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Validation and clinical implications of the IDSA/ATS minor criteria for severe community-acquired pneumonia
  1. Jason Phua (phua_jason{at}yahoo.com.sg)
  1. Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore
    1. Kay Choong See
    1. Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore
      1. Yiong Huak Chan
      1. Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
        1. Louis Sutrisno Widjaja
        1. Medical Affairs, National University Hospital, Singapore
          1. Ngu Wah Aung
          1. School of Health Sciences, Ngee Ann Polytechnic, Singapore
            1. Wang Jee Ngerng
            1. Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore
              1. Tow Keang Lim (mdclimtk{at}nus.edu.sg)
              1. Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore

                Abstract

                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 3 out of 9 minor criteria. These criteria have not been validated.

                Methods: We reviewed all patients admitted to our hospital from 2004-2007 for CAP retrospectively. We excluded patients who fulfilled any IDSA/ATS major criteria for severe CAP at the emergency department, i.e. the need for mechanical ventilation or vasopressors. We compared the predictive characteristics of the IDSA/ATS minor criteria with those of the Pneumonia Severity Index (PSI) and the CURB-65 score for hospital mortality and ICU admission.

                Results: 1242 patients were studied (mean age 65.7 years, hospital mortality 14.7%). The areas under the receiver operating characteristic curves for the IDSA/ATS minor criteria were 0.88 (95% confidence interval [CI] 0.86-0.91) and 0.85 (95% CI 0.81-0.88) for predicting hospital mortality and ICU admission respectively. These were greater than the corresponding areas for the PSI and the CURB-65 score (p<0.05). The sensitivity, specificity, positive and negative predictive values of the minor criteria were respectively 81.4%, 82.9%, 45.2% and 96.3% for hospital mortality, and 58.3%, 90.6%, 52.9% and 92.3% for ICU admission. The minor criteria were more specific than the PSI and more sensitive than the CURB-65 score for both outcomes.

                Conclusion: Our findings support the use of the IDSA/ATS minor criteria to predict hospital mortality and guide ICU admission in inpatients with CAP who do not require emergent mechanical ventilation or vasopressors.

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