ORIGINAL ARTICLE

Description of a cohort of low-risk patients with community-acquired pneumonia admitted to a university hospital
ELISA GARCA VZQUEZ1, SILVIA SOTO2, ALICIA HERNNDEZ-TORRES1, JOS ANTONIO HERRERO1, JOAQUN GMEZ1
Servicio de Medicina Interna-Infecciosas. Hospital Universitario Virgen de la Arrixaca. Murcia, Spain. 2Servicio de Nefrologa. Hospital Mndez lvarez de Lorca. Murcia, Spain.
1

CORRESPONDENCE:
Dr. Elisa Garca Vzquez Servicio de Medicina InternaInfecciosas Hospital Universitario Virgen de la Arrixaca Ctra. Madrid-Cartagena, s/n 30120 El Palmar Murcia, Spain E-mail: elisag@eresmas.net

RECEIVED:
8-3-2010

ACCEPTED:
16-4-2010

CONFLICT OF INTEREST:
None

Objectives: The aim of this study is to describe the characteristics of low risk patients with Community-Acquired Pneumonia (CAP) admitted at a university hospital, to compare those who are older and younger than 65 year old and to compare those in low-risk groups ( III) with those in high-risk groups (> III). Patients and Methods: Observational and retrospective study of low-risk patients with CAP admitted at a tertiary hospital. Epidemiological, clinical and outcome data were recorded. Results: Ninety nine (46.9%) out of 211 patients with CAP were classified in Fine categories I, II and III (26, 33 and 40 respectively); 99 (100%) were hospitalised in general medical wards. Mean age was 50 years (range, 13 to 85 years), and a coexisting condition was present in 32% patients. More frequent physical-examination findings were systolic blood pressure < 90 mmgHg (8%), pulse > 125/min (7%) and respiratory rate 30/min (6%). More prevalent laboratory and radiological findings were pO2 < 60 mmHg (26%), pleural effusion (9%) and glucose 250 mg/dl (8%); 1 patient (1%) in group III died. Mean hospital stay was 6 days (range, 1 to 24 days). There were statistically significant differences in all variables included in Fine score (more frequent in high-risk patients) except for liver disease, low systolic blood pressure, high heat rate, temperature abnormalities, pleural effusion, low sodium and hematocrit figures; within low-risk patients < or >65 year-old there were not statistically significant differences except in the rate of COPD (9.7% vs 25.6%). Conclusions: out of all admitted patients with CAP, 46% were low-risk patients according to Fine score; there were not statistically significant differences in relation to age group (>/< 65 year old) except in the rate of COPD and there were differences in some but not all of the variables in Fine-score in patients in low-risk groups compare to those in high risk-groups. [Emergencias 2010;22:275-281] Key words: Community-acquired pneumonia. PORT-score. Low-risk group.

Introduction
Community-acquired pneumonia (CAP) remains a serious disease with a major impact on health spending. The annual incidence in Spain is between 1.6 and 3.8 cases per 1,000 people, and worldwide between 1 and 30 cases per 1,000 people. In Europe, the percentage of hospital admission due to CAP varies from 20 to 40%1,2. The direct cost of CAP treatment in the United States is estimated to be nearly 8,500 million dollars a year, with patient hospitalization accounting for
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approximately 95% of that amount. The cost of inpatient treatment is 8 times higher than outpatient treatment3-5. The Pneumonia Patient Outcomes Research Team (PORT)] developed a predictive scale to identify the risk of death and other adverse events in CAP patients (Fine scale)6. This scale uses 20 variables to classify patients as low and high risk of short-term mortality, and links this with the most appropriate place for treatment, which may be ambulatory (Risk class I and II), brief observation (Risk class III) or admission to a conventional 275

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hospital ward (Risk class IV and V). Although initially designed to identify patients with low-risk of mortality, different studies7-10 have reported that use of the Fine scale in emergency departments increases the percentage of ambulatory patients with low-risk CAP without compromising safety. ATS and IDSA clinical guidelines11-13 approved the use of this scale to predict short-term outcome and aid decision making on where to initially treat adults with CAP 14. However, many of these patients are admitted, suggesting that clinicians use inconsistent criteria when deciding on the appropriate care unit15-17. We conducted a retrospective observational study of patients with CAP (Fine scale risk classes I, II and III) admitted to a tertiary level university hospital. The aim of our study was to describe the characteristics of these hospitalized patients with low-risk CAP and compare them with those of high risk patients (Fine scale risk classes IV and V). The Fine scale may minimize the severity of risk in younger patients (the relative weight of age is high on this scale), so we also studied a sub-cohort of low-risk CAP patients applying an age cut off point of 65 years, in order to detect any difference in other variables, besides age, included in the Fine scale.

