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Pereira JM, Moreno RP, Matos R, Rhodes A, Martin-Loeches I, Cecconi M, Lisboa T, Rello J. Severity assessment tools in ICU patients with 2009 influenza A (H1N1) pneumonia. Clin Microbiol Infect 2012; 18:1040-8. [PMID: 22264290 DOI: 10.1111/j.1469-0691.2011.03736.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to determine if severity assessment tools (general severity of illness and community-acquired pneumonia specific scores) can be used to guide decisions for patients admitted to the intensive care unit (ICU) due to pandemic influenza A pneumonia. A prospective, observational, multicentre study included 265 patients with a mean age of 42 (±16.1) years and an ICU mortality of 31.7%. On admission to the ICU, the mean pneumonia severity index (PSI) score was 103.2 ± 43.2 points, the CURB-65 score was 1.7 ± 1.1 points and the PIRO-CAP score was 3.2 ± 1.5 points. None of the scores had a good predictive ability: area under the ROC for PSI, 0.72 (95% CI, 0.65-0.78); CURB-65, 0.67 (95% CI, 0.59-0.74); and PIRO-CAP, 0.64 (95% CI, 0.56-0.71). The PSI score (OR, 1.022 (1.009-1.034), p 0.001) was independently associated with ICU mortality; however, none of the three scores, when used at ICU admission, were able to reliably detect a low-risk group of patients. Low risk for mortality was identified in 27.5% of patients using PIRO-CAP, but above 40% when using PSI (I-III) or CURB65 (<2). Observed mortality was 13.7%, 13.5% and 19.4%, respectively. Pneumonia-specific scores undervalued severity and should not be used as instruments to guide decisions in the ICU.
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Affiliation(s)
- J M Pereira
- Intensive Care Department, Hospital S. João EPE, Faculdade de Medicina do Porto, Porto, Portugal.
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Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--summary. Clin Microbiol Infect 2012; 17 Suppl 6:1-24. [PMID: 21951384 DOI: 10.1111/j.1469-0691.2011.03602.x] [Citation(s) in RCA: 195] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.
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Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--full version. Clin Microbiol Infect 2011; 17 Suppl 6:E1-59. [PMID: 21951385 PMCID: PMC7128977 DOI: 10.1111/j.1469-0691.2011.03672.x] [Citation(s) in RCA: 592] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.
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Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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Bordon J, Kapoor R, Martinez C, Portela D, Duvvuri P, Klochko A, Ayesu K, Peyrani P, Cillóniz C, Wiemken T, Parra A, Torres A, Rello J, Ramirez J. CD4+ cell counts and HIV-RNA levels do not predict outcomes of community-acquired pneumonia in hospitalized HIV-infected patients. Int J Infect Dis 2011; 15:e822-7. [PMID: 21885316 DOI: 10.1016/j.ijid.2011.05.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 04/26/2011] [Accepted: 05/30/2011] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Outcomes of community-acquired pneumonia (CAP) in relation to CD4+ cell counts have not been established. We examined the correlation of CD4+ cell count and HIV-RNA level with the clinical outcomes of CAP in hospitalized HIV-infected patients. METHODS This was a retrospective study of 127 adult hospitalized patients with HIV infection enrolled with the CAP Organization (CAPO), examining the time to clinical stability (TCS), length of hospital stay (LOS), and all-cause mortality. RESULTS Mortality data were available for 117 HIV-infected patients with CAP. Death within 28 days was reported in 28 patients. The risk of mortality at 28 days was not significant when adjusted for CD4+ cell count (p=0.123), HIV-RNA <400-1000 copies/ml (p=0.093), HIV-RNA ≥ 1000-10,000 copies/ml (p=0.543), and HIV-RNA ≥ 10,000-100,000 copies/ml (p=0.383). The propensity-adjusted Cox proportional hazards regression models did not show any statistically significant differences in LOS or TCS for CD4+ cell counts (p=0.590 and p=0.420, respectively) or HIV-RNA levels (p=0.470 and p=0.080, respectively). Multivariable Cox proportional hazards models did not reveal any statistically significant relationships between CD4+ cell counts or HIV-RNA levels with LOS or TCS. CONCLUSIONS Our study shows that clinical outcomes of HIV-infected patients with CAP are not predicted by CD4+ cell counts or HIV-RNA levels after adjusting for confounders. The management of CAP in patients with HIV infection should not be based on CD4+ cell counts or HIV-RNA levels of the HIV infection.
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Affiliation(s)
- Jose Bordon
- Department of Medicine, Section of Infectious Diseases, Providence Hospital, 1150 Varnum street, NE, Washington, DC 20017, USA.
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Abstract
Pneumonia is an important clinical and public health problem. Identification and prediction of severe pneumonia are significant concerns. Attempts to define severe pneumonia should recognize that different purposes are served by different definitions; no single definition meets all needs. At present, several prediction models have been proposed or validated. Biomarkers are not yet ready for routine use. The authors recommend careful consideration of the implications of any given definition of pneumonia severity. Outcome studies are needed to integrate human and health care system factors with the application of pneumonia severity definitions.
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Affiliation(s)
- Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.
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Chalmers JD, Mandal P, Singanayagam A, Akram AR, Choudhury G, Short PM, Hill AT. Severity assessment tools to guide ICU admission in community-acquired pneumonia: systematic review and meta-analysis. Intensive Care Med 2011; 37:1409-20. [PMID: 21660535 DOI: 10.1007/s00134-011-2261-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 03/29/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of this meta-analysis was to determine if severity assessment tools can be used to guide decisions regarding intensive care unit (ICU) admission of patients with community-acquired pneumonia. METHODS A search of PUBMED and EMBASE (1980-2009) was conducted to identify studies reporting pneumonia severity scores and prediction of ICU admission. Two reviewers independently collected data and assessed study quality. Performance characteristics were pooled using a random-effects model. RESULTS Sufficient data were collected to perform a meta-analysis on five current scoring systems: the Pneumonia Severity Index (PSI), the CURB65 score, the CRB65 score, the American Thoracic Society (ATS) 2001 criteria and the Infectious Disease Society of America/ATS (IDSA/ATS) 2007 criteria. The analysis was limited due to large variations in the ICU admission criteria, ICU admission rates and patient characteristics between different studies and different healthcare systems. In the pooled analysis, PSI, CURB65 and CRB65 performed similarly in terms of sensitivity and specificity across a range of cut-offs. Patients in CURB65 group 0 were at lowest risk of ICU admission (negative likelihood ratio 0.14; 95% confidence interval 0.06-0.34) while the ATS 2001 criteria had the highest positive likelihood ratio (7.05; 95% confidence interval 4.39-11.3). CONCLUSION Large variations exist in the use of ICU resources between different studies and different healthcare systems. Scoring systems designed to predict 30-day mortality perform less well when ICU admission is taken into account. Further studies of dedicated ICU admission scores are required.
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Schuur JD, Baugh CW, Hess EP, Hilton JA, Pines JM, Asplin BR. Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care. Acad Emerg Med 2011; 18:e52-63. [PMID: 21676050 PMCID: PMC3717297 DOI: 10.1111/j.1553-2712.2011.01096.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The decision to admit a patient to the hospital after an emergency department (ED) visit is expensive, frequently not evidence-based, and variable. Outpatient critical pathways are a promising approach to reduce hospital admission after emergency care. Critical pathways exist to risk stratify patients for potentially serious diagnoses (e.g., acute myocardial infarction [AMI]) or evaluate response to therapy (e.g., community-acquired pneumonia) within a short time period (i.e., less than 36 hours), to determine if further hospital-based acute care is needed. Yet, such pathways are variably used while many patients are admitted for conditions for which they could be treated as outpatients. In this article, the authors propose a model of post-ED critical pathways, describe their role in emergency care, list common diagnoses that are amenable to critical pathways in the outpatient setting, and propose a research agenda to address barriers and solutions to increase the use of outpatient critical pathways. If emergency providers are to routinely conduct rapid evaluations in outpatient or observation settings, they must have several conditions at their disposal: 1) evidence-based tools to accurately risk stratify patients for protocolized care, 2) systems of care that reliably facilitate workup in the outpatient setting, and 3) a medical environment conducive to noninpatient pathways, with aligned risks and incentives among patients, providers, and payers. Increased use of critical pathways after emergency care is a potential way to improve the value of emergency care.
