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Brief Communications
CORB is the best pneumonia severity score for elderly hospitalised patients with suspected pneumonia E. Williams,1 J. Girdwood,1 E. Janus2 and H. Karunajeewa1 1
General Internal Medicine, Western Health and 2Department of Medicine, North West Academic Centre, The University of Melbourne, Western
Hospital, Melbourne, Victoria, Australia
Key words respiratory tract infection, pneumonia, internal medicine, communicable disease, aged. Correspondence Eloise Williams, Western Health, Gordon Street, Footscray, Vic. 3011, Australia. Email: [email protected]
Abstract Pneumonia severity scoring systems have been developed to identify patients at highest mortality risk, and are used in guidelines to limit use of broad-spectrum antibiotics to patients with severe community-acquired pneumonia. A retrospective audit of hospitalised general internal medicine patients with pneumonia was performed to assess the diagnostic performance of various pneumonia severity scores in an elderly general internal medicine population.
Received 7 October 2013; accepted 17 January 2014. doi:10.1111/imj.12445
Community-acquired pneumonia (CAP) is the leading infectious cause of death in developed countries and represents the leading cause of admission to the General Internal Medical (GIM) service at our institution. Numerous pneumonia severity scoring systems (PSSS), such as CORB,1 CURB-652 and SMART-COP3 have been developed to identify patients at highest mortality risk, enable optimal medical treatment and have been employed in Australian guidelines4 that aim to limit use of broadspectrum antibiotics to the sickest patients. However, these scoring systems have been developed in emergency department settings and include patients managed by various inpatient units. Their applicability and usefulness are unclear in the GIM patient population, a group characterised by advanced age, multiple comorbidities and diagnostic uncertainty due to overlap syndromes. This group represents 53% of all adults with a pneumonia-related discharge-related group code (DRG) at our institution where the median age of patients admitted under GIM with a DRG of pneumonia is 83. Given the high mortality and high resource utilisation needs of this group, and our rapidly ageing population, they will become an increasingly important subgroup of CAP patients treated in the modern Australian hospital system. We describe a study that aimed to assess the utility of the
Funding: None. Conflict of interest: None. © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
CORB’, CURB-65 and SMART-COP PSSS in the GIM population at a single institution. A retrospective audit was conducted of consecutive adult (age >18 years) patients admitted under a GIM unit at Footscray Hospital campus of Western Health, a tertiary teaching hospital servicing the Western suburbs of Melbourne. Those with a DRG code consistent with CAP during the winter months of 2010 and 2011 had medical record review and data collected onto a standardised case record form to document baseline demographic and clinical variables, determine disease severity according to CORB, CURB-65 and SMART-COP tools (‘mild’, ‘moderate’ and ‘severe’), antibiotics administered and clinical outcomes. Chest X-ray (CXR) findings were classified as either ‘definite’, ‘possible’ or ‘nil infiltrate’ based on the radiologist’s report. Those with ‘nil infiltrate’ on CXR, who therefore did not meet a radiological definition of CAP, were excluded from subsequent analysis. Those in whom an early decision was made to withdraw treatment on palliative grounds were also excluded. Chi-squared, independent t-tests and Mann–Whitney U-tests were used as appropriate to explore associations between patients who died versus those who survived. Multivariate analysis using binary logistic regression was employed to define further independent predictors of mortality amongst clinical markers previously described as determinants of mortality and additional factors we considered relevant to this elderly comorbid population. Diagnostic performances of CORB, CURB-65 and 613
Brief Communications
Table 1 Severity according to scoring criteria (n = 157) Pneumonia severity score
Mild (%)
Moderate (%)
Severe (%)
CORB CURB-65 SMART-COP
9 (5.7) 19 (12) 94 (60)
50 (32) 30 (19) 40 (25)
98 (62) 108 (69) 23 (15)
SMART-COP were determined by calculating sensitivity, specificity and negative predictive value (NPV) of a ‘severe’ classification relative to mortality, where a ‘severe’ classification is a positive test result and mortality is the ‘gold standard’. Importantly, each of these scores uses objective criteria that can be reliably defined retrospectively. The primary study outcome was the diagnostic performance of PSSS in GIM patients. The secondary outcome of the study was the association between various demographic, clinical and pathological variables and mortality. Of the 199 patients eligible for the audit, medical records were available for 196 of whom 29 (15%) were excluded because of having no CXR infiltrate and a further 10 (5%) because of early palliation. This left a total of 157 in whom data were analysed.
