A PREDICTION RULE TO IDENTIFY LOW-RISK PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA.

Fine MJ, et al. N Engl J Med 1997 Jan 23;336(4):243-50.

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 <7.35, a blood urea nitrogen concentration > or = 30 mg per deciliter [11 mmol per liter] or a sodium concentration <130 mmol per liter) at presentation.

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.

COMMENTS: Independent predictors of increased mprtality included age > 50, coexisting illnesses (CHF, neoplastic, cerebrovascular, renal or liver disease), and abnormal physical findings (AMS, HR > 125, RR > 30, SBP < 90mm Hg, and T < 35ºC or > 40ºC). Additional risk factors identified included male sex, nursing home residence, and abnormal laboratory or radiographic findings (BUN > 30mg/dl, gluc > 250mg/dL, Hct < 30%, Na < 130mmol/L, PaO2 < 60mm Hg, pH < 7.35, and pleural effusion). These findings still require confirmation.