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Affiliation(s)
- Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Risk factors and severity scores in hospitalized patients with community-acquired pneumonia: prediction of severity and mortality. Eur J Clin Microbiol Infect Dis 2011; 31:33-47. [PMID: 21533875 DOI: 10.1007/s10096-011-1272-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 04/12/2011] [Indexed: 12/27/2022]
Abstract
Morbidity and mortality in patients with moderate to severe community-acquired pneumonia (CAP) is a global problem, and CAP is a leading cause of death due to infectious diseases. Prompt initiation of expanded-spectrum antimicrobials is essential for the prevention of unnecessary mortality and complications in patients, particularly in the elderly and other at-risk populations, and the treatment decisions made by practitioners have important implications for healthcare systems when hospitalization is required. Empirical antimicrobial treatment and the appropriate management of CAP patients will initially require the proper assessment of severity and patient risk for increased mortality, as well as risk factors for difficult-to-treat bacteria. This review will examine risk factors and scoring systems that may be predictive of moderate to severe CAP, which is often linked to increased risk of mortality. Understanding and recognizing potential risk factors will allow practitioners to proactively identify patients at the highest risk for severe illness or complications, thereby, guiding site-of-care decisions, as well as the choices for empiric antibiotic regimens. The decision to hospitalize a patient with CAP should include not only a clinical perspective and laboratory and radiographic findings, but also at least one objective tool of risk assessment, all in combination with sound clinical judgment.
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Mortality following nursing home-acquired lower respiratory infection: LRI severity, antibiotic treatment, and water intake. J Am Med Dir Assoc 2011; 13:376-83. [PMID: 21514897 DOI: 10.1016/j.jamda.2011.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Revised: 03/13/2011] [Accepted: 03/14/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE In some nursing home populations, antibiotic treatment may not reduce mortality following lower respiratory infection (LRI). To better inform treatment decisions, we determined influences on mortality following LRI among antibiotic-treated and non-antibiotic-treated residents in 2 populations. DESIGN Observational, prospective, cohort studies. SETTING Ninety-seven nursing homes (36 US, 61 Netherlands). PARTICIPANTS Residents (1044 US, 513 Netherlands) who met a standardized study definition for LRI. MEASUREMENTS Demographics, symptoms and physical findings of LRI, functional status, major illness diagnoses, dementia status, treatments, and date of death within 6 months after diagnosis. METHODS We estimated a 2-period (0-14/15-90 days) weighted proportional hazards model of mortality for antibiotic-treated (n = 1280) and non-antibiotic-treated (n = 277) residents; both weights and regressors provide "doubly robust" risk adjustment-for LRI (illness) severity using a prognostic score and for nonrandom receipt of antibiotic treatment using a propensity score. RESULTS In both the United States and the Netherlands, 14-day mortality was associated with three factors-LRI severity, water intake at diagnosis, and antibiotic use (not directly by severe dementia)-that accounted for 82% or, sequentially, 39%, 42%, and 1% of the cross-national mortality difference. The LRI Severity Score (based only on at-diagnosis eating dependency, pulse rate, decreased alertness, and breathing difficulty, with adequate discrimination [c ≥ 0.74] and calibration, and cross-indexed to commonly used LRI mortality measures) was related to mortality through 90 days, regardless of treatment. With sufficient water intake at diagnosis, 14-day mortality was unrelated to not receiving antibiotic treatment (adjusted hazard ratio [AHR], 1.20; 95% confidence interval, 0.70-2.04); insufficient water intake was related to increased 14-day mortality with antibiotics (AHR, 1.90; 1.38-2.60) or without (AHR, 7.12; 4.83-10.5). After 14 days, relative mortality worsened for antibiotic-treated residents with insufficient water intake. Inadequate water intake was related to increased eating dependence at onset of the LRI (OR, 4.2; 3.0-5.8). CONCLUSION LRI severity, water intake, and antibiotic use explain mortality in both studies and reconcile cross-study Dutch/US 14-day mortality differences. LRI severity, derived at 14 days, is related to mortality through 90 days, regardless of treatment, and is key to risk adjustment. With adequate hydration, the survival benefit from antibiotic use is nonsignificant. Conversely, hydration, even without antibiotic treatment, appears central to curative treatment. In LRI guidelines, treatment, and research, the relative benefits of antibiotics and hydration for curative treatment should be addressed.
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Renaud B, Santin A. Critères de gravité et outils d’évaluation de la gravité des pneumopathies aiguës communautaires. ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-011-0057-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dwyer R, Hedlund J, Darenberg J, Henriques-Normark B, Naucler P, Runesdotter S, Kalin M. Improvement of CRB-65 as a prognostic scoring system in adult patients with bacteraemic pneumococcal pneumonia. ACTA ACUST UNITED AC 2011; 43:448-55. [PMID: 21370939 DOI: 10.3109/00365548.2011.562529] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is the leading cause of hospitalization among infectious diseases, and is mainly caused by Streptococcus pneumoniae. Modifications were tested to improve the accuracy of CRB-65 as a simple but useful bedside scoring system, and to compare it with 3 established severity scoring systems (PSI, CURB-65 and CRB-65) to predict 30-day mortality in bacteraemic pneumococcal CAP. METHODS A retrospective analysis was performed on data from 375 adult patients with bacteraemic pneumococcal pneumonia. Mortality, sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic (ROC) curve were calculated for stratifications of the PSI, CURB-65 and CRB-65. The prognostic accuracy after addition of underlying disease and/or a peripheral oxygen saturation (SaO₂) < 90% was evaluated (DS CRB-65). RESULTS The mean age of the patients was 61.5 y, and the 30-day mortality was 9%. Coexisting conditions defined according to the pneumonia severity index (PSI) rule (malignancy, liver, cerebrovascular, and renal disease and congestive heart failure, p = 0.006) and SaO₂ < 90% (p < 0.0001) were independently associated with mortality. By adding these variables, the area under the ROC curve of CRB-65 increased from 0.77 (95% confidence interval (CI) 0.66-0.84) to 0.83 (95% CI 0.73-0.89) (p = 0.01), similar to that of PSI (0.84) and CURB-65 (0.81). CONCLUSIONS Modification of CRB-65 with the addition of 1 point for the presence of any underlying disease according to the PSI rule, and with 1 point if SaO₂ was < 90%, increased its prognostic accuracy in bacteraemic pneumococcal pneumonia with retained independence of laboratory data. The modified CRB-65 may have potential use in the assessment of prognosis in patients with CAP.
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Affiliation(s)
- Richard Dwyer
- Department of Infectious Diseases, Karolinska Institutet, Karolinska University Hospital Huddinge/Södersjukhuset, Infektionsenheten, Sweden.
