The Study On The Predictive Value Of Extended CURB-65 Score For Initial Treatment Outcome In Patients With Community-acquired Pneumonia

Objective:This study retrospectively analyzed and compared the differences in demographic,imaging,laboratory parameters and CURB-65 score between initial treatment failure and initial treatment success in hospitalized patients with community-acquired pneumonia(CAP),and explored the factors that may affect the initial treatment outcome of CAP.The independent risk factors for initial treatment failure were included in CURB-65 score.To develop new scoring systems to improve their predictive value for initial treatment outcomes in patients hospitalized with CAP.Methods:This study collected the clinical data of 365 patients with community-acquired pneumonia in the Department of Respiratory and Critical Care Medicine from January 1,2018 to June 30,2021:age,sex,underlying disease,CURB-65 score,imaging examination,antibiotic usage,blood routine,inflammation index,blood coagulation index,and initial treatment results.All clinical data were collected at the time of initial treatment.According to the guidelines for the diagnosis and treatment of community-acquired pneumonia in Chinese adults(2016 edition),the results of initial treatment are divided into effective treatment and treatment failure.The evaluation after initial treatment includes clinical manifestations,vital signs,general laboratory tests,microbiological indicators and chest videography.If the patient’s symptoms do not improve after the initial treatment,the anti-infective drugs need to be replaced,or the initial treatment improves and then worsens,and the disease progresses,the initial treatment failure is considered.Clinically,it mainly includes two forms:progressive pneumonia and unresponsive to treatment.The 365 patients enrolled were divided into 300 cases(300/365)in the initial treatment effective group and 65 cases(65/365)in the initial treatment failure group.The CURB-65 score of each patient before the initial treatment was evaluated,and the imaging examination evaluation The content includes whether there is pleural effusion,unilateral or bilateral pneumonia,and the number of lung lobes infiltrated by inflammation.The laboratory observation indicators are mainly white blood cells(WBC),neutrophils(NE),lymphocytes(LY),neutrophils Granulocyte-to-lymphocyte ratio(NLR),monocytes(MO),albumin(ALB),lactate dehydrogenase(LDH),procalcitonin(PCT),C-reactive protein(CRP),platelets(PLT),prothrombin time(PT),activated partial thromboplastin time(APTT),thrombin time(TT),fibrinogen(Fbg),D-dimer(D-D),plasma antithrombin III activity(AT-III)and fibrinogen degradation products(FDP).Mann-Whitney U test and Chi-square test were used to compare the differences in the basic clinical data of the two groups of patients.Multivariate Logistic regression was used to analyze the independent risk factors for initial treatment failure.R language was used to analyze the weight of each risk factor and assign a score.Risk factors were included in the CURB-65 score.After the extended CURB-65 scoring system was established,the area under the curve(AUC)of the receiver operating characteristic curve(ROC)was analyzed to compare the predictive value of different scoring methods for initial treatment failure in CAP patients.P<0.05 considered the difference to be statistically significant.Results:1.Baseline characteristics of patients A total of 365 CAP inpatients were enrolled according to the inclusion and exclusion criteria,including 65 patients in the initial treatment failure group and 300 patients in the initial treatment response group.The gender,age and underlying diseases of the two groups were compared.Compared with the initial treatment response group,the median age of the initial treatment failure group was older(56.7[44.5-67]years vs.51.7[38-63.7]years,P=0.028),underlying diabetes(29.2%vs.14.7%,P=0.028),kidney disease(12.3%vs.3.3%,P=0.002)and heart disease(10.8%vs.3.7%,P=0.017)The proportion is higher.There was no significant difference between the two groups in gender,hypertension and liver disease(P>0.05).2.Initial antibiotic use All 365 patients were treated with antibiotics after admission.Antibiotics were divided into β-lactam antibiotics and non-β-lactam antibiotics,quinolone antibiotics and non-quinolone antibiotics.The use of β-lactam antibiotics(93.9%vs.91.3%,P=0.504)and quinolone antibiotics(63.1%vs.70.0%,P=0.275)in the two groups were similar,and the difference was not statistically significant(P>0.05).3.Abnormal laboratory findings in the initial treatment failure cohort In terms of blood cells,the median levels of platelets in the two groups were similar(256[184-3 83]×109/L vs.233[172-295]×109/L,P=0.902),and the white blood cells in the initial treatment failure group(13.4[10.5-20.3]×109/L vs.7.2[4.9-9.8]×109/L,P<0.001),neutrophils(11.2[9.2-16.7]×109/L vs.4.9[3.0-7.7]×109/L,P<0.001),the ratio of neutrophils to lymphocytes(11.9[6.8-19.9]vs.3.6[2.1-6.5],P<0.001),monocytes(0.9[0.4-1.2]×109/L vs.0.5[0.4-0.7]×109/L,P=0.008)was higher,and lymphocytes(0.9[0.6-1.4]×109/L vs.1.3[0.9-1.7]×109/L,P<0.001)were lower(P<0.05).In terms of coagulation indicators,the prothrombin