Validation of IDSA/ATS Guidelines for ICU Admission in Adults Over 80 Years Old With Community-Acquired Pneumonia

Abstract

IntroductionThe 2007 IDSA/ATS guidelines for community-acquired pneumonia (CAP) recommended intensive care unit (ICU) admission for adults meeting severe CAP criteria. We aimed to validate the accuracy of IDSA/ATS criteria in patients≥80 years old (very elderly patients, VEP) with CAP. MethodsProspective cohort study of VEP with CAP admitted to three Spanish hospitals between 1996 and 2019. We compared patients who did and did not require ICU admission. We also assessed factors independently associated with ICU admission, as well as the accuracy of severe CAP criteria for ICU admission and mortality. Major criteria include septic shock and invasive mechanical ventilation while minor criteria encompass other variables related to hemodynamics and respiratory insufficiency as well as level of consciousness, renal function, blood parameters indicative of sepsis and body temperature. ResultsOf the 2006 VEP with CAP, 519 (26%) met severe CAP criteria, while 204 (10%) required ICU admission. Concordance between severe CAP criteria and the decision to admit the patient to the ICU occurred in 1591 (79%) cases (k coefficient, 0.33), with a sensitivity of 75% and specificity of 80% in predicting ICU admission. All patients with invasive mechanical ventilation received care in ICUs, while 45 (44%) patients with septic shock—previously stabilized in the emergency room—did not. Thirty-day mortality of ICU-admitted patients with septic shock was lower than that of patients in wards (30% vs. 60%, p=0.013). In contrast, patients with severe CAP and only minor criteria had similar mortality. ConclusionsIDSA/ATS criteria for severe CAP predict ICU admission in VEP moderately well. While patients with septic shock and invasive mechanical ventilation warrant ICU admission, severe CAP without major severity criteria in VEP may be acceptably manageable in wards.