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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 11  |  Page : 1706-1711

Prognostic utility of CURB-65 and E-CURB-65 scoring systems in healthcare associated pneumonia patients: Short- and long-term mortality


1 Department of Emergency Medicine, Istanbul Education and Research Hospital, Istanbul, Turkey
2 Department of Emergency Medicine, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
3 Department of Emergency Medicine, Taksim Education and Research Hospital, Istanbul, Turkey
4 Department of Emergency Medicine, Beylikdüzü Public Hospital, Istanbul, Turkey
5 Department of Emergency Medicine, Kahta Public Hospital, Adıyaman, Turkey
6 Department of Emergency Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey

Date of Submission21-Aug-2018
Date of Acceptance16-Apr-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Dr. T Cimilli Ozturk
Department of Emergency, Istanbul Fatih Sultan Mehmet Training and Research Hospital, E-5 over Atasehir/Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_433_18

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   Abstract 


Background: The aim of our study is to evaluate whether the CURB-65 or expanded-CURB-65 score can be used in healthcare-associated pneumonia (HCAP) and subgroups of HCAP patients at the same efficiency. Thirty and 90-day mortality rates of the patients and predictive values of CURB-65 and E-CURB-65 scores were compared. Patients and Methods: This is a retrospective study of patients who presented to the Emergency Department between January 2015 and January 2016. All patient charts above 18 years of age were evaluated according to American Thoracic Society and the Infectious Diseases Society of America (ATS/IDSA) pneumonia diagnostic criteria and pneumonia diagnoses were confirmed. Results: 167 pneumonia patients (27.8%) of all pneumonia cases were grouped as HCAP and 433 (54.4%) were grouped as community-acquired pneumonia (CAP). 43% (n = 72) of HCAP patients were classified as nursing home-associated pneumonia (NHAP) and 57% (n = 95) were classified as HCAP (except NHAP) group. NHAP patients were older than the other groups. HCAP (except NHAP) group had somehow more comorbid diseases when compared with the other groups. However, the NHAP group had more unstable vital signs and confusion rates. Hospital and ICU admissions, 30–90-day mortality rates were all significantly higher in NHAP group E-CURB-65 was found to have better predictive values than CURB-65 for 30-day and 90-day mortalities overall. Conclusion: According to our results, commonly used scoring systems, CURB 65 and E-CURB 65, are not suitable for HCAP, NHAP, and HCAP (except NHAP) patients. NHAP patients have significant worse prognosis compared with CAP and HCAP (except NHAP) in terms of admission to intensive care and 30 and 90-day mortality rates.

Keywords: E-CURB 65, HCAP, NHAP, pneumonia


How to cite this article:
Kurt E, Ak R, Eke Kurt S Z, Bahadirli S, Nakis B, Ozturk T C, Akoglu E U. Prognostic utility of CURB-65 and E-CURB-65 scoring systems in healthcare associated pneumonia patients: Short- and long-term mortality. Niger J Clin Pract 2021;24:1706-11

How to cite this URL:
Kurt E, Ak R, Eke Kurt S Z, Bahadirli S, Nakis B, Ozturk T C, Akoglu E U. Prognostic utility of CURB-65 and E-CURB-65 scoring systems in healthcare associated pneumonia patients: Short- and long-term mortality. Niger J Clin Pract [serial online] 2021 [cited 2021 Dec 2];24:1706-11. Available from: https://www.njcponline.com/text.asp?2021/24/11/1706/330465




   Introduction Top


Pneumonia has been defined as the infection of the lung or its parts where gas exchange is performed. The presence of infiltrates in radiological imaging with signs of respiratory tract infection is sufficient for diagnosis.[1],[2] Pneumonia has been classified as either community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP) according to the type of development. In 2005, the American Thoracic Society and the Infectious Diseases Society of America (ATS/IDSA) expanded their classification and introduced new subcategorization of hospital-acquired pneumonia (HAP) which was called the HCAP. The HCAP group was defined as the patients from the community but who had frequent contacts with health care. The definition includes residents in a long-term care facility (nursing home), patients hospitalized for at least 2 days in the prior 90 days, patients receiving outpatient infusion therapy (antibiotics and/or chemotherapy), home wound care and attending a hemodialysis center in the prior 30 days.[3] Therefore, management strategies were defined under the heading of the HAP/VAP guidelines.[4],[5] However, there are debates still going on about the definition and the management of this specific group of patients. Thus, 2016 HAP/VAP guideline took attention to HCAP definitions and emphasized that treatment strategies would probably be changed in the upcoming guidelines[5] Besides some researchers thought that nursing home residents should be evaluated separately from the HCAP patients also. This specific type of pneumonia was called as nursing home-associated pneumonia (NHAP).[6]

