Avoid Unnecessary Broad-Spectrum Antibiotics with the DRIP Score

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How do you decide which patients with bacterial pneumonia are likely to have antibiotic resistance? Decrease use of unnecessary coverage with the Drug Resistance in Pneumonia (DRIP) Score

Use the DRIP Score to predict the risk of community-acquired pneumonia due to drug-resistant pathogens.  Calculate the total points for both Major and Minor Risk Factors.  A score of ≥4 is associated with higher risk of drug-resistant pneumonia and extended-spectrum antibiotic coverage is recommended.

Major Risk Factors
Points
Antibiotic use within 60 days 2
Long-term care resident, not including assisted living or group home 2
Tube feeding, with NG, nasojejunal or PEG tube 2
Drug-resistant PNA within last year 2
Minor Risk Factors
Points
Hospitalization within 60 days 1
Chronic pulmonary disease 1
Poor function status, Karnofsky score of <70 or non-ambulatory 1
H2 blocker or PPI use within 14 days 1
Active wound care 1
MRSA colonization within one year 1

 


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The Good

Why Use It

The Bad

Limitations

The Ugly

Misapplication

●     Highlights risk factors for higher Abx resistance including recent Abx or hospitalization, tube feeds, chronic pulm disease and MRSA colonization

●     Enables precision medicine by reserving combo anti-MRSA/anti-Pseudomonas therapy for patients with the highest pre-test probability for resistance

●     Decreases unnecessary nephrotoxicity and C. diff risks from unnecessary combo Abx regimens

●     Limited to inpatient treatment of bacterial CAP


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●     Not perfectly sensitive (though more sensitive than HCAP criteria)

●     Currently in use clinically, but likely needs more outcomes studies before widespread use

●     False negatives can occur with MRSA, P. aeruginosa, and in patients with COPD, IVDU, and psychiatric illness

●     False positives occur for S pneumoniae and MSSA

 

Derivation
●     200 microbiologically-confirmed cases of pneumonia


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●     18 risk factors evaluated with logistic regression

●     DRIP study identified 4 major and 6 minor risk factors

Validation
●     200 patients from 4 hospitals

●     Sens 0.82, spec 0.81, PPV 0.68, NPV 0.9, and accuracy 81.5%.

●     DRIP outperformed 8 other predictive models, including the HCAP criteria, where DRIP resulted in 46% less use of extended-spectrum antibiotics

 

Reference:

Webb BJ, Dascomb K, Stenehjem E, Vikram HR, Agrwal N, Sakata K, Williams K, Bockorny B, Bagavathy K, Mirza S 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; 60: 2652–63.

ABOUT THE AUTHOR

Dr. Dayton is an emergency physician, educator, and entrepreneur. He is an adjunct professor at the University of Utah, immediate past president of Utah ACEP and the Chair for the Freestanding Emergency Center Section of ACEP.  John writes about medical innovation, he also contributed to MDCalc and ACEPNow, and he is the founder of MedForums.com. He can be reached on Twitter at @drjohnnyd and at drdayton@gmail.com.

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