Intensive Care Unit Admission With Community-Acquired Pneumonia

Vohra, Adam; Meltzer, David O.; Ruhnke, Gregory W.; Tak, Hyo Jung; Shah, Maulin

doi:10.1097/maj.0000000000000568

Cited by 11 publications

(4 citation statements)

References 35 publications

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“…CABP more frequently had PSI ≥ class IV, however CAVP significantly showed higher frequencies of ICU admission, intubation, vasopressor support, and in hospital mortality. Though it has been previously demonstrated that PSI ≥ class IV indicates increased disease severity and is strongly associated with ICU admission [28,29], our results show that PSI scores cannot be used to accurately prognosticate viral CAPs. Furthermore, literature suggests that PSI often underestimates the risk of patients with Influenza A H1N1 pneumonia [30,31] and neither PSI nor CURB-65 scores can be used to predict ICU admission or need for mechanical ventilation in influenza patients31.…”

Section: Discussioncontrasting

confidence: 76%

Severity of disease and mortality for hospitalized patients with community-acquired viral pneumonia compared to patients with community-acquired bacterial pneumonia

Kim¹,

Chandler²,

Furmanek³

et al. 2019

JRI

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Background: There exists a large body of literature to help identify, diagnose, treat, and manage community-acquired pneumonia (CAP). Despite this, there is little data that directly compares the clinical syndromes and complications of pure bacterial pneumonia to pure viral pneumonia. Our study compares the clinical presentation, morbidity and mortality of viral vs. bacterial etiologies of CAP. Methods: This was a secondary data analysis of the Community-Acquired Pneumonia Organization (CAPO) international study database. Data was collected concerning patient demographics, physical examination findings, laboratory findings, radiological findings, severity of illness, and clinical outcomes and stratified according to the two study groups, CAVP and CABP. A microbiological diagnosis of CABP was based on the isolation of a bacterium from a respiratory sample, blood culture and/or identification of a urinary antigen for Streptococcus or Legionella; microbiological diagnosis of CAVP was based on polymerase chain reaction or antigen detection from respiratory samples. Results: Our study included 1,913 patients. Of these, 286 (15.0%) had viral infection, while 1,627 (85.0%) had CAVP. We found that bacterial CAP patients are older, more frequently male, and suffer from a higher proportion of comorbidities when compared to viral CAP patients. Comparison of physical exam findings and laboratory values failed to find a clinically significant difference between bacterial and viral CAP patients. When comparing severity of illness, bacterial CAP patients had greater frequency of PSI ≥ class IV; however, viral CAP patients more frequently needed ICU admission, ventilator support, vasopressor support, and had higher rate of in hospital mortality. Conclusions: Our study confirms the extreme difficulty differentiating CABP from CAVP using demographics, physical exam, or x-ray findings. We found no major clinical or laboratory findings distinguishing CABP from CAVP. The increased severity of illness of CAVP compared to bacterial etiologies shows that PSI scores may not be an accurate indicator of severity of disease. More studies are needed to identify the best process of care for patients with CAP, including the potential benefits of routine respiratory viral panel testing and empiric antiviral therapy.

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Section: Discussioncontrasting

confidence: 76%

Severity of disease and mortality for hospitalized patients with community-acquired viral pneumonia compared to patients with community-acquired bacterial pneumonia

Kim¹,

Chandler²,

Furmanek³

et al. 2019

JRI

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“…We then repeated the analysis, adjusting for disease severity by including binary categorical variables representing PSI risk class (I, II, and III constituting an aggregated reference group, creating three groups of similar sample size 30,38 ). Although inclusion of the PSI creates the potential for collinearity given the concurrent inclusion of certain comorbid conditions that are also PSI components, we thought this pre-specified sensitivity analysis would make our findings more robust .…”

Section: Methodsmentioning

confidence: 99%

The Relative Ability of Comorbidity Ascertainment Methodologies to Predict In-Hospital Mortality Among Hospitalized Community-acquired Pneumonia Patients

Weir¹,

Lyttle

Meltzer

et al. 2018

Medical Care

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Background– Despite widespread use of comorbidities for population health descriptions and risk adjustment, the ideal method for ascertaining comorbidities is not known. We sought to compare the relative value of several methodologies by which comorbidities may be ascertained. Methods– This is an observational study of 1,596 patients admitted to the University of Chicago for community-acquired pneumonia from 1998–2012. We collected data via chart abstraction, administrative data, and patient report, then performed logistic regression analyses, specifying comorbidities as independent variables and in-hospital mortality as the dependent variable. Finally, we compared area under the curve (AUC) statistics to determine the relative ability of each method of comorbidity ascertainment to predict in-hospital mortality. Results– Chart review (area under curve [AUC] 0.72) and administrative data (Charlson AUC 0.83, Elixhauser AUC 0.84) predicted in-hospital mortality with greater fidelity than patient report (AUC 0.61). However, multivariate logistic regression analyses demonstrated that individual comorbidity derivation via chart review had the strongest relationship with in-hospital mortality. This is consistent with prior literature suggesting that administrative data has inherent, paradoxical biases with important implications for risk adjustment based solely on administrative data. Conclusions– Although comorbidities derived through administrative data did produce an AUC greater than chart review, our analyses suggest a coding bias in several comorbidities with a paradoxically protective effect. Therefore, chart review, while labor and resource intensive, may be the ideal method for ascertainment of clinically-relevant comorbidities.

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“…With regard to predictors of ICU admission in patients with CAP, one study documented that severity of illness, as documented by PSI class IV (OR 3.06; 95% CI, 1.63-5.72), PSI class V (OR 4.84; 95% CI, 2.44-9.62), CURB-65 > 3 (OR 2.90; 95% CI, 1.51-5.56) and presence of underlying chronic obstructive pulmonary disease (COPD)(34.7% versus 19.1% among patients not admitted to ICU) were important factors [40]. The latter is an interesting observation, since a systematic review and meta-analysis indicated that COPD does not appear to be associated 13 with more frequent ICU admission (RR 0.97; 95% CI, 0.70-1.35; p=0.87), need for mechanical ventilation (RR 0.91; 95% CI, 0.71-1.16; p=0.44), or greater mortality in hospitalized patients with CAP (RR1.20; 95% CI, 0.92-1.56; p=0.19) in cohort studies, but a reduced mortality in case-control studies (RR 0.82; 95% CI, 0.74-0.90; p<0.0001) [41].…”

Section: Icu Admission and Management For Capmentioning

confidence: 99%