Method
We performed a retrospective observational study of patients with CAP admitted to the University Hospital Virgen de la Arrixaca (Murcia), a tertiary level university hospital with 900 beds, from January to December 2003. Our emergency department (ED) does not routinely use the Fine scale as a guide to help in making decisions on the treatment site. From an initial cohort of 484 CAP patients, over 12 years of age, we randomly selected a sample of 211 patients for data analysis from clinical records, epidemiological and clinical data, radiological and laboratory test results and prognosis of hospitalized low-risk patients. We also carried out an analysis of patients according to age (cutoff point 65 years). CAP was defined as the presence of a new infiltrate on chest radiograph together with clinical history and physical signs of lower respiratory tract infection in a patient not hospitalized in the previous month and without an alternative diagnosis during follow up. Clinical, radiological and laboratory findings, as well as other epidemiological data were collected using a specific question276

naire and entered on an electronic data base. The severity of CAP was assessed on the first day of admission using the Fine scale. Patients with neutropenia (<1.0 x 109/l), HIV infection, tuberculosis and fungal infection were excluded. Microbiological tests were performed as deemed necessary by the attending physician and could include a sample of sputum, two blood cultures, Binax Streptococcus pneumoniae urinary antigen and Bio Test Legionella pneumophila urinary antigen) and two blood samples for serology (4-8 weeks apart). Pleural puncture, transthoracic biopsy, tracheobronchial aspiration (in patients with mechanical ventilation) and bronchoalveolar sample collection were performed according to clinical indication or when deemed necessary by the attending physician responsible for care of each patient. The etiology of pneumonia was considered definitive when one of the following criteria were met: (1) isolation of pathogenic bacteria in blood cultures (in the absence of an extrapulmonary focus); (2) isolation of pathogenic bacteria in pleural fluid or transthoracic fine needle aspiration cultures, (3) seroconversion [a fourfold increase in IgG titers for Chlamydia pneumoniae, Chlamydia psittaci, L. pneumophila, Coxiella burnetii and respiratory viruses (Influenza viruses A and B, parainfluenza viruses 1-3, respiratory syncytial virus and adenovirus)], (4) a single titer of IgM 1:32 for C. pneumoniae, 1:80 for C. burnetii and any title for Mycoplasma pneumoniae; (5) positive antigen for L. pneumophila or S. pneumoniae (6) quantitative bacterial growth > 10 5 cfu/ml in TBA (traqaueobronquial aspirate), > 10 3 CFU/ml in PBS (selective bronchial aspirate) and > 104 cfu/ml in BAL (bronchoalveolar lavage) and (7) positive culture positive (habitual respiratory pathogen) from a sample of sputum. The medical records of patients were assessed up to hospital discharge or in-hospital death. Descriptive data of quantitative variables are expressed as mean standard deviation (SD) and qualitative variables as percentages. Statistical comparisons between qualitative variables were performed using chi2 test with Yates correction or Fisher's exact test when necessary. Comparisons of means were performed using Student t test, analysis of variance (ANOVA) and nonparametric tests (Kruskal-Wallis). Multivariate analysis was performed using a logistic regression model. Statistical significance was defined as a value of p < 0.05. All statistical tests were carried out with the statistical package SPSS 12.0.
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DESCRIPTION OF A COHORT OF LOW-RISK PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA ADMITTED TO A UNIVERSITY HOSPITAL

