a CURB-65 score of 3 or more. These two scores, derived and validated to predict 30day mortality, perform poorly to predict ICU admission, with an estimated AUC of 0.80. Sanz et al. [3] found mortality rate to be 5.4% and no difference was found regarding the ability to predict mortality between the 4 different scores (AUC: PSI 0.716: CURB-65 0.679: ATS/IDSA minor criteria 0.670 m, SIPF score 0.707: p 0.05). Our study had its limitations as it was retrospective and included a small number of patients which will not make it
Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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easy to give firm conclusions, so it is recommended to do prospective studies on a large scale to confirm our study results. Conclusions – The ability of SIPF score to predict ICU admission in CAP is higher than that of CURB-65 and PSI. – The simple SIPF score could be a useful tool to predict ICU admission and mortality in CAP.
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[7,8].
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References [1] Alavi-Moghaddam M, Bakhshi H, Rezaei B, Khashayar P. Pneumonia severity index compared to CURB-65 in predicting the outcome of community acquired pneumonia among patients referred to an Iranian emergency department: a prospective survey. Braz J Infect Dis 2013;17(2):179–83. [2] Mene´ndez R, Torres A, Aspa J, Capelastegui A, Prat C, eand Rodrı´ guez de Castro F: SEPAR Guidelines. CommunityAcquired Pneumonia. New Guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR); Arch Bronconeumol., 2010; 46(10):543–558. [3] Sanz FH, Ferna´ndez-Fabrellas E, Chiner E, Briones ML, Cervera A, Aguar MC, Lera R, Lera R, Sancho-Chust, et al. Physiological score SIPF (shock index and hypoxemia) is an accurate predictor of ICU admission in community-acquired pneumonia. Am J Respir Crit Care Med 2014;189:A4627. [4] Sanz F, Restrepo MR, Ferna´ndez EF, BrionesM L, Blanquer R, Eric MM, Chiner E, Blanquer J. Is it possible to predict which patients with mild pneumonias will develop hypoxemia? Respir Med 2009;103:1871e1877. [5] Singannayagam A, Chalmers JD, Hill AT. Severity assessment in community-acquired pneumonia: a review. Q J Med 2009;102:379–88.
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S.A.M. Eldaboosy et al. [6] Chalmers JD. ICU admission and severity assessment in community-acquired pneumonia. Queens Medical Research Institute, Centre for Inflammation Research, Little France, Edinburgh EH16 4TJ, UK. Crit Care 2009;13:156. [7] Curtain JP, Sankaran P, Kamath AV, Myint PK. The usefulness of confusion, urea, respiratory rate, and shock index or adjusted shock index criteria in predicting combined mortality and/or ICU admission compared to CURB-65 in community-acquired pneumonia. Hindawi Publishing Corporation BioMed Research International Volume 2013, Article ID 590407. p. 6. doi: 10.1155/2013/ 590407. [8] Ewig S, Walter T. CRB-65 for assessment of pneumonia severity. Who could ask for more? Thorax 2008;63, 665–6. [9] Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243–50. [10] Liapikou A, Ferrer M, Polverino E, Balasso V, Esperatti M, Piner R, Mensa J, Luque N, Ewig S, Menendez R, et al. Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission. Clin Infect Dis 2009;48:377–85. [11] Man SY, Lee N, Ip M, Antonio GE, Chau SS, Mak P, Graham CA, Zhang M, Lui G, Chan PK, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax 2007;62:348–53. [12] Marti C, Garin N, Grosgurin O, Poncet A, Combescure C, Carballo S, Perrier. A prediction of severe community-acquired pneumonia: a systematic review and meta-analysis. Crit Care 2012;16:R141. [13] Mbata GC, Chukwuka CJ, Onyedum CC, Onwubere BJC, Aguwa EN. Comparison of two predictive rules for assessing severity of community acquired pneumonia. Afr J Respir Med 2014;10(1). [14] Restrepo MI, Mortensen EM, Velez JA, Frei C, Anzueto A. A comparative study of community-acquired pneumonia patients admitted to the ward and the ICU. Chest 2008;133:610–7. [15] Suter-Widmer I, Christ-Crain M, Zimmerli W, Albrich W, Mueller B, Schuetz P. Predictors for length of hospital stay in patients with community-acquired pneumonia: results from a Swiss Multicenter study for the ProHOSP Study Group. BMC Pulmonary Med 2012;12:21.
