Infectious Diseases Society Of America/American Thoracic Society Research Articles

Is the fluoroquinolone combination necessary for empirical antibiotic regimen in severe community-acquired pneumonia?

ABSTRACT Objectives This study aimed to assess whether superior clinical outcomes can be attained through piperacillin/tazobactam (TZP)+fluoroquinolone (FQ) combination therapy for severe community-acquired pneumonia (CAP) compared to TZP monotherapy. Methods This retrospective study was conducted at a tertiary care hospital in Korea. Adult inpatients diagnosed with pneumonia within 48 hours of hospitalization were included. Severe CAP was defined as a CURB-65 score of ≥ 3 or based on the 2007 guidelines of the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) definition. Only patients who received either TZP and FQ combination or TZP as initial empirical therapy were included. Results The final analysis included 145 patients; 57.9% received combination therapy and 42.1% received monotherapy. In the combination therapy group, body mass index (20.67 ± 3.28 vs. 22.26 ± 4.80, p = 0.030) and asthma prevalence (0 vs. 8.3%, p = 0.022) were significantly higher; initial symptoms, clinical severity, and causative pathogens were not significantly different between groups. White blood cell counts (12,641.64 ± 6,544.66 vs. 12,491.67 ± 10,528.24, p = 0.008), and C-reactive protein levels (18.78 ± 11.47 vs. 26.58 ± 14.97, p < 0.001) were significantly higher in the combination therapy group. Clinical outcomes, including all-cause in-hospital mortality rate (26.2 vs. 33.3%, p = 0.358), were not significantly different between the groups. Multivariate analysis identified no significant association between FQ combination and all-cause in-hospital mortality. Conclusion In patients with severe CAP, there were no differences in the clinical outcomes, including mortality, between the TZP and FQ combination therapy and TZP monotherapy. FQ combination was not significantly associated with in-hospital mortality.

Staphylococcus aureus Pneumonia in Can Tho, Vietnam: Clinical Characteristics, Antimicrobial Resistance Profile and Risk Factors of Mortality.

Staphylococcus aureus (S.aureus) is an important pathogen in both community-acquired and hospital-acquired pneumonia. S.aureus pneumonia has a high mortality rate and serious complications. Resistance to multiple antibiotics is a major challenge in the treatment of S.aureus pneumonia. Understanding the antibiotic resistance profile of S.aureus and the risk factors for mortality can help optimize antibiotic regimens and improve patient outcomes in S.aureus pneumonia. A prospective cohort study of 118 patients diagnosed with S.aureus pneumonia between May2021 and June 2023 was conducted, with a 30-day follow-up period. Demographic information, comorbidities, Charlson Comorbidity Index, clinical characteristics, outcomes, and complications were collected for each enrolled case. The data were processed and analyzed using R version 3.6.2. S.aureus pneumonia has a 30-day mortality rate of approximately 50%, with complication rates of 22% for acute respiratory distress syndrome (ARDS), 26.3% for septic shock, and 14.4% for acute kidney injury (AKI). Among patients with methicillin-resistant S.aureus (MRSA) pneumonia treated with vancomycin (n = 40), those with a vancomycin minimum inhibitory concentration (MIC) ≤ 1had significantly higher cumulative survival at day30 compared to those with MIC ≥ 2 (log-rank test p = 0.04). The prevalence of MRSA among S.aureus isolates was 84.7%. Hemoptysis, methicillin resistance, acidosis (pH < 7.35), and meeting the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) criteria for severe pneumonia were significantly associated with mortality in a multivariate Cox regression model based on the adaptive least absolute shrinkage and selection operator (LASSO). S.aureus pneumonia is a severe clinical condition with high mortality and complication rates. MRSA has a high prevalence in Can Tho City, Vietnam. Hemoptysis, methicillin resistance, acidosis (pH < 7.35), and meeting the IDSA/ATS criteria for severe pneumonia are risk factors for mortality in S.aureus pneumonia.

