Diagnostic Criteria: Severe Community-Acquired Pneumonia Antonio Anzueto The University of Texas Health Science Center at San Antonio, Texas

Our Secret weapon !!!

Diagnostic criteria SCAP Are we aware of existing criteria and if so, do we use them ? Validity of Criteria Where we need to go

Diagnostic criteria SCAP Are we aware of existing criteria and if so, do we use them ? Validity of Criteria Where we need to go

Aims Hypothesis To understand the perception of physician attitudes to define which patients with CAP should be admitted to the intensive care unit (ICU)  Significant variation among physicians occur regarding who should be admitted to the ICU

Demographics Practice variablesNo (%) Profession Physician370 (98.7) Other5 (1.3) Specialty Pulmonary disease290 (75.5) Critical care262 (68.2) Type Academic161 (41.9) Other Location Urban220 (57.3) Other164 (42.7) n=383

Aware and Use it!! Percentage

Aware and DO NOT Use it!! Percentage

NOT Aware and DO NOT Use it!! Percentage

Practice setting Percentage Academic (n=182) vs. Non-academic (n=203) p=0.04 p=0.02p<0.01

Conclusions Criteria to define the need for ICU admission were infrequently reported by survey responders Important differences were found in academic vs. non-academic practitioners regarding the criteria used to admit patients to the ICU with CAP

Implications There is a need for more unified and appropriate criteria to define which patients with CAP require admission to the ICU

Diagnostic criteria SCAP Are we aware of existing criteria and if so, do we use them ? Validity of Criteria Where we need to go

Mortality and Care Risk of dying due to CAP Home Ward ICU

Stratification CAP-PORT Fine MJ, et al. N Engl J Med. 1997;336: Step-1 Risk class I (lowest severity level) Age < 50 years No comorbid conditions (neoplastic diseases, liver disease, congestive heart failure, cerebrovascular disease, or renal disease) Normal or only mildly deranged vital signs and normal mental status Step-2 Not Risk class I Classes II-V 3 -Demographics 5 -Comorbid conditions 5 -Physical exam findings 7 -Laboratory or radiographic findings

Risk-class mortality rates Risk Class No. of points Mortality % Recommended site of care I--0.1Outpatient II<700.6Outpatient III Outpatient or brief inpatient IV Inpatient V> Inpatient Fine MJ, et al. N Engl J Med. 1997;336: Step-1 (Pre-morbid conditions) + Step-2 (PSI score) + Step-3 (Clinical judgment)

Mortality – CURB-65 score  Confusion; U rea (>19.1 mg/dL); Respirations (> 30 rpm); Blood pressure (DBP < 60); 65 years of age CURB-65 Score Lim et al. Thorax :377 n=1,068 n=324 n=184 n=210

Severe Pneumonia Criteria MAJOR Mechanical ventilation Multilobar or increase infiltrates >50% in 48h Septic Shock or need for vasopressors >4h Acute renal failure MINOR SBP < 90 mm Hg DBP < 60 mm Hg RR >30/min Pa O2 /Fi O2 < 250 Bilateral or multilobar infiltrates 1 of 2 major criteria 2 of 3 minor criteria ATS guidelines. AJRCCM. 2001;163:

Methods Study Design  A retrospective observational cohort study of patients hospitalized at a two teaching hospitals in San Antonio, Texas  VA medical center and county-run referral hospital  Admission between Jan 1, 1999 and Dec 31, 2001  Study was approved by the institutional board review

Demographics VariablesAlive n= 714 (%) Dead n=72 (%) p value Age in years, mean + SD Sex, n (%) male561 (79)60 (83)NS Nursing home resident41 (6)13 (18)< Admission thru ED598 (84)58 (81)NS ICU admission within 24 h118 (17)36 (50)< n=787 NS=p>0.05

