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Risk Classification in Community-acquired Pneumonia

Risk Classification in Community-acquired Pneumonia. Thomas M File, Jr MD MACP FIDSA FCCP Chair, Infectious Disease Division Summa Health System Akron, Ohio; Professor of Internal Medicine, Chair Infectious Disease Section Northeast Ohio Medical University Rootstown, Ohio.

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Risk Classification in Community-acquired Pneumonia

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  1. Risk Classification in Community-acquired Pneumonia Thomas M File, Jr MD MACP FIDSA FCCP Chair, Infectious Disease Division Summa Health System Akron, Ohio; Professor of Internal Medicine, Chair Infectious Disease Section Northeast Ohio Medical University Rootstown, Ohio

  2. Community-acquired Pneumonia (CAP) Leading cause of morbidity and mortality No. I cause due to infection 5-6 million cases/year > 75% treated as outpatients Approx. 1 million admissions/year 40% one year mortality; Kaplan et al. Arch Intern Med 2003; 163: 317-323) 50% mortality at 30 months (Bordon et al. chest) Cost of treating CAP exceeds $17 billion/year File T. Lancet 2003; File and Tan JAMA 2005 File T and Marrie T Postgrad Med. 2010

  3. Patient Stratification for Management of Community-acquired Pneumonia • Patient stratification valuable for optimal management • Helpful in • Assessing NEED for antimicrobial therapy (i.e., viral vs bacterial etiology) • Determining Severity of illness (site of care for CAP) • Prognosis/Outcomes • Predicting likely pathogen/Risk of Resistance • Guidelines recommend stratifying patients according to risk factors1,2 1. Mandell LA et al. Clin Infect Dis. 2007;44(suppl 2):Lim et al.. BTS, Thorax 2009; 64: Suppl 3.

  4. CAP Case 66 Y/O MALE Smoke, Diabetes, CHF Treated with macrolide for ‘sinusitis’ 8 weeks ago Headache, Fever, Cough for 3 days, New Confusion T-38.60 C; P-110; RR-28; Ausc-rhonchi RLL O2 sat-92% Room Air Should he be admitted?

  5. Patient Stratification: CAP Site of Care • Variability in hospital admission rates • Clinicians use inconsistent criteria • Likely overestimate need for admission • Several prediction tools of severity of illness of CAP* • Legitimate decision aids • Two best studied: PSI and CURB 65 • Assessment of mortality risk • PSI best studied and only prognostic rule shown to safely reduce proportion of low risk patients hospitalized for care** • PSI may oversimplify some predictor variables (no degree of abnormality) and based on 19 variables • CURB 65 simpler; better for mortality; does not include most comorbidities • *Marrie T. UptoDate 2008; Aujesky and Fine Clin Infect dis. 2008; 47: S133 • **Atlas et al. Arch Intern Med. 1998; Marrie et al. JAMA 2000; Yealy et al Ann Intern Med. 2005

  6. Risk Stratification: Site of Care Decision Determines Cost of care Intensity of diagnostic testing Empiric choice of antibiotics Advantages of outpatient therapy Cost Patient preference Faster convalescence and avoidance of nosocomial complications Science and Art Mortality prediction rules (PSI, CURB-65) Social circumstances Co-existing conditions

  7. Pneumonia PORT Prediction Rule for Mortality Risk Assessment (PSI) STEP 1 STEP 2 Yes Is the patient >50 years of age? Class II(70 points) Assign points for: Demographic variables Comorbid conditions Physical observations Laboratory and radiographic findings No Does the patient have any of the following coexisting conditions: Neoplastic disease; congestive heart failure; cerebrovascular disease; renal disease; liver disease Class III(71–90 points) Yes Class IV(91–130 points) No Yes Does the patient have any of thefollowing abnormalities: Altered mental status; pulse 125/min; respiratory rate 30/min; systolic blood pressure <90 mm Hg; temperature <35ºC or 40ºC Class V(>130 points) No Class I Fine MJ, et al. N Engl J Med. 1997;336:243-50.; PSI=Pneumonia Severity Index