The most important problem in the diagnostic process of pneumonia patients is to determine which patient group should be hospitalized and which should be followed up as outpatients. Timely and correct determination of the patient group to be hospitalized is very important both to initiate early treatment and to decrease unnecessary use of resources. Many risk scoring systems have been developed to determine whether treatment in pneumonia patients will be as outpatient, inpatient, or be in the intensive care unit. The most commonly used risk scoring systems include CURB-65 (acronym for Confusion, Urea, Respiratory rate, Blood pressure, and age over 65 years), Pneumonia Severity Index (PSI), Severe Community-Acquired Pneumonia (SCAP), SMART COP (acronym for systolic blood pressure, Multilobar infiltrates, Albumin, Respiratory rate, Tachycardia, Confusion, Oxygen, and pH), SOAR (acronym for Systolic blood pressure, Oxygenation, Age and Respiratory rate) and Expanded CURB-65. PSI is the first scoring system for community-acquired pneumonia. It was defined by the American Thorax Society and includes 20 parameters.[7] Subsequently, the CURB-65, developed by the British Thoracic Society and more practical than the PSI was defined.[8] While searching for a safer and easier scoring system than these risk scoring systems, Expanded-CURB-65 was defined in 2016. Currently, the most widely used E-CURB-65 scoring system was developed by adding increased LDH and decreased albumin and platelet count to the CURB-65 scoring system.[9]

Although many scoring systems have been defined for CAP there is no scoring system for HCAP. The primary aim of our study is to evaluate whether the CURB-65 or expanded-CURB-65 score can be used in HCAP and subgroups of HCAP patients at the same efficiency. Thirty and 90-day mortality rates of the patients and predictive values of CURB-65 and E-CURB-65 scores for 30 and 90-day mortality are compared retrospectively.


   Materials and Methods Top


Our study was conducted retrospectively at Fatih Sultan Mehmet Education Hospital Emergency Department in Istanbul, Turkey after approval of the hospital ethics committee.

Study data were reached by searching ICD codes of “J15, J15.8, J15.9, J17, J18.8, J18.9” retrospectively in-hospital database among patients who presented to emergency department between January 2015 and January 2016. All patient charts above 18 years of age were evaluated according to ATS/IDSA pneumonia diagnostic criteria and pneumonia diagnoses were confirmed.

Patients who were suspected to meet the criteria for Hospital-Acquired Pneumonia or Ventilator Associated Pneumonia, had a current diagnosis of pulmonary tuberculosis or new diagnosis, had another diagnosis after hospitalization (cancer, aspergillosis), had missing variables at automation system, whose 30 and 90-day mortality couldn't be detected, and who were pregnant at the time of the study were excluded. Each patient was taken to the study only once.

Among the patients, those who meet any of the following criteria defined in the guideline were categorized as HCAP and formed the study universe. The rest of the patients were accepted as CAP.

  • Hospitalization for two or more days in the last 90 days,
  • Staying in long-term nursing homes,
  • Receiving infusion therapy (including antibiotics) at home or nursing home,
  • Receiving care for pressure wound at home or nursing home,
  • Treatment at the hemodialysis center within the last 30 days,
  • Presence of multiple drug-resistant bacterial infections in family members.


Demographic characteristics, comorbid diseases, vital parameters, physical examination findings, laboratory, and radiological findings were examined. In addition, the CURB-65 and the E-CURB-65 scores of all patients were calculated according to the parameters in the medical records. Patients' 30 and 90-day mortalities were questioned from “Death Notification System” of the Public Health Agency of Ministry of Health on 30th and 90th days.

We further grouped HCAP patients in our study as “NHAP” (NHAP-patients who are residents of a nursing home or long-term care facility and did not get in contact with any kind of healthcare) and “HCAP except NHAP” (patients who had been in contact with at least one of the healthcare modalities defined in the HCAP criteria above, either resident of a nursing home/long-term care facility or living at home) in order to search whether the general characteristics, mortality and hospitalization rates differ.

