E1 Chest CT scan and Pneumoniae_YE Claessens et al- Supplementary methods Level of CAP probability according to CT scan - definite CAP: systematic alveolar condensation, or alveolar condensation with peripheral and localized ground glass opacities, or bronchiolar focal or multifocal micronodules; - probable CAP: peripheral alveolar condensation, or retractile systematic alveolar condensation, or diffuse ground glass opacities; - possible CAP : pulmonary infarct; - excluded CAP : pulmonary mass, or other abnormalities, or normal images.
E2 1. Chest X ray results in the patients included in the ESCAPED study. Total Radiographic views and technical characteristics Posteroanterior 305 (96%) Lateral 54 (17%) Upright 123 (39%) Seated (90%) and entirely prone 143 (45%) Other position 51 (16%) Film quality Good 110 (35%) Fair 141 (45%) Poor 62 (20%) Major morphological abnormality compromising X-ray interpretation 21 (7%) Main findings Parenchymal infiltrate 188 (61%) Distribution Focal 206 (65%) Unifocal 105 (33%) Multifocal 41 (13%) Systematized 39 (12%) Diffuse 42 (13%) Air bronchogram 76 (24%) Cavitation 4 (1%) Retractile 16 (5%) Nodule and mass 13 (4%) Pleural effusion 75 (25%) Minor 46 (14%) Mild 42 (13%) Strong 4 (1%) Mediastinum enlargement 65 (22%) Cardiomegaly 44 (15%) Miscellaneous 20 (7%) Pre-existing abnormalities 45 (15%) Bronchiectasis 8 (3%) Retractile sequellae 16 (5%) Epicardial fatty infiltration 3 (1%) Other 12 (3%) Probability of CAP according to the local radiologist High 80 (26%) Intermediate 88 (28%) Low 118 (38%) Ruled out 26 (8%) Note: 7 patients had a chest X-ray before referral to the Emergency unit.
E3 2. ChestCT-scan results in the patients included in the ESCAPED study. Technical characteristics CT-scan model Median [IQR] N (%) Somatom 16 plus SIEMENS 4 (1%) ICT 128 PHILIPS 73 (23%) MX 8000 IDT PHILIPS 15 (5%) Lightspeed VCT 64 - GENERAL ELECTRIC 51 (16%) Sensation 16 SIEMENS 147 (47%) Brillance 64 PHILIPS 24 (8%) Full dose 105 (34%) Low dose 204 (66%) Use of contrast material 53 (17%) Senior radiologist 138 (43%) Junior radiologist 180 (57%) Years of practice in radiology 10.5 [6.0-17.0] Main findings Distribution of abnormalities Unifocal (1 lobe) 77 (24%) Multifocal (> 1 lobe) 130 (41%) Lobar systematization 101 (32%) Aeric bronchogram 117 (37%) Alveolar consolidation 141 (45%) Ground-glass attenuation 128 (40%) Bronchiolar micronodules 95 (30%) Pulmonary nodules (< ou = 3cm) 54 (17%) Pulmonary mass (>3cm) 6 (2%) Excavation 4 (1%) Atelectasis 104 (33%) Pulmonary infarct suspected 1 Lymphadenopathy 72 (23%) Mediatinal mass 7 (2%) Cardiomegaly 61 (19%) Aortic abnormality 76 (24) Pleural effusion Right sided 70 (22%) Minor 22 (7%) Mild 38 (12%)
E4 Chest CT scan and Pneumoniae_YE Claessens et al- Median [IQR] N (%) Strong 7 (2%) Left sided 68 (21%) Minor 24 (8%) Mild 36 (11%) Strong 4 (1%) Pericardial effusion 19 (6%) Pre-existing abnormalities 124 (39%) Bronchiectasis 52 (16%) Retractile sequellae 48 (15%) Epicardial fatty infiltration 14 (4%) Bronchial obstruction 6 (2%) Probability of Community Acquired Pneumoniae according to the local radiologist High 138 (43%) Intermediate 38 (12%) Low 37 (12%) Excluded 105 (33%) Note: - definite CAP: systematic alveolar condensation, or alveolar condensation with peripheral and localized ground glass opacities, or bronchiolar focal or multifocal micronodules; - probable CAP: peripheral alveolar condensation, or retractile systematic alveolar condensation, or diffuse ground glass opacities; - possible CAP : pulmonary infarct; - excluded CAP : pulmonary mass, or other abnormalities, or normal images.
