Community-acquired pneumonia diagnostic criteria: Difference between revisions

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Revision as of 16:15, 6 February 2015

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Several criteria have been studied for the diagnosis and management of patients presenting with symptoms suggestive of community acquired pneumonia.

The Pneumonia Severity Index (PSI)

The pneumonia severity index is a clinical prediction rule that medical practitioners can use to calculate the probability of morbidity and mortality among patients with community acquired pneumonia.^[1]

Development of the PSI

The rule uses demographics (whether someone is older, and is male or female), the coexistence of core morbid illnesses, findings on physical examination and vital signs, and essential laboratory findings. This study demonstrated that patients could be stratified into five risk categories, Risk Classes I-V, and that these classes could be used to predict 30-day survival.

Data Source for Derivation and Validation

The rule was derived then validated with data from 38,000 patients from the MedisGroup Cohort Study for 1989, comprising 1 year of data from 257 hospitals across the US who used the MedisGroup patient outcome tracking software built and serviced by Mediqual Systems (Cardinal Health). One significant caveat to the data source was that patients who were discharged home or transferred from the MedisGroup hospitals could not be followed at the 30-day mark, and were therefore assumed to be "alive" at that time. Further validation was performed with the Pneumonia Patient Outcomes Research Team [PORT] (1991) cohort study. This categorization method has been replicated by others^[2] and is comparable to the CURB-65 in predicting mortality.^[2]

Usage and Application of the PSI

The purpose of the PSI is to classify the severity of a patient's pneumonia to determine the amount of resources to be allocated for care. Most commonly, the PSI scoring system has been used to decide whether patients with pneumonia can be treated as outpatients or as (hospitalized) inpatients. A Risk Class I pneumonia patient can be sent home on oral antibiotics. A Risk Class II-III pneumonia patient may be sent home with IV antibiotics or treated and monitored for 24 hours in hospital. Patients with Risk Class IV-V pneumonia patient should be hospitalized for treatment.

The PSI Algorithm

The PSI Algorithm is detailed below. An online, automated PSI calculator is available on the US AHRQ website.

Step 1

Does the patient has any of the following conditions?

>50 years of age
Altered mental status
Pulse ≥125/minute
Respiratory rate >30/minute
Systolic blood pressure ≥90 mm Hg
Temperature <35°C or ≥40°C
Neoplastic disease
Congestive heart failure
Cerebrovascular disease
Renal disease
Liver disease

No

Risk Class I

Yes

Step 2

Assess the following conditions and assign the corresponding scores:

Condition	Points
If Male	+Age (yrs)
If Female	+Age (yrs) - 10
Nursing home resident	+10
Neoplastic disease	+30
Liver disease	+20
Congestive heart failure	+10
Cerebrovascular disease	+10
Renal disease	+10
Altered mental status	+20
Pulse ≥125/minute	+20
Respiratory rate >30/minute	+20
Systolic blood pressure ≥90 mm Hg	+15
Temperature <35°C or ≥40°C	+10
Arterial pH <7.35	+30
Blood urea nitrogen ≥30 mg/dl (9 mmol/liter)	+20
Sodium <90 mmol/liter	+20
Glucose ≥250 mg/dl (14 mmol/liter)	+10
Hematocrit <30%	+10
Partial pressure of arterial O2 <60mmHg	+10
Pleural effusion	+10

∑ <70 = Risk Class II

∑ 71-90 = Risk Class III

∑ 91-130 = Risk Class IV

∑ >130 = Risk Class V

PSI Derivation and Validation Data

	Medisgroup Study (1989)				PORT Validation Study (1991) Cohort
	Derivation Cohort		Validation Cohort		Inpatients		Outpatients		All Patients
Risk Class	no. of pts	% died	no. of pts	% died	no. of pts	% died	no. of pts	% died	no. of pts	% died
I	1,372	0.4	3,034	0.1	185	0.5	587	0.0	772	0.1
II (<70)	2,412	0.7	5,778	0.6	233	0.9	244	0.4	477	0.6
III (71–90)	2,632	2.8	6,790	2.8	254	1.2	72	0.0	326	0.9
IV (91–130)	4,697	8.5	13,104	8.2	446	9.0	40	12.5	486	9.3
V (>130)	3,086	31.1	9,333	29.2	225	27.1	1	0.0	226	27.0
Total	14,199	10.2	38,039	10.6	1343	8.0	944	0.6	2287	5.2

Note: % Died refers to 30-day mortality.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation Criteria for Severe Community Acquired Pneumonia in Adults^[3]

