ORIGINAL INVESTIGATION

Severity Assessment of Lower Respiratory Tract

Infection in Elderly Patients in Primary Care
Yrjo Seppa, MD; Aini Bloigu, BSc; Pekka O. Honkanen, MD, PhD; Liisa Miettinen, MD; Hannu Syrjala, MD, PhD

Background: Simple markers for evaluating the severity of lower respiratory tract infections (LRTI) in primary care are lacking. It is of value to examine whether
the information available to the primary care physician
during a patients initial visit can be used to assess the
severity of LRTI.
Methods: The associations between different baseline
variables and outcomes (survival within or more than
30 days) were investigated prospectively in a series of
950 home-living patients 65 years or older with severe
LRTI that their primary care physicians suspected to be
pneumonia.
Results: Twenty-one men and 17 women died (4.1%)
within 30 days. According to univariate analysis, the following parameters differed (P.01) between the fatalities and survivors: acute aggravation of a coexisting ill-

From the Department of

Infection Control, Oulu
University Hospital, Oulu
(Drs Seppa and Syrjala); the
National Public Health
Institute, Oulu (Ms Bloigu); the
Department of Public Health
Science and General Practice,
University of Oulu, Oulu
(Dr Honkanen); Oulu
University Hospital, Oulu, and
Oulaskangas Hospital,
Oulainen (Dr Miettinen); and
Kemi Health Center, Kemi
(Dr Honkanen), Finland.

ness, age, respiratory rate, white blood cell count, and

C-reactive protein (CRP) level. According to Cox forward stepwise regression analysis (P=.01 for entry and
.05 for removal), acute aggravation of a concurrent illness, respiratory rate (25/min), and CRP concentration (100 mg/L) were independently associated with
death. The mortality rate was 2.2% if the patients had none
or only 1 of the independent risk factors and 20% if they
had all 3 risk factors.
Conclusions: Preceding aggravation of a concurrent ill-

ness and respiratory rate of 25/min or higher, together

with an elevated serum CRP level (100 mg/L), can be
used as simple markers for identifying patients with the
highest risk for LRTI and improve management decisions among elderly people in primary care.
Arch Intern Med. 2001;161:2709-2713

tract infections (LRTI) include

infections of the tracheobronchial tree (bronchitis)
and the lung parenchyma
(pneumonia). It has been estimated, based
on the data published from the United
Kingdom, that a third of the adult patients with LRTI in community settings
seek help for their symptoms. Antibiotic
agents are prescribed to a fourth of these
patients, and community-acquired pneumonia (CAP) is diagnosed in less than
2% of the cases (less than 0.5% of the
whole adult population with LRTI in
community settings).1 However, the incidence of CAP is higher than this in the
elderly population.2,3
Community-acquired pneumonia is
the fifth most common reason for hospitalization among patients aged 65 to 74
years and the leading cause for hospitalization among those 85 years or older.4 The
cost of treating CAP depends crucially on
the place of treatment.5 Safe strategies to
minimize hospitalization would lead to
marked cost savings.6 Moreover, most patients with CAP with little risk of death prefer treatment outside the hospital,7 and,
presently, most patients with CAP are acOWER RESPIRATORY

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tually treated as outpatients.1,8 Several

models have been developed for assessing the severity of CAP.9-18 However, these
models have been typically developed
among hospitalized patients with CAP and
are not necessarily applicable to outpatients with CAP or, more generally, to patients with LRTI in primary care because
the scoring systems in the models often require both chest radiography and laboratory analyses, which are not necessarily
available in primary care units.
The purpose of our prospective study
was to find out whether the information
available in the primary care consulting office can be used to assess the severity of
LRTI and the need for hospital treatment. Toward this end, we investigated the
outcomes of 950 home-living immunocompetent elderly patients (age, 65
years) with LRTI who had signs suggestive of pneumonia.
RESULTS

PATIENT POPULATION
AND MORTALITY
The final study population consisted of 950
home-living elderly patients with LRTI, 38

