DAWN

Good day!
We are group C. I am Dawn Marie Acosta with Dr. Richard Alovera III and Dr.
Ferdinand Buendia.
We will be presenting an actual research paper from the Lung Center of Philippines.
Community Acquired Pneumonia (CAP) is the most common cause of death associated
with infectious disease. It is the leading cause of morbidity and the fifth cause of
mortality according to the Department of Health. More than 1 million patients with CAP
require hospitalization annually, 10% of whom will be admitted to the intensive care unit
(ICU). CAP, effectively controlled and treated in the outpatient setting, has a mortality
rate of < 5%. However, when hospitalization is required, the mortality of CAP reaches
12% and increases to 22% if the patient is admitted to the ICU.
Care for adult patients with Community Acquired Pneumonia (CAP) has gone several
changes through-out the years. Currently, the Infectious Diseases Society of America
and the American Thoracic Society (IDSA/ATS) has brought out a joint consensus
guidelines for the management of Community Acquired Pneumonia. Based on this
consensus, site-of-care decisions are important for the determination of admission of
patients with CAP as well as an area of improvement for CAP management.
The initial management decision after diagnosing CAP is to determine the site of care:
outpatient, hospitalization in a medical ward, or admission to an ICU. The decision to
admit the patient is the most costly issue in the management of CAP, because the cost
of inpatient care for pneumonia is up to 25 times greater than that of outpatient care. It
is a well documented fact that significant variation in admission rates among hospitals
and among individual physicians occurs. Physicians often overestimate severity and
hospitalize a significant number of patients at low risk for death. Based on this, site-of-
care decisions are important for the determination of admission of patients with CAP.
The objectives of stratifying groups of patients are multiple: to define patients with more
severe disease who will require more aggressive and broad-spectrum empiric
antimicrobial treatment, to establish criteria for inpatient care especially for the need for
admission to the intensive care unit (ICU), to determine the prognosis in relation to
disease severity at the time of hospital admission.
The two foremost criteria are the British Thoracic Society criteria (CURB-65) and the
Pneumonia Severity Index (PSI). The CURB-65 and the Pneumonia Severity Index
(PSI) are objective scores which can assist physicians in identifying patients whom will
benefit from in-patient treatment or who may be treated as an out-patient. The PSI has
been validated as an effective prognostic tool for CAP. However, the PSI includes 19
different variables and relies on the availability of scoring sheets, limiting its
practicability in a busy emergency department. In contrast, the CURB-65 score is easily
remembered entailing only 5 criteria. It is a 6-point scoring system, one point for each of
Confusion (defined as disorientation to time, place and person), elevated Urea level,
elevated respiratory rate, low systolic or diastolic Blood pressure, age >= 65 years.
based on information available at initial hospital assessment, enabled patients to be
stratified according to increasing risk of mortality or need for intensive care admission.
The IDSA/ATS committee preferred the CURB-65 criteria because of ease of use and
because they were designed to measure illness severity more than the likelihood of
mortality. Patients with a CURB-65 score >2 are not only at increased risk of death but
also are likely to have clinically important physiologic derangements requiring active
intervention. These patients should usually be considered for hospitalization.
The general objective of the study are: determine and compare mortality rates of the
admitted cases of Community Acquired Pneumonia assessed by either CURB-65
criteria or the Philippine Clinical Practice Guidelines on CAP, and to determine the
applicability of CURB-65 as a site-of-care tool in the admission of patients with
Community Acquired Pneumonia either at the Wards or the Intensive Care Unit
This is a Prospective Randomized Trial
All patients seen at the Emergency Room and Out-Patient Department with the
diagnosis of Community Acquired Pneumonia were included in the study
Inclusion Criteria as enumerated
a. Categories of CAP using the Clinical Practice Guidelines
i. Low Risk
ii. Moderate Risk
iii. High Risk
b. CURB-65 criteria as enumerated
Patient’s who signed the informed consent to be included in the study
Exclusion Criteria as enumerated