IBM SPSS Statistics 22 (SPSS IBM, Turkey) program was used for statistical analysis while assessing the results obtained in this study. To assess the study data, suitability of the parameters for normal distribution were evaluated by the Shapiro Wilk test. While evaluating the study data, in addition to the descriptive statistical methods (mean, standard deviation, frequency), the Student t-test was used for the two-group comparisons of the normally distributed quantitative parameters, and the Mann–Whitney U test was used for the two-group comparisons of the quantitative parameters without normal distribution. Chi-square test, Fisher's Exact Test, and Continuity (Yates) correction were used for comparison of qualitative data. The Kruskal-Wallis test was used to compare three groups on continuous parameters that showed abnormal distribution; the Chi-square test was used for comparison of categorical variables. The ROC curve was used to assess the effect of CURB-65 and E-CURB-65 scores on mortality. The significance level was accepted to be P < 0.05.


   Results Top


According to study criteria, medical records of 1152 cases were evaluated. Four hundred were excluded because of the absence of new or progressing infiltration in radiologic imaging method or lack of at least one criterion (fever, cough, dyspnea, pleuritic chest pain) that should accompany infiltration. Of the remaining 752 cases, 110 were excluded due to missing data in the hospital computer registry system, 22 were excluded due to a newly diagnosed or identified tuberculosis disease on radiological examination, 10 were excluded because of a disease (cancer, aspergillosis, etc.) other than pneumonia was diagnosed after admission and 10 were excluded due to the risk of meeting hospital-acquired pneumonia criteria when the data in the computer registry was examined. The data of all pneumonia patients whose hospital records could be reached completely and who didn't have hospital-acquired pneumonia according to mentioned criteria were analyzed. As a result, 600 patients were evaluated [Figure 1].
Figure 1: Patient flowchart

Click here to view


167 pneumonia patients (27.8%) of all pneumonia cases were grouped as HCAP and 433 (54.4%) were grouped as CAP. 43% (n = 72) of HCAP patients were classified as NHAP and 57% (n = 95) were classified as HCAP (except NHAP) group. Demographic features and general clinical status, laboratory findings, and hospitalization and mortality rates were compared [Table 1]. NHAP patients were older than the other groups. HCAP (except NHAP) group had somehow more comorbid diseases when compared with the other groups. However, the NHAP group had more unstable vital signs and confusion rates. Hospital and ICU admissions, 30–90-day mortality rates were all significantly higher in the NHAP group.
Table 1: Demographics, clinical features, laboratory findings

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CURB-65 score was ≥3 in 12.7% of CAP patients, in 32.6% of HCAP (except NHAP) patients, and in 66.6% of NHAP patients; E-CURB-65 score was ≥5 in 7.6% of CAP patients, in 25.2% of HCAP (except NHAP) patients, and in 55.6% of NHAP patients and the difference was statistically significant (P < 0.01).

Prognostic utility of CURB-65% and E-CURB-65 scoring systems were also tested for 30 and 90-day mortalities in CAP and NHAP and HCAP (except NHAP) patients. E-CURB-65 was found to have better predictive values than CURB-65 for 30-day and 90-day mortalities overall. Comparisons between the groups showed no statistically significant difference for predictive values of CURB-65. However; analysis for E-CURB-65 showed significant differences between the groups. E-CURB-65 had better predictive values for 30-day and 90-day mortalities in CAP group than the other groups as expected [Table 2]. Our results did not support the use of both scoring systems in HCAP, NHAP, and (HCAP except NHAP) patients for predicting the 30 and 90-day mortality.
Table 2: Prognostic utility of CURB-65 and E-CURB-65 for short- and long-term mortality in CAP, NHAP, and HCAP (except NHAP) patients

Click here to view



   Discussion Top


Pneumonia is a serious illness that can affect people of any age. It is most dangerous in very young children, people older than 65, and in those with underlying medical problems such as diabetes, heart disease, and chronic lung disease.[5] It is the leading cause of health problems in elderly population and is the fifth leading cause of mortality in people over the age of 65. Pneumonia-related mortality rates are increasing every year; this is thought to be related to the increase in the number of elderly population and comorbid diseases.[10]

Life expectancy is increasing due to new medical supplements. However, this brings about new comorbid diseases, care needs, and disability-adjusted life years together. Some of the people who need care due to their chronic diseases are living in their own homes; while others live in nursing homes or long-term care facilities. It is inevitable that these patients often have contact with one type or another of healthcare facilities.

Although we had determined our study group as adults over 18 years old, the median age in all groups was higher than 65 years and all have multiple comorbid diseases. Significant proportion of patients were staying in nursing homes or long-term care facilities.