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PATIENTS AND METHODS

PATIENTS
The study was carried out in association with a pneumococcal and influenza trial among persons 65 years or older
in northern Finland.19 During September and October 1992,
before the baseline of the study, one of the researchers
(P.O.H.) visited all the municipal health centers and municipal district hospitals in the follow-up area to inform the
physicians about the research design and the way of reporting patients with LRTI. The follow-up visits to the participating centers were made in the autumns of 1993 and
1994. The study population consisted of all persons 65 years
or older living in 55 municipalities in northern Finland.
The census on December 31, 1992, included 59790 people,
38.8% of whom were male. The study protocol was approved by the ethical review committee of the medical faculty of the University of Oulu, Oulu, Finland. Enrollment
in the follow-up study was voluntary. The physician made
the diagnosis of LRTI on the basis of the patients history
and physical examination findings. During the whole study
period, the primary care physicians made their decisions
concerning the prescription of antibiotics and the possible referral of their patients independently.
METHODS
During the 2-year study period, 1743 cases of LRTI with
signs suggestive of pneumonia were reported among the
study population of 59790 persons 65 years or older. The
number of patients visiting health centers with signs suggestive of pneumonia is not known, nor is the proportion
of patients with LRTI but without signs suggestive of pneumonia. Of the cases, 22 were excluded: 21 because of missing information on the day of the initial visit and 1 because of age (60 years). One episode of suspected LRTI
per patient was reported in 1424 cases. Only the first episode was included in the study for 133 patients with more
than 1 episode of LRTI. Only home-living patients were included in the further analysis (1072 cases). Patients reported to be in a terminal state (10 cases) or with dementia (89 cases) were excluded because our questionnaire did
not include information about whether their treatment was
active or not. Of the remaining patients, those reported to
be bedridden (14 cases) were excluded because our primary goal was to investigate an elderly population capable of normal daily activities. Nine patients receiving immunosuppressive medication (5 mg/d of cytostatics or
prednisolone) were excluded.
The following patient information was recorded on the
case report form by the attending physician to describe the
patients condition during the first visit: presence or absence of respiratory and other symptoms (cough, dyspnea
at rest, pleuritic chest pain, acute confusion, acute deterioration of general condition, and/or acute aggravation of
a coexisting chronic disease [eg, the impairment of glucose balance in diabetes or the deterioration of congestive

(4.1%) of whom died within 30 days after the initial visit.

Of these deaths, 37% occurred within the first 7 days
(Figure). Their deaths were not dependent on the initial place of treatment (Table 1). The mortality rates were