E5 3. Comparision of the characteristics of patients without infiltrate on chest X- ray included in the ESCAPED study according to the results of chest CT-scan. Age Patients without infiltrate on chest X-ray Infiltrate on chest CT-scan No infiltrate on chest CT-scan P value (n=40) (n=80) Mean age (years) 64.0 (20.4) 62.0 (19.9) 0.6030 >65 years 25 (62.5%) 36 (45.0%) 0.0707 Gender Female 23 (57.5%) 42 (52.5%) 0.6789 Male 17 (42.5%) 38 (47.5%) 0.6043 Nursing home resident 0 (0.0%) 2 (2.5%) 0.5518 Background and vaccinations Comorbidities At least 1 comorbidity 22 (55.0%) 53 (66.3%) 0.2301 Chronic respiratory disease 12 (30.0%) 22 (27.5%) 0.7745 COPD 5 (12.5%) 16 (20.0%) 0.3081 Asthma 8 (20.0%) 16 (20.0%) 1.0000 Congestive heart failure 3 (7.5%) 7 (8.9%) 1.0000 Previous antibiotic treatment 10 (25.0%) 28 (35.0%) 0.2670 Signs and symptoms in the Emergency unit Cough 30 (76.9%) 52 (65.8%) 0.2180 Chest pain 14 (35.0%) 27 (33.8%) 0.8917 Sputum production 19 (48.7%) 33 (41.3%) 0.4408 Dyspnea 26 (65.0%) 57 (71.3%) 0.4846 Respiratory rate > 30/min 5 (12.5%) 6 (7.5%) 0.5031 Crackles 19 (48.7%) 21 (26.6%) 0.0169 Chills 8 (20.0%) 26 (32.5%) 0.1520 Headaches 4 (10.0%) 13 (16.3%) 0.3547 Myalgia 5 (12.5%) 17 (21.3%) 0.2429 Fever 15 (37.5%) 56 (70.0%) 0.4083 Confusion 2 (5.0%) 3 (3.8%) 1.0000 Heart rate > 125/min 4 (10.0%) 4 (5.0%) 0.4384 Systolic ABP <90 mmhg Diastolic ABP < 60 mmhg Biological data 0 (0.0%) 0 (0.0%) - 1 (2.5%) 6 (7.5%) 0.4221 White blood cell (10 3 /mm 3 ) 12.3 (4.8) 10.2 (5.1) 0.0387 Procalcitonin (µg/l) 1.1 (3.2) 2.8 (8.8) 0.3952 CRP (mg/l) 138.1 (101.4) 59.9 (61.5) 0.0037
E6 Chest CT scan and Pneumoniae_YE Claessens et al- Urea>11 mmol/l 3 (7.5%) 8 (10.0%) 0.7499 ph<7.35 1 (2.5%) 0 (0.0%) 0.3333 PaO2<60 mmhg or Sp02<90% 7 (21.9%) 7 (8.9%) 0.1099 Note: bold p values are those statistically significant
E7 4. Comparision of the patients with infiltrate on chest X-ray included in the ESCAPED study according to the results of chest CT-scan. Patients with infiltrate on chest X-ray No infiltrate on chest CT-scan (n=56) Infiltrate on chest CT-scan (n=132) P value Age Mean age (years) 71.1 (17.7) 63.2 (20.6) 0.0131 >65 years 37 (66.1%) 71 (53.8%) 0.1193 Gender Female 27 (48.2%) 68 (51.5%) 0.6789 Male 29 (51.8%) 64 (48.5%) 0.6043 Nursing home resident 4 (7.1%) 6 (4.5%) 0.4878 Background and vaccinations Comorbidities At least 1 comorbidity 38 (67.9%) 83 (62.9%) 0.5145 Chronic respiratory disease 19 (34.5%) 32 (24.2%) 0.1495 COPD 9 (16.1%) 30 (22.7%) 0.3033 Asthma 8 (14.3%) 12 (9.1%) 0.2908 Congestive heart failure 6 (10.7%) 19 (14.4%) 0.4968 Previous antibiotic treatment 10 (17.9%) 59 (44.7%) 0.0005 Signs and symptoms in the Emergency unit Cough 41 (73.2%) 106 (80.3%) 0.2817 Chest pain 17 (30.4%) 42 (32.1%) 0.8184 Sputum production 22 (39.3%) 69 (52.3%) 0.1032 Dyspnea 46 (82.1%) 90 (68.2%) 0.0503 Respiratory rate > 30/min 8 (14.3%) 23 (17.4%) 0.5659 Crackles 18 (32.1%) 43 (32.8%) 0.9274 Chills 17 (30.4%) 39 (29.8%) 0.9361 Headaches 6 (10.7%) 26 (19.8%) 0.1288 Myalgia 8 (14.3%) 27 (20.6%) 0.3098 Fever 16 (28.6%) 53 (40.8%) 0.1142 Confusion 0 (0.0%) 7 (5.3%) 0.1056 Heart rate > 125/min 4 (7.1%) 11 (8.3%) 1.0000 Systolic ABP < 90 mmhg 0 (0.0%) 4 (3.0%) 0.3196 Diastolic ABP < 60 mmhg 5 (8.9%) 14 (10.6%) 0.7271 Biological data White blood cell (10 3 /mm 3 ) 10.2 (4.2) 12.6 (6.4) 0.0283 Procalcitonin (µg/l) 0.9 (3.1) 2.0 (4.4) 0.2039 CRP (mg/l) 78.0 (81.7) 163.3 (123.4) 0.0074
