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Emergencias 2010; 22: 275-281 275

ORIGINAL ARTICLE

Objectives: The aim of this study is to describe the characteristics of low risk patientswith Community-Acquired Pneumon ia (CAP) admitted at a university hospital, tocompare those who are older and younger than 65 year old and to compare those inlow-risk groups ( III) with those in high-risk groups (> III).Patients and Methods: Observational and retrospective study of low-risk patients withCAP admitted at a tertiary hospital. Epidemiological, clinical and outcome data wererecorded.Results: Ninety nine (46.9%) out of 211 patients with CAP were classified in Finecategories I, II and III (26, 33 and 40 respectively); 99 (100%) were hospitalised ingeneral medical wards. Mean age was 50 years (range, 13 to 85 years), and a coexistingcondition was present in 32% patients. More frequent physical-examination findingswere systolic blood pressure < 90 mmgHg (8%), pulse > 125/min (7%) and respiratoryrate 30/min (6%). More prevalent laboratory and radiological findings were pO2 < 60mmHg (26%), pleural effusion (9%) and glucose 250 mg/dl (8%); 1 patient (1%) ingroup III died. Mean hospital stay was 6 days (range, 1 to 24 days). Ther e were

statistically significant differences in all variables included in Fine score (more frequent inhigh-risk patients) except for liver disease, low systolic blood pressure, high heat rate,temperature abnormalities, pleural effusion, low sodium and hematocrit figures; withinlow-risk patients < or >65 year-old there were not statistically significant differencesexcept in the rate of COPD (9.7% vs 25.6%).Conclusions: out of all admitted patients wi th CAP, 46% were low-risk patientsaccording to Fine score; there were not statistically significant differences in relation toage group (>/< 65 year old) except in the rate of COPD and there were differences insome but not all of the variables in Fine-score in patients in low-risk groups compare tothose in high risk-groups. [Emergencias 2010;22:275-281]

Key words: Community-acquired pneumonia. PORT-score. Low-risk group.

CORRESPONDENCE:Dr. Elisa Garca VzquezServicio de Medicina Interna-InfecciosasHospital UniversitarioVirgen de la ArrixacaCtra. Madrid-Cartagena, s/n30120 El PalmarMurcia, SpainE-mail: [email protected]

RECEIVED:8-3-2010

ACCEPTED:16-4-2010

CONFLICT OF INTEREST:None

Description of a cohort of low-risk patients

with community-acquired pneumonia admittedto a university hospital

ELISA GARCA VZQUEZ1, SILVIA SOTO2, ALICIA HERNNDEZ-TORRES1, JOS ANTONIO HERRERO1,JOAQUN GMEZ1

1Servicio de Medicina Interna-Infecciosas. Hospital Universitario Virgen de la Arrixaca. Murcia, Spain. 2Serviciode Nefrologa. Hospital Mndez lvarez de Lorca. Murcia, Spain.

Introduction

Community-acquired pneumonia (CAP) re-mains a serious disease with a major impact onhealth spending. The annual incidence in Spain isbetween 1.6 and 3.8 cases per 1,000 people, andworldwide between 1 and 30 cases per 1,000people. In Europe, the percentage of hospital ad-mission due to CAP varies from 20 to 40%1,2. Thedirect cost of CAP treatment in the United Statesis estimated to be nearly 8,500 million dollars a

year, with patient hospitalization accounting for

approximately 95% of that amount. The cost ofinpatient treatment is 8 times higher than outpa-tient treatment3-5.

The Pneumonia Patient Outcomes ResearchTeam (PORT)] developed a predictive scale toidentify the risk of death and other adverse eventsin CAP patients (Fine scale)6. This scale uses 20variables to classify patients as low and high riskof short-term mortality, and links this with themost appropriate place for treatment, which maybe ambulatory (Risk class I and II), brief observa-

tion (Risk class III) or admission to a conventional

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E. Garca Vzquez et al.

276 Emergencias 2010; 22: 275-281

hospital ward (Risk class IV and V). Although ini-tially designed to identify patients with low-risk ofmortality, different studies7-10 have reported thatuse of the Fine scale in emergency departmentsincreases the percentage of ambulatory patients

with low-risk CAP without compromising safety. ATS and IDSA clinical guidelines11-13 approved theuse of this scale to predict short-term outcomeand aid decision making on where to initially treatadults with CAP14. However, many of these pa-tients are admitted, suggesting that clinicians useinconsistent criteria when deciding on the appro-priate care unit15-17.

