Prediction of severe community-acquired pneumonia: a systematic review and meta-analysis

Christophe Marti, Nicolas Garin, Olivier Grosgurin, Antoine Poncet, Christophe Combescure, Sebastian Carballo, Arnaud Perrier, Christophe Marti, Nicolas Garin, Olivier Grosgurin, Antoine Poncet, Christophe Combescure, Sebastian Carballo, Arnaud Perrier

Abstract

Introduction: Severity assessment and site-of-care decisions for patients with community-acquired pneumonia (CAP) are pivotal for patients' safety and adequate allocation of resources. Late admission to the intensive care unit (ICU) has been associated with increased mortality in CAP. We aimed to review and meta-analyze systematically the performance of clinical prediction rules to identify CAP patients requiring ICU admission or intensive treatment.

Methods: We systematically searched Medline, Embase, and the Cochrane Controlled Trials registry for clinical trials evaluating the performance of prognostic rules to predict the need for ICU admission, intensive treatment, or the occurrence of early mortality in patients with CAP.

Results: Sufficient data were available to perform a meta-analysis on eight scores: PSI, CURB-65, CRB-65, CURB, ATS 2001, ATS/IDSA 2007, SCAP score, and SMART-COP. The estimated AUC of PSI and CURB-65 scores to predict ICU admission was 0.69. Among scores proposed for prediction of ICU admission, ATS-2001 and ATS/IDSA 2007 scores had better operative characteristics, with a sensitivity of 70% (CI, 61 to 77) and 84% (48 to 97) and a specificity of 90% (CI, 82 to 95) and 78% (46 to 93), but their clinical utility is limited by the use of major criteria.

Conclusions: New severity scores for predicting the need for ICU or intensive treatment in patients with CAP, such as ATS/IDSA 2007 minor criteria, SCAP score, and SMART-COP, have better discriminative performances compared with PSI and CURB-65. High negative predictive value is the most consistent finding among the different prediction rules. These rules should be considered an aid to clinical judgment to guide ICU admission in CAP patients.

Figures

Figure 1
Figure 1
Study flow chart.
Figure 2
Figure 2
Components of the main severity scores. Criteria used in the score appear as shaded areas. BP, blood pressure; HR, heart rate; RR, respiratory rate; T, temperature.
Figure 3
Figure 3
SROC curve and area under the curve (AUC) of Pneumonia Severity Index (PSI) and CURB-65 to predict ICU admission. Individual studies are represented by a number indicating the cut-off used. Their place on the diagram represents the sensitivity and specificity of the individual study. Diamonds represent meta-analytic test statistics for each cut-off.
Figure 4
Figure 4
Pooled discriminative performance of the principal scores for severe CAP compared with Pneumonia Severity Index (PSI) and CURB-65 ROC curve.