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Bui H, Vargas F, Gruson D, Hilbert G. Où traiter une pneumopathie aiguë communautaire : évaluation de la sévérité ? Rev Mal Respir 2011; 28:240-53. [DOI: 10.1016/j.rmr.2010.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 08/04/2010] [Indexed: 10/18/2022]
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Fang WF, Yang KY, Wu CL, Yu CJ, Chen CW, Tu CY, Lin MC. Application and comparison of scoring indices to predict outcomes in patients with healthcare-associated pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R32. [PMID: 21247444 PMCID: PMC3222068 DOI: 10.1186/cc9979] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 10/18/2010] [Accepted: 01/19/2011] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Healthcare-associated pneumonia (HCAP) is a relatively new category of pneumonia. It refers to infections that occur prior to hospital admission in patients with specific risk factors following contact or exposure to a healthcare environment. There is currently no scoring index to predict the outcomes of HCAP patients. We applied and compared different community acquired pneumonia (CAP) scoring indices to predict 30-day mortality and 3-day and 14-day intensive care unit (ICU) admission in patients with HCAP. METHODS We conducted a retrospective cohort study based on an inpatient database from six medical centers, recruiting a total of 444 patients with HCAP between 1 January 2007 and 31 December 2007. Pneumonia severity scoring indices including PSI (pneumonia severity index), CURB 65 (confusion, urea, respiratory rate, blood pressure, age 65), IDSA/ATS (Infectious Diseases Society of America/American Thoracic Society), modified ATS rule, SCAP (severe community acquired pneumonia), SMART-COP (systolic blood pressure, multilobar involvement, albumin, respiratory rate, tachycardia, confusion, oxygenation, pH), SMRT-CO (systolic blood pressure, multilobar involvement, respiratory rate, tachycardia, confusion, oxygenation), and SOAR (systolic blood pressure, oxygenation, age, respiratory rate) were calculated for each patient. Patient characteristics, co-morbidities, pneumonia pathogen culture results, length of hospital stay (LOS), and length of ICU stay were also recorded. RESULTS PSI (>90) has the highest sensitivity in predicting mortality, followed by CURB-65 (≥2) and SCAP (>9) (SCAP score (area under the curve (AUC): 0.71), PSI (AUC: 0.70) and CURB-65 (AUC: 0.66)). Compared to PSI, modified ATS, IDSA/ATS, SCAP, and SMART-COP were easy to calculate. For predicting ICU admission (Day 3 and Day 14), modified ATS (AUC: 0.84, 0.82), SMART-COP (AUC: 0.84, 0.82), SCAP (AUC: 0.82, 0.80) and IDSA/ATS (AUC: 0.80, 0.79) performed better (statistically significant difference) than PSI, CURB-65, SOAR and SMRT-CO. CONCLUSIONS The utility of the scoring indices for risk assessment in patients with healthcare-associated pneumonia shows that the scoring indices originally designed for CAP can be applied to HCAP.
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Affiliation(s)
- Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Ta-Pei Road, Kaohsiung 833, Taiwan
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Yoo SS, Cha SI, Shin KM, Lee SY, Kim CH, Park JY, Jung TH. Bacterial pneumonia following cytotoxic chemotherapy for lung cancer: clinical features, treatment outcome and prognostic factors. ACTA ACUST UNITED AC 2011; 42:734-40. [PMID: 20524784 DOI: 10.3109/00365548.2010.489569] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Data regarding treatment outcomes and prognosis in pneumonia that occurs after lung cancer chemotherapy are lacking. We performed a retrospective study of 84 patients with clinically suspected bacterial pneumonia after cytotoxic chemotherapy for lung cancer. Small cell carcinoma was the most common histological type (36.9%, n = 31), followed by squamous cell carcinoma (35.7%, n = 30) and adenocarcinoma (21.4%, n = 18). The most frequent pathogen was Streptococcus pneumoniae (n = 14), followed by Klebsiella pneumoniae (n = 10), Staphylococcus aureus (n = 8), and Pseudomonas aeruginosa (n = 7). Of 84 patients, treatment outcome was determined for 80; the outcome was success in 52 (61.9%) and failure in 28 (33.3%); outcome remained undetermined for 4 patients (4.8%). Based on multivariate analysis, tachypnoea (respiratory rate ≥20/min) was the only significant predictor of treatment failure (odds ratio 4.79, 95% confidence interval 1.17-19.70; p = 0.030). In conclusion, bacterial pneumonia after cytotoxic chemotherapy for lung cancer was found to be caused more often by S. pneumoniae and K. pneumoniae than P. aeruginosa, and treatment failure leading to death was found to be high. Tachypnoea was independently associated with treatment failure in this population.
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Affiliation(s)
- Seung Soo Yoo
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, South Korea
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Brito V, Niederman MS. How Does One Diagnose and Manage Severe Community-Acquired Pneumonia? EVIDENCE-BASED PRACTICE OF CRITICAL CARE 2011. [PMCID: PMC7152406 DOI: 10.1016/b978-1-4160-5476-4.00038-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Fresenius M, Heck M. Pneumonie. REPETITORIUM INTENSIVMEDIZIN 2011. [PMCID: PMC7123275 DOI: 10.1007/978-3-642-16879-6_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Die maximale Inzidenz von ventilatorassoziierter Pneumonie (VAP) liegt nach Ibrahim et al. (2001) zwischen dem 6. und dem 10. Tag (◘ Abb. 13.1).
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Affiliation(s)
- Michael Fresenius
- Chefarzt der Klinik für Anästhesie und Intensivmedizin, Marienhaus Klinikum Bendorf-Neuwied-Waldbreitbach, Friedrich-Ebert-Straße 59, 56564 Neuwied
| | - Michael Heck
- Facharzt für Anästhesiologie – ambulante Narkosen –, Max-Reger-Str. 10, 69121 Heidelberg
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Berdyev D, Scapin R, Labille C, Lambin L, Fartoukh M. Infections communautaires graves — Les pneumonies aiguës communautaires bactériennes de l’adulte. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0031-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Validity of British Thoracic Society guidance (the CRB-65 rule) for predicting the severity of pneumonia in general practice: systematic review and meta-analysis. Br J Gen Pract 2010; 60:e423-33. [PMID: 20883616 DOI: 10.3399/bjgp10x532422] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The CRB-65 score is a clinical prediction rule that grades the severity of community-acquired pneumonia in terms of 30-day mortality. AIM The study sought to validate CRB-65 and assess its clinical value in community and hospital settings. DESIGN OF STUDY Systematic review and meta-analysis of validation studies of CRB-65. METHOD Medline (1966 to June 2009), Embase (1988 to November 2008), British Nursing Index (BNI) and PsychINFO were searched, using a diagnostic accuracy search filter combined with subject-specific terms. The derived (index) rule was used as a predictive model and applied to all validation studies. Comparison was made between the observed and predicted number of deaths stratified by risk group (low, intermediate, and high) and setting of care (community or hospital). Pooled results are presented as risk ratios (RRs) in terms of over-prediction (RR>1) or under-prediction (RR<1) of 30-day mortality. RESULTS Fourteen validation studies totalling 397 875 patients are included. CRB-65 performs well in hospitalised patients, particularly in those classified as intermediate (RR 0.91, 95% confidence interval [CI] = 0.71 to 1.17) or high risk (RR 1.01, 95% CI = 0.87 to 1.16). In community settings, CRB-65 over-predicts the probability of 30-day mortality across all strata of predicted risk, low (RR 9.41, 95% CI = 1.75 to 50.66), intermediate (RR 4.84, 95% CI = 2.61 to 8.69), and high (RR 1.58, 95% CI = 0.59 to 4.19). CONCLUSION CRB-65 performs well in stratifying severity of pneumonia and resultant 30-day mortality in hospital settings. In community settings, CRB-65 appears to over-predict the probability of 30-day mortality across all strata of predicted risk. Caution is needed when applying CRB-65 to patients in general practice.
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Albumin and C-reactive protein have prognostic significance in patients with community-acquired pneumonia. J Crit Care 2010; 26:287-94. [PMID: 21129911 DOI: 10.1016/j.jcrc.2010.10.007] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 09/28/2010] [Accepted: 10/02/2010] [Indexed: 11/20/2022]
Abstract
PURPOSE This study aims to determine the association of commonly used biochemical markers, such as albumin and C-reactive protein (CRP), with mortality and the prognostic performance of these markers combined with the pneumonia severity index (PSI) for mortality and adverse outcomes in patients with community-acquired pneumonia (CAP). MATERIALS AND METHODS The data were gathered prospectively for patients hospitalized with CAP via the emergency department. Laboratory values, including CRP and albumin, clinical variables, and the PSI were measured. Primary outcomes were 28-day mortality and survival times. Secondary outcome was admission to the intensive care unit, vasopressor use, or the need for mechanical ventilation during the hospital stay. RESULTS A total of 424 patients were included. The 28-day mortality was 13.7%. C-reactive protein and albumin were significantly different between survivors and nonsurvivors. In logistic regression analysis, CRP and albumin were independently associated with 28-day mortality (P < .05). Receiver operating characteristic curves showed improved mortality prediction by adding CRP or albumin to the PSI scale. The Cox proportional hazards analysis showed that high serum albumin (≥3.3 mg/dL) had a hazard ratio of 0.5 (95% confidence interval, 0.3-0.9), and high CRP (≥14.3 mg/dL) had a hazard ratio of 2.0 (95% confidence interval, 1.1-3.4). For predicting secondary outcome, adding albumin to PSI increased areas under the curve significantly, but CRP did not. CONCLUSION Albumin and CRP were associated with 28-day mortality in hospitalized patients with CAP, and these markers increased prognostic performance when combined with the PSI scale.
