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Journal ArticleDOI

Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study

01 May 2003-Thorax (BMJ Group)-Vol. 58, Iss: 5, pp 377-382
TL;DR: A simple six point score based on confusion, urea, respiratory rate, blood pressure, and age can be used to stratify patients with CAP into different management groups.
Abstract: Background: In the assessment of severity in community acquired pneumonia (CAP), the modified British Thoracic Society (mBTS) rule identifies patients with severe pneumonia but not patients who might be suitable for home management. A multicentre study was conducted to derive and validate a practical severity assessment model for stratifying adults hospitalised with CAP into different management groups. Methods: Data from three prospective studies of CAP conducted in the UK, New Zealand, and the Netherlands were combined. A derivation cohort comprising 80% of the data was used to develop the model. Prognostic variables were identified using multiple logistic regression with 30 day mortality as the outcome measure. The final model was tested against the validation cohort. Results: 1068 patients were studied (mean age 64 years, 51.5% male, 30 day mortality 9%). Age ⩾65 years (OR 3.5, 95% CI 1.6 to 8.0) and albumin C onfusion, U rea >7 mmol/l, R espiratory rate ⩾30/min, low systolic( B lood pressure), age ⩾65 years (CURB-65 score) based on information available at initial hospital assessment, enabled patients to be stratified according to increasing risk of mortality: score 0, 0.7%; score 1, 3.2%; score 2, 3%; score 3, 17%; score 4, 41.5% and score 5, 57%. The validation cohort confirmed a similar pattern. Conclusions: A simple six point score based on confusion, urea, respiratory rate, blood pressure, and age can be used to stratify patients with CAP into different management groups.
Citations
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Journal ArticleDOI
TL;DR: This work presents a meta-analyses of the immune system’s response to chronic obstructive pulmonary disease and shows clear patterns of decline in the immune systems of elderly patients with compromised immune systems.
Abstract: Lionel A. Mandell, Richard G. Wunderink, Antonio Anzueto, John G. Bartlett, G. Douglas Campbell, Nathan C. Dean, Scott F. Dowell, Thomas M. File, Jr. Daniel M. Musher, Michael S. Niederman, Antonio Torres, and Cynthia G. Whitney McMaster University Medical School, Hamilton, Ontario, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, and Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas; Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; Division of Pulmonary and Critical Care Medicine, LDS Hospital, and University of Utah, Salt Lake City, Utah; Centers for Disease Control and Prevention, Atlanta, Georgia; Northeastern Ohio Universities College of Medicine, Rootstown, and Summa Health System, Akron, Ohio; State University of New York at Stony Brook, Stony Brook, and Department of Medicine, Winthrop University Hospital, Mineola, New York; and Cap de Servei de Pneumologia i Allergia Respiratoria, Institut Clinic del Torax, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biomediques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain.

5,558 citations


Cites background or methods from "Defining community acquired pneumon..."

  • ...Objective criteria to identify patients for ICU admission include the initial ATS definition of severe CAP [5] and its subsequent modification [6, 82] , the CURB criteria [39, 45] , and PSI severity class V (or IV and V) [42] ....

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  • ...In a cohort of ∼3000 patients, the mortality with a CURB-65 score of 0 was only 1.2%, whereas 3-4 points were associated with 31% mortality [45] ....

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  • ...The most recent modification of the BTS criteria includes 5 easily measurable factors [45] ....

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  • ...Age, by itself, was not felt to be an appropriate factor for the ICU admission decision, but the remainder of the CURB-65 criteria [45] were retained as minor criteria (with the exception of hypotension requiring vasopressors as a major criterion)....

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  • ...The 2 most interesting are the PSI [42] and the British Thoracic Society (BTS) criteria [39, 45] ....

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Journal ArticleDOI
TL;DR: Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions.
Abstract: Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia.Methods: A multidisciplinary panel conducted pra...

1,708 citations


Cites methods from "Defining community acquired pneumon..."

  • ...pneumonia, using patient demographic and clinical variables from the time of diagnosis to predict 30-day mortality (39, 40)....

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Journal ArticleDOI
TL;DR: Eidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery.
Abstract: Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

