P-822. Invasive but Ineffective: Routine Mycoplasma testing for CAP: A Retrospective Study

BackgroundGiven the disparity in cost between inpatient and outpatient care, the IDSA/ATS community-acquired pneumonia (CAP) guidelines recommend use of site-of-care severity of illness indicators to identify CAP patients who may be candidates for outpatient treatment. Despite this level 1 recommendation, there are limited data on US hospital community-acquired bacterial pneumonia (CABP) admissions patterns stratified by Pneumonia Severity Index (PSI) score and presence of comorbidities. This study described hospitalization and length of stay (LOS) patterns among adult patients with CABP who received ceftriaxone (CTX) and a macrolide (M) at admission in the MedAssets database. The primary objective was to quantify the proportion of admissions and associated hospital LOS among “low-risk” patients (PSI score ≤ 90) where outpatient or short admission is advocated.MethodsA retrospective study of patients hospitalized for CABP and in the MedAssets database during 2012–2015 was performed. Inclusion criteria: (1) age ≥ 18 years, (2) a primary diagnosis for CABP, (3) received CTX and a M on hospitalization Day 1 or 2, and (3) ≥1-year enrollment before the index date. For patients with multiple hospitalizations for CABP during the study period, only the first episode was considered. Distribution of hospital admissions was stratified by PSI categories and Charlson Comorbidity Index (CCI). Both PSI and CCI were derived from diagnosis codes. Hospital LOS and mortality rates were tabulated across resulting PSI-CCI categories.ResultsDuring the study period, 68,254 patients met inclusion criteria. Among hospitalized CABP patients, 35% had a PSI score ≤ 70 and 33% had a PSI score between 71–90. The mean LOS for patients with a PSI score ≤70 and 71–90 ranged between 5.2 and 6.6 days, depending on CCI score. Mortality was less than 0.5% for patients with PSI score ≤70 and 1.4% for patients with a 71–90 PSI score.ConclusionMore than two-thirds of hospitalized CABP patients who received CTX and an M had a PSI score ≤ 90. On average, hospital LOS was 5–6 days for CABP patients with PSI ≤ 90. These findings reflect the critical need to identify outpatient treatments that can effectively reduce hospital admissions.Disclosures T. Lodise, Paratek Pharmaceuticals: Consultant and Scientific Advisor, Consulting fee. K. LaPensee, Paratek Pharmaceuticals: Employee, Salary.

Aim To investigate infl uence of neutrophil-to-lymphocyte ratio (NLR) and proatherogenic risk factors to improve the accuracy of pneumonia severity index (PSI) in the prediction of community acquired pneumonia (CAP) outcome in healthy individuals. Methods A retrospective observational cross-sectional study conducted at the Clinic for Pulmonary Diseases and Tuberculosis "Podhrastovi", University Clinical Centre Sarajevo, included 83 patients with the diagnosis of CAP during the period March 2019-March 2021. Once diagnosed with CAP, PSI score was calculated and according to its value the need for hospital treatment was identifi ed. Patients were divided in two groups: low risk of CAP (PSI <90), and high risk of CAP (PSI> 90). Results The overall average hospital stay was 22.76±10.154 days. In the patients diagnosed with CAP, a positive correlation was established between the following parameters PSI score and age (r=0.670; p<0.01), C-reactive protein-CRP (rho=0.287; p<0.01), leukocytes (rho=0.406; p<0.01), NLR (rho=0.313; p<0.01) and platelet to lymphocyte ratio (PLR) (0.296; p<0.05). CRP, leukocytes, NLR and PLR were statistically signifi cantly higher in patients with high risk of CAP compared to patients with low risk of CAP. Diastolic blood pressure, lymphocytes, eosinophils were signifi cantly lower in patients with high risk of CAP (p<0.05;) compared to patients with low risk of CAP (p<0.01). The optimal cut-off value of NLR for CAP patients was 3.089 with an estimated area under curve (AUC) of 0.664. Conclusion Proatherogenic parameters such as age, systolic blood pressure and leukocytes in combination with neutrophil-lymphocyte count ratio could improve accuracy of the pneumonia severity index in community acquired pneumonia outcome.