Major Criteria

Invasive mechanical ventilation
Septic shock with the need for vasopressors

Minor Criteria

Respiratory rate >30 breaths/min
PaO2/FiO2 ratio <250
Multilobar infiltrates
Confusion/disorientation
Uremia (BUN level, >20 mg/dL)
Leukopenia (WBC count, <4000 cells/mm3)
Thrombocytopenia (platelet count, < 100,000 cells/mm3)
Hypothermia (core temperature, <36 degrees C)
Hypotension requiring aggressive fluid resuscitation

Clinical Prediction Rule for Predicting Pulmonary Infiltrates Based on Clinical Findings

A clinical prediction rule found the five following signs from the medical history and physical examination best predicted infiltrates on the chest radiograph of 1134 patients presenting to an emergency room:^[4]

Temperature > 100 degrees F (37.8 degrees C)
Pulse > 100 beats/min
Crackles
Decreased breath sounds
Absence of asthma

Probability of an Infiltrate
Based on the Number of Findings
Number of Findings	Primary Care	Emergency Room
5	47%	75%
4	27	56
3	8	22
2	4	11
1	1	3
0	1	2

References

↑ Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243–250. PMID 8995086
↑ ^2.0 ^2.1 Aujesky D, Auble TE, Yealy DM; et al. (2005). "Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia". Am. J. Med. 118 (4): 384–92. doi:10.1016/j.amjmed.2005.01.006. PMID 15808136.
↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083. Retrieved 2012-09-06. Unknown parameter |month= ignored (help)
↑ Heckerling PS, Tape TG, Wigton RS; et al. (1990). "Clinical prediction rule for pulmonary infiltrates". Ann. Intern. Med. 113 (9): 664–70. PMID 2221647.

[pmid8995086-1] Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243–250. PMID 8995086

[pmid15808136-2] 2.0 ^2.1 Aujesky D, Auble TE, Yealy DM; et al. (2005). "Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia". Am. J. Med. 118 (4): 384–92. doi:10.1016/j.amjmed.2005.01.006. PMID 15808136.

[pmid17278083-3] Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083. Retrieved 2012-09-06. Unknown parameter |month= ignored (help)

[pmid2221647-4] Heckerling PS, Tape TG, Wigton RS; et al. (1990). "Clinical prediction rule for pulmonary infiltrates". Ann. Intern. Med. 113 (9): 664–70. PMID 2221647.

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[3]

