Original ContributionRisk stratification and prediction value of procalcitonin and clinical severity scores for community-acquired pneumonia in ED
Introduction
Community-acquired pneumonia (CAP) is one of the most common causes of mortality worldwide and accounts for a substantial use of healthcare resources [1]. It results in 29,000 death every year in UK and is being associated with high rates of hospital admission and length of stay [2]. The mortality rate of patients with CAP varies according to its severity, treatment failure and the requirement for hospitalization and/or intensive care unit (ICU) management [3]. Stratifying severity and predicting prognosis of CAP is of vital importance as they can be helpful for hospitalization decisions.
Current guidelines recommend the application of several severity scores, such as CURB65 (confusion, urea >7 mmol/L, respiratory rate 30/min, low systolic (<90 mm Hg) or diastolic blood pressure (≤60 mm Hg) and age 65 years) and pneumonia severity index (PSI), to classify and stratify CAP patients to determine whether the patients should receive outpatient care or hospital admission [4]. The PSI score, introduced in 1997 following a study of >50,000 patients with CAP, is a 20-point score which classified patients into five risk categories according to their percent risk of death within 30 days [5]. Comparatively, the CURB65 score is significantly easier to remember and use than the PSI and is composed of only five variables with a single point awarded to each [5]. The CRB65, without requirement to measure blood urea, is recommended for outpatient use [5]. Previous study revealed that there were no significant differences in overall test performance between PSI, CURB65 and CRB65 for predicting mortality from CAP [5]. The Sepsis-3 Task Force updated the clinical criteria for sepsis, but the clinical implication of SOFA and qSOFA remained unknown [6]. Ranzani et al. reported that qSOFA outperformed systemic inflammatory response syndrome (SIRS) and presented better clinical usefulness as prompt tools for patients with CAP in ED and PSI had the best decision-aid tool profile [6].
Nonetheless, previous studies have demonstrated the limitations of existing severity scores and advised that they should be used with caution and in conjunction with clinical judgment [7]. Moreover, there has been considerable interest in the development of rapid biomarkers for reliable prognosis prediction [7]. Among them, C-reactive protein (CRP) and precalcitonin (PCT) are widely used in virtue of their higher predictive capacity [8]. Frank et al. reported that PCT is associated with the severity of illness in patients with severe pneumonia and appears to be a prognostic marker of morbidity and mortality [9]. Kim et al. proved that PCT is a reliable single predictor for short-term mortality [10]. Regrettably, previous studies are inconsistent in regard to whether biomarkers are superior to severity scores in predicting prognosis of patients with CAP [7].
The purpose of the study is to investigate the risk stratification and prognostic prediction value of PCT and clinical severity scores (CURB65, PSI, SOFA and qSOFA) for patients with CAP in the ED. The primary end-point used in this study is 28-day mortality.
Section snippets
Methods
This study was approved by the Institutional Review Board and Medical Ethics Committee of Beijing Chao-yang Hospital, Capital Medical University, which is an urban university hospital with approximately 250,000 ED admissions every year. Written informed consents were collected from all enrolled patients. Adult patients who fulfilled the CAP criteria [4] admitted to the Emergency Department of Beijing Chao-yang Hospital between January 2016 and October 2017 were enrolled. The following patients
Statistical analysis
Continuous variables were described as the mean ± standard deviation and compared using one-way analysis of variance (ANOVA) for the normally distributed data. For skewed distributions, the data are presented as the median (interquartile range) and compared using Mann Whitney-U nonparametric test. The categorical variables were described as percentages and compared using the Chi-Squared test or Fisher's exact test. Multivariate logistic regression was performed to analyze the potential
Results
A total of 226 patients were enrolled in this study. Of them, fifty-one patients were classified as having SCAP and forty-nine patients were dead after a 28-day follow-up (Table 1). The total mortality rate was 21.68% (49/226). The overall mean age of the patients was 65 (58,71) years old and the male to female ratio was 5.28:1 (190:36). Past history of enrolled patients includes COPD (26.11%), cardiovascular disease (18.58%), cerebral vascular disease (28.76%), chronic renal disease (6.19%),
Discussion
Community-acquired pneumonia is one of the most common infectious diseases and is an important cause of mortality and morbidity worldwide, especially among elderly patients with several comorbidities. Identifying patients with CAP with higher risk of mortality is crucial to anticipate prognosis and program follow-up.
Many different CAP severity scoring systems have been developed in order to evaluate the severity of CAP, but debate is still going on about their performances. Pneumonia severity
Competing interest
The authors declare that they have no competing interest.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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