E8 Chest CT scan and Pneumoniae_YE Claessens et al- Urea>11 mmol/l 14 (25.0%) 15 (11.4%) 0.0179 ph<7.35 1 (1.8%) 1 (0.8%) 0.5081 PaO2<60 mmhg or Sp02<90% 8 (16.3%) 26 (22.0%) 0.4043
E9 5. Appropriateness of the impact of the multidetector chest CT-scan on the physicians probability level of community-acquired pneumoniae (CAP). 5A. Emergency physicians probability level of CAP before and after multidetector chest CT-scan in 163 patients classified definite/probable by the gold standard. Diagnosis agreement after chest CT-scan Diagnosis agreement Definite/probable Possible/excluded Total before chest CT-scan Definite/probable 137 12 149 Possible/excluded 10 4 14 Total 147 16 163 5B. Emergency physicians probability level of CAP before and after multidetector chest CT-scan in 156 patients classified possible/excluded by the gold standard. Diagnosis agreement after chest CT-scan Diagnosis agreement Definite/probable Possible/excluded Total before chest CT-scan Definite/probable 42 70 112 Possible/excluded 8 36 44 Total 50 106 156
E10 6. Factors associated with final adjudicated diagnosis of CAP based on chest CT in the 319 patients of the ESCAPED study (univariate analysis). Results are presented as number (%), median [interquartile range, IQR]. P value below 0.05 were statistically significant. Total (N=319) Adequate change (N=80) No or inadequate change (N=239) p-value Age 68.0 [51.0-81.0] 67.5 [55.5-79.5] 68.0 [50.0-81.0] 0.7766 Gender Male 155 ( 48.6%) 45 ( 56.3%) 110 ( 46.0%) 0.1132 COPD 64 ( 20.1%) 19 ( 23.8%) 45 ( 18.8%) 0.3414 Asthma 46 ( 14.4%) 11 ( 13.8%) 35 ( 14.6%) 0.8437 Previous antimicrobial therapy 111 ( 34.8%) 20 ( 25.0%) 91 ( 38.1%) 0.0336 Physicians agreement before multidetector chest CT-scan 143 ( 44.8%) 15 ( 18.8%) 128 ( 53.6%) Definite Probable 118 ( 37.0%) 55 ( 68.8%) 63 ( 26.4%) Possible 54 ( 16.9%) 9 ( 11.3%) 45 ( 18.8%) Excluded 4 ( 1.3%) 1 ( 1.3%) 3 ( 1.3%) < 0.0001 Parenchyma infiltrate on chest X-ray 188 ( 61.0%) 31 ( 40.8%) 157 ( 67.7%) < 0.0001 Chest X-ray quality Good 110 ( 35.1%) 24 ( 30.4%) 86 ( 36.8%) 0.3050 Poor / bad 203 ( 64.9%) 55 ( 69.6%) 148 ( 63.2%) Nursing home resident 12 ( 3.8%) 2 ( 2.5%) 10 ( 4.2%) 0.7369 Unilateral crackles 105 ( 33.2%) 20 ( 25.3%) 85 ( 35.9%) 0.0847 Respiratory rate (/min) 24.0 [19.0-28.0] 22.0 [18.0-28.0] 24.0 [20.0-28.0] 0.2002 Dyspnea 229 ( 71.8%) 61 ( 76.3%) 168 ( 70.3%) 0.3055 Symptoms duration before EU visit 96.0 [48.0-192.0] 48.0 [24.0-168.0] 96.0 [48.0-192.0] 0.2741 Note: COPD Chronic obstructive pulmonary disease; EU emergency unit