heart failure]); duration of symptoms; date of examination; residential information (home, nursing home, municipal health center, or hospital ward); initial place of treatment (home, nursing home, municipal health center
ward, or hospital ward); results of the initial physical
examination (body temperature, respiratory rate, systolic
and diastolic blood pressure, heart rate, and abnormal finding on chest auscultation, ie, rales); and whether the patient was in a terminal state. The patient data were complemented during the follow-up visit (or after death, if the
patient died before the scheduled follow-up visit) with the
basic laboratory data recorded at the initial visit: hemoglobin and C-reactive protein (CRP) levels; platelet and white
blood cell (WBC) counts; erythrocyte sedimentation
rate; concurrent illnesses or disabilities (eg, congestive heart
failure, asthma, chronic obstructive pulmonary disease,
dementia, chronic pyelonephritis, and/or type of diabetes); residence on a long-term ward; bedridden state;
immunosuppressive treatment (ie, 5 mg/d of cytostatic
medication or prednisolone); previous and current smoking habits; consumption of alcohol; information about possible travel abroad within the past month; final diagnosis;
and, in fatal cases, whether the death was due to LRTI. To
obtain valid and accurate information on the date of death
and to confirm the registered coexisting illnesses, data concerning the study population were also drawn from the national register of the Finnish Social Insurance Institution,
Kela. Information on dementia, dietary diabetes, alcohol
abuse, and bedridden and terminal state was not available
in the national register and was therefore obtained by a questionnaire. All data were stored in a computer database.
STATISTICAL ANALYSIS
The end point of the severity of LRTI was defined as
mortality due to LRTI within 30 days after the first visit to
a primary care physician.16 The statistical analysis was performed using the SPSS software (SPSS Inc, Chicago, Ill).
Survival after the initial visit was calculated with the KaplanMeier method. For the analysis of categorical variables, the
2 test (or the Fisher 2-tailed exact test when appropriate)
was used. The continuous variables were skewed, and
median values and interquartile ranges (25th to 75th percentile) were therefore used. The association between the
continuous variables and survival was analyzed using the
Mann-Whitney test. For further analysis, the statistically
significant continuous variables were dichotomized by selecting clinically relevant cutoff points. To identify the independent risk factors among the variables that showed statistically significant associations (P.01) with mortality in
univariate analyses, the relative risk of death was estimated using hazard ratios calculated by Cox forward stepwise regression analysis. The P value for entry into the model
was .01 and for removal, .05. The patients having none or
only 1 missing value of predictor variables were included
for Cox regression analysis, and missing data were replaced by the geometric means of the study population: 51
mg/L for CRP level, 22/min for respiratory rate, and
9.3103/L for WBC count.

similar for both sexes (Table 2). In this population with

LRTI, dyspnea at rest tended to be more often observed
in the patients who died within 30 days (63%) than in
those who survived (48%) (P=.07; Table 2), while the

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tude of hazard ratios) as independent relative risk factors of death within 30 days (Table 4). The mortality
rate of these patients with LRTI was 2.2% within 30 days
if they had none or only 1 independent risk factor. The
corresponding mortality rate was 20% if they had all 3
risk factors.

presence of rales did not statistically differ between the

groups (81% vs 85%). Most of our patients with LRTI
actually had real pneumonia; 83% of them had rales on
chest auscultation, and 48% had dyspnea at rest during
the first visit to a primary care physician. Moreover, results of a retrospective analysis of the chest roentgenograms (CRXs) showed definite pneumonia in 61% and
probable pneumonia in 13%. However, we excluded the
CRX findings from this study to mimic the real conditions because CRX was only available in 44% of the cases
at the time of the first visit to a primary care physician
in our series.

COMMENT

In this study, 2 parameters immediately available in the

consulting office (preceding aggravation of a coexisting
illness and respiratory rate of 25/min) together with
an elevated serum CRP level (100 mg/L) at the initial
visit to a primary care unit, were independently associated with the risk of death within 30 days among elderly
patients with LRTI and can be used to assess the severity of LRTI.
As our results show, in most of the patients with LRTI
in whom the attending physicians had primarily suspected to have pneumonia, the diagnosis of CAP was later
verified by CXR. Thus, a comparison of our results with
earlier reports concerning mainly CAP seemed justifiable.
It is well known that elderly patients may lack the
typical symptoms of pneumonia; the earliest clues may
be unspecific symptoms, such as lethargy, mental confusion, and failure to thrive, as well as the deterioration of a preexisting disease (eg, congestive heart failure).20
In our series, acute aggravation of a coexisting illness,
such as the impairment of glucose balance in diabetes or
the deterioration of congestive heart failure, was independently associated with mortality within 30 days. This

SIGNIFICANT VARIABLES ASSOCIATED

WITH MORTALITY
Of the categorical variables, only acute aggravation of a
coexisting illness had a statistically significant association with survival (Table 2). However, the comorbidity
was not associated with mortality in univariate analysis
(data not shown). Of the continuous variables, the patients age, respiratory rate, WBC count, and CRP values were statistically associated with death within 30 days
(Table 3). When the importance of these variables was
evaluated in the Cox forward stepwise regression model
that included 719 cases, acute aggravation of a coexisting illness, respiratory rate (25/min), and CRP level
(100 mg/L) were identified (in this order of magni100

