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Evaluation of ICU Admission Criteria and Diagnostic Methods for Patients With Severe Community-Acquired Pneumonia : Current Practice Survey FREE TO VIEW

Marcos I. Restrepo, MD, MSc, FCCP; Thomas Bienen, MD; Eric M. Mortensen, MD, MSc; Antonio Anzueto, MD, FCCP; Mark L. Metersky, MD, FCCP; Patricio Escalante, MD, MSc, FCCP; Richard G. Wunderink, MD, FCCP; Bonita T. Mangura, MD, FCCP; On Behalf of the Chest Infections Network
Author and Funding Information

American College of Chest Physicians

Correspondence to: Marcos I. Restrepo, MD, MSc, FCCP, South Texas Veterans Health Care System, Audie L. Murphy Division, 7400 Merton Minton Blvd (11c6), San Antonio, TX; e-mail: RESTREPOM@uthscsa.edu



Chest. 2008;133(3):828-829. doi:10.1378/chest.07-2887
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To the Editor:

Community-acquired pneumonia (CAP) is a common disease seen in clinical practice. Various professional societies have released guidelines12 regarding criteria for ICU admission and appropriate diagnostic testing after admission.

We e-mailed self-administered surveys to American College of Chest Physicians members (in the Chest Infections and Critical Care Network) in 2004 to elucidate which of these admission guidelines and diagnostic criteria are utilized in practice.

The first questionnaire asked physicians which of the following ICU admission criteria they use: American Thoracic Society (ATS) 1993 and 2001,1 British Thoracic Society (BTS) CURB or CURB-65,1 pneumonia severity index (PSI) class IV and V,3APACHE (acute physiology and chronic health evaluation) II or III, and simplified acute physiology score (SAPS) of 1 or 2.4 We compared academic vs nonacademic practitioners.

The second questionnaire involved diagnostic testing.12 We compared academic vs nonacademic clinicians and whether they work in closed vs open ICUs.

Three hundred ninety-three questionnaires (19%) were returned. The most commonly stated admission criteria used were as follows: ATS 2001, 50%; APACHE II or III, 28%; and PSI class V, 27%. Responders were aware of SAPS (74%), ATS 1993 (68%), and APACHE (67%) but did not use them in clinical practice; 77% and 72% of responders were not aware or did not use the CURB and CURB-65 criteria, respectively. Differences were found when comparing academicians (n = 182) vs nonacademicians (n = 203). Academicians preferred the BTS guidelines (63% vs 51%, p = 0.04), PSI class IV (69% vs 56%, p = 0.02), and SAPS (87% vs 71%, p < 0.01).

The most common diagnostic tests selected for ICU patients with pneumonia were blood cultures (97%), sputum Gram stain (83%), Legionella urinary antigen (77%), and endotracheal aspirate (76%). Academic physicians ordered more endotracheal aspirates (79% vs 68%, p = 0.03) and Legionella cultures (37% vs 27%, p = 0.05) but fewer serologic tests for atypical pathogens (34% vs 46%, p = 0.03). Physicians working in closed ICUs (n = 159) ordered more blood cultures (99% vs 93%, p = 0.01) and Legionella sputum cultures (39% vs 26%, p = 0.01) than those working in open ICUs (n = 224).

It is evident that practice environment (academia vs private practice) has an effect on which ICU admission guidelines are followed.12 In addition, different diagnostic tests were ordered in open vs closed ICUs. This suggests that additional education and research are needed for severely ill CAP patients admitted to the ICU.

The authors have no conflicts of interest to disclose.

Mandell, LA, Wunderink, RG, Anzueto, A, et al (2007) Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.Clin Infect Dis44,S27-S72
 
Woodhead, M, Blasi, F, Ewig, S, et al Guidelines for the management of adult lower respiratory tract infections.Eur Respir J2005;26,1138-1180
 
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
 
Herridge, MS Prognostication and intensive care unit outcome: the evolving role of scoring systems.Clin Chest Med2003;24,751-762
 

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References

Mandell, LA, Wunderink, RG, Anzueto, A, et al (2007) Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.Clin Infect Dis44,S27-S72
 
Woodhead, M, Blasi, F, Ewig, S, et al Guidelines for the management of adult lower respiratory tract infections.Eur Respir J2005;26,1138-1180
 
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
 
Herridge, MS Prognostication and intensive care unit outcome: the evolving role of scoring systems.Clin Chest Med2003;24,751-762
 
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