  8. Prediction Rule Step 2: Algorithm Pt CharacteristicPoints Age No. of years (-10 for female) Cancer 30 Liver disease 20 CHF, CVD, Renal disease 10 RR >30/min, SBP <90 mmHg, Confusion 20 Temp <35ºC, >50ºC 15 Pulse, beats/min 10 BUN; Sodium <130 mmol/l 20 Glucose >250 mg/dl; Hct < 30% 10 pO2 < 60 mmHg 10

  9. Prediction Rule: Risk Categories Risk categories according to two validation cohorts (38,039 inpatients and 2287 in- and outpatients) [Mortality 1 year after hospital discharge: 33% for patients >65 years old(Kaplan V, et al. Arch Intern Med 2003; 163:317-23.)] Fine MJ, et al. N Engl J Med. 1997;336:243-50.

  10. PSI: Amended Algorithm 1. Assessment of preexisting conditions that compromise homecare: hypoxemia; severe social or psychiatric problems; inability to take oral meds 2. Calculation of PORT Severity Index 3. Clinical judgment regarding overall health of the patient and suitability for home care. Clinical judgment should supersede the severity of illness Metlay and Fine Ann Intern Med. 2003; 138: 109-118

  11. Applying the CURB-65 Rule Group 1 Mortality Low (1.5%) (n=324, died=5) Treatment Options CURB-65 Score Likely suitable for home treatment 0 or 1 • Any of: • Confusion* • Urea >7 mmol/l • Respiratory Rate ≥30/min • Blood pressure (SBP <90 mmHg or DBP ≤60 mm Hg) • Age ≥65 years Consider hospital supervised treatment Options may include: Short stay inpatient; Hospital-supervised outpatient Group 2 Mortality Intermediate (9.2%) (n=184, died=17) 2 3 + Group 3 Mortality High (22%) (n=210, died=47) Manage in hospital as severe pneumonia Assess for ICU admission especially if CURB-65 score = 4 or 5 Lim WS, et al. Thorax. 2003;58:377-82.

  12. Practical Severity Assessment Model(without blood test) Lim et al. Thorax 2003: 58: 377-82

  13. PSI, CRB-65 versus CURB-65 CRB-65 omits blood urea measurement Applicable to office-based settings Scores of 0 = home treatment, 1= hospital-supervised treatment, ≥2 = hospitalization ———: PSI (area under the curve (AUC) 0.888 – – – –: CURB-65 AUC 0.870 ---------: CRB-65 AUC 0.864 Capelastegui A, et al. Eur Respir J. 2006;27:151-57.

  14. Predicting outcomes using CRB-65 From CAPO database; 2926 patients CAPO= Community acquired pneumonia organization; TCS=Time to clinical stability; LOS=Length of stay Arnold F. et al. Community Acquired Pneumonia Organization 2006

  15. CURB-65-as continuous variable • Traditional CURB assessment is binary • 62 oriented male, BUN 44, BP 95/65, RR 28 = CURB-65 of 1 (mortality of 2%) • Continuous Variable • Same patient with predicted mortality of 14% Jones BE et al. Chest 2011; 140: 156-63

  16. Criteria for ICU Admission Major Criteria Invasive mechanical ventilation Septic shock with the need for vasopressors Minor Criteria Confusion/disorientation Blood urea nitrogen ≥20 mg/dL Respiratory rate ≥30 breaths/min Hypotension requiring aggressive fluid resuscitation PaO2/FiO2 ratio ≤250 Multilobar infiltrates WBC <4000 cells/mm Platelet count <100,000 cells/mm Core temperature <36oC Direct admission to ICU recommended if 1 major (strong recommendation) or 3 minor criteria (moderate recommendation) Mandell L, et al. Clin Infect Dis. 2007;44 (Suppl 2):S27-72.