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Ewig S, Woodhead M, Torres A. Towards a sensible comprehension of severe community-acquired pneumonia. Intensive Care Med 2010; 37:214-23. [PMID: 21080155 DOI: 10.1007/s00134-010-2077-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Accepted: 10/13/2010] [Indexed: 01/20/2023]
Abstract
Four different rules have been suggested and validated for intensive care unit (ICU) admission for community-acquired pneumonia: modified American Thoracic Society (ATS) rule, Infectious Diseases Society of America (IDSA)/ATS rule, España rule, and SMART-COP. Their performance varies, with sensitivity of around 70% and specificity of around 80-90%. Only negative predictive values are consistently high. Critical methodological issues include the appropriate reference for derivation, the populations studied, the variables included, and the time course of pneumonia. Severe community-acquired pneumonia (SCAP) may evolve because of acute respiratory failure or/and severe sepsis/septic shock. Pneumonia-related complications and decompensated comorbidities may be additional or independent reasons for a severe course. All variables included in predictive rules relate to the two principal reasons for SCAP. However, taken as major criteria, they are of little value for clinical assessment. Instead, a limited set of minor criteria reflecting severity seems appropriate. However, predictive rules may not meet principal needs of severity assessment because of failure in sensitivity, ignorance of the potential contribution of complications or decompensated comorbidity to pneumonia severity, and poor sensitivity for the lower extreme in the spectrum of severe pneumonia, i.e., patients at risk of SCAP. We therefore advocate an approach that refers to the evaluation of the need for intensified treatment rather than ICU, based on a set of minor criteria and sensitive to the dynamic nature of pneumonia. Intensified treatment such as monitoring and treatment of acute respiratory failure or/and severe sepsis/septic shock is thought to improve management and possibly outcomes by setting the focus on both patients with severity criteria at admission and those at risk for SCAP.
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Affiliation(s)
- Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, Evangelisches Krankenhaus Herne und Augusta-Kranken-Anstalt Bochum, Bergstrasse 26, 44791 Bochum, Germany.
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71
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Brar NK, Niederman MS. Management of community-acquired pneumonia: a review and update. Ther Adv Respir Dis 2010; 5:61-78. [PMID: 20935033 DOI: 10.1177/1753465810381518] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide, affecting approximately 5.6 million patients annually in the USA, where the annual cost exceeds US$12 billion. Optimal management should be based on knowledge of the most likely etiologic pathogens for each patient, based on an assessment of specific risk factors. It is also essential to assess severity of illness, to determine the appropriate site of care, and to order appropriate diagnostic testing. New developments in CAP management have focused on recognizing newly identified pathogens, such as methicillin-resistant Staphylococcus aureus and novel H1N1 influenza, understanding when to utilize new microbiological diagnostic techniques, and how to use biomarkers to direct the appropriate utilization of antibiotics and to define the duration of therapy. This paper reviews recent advances in our knowledge about the diagnosis and optimal management of CAP.
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Affiliation(s)
- Navdeep K Brar
- Department of Pulmonary, Critical Care and Sleep Medicine, Winthrop University Hospital, Mineola, NY 11501, USA
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72
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Gajic O, Dabbagh O, Park PK, Adesanya A, Chang SY, Hou P, Anderson H, Hoth JJ, Mikkelsen ME, Gentile NT, Gong MN, Talmor D, Bajwa E, Watkins TR, Festic E, Yilmaz M, Iscimen R, Kaufman DA, Esper AM, Sadikot R, Douglas I, Sevransky J, Malinchoc M. Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med 2010; 183:462-70. [PMID: 20802164 DOI: 10.1164/rccm.201004-0549oc] [Citation(s) in RCA: 444] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
RATIONALE Accurate, early identification of patients at risk for developing acute lung injury (ALI) provides the opportunity to test and implement secondary prevention strategies. OBJECTIVES To determine the frequency and outcome of ALI development in patients at risk and validate a lung injury prediction score (LIPS). METHODS In this prospective multicenter observational cohort study, predisposing conditions and risk modifiers predictive of ALI development were identified from routine clinical data available during initial evaluation. The discrimination of the model was assessed with area under receiver operating curve (AUC). The risk of death from ALI was determined after adjustment for severity of illness and predisposing conditions. MEASUREMENTS AND MAIN RESULTS Twenty-two hospitals enrolled 5,584 patients at risk. ALI developed a median of 2 (interquartile range 1-4) days after initial evaluation in 377 (6.8%; 148 ALI-only, 229 adult respiratory distress syndrome) patients. The frequency of ALI varied according to predisposing conditions (from 3% in pancreatitis to 26% after smoke inhalation). LIPS discriminated patients who developed ALI from those who did not with an AUC of 0.80 (95% confidence interval, 0.78-0.82). When adjusted for severity of illness and predisposing conditions, development of ALI increased the risk of in-hospital death (odds ratio, 4.1; 95% confidence interval, 2.9-5.7). CONCLUSIONS ALI occurrence varies according to predisposing conditions and carries an independently poor prognosis. Using routinely available clinical data, LIPS identifies patients at high risk for ALI early in the course of their illness. This model will alert clinicians about the risk of ALI and facilitate testing and implementation of ALI prevention strategies. Clinical trial registered with www.clinicaltrials.gov (NCT00889772).
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Johnstone J, Majumdar SR, Marrie TJ. The value of prognostic indices for pneumonia. Curr Infect Dis Rep 2010; 10:215-22. [PMID: 18510884 DOI: 10.1007/s11908-008-0036-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
One of the most important decisions in the management of community-acquired pneumonia is deciding the care site, which affects morbidity, mortality, and costs. Clinical judgment alone is difficult and imprecise. The Pneumonia Severity Index score and the CURB-65 (confusion, urea nitrogen, respiratory rate, blood pressure, 65 years of age and older) score are validated prognostic indices to predict mortality, and they can identify low-risk patients who may be eligible for outpatient management. However, limitations of the scoring systems preclude their isolated use, and they can only be recommended as an aid to guide hospital admission decisions. The Pneumonia Severity Index score is slightly better at identifying the lowest risk patients, whereas CURB-65 is much simpler to use. As an adjunct to clinical judgment, we consider CURB-65 to be the most useful prognostic index for identifying low-risk patients.
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Affiliation(s)
- Jennie Johnstone
- Division of Infectious Diseases, University of Alberta, Faculty of Medicine and Dentistry, 8440-112 Street, 2J2.00 WC Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada, T6G 2R7
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74
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Hyponatremia and predictive rules for prognosis in adult patients with community-acquired pneumonia. J Infect 2010; 60:503-5. [DOI: 10.1016/j.jinf.2010.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 03/22/2010] [Accepted: 03/24/2010] [Indexed: 11/23/2022]
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Abstract
PURPOSE OF REVIEW Community-acquired pneumonia is a significant clinical and public health problem. Defining and predicting severe pneumonia is difficult but important. RECENT FINDINGS Several new predictive models and more sophisticated approaches to describing pneumonia severity have been recently proposed, with subsequent validation in varied patient populations. Early data suggest that biomarkers may be useful in the future. SUMMARY Definitions of pneumonia severity depend on the relevant clinical or public health question. A health services reference definition seems most useful in most settings. The Infectious Disease Society of America/American Thoracic Society 2007 guidelines and SMART-COP are two recent promising methods for predicting severe pneumonia at the time of presentation. The traditional pneumonia severity index and Confusion Uremia Respiratory rate Blood pressure (CURB)-65 models are less useful. Accurate assessment of severity has important implications for triage, outcome, and defining populations for research applications. Novel biomarkers, while somewhat promising, do not yet have a validated role in pneumonia severity assessment.
