title: A clinical score (RAPID) to identify those at risk for poor outcome at presentation in patients with pleural infection.
abstract: BACKGROUND
  Pleural infection is associated with a high morbidity and mortality. Development of a validated clinical risk score at presentation to identify those at high risk of dying would enable patient triage and may help formulate early management strategies.
  
  
  METHODS
  A clinical risk score was derived based on data from patients entering the multicenter UK pleural infection trial (first Multicenter Intrapleural Sepsis Trial [MIST1], n=411). From 22 baseline clinical characteristics, model selection was undertaken to find variables predictive of poor clinical outcome. Outcomes were mortality at 3 months (primary), need for surgical intervention at 3 months, and time from randomization to discharge. The derived scoring system RAPID (renal, age, purulence, infection source, and dietary factors) was validated using patients enrolled in the subsequent MIST2 trial (n=191).
  
  
  RESULTS
  Age, urea, albumin, hospital-acquired infection, and nonpurulence predicted poor outcome. Patients were stratified into low-risk (0-2), medium-risk (3-4), and high-risk (5-7) groups. Using the low-risk group as a reference, a RAPID score of 3 to 4 and >4 was associated with an OR of 24.4 (95% CI, 3.1-186.7; P=.002) and 192.4 (95% CI, 25.0-1480.4; P<.001), respectively, for death at 3 months. In the validation cohort (MIST2), a medium-risk RAPID score was nonsignificantly associated with mortality (OR, 3.2; 95% CI, 0.8-13.2; P=.11), and a high-risk score was associated with increased mortality (OR, 14.1; 95% CI, 3.5-56.8; P<.001). Hospitalization duration was associated with increasing RAPID score (score 0-2: median duration=7, interquartile range 6-13; score>5: median duration=15, interquartile range 9-28, P=.08).
  
  
  CONCLUSIONS
  The RAPID score may permit risk stratification of patients with pleural infection at presentation.
authors.affiliation: Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Oxford University Hospitals NHS Trust, Oxford; Department of Radiology, Oxford University Hospitals, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford; National Institute of Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford. Electronic address: najib.rahman@ndm.ox.ac.uk.
authors.forename: Najib M
authors.initials: NM
authors.lastname: Rahman
authors.affiliation: Medical Research Council Clinical Trials Unit.
authors.forename: Brennan C
authors.initials: BC
authors.lastname: Kahan
authors.affiliation: Research Department of Infection and Population Health, Institute of Epidemiology and Healthcare, University College London, London.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Miller
authors.affiliation: Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Oxford University Hospitals NHS Trust, Oxford; Department of Radiology, Oxford University Hospitals, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford.
authors.forename: Fergus V
authors.initials: FV
authors.lastname: Gleeson
authors.affiliation: Medical Research Council Clinical Trials Unit.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Nunn
authors.affiliation: Academic Respiratory Unit, School of Clinical Sciences, Southmead Hospital, University of Bristol, Bristol, England.
authors.forename: Nicholas A
authors.initials: NA
authors.lastname: Maskell
mesh_terms: D001424:Bacterial Infections / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010995:Pleural Diseases / Q000175:diagnosis* / Q000382:microbiology*; D011379:Prognosis; D018570:Risk Assessment