Can Scoring Systems Be Used to Determine Prognosis and Site of Care for CAP?

1. Can Scoring Systems Be Used to Determine Prognosis and Site of Care for CAP? Michael S. Niederman, MD Chairman, Department of Medicine Winthrop-University Hospital Mineola, New York Professor of Medicine Vice-Chairman, Department of Medicine State University of New York at Stony Brook

2. When ICU care is late, and most (93%) ICU admitted patients are ventilated, mortality is high (> 75%) in pneumococcal bacteremic pneumonia. Hook et al: JAMA 1983;249:1055. CAN EXPECTANT ICU CARE IMPROVE OUTCOMES IN SEVERE CAP?

3. When is the ICU Used in CAP? • National database in UK of 172 ICU’s with 17,869 CAP cases (5.9% of all ICU admits) • 59% admitted within first 2 days, 21.5% days 2-7, 19.5% > 7 days. • 54.6% mechanically ventilated on admission to ICU • Mortality rate in ICU 34.9%, 49.4% in hospital • 46.3% mortality if admit in first 2 days • 50.4% if admit day 2-7, 57.6% if after day 7 ( p<0.001) • Woodhead et al. Critical Care 2006; 10: S1

4. Why The PSI and CURB-65 Alone Cannot Help with Site of Care Decisions • PSI is not very accurate for deciding who should be admitted to the hospital or ICU • PSI is good for mortality prediction. BUT : Risk of death does not equate with need for hospitalization or need for ICU Care • PSI is not a direct measure of disease severity • PSI is too complex for routine clinical use • PSI does not account for “social” factors and disease factors that influence site of care decision

5. Why The PSI and CURB-65 Alone Cannot Help with Site of Care Decisions • PSI is not very accurate for deciding who should be admitted to the hospital or ICU • PSI is good for mortality prediction. BUT : Risk of death does not equate with need for hospitalization or need for ICU Care • PSI is not a direct measure of disease severity • PSI is too complex for routine clinical use • PSI does not account for “social” factors and disease factors that influence site of care decision

6. PSI System

7. Predicting Low-Risk Patients 1575/2287 PORT patients in classes I-III, with only 7 deaths. 15,500/38,039 Medis Group patients in classes I-III. Suggest outpatient for I, II; brief admit for III; inpatient care for IV and V. PORT PATIENTS: 30 Class I Class II Class III Class IV Class V 25 20 15 10 5 0 % Inpatientto ICU % Outpatientto Hospital Mortality Fine et al: N Engl J Med 1997;336:243-250

8. Predictive Rules for Severe CAP • Modified ATS • One major: Mechanical vent, septic shock OR • 2 of 3 minor: SBP < 90 mm Hg, multilobar, P/F< 250 • BTS 1: 2 of 3 of R > 30/min, DBP < 60 mm Hg, BUN > 19.6 mg/dL • BTS 2: Use confusion instead of BUN • Modified BTS: 2 of 4 present (CURB) • PSI calculated on Admit • Ewig et al: Thorax 2004; 59: 421-427

9. Predictive Rules for Severe CAP • 696 CAP admits, 116 to ICU • Evaluate ICU need by modified ATS rule, two BTS rules and the PSI • 37% of ICU admits PSI I-III • 15% with positive modified ATS rule in PSI I-III. • Once again, PSI good for mortality prediction, but NOT for identifying need for ICU care. • Ewig et al: Thorax 2004; 59: 421-427 PREDICTION OF ICU ADMIT

10. Predicting Need for ICU Admit • 1339 inpatients in PORT study, 170 admitted to ICU • 6% of Class I, 5.6% of Class II, 8.7% of Class III, 15.9% of Class IV, 23.8% of Class V to ICU. Overall 27% of all ICU patients Class I-III • Most rules sensitive, not specific. Many who meet criteria NOT admitted to ICU • Revised ATS rule best for ICU admit need , BUT sens=70.7%, specif= 72.4%. High PSI less specific, original ATS criteria more sensitive • Angus et al: Am J Respir Crit Care Med 2002; 166:717 Overall mortality= 18.2%. NEED for ICU Not correlate with Mortality

