Simplification of the IDSA/ATS criteria for severe CAP using meta-analysis and observational data

Abstract

The 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) guidelines proposed ''minor'' criteria to predict intensive care unit (ICU) admission in patients with community-acquired pneumonia. These criteria were based on expert opinion. Consequently, the authors of the guidelines asked investigators to determine whether the score could be simplified by excluding noncontributory variables.Each IDSA/ATS minor criterion was validated using a random effects meta-analysis of seven studies. Variables present in ,5% of cases or that were nonsignificantly associated with mortality/ICU admission were excluded. A simplified score excluding these variables was tested for prediction of mortality and ICU admission in an established database. Prediction was assessed using the area under the receiver operator characteristic curve (AUC).Leukopenia (,4000 cells?mm -3 ), thrombocytopenia (,100 000 cells?mm -3 ) and hypothermia ,36uC occurred in ,5% of cases. A simplified score excluding these variables was performed similarly for prediction of mortality, AUC 0.77 (95% CI 0.73-0.81) versus 0.78 (95% CI 0.74-0.82) (p50.9) and intensive care unit admission, AUC 0.85 (95% CI 0.82-0.87) versus 0.85 (95% CI 0.82-0.88) (p50.9). Additional predictors suggested by the IDSA/ATS were associated with mortality and ICU admission, but only incorporating acidosis (pH ,7.35) altered the AUC (0.82 (95% CI 0.78-0.86) (p50.6) for mortality and 0.86 (95% CI 0.82-0.88) (p50.8) for ICU admission). No improvements were statistically significant.The IDSA/ATS criteria can be simplified by removing three infrequent variables. @ERSpublicationsThe IDSA/ATS criteria can be simplified by removing three infrequent variables

Corticosteroids for community-acquired pneumonia: a critical view of the evidence

“…Community acquired pneumonia (CAP) remains a leading cause of morbidity and mortality, with mortality rates between 5% and 15% in hospitalised patients, rising to up to 30% in patients admitted to the intensive care unit (ICU) [1][2][3].…”

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@ERSpublicationsThe current evidence raises more questions than answers, and does not support routine use of corticosteroids for CAP http://ow.ly/t01g302QDhGCommunity acquired pneumonia (CAP) remains a leading cause of morbidity and mortality, with mortality rates between 5% and 15% in hospitalised patients, rising to up to 30% in patients admitted to the intensive care unit (ICU) [1][2][3].There has been little progress in the management of CAP since the widespread introduction of antibiotics in the 1950s, with no new classes of drugs licensed specifically for CAP and little progress in reducing mortality. The focus of international guidelines for CAP have been on "doing the simple things well", since early antibiotic administration, appropriate fluid resuscitation, early mobilisation and guideline-concordant antibiotics have been associated with improved outcomes, albeit with low-quality evidence [3][4][5].

Some of the lack of progress reflects the fact that, in many cases, mortality from CAP may be unavoidable.

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“…Severe CAP was defined as a Pneumonia Severity Index (PSI) of V or the Infectious Diseases Society of America/American Thoracic Society criteria [1]. The study was conducted over 8 years, and randomised 61 patients to methylprednisolone and 59 patients to placebo for 5 days.…”

“…Major improvements in length of stay, duration of antibiotic therapy and even mortality, greater than those demonstrated with corticosteroids, can be achieved through compliance with high-quality care recommendations, and yet audits show persistently poor compliance with guidelines [1][2][3][4][5]. Doing the simple things well should continue to take priority over the use of corticosteroids, for now.…”

Pneumonia as an actual medical problem of the 21th century

“…Целью метаанализа W.Salih et al [12] была разра ботка новых, упрощенных рекомендаций по опреде лению степени тяжести пневмонии. В данной рабо те введено понятие малых и больших признаков, которые рассматриваются как критерии тяжести течения пневмонии.…”