title: Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score.
abstract: The health care-associated pneumonia (HCAP) criteria have a limited ability to predict pneumonia caused by drug-resistant bacteria and favor the overutilization of broad-spectrum antibiotics. We aimed to derive and validate a clinical prediction score with an improved ability to predict the risk of pneumonia due to drug-resistant pathogens compared to that of HCAP criteria. A derivation cohort of 200 microbiologically confirmed pneumonia cases in 2011 and 2012 was identified retrospectively. Risk factors for pneumonia due to drug-resistant pathogens were evaluated by logistic regression, and a novel prediction score (the drug resistance in pneumonia [DRIP] score) was derived. The score was then validated in a prospective, observational cohort of 200 microbiologically confirmed cases of pneumonia at four U.S. centers in 2013 and 2014. The DRIP score (area under the receiver operator curve [AUROC], 0.88 [95% confidence interval {CI}, 0.82 to 0.93]) performed significantly better (P = 0.02) than the HCAP criteria (AUROC, 0.72 [95% CI, 0.64 to 0.79]). At a threshold of ≥4 points, the DRIP score demonstrated a sensitivity of 0.82 (95% CI, 0.67 to 0.88), a specificity of 0.81 (95% CI, 0.73 to 0.87), a positive predictive value (PPV) of 0.68 (95% CI, 0.56 to 0.78), and a negative predictive value (NPV) of 0.90 (95% CI, 0.81 to 0.93). By comparison, the performance of HCAP criteria was less favorable: sensitivity was 0.79 (95% CI, 0.67 to 0.88), specificity was 0.65 (95% CI, 0.56 to 0.73), PPV was 0.53 (95% CI, 0.42 to 0.63), and NPV was 0.86 (95% CI, 0.77 to 0.92). The overall accuracy of the HCAP criteria was 69.5% (95% CI, 62.5 to 75.7%), whereas that of the DRIP score was 81.5% (95% CI, 74.2 to 85.6%) (P = 0.005). Unnecessary extended-spectrum antibiotics were recommended 46% less frequently by applying the DRIP score (25/200, 12.5%) than by use of HCAP criteria (47/200, 23.5%) (P = 0.004), without increasing the rate at which inadequate treatment recommendations were made. The DRIP score was more predictive of the risk of pneumonia due to drug-resistant pathogens than HCAP criteria and may have the potential to decrease antibiotic overutilization in patients with pneumonia. Validation in larger cohorts of patients with pneumonia due to all causes is necessary.
authors: Intermountain Healthcare, Division of Epidemiology and Infectious Diseases, Salt Lake City, Utah, USA Brandon.Webb@imail.org.
authors: Brandon J
authors: 0000-0002-1799-3315
authors: BJ
authors: Webb
authors: Intermountain Healthcare, Division of Epidemiology and Infectious Diseases, Salt Lake City, Utah, USA.
authors: Kristin
authors: K
authors: Dascomb
authors: Intermountain Healthcare, Division of Epidemiology and Infectious Diseases, Salt Lake City, Utah, USA.
authors: Edward
authors: E
authors: Stenehjem
authors: Mayo Clinic in Arizona, Division of Infectious Diseases, Phoenix, Arizona, USA.
authors: Holenarasipur R
authors: HR
authors: Vikram
authors: Mayo Clinic in Arizona, Division of Hospital Internal Medicine, Phoenix, Arizona, USA.
authors: Neera
authors: N
authors: Agrwal
authors: Mayo Clinic in Arizona, Division of Pulmonary Medicine, Phoenix, Arizona, USA.
authors: Kenneth
authors: K
authors: Sakata
authors: Mayo Clinic in Arizona, Department of Internal Medicine, Scottsdale, Arizona, USA.
authors: Kathryn
authors: K
authors: Williams
authors: University of Connecticut Medical Center, Department of Internal Medicine, Farmington, Connecticut, USA.
authors: Bruno
authors: B
authors: Bockorny
authors: University of Connecticut Medical Center, Department of Internal Medicine, Farmington, Connecticut, USA.
authors: Kavitha
authors: K
authors: Bagavathy
authors: University of Connecticut Medical Center, Department of Internal Medicine, Farmington, Connecticut, USA.
authors: Shireen
authors: S
authors: Mirza
authors: University of Connecticut Medical Center, Division of Pulmonary and Critical Care Medicine, Farmington, Connecticut, USA.
authors: Mark
authors: M
authors: Metersky
authors: Division of Pulmonary and Critical Care Medicine at Intermountain Medical Center and the University of Utah, Salt Lake City, Utah, USA.
authors: Nathan C
authors: NC
authors: Dean
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D024881:Drug Resistance, Bacterial / Q000235:genetics; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000188:drug therapy*; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors
chemical_list: D000900:Anti-Bacterial Agents