11. Why Are So Few PSI V Patients Admitted to ICU? P < 0.001 • 457 admitted CAP patients with PSI V, 1996-2003. • 92 admitted to ICU • ICU used more if: young (OR=12.9 if < 80, p<0.001), less comorbidity (8% vs. 34%, p<0.001), more acute illness parameters (lower diastolic BP, lower P/F ratio, more with pH < 7.35). • All PSI patients with similar bacteriology (incl. P. aeruginosa in 17% ICU and 11% non-ICU : reflection of comorbidity??) • Mortality 37% vs. 20% , ICU vs. not, (p=.001) • THUS PSI good for many things, but NOT site of care decision. • Valencia M, et al. , In Press, Chest 2007 Acute= physical exam, lab data Chronic= age, comorbidity, nurnsing home

12. Which Prognostic Scoring System? • Pneumonia Severity Index (PSI) is complex, heavily weights age and comorbidity, and divides patients into 5 risk groups for mortality. • Since age is so heavily weighted, it does not really measure pneumonia severity • British Thoracic Society (BTS) rule and its modifications are simple • Measure severity of illness more directly, often without the need for laboratory data

13. Defining Pneumonia Severity: CURB-65 • Three prospective inpatient CAP studies, 1068 patients • 80% as derivation cohort, 20% validation • Mortality predictors (p <0.001): Confusion, BUN > 7 mmol/L, R> 30/min, SBP < 90 or DBP < 60 mm Hg), age >65, fever < 37 C, albumin < 30 g/ dL • 1 point for CURB and 65 • Lim et al: Thorax 2003; 58: 377-382 N=210 N=184 N=324 CURB- 65 SCORE

14. A Comparision of PSI vs. CURB • Prospective study of 3181 CAP patients seen in ED • PSI, CURB, CURB-65 • Low risk: PSI I-III, CURB<1, CURB-65 <2 • Low risk: • 68% by PSI(mortality 1.4%), • 51% by CURB (mort 1.7%), • 61% by CURB-65 (mort 1.7%) • For higher risk: • 26% PSI IV(8.1% mortality), 6% PSI V (24% mortality) • 24% CURB-65 2 (6.1% mortality), CURB –65 3,4,5 (mortality): 12% (13%), 2%(17%), 0.2% (43%) ROC Curve For 30-day Mortality Aujesky D, et al: Am J Med 2005; 118: 384

15. A European Comparison of PSI and CURB-65 • Apply both tools to 1100 outpatients and 676 inpatients • 30 day mortality for CURB-65 of:1,2,3,4,5: 0%, 1.1%, 7.6%, 21%, 41.9%,60% • 29.2% of admitted patients with score of 0,1 2 had comorbid illness • CURB-65 correlated with need for mechanical ventilation, hospital admission, LOS • CRB-65 equally effective (without measure of BUN). • CURB-65, CRB-65, PSI all with similar ROC for Mortality • Capelastegui A, et al. Eur Resp J 2006; 27: 151-157

16. A European Comparison of PSI and CURB-65 • Comparision of PSI and CURB-65 • Capelastegui A, et al. Eur Resp J 2006; 27: 151-157

17. Why The PSI and CURB-65 Alone Cannot Help with Site of Care Decisions • PSI is not very accurate for deciding who should be admitted to the hospital or ICU • PSI is good for mortality prediction. BUT : Risk of death does not equate with need for hospitalization or need for ICU Care • PSI is not a direct measure of disease severity • PSI is too complex for routine clinical use • PSI does not account for “social” factors and disease factors that influence site of care decision

18. PSI System

19. Why The PSI and CURB-65 Alone Cannot Help with Site of Care Decisions • PSI is not very accurate for deciding who should be admitted to the hospital or ICU • PSI is good for mortality prediction. BUT : Risk of death does not equate with need for hospitalization or need for ICU Care • PSI is not a direct measure of disease severity • PSI is too complex for routine clinical use • PSI does not account for “social” factors and disease factors that influence site of care decision

20. Limits of The PSI In a Public Hospital • Does the PSI help guide admission in a public hospital? • 253/425 admits in non-HIV population in Seattle were PSI classes I-III. • 76 Class I, 89 Class II, 88 Class III • 1.6% died, BUT • 115 (45%) with at least one acute process for admit: hypoxemia, hypotension, altered MS • 138 (55%) potentially outpt., but 44% homeless, 33% R/O TB, 7% IVDA with R/O endocarditis, 20% drunk. Only 14% could be D/C. • Low risk accounts for 45% of all CAP days and 35.4% of all CAP costs. Median LOS 4-5 days • Do we need alternate sites of care for such patients? • Goss et al: Chest 2003; 124: 2148.