The classification of pneumonia types as CAP, HAP, or VAP is primarily required to identify responsible pathogens and treatments for them, and to form an appropriate algorithm. Older studies supported that HCAP patients are potentially risky and patients come in contact with MDR pathogens frequently. Therefore; they should be treated as HAP initially and treatment should be modified according to culture results.[11] Another view is that microorganisms responsible for HCAP are similar to CAP and therefore their treatment algorithms should be similar.[12],[13]

On the other hand, researchers agree that HCAP patients have higher mortality rates than CAP patients. There might be a risky group among HCAP patients and these risks probably are not related to the responsible pathogens. “Being a resident of a nursing home or a long-term care facility” which is one of the criteria of HCAP, formerly known as the NHAP, was evaluated specifically in recent studies.[14]

Here in this study we also grouped our pneumonia patients as CAP and HCAP according to the defined criteria. HCAP patients were further classified as NHAP and HCAP (except NHAP) patients who come in contact with any kind of healthcare. Predictive values of CURB 65 and E-CURB 65 and 30 and 90-day mortality rates of each group were evaluated in all groups.

When the cases in our study were evaluated according to the types of pneumonia, the median age of the patients in the NHAP group was 84 years consistent with the literature. NHAP patients in our study were older than the other groups with a predominance of the female sex. Ugojin et al.[15] studied 535 pneumonia cases; the mean age of the NHAP patients was 85 years which was significantly higher than the CAP group. Polverino et al.[16] studied 150 NHAP patients; they found the median age as 82 years and 49.1% of the patients were male.

In terms of comorbid diseases, HCAP (except NHAP) group in our study seemed to have more comorbid diseases than CAP and NHAP, especially the malignancies, chronic renal failure, and diabetes. Asthma and COPD were observed much more commonly in CAP patients.

Hospitalization rates and ICU admissions as well as the 30 and 90-day mortalities were significantly higher in NHAP patients than both CAP and HCAP (except NHAP) patients. These results might be perceived as surprising because NHAP patients did not come in contact with any kind of healthcare as well as with MDR pathogens defined in the guideline and they had relatively less comorbid diseases. However, as we evaluated the clinical status on admission, we observed that vital signs and confusion rates at admission were significantly worse in NHAP patients than in the other groups. Our results are consistent with the literature[16],[17] The disease might have been diagnosed late in the NHAP group due to insufficient clinical follow-up programs in nursing homes. Probability of facing MDR pathogens is much higher in HCAP (except NHAP) patients as they are frequently in contact with healthcare due to their comorbidities.[18]

The increase in the incidence of pneumonia has led to some problems in the treatment protocols of patients. The greatest aim of risk-scoring systems is to distinguish low-risk patients from moderate- and high-risk patients according to certain parameters, thus determining the need for treatment as outpatient or inpatient and requirement for intensive care unit. Liu et al.[9] retrospectively evaluated the severity of pneumonia in 1640 patients in 2016. They assessed CURB-65 scores in CAP patients and found that 74% were ≤1 and 26% were ≥2. Jeong et al.[19] found that CURB-65 ≥3 and PSI ≥class IV scores were higher in NHAP patients than CAP patients and the difference was statistically significant.

Alessio F. and friends evaluated 1164 pneumonia cases for validation study of Expanded CURB-65 score and they found that predictive power of E-CURB-65 score for 30-day mortality in CAP patients was high. In the same study, no statistically significant difference was found between E-CURB-65 and other scores to predict 30-day mortality in HCAP patients which formed 39.5% of the cases.[9] E- CURB 65 was not validated in NHAP subgroup in that study. Probably if it was evaluated in that study, results would be similar as with the HCAP patients. In our study when comparison was made according to the type of pneumonia CURB-65 score was ≥3 in 12.7% of CAP patients, in 32.6% of HCAP (except NHAP) patients, and in 66.6% of NHAP patients; E-CURB-65 score was ≥5 in 7.6% of CAP patients, in 25.2% of HCAP (except NHAP) patients, and in 55.6% of NHAP patients and the difference was statistically significant. However, overall results did not support the use of both of the scoring systems in HCAP, NHAP, and HCAP (except NHAP) patients for predicting the 30 and 90-day mortality. Different scoring systems should be developed and specific criteria should be added because of the specific characteristics of the patients in each group. For example, using home-vent for ventilatory support or feeding with nasogastric tubes might be particular risk factors for NHAP patients.

