Clicky

TabletWise.com
Pharmacy Website
Clinic Website
 
 

Drug Resistance in Pneumonia (DRIP) Score

Calculators  Multiple body systems
The Drug Resistance in Pneumonia (DRIP) score is utilized in patients with community-acquired pneumonia in order to determine whether they are at risk of drug-resistant pneumonia and should be treated with broad-spectrum antibiotics.
Antibiotic use in 60 days
No 0
Yes 2
Long term care resident
Not including assisted living or group home facilities
No 0
Yes 2
Feeding of tube
NG, nasojejunal, or PEG
No 0
Yes 2
Prior drug resistant pneumonia diagnosis within 1 year
No 0
Yes 2
Hospitalization within 60 days
No 0
Yes 1
Chronic pulmonary disease
No 0
Yes 1
Poor functional status
Karnofsky Performance Status <70 or non-ambulatory status
No 0
Yes 1
Histamine 2 blocker or Proton pump inhibitor within 14 days
No 0
Yes 1
Active wound care during time of admission
No 0
Yes 1
Methicillin resistant Staphylococcus aureus colonization within 1 year
No 0
Yes 1
Result:

Background

Measured Factor
DRIP Score
Measured Factor Disease
  • Lower risk of drug-resistant pneumonia
  • Effective treatment without a broad-spectrum antibiotic
  • Higher risk of drug-resistant pneumonia
  • Effective treatment with a broad-spectrum antibiotic
Measured Factor Detail
The DRIP Score is utilized in patients with community acquired pneumonia, of bacterial origin,
Speciality
Multi-Speciality
Body System
Multiple body systems
Measured Factor Low Impact
  • A patient with a DRIP Score of < 4 can effectively be treated without broad-spectrum antibiotic coverage to avoid increasing antibiotic resistance.
Measured Factor High Impact
  • A patient with a DRIP Score of ≥ 4 is more likely to require broad-spectrum antibiotic coverage since higher scores are associated with a higher risk of drug-resistant pneumonia.

Result Interpretation

Ranges Ranges
  • Critical High: 400%
  • Normal: 0 - 3
  • Normal Adult Male: 0 - 3
  • Normal Adult Female: 0 - 3
  • Normal Pediatric: 0 - 3
  • Normal Neonate Female: 0 - 3
  • Normal Geriatric Male: 0 - 3
  • Normal Geriatric Female: 0 - 3
Result Low Conditions
  • Lower risk of drug-resistant pneumonia
  • Effective treatment without a broad-spectrum antibiotic
Result High Conditions
  • Higher risk of drug-resistant pneumonia
  • Effective treatment with a broad-spectrum antibiotic
False Positive
  • The majority of false positive cases with DRIP = 4 were due to S. pneumoniae or MSSA.
References: 2
Test Limitations
The derivation and validation cohorts were limited by small sample size which may affect generalizability. Despite careful efforts to identify and include bacterial culture-positive cases, not all patients underwent standardized microbiological testing. Inclusion of organisms identified by sputum cultures may also be inaccurate due to detection of colonizing species rather than true lower-tract pathogens. Finally, the test performance of DRIP reported in this cohort does not reflect real-world application. Evaluation in a larger cohort of all-cause pneumonia is needed to confirm these results.
References: 1

