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ONLINE DATA SUPPLEMENT FOR:Severity assessment tools for predicting mortality in hospitalised patients with Community-Acquired Pneumonia: Systematic review and Meta-Analysis.James D Chalmers1, Aran Singanayagam2, Ahsan R Akram2, Pallavi Mandal2, Philip M Short3, Gourab Chowdhury2, Victoria Wood1, Adam T Hill2University of Edinburgh, Edinburgh, UK.Department of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UKUniversity of Dundee, Tayside, UK.Corresponding authorDr James ChalmersDepartment of Respiratory MedicineRoyal Infirmary of Edinburgh51 Little France CrescentOld Dalkeith RoadEdinburghEH16 4SAE-mail: jamesdchalmers@Keywords: Pneumonia, Severity assessment, mortality, meta-analysisADDITIONAL METHODSDefinition of Severity scoresPneumonia Severity Index[1]The Pneumonia Severity Index is a well-validated prediction scale for 30-day mortality in community-acquired pneumonia is composed of the following twenty characteristics: demographics including age, sex and nursing home residence; co-morbid illness including neoplastic disease, cerebrovascular disease, congestive cardiac failure, chronic renal disease and chronic liver disease; physical examination findings including altered mental status, respiratory rate > 30/min, systolic blood pressure <90mmHg, temperature <35oC or >40oC and pulse >125/min; laboratory findings including pH <7.35, blood urea >10.7 mmol/L, sodium <130 mEq/L, glucose >13.9 mmol/L, haematocrit <30% and PaO2 <60mmHg; radiographic findings including pleural effusion. Using these data, patients are classified into 5 risk classes. In the original Pneumonia Patient Outcome Research Team cohort study, 30-day mortality ranged from 0.1% for patients with a class 1 rating to 27% for patients with a class 5 rating. Typically, patients with PSI class IV/V are regarded as severe pneumonia and recommended for hospitalization. For the purposes of this meta-analysis, 2x2 tables were constructed for mortality in both PSI class IV/V and class V alone.CURB65/CRB65[2]CURB65 is a validated method of predicting inpatient mortality associated with CAP that is recommended by the British Thoracic Society. It consists of new onset mental confusion, urea >7 mmol/L, respiratory rate >30 breaths/min, systolic blood pressure <90mmHg or diastolic blood pressure <60 mmHg and age > 65 years.British Thoracic Society guidelines suggest that patients with a CURB65 score of 0–1 be considered for outpatient treatment; that patients with a CURB65 score of 2 be considered for short inpatient hospital stay; and that patients with a CURB65 score >3 have severe pneumonia that requires inpatient management, and intensive care or high dependency environment care should be considered, particularly for patients with a CURB65 score >4. For the purposes of this meta-analysis both > 3 and > 4 were used to construct 2 x 2 tables of the relationship between CURB65 and mortality.CRB65 is a simplified version of the CURB65 score that does not include the urea criterion. It stratifies patients into low risk (CRB65= 0 or 1), intermediate risk (CRB65= 2) or high risk groups (CRB65 = 3 or 4). CRB65 is recommended for outpatient use in the British Thoracic Society guidelines.[3]HAYDENS CRITERIA FOR QUALITY ASSESSMENTThe following table (Table E1) describe Haydens criteria.[4] These quality assessment criteria were modified to apply to observational studies of community acquired pneumonia severity scores. Haydens criteriaComponentsAs applied to CAP studiesStudy sample represents the population of interest, design appropriate to limit potential biasSource population clearly definedStudy population describedStudy population represents population of interestPopulation limited to CAP and excludes other diagnosesRequires Chest x-ray confirmation and uses recognised definitionEnrolls consecutive, unselected patientsDemographics are representative of CAP cohorts internationally.Loss to follow-up, study data adequately represent the sampleCompleteness of follow-up describedCompleteness