References

    1. Marston BJ, Plouffe JF, File TM Jr, Hackman BA, Salstrom SJ, Lipman HB, Kolczak MS, Breiman RF. Incidence of community-acquired pneumonia requiring hospitalization: results of a population-based active surveillance study in Ohio: The Community-Based Pneumonia Incidence Study Group. Arch Intern Med. 1997;157:1709–1718. doi: 10.1001/archinte.1997.00440360129015.
    1. Ewig S, Torres A. Severe community-acquired pneumonia. Clin Chest Med. 1999;20:575–587. doi: 10.1016/S0272-5231(05)70237-9.
    1. 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;336:243–250. doi: 10.1056/NEJM199701233360402.
    1. Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:1477–1483. doi: 10.1097/01.CCM.0000266585.74905.5A.
    1. 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;133:610–617. doi: 10.1378/chest.07-1456.
    1. Renaud B, Santin A, Coma E, Camus N, Van Pelt D, Hayon J, Gurgui M, Roupie E, Herve J, Fine MJ, Brun-Buisson C, Labarere J. Association between timing of intensive care unit admission and outcomes for emergency department patients with community-acquired pneumonia. Crit Care Med. 2009;37:2867–2874. doi: 10.1097/CCM.0b013e3181b02dbb.
    1. Niederman MS, Bass JB Jr, Campbell GD, Fein AM, Grossman RF, Mandell LA, Marrie TJ, Sarosi GA, Torres A, Yu VL. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy: American Thoracic Society, Medical Section of the American Lung Association. Am Rev Respir Dis. 1993;148:1418–1426.
    1. Niederman MS, Mandell LA, Anzueto A, Bass JB, Broughton WA, Campbell GD, Dean N, File T, Fine MJ, Gross PA, Martinez F, Marrie TJ, Plouffe JF, Ramirez J, Sarosi GA, Torres A, Wilson R, Yu VL. 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;163:1730–1754.
    1. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Suppl 2):S27–S72.
    1. Charles PG, Wolfe R, Whitby M, Fine MJ, Fuller AJ, Stirling R, Wright AA, Ramirez JA, Christiansen KJ, Waterer GW, Pierce RJ, Armstrong JG, Korman TM, Holmes P, Obrosky DS, Peyrani P, Johnson B, Hooy M, Grayson ML. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis. 2008;47:375–384. doi: 10.1086/589754.
    1. Espana PP, Capelastegui A, Gorordo I, Esteban C, Oribe M, Ortega M, Bilbao A, Quintana JM. Development and validation of a clinical prediction rule for severe community-acquired pneumonia. Am J Respir Crit Care Med. 2006;174:1249–1256. doi: 10.1164/rccm.200602-177OC.
    1. Renaud B, Labarere J, Coma E, Santin A, Hayon J, Gurgui M, Camus N, Roupie E, Hemery F, Herve J, Salloum M, Fine MJ, Brun-Buisson C. Risk stratification of early admission to the intensive care unit of patients with no major criteria of severe community-acquired pneumonia: development of an international prediction rule. Crit Care (London) 2009;13:R54. doi: 10.1186/cc7781.
    1. Worster A, Carpenter C. Incorporation bias in studies of diagnostic tests: how to avoid being biased about bias. Canadian J Emerg Med. 2008;10:174–175.
    1. Hayden JA, Cote P, Bombardier C. Evaluation of the quality of prognosis studies in systematic reviews. Ann Intern Med. 2006;144:427–437.
    1. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–188. doi: 10.1016/0197-2456(86)90046-2.
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–560. doi: 10.1136/bmj.327.7414.557.
    1. Moses LE, Shapiro D, Littenberg B. Combining independent studies of a diagnostic test into a summary ROC curve: data-analytic approaches and some additional considerations. Stat Med. 1993;12:1293–1316.
    1. Lamy O, Van Melle G, Cornuz J, Burnand B. Clinical management of immunocompetent hospitalized patients with community-acquired pneumonia. Eur J Intern Med. 2004;15:28–34. doi: 10.1016/j.ejim.2003.11.003.