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The Egyptian College of Critical Care Physicians
The Egyptian Journal of Critical Care Medicine http://ees.elsevier.com/ejccm www.sciencedirect.com
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ORIGINAL ARTICLE
Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia Safwat A.M. Eldaboosy a, Khalid M. Halima a, Ahmad T. Shaarawy a, Hatim M. Kanany b,*, Eman M. Elgamal c, Abdel-Aleem El-Gendi d, Mohamed O. Nour e, Usama G. Abuelhassan f, Hessa A. Alshamery g a
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Department of Chest Diseases, Al Azhar Faculty of Medicine, Egypt Department of Anesthesia and Critical Care, Al Azhar Faculty of Medicine, Egypt c Department of Internal Medicine, Al Azhar Faculty of Medicine for Girls, Egypt d Department of Clinical Pathology, Al Azhar Faculty of Medicine, Egypt e Department of Community Medicine & Occupational Medicine, Al Azhar Faculty of Medicine, Damietta Branch, Egypt f Department of Chest Diseases, Kasr Alainy Faculty of Medicine, Cairo University, Egypt g Department of Internal medicine, King Khalid Hospital, Hail, Saudi Arabia
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Received 10 May 2015; revised 6 October 2015; accepted 13 October 2015
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KEYWORDS
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SIPF; CURB-65; PSI; Community-acquired pneumonia
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Abstract Objective: To compare the prognostic value of the SIPF (shock index and hypoxemia) score as the combination of shock index (heart rate/systolic blood pressure) >0.7 (1 point) plus PaO2/FiO2 < 250 (1 point), and the severity score for community-acquired pneumonia (CAP) (CURB-65) and pneumonia severity index (PSI) in predicting the need for ICU admission and mortality of patients with community-acquired pneumonia. Patients and methods: This retrospective study was conducted on patients with CAP admitted to AL-Hussein University hospital (Egypt), Muhayl general hospital and King Khalid hospital at Hail, (KSA). The information required for calculating SIPF, PSI and CURB-65 was extracted from the medical records. Results: We studied 100 patients with community-acquired pneumonia (64 men, 36 women). Thirty-four patients needed ICU admission (while 66 did not need ICU admission and admitted in observation room or general ward) and among the ICU patients 21 cases needed mechanical ventilation. Ten cases died; 9 cases in ICU and one case in observation room (ward). The ability to
* Corresponding author. Peer review under responsibility of The Egyptian College of Critical Care Physicians.
Production and hosting by Elsevier http://dx.doi.org/10.1016/j.ejccm.2015.10.001 2090-7303 Ó 2015 Production and hosting by Elsevier B.V. The Egyptian College of Critical Care Physicians. Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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S.A.M. Eldaboosy et al. predict ICU admission was higher for SIPF score compared to CURB-65 (AUC SIPF 0.88 vs. 0.83; p < 0.001) and PSI (AUC SIPF 0.88 vs. 0.79; p < 0.001). The ability to predict mortality was higher for SIPF score compared to CURB-65(AUC SIPF 0.80 vs. 0.84; p < 0.001) and PSI (AUC SIPF 0.80 vs. 0.83; p < 0.001). Conclusion: The ability of SIPF score to predict ICU admission in CAP is higher than that of CURB-65 and PSI. Simple SIPF score could be a useful tool to predict mortality in CAP.
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Ó 2015 Production and hosting by Elsevier B.V. The Egyptian College of Critical Care Physicians.
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1. Introduction
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Community-acquired pneumonia (CAP) is a complex and evolving inflammatory disease and critical clinical deterioration can result from various processes: respiratory failure, circulatory failure, de-stabilization of a preexisting comorbidity, appropriateness of initial antibiotic therapy, or hospitalacquired illnesses. It is not surprising that no single clinical rule has sufficient operating characteristics to be useful in this wide spectrum of evolution profiles [12]. CAP represents an important therapeutic challenge to physicians, as they have to decide whether the patient is to be treated as outpatient or needs hospital admission. Therefore, it is crucial to assess the severity of the disease, as it forms a starting point in the management algorithm and helps in achieving favorable patient outcomes [13]. Several scoring systems are available to help clinicians assess the severity of the illness. While clinical judgment can vary from person to person and place to place, objective assessment based on scoring systems would probably remain the same across the board. Hence, this helps to standardize the criteria required to judge the severity of CAP [1]. The guidelines help in both severity assessment and rationale for antibiotics use. Different regions have adopted differ-
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ent guidelines for the management of CAP. The pneumonia severity index (PSI) is adopted by the American Thoracic Society and used in a wide scale in North America, which was introduced in 1997, by Fine et al. as a product of the pneumonia PORT study of ambulatory and hospitalized patients with CAP. The rule was to stratify patients into five classes of risk for death within 30 days of presentation. The lowest risk class (risk class I) comprises patients who are younger than 50 years of age, have none of the five important coexisting illnesses and have normal mental status and normal or only mildly abnormal vital signs at presentation. Assignment to the remaining risk classes depends on the presence or absence of a set of medical history, physical examination, and laboratory findings. Total point scores of 70 or less correspond to class II, 71–90 to class III, 91–130 to class IV, and more than 130 to class V. Mortality rates in risk classes I, II, and III are low (0.1– 0.4% in class I and 0.9–2.8% in class III), with correspondingly higher mortality rates in risk classes IV and V. The cumulative mortality rate of patients in risk classes I–III is less than one percent (see Diagrams 1 and 2). Pneumonia severity index (PSI):
Patient Characteristics Demographics Age (years):
Male: age Female: age Nursing home resident
Co-morbidities Neoplastic disease Liver disease Congestive heart failure Cerebrovascular disease Renal disease Examination findings Altered mental status Respiratory rate 330/minute Systolic blood pressure <90 mmHg Temperature <35 °C or 340°C Pulse 3125/minute
Diagram 1 ROC curve for different prediction scores for ICU admission in severe community-acquired pneumonia.
