Abstract
In December 2019, cases of serious illness causing pneumonia and death were first reported in Wuhan, China.
The PIRO (predisposition, insult, response, and organ dysfunction) scoring was developed for use in the emergency department to risk stratify sepsis cases.
To validate PIRO score as an assessment tool for COVID-19 mortality risk among patients with confirmed COVID-19 RT-PCR test among patients aged 19 and above admitted in World Citi Medical Center from March 2020 to August 2020
This study included 93 patients aged 19 and above admitted in World Citi Medical Center with a primary diagnosis of COVID-19 Confirmed with pneumonia between March 2020 to August 2020. The patients charts were retrieved from the hospital medical records and case notes were reviewed. A severity assessment score was developed based on PIRO score (Predisposition comorbidities and age; Insult multilobar opacities and viremia; Response shock and hypoxemia; Organ Dysfunciton) were extracted. The patients were stratified in four levels of risk: a)Low,0-2 points; b)Mild,3 points; c)High,4 points; d)Very High,5-8 points. The PIRO score and the clinical outcome were compared. The discriminative ability of PIRO score to predict mortality risk was evaluated under receiver operating characteristic curve (AUC).
The PIRO score had an excellent predictive ability for in-hospital mortality (AUC0.9197). Analysis of variance showed that higher levels of PIRO scores were significantly associated with higher mortality (p<0.001). Patients with Mild PIRO risk category were 98.65% less likely to expire (p<0.001, 95%CI 0.0015) and High PIRO risk category were 94.47% less likely to expire (p<0.001, 95%CI 0.0124), both compared to patients with Very high PIRO risk category. Finally, Very High PIRO risk category were more than 44 times likely to expire compared to patients with Low, Mild and High PIRO risk category (p<0.001, 95%CI 11.738).
The PIRO score is a valid risk model that can be used to predict in-hospital mortality, that can help clinicians provide timely and accurate assessment, and hence appropriate management to patients with COVID-19 Pneumonia.
Author Contributions
Copyright© 2021
D. Natividad III Graciano, et al.
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests The authors have declared that no competing interests exist.
Funding Interests:
Citation:
Results
This study included 93 patients with a primary discharged diagnosis of COVID-19 pneumonia at World Citi Medical Center from March 01, 2020 to August 31, 2020. The mean age of patients with confirmed COVID-19 pneumonia was 56 years old. There was statistical difference between the mean age of those who expired was 67 and mean age of recovered was 52. In terms of gender, there were more males (56.99%) than females (43.01%) who got infected with COVID-19. Among the co-morbidities in patients with COVID-19 Pneumonia, Hypertension (49.46%) and Diabetes mellitus (29.03%) are the two most common. The two most statistically significant comorbidities that may have contributed to mortality risk are hypertension and COPD with P-value of 0.049 and 0.022, respectively. Note: a - Very high risk as reference category; b - Low, Mild and High risk as reference categories
Total (n=93)
Expired (n=24, 26%)
Recovered (n=69, 74%)
P-value
Frequency (%); Mean + SD; Median (IQR)
Age
56.7 ± 18.08
67.42 ± 18.12
52.97 ± 16.63
Sex
0.634
Male
53 (56.99)
15 (62.5)
38 (55.07)
Female
40 (43.01)
9 (37.5)
31 (44.93)
Comorbidities
Hypertension
46 (49.46)
16 (66.67)
30 (43.48)
Diabetes Mellitus
27 (29.03)
9 (37.5)
18 (26.09)
0.289
COPD
4 (4.30)
3 (12.5)
1 (1.45)
Cardiovascular
20 (21.51)
8 (33.33)
12 (17.39)
0.147
Cerebrovascular
1 (1.08)
0
1 (1.45)
1.000
CA
3 (3.23)
2 (8.33)
1 (1.45)
0.162
BA
9 (9.68)
3 (12.5)
