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      Community-acquired pneumonia and survival of critically ill acute exacerbation of COPD patients in respiratory intensive care units

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          Abstract

          Dear editor Community acquired pneumonia (CAP) leads to more than 1 million hospital admissions per year according to the severity of the disease or exacerbation of underlying comorbid conditions in the USA.1,2 COPD is the most frequent comorbidity in patients with pneumonia, which induces acute exacerbation of COPD and respiratory failure. In a recent study, pneumonia was the second cause (19.7%) for intensive care unit (ICU) admissions among COPD patients,3 and a long-term (12 months) follow-up showed that the mortality of the COPD patients who were admitted to ICU due to pneumonia was higher than patients admitted for other reasons.3 We read with great pleasure the recent paper by Lu et al4 entitled “Community-acquired pneumonia and survival of critically ill acute exacerbation of COPD patients in respiratory intensive care units” published in International Journal of COPD. This study was a retrospective observational design and was conducted in a respiratory intensive care unit for a 3-year period in China. They aimed to investigate the effect of CAP on hospital mortality in critically ill patients with acute exacerbation of COPD. A total of 80 patients were evaluated, of whom 38 had CAP, and they concluded that COPD patients with CAP had higher inhospital mortality than patients without CAP. This study is valuable to emphasize the mortality rates in patients with COPD and SCAP. However, we believe that there are some issues worthy for further comment. First, there are no data about the criterion(s) for ICU admission of severe CAP (SCAP). The minor criteria of Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) 2007 were tested in clinical practice to identify SCAP cases for early aggressive resuscitation and prevent ICU admission delay.5 Different combinations out of 9 minor criteria of 2007 IDSA/ATS are associated with diverse mortality.6 Li et al6 investigated 385 SCAP patients in a prospective 2-center study and concluded that patients with PaO2/FiO2 level ≤250 mmHg and with confusion and uremia were predicted with more severity and higher mortality when compared with others. Chalmers et al7 found that each minor criterion was predictive of mortality, but hypotension, multilobar radiographic shadowing and hypothermia had the strongest association with mortality. Second, one of the most important issues about CAP is the fact that there is very close correlation between hospital mortality, time to initiate appropriate empirical antibiotic treatment and time to respiratory intensive care unit admission. Mortality increases according to ICU admission delays.5 In the present study it is not clarified whether the patients were admitted from the emergency department or general ward. COPD patients were predisposed to pneumonia with several microorganisms such as Pseudomonas aeruginosa and Legionella pneumophila. Because COPD patients use corticosteroids and antibiotics, have malnutrition and frequent hospital admissions. It is undetermined in the study whether empiric antibiotic treatment covers these probable microorganisms. We believe that a resuscitation bundle should be performed, including appropriate empiric antibiotic treatment, fluid challenge, organ failure and tissue hipoperfusion assessments, immediately after the COPD patients are encountered with SCAP in order to reduce mortality.

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          Most cited references 7

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          Validation of the Infectious Diseases Society of America/American Thoratic Society minor criteria for intensive care unit admission in community-acquired pneumonia patients without major criteria or contraindications to intensive care unit care.

          The 2007 Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) guidelines for community-acquired pneumonia (CAP) recommended new criteria to guide admission to the intensive care unit (ICU) for patients with this condition. Although the major criteria (requirement for mechanical ventilation or septic shock requiring vasopressor support) are well established, the value of the minor criteria alone have not been fully validated. We performed a prospective observational study of consecutive adult patients with CAP admitted to NHS Lothian (Scotland, United Kingdom). Patients meeting the IDSA/ATS major criteria on admission were excluded, along with patients not suitable for ICU care owing to advanced directives or major comorbid illnesses. Performance characteristics for the IDSA/ATS minor criteria were calculated and compared with those for alternative scoring systems identified in the literature. Two definitions of severe CAP were used as primary end points: ICU admission, and subsequent requirement for mechanical ventilation or vasopressor support (MV/VS); 30-day mortality was a secondary outcome. The study included 1062 patients with CAP potentially eligible for ICU admission. Each of the 9 minor criteria was associated with increased risk of MV/VS and 30-day mortality in univariate analysis. Two hundred seven patients had ≥ 3 minor criteria (19.5%). The IDSA/ATS 2007 criteria had an area under the receiver operating characteristic curve of 0.85 (0.82-0.88) for prediction of MV/VS, 0.85 (0.82-0.88) for prediction of ICU admission, and 0.78 (0.74-0.82) for prediction of 30-day mortality. The IDSA/ATS 2007 criteria were at least equivalent to more established scoring systems for prediction of MV/VS and ICU admission and equivalent to alternative scoring systems for predicting 30-day mortality in this patient population. In a population of patients with CAP without contraindications to ICU care, the IDSA/ATS minor criteria predict subsequent requirement for MV/VS, ICU admission, and 30-day mortality.
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            IDSA/ATS minor criteria aid pre-intensive care unit resuscitation in severe community-acquired pneumonia.

