L.A.M. In adults with CAP, should Legionella and Pneumococcal urinary antigen testing be performed at the … The original ATS CAP guidelines listed 9 criteria, and the presence of any 1 of these criteria implied that the patient had severe CAP. Angus et al. Identifying patients with severe community-acquired pneumonia (CAP) who require admission to an intensive care unit (ICU) can, at times, be a difficult and daunting task. 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. [12] in this issue of Clinical Infectious Diseases is an attempt to validate the predictive rule suggested by the IDSA/ATS CAP guidelines for the identification of patients with severe CAP and the selection of those individuals who require ICU admission. This is an unprecedented time. 503, Hamilton, Ontario L8V 1C3, Canada (. Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit. “Severe” vs “Nonsevere” CAP Most children with “Severe CAP” will be in the PICU, but some may be in an intermediate-status bed outside the PICU. Copyright © 1987-2020 American Thoracic Society, All Rights Reserved. Severe community- acquired pneumonia in ICUs: prospective validation of a prognostic score. IDSA/ATS Criteria for Defining Severe CAP (2007) Major Criteria (1) • Septic shock requiring vasopressor • Respiratory failure requiring mechanical ventilation Minor Criteria (≥ 3) Stratified IDSA/ATS major/minor criteria defined severe CAP as what the original criteria did (Table 1). The subsequent transfer of patients with CAP who are first admitted to a hospital ward to the ICU for delayed onset of respiratory failure or septic shock is associated with increased mortality [1]. Table 1: Hospitalized children with CAP are defined as having “Severe CAP” if they have ANY Major Criteria OR two or more Minor Criteria: ANY Major Criteria: progression to severe sepsis (odds ratios [ORs], 0.65 and 0.89 for two or more SIRS criteria and three or more SIRS criteria, respectively), septic shock (ORs, 0.80 and 0.55), or death (ORs, 0.65 and 0.39), with poor discrimination (all receiver operating characteristic [ROC] areas under the Scored minor criteria of ≥2 scores or the presence of 2 or more IDSA/ATS minor criteria might be more valuable cut-off value for severe CAP. To anyone who cares for patients who may have severe CAP, it is obvious that the course of the disease is dynamic and that neither clinical nor laboratory values remain static. The IDSA/ATS prediction rule was retrospectively applied to the patient database, but such an approach should have no bearing on the results. : no conflicts. Such an approach, however, resulted in a definition that was extremely sensitive but not specific [ 8 ]. Involvement of > 2 lobes in chest radiograph (multilobar involvement), “Major” criteria assessed at admission or during clinical course, 1. We are then told, however, that the poorer outcome in such patients “confirms the need for close monitoring and ICU care of these patients” [12, p. 383]. It is not always clear which patients will benefit from the additional diagnostic, treatment, and management protocols and procedures of the ICU, and the consequences of a poor selection process can be disastrous. It is unfortunate that studies of ICU admission do not account for patients who have a “do not resuscitate” status. The majority of patients are managed out of the hospital. Part of the problem has been that there has not been a universally agreed upon definition of severe CAP. Requirement of vasopressors > 4 h (septic shock), 4. For the relationship between severe CAP criteria and ICU admission, the sensitivity and specificity were 71% and 88%, respectively, whereas for mortality, the sensitivity and specificity were 58% and 88%, respectively. CAP was severe with 1 major criterion or 3 minor criteria. Either the need for mechanical ventilation with endotracheal intubation or the presence of septic shock requiring receipt of vasopressors are absolute indications. Additionally, severe CAP is a clinical setting where the authors provide a ‘conditional’ recommendation to perform urinary legionella and streptococcal antigen testing; it is conditional, most likely, because randomized trials have failed to identify a benefit for urinary … We are told that 235 patients were admitted to the ICU and that this included 41 patients from other wards who were admitted to the ICU after their condition deteriorated. Whether the detection of infiltrates in the chest radiographs of patients with acute lower respiratory tract infection (LRTI) suggestive of mild pneumonia has an independent prognostic impact Diagnosis and Treatment of Adults with Community-acquired Pneumonia. A study by Angus et al. >2 (If criteria for sepsis) = Severe Sepsis. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. The guidelines for the initial management of adults with CAP published by the American Thoracic Society (ATS) in 1993 have included 10 criteria in order to provide a tentative definition of severe illness, and the presence of any one of them was used to determine a pneumonia case as severe (12). Therefore, the inappropriate admission to the ICU of patients with CAP who do not require such care may prevent a patient who does require such care from accessing it. Vaccination against influenza and, in some high risk groups, against S. pneumoniae,are important for preventing pneumonia Such an approach, however, resulted in a definition that was extremely sensitive but not specific [8]. The decision regarding site of care (i.e., whether the patient should be treated as an outpatient, in a hospital ward, or in the ICU) carries with it a number of important implications. Overall 331 nonsevere (84%) and 64 severe cases (16%) of CAP were prospectively studied. The study is an important one from both academic and clinical standpoints, and it is the first study, to our knowledge, to validate the recent prediction rule. Lactate in Severe Sepsis. I would agree with the authors when they state that “the need for ICU admission derived from minor criteria alone is uncertain in our population and deserves further prospective evaluation” [12, p. 377]. Invasive mechanical ventilation was the main determinant for ICU admission, followed by septic shock. Severe community acquired pneumonia: epidemiology and prognosis factors. doi: 10.1164/rccm.201908-1581ST. As might be expected, severity determined on the basis of a major criterion had the strongest association with mortality. Please see below. Severe pneumonia was defined as admission to the intensive care unit (ICU). Prognosis and outcome of patients with community-acquired pneumonia: a meta-analysis. This seems like a high percentage of such patients to do so well. 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