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Original Research: PNEUMONIA |

Prospective Comparison of Severity Scores for Predicting Clinically Relevant Outcomes for Patients Hospitalized With Community-Acquired Pneumonia FREE TO VIEW

Pedro Pablo España Yandiola, MD; Alberto Capelastegui, MD; José Quintana, MD; Rosa Diez, RN; Inmaculada Gorordo, MD; Amaia Bilbao, MSc; Rafael Zalacain, MD; Rosario Menendez, MD; Antonio Torres, MD
Author and Funding Information

Correspondence to: Pedro Pablo España Yandiola, MD, Service of Pneumology, Hospital Galdakao-Usansolo, Barrio Labeaga s/n. 48960 Galdakao, Bizkaia, Spain; e-mail: pedropablo.espanayandiola@osakidetza.net


The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(6):1572-1579. doi:10.1378/chest.08-2179
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Published online

Background:  The comparative accuracy and discriminatory power of three validated rules for predicting clinically relevant outcomes other than mortality in patients hospitalized with community-acquired pneumonia (CAP) are unknown.

Methods:  We prospectively compared the newly developed severe community-acquired pneumonia (SCAP) score, pneumonia severity index (PSI), and the British Thoracic Society confusion, urea > 7 mmol/L, respiratory rate ≥ 30 breaths/min, BP < 90 mm Hg systolic or < 60 mm Hg diastolic, age ≥ 65 years (CURB-65) rule in an internal validation cohort of 1,189 consecutive adult inpatients with CAP from one hospital and an external validation cohort of 671 consecutive adult inpatients from three other hospitals. Major adverse outcomes were admission to ICU, need for mechanical ventilation, progression to severe sepsis, or treatment failure. Mean hospital length of stay (LOS) was also evaluated. The rules were compared based on sensitivity, specificity, and area under the curve (AUC) of the receiver operating characteristic.

Results:  The rate of all adverse outcomes and hospital LOS increased directly with increasing SCAP, PSI, or CURB-65 scores (p < 0.001) in both cohorts. Patients classified as high risk by the SCAP score showed higher rates of adverse outcomes (ICU admission, 35.8%; mechanical ventilation, 16.4%; severe sepsis, 98.5%; treatment failure, 22.4%) than PSI and CURB-65 high-risk classes. The discriminatory power of SCAP, as measured by AUC, was 0.75 for ICU admission, 0.76 for mechanical ventilation, 0.79 for severe sepsis, and 0.61 for treatment failure in the external validation cohort. AUC differences with PSI or CURB-65 were found.

Conclusions:  The SCAP score is as accurate or better than other current scoring systems in predicting adverse outcomes in patients hospitalized with CAP while helping classify patients into different categories of increasing risk for potentially closer monitoring.

Figures in this Article

Severity scores provide pivotal direction for the management of community-acquired pneumonia (CAP), helping guide decisions such as the appropriate venue for care, diagnostic strategies, and antibiotic therapies. The most popular severity scores, the pneumonia severity index (PSI)1 and the British Thoracic Society's CURB-65 Confusion, Urea > 7 mmol/L, Respiratory rate ≥ 30 breaths/min, Blood pressure < 90 mm Hg systolic or < 60 mm Hg diastolic, age ≥ 65 years2 are accurate for predicting pneumonia-related mortality.39 But clinical care should be based on a broader set of medical outcomes than just mortality.10,11 Unfortunately, there is no consensus surrounding serious complications that warrant hospitalization for patients with pneumonia.

We recently developed a clinical prediction rule for severe CAP, called the severe community-acquired pneumonia (SCAP) score,12 that predicts hospital mortality, need for mechanical ventilation, and risk for septic shock. The aims of this study were to validate in two independent cohorts of patients hospitalized with CAP the accuracy and discriminatory power of the SCAP score in predicting several clinically relevant outcomes, such as admission to the ICU, need for mechanical ventilation, progression to severe sepsis and treatment failure and their correlation with length of stay (LOS) in the hospital, and thus to evaluate its ability to stratify patients with CAP into different management groups and to compare it with the PSI and CURB-65.