    1. Ewig S, Seifert K, Kleinfeld T, Goke N, Schafer H. Management of patients with community-acquired pneumonia in a primary care hospital: a critical evaluation. Respir Med. 2000;94:556–563. doi: 10.1053/rmed.1999.0775.
    1. Neill AM, Martin IR, Weir R, Anderson R, Chereshsky A, Epton MJ, Jackson R, Schousboe M, Frampton C, Hutton S, Chambers ST, Town GI. Community acquired pneumonia: aetiology and usefulness of severity criteria on admission. Thorax. 1996;51:1010–1016. doi: 10.1136/thx.51.10.1010.
    1. Ananda-Rajah MR, Charles PGP, Melvani S, Burrell LL, Johnson PDR, Grayson ML. Comparing the pneumonia severity index with CURB-65 in patients admitted with community acquired pneumonia. Scand J Infect Dis. 2008;40:293–300. doi: 10.1080/00365540701663381.
    1. Angus DC, Marrie TJ, Scott Obrosky D, Clermont G, Dremsizov TT, Coley C, Fine MJ, Singer DE, Kapoor WN. 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;166:717–723. doi: 10.1164/rccm.2102084.
    1. Brown SM, Jones BE, Jephson AR, Dean NC. Validation of the Infectious Disease Society of America/American Thoracic Society 2007 guidelines for severe community-acquired pneumonia. Crit Care Med. 2009;37:3010–3016. doi: 10.1097/CCM.0b013e3181b030d9.
    1. Buising KL, Thursky KA, Black JF, MacGregor L, Street AC, Kennedy MP, Brown GV. A prospective comparison of severity scores for identifying patients with severe community acquired pneumonia: reconsidering what is meant by severe pneumonia. Thorax. 2006;61:419–424. doi: 10.1136/thx.2005.051326.
    1. Buising KL, Thursky KA, Black JF, MacGregor L, Street AC, Kennedy MP, Brown GV. Identifying severe community-acquired pneumonia in the emergency department: a simple clinical prediction tool. Emerg Med Australas. 2007;19:418–426. doi: 10.1111/j.1742-6723.2007.01003.x.
    1. Calbo E, Ochoa de Echaguen A, Rodriguez-Carballeira M, Ferrer C, Garau J. Hospital admission, duration of stay and mortality in community-acquired pneumonia in an acute care hospital: correlation between a pneumonia prognosis index and conventional clinical criteria for assessing severity. Enferm Infecc Microbiol Clin. 2004;22:64–69. doi: 10.1157/13056884.
    1. Capelastegui A, Espana PP, Quintana JM, Areitio I, Gorordo I, Egurrola M, Bilbao A. Validation of a predictive rule for the management of community-acquired pneumonia. Eur Respir J. 2006;27:151–157. doi: 10.1183/09031936.06.00062505.
    1. Chalmers JD, Singanayagam A, Hill AT. Systolic blood pressure is superior to other haemodynamic predictors of outcome in community acquired pneumonia. Thorax. 2008;63:698–702. doi: 10.1136/thx.2008.095562.
    1. Davis JS, Cross GB, Charles PG, Currie BJ, Anstey NM, Cheng AC. Pneumonia risk stratification in tropical Australia: does the SMART-COP score apply? Med J Aust. 2010;192:133–136.
    1. Escobar GJ, Fireman BH, Palen TE, Gardner MN, Lee JY, Clark MP, Kipnis P. Risk adjusting community-acquired pneumonia hospital outcomes using automated databases. Am J Manag Care. 2008;14:158–166.
    1. Espana PP, Capelastegui A, Quintana JM, Bilbao A, Diez R, Pascual S, Esteban C, Zalacain R, Menendez R, Torres A. Validation and comparison of SCAP as a predictive score for identifying low-risk patients in community-acquired pneumonia. J Infect. 2010;60:106–113. doi: 10.1016/j.jinf.2009.11.013.
    1. Ewig S, de Roux A, Bauer T, Garcia E, Mensa J, Niederman M, Torres A. Validation of predictive rules and indices of severity for community acquired pneumonia. Thorax. 2004;59:421–427. doi: 10.1136/thx.2003.008110.
    1. Ewig S, Ruiz M, Mensa J, Marcos MA, Martinez JA, Arancibia F, Niederman MS, Torres A. Severe community-acquired pneumonia: assessment of severity criteria. Am J Respir Crit Care Med. 1998;158:1102–1108.
    1. Feagan BG, Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK. Treatment and outcomes of community-acquired pneumonia at Canadian hospitals. CMAJ. 2000;162:1415–1420.