This population had a median age of 83 [IQR: 74–87], with 93 (59%) being male and 39 (25%) from residential care. Most spoke English at home (72%); however, over a half were born outside Australia (59%). The population also had multiple comorbidities, with 69 (44%) having cardiovascular disease, 58 (37%) diabetes mellitus, 59 (38%) asthma or chronic obstructive pulmonary disease, 43 (27%) dementia, 34 (22%) chronic kidney disease and 25 (16%) having a malignancy. Median length of stay was 6 days [IQR: 3–9] CXR findings showed that 101 (64%) were defined as having a definite infiltrate and 56 (36%) a possible infiltrate. Severity according to the three PSSS is described in Table 1. Overall mortality was 23 (15%). Deceased patients (n = 23) were compared with survivors (n = 134) with respect to demographic and clinical associations with mortality (Table 2). The diagnostic accuracy of a ‘severe’ score (CORB, CURB-65 and SMART-COP) relative to mortality outcome in terms of sensitivity, specificity and NPV was also calculated (Table 3). The odds ratio of a severe pneumonia severity score with respect to the gold standard of mortality in this population was 2.4 [CI 0.9–6.9] (P = 0.09), 1.7 [CI: 0.6–
Table 2 Associations with mortality (n = 157) Variable
Residential Care Dementia Malignancy Acute confusion Oxygen SaO2 ≤90% Variable
Age (years) Respiratory rate Systolic blood pressure Heart rate Urea (mmol/L) Albumin (g/L) †
Mortality (%)
Odds ratio [95% CI] (univariate analysis)
P value (univariate analysis)
P value (multivariate analysis)†
31 28 28 26 19
4.3 [1.7–10.9] 3.6 [1.5–9.0] 2.8 [1.0–7.8] 3.2 [1.3–7.9] 5.9 [1.9–18.1]
0.001 0.004 0.04 0.01 0.001
0.17 0.02 0.07 NS 0.02
Died (median [IQR] or mean ± SD)
Survived (median [IQR] or mean ± SD)
P value (univariate analysis)
P value (multivariate analysis)†
86 [83–89] 30 ± 7 100 ± 19 115 ± 23 18 ± 9 30 ± 6
81 [72–87] 27 ± 6 105 ± 18 107 ± 23 11 ± 8 34 ± 5
0.005 0.0 0.24 0.12 0.001 0.005
0.29 NS NS NS 0.07 0.03
Binary logistic regression. NS, not significant.
Table 3 Diagnostic performance of pneumonia severity scoring systems Pneumonia severity score, ‘severe’ CORB ≥ 2 CURB65 ≥ 3 SMART-COP ≥ 5
614
Mortality of those not meeting ‘severe’ PSSS criteria (%)
Mortality of those meeting ‘severe’ PSSS criteria (%)
Sensitivity (%)
Specificity (%)
Negative predictive value (%)
5/59 (8) 5/49 (10) 13/134 (10)
18/98 (18) 18/108 (17) 10/23 (43)
78 78 43
40 33 90
92 90 90
© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
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5.1] (P = 0.29) and 7.1 [CI: 2.6–19.5] (P < 0.001) for CORB, CURB-65 and SMART-COP respectively. In conclusion, our GIM treats CAP in a population that is extremely elderly and has multiple comorbidities, with a high proportion coming from residential care. Of those meeting a case definition of CAP, scoring criteria defined 98 (62%) and 108 (69%) with ‘severe’ CAP using the CORB and CURB-65 criteria respectively, contrasting with only 23 (15%) by SMART-COP criteria. Notably, as predictors of mortality, ‘severe’ CORB, CURB-65 and SMART-COP scores had diagnostic sensitivities of 78%, 78% and 44%, specificities of 40%, 33% and 90% and NPV of approximately 90% (92%, 90% and 90% respectively). Although limited to a single-unit, single-centre study with retrospective ascertainment and data collection, this
References 1 Buising KL, Thursky KA, Black JF, MacGregor L, Street AC, Kennedy MP et al. Identifying severe community-acquired pneumonia in the emergency department: a simple clinical prediction tool. Emerg Med Australas 2007; 19: 418–26.
study illustrates that the three PSSS performed similarly well in safely classifying patients at lowest risk of death in this GIM population. SMART-COP, although more specific, was much less sensitive. CORB and CURB-65 performed similarly. In addition to the diagnostic performance of PSSS evaluated in this study, practical considerations may also be important in choosing the best test to use in this setting. As well as being less sensitive, SMART-COP is also the most difficult to perform (requiring arterial blood gases). Similarly, although CORB and CURB65 have similar diagnostic performance, CORB is simpler to use (CURB65 requires the results of a blood urea) and therefore has added advantages of practicality. Clinicians should also recognise that residential care, dementia and malignancy may predict poor prognosis in this group.