Study Setting and Design

The SCAP score12 PSI,1 and CURB-652 were internally validated in Galdakao Hospital, a 400-bed teaching hospital in the Basque Country (northern Spain) that serves a population of 300,000 residents. It belongs to the network of public hospitals of the Basque Health Care Service, which provides free unrestricted care to nearly 100% of the population. Consecutive patients with a diagnosis of CAP who visited the hospital's emergency department (ED) between July 15, 2003, and June 30, 2007, were included in the study. During the study, a guideline for the management of patients with CAP (described in more detail elsewhere3,13) was implemented.

The SCAP score was externally validated using data from 671 consecutive adult patients hospitalized for CAP between November 1, 2005, and July 31, 2006, in one of the following three nearby large teaching hospitals: Cruces Hospital in Vizcaya, Clinical Hospital in Barcelona, and La Fe Hospital in Valencia.

Study Population

In both the internal and external validation cohorts, the study population consisted of adults 18 years or older consecutively admitted to the ED with a diagnosis of CAP. Only individuals for whom CAP was suspected within the first 24 h after ED arrival were included. Pneumonia was defined as pulmonary infiltrates on chest radiograph not known to be old and symptoms that were consistent with pneumonia, including cough, dyspnea, fever, and/or pleuritic chest pain. Patients with pneumonia were excluded if they were known to be positive for HIV, were chronically immunosuppressed, had been hospitalized for the previous 14 days, or were living in a nursing home.

Patient Characteristics and Assessment of Indicators

Clinical and demographic characteristics of each patient were recorded, including variables needed to determine the PSI (20 variables), CURB-65 (5 variables), and SCAP score (8 variables (Fig 1). Missing values were set to normal. PSI, CURB-65, and SCAP score classes were assigned according to the original authors' designations.1,2,12 Patients were assigned to low-, intermediate-, and high-risk classes as follows: PSI score: low risk, classes I through III; intermediate risk, class IV; and high risk, class V; CURB-65: low risk, classes 0 to 1; intermediate risk, class 2; and high risk, classes 3 through 5; SCAP score: low risk, classes 0 to 1 (0 to 9 points); intermediate risk, class 2 (10 to 19 points); and high risk, classes 3 to 4 (≥ 20 points). All patients were treated empirically with antibiotics according to local practice guidelines.14,15

Figure Jump LinkFigure 1 SCAP12 score classification algorithm.Grahic Jump Location
Assessment of Outcomes

The following four adverse outcomes were evaluated: ICU admission, need for mechanical ventilation, progression to severe sepsis, and treatment failure. Severe sepsis was defined as sepsis associated with organ dysfunction and perfusion abnormalities.16 One of the following criteria had to be met: pH < 7.30, systolic BP < 90 mm Hg, pneumonia-associated altered mental status, Pao2/fraction of inspired oxygen ratio < 250, acute renal failure (creatinine > 2 mg/100 mL), disseminated intravascular coagulopathy, or hematocrit < 25. A patient was classified as having treatment failure if during the hospital stay clinical deterioration developed (understood as a persistence/reappearance of the clinical symptoms consistent with pneumonia) with any of the following: hemodynamic instability; demonstrated respiratory failure or the appearance of it; required mechanical ventilation; demonstrated radiographic progression of pneumonia or the appearance of new infectious foci, irrespective of the time but during hospital stay; or absence or delay in achieving clinical stability after the first 72 h.17 Patients with terminal conditions were defined as any patient with metastatic cancer, advanced dementia, or a disease or condition with a high likelihood of mortality within 30 days. Hospital LOS was estimated by subtracting the admission date from the discharge date (in-hospital deaths were excluded). The project was approved by the respective hospitals' ethics review boards.

Statistical Analysis

Descriptive statistics of sociodemographic and clinical variables included frequencies, percentages, means, and SDs. For the comparison of both cohorts, we used the Fisher exact test for dichotomous variables and the Student t test, or the nonparametric Wilcoxon test when normality could not be assumed.

For evaluating adverse outcomes across the three instruments and three risk classes, analysis of variance (ANOVA) with the Scheffé method for multiple comparisons or the Kruskal-Wallis test were used for continuous variables and the χ2 test for categorical variables.