We conducted a retrospective observationalstudy of patients with CAP (Fine scale risk classesI, II and III) admitted to a tertiary level universityhospital. The aim of our study was to describe

the characteristics of these hospitalized patientswith low-risk CAP and compare them with thoseof high risk patients (Fine scale risk classes IVand V).

The Fine scale may minimize the severity ofrisk in younger patients (the relative weight ofage is high on this scale), so we also studied asub-cohort of low-risk CAP patients applying anage cut off point of 65 years, in order to detectany difference in other variables, besides age, in-cluded in the Fine scale.

Method

We performed a retrospective observationalstudy of patients with CAP admitted to the Uni-versity Hospital Virgen de la Arrixaca (Murcia), atertiary level university hospital with 900 beds,from January to December 2003. Our emergencydepartment (ED) does not routinely use the Finescale as a guide to help in making decisions onthe treatment site. From an initial cohort of 484CAP patients, over 12 years of age, we randomlyselected a sample of 211 patients for data analysis

from clinical records, epidemiological and clinicaldata, radiological and laboratory test results andprognosis of hospitalized low-risk patients. We al-so carried out an analysis of patients according toage (cutoff point 65 years).

CAP was defined as the presence of a new in-filtrate on chest radiograph together with clinicalhistory and physical signs of lower respiratorytract infection in a patient not hospitalized in theprevious month and without an alternative diag-nosis during follow up. Clinical, radiological andlaboratory findings, as well as other epidemiologi-

cal data were collected using a specific question-

naire and entered on an electronic data base. Theseverity of CAP was assessed on the first day ofadmission using the Fine scale. Patients with neu-tropenia ( 10 5 cfu/ml in TBA (traqaueobronquial aspi-rate), > 103 CFU/ml in PBS (selective bronchialaspirate) and > 104 cfu/ml in BAL (bronchoalve-olar lavage) and (7) positive culture positive (ha-bitual respiratory pathogen) from a sample ofsputum. The medical records of patients were as-sessed up to hospital discharge or in-hospitaldeath.

Descriptive data of quantitative variables areexpressed as mean standard deviation (SD) andqualitative variables as percentages. Statisticalcomparisons between qualitative variables wereperformed using chi2 test with Yates correction or

Fisher's exact test when necessary. Compa-risons of means were performed using Student ttest, analysis of variance (ANOVA) and nonpara-metric tests (Kruskal-Wallis). Multivariate analysiswas performed using a logistic regression model.Statistical significance was defined as a value ofp < 0.05. All statistical tests were carried out with

the statistical package SPSS 12.0.

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Results

Of the 211 patients with CAP, 99 (46.9%)were classified as risk classes I, II and III using theFine scale (26, 33 and 40 cases respectively); all

were admitted to a conventional medical depart-ment ward and none in the intensive care unit. Inthe low-risk group there were 54 men (54.5%)and in the high-risk group men accounted for76% (p < 0.05). In the low-risk group (Table 1),mean age was 50 years (range: 13-85 years): 72%< 65 years, 19% between 65 and 75 years, and8% > 75 years.

Only one patient in the low-risk group camefrom a nursing home compared with 5 (4.5%) inthe high-risk group (p > 0.05). The average staywas 6.5 days in low-risk patients and 8.9 days in

the high-risk group (P< 0.05).The etiological diagnosis was obtained in18.2% of low-risk patients and in 19.6% in thehigh-risk group. S. pneumoniae was the mostcommon organism identified in both groups. P.aeruginosawas not isolated in the low-risk group,and where Legionella sp. was most frequentlyfound in this group.

In 32% of patients in the low-risk group wefound an association with at least one underlyingdisease [most frequently heart failure (15%) andchronic obstructive pulmonary disease (COPD)(14%)]; these diseases were significantly moreprevalent in high-risk patients (except liver dis-ease); 32% of low-risk patients had one or morecomorbidities. The most frequent clinical signs onphysical examination of low-risk patients were:systolic blood pressure < 90 mmHg (8%), heartrate > 125 bpm (7%) and respiratory rate 30rpm (6%). Of all clinical signs, including Finescale scores, only respiratory rate 30 rpm andaltered mental status were statistically more fre-quent and significant in high-risk patients. Themost frequent radiological and laboratory findingsin low-risk patients were partial arterial oxygen

pressure < 60 mmHg (26%), pleural effusion (9%)and plasma glucose 250 mg/dl (8%), but of allthe radiological and laboratory included in theFine scale, only pO2 < 60 mmHg, hyperglycemia,renal failure and acidosis were more common andstatistically significant in high-risk patients (Table1). Only one (1%) patient in group III died of res-piratory failure with severe hypoxemia and hyper-capnia.

