The pneumonia severity index (PSI) and CURB-65 (confusion, uremia, respiratory rate, BP, age 65 years and older) criteria, established predictors of mortality in patients hospitalized with community-acquired pneumonia (CAP), may have even greater value for predicting mortality in patients with SARS-CoV-2 CAP, according to research recently published in CHEST. Notably, researchers also found that adding criteria related to D-dimer or procalcitonin to these scoring tools did not improve their predictive value, regardless of the etiology of CAP.

Although PSI and CURB-65 have been used to predict CAP, their use with regard to COVID-related CAP has not been widely investigated. According to the authors, quick and accurate analysis of mortality risk permits clinicians to triage/optimize management of high-risk patients, thus the importance of optimized models.

In the current secondary, population-based analysis, investigators assessed the predictive value of PSI and CURB-65 as prognostic tools for CAP mortality using 2 prospective cohorts of adult patients — a SARS-CoV-2 CAP cohort and a non-SARS-CoV-2 CAP cohort — from 8 hospitals in Louisville, KY. The study involved a total of 8081 patients, including 632 (8%) with SARS-CoV-2 CAP. The SARS-CoV-2 CAP cohort had a median age of 63 and included 47% males, 31% Black individuals, 12% Hispanic individuals. The in-hospital mortality rate was 19% for patients with SARS-CoV-2 CAP and 6.5% for patients with non-SARS-CoV-2 CAP. Notably, in the SARS-CoV-2 CAP cohort, those who died were older and had more comorbidities.


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Compared to patients with non-SARS-CoV-2 CAP, patients presenting with SARS-CoV-2 CAP had a higher mortality rate in every PSI risk class and every CURB-65 score. The AUC for PSI was 0.82 (95% bCI [bootstrap standard CI], 0.78-0.86) in patients with SARS-CoV-2 CAP and 0.79 (95% bCI, 0.77-0.80) in patients with non-SARS-CoV-2 CAP. The AUC for CURB-65 was 0.79 (95% bCI, 0.75-0.84) in patients with SARS-CoV-2 CAP and 0.75 (95% bCI, 0.73-0.77) in patients with non-SARS-CoV-2 CAP. Notably, the addition of D-dimer and procalcitonin criteria did not substantially improve the predictive ability of PSI or CURB-65, despite the biological rationale for adding these measures.

Investigators noted that a remarkable difference in the positive predictive value of the 2 tools between patients with SARS-CoV-2 CAP vs non-SARS-CoV-2 CAP was found, which was likely attributable to the increased prevalence of poor outcomes in patients with SARS-CoV-2 CAP. Researchers thus concluded that the high negative-predictive value of the 2 scoring tools for CAP regardless of etiology (> 94%) suggested that the scoring systems were best suited for picking out patients at low-risk for death.

A limitations of the current study was that participants were recruited from only 1 city, potentially inhibiting extrapolation of study findings to other populations. Other limitations are that D-dimer and procalcitonin were not analyzed in all patients, and the treatment of COVID is continuously changing.

Reference

Bradley J, Sbaih N, Chandler TR, et al. Pneumonia severity index and curb-65 are good predictors of mortality in hospitalized patients with SARS-COV-2 community-acquired pneumonia. Chest. Published online November 2, 2021. doi:10.1016/j.chest.2021.10.031