We also dichotomized risk classes into low vs intermediate-high severity. For this analysis, we estimated severity, specificity, odds ratio, 95% confidence intervals, and area under the curve (AUC) of the receiver operating characteristic for all rules and adverse outcomes but only in the external validation cohort. Receiver operating characteristic curves were calculated for the PSI, CURB-65, and SCAP scores to evaluate how well they identified patients who had an adverse outcome.18 Estimated AUC values were compared by using the nonparametric method described by Hanley and NcNeil.19

A two-tailed p value < 0.05 was considered statistically significant. All statistical analyses were performed using a statistical software package (SAS for Windows, version 9.0; SAS Institute; Cary, NC).

A total of 1,189 patients were enrolled in the internal validation cohort and 671 inpatients in the external validation cohort. Sociodemographic features and outcomes for both cohorts are described in Table 1. In the internal validation cohort, adverse outcomes occurred in 462 patients (38.9%) and the in-hospital mortality rate was 6.1%. In the external validation cohort, adverse outcomes occurred in 261 patients (38.8%) and the in-hospital mortality rate was 3.7%. After adjusting for terminal conditions and age, mortality rates did not differ significantly between the two cohorts (p = 0.18).

Table Graphic Jump Location
Table 1 Sociodemographic Characteristics in the Prospective Internal and External Validation Cohorts*

*Values are given as No. (%), unless otherwise indicated. Proportions were calculated after subtracting missing observations from the denominator. Fio2 = fraction of inspired oxygen.

†p Value compares inpatients from the internal and the external validation cohorts.

‡Values given as mean (SD).

§Terminal conditions were defined as any patient with metastatic cancer, advanced dementia, or a disease or condition with a high likelihood of mortality within 30 days.

Tables 2, 3, and 4 show the predictive accuracy of the PSI, CURB-65, and SCAP score for ICU admission, need for mechanical ventilation, development of severe sepsis, prediction of treatment failure, and LOS for all patients in both cohorts. The adverse outcome rate increased steadily from low- to high-risk classes for all three instruments (p < 0.001) in the external validation cohort. In the internal validation cohort, no significant increase in outcomes such as ICU admission or mechanical ventilation was observed for the PSI and CURB-65. The average LOS increased steadily from low- to high-risk classes, but differences were observed only among the three risk classes for the SCAP score in the two validation cohorts. The SCAP score correctly classified a significantly greater proportion of patients as low risk in both cohorts than did PSI or CURB-65. Patients classified by SCAP as high-risk class had a higher rate of ICU admission, need for mechanical ventilation, and severe sepsis or treatment failure than patients classified as high-risk class by PSI and CURB-65.

Table Graphic Jump Location
Table 2 Comparison of Different Outcome Measures of SCAP Predictive Score

*Statistically significant differences (by ANOVA with Scheffé test) in hospital LOS among the three SCAP classes were found among all three classes in both cohorts.

Table Graphic Jump Location
Table 3 Comparison of Different Outcome Measures of PSI Predictive Rule

*Statistically significant differences (by ANOVA with Scheffé test) in hospital LOS among the three PSI classes were found between all of them in the external cohort while in the internal just between low vs intermediate or high classes.

†In the external validation three cases were missing for PSI evaluation.

Table Graphic Jump Location
Table 4 Comparison of Different Outcome Measures of the CURB-65 Predictive Rule

*Statistically significant differences (by ANOVA with Scheffé test) in hospital LOS among the three CURB-65 classes were found between low vs intermediate or high classes in the internal cohort, whereas in the external cohort they were found between high vs intermediate or low classes.

Table 5 shows the sensitivity, specificity, and AUC values for the four adverse outcomes in the external validation cohorts when all rules were dichotomized as low risk vs higher risk. The SCAP score had higher sensitivity, specificity, and AUC than the PSI and CURB-65. All three scores were associated with low AUC discrimination for treatment failure. There were statistically significant differences among the three scores in sensitivity, specificity, and AUC, all favoring the SCAP score.