1,333 citations

Journal ArticleDOI
01 Oct 2009-Thorax
TL;DR: A summary of the initial management of patients admitted to hospital with suspected community acquired pneumonia (CAP) is presented and the relevant microbiological investigations and empirical antibiotic choices recommended in patients with CAP are summarized.
Abstract: A summary of the initial management of patients admitted to hospital with suspected community acquired pneumonia (CAP) is presented in fig 8. Tables 4 and 5, respectively, summarise (1) the relevant microbiological investigations and (2) empirical antibiotic choices recommended in patients with CAP. Figure 8 Hospital management of community acquired pneumonia (CAP) in the first 4 h. CXR, chest x ray; DBP, diastolic blood pressure; SBP, systolic blood pressure. View this table: Table 4 Recommendations for the microbiological investigation of community acquired pneumonia (CAP) View this table: Table 5 Initial empirical treatment regimens for community acquired pneumonia (CAP) in adults ### Investigations ( Section 5 ) #### When should a chest radiograph be performed in the community? 1. It is not necessary to perform a chest radiograph in patients with suspected CAP unless: 2. #### When should a chest radiograph be performed in hospital? 1. All patients admitted to hospital with suspected CAP should have a chest radiograph performed as soon as possible to confirm or refute the diagnosis. [D] The objective of any service should be for the chest radiograph to be performed in time for antibiotics to be administered within 4 h of presentation to hospital should the diagnosis of CAP be confirmed. #### When should the chest radiograph be repeated during recovery? 1. The chest radiograph need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery from CAP. [D] 2. A chest radiograph should be arranged after about 6 weeks for all those patients who have persistence of symptoms or physical signs or who are at higher risk of underlying malignancy (especially smokers and those aged >50 years) whether or not they have been admitted to hospital. [D] 3. Further investigations which may include bronchoscopy should be considered in patients with persisting signs, symptoms …

1,204 citations


Cites background or methods or result from "Defining community acquired pneumon..."

  • ...The CURB65 score was developed based on a study of over 1000 prospectively studied patients with CAP from three countries: the UK, New Zealand and the Netherlands.255 [Ib] The 6-point CURB65 score, one point for each of Confusion, Urea ....

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  • ...CURB65 score The CURB65 score was developed based on a study of over 1000 prospectively studied patients with CAP from three countries: the UK, New Zealand and the Netherlands.(255) [Ib] The 6-point CURB65 score, one point for each of Confusion, Urea ....

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  • ...298 [II] [Ib] In prospective studies reporting from the UK, 41–45% of patients hospitalised with CAP had CURB65 scores of 0–1, 25–28% had a CURB65 score of 2 and 29–34% had CURB65 scores of 3 or more.(255) 257 Other predictive models have been developed, including models to predict admission to intensive care as the primary outcome, or to predict a composite outcome comprising either mortality or need for intensive care....

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  • ...The CRB65 score has been specifically studied in over 6000 patients representing a mix of patients seen both in the community and in hospitals.(255) 286 287 289 296–299 [Ib] [II] [Ib] [II] [Ib] [II] [Ib] [II] All studies reported findings similar to the derivation study and, in certain studies, the CRB65 score was reported to be of similar discriminatory value to the CURB65 score....

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References
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Journal ArticleDOI
TL;DR: A prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes and may help physicians make more rational decisions about hospitalization for patients with pneumonia.
Abstract: Background There is considerable variability in rates of hospitalization of patients with community-acquired pneumonia, in part because of physicians' uncertainty in assessing the severity of illness at presentation. Methods From our analysis of data on 14,199 adult inpatients with community-acquired pneumonia, we derived a prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days. The rule was validated with 1991 data on 38,039 inpatients and with data on 2287 inpatients and outpatients in the Pneumonia Patient Outcomes Research Team (PORT) cohort study. The prediction rule assigns points based on age and the presence of coexisting disease, abnormal physical findings (such as a respiratory rate of > or = 30 or a temperature of > or = 40 degrees C), and abnormal laboratory findings (such as a pH or = 30 mg per deciliter [11 mmol per liter] or a sodium concentration Results There were no significant differences in mortality in each of the five risk classes among the three cohorts. Mortality ranged from 0.1 to 0.4 percent for class I patients (P=0.22), from 0.6 to 0.7 percent for class II (P=0.67), and from 0.9 to 2.8 percent for class III (P=0.12). Among the 1575 patients in the three lowest risk classes in the Pneumonia PORT cohort, there were only seven deaths, of which only four were pneumonia-related. The risk class was significantly associated with the risk of subsequent hospitalization among those treated as outpatients and with the use of intensive care and the number of days in the hospital among inpatients. Conclusions The prediction rule we describe accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes. This prediction rule may help physicians make more rational decisions about hospitalization for patients with pneumonia.

3,996 citations

Journal ArticleDOI

2,584 citations

Journal ArticleDOI
TL;DR: This study highlights the need to understand more fully the role of Epstein-Barr virus in the development of central giant cell granuloma and its role in the immune system.
Abstract: John G. Bartlett,1 Scott F Dowell,2 Lionel A. Mandell,6 Thomas M. File, Jr.,3 Daniel M. Musher,4 and Michael J. Fine5 'Johns Hopkins University School of Medicine, Baltimore, Maryland, 2Centers for Disease Control and Prevention, Atlanta, Georgia, 3Northeastern Ohio Universities College of Medicine, Cleveland, Ohio, 4Baylor College of Medicine and Veterans Affairs Medical Center, Houston, Texas, and 5University of Pittsburgh, Pennsylvania, USA; and 6McMaster University, Toronto, Canada

2,292 citations

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