Laboratory findings pH <7.35 (do ABG only if hypoxic or COPD) BUN >10.7 mmol/L Sodium <130 mEq/L Glucose 313.9 mmol/L Hematocrit <0.30 PaO2 <60 mmHg or oxygen saturation <90% Pleural effusion
Points
60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 86 84 87 88 89 90
– – +10
91 92 93 94 95 96 97 98 99
+30 +20 +10 +10 +10
100 101 102 103 104 105 106 107 108 109 110 111 112
+20 +20 +20 +15 +10
113 114 115 116 117 118 119 120 121 122 123 124 125
+30 +20 +20 +10 +10 +10 +30
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Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission
Diagram 2
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ROC curve for different prediction scores for mortality in severe community-acquired pneumonia.
Risk
Class
Score
Low Low Low Medium High
I II III IV V
<51 51–70 71–90 90–130 130
pressure normal:0.5–0.7 and if it is>0.7 it is considered abnormal and means presence of shock. It is identified as being atrisk for severe sepsis on initial presentation, before any laboratory testing is performed. Also the alteration of PaO2/FiO2 ratio, if less than 250 will mean presence of hypoxemia (see Tables 1–5). SIPF = {Shock Index (heart rate/systolic blood pressure) >0.7 + PaO2/FiO2 < 250}.
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Fine et al. [9]. The British Thoracic Society (BTS) in 2004 adopted CURB-65 as a guideline for managing CAP. The CURB-65 is a six-point scoring system (0–5) based on both clinical and laboratory parameters (confusion, serum urea, respiratory rate, blood pressure, and age >65 years) for assessing patients. CURB-65 score:
Confusion Blood urea >7 mmol/L at the time of admission Respiratory rate of P30/minute Systolic BP 690 mmHg or diastolic BP 660 mmHg Age P65 years A score of 1 is given for presence of each of the variables BP = blood pressure
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Man et al. [11]. Physiological score SIPF (shock index and hypoxemia) (SIPF) score: as the combination of shock index (heart rate/ systolic blood pressure) >0.7 (=1 point) plus PaO2/ FiO2 < 250 (=1 point), scoring 0–2 points. Shock index emphasizes current physiologic dynamics, rather than static criteria. Shock index is defined as heart rate/systolic blood
Heart rate/Systolic blood pressure >0.7
1 point
PaO2/FiO2 < 250
1 point 188
Sanz et al. [3,4].
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Aim of the work
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To compare the prognostic value of the two point simple SIPF (shock index and hypoxemia) score and the two other widely used severity scores for community-acquired pneumonia (CURB-65 and PSI) in predicting the need for ICU admission and prediction of mortality for community-acquired pneumonia patients (see Tables 6–10).
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Patients and methods
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In this study, medical records of 100 patients diagnosed as having community acquired pneumonia (CAP) were reviewed. They were selected from the departments of chest diseases, AL-Hussein University hospital- (Egypt), Muhayl general hospital and King Khalid hospital at Hail (Kingdom of Saudi Arabia) in the period between June 2013 and December
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S.A.M. Eldaboosy et al. Table 1 Descriptive statistics of the studied patients at admission.
Table 3
Relation between comorbidities and PSI score.
PSI score
Comorbidities
p-value
Variables
ICU admitted group (N = 34)
Non ICU admitted group (N = 66)
Age (yrs)1 Gender2
56.0 ± 25.2 22 (64.7%) 12 (35.3%) 9 (26.5%) 25 (73.5%)
48.8 ± 17.5 39 (59.1%) 27 (40.9%) 22 (33.3%) 44 (66.7%)
13.6 ± 1.7 117.1 ± 21.8 37.7 ± 5.1 111.6 ± 21.8
14.9 ± 0.4 101.0 ± 15.1 27.0 ± 6.1 133.0 ± 21.2
<0.001 <0.001 <0.001 <0.001
64.4 ± 8.4
73.7 ± 12.2
<0.001
Table 4 Comparison between ICU and non ICU admitted groups regarding PSI class.