  17. Prediction for Severe CAP (SCAP) Major Criteria Points pH < 7.30 13 Systolic pressure < 90 mm Hg 11 Minor Criteria Resp rate > 30 9 Blood urea nitrogen > 30 mg/dL 5 Respiratory rate ≥30 breaths/min Altered mental status 5 PaO2/FiO2 ratio ≤250 6 Age > 80 5 Multilobar/bilateral infiltrates 5 SCAP= 1 Major or 2 minor Mortality based on points: 1-9 2.4%; 10-19 9.26%; 20-29 42.37%; ≥ 30 75% Espana PD et al. Am J Resp Crit Care Med. 2006; 174: 1249-56

  18. Pitt Bacteremia Score (PBS) Criteria Points Fever ≤ 35C or ≥ 40C 2 35.1C-36C or 39.0-39.9 1 36.1-38.9C 0 Hypotension 2 Mech Vent 2 Cardiac Arrest 4 Mental status Alert 0 Disoriented 1 Stuporous 2 Comatose 4 SEVERE = > 4 Paterson D et al. Ann Intern Med 2004; 140: 26-32

  19. SMART-COP: predicting need for ICU Score: 3-4 low risk; 5-6 high risk (33%); ≥ 7 Very High Risk (66%) PG Charles et al. Clin Infect Dis. 2008; 47: 375-84

  20. Modified ATS Score Major Criteria Mech Vent Septic shock Minor Criteria Systolic BP < 90 mmHg Multilobar (> lobes) involvement PaO2/FiO2 ratio < 250 Severe = 1 Major or 2 minor Angus DC et al. Am J Respir Crit Care Med 2002; 166: 717-723

  21. Late admission to the ICU is associated with higher mortality “Further studies should examine variables that may allow clinicians to determine patients who will have a late clinical failure, and processes of care that may reduce the need for these late transfers. An effective tool for evaluation of disease progression will identify patients who are at risk for clinical deterioration.” EICUA=early ICU admission; LICAUA=late ICU admission Restrepo MI et al. Chest 2010; 137: 552-557

  22. Validation of IDSA/ATS minor criteria for ICU admission “The IDSA/ATS 2007 minor criteria are not perfect and require additional impact and validation analyses but seem to be the scoring system closest to achieving these goals so far; we conclude that they accurately predict requirement for MV/VS, ICU admission, and 30-day mortality in patients with CAP.” Chalmers JD et al. Clin Infect Dis. 2011; 53:503-11

  23. Severity scoring systems in bacteremic pneumococcal pneumonia: implications for ICU care Feldman C et al. Clin Microbiol Infect 2009; 15: 850-857

  24. CAP Case 66 Y/O MALE Smoke, Diabetes, CHF Treated with macrolide for ‘sinusitis’ 8 weeks ago Headache, Fever, Cough for 3 days, New Confusion T-38.60 C; P-110; RR-28; Ausc-rhonchi RLL O2 sat-92% Room Air Patient is admitted (PSI IV, CURB-65 2; mortality 8-9%) What antimicrobial therapy?

  25. Empiric Therapy in CAP: IDSA/ATS 26 *Includes healthy patients in regions with high rates of macrolide resistance. ** levofloxacin 750 mg, moxifloxacin 400 mg, gemifloxacin 320 mg. *** ceftriaxone, cefotaxime, amp/sulbactam, ertapenem †Treatment of Pseudomonas (anti-pseudomonal beta-lactam regimen) or MRSA (vancomycin or linezolid) is the main reason to modify standard therapy for ICU patients. IDSA= Infectious Diseases Society of America; ATS=American Thoracic Society; ICU = intensive care unit Mandell L, et al. Clin Infect Dis. 2007;44(Suppl 2):S27-S72.

  26. BTS Guidelines for CAP-2009 UpdateThorax 2009: 64 Suppl III

  27. Use of Procalcitonin for Stratification of Antimicrobial Use for RTIs File TM Jr. Clin Chest Med. 2011; modified from Schuetz P. et al. Eur Respir J 2011;37(2): 384–92.

  28. Risk Classification in Community-acquired Pneumonia: Summary • Multiple severiy assessment tools based on different outcomes have been developed to risk stratify patients with CAP • Clinicians should combine clinical judgment with risk assessment tools to consider management decisions to provide optimal outcomes for our patients

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