Studies

Study Validation 1
A derivation cohort of 200 microbiologically-confirmed pneumonia cases was identified retrospectively, 2011-2012. Risk factors for drug resistant pathogens were evaluated by logistic regression and a novel prediction score (DRIP - Drug Resistance In Pneumonia) was derived. The score was then validated in a prospective, observational cohort of 200 microbiologically-confirmed cases of pneumonia at four U.S. centers (2013 - 2014). DRIP (AUROC of 0.88 [95% CI 0.82-0.93]) performed significantly better than HCAP (AUROC 0.72 [95% CI 0.64-0.79], p=0.02). At a threshold of ≥ 4 points, DRIP demonstrated sensitivity of 0.82 (95% CI 0.67-0.88), specificity 0.81 (95% CI 0.73-0.87), PPV 0.68 (95% CI 0.56-0.78) and NPV 0.90 (95% CI 0.81-0.93). By comparison, HCAP performance was less favorable: sensitivity 0.79 (95% CI 0.67-0.88), specificity 0.65 (95% CI 0.56-0.73), PPV 0.53 (95% CI 0.42-0.63) and NPV 0.86 (95% CI 0.77-0.92) and accuracy of 69.5% (95% CI 62.5-75.7) versus 81.5% (95% CI 74.2-85.6), p=0.005. Compared to HCAP (47/200, 23.5%), unnecessary extended-spectrum antibiotics were recommended 46% less frequently by DRIP (25/200, 12.5%, p=0.004) without increasing inadequate treatment recommendations.
References: 3
Study Validation 2
A retrospective study was conducted using adult patients with pneumonia present on admission based on ICD9/10 coding between February 2016 and April 2017. Both DRIP and HCAP scores were calculated for each patient and antibiotic selection was collected by manual chart review. We compared actual antibiotic selection with potential changes in broad-spectrum antibiotic use in all patients and patients with a DRIP score ≥4, the cutoff where broad-spectrum antibiotic use is suggested. Microbiology results, mortality, and 30-day readmission were also collected. We identified 184 patients during the study period. Respiratory cultures were obtained in 27% (50/184) of participants with 2% (3/184) positive for a CAP-DRp. 7% (12/169) were positive for MRSA colonization upon admission. 24% (45/184) had DRIP ≥4 as compared with 47% (87/184) meeting HCAP criteria. 158 were treated for bacterial pneumonia of which 85% (134/158) received CAP antibiotics. Strict DRIP adherence upon admission would have led to 13% (21/158) more patients on broad-spectrum antibiotics. In the subset of patients with a DRIP score ≥4, DRIP adherence would have led to 65% (26/40) more patients on broad-spectrum antibiotics. 30-day mortality (9%) and read mission (15%) rates were comparable with Centers for Medicare Services (CMS) statistics.
References: 4
Study Additional 1
Researchers derived and validated an alternative prediction tool (DRIP) and integrated it into an electronic decision support tool used in 4 U.S. hospitals. The use of this electronic tool and/or calculation of DRIP was optional for physicians. For DRIP ≥ 4 anti-pseudomonal, vancomycin and azithromycin therapy was recommended. We identified two concurrent cohorts from 11/2014 to 10/2015: 1) cases where DRIP was calculated and 2) usual care. We compared observed rates of antibiotic use between groups and used logistic regression to severity adjust outcomes. DRIP and usual care comprised 894 and 324 inpatients. Drug resistance incidence was 2.4% and 4%. Severity was higher for usual care. Compared to HCAP, DRIP demonstrated equivalent sensitivity but better specificity. Inadequate therapy was <1% in both groups. Relative reduction in unnecessary broad spectrum use (25.9% p=0.008) was observed in the DRIP group. DRIP was associated with decreased length of stay (LOS) (coeff - 0.147; upper 95% CI - 0.137; p < 0.001). Odds of in-hospital mortality did not reach statistical significance (OR 6.43; upper 95% CI 1.04; p = 0.063).
References: 5

Authors

Brandon Webb
MD, Intermountain Healthcare in Utah
Adjunct assistant professor at the University of Utah School of Medicine, Practicing Infectious Disease Physician in the Division of Epidemiology and Infectious Diseases
Research Interests: https://www.researchgate.net/profile/Brandon_Webb3

References

  1. Webb BJ, Dascomb K, Stenehjem E, Vikram HR, Agrwal N, Sakata K, et al. Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score. Antimicrob Agents Chemother. 2016;60(5):2652-63.
  2. Webb BJ, Dascomb K, Stenehjem E, Vikram HR, Agrwal N, Sakata K, et al. Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score. Antimicrob Agents Chemother. 2016 Apr 22;60(5):2652-63.
  3. Webb BJ, Dascomb K, Stenehjem E, Vikram HR, Agrwal N, Sakata K, et al. The DRIP Score: Derivation and Prospective Multi-center Validation of a Model to Predict Drug Resistance in Community-Onset Pneumonia. Antimicrob. Agents Chemother. 2016 Feb 8; doi: 10.1128/AAC.03071-15.
  4. Babbel D, Sutton J, Rose R, Yarbrough P, Spivak E. Potential Impact of the DRIP Score on Antibiotic Use: a Retrospective Single-Center Study. Open Forum Infect Dis. 2017; 4(Suppl 1): S497.
  5. Webb B, Sorensen J, Post H, Jones P, Swistun D, Jephson A, et al. Clinical impact of a prediction score for drug-resistance in community-onset pneumonia. Eur Respir J. 2016; DOI: 10.1183/13993003.congress-2016.PA607