Table Graphic Jump Location
Table 5 Predictive Values of Scores for Adverse Outcomes in the External Validation Cohort*

*The scores were dichotomized as low risk vs higher risk (SCAP score ≥ 2, CURB-65 ≥ 2, and PSI ≥ IV). CI = confidence interval.

†Statistically significant difference (vs PSI and CURB-65).

‡Statistically significant difference (vs CURB-65).

§Statistically significant difference (vs SCAP).

‖Statistically significant difference (vs SCAP and CURB-65).

¶No difference.

#Statistically significant difference (vs SCAP and PSI).

Accurately assessing the severity of pneumonia is the key to managing patients with CAP appropriately. Clinical care should be based on a broader set of medical outcomes than mortality alone.10,11 In this study, conducted in two large cohorts of patients hospitalized with CAP, the SCAP score is slightly more accurate than the widely used PSI and CURB-65 in predicting adverse outcomes in patients hospitalized with CAP and performed best for all four outcomes.

Several previous studies comparing the PSI and CURB-65 found that these tools were not ideal for predicting ICU admission.6,9 In an effort to better predict which patients require ICU admission, the American Thoracic Society and the Infectious Diseases Society of America have proposed a new severity risk score, but it has yet to be evaluated.20 Capelastegui et al9 and Buising et al7 have shown that the PSI and CURB-65 appropriately stratify the need for mechanical ventilation and the duration of hospital stay.

Early identification and treatment of severe sepsis, especially in the ED, may improve short-term mortality.21 In an analysis22 of the Patient Outcome and Research Team study, 48% of hospitalized CAP patients developed severe sepsis during the course of the disease, and PSI scores were correlated with severe sepsis (p < 0.001).

The rate of treatment failure in CAP is 10 to 15%, and it increases mortality nearly fivefold.17 Although it is reasonable to assume that more severe CAP is associated with a higher incidence of empirical treatment failure, few studies have related severity scores with this outcome. Menéndez et al23 found that the PSI score was an independent risk factor associated with treatment failure.

In this study, the 5-day difference in average LOS and the appreciable difference in in-hospital mortality between the two cohorts are almost certainly related to the implementation of practice guidelines for CAP at Galdakao Hospital.3,13 The use of practice guidelines may have led to higher admission rates among older patients and those with poorer functional status on admission, as well as shorter LOS.24 In addition, mortality in the external validation cohort was lower than the average mortality reported for other CAP studies.1,8

Our study shows that the SCAP score is slightly better than the PSI and CURB-65 in predicting adverse outcomes other than mortality in two independent cohorts. In the external validation cohort, the rate of these outcomes increased steadily from low- to high-risk classes for the SCAP score as well as for the PSI and CURB-65 (p < 0.001). In the internal validation cohort, there were no significant differences in outcomes such as ICU admission and mechanical ventilation for the PSI and CURB-65. This could be attributed to a lower proportion of these two outcomes in the internal validation cohort.

All three scores predicted treatment failure with low to moderate discrimination in the external validation cohort. It must be noted that the initial severity of CAP is only one factor predicting treatment failure. Other factors, such as the causal microorganism and treatment-related factors,17 are not part of the three prediction tools.

The SCAP score classified a significantly higher proportion of patients as low risk in both cohorts than the PSI and CURB-65, with lower rates of all adverse outcomes. Another goal of the tool is its negative predictive value. If the score is low, ICU admission and others adverse outcomes are very unlikely. In addition, patients identified as high risk by the SCAP score had somewhat higher rates of ICU admissions, need for mechanical ventilation, and severe sepsis compared with the PSI and CURB-65. Thus, applying the SCAP score as in Figure 1 would identify CAP patients who should receive closer monitoring and more aggressive treatment.

Given the somewhat poorer predictive power of the PSI and CURB-65 in the internal validation cohort, the sensitivity, specificity, and AUC of the three scores were compared in the external validation cohort. Although the SCAP score had significantly better sensitivities and specificities than the PSI and CURB-65, the differences were small and of uncertain clinical relevance.