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76
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Saracino A, Weiland TJ, Jolly B, Dent AW. Verbal dyspnoea score predicts emergency department departure status in patients with shortness of breath. Emerg Med Australas 2010; 22:21-9. [PMID: 20136641 DOI: 10.1111/j.1742-6723.2009.01254.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We examined whether a previously validated verbal dyspnoea rating scale, and/or other demographic and clinical parameters, could predict ED departure status, among ED patients presenting with shortness of breath. METHODS In this prospective observational study, a convenience sample of patients presenting to an inner urban adult tertiary hospital ED with shortness of breath were assessed at triage using objective and subjective breathlessness parameters. These included respiratory rate, oxygen saturation, heart rate, systolic blood pressure and verbal dyspnoea scores. A verbal dyspnoea score for worst dyspnoea during the current episode and basic demographic and presentation characteristics were also collected. These variables were assessed as predictors of ED departure status (inpatient admission or ED discharge) using logistic regression. RESULTS From a sample of 253 participants, verbal dyspnoea scores > or =8 predicted inpatient admission 89% specificity (95% confidence interval [CI] 82.1-93.4), and scores < or =3 predicted discharge with 95% specificity (95% CI 89.5-98.0). For patients with shortness of breath as the primary complaint, the combination of verbal dyspnoea score > or =6, heart rate > or =94 bpm at triage and ambulance arrival predicted admission with 90% sensitivity (95% CI 82-95%) and 84% specificity (95% CI 73-92%). These same variables predicted admission for all patients with 84% sensitivity (95% CI 75.8-89.2) and 79% specificity (95% CI 71.5-85.5). CONCLUSION Verbal dyspnoea score, alone and in combination with heart rate and arrival transport, can accurately predict admission. Once validated they might be useful in assessing, prioritizing and making rapid site of care decisions for breathless patients presenting to the ED.
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Affiliation(s)
- Amanda Saracino
- Emergency Practice Innovation Centre, St. Vincent's Hospital, Melbourne, Victoria 3068, Australia
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Sabatier C, Peredo R, Villagrá A, Bacelar N, Mariscal D, Ferrer R, Gallego M, Vallés J. [Community-acquired pneumonia: a 7-years descriptive study. Usefulness of the IDSA/ATS 2007 in the assessment of ICU admission]. Med Intensiva 2010; 34:237-45. [PMID: 20116135 DOI: 10.1016/j.medin.2009.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 11/24/2009] [Accepted: 11/24/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe the clinical characteristics and outcomes of patients with community-acquired pneumonia (CAP) admitted to the Intensive Care Unit (ICU). To evaluate new ATS/IDSA criteria to identify patients with CAP who required admission to ICU. DESIGN Retrospective analysis of prospective collected data in a 7-year period (2000-2007). SETTING Medical-surgical ICU with 16 beds. PATIENTS All patients with severe CAP admitted to the ICU (n=147). PRIMARY ENDPOINTS: Clinical and microbiological characteristics. Prognostic factors. Comparison of patients admitted in the ICU and ATS/IDSA criteria (group 1: > or = 1 major criterion, group 2: > or = 3 minor criteria and group 3: no criterion). INTERVENTION None. RESULTS Admission to the ICU is required for patients with acute respiratory failure (60.5%) and with septic shock (28.5%). A total of 71.4%, had an identifiable microbial etiology, S. pneumoniae being the most frequently isolated. Mean time to antibiotic therapy was 4.3+/-4.2h, this being adequate in 97.1%. ICU global mortality rate was 32%. Prognostic factors associated with higher mortality were acute renal failure (OR:4.7), mechanical ventilation (OR:3.4), non-identifiable etiology (OR:4.2) and non-S. pneumonia etiology (OR:3.5). Sixty-eight percent of the patients were included in the first group of the ATS/IDSA criteria and 21% in the second group. CONCLUSIONS CAP mortality is still high despite early antibiotic therapy, especially in those patients with a non-S. pneumonia etiology or who require mechanical ventilation. Almost 90% of the ICU admissions were identified by the new criteria from ATS/IDSA.
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Affiliation(s)
- C Sabatier
- Centro de Críticos, Hospital de Sabadell, Instituto Universitario Parc Taulí, UAB, CIBER-Enfermedades Respiratorias, España
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78
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Malinis M, Myers J, Bordon J, Peyrani P, Kapoor R, Nakamatzu R, Lopardo G, Torres A, Feldman C, Allen M, Arnold F, Ramirez J. Clinical outcomes of HIV-infected patients hospitalized with bacterial community-acquired pneumonia. Int J Infect Dis 2010; 14:e22-7. [DOI: 10.1016/j.ijid.2009.03.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 02/10/2009] [Accepted: 03/01/2009] [Indexed: 11/30/2022] Open
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Validation of the Infectious Disease Society of America/American Thoracic Society 2007 guidelines for severe community-acquired pneumonia. Crit Care Med 2009; 37:3010-6. [PMID: 19789456 DOI: 10.1097/ccm.0b013e3181b030d9] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Validate the Infectious Disease Society of America/American Thoracic Society 2007 (IDSA/ATS 2007) criteria for predicting severe community-acquired pneumonia (SCAP) and evaluate a health-services definition for SCAP. DESIGN Retrospective cohort study. SETTING LDS Hospital, an academic tertiary care facility in the western United States. PATIENTS Consecutive patients with International Classification of Diseases, Ninth Edition, codes and chest radiographs consistent with community-acquired pneumonia from 1996 to 2006 seen at LDS Hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We utilized the electronic medical record to examine intensive care unit admission, intensive therapies received, and predictors of severity, as well as 30-day mortality. We also developed logistic regression models of mortality and disease severity. We calculated the IDSA/ATS 2007 criteria as well as three other pneumonia severity scores. We defined SCAP as receipt of intensive therapy in the intensive care unit. In 2413 episodes of pneumonia, 1540 were admitted to the hospital, while 379 were admitted to the intensive care unit. Overall 30-day mortality was 3.7% but was 16% among intensive care patients. The IDSA/ATS 2007 minor criteria predicted SCAP with an area under the curve of 0.88 (95% confidence interval 0.85-0.90), which improved to 0.90 (95% confidence interval 0.88-0.92) with weighting. Competing models had area under the curve of 0.76 to 0.83. Using four rather than three minor criteria improved the positive predictive value from 54% to 81%, with a stable negative predictive value of 94% to 92%. CONCLUSIONS The IDSA/ATS 2007 criteria predicted pneumonia severity better than other models. Using four rather than three minor criteria may be a superior cutoff, although this will depend on institutional characteristics.
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Validation of the Infectious Diseases Society of America/American Thoracic Society criteria to predict severe community-acquired pneumonia caused by Streptococcus pneumoniae. Am J Emerg Med 2009; 27:968-74. [PMID: 19857416 DOI: 10.1016/j.ajem.2008.07.037] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Revised: 07/29/2008] [Accepted: 07/30/2008] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Severe community-acquired pneumonia (CAP) is usually defined as pneumonia that requires intensive care unit (ICU) admission; the primary pathogen responsible for ICU admission is Streptococcus pneumoniae. In this study, the 2007 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) consensus criteria for ICU admission were compared with other severity scores in predicting ICU admission and mortality. METHODS We retrospectively studied 158 patients with pneumococcal CAP (1999-2003). Clinical and laboratory features at the emergency department were recorded and used to calculate the 2007 IDSA/ATS rule, the 2001 ATS rule, 2 modified 2007 IDSA/ATS rules, the Pneumonia Severity Index (PSI), and the CURB (confusion, urea, respiratory rate, blood pressure) score. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) were assessed for the various indices. We also determined the criteria that were independently predictive of ICU admission and of mortality in our population. RESULTS The 2007 IDSA/ATS criteria performed as well as the 2001 ATS rule in predicting ICU admission both demonstrated high sensitivity (90%) and NPV (97%). For the prediction of mortality, the best tool proved to be the PSI score (sensitivity, 95%; NPV, 99%). The variables associated with ICU admission in this patient population included tachypnea, confusion, Pao(2)/Fio(2) ratio of 250 or lower, and hypotension requiring fluid resuscitation. Mechanical ventilation and PSI class V were independently associated with mortality. CONCLUSIONS This study confirms the usefulness of the new criteria in predicting severe CAP. The 2001 ATS criteria seem an attractive alternative because they are simple and as effective as the 2007 IDSA/ATS criteria.
