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Identifying severe community-acquired pneumonia: moving beyond mortality
  1. James D Chalmers
  1. Correspondence to Dr James D Chalmers, College of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK; jchalmers{at}dundee.ac.uk

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Hospitalisations for community-acquired pneumonia (CAP) are increasing in the UK and internationally.1 Five to fifteen per cent of patients admitted to hospital with CAP die, and improvements in supportive care have maintained this death rate in the face of rising co-morbidity but have not resulted in substantial improvements.2 This lack of progress contrasts sharply with other medical emergencies such as acute myocardial infarction where there is an established pathway from recognition to early management and long-term care, which has brought substantial reductions in mortality.3

Kolditz et al4 report a new concept in CAP management, the idea of ‘emergency CAP’ to define patients at increased risk of early deterioration. In a large database of 3427 prospectively recruited patients with CAP from the multicentre CAPNETZ cohort only 173 (5%) required mechanical ventilation and/or vasopressor support (MV/VS) or died within 7 days of admission. Twenty-seven per cent of such patients died within 30 days while in contrast only 2% of patients not requiring MV/VS in the first week of admission ultimately died.4

Importantly they demonstrated, as other authors have found in the past, that deterioration was largely predictable.5–7 The absence of any of the nine Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) criteria for severe pneumonia had a 99.7% negative predictive value and effectively excluded a poor outcome.4 This study also extended previous observations that the highest mortality in CAP is reserved for patients who deteriorate later in admission.8 Patients who required invasive MV/VS immediately on admission had a 30-day mortality rate of 24%. In patients who did not require this intervention on …

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