Results
Of the 211 patients with CAP, 99 (46.9%) were classified as risk classes I, II and III using the Fine scale (26, 33 and 40 cases respectively); all were admitted to a conventional medical department ward and none in the intensive care unit. In the low-risk group there were 54 men (54.5%) and in the high-risk group men accounted for 76% (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, and 8% > 75 years. Only one patient in the low-risk group came from a nursing home compared with 5 (4.5%) in the high-risk group (p > 0.05). The average stay was 6.5 days in low-risk patients and 8.9 days in the high-risk group (P < 0.05). The etiological diagnosis was obtained in 18.2% of low-risk patients and in 19.6% in the high-risk group. S. pneumoniae was the most common organism identified in both groups. P. aeruginosa was not isolated in the low-risk group, and where Legionella sp. was most frequently found in this group. In 32% of patients in the low-risk group we found an association with at least one underlying disease [most frequently heart failure (15%) and chronic obstructive pulmonary disease (COPD) (14%)]; these diseases were significantly more prevalent in high-risk patients (except liver disease); 32% of low-risk patients had one or more comorbidities. The most frequent clinical signs on physical examination of low-risk patients were: systolic blood pressure < 90 mmHg (8%), heart rate > 125 bpm (7%) and respiratory rate 30 rpm (6%). Of all clinical signs, including Fine scale scores, only respiratory rate 30 rpm and altered mental status were statistically more frequent and significant in high-risk patients. The most frequent radiological and laboratory findings in low-risk patients were partial arterial oxygen pressure < 60 mmHg (26%), pleural effusion (9%) and plasma glucose 250 mg/dl (8%), but of all the radiological and laboratory included in the Fine scale, only pO2 < 60 mmHg, hyperglycemia, renal failure and acidosis were more common and statistically significant in high-risk patients (Table 1). Only one (1%) patient in group III died of respiratory failure with severe hypoxemia and hypercapnia. In the low-risk group of patients, a sub-analysis was performed applying an upper cut off point of 65 years; there were no significant differences in epidemiological data, clinical, radiological, laboraEmergencias 2010; 22: 275-281

tory data and prognosis, except for the percentage of COPD (Table 2). All other variables included in the Fine scale were more frequent in this sub-group of patients < 65 years, but without reaching statistical significance.

Discussion
We performed a retrospective observational study of CAP patients at low-risk (according to the Fine scale), admitted to a tertiary hospital where the ED does not routinely apply this severity index as a guide to decision-making on where the patient is to be treated. Our aim was to describe and compare their characteristics with those of patients 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 while 51% of high-risk patients were over 75 years (p < 0.05), suggesting that the variable age carries high weight in the Fine scale. The percentage of males was also significantly higher in high-risk patients (75% vs 54%), as expected since the Fine scale places greater weight on age in men than in women. However, one result highlighted by our study is that high-risk patients had significantly greater comorbidity, and alterations in the physical examination, laboratory and radiological tests than low-risk patients, although only the following variables were significantly more frequent in the high-risk group: heart failure, COPD, cerebrovascular disease, cancer, kidney disease, tachypnea, altered level of consciousness, hypoxemia, hyperglycemia, renal failure and acidosis. These results also validate to some extent the Fine scale as a predictive tool that correctly identifies CAP patients at low and high risk. However, when a clinician decides whether a low-risk patient should be admitted or discharged, certain variables included in the Fine scale may be over or under-weighted. Thus, the percentage of patients with systolic blood pressure < 90 mmHg did not differ significantly between high and lowrisk patients (a parameter included in the definition of sepsis), nor did the percentage of patients with tachycardia, elevated temperature, pleural effusion, hyperglycemia, hyponatremia or anemia. The fact that these clinical features are common in both high and low-risk groups of in-patients suggests that more importance was attached to arterial hypotension (an indicator of sepsis), pleural effusion or abnormal laboratory findings. Although our study sample size was limited, which could affect statistical power, these data are con277

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Table 1. Demographic and clinical characteristics of patients according toFine scale risk categories
Category I, II and III (N = 99) Age (years) [mean (range)] Age Group [Total (%)] < 65 years 65-75 years > 75 years Male sex [Total (%)] Hospital stay (days) [mean (range)] Institutionalized [Total (%)] Underlying disease [Total (%)] Heart failure COPD Cerebrovascular disease Neoplasia Liver disease Kidney Disease Etiologic diagnosis [Total (%)] S. pneumoniae L. pneumophila M. pneumoniae P. aeruginosa Physical examination findings [Total (%)] Systolic blood pressure < 90 mmHg Heart rate > 125 lpm Respiratory rate > 30/min Altered consciousness level Temperature < 35 or > 40C Laboratory and radiological findings [Total (%)] pO2 < 60 mmHg Pleural effusion Glucose > 250 mg/dL Serum sodium < 130 mg/dL Hematocrit < 30% BUN > 30 mg/dL Arterial pH < 7.35 COPD: chronic obstructive pulmonary disease; ns: statistically non-significant. 50 (13-85) 72 (72.7) 19 (19.2) 8 (8.1) 54 (54.5) 6.54 (1-24) 1 (1) 32 (32.3) 15 (15.2) 14 (14.1) 4 (4) 1 (1) 1 (1) 1 (1) 18 (18.2) 14 (14.1) 3 (3) 1 (1) 0 (0) 8 (8.1) 7 (7.1) 6 (6.1) 2 (2) 1 (1) 26 (26.3) 9 (9.1) 8 (8.1) 4 (4) 4 (4) 2 (2) 1 (1) 20 (17) 35 (31.3) 57 (50.9) 85 (75.9) 8.9 (1-36) 5 (4.5) 98 (87.5) 56 (50) 49 (43.7) 20 (17.9) 15 (13.4) 4 (3.6) 23 (20.5) 22 (19.6) 15 (13.4) 1 (0.9) 2(1.8) 4 (3.2) 11 (9.8) 14 (12.5) 44 (39.3) 25 (22.3) 5 (4.5) 71 (63.4) 14 (12.5) 19 (17) 9 (8) 10 (8.9) 46 (41) 21 (18.7) Category IV and V (N = 112) p < 0.05 < 0.05

