Original ContributionValidation of the Infectious Diseases Society of America/American Thoracic Society criteria to predict severe community-acquired pneumonia caused by Streptococcus pneumoniae☆,☆☆
Introduction
Despite advances in antimicrobials and vaccines, community-acquired pneumonia (CAP) remains a common illness and a major cause of morbidity and mortality. Approximately 5 to 6 million people are diagnosed with CAP annually, whereas more than 1 million require hospitalization [1], [2]. The average mortality for hospitalized patients is 13.7% but ranges from approximately 8% in patients not requiring admission to an intensive care unit (ICU) to 36.5% for patients admitted to the ICU [3], [4], [5]. The pathogen responsible for CAP is difficult to identify in many cases; however, Streptococcus pneumoniae remains the most commonly isolated pathogen. In a large meta-analysis, it was found to be responsible for two thirds of bacteremic pneumonia cases and one third of patients admitted to the ICU [3].
Community-acquired pneumonia is a disease with a wide spectrum of presentation, ranging from a mild self-limiting condition to one that is occasionally fatal. Although there is no universally accepted definition for severe CAP, it is usually referred to as one that requires ICU admission. Approximately 10% of patients who are hospitalized with CAP require ICU admission [6]. In most situations, the decision to admit a patient to the ICU depends on the clinical judgment of the physician and on that of local practices in the health care system. Because delayed transfer to the ICU has been shown to be associated with increased mortality, there is a need for establishment of valid criteria for the identification of severe CAP and subsequent ICU admission. Various prognostic models such as the 2001 ATS guidelines [7], the criteria of the British Thoracic Society [8], and the Pneumonia Severity Index (PSI) score [9] have been used to evaluate the severity of CAP and to predict mortality rates for different patients. In general, these rules are thought to be overly sensitive and poorly specific. As a result, the 2007 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) consensus recommend new criteria for ICU admission [6]. The new proposed criteria for severe CAP have not been validated in any clinical population. The aim of this study was to evaluate these criteria and compare their accuracy with other severity scores for prediction of ICU admission and mortality in a population with CAP caused by S pneumoniae.
Section snippets
Study design
This was a retrospective cohort study of adult patients admitted to Hartford Hospital between 1999 and 2003 with documented pneumococcal CAP, who were previously included in a pharmacoeconomic analysis [10]. Hartford Hospital is an 810-bed private teaching hospital located in Hartford, Conn. This study was reviewed and approved by our hospital's institution review board; no consent was required because the data were already in existence.
Patients
We studied all patients with CAP admitted to the hospital
Population
A total of 158 patients met the criteria and were included in the analysis (Table 1). Thirty-one (19.6%) patients were admitted to the ICU directly from the ED, and 11 (7%) were transferred to the ICU from the floors later during their hospitalization (3 on the first day, 5 by day 3, and 3 afterward). The overall mortality rate was 12.7%, 7.9% for patients not initially admitted to the ICU and 32.3% for those admitted to the ICU. Mortality was 45.5% for the 11 patients who were later
Discussion
This is the first study to evaluate the 2007 IDSA/ATS criteria for severe pneumonia and to compare their performance with other published scores for different outcomes, such as ICU admission and mortality in a population with pneumonia caused by S pneumoniae. We observed that the 2007 IDSA/ATS rule was a sensitive tool for ICU admission, but it did not demonstrate superiority to the previous 2001 ATS guidelines. The new guidelines propose a greater number of variables that can be considered to
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Cited by (34)
Predicting the need for ICU admission in community-acquired pneumonia
2019, Respiratory MedicineCitation Excerpt :In this retrospective analysis of over 8000 adult hospitalizations for CAP at nine different hospitals in Louisville, KY we tested and compared the accuracy of 4 different models in predicting ICU admission for severe CAP and were able to achieve higher accuracy and specificity than previously described scoring systems. In 2007, the IDSA/ATS Guidelines on Management of CAP were published providing major and minor criteria for severe CAP that were later studied by multiple groups with different findings in regards to its validation [14–19]. Studies from Chalmers et al., Phua et al. and Brown et al. validated the 2007 IDSA/ATS minor criteria as predictors of ICU admission, however with smaller samples than our study [14,16,17].
Validity of SMART-COP score in prognosis and severity of community acquired pneumonia in the emergency department
2019, American Journal of Emergency MedicineCitation Excerpt :Community acquired pneumonia (CAP), is a type of pneumonia happened in non-hospitalized patients [2]. Pneumonia incidence is 20–30% in developing countries while 3–4% in developed ones [1-3]. It is one of the most common reasons of morbidity and mortality.
Severe Community-Acquired Pneumonia
2013, Critical Care ClinicsCitation Excerpt :Minor criteria include PaO2:FiO2 ratio less than 250, respiratory rate greater than 30 breaths/min, multilobar infiltrates, systolic blood pressure less than 90 mm Hg despite aggressive fluid resuscitation, blood urea nitrogen level greater than 20 mg/dL, leukopenia (<4000 cells/mm3), thrombocytopenia (<100,000 cells/mm3), and hypothermia (<36 C). Numerous validation studies support the use of these criteria.143–146 Other more recently derived prediction rules include SMART-COP (Box 6), a tool that aims to predict the need for intensive respiratory or vasopressor support (IRVS) in patients with CAP.147
Pneumococcal pneumonia-are the new severity scores more accurate in predictingadverse outcomes?
2013, Revista Portuguesa de PneumologiaDefining severe pneumonia
2011, Clinics in Chest MedicineCitation Excerpt :The American Thoracic Society has also proposed severity models with multiple iterations45,64 and validations.46–48,57 The IDSA/ATS 20075 guidelines include new predictors that are in the process of validation with reasonable performance.52,65–67 Other models specific to SCAP have been developed, including a recent Australian model called SMART-COP,51 a Spanish model called CURXO (although the investigators of this prediction model designate it SCAP, the authors find this usage confusing because the score is designed to predict SCAP but is one of several competing prediction models; the authors therefore refer to it as CURXO),68–70 and a mixed French-American score called the REA-ICU index.71
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The study was internally funded by the Center for Anti-Infective Research and Development, Hartford Hospital.
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Drs. Kuti and Nicolau are employees of the Center for Anti-Infective Research and Development, Hartford Hospital. The authors report no other conflicts of interest.