Comparative analysis of clinical features between severe coronavirus disease 2019 and severe community acquired pneumonia

To compare and analyze the clinical features of patients with severe coronavirus disease 2019 (sCOVID-19) and severe community acquired pneumonia (sCAP) who meet the diagnostic criteria for severe pneumonia of the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS). A retrospective comparative analysis of the clinical records of 116 patients with sCOVID-19 admitted to the department of critical care medicine of Wuhan Third Hospital from January 1, 2020 to March 31, 2020 and 135 patients with sCAP admitted to the department of critical care medicine of Shanghai First People's Hospital from January 1, 2010 to December 31, 2017 was conducted. The basic information, diagnosis and comorbidities, laboratory data, etiology and imaging results, treatment, prognosis and outcome of the patients were collected. The differences in clinical data between sCOVID-19 and sCAP patients were compared, and the risk factors of death were analyzed. The 28-day mortality of sCOVID-19 and sCAP patients were 50.9% (59/116) and 37.0% (50/135), respectively. The proportion of arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ≤ 250 mmHg (1 mmHg ≈ 0.133 kPa) in sCOVID-19 patients was significantly higher than that of sCAP [62.1% (72/116) vs. 34.8% (47/135), P < 0.01]. The possible reason was that the proportion of multiple lung lobe infiltration in sCOVID-19 was significantly higher than that caused by sCAP [94.0% (109/116) vs. 40.0% (54/135), P < 0.01], but the proportion of sCOVID-19 patients requiring mechanical ventilation was significantly lower than that of sCAP [45.7% (53/116) vs. 60.0% (81/135), P < 0.05]. Further analysis of clinical indicators related to patient death found that for sCOVID-19 patients PaO2/FiO2, white blood cell count (WBC), neutrophils (NEU), neutrophil percentage (NEU%), neutrophil/lymphocyte ratio (NLR), total bilirubin (TBil), blood urea nitrogen (BUN), albumin (ALB), Ca2+, prothrombin time (PT), D-dimer, C-reactive protein (CRP) and other indicators were significantly different between the death group and the survival group, in addition, the proportion of receiving mechanical ventilation, gamma globulin, steroid hormones and fluid resuscitation in death group were higher than survival group. Logistic regression analysis showed that the need for mechanical ventilation, NLR > 10, TBil > 10 μmol/L, lactate dehydrogenase (LDH) > 250 U/L were risk factors for death at 28 days. For sCAP patients, there were significant differences in age, BUN, ALB, blood glucose (GLU), Ca2+ and D-dimer between the death group and the survival group, but there was no significant difference in treatment. Logistic regression analysis showed that BUN > 7.14 mmol/L and ALB < 30 g/L were risk factors for 28-day death of sCAP patients. The sCOVID-19 patients in this cohort have worse oxygen condition and symptoms than sCAP patients, which may be due to the high proportion of lesions involving the lungs. The indicators of the difference between the death group and the survival group were similar in sCOVID-19 and sCAP patients. It is suggested that the two diseases have similar effects on renal function, nutritional status and coagulation function. But there were still differences in risk factors affecting survival. It may be that sCOVID-19 has a greater impact on lung oxygenation function, inflammatory cascade response, and liver function, while sCAP has a greater impact on renal function and nutritional status.

Respiratory syncytial virus-associated acute respiratory illness in adult non-immunocompromised patients: Outcomes, determinants of outcomes, and the effect of oral ribavirin treatment.