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España PP, Capelastegui A, Quintana JM, Bilbao A, Diez R, Pascual S, Esteban C, Zalacaín R, Menendez R, Torres A. Validation and comparison of SCAP as a predictive score for identifying low-risk patients in community-acquired pneumonia. J Infect 2009; 60:106-13. [PMID: 19961875 DOI: 10.1016/j.jinf.2009.11.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 11/25/2009] [Accepted: 11/26/2009] [Indexed: 11/28/2022]
Abstract
PURPOSES (1) To validate the Severe Community Acquired Pneumonia (SCAP) score in predicting 30-day mortality. (2) To validate its ability to identifying patients at low risk of death. (3) To compare it against the Pneumonia Severity Index (PSI), and the British Thoracic Society's CURB-65 rules. METHODS The SCAP score was validated to predict 30-day mortality in an internal validation cohort of consecutive adult patients seen in one hospital. Consecutive inpatients from other three hospitals were used to externally validate the score and compare the SCAP with the PSI and CURB-65. The discriminatory power of these rules to predict 30-day mortality was tested by the Area under Curve (AUC), and their predictive accuracy with the sensitivity, specificity and predictive values. RESULTS The 30-day mortality rate increased directly with increasing SCAP score (class 0: 0.5%, to class 4: 66.5% risk) in the internal validation cohort, and from 1.3% to 29.2% in external cohort (P<0.001) with an AUC of 0.83 and 0.75, respectively (P=0.024). The SCAP score identified 62.4% (95% IC 58.8-66.0) low-risk patients, 52.5% (95% IC 48.8-56.2) the PSI and 46.2% (95% CI 42.5-49.9) the CURB-65 in the external cohort. Patients classified as low risk by the three rules had similar 30-day mortality (SCAP: 2.5%, PSI: 1.6% and CURB-65: 2.7%). CONCLUSION The SCAP is valid to predict 30-day mortality among low-risk patients and identifies a larger proportion of patients as low-risk than the other studied rules.
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Affiliation(s)
- Pedro P España
- Pneumology Service Hospital Galdakao, E-48960 Galdakao, Bizkaia, Spain.
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Ewig S, Birkner N, Strauss R, Schaefer E, Pauletzki J, Bischoff H, Schraeder P, Welte T, Hoeffken G. New perspectives on community-acquired pneumonia in 388 406 patients. Results from a nationwide mandatory performance measurement programme in healthcare quality. Thorax 2009; 64:1062-9. [PMID: 19454409 PMCID: PMC2782114 DOI: 10.1136/thx.2008.109785] [Citation(s) in RCA: 245] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Accepted: 04/27/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND The database of the German programme for quality in healthcare including data of every hospitalised patient with community-acquired pneumonia (CAP) during a 2-year period (n = 388 406 patients in 2005 and 2006) was analysed. METHODS End points of the analysis were: (1) incidence; (2) outcome; (3) performance of the CRB-65 (C, mental confusion; R, respiratory rate >or=30/min; B, systolic blood pressure <90 mm Hg or diastolic blood pressure or=65 years) score in predicting death; and (4) lack of ventilatory support as a possible indicator of treatment restrictions. The CRB-65 score was calculated, resulting in three risk classes (RCs). RESULTS The incidence of hospitalised CAP was 2.75 and 2.96 per 1000 inhabitants/year in 2005 and 2006, respectively, higher for males (3.21 vs 2.52), and strongly age related, with an incidence of 7.65 per 1000 inhabitants/year in patients aged >or=60 years over 2 years. Mortality (13.72% and 14.44%) was higher than reported in previous studies. The CRB-65 RCs accurately predicted death in a three-class pattern (mortality 2.40% in CRB-65 RC 1, 13.43% in CRB-65 RC 2 and 34.39% in CRB-65 RC 3). The first days after admission were consistently associated with the highest risk of death throughout all risk classes. Only a minority of patients who died had received mechanical ventilation during hospitalisation (15.74%). CONCLUSIONS Hospitalised CAP basically is a condition of the elderly associated with a higher mortality than previously reported. It bears a considerable risk of early mortality, even in low risk patients. CRB-65 is a simple and powerful tool for the assessment of CAP severity. Hospitalised CAP is a frequent terminal event in chronic debilitated patients, and a limitation of treatment escalation is frequently applied.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, Herne und Bochum, Germany
| | - N Birkner
- BQS Bundesgeschäftsstelle Qualitätssicherung, Duesseldorf, Germany
| | - R Strauss
- Universitaetsklinikum Erlangen, Germany
| | - E Schaefer
- BQS Bundesgeschäftsstelle Qualitätssicherung, Duesseldorf, Germany
| | | | | | - P Schraeder
- BQS Bundesgeschäftsstelle Qualitätssicherung, Duesseldorf, Germany
| | - T Welte
- Universitaetsklinikum Carl Gustav Carus, Fachkrankehaus Coswig, Germany
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Association between timing of intensive care unit admission and outcomes for emergency department patients with community-acquired pneumonia. Crit Care Med 2009; 37:2867-74. [PMID: 19770748 DOI: 10.1097/ccm.0b013e3181b02dbb] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the 28-day mortality and hospital length of stay of patients with community-acquired pneumonia who were transferred to an intensive care unit on the same day of emergency department presentation (direct-transfer patients) with those subsequently transferred within 3 days of presentation (delayed-transfer patients). DESIGN Secondary analysis of the original data from two North American and two European prospective, multicenter, cohort studies of adult patients with community-acquired pneumonia. PATIENTS In all, 453 non-institutionalized patients transferred within 3 days of emergency department presentation to an intensive care unit were included in the analysis. Supplementary analysis was restricted to patients without an obvious indication for immediate transfer to an intensive care unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The sample consisted of 138 delayed-transfer and 315 direct-transfer patients, among whom 150 (33.1%) were considered to have an obvious indication for immediate intensive care unit admission. After adjusting for the quintile of propensity score, delayed intensive care unit transfer was associated with an increased odds ratio for 28-day mortality (2.07; 95% confidence interval, 1.12-3.85) and a decreased odds ratio for discharge from hospital for survivors (0.53; 95% confidence interval, 0.39-0.71). In a propensity-matched analysis, delayed-transfer patients had a higher 28-day mortality rate (23.4% vs. 11.7%; p = 0.02) and a longer median hospital length of stay (13 days vs. 7 days; p < .001) than direct-transfer patients. Similar results were found after excluding the 150 patients with an obvious indication for immediate intensive care unit admission. CONCLUSIONS Our findings suggest that some patients without major criteria for severe community-acquired pneumonia, according to the recent Infectious Diseases Society of America/American Thoracic Society consensus guideline, may benefit from direct transfer to the intensive care unit. Further studies are needed to prospectively identify patients who may benefit from direct intensive care unit admission despite a lack of major severity criteria for community-acquired pneumonia based on the current guidelines.
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Rello J. Demographics, guidelines, and clinical experience in severe community-acquired pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 12 Suppl 6:S2. [PMID: 19105795 PMCID: PMC2607112 DOI: 10.1186/cc7025] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Mortality in patients with community-acquired pneumonia (CAP) who require intubation or support with inotropes in an intensive care unit setting remains extremely high (up to 50%). Systematic use of objective severity-of-illness criteria, such as the Pneumonia Severity Index (PSI), British Thoracic Society CURB-65 (an acronym meaning Confusion, Urea, Respiratory rate, Blood pressure, age ≥65 years), or criteria developed by the Infectious Diseases Society of America/American Thoracic Society, to aid site-of-care decisions for pneumonia patients is emerging as a step forward in patient management. Experience with the Predisposition, Infection, Response, and Organ dysfunction (PIRO) score, which incorporates key signs and symptoms of sepsis and important CAP risk factors, may represent an improvement in staging severe CAP. In addition, it has been suggested that implementing a simple care bundle in the emergency department will improve management of CAP, using five evidence-based variables, with immediate pulse oxymetry and oxygen assessment as the cornerstone and initial step of treatment.