of follow-up adequateAppropriate follow up to determine mortality Limited number of patients lost to follow-up.Prognostic factor of interest is adequately measured in study participants Prognostic factors definedPrognostic factors appropriately measuredi)CURB65/CRB65/PSI score calculated according to standard definitionII) Measurement made on admission and recorded prospectivelyIII) Missing values minimised and appropriately dealt withThe outcomes of interest are adequately measured in study participants Outcome definedOutcome measured appropriatelyMortality 30-day mortality or alternative outcome determined appropriately.Important confounders are accounted for.Confounders defined and measuredConfounders accounted forNot applicable as prognostic scores are used independently.Appropriate statistical analysisAnalysis describedAnalysis appropriateAnalysis provides sufficient presentation of datal) Uses and reports PPV/NPV/sensitivity/specificity and/or receiver operator characteristic curve for pneumonia severity scores.II) displays data for different cut-points of each pneumonia severity scoreTABLE E1- Haydens Criteria for quality assessment, modified to apply to studies of community acquired pneumonia.ADDITIONAL RESULTSThe Table (E2) provides details of each of the studies included in the meta-analysis. First author nameStudy PopulationScore(s) assessedSetting and designNAge(years)Study OutcomeMortality rateStudy Objective/ConclusionAnanda-Rajah[24]Retrospective chart reviewPSI, CURB65Melbourne, Australia, 200240872 +/- 1630-day mortality15.4%Comparison of PSI and CURB65Aujesky, D[15]Guideline implementation trialPSI, CURB6532 hospitals in Pennsylvania, Connecticut USA200131816330-day mortality4.6%Randomised controlled trial comparing effect of intensity of guideline implementation (PSI)Barlow, G[25]Prospective, before and after quality improvement studyCURB65, CRB652 Hospitals, Tayside, UK. 2001-2003.419Median 7430-day mortality18.9%Study to increase proportion of patients receiving antibiotics within 4 hours of admissionBauer, TT (CAPNETZ)[37]Prospective cohort studyCRB6510 inpatient and outpatient centres Germany, 2003-2004196766 +/- 1830-day mortality4.3%Validation of CRB65Buising, KL[26]Prospective cohort studyCURB65, PSIMelbourne, Australia, 2003-2006722Median 74In-hospital mortality9.8%Derivation of a new severity score (CORB)Capelastegui , A[27]Prospective cohort studyPSI, CURB65, CRB65Galdakao Hospital, Basque region, Spain2000-2004177661.8 +/- 20.530-day mortality6.7%Validation of severity scoresChallen, K[28]Retrospective case note reviewCURB65Manchester, UK 2005.186NRIn-hospital mortality22.6%Comparison of CURB65 with modified early warning scoreChalmers, JD[20]Prospective cohort studyPSI, CURB65, CRB652 hospitals, Edinburgh, UK 2005-2008100766 (50-78)30-day mortality9.6%Modification of the CURB65 score.Charles, PG[29]Prospective cohort studyPSI, CURB65Multicentre, Australia,2004-2006.88265.1 +/- 19.930-day mortality5.7%Derivation of new severity score (SMART-COP)Chen CZ[41]Prospective cohort studyPSITaiwan, 2005-2006250NRIn hospital mortality12%Evaluation of repeated measurements of PSIDavydov L[42]Prospective cohort studyPSIMulticentre,USA1998-199987566.5 +/- 17.7In hospital mortality2.7%Audit treatment of patients according to PSI class.Dedier, J [43]Retrospective databasePSI38 US Academic hospitals1062Median 64 (range 18-98)Hospital mortality6%Study the effect of processes of care on outcome.Ewig, S[44]Prospective cohort studyPSISingle centre, unknown location, 1998-200148967.8 +/- 17.1In-hospital mortality within 30-days6.8%Comparison of severity scores.Ewig S[38]Retrospective administrative databaseCRB65Nationwide database, Germany 2005-2006388,406Median 76In-hospital mortality14.1%National epidemiological surveyFeagan, B[45]Retrospective chart reviewPSI20 hospitals across Canada1996-199785869.4 +/- 17.730-day in hospital mortality14.1%Evaluate the treatment and outcome of CAP in CanadaFine, MJ- Medisgroup[7]Administrative databasePSIMEDISGROUP 178 hospitals in USA, 