In the low-risk group of patients, a sub-analysiswas performed applying an upper cut off point of65 years; there were no significant differences in

epidemiological data, clinical, radiological, labora-

tory data and prognosis, except for the percent-age of COPD (Table 2). All other variables includ-ed in the Fine scale were more frequent in thissub-group of patients < 65 years, but withoutreaching statistical significance.

Discussion

We performed a retrospective observationalstudy of CAP patients at low-risk (according to theFine scale), admitted to a tertiary hospital wherethe ED does not routinely apply this severity indexas a guide to decision-making on where the pa-tient is to be treated. Our aim was to describeand compare their characteristics with those ofpatients at high risk according to the Fine scale.

In low-risk patients, mean age was 50 years(range 13-85), but 72% were under 65 while51% of high-risk patients were over 75 years(p < 0.05), suggesting that the variable age car-ries high weight in the Fine scale. The percentageof males was also significantly higher in high-riskpatients (75% vs 54%), as expected since the Finescale places greater weight on age in men than inwomen. However, one result highlighted by ourstudy is that high-risk patients had significantlygreater comorbidity, and alterations in the physi-cal examination, laboratory and radiological teststhan low-risk patients, although only the follo-wing variables were significantly more frequent inthe high-risk group: heart failure, COPD, cere-brovascular disease, cancer, kidney disease,tachypnea, altered level of consciousness, hypo-xemia, hyperglycemia, renal failure and acidosis.

These results also validate to some extent theFine scale as a predictive tool that correctly identi-fies CAP patients at low and high risk. However,when a clinician decides whether a low-risk pa-tient should be admitted or discharged, certainvariables included in the Fine scale may be overor under-weighted. Thus, the percentage of pa-

tients with systolic blood pressure < 90 mmHgdid not differ significantly between high and low-risk patients (a parameter included in the defini-tion of sepsis), nor did the percentage of patientswith tachycardia, elevated temperature, pleural ef-fusion, hyperglycemia, hyponatremia or anemia.The fact that these clinical features are commonin both high and low-risk groups of in-patientssuggests that more importance was attached toarterial hypotension (an indicator of sepsis), pleu-ral effusion or abnormal laboratory findings. Al-though our study sample size was limited, which

could affect statistical power, these data are con-

DESCRIPTION OF A COHORT OF LOW-RISK PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA ADMITTED TO A UNIVERSITY HOSPITAL

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sistent with those of other authors18,19. In addition,32% of low-risk patients had one or more associ-ated diseases, which increases the probability ofdecompensation due to pneumonia (eg. COPD,heart disease or cerebrovascular dise-ase). In fact, 26% presented hypoxemia, 8% hy-perglycemia and 9% pleural effusion. All thesefindings may constitute contraindications for out-patient treatment. A recent study investigated thereasons why 845 low-risk patients were admittedto hospital, all being classified as risk class II-III on

the Fine scale, and evaluated the presence ofmedical and psychosocial diseases not included inthe Fine scale20. The conclusions were that this in-dex of severity should be complemented with theassessment of other factors like living on thestreet, suffering psychiatric illness, social depriva-tion, previous failure of outpatient treatment, in-tolerance to oral route treatment, non-compliancewith prescribed medication, suspected sepsis andhypoxemia, before deciding on outpatient treat-ment.

Our study should be considered in the light of

its limitations: it lacked a control group of Fine

scale I, II and III ambulatory patients; it was a re-trospective study where the Fine scale classifica-tion was made post hoc from medical records re-viewed (because of this retrospective aspect, thereason for admission of low-risk patients could notbe evaluated); and that the patients included inthe study were randomly selected from a largercohort of CAP patients and therefore the percent-age of patients with low-risk pneumonia admittedto our hospital may have been affected.

The mortality rate in low risk hospitalized pa-

tients was very low (1%), similar to that describedby Fine and colleagues (even though our studywas limited to evaluating mortality only up to dis-charge and not 30 days). Whether this low-risk ofmortality can be extrapolated to ambulatory treat-ment is a question we cannot answer21.