29 (85.3%) 5 (14.7%) 14.4 ± 5.4 11.7 ± 2.4 212.0 ± 86.3 1.9 ± 1.0 56.0 ± 29.8 3.6 ± 0.7 7.35 ± 0.05 37.5 ± 12.3 50.2 ± 7.5 230.6 ± 44.8 21.1 ± 4.0 32 (94.1%)
10 (15.2%) 56 (84.8%) 13.5 ± 4.5 12.7 ± 2.1 247.3 ± 107.7 1.4 ± 0.9 38.0 ± 17.6 4.3 ± 0.6 7.37 ± 0.03 35.6 ± 5.1 64.8 ± 8.3 307.2 ± 39.1 22.9 ± 2.5 29 (43.9%)
<0.001
PSI score
2 (5.9%)
37 (56.1%)
Smoking habit 2
Males Females Smoker Nonsmoker
GCS Pulse (beats/min) RR (breaths/min) Systolic Bl. P (mmHg) Diastolic Bl. P (mmHg) Cyanosis Present Absent WBCs (cells/mm3) HB (gm/dl) Platelets (cells/mm3) Creatinine (mg/dl) Urea (mg/dl) Albumin (mg/dl) PH PaCO2 (mmHg) PaO2 (mmHg) PaO2%FiO2 HCO3 (mEq/L) Multi-lobar pneumonia Lobar pneumonia
p-value
0.099 0.668 0.649
0.373 0.035 0.101 0.012 <0.001 <0.001 0.036 0.287 <0.001 <0.001 0.008 <0.001
I II III IV V
Present (n = 70) Mean ± SD
Absent (n = 30) Mean ± SD
36.4 ± 10.6 63.8 ± 6.5 85.7 ± 11.3 112.7 ± 13.1 168.3 ± 26.9
37.8 ± 9.0 63.7 ± 6.4 75.0 – 190.0
0.840 0.969 0.221 0.098
Values presented as mean ± SD and analyzed by Mann–Whitney U test.
I II III IV V Mean ± SD
ICU admission
p-value
Yes (n = 34)
No (n = 66)
No.
No.
%
3 8.8 4 11.8 4 11.8 12 35.3 11 32.4 119.88 ± 50.3
%
30 45.4 16 24.2 9 13.6 5 7.6 6 9.1 65.95 ± 37.8
<0.0011
<0.0012
1 Values presented as number & % and analyzed by Chi-square test. 2 Values presented as mean ± SD and analyzed by Independent samples t test.
1
Values presented as mean ± SD and analyzed by Independent samples t test. 2 Values presented as number and % and analyzed by Fisher’s exact test.
Table 5 Comparison between ICU and non ICU admitted groups regarding PSI score. PSI score
Table 2 Distribution of comorbidities between ICU and non ICU admitted cases. Comorbidities
ICU admission Yes (n = 34)
Present Absent
p-value No (n = 66)
No.
%
No.
%
30 4
88.2 11.8
40 26
60.6 39.4
0.003
I II III IV V
ICU admission
p-value
Yes (n = 34) Mean ± SD
No (n = 66) Mean ± SD
38.0 ± 13.1 65.0 ± 6.4 92.5 ± 16.6 112.2 ± 11.8 180.4 ± 21.1
37.2 ± 9.4 63.5 ± 6.5 81.4 ± 6.5 113.8 ± 17.3 153.3 ± 27.1
0.975 0.737 0.182 0.833 0.037
Values presented as mean ± SD and analyzed by Mann–Whitney U test.
Values presented as number & % and analyzed by Fisher’s exact test.
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2014. Community acquired pneumonia was defined as the presence of new shadowing on admission chest X-ray and clinical features consistent with pneumonia (e.g., cough, sputum expectoration, shortness of breath, and pleuritic chest pain with or without fever). Only patients in whom CAP was the main reason for admission were included. The following data were obtained from medical records: complete medical history and physical examination, plain chest x ray (postero-anterior and lateral views), CT scanning of the chest, blood count, erythrocyte sedimentation rate (ESR), liver function tests, renal function tests, bleeding profile
(prothrombin time and concentration), and arterial blood gases (ABG). Data from routine sputum smears examination for Grams stain and culture and PCR for viral detection in selected cases were also obtained from medical records.
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Study protocol
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Based on clinical judgment of the attending physician, all cases were admitted in the hospital either in wards (observation rooms) or in ICU. Five cases were admitted first to the observation room in the ward but within 48 h they were shifted to
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Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission Table 6
Comparison between the two groups regarding CURB-65 score. ICU group (n = 34)
Ward group (n = 66)
p-value
CURB-65
2.5 ± 1.4 [(MV = 21) 2.67 ± 1.46]
0.9 ± 1.0
<0.0011
Ward 30 (45.5%) 23 (34.8%) 9 (13.6%) 2 (3.0%) 1 (1.5%) 1 (1.5%)
<0.0012
Score Score Score Score Score Score
ICU 1 (2.9%) 10 (29.4%) 6 (17.6%) 8 (23.5%) 6 (17.6%) 3 (8.8%)
1 2
(0) (1) (2) (3) (4) (5)
[MV(n = 21)] 1 (4.8%) 5 (23.8%) 3 (14.3%) 5 (23.8%) 5 (23.8%) 2 (9.5%)
Values presented as mean ± SD and analyzed by Independent samples t test. Values presented as number & % and analyzed by Chi-square t test.
