This Article Full Text Full Text (PDF) Online Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Angus, D. C. Articles by Kapoor, W. N. Search for Related Content PubMed PubMed Citation Articles by Angus, D. C. Articles by Kapoor, W. N.

Severe Community-acquired Pneumonia

Use of Intensive Care Services and Evaluation of American and British Thoracic Society Diagnostic Criteria

The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, and Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine; Center for Research on Health Care, University of Pittsburgh Medical Center; and Division of Health Policy and Management, Department of Health Services Administration, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Harvard University Health Services, Cambridge; and Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts

Correspondence and requests for reprints should be addressed to Derek C. Angus, M.D., M.P.H., Room 604, Scaife Hall, Department of Critical Care Medicine, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213. E-mail: angusdc{at}ccm.upmc.edu

Despite careful evaluation of changes in hospital care for community-acquired pneumonia (CAP), little is known about intensive care unit (ICU) use in the treatment of this disease. There are criteria that define CAP as "severe," but evaluation of their predictive value is limited. We compared characteristics, course, and outcome of inpatients who did (n = 170) and did not (n = 1,169) receive ICU care in the Pneumonia Patient Outcomes Research Team prospective cohort. We also assessed the predictive characteristics of four prediction rules (the original and revised American Thoracic Society criteria, the British Thoracic Society criteria, and the Pneumonia Severity Index [PSI]) for ICU admission, mechanical ventilation, medical complications, and death (as proxies for severe CAP). ICU patients were more likely to be admitted from home and had more comorbid conditions. Reasons for ICU admission included respiratory failure (57%), hemodynamic monitoring (32%), and shock (16%). ICU patients incurred longer hospital stays (23.2 vs. 9.1 days, p < 0.001), higher hospital costs ($21,144 vs. $5,785, p < 0.001), more nonpulmonary organ dysfunction, and higher hospital mortality (18.2 vs. 5.0%, p < 0.001). Although ICU patients were sicker, 27% were of low risk (PSI Risk Classes I–III). Severity-adjusted ICU admission rates varied across institutions, but mechanical ventilation rates did not. The revised American Thoracic Society criteria rule was the best discriminator of ICU admission and mechanical ventilation (area under the receiver operating characteristic curve, 0.68 and 0.74, respectively) but none of the prediction rules were particularly good. The PSI was the best predictor of medical complications and death (area under the receiver operating characteristic curve, 0.65 and 0.75, respectively), but again, none of the prediction rules were particularly good. In conclusion, ICU use for CAP is common and expensive but admission rates are variable. Clinical prediction rules for severe CAP do not appear adequately robust to guide clinical care at the current time.

Key Words: artificial ventilation • community-acquired infections • intensive care • outcomes assessment • pneumonia

This article has been cited by other articles:

				L. A. Diaz, E. M. Mortensen, A. Anzueto, and M. I. Restrepo Review: Novel targets in the management of pneumonia Therapeutic Advances in Respiratory Disease, December 1, 2008; 2(6): 387 - 400. [Abstract] [PDF]

				E. M. Mortensen, M. I. Restrepo, and A. Anzueto When to Switch Therapy in Patients with Severe Community-Acquired Pneumonia Ann Intern Med, April 15, 2008; 148(8): 625 - 625. [Full Text] [PDF]

				M. I. Restrepo, E. M. Mortensen, J. A. Velez, C. Frei, and A. Anzueto A Comparative Study of Community-Acquired Pneumonia Patients Admitted to the Ward and the ICU Chest, March 1, 2008; 133(3): 610 - 617. [Abstract] [Full Text] [PDF]

				M. Masia, J. Papassotiriou, N. G. Morgenthaler, I. Hernandez, C. Shum, and F. Gutierrez Midregional Pro-A-Type Natriuretic Peptide and Carboxy-Terminal Provasopressin May Predict Prognosis in Community-Acquired Pneumonia Clin. Chem., December 1, 2007; 53(12): 2193 - 2201. [Abstract] [Full Text] [PDF]

				M. Valencia, J. R. Badia, M. Cavalcanti, M. Ferrer, C. Agusti, J. Angrill, E. Garcia, J. Mensa, M. S. Niederman, and A. Torres Pneumonia Severity Index Class V Patients With Community-Acquired Pneumonia: Characteristics, Outcomes, and Value of Severity Scores Chest, August 1, 2007; 132(2): 515 - 522. [Abstract] [Full Text] [PDF]

				S. Yan Man, N. Lee, M. Ip, G. E Antonio, S. S L Chau, P. Mak, C. A Graham, M. Zhang, G. Lui, P. K S Chan, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong Thorax, April 1, 2007; 62(4): 348 - 353. [Abstract] [Full Text] [PDF]

				P. P. Espana, A. Capelastegui, and J. M. Quintana Am. J. Respir. Crit. Care Med., February 1, 2007; 175(3): 289a - 290. [Full Text] [PDF]

				P. P. Espana, A. Capelastegui, I. Gorordo, C. Esteban, M. Oribe, M. Ortega, A. Bilbao, and J. M. Quintana Development and Validation of a Clinical Prediction Rule for Severe Community-acquired Pneumonia Am. J. Respir. Crit. Care Med., December 1, 2006; 174(11): 1249 - 1256. [Abstract] [Full Text] [PDF]

