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Some progress in identifying the risk factors associated with treatment failure in CAP
In patients with community acquired pneumonia (CAP), clinical and radiological features at the time of presentation do not predict the microbiological aetiology with any certainty.1 Initial treatment is therefore usually empirical and directed by the severity of the illness at the time of presentation. A large number of studies have been conducted over the last 10 years to determine prognostic factors in CAP. In turn, clinical prediction rules based on a number of key prognostic factors have been developed, such as the pneumonia severity index (PSI) and the CURB-65 score, and incorporated into CAP management guidelines.2–6 Most of these CAP severity studies, and the resulting prediction rules, use mortality as the main outcome measure. However, mortality is not the only clinically important outcome. In this issue of Thorax, Menéndez and colleagues report on a large observational study of the risk factors related to failure of initial empirical treatment for CAP.7
The definition of treatment failure adopted was complex and based on (a) the time from admission (less than or more than 72 hours corresponding to “early” and “late” treatment failure) and (b) the occurrence of clinical features such as “haemodynamic instability”, “the appearance or impairment of respiratory failure”, and “radiographic progression”. While pragmatic, these features were not rigorously defined, thus making it difficult …