Table 7
Comparison between both groups regarding SIPF score. ICU Group (n = 34)
SIPF Score (0) Score (1) Score (2) 1 2
ICU
MV (n = 21)
1.7 ± 0.5 1 (2.9%) 8 (23.5%) 25 (73.5%)
1.81 ± 0.40 0 (0%) 4 (19%) 17 (81%)
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Statistical analysis
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Statistical analysis was carried out using the SPSS computer package version 17.0 (SPSS Inc., Chicago, IL, USA). The mean ± SD were used for quantitative variables while number and% were used for qualitative variables. In order to assess the differences in frequency of qualitative variables Chi-square test (v2) or Fisher’s exact test (FET) was applied when appropriate. In order to assess differences in means of quantitative variables Independent samples t-test was applied while Mann–Whitney test was used for non-parametric statistics. To determine the ability of different scores to predict ICU admission or mortality, ROC curve was generated. The statistical methods were verified, assuming a significance level of p < 0.05 and a highly significance level of p < 0.001.
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Results
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From one hundred patients with CAP included in this study, 34 patients were admitted to ICU and 66 patients were admitted to the ward according to clinical judgment of the attending physician. Only 5 patients were admitted first to the observation room but within the next 48 h were shifted to the ICU. Twenty-one patients needed mechanical ventilation and 9 (9%) patients died (8 in ICU and one in the observation room
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Non-ICU group (n = 66)
p-value
0.7 ± 0.5 22 (33.3%) 41 (62.1%) 3 (4.5%)
<0.0011 <0.0012
Values presented as mean ± SD and analyzed by independent samples t test. Values presented as number & % and analyzed by Chi-square test.
ICU because there was no available ICU bed at time of admission. A questionnaire including the demographic data, clinical, para-clinical and imaging findings of the patients was completed for each patient. SIPF, PSI and CURB-65 scores were calculated for each patient. The prediction of mortality and the need for ICU stay were compared according to the calculated SIPF, PSI and CURB-65.
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in the ward). The mean age in the ICU group was 56.0 ± 25.2 years and 48.8 ± 17.5 years in the ward group, with a statistically significant difference between the two groups. As regards gender, the ICU group comprised 22 (64.7%) males and 12 (35.3%) females while in the ward group 39 (59.1%) were males and 27 (40.9%) were females, with no statistically significant difference between the two groups. As regards clinical parameters on admission there was a statistically significant difference between the two groups in all the parameters, GCS, heart rate, respiratory, systolic and diastolic blood pressures. As regards laboratory parameters on admission there was a statistically significant difference between the two groups except in WBC count and Paco2. As regards CXR findings, recorded as lobar or multi-lobar consolidation there was a statistically significant difference between the two groups. As regards comorbidities in the form of old age, diabetes mellitus, old cerebral insult, renal impairment and/or heart failure there was a statistically significant difference between the two groups. As regards comorbidities in relation to PSI score there was no statistically significant difference within each class. As regard PSI class there was a statistically significant difference between the two groups as PSI class was higher in the ICU admitted group than the non-ICU admitted group. Most cases admitted to ICU were in the classes IV and V 23/34 (67%), and most cases admitted to the ward were in the classes I and II 46/66 (69%). As regards PSI score in relation to ICU admission there was a statistically significant difference between the two groups only in class V which was higher in the ICU admitted group (mean 180.4 ± 21.1) than in the non-ICU admitted group (mean 153.3 ± 27.1).
Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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EJCCM 35 5 November 2015
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S.A.M. Eldaboosy et al. Table 8
Comparison between survivors and non-survivors as regards other parameters. FET#/t
Non-survivor (n = 10)
Survivor (n = 90)
Gender Male Female Age [Mean ± SD]
5 (55.6%) 5(55.6%) 60.4 ± 27.5
55 (61.1%) 35 (38.9%) 50.4 ± 19.9
0.106#
0.745
1.397
0.166
Comorbidity Present Absent PH. [Mean ± SD] PaO2 [Mean ± SD] (mmHg) Pulse [Mean ± SD] (beats/min) GCS [Mean ± SD] Systolic blood pressure [Mean ± SD] (mmHg) Diastolic blood pressure [Mean ± SD] (mmHg) Urea [Mean ± SD] (mg/dl) RR [Mean ± SD] (breaths/m) Hb. [Mean ± SD] (gm/dl) PSI [Mean ± SD] SIPF CURB-65
9 (90%) 1 (10%) 7.4 ± 0.1 45.4 ± 4.7 112.2 ± 24.9 13.0 ± 2.1 110.0 ± 25.0 62.2 ± 9.4 58.3 ± 15.6 39.6 ± 3.7 10.9 ± 1.8 4.3 ± 0.7 1.78 ± 0.44 3.11 ± 1.27
61 (67.8%) 29 (32.2%) 7.4 ± 0.0 61.2 ± 9.9 105.9 ± 18.7 14.6 ± 1.0 126.9 ± 22.9 71.0 ± 11.5 42.9 ± 24.3 29.9 ± 7.3 12.5 ± 2.3 2.5 ± 1.5 1.83 ± 0.39 2.33 ± 1.56
1.727#
0.189
#
0.105 4.686 0.938 4.189 2.101 2.227 1.869 3.862 2.080 3.703 0.306 1.222
p-value
0.917 <0.001 0.350 <0.001 0.038 0.028 0.065 <0.001 0.040 <0.001 0.763 0.236
FET: Fisher exact test; t-independent sample t-test. p-Value <0.05 S; p-value <0.001 HS.