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Affiliation(s)
- Jordi Rello
- Critical Care Department, Joan XXIII University Hospital University Rovira i Virgili, Pere Virgili Health Institut, CIBER Enfermedades Respiratorias (CIBERES), Tarragona 43007, Spain.
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Why do nice people get bad pneumonia? “Be quick or be dead” (Iron Maiden)*. Crit Care Med 2009; 37:2979-80. [DOI: 10.1097/ccm.0b013e3181aff91a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Thiem U, Niklaus D, Sehlhoff B, Stückle C, Heppner HJ, Endres HG, Pientka L. C-reactive protein, severity of pneumonia and mortality in elderly, hospitalised patients with community-acquired pneumonia. Age Ageing 2009; 38:693-7. [PMID: 19729453 DOI: 10.1093/ageing/afp164] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND increasingly, markers of systemic inflammation like C-reactive protein (CRP) levels and white blood count (WBC) are being used for assessing the prognosis of patients with community-acquired pneumonia (CAP). However, their predictive value has not been validated in populations of elderly patients. OBJECTIVE to evaluate the prognostic value of CRP and WBC in comparison with the CURB score and the pneumonia severity index (PSI) in elderly, hospitalised patients with CAP. METHODS the charts of all patients, aged 65 years and older, who were consecutively admitted to the Department of Geriatrics, Marienhospital Herne, Germany, for treatment of CAP between January 2001 and September 2005, were reviewed. CRP, WBC, CURB and PSI were analysed in relation to 30-day mortality. RESULTS in a total of 391 patients, median age 80 years, no association was found between CRP or WBC and mortality. In contrast, the CURB score and PSI were significantly associated with mortality and treatment in the intensive care unit (ICU). CONCLUSION in elderly, hospitalised patients with CAP, admission CRP and WBC are not predictors of the prognosis.
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Affiliation(s)
- Ulrich Thiem
- Department of Geriatrics, Marienhospital Herne, University of Bochum, Widumer Str. 8, D-44627 Herne, Germany.
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87
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Restrepo MI, Mortensen EM, Rello J, Brody J, Anzueto A. Late admission to the ICU in patients with community-acquired pneumonia is associated with higher mortality. Chest 2009; 137:552-7. [PMID: 19880910 DOI: 10.1378/chest.09-1547] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Limited data are available on the impact of time to ICU admission and outcomes for patients with severe community acquired pneumonia (CAP). Our objective was to examine the association of time to ICU admission and 30-day mortality in patients with severe CAP. METHODS A retrospective cohort study of 161 ICU subjects with CAP (by International Classification of Diseases, 9th edition, codes) was conducted over a 3-year period at two tertiary teaching hospitals. Timing of the ICU admission was dichotomized into early ICU admission (EICUA, direct admission or within 24 h) and late ICU admission (LICUA, >or= day 2). A multivariable analysis using Cox proportional hazard model was created with the primary outcome of 30-day mortality (dependent measure) and the American Thoracic Society (ATS) severity adjustment criteria and time to ICU admission as the independent measures. RESULTS Eighty-eight percent (n = 142) were EICUA patients compared with 12% (n = 19) LICUA patients. Groups were similar with respect to age, gender, comorbidities, clinical parameters, CAP-related process of care measures, and need for mechanical ventilation. LICUA patients had lower rates of ATS severity criteria at presentation (26.3% vs 53.5%; P = .03). LICUA patients (47.4%) had a higher 30-day mortality compared with EICUA (23.2%) patients (P = .02), which remained after adjusting in the multivariable analysis (hazard ratio 2.6; 95% CI, 1.2-5.5; P = .02). CONCLUSION Patients with severe CAP with a late ICU admission have increased 30-day mortality after adjustment for illness severity. Further research should evaluate the risk factors associated and their impact on clinical outcomes in patients admitted late to the ICU.
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Affiliation(s)
- Marcos I Restrepo
- Veterans Evidence Based Research Dissemination and Implementation Center, South Texas Veterans Health Care System, San Antonio, TX 78229, USA.
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88
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Feldman C, Alanee S, Yu VL, Richards GA, Ortqvist A, Rello J, Chiou CCC, Chedid MBF, Wagener MM, Klugman KP. Severity of illness scoring systems in patients with bacteraemic pneumococcal pneumonia: implications for the intensive care unit care. Clin Microbiol Infect 2009; 15:850-7. [PMID: 19702589 DOI: 10.1111/j.1469-0691.2009.02901.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Severity of illness scoring systems are useful for decisions on the management of patients with community-acquired pneumonia (CAP), including assessing the need for intensified therapy and monitoring, or for intensive care unit (ICU) admission. We compared the accuracy of the Pneumonia Severity Index (PSI), the CURB-65 and CRB-65 score, the modified-American Thoracic Society score (ATS), the IDSA/ATS guidelines and the Pitt Bacteraemia score (PBS) in evaluating severity of illness in 766 patients with bacteraemic pneumococcal pneumonia. We evaluated the sensitivity and specificity, the positive predictive value (PPV) and the negative predictive value (NPV) and the accuracy of the classification in predicting 14-day mortality. The PSI and the IDSA/ATS guidelines were the most sensitive whereas the PBS and modified-ATS scoring systems were the most specific in predicting mortality. The NPV was comparable for all four scoring systems (all above 90%), but the PPV was highest for PBS (54.2%) and lowest for PSI (23.2%). The predictive accuracy and discriminating power as measured by the receiver-operating characteristic (ROC) curve was highest for the PBS. Both the modified-ATS and the PBS scoring systems identified those patients who might benefit most from intensified care and monitoring. The PBS and modified-ATS proved superior to the IDSA/ATS guidelines, CURB-65 and CRB-65 with respect to their specificity and PPV. The low PPV of the PSI rendered it not usable as a parameter for decision-making in severely-ill patients with pneumococcal bacteraemia.
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Affiliation(s)
- C Feldman
- Division of Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
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89
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90
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Chalmers JD. ICU admission and severity assessment in community-acquired pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:156. [PMID: 19591640 PMCID: PMC2717437 DOI: 10.1186/cc7889] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The past 15 years have seen major advances in our understanding of severity assessment in community-acquired pneumonia (CAP). Prognostic tools have been promoted to guide all major management decisions in CAP, including admission to the critical care unit. Several recent studies, including the study by Renaud and colleagues, have challenged us to re-evaluate how we consider severe CAP, a concept for which there is still no universally accepted definition. Existing severity scores such as the Pneumonia Severity Index and the CURB65 score are designed to predict 30-day mortality. As a result, they are heavily weighted by age and co-morbidity. They perform less well when predicting other outcomes such as requirement for ICU admission and are of limited use in the critical care environment. This commentary discusses recent attempts to develop useful severity criteria to guide the use of ICU resources in patients with severe CAP.
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Affiliation(s)
- James D Chalmers
- Queens Medical Research Institute, Centre for Inflammation Research, Little France, Edinburgh EH16 4TJ, UK.
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91
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Abstract
Severity assessment is an important early step in the management of patients presenting with community-acquired pneumonia. Various pneumonia-specific scores, generic sepsis scores and predictive biomarkers have been proposed as tools to aid clinicians in key management decisions. However, there is no uniform agreement about the optimum severity assessment tool to use. This review provides a summary of current evidence surrounding severity assessment in adult patients presenting with community-acquired pneumonia.
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Affiliation(s)
- A Singanayagam
- Department of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.