    1. Frei CR, Burgess DS. Community-acquired pneumonia: objective criteria to predict severe disease. J Infect Dis Pharmacother. 2004;6:39–48.
    1. Garau J, Baquero F, Perez-Trallero E, Perez JL, Martin-Sanchez AM, Garcia-Rey C, Martin-Herrero JE, Dal-Re R. Factors impacting on length of stay and mortality of community-acquired pneumonia. Clin Microbiol Infect. 2008;14:322–329. doi: 10.1111/j.1469-0691.2007.01915.x.
    1. Garcia-Vidal C, Fernandez-Sabe N, Carratala J, Diaz V, Verdaguer R, Dorca J, Manresa F, Gudiol F. Early mortality in patients with community-acquired pneumonia: causes and risk factors. Eur Respir J. 2008;32:733–739. doi: 10.1183/09031936.00128107.
    1. Kamath A, Pasteur MC, Slade MG, Harrison BD. Recognising severe pneumonia with simple clinical and biochemical measurements. Clin Med. 2003;3:54–56.
    1. Liapikou A, Ferrer M, Polverino E, Balasso V, Esperatti M, Piner R, Mensa J, Luque N, Ewig S, Menendez R, Niederman MS, Torres A. 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;48:377–385. doi: 10.1086/596307.
    1. Man SY, Lee N, Ip M, Antonio GE, Chau SS, Mak P, Graham CA, Zhang M, Lui G, Chan PK, Ahuja AT, Hui DS, Sung JJ, Rainer TH. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax. 2007;62:348–353. doi: 10.1136/thx.2006.069740.
    1. Marrie TJ, Shariatzadeh MR. Community-acquired pneumonia requiring admission to an intensive care unit: a descriptive study. Medicine (Baltimore) 2007;86:103–111. doi: 10.1097/MD.0b013e3180421c16.
    1. Phua J, See KC, Chan YH, Widjaja LS, Aung NW, Ngerng WJ, Lim TK. Validation and clinical implications of the IDSA/ATS minor criteria for severe community-acquired pneumonia. Thorax. 2009;64:598–603. doi: 10.1136/thx.2009.113795.
    1. Putinati S, Ballerin L, Piattella M, Ritrovato L, Zabini F, Potena A. Clinical policy for management and risk stratification of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria. Rec Progr Med. 2003;94:199–203.
    1. Renaud B, Coma E, Hayon J, Gurgui M, Longo C, Blancher M, Jouannic I, Betoulle S, Roupie E, Fine MJ. Investigation of the ability of the Pneumonia Severity Index to accurately predict clinically relevant outcomes: a European study. Clin Microbiol Infect. 2007;13:923–931. doi: 10.1111/j.1469-0691.2007.01772.x.
    1. Riley PD, Aronsky D, Dean NC. Validation of the 2001 American Thoracic Society criteria for severe community-acquired pneumonia. Crit Care Med. 2004;32:2398–2402. doi: 10.1097/01.CCM.0000147443.38234.D2.
    1. Roson B, Carratala J, Dorca J, Casanova A, Manresa F, Gudiol F. Etiology, reasons for hospitalization, risk classes, and outcomes of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria. Clin Infect Dis. 2001;33:158–165. doi: 10.1086/321808.
    1. Shah BA, Ahmed W, Dhobi GN, Shah NN, Khursheed SQ, Haq I. Validity of pneumonia severity index and CURB-65 severity scoring systems in community acquired pneumonia in an Indian setting. Indian J Chest Dis. 2010;52:9–17.
    1. van der Eerden MM, de Graaff CS, Bronsveld W, Jansen HM, Boersma WG. Prospective evaluation of pneumonia severity index in hospitalised patients with community-acquired pneumonia. Respir Med. 2004;98:872–878. doi: 10.1016/j.rmed.2004.02.022.
    1. Fukuyama H, Ishida T, Tachibana H, Nakagawa H, Iwasaku M, Saigusa M, Yoshioka H, Arita M, Hashimoto T. Validation of scoring systems for predicting severe community-acquired pneumonia. Intern Med. 2011;50:1917–1922. doi: 10.2169/internalmedicine.50.5279.
    1. Chalmers JD, Taylor JK, Mandal P, Choudhury G, Singanayagam A, Akram AR, Hill AT. Validation of the Infectious Diseases Society of America/American Thoratic Society Minor Criteria for Intensive Care Unit Admission in Community-Acquired Pneumonia Patients Without Major Criteria or Contraindications to Intensive Care Unit Care. Clin Infect Dis. 2011;53:503–511. doi: 10.1093/cid/cir463.