Cumulative Survival, %

99

Table 1. Initial Place of Treatment and Mortality

Within 30 Days Among Home-Living Elderly Patients
With Lower Respiratory Tract Infections*

98

97

Initial Place
of Treatment

96

10

15

20

25

30

Mortality, %

10/257
0/4
19/420
9/256
38/937

3.9
0.0
4.5
3.5
4.1

Home
Nursing home
Health center ward
Hospital ward
Total

95
0

No. of Deaths/
No. of Patients

35

Time, d

Survival after the initial visit among 950 home-living elderly patients with
lower respiratory tract infection in primary care during 30 days (note the
scale on the y-axis).

*P .2, Fisher 2-tailed exact test.

Information was not available for 13 patients.

Table 2. Essential Clinical Data of Home-Living Elderly Patients Seeking Care

From Primary Care Physicians for Lower Respiratory Tract Infection
Survival 30 d

Death Within 30 d
Variable
Male sex
Cough
Dyspnea at rest
Pleuritic pain
Acute confusion
Acute aggravation of
General condition
Coexisting illness
Abnormal chest auscultation (rales)

No. of Observations

Positive, %

No. of Observations

Positive, %

P Value*

38
38
38
37
38

55.3
68.4
63.2
35.1
2.6

912
896
895
876
868

51.8
77.5
47.9
37.7
6.3

.2
.2
.07
.2
.2

37
38
36

86.5
39.5
80.6

892
875
888

73.1
20.9
85.0

.07
.007
.2

*By 2 test (Fisher 2-tailed exact test when appropriate).

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Table 3. Clinical and Laboratory Findings of Home-Living Elderly Patients With Symptomatic Lower Respiratory Tract Infection
Survival 30 d

Death Within 30 d
Variable
Age, y
Duration of symptoms, d
Physical findings on admission
Body temperature, C
Respiratory rate, per minute
Heart rate, per minute
Systolic blood pressure, mm Hg
Diastolic blood pressure, mm Hg
Laboratory findings on admission
Hemoglobin, g/dL
Platelets, 103/L
Leukocytes, 103/L
Erythrocyte sedimentation rate, mm/h
C-reactive protein, mg/L

No. of Cases

Median

IQR*

No. of Cases

Median

IQR*

P Value

38
28

80
3

73-86
1-5

912
843

76
3

71-81
1-7

.003
.2

35
31
37
36
36

37.5
26
89
135
79

37.0-38.3
21-36
70-104
116-164
70-89

871
675
832
859
855

37.6
22
80
142
80

36.8-38.4
18-27
72-94
130-160
70-90

.2
.002
.2
.2
.2

29
18
29
15
27

13.0
230
12.2
52
136

11.6-13.5
155-371
9.4-18.3
40-84
80-214

627
320
667
515
597

13.3
252
9.3
38
76

12.1-14.3
191-320
7.0-12.2
20-66
24-142

.08
.2
.001
.04
.001

*Interquartile range (25th to 75th percentile).

Mann-Whitney test.

Table 4. Cox Forward Stepwise Regression Analysis

of Independent Risk Factors
Relative Risk
of Death
(95% CI*)

Variable
Acute aggravation of coexisting illness
No
Yes
Respiratory rate, per minute
25
25
C-reactive protein, mg/L
100
100

P Value
to Remove
.006

1.0
2.8 (1.4-5.6)
.005
1.0
2.8 (1.4-5.5)
.01
1.0
2.5 (1.2-5.1)

*CI indicates confidence interval.

