Validation and clinical implications of the IDSA/ATS minor criteria for severe community-acquired pneumonia

Abstract

Background: The 2007 Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) guidelines defined severe community-acquired pneumonia (CAP) and recommended intensive care unit (ICU) admission when patients fulfilled three out of nine minor criteria. These criteria have not been validated. Methods: All patients admitted to our hospital from 2004 to 2007 for CAP were reviewed retrospectively. Patients who fulfilled any IDSA/ATS major criteria for severe CAP at the emergency department (ie, the need for mechanical ventilation or vasopressors) were excluded. The predictive characteristics of the IDSA/ATS minor criteria were compared with those of the Pneumonia Severity Index (PSI) and the CURB-65 score for hospital mortality and ICU admission. Results: 1242 patients were studied (mean age 65.7 years, hospital mortality 14.7%). The areas under the receiver operating characteristic curves for the IDSA/ATS minor criteria were 0.88 (95% CI 0.86 to 0.91) and 0.85 (95% CI 0.81 to 0.88) for predicting hospital mortality and ICU admission, respectively. These were greater than the corresponding areas for the PSI and the CURB-65 score (p,0.05). The sensitivity, specificity, positive and negative predictive values of the minor criteria were 81.4%, 82.9%, 45.2% and 96.3%, respectively, for hospital mortality and 58.3%, 90.6%, 52.9% and 92.3%, respectively, for ICU admission. The minor criteria were more specific than the PSI and more sensitive than the CURB-65 score for both outcomes. Conclusion: These findings support the use of the IDSA/ ATS minor criteria to predict hospital mortality and guide ICU admission in inpatients with CAP who do not require emergency mechanical ventilation or vasopressors.

Weight of the CURB-65 Criteria for Community-Acquired Pneumonia in a Very Low-Mortality-Rate Setting

“…A criterion not impacting in low-mortality-rate institutions might be important for places where mortality is high (19). The overall 30-day mortality was 1.3% in the current study, whereas they were 14.7% in Phua's study (9), 9% in Lim's study (15) and 3.6% in Liapikou's study (16). The mortalities in the current and Liapikou's studies were low, which might explain the lack of an association of hypotension with mortality.…”

“…Lim's international derivation and validation study revealed that the weight of each of the CURB-65 criteria were 8.1, 5.6, 1.7, 2.4 and 5.5, respectively (15), which were different from that currently reported. Liapikou et al (16) and Phua et al (9) discovered that confusion, urea >7 mmol·L -1 , respiratory rate ! 30-minutes -1 and low blood pressure were of unequal weight in predicting hospital mortality and that confusion had the strongest association with mortality when validating the IDSA/ATS minor criteria for severe CAP.…”

“…CAP was defined as an acute infection of the pulmonary parenchyma associated with an acute infiltrate on a chest radiograph with two or more symptoms including fever (>38 ), hypothermia (<36 ), rigors, sweats, new cough or change in color of respiratory secretions, chest discomfort or dyspnoea (9). All the patients underwent chest radiography.…”

The impact of a delay in intensive care unit admission for community-acquired pneumonia

“…To eliminate confounding by nosocomial complications, we excluded patients who were admitted to the ICU .72 h after presentation at the ED. Some patients were included in a separate study conducted [2004][2005][2006][2007]; this previous study, however, included non-critically ill patients and excluded those who were intubated or started on vasopressors in the ED [11]. The present study was approved by our institutional review board.…”

“…Part of the problem is that while patients who require emergent mechanical ventilation and/or vasopressors (defined by the IDSA/ATS as major criteria for severe CAP) and hence direct ICU admission may easily be identified [2], clinical findings at the ED which suggest a rapidly progressive pneumonia are often more subtle. Accordingly, numerous clinical criteria for severe CAP requiring ICU admission have recently been proposed [3,9,10], including the IDSA/ATS minor criteria [1,11,12].…”