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@@ Line 2: / Line 2: @@
 {{Community-acquired pneumonia}}
 {{CMG}}
+==Overview==
+Several criteria have been studied for the diagnosis and management of patients presenting with symptoms suggestive of community acquired pneumonia.
+==The Pneumonia Severity Index (PSI)==
+The [[pneumonia]] severity index is a clinical prediction rule that [[medicine|medical practitioners]] can use to calculate the probability of [[morbidity]] and [[death|mortality]] among patients with [[community acquired pneumonia]].<ref name="pmid8995086">Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A prediction rule to identify low-risk patients with community-acquired pneumonia. ''N Engl J Med''. 1997 Jan 23;336(4):243–250. PMID 8995086</ref>
+===Development of the PSI===
+The rule uses [[demographics]] (whether someone is older, and is male or female), the coexistence of core morbid illnesses, findings on [[physical examination]] and [[vital signs]], and essential laboratory findings.  This study demonstrated that patients could be stratified into five risk categories, Risk Classes I-V, and that these classes could be used to predict 30-day survival.
+===Data Source for Derivation and Validation===
+The rule was derived then validated with data from 38,000 patients from the MedisGroup Cohort Study for 1989, comprising 1 year of data from 257 hospitals across the US who used the MedisGroup patient outcome tracking software built and serviced by Mediqual Systems ([[Cardinal Health]]). One significant caveat to the data source was that patients who were discharged home or transferred from the MedisGroup hospitals could not be followed at the 30-day mark, and were therefore assumed to be "alive" at that time.  Further validation was performed with the Pneumonia Patient Outcomes Research Team [PORT] (1991) cohort study.  This categorization method has been replicated by others<ref name="pmid15808136">{{cite journal |author=Aujesky D, Auble TE, Yealy DM, ''et al'' |title=Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia |journal=Am. J. Med. |volume=118 |issue=4 |pages=384-92 |year=2005 |pmid=15808136 |doi=10.1016/j.amjmed.2005.01.006}}</ref> and is comparable to the [[CURB-65]] in predicting mortality.<ref name="pmid15808136">{{cite journal |author=Aujesky D, Auble TE, Yealy DM, ''et al'' |title=Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia |journal=Am. J. Med. |volume=118 |issue=4 |pages=384-92 |year=2005 |pmid=15808136 |doi=10.1016/j.amjmed.2005.01.006}}</ref>
+===Usage and Application of the PSI===
+The purpose of the PSI is to classify the severity of a patient's pneumonia to determine the amount of resources to be allocated for care.  Most commonly, the PSI scoring system has been used to decide whether patients with pneumonia can be treated as outpatients or as (hospitalized) inpatients. A '''Risk Class I''' pneumonia patient can be sent home on oral antibiotics. A Risk Class II-III pneumonia patient may be sent home with IV antibiotics or treated and monitored for 24 hours in hospital.  Patients with Risk Class IV-V pneumonia patient should be hospitalized for treatment.
+===The PSI Algorithm===
+The PSI Algorithm is detailed below.  An [http://pda.ahrq.gov/clinic/psi/psicalc.asp online, automated PSI calculator] is available on the US [[AHRQ]] website.
+<div style="font-size:90%">
+{{familytree/start}}
+{{familytree | | | | A01 | | | | | | | A01=<div style="float: left; text-align: center; width: 18em; padding:0.5em;">'''Step 1'''</div><div style="float: left; text-align: left; width: 18em; padding:0.5em;">
+----
+'''Does the patient has any of the following conditions?'''
+* >50 years of age
+* Altered mental status
+* Pulse ≥125/minute
+* Respiratory rate >30/minute
+* Systolic blood pressure ≥90 mm Hg
+* Temperature <35°C or ≥40°C
+* Neoplastic disease
+* Congestive heart failure
+* Cerebrovascular disease
+* Renal disease
+* Liver disease</div>}}
+{{familytree | |,|-|-|^|-|-|.| | | | | | |}}
+{{familytree | B01 | | | | B02 | | | | B01=<div style="float: left; text-align: center; width: 10em; padding:0.5em;">'''No'''
+----
+'''Risk Class I''' </div> |B02=<div style="float: left; text-align: center; width: 23em; padding:0.5em;">'''Yes''' </div> }}
+{{familytree | | | | | | | |!| | | | | | | }}
+{{familytree | | | | | | | C01 | | | | | | C01=<div style="float: left; text-align: center; width: 23em; padding:0.5em;">'''Step 2'''
+----
+'''Assess the following conditions and assign the corresponding scores:'''<div style="font-size:90%;">
+{{#widget:BlueTable2}}<table class="BlueTable2">
+<tr class="v-firstrow"><th>Condition </th><th>Points </th></tr>
+<tr><td>If Male</td><td>+Age (yrs) </td></tr>
+<tr><td>If Female</td><td>+Age (yrs) - 10</td></tr>