1989MEDISGROUP 2193 Hospitals in Pensylvania 199152,238NR30-day mortality10.5%Derivation and internal validation of PSIFine MJ- PORT[7]Prospective cohort studyPSI5 Hospitals, USA and Canada, 1991-19942287NR30-day mortality4.9%Validation of PSIFlanders, WD[46]Retrospective chart reviewPSI22 Hospitals, Atlanta, USA1994-19951,024NRNot reported. Assumed in-hospital mortality4.8%Recalibration of PSIGarau J[47]Retrospective care note reviewPSIMulticentre, Spain 2001-2002323366.6 +/- 18.5In-hospital mortality8.7%Investigating factors affecting length of stay and mortality.Garcia-Vazquez E[48]Retrospective studyPSIMurcia, Spain, 2003.21163 (range 13-100)In hospital mortality7.1%Derivation of simplified score.Goss CH[49]Prospective cohort studyPSISeattle, WA, USA 1994-199652246 (range 18-100)In hospital mortality3.3%To evaluate resource utilisation among patients in low risk PSI groups.Huang, DT[30]Prospective cohort studyPSI, CURB65Multicentre, USA2001-2003165165 +/- 18.530-day mortality, 90 day mortality6.4%9.8%Assessment of procalcitonin as a severity marker (GenIMS)Johnstone, J[39]Prospective, population based cohort studyPSI6 hospitals, Alberta, Canada 2000-20022,90668.9 +/- 17.91 year mortality (30-day mortality as secondary end-point)13%Long term mortality and morbidity of CAP patientsLim, WS[10]Combination of 3 prospective cohort studiesCURB65, CRB65Nottingham, UK 1998-2000. Christchurch and Waikato, New Zealand 1999-2000. Alkmaar, Netherlands, 1998-2000.1068Mean 64.130-day mortality8.3%Derivation of CURB65, CRB65Man, SY[18]Prospective cohort studyPSI, CURB65, CRB65Hong Kong2004101672 +/- 7.230-day mortality8.6%Validation of severity scores for 30-day mortalityMenendez, R[31]Prospective cohort studyPSI, CURB65, CRB652 Hospitals, Spain2003-200445367.3 +/- 17.1Treatment failure(includes mortality)6.8%Investigation of CRP, cytokines and procalcitonin as markers of treatment failureMigliorati, PL [50]Retrospective chart reviewPSISingle Centre, Italy14870.3 +/- 17.330-day mortality12.2%Validation of PSI in Italy.Ortega L[40]Prospective cohort studyPSIBarcelona, Spain, Dates not stated12864 +/- 8In-hospital mortality3.1%Evaluation of the pneumonia severity indexPhua, J[32]Retrospective cohort studyPSI, CURB65Singapore, 2004-2007124265.7 +/- 20.1In hospital mortaity14.7%Validation of IDSA/ATS criteria for severe CAP.Renaud, B[8]Pneumocom 1Randomised controlled trialPSI16 Hospitals, France. 2002-2003925Mean 6628 day mortality10.6%Randomised controlled trial using PSI to determine site of careRenaud, B[51]Pneumocom 2Prospective cohort studyPSI14 hospitals, Catalonia, Spain,2003 853Mean 6528 day mortality6.3%Validation of PSI in European populationQuerol-Ribelles JM[52]Prospective cohort studyPSIValencia, Spain, 200024363 +/- 1930-day mortality6.2%Validation of PSIRestrepo, M[53]Retrospective chart reviewPSI2 hospitals, San Antonio, Texas, USA1999-200273059.2 +/- 16.230-day mortality8.1%Compare patients admitted to the ward and intensive care units with CAPReyes Calzada S[54]Prospective observational studyPSIMulticentre, Valencia, Spain Dates not stated42569 +/- 1630-day mortality8.2%Evaluate adherence to community-acquired pneumonia guidelinesRoson, B[55]Prospective cohort studyPSIBarcelona, Spain1995-1997533Mean 6430-day mortality6.6%Use of PSI to determine site of careSchuetz , P[33]Randomised controlled trialPSI, CURB65, CRB65Basel, Switzerland, 2002-200537373 (59-82)30-day mortality11%Validation and recalibration of severity scoresShindo, Y[34]Retrospective cohort studyCURB65Handa City, Japan 2005-200732975 +/- 15.730-day in hospital mortality9.4%Compare CURB65 with ADROP (Alternative scoring system)Tejera, A[35]Prospective cohort studyPSI, CURB65Tenerife, SpainDates not available22674 (61-82)In hospital mortality12.4%Assessment of TREM-1 as a prognostic marker in CAPVan der Eerden[56]Prospective cohort studyPSIAlkmaar, Netherlands, 1998-2000260Mean 6430-day mortality10%Validation of PSIZuberi, FF[36]Prospective chart reviewCURB65, CRB65Karachi, Pakistan. 