The SCAP is easier to implement than the PSI because it uses only 8 variables compared to 20 for the PSI. The CURB-65, with just five variables, is probably the easiest to remember and apply, although it is less accurate at predicting adverse outcomes. The discriminatory power of CURB-65 appears to be reduced by the use of cut points for diastolic BP of ≤ 60 mm Hg and a serum urea level of 20 mg/dL, especially in elderly patients for whom a low diastolic pressure and a raised urea level are common.25,26 The CURB-65 also lacks a formal assessment of vital signs like hypoxemia, a major drawback in light of the importance of assessing oxygenation immediately on arrival at the ED.27

Recently, a new score has been published, namely the SMART-COP,28 for predicting the need for intensive respiratory or vasopressor support. This score is similar to the SCAP, although somewhat more complex, because it consists of the following eight clinical and laboratory factors with different cutoff values for different age groups: S, low systolic BP, 2 points; M, multilobar chest radiography involvement, 1 point; A, low albumin level, 1 point; R, high respiratory rate, 1 point; T, tachycardia, 1 point; C, confusion, 1 point; O, poor oxygenation, 2 points, and P, low arterial pH, 2 points. Among a small sample of patients (n = 288) in our internal validation prospective cohort who presented all eight of the variables of SMART-COP, this tool had sensitivities ranging between 69% and 75% for all of our adverse outcomes (except 100% for mechanical ventilation) and specificities approximately 51% (except 71.9% for severe sepsis).

Our study has several strengths. It included two large independent cohorts of hospitalized CAP patients. The accuracy and generalizability of the SCAP score are supported by its external validation. Patients were assessed using data readily available at the point of care in the ED when most management decisions are made. Data for each patient were recorded prospectively, which allowed us to compile relevant clinical information.

Limitations of the study deserve consideration. It is possible that the study sample did not reflect the full spectrum of adverse outcomes that can occur in the evolution of CAP. However, some of these outcomes, although relevant, are subject to a certain degree of variability in their interpretation. For example, it is well known that ICU admission depends on individual and hospital-dependent clinical practices.29 The use of other criteria to define treatment failure or the use of different cut points for defining the presence of organ dysfunction for severe sepsis may also lead to different outcomes.

In conclusion, the SCAP score is a simple severity assessment tool that is slightly better than other current scoring systems in predicting adverse outcomes such as ICU admission, development of severe sepsis, need for mechanical ventilation, and therapeutic failure. The main usefulness of the SCAP score is its ability to identify patients who need more aggressive monitoring and treatment after their initial evaluation in the ED. Further research is needed before the SCAP score is widely implemented as a decision aid. In the meantime, the consistency of our findings suggests that this rule can be applied with some confidence in current practice.

ANOVA

analysis of variance

AUC

area under the curve

CAP

community-acquired pneumonia

CURB-65

confusion, urea > 7 mmol/L, respiratory rate ≥ 30 breaths/min, BP < 90 mm Hg systolic or < 60 mm Hg diastolic, age ≥ 65 years

ED

emergency department

LOS

length of stay

PSI

pneumonia severity index

SCAP

severe community-acquired pneumonia

We appreciate the support of staff members from the different services. We also acknowledge the editorial assistance provided by Patrick J. Skerrett.

Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243-250. [PubMed] [CrossRef]
 
Lim WS, van der Eerden MM, Laing R, et al. Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58:377-382. [PubMed]
 
España PP, Capelastegui A, Quintana JM, et al. A prediction rule to identify allocation of inpatient care in community-acquired pneumonia. Eur Respir J. 2003;21:695-701. [PubMed]
 
Marras TK, Gutierrez C, Chan CK. Applying a prediction rule to identify low-risk patients with community-acquired pneumonia. Chest. 2000;118:1339-1343. [PubMed]
 
Aujesky D, Auble TE, Yealy DM, et al. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med. 2005;118:384-392. [PubMed]
 
Man SY, Lee N, Ip M, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax. 2007;62:348-353. [PubMed]
 
Buising KL, Thursky KA, Black JF, et al. 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. [PubMed]
 
Ananda-Rajah MR, Charles PG, Melvani S, et al. Comparing the pneumonia severity index with CURB-65 in patients admitted with community acquired pneumonia. Scand J Infect Dis. 2007;4:1-8
 