Our study was conducted retrospectively only in one center with relatively limited number of patients. Causative agents could not be identified. Relatively higher number of nursing homes located around the hospital might have affected the proportion of NHAP patients in respect to CAP when compared with other populations. The lack of provision of standard care, since the patients were brought from different nursing homes, may have affected our mortality rates. Unfortunately, antibiotic choices should not be evaluated due to missing medical records in the majority of patients.


   Conclusion Top


According to our results, commonly used scoring systems, CURB 65 and E-CURB 65, are not suitable for HCAP, NHAP, and HCAP (except NHAP) patients. NHAP patients have significant worse prognosis compared with CAP and HCAP (except NHAP) in terms of admission to intensive care and 30- and 90-day mortality rates. Different scoring systems should be developed and specific criteria should be added because of the specific characteristics of the patients in each group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Bates JH, Campbell GD, Barton AL, McCracken GA, Morgan PN, Moses EB, et al. Microbial etiology of acute pneumonia in hospitalized patients. Chest 1992;101:1005-12.  Back to cited text no. 1
    
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Fang G-D, Fine M, Orloff J, Arisumi D, Victor LY, Kapoor W, et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy: A prospective multicenter study of 359 cases. Medicine 1990;69:307-16.  Back to cited text no. 2
    
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American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.  Back to cited text no. 3
    
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Umeki K, Tokimatsu I, Yasuda C, Iwata A, Yoshioka D, Ishii H, et al. Clinical features of healthcare-associated pneumonia (HCAP) in a Japanese community hospital: Comparisons among nursing home-acquired pneumonia (NHAP), HCAP other than NHAP, and community-acquired pneumonia. Respirology 2011;16:856-61.  Back to cited text no. 6
    
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Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-50.  Back to cited text no. 7
    
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Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, et al. Defining community acquired pneumonia severity on presentation to hospital: An international derivation and validation study. Thorax 2003;58:377-82.  Back to cited text no. 8
    
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Liu JL, Xu F, Zhou H, Wu XJ, Shi LX, Lu RQ, et al. Expanded CURB-65: A new score system predicts severity of community-acquired pneumonia with superior efficiency. Sci Rep 2016;6:22911.  Back to cited text no. 9
    
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Koh SJ, Lee JH. Clinical characteristics of nursing home-acquired pneumonia in elderly patients admitted to a Korean teaching hospital. Korean J Intern Med 2015;30:638-47.  Back to cited text no. 10
    
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Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: A systematic review and meta-analysis. Clin Infect Dis 2013;58:330-9.  Back to cited text no. 12
    
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Gross AE, Van Schooneveld TC, Olsen KM, Rupp ME, Bui TH, Forsung E, et al. Epidemiology and predictors of multidrug-resistant community-acquired and health care-associated pneumonia. Antimicrobial agents and chemotherapy, 2014, 58.9: 5262-8.  Back to cited text no. 13
    
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Rothberg MB, Haessler S, Lagu T, Lindenauer PK, Pekow PS, Priya A, et al. Outcomes of patients with healthcare-associated pneumonia: Worse disease or sicker patients? Infect Control Hosp Epidemiol 2014;35(Suppl 3):S107-15.  Back to cited text no. 14
    
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Ugajin M, Yamaki K, Hirasawa N, Kobayashi T, Yagi T. Prognostic value of severity indicators of nursing-home-acquired pneumonia versus community-acquired pneumonia in elderly patients. Clin Interv Aging 2014;9:267-74.  Back to cited text no. 15
    
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Polverino E, Dambrava P, Cillóniz C, Balasso V, Marcos M, Esquinas C, et al. Nursing home-acquired pneumonia: A 10 year single-centre experience. Thorax 2010;65:354-9.  Back to cited text no. 16
    
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Ewig S, Klapdor B, Pletz MW, Rohde G, Schütte H, Schaberg T, et al. Nursing-home-acquired pneumonia in Germany: An 8-year prospective multicentre study. Thorax 2012;67:132-8.  Back to cited text no. 17
    
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Lim CW, Choi Y, An CH, Park SJ, Hwang HJ, Chung JH, et al. Facility characteristics as independent prognostic factors of nursing home-acquired pneumonia. Korean J Intern Med 2016;31:296-304.  Back to cited text no. 18
    
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Jeong B-H, Koh W-J, Yoo H, Um S-W, Suh GY, Chung MP, et al. Performances of prognostic scoring systems in patients with healthcare-associated pneumonia. Clin Infect Dis 2013;56:625-32.  Back to cited text no. 19
    


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