Table 9
Different prediction scores for ICU admission in severe community-acquired pneumonia.
Scores
Cutoff values
Sensitivity (%)
Specificity (%)
ROC (AUC) (95% CI)
p-value
CURB-65 SIPF PSI
>0.5 >0.5 >1.5
97.1 97.1 91.2
45.5 33.3 45.5
0.83 (0.75–0.91) 0.88 (0.80–0.95) 0.79 (0.70–0.89)
<0.001 <0.001 <0.001
Table 10
Different prediction scores for mortality in severe community-acquired pneumonia.
Scores
Cutoff values
Sensitivity (%)
Specificity (%)
ROC (AUC) (95% CI)
p-value
CURB-65 SIPF PSI
>1.5 >1.5 >2.5
90.0 90.0 90.0
70.0 79.9 58.8
0.81 (0.66–0.96) 0.86 (0.76–0.95) 0.80 (0.65–0.95)
0.001 <0.001 0.002
The ability to predict mortality was higher for SIPF score at cutoff value of >1.5 compared to PSI (AUC SIPF 0.86 vs. PSI 0.80; p < 0.001) and CURB-65 (AUC SIPF 0.86 vs. 0.81; p < 0.001).
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There was a statistically significant difference between the two groups regarding CURB-65 score which was higher for the ICU group with a mean of 2.5 + 1.4 while it was lower in the ward group with a mean of 0.9 + 1.0. As 70% (24/34) of cases admitted to ICU were in the classes 1–3, 80% (53/66) of cases admitted to the ward were in the classes 0–1. SIPF score was higher in the ICU admitted group (mean 1.7 ± 0.5) than in the non-ICU group (mean 0.7 ± 0.5). Most cases admitted to ICU had a SIPF score of (2) 25/34 (73.5%). Most cases admitted to the ward had a SIPF score of (0 or 1) 63/66 (95.4%). Also within the ICU admitted group those who were mechanically ventilated (n = 21) had a higher SIPF score with a high statistically significant difference. This table shows a statistically significant difference between groups as regards PaO2, GCS, systolic blood pressure, diastolic blood pressure, RR, Hb. and PSI. PSI was higher in non-survived patients (4.3 ± 0.7) than survived (2.5 ± 1.5)
with p-value (<0.001) but no significant difference between the two groups as regards CURB-65 and SIPF was found. Definition of abbreviations: CURB-65 = confusion, BUN > 7 mmol/l, respiratory rate > 30, systolic blood pressure < 90 mmHg and age > 65; SIPF = shock index (heart rate/systolic blood pressure) > 0.7 plus PaO2/ FiO2 < 250; PSI = pneumonia severity index; ROC = receiver operator characteristic; AUC = area under the curve; CI = confidence interval. The ability to predict ICU admission was higher for SIPF score at cutoff value of >0.5 compared to PSI (AUC SIPF 0.88 vs. PSI 0.79; p < 0.001) and CURB-65 (AUC SIPF 0.88 vs. 0.83; p < 0.001).
