Department of Respiratory Medicine, New Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, UK.
QJM. 2011 Oct;104(10):871-9. doi: 10.1093/qjmed/hcr088. Epub 2011 Jul 18.
In community-acquired pneumonia, severity assessment tools, such as CRB65, CURB65 and Pneumonia Severity Index (PSI), have been promoted to increase the proportion of patients treated in the community. The prognostic accuracy of these scores is established in hospitalized patients, but less is known about their use in out-patients. We aimed to study the accuracy of these severity tools to predict mortality in patients managed as out-patients.
We performed a systematic review and meta-analysis according to MOOSE guidelines. From 1980 to 2010, we identified 13 studies reporting prognostic information for the CRB65, CURB65 and PSI severity scores in out-patients (either exclusively managed in the community or discharged from an emergency department <24 h after admission). Two reviewers independently collected data and assessed study quality. Performance characteristics across the studies were pooled using a random-effects model. Relationships between sensitivity and specificity were plotted using summary receiver operator characteristic curves (sROC).
Out-patient mortality ranged from 0% to 3.5%. Four studies were identified for CRB65, 2 for CURB65 and 10 for PSI. Mortality was low for out-patients in the low-risk CRB65 classes [CRB65 0 or 1: mortality occurred in 3 of 1494 patients (0.2%)] but higher in CRB65 Groups 2-4 [mortality 13 of 154 patients (8.4%)]. Similarly, mortality was low in PSI Classes I-III [mortality 8 of 3655 patients (0.2%)] managed as out-patients but higher in Classes IV and V [mortality 32 of 317 patients (10.1%)]. CRB65 showed pooled sensitivity of 81% (54-96%), pooled specificity of 91% (90-93%) and the area under the sROC was 0.91 [standard error (SE) 0.05]. For PSI, pooled sensitivity was 92% (64-100%), pooled specificity was 90% (89-91%) and area under the sROC was 0.92 (SE 0.03). There were insufficient studies to analyse CURB65.
The limited data available suggest that CRB65 and PSI can identify groups of patients at low risk of mortality that can be safely managed in the community.
在社区获得性肺炎中，严重程度评估工具（如 CRB65、CURB65 和肺炎严重指数（PSI））已被推广使用，以增加在社区中接受治疗的患者比例。这些评分的预后准确性已在住院患者中得到证实，但在门诊患者中的应用知之甚少。我们旨在研究这些严重程度工具在预测门诊患者死亡率方面的准确性。
我们根据 MOOSE 指南进行了系统评价和荟萃分析。从 1980 年到 2010 年，我们确定了 13 项研究，这些研究报告了 CRB65、CURB65 和 PSI 严重程度评分在门诊患者（无论是在社区中单独管理还是在入院后 24 小时内从急诊科出院）中的预后信息。两名评审员独立收集数据并评估研究质量。使用随机效应模型汇总研究间的性能特征。使用汇总受试者工作特征曲线（sROC）绘制敏感性和特异性之间的关系。
门诊患者的死亡率范围为 0%至 3.5%。确定了 4 项 CRB65 研究、2 项 CURB65 研究和 10 项 PSI 研究。低危 CRB65 级别的门诊患者死亡率较低[CRB65 0 或 1：1494 例患者中有 3 例（0.2%）死亡]，而 CRB65 组 2-4 级的死亡率较高[154 例患者中有 13 例（8.4%）死亡]。同样，PSI 分级 I-III 的门诊患者死亡率较低[3655 例患者中有 8 例（0.2%）死亡]，而 IV 级和 V 级的死亡率较高[317 例患者中有 32 例（10.1%）死亡]。CRB65 的汇总敏感性为 81%（54%-96%），汇总特异性为 91%（90%-93%），sROC 下面积为 0.91[标准误（SE）为 0.05]。PSI 的汇总敏感性为 92%（64%-100%），汇总特异性为 90%（89%-91%），sROC 下面积为 0.92（SE 为 0.03）。CURB65 的研究数据不足。
现有数据有限表明，CRB65 和 PSI 可以识别出死亡率低、可在社区安全管理的患者群体。
