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Diagnostic Criteria: Severe Community-Acquired Pneumonia

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

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Diagnostic Criteria: Severe Community-Acquired Pneumonia

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

  2. Our Secret weapon !!!

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

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

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

  6. Demographics n=383

  7. Aware and Use it!! Percentage

  8. Aware and DO NOT Use it!! Percentage

  9. NOT Aware and DO NOT Use it!! Percentage

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

  11. 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

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

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

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

  15. 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 Stratification CAP-PORT Fine MJ, et al. N Engl J Med. 1997;336:243-250

  16. Risk-class mortality rates Step-1(Pre-morbid conditions) + Step-2(PSI score) + Step-3(Clinical judgment) Fine MJ, et al. N Engl J Med. 1997;336:243-250

  17. Mortality – CURB-65 score • Confusion; U rea (>19.1 mg/dL); Respirations (> 30 rpm); Blood pressure (DBP < 60); 65 years of age n=1,068 n=210 n=184 n=324 CURB-65 Score Lim et al. Thorax 2003 58:377

  18. MAJOR Mechanical ventilation Multilobar or increase infiltrates >50% in 48h Septic Shock or need for vasopressors >4h Acute renal failure Severe Pneumonia Criteria • MINOR • SBP < 90 mm Hg • DBP < 60 mm Hg • RR >30/min • PaO2/FiO2 < 250 • Bilateral or multilobar infiltrates • 1 of 2 major criteria • 2 of 3 minor criteria ATS guidelines. AJRCCM. 2001;163:1730-1754

  19. 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

  20. Demographics n=787 NS=p>0.05

  21. Predictors Frequency n=787

  22. ICU admission* * Sn, sensitivity; Sp, specificity; PPV, positive predictive value; NPV, negative predictive value; ROC, receiver operating curves

  23. 30-day Mortality * * Sn, sensitivity; Sp, specificity; PPV, positive predictive value; NPV, negative predictive value; ROC, receiver operating curves

  24. ICU admission Restrepo CURENT vs. Angus et al. AJRCCM 2002

  25. Best severity predictors Restrepo CURRENT vs. Angus et al. AJRCCM 2002

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

  27. CURXO - 80 • C – Confusion • U – Urea > 30 mg/dl • R – Resp rate > 30/min • X – X Ray – multilobar, bilateral • O – PaO2/FiO2 < 250 • 80 – Age > 80 Years Espana et al. AJRCCM 2006;174:1249

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

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

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

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

  32. 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

  33. PCT and Diagnosis P=0.0004 NyamandeInt J TB Lung Dz 2006; 10: 510

  34. PCT and Antibiotics • RCT to examine whether PCT guidance associated with less antibiotic use • PCT strata • <0.1- Antibiotics strongly discouraged • 0.1-0.25- Antibiotics discouraged • 0.25-0.5- Antibiotics advised • >0.5- Antibiotics strongly recommended Christ-Crain AJRCCM 2006 174: 84

  35. PCT and Antibiotic Discontinuation

  36. 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. 23.2 • PCT: 0.5 vs. 1.5 • Day 3 • CRP: 4.5 vs. 12.1 • PCT 0.3 vs. 0.5 Menendez Thorax 2008; 63:447

  37. 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

  38. 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

  39. Obrigado

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