2 Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58: 377–82. 3 Charles PGP, Wolfe R, Whitby M, Fine MJ, Fuller AJ, Stirling R et al. SMART-COP: A tool for predicting the
need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008; 47: 375–83. 4 eTG complete [Internet]. Therapeutic Guidelines (Antibiotic). Melbourne: Therapeutic Guidelines Limited 2013 [cited 2013 Dec 6]. Available from URL: http://online.tg.org.au
L E T T E R S TO T H E E D I TO R
Clinical-scientific notes
High-dose methylprednisolone is effective in treating radiation-induced refractory haemorrhagic cystitis Haemorrhagic cystitis (HC), characterised by the presentation of painful macroscopic haematuria and even obstructive renal failure or death, is commonly seen in patients undergoing cyclophosphamide and/or radiation therapy. Conventional management for HC includes continuous bladder irrigation, cystoscopic clot evacuation, electrocoagulation of bleeding vessels, intravesical therapy with chemicals (sodium hyaluronate, aluminum, granulocyte-macrophage colony-stimulating factor and prostaglandin), oestrogens and hyperbaric oxygen therapy. However, there is no standard treatment for HC.1 We report here a severe case of HC that was suc© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
cessfully treated with high-dose methylprednisolone after all the above-mentioned treatments had failed to produce an effective response. A 60-year-old Chinese man presented with systemic lymph node enlargement and fatigue in May 2008. Both bone marrow and cervical lymph node biopsies revealed mantle cell lymphoma. The patient reached complete response after two cycles of dose-adjusted R-EPOCH (rituximab, etoposide, vincristine, doxorubicin, cyclophosphamide and prednisone), which included rituximab 375 mg/m2 IV and etopside 50 mg/m2 on day 1; cyclophosphamide 750 mg/m2 IV on day 5, doxorubicin 10 mg/m2 IV on day 1, vincristine 0.4 mg IV on days 1–4 and prednisone 60 mg/m2 PO on days 1–5, every 21 days for 4 cycles. In November 2011, mantle cell lymphoma relapse was confirmed by cervical lymph node biopsies. He 615
Brief Communications
CORB is the best pneumonia severity score for elderly hospitalised patients with suspected pneumonia E. Williams,1 J. Girdwood,1 E. Janus2 and H. Karunajeewa1 1
General Internal Medicine, Western Health and 2Department of Medicine, North West Academic Centre, The University of Melbourne, Western
Hospital, Melbourne, Victoria, Australia
Key words respiratory tract infection, pneumonia, internal medicine, communicable disease, aged. Correspondence Eloise Williams, Western Health, Gordon Street, Footscray, Vic. 3011, Australia. Email: [email protected]
Abstract Pneumonia severity scoring systems have been developed to identify patients at highest mortality risk, and are used in guidelines to limit use of broad-spectrum antibiotics to patients with severe community-acquired pneumonia. A retrospective audit of hospitalised general internal medicine patients with pneumonia was performed to assess the diagnostic performance of various pneumonia severity scores in an elderly general internal medicine population.
