Fine M J, Orloff J J, Arisumi D, Fang G D, Arena V C, Hanusa B H, Yu V L, Singer D E, Kapoor W N
Department of Medicine, University of Pittsburgh, Pennsylvania.
Am J Med. 1990 May;88(5N):1N-8N.
Our purpose was to determine which clinical features predict short-term mortality in patients with community-acquired pneumonia.
We conducted a prospective multicenter study of 347 patients hospitalized in Pittsburgh (the derivation cohort) and 253 hospitalized and ambulatory patients in Boston (the validation cohort) with clinical and radiographic evidence of pneumonia. Patients in the derivation cohort underwent an extensive microbiologic evaluation including bacteriologic sputum culture, blood cultures, direct fluorescent antibody testing for Legionella species, and serologic testing for Mycoplasma pneumoniae, Legionella species, and Chlamydia TWAR.
The overall mortality was 18% in the derivation cohort and 13.2% in the validation cohort. We identified five independent predictors of mortality in the derivation cohort: pleuritic chest pain (risk ratio, 0.4; 95% confidence interval [CI], 0.17 to 0.99), mental status changes (risk ratio, 2.6; 95% CI, 1.4 to 4.6), a severe vital sign abnormality (risk ratio, 2.1; 95% CI 1.2 to 3.6), neoplastic disease (risk ratio, 5.0; 95% CI, 2.7 to 9.1), and "high-risk" pneumonia etiology (risk ratio, 2.8; 95% CI, 1.6 to 5.0). A mortality index based on these factors accurately classified patients into five risk classes of increasing mortality. In the derivation cohort, the 6-week mortality rates were 0% in class I, 2.9% in class II, 13.1% in class III, 32.7% in class IV, and 89.5% in class V. There was little deterioration in the predictive accuracy of the model when tested in the validation cohort: mortality was 2.2% in class I, 0% in class II, 13.5% in class III, 33.3% in class IV, and 55.6% in class V.
This prognostic classification may help direct triage decisions, assess appropriateness of care, and guide the design and analysis of therapeutic trials in patients with community-acquired pneumonia.
我们的目的是确定哪些临床特征可预测社区获得性肺炎患者的短期死亡率。
我们对匹兹堡的347例住院患者（推导队列）以及波士顿的253例住院和门诊患者（验证队列）进行了一项前瞻性多中心研究，这些患者均有肺炎的临床和影像学证据。推导队列中的患者接受了广泛的微生物学评估，包括痰细菌培养、血培养、军团菌属直接荧光抗体检测以及肺炎支原体、军团菌属和沙眼衣原体TWAR的血清学检测。
推导队列的总死亡率为18%，验证队列的总死亡率为13.2%。我们在推导队列中确定了五个死亡率的独立预测因素：胸膜炎性胸痛（风险比，0.4；95%置信区间[CI]，0.17至0.99）、精神状态改变（风险比，2.6；95%CI，1.4至4.6）、严重生命体征异常（风险比，2.1；95%CI 1.2至3.6）、肿瘤性疾病（风险比，5.0；95%CI，2.7至9.1）以及“高危”肺炎病因（风险比，2.8；95%CI，1.6至5.0）。基于这些因素的死亡率指数可将患者准确地分为死亡率逐渐增加的五个风险类别。在推导队列中，I类的6周死亡率为0%，II类为2.9%，III类为13.1%，IV类为32.7%，V类为89.5%。在验证队列中进行测试时，该模型的预测准确性几乎没有下降：I类的死亡率为2.2%，II类为0%，III类为13.5%，IV类为33.3%，V类为55.6%。
这种预后分类可能有助于指导分诊决策、评估护理的适宜性，并指导社区获得性肺炎患者治疗试验的设计和分析。
