An Assessment of the Validity of the Comprehensive Severity Index (CSI) as a Measure of Severity of Influenza Infection in Children

A standardized quantitative severity score that reflects the breadth of influenza-related complications would prove valuable in epidemiologic analyses. The maximum CSI score (maxCSI) is a composite, continuous measure of illness severity, based on the degree of abnormality of individual signs and symptoms of a patient’s disease or diseases. Importantly, the index contains criteria for influenza as well as related complications. We evaluated the spectrum of influenza illness as measured by maxCSI and assessed its discriminatory power on 321 influenza-infected, otherwise healthy children (0–17 years) enrolled into a prospective study from the emergency department and inpatient units of a pediatric tertiary care hospital and an urban community pediatric clinic. The area under ROC curve (AUC) was computed for univariate (maxCSI as a sole predictor variable) and multivariable logistic regression models of two outcome measures: (1) influenza-related respiratory and extra-respiratory complications based on physician diagnosis and (2) hospitalization. Multivariable models incorporated maxCSI, age, household crowding, influenza type/subtype and antiviral therapy. For each outcome, the Hanley-McNeil method was used to compare AUCs of univariate and multivariable models. Of the 321 children enrolled, 200 (62.3%) were male and the median age was 5.25 years (range 0.07–17.96). 73 (22.7%) had complications while 61 (19.0%) were hospitalized; the median maxCSI was 25 (range 0–140). In univariate and multivariable modeling, maxCSI was significantly associated with both influenza-related complications and hospitalization (all P < 0.0001). The univariate models discriminated well between children with and without complications [AUC 0.88 (95% CI 0.83–0.93)] and between those who were and were not hospitalized [AUC 0.94 (95% CI 0.91–0.97)]. The AUCs for the corresponding multivariable models were not statistically significantly different: 0.90 (95% CI 0.86–0.94; P = 0.13) for complications and 0.94 (95% CI 0.91–0.97; P = 0.34) for hospitalization. The maxCSI represents a valid continuous outcome measure that can be leveraged to increase statistical power in epidemiologic studies aimed at identifying factors associated with severe influenza. All authors: No reported disclosures.

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