Validity of Pneumonia Severity Assessment Scores in Africa and South Asia: A Systematic Review and Meta-Analysis

Severe community-acquired pneumonia at a tertiary academic hospital in Johannesburg, South Africa

PURPOSE

There is a paucity of data from sub-Saharan Africa describing Severe Community Acquired Pneumonia (SCAP), a condition with significant morbidity and mortality.

MATERIALS AND METHODS

This was a retrospective, single-centre, observational study of consecutive patients with SCAP admitted to the ICU at Charlotte Maxeke Johannesburg Academic Hospital, in South Africa between 1 July 2007 and 31 May 2019. Pneumonia was categorised as community-acquired if there had been no hospitalization in the preceding 2 weeks.

RESULTS

We identified 931 patients, (median age 37 [IQR 30-48] years), with the predominant co-morbidity being HIV co-infection (77.1 %). The median CURB-65 and APACHE II scores were 3 (IQR 2-3) and 18 (IQR 14-23) respectively, and most patients had multilobar consolidation on chest X-ray. Mycobacterium tuberculosis was the most common aetiology, followed by Streptococcus pneumoniae. The latter, and Pneumocystis jirovecii were more common amongst survivors and non-survivors, respectively. ICU mortality was 50.1 % and 85 % of patients required ventilation, mostly invasive mechanical ventilation. Ventilated patients and those requiring inotropic support and/or dialysis were more likely to die.

CONCLUSION

We have described a cohort of patients with SCAP, with a comprehensive overview of all putative microbiological causes, which to our knowledge, is the largest reported in the literature.

The National Early Warning Score 2(NEWS2) to Predict Early Progression to Severe Community-Acquired Pneumonia

This study aimed to assess the predictive performance of the National Early Warning Score 2 (NEWS2) to identify the early progression to severe disease in patients with community-acquired pneumonia (CAP). A prospective-cohort study was conducted among patients with CAP admitted to a university hospital between October 2020 and December 2021. The endpoint of interest was the progression to severe CAP, defined as the requirement for a mechanical ventilator, a vasopressor, or death within 72 h after hospital admission. Among 260 patients, 53 (25.6%) had early progression to severe CAP. The median NEWS2 of the early progression group was higher than that of the non-progression group [8 (6-9) vs. 7 (5-8), p = 0.015, respectively]. The AUROC of NEWS2 to predict early progression to severe CAP was 0.61 (95% CI: 0.52-0.70), while IDSA/ATS minor criteria ≥ 3 had AUROC 0.56 (95% CI 0.48-0.65). The combination of NEWS2 ≥ 8, albumin level < 3 g/dL and BUN ≥ 30 mg/dL improved AUROC from 0.61 to 0.71 (p = 0.015). NEWS2 and IDSA/ATS minor criteria showed fair predictive-accuracy in predicting progression to severe CAP. The NEWS2 cut-off ≥ 8 in combination with low albumin and uremia improved predictive-accuracy, and could be easily used in general practice.

Global emergency medicine: A scoping review of the literature from 2021

OBJECTIVE

The objective was to identify the most important and impactful peer-reviewed global emergency medicine (GEM) articles published in 2021. The top articles are summarized in brief narratives and accompanied by a comprehensive list of all identified articles that address the topic during the year to serve as a reference for clinicians, researchers, and policy makers.

METHODS

A systematic PubMed search was carried out to identify all GEM articles published in 2021. Title and abstract screening was performed by trained reviewers and editors to identify articles in one of three categories based on predefined criteria: disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine development (EMD). Included articles were each scored by two reviewers using established rubrics for original (OR) and review (RE) articles. The top 5% of articles overall and the top 5% of articles from each category (DHR, ECRLS, EMD, OR, and RE) were included for narrative summary.

RESULTS

The 2021 search identified 44,839 articles, of which 444 articles screened in for scoring, 25% and 22% increases from 2020, respectively. After removal of duplicates, 23 articles were included for narrative summary. ECRLS constituted the largest category (n = 16, 70%), followed by EMD (n = 4, 17%) and DHR (n = 3, 13%). The majority of top articles were OR (n = 14, 61%) compared to RE (n = 9, 39%).

