When, where and how should a patient with community acquired pneumonia be admitted?

Diagnosis and treatment of community-acquired pneumonia in adults: 2016 clinical practice guidelines by the Chinese Thoracic Society, Chinese Medical Association

Community‐acquired pneumonia (CAP) in adults is an infectious disease with high morbidity in China and the rest of the world. With the changing pattern in the etiological profile of CAP and advances in medical techniques in diagnosis and treatment over time, Chinese Thoracic Society of Chinese Medical Association updated its CAP guideline in 2016 to address the standard management of CAP in Chinese adults. Extensive and comprehensive literature search was made to collect the data and evidence for experts to review and evaluate the level of evidence. Corresponding recommendations are provided appropriately based on the level of evidence. This updated guideline covers comprehensive topics on CAP, including aetiology, antimicrobial resistance profile, diagnosis, empirical and targeted treatments, adjunctive and supportive therapies, as well as prophylaxis. The recommendations may help clinicians manage CAP patients more effectively and efficiently. CAP in pediatric patients and immunocompromised adults is beyond the scope of this guideline. This guideline is only applicable for the immunocompetent CAP patients aged 18 years and older. The recommendations on selection of antimicrobial agents and the dosing regimens are not mandatory. The clinicians are recommended to prescribe and adjust antimicrobial therapies primarily based on their local etiological profile and results of susceptibility testing, with reference to this guideline.

Usefulness and prognostic value of biomarkers in patients with community-acquired pneumonia in the emergency department

Between all patients treated in the Emergency Department (ED), 1.35% are diagnosed with community-acquired pneumonia (CAP). CAP is the main cause of death due to infectious disease (10-14%) and the most frequent reason of sepsis-septic shock in the ED. In the last decade, the search for objective tools to help establishing an early diagnosis, bacterial aetiology, severity, suspicion of bacteremia and the prognosis of mortality has increased. Biomarkers have shown their usefulness in this matter. Procalcitonin (obtains the highest accuracy for CAP diagnosis, bacterial aetiology and the presence of bacteremia), lactate (biomarker of hypoxia and tissue hypoperfusion) and proadrenomedullin (which has the greatest accuracy to predict mortality which in combination with the prognostic severity scales obtains even better results). The aim of this review is to highlight recently published scientific evidence and to compare the utility and prognostic accuracy of the biomarkers in CAP patients treated in the ED.

[Diagnostic and prognostic power of biomarkers to improve the management of community acquired pneumonia in the emergency department]

OBJECTIVES

To analyse the usefulness and performance of several biomarkers [C-reactive protein (CRP), mid-regional pro-adrenomedullin (MR-proADM), procalcitonin (PCT)] and lactate in predicting short- and medium-term mortality compared with the prognostic severity scales (PSS) usually employed for community-acquired pneumonia (CAP) and in assessing the aetiological suspicion of infection by Streptococcus pneumoniae and bacteraemia.

METHODS

Observational, prospective and analytical study was conducted on patients who were diagnosed with CAP in our emergency department (ED). The data collected included socio-demographic and comorbidity variables, Charlson index, priority level according to the Spanish Triage System (STS), stage in the Pneumonia Severity Index (PSI) and in the CURB-65 (confusion, urea, respiratory rate, blood pressure and age ≥65years), criteria of severe CAP, microbiological studies, and biomarkers determinations. The patients were followed-up for 180days to calculate the prognostic power and the diagnostic performance for bacteraemia and aetiology.

RESULTS

A total of 127patients were finally enrolled in the study. The 30-day mortality was 10.3% (13), and 22.6% (28) at 180 days. Blood cultures were positive in 29 patients (23%) and S.pneumoniae was identified as the responsible pathogen in 28 cases (22.2%). The area under the ROC curve (AUC-ROC) for lactate and MR-proADM to predict 30-day mortality was 0.898 (95%CI: 0.824-0.973; P<.0001) and 0.892 (95%CI: 0.811-0.974; P<.0001), respectively, and for MR-proADM at 180 days it was 0.921 (95%CI: 0.874-0.968; P<.0001). The AUC-ROC for PCT to predict bacteraemia was 0.952 (95%CI: 0.898-1.000; P<.0001) and, considering a cut-off value ≥0.95ng/ml, the negative predictive value (NPV) and the likelihood ratio (LR+) were 97.8% and 9.03, respectively. Using a PCT cut-off value >0.85ng/ml, the NPV and the LR+ were 96.6% and 5.89%, respectively, to predict a S.pneumoniae infection.

CONCLUSIONS

MR-proADM and lactate showed a similar or even better performance for 30-day intra-hospital mortality than PSI, CURB-65, STS and CAP severity criteria in patients diagnosed with CAP (P>.05). Furthermore, the MR-proADM capacity to predict 180-day mortality was higher than PSS and the rest of biomarkers (P>.05), and its AUC-ROC increased if it was used in combination with PSI, CURB65 and STS. The determination of PCT has a remarkable diagnostic performance to rule out bacteraemia and to orientate the aetiology towards a S.pneumoniae infection.