Community-Acquired Pneumonia Incidence in Adults Aged 18 Years and Older in Goto City, Japan: A Prospective Population-Based Study

MACHINE LEARNING PREDICTION OF IN-HOSPITAL DISEASE PROGRESSION IN COMMUNITY-ACQUIRED PNEUMONIA: DERIVATION AND VALIDATION OF CLINICAL DETERIORATION IN PNEUMONIA (CDIP)

To explore and evaluate the predictive value of coagulopathy in patients with community-acquired pneumonia (CAP) METHODS: A retrospective study was performed by investigating the prothrombin time (PT), activated partial thromboplastin time (APTT), plasma fibrinogen (FIB), thrombin time (TT), platelets (PLT), and D-dimer in 385 patients with CAP, who were admitted to the Respiratory Medical Department of the First Affiliated Hospital of Xiamen University from June, 2010 to May, 2011. The differences of the aforementioned results in patients with different prognostic risks were compared and analyzed. The Pneumonia Severity Index (PSI) was calculated to assess the severity. The serum levels of PT, TT and D-dimer in high-risk patients with CAP were (15.1 ± 1.4) s, (16.0 ± 1.8) s, (7.5 ± 8.3) mg/L, respectively. They were all increased compared with those in the low-risk group (14.5 ± 0.9) s, (15.4 ± 1.2) s, (1.6 ± 2.0) mg/L]; the differences being statistically significant (P < 0.001), while PLT, APTT, and FIB were not statistically different (P > 0.05). The difference of the abnormal rate of PLT, PT, and D-dimer in high-risk group and the low-risk group were 30% (45/148) and 20% (47/237), 18% (26/148) and 5% (13/237), 99% (146/148) and 85% (202/237), respectively, the differences being statistically significant (χ² value were 5.602, 14.609, 23.442, respectively, P < 0.05), while TT, APTT, FIB were not (P > 0.05). Rank correlation existed between D-dimer and PSI (r = 0.798, P < 0.001), while there was no correlation between PLT and PSI (χ² = 6.040, P > 0.05). D-dimer in patients with respiratory failure was (10.0 ± 9.9) mg/L, which was significantly increased compared with that in patients without respiratory failure (2.4 ± 3.6) mg/L, P < 0.001, and there was no significant difference in PLT (χ² = 3.457, P > 0.05). D-dimer was significantly higher in patients who died of pneumonia as compared to those who survived [(14.0 ± 8.8) mg/L, (2.8 ± 4.6) mg/L, P < 0.001], and there was a significant difference in PLT (χ² = 4.909, P < 0.05). The area under the receiver operator characteristic curve (ROC) of D-dimer, PSI and PLT were 0.962, 0.906, 0.583, respectively. Concerning the predictive value of mortality, both D-dimer and PSI showed ideal predictive accuracy (P < 0.001). The sensitivity of D-dimer was superior to its specificity. PLT showed poor predictive value for mortality. D-dimer was significantly higher in patients with CAP. D-dimer level was positively correlated with severity and mortality. D-dimer could be a good biomarker to assess the severity and mortality of patients with CAP.

Severe thinness is associated with mortality in patients with community-acquired pneumonia: a prospective observational study

Pneumonia Severity Index Class V Patients With Community-Acquired Pneumonia: Characteristics, Outcomes, and Value of Severity Scores

To evaluate the outcome of elderly patients with community-acquired pneumonia (CAP) seen at an acute-care hospital, analyzing the importance of CAP severity, functional status, comorbidity, and frailty. Prospective observational study. Emergency department and geriatric medical day hospital of a university teaching hospital. Ninety-nine patients aged 65 and older seen for CAP over a 6-month recruitment period. Clinical data were used to calculate Pneumonia Severity Index (PSI), Barthel Index (BI), Charlson Comorbidity Index, and Hospital Admission Risk Profile (HARP). Patients were then assessed 15 days later to determine functional decline and 30 days and 18 months later for mortality and readmission. Multiple logistic regression was used to analyze outcomes. Functional decline was observed in 23% of the 93 survivors. Within the 30-day period, case-fatality rate was 6% and readmission rate 11%; 18-month rates were 24% and 59%, respectively. Higher BI was a protective factor for 30-day and 18-month mortality (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.94-0.98 and OR=0.97, 95% CI=0.95-0.99, respectively; P<.01), and PSI was the only predictor for functional decline (OR=1.03, 95% CI=1.01-1.05; P=.01). Indices did not predict readmission. Analyses were repeated for the 74 inpatients and indicated similar results except for 18-month mortality, which HARP predicted (OR=1.73; 95% CI=1.16-2.57; P<.01). Functional status was an independent predictor for short- and long-term mortality in hospitalized patients whereas CAP severity predicted functional decline. Severity indices for CAP should possibly thus be adjusted in the elderly population, taking functional status assessment into account.

