HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS REGISTER		Author Keyword(s) Vol Page [Advanced]

This Article Full Text Full Text (PDF) All Versions of this Article: thx.2005.051326v1 61/5/419    most recent Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this link to a friend Similar articles in this journal Similar articles in PubMed Add article to my folders Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Buising, K L Articles by Brown, G V Search for Related Content PubMed PubMed Citation Articles by Buising, K L Articles by Brown, G V

A prospective comparison of severity scores for identifying patients with severe community acquired pneumonia: reconsidering what is meant by severe pneumonia

¹ Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
² Centre for Clinical Research Excellence in Infectious Diseases, Department of Medicine, University of Melbourne, Parkville, Victoria 3050, Australia
³ Emergency Department, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia

Correspondence to:
Correspondence to:
Dr K L Buising
Victorian Infectious Diseases Service, 9th Floor, Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050, Australia; Kirsty.Buising{at}mh.org.au

Background: Several severity scores have been proposed to predict patient outcome and to guide initial management of patients with community acquired pneumonia (CAP). Most have been derived as predictors of mortality. A study was undertaken to compare the predictive value of these tools using different clinically meaningful outcomes as constructs for "severe pneumonia".

Methods: A prospective cohort study was performed of all patients presenting to the emergency department with an admission diagnosis of CAP from March 2003 to March 2004. Clinical and laboratory features at presentation were used to calculate severity scores using the pneumonia severity index (PSI), the revised American Thoracic Society score (rATS), and the British Thoracic Society (BTS) severity scores CURB, modified BTS severity score, and CURB-65. The sensitivity, specificity, positive and negative predictive values were compared for four different outcomes (death, need for ICU admission, and combined outcomes of death and/or need for ventilatory or inotropic support).

Results: 392 patients were included in the analysis; 37 (9.4%) died and 26 (6.6%) required ventilatory and/or inotropic support. The modified BTS severity score performed best for all four outcomes. The PSI (classes IV+V) and CURB had a very similar performance as predictive tools for each outcome. The rATS identified the need for ICU admission well but not mortality. The CURB-65 score predicted mortality well but performed less well when requirement for ICU was included in the outcome of interest. When the combined outcome was evaluated (excluding patients aged >90 years and those from nursing homes), the best predictors were the modified BTS severity score (sensitivity 94.3%) and the PSI and CURB score (sensitivity 83.3% for both).

Conclusions: Different severity scores have different strengths and weaknesses as prediction tools. Validation should be done in the most relevant clinical setting, using more appropriate constructs of "severe pneumonia" to ensure that these potentially useful tools truly deliver what clinicians expect of them.

Abbreviations: CAP, community acquired pneumonia; PSI, pneumonia severity index

Keywords: community acquired pneumonia; severity scores; prediction

This article has been cited by other articles:

				J. I. F. Salluh, F. A. Bozza, M. Soares, J. C. R. Verdeal, H. C. Castro-Faria-Neto, J. R. Lapa e Silva, and P. T. Bozza Adrenal Response in Severe Community-Acquired Pneumonia: Impact on Outcomes and Disease Severity Chest, November 1, 2008; 134(5): 947 - 954. [Abstract] [Full Text] [PDF]

				J D Chalmers, A Singanayagam, and A T Hill Systolic blood pressure is superior to other haemodynamic predictors of outcome in community acquired pneumonia Thorax, August 1, 2008; 63(8): 698 - 702. [Abstract] [Full Text] [PDF]

				J. Bont, E. Hak, A. W. Hoes, J. T. Macfarlane, and T. J. M. Verheij Predicting Death in Elderly Patients With Community-Acquired Pneumonia: A Prospective Validation Study Reevaluating the CRB-65 Severity Assessment Tool Arch Intern Med, July 14, 2008; 168(13): 1465 - 1468. [Full Text] [PDF]

				H. J Durrington and C. Summers Recent changes in the management of community acquired pneumonia in adults BMJ, June 21, 2008; 336(7658): 1429 - 1433. [Full Text] [PDF]

				S. Kruger, S. Ewig, R. Marre, J. Papassotiriou, K. Richter, H. von Baum, N. Suttorp, T. Welte, and on behalf of the CAPNETZ Study Group Procalcitonin predicts patients at low risk of death from community-acquired pneumonia across all CRB-65 classes Eur. Respir. J., February 1, 2008; 31(2): 349 - 355. [Abstract] [Full Text] [PDF]

				W. S. Lim Severity assessment in community-acquired pneumonia: moving on Thorax, April 1, 2007; 62(4): 287 - 288. [Full Text] [PDF]

				P. P. Espana, A. Capelastegui, and J. M. Quintana Am. J. Respir. Crit. Care Med., February 1, 2007; 175(3): 289a - 290. [Full Text] [PDF]

				G. D Mills and R. Laing Severe community acquired pneumonia BMJ, December 9, 2006; 333(7580): 1181 - 1182. [Full Text] [PDF]

				P G P Charles, P D R Johnson, M L Grayson, and K L Buising Still awaiting a useful tool for predicting severe CAP. Thorax, December 1, 2006; 61(12): 1098 - 1099. [Full Text] [PDF]