Modified PIRO (predisposition, insult, response, organ dysfunction) severity score as a predictor for mortality of children with pneumonia in Hasan Sadikin Hospital, Bandung, Indonesia

Vebri Valentania; Dadang H. Somasetia; Dany Hilmanto; Djatnika Setiabudi; Heda Melinda N. Nataprawira

doi:10.4081/mrm.2021.735

Modified PIRO (predisposition, insult, response, organ dysfunction) severity score as a predictor for mortality of children with pneumonia in Hasan Sadikin Hospital, Bandung, Indonesia

Authors

Vebri Valentania Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung
Dadang H. Somasetia Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung https://orcid.org/0000-0002-4328-6120
Dany Hilmanto Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung https://orcid.org/0000-0003-3684-4144
Djatnika Setiabudi Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung
Heda Melinda N. Nataprawira Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung https://orcid.org/0000-0001-8079-6544

DOI: https://doi.org/10.4081/mrm.2021.735

Keywords:

Children, modified PIRO, pneumonia, severity score

Abstract

Background: Clinical manifestations for pneumonia vary from mild to severe. The PIRO model (predisposition, insult, response, organ dysfunction) was used as scoring system to determine severity of sepsis and pneumonia in adult patients. The PIRO model was modified for sorting the severity of pneumonia in children and predicting its risk of mortality.
Methods: An ambispective cohort study of pneumonia patients aged 1 month ≤18 years admitted over the period from May to September 2020. Data were collected from history, physical examination, laboratory examination, and chest radiography. Based on bivariate analysis (p<0.05 and relative risk (RR) with 95% confidence interval), variables of each PIRO component that were significant for mortality were assigned a value of 1. The cut-off score for predictor of mortality was calculated using the receiver operating characteristics (ROC) curve. Stratify the score into three degrees of risk based on interquartile range. Score ≤Q1 is categorized as low risk; Q1-Q3 is categorized as moderate risk; and score >Q3 is categorized as high risk.
Results: Out of the 80 subjects subjects enrolled, 6 months-5 years was the largest age group (56.3%). The observed mortality was 15/80 (18.8%). The modified PIRO severity score was compiled from significant variable of predisposition (malnutrition), insult (chest radiograph), response (hypoxemia, hypotension, CRP >0.5 mg/dL, PCT >0.5 ng/dL) and organ dysfunction, with range of score 0-7. Score >3 as a cutoff point score for predictor of mortality with AUC 0.919 (95% CI 0.836–0.968), sensitivity of 80%, and specificity of 84.62%. Subjects with score >3 have RR of 10.544 compared to those with score ≤3. The stratification of score level was low (≤2), moderate (3-4), and high (5-7). The mortality levels were 0%, 46.7%, and 53.3%, respectively.
Conclusions: Modified PIRO severity score can be used as a sorting tool and predictor of mortality risk in children with pneumonia. This score can also be used to select candidates for intensive care, especially in health facilities with limited intensive care capacity.

References

WHO. Pneumonia. 2019. Accessed: 21 September 2020. Available from: https://www.who.int/news-room/factsheets/detail/pneumonia/

UNICEF. Pneumonia. 2019. Accessed: 2 September 2020. Available from: https://data.unicef.org/topic/child-health/pneumonia/

Arbo A, Lovera D, Martínez-cuellar C. Mortality predictive scores for community-acquired pneumonia in children. Curr Infect Dis Rep 2019;21:1-8.

Rello J, Rodriguez A, Lisboa T, Gallego M, Lujan M, Wunderink R. PIRO score for community-acquired pneumonia: A new prediction rule for assessment of severity in the intensive care unit patients with community-acquired pneumonia. Crit Care Med 2009;37:456-62.

Niederman MS, Feldman C, Richards GA. Combining information from prognostic scoring tools for CAP: An American view on how to get the best of all worlds. Eur Respir J 2006;27:9-11.

Uwaezuoke SN, Come AC. Prognostic scores and biomarkers for pediatric community-acquired pneumonia: how far have we come? Ped Health Med and Therap 2017;8:9-18.

Marshall JC. The PIRO (predisposition, insult, response, organ dysfunction) model toward a staging system for acute illness. Virulence 2014;5:27-35.

Araya S, Lovera D, Zarate C, Apodaca S, Acuna J, Sanabria G, et al. Application of a prognostic scale to estimate the mortality of children hospitalized with community-acquired pneumonia. Pediatr Infect Dis J 2016;35:369-73.

