Severity assessment tools to guide ICU admission in community-acquired pneumonia: systematic review and meta-analysis

Abstract

Large variations exist in the use of ICU resources between different studies and different healthcare systems. Scoring systems designed to predict 30-day mortality perform less well when ICU admission is taken into account. Further studies of dedicated ICU admission scores are required.

Management-based risk prediction in community-acquired pneumonia by scores and biomarkers

“…Both the CRB-65/CURB (pooled sensitivity only 49%) and PSI scores (pooled specificity only 48%) lack accuracy for prediction of ICU admission [22]. Even the 2007 ATS/IDSA rule showed a pooled sensitivity of only 61% in a recent metaanalysis, meaning that 39% of patients deteriorating in the course would be missed [22]. Additionally, the two major criteria of the ATS rules rather reflect critical disease by themselves instead of being risk factors for it, and ICU referral for patients presenting with manifest respiratory failure or septic shock is self-evident.…”

“…In a recent study 35% (563 out of 1,625) of consecutive patients showed ''contraindications'' for ICU admission [23]. Both the CRB-65/CURB (pooled sensitivity only 49%) and PSI scores (pooled specificity only 48%) lack accuracy for prediction of ICU admission [22]. Even the 2007 ATS/IDSA rule showed a pooled sensitivity of only 61% in a recent metaanalysis, meaning that 39% of patients deteriorating in the course would be missed [22].…”

“…The 2001 rule consists of two major criteria (requirement for mechanical ventilation, presence of septic shock) and three minor criteria (systolic blood pressure ,90 mmHg, multilobar infiltrate, arterial oxygen tension/inspiratory oxygen fraction ,250), while the 2007 rule added six more minor criteria (respiratory rate .30 min -1 ; confusion; blood urea nitrogen .20 mg?dL -1 ; leukopenia; thrombocytopenia; hypothermia). Both have a superior performance to the PSI or CURB scores for prediction of ICU admission (pooled sensitivity of 61-67%, positive likelihood ratio 6.2-7.1) [22]. Other scoring systems, such as the SMART-COP rule [24], the SCAP/Espana rule [25,26], the CORB score [27] and the REA-ICU rule [28] have been introduced and incorporate variations of the ATS minor criteria and/or additional factors such as low arterial pH, albumin, tachycardia and hyponatraemia.…”

“…Here, the 2001 American Thoracic Society (ATS)- [20] and 2007 ATS/Infectious Diseases Society of America (IDSA)-rules [21] indicating features of sepsis-related organ dysfunction or respiratory disturbance performed best and are widely recommended [21][22][23]. The 2001 rule consists of two major criteria (requirement for mechanical ventilation, presence of septic shock) and three minor criteria (systolic blood pressure ,90 mmHg, multilobar infiltrate, arterial oxygen tension/inspiratory oxygen fraction ,250), while the 2007 rule added six more minor criteria (respiratory rate .30 min -1 ; confusion; blood urea nitrogen .20 mg?dL -1 ; leukopenia; thrombocytopenia; hypothermia).…”

Evaluación de los índices predictores de eventos adversos en el adulto inmunocompetente hospitalizado por neumonía adquirida en la comunidad

“…En nuestro estudio, el poder discriminatorio de los diferentes índices para predecir la admisión a UCI fue moderado con AUC entre 0,70 y 0,76 (Tabla 3). Similar a lo descrito en la literatura, el SMART-COP fue más sensible y el SCAP fue más específico en la pesquisa de pacientes con falla respiratoria grave que requirieron conexión a ventilador mecánico 20,21,27,28 . Los índices pronósticos no fueron muy precisos en la detección de los pacientes con neumonía que desarrollaron complicaciones durante su estadía en el hospital (AUC entre 0,63 y 0,71).…”