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92
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Horo K, Gode VC, Ahui JMB, Kouassi AB, Djereke GB, Cardenat M, N'gom A, Koffi N, Aka-Danguy E. [Characteristics of supposedly bacterial community acute pneumonia among HIV-positive patients: prospective preliminary study]. REVUE DE PNEUMOLOGIE CLINIQUE 2009; 65:137-142. [PMID: 19524801 DOI: 10.1016/j.pneumo.2009.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 12/25/2008] [Accepted: 03/06/2009] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) is the second leading cause of hospitalization in the respirology department in Abidjan after tuberculosis. Frequently associated with HIV infection, it has a high mortality rate of about 20% to 30%. The aim of this study is to identify the specificities and severity factors associated with bacterial CAP (BCAP) outcome in HIV-positive patients. METHODS The authors conducted a prospective and comparative preliminary study on two groups of patients: 29 HIV-positive patients with BCAP and 21 HIV-negative patients with BCAP. All of the patients were hospitalized for BCAP with symptoms of severity according to the usual score of severity. RESULTS The sociodemographic, clinical and paraclinical characteristics were similar in both groups. Failures and deaths were more frequent in the group with HIV infection. In particular, HIV infected patients with a body mass index under 18.5 and a rate of T CD4 lymphocytes lower than 200/mm(3) presented the least favourable evolution. CONCLUSIONS A more extensive study should help define the appropriate severity criteria for BCAP associated with HIV infection.
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Affiliation(s)
- K Horo
- Service de pneumologie, CHU de Cocody, 22 BP 917, Abidjan 22, Côte d'Ivoire.
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93
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[Evaluation of the status of patients with severe infection, criteria for intensive care unit admittance. Spanish Society for Infectious Diseases and Clinical Microbiology. Spanish Society of Intensive and Critical Medicine and Coronary Units]. Enferm Infecc Microbiol Clin 2009; 27:342-52. [PMID: 19409668 DOI: 10.1016/j.eimc.2008.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Accepted: 05/26/2008] [Indexed: 12/11/2022]
Abstract
Recent studies have shown that early attention in patients with serious infections is associated with a better outcome. Assistance in intensive care units (ICU) can effectively provide this attention; hence patients should be admitted to the ICU as soon as possible, before clinical deterioration becomes irreversible. The objective of this article is to compile the recommendations for evaluating disease severity in patients with infections and describe the criteria for ICU admission, updating the criteria published 10 years ago. A literature review was carried out, compiling the opinions of experts from the Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC, Spanish Society for Infectious Diseases and Clinical Microbiology) and the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC, Spanish Society for Intensive Medicine, Critical Care and Coronary Units) as well as the working groups for infections in critically ill patients (GEIPC-SEIMC and GTEI-SEMICYUC). We describe the specific recommendations for ICU admission related to the most common infections affecting patients, who will potentially benefit from critical care. Assessment of the severity of the patient's condition to enable early intensive care is stressed.
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94
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95
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Mandell L. Severe Community‐Acquired Pneumonia (CAP) and the Infectious Diseases Society of America/American Thoracic Society CAP Guidelines Prediction Rule: Validated or Not. Clin Infect Dis 2009; 48:386-8. [DOI: 10.1086/596308] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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96
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Liapikou A, Ferrer M, Polverino E, Balasso V, Esperatti M, Piñer R, Mensa J, Luque N, Ewig S, Menendez R, Niederman M, Torres A. Severe Community‐Acquired Pneumonia: Validation of the Infectious Diseases Society of America/American Thoracic Society Guidelines to Predict an Intensive Care Unit Admission. Clin Infect Dis 2009; 48:377-85. [DOI: 10.1086/596307] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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97
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Pneumonia in the elderly: a review of severity assessment, prognosis, mortality, prevention, and treatment. South Med J 2009; 101:1134-40; quiz 1132, 1179. [PMID: 19088524 DOI: 10.1097/smj.0b013e31818247f1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pneumonia is an increasingly common disease in the elderly due to an aging population. This is a comprehensive literature review outlining the severity assessment, morbidity, mortality, prevention and treatment options. Several models have been postulated to predict severity assessment and prognosis in older patients. Mortality increases with age and functional status is also an independent predictor for short- and long-term mortality. The effectiveness of the pneumococcal vaccine is controversial, whereas the influenza vaccine is universally recommended. Treatment involves antibiotics with the type and method depending on the severity of the pneumonia. However, treatment of nursing home patients is challenging and there are no validated guidelines at present to determine when transfer to the hospital is necessary.
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98
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Díaz LA, Mortensen EM, Anzueto A, Restrepo MI. Review: Novel targets in the management of pneumonia. Ther Adv Respir Dis 2008; 2:387-400. [DOI: 10.1177/1753465808098694] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Community-acquired pneumonia (CAP) is the leading cause of death from infectious diseases in the US. It accounts each year for 500,000 hospitalizations and 45,000 deaths and represents one of the most common causes of intensive care unit (ICU) admission. The mortality rate due to severe CAP has shown little improvement in the past three decades, remaining between 21% and 58% in patients admitted to the intensive care unit. Antimicrobial agents are the cornerstone of therapy against CAP, but there are some novel antibiotic and nonantibiotic therapies that have been recently tested that may potentially impact outcomes of patients with severe CAP. We will review the most recent data regarding novel therapies in patients with the highest risk of death such as those with severe CAP.
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Affiliation(s)
- Luis A. Díaz
- Geisinger Health System and Fundación Universitaria de Ciencias de la Salud, Hospital de San José, Bogotá DC, Colombia
| | - Eric M. Mortensen
- General Internal Medicine, VERDICT, South Texas Veterans Health Care System and Audie L Murphy Division, University of Texas Health Science Center, San Antonio, USA
| | - Antonio Anzueto
- Division of Pulmonary and Critical Care Medicine, South Texas Veterans Health Care System and Audie L Murphy Division, University of Texas Health Science Center, San Antonio, USA
| | - Marcos I. Restrepo
- Division of Pulmonary and Critical Care Medicine, VERDICT, South Texas Veterans Health Care System and Audie L Murphy Division, University of Texas Health Science Center, San Antonio, USA,
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Figueiredo S, Vaz AP, Bento J, Pinheiro MD, Amorim A, Damas C. Internamento devido a PAC por Streptococcus pneumoniae – Avaliação de factores de mortalidade. REVISTA PORTUGUESA DE PNEUMOLOGIA 2008. [DOI: 10.1016/s0873-2159(15)30271-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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100
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Charles PGP, Wolfe R, Whitby M, Fine MJ, Fuller AJ, Stirling R, Wright AA, Ramirez JA, Christiansen KJ, Waterer GW, Pierce RJ, Armstrong JG, Korman TM, Holmes P, Obrosky DS, Peyrani P, Johnson B, Hooy M, Grayson ML. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008; 47:375-84. [PMID: 18558884 DOI: 10.1086/589754] [Citation(s) in RCA: 328] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Existing severity assessment tools, such as the pneumonia severity index (PSI) and CURB-65 (tool based on confusion, urea level, respiratory rate, blood pressure, and age >or=65 years), predict 30-day mortality in community-acquired pneumonia (CAP) and have limited ability to predict which patients will require intensive respiratory or vasopressor support (IRVS). METHODS The Australian CAP Study (ACAPS) was a prospective study of 882 episodes in which each patient had a detailed assessment of severity features, etiology, and treatment outcomes. Multivariate logistic regression was performed to identify features at initial assessment that were associated with receipt of IRVS. These results were converted into a simple points-based severity tool that was validated in 5 external databases, totaling 7464 patients. RESULTS In ACAPS, 10.3% of patients received IRVS, and the 30-day mortality rate was 5.7%. The features statistically significantly associated with receipt of IRVS were low systolic blood pressure (2 points), multilobar chest radiography involvement (1 point), low albumin level (1 point), high respiratory rate (1 point), tachycardia (1 point), confusion (1 point), poor oxygenation (2 points), and low arterial pH (2 points): SMART-COP. A SMART-COP score of >or=3 points identified 92% of patients who received IRVS, including 84% of patients who did not need immediate admission to the intensive care unit. Accuracy was also high in the 5 validation databases. Sensitivities of PSI and CURB-65 for identifying the need for IRVS were 74% and 39%, respectively. CONCLUSIONS SMART-COP is a simple, practical clinical tool for accurately predicting the need for IRVS that is likely to assist clinicians in determining CAP severity.
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Affiliation(s)
- Patrick G P Charles
- Departments of 1Infectious Diseases and 2Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC 3084, Australia.
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