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Enhancement of CURB65 score with proadrenomedullin (CURB65-A) for outcome prediction in lower respiratory tract infections: derivation of a clinical algorithm.

Albrich WC, Dusemund F, Rüegger K, Christ-Crain M, Zimmerli W, Bregenzer T, Irani S, Buergi U, Reutlinger B, Mueller B, Schuetz P - BMC Infect. Dis. (2011)

Bottom Line: Within each CURB65 class, higher ProADM-levels were associated with an increased risk of adverse events and mortality.The new CURB65-A risk score combining CURB65 risk classes with ProADM cut-off values accurately predicts adverse events and mortality in patients with CAP and non-CAP-LRTI.Additional prospective cohort or intervention studies need to validate this score and demonstrate its safety and efficacy for the management of patients with LRTI.

View Article: PubMed Central - HTML - PubMed

Affiliation: Medical University Department of the University of Basel, Kantonsspital Aarau, Switzerland.

ABSTRACT

Background: Proadrenomedullin (ProADM) confers additional prognostic information to established clinical risk scores in lower respiratory tract infections (LRTI). We aimed to derive a practical algorithm combining the CURB65 score with ProADM-levels in patients with community-acquired pneumonia (CAP) and non-CAP-LRTI.

Methods: We used data of 1359 patients with LRTI enrolled in a multicenter study. We chose two ProADM cut-off values by assessing the association between ProADM levels and the risk of adverse events and mortality. A composite score (CURB65-A) was created combining CURB65 classes with ProADM cut-offs to further risk-stratify patients.

Results: CURB65 and ProADM predicted both adverse events and mortality similarly well in CAP and non-CAP-LRTI. The combined CURB65-A risk score provided better prediction of death and adverse events than the CURB65 score in the entire cohort and in CAP and non-CAP-LRTI patients. Within each CURB65 class, higher ProADM-levels were associated with an increased risk of adverse events and mortality. Overall, risk of adverse events (3.9%) and mortality (0.65%) was low for patients with CURB65 score 0-1 and ProADM ≤0.75 nmol/l (CURB65-A risk class I); intermediate (8.6% and 2.6%, respectively) for patients with CURB65 score of 2 and ProADM ≤1.5 nmol/l or CURB classes 0-1 and ProADM levels between 0.75-1.5 nmol/L (CURB65-A risk class II), and high (21.6% and 9.8%, respectively) for all other patients (CURB65-A risk class III). If outpatient treatment was recommended for CURB65-A risk class I and short hospitalization for CURB65-A risk class II, 17.9% and 40.8% of 1217 hospitalized patients could have received ambulatory treatment or a short hospitalization, respectively.

Conclusions: The new CURB65-A risk score combining CURB65 risk classes with ProADM cut-off values accurately predicts adverse events and mortality in patients with CAP and non-CAP-LRTI. Additional prospective cohort or intervention studies need to validate this score and demonstrate its safety and efficacy for the management of patients with LRTI.

Trial registration: Procalcitonin-guided antibiotic therapy and hospitalisation in patients with lower respiratory tract infections: the prohosp study; isrctn.org Identifier: ISRCTN: ISRCTN95122877.

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Observed and expected adverse events (A) and mortality (B) within CURB65 class 3-5 (high risk patients). Observed and expected adverse events and mortality within CURB65 class 3-5 (high risk patients). A. Calibration of ProADM deciles and adverse events. B. Calibration of initial ProADM deciles and mortality.
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Figure 3: Observed and expected adverse events (A) and mortality (B) within CURB65 class 3-5 (high risk patients). Observed and expected adverse events and mortality within CURB65 class 3-5 (high risk patients). A. Calibration of ProADM deciles and adverse events. B. Calibration of initial ProADM deciles and mortality.

Mentions: In Figure 1, the estimated smoothed associations between admission ProADM levels and predicted adverse events risks (black line) and predicted mortality risk (blue line) are displayed. Hosmer-Lemeshow goodness of fit test showed no evidence for miscalibration (p > 0.05 for all calculations) in the plots based on a logistic regression model depicting adverse events and mortality for ProADM within CURB65 groups. Within low risk CURB65 classes 0 and 1, patients in the lowest three ProADM deciles (approximately corresponding to a ProADM level of <0.75 nmol/L), the probability for adverse events was <5% and the probability for mortality was <0.5%, but increased to >20% and >3% in the highest decile (Figure 2). Within a priori high-risk CURB65 classes 3-5, the risk for adverse events and mortality increased to >20% and >9% in the highest three deciles of ProADM levels (approximately corresponding to a ProADM level of >1.5 nmol/L) (Figure 3).