            The effect of employing severity scores to identify severe community-acquired pneumonia (SCAP) cases for early aggressive resuscitation is unknown. Optimising pre-intensive care unit (ICU) care may improve outcomes in patients at risk of SCAP. We conducted a before-and-after study of patients classified into control and intervention groups (January 2004 to December 2007 and January 2008 to December 2010, respectively). Our intervention was two-pronged, using the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) minor criteria to identify SCAP for aggressive emergency department resuscitation. Patients with SCAP, defined as those with three or more IDSA/ATS minor criteria, were targeted. Differences in mortality, triage and compliance with emergency department resuscitation were compared between the groups. The hospital mortality rate was lower in the intervention versus the control group (5.7% versus 23.8%, p<0.001). On multivariate analysis, the intervention group was associated with lower mortality (OR 0.24, 95% CI 0.09-0.67). ICU admission rates decreased from 52.9% to 38.6% (p=0.008) and inappropriately delayed ICU admissions decreased from 32.0% to 14.8% (p<0.001). There was increased compliance with the aggressive resuscitation protocol after the intervention. A combined intervention, using a pneumonia score to identify those at risk of SCAP early and an aggressive pre-ICU resuscitation protocol may reduce mortality and ICU admissions.
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              Community-acquired pneumonia and survival of critically ill acute exacerbation of COPD patients in respiratory intensive care units

              Purpose The aim of this study was to appraise the effect of community-acquired pneumonia (CAP) on inhospital mortality in critically ill acute exacerbation of COPD (AECOPD) patients admitted to a respiratory intensive care unit. Patients and methods A retrospective observational study was performed. Consecutive critically ill AECOPD patients receiving treatment in a respiratory intensive care unit were reviewed from September 1, 2012, to August 31, 2015. Categorical variables were analyzed using chi-square tests, and continuous variables were analyzed by Mann–Whitney U-test. Kaplan–Meier analysis was used to assess the association of CAP with survival of critically ill AECOPD patients for univariate analysis. Cox’s proportional hazards regression model was performed to identify risk factors for multivariate analysis. Results A total of 80 consecutive eligible individuals were reviewed. These included 38 patients with CAP and 42 patients without CAP. Patients with CAP had a higher inhospital rate of mortality than patients without CAP (42% vs 33.3%, P<0.05). Kaplan–Meier survival analysis showed that patients with CAP had a worse survival rate than patients without CAP (P<0.05). Clinical characteristics, including Acute Physiology and Chronic Health Evaluation II (APACHE II) score, C-reactive protein, and CAP, were found to be closely associated with survival of AECOPD individuals. Further multivariate Cox regression analysis confirmed that CAP and APACHE II were independent risk factors for inhospital mortality in critically ill AECOPD patients (CAP: hazard ratio, 5.29; 95% CI, 1.50–18.47, P<0.01 and APACHE II: hazard ratio, 1.20; 95% CI, 1.06–1.37, P<0.01). Conclusion CAP may be an independent risk factor for higher inhospital mortality in critically ill AECOPD patients.
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                Author and article information

                Journal
                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                1176-9106
                1178-2005
                2017
                02 March 2017
                : 12
                : 783-784
                Affiliations
                [1 ]Department of Intensive Care Unit, Sureyyapasa Chest Disease and Research Hospital, Istanbul, Turkey
                [2 ]Intensive Care and Non Invasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, Spain
                Author notes
                Correspondence: Huriye Berk Takir, Department of Intensive Care Unit, Sureyyapasa Chest Disease and Research Hospital, Zumrutevler Mah., Handegul Sok., Adatepe Sitesi A-1 Blok K:4 D:11 Maltepe, Istanbul 34852, Turkey, Tel +90 505 774 5988, Email huriyeberk@ 123456yahoo.com
                Article
                copd-12-783
                10.2147/COPD.S124812
                5338850
                © 2017 Takir and Esquinas. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Letter

                Respiratory medicine

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