< 0.05 < 0.05 ns < 0.05 < 0.05 < 0.05 < 0.05 < 0.05 ns < 0.05 ns ns ns ns ns ns ns < 0.05 < 0.05 ns < 0.05 ns 0.05 ns ns < 0.05 < 0.05

sistent with those of other authors18,19. In addition, 32% of low-risk patients had one or more associated diseases, which increases the probability of decompensation due to pneumonia (eg. COPD, heart disease or cerebrovascular disease). In fact, 26% presented hypoxemia, 8% hyperglycemia and 9% pleural effusion. All these findings may constitute contraindications for outpatient treatment. A recent study investigated the reasons why 845 low-risk patients were admitted to hospital, all being classified as risk class II-III on the Fine scale, and evaluated the presence of medical and psychosocial diseases not included in the Fine scale20. The conclusions were that this index of severity should be complemented with the assessment of other factors like living on the street, suffering psychiatric illness, social deprivation, previous failure of outpatient treatment, intolerance to oral route treatment, non-compliance with prescribed medication, suspected sepsis and hypoxemia, before deciding on outpatient treatment. Our study should be considered in the light of its limitations: it lacked a control group of Fine 278

scale I, II and III ambulatory patients; it was a retrospective study where the Fine scale classification was made post hoc from medical records reviewed (because of this retrospective aspect, the reason for admission of low-risk patients could not be evaluated); and that the patients included in the study were randomly selected from a larger cohort of CAP patients and therefore the percentage of patients with low-risk pneumonia admitted to our hospital may have been affected. The mortality rate in low risk hospitalized patients was very low (1%), similar to that described by Fine and colleagues (even though our study was limited to evaluating mortality only up to discharge and not 30 days). Whether this low-risk of mortality can be extrapolated to ambulatory treatment is a question we cannot answer21. The initial decision on where best to treat patients with pneumonia (outpatient attention or hospitalization), is a medical decision of considerable economic importance 22,23 . In economic terms, hospitalization costs per episode of pneumonia are 25 times greater than outpatient treatment. In medical terms, hospitalization increases
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DESCRIPTION OF A COHORT OF LOW-RISK PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA ADMITTED TO A UNIVERSITY HOSPITAL

Table 2. Demographic and clinical characteristics of Fine scale low-risk patients according to age
< 65 years (N = 72) n (%) 65 years (N = 27) n (%) p

Mortality 0 (0) 1 (3,7) ns Male Sex 41 (56,7) 13 (48,1) ns Institutionalized 1 (1,4) 0 (0) ns Neoplasia 1 (1,4) 0 (0) ns Liver disease 1 (1,4) 0 (0) ns Heart failure 8 (11,1) 7 (25,6) ns Kidney disease 1 (1,4) 0 (0) ns Cerebrovascular disease 4 (5,5) 0 (0) ns COPD 7 (9,7) 7 (25,6) < 0,05 Altered consciousness 2 (2,8) 0 (0) ns Respiratory rate > 30/min 6 (8,3) 0 (0) ns Systolic blood pressure < 90 mmHg 7 (9,7) 1 (3,7) ns Temperature < 35 or > 40C 1 (1,4) 0 (0) ns Heart rate > 125 lpm 6 (8,3) 1 (3,7) ns arterial pH < 7,35 0 (0) 1 (3,7) ns pO2 < 60 mmHg 17 (23,6) 9 (33,3) ns BUN > 30 mg/dL 2 (2,7) 0 (0) ns Serum sodium < 130 mg/dL 3 (4,2) 1 (3,7) ns Glucose > 250 mg/dL 6 (8,3) 2 (7,4) ns Hematocrit < 30% 3 (4,2) 1 (3,7) ns Pleural effusion 6 (8,3) 3 (11,1) ns ns: statistically non-significant. COPD: chronic obstructive pulmonary disease.

