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Original Research: Disorders of the Pleura |

A Clinical Score (RAPID) to Identify Those at Risk for Poor Outcome at Presentation in Patients With Pleural InfectionOutcome Prediction in Pleural Infection

Najib M. Rahman, DPhil; Brennan C. Kahan, MSc; Robert F. Miller, MBBS; Fergus V. Gleeson, MD; Andrew J. Nunn, MSc; Nicholas A. Maskell, DM
Author and Funding Information

From the Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit (Drs Rahman and Gleeson) and Department of Radiology (Dr Gleeson), Oxford University Hospitals, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford; National Institute of Health Research (NIHR) Oxford Biomedical Research Centre (Dr Rahman), University of Oxford, Oxford; Medical Research Council Clinical Trials Unit (Mr Kahan and Prof Nunn), Research Department of Infection and Population Health (Prof Miller), Institute of Epidemiology and Healthcare, University College London, London; and Academic Respiratory Unit, (Dr Maskell) School of Clinical Sciences, Southmead Hospital, University of Bristol, Bristol, England.

Correspondence: Najib M. Rahman, DPhil, Oxford Respiratory Trials Unit, Oxford Centre for Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Churchill Hospital Site, Headington, Oxford, OX3 7LJ UK, England; e-mail: najib.rahman@ndm.ox.ac.uk


Funding/Support: Drs Rahman and Gleeson are funded by the UK NIHR Oxford Biomedical Research Centre Programme. Dr Maskell is funded by a Clinical Senior Lectureship Higher Education Funding Council for England/United Kingdom Clinical Research Collaboration award.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(4):848-855. doi:10.1378/chest.13-1558
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Background:  Pleural infection is associated with a high morbidity and mortality. Development of a validated clinical risk score at presentation to identify those at high risk of dying would enable patient triage and may help formulate early management strategies.

Methods:  A clinical risk score was derived based on data from patients entering the multicenter UK pleural infection trial (first Multicenter Intrapleural Sepsis Trial [MIST1], n = 411). From 22 baseline clinical characteristics, model selection was undertaken to find variables predictive of poor clinical outcome. Outcomes were mortality at 3 months (primary), need for surgical intervention at 3 months, and time from randomization to discharge. The derived scoring system RAPID (renal, age, purulence, infection source, and dietary factors) was validated using patients enrolled in the subsequent MIST2 trial (n = 191).

Results:  Age, urea, albumin, hospital-acquired infection, and nonpurulence predicted poor outcome. Patients were stratified into low-risk (0-2), medium-risk (3-4), and high-risk (5-7) groups. Using the low-risk group as a reference, a RAPID score of 3 to 4 and > 4 was associated with an OR of 24.4 (95% CI, 3.1-186.7; P = .002) and 192.4 (95% CI, 25.0-1480.4; P < .001), respectively, for death at 3 months. In the validation cohort (MIST2), a medium-risk RAPID score was nonsignificantly associated with mortality (OR, 3.2; 95% CI, 0.8-13.2; P = .11), and a high-risk score was associated with increased mortality (OR, 14.1; 95% CI, 3.5-56.8; P < .001). Hospitalization duration was associated with increasing RAPID score (score 0-2: median duration = 7, interquartile range 6-13; score > 5: median duration = 15, interquartile range 9-28, P = .08).

Conclusions:  The RAPID score may permit risk stratification of patients with pleural infection at presentation.

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