Enhancement of CURB65 score with proadrenomedullin (CURB65-A) for outcome prediction in lower respiratory tract infections: derivation of a clinical algorithm.

Albrich WC, Dusemund F, Rüegger K, Christ-Crain M, Zimmerli W, Bregenzer T, Irani S, Buergi U, Reutlinger B, Mueller B, Schuetz P - BMC Infect. Dis. (2011)

Observed and expected adverse events (A) and mortality (B) within CURB65 class 3-5 (high risk patients). Observed and expected adverse events and mortality within CURB65 class 3-5 (high risk patients). A. Calibration of ProADM deciles and adverse events. B. Calibration of initial ProADM deciles and mortality.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3119069&req=5

Figure 3: Observed and expected adverse events (A) and mortality (B) within CURB65 class 3-5 (high risk patients). Observed and expected adverse events and mortality within CURB65 class 3-5 (high risk patients). A. Calibration of ProADM deciles and adverse events. B. Calibration of initial ProADM deciles and mortality.
Mentions: In Figure 1, the estimated smoothed associations between admission ProADM levels and predicted adverse events risks (black line) and predicted mortality risk (blue line) are displayed. Hosmer-Lemeshow goodness of fit test showed no evidence for miscalibration (p > 0.05 for all calculations) in the plots based on a logistic regression model depicting adverse events and mortality for ProADM within CURB65 groups. Within low risk CURB65 classes 0 and 1, patients in the lowest three ProADM deciles (approximately corresponding to a ProADM level of <0.75 nmol/L), the probability for adverse events was <5% and the probability for mortality was <0.5%, but increased to >20% and >3% in the highest decile (Figure 2). Within a priori high-risk CURB65 classes 3-5, the risk for adverse events and mortality increased to >20% and >9% in the highest three deciles of ProADM levels (approximately corresponding to a ProADM level of >1.5 nmol/L) (Figure 3).

Bottom Line: Within each CURB65 class, higher ProADM-levels were associated with an increased risk of adverse events and mortality.The new CURB65-A risk score combining CURB65 risk classes with ProADM cut-off values accurately predicts adverse events and mortality in patients with CAP and non-CAP-LRTI.Additional prospective cohort or intervention studies need to validate this score and demonstrate its safety and efficacy for the management of patients with LRTI.

View Article: PubMed Central - HTML - PubMed

Affiliation: Medical University Department of the University of Basel, Kantonsspital Aarau, Switzerland.

ABSTRACT

Background: Proadrenomedullin (ProADM) confers additional prognostic information to established clinical risk scores in lower respiratory tract infections (LRTI). We aimed to derive a practical algorithm combining the CURB65 score with ProADM-levels in patients with community-acquired pneumonia (CAP) and non-CAP-LRTI.

Methods: We used data of 1359 patients with LRTI enrolled in a multicenter study. We chose two ProADM cut-off values by assessing the association between ProADM levels and the risk of adverse events and mortality. A composite score (CURB65-A) was created combining CURB65 classes with ProADM cut-offs to further risk-stratify patients.

Results: CURB65 and ProADM predicted both adverse events and mortality similarly well in CAP and non-CAP-LRTI. The combined CURB65-A risk score provided better prediction of death and adverse events than the CURB65 score in the entire cohort and in CAP and non-CAP-LRTI patients. Within each CURB65 class, higher ProADM-levels were associated with an increased risk of adverse events and mortality. Overall, risk of adverse events (3.9%) and mortality (0.65%) was low for patients with CURB65 score 0-1 and ProADM ≤0.75 nmol/l (CURB65-A risk class I); intermediate (8.6% and 2.6%, respectively) for patients with CURB65 score of 2 and ProADM ≤1.5 nmol/l or CURB classes 0-1 and ProADM levels between 0.75-1.5 nmol/L (CURB65-A risk class II), and high (21.6% and 9.8%, respectively) for all other patients (CURB65-A risk class III). If outpatient treatment was recommended for CURB65-A risk class I and short hospitalization for CURB65-A risk class II, 17.9% and 40.8% of 1217 hospitalized patients could have received ambulatory treatment or a short hospitalization, respectively.

Conclusions: The new CURB65-A risk score combining CURB65 risk classes with ProADM cut-off values accurately predicts adverse events and mortality in patients with CAP and non-CAP-LRTI. Additional prospective cohort or intervention studies need to validate this score and demonstrate its safety and efficacy for the management of patients with LRTI.

Trial registration: Procalcitonin-guided antibiotic therapy and hospitalisation in patients with lower respiratory tract infections: the prohosp study; isrctn.org Identifier: ISRCTN: ISRCTN95122877.

Show MeSH
Related in: MedlinePlus