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Discussion
318
The majority of admissions in cases of CAP to the ICU occur within the first 24 h of admission in the hospital. Delayed
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Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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transfer to the ICU is associated with increased mortality, and therefore early recognition of these patients is important. PSI and CURB-65 don’t have sufficient operating characteristics to be useful for making ICU triage decisions in severe CAP [6]. In this study 100 CAP patients were recruited from 3 different tertiary hospitals in 2 countries, 34% of patients were admitted to ICU and 66% were admitted to the ward. This is in agreement with [14] who found that about 36% of CAP patients necessitated ICU care. Comorbidities in the form of old age, high blood sugar, old cerebral insult, renal impairment and heart failure were present in 88.2% in the ICU group and in 60.6% in the ward group. The BTS guidelines illustrated the importance of pre-existing comorbidities, including chronic obstructive pulmonary diseases (COPD; 32%), asthma (13%), and cardiac disease (15%). Other significant conditions include diabetes, chronic liver diseases, chronic renal failure, immunosuppression, and alcoholism. The incidence of severe CAP and adverse events increases with age. For example, 90% of pneumonia deaths occurred in patients over the age of 70. Marti and coworkers, 2012 in a meta-analysis found 10–20% of CAP is admitted to the intensive care unit. In this study ICU admitted patients had lower GCS, higher heart rate, higher respiratory rate, lower systolic and diastolic blood pressures, higher levels of serum creatinine and urea, lower PaO2 and PaO2%FiO2 and multilobar radiographic appearances than ward patients. [15] reported older age, respiratory rate >20bpm, nursing home residence, chronic pulmonary disease, diabetes, and multilobar CAP were independently associated with longer stay in ICU. Liapikou and coworkers [10] found the patients who were admitted to the ICU were younger; more likely to have a smoking history, had worse oxygenation; had higher PSI and CURB-65 risk classes compared with patients who were not admitted to the ICU. In this study CURB-65 was higher in the ICU admitted group (mean 2.5 ± 1.4) than in the ward group (mean 0.9 ± 1.0) with 97% sensitivity, 45.5% specificity and AUC 0.83. In the meta-analysis done by Marti and coworkers 2012, patients with CURB-65 of 3 or more were admitted to ICU, with a pooled sensitivity of 56%, and specificity, of 74% while Mene´ndez and coworkers [2] reported that CAP patients with CURB-65 more than or equal 2 or if there were multilobar and/or bilateral radiographic involvement or a SpO2 < 92% would also be criteria to send the patient to the hospital and need for ICU admission. In this study, PSI total sensitivity was 91.5% and specificity was 45.5% and AUC 0.79. Mbata and coworkers [13] found the global performance of PSI to predict ICU admission was modest, with an AUC of 0.69 with a pooled sensitivity of 92.4% (CI, 89–95) and specificity of 56.2% (CI, 43–69) in four cohorts including 3,195 patients and significant heterogeneity was present. Sanz and co-workers [3] modified shock index if heart rate/ systolic BP more than 0.7 = 1 score. In this study the ability to predict ICU admission was higher for SIPF score compared to PSI (AUC SIPF 0.88 vs. PSI 0.79) and CURB-65 (AUC SIPF 0.88 vs. 0.83). Sanz and co-workers [3] analyzed 1090 CAP patients from whom 54% (589 cases) showed PSI score IV-V, 462 (42.4%) with CURB-65 score equal to or more than 2, 149 (13.7%) scored 3 or more of the American Thoracic society and Infectious diseases society of America (ATS/IDSA) minor criteria, and 16.9% (184) rated 2 points in SIPF score. The ability to predict
7
ICU admission was higher for SIPF score compared to PSI (AUC SIPF 0.735 vs. PSI 0.618) and CURB-65 (AUC SIPF 0.735 vs. 0.573) and similar to ATS/IDSA minor criteria (AUC SIPF 0.735 vs. 0.720; 0.636). Other studies have evaluated PSI and CURB-65 for their predictive accuracy for the major ATS criteria of need for mechanical ventilation, or presence of septic shock with need for vasopressors. These outcomes appear to be more robust measures. One disadvantage of both PSI and CURB65 was their reliance on laboratory investigations for calculation which limits their use by health care professionals in the community [5]. The mortality rate in this study was 10% and mortality was higher in the elderly and patients with comorbidities. Those patients who died had lower PaO2, GCS, systolic blood pressure, and diastolic blood pressure, RR, Hb and PSI. PSI was higher in non-survived patients (4.3 ± 0.7) than survived (2.5 ± 1.5). The ability to predict mortality was higher for SIPF score at cutoff value of >1.5 compared to PSI (AUC SIPF 0.86 vs. PSI 0.80) and CURB-65 (AUC SIPF 0.86 vs. 0.81). Mbata et al. [13] found mortality rate was 15% and found both CURB-65 and CRB-65 can be applied in the community setting to augment clinical judgment regarding the need for hospital admission but did not appear to be useful for identifying patients requiring ICU care because of their low specificities and low positive predictive values due to disease severity is not the only factor to consider; premorbid status, age of patient, and availability of the resources are all considered by ICU physicians before admitting a patient into ICU. Alavi-Moghaddam et al. [1] found that CURB-65 had better accuracy in predicting mortality and the need for ICU admission among patients with CAP. While CURB-65 had a high sensitivity in predicting mortality and need for ICU admission, PSI was shown to have a high specificity in this regard. Alavi-Moghaddam et al. [1] reported also mortality increased with age, presence of underlying heart failure, high blood levels of urea, pH lower than 7.35, and decreased consciousness level. Man et al. [11] used the ROC curves to assess 30 day mortality for each prediction scoring method PSI, CRB-65, and CURB-65. They found no significant difference in the area under the ROC curves for each of the PSI 0.728 (95% CI 0.662–0.793), CURB-65 0.713 (95% CI 0.639–0.788) and CRB-65 0.654 (95% CI 0.572–0.736) and no significant differences were found between PSI, CURB65 and CRB65 in predicting 30 day mortality. Marti et al. [12] in a systematic review of clinical prediction rules to predict severe CAP, PSI and CURB-65 found similar performances to identify patients requiring ICU admission. A PSI class of IV or more is more sensitive (75% vs. 56%) but less specific (47% vs. 74%) than a CURB-65 score of 3 or more. These two scores, derived and validated to predict 30day mortality, perform poorly to predict ICU admission, with an estimated AUC of 0.80. Sanz et al. [3] found mortality rate to be 5.4% and no difference was found regarding the ability to predict mortality between the 4 different scores (AUC: PSI 0.716: CURB-65 0.679: ATS/IDSA minor criteria 0.670 m, SIPF score 0.707: p 0.05). Our study had its limitations as it was retrospective and included a small number of patients which will not make it
Please cite this article in press as: Eldaboosy SAM et al. Comparison between CURB-65, PSI, and SIPF scores as predictors of ICU admission and mortality in community-acquired pneumonia, Egypt J Crit Care Med (2015), http://dx.doi.org/10.1016/j.ejccm.2015.10.001
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easy to give firm conclusions, so it is recommended to do prospective studies on a large scale to confirm our study results. Conclusions – The ability of SIPF score to predict ICU admission in CAP is higher than that of CURB-65 and PSI. – The simple SIPF score could be a useful tool to predict ICU admission and mortality in CAP.