Received 7 October 2013; accepted 17 January 2014. doi:10.1111/imj.12445
Community-acquired pneumonia (CAP) is the leading infectious cause of death in developed countries and represents the leading cause of admission to the General Internal Medical (GIM) service at our institution. Numerous pneumonia severity scoring systems (PSSS), such as CORB,1 CURB-652 and SMART-COP3 have been developed to identify patients at highest mortality risk, enable optimal medical treatment and have been employed in Australian guidelines4 that aim to limit use of broadspectrum antibiotics to the sickest patients. However, these scoring systems have been developed in emergency department settings and include patients managed by various inpatient units. Their applicability and usefulness are unclear in the GIM patient population, a group characterised by advanced age, multiple comorbidities and diagnostic uncertainty due to overlap syndromes. This group represents 53% of all adults with a pneumonia-related discharge-related group code (DRG) at our institution where the median age of patients admitted under GIM with a DRG of pneumonia is 83. Given the high mortality and high resource utilisation needs of this group, and our rapidly ageing population, they will become an increasingly important subgroup of CAP patients treated in the modern Australian hospital system. We describe a study that aimed to assess the utility of the
Funding: None. Conflict of interest: None. © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
CORB’, CURB-65 and SMART-COP PSSS in the GIM population at a single institution. A retrospective audit was conducted of consecutive adult (age >18 years) patients admitted under a GIM unit at Footscray Hospital campus of Western Health, a tertiary teaching hospital servicing the Western suburbs of Melbourne. Those with a DRG code consistent with CAP during the winter months of 2010 and 2011 had medical record review and data collected onto a standardised case record form to document baseline demographic and clinical variables, determine disease severity according to CORB, CURB-65 and SMART-COP tools (‘mild’, ‘moderate’ and ‘severe’), antibiotics administered and clinical outcomes. Chest X-ray (CXR) findings were classified as either ‘definite’, ‘possible’ or ‘nil infiltrate’ based on the radiologist’s report. Those with ‘nil infiltrate’ on CXR, who therefore did not meet a radiological definition of CAP, were excluded from subsequent analysis. Those in whom an early decision was made to withdraw treatment on palliative grounds were also excluded. Chi-squared, independent t-tests and Mann–Whitney U-tests were used as appropriate to explore associations between patients who died versus those who survived. Multivariate analysis using binary logistic regression was employed to define further independent predictors of mortality amongst clinical markers previously described as determinants of mortality and additional factors we considered relevant to this elderly comorbid population. Diagnostic performances of CORB, CURB-65 and 613
Brief Communications
Table 1 Severity according to scoring criteria (n = 157) Pneumonia severity score
Mild (%)
Moderate (%)
Severe (%)
CORB CURB-65 SMART-COP
9 (5.7) 19 (12) 94 (60)
50 (32) 30 (19) 40 (25)
98 (62) 108 (69) 23 (15)
SMART-COP were determined by calculating sensitivity, specificity and negative predictive value (NPV) of a ‘severe’ classification relative to mortality, where a ‘severe’ classification is a positive test result and mortality is the ‘gold standard’. Importantly, each of these scores uses objective criteria that can be reliably defined retrospectively. The primary study outcome was the diagnostic performance of PSSS in GIM patients. The secondary outcome of the study was the association between various demographic, clinical and pathological variables and mortality. Of the 199 patients eligible for the audit, medical records were available for 196 of whom 29 (15%) were excluded because of having no CXR infiltrate and a further 10 (5%) because of early palliation. This left a total of 157 in whom data were analysed.
This population had a median age of 83 [IQR: 74–87], with 93 (59%) being male and 39 (25%) from residential care. Most spoke English at home (72%); however, over a half were born outside Australia (59%). The population also had multiple comorbidities, with 69 (44%) having cardiovascular disease, 58 (37%) diabetes mellitus, 59 (38%) asthma or chronic obstructive pulmonary disease, 43 (27%) dementia, 34 (22%) chronic kidney disease and 25 (16%) having a malignancy. Median length of stay was 6 days [IQR: 3–9] CXR findings showed that 101 (64%) were defined as having a definite infiltrate and 56 (36%) a possible infiltrate. Severity according to the three PSSS is described in Table 1. Overall mortality was 23 (15%). Deceased patients (n = 23) were compared with survivors (n = 134) with respect to demographic and clinical associations with mortality (Table 2). The diagnostic accuracy of a ‘severe’ score (CORB, CURB-65 and SMART-COP) relative to mortality outcome in terms of sensitivity, specificity and NPV was also calculated (Table 3). The odds ratio of a severe pneumonia severity score with respect to the gold standard of mortality in this population was 2.4 [CI 0.9–6.9] (P = 0.09), 1.7 [CI: 0.6–
Table 2 Associations with mortality (n = 157) Variable
Residential Care Dementia Malignancy Acute confusion Oxygen SaO2 ≤90% Variable
Age (years) Respiratory rate Systolic blood pressure Heart rate Urea (mmol/L) Albumin (g/L) †
Mortality (%)
Odds ratio [95% CI] (univariate analysis)
P value (univariate analysis)
P value (multivariate analysis)†
31 28 28 26 19
4.3 [1.7–10.9] 3.6 [1.5–9.0] 2.8 [1.0–7.8] 3.2 [1.3–7.9] 5.9 [1.9–18.1]
0.001 0.004 0.04 0.01 0.001
0.17 0.02 0.07 NS 0.02
Died (median [IQR] or mean ± SD)
Survived (median [IQR] or mean ± SD)
P value (univariate analysis)
P value (multivariate analysis)†
86 [83–89] 30 ± 7 100 ± 19 115 ± 23 18 ± 9 30 ± 6
81 [72–87] 27 ± 6 105 ± 18 107 ± 23 11 ± 8 34 ± 5
0.005 0.0 0.24 0.12 0.001 0.005
0.29 NS NS NS 0.07 0.03
Binary logistic regression. NS, not significant.