BackgroundThis study aimed to determine whether community-acquired pneumonia (CAP) had a metabolic profile and whether this profile can be used for disease severity assessment.MethodsA total of 175 individuals including 119 CAP patients and 56 controls were enrolled and divided into two cohorts. Serum samples from a discovery cohort (n = 102, including 38 non-severe CAP, 30 severe CAP, and 34 age and sex-matched controls) were determined by untargeted ultra-high-performance liquid chromatography with tandem mass spectrometry (LC-MS/MS)-based metabolomics. Selected differential metabolites between CAP patients versus controls, and between the severe CAP group versus non-severe CAP group, were confirmed by targeted mass spectrometry assays in a validation cohort (n = 73, including 32 non-severe CAP, 19 severe CAP and 22 controls). Pearson’s correlation analysis was performed to assess relationships between the identified metabolites and clinical severity of CAP. The area under the curve (AUC), sensitivity and specificity of the metabolites for predicting the severity of CAP were also investigated.ResultsThe metabolic signature was markedly different between CAP patients and controls. Fifteen metabolites were found to be significantly dysregulated in CAP patients, which were mainly mapped to the metabolic pathways of sphingolipid, arginine, pyruvate and inositol phosphate. The alternation trends of five metabolites among the three groups including sphinganine, p-Cresol sulfate, dehydroepiandrosterone sulfate (DHEA-S), lactate and l-arginine in the validation cohort were consistent with those in the discovery cohort. Significantly lower concentrations of sphinganine, p-Cresol sulfate and DHEA-S were observed in CAP patients than in controls (p < 0.05). Serum lactate and sphinganine levels were positively correlated with confusion, urea level, respiratory rate, blood pressure, and age > 65 years (CURB-65), pneumonia severity index (PSI) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, while DHEA-S inversely correlated with the three scoring systems. Combining lactate, sphinganine and DHEA-S as a metabolite panel for discriminating severe CAP from non-severe CAP exhibited a better AUC of 0.911 (95% confidence interval 0.825–0.998) than CURB-65, PSI and APACHE II scores.ConclusionsThis study demonstrates that serum metabolomics approaches based on the LC-MS/MS platform can be applied as a tool to reveal metabolic changes during CAP and establish a metabolite signature related to disease severity.Trial registrationClinicalTrials.gov, NCT03093220. Registered retrospectively on 28 March 2017.

Introduction: Pneumonia Severity Index (PSI) and CURB-65 rule for community acquired pneumonia (CAP) have been developed to stratify patients based on mortality. Lack of a risk stratifying score like PSI or CURB-65 can lead to significant delay in starting treatment. This study was conducted to find out the ability of CURB-65 score and PSI to predict clinically relevant outcomes. Methods: 78 patients diagnosed as CAP admitted to a tertiary care hospital were enrolled into the study. Detailed clinical history was noted and CURB-65 and PSI scores were given with the help of a structured questionnaire in <24 hours of admission. The patients were revisited at day 3 and at discharge and data collected. Results:Out of 78 patients included in the study, 60 were males and 18 were females. Of the 78 patients, 14 died accounting for aninhospital mortality of 17.94%. Mortality in the mild, moderate and severe groups of CURB-65 were 0%, 16.7% and 47.8% respectively. Mortality in the mild, moderate and severe groups of PSI were 1.8%, 50% and 80% respectively. Area under the curve (AUC) for CURB-65 and PSI in terms of in hospital mortality were 0.935 and 0.920 respectively. Conclusion: The CURB-65 and PSI scores correlated well with mortality and other severity indicators. The CURB-65 has a better discriminatory power than PSI inour study. Because of its simplicity in addition to its better discriminatory power than PSI, CURB-65 may be better suited as a severity scoring system in CAP.