Capelastegui A, España PP, Quintana JM, et al. Validation of a predictive rule for the management of community-acquired pneumonia. Eur Respir J. 2006;27:151-157. [PubMed]
 
Marrie TJ, Huang JQ. Low-risk patients admitted with community- acquired pneumonia. Am J Med. 2005;118:1357-1363. [PubMed]
 
Siegel RE. Clinical opinion prevails over the pneumonia severity index. Am J Med. 2005;118:1312-1313. [PubMed]
 
España PP, Capelastegui A, Gorordo I, et al. Development and validation of a clinical prediction rule for severe community- acquired pneumonia. Am J Respir Crit Care Med. 2006;174:1249-1256. [PubMed]
 
Capelastegui A, España PP, Quintana JM, et al. Improvement of process-of-care and outcomes after implementing a guideline for management of community-acquired pneumonia: a controlled before-and-after study. Clin Infect Dis. 2004;39:955-963. [PubMed]
 
Zalacain R, Dorca J, Torres A, et al. Tratamiento antibiótico empírico inicial de la neumonia adquirida en la comunidad en el paciente adulto inmunocompetente. Rev Esp Quimioterap. 2003;16:457-466
 
Alfageme I, Aspa J, Bello S, et al. Normativa para el diagnóstico y el tratamiento de la neumonía adquirida en la comunidad: Sociedad Española de Neumología y Cirugía Torácica (SEPAR). Arch Bronconeumol. 2005;41:272-289. [PubMed]
 
Levy MM, Fink M, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250-1256. [PubMed]
 
Menendez R, Torres A. Treatment failure in community-acquired pneumonia. Chest. 2007;132:1348-1355. [PubMed]
 
Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143:29-36. [PubMed]
 
Hanley JA, McNeil BJ. A method of comparing areas under receiver operating characteristic curves derived from the same cases. Radiology. 1983;148:839-843. [PubMed]
 
Mandell L, Wunderink R, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44:S27-S72. [PubMed]
 
Rivers E, Nguyen B, Ilavstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377. [PubMed]
 
Dremsizov T, Clermont G, Kellum JA, et al. Severe sepsis in community-acquired pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course? Chest. 2006;129:968-978. [PubMed]
 
Menéndez R, Torres A, Zalacain R, et al. Risk factors of treatment failure in community-acquired pneumonia: implications for disease outcome. Thorax. 2004;59:960-965. [PubMed]
 
Marrie TJ, Lau CY, Wheeler SI, et al. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. JAMA. 2000;283:749-755. [PubMed]
 
Myint PK, Kamanth AV, Vowler SL, et al. The CURB (confusion, urea, respiratory rate, and blood pressure) criteria in community-acquired pneumonia (CAP) in hospitalized elderly patients age 65 years and over: a prospective observational cohort study. Age Ageing. 2005;34:75-77. [PubMed]
 
Kamanth AV, Myint PK, Vowler SL, et al. Is it time to rethink the urea criterion in CURB-65? Eur Respir J. 2006;27:1321-1322. [PubMed]
 
Blot SI, Rodríguez A, Solé-Violán J, et al. Effects of delayed oxygenation assessment on time to antibiotic delivery and mortality in patients with severe community-acquired pneumonia. Crit Care Med. 2007;35:2509-2514. [PubMed]
 
Charles PG, Wolfe R, Whitby M, et al. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis. 2008;47:375-384. [PubMed]
 
Angus DC, Marrie TJ, Obrosky DS, et al. Severe community-acquired pneumonia: use of intensive care services and evaluation of American and British Thoracic Society diagnosis criteria. Am J Respir Crit Care Med. 2002;166:717-723. [PubMed]
 

Figures

Figure Jump LinkFigure 1 SCAP12 score classification algorithm.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 Sociodemographic Characteristics in the Prospective Internal and External Validation Cohorts*

*Values are given as No. (%), unless otherwise indicated. Proportions were calculated after subtracting missing observations from the denominator. Fio2 = fraction of inspired oxygen.

†p Value compares inpatients from the internal and the external validation cohorts.

‡Values given as mean (SD).

§Terminal conditions were defined as any patient with metastatic cancer, advanced dementia, or a disease or condition with a high likelihood of mortality within 30 days.