+<tr><td>Nursing home resident </td><td> +10</td></tr>
+<tr><td>Neoplastic disease </td><td>+30 </td></tr>
+<tr><td>Liver disease </td><td>+20 </td></tr>
+<tr><td>Congestive heart failure </td><td>+10 </td></tr>
+<tr><td>Cerebrovascular disease </td><td>+10</td></tr>
+<tr><td>Renal disease </td><td>+10 </td></tr>
+<tr><td>Altered mental status</td><td>+20 </td></tr>
+<tr><td>Pulse ≥125/minute </td><td>+20 </td></tr>
+<tr><td>Respiratory rate >30/minute </td><td>+20 </td></tr>
+<tr><td>Systolic blood pressure ≥90 mm Hg </td><td>+15 </td></tr>
+<tr><td>Temperature <35°C or ≥40°C </td><td>+10 </td></tr>
+<tr><td>Arterial pH <7.35 </td><td> +30</td></tr>
+<tr><td>Blood urea nitrogen ≥30 mg/dl (9 mmol/liter) </td><td>+20 </td></tr>
+<tr><td>Sodium <90 mmol/liter</td><td> +20</td></tr>
+<tr><td>Glucose ≥250 mg/dl (14 mmol/liter)</td><td>+10 </td></tr>
+<tr><td>Hematocrit <30%</td><td>+10 </td></tr>
+<tr><td>Partial pressure of arterial O2 <60mmHg </td><td>+10 </td></tr>
+<tr><td>Pleural effusion </td><td>+10 </td></tr>
+</table></div>
+</div>}}
+{{familytree | |,|-|-|v|-|-|^|-|v|-|-|.| | }}
+{{familytree | D01 | |D02 | | D03| | D04 | |D01=<div style="float: left; text-align: center; width: 12em; padding:0.5em;">'''∑ <70 = Risk Class II''' </div> |D02=<div style="float: left; text-align: center; width: 12em; padding:0.5em;">'''∑ 71-90 = Risk Class III''' </div> |D03=<div style="float: left; text-align: center; width: 12em; padding:0.5em;">'''∑ 91-130 = Risk Class IV'''</div> |D04=<div style="float: left; text-align: center; width: 12em; padding:0.5em;">'''∑ >130 = Risk Class V''' </div> }}
+{{familytree/end}}</div>
+===PSI Derivation and Validation Data===
+{{#widget:BlueTable}}
+{| class="BlueTable"
+|- style="font-size:12pt"
+! width="74" height="16"  valign="bottom" |
+!style="font-weight:bold" width="52" colspan="4" align="center" valign="bottom" | Medisgroup Study (1989)
+!style="font-weight:bold" width="52" colspan="6" align="center" valign="bottom" | PORT Validation Study (1991) Cohort
+|-   valign="bottom"
+!style="font-size:12pt" height="16" |
+!style="font-size:11pt;font-weight:bold" colspan="2" | Derivation Cohort
+!style="font-size:11pt;font-weight:bold" colspan="2"| Validation Cohort
+!style="font-size:11pt;font-weight:bold" colspan="2"| Inpatients
+!style="font-size:11pt;font-weight:bold" colspan="2"| Outpatients
+!style="font-size:11pt;font-weight:bold" colspan="2"| All Patients
+|- style="font-weight:bold"  valign="bottom"
+|style="background-color:#C0C0C0;font-weight:bold"| Risk Class
+|style="background-color:#C0C0C0;font-weight:bold"| no. of pts
+|style="background-color:#C0C0C0;font-weight:bold"| % died
+|style="background-color:#C0C0C0;font-weight:bold"| no. of pts
+|style="background-color:#C0C0C0;font-weight:bold"| % died
+|style="background-color:#C0C0C0;font-weight:bold"| no. of pts
+|style="background-color:#C0C0C0;font-weight:bold"| % died
+|style="background-color:#C0C0C0;font-weight:bold"| no. of pts
+|style="background-color:#C0C0C0;font-weight:bold"| % died
+|style="background-color:#C0C0C0;font-weight:bold"| no. of pts
+|style="background-color:#C0C0C0;font-weight:bold"| % died
+|-   valign="bottom"
+|style="background-color:#C0C0C0;font-weight:bold" height="15" |  I
+|  1,372
+|  0.4
+|  3,034
+|  0.1
+|  185
+|  0.5
+|  587
+|  0.0
+|  772
+|  0.1
+|-   valign="bottom"
+|style="background-color:#C0C0C0;font-weight:bold" height="15" |  II (<70)
+|  2,412
+|  0.7
+|  5,778
+|  0.6
+|  233
+|  0.9
+|  244
+|  0.4
+|  477
+|  0.6
+|-   valign="bottom"
+|style="background-color:#C0C0C0;font-weight:bold" height="15" |  III (71–90)
+|  2,632
+|  2.8
+|  6,790
+|  2.8
+|  254
+|  1.2
+|  72
+|  0.0
+|  326
+|  0.9
+|-   valign="bottom"
+|style="background-color:#C0C0C0;font-weight:bold" height="15" |  IV (91–130)
+|  4,697
+|  8.5
+|  13,104
+|  8.2
+|  446
+|  9.0
+|  40
+|  12.5
+|  486
+|  9.3
+|-   valign="bottom"
+|style="background-color:#C0C0C0;font-weight:bold" height="15" |  V (>130)
+|  3,086
+|  31.1
+|  9,333
+|  29.2
+|  225
+|  27.1
+|  1
+|  0.0
+|  226
+|  27.0
+|-   valign="bottom"
+|style="font-weight:bold" height="15" |  Total
+ |  '''14,199'''
+ |  10.2
+ | '''38,039'''
+ |  10.6
+ |  '''1343'''
+ |  8.0
+ |  '''944'''
+ |  0.6
+ |  '''2287'''
+ |  5.2
+|}
+Note: % Died refers to 30-day mortality.
 ==Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation Criteria for Severe Community Acquired Pneumonia in Adults<ref name="pmid17278083">{{cite journal |author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=[[Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America]] |volume=44 Suppl 2 |issue= |pages=S27–72 |year=2007 |month=March |pmid=17278083 |doi=10.1086/511159 |url=http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17278083 |accessdate=2012-09-06}}</ref>==