BackgroundRespiratory syncytial virus (RSV) is an increasingly common cause of respiratory illness in adult non‐immunocompromised patients. Oral ribavirin was reported to improve outcomes of RSV infection in immunocompromised patients. This study aimed to determine the outcomes of non‐immunocompromised patients hospitalized with RSV‐associated acute respiratory illnesses (RSV‐ARI), the factors independently associated with the outcomes and the effect of oral ribavirin treatment.MethodsThis retrospective, observational cohort study included 175 adults admitted to the hospital with virologically confirmed RSV‐ARI during 2014–2019. Severe ARI was identified using Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) criteria for severe community‐acquired pneumonia. The primary outcome was all‐cause mortality within 30 days after enrollment. A multivariable Cox model was performed to identify significant predictors of mortality.ResultsMean age was 76 ± 12.7 years. Seventy‐eight (44.6%) patients met the diagnostic criteria for severe ARI. Thirty‐six (20.6%) patients required invasive mechanical ventilation, and 11 (6.3%) required vasopressor. Ninety‐nine (56.6%) patients received oral ribavirin treatment, and 52 (29.7%) received systemic corticosteroids. Forty‐one (23.4%) patients had evidence of bacterial infection. Overall mortality was 7.4%. Mortality among patients with non‐severe ARI and severe ARI was 1.04% and 15.4%, respectively. Estimated glomerular filtration rate <50 ml/min/1.73 m2, severe ARI, systemic corticosteroids, and bacterial infection were independently associated with higher risk of mortality. Treatment with oral ribavirin was the only factor associated with reduced mortality (adjusted HR: 0.19, 95% CI: 0.04–0.9, P = 0.03).ConclusionRSV‐ARI may result in significant mortality and health care utilization. Treatment with oral ribavirin may improve survival in these patients.

Levels of evidence supporting European and American community-acquired pneumonia guidelines.

Optimal clinical decisions should be supported by clinical practice guidelines (CPG) based on evidence generated from randomized clinical trials (RCT). We aimed to evaluate the class and level of evidence (LOE) supporting the international community-acquired pneumonia (CAP) guidelines and their variation over time. The 2019 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) and the 2011 European Respiratory Society/European Society Clinical Microbiology Infectious Diseases (ERS/ESCMID) CPG and its immediate predecessors (2007 and 2005) were evaluated. The number of recommendations and distribution as LOE A (supported by multiple RCT or a single, large RCT), B (supported by data from a single RCT or observational studies) and C (expert opinion, case studies, or standard of care) was identified. Overall, recommendations for diagnosis, management, and prevention were graded as strong in 51.4%, 62.9%, and 23.5% in spite that they were supported by LOE A in 5.7%, 11.1%, and 52.9%, respectively. In the 2019 ATS/IDSA guidelines (39 recommendations), 7.7% (n= 3) recommendations were classified as LOE A, 30.8% (n= 12) as LOE B, and 61.5% (24%) as LOE C. Across the 2011 ERS/ESCMID guidelines (68 recommendations), 21.2% (n= 14) recommendations were classified as LOE A, 4.6% (n= 3) as LOE B, and 74.2% (n= 49) as LOE C. When comparing with prior versions, the proportion of recommendations that were LOE A did not significantly increase in ERS/ESCMID (21.2% vs 20%) and decreased in ATS/IDSA (7.7% vs 32.0%). In conclusion, large randomized trials or network meta-analysis including comparison of regimens to identify high probability of best cure and mortality is an unmet clinical need on CAP.

Levels of evidence supporting clinical practice guidelines on invasive aspergillosis.

Invasive aspergillosis (IA) is a severe life-threatening infection with challenges in therapy. The aim was to evaluate the level of evidence (LOE) supporting recommendations in clinical practice guidelines (CPGs) of IA and changes over time. Search on CPG on IA released between 2000 and 2019 was done. Last versions were evaluated and compared with previous versions. Recommendations were classified by LOE as A (multiple randomized controlled trial (RCT) or meta-analysis), B (data from a single RCT or observational studies), or C (observational studies with limitations, case series, or expert opinion). Diagnosis recommendations were excluded. Five CPG from three groups of scientific societies were identified: the 2016 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS), 2017 European Society of Clinical Microbiology Infectious Diseases/European Confederation of Medical Mycology/European Respiratory Society (ESCMID/ECMM/ERS), 2018 Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) CPGs, and their previous versions (2008 IDSA/ATS and 2011 GEMICOMED/SEIMC). ECMID/ECMM/ERS have not published any previous version. From 511 recommendations analyzed, 80 were classified as LOE A (15.7%), 223 LOE B (43.6%), and 208 LOE C (40.7%). Among 238 strong recommendations, only 57 (24.0%) were supported by LOE A. When comparing recent CPGs with previous versions, the proportion of recommendations supported by LOE A did not significantly increase over time (IDSA/ATS: 13.3% [2016] vs. 14.8% [2008], p = 0.798; and SEIMC: 22.6% [2018] vs. 19% [2011], p = 0.568). In conclusion, IA is a condition with an urgent unmet clinical need for more high-quality randomized trials.

