Severe Community‐Acquired Pneumonia: Validation of the Infectious Diseases Society of America/American Thoracic Society Guidelines to Predict an Intensive Care Unit Admission

Abstract

The predictive rule to identify severe CAP is accurate for ICU admission and improved the prediction of mortality, compared with the previous American Thoracic Society guidelines. The need for ICU admission derived from minor severity criteria alone is uncertain and deserves further investigation.

The impact of a delay in intensive care unit admission for community-acquired pneumonia

“…A pproximately 10% of hospitalised patients with community-acquired pneumonia (CAP) are admitted to the intensive care unit (ICU) [1][2][3][4][5]. The mortality for this group of patients is extremely high and ranges 20-50% in some studies [6].…”

“…Although the Infectious Disease Society of America (IDSA) and the American Thoracic Society (ATS) issued guidelines in 2007 which recommended that patients with severe CAP be promptly admitted to the ICU [1], onethird to a half of such patients are in fact first transferred from the emergency department (ED) to the general wards [7,8]. Part of the problem is that while patients who require emergent mechanical ventilation and/or vasopressors (defined by the IDSA/ATS as major criteria for severe CAP) and hence direct ICU admission may easily be identified [2], clinical findings at the ED which suggest a rapidly progressive pneumonia are often more subtle. Accordingly, numerous clinical criteria for severe CAP requiring ICU admission have recently been proposed [3,9,10], including the IDSA/ATS minor criteria [1,11,12].…”

Weight of the CURB-65 Criteria for Community-Acquired Pneumonia in a Very Low-Mortality-Rate Setting

“…A criterion not impacting in low-mortality-rate institutions might be important for places where mortality is high (19). The overall 30-day mortality was 1.3% in the current study, whereas they were 14.7% in Phua's study (9), 9% in Lim's study (15) and 3.6% in Liapikou's study (16). The mortalities in the current and Liapikou's studies were low, which might explain the lack of an association of hypotension with mortality.…”

“…30-minutes -1 and low blood pressure were of unequal weight in predicting hospital mortality and that confusion had the strongest association with mortality when validating the IDSA/ATS minor criteria for severe CAP. Liapikou et al (16) were also unable to demonstrate any association be- (17) could. Chalmers' prospective study showed that the diastolic blood pressure was less related to mortality and even recommended that the CURB65 score could be simplified to a modified CRB65 score by omission of the diastolic blood pressure criterion without compromising its accuracy.…”

“…Lim's international derivation and validation study revealed that the weight of each of the CURB-65 criteria were 8.1, 5.6, 1.7, 2.4 and 5.5, respectively (15), which were different from that currently reported. Liapikou et al (16) and Phua et al (9) discovered that confusion, urea >7 mmol·L -1 , respiratory rate ! 30-minutes -1 and low blood pressure were of unequal weight in predicting hospital mortality and that confusion had the strongest association with mortality when validating the IDSA/ATS minor criteria for severe CAP.…”