2006-200713760.4 +/- 18.530-day mortality13.1%Validation of CURB65/CRB65 in a developing countryTABLE E2- Characteristics of studies included in the meta-analysis (note- references refer to those in the main document).The following studies contained data on PSI, CURB65 or CRB65 but were excluded from the main analysis due to duplicate publication of data, or failure to meet the inclusion criteria of non-selected CAP populations. The reasons for exclusion are listed.First author nameyearscore(s) assessedReason for exclusionAngus DC[5]2002PSIData contained in (1)Arnold FW[6]2003PSILow risk patients onlyBont J[7]2008CRB65Outpatient onlyBruns, AH[8]2008PSILimited to severe CAP (PSI IV and V)Buising KL[9]2007CURB65, PSIData contained in (10)Cabre M[11]2004PSINot consecutive, unselected CAP patients. Data not presented.Campbell, SG[12]2006PSIPatients discharged from emergency department only.Chalmers JD[13]2008PSI, CURB65, CRB65 Data contained in (14)Chalmers, JD[15]2008PSI, CURB65, CRB65Data contained in (14)Cham, G[16]2009PSINo mortality data included.Christ-Crain, M[17]2006PSIData reported in (18)Curran, A[19]2008PSIHIV positive patients onlyDremsizov T[20]2009PSIData reported in (1)Escobar GJ[21]2008PSIModified version of the PSI excluding some parametersEspana PP[22]2006PSI, CURB65Data contained in (23)Ewig S[24]1999PSILimited to elderly patients (aged >65 years only)Gotoh, S[25]2008PSIData not reportedHaeuptle J[26]2009PSILimited to Legionella pneumonia.Hohenthal, U[27]2009PSINo mortality data presented.Huang, DT[28]2009PSI, CURB65Data contained in (29)Ioachimescu OC[30]2004PSILimited to Streptococcus pneumoniae pneumonia patients only.Kollef KE[31]2008CURB65Single organism only (MRSA)Kruger, S[32]2008CRB65Data contained in (33)Lin CC[34]2005PSIData reported in (35)Masia, M[36]2005PSIData not reported.Muller, B[37]2007PSINot limited to CAP. Data reported in (17)Myint, PK[38]2006CURB65Limited to elderly patients onlyNaito T[39]2006PSIElderly patients aged >80 years only.Pauls S[40]2008CRB65Did not report mortality data.Pilotto, A[41]2009PSI1 year mortality as end-point. Age limited to >65 years.Prat, C [42]2006PSINot exclusively CAP (including tuberculosis and PCP). Salluh JI[43]2008CURB65Limited to severe CAP in ICUSanders KM[44]2006PSIImmunocompromised patients onlySanz, F [45]2009PSILow risk (PSI I-III) only.Schaaf, B[46]2007CRB65Limited to a single organism (Streptococcus Pneumoniae)Spindler, C[47]2006CURB65Limited to a single organism (Streptococcus Pneumoniae)Teramoto, S [48]2008CURB65Data not reportedValencia, M[49]2007PSI, CURB65Pneumonia severity index class V patients only.Vecchiarino, P [50]2004PSIData not presented.Wilson PA[51]2005PSIICU admitted patients only.Yealy DM[52]2005PSIData contained in (53)Table E3- Studies of severity scores excluded from the meta-analysis.ADDITIONAL RESULTS- PERFORMANCE CHARACTERISTICS AND FOREST PLOTS FOR SEVERITY SCORESCalibration analysisThe performance of scores were compared to predicted values obtained from the initial derivation studies. For PSI, fine et al reported mortality rates of 0.3%, 0.4%, 9.3% and 27% for PSI classes I-II (lowest risk), PSI classes I-III (low risk), PSI class IV and class V respectively. For CURB65, predicted values were 1.2% (CURB65 0-1), 9.0% (CURB65=2) and 22.6% (CURB65 3-5). For CRB65, predicted mortality rates were 0.9% (CRB65 0), 8.1% (CRB65 1-2) and 31.2% (CRB65 3-4). The results of the calibration analysis are shown in the forest plots below. The observed mortality in the validation studies was significantly higher for both PSI and CURB65 for low risk patients (PSI I-III and CURB65 0-1) than estimated in the original derivation studies. All 3 scores were well calibrated (p>0.05) at the higher cut-offs, although significant heterogeneity was observed, suggesting variation in mortality rates between different studies within these groups. Forest plots for each group are displayed in the online supplement. Pneumonia severity index I-IIPneumonia severity index I-IIIPneumonia severity index class IVPneumonia severity index class VCURB65 calibrationCURB65 