United Nations. World economic situation and prospects. 2019. Accessed: 2 September 2020. Available from: https://www.un.org/development/desa/dpad/publication/world-economic-situation-and-prospects-2019/

Gereige RS, Laufer PM. Pneumonia. Pediatr Rev 2013;34:438-56.

Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005;6:2-8.

Zar HJ. Pneumonia in HIV-infected and HIV-uninfected children in developing countries: Epidemiology, clinical features, and management. Curr Opin Pulm Med 2004;10:176-82.

Reed C, Madhi SA, Klugman KP, Kuwanda L, Ortiz JR, Finelli L, et al. Development of the Respiratory Index of Severity in Children (RISC) score among young children with respiratory infections in South Africa. PLoS One 2012;7:1-8.

Ibraheem RM, Abdulkadir MB, Gobir AA, Johnson WBR. Socio-demographic and clinical factors predicting time to presentation for children with pneumonia in Ilorin, Nigeria. Alexandria J Med 2018;54:247-50.

Bokade CM, Madhura AD, Bagul AS, Thakre SB. Predictors of mortality in children due to severe and very severe pneumonia. Niger Med J 2015;56:287-91.

Atwa ZT. Usefulness of gender and abnormal blood count for predicting pneumonia outcome in children. Egypt J Chest Dis Tuberc 2015;64:169-74.

Fonseca da Lima EJ, Mello MJG, Albuquerque M de FPM de, Lopes MIL, Serra GHC, Lima DEP, et al. Risk factors for community-acquired pneumonia in children under five years of age in the post-pneumococcal conjugate vaccine era in Brazil: A case control study. BMC Pediatr 2016;16:1-9.

Amorim PG, Morcillo AM, Tresoldi AT, Fraga A de MA, Pereira RM, Baracat ECE. Factors associated with complications of community-acquired pneumonia in preschool children. J Bras Pneumol 2012;38:614-21.

WHO. Child Growth Standards. Geneva: World Health Otganization; 2006.

de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ 2007;85:660-7.

Hadisuwarno W, Setyoningrum RA, Umiastuti P. Host factors related to pneumonia in children under 5 years of age. Paediatr Indones 2015;55:248-51.

Ginsburg AS, Izadnegahdar R, Berkley JA, Walson JL, Rollins N, Klugman KP. Undernutrition and pneumonia mortality. Lancet Glob Health 2015;3:735.6.

Menendez R, Montull B, Reyes S, Amara-elori I, Zalacain R, Capelastegui A, et al. Pneumonia presenting with organ dysfunctions: Causative microorganisms, host factors and outcome. J Infect 2016;73:419-26.

Andonegui G, Goring K, Liu D, McCafferty DM, Winston BW. Characterization of S. pneumoniae pneumonia-induced multiple organ dysfunction syndrome: An experimental mouse model of gram-positive sepsis. Shock 2009;31:423–8.

Blot SI, Rodriguez A, Solé-Violán J, Blanquer J, Almirall J, Rello J. Effects of delayed oxygenation assessment on time to antibiotic delivery and mortality in patients with severe community-acquired pneumonia. Crit Care Med 2007;35:2509-14.

Duke T, Mgone J, Frank D. Hypoxaemia in children with severe pneumonia in Papua New Guinea. Int J Tuberc Lung Dis 2001;5:511-9.

Duke T, Subhi R, Peel D, Frey B. Pulse oximetry: Technology to reduce child mortality in developing countries. Ann Trop Paediatr 2009;29:165-75.

Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, et al. Pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics 2010;126:1-41.

Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020:46:10-67.

Yadav KK, Awasthi S, Takia L, Agarwal J, Agarwal GG. Procalcitonin and C-reactive protein in WHO defined severe and very severe community acquired pneumonia: A hospital based cross-sectional study. Clin Epidemiol Glob Health 2015;3:3-9.

Wu J, Jin Y, Li H, Xie Z, Li J, Ao Y, et al. Evaluation and significance of C-reactive protein in the clinical diagnosis of severe pneumonia. Exp Ther Med 2015;10:175-80.

Akech SO, Kinuthia DW, Macharia W. Serum procalcitonin levels in children with clinical syndromes for targeting antibiotic use at an emergency department of a Kenyan Hospital. J Trop Pediatr 2020;66:29-37.