For the methodology: A thorough history-taking and physical examination were taken by
the ER/OPD fellow whom would determine if the patient has pneumonia. Subsequently,
laboratories (CXR, CBC, BUN, ABG) were requested. Randomization were done for
severity assessment, a randomization schedule were prepared and used to allocate
patients to either of the two groups: the CURB-65 group and the CPG group. Severity
assessment were done by the ER fellow together with the investigator not more than
one hour of the patient’s arrival at the ER/OPD. Patient were followed-up by the
investigator within 24 hours of admission (ward or ICU) and until discharge or death.
For the sample size calculation: A sample size of 206 CAP patients were required,
which would be randomized to the CURB-65 group (n: 103pxs) and the CPG-CAP
group (n: 103pxs). This was computed based on the unpublished local study for CURB-
65 by Socan, derive from the summation of the admission and mortality of the CAP
patients scored 3 to 5 in the CURB-65 criteria.
For the Statistical Analysis: Data were recorded with Windows Microsoft Excel 2007 and
were analyzed using EPI Info software 3.45. P-values <0.05 were considered
statistically significant.
DING
For the results:
1. The age range for the CURB group is from 18 to 100 years of age with a
mean age of 62.33±18.25 years, while in the CPG group, 16 to 97 years of
age with a mean age of 57.20±20.85 years. No significant difference were
noted (p=0.564). For the age distribution, a third of whom came from the 71yo
and above age group, 36.9% and 31.1%, CURB group and CPG group,
respectively.
2. There was female predominance in both CURB and CPG group at 55 and 57,
respectively. No significant difference were noted in the gender of both
groups (p=0.889).
3. There was a significant difference noted in the presence of comorbidities
(p=0.001) between the two groups, 70.9% and 47.6%, CURB group and CPG
group, respectively. When we talk about comorbidities, these are other
conditions or disease that the patient has. It should be noted that on both
groups, the presence of previous PTB treatment, Cardiovascular disease and
COPD, ranks as the three most common comorbidity.
4. Clinical Features: Dyspnea (94.7%), cough (85%) and fever (72.3%) are the
three most common symptoms noted. There were no significant difference
noted in these symptoms (p= 1.00, 0.697, 1.00, respectively). Only the
symptom of “altered sensorium” was noted to have a significant difference
(p=0.0002) in both groups.
5. With regards to the physical findings: crackles (89.3%), tachypnea (44.7%),
wheezes (22.3%) are the three most common signs noted. No significant
difference were noted in most of the signs, except for “tachypnea” and
“hypotension” (p= 0.000, 0.0007, respectively).
6. For the CXR: There are no significant difference in the radiographic findings
between both groups. Though it should be noted that there is slight
predominance of unilobar involvement (48.1%), followed by multilobar
involvement (46.6%) overall.
7. For the BUN: There is a significant difference in the Blood Urea Nitrogen
(p=0.00002).
8. For the Severity Assessment and Outcome of patients with CAP: More than
half of the population in the CURB-65 group was assessed with the score of 2
(In-patient) these were patients admitted at the regular wards or private
rooms, at 52.4%, followed by patients with a score of 0-1(Out-patient) at
27.2% then by patients with scores of >3, these are patients admitted at the
ICU, at 20.4%. For the CPG group, more than half was assessed under the
Moderate risk, 56.3% these are patients admitted at the regular wards or
private rooms, followed by patients assessed as Low risk, 35%, patients
 managed as an out-patient basis, then by patients assessed as High risk,
8.7%, patients admitted at the ICU.
9. All of the patients stratified in the lower severity class, either thru the CURB-
65 or the CPG, had been discharged improved. The overall mortality rate per
group was: 5.8% for the CURB-65 group, six (6) out of the 103 patients, and
1.9% for the CPG group, two (2) out of the 103 patients. Mortalities were
noted only on those with higher severity ratings. On further determination of
mortality rate per level of severity, it revealed that those with a CURB-65
score of ≥3 has a mortality rate of 28.6% (six out of the 21 patients), while
those on the CPG, 22.2% (two out of the nine patients). No difference was
noted, though there was a slight increase number of mortalities in the CURB-
65 group because more patients have graver conditions (altered sensorium,
tachypnea, hypotension) randomized under the group.

CHAD

Physicians in teaching institutions are familiar with the Clinical Practice Guidelines for
CAP (Joint Statement of PSMID, PCCP, PAFP). Most of the physicians, be it general
practitioners or specialists uses the CPG. As such, we wanted to know if the CURB-65
criteria could be used interchangeably with the CPG. We found out that using the
CURB-65 criteria does not offer additional benefits as compared with the usage of the
CPG. Most of the medical consultants and pulmonary fellows in the institution readily
opined that they are more familiar with the CPG than the CURB-65 criteria, therefore
are more adept in assessing patients with CAP using the former than the latter.
In conclusion, the CURB-65 criteria is a useful severity tool because of the ease in its
use, and because they were designed to measure illness severity more than the
likelihood of mortality. In this study, we determined that all of the mortality came from
the higher severity levels: CURB-65 score ≥3 (28.6%), CPG High risk (22.2%), none
from the lower severity ratings. Usage of CURB-65 criteria does not offer additional
benefits compared to the use of the CPG, in fact because of familiarity of physicians
with the latter, they are more adept in using it.
We do recommend further study, with a bigger population, be done using CURB-65
criteria not only as a site-of-care tool but more so as a severity assessment instrument
(validity study). The five parameters of the CURB-65 criteria are easily remembered as
such, these criteria can be used in busy tertiary metropolitan hospitals or in primary and
secondary hospitals in the provinces. We also recommend inclusion of patients with
immunocompromised states (eg. Malignancy, PTB) so as to determine the criteria’s
effectiveness in such cases.
Ultimately, the physician’s decision to hospitalize a patient is based on the stability of
patient’s clinical condition, presence or absence of other active medical problems, risk
of death and complications and sometimes psychosocial considerations. These
guidelines should always be applied with the physician’s clinical judgment.
That’s our presentation. Thank you very much.