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Uncited references
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[7,8].
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References [1] Alavi-Moghaddam M, Bakhshi H, Rezaei B, Khashayar P. Pneumonia severity index compared to CURB-65 in predicting the outcome of community acquired pneumonia among patients referred to an Iranian emergency department: a prospective survey. Braz J Infect Dis 2013;17(2):179–83. [2] Mene´ndez R, Torres A, Aspa J, Capelastegui A, Prat C, eand Rodrı´ guez de Castro F: SEPAR Guidelines. CommunityAcquired Pneumonia. New Guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR); Arch Bronconeumol., 2010; 46(10):543–558. [3] Sanz FH, Ferna´ndez-Fabrellas E, Chiner E, Briones ML, Cervera A, Aguar MC, Lera R, Lera R, Sancho-Chust, et al. Physiological score SIPF (shock index and hypoxemia) is an accurate predictor of ICU admission in community-acquired pneumonia. Am J Respir Crit Care Med 2014;189:A4627. [4] Sanz F, Restrepo MR, Ferna´ndez EF, BrionesM L, Blanquer R, Eric MM, Chiner E, Blanquer J. Is it possible to predict which patients with mild pneumonias will develop hypoxemia? Respir Med 2009;103:1871e1877. [5] Singannayagam A, Chalmers JD, Hill AT. Severity assessment in community-acquired pneumonia: a review. Q J Med 2009;102:379–88.
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S.A.M. Eldaboosy et al. [6] Chalmers JD. ICU admission and severity assessment in community-acquired pneumonia. Queens Medical Research Institute, Centre for Inflammation Research, Little France, Edinburgh EH16 4TJ, UK. Crit Care 2009;13:156. [7] Curtain JP, Sankaran P, Kamath AV, Myint PK. The usefulness of confusion, urea, respiratory rate, and shock index or adjusted shock index criteria in predicting combined mortality and/or ICU admission compared to CURB-65 in community-acquired pneumonia. Hindawi Publishing Corporation BioMed Research International Volume 2013, Article ID 590407. p. 6. doi: 10.1155/2013/ 590407. [8] Ewig S, Walter T. CRB-65 for assessment of pneumonia severity. Who could ask for more? Thorax 2008;63, 665–6. [9] Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243–50. [10] Liapikou A, Ferrer M, Polverino E, Balasso V, Esperatti M, Piner R, Mensa J, Luque N, Ewig S, Menendez R, et al. Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission. Clin Infect Dis 2009;48:377–85. [11] Man SY, Lee N, Ip M, Antonio GE, Chau SS, Mak P, Graham CA, Zhang M, Lui G, Chan PK, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax 2007;62:348–53. [12] Marti C, Garin N, Grosgurin O, Poncet A, Combescure C, Carballo S, Perrier. A prediction of severe community-acquired pneumonia: a systematic review and meta-analysis. Crit Care 2012;16:R141. [13] Mbata GC, Chukwuka CJ, Onyedum CC, Onwubere BJC, Aguwa EN. Comparison of two predictive rules for assessing severity of community acquired pneumonia. Afr J Respir Med 2014;10(1). [14] Restrepo MI, Mortensen EM, Velez JA, Frei C, Anzueto A. A comparative study of community-acquired pneumonia patients admitted to the ward and the ICU. Chest 2008;133:610–7. [15] Suter-Widmer I, Christ-Crain M, Zimmerli W, Albrich W, Mueller B, Schuetz P. Predictors for length of hospital stay in patients with community-acquired pneumonia: results from a Swiss Multicenter study for the ProHOSP Study Group. BMC Pulmonary Med 2012;12:21.
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