摘要
从CAP 3天的死亡率对应于在医院死亡的33%;的CRB-65标准是独立的预测因子http://ow.ly/XFMlB
致编辑:
社区获得性肺炎(CAP)住院患者的死亡率仍然很高,并且已经努力确定一个急诊亚组的特征,该亚组被定义为早期临床恶化或死亡的高风险,以便将最初的管理干预措施针对具有高潜势的预后改善[1-3]。然而,在CAP紧急呈现的实际规模仍不清楚是受灾最严重的病人在前瞻性研究[频繁人数不足1,3]. 此外,到目前为止,对CAP患者3 天内早期死亡率的研究很少[3-五]. 本分析的目的是利用德国全国强制性质量保证计划的独特数据库,描述因CAP住院后3 天内死亡的患者,该数据库要求德国所有医院根据预先指定的电子数据表记录所有因CAP住院的病例。
在这项研究中,纳入了2009年至2013年5年期间的数据。有CAP的病例是由一套国际疾病分类码确定的,如其他地方所列[1]。合并症没有被纳入分析,因为它不是始终在所有患者记录,并因为有其严重程度没有数据。此外,还有对不复苏订单或死亡的原因,没有数据。Ťhe primary outcome parameter was death within 3 days after hospital admission. The CRB-65 (confusion, respiratory rate ≥30 breaths per min, systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg) and age ≥65 years) score was determined as described previously [6]. 2010年后,呼吸频率不是必须记录的字段;呼吸频率缺失的病例被认为是正常的。对于单变量分析,使用Student t检验比较连续变量,使用卡方检验比较分类变量。为了评价预测参数与3天死亡率的独立相关性,采用逐步向前选择的多元logistic回归模型。危险因素包括CRB-65标准和入院时机械通气。采用受试者工作特性(ROC)曲线分析法确定CRB-65评分的诊断特征。
一种total of 1 195 461 patients with hospitalised CAP were documented in Germany between 2009 and 2013. Of those, 49 538 patients transferred from other hospitals were excluded in order to avoid redundant documentation. The remaining 1 145 923 patients showed a hospital mortality of 13.1% (150 116 out of 1 145 923). Of these deaths, 38.6% (58 087) occurred within the first 3 days of hospitalisation (3-day mortality 5.1%).
In order to overcome the problem of treatment restrictions in patients already severely compromised before the CAP episode, patients who were either bedridden prior to admission and/or residing in a nursing home, and/or not receiving antibiotic treatment (366 207 cases; 3-day mortality 10.8%, hospital mortality 25.7%) were excluded from the analysis. The remaining 779 716 patients showed a 3-day mortality of 2.4% (18 474 deaths), corresponding to 33% of all in-hospital deaths (56 250; hospital mortality 7.2%). Characteristics of these patients are shown in表1。年龄,性别和CRB-65标准,用3天的死亡率显著相关。在机械通气患者中,3天的死亡率为8.6%,与1.9%的患者没有机械通气(P <0.001)。However, of the patients dying within 3 days, only 23.3% had received mechanical ventilation before. In multivariate analysis, mechanical ventilation on admission showed the highest risk of 3-day mortality. Additionally, all CRB-65 criteria were independently associated with 3-day mortality, with pneumonia-related confusion showing the highest risk. 3-day mortality increased with each CRB-65 point and was 0.6% in CRB-65 0, 1.9% in CRB-65 1, 4.2% in CRB-65 2, 10.4% in CRB-65 3 and 20.9% in CRB-65 4. After ROC analysis, the CRB-65 score showed an area under the curve (AUC) of 0.69 (95% CI 0.68–0.69, p<0.001) for predicting 3-day mortality. Optimal cut-off according to the Youden index was two or more criteria (sensitivity 51.3%, specificity 77.7%). A score of 0 showed a negative predictive value of 99.4% (negative likelihood ratio 0.27), whereas scores of three or more and four criteria had positive predictive values of 11.4% (positive likelihood ratio 5.25) and 20.9% (positive likelihood ratio 10.0), respectively.
我们的研究结果谎言几乎不包括在内的所有德国人住院CAP患者,从而能够实现无与伦比的,科学和教育的重要洞察流行病学和CAP的往往被低估紧急呈现任何选择偏见的评价数据库的主要力量。Our data demonstrate that there is a relevant subgroup of CAP patients dying within 3 days of hospital admission, even after exclusion of patients with poor functional status, nursing home residents and those not receiving antibiotic treatment to avoid bias due to possible treatment restrictions. The resulting 3-day mortality rate of 2.4% is higher than that reported by two recent populations from prospective studies evaluating this end-point [3,4]仍然高时相比,报告的48小时死亡率中,包括在西班牙医院所有患者的CAP研究了2.3%,但不排除养老院或长期卧床的病人[五]. 对德国来说,这意味着每年近3700名患者受到影响。这对计划和评估可能的干预措施以改进对这些患者的管理具有启示。
在只有23.3%3天死之前我们在机械通气率,甚至谁是卧床不起或居住在疗养院患者排除后,火柴,最近这个数据库的分析,并可能反映两个治疗限制或缺乏的临床表现[7]。
据我们所知,没有其他研究评估了CRB-65评分3天死亡为止。我们的数据表明一个CRB-65的0的阴性预测值是非常高的(99.4%)。However, even this favourable performance implies that 1146 patients not being bedridden or coming from a nursing home with a score of 0 died within 3 days in Germany during the 5-year study period. Additionally, the AUC of 0.69 for prediction of 3-day mortality in our database was lower than that reported by recent studies and meta-analyses for hospital mortality [8,9],这可能反映了这一成绩。这一早期结果的性能较差。可减少早期死亡的风险,尽管低CRB-65得分策略包括sepsis-或合并症相关的器官功能障碍的评估,包括氧和其他提出参数,如美国胸科协会/美国感染性疾病协会(ATS / IDSA)次要标准[10-13]。中号oreover, patients should be clinically assessed repeatedly during the first 3 days of hospitalisation [14,15]。
我们研究的一些局限性,必须提及。我们的研究结果的解释是缺乏其他重要的危险因素和管理参数,如合并症,微生物学,重症监护病房,抗菌药物治疗的适当性,当然患者和治疗限制恶化的数据的限制,因为这些参数的有效信息不能从质量性能程序检索。此外,我们也不能对死亡原因提供数据。最后,像肺炎严重程度指数或ATS / IDSA次要标准等提出的风险评分无法从数据库中。然而,几乎所有的住院CAP患者在德国的报道反映了现实世界的管理,最大限度地减少选择偏倚。此外,预定义的结果参数的数据完整性以及对CRB-65得分使得CAP公布的研究中评估的数据库中唯一。
总之,我们在一大群谁不卧床或住在疗养院住院CAP患者的发现了一个高3天的死亡率为2.4%(三分之一都在医院死亡)。该CRB-65评分显示早期死亡高阴性预测值。患者严重程度的标准提出应仔细评估sepsis-或合并症相关的急性器官功能障碍。
致谢
作者感谢为社区获得性肺炎质量控制计划和德国哥廷根AQUA研究所工作的所有医生和技术人员。
脚注
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- 收到2015年11月30日。
- 公认2016年1月19日。
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