time(13.5[12.6-14.6]sec vs.12.7[11.9-13.7]sec,P<0.001)and activated partial thromboplastin time(31.1[26.8-39.2]sec vs.30.9[26.7-34.8]sec,P=0.002),fibrinogen(6.6±2.1g/L vs.5.4±1.9g/L,P=0.015),fibrin degradation products(9.7[3.9-15.3]mg/L vs.3.7[2.1-6.9]mg/L,P<0.001),D-dimer(2.3[1-4.1]μg/ml vs.0.8[0.4-1.8]μg/ml,P<0.001)Higher levels,thrombin time(17.2[16.1-18]sec vs.17.6[16.9-18.6]sec,P=0.003),antithrombin III activity(82.5±16.8%vs.89.4±13.6%,P=0.036)were low(both P<0.05).In addition,lactate dehydrogenase(215.6[164.9-278.8]U/L vs.190.3[149.9-260.5]U/L,P<0.001),C-reactive protein(148[83.3-248]mg/L vs.50.9[11.7-103.5]mg/L,P<0.001)and procalcitonin(0.3[0.2-2.3]ng/ml vs.0.2[0.04-0.3]ng/ml,P=0.002)The level of albumin(29.7±6.4g/L vs.35.4±5.8g/L,P=0.035)was lower than that of the initial treatment effective group(both P<0.05),suggesting that the initial treatment failure group There is a higher systemic inflammatory response,a more impaired coagulation system,and greater nutrient consumption.4.Initial chest imaging features in the initial treatment failure cohort More patients in initial TF cohort exhibited bilateral and multi-lobar distribution of lung lesions,which was significantly higher than those of initial treatment success cohort(66.2%vs.44.3%,P=0.004;78.5%vs 57.7%,P=0.002),and the ratio of combined pleural effusion in treatment failure cohort was also higher than that of the initial treatment success cohort(67.7%vs 42.0%,P<0.001),the difference was statistically significant.The CT progress of patients with failed treatment of CAP.There was no correlation between radiographic progression and the initial involvement of unilateral or bilateral lobes.5.CURB-65 score It was possible to calculate CURB-65 for 365 patients involved in the study.The median(IQR)CURB-65 score was 0(0-1).There was a statistically significant difference between the initial TF cohort and initial treatment success cohort in median(IQR)(1 vs.0)scores(p<0.001).CURB-65 score was categorized further into three classes as follows:0-1 as low risk,2 intermediate risk,and 3-5 high risk.The initial TF cohort had 49 low risk patients(49/65,75.4%),13 intermediate risk patients(13/65,20.0%),and 3 high risk patients(3/65,4.6%).As for the initial treatment success cohort,268 patients(268/300,89.3%)were low risk,23(23/300,7.7%)were intermediate risk,and 9(9/300,3.0%)were high risk.The scores of both cohorts were mainly low risk,but the initial TF cohort had a higher risk class than initial treatment success cohort,and the difference was statistically significant through analysis(P=0.003).6.Factors with P<0.05 and those considered to be related to the severity of the disease in previous studies were included in the Logistic regression model for multivariate analysis,and the results showed that CURB-65 score≥1(OR 1.944,[95%CI 1.607-3.556],P=0.034),NLR>6.89(OR 1.183,[95%CI 1.106-1.393],P=0.043),APTT≥32.85s(OR 1.877,[95%CI 1.361-2.988],P=0.009),D-D≥1.72ug/ml(OR 1.503,[95%CI 1.071-2.236],P=0.018),FDP≥8.78mg/l(OR 1.911,[95%CI 1.308-2.296],P=0.015)and CRP≥89.60 mg/l(OR 1.412,[95%CI 1.364-2.219],P=0.024)were the independent influencing factors of initial treatment failure in hospitalized CAP patients.7.Establishment of the expended CURB-65 score Furthermore,based on the results of multivariate logistic analysis,NLR,ATTT,D-D,FDP,and CRP were introduced into R 4.2.1 software,and a nomogram model for predicting the risk of initial treatment failure in hospitalized patients with CAP was established.According to the prediction model,2 points for NLR≥6.89,2 points for CRP≥89.60 mg/l,1 point for APTT≥32.85 sec,1 point for D-D≥1.72 ug/ml,1 point for FDP≥8.78 mg/l,incorporation of five factors into the CURB-65 score results in an expanded CURB-65 score of 12 points.8.Finally,the ability of the two scoring systems to predict the risk of treatment failure was compared by ROC curve.The optimal cut-off value of CURB-65 score corresponding to failure treatment wasl computed using the receiver operating curve(ROC),the sensitivity and specificity of the CURB-65 score were 61.5%and 67.0%respectively,and the area under the curve(AUC)was 0.650.Meanwhile,the cut-off value of the expended CURB-65 score was 4,the sensitivity and specificity were 80.0%and 70.3%respectively,and the AUC was 0.802.The difference Statistically significant(P<0.001).It can be seen that the ability of expended CURB-65 score to predict treatment failure is significantly better than that of CURB-65 score.Conclusion:1.The CAP initial treatment failure group was older than the initial treatment effective group,had a higher proportion of underlying diabetes,kidney disease,and heart disease,more obvious lung inflammation and pleural effusion,and more serious inflammation and coagulation disorders.2.Except that the CURB-65 score can evaluate the condition of CAP patients,and the scores and grades of the initial treatment failure group are higher,our study found that CRP,NLR,APTT,D-D,and FDP are risk factors for CAP initial treatment failure.3.CURB-65 score combined with CRP,NLR,APTT,D-D,and FDP five independent risk factors,and the expended CURB-65 score constructed has a better predictive performance on the risk of initial treatment failure of CAP.