Table Graphic Jump Location
Table 2 Comparison of Different Outcome Measures of SCAP Predictive Score

*Statistically significant differences (by ANOVA with Scheffé test) in hospital LOS among the three SCAP classes were found among all three classes in both cohorts.

Table Graphic Jump Location
Table 3 Comparison of Different Outcome Measures of PSI Predictive Rule

*Statistically significant differences (by ANOVA with Scheffé test) in hospital LOS among the three PSI classes were found between all of them in the external cohort while in the internal just between low vs intermediate or high classes.

†In the external validation three cases were missing for PSI evaluation.

Table Graphic Jump Location
Table 4 Comparison of Different Outcome Measures of the CURB-65 Predictive Rule

*Statistically significant differences (by ANOVA with Scheffé test) in hospital LOS among the three CURB-65 classes were found between low vs intermediate or high classes in the internal cohort, whereas in the external cohort they were found between high vs intermediate or low classes.

Table Graphic Jump Location
Table 5 Predictive Values of Scores for Adverse Outcomes in the External Validation Cohort*

*The scores were dichotomized as low risk vs higher risk (SCAP score ≥ 2, CURB-65 ≥ 2, and PSI ≥ IV). CI = confidence interval.

†Statistically significant difference (vs PSI and CURB-65).

‡Statistically significant difference (vs CURB-65).

§Statistically significant difference (vs SCAP).

‖Statistically significant difference (vs SCAP and CURB-65).

¶No difference.

#Statistically significant difference (vs SCAP and PSI).

References

Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243-250. [PubMed] [CrossRef]
 
Lim WS, van der Eerden MM, Laing R, et al. Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58:377-382. [PubMed]
 
España PP, Capelastegui A, Quintana JM, et al. A prediction rule to identify allocation of inpatient care in community-acquired pneumonia. Eur Respir J. 2003;21:695-701. [PubMed]
 
Marras TK, Gutierrez C, Chan CK. Applying a prediction rule to identify low-risk patients with community-acquired pneumonia. Chest. 2000;118:1339-1343. [PubMed]
 
Aujesky D, Auble TE, Yealy DM, et al. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med. 2005;118:384-392. [PubMed]
 
Man SY, Lee N, Ip M, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax. 2007;62:348-353. [PubMed]
 
Buising KL, Thursky KA, Black JF, et al. 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. [PubMed]
 
Ananda-Rajah MR, Charles PG, Melvani S, et al. Comparing the pneumonia severity index with CURB-65 in patients admitted with community acquired pneumonia. Scand J Infect Dis. 2007;4:1-8
 
Capelastegui A, España PP, Quintana JM, et al. Validation of a predictive rule for the management of community-acquired pneumonia. Eur Respir J. 2006;27:151-157. [PubMed]
 
Marrie TJ, Huang JQ. Low-risk patients admitted with community- acquired pneumonia. Am J Med. 2005;118:1357-1363. [PubMed]
 
Siegel RE. Clinical opinion prevails over the pneumonia severity index. Am J Med. 2005;118:1312-1313. [PubMed]
 
España PP, Capelastegui A, Gorordo I, et al. Development and validation of a clinical prediction rule for severe community- acquired pneumonia. Am J Respir Crit Care Med. 2006;174:1249-1256. [PubMed]
 
Capelastegui A, España PP, Quintana JM, et al. Improvement of process-of-care and outcomes after implementing a guideline for management of community-acquired pneumonia: a controlled before-and-after study. Clin Infect Dis. 2004;39:955-963. [PubMed]
 
Zalacain R, Dorca J, Torres A, et al. Tratamiento antibiótico empírico inicial de la neumonia adquirida en la comunidad en el paciente adulto inmunocompetente. Rev Esp Quimioterap. 2003;16:457-466
 
Alfageme I, Aspa J, Bello S, et al. Normativa para el diagnóstico y el tratamiento de la neumonía adquirida en la comunidad: Sociedad Española de Neumología y Cirugía Torácica (SEPAR). Arch Bronconeumol. 2005;41:272-289. [PubMed]
 
Levy MM, Fink M, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250-1256. [PubMed]
 
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