Severity assessment in community-acquired pneumonia

Abstract

In current guidelines for the management of adults with community‐acquired pneumonia (CAP), the triaging decision about hospitalization or intensive care unit (ICU) admission, and, as a consequence, selection of initial antimicrobial treatment is largely based on the assessment of pneumonia severity. The proposed severity criteria are mainly derived from studies determining pre‐dictors of adverse outcome. These include age, male sex, comorbidity, acute respira‐tory failure, severe sepsis and septic shock, extension of radiographic infiltrates, bacteraemia and CAP through several different pathogens such as Streptococcus pneumoniae, Staphylococcus aureus, Gram‐negative enteric bacilli (GNEB), and signs of disease progression within the first 48–72 h. In addition, prediction rules and need for a complicated course in ambulatory and hospitalized patients, for the individual risk of death have been developed which may be helpful in determining the patient who might require hospitalization or intensive care, respectively. Risk classifications such as the scores developed by F ineet al. [40] are not only useful for identifying low risk patients who might safely be treated as outpatients, but apparently they will also play a major role in the evaluation of processes and outcomes of care for patients with CAP. Recent investigations have provided objective criteria for the definition of severe CAP requiring ICU admission. Whether the detection of infiltrates in the chest radiographs of patients with acute lower respiratory tract infection (LRTI) suggestive of mild pneumonia has an independent prognostic impact which fundamentally affects the concept of mild LRTI remains to be seen. Based on objective criteria for severity assessment it will be possible to define interventions aimed at reducing hospital admission rates, define a risk‐adapted anti‐microbial treatment regimen, reduce costs for antimicrobial treatment and supportive measures, shorten hospital stay, and, thereby, improve the quality of care for patients with community‐acquired pneumonia.

Severe community-acquired pneumonia: assessment of microbial aetiology as mortality factor

“…A multivariate analysis of these factors only found septic shock, SAPS II and positive blood cultures to be independently associated with mortality. All these findings were consistent with those reported in the literature [2][3][4][5][6][7][8][9][10][11][12].…”

“…Many studies have investigated CAP prognosis factors [1][2][3][4][5][6][7][8][9][10][11][12], and guidelines have been proposed by several medical societies to define the optimal management of patients with CAP [13][14][15][16][17].…”

Validation of predictive rules and indices of severity for community acquired pneumonia

“…6 However, in contrast to the PORT population, the rate of ICU admissions in our population was twice as high as the upper limit of reported rates of 10-18% in the literature. 1 This difference is most probably due to different medical attitudes to the treatment of patients with severity criteria but not requiring mechanical ventilation and/or vasopressors. In our view, these patients are at higher risk of adverse outcomes and, whether treated in the ICU or any facility comparable to intermediate care units, should be considered as severe CAP.…”

“…1 However, the decision to admit a patient with CAP to the ICU may depend on subjective clinical views and peculiarities of the local healthcare setting. The establishment of valid criteria for a definition of severe pneumonia would therefore provide a more reliable basis for improving patient risk assessment in daily practice as well as in diagnostic or therapeutic trials.…”

Recent developments in pulmonary infections

“…EWIG et al [11] describe severity assessment in community-acquired pneumonia, which is one of the most critical steps to the direction of patient investigation and management. At first sight, the various severity prediction rules that have been described can appear confusing, but the place of the most recently described methodologies are clarified and what further work is needed is identified.…”