Abstract
BackgroundSeveral biomarkers and prognostic scores have been evaluated to predict prognosis in community-acquired pneumonia (CAP). Optimal risk stratification remains to be evaluated. The aim of this study was to evaluate serum cortisol as biomarker for the prediction of adverse outcomes independently of the CRB-65 score und inflammatory biomarkers in a large cohort of hospitalised patients with CAP.Methods984 hospitalised CAP-patients were included. Serum cortisol was measured and its prognostic accuracy compared to the CRB-65 score, leucocyte count and C-reactive protein. Predefined endpoints were 30-day mortality and the combined endpoint critical pneumonia, defined as presence of death occurring during antibiotic treatment, mechanical ventilation, catecholamine treatment or ICU admission.Results64 patients died (6.5%) and 85 developed critical pneumonia (8.6%). Cortisol levels were significantly elevated in both adverse outcomes (p < 0.001) and predicted mortality (AUC 0.70, cut-off 795 nmol/L) and critical pneumonia (AUC 0.71) independently of all other measured variables after logistic regression analysis (p = 0.005 and 0.001, respectively). Prognostic accuracy of CRB-65 was significantly improved by adding cortisol levels (combined AUC 0.81 for both endpoints). In Kaplan-Meier analysis, cortisol predicted survival within different CRB-65 strata (p = 0.003). In subgroup analyses, cortisol independently predicted critical pneumonia when compared to procalcitonin, the CURB65 score and minor criteria for severe pneumonia according to the 2007 ATS/IDSA-guideline.ConclusionCortisol predicts mortality and critical disease in hospitalised CAP-patients independently of clinical scores and inflammatory biomarkers. It should be incorporated into trials assessing optimal combinations of clinical criteria and biomarkers to improve initial high risk prediction in CAP.
Highlights
Several biomarkers and prognostic scores have been evaluated to predict prognosis in communityacquired pneumonia (CAP)
The predefined criteria for the combined endpoint of critical pneumonia occurred in 85 patients (8.6%): Death during antimicrobial treatment (N = 37), ICU-admission (N = 19, 2 died during antimicrobial treatment), mechanical ventilation (N = 44, 11 of them on ICU, 2 more died during antimicrobial treatment) or catecholamine treatment (N = 5, all on ICU)
We found the known risk factors age, male sex, nursing home residence, chronic comorbidities, CRB-65 score and the measured inflammatory biomarkers to be associated with both endpoints [26,27]
Summary
Several biomarkers and prognostic scores have been evaluated to predict prognosis in communityacquired pneumonia (CAP). The aim of this study was to evaluate serum cortisol as biomarker for the prediction of adverse outcomes independently of the CRB-65 score und inflammatory biomarkers in a large cohort of hospitalised patients with CAP. International guidelines recommend prognostic scores to support clinical decision on management as outpatient, inpatient or admission to ICU. The most established score systems are the PSI-score and the CURB or CRB-65 scores, which perform comparably for mortality prediction and identification of low risk patients suitable for an outpatient management strategy [1,2,3]. Biomarkers have been found to improve risk stratification and management decisions in CAP. Other biomarkers like pro-ADM, pro-ANP, pro-BNP, provasopressin and d-dimer have been associated with mortality in CAP [9,10,11,12,13]
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