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Eur Respir J 2008; 31:477-478
Copyright ©ERS Journals Ltd 2008

Lower respiratory tract infection outcomes are predicted better by an age >80 years than by CURB-65

S. Teramoto1, H. Yamamoto1, Y. Yamaguchi1, Y. Hanaoka1, M. Ishii1, S. Hibi1, H. Kume2 and Y. Ouchi1

1 Depts of Geriatric Medicine, and 2 Urology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.

To the Editors:

In a recent issue of the European Respiratory Journal, Bont et al. 1 demonstrated that increasing age, previous hospitalisation, heart failure, diabetes, use of oral glucocorticoids, previous use of antibiotics, a diagnosis of pneumonia and an exacerbation of chronic obstructive pulmonary disease were independent predictors of 30-day hospitalisation or death in patients with lower respiratory tract infections (LRTI). They provided a new scoring system using the variables above for the prognostic predictors in the elderly primary-care patients with LRTI 1.

Although some of the predictor variables have been confirmed by other studies, we would like to point out that their results are very important, much more so than previous results.

Age is a well known risk factor for a poor outcome in LRTI. However, most related studies have recommended that an age ≥65 yrs presents the greatest risk for a poor outcome of LRTI or community-acquired pneumonia (CAP) 2–4. It has been recommended by the British Thoracic Society that a simple clinical prediction rule based on the five clinical features of age, confusion, urea, respiratory rate and blood pressure (the CURB-65 score) may be a practical means of stratifying patients with CAP into low-, intermediate- and high-mortality risk groups 4. However, the study by Bont et al. 1 clearly indicated that an age >80 yrs presents the greatest risk for a poor outcome of LRTI.

We prospectively examined hospitalised pneumonia patients for 3 yrs (fig. 1Go). Most of the hospitalised pneumonia patients were ≥65 yrs old. In fact, 75% of hospitalised patients with pneumonia were aged >70 yrs; therefore, an age ≥65 yrs cannot be a meaningful cut-off level in terms of hospital admission risk and pneumonia risk. A similar phenomenon may occur in all developed countries, since the aged population is growing very rapidly; thus, in developed countries, CURB-65 may not be advantageous in the prediction of poor outcome in hospitalised LRTI or CAP. Unfortunately, most other studies in this area, which include a low number of elderly subjects, do not examine the significance of new age criteria, such as age ≥80 yrs, being a better predictor for poor outcome than the conventional age criteria determined as age ≥65 yrs.


Figure 1
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  		Fig. 1— The mean values of pneumonia incidence in the different ages for 3 yrs are presented. Data are presented as mean±SD.

 
It has been recently suggested that CURB-65 should not be supplanted by systemic inflammatory response syndrome (SIRS) or the standardised early warning score (SEWS) for initial prognostic assessment in CAP. Further research to identify better generic prognostic tools is required 5. Although the SIRS and SEWS are different from LRTI and CAP, variables of age and pneumonia may be common contributors for the prognosis.

We would like to reinforce the fact that aspiration and silent aspiration are very important mechanisms of aspiration pneumonia in the elderly 6–9. Since silent aspirations are very common in patients with stroke and frail elderly patients with advancing age, aspiration risk and dysphagia are significant predictors for the development of pneumonia and poor outcome of LRTI. Suspected aspiration is associated with more aggressive antibiotic treatment of suspected pneumonia episodes in nursing home residents dying with advanced dementia 10

In conclusion, the current authors respect the fact that the CURB-65 score is useful to predict the outcome of patients with lower respiratory tract infections in the general population. However, the age cut-off point should be seriously reconsidered as significant as a good predictor for the outcome in the current clinical settings in aged populations of developed countries.

Statement of interest

None declared.

REFERENCES

  1. Bont J, Hak E, Hoes AW, Schipper M, Schellevis FG, Verheij TJ. A prediction rule for elderly primary-care patients with lower respiratory tract infections. Eur Respir J 2007;29:969–975.[Abstract/Free Full Text]
  2. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243–250.[Abstract/Free Full Text]
  3. Hak E, Wei F, Nordin J, Mullooly J, Poblete S, Nichol KL. Development and validation of a clinical prediction rule for hospitalization due to pneumonia or influenza or death during influenza epidemics among community-dwelling elderly persons. J Infect Dis 2004;189:450–458.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
  4. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58:377–382.[Abstract/Free Full Text]
  5. Barlow G, Nathwani D, Davey P. The CURB65 pneumonia severity score outperforms generic sepsis and early warning scores in predicting mortality in community-acquired pneumonia. Thorax 2007;62:253–259.[Abstract/Free Full Text]
  6. Teramoto S, Ishii T, Yamamoto H, et al. Significance of chronic cough as a defence mechanism or a symptom in elderly patients with aspiration and aspiration pneumonia. Eur Respir J 2005;25:210–211.[Free Full Text]
  7. Teramoto S, Matsuse T, Fukuchi Y, Ouchi Y. Simple two-step swallowing provocation test for elderly patients with aspiration pneumonia. Lancet 1999;353:1243[Web of Science][Medline] [Order article via Infotrieve]
  8. Teramoto S, Ishii T, Yamamoto H, Yamaguchi Y, Ouchi Y. Nasogastric tube feeding is a cause of aspiration pneumonia in ventilated patients. Eur Respir J 2006;27:436–437.[Free Full Text]
  9. Teramoto S, Yamamoto H, Yamaguchi Y, et al. ACE inhibitors prevent aspiration pneumonia in Asian, but not Caucasian, elderly patients with stroke. Eur Respir J 2007;29:218–219.[Free Full Text]
  10. Chen JH, Lamberg JL, Chen YC, et al. Occurrence and treatment of suspected pneumonia in long-term care residents dying with advanced dementia. J Am Geriatr Soc 2006;54:290–295.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]




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