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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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Combination of CURB65 risk classes and ProADM tertiles in all LRTI patients. Combination of CURB65 risk classes and initial ProADM tertiles in all LRTI patients. A. Adverse events in CURB65 and ProADM categories. B. Mortality in CURB65 and ProADM categories. Risk class I = green, risk class II = orange, risk class III = red.
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Figure 4: Combination of CURB65 risk classes and ProADM tertiles in all LRTI patients. Combination of CURB65 risk classes and initial ProADM tertiles in all LRTI patients. A. Adverse events in CURB65 and ProADM categories. B. Mortality in CURB65 and ProADM categories. Risk class I = green, risk class II = orange, risk class III = red.

Mentions: We assessed observed risks for adverse outcome and mortality within all patients and within CAP patients only based on the two ProADM cut offs and the three a priori CURB65 risk groups (Table 3 Figures 4 &5). Thereby, patients in lowest CURB65 groups and with ProADM levels of <0.75 nmol/L had very low risks for both adverse events and mortality (CURB65-A risk class I). Conversely, patients in the highest CURB65 group and in the highest ProADM groups (CURB65-A risk class III) had high risk for adverse events and for mortality. Only 11 patients had ProADM levels of <0.75 nmol/L but were in the highest CURB65 classes 3-5 and none of them had an adverse outcome. Finally, patients within CURB65 class 2 but with ProADM levels of <1.5 nmol/L or CURB classes 0-1 and ProADM levels between 0.75-1.5 nmol/L had intermediate risks (CURB65-A risk class II). In patients with high CURB65 classes, increasing ProADM levels indicated increasing risk of adverse events and of mortality (p for trend 0.03 and p = 0.09, respectively, in CURB65 class 2; and p for trend <0.001 and p = 0.02, respectively, in CURB65 classes 3-5). In low-risk patients (CURB65 classes 0-1) increasing ProADM levels provided no additional information on mortality risk (p for trend: 0.98), but indicated significantly increased risk of adverse events (p for trend: 0.008).


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)

Combination of CURB65 risk classes and ProADM tertiles in all LRTI patients. Combination of CURB65 risk classes and initial ProADM tertiles in all LRTI patients. A. Adverse events in CURB65 and ProADM categories. B. Mortality in CURB65 and ProADM categories. Risk class I = green, risk class II = orange, risk class III = red.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 4: Combination of CURB65 risk classes and ProADM tertiles in all LRTI patients. Combination of CURB65 risk classes and initial ProADM tertiles in all LRTI patients. A. Adverse events in CURB65 and ProADM categories. B. Mortality in CURB65 and ProADM categories. Risk class I = green, risk class II = orange, risk class III = red.
Mentions: We assessed observed risks for adverse outcome and mortality within all patients and within CAP patients only based on the two ProADM cut offs and the three a priori CURB65 risk groups (Table 3 Figures 4 &5). Thereby, patients in lowest CURB65 groups and with ProADM levels of <0.75 nmol/L had very low risks for both adverse events and mortality (CURB65-A risk class I). Conversely, patients in the highest CURB65 group and in the highest ProADM groups (CURB65-A risk class III) had high risk for adverse events and for mortality. Only 11 patients had ProADM levels of <0.75 nmol/L but were in the highest CURB65 classes 3-5 and none of them had an adverse outcome. Finally, patients within CURB65 class 2 but with ProADM levels of <1.5 nmol/L or CURB classes 0-1 and ProADM levels between 0.75-1.5 nmol/L had intermediate risks (CURB65-A risk class II). In patients with high CURB65 classes, increasing ProADM levels indicated increasing risk of adverse events and of mortality (p for trend 0.03 and p = 0.09, respectively, in CURB65 class 2; and p for trend <0.001 and p = 0.02, respectively, in CURB65 classes 3-5). In low-risk patients (CURB65 classes 0-1) increasing ProADM levels provided no additional information on mortality risk (p for trend: 0.98), but indicated significantly increased risk of adverse events (p for trend: 0.008).

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