Utility of community-acquired pneumonia severity scores in guiding disposition from the emergency department: Intensive care or short-stay unit?

To assess community-acquired pneumonia severity scores from two perspectives: (i) prediction of ICU admission or mortality; and (ii) utility of low scores for prediction of discharge within 48 h, potentially indicating suitability for short-stay unit admission. Patients with community-acquired pneumonia were identified from a prospective database of emergency patients admitted with infection. Pneumonia severity index (PSI), CURB-65, CORB, CURXO, SMARTCOP scores and the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) minor criteria were calculated. Diagnostic accuracy statistics (sensitivity, specificity, predictive values, likelihood ratios and area under receiver operating characteristic curves [AUROC]) were determined for both end-points. Of 618 patients admitted with community-acquired pneumonia judged eligible for invasive therapies, 75 (12.1%) were admitted to ICU or deceased at 30 days, and 87 (14.1%) were discharged within 48 h. All scores effectively stratified patients into categories of risk. For prediction of severe pneumonia, SMARTCOP, CURXO and IDSA/ATS discriminated well (AUROC 0.84-0.87). SMARTCOP and CURXO showed optimal sensitivity (85% [95% confidence interval (CI) 75-92]), while specificity was highest for CORB and CURB-65 (93% and 94%, respectively). Using lowest risk categories for prediction of discharge within 48 h, only SMARTCOP and CURXO showed specificity >80%. PSI demonstrated highest positive predictive value (31% [95% CI 24-39]) and AUROC (0.74 [95% CI 0.69-0.79]). Community-acquired pneumonia severity scores had different strengths; SMARTCOP and CURXO were sensitive with potential to rule out severe disease, while the high specificity of CORB and CURB-65 facilitated identification of patients at high risk of requirement for ICU. Low severity scores were not useful to identify patients suitable for admission to short-stay units.

Improved survival among ICU-hospitalized patients with community-acquired pneumonia by unidentified organisms: a multicenter case-control study.

A retrospective analysis from prospectively collected data was conducted in intensive care units (ICUs) at 33 hospitals in Europe comparing the trend in ICU survival among adults with severe community-acquired pneumonia (CAP) due to unknown organisms from 2000 to 2015. The secondary objective was to establish whether changes in antibiotic policies were associated with different outcomes. ICU mortality decreased (p = 0.02) from 26.9% in the first study period (2000-2002) to 15.7% in the second period (2008-2015). Demographic data and clinical severity at admission were comparable between groups, except for age over 65 years and incidence of cardiomyopathy. Over time, patients received higher rates of combination therapy (94.3 vs. 77.2%; p < 0.01) and early (<3h) antibiotic delivery (72.9 vs. 50.3%; p < 0.01); likewise, the 2008-2015 group was more likely to receive adequate antibiotic prescription [as defined by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines] than the 2000-2002 group (70.7 vs. 48.2%; p < 0.01). Multivariate analysis showed an independent association between decreased ICU mortality and early (<3h) antibiotic administration [odds ratio (OR) 3.48 [1.70-7.15], p < 0.01] or adequate antibiotic prescription according to guidelines (OR 2.22 [1.11-4.43], p = 0.02). In conclusion, our findings suggest that ICU mortality in severe CAP due to unidentified organisms has decreased in the last 15years. Several changes in management and better compliance with guidelines over time were associated with increased survival.