CONCLUSIONS

The GEM peer-reviewed literature continued to grow at a fast rate in 2021, reflecting the continued expansion and maturation of this subspecialty of emergency medicine. Few high-quality articles focused on DHR and EMD, suggesting a need for further efforts in those fields. Future efforts should focus on improving the diversity of GEM research and equitable representation.

A Service Evaluation of Adherence with Antimicrobial Guidelines in the Treatment of Community-Acquired Pneumonia Before and During the SARS-CoV-2 Outbreak

Antimicrobial stewardship is essential to reducing antimicrobial resistance, reducing costs, and, crucially, ensuring good patient care. Community-acquired pneumonia (CAP) is a common medical condition, the symptoms of which show a significant overlap with those of COVID-19. Following the COVID-19 outbreak in Ireland, patients presenting to our hospital with features of a respiratory infection were more commonly reviewed within 24 hours (24h) of admission by an infectious disease (ID) or respiratory specialist. We aimed to assess how the change in service provision, involving frequent specialist reviews of patients admitted with features of CAP during the first wave of the COVID-19 pandemic, affected antimicrobial stewardship and prescribing practices. Patients admitted under general medical teams treated for CAP from March–April 2020 were included. Retrospective data including demographics, CURB-65 score, and antimicrobial therapy were collected, as well as information on whether the patient had undergone specialist review by an ID or respiratory physician. Data were compared to a similar cohort treated for CAP between November 2019 and January 2020, though in this cohort, before the era of COVID-19, none of the patients had undergone specialist review. Seventy-six patients were included from the March–April 2020 cohort, with 77 from November 2019–January 2020 for comparison. An ID or respiratory specialist reviewed 35 patients from the March–April cohort within 24 h of admission. There was a higher rate of appropriate escalation, de-escalation, and continuation of antibiotics among those reviewed. Less than 20% of patients were started on antibiotics in accordance with CAP guidelines on admission, though the antibiotics initiated were frequently deemed appropriate in the clinical setting. Specialist review increases rates of appropriate antimicrobial prescribing and adherence with hospital guidelines in patients with CAP.

Comparison of Different Scoring Systems for Prediction of Mortality and ICU Admission in Elderly CAP Population

Background

The incidence and mortality rate of community-acquired pneumonia (CAP) in elderly patients were higher than the younger population. Different scoring systems, including The quick Sequential Organ Function Assessment (qSOFA), Combination of Confusion, Urea, Respiratory Rate, Blood Pressure, and Age ≥65 (CURB-65), Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS), were used widely for predicting mortality and ICU admission of patients with community-acquired pneumonia (CAP). This study aimed to identify the most suitable score system for better hospitalization.

Methods

We retrospectively analyzed elderly patients with CAP in Minhang Hospital, Fudan University from 1 January 2018 to 1 January 2020. We recorded information of the patients including age, gender, underlying disease, consciousness state, vital signs, physiological and laboratory variables and further calculated the qSOFA, CURB-65, MEWS, and NEWS scores. Receiver operating characteristic (ROC) curves were used to predict the mortality risk and ICU admission. Kaplan–Meier survival curves were used in survival rate.

Results

In total, 1044 patients were selected for analysis and divided into two groups, namely survivor groups (902 cases) and non-survivor groups (142 cases). Depending on ICU admission enrolled patients were classified into ICU admission (n = 102) and non-ICU admission (n = 942) groups. Mortality expressed as AUC values were 0.844 (p < 0.001), 0.868 (p < 0.001), 0.927 (p < 0.001) and 0.892 (p < 0.001) for qSOFA, CURB 65, MEWS and NEWS, respectively. There were clear differences in MEWS vs CURB-65 (p < 0.0001), MEWS vs NEWS (p < 0.001), MEWS vs qSOFA (p < 0.0001). For ICU-admission, the AUC values of qSOFA, CURB-65, MEWS and NEWS scores were 0.866 (p < 0.001), 0.854 (p < 0.001), 0.922 (p < 0.001), 0.976 (p < 0.001), respectively. There were significant differences in NEWS vs CURB-65 (p < 0.0001), NEWS vs MEWS (p < 0.001), NEWS vs qSOFA (p < 0.0001).

Conclusion

We explored the outcome prediction values of CURB65, qSOFA, MEWS and NEWS for patients aged 65-years and older with community-acquired pneumonia. We found that MEWS showed superiority over the other severity scores in predicting hospital mortality, and NEWS showed superiority over the other scores in predicting ICU admission.