Pneumonia in hospitalized patients with community acquired pneumonia diagnosis and treatment of indices of weight value, and the relationship with each other

VII. SUMMARYCAP is a common and serious health problem in worldwide. In ourcountry, lower respiratory tract infections are the 5th common cause of deathand are responsible from 4.2% of all deaths. Initiation of appropriateantibiotic therapy immediate after the diagnosis has been shown to affectmortality (3). Delayed treatment of pneumonia is known to increase mortalityand morbidity (14). In these cases, inappropriate antibiotic treatment isconsidered as a poor prognostic factor (15). The guidelines that include theindexes evaluating the severity of pneumonia have been published for thediagnosis and treatment of adult patients with CAP. In addition to guiding thedecision of hospitalization and treatment, the pneumonia severity indexscores and markers of infection can also predict the length of hospital stay,prognosis, mortality and cost.In our study, it was aimed to evaluate the role of some PneumoniaSeverity Indexes including PSI, CURB-65, CRB-65, A-DROP and SOARindexes in the diagnosis and treatment and their relation with each other.A total of 90 patients diagnosed with CAP who have been hospitalizedaccording to the hospitalization criteria of Turkish Thoracic Society,Consensus Report on Diagnosis and Treatment of Community AcquiredPneumonia in Adults were included to the study. The patient information atthe first day of hospitalization, during hospitalization, and discharge and totaltreatment cost are recorded on he patient follow-up form prepared by usingthe Pneumonia Data Base prepared by the Turkish Thoracic SocietyPneumonia Respiratory Infections Working Group.Of the 90 patients included to the study, 28 (31%) were male and 62(68.9%) were female. The mean age was 68. The most common symptomswere fatigue, sputum production and cough, respectively. Among thepatients with co-morbidity, the most common co-morbidity was COPD in 74(82.2%) patients and 17.8% of all patients were actively smoking. The114number of patients previously using inhaled corticosteroids was 32 (58%)and that of using systemic corticosteroids was 10 (11.1%). Systolic bloodpressure was <90 mmHg in 13/90 (14.4%) patients, the diastolic bloodpressure was ? 60 mmHg in 38 patients (42.2%), and the most commonauscultation findings were localized crackles and bronchial breathingsounds. The most common radiological finding was consolidation in 1 or 2lobes. Nineteen (21.1%) patients had pleural effusion. The biochemistry,complete blood count, arterial blood gas analysis, and CRP and PCT levelsas a marker of infection were measured. Pneumonia Severity score wascalculated in all cases and the average score values of individual indiceswere found to be the values that necessiate hospitalization. The patientswere classified according to the Turkish Thoracic Society, Consensus Reporton Diagnosis and Treatment of Community Acquired Pneumonia in Adultsand appropriate antibiotic treatment was initiated. Majority of the patientswere in Group II and 64 patients have been treated appropriately accordingto the guidelines. Complications were developed in 19 patients (21.1%) andthe treatment was changed in 13 (14.4%) patients. The average length ofstay in hospital was 9.46 ± 5.11 days and the average hospital cost was2989 ± 4209 Turkish liras. In terms of response to treatment after 1 month,complete recovery and death was found in 70 (77.8%) and 5 (5.6%) of thecases, respectively.In our study, we evaluated the some pneumonia severity indexesincluding PSI, CURB-65, CRB-65, SOAR and A-DROP indexes and whenwe scored and compared these indexes for each patient, it was found that allindexes were correlated with each other in terms of predicting the severity ofpneumonia and they detected the severity of disease in a similar manner. Asthe severity of the disease increased according to PSI, the scores of otherindexes and PCT and CRP were also increased. There was a statisticallysignificant relationship between the PSI index and CURB-65, CRB-65, ADROPand SOAR indexes and CRP and PCT. CURB-65 and CRB-65115indexes showed the strongest correlation and both indexes were positivelycorrelated with PSI, A-DROP and SOAR indexes and PCT values. In termsof predicting the severity of pneumonia, the second strongest correlation wasbetween PSI and A-DROP, and as the pneumonia severity according to ADROPwas increased, the severity according to PSI was also increased.There was no increase or decrease in CRP and PCT with the increasingseverity of disease according to A-DROP and no statistically significantcorrelation was found between them. As the severity of disease increasedaccording to SOAR index, the severity of disease was also increasedaccording to PSI, CURB-65, CRB-65, A-DROP and SOAR indexes and itwas correlated with PSI, CURB-65, CRB-65, A-DROP and SOAR indexes.However, PCT and CRP did not increase with the increasing severity ofpneumonia according to SOAR index, and no statistically significantcorrelation was found between them.The correlation between the indexes and other parameters were alsoinvestigated and it was found that when the severity of pneumonia wasincreased according to PSI, A-DROP and SOAR indexes, PaO2/FiO2 ratiowas decreased, however there was no statistically significant correlationbetween PaO2/FiO2 ratio and CURB-65 and CRB-65 indexes. Thecomplication rate was increased as the severity of pneumonia increasedaccording to the scores of PSI and A-DROP indexes, while no statisticallysignificant relationship was found between the CURB-65, CRB-65 andSOAR indexes and the development of complications. While there was nostatistically significant relationship between PSI and SOAR indexes and thehospital costs, the costs were increased with the increasing severity ofpneumonia according to CURB-65, CRB-65 and A-DROP indexes. Therewas no significant correlation between the severity of pneumonia accordingto PSI, CURB-65, CRB-65, A-DROP and SOAR indexes and the radiologicalextensiveness of pneumonia and length of hospital stay.116The markers of infection, CRP and PCT, did not correlate with eachother and they did not increase similarly in pneumonia cases with the similarseverity. CRP was positively correlated with the PSI and when the severity ofpneumonia increased according to PSI, CRP levels were increased.However, the severity of pneumonia according to PSI, CURB-65 and CRB-65 was increased with the increasing level of PCT.In terms of treatment outcome and the parameters affecting theoutcome of treatment, the use of inhaled corticosteroid, PaO2/FiO2 ratio,age, change in systolic and diastolic blood pressures, and theappropriateness of the treatment to the guidelines did not affect thetreatment outcome, while mortality after 1 month of treatment was increasedin patients in whom the treatment was changed.In conclusion, the pneumonia severity scores including PSI, CURB-65, CRB-65, A-DROP and SOAR indexes were found to be correlated witheach other. Therefore, every institution and physician may choose the mostappropriate scoring system for them. Because of showing the strongestcorrelation with clinical parameters, PSI is the most effective scoring systemfor diagnostic and therapeutic use. However, its use is troublesome and timeconsuming because of the excess number of parameters. A-DROP indexmay be used instead of the PSI, because it contains fewer parameters, itsuse is easier, it includes the oxygenation parameter which is not included inCURB-65 index and it is closely correlated with PSI. Because there is astrong correlation between CURB-65 and CRB-65, CURB-65 can be usedinstead of CRB-65 in the health facilities where blood urea level cannot bemeasured. Among the markers of infection, PCT can be preferred instead ofCRP, because PCT is more strongly correlated with the severity indexes ofpneumonia. Larger studies with more patients should be conducted todemonstrate the usefulness of diagnosis and treatment according to theguidelines and pneumonia severity indexes, and each country shouldestablish their own guideline.