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Abstract

IntroductionThis paper describes the case mix, outcome and activity for admissions to intensive care units (ICUs) with community-acquired pneumonia (CAP).MethodsWe conducted a secondary analysis of a high quality clinical database, the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database, of 301,871 admissions to 172 adult ICUs across England, Wales and Northern Ireland, 1995 to 2004. Cases of CAP were identified from pneumonia admissions excluding nosocomial pneumonias and the immuno-compromised. It was not possible to review data from the time of hospital admission; therefore, some patients who developed hospital-acquired/nosocomial pneumonia may have been included.ResultsWe identified 17,869 cases of CAP (5.9% of all ICU admissions). There was a 128% increase in admissions for CAP from 12.8 per unit to 29.2 per unit during the study period compared to only a 24% rise in total ICU admissions (p < 0.001). Eighty-five percent of admissions were from within the same hospital. Fifty-nine percent of cases were admitted to the ICU <2 days, 21.5% between 2 and 7 days, and 19.5% >7 days after hospital admission. Between 1995 and 1999 and 2000 and 2004 there was a rise in admissions from accident and emergency (14.8% to 16.8%; p < 0.001) and high dependency units (6.9% to 11.9%; p < 0.001) within the same hospital, those aged >74 (18.5 to 26.1%; p < 0.001), and mean APACHE II score (6.83 to 6.91; p < 0.001). There was a fall in past history of severe respiratory problems (8.7% to 6.4%; p < 0.001), renal replacement therapy (1.6% to 1.2%; p < 0.01), steroid treatment (3.4% to 2.8%; p < 0.05), sedation/paralysis (50.2% to 40.4%; p < 0.001), cardiopulmonary resuscitation prior to admission (7.5% to 5.5%; p < 0.001), and septic shock (7.3% to 6.6%; p < 0.001). ICU mortality was 34.9% and ultimate hospital mortality 49.4%. Mortality was 46.3% in those admitted to the ICU within 2 days of hospital admission rising to 50.4% in those admitted at 2 to 7 days and 57.6% in those admitted after 7 days following hospital admission.ConclusionCAP makes up a small, but important and rising, proportion of adult ICU admissions. Survival of over half of all cases vindicates the use of ICU facilities in CAP management. Nevertheless, overall mortality remains high, especially in those admitted later in their hospital stay.

Defining and predicting severe community-acquired pneumonia

“…[79,80] One early study suggested that admission to the ICU did not improve patient outcomes, though it had methodological limitations, as patients were only admitted to the ICU late in their course, perhaps too late to derive much benefit from intensive therapy. [81] One recent study showed that patients with CAP requiring vasopressor therapy in the ED who were admitted to the ICU had lower mortality than those admitted to the floor, though this could reflect unstated or unrecorded requests to limit care, as it seems unusual to admit a patient with vasopressor dependence to the hospital ward.…”

“…[54] A study of a large British cohort suggested worse outcome for late ICU admissions but did not control for disease severity. [80] Our preliminary data[82] and a recent post hoc analysis of multi-center prospective observational studies[83] suggest that initial ICU triage may be associated with better outcomes, though neither analysis has yet controlled for rapidly progressive pneumonia, a crucial confounder of the proposed relationship between ICU triage and mortality. [84]…”

Concept for a study design in patients with severe community-acquired pneumonia: A randomised controlled trial with a novel IGM-enriched immunoglobulin preparation – The CIGMA study

“…Up to 10% of hospitalized adult CAP patients require intensive medical care and are transferred to intensive care units (ICUs) [5] with great impact on health care costs [3,6] and outcome. Mortality of sCAP patients admitted to ICUs usually ranges from 35 to 58% depending on time and admission to hospital [7]. However, two recent trials on sCAP found a mortality rate of only 17.9% [ 8] and 23.1% [9].…”

Defining Severe Pneumonia

“…102, 103 One early study suggested that admission to the ICU did not improve patient outcomes. However, it had methodological limitations as patients were only admitted to the ICU late in their course, perhaps too late for benefit from intensive therapy.…”