    1. Putinati S, Ballerin L, Zabini F, Piattella M, Ritrovato L, Simoni M, Potena A. Predictive rules for prognosis in community-acquired pneumonia. Minerva Pneumol. 2005;44:85–91.
    1. Renaud B, Coma E, Labarere J, Hayon J, Roy PM, Boureaux H, Moritz F, Cibien JF, Guerin T, Carre E, Lafontaine A, Bertrand MP, Santin A, Brun-Buisson C, Fine MJ, Roupie E. Routine use of the Pneumonia Severity Index for guiding the site-of-treatment decision of patients with pneumonia in the emergency department: a multicenter, prospective, observational, controlled cohort study. Clin Infect Dis. 2007;44:41–49. doi: 10.1086/509331.
    1. Chalmers JD, Singanayagam A, Akram AR, Mandal P, Short PM, Choudhury G, Wood V, Hill AT. Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia: systematic review and meta-analysis. Thorax. 2010;65:878–883. doi: 10.1136/thx.2009.133280.
    1. Schuetz P, Suter-Widmer I, Chaudri A, Christ-Crain M, Zimmerli W, Mueller B. Prognostic value of procalcitonin in community-acquired pneumonia. Eur Respir J. 2011;37:384–392. doi: 10.1183/09031936.00035610.
    1. Schuetz P, Christ-Crain M, Zimmerli W, Mueller B. Repeated measurements of endothelin-1 precursor peptides predict the outcome in community-acquired pneumonia. Intensive Care Med. 2011;37:970–980. doi: 10.1007/s00134-011-2208-2.
    1. Kruger S, Ewig S, Kunde J, Hanschmann A, Marre R, Suttorp N, Welte T. C-terminal provasopressin (copeptin) in patients with community-acquired pneumonia: influence of antibiotic pre-treatment: results from the German competence network CAPNETZ. J Antimicrob Chemother. 2009;64:159–162. doi: 10.1093/jac/dkp148.
    1. Christ-Crain M, Breidthardt T, Stolz D, Zobrist K, Bingisser R, Miedinger D, Leuppi J, Tamm M, Mueller B, Mueller C. Use of B-type natriuretic peptide in the risk stratification of community-acquired pneumonia. J Intern Med. 2008;264:166–176. doi: 10.1111/j.1365-2796.2008.01934.x.
    1. Kruger S, Ewig S, Kunde J, Hartmann O, Suttorp N, Welte T. Pro-atrial natriuretic peptide and pro-vasopressin for predicting short-term and long-term survival in community-acquired pneumonia: results from the German Competence Network CAPNETZ. Thorax. 2010;65:208–214. doi: 10.1136/thx.2009.121178.
    1. Christ-Crain M, Morgenthaler NG, Stolz D, Muller C, Bingisser R, Harbarth S, Tamm M, Struck J, Bergmann A, Muller B. Pro-adrenomedullin to predict severity and outcome in community-acquired pneumonia [ISRCTN04176397] Crit Care. 2006;10:R96. doi: 10.1186/cc4955.
    1. Chalmers JD, Mandal P, Singanayagam A, Akram AR, Choudhury G, Short PM, Hill AT. Severity assessment tools to guide ICU admission in community-acquired pneumonia: systematic review and meta-analysis. Intensive Care Med. 2011;37:1409–1420. doi: 10.1007/s00134-011-2261-x.
    1. Spindler C, Ortqvist A. Prognostic score systems and community-acquired bacteraemic pneumococcal pneumonia. Eur Respir J. 2006;28:816–823. doi: 10.1183/09031936.06.00144605.
    1. Kontou P, Kuti JL, Nicolau DP. Validation of the Infectious Diseases Society of America/American Thoracic Society criteria to predict severe community-acquired pneumonia caused by Streptococcus pneumoniae. Am J Emerg Med. 2009;27:968–974. doi: 10.1016/j.ajem.2008.07.037.
    1. Feldman C, Alanee S, Yu VL, Richards GA, Ortqvist A, Rello J, Chiou CC, Chedid MB, Wagener MM, Klugman KP. Severity of illness scoring systems in patients with bacteraemic pneumococcal pneumonia: implications for the intensive care unit care. Clin Microbiol Infect. 2009;15:850–857. doi: 10.1111/j.1469-0691.2009.02901.x.

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