Adherence to Guidelines for Treating Community‐Acquired Pneumonia at a New Zealand Hospital

ABSTRACTBackgroundAdherence to guidelines for community‐acquired pneumonia (CAP) has been shown to improve patient outcomes and slow the emergence of antimicrobial resistance. Guidelines for treating CAP vary considerably.AimTo determine the initial antimicrobial therapy used in hospitalised adults with CAP and to compare it with local and international CAP treatment guidelines.MethodA retrospective cohort study of adults presenting to an Auckland hospital with CAP. Initial choice of antimicrobial therapy was compared to the local hospital guidelines and the British Thoracic Society (BTS), Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) and Swedish Society of Infectious Diseases (SSID) guidelines.ResultsInitial treatment in 177 patients presenting with their first episode of CAP included parenteral cephalosporin (61%), amoxycillin+clavulanate (37%), amoxycillin (2.8%) and macrolide (53%). 83/92 (90%) patients with a CURB‐65 score of 0–1 were treated with a cephalosporin or amoxycillin+clavulanate. 42/85 (49%) patients with a CURB‐65 score ≥ 2 were treated with a macrolide. Adherence with treatment guidelines was 97% (hospital), 53% (IDSA/ATS), 11% (BTS) and 10% (SSID).ConclusionInitial treatment of adults with CAP adhered closely with local guidelines was discordant with the BTS and SSID guidelines.

Prognostic value of plasma N‐terminal pro B‐type natriuretic peptide levels in pneumonia patients requiring intensive care unit admission

Correct and early risk stratification for critically ill pneumonia patients remains an unmet medical need. This study aimed to test whether N-terminal pro B-type natriuretic peptide (NT-proBNP) can serve as a prognostic marker in this setting. This prospective study enrolled 216 pneumonia patients admitted to intensive care unit. Plasma NT-proBNP samples were obtained upon admission and primary outcome was all-cause mortality at 30 days. Meanwhile, Acute Physiology and Chronic Health Evaluation (APACHE) II and Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) 2007 minor criteria were assessed. Overall 30-day mortality was 30%. NT-proBNP levels were significantly higher in nonsurvivors than survivors (11 938 ± 13 121 vs 5658 ± 9240 pg/mL, P = 0.001). Area under receiver operating characteristic curves of NT-proBNP, APACHE II and IDSA/ATS 2007 minor criteria were not significantly different regarding prediction of mortality (0.715, 0.754 vs 0.654, P = 0.085). Adding NT-proBNP to APACHE II significantly increased the area under receiver operating characteristic curve from 0.754 to 0.794 (P = 0.048). Receiver operating characteristic analysis revealed optimal NT-proBNP and APACHE II cut-offs of 2177.5 pg/mL and 25.5, respectively. In multivariate analysis, both NT-proBNP and APACHE II values above cut-offs had a significantly higher probability of death than those below cut-offs. A categorical approach combining NT-proBNP and APACHE II cut-offs provides additional risk stratification over a single marker approach. For pneumonia patients admitted to intensive care unit, NT-proBNP strongly and independently predicts mortality, and its prognostic accuracy is comparable with APACHE II and IDSA/ATS 2007 minor criteria.

Impact of infectious etiology on the outcome of Taiwanese patients hospitalized with community acquired pneumonia

This study aimed to assess the relationships between infectious etiology, empiric treatment, and outcomes in Taiwanese patients with community acquired pneumonia (CAP). A retrospective analysis of the data of 208 adult patients from a single medical center was performed with patients classified as having low or high disease severity based on the Pneumonia Severity Index (PSI). Patients with PSI ≤ 90 (n=120) were classified as low severity and patients with PSI > 90 (n=88) were classified as high severity. The low-risk group had significantly higher rates of infection with Chlamydia pneumoniae (C. pneumoniae) and Mycoplasma pneumoniae (M. pneumoniae), whereas the high-risk group had significantly higher rates of infection with Klebsiella pneumoniae (K. pneumoniae) and Pseudomonas aeruginosa (P. aeruginosa) (p < 0.05). Empiric treatment in both groups was in accordance with the 2007 guidelines issued by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS). Twenty-nine of 208 patients (13.9%) died, one in the low-risk group and 28 in the high-risk group. The highest rates of mortality were in patients infected with P. aeruginosa or K. pneumoniae. In the present study, we demonstrated that the patients with different severity had different microbiologic etiology. In general, P. aeruginosa and K. pneumoniae were the most commonly isolated organisms in high-risk patients who died from CAP. We showed that use of the IIDSA/ATS guidelines for treatment of CAP in Taiwan resulted in a better outcome in the low PSI group.

Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations

Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the USA. The objective of this study was to evaluate management practices for inpatient CAP in relation to Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines to identify opportunities for antibiotic and health care resource stewardship. This was a retrospective cohort study of adults hospitalized for CAP at a single institution from 15 April 2008 to 31 May 2009. Of the 209 patients with CAP who presented to Denver Health Medical Center during the study period and were hospitalized, 166 (79 %) and 43 (21 %) were admitted to a medical ward and the intensive care unit (ICU), respectively. Sixty-one (29 %) patients were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. Sputum cultures were ordered for 110 specimens; however, an evaluable sample was obtained in only 49 (45 %) cases. Median time from antibiotic initiation to specimen collection was 11 [interquartile range (IQR) 6-19] h, and a potential pathogen was identified in only 18 (16 %) cultures. Blood cultures were routinely obtained for both non-ICU (81 %) and ICU (95 %) cases, but 15 of 36 (42 %) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone + azithromycin (182, 87 % cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66 %), most commonly levofloxacin (101, 55 %). Treatment durations were typically longer than suggested with a median of 10 (IQR 8-12) days. In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations, revealing potential targets to reduce unnecessary antibiotic and healthcare resource utilization.

Application and comparison of scoring indices to predict outcomes in patients with healthcare-associated pneumonia

IntroductionHealthcare-associated pneumonia (HCAP) is a relatively new category of pneumonia. It refers to infections that occur prior to hospital admission in patients with specific risk factors following contact or exposure to a healthcare environment. There is currently no scoring index to predict the outcomes of HCAP patients. We applied and compared different community acquired pneumonia (CAP) scoring indices to predict 30-day mortality and 3-day and 14-day intensive care unit (ICU) admission in patients with HCAP.MethodsWe conducted a retrospective cohort study based on an inpatient database from six medical centers, recruiting a total of 444 patients with HCAP between 1 January 2007 and 31 December 2007. Pneumonia severity scoring indices including PSI (pneumonia severity index), CURB 65 (confusion, urea, respiratory rate, blood pressure, age 65), IDSA/ATS (Infectious Diseases Society of America/American Thoracic Society), modified ATS rule, SCAP (severe community acquired pneumonia), SMART-COP (systolic blood pressure, multilobar involvement, albumin, respiratory rate, tachycardia, confusion, oxygenation, pH), SMRT-CO (systolic blood pressure, multilobar involvement, respiratory rate, tachycardia, confusion, oxygenation), and SOAR (systolic blood pressure, oxygenation, age, respiratory rate) were calculated for each patient. Patient characteristics, co-morbidities, pneumonia pathogen culture results, length of hospital stay (LOS), and length of ICU stay were also recorded.ResultsPSI (>90) has the highest sensitivity in predicting mortality, followed by CURB-65 (≥2) and SCAP (>9) (SCAP score (area under the curve (AUC): 0.71), PSI (AUC: 0.70) and CURB-65 (AUC: 0.66)). Compared to PSI, modified ATS, IDSA/ATS, SCAP, and SMART-COP were easy to calculate. For predicting ICU admission (Day 3 and Day 14), modified ATS (AUC: 0.84, 0.82), SMART-COP (AUC: 0.84, 0.82), SCAP (AUC: 0.82, 0.80) and IDSA/ATS (AUC: 0.80, 0.79) performed better (statistically significant difference) than PSI, CURB-65, SOAR and SMRT-CO.ConclusionsThe utility of the scoring indices for risk assessment in patients with healthcare-associated pneumonia shows that the scoring indices originally designed for CAP can be applied to HCAP.