0-1CURB65 group 2CURB65 group 3-5CRB65 scoreCRB65 0CRB65 1-2CRB65 3-4Discrimination analysisPneumonia Severity IndexThe Forest plots show the pooled sensitivity, specificity, positive likelihood ratio, pooled negative likelihood ratio and diagnostic odds ratio for the Pneumonia Severity Index. Forest plots are displayed for the following cut-offsPSI III+PSI 4+ PSI V CURB65 CURB65 1+ CURB65 2+ CURB65 3+ CURB65 4+ CRB65CRB65 1+ CRB65 2+ CRB65 3+ SUBANALYSESA priori the authors decided to conduct subgroup analyses to explore sources of heterogeneity in the main analysis. Preplanned analyses included; analyses limited to studies only including hospital inpatients; analysis limited to high quality studies only; analysis of prospective studies only. An additional subanalysis was performed for studies directly comparing PSI and CURB65.AnalysisAUCPSIAUCCURB65AUCCRB65p-valuePSI v CURB65p-valuePSI v CRB65p-valueCURB65 v CRB65Excluding outpatients0.80 (+/- 0.010)0.80 (+/- 0.008)0.77 (+/- 0.014)0.90.050.1High quality only0.82 (+/- 0.012)0.80 (+/- 0.011)0.80 (+/- 0.015)0.30.20.7Prospective studies only0.81 (+/- 0.010)0.81 +/- 0.011)0.79 (+/- 0.014)0.40.060.3Direct comparison* PSI v CURB650.81 (+/- 0.014)0.79 (+/- 0.010)N/A0.08N/AN/ADirect comparison*- PSI v CRB650.82 (+/- 0.024)N/A0.79 (+/- 0.02)N/A0.3N/ATable E4- Subanalysis of severity scores for predicting mortality. *Comparisons made using the Hanley-MacNeil method for comparing data from the SAME set of cases.[ QUALITY ASSESSMENTThe following table contains the consensus quality assessment for each included study after applying Haydens criteria. There was significant agreement between reviewers in the quality assessment (kappa statistic 0.7).First author namePopulationFollow-upMeasurement of severity scoresOutcome definitionConfoundingStatistical analysisOverall assessment by reviewersAnanda-Rajah23U3232Aujesky, D3333233Barlow GD1212131Bauer TT (CAPNETZ)3323233Buising KL3223332Capelastegui , A3333333Challen, K1111121Chalmers JD3U32333Chan, CZ3U31232Charles, P23U3233Davydov L2UUU121Dedier, J1233132Ewig, S3223233Ewig, S2233333Feagan B111U121Fine MJ- PORT3333333Fine, MJ- Medisgroup1111131Flanders, WD111U121Garau J1232222Garcia-Vazquez E1212221Goss CH3U2U232Huang, DT3323333Johnstone, J2211232Lim, WS3333323Man, SY3U33333Menendez R3323333Migliorati PL2122121Ortega L22U2232Phau, J2322232Querol-Ribelles JM3U22232Renaud BPneumocom 13U33333Renaud BPneumocom 23U33333Restrepo MI1U2U132Reyes Calzada S1233132Roson, B3333333Schuetz , P2333232Shindo, Y1112131Tejera, A21U1231Van der Eerden3333333Zuberi FF22U2232TABLE E4- Quality assessment of included and excluded studies. U= unclear. 3= Good methodology, low likelihood of significant bias or confounding. 2= moderate methodology, possible confounding or bias. 1= Suboptimal methodology, significant likelihood of bias or confounding.Online Supplement ReferencesFine MJ, Auble TE, Yealy DM, Iet al.. A prediction rule to identify low-risk patients with community- acquired pneumonia. N Engl J Med 1997;336: 243–50 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: 377-82Lim WS, Baudouin SV, George RC, et al. The British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Adults. Update 2009. Thorax 2009; 64 (Suppl 3):iii1-iii55.Hayden JA, Cote P, Bombardier C. Evaluation of the quality of prognostic studies in systematic reviews. Ann intern Med 2006; 144:427-437.Angus DC, Marrie TJ, Obrosky DS, et al. 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Severe sepsis in community-acquired pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course? Chest 2006; 129(4):968-78.Escobar GJ, Fireman BH, Palen TE, et al. Risk adjusting community-acquired pneumonia hospital outcomes using automated databases. Am J Manag Care 2008; 14(3):158-66.Espana PP, Capelastegui A, Gorordo I, et al. Development and validation of a clinical prediction rule for severe community-acquired pneumonia. Am J Respir Crit Care Med. 2006; 174(11):1249-56.Yandiola PP, Capelastegui A, Quintana J, et al. Prospective comparison of severity scores