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

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.