Validation of Scoring Systems for Predicting Severe Community-Acquired Pneumonia

Several scoring systems have been derived to identify patients with severe community-acquired pneumonia (CAP). Recently, España et al (Am J Respir Crit Care Med 174:1249-1256, 2006) developed a clinical prediction rule that predicts hospital mortality, the need for mechanical ventilation, and risk for septic shock. We assessed the performance of this rule and compared it with other published scoring systems. A prospective study was conducted of patients with CAP who were hospitalized at our hospital from April 2007 till May 2009. Clinical and laboratory features at presentation were recorded and used in order to calculate España rule, the pneumonia severity index (PSI), CURB-65, A-DROP, the 2007 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) prediction rule and SMART-COP. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were compared for adverse outcomes. We also assessed the association of the España rule criteria and adverse outcomes. A total of 505 patients were enrolled in the study. The overall in-hospital mortality rate was 6.5%, and 6.3% of patients were admitted to the intensive care unit (ICU). Sixty-two (12.3%) patients were defined as having severe CAP (in-hospital death or need for mechanical ventilation or septic shock). España rule achieved highest sensitivity and NPV in predicting severe CAP. When ICU admission was the outcome measure, the IDSA/ATS rule and SMART-COP were regarded to be good predictors. España rule performed well in identifying patients with severe CAP. As a result, each of the severity scores has advantages and limitations for predicting adverse outcomes.

Validation of the Infectious Diseases Society of America/American Thoracic Society criteria to predict severe community-acquired pneumonia caused by Streptococcus pneumoniae

Background Severe community-acquired pneumonia (CAP) is usually defined as pneumonia that requires intensive care unit (ICU) admission; the primary pathogen responsible for ICU admission is Streptococcus pneumoniae. In this study, the 2007 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) consensus criteria for ICU admission were compared with other severity scores in predicting ICU admission and mortality. Methods We retrospectively studied 158 patients with pneumococcal CAP (1999-2003). Clinical and laboratory features at the emergency department were recorded and used to calculate the 2007 IDSA/ATS rule, the 2001 ATS rule, 2 modified 2007 IDSA/ATS rules, the Pneumonia Severity Index (PSI), and the CURB (confusion, urea, respiratory rate, blood pressure) score. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) were assessed for the various indices. We also determined the criteria that were independently predictive of ICU admission and of mortality in our population. Results The 2007 IDSA/ATS criteria performed as well as the 2001 ATS rule in predicting ICU admission both demonstrated high sensitivity (90%) and NPV (97%). For the prediction of mortality, the best tool proved to be the PSI score (sensitivity, 95%; NPV, 99%). The variables associated with ICU admission in this patient population included tachypnea, confusion, Pa o 2/Fi o 2 ratio of 250 or lower, and hypotension requiring fluid resuscitation. Mechanical ventilation and PSI class V were independently associated with mortality. Conclusions This study confirms the usefulness of the new criteria in predicting severe CAP. The 2001 ATS criteria seem an attractive alternative because they are simple and as effective as the 2007 IDSA/ATS criteria.

Making sense of scoring systems in community acquired pneumonia

The site of care decision is one of the most important in the management of patients with community-acquired pneumonia (CAP). Several scoring systems have been developed to predict mortality risk in CAP, and these have been applied to guide physicians about whether patients should be admitted to the hospital or to the intensive care unit (ICU). However, these tools were initially developed to predict mortality risk, and studies have demonstrated that the risk for death does not always equate with need for hospitalization or ICU care. The most widely studied scoring systems are the Pneumonia Severity Index (PSI) and the CURB-65 (a modification of the British Thoracic Society rule). Each has advantages and limitations, with the more-complex PSI developed to identify low-mortality risk patients, and the CURB-65, which is simpler, being developed to easily identify more severely ill individuals. No scoring system can replace clinical judgement about the admission decision, and prospective studies have shown that physicians still admit at least 30-60% of low mortality risk patients when using the PSI to guide this decision. Limitations of these prognostic tools include their variable utility in the elderly, and their failure to include certain comorbidities (COPD, immune suppression) and social factors, in their calculations. The need for ICU care is also not well-defined by measuring the PSI or CURB-65, and other tools such as those developed by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guideline committee and the SMART-COP rule may have greater utility for this purpose. In the future, measurements of serum biomarkers, such as procalcitonin, may augment the information provided by prognostic scoring tools for patients with CAP.

CAP Treatment Recommendations: Guided in the Right Direction

Although guidelines for treating community-acquired pneumonia (CAP) have existed for years, controversy persists regarding guideline-recommended antibiotic regimens, and compliance remains lower than desired. Now, two research groups have examined the outcomes associated with adherence to the 2007 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) clinical practice guidelines …