6 (8.7)
0.690
PTB
4 (4.30)
1 (4.17)
3 (4.35)
1.000
Immunodeficiency
1 (1.08)
1 (4.17)
0
0.258
Chronic Kidney Disease
12 (12.9)
4 (16.67)
8 (11.59)
0.499
Liver Pathology
1 (1.08)
0
1 (1.45)
1.000
PIRO score
4 (3 to 5)
7 (5 to 8)
3 (3 to 4)
Low
17 (18.28)
0
17 (24.64)
Mild
27 (29.03)
1 (4.17)
26 (37.68)
High
22 (23.66)
3 (12.5)
19 (27.54)
Very high
27 (29.03)
20 (83.33)
7 (10.14)
Low riska
Mild riska
0.0135
0.0015 to 0.1185
<0.001
High riska
0.0553
0.0124 to 0.2455
<0.001
Very high riskb,
44.2857
11.738 to 167.09
<0.001
20 (83.33)
7(10.14)
27 (29.03)
62 (89.86)
66 (70.97)
24 (100)
69 (100)
93 (100)
Sensitivity
83.33%(62.62 to 95.26)
Positive LR
8.21 (3.98 to 16.95)
Specificity
89.86%(80.21 to 95.82)
Negative LR
0.19 (0.08 to 0.46)
PPV
74.07%(58.06 to 85.50)
Prevalence
25.81% (17.29 to 35.92)
NPV
93.94%(86.33 to 97.44)
Accuracy
88.17% (79.82 to 93.95)
Discussion
COVID-19 Pneumonia is caused by novel Coronavirus. The clinical features of COVID-19 are varied, ranging from asymptomatic state to acute respiratory distress syndrome and multi organ dysfunction. They are indistinguishable from other respiratory infections. In a subset of patients, by the end of the first week the disease can progress to pneumonia, respiratory failure and death. To our knowledge, this is the first study to objectively measure the mortality risk of COVID-19 pneumonia on the basis of risk category of PIRO scoring. Many other models have been developed, some of which are designed to predict mortality. The diversity of scoring tools may pose difficulties for clinicians who are attempting to choose a tool for use in their daily practice. There were 277 subjects admitted as either COVID-19 Suspect or Confirmed. 159 subjects were excluded for testing negative for COVID-19 RT-PCR and 25 subjects were excluded for having no evidence of pneumonia either by chest radiograph or chest CT-scan. A total of 93 patients met the inclusion criteria and among these patients, 24 (26%) of which expired and 69 (74%) were recovered and discharged. There was statistical difference between recovered and expired patients in terms of Age, Hypertension, COPD, PIRO score and PIRO category. The mean age of subjects infected was 56.7 and mean age of subjects who expired is 67. Analysis showed that the older the age were significantly associated with higher mortality (p<0.001). Likewise in the study of Farha et al (September 2020), a significant association were found between mortality among COVID-19 infected patients and older age (>65 years vs <65 years) (RR 3.59, 95% CI (1.87-6.90), p<0.001). The two most statistically significant comorbidities that may have contributed to mortality risk are hypertension and COPD with P-value of 0.049 and 0.022, respectively. It is parallel with the recent study of Farha et al (September 2020) shows that a significant association were found between mortality among COVID-19 infected patients and hypertension (RR 2.08, 95% CI (1.79-2.43), p<0.001). This tool can be used as an initial risk assessment and stratification that predicts not only the severity of COVID-19 Pneumonia but also in-hospital mortality These results showed that higher levels of PIRO score were significantly associated with higher mortality. (p<0.001) Further, the calculated AUC for predicting in-hospital mortality of COVID-19 Pneumonia is 0.9197, which shows that the tool has excellent discriminative ability. These findings were also parallel with the recent studies, by Pinera et al (2016),
Conclusion
The PIRO score can be used as an assessment tool to identify the severity and in-hospital mortality risk of COVID-19 pneumonia among patients, aged 19 and above. It is simple, readily measurable, easily accessible, reliable, non-invasive and most of all inexpensive.