Evaluation of the Winthrop-University Hospital criteria to identify Legionella pneumonia

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Abstract

Study objective: To measure the ability of a set of clinical parameters, the Winthrop-University Hospital (WUH) criteria, to identify Legionella pneumonia while discriminating against bacteremic pneumococcal pneumonia at the time of hospitalization for community-acquired pneumonia (CAP). Design: Retrospective case-control study. Setting: An urban county hospital and a tertiary-care Veterans Affairs hospital. Patients: Thirty-seven patients with Legionella pneumonia (diagnosed by a positive result of a urinary Legionella antigen test) and 31 patients with bacteremic pneumococcal pneumonia. A subgroup of patients with all required laboratory criteria were studied further. Results: The WUH criteria correctly identified 29 of 37 patients with Legionella pneumonia (sensitivity, 78%; 95% confidence interval [CI], 61 to 90%), while successfully excluding legionellosis in 20 of 31 patients with bacteremic pneumococcal pneumonia (specificity, 65%; 95% CI, 45 to 80%). The positive and negative predictive values, adjusted for a relative prevalence of 1:3 between Legionella and Streptococcus pneumoniae bacteremia, were 42% (95% CI, 25 to 61%) and 90% (95% CI, 74 to 97%), respectively. In the subgroup analysis, the WUH criteria were successful in identifying 20 of 23 patients with Legionella pneumonia (sensitivity, 87%; 95% CI, 65 to 97%), while excluding legionellosis in 9 of 18 patients with bacteremic pneumococcal pneumonia (specificity, 50%; 95% CI, 27 to 73%). The adjusted positive and negative predictive values for a 1:3 relative prevalence were 37% (95% CI, 20 to 59%) and 92% (95% CI, 62 to 98%), respectively. The predictive values were changed in the directions expected for an increased relative prevalence of 1:1. The areas under the receiver operating characteristic curves were 0.72±0.06 for the entire study group and 0.68±0.09 for the subgroup. Conclusions: Although the WUH criteria discriminated fairly well between cases (mean±SE) and control subjects, the sensitivity is not high enough to exclude legionellosis confidently. These results suggest that empiric therapy for Legionella pneumonia should be included in the initial antibiotic regimen for hospitalized patients with CAP.

Original languageEnglish (US)
Pages (from-to)1064-1071
Number of pages8
JournalChest
Volume120
Issue number4
DOIs
StatePublished - Jan 1 2001

Fingerprint

Legionella
Pneumonia
Confidence Intervals
Pneumococcal Pneumonia
Legionellosis
Veterans Hospitals
County Hospitals
Urban Hospitals
Tertiary Healthcare
Bacteremia
Streptococcus pneumoniae
ROC Curve
Case-Control Studies
Hospitalization
Anti-Bacterial Agents
Antigens

Keywords

  • Atypical
  • Clinical decision aids
  • Community-acquired infections
  • Legionella
  • Legionellosis
  • Pneumococcal pneumonia
  • Pneumonia

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine

Cite this

Evaluation of the Winthrop-University Hospital criteria to identify Legionella pneumonia. / Gupta, Samir K.; Imperiale, Thomas F.; Sarosi, George A.

In: Chest, Vol. 120, No. 4, 01.01.2001, p. 1064-1071.

Research output: Contribution to journalArticle

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abstract = "Study objective: To measure the ability of a set of clinical parameters, the Winthrop-University Hospital (WUH) criteria, to identify Legionella pneumonia while discriminating against bacteremic pneumococcal pneumonia at the time of hospitalization for community-acquired pneumonia (CAP). Design: Retrospective case-control study. Setting: An urban county hospital and a tertiary-care Veterans Affairs hospital. Patients: Thirty-seven patients with Legionella pneumonia (diagnosed by a positive result of a urinary Legionella antigen test) and 31 patients with bacteremic pneumococcal pneumonia. A subgroup of patients with all required laboratory criteria were studied further. Results: The WUH criteria correctly identified 29 of 37 patients with Legionella pneumonia (sensitivity, 78{\%}; 95{\%} confidence interval [CI], 61 to 90{\%}), while successfully excluding legionellosis in 20 of 31 patients with bacteremic pneumococcal pneumonia (specificity, 65{\%}; 95{\%} CI, 45 to 80{\%}). The positive and negative predictive values, adjusted for a relative prevalence of 1:3 between Legionella and Streptococcus pneumoniae bacteremia, were 42{\%} (95{\%} CI, 25 to 61{\%}) and 90{\%} (95{\%} CI, 74 to 97{\%}), respectively. In the subgroup analysis, the WUH criteria were successful in identifying 20 of 23 patients with Legionella pneumonia (sensitivity, 87{\%}; 95{\%} CI, 65 to 97{\%}), while excluding legionellosis in 9 of 18 patients with bacteremic pneumococcal pneumonia (specificity, 50{\%}; 95{\%} CI, 27 to 73{\%}). The adjusted positive and negative predictive values for a 1:3 relative prevalence were 37{\%} (95{\%} CI, 20 to 59{\%}) and 92{\%} (95{\%} CI, 62 to 98{\%}), respectively. The predictive values were changed in the directions expected for an increased relative prevalence of 1:1. The areas under the receiver operating characteristic curves were 0.72±0.06 for the entire study group and 0.68±0.09 for the subgroup. Conclusions: Although the WUH criteria discriminated fairly well between cases (mean±SE) and control subjects, the sensitivity is not high enough to exclude legionellosis confidently. These results suggest that empiric therapy for Legionella pneumonia should be included in the initial antibiotic regimen for hospitalized patients with CAP.",
keywords = "Atypical, Clinical decision aids, Community-acquired infections, Legionella, Legionellosis, Pneumococcal pneumonia, Pneumonia",
author = "Gupta, {Samir K.} and Imperiale, {Thomas F.} and Sarosi, {George A.}",
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AU - Sarosi, George A.

