title: Assessment of oxygenation and comorbidities improves outcome prediction in patients with community-acquired pneumonia with a low CRB-65 score.
abstract: BACKGROUND
  Addition of assessment of comorbid diseases ('D') and oxygen saturation ('S') to the CRB-65 score has been recommended to improve its accuracy for risk stratification in community-acquired pneumonia (CAP). The aim of this study was to validate the resulting DS-CRB-65 score in a large cohort of patients with CAP.
  
  
  METHODS
  A total of 4432 patients prospectively enrolled in the CAPNETZ cohort were included in this study. Predefined end points were 28-day mortality, requirement for mechanical ventilation or vasopressors (MV/VS) and requirement for MV/VS or intensive care unit admission (MV/VS/ICU). Receiver operating characteristic curve analysis was used to determine the accuracy of the CRB-65 score and the addition of D (extra-pulmonary comorbidities) and S (oxygen saturation <90% or partial pressure of oxygen <8 kPa). Binary logistic regression and the method of Hanley and McNeil were used to compare the criteria.
  
  
  RESULTS
  The mortality rate was 4.0%, and 4.2% of patients required MV/VS and 6.6% required MV/VS/ICU. After multivariate analysis, D and S independently were added to the CRB-65 criteria for mortality prediction, but only S improved prediction of MV/VS and MV/VS/ICU (P < 0.001 for all). The area under the curve of the CRB-65 score was significantly improved by adding D and S for all end points (P < 0.02). Amongst patients who died or required MV/VS despite a CRB-65 score of 0, 64-80% would have been identified by the DS-CRB-65 score.
  
  
  CONCLUSIONS
  The addition of assessment of oxygenation and comorbidities significantly improved the prognostic accuracy of the CRB-65 score. Consequently, the DS-CRB-65 score may have a useful role in risk stratification algorithms for CAP.
authors.affiliation: Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technical University, Dresden, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Kolditz
authors.affiliation: Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, EVK Herne and Augusta-Kranken-Anstalt, Bochum, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Ewig
authors.affiliation: Department of Pulmonology, Klinikum Ernst von Bergmann, Potsdam, Germany.|Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.|CAPNETZ STIFTUNG, Hannover, Germany.
authors.forename: H
authors.initials: H
authors.lastname: Schütte
authors.affiliation: Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.|CAPNETZ STIFTUNG, Hannover, Germany.
authors.forename: N
authors.initials: N
authors.lastname: Suttorp
authors.affiliation: CAPNETZ STIFTUNG, Hannover, Germany.|Department of Respiratory Medicine, Medizinische Hochschule, Hannover, Germany.|Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), The German Center for Lung Research (DZL), Hannover, Germany.
authors.forename: T
authors.initials: T
authors.lastname: Welte
authors.affiliation: CAPNETZ STIFTUNG, Hannover, Germany.|Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), The German Center for Lung Research (DZL), Hannover, Germany.|Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: G
authors.initials: G
authors.lastname: Rohde
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017714:Community-Acquired Infections / Q000175:diagnosis / Q000453:epidemiology* / Q000378:metabolism; D015897:Comorbidity / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D010101:Oxygen Consumption; D011014:Pneumonia / Q000175:diagnosis / Q000453:epidemiology* / Q000378:metabolism; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment; D012720:Severity of Illness Index; D015996:Survival Rate / Q000639:trends; D055815:Young Adult
keywords: community-acquired pneumonia; mortality; prediction; risk score; risk stratification