The initial decision on where best to treat pa-tients with pneumonia (outpatient attention orhospitalization), is a medical decision of conside-rable economic importance22,23. In economicterms, hospitalization costs per episode of pneu-monia are 25 times greater than outpatient treat-

ment. In medical terms, hospitalization increases


278 Emergencias 2010; 22: 275-281

Table 1. Demographic and clinical characteristics of patients according toFine scale risk categories

Category I, II and III Category IV and V p(N = 99) (N = 112)

Age (years) [mean (range)] 50 (13-85) < 0.05Age Group [Total (%)] < 0.05

< 65 years 72 (72.7) 20 (17)65-75 years 19 (19.2) 35 (31.3)> 75 years 8 (8.1) 57 (50.9)

Male sex [Total (%)] 54 (54.5) 85 (75.9) < 0.05Hospital stay (days) [mean (range)] 6.54 (1-24) 8.9 (1-36) < 0.05Institutionalized [Total (%)] 1 (1) 5 (4.5) nsUnderlying disease [Total (%)] 32 (32.3) 98 (87.5) < 0.05

Heart failure 15 (15.2) 56 (50) < 0.05COPD 14 (14.1) 49 (43.7) < 0.05Cerebrovascular disease 4 (4) 20 (17.9) < 0.05Neoplasia 1 (1) 15 (13.4) < 0.05Liver disease 1 (1) 4 (3.6) nsKidney Disease 1 (1) 23 (20.5) < 0.05

Etiologic diagnosis [Total (%)] 18 (18.2) 22 (19.6) nsS. pneumoniae 14 (14.1) 15 (13.4) nsL. pneumophila 3 (3) 1 (0.9) nsM. pneumoniae 1 (1) 2(1.8) ns

P. aeruginosa 0 (0) 4 (3.2) nsPhysical examination findings [Total (%)]

Systolic blood pressure < 90 mmHg 8 (8.1) 11 (9.8) nsHeart rate > 125 lpm 7 (7.1) 14 (12.5) nsRespiratory rate > 30/min 6 (6.1) 44 (39.3) < 0.05

Altered consciousness level 2 (2) 25 (22.3) < 0.05Temperature < 35 or > 40C 1 (1) 5 (4.5) ns

Laboratory and radiological findings [Total (%)]pO2 < 60 mmHg 26 (26.3) 71 (63.4) < 0.05Pleural effusion 9 (9.1) 14 (12.5) nsGlucose > 250 mg/dL 8 (8.1) 19 (17) 0.05Serum sodium < 130 mg/dL 4 (4) 9 (8) nsHematocrit < 30% 4 (4) 10 (8.9) nsBUN > 30 mg/dL 2 (2) 46 (41) < 0.05Arterial pH < 7.35 1 (1) 21 (18.7) < 0.05

COPD: chronic obstructive pulmonary disease; ns: statistically non-significant.

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the risk of thromboembolic events and furtherbacterial infection by microorganisms circulatingin hospitals that are more resistant and virulent.

We recommend the use of prognostic models,such as the Fine scale, to identify pneumonia pa-tients who could be safely treated on an outpa-tient basis; considering associated mortality, it hasbeen suggested that patients in class I and IIshould be treated on an outpatient basis and classIII should be observed for 24 hours and thentreated on an outpatient basis if no complicationsarise during observation24-28.

In our study, almost half the patients admittedwere classed as low-risk on the Fine scale. Thishigh rate of admission to a tertiary hospitalwhere the ED did not use Fine scale classificationto guide decision-making on place of treatmentis similar to those EDs with low use of such

scales8, which leads us to consider that our ED isa candidate for an intervention program to en-hance the Fine scale, as in a recent study24, andapply it before decisions are made on the bestplace to treat CAP patients. However, other au-thors29,30 have indicated that this high percentageof hospitalizing low-risk CAP patients is becauseclinicians consider other variables not included insuch scales, or that the scales and objective crite-ria should always be complemented by consider-ing other factors such as patient safety and thepossibility of real compliance with oral medica-

tion, outpatient resource capacity and functional

status assessment of the patient31-33. Home carereduces direct interaction with the physician anddepends heavily on nurses, patient attitude andinformal caregivers34. The objectives of home careare to achieve the same levels of quality, recovery

and functional status as any other mode of care,although this is not always possible. Home careunits and social services should probably be en-couraged to help decrease the rate of CAP pa-tient hospital admission.

As already indicated, the Fine scale may mini-mize the severity of risk in young patients (therelative weight of age on the Fine scale is high).The analysis of a low-risk sub-group with a maxi-mum age of 65 years showed no differences ex-cept in the percentage of patients with COPD,which was significantly higher in more elderly pa-

tients. However, the small sample size may under-estimate the presence of certain clinical and socialvariables in the younger patients.

Microbiological diagnosis was made in a verylow percentage of patients, with no significant dif-ferences found low and high-risk patients (18.2%vs 19.6%). This could be because in our hospitalmicrobiological tests are performed according tothe attending physicians criteria, and becauseprotocols for the management of CAP patients donot include routine use of these microbiologicaltests (sputum, blood culture, urinary detection ofsoluble pneumococcal antigen or L. pneumophilaand blood samples for serology).

