Validation of IDSA/ATS guidelines for ICU admission in very elderly patients with community-acquired pneumonia

Abstract

<b>Background:</b> The 2007 IDSA/ATS guidelines for community-acquired pneumonia (CAP) recommended intensive care unit (ICU) admission for adults meeting severe CAP criteria (1 major criterion or 3 minor criteria). We aimed to validate the accuracy of IDSA/ATS criteria in very elderly patients (VEP, i.e. ≥80 years) with CAP. <b>Study design and methods:</b> Prospective 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. <b>Results:</b> Of the 1797 VEP with CAP, 503 (28%) met severe CAP criteria, while 199 (11%) required ICU admission. Concordance between severe CAP criteria and the decision to admit the patient to the ICU occurred in 1397 (78%) cases (k coefficient, 0.32; sensitivity, 76%; specificity 78%). All patients with invasive mechanical ventilation received care in ICUs, while 45 (42%) 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 (8 [30%] vs. 27 [60%], p=0.013). In contrast, regardless of the site of care, patients with severe CAP and only minor criteria had similar mortality. <b>Conclusion:</b> IDSA/ATS criteria for severe CAP predict ICU admission in VEP moderately well. While patients with septic shock should warrant ICU admission, even if previously stabilized, severe CAP without major severity criteria may be acceptably manageable in wards.