the risk of thromboembolic events and further bacterial infection by microorganisms circulating in hospitals that are more resistant and virulent. We recommend the use of prognostic models, such as the Fine scale, to identify pneumonia patients who could be safely treated on an outpatient basis; considering associated mortality, it has been suggested that patients in class I and II should be treated on an outpatient basis and class III should be observed for 24 hours and then treated on an outpatient basis if no complications arise during observation24-28. In our study, almost half the patients admitted were classed as low-risk on the Fine scale. This high rate of admission to a tertiary hospital where the ED did not use Fine scale classification to guide decision-making on place of treatment is similar to those EDs with low use of such scales8, which leads us to consider that our ED is a candidate for an intervention program to enhance the Fine scale, as in a recent study24, and apply it before decisions are made on the best place to treat CAP patients. However, other authors29,30 have indicated that this high percentage of hospitalizing low-risk CAP patients is because clinicians consider other variables not included in such scales, or that the scales and objective criteria should always be complemented by considering other factors such as patient safety and the possibility of real compliance with oral medication, outpatient resource capacity and functional
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status assessment of the patient31-33. Home care reduces direct interaction with the physician and depends heavily on nurses, patient attitude and informal caregivers34. The objectives of home care are to achieve the same levels of quality, recovery and functional status as any other mode of care, although this is not always possible. Home care units and social services should probably be encouraged to help decrease the rate of CAP patient hospital admission. As already indicated, the Fine scale may minimize the severity of risk in young patients (the relative weight of age on the Fine scale is high). The analysis of a low-risk sub-group with a maximum age of 65 years showed no differences except in the percentage of patients with COPD, which was significantly higher in more elderly patients. However, the small sample size may underestimate the presence of certain clinical and social variables in the younger patients. Microbiological diagnosis was made in a very low percentage of patients, with no significant differences found low and high-risk patients (18.2% vs 19.6%). This could be because in our hospital microbiological tests are performed according to the attending physicians criteria, and because protocols for the management of CAP patients do not include routine use of these microbiological tests (sputum, blood culture, urinary detection of soluble pneumococcal antigen or L. pneumophila and blood samples for serology). In conclusion, in our cohort of hospitalized CAP patients, 46% were classified as low-risk patients on the Fine scale, and there were no statistically significant differences regarding age groups (under or over 65 years) except in the percentage of COPD (greater in elderly patients), although almost all the variables of severity included in the Fine scale were non-significantly more frequent in younger patients. On comparing low and high-risk patients, differences were statistically significant for all the variables included in the Fine scale (more common in high-risk patients) except for liver disease, arterial hypotension, tachycardia, temperature alterations, pleural effusion, hyponatremia and anemia.

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

Estudio de una cohorte de pacientes con neumona adquirida en la comunidad de bajo riesgo ingresados en un hospital universitario
Garca-Vzquez E, Soto S, Hernndez-Torres A, Herrero JA, Gmez J Objetivos: El objetivo principal de este trabajo fue describir las caractersticas de los pacientes con neumona adquirida en la comunidad (NAC) de bajo riesgo ingresados en un hospital terciario universitario. Los objetivos secundarios fueron comparar los pacientes con NAC en funcin de la edad (mayor o menor de 65 aos) y del riesgo agrupado segn la 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 terciario universitario. 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, II o III de la clasificacin de Fine (26, 33 y 40 respectivamente) con una edad media de 50 aos (rango 13 a 85); el 8% tenan una presin arterial sistlica menor de 90 mmHg, el 7% una frecuencia cardiaca mayor de 125/min, el 6% una frecuencia respiratoria mayor de 30/min, el 26% pO2 < 60 mmHg, el 9% derrame pleural y el 8% glucemia > 250 mg/dl. Todos los pacientes fueron ingresados en plantas convencionales de hospitalizacin y la estancia fue de 6 das (rango 1-24). Un paciente 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 todas la variables que recoge la escala de Fine, que fueron ms frecuentes en el grupo de alto riesgo (grupo IV-V), excepto en el porcentaje de enfermedad heptica, hipotensin arterial, taquicardia, alteraciones de la temperatura, presencia de derrame 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 en el 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 la escala de Fine. En dicho subgrupo, no hubo diferencias estadsticamente significativas en funcin de la edad excepto en el porcentaje de pacientes con EPOC y hubo diferencias en algunas de las variables incluidas en la escala de Fine en los 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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