In conclusion, in our cohort of hospitalizedCAP patients, 46% were classified as low-risk pa-tients on the Fine scale, and there were no statis-tically significant differences regarding age groups(under or over 65 years) except in the percentageof COPD (greater in elderly patients), although al-most all the variables of severity included in theFine scale were non-significantly more frequent in

younger patients.On comparing low and high-risk patients, dif-

ferences were statistically significant for all the vari-

ables included in the Fine scale (more common inhigh-risk patients) except for liver disease, arterialhypotension, tachycardia, temperature alterations,pleural effusion, hyponatremia and anemia.

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Emergencias 2010; 22: 275-281 279

Table 2. Demographic and clinical characteristics of Fine scalelow-risk patients according to age

< 65 years 65 years p(N = 72) (N = 27)

n (%) n (%)

Mortality 0 (0) 1 (3,7) nsMale Sex 41 (56,7) 13 (48,1) nsInstitutionalized 1 (1,4) 0 (0) nsNeoplasia 1 (1,4) 0 (0) nsLiver disease 1 (1,4) 0 (0) nsHeart failure 8 (11,1) 7 (25,6) nsKidney disease 1 (1,4) 0 (0) nsCerebrovascular disease 4 (5,5) 0 (0) nsCOPD 7 (9,7) 7 (25,6) < 0,05

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Estudio de una cohorte de pacientes con neumona adquirida en la comunidad de bajoriesgo ingresados en un hospital universitario

Garca-Vzquez E, Soto S, Hernndez-Torres A, Herrero JA, Gmez JObjetivos: El objetivo principal de este trabajo fue describir las caractersticas de los pacientes con neumona adquiridaen la comunidad (NAC) de bajo riesgo ingresados en un hospital terciario universitario. Los objetivos secundarios fue-ron comparar los pacientes con NAC en funcin de la edad (mayor o menor de 65 aos) y del riesgo agrupado segnla clasificacin de Fine (mayor de III o igual o menor de III).Mtodo: Estudio descriptivo retrospectivo de pacientes con NAC de bajo riesgo ingresados en un hospital terciariouniversitario. Se recogieron variables epidemiolgicas, clnicas y evolutivas.Resultados: Del total de los 211 pacientes ingresados con NAC, 99 (46,9%) correspondan a los grupos de bajo riesgo I, IIo III de la clasificacin de Fine (26, 33 y 40 respectivamente) con una edad media de 50 aos (rango 13 a 85); el 8% ten-an una presin arterial sistlica menor de 90 mmHg, el 7% una frecuencia cardiaca mayor de 125/min, el 6% una frecuen-cia respiratoria mayor de 30/min, el 26% pO2 < 60 mmHg, el 9% derrame pleural y el 8% glucemia > 250 mg/dl. Todoslos pacientes fueron ingresados en plantas convencionales de hospitalizacin y la estancia fue de 6 das (rango 1-24). Unpaciente falleci (previamente clasificado como de grupo III). Cuando se compararon los pacientes en funcin del riesgo

(grupo bajo riesgo = I-II-III y grupo alto riesgo = grupo IV-V), hubo diferencias estadsticamente significativas respecto a to-das la variables que recoge la escala de Fine, que fueron ms frecuentes en el grupo de alto riesgo (grupo IV-V), excepto enel porcentaje de enfermedad heptica, hipotensin arterial, taquicardia, alteraciones de la temperatura, presencia de derra-me pleural, hiponatremia y anemia. Al comparar los pacientes del subgrupo de bajo riesgo en funcin de la edad ( 65 o> 65 aos), no hubo diferencias estadsticamente significativas excepto en el porcentaje de EPOC asociado (grupo 65 enel 9,7% vs 25,6% en el grupo > 65 aos; p < 0,05).Conclusiones: Del total de pacientes con NAC ingresados, el 46,9% correspondan a grupos de bajo riesgo segn laescala de Fine. En dicho subgrupo, no hubo diferencias estadsticamente significativas en funcin de la edad exceptoen el porcentaje de pacientes con EPOC y hubo diferencias en algunas de las variables incluidas en la escala de Fine enlos pacientes de bajo riesgo cuando se compararon con aquellos de alto riesgo. [Emergencias 2010;22:275-281]

Palabras clave: Neumona adquirida en la comunidad. Clasificacin Fine. Grupo de bajo riesgo.

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