21. Features of Low Risk Patients Who Are Amitted • 11% COPD • 12% Asthma • 19% Malignancy • 10% Seizure disorder • Mean APACHE II 7.5 • Goss et al: Chest 2003; 124: 2148.

22. COPD Is NOT a Comorbid Factor in The PSI • 744 CAP patients, 215 with COPD • COPD with higher PSI than non-COPD (105 vs. 87, p=0.05) ) and more ICU admit (25% vs. 18%,p=0.04) • BUT even after adjusting for severity of illness, COPD patients had a higher 30 and 90 day mortality (HR= 1.32,1.34) • Restropo MI, et al. Eur Resp J 2006, in press.

23. What is the Best Approach for ICU Admission? • Identify at risk patients early • Use clinical assessment • Use prognostic scoring systems • BOTH PSI and CURB-65 • Consider the role of serum markers • CRP • PCT

24. Combining Data from The PSI and CURB-65: Getting the Best of Both Worlds • PSI was developed to define LOW RISK patients, and often UNDERESTIMATES need for hospital or ICU • Young, no comorbid illness, clinical variable below a dichotomous variable cutoff • BUT may also OVERESTIMATE need for expensive resources by emphasis on age and comorbitity and NOT severity features • CURB-65 good for avoiding overlooking severe illness, BUT may be limited in elderly and those with comorbidity • Suggest: Draw from BOTH. Either can define low risk (PSI of I-III, CURB-65 of 0-1). IF use PSI, add vital sign and severity evaluation; if use CURB-65, add assessment of comorbid illness and its stability. Add social factors to both. • Niederman MS, et al. Eur Resp J 2006;27: 9-11.

25. A New Rule for ICU Admission • A study using one derivation cohort and two validation cohorts found that a rule identifying patients with: • one oftwo major criteria (arterial pH < 7.30 or systolic blood pressure < 90 mm Hg ) • OR 2 of 6 minor criteria (confusion, BUN > 30 mg/dL, respiratory rate > 30/minute, multilobar infiltrates, PaO2/FiO2 < 250 mm Hg, and age of at least 80 ) • Up to 92% sensitive with a score of 10 or more for identifying those with severe CAP, and was more accurate than other rules such as the PSI, modified ATS criteria and CURB-65. • Espana PP, et al. Am J Respir Crit Care Med 2006; 174: 1249-1256.

26. Criteria for Severe CAP: New IDSA/ATS Guidelines • Thrombocytopenia • Muliticenter study of 822 patients with severe CAP • 3 categories according to platelet count: >150x10(9)/L, 51-149x10(9)/L, and < 50x10(9)/L • ICU mortality rates were 30.8% ,44.1% and 70.7% , respectively (p<0.0001). • Brogly et al: Infection 2007 e pub. • Hyponatremia • On admit: 28% of 342 CAP patients with hyponatremia ( < 136 mEq/L). 4.1% < 130 mEq/L. • Hyponatremia on admit with higher HR, WBC, PSI class • Had increased mortality and increased length of stay • 10.5% developed in hospital, unrelated to severity of illness on admit. • Nair, Niederman, et al: Am J 2007; 27:184-190. • Mandell LA et al. Clin Infect Dis 2007;44 Suppl 2:S27-72

27. Relation of PCT to Severity of CAP • Measure of serum PCT in 185 CAP patients within 24 hours of admit • Relate levels to PORT score, bacteriology and complications • No differences in PCT by etiology for groups overall. • In low PSI classes (I-II), PCT tended to be higher with bacterial etiology; no difference in PCT by etiology in higher PSI groups. • Masia M, et al. Chest 2005; 128:2223- 2229.

28. Prognostic Value of PCT in ICU CAP • 110 patients with severe CAP. Measure PCT within 48 hours admit (not serially). • 20% <0.5 ng/ml, 30% 0.5-2.0 ng/ml, 50% > 2.0 ng/ml • PCT 4.9 vs. 1.5 ng/ml for bacteriologically positive vs. negative patients (p<0.001); higher in those who died ( 5.6 vs. 1.5 ng/ml, p <0.0001) • CRP did not predict outcomes • Boussekey N, et al. Infection 2005; 33: 257-63.