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Am. J. Respir. Crit. Care Med., Volume 158, Number 4, October 1998, 1102-1108

Severe Community-acquired Pneumonia
Assessment of Severity Criteria

SANTIAGO EWIG, MAURICIO RUIZ, JOSEP MENSA, MARIA ANGELES MARCOS, JOSE ANTONIO MARTINEZ, FRANCISCO ARANCIBIA, MICHAEL S. NIEDERMAN, and ANTONI TORRES

Servei de Pneumologia i Al·lèrgia Respiratoria, Servei de Malalties Infeccioces, Servei de Microbiologia, Hospital Clinic, Universitat de Barcelona, Spain; and Pulmonary and Critical Care Medicine, Winthrop University Hospital, Mineola, New York

The purpose of the study was to validate the criteria used in the guidelines of the American Thoracic Society (ATS) for severe community-acquired pneumonia (CAP). Severe pneumonia was defined as admission to the intensive care unit (ICU). Overall 331 nonsevere (84%) and 64 severe cases (16%) of CAP were prospectively studied. Mortality was 19 of 395 (5%) and 19 of 64 (30%), respectively. Single severity criteria as well as the ATS definition of severe pneumonia were assessed calculating the operative indices. A modified prediction rule including minor (baseline) and major (baseline or evolutionary) criteria was derived. Single minor criteria at admission had a low sensitivity and positive predictive value. Defining severe pneumonia according to the ATS guidelines had a high sensitivity (98%). However, specificity and positive predictive value were low (32% and 24%, respectively). A modified prediction rule (presence of two or three minor criteria [systolic blood pressure < 90 mm Hg, multilobar involvement, PaO2/FIO2 < 250] or one of two major criteria [requirement of mechanical ventilation, presence of septic shock]) had a sensitivity of 78%, a specificity of 94%, a positive predictive value of 75%, and a negative predictive value of 95%. The ATS definition of severe pneumonia was highly sensitive but insufficiently specific and had a low positive predictive value. Our suggested modified rule had a more balanced performance and, if validated in an independent population, may represent a more accurate definition of severe CAP.




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