Validation of the Infectious Diseases Society of America/American Thoratic Society Minor Criteria for Intensive Care Unit Admission in Community-Acquired Pneumonia Patients Without Major Criteria or Contraindications to Intensive Care Unit Care

Abstract

In a population of patients with CAP without contraindications to ICU care, the IDSA/ATS minor criteria predict subsequent requirement for MV/VS, ICU admission, and 30-day mortality.

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

“…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. While their prediction of severe CAP showed accuracies comparable to those of the ATS rules [23,29], the latter three have not been validated in external cohorts so far. A recent study compared most of these scores with a rigorous design, excluding patients with immediate need for vasopressor use and/or mechanical ventilation as well as patients not suitable for ICU care owing to advanced directives or major comorbid illnesses [23].…”

“…While their prediction of severe CAP showed accuracies comparable to those of the ATS rules [23,29], the latter three have not been validated in external cohorts so far. A recent study compared most of these scores with a rigorous design, excluding patients with immediate need for vasopressor use and/or mechanical ventilation as well as patients not suitable for ICU care owing to advanced directives or major comorbid illnesses [23]. Evaluated end-points included the need for mechanical ventilation or vasopressor use, and the 2007 minor criteria achieved the highest prediction (area under the curve 0.85: sensitivity 79%, positive predicted value 23%).…”

“…Treatment restrictions bias this end-point further. 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].…”

“…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).…”

“…Consequently, recent studies used the major criteria as end-points [23-25, 27, 34, 35]. By this approach, the 2007 ATS minor criteria achieved a positive likelihood ratio of 4.3 and a negative likelihood ratio of 0.26 [23], clearly missing the recommended threshold of 10/0.1 for diagnostic instruments [36]. Their sensitivity of 79% still means that 21% of patients deteriorating in the course are missed [23].…”