for predicting clinically revelant outcomes for patients hospitalized with community-acquired pneumonia. Chest 2009; 135(6):1572-9.Ewig S, Kleinfeld T, Bauer T, et al. Comparative validation of prognostic rules for community-acquired pneumonia in an elderly population. Eur Respir J 1999; 14(2):370-5. Gotoh S, Nishimura N, Takahashi O et al. Adrenal function in patients with community-acquired pneumonia. Eur Respir J. 2008;31(6):1268-73.Haeuptle J, Zaborsky R, Flumefreddo R, et al. Prognostic value of procalcitonin in legionella pneumonia. Eur J Clin Microbiol Infect Dis. 2009; 28(1):55-60. Hohenthal U, Hurme S, Helenius H et al. Utility of C-reactive protein in assessing the disease severity and complications of community-acquired pneumonia. Clin Microbiol Infect. 2009; 15(11):1026-32.Huang DT, Angus DC, Kellum JA et al. Midregional proadrenomedullin as a prognostic tool in community-acquired pneumonia. Chest 2009; 136(3):823-31.Huang DT, Weissfeld LA, Kellum JA, et al. Risk prediction with procalcitonin and clinical rules in community-acquired pneumonia. Ann Emerg Med 2008; 52(1):48-58.e2.Ioachimescu OC, Ioachimescu AG, Iannini PB. Severity scoring in community-acquired pneumonia caused by Streptococcus pneumonia: a 5 year experience. Int J Antimicrob Agents. 2004; 24(5):485-90. Kollef KE, Reichley RM, Micek ST, et al. 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Assessment of pneumonia severity: Multidetector-row CT in comparisons to clinical score CRB-65. Clin Imaging 2008; 32(5):342-5.Pilotto A, Addante F, Ferrucci L et al. The multidimensional prognostic index predicts short and long term mortality in hospitalized geriatric patients with pneumonia. J Gerontol A Biol Sci Med Sci. 2009; 64(8):880-7.Prat C, Lacoma A, Dominguez J et al. Midregional pro-atrial natriuretic peptide as a prognostic marker in pneumonia. J Infect 2007; 55(5):400-7.Salluh JI, Bozza FA, Soares M, et al. Adrenal response in severe community-acquired pneumonia: impact on outcomes and disease severity. Chest 2008; 134(5):947-54. Sanders KM, Marras TK, Chan CK. Pneumonia severity index in the immunocompromised. Can Respir J 2006; 13(2):89-93.Sanz F, Restrepo MI, Fernandez E et al. Is it possible to predict which patients with mild pneumonias will develop hypoxaemia? Respir Med. 2009’ 103(12):1871-7.Schaaf B, Kruse J, Rupp J, et al. Sepsis severity predicts outcome in community-acquired pneumococcal pneumonia. Eur Respir J 2007; 30(3):517-24.Spindler C, Ortqvist A. Prognostic score systems and community-acquired bacteraemia pneumococcal pneumonia. Eur Respir J 2006; 28:816-23.Teramoto S, Yamamoto H, Yamaguchi Y et al. Lower respiratory tract infection outcomes are predicted better by an age >80 years than by CURB-65. Eur Respir J. 2008; 31(2):477-8.Valencia M, Badia JR, Cavalcanti M, et al. Pneumonia severity index class V patients with community acquired pneumonia: characteristics, outcomes and value of severity scores. Chest 2007; 132(2):515-22.Vecchiarino P, Bohannon RW, Ferullo J, Maljanian R. Short-term outcomes and their predictors for patients hospitalized with community-acquired pneumonia. Heart Lung 2004;33(5):301-7. Wilson PA, Ferguson J. Severe community-acquired pneumonia: an Australian perspective. Intern Med J. 2005; 35(12):699-705.Yealy DM, Auble TE, Stone RA, et al. Effect of increasing the intensity of implanting pneumonia guidelines: a randomized, controlled trial. Ann Intern Med; 2005; 143(12):881-94.Aujesky D, Auble TE, Yealy DM, et al. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med 2005; 118(4):384-92.SUPPLEMENTAL FIGURE LEGENDSFigure E1: Forest plots for positive likelihood ratio, negative likelihood ratio and Diagnostic odds ratio for Pneumonia severity index.Figure E2: Forest plots for positive likelihood ratio, negative likelihood ratio and Diagnostic odds ratio for the CURB65 score.Figure E3- Forest plots of positive likelihood ratio, negative likelihood ratio and Diagnostic odds ratio for the CURB65 score. ................
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