Predictors Frequency Predictors30-day Mortality, n (%) ICU admission, n (%) CURB-65 Group 1 (scores 0-1)20/461 (4)63/461 (14) CURB-65 Group 2 (scores 2)29/187 (15)47/187 (25) CURB-65 Group 3 (scores 3-5)20/116 (17)36/116 (31) CURB-65 Group 3 (scores 4-5)5/23 (22)9/23 (39) rATS – Severe CAP criteria21/74 (28)70/74 (95) PSI low risk class (I-III)16/409 (10)44/409 (11) PSI moderate risk class (IV)26/266 (10)62/266 (23) PSI high risk class (V)30/112 (27)48/112 (43) n=787

ICU admission* ICU admissionSn (%) Sp (%) PPV (%) NPV (%) ROC (95% CI)  Criteria rev. ATS ( )  Criteria CURB ( )  PSI high class V ( ) * Sn, sensitivity; Sp, specificity; PPV, positive predictive value; NPV, negative predictive value; ROC, receiver operating curves

30-day Mortality * ICU admissionSn (%) Sp (%) PPV (%) NPV (%) ROC (95% CI)  Criteria rev. ATS ( )  Criteria CURB ( )  PSI high class V ( ) * Sn, sensitivity; Sp, specificity; PPV, positive predictive value; NPV, negative predictive value; ROC, receiver operating curves

ICU admission Sn (%) Sp (%) PPV (%) NPV (%) ROC (95% CI)  Criteria rev. ATS ( )  Criteria rev. ATS ( )  CURB-65 (4-5 criteria) ( )  CURB (3-4 criteria) ( )  PSI high (class V) ( )  PSI high (class V) ( ) Restrepo CURENT vs. Angus et al. AJRCCM 2002

Best severity predictors EventsBest CriteriaROC (95% CI)  ICU admission Criteria rev. ATS 0.73 ( )  ICU admission Criteria rev. ATS 0.68 ( )  30-day Mortality PSI high (IV or V) 0.71 ( )  Death PSI high (IV or V) 0.75 ( ) Restrepo CURRENT vs. Angus et al. AJRCCM 2002

Diagnostic criteria SCAP Are we aware of existing criteria and if so, do we use them ? Validity of Criteria Where we need to go

CURXO - 80 C – Confusion U – Urea > 30 mg/dl R – Resp rate > 30/min X – X Ray – multilobar, bilateral O – PaO2/FiO2 < – Age > 80 Years Espana et al. AJRCCM 2006;174:1249

Charles et al CID 2008; 47:375 Need for Intensive respiratory - Vasopressors support (IRVS)

Need for Intensive respiratory - Vasopressors support, IRVS Charles et al CID 2008; 47:375

Predicting 30 day Mortality Charles et al CID 2008; 47:375

AUC analysis severity assessment Charles et al CID 2008; 47:375

Procalcitonin (PCT) Stimulated by bacterial endotoxin Viral and localized infection have lower PCT levels than systemic infections Autoimmune and neoplastic disease do not induce Short half life

PCT and Diagnosis Nyamande Int J TB Lung Dz 2006; 10: 510 P=0.0004

PCT and Antibiotics RCT to examine whether PCT guidance associated with less antibiotic use PCT strata  <0.1- Antibiotics strongly discouraged  Antibiotics discouraged  Antibiotics advised  >0.5- Antibiotics strongly recommended Christ-Crain AJRCCM : 84

PCT and Antibiotic Discontinuation

PCT/CRP and Treatment Failure Prospective cohort of 453 CAP patients  18% treatment failures CRP & PCT higher in failures  Day 1 »CRP: 13.6 vs »PCT: 0.5 vs. 1.5  Day 3 »CRP: 4.5 vs »PCT 0.3 vs. 0.5 Menendez Thorax 2008; 63:447

Conclusions Revisited ATS rule has the best power to predict the need for ICU admission PSI score is the best predictor for mortality due to CAP The CURB-65 rule may be used as an alternative tool to the PSI for the detection of low risk patients, but is not a good rule to define ICU admission

Conclusions Described rules are imperfect and have significant limitations due to the the difficult of application to individual patients Further studies are needed to develop clinical prediction tools for high-risk patients requiring ICU admission

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