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Correspondence |

Predicting Need for ICU in Community-Acquired PneumoniaResponse FREE TO VIEW

Patrick G. P. Charles, MBBS
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Affiliations: Austin Health, Heidelberg, VIC, Australia,  Respiratory Intensive Care Unit, Pulmonology Department, Institut Clinic del Tòrax, Barcelona, Spain

Correspondence to: Patrick G. P. Charles, MBBS, Department of Infectious Diseases, Austin Health, PO Box 5555, Heidelberg, VIC 3084, Australia; e-mail: patrick.charles@austin.org.au



Chest. 2008;133(2):587-588. doi:10.1378/chest.07-2253
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Published online

Valencia et al1studied patients with community-acquired pneumonia who were in pneumonia severity index class V. In this severity-assessment tool, designed by Fine et al,2 points are available for age, patient demographics, comorbidities, initial vital signs, and results of investigations, with a score of > 130 (class V) signifying that the risk of dying within 30 days is 27%.2Comparison was made between those class V community-acquired pneumonia patients who did and did not require treatment in the ICU. Because only 17.3% of patients required ICU admission, the authors assessed other severity scores for their ability to “predict” this outcome and concluded that the modified American Thoracic Society (mATS) criteria were the most accurate.3 However, the major criterion for this mATS rule is the need for either mechanical ventilation or inotropic support.3 Thus, in its current form, this tool is probably equivalent in accuracy to looking at the patient’s bed card to see what ward they are in and claiming that those patients who are in the ICU will probably need to be managed there. The mATS rule cannot be promoted as a predictive tool but rather as one that identifies patients already being managed in the ICU.

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

The authors have no conflicts of interest to disclose.

Valencia, M, Badia, JR, Cavalcanti, M, et al (2007) Pneumonia severity index class V patients with community-acquired pneumonia: characteristics, outcomes, and value of severity scores.Chest132,515-522. [PubMed] [CrossRef]
 
Fine, MJ, Auble, TE, Yealy, DM, et al A prediction rule to identify low-risk patients with community-acquired pneumonia.N Engl J Med1997;336,243-250. [PubMed]
 
Ewig, S, Ruiz, M, Mensa, J, et al Severe community-acquired pneumonia: assessment of severity criteria.Am J Respir Crit Care Med1998;158,1102-1108. [PubMed]
 
To the Editor:

We appreciate the interest of Dr. Charles in our article.1We agree with him that the pneumonia severity index (PSI) has several limitations to stratify the site of admission of patients with community-acquired pneumonia (CAP). One the main limitations of this score is the unbalanced impact of the age in the score, resulting in a potential underestimation of severe pneumonia, particularly in younger healthy people.2Obviously, the PSI is not a good score to help clinicians in ICU admission decisions. Recently, Ananda-Rajah et al3 confirmed that neither PSI nor CURB-65 rules were sufficiently accurate for predicting need for ICU admission, even when patients with “do-not-resuscitate” orders were excluded.

We agree with Dr. Charles that the major criteria (shock and mechanical ventilation) of the modified American Thoracic Society (ATS) rule are obvious for admitting patients in a ICU. They define by themselves the most severe CAP population.

Most importantly, the minor criteria of the modified ATS rule are able to detect a severe CAP population for whom the risk of mortality could not be detected by one these criteria alone. Overall, the ATS-modified rule is the best we have for determining ICU admission of patients with CAP with a sensitivity and specificity of approximately 70%, which is not optimal. In an attempt to increase the performance of the old ATS rule, the new Infectious Diseases Society of America/ATS guidelines propose a new set of minor criteria.4 These criteria include respiratory rate ≥ 30 breaths/min; Pao2/fraction of inspired oxygen ratio ≤ 250; multilobar infiltrates; confusion/disorientation; uremia (BUN level > 20 mg/dL); leukopenia (WBC < 4,000 cells/μL); thrombocytopenia (platelet count < 100,000 cells/μL); hypothermia (temperature < 36°C); and hypotension requiring aggressive fluid resuscitation. ICU admission is recommended for patients presenting three of these minor criteria. However, these new recommendations have to be validated prospectively.

References
Valencia, M, Badia, JR, Cavalcanti, M, et al Pneumonia severity index class V patients with community-acquired pneumonia: characteristics, outcomes, and value of severity scores.Chest2007;132,515-522. [PubMed] [CrossRef]
 
Van der Eerden, MM, de Graaff, CS, Bronsveld, W, et al Prospective evaluation of pneumonia severity index in hospitalised patients with community-acquired pneumonia.Respir Med2004;98,872-878. [PubMed]
 
Ananda-Rajah MR, Charles PG, Melvani S, et al. Comparing the pneumonia severity index with CURB-65 in patients admitted with community acquired pneumonia. Scand J Infect Dis October 4, 2007 [Epub ahead of print].
 
Mandell, LA, Wunderink, RG, Anzueto, A, et al Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.Clin Infect Dis2007;44(suppl 2),S27-S72. [PubMed]
 

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References

Valencia, M, Badia, JR, Cavalcanti, M, et al (2007) Pneumonia severity index class V patients with community-acquired pneumonia: characteristics, outcomes, and value of severity scores.Chest132,515-522. [PubMed] [CrossRef]
 
Fine, MJ, Auble, TE, Yealy, DM, et al A prediction rule to identify low-risk patients with community-acquired pneumonia.N Engl J Med1997;336,243-250. [PubMed]
 
Ewig, S, Ruiz, M, Mensa, J, et al Severe community-acquired pneumonia: assessment of severity criteria.Am J Respir Crit Care Med1998;158,1102-1108. [PubMed]
 
Valencia, M, Badia, JR, Cavalcanti, M, et al Pneumonia severity index class V patients with community-acquired pneumonia: characteristics, outcomes, and value of severity scores.Chest2007;132,515-522. [PubMed] [CrossRef]
 
Van der Eerden, MM, de Graaff, CS, Bronsveld, W, et al Prospective evaluation of pneumonia severity index in hospitalised patients with community-acquired pneumonia.Respir Med2004;98,872-878. [PubMed]
 
Ananda-Rajah MR, Charles PG, Melvani S, et al. Comparing the pneumonia severity index with CURB-65 in patients admitted with community acquired pneumonia. Scand J Infect Dis October 4, 2007 [Epub ahead of print].
 
Mandell, LA, Wunderink, RG, Anzueto, A, et al Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.Clin Infect Dis2007;44(suppl 2),S27-S72. [PubMed]
 
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