The Risk of Early Admission to the Intensive Care Unit (REA-ICU) index is a clinical prediction model that was derived based on 4,593 patients with community-acquired pneumonia (CAP) for predicting early admission to the intensive care unit (ICU; i.e., within 3 days following emergency department [ED] presentation). This study aimed to validate the REA-ICU index in an independent sample. The authors retrospectively stratified 850 CAP patients enrolled in a multicenter prospective randomized trial conducted in Switzerland, using the REA-ICU index, alternate clinical prediction models of severe pneumonia (SMART-COP, CURXO-80, and the 2007 IDSA/ATS minor severity criteria), and pneumonia severity assessment tools (the Pneumonia Severity Index [PSI] and CURB-65). The rate of early ICU admission did not differ between the validation and derivation samples within each risk class of the REA-ICU index, ranging from 1.1% to 1.8% in risk class I to 27.1% to 27.6% in risk class IV. The areas under the receiver operating characteristic (ROC) curve were 0.76 (95% confidence interval [CI] = 0.70 to 0.83) and 0.80 (95% CI = 0.77 to 0.83) in the validation and derivation samples, respectively. In the validation sample, the REA-ICU index performed better than the pneumonia severity assessment tools, but failed to demonstrate an accuracy advantage over alternate prediction models in predicting ICU admission. The REA-ICU index reliably stratifies CAP patients into four categories of increased risk for early ICU admission within 3 days following ED presentation. Further research is warranted to determine whether inflammatory biomarkers may improve the performance of this clinical prediction model.

Evaluation of an algorithm for switching from IV to PO therapy in clinical practice in patients with community-acquired pneumonia

The relationship between body mass index (BMI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) has not been fully investigated in patients with community-acquired pneumonia (CAP). This prospective observational study examined 510 consecutive patients hospitalized for CAP. NT-proBNP, BMI, and the pneumonia severity index (PSI) were determined for all participants. The moderating effects of BMI on the relationship between NT-proBNP and CAP mortality were examined using interaction terms in a multivariable regression model. The ability of NT-proBNP to predict mortality was evaluated using the area under the curve (AUC). A significant inverse relationship was observed between BMI and NT-proBNP. After multivariable adjustment including BMI, NT-proBNP remained a significant predictor of CAP mortality. The AUC of the fully adjusted (including BMI) NT-proBNP model was significantly higher than that excluding BMI (p = 0.021) and that of PSI (p = 0.038), respectively. The predictive performance of NT-proBNP for mortality significantly differed by BMI group, with the NT-proBNP of the overweight and obesity group having a significantly higher AUC than that of the underweight and normal-weight group. The AUC of NT-proBNP was significantly higher and tended to be higher than that of PSI in the overweight group (p = 0.013) and the obesity group (p = 0.113), respectively. BMI significantly strengthens the prognostic performance of NT-proBNP in CAP patients. The BMI-NT-proBNP interaction is significantly associated with CAP mortality, but as a prognostic determinant for CAP, NT-proBNP seems to be more useful for overweight and obese patients than for underweight and normal-weight patients.

Evaluation of ICU Admission Criteria and Diagnostic Methods for Patients With Severe Community-Acquired Pneumonia: Current Practice Survey

CAP is the most common cause of death in infectious diseases in developing countries, while also an important cause of death and morbidity in developed countries. In recent years, CURB-65 (or CRB-65) and pneumonia severity index (PSI) scoring systems have been widely used in the prognosis scoring system of CAP. However, each of them has some shortcomings in predicting ICU admission in CAP patients. The aim of this study is to analyze serum inflammatory biomarkers combined age to established a new prediction model in predicting ICU admission in CAP patients. This is a retrospective study. The enrolled CAP patients received serum inflammatory biomarker tests, including procalcitonin (PCT), white blood cell count (WBC), hypersensitive C-reactive protein (hs-CRP), and erythrocyte sedimentation rate (ESR). Body temperature and age were also recorded. The main outcome measures were ICU admission. Univariate analysis and binary logistic regression analysis were used to explore the in-dependent risk factors which could be components of a new predicting model for ICU admission in CAP patients. Receiver operating characteristic curves (ROC) were used to evaluate the sensitivity and specificity of the new model, which consisted of the combination of all independent risk factors in predicting the main outcomes. Initially, 246 CAP patients were admitted to general wards, 61 of whom were subsequently transferred to ICU (61/246). Age, PCT, WBC, and hs-CRP were independent risk factors for subsequent admission to ICU for CAP patients in general wards. The AUC of the ROC curve of new prediction model (the joint model consists of age, PCT, WBC, and hs-CRP) was 0.93 (95% CI 0.85 - 0.96), the sensitivity and specificity were 85.2% and 88.1%, respectively. Serum inflammatory biomarkers combined age have high specificity and sensitivity in predicting ICU admission in adult CAP patients.