acute aggravation of a chronic illness was judged by the

criteria of the attending physicians.
The measurement of respiratory rate is a useful
marker of acute respiratory dysfunction.21 Its prognostic importance in CAP has been shown in several investigations.9-12,14-16,18 The cutoff value of respiratory
rate has varied from 20/min or higher22 to 30/min or
higher.9-12,14-16,18 In our study, tachypnea (with respiratory rates of 25/min used as a cutoff point) remained a
significant predictor of mortality even in multivariate
analysis. Our results stress once again the importance of
respiratory ratea simple measurementin the clinical assessment of respiratory infections. On the other hand,
heart rate, systolic and diastolic blood pressure, and body
temperature, which have previously been reported as important risk factors associated with death in CAP, did not
have similar predictive value in the present series.
Because CRP level is more sensitive, decreases faster
after a favorable treatment response, and is independent
of age, its use as a marker instead of erythrocyte sedimentation rate has been recommended for the diagnosis and follow-up of infections.23,24 In adults with acute
LRTI, a CRP level of 50 to 75 mg/L has been considered

suggestive of CAP.1,23 Our results showed that a CRP level

100 mg/L or higher was independently associated with
mortality in elderly patients with LRTI in primary care.
Thus, our study emphasizes the importance of CRP in
assessing the severity of LRTI among elderly patients in
primary care. Our results also suggest that the use of CRP
as a marker is recommendable in the severity assessment of respiratory tract infections.
In our series, the overall rate of mortality of elderly
home-living patients with LRTI within 30 days was 4%,
which was lower than the percentage published in, for
example, a recent meta-analysis in which the mortality
rate of elderly hospitalized patients with CAP varied from
5.7% to 32.9%.22 In our primary care population, the mortality rate was even lower (2%) if the patients had no or
only 1 of the independent risk factors associated with mortality. However, the mortality rate was 20% among our
patients with 3 positive risk factors. The latter figure agrees
with an earlier report on mortality (21%) from pneumococcal bacteremia in Finland.25
In earlier studies, controversial observations on the
influence of age on the mortality in CAP have been reported, with some studies supporting its importance11,17,26,27 and others not.28-30 In our series, age was a
significant factor in univariate analysis but did not remain significantly associated with mortality in multivariate analysis. In many series, comorbidity has been shown
to be an independent risk factor of mortality.16,17,22 No
such association was seen in our series. In the earlier studies in which comorbidity has been recognized as a risk
factor, patients with CAP have been typically treated in
the hospital. In earlier studies, leukopenia and leukocytosis have also been shown to be independent prognostic markers in CAP.9,11,18,22,27 In our series, WBC count
was significantly associated with death in univariate analysis, but when contrasting the patients with a WBC count
of less than 4103/L or higher than 11 103/L with
those with a WBC count within the normal range, WBC
count was no longer independently associated with death
in Cox regression analysis. Whether the use of cytostatics or steroids could be an independent prognostic vari-

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able even in primary care patients should be investigated in a population with a larger proportion of patients
undergoing such treatments.
Recently, a prognostic model for the evaluation of
the severity of CAP has been described15 and validated
in elderly hospitalized patients with CAP.31 We were unable to use this prognostic system, however, as some of
the laboratory measurements essential for the calculation of the risk scores of individual patients, such as arterial blood gas analysis and serum urea nitrogen, were
not available in the consulting offices of our primary care
physicians.
We tried to find markers for the assessment of the
severity of LRTI among elderly patients in primary care.
These 950 home-living LRTI patients with a clinical suspicion of pneumonia were encountered by primary care
physicians in their everyday practice, and the ongoing
study did not influence on their treatment decisions. At
least 3 parameters independently associated with mortality within 30 days are easily available: patient history
(preceding aggravation of a coexisting illness); physical
findings (respiratory rate 25/min); and laboratory measurement (CRP level 100 mg/L). Whether these markers are generally applicable to the evaluation of the severity and treatment decisions of LRTI among elderly
patients in primary care should be ascertained and validated in a new prospective study.
Accepted for publication March 29, 2001.
Corresponding author and reprints: Hannu Syrjala, MD,
PhD, Department of Infection Control, Oulu University Hospital, FIN-90220 Oulu, Finland (e-mail: hannu.syrjala
@ppshp.fi).
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