A clinical score (RAPID) to identify those at risk for poor outcome at presentation in patients with pleural
Najib M Rahman1, Brennan C Kahan2, Robert F Miller3
1Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Oxford University Hospitals NHS Trust, Oxford; Department of Radiology, Oxford University Hospitals, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford; National Institute of Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford.
Insights
The RAPID score effectively stratifies pleural infection patients by risk. High RAPID scores significantly correlate with increased mortality and longer hospital stays, aiding early management strategies.
Area of Science:
- Thoracic Medicine
- Infectious Diseases
- Clinical Risk Stratification
Background:
- Pleural infection presents a significant challenge with high morbidity and mortality rates.
- Effective risk stratification at presentation is crucial for timely patient triage and management.
- Identifying high-risk individuals can guide early therapeutic interventions.
Purpose of the Study:
- To derive and validate a clinical risk score for patients with pleural infection.
- To identify baseline clinical characteristics predictive of poor outcomes in pleural infection.
- To enable early identification of patients at high risk of mortality.
Main Methods:
- A clinical risk score, RAPID (renal, age, purulence, infection source, dietary factors), was developed using data from the MIST1 trial (n=411).
- Model selection identified key predictors of poor outcomes from 22 baseline clinical characteristics.
- The RAPID score was validated in an independent cohort from the MIST2 trial (n=191).
Main Results:
- Age, urea, albumin, hospital-acquired infection, and nonpurulence were significant predictors of poor outcome.
- The RAPID score stratified patients into low-risk (0-2), medium-risk (3-4), and high-risk (5-7) groups.
- High RAPID scores (3-4 and >4) were strongly associated with increased 3-month mortality (ORs 24.4 and 192.4, respectively) and longer hospitalization.
Conclusions:
- The RAPID score provides a validated tool for risk stratification of pleural infection patients upon presentation.
- This score can aid clinicians in identifying high-risk individuals, potentially improving patient outcomes.
- The RAPID score's utility in guiding early management strategies warrants further investigation.
Background:
Pleural infection is associated with a high morbidity and mortality. Development of a validated clinical risk score at presentation to identify those at high risk of dying would enable patient triage and may help formulate early management strategies.
Methods:
A clinical risk score was derived based on data from patients entering the multicenter UK pleural infection trial (first Multicenter Intrapleural Sepsis Trial [MIST1], n=411). From 22 baseline clinical characteristics, model selection was undertaken to find variables predictive of poor clinical outcome. Outcomes were mortality at 3 months (primary), need for surgical intervention at 3 months, and time from randomization to discharge. The derived scoring system RAPID (renal, age, purulence, infection source, and dietary factors) was validated using patients enrolled in the subsequent MIST2 trial (n=191).
Results:
Age, urea, albumin, hospital-acquired infection, and nonpurulence predicted poor outcome. Patients were stratified into low-risk (0-2), medium-risk (3-4), and high-risk (5-7) groups. Using the low-risk group as a reference, a RAPID score of 3 to 4 and >4 was associated with an OR of 24.4 (95% CI, 3.1-186.7; P=.002) and 192.4 (95% CI, 25.0-1480.4; P<.001), respectively, for death at 3 months. In the validation cohort (MIST2), a medium-risk RAPID score was nonsignificantly associated with mortality (OR, 3.2; 95% CI, 0.8-13.2; P=.11), and a high-risk score was associated with increased mortality (OR, 14.1; 95% CI, 3.5-56.8; P<.001). Hospitalization duration was associated with increasing RAPID score (score 0-2: median duration=7, interquartile range 6-13; score>5: median duration=15, interquartile range 9-28, P=.08).
Conclusions:
The RAPID score may permit risk stratification of patients with pleural infection at presentation.
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