Table 3 Diagnostic performance of pneumonia severity scoring systems Pneumonia severity score, ‘severe’ CORB ≥ 2 CURB65 ≥ 3 SMART-COP ≥ 5
614
Mortality of those not meeting ‘severe’ PSSS criteria (%)
Mortality of those meeting ‘severe’ PSSS criteria (%)
Sensitivity (%)
Specificity (%)
Negative predictive value (%)
5/59 (8) 5/49 (10) 13/134 (10)
18/98 (18) 18/108 (17) 10/23 (43)
78 78 43
40 33 90
92 90 90
© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
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5.1] (P = 0.29) and 7.1 [CI: 2.6–19.5] (P < 0.001) for CORB, CURB-65 and SMART-COP respectively. In conclusion, our GIM treats CAP in a population that is extremely elderly and has multiple comorbidities, with a high proportion coming from residential care. Of those meeting a case definition of CAP, scoring criteria defined 98 (62%) and 108 (69%) with ‘severe’ CAP using the CORB and CURB-65 criteria respectively, contrasting with only 23 (15%) by SMART-COP criteria. Notably, as predictors of mortality, ‘severe’ CORB, CURB-65 and SMART-COP scores had diagnostic sensitivities of 78%, 78% and 44%, specificities of 40%, 33% and 90% and NPV of approximately 90% (92%, 90% and 90% respectively). Although limited to a single-unit, single-centre study with retrospective ascertainment and data collection, this
References 1 Buising KL, Thursky KA, Black JF, MacGregor L, Street AC, Kennedy MP et al. Identifying severe community-acquired pneumonia in the emergency department: a simple clinical prediction tool. Emerg Med Australas 2007; 19: 418–26.
study illustrates that the three PSSS performed similarly well in safely classifying patients at lowest risk of death in this GIM population. SMART-COP, although more specific, was much less sensitive. CORB and CURB-65 performed similarly. In addition to the diagnostic performance of PSSS evaluated in this study, practical considerations may also be important in choosing the best test to use in this setting. As well as being less sensitive, SMART-COP is also the most difficult to perform (requiring arterial blood gases). Similarly, although CORB and CURB65 have similar diagnostic performance, CORB is simpler to use (CURB65 requires the results of a blood urea) and therefore has added advantages of practicality. Clinicians should also recognise that residential care, dementia and malignancy may predict poor prognosis in this group.
2 Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58: 377–82. 3 Charles PGP, Wolfe R, Whitby M, Fine MJ, Fuller AJ, Stirling R et al. SMART-COP: A tool for predicting the
need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008; 47: 375–83. 4 eTG complete [Internet]. Therapeutic Guidelines (Antibiotic). Melbourne: Therapeutic Guidelines Limited 2013 [cited 2013 Dec 6]. Available from URL: http://online.tg.org.au
L E T T E R S TO T H E E D I TO R
Clinical-scientific notes
High-dose methylprednisolone is effective in treating radiation-induced refractory haemorrhagic cystitis Haemorrhagic cystitis (HC), characterised by the presentation of painful macroscopic haematuria and even obstructive renal failure or death, is commonly seen in patients undergoing cyclophosphamide and/or radiation therapy. Conventional management for HC includes continuous bladder irrigation, cystoscopic clot evacuation, electrocoagulation of bleeding vessels, intravesical therapy with chemicals (sodium hyaluronate, aluminum, granulocyte-macrophage colony-stimulating factor and prostaglandin), oestrogens and hyperbaric oxygen therapy. However, there is no standard treatment for HC.1 We report here a severe case of HC that was suc© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
cessfully treated with high-dose methylprednisolone after all the above-mentioned treatments had failed to produce an effective response. A 60-year-old Chinese man presented with systemic lymph node enlargement and fatigue in May 2008. Both bone marrow and cervical lymph node biopsies revealed mantle cell lymphoma. The patient reached complete response after two cycles of dose-adjusted R-EPOCH (rituximab, etoposide, vincristine, doxorubicin, cyclophosphamide and prednisone), which included rituximab 375 mg/m2 IV and etopside 50 mg/m2 on day 1; cyclophosphamide 750 mg/m2 IV on day 5, doxorubicin 10 mg/m2 IV on day 1, vincristine 0.4 mg IV on days 1–4 and prednisone 60 mg/m2 PO on days 1–5, every 21 days for 4 cycles. In November 2011, mantle cell lymphoma relapse was confirmed by cervical lymph node biopsies. He 615