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N2 - Study objective: To measure the ability of a set of clinical parameters, the Winthrop-University Hospital (WUH) criteria, to identify Legionella pneumonia while discriminating against bacteremic pneumococcal pneumonia at the time of hospitalization for community-acquired pneumonia (CAP). Design: Retrospective case-control study. Setting: An urban county hospital and a tertiary-care Veterans Affairs hospital. Patients: Thirty-seven patients with Legionella pneumonia (diagnosed by a positive result of a urinary Legionella antigen test) and 31 patients with bacteremic pneumococcal pneumonia. A subgroup of patients with all required laboratory criteria were studied further. Results: The WUH criteria correctly identified 29 of 37 patients with Legionella pneumonia (sensitivity, 78%; 95% confidence interval [CI], 61 to 90%), while successfully excluding legionellosis in 20 of 31 patients with bacteremic pneumococcal pneumonia (specificity, 65%; 95% CI, 45 to 80%). The positive and negative predictive values, adjusted for a relative prevalence of 1:3 between Legionella and Streptococcus pneumoniae bacteremia, were 42% (95% CI, 25 to 61%) and 90% (95% CI, 74 to 97%), respectively. In the subgroup analysis, the WUH criteria were successful in identifying 20 of 23 patients with Legionella pneumonia (sensitivity, 87%; 95% CI, 65 to 97%), while excluding legionellosis in 9 of 18 patients with bacteremic pneumococcal pneumonia (specificity, 50%; 95% CI, 27 to 73%). The adjusted positive and negative predictive values for a 1:3 relative prevalence were 37% (95% CI, 20 to 59%) and 92% (95% CI, 62 to 98%), respectively. The predictive values were changed in the directions expected for an increased relative prevalence of 1:1. The areas under the receiver operating characteristic curves were 0.72±0.06 for the entire study group and 0.68±0.09 for the subgroup. Conclusions: Although the WUH criteria discriminated fairly well between cases (mean±SE) and control subjects, the sensitivity is not high enough to exclude legionellosis confidently. These results suggest that empiric therapy for Legionella pneumonia should be included in the initial antibiotic regimen for hospitalized patients with CAP.

AB - Study objective: To measure the ability of a set of clinical parameters, the Winthrop-University Hospital (WUH) criteria, to identify Legionella pneumonia while discriminating against bacteremic pneumococcal pneumonia at the time of hospitalization for community-acquired pneumonia (CAP). Design: Retrospective case-control study. Setting: An urban county hospital and a tertiary-care Veterans Affairs hospital. Patients: Thirty-seven patients with Legionella pneumonia (diagnosed by a positive result of a urinary Legionella antigen test) and 31 patients with bacteremic pneumococcal pneumonia. A subgroup of patients with all required laboratory criteria were studied further. Results: The WUH criteria correctly identified 29 of 37 patients with Legionella pneumonia (sensitivity, 78%; 95% confidence interval [CI], 61 to 90%), while successfully excluding legionellosis in 20 of 31 patients with bacteremic pneumococcal pneumonia (specificity, 65%; 95% CI, 45 to 80%). The positive and negative predictive values, adjusted for a relative prevalence of 1:3 between Legionella and Streptococcus pneumoniae bacteremia, were 42% (95% CI, 25 to 61%) and 90% (95% CI, 74 to 97%), respectively. In the subgroup analysis, the WUH criteria were successful in identifying 20 of 23 patients with Legionella pneumonia (sensitivity, 87%; 95% CI, 65 to 97%), while excluding legionellosis in 9 of 18 patients with bacteremic pneumococcal pneumonia (specificity, 50%; 95% CI, 27 to 73%). The adjusted positive and negative predictive values for a 1:3 relative prevalence were 37% (95% CI, 20 to 59%) and 92% (95% CI, 62 to 98%), respectively. The predictive values were changed in the directions expected for an increased relative prevalence of 1:1. The areas under the receiver operating characteristic curves were 0.72±0.06 for the entire study group and 0.68±0.09 for the subgroup. Conclusions: Although the WUH criteria discriminated fairly well between cases (mean±SE) and control subjects, the sensitivity is not high enough to exclude legionellosis confidently. These results suggest that empiric therapy for Legionella pneumonia should be included in the initial antibiotic regimen for hospitalized patients with CAP.

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KW - Clinical decision aids

KW - Community-acquired infections

KW - Legionella

KW - Legionellosis

KW - Pneumococcal pneumonia

KW - Pneumonia

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