Department of Respiratory Medicine, Shenzhen Hospital, Peking University, Lianhua road No. 1120, Shenzhen, 518036, Guangdong, China.
Department of Respiratory Medicine, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen, 518033, Guangdong, China.
Respir Res. 2019 Jan 31;20(1):22. doi: 10.1186/s12931-019-0991-4.
Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) minor criteria for severe community-acquired pneumonia (CAP) are of unequal weight in predicting mortality, but the major problem associated with IDSA/ATS minor criteria might be a lack of consideration of weight in prediction in clinical practice. Would awarding different points to the presences of the minor criteria improve the accuracy of the scoring system? It is warranted to explore this intriguing hypothesis.
A total of 1230 CAP patients were recruited to a retrospective cohort study. This was tested against a prospective two-center cohort of 1749 adults with CAP. 2 points were assigned for the presence of PaO/FiO ≤ 250 mmHg, confusion, or uremia on admission and 1 point for each of the others.
The mortality rates, and sequential organ failure assessment (SOFA) and pneumonia severity index (PSI) scores increased significantly with the numbers of IDSA/ATS minor criteria present and minor criteria scores. The correlations of the minor criteria scores with the mortality rates were higher than those of the numbers of IDSA/ATS minor criteria present. As were the correlations of the minor criteria scores with SOFA and PSI scores, compared with the numbers of IDSA/ATS minor criteria present. The pattern of sensitivity, specificity, positive predictive value, and Youden's index of scored minor criteria of ≥2 scores or the presence of 2 or more IDSA/ATS minor criteria for prediction of mortality was the best in the retrospective cohort, and the former was better than the latter. The validation cohort confirmed a similar pattern. The area under the receiver operating characteristic curve of scored minor criteria was higher than that of IDSA/ATS minor criteria in the retrospective cohort, implying higher accuracy of scored version for predicting mortality. The validation cohort confirmed a similar paradigm.
Scored minor criteria orchestrated improvements in predicting mortality and severity in patients with CAP, and scored minor criteria of ≥2 scores or the presence of 2 or more IDSA/ATS minor criteria might be more valuable cut-off value for severe CAP, which might have implications for more accurate clinical triage decisions.
美国传染病学会/美国胸科学会（IDSA/ATS）重度社区获得性肺炎（CAP）的次要标准在预测死亡率方面权重不等，但 IDSA/ATS 次要标准的主要问题可能是在临床实践中没有考虑到权重预测。为次要标准的存在赋予不同的分数是否会提高评分系统的准确性？探索这一有趣的假设是合理的。
共纳入 1230 例 CAP 患者进行回顾性队列研究，并与前瞻性的 1749 例成人 CAP 双中心队列进行对比。入院时 PaO/FiO2≤250mmHg、意识障碍或尿毒症记 2 分，其他每项记 1 分。
随着 IDSA/ATS 次要标准数量和次要标准评分的增加，死亡率、序贯器官衰竭评估（SOFA）和肺炎严重指数（PSI）评分显著增加。次要标准评分与死亡率的相关性高于 IDSA/ATS 次要标准数量的相关性。与 IDSA/ATS 次要标准数量相比，次要标准评分与 SOFA 和 PSI 评分的相关性更高。≥2 分的评分次要标准或 2 项及以上 IDSA/ATS 次要标准对死亡率预测的灵敏度、特异性、阳性预测值和 Youden 指数模式在回顾性队列中最佳，前者优于后者。验证队列也证实了类似的模式。在回顾性队列中，评分次要标准的受试者工作特征曲线下面积高于 IDSA/ATS 次要标准，表明评分版本在预测死亡率方面的准确性更高。验证队列也证实了类似的模式。
评分次要标准可改善 CAP 患者死亡率和严重程度的预测，≥2 分的评分次要标准或 2 项及以上 IDSA/ATS 次要标准可能是重度 CAP 更有价值的截断值，这可能对更准确的临床分诊决策有意义。