				A. F. Shorr, M. Bodi, A. Rodriguez, J. Sole-Violan, J. Garnacho-Montero, J. Rello, and for the CAPUCI Study Investigators Impact of antibiotic guideline compliance on duration of mechanical ventilation in critically ill patients with community-acquired pneumonia. Chest, July 1, 2006; 130(1): 93 - 100. [Abstract] [Full Text] [PDF]

				J. Vestbo Clinical Assessment, Staging, and Epidemiology of Chronic Obstructive Pulmonary Disease Exacerbations Proceedings of the ATS, May 1, 2006; 3(3): 252 - 256. [Abstract] [Full Text] [PDF]

				K L Buising, K A Thursky, J F Black, L MacGregor, A C Street, M P Kennedy, and G V Brown A prospective comparison of severity scores for identifying patients with severe community acquired pneumonia: reconsidering what is meant by severe pneumonia Thorax, May 1, 2006; 61(5): 419 - 424. [Abstract] [Full Text] [PDF]

				T. Dremsizov, G. Clermont, J. A. Kellum, K. G. Kalassian, M. J. Fine, and D. C. Angus Severe sepsis in community-acquired pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course? Chest, April 1, 2006; 129(4): 968 - 978. [Abstract] [Full Text] [PDF]

				S. Ewig, A. Torres, and M. Woodhead Assessment of pneumonia severity: a European perspective Eur. Respir. J., January 1, 2006; 27(1): 6 - 8. [Full Text] [PDF]

				M. S. Niederman, C. Feldman, and G. A. Richards Combining information from prognostic scoring tools for CAP: an American view on how to get the best of all worlds. Eur. Respir. J., January 1, 2006; 27(1): 9 - 11. [Full Text] [PDF]

				A. Capelastegui, P. P. Espana, J. M. Quintana, I. Areitio, I. Gorordo, M. Egurrola, and A. Bilbao Validation of a predictive rule for the management of community-acquired pneumonia Eur. Respir. J., January 1, 2006; 27(1): 151 - 157. [Abstract] [Full Text] [PDF]

				M. Woodhead, F. Blasi, S. Ewig, G. Huchon, M. Leven, A. Ortqvist, T. Schaberg, A. Torres, G. van der Heijden, and T. J. M. Verheij Guidelines for the management of adult lower respiratory tract infections Eur. Respir. J., December 1, 2005; 26(6): 1138 - 1180. [Abstract] [Full Text] [PDF]

				M. I. Restrepo, L. F. Angel, E. M. Mortensen, and A. Anzueto Steroid Infusion for Severe Pneumonia: Not so Fast... Am. J. Respir. Crit. Care Med., September 15, 2005; 172(6): 781 - 781. [Full Text] [PDF]

				A. Torres Monotherapy in Severe Community-Acquired Pneumonia: Is It Worthy? Chest, July 1, 2005; 128(1): 10 - 13. [Full Text] [PDF]

				N. A. Smyrnios, O. P. Schaefer, R. M. Collins, and J. M. Madison Applicability of Prediction Rules in Patients With Community-Acquired Pneumonia Requiring Intensive Care: A Pilot Study J Intensive Care Med, July 1, 2005; 20(4): 226 - 232. [Abstract] [PDF]

				O. Leroy, P. Saux, J.-P. Bedos, E. Caulin, and for the Levofloxacin Study Group Comparison of Levofloxacin and Cefotaxime Combined With Ofloxacin for ICU Patients With Community-Acquired Pneumonia Who Do Not Require Vasopressors Chest, July 1, 2005; 128(1): 172 - 183. [Abstract] [Full Text] [PDF]

				L. Mandell Decisions about Treating Community-Acquired Pneumonia Ann Intern Med, February 1, 2005; 142(3): 215 - 216. [Full Text] [PDF]

				G. L. Colice, M. A. Morley, C. Asche, and H. G. Birnbaum Treatment Costs of Community-Acquired Pneumonia in an Employed Population Chest, June 1, 2004; 125(6): 2140 - 2145. [Abstract] [Full Text] [PDF]

				S Ewig, A de Roux, T Bauer, E Garcia, J Mensa, M Niederman, and A Torres Validation of predictive rules and indices of severity for community acquired pneumonia Thorax, May 1, 2004; 59(5): 421 - 427. [Abstract] [Full Text] [PDF]

				E. Azoulay, F. Fieux, D. Moreau, G. Thiery, P. Rousselot, A. Parrot, J.-R. Le Gall, H. Dombret, and B. Schlemmer Acute Monocytic Leukemia Presenting as Acute Respiratory Failure Am. J. Respir. Crit. Care Med., May 15, 2003; 167(10): 1329 - 1333. [Abstract] [Full Text] [PDF]

				M Woodhead Assessment of illness severity in community acquired pneumonia: a useful new prediction tool? Thorax, May 1, 2003; 58(5): 371 - 372. [Full Text] [PDF]

				M. J. Tobin Critical Care Medicine in AJRCCM 2002 Am. J. Respir. Crit. Care Med., February 1, 2003; 167(3): 294 - 305. [Full Text] [PDF]

				M. J. Tobin Tuberculosis, Lung Infections, Interstitial Lung Disease, and Journalology in AJRCCM 2002 Am. J. Respir. Crit. Care Med., February 1, 2003; 167(3): 345 - 355. [Full Text] [PDF]

				Pneumonia Severity Doesn't Predict an ICU Stay Journal Watch Infectious Diseases, October 11, 2002; 2002(1011): 7 - 7. [Full Text]