Prospective validation of the RAPID clinical risk prediction score in adult patients with pleural infection: the PILOT study

Abstract

BackgroundOver 30% of adult patients with pleural infection either die and/or require surgery. There is no robust means of predicting at baseline presentation which patients will suffer a poor clinical outcome. A validated risk prediction score would allow early identification of high-risk patients, potentially directing more aggressive treatment thereafter.ObjectivesTo prospectively assess a previously described risk score (RAPID - Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)) in adults with pleural infection.MethodsProspective observational cohort study recruiting patients undergoing treatment for pleural infection. RAPID score and risk category were calculated at baseline presentation. The primary outcome was mortality at 3 months; secondary outcomes were mortality at 12 months, length of hospital stay, need for thoracic surgery, failure of medical treatment, and lung function at 3 months.ResultsMortality data were available in 542 of 546 (99.3%) patients recruited. Overall mortality was 10% (54/542) at 3 months and 19% (102/542) at 12 months. The RAPID risk category predicted mortality at 3 months; low-risk (RAPID score 0–2) mortality 5/222 (2.3%, 95%CI 0.9 to 5.7), medium-risk (RAPID score 3–4) mortality 21/228 (9.2%, 95%CI 6.0 to 13.7), and high-risk (RAPID score 5–7) mortality 27/92 (29.3%, 95%CI 21.0 to 39.2). C-statistics for the score at 3 and 12 months were 0.78 (95%CI 0.71 to 0.83) and 0.77 (95%CI 0.72 to 0.82) respectively.ConclusionsThe RAPID score stratifies adults with pleural infection according to increasing risk of mortality and should inform future research directed at improving outcomes in this patient population.

Pleural infection: moving from treatment to prevention

“…Categorisation of patients in to low risk (RAPID score 0-2), medium risk (RAPID score 3-4) and high risk (RAPID score 5-7) groups was associated with mortality at 3 months of 3%, 9% and 31%, respectively [108]. Since its publication, positive correlation of clinical outcomes with the RAPID score has been demonstrated [109] and prospective assessment has recently been completed in an international, multicentre study [110] due to publish later this year. This should add greater insight into its potential utility in the clinical setting.…”

Pleural Fluid suPAR Levels Predict the Need for Invasive Management in Parapneumonic Effusions

“…Second, some of the clinical outcomes such as fibrinolytic use and surgical referral may have been confounded by other factors not related to the pleural infection alone. The recently presented PILOT (Pleural Infection Longitudinal Outcome Study) trial has demonstrated that a significant proportion of patients with the most serious pleural infection do not go on to have surgery due to frailty and/or comorbidity (31). Additionally, the routine use of the fibrinolytic agents tPA (tissue plasminogen activator)/DNase was not adopted for several years into this study's recruitment.…”

Management of Pleural Infection

“…Now this score has been validated prospectively in the Pleural Infection Longitudinal Outcome (PILOT) study. Across 546 patients, the PILOT study demonstrated that low-risk patients (RAPID score 0–2) had a 3-month mortality of 2.3%, medium-risk (RAPID score 3–4) 9.2% mortality and high-risk (RAPID score 5–7) 29.3% mortality [ 106 ]. It is hoped that through the use of the RAPID score, a more nuanced approach can be taken in risk-stratifying patients and thereby informing clinicians of the optimal approaches in management.…”