American Review of Respiratory Medicine - Volumen 22, Número 2 - June 2022

Editorials

Role of the Stratification of Patients with Community-Acquired Pneumonia: the Importance of the Tools Adjusted to Local Reality

El papel de la estratificación de pacientes con neumonía adquirida en la comunidad: la importancia de las herramientas adecuadas a la realidad locala

Community-acquired pneumonia (CAP) is still an important cause of morbidity and mortality in the adult population¹ . One important aspect for the management of this disease is the decision-making process regarding the suggested antibiotic treat­ment, the choice between outpatient and inpatient treatment (both in general areas and intensive care units) and the assessment of the patient’s prognosis.

Some currently validated tools for the assess­ment of patients with community-acquired pneu­monia (CAP) are the CURB 65 score (confusion, urea, respiratory rate, blood pressure, and age ≥ 65 years)² , which allows for risk estimation and choice between outpatient and inpatient management, and the Pneumonia Severity Index (PSI)³.

Randomized, multicenter studies showed that the PSI is superior to CURB 65 in terms of deciding between hospitalization and outpatient manage­ment without affecting mortality⁴ . However, the ATS/IDSA (American Thoracic Society/Infec­tious Diseases Society of America) Guidelines⁵ emphasize that these indices must not be used separately when determining whether the patient is to be hospitalized or not; instead, they must be supplemented with the assessment of other clinical and psychosocial aspects, the possibility to receive outpatient drugs, etc. Given the fact that neither the CURB 65 nor the PSI were designed to define the hospitalization level of care, the same guidelines suggest admission to an intensive care unit in cases of hypotension requiring vasopres­sors or respiratory failure requiring mechanical respiratory assistance; and in cases under different conditions, the recommendation is to apply a series of minor criteria (breathing rate > 30/min, PaO₂ / FiO₂ [arterial oxygen pressure/fraction of inspired oxygen] < 250, multilobar infiltrates, confusion, urea > 20 mg/dL, white blood count < 4000 cells/ mL, platelets < 1000 000/mL, hypothermia and hypotension requiring fluid resuscitation) plus the clinical criterion regarding the need to increase treatment intensity.

In this RAMR issue, Corona Martínez et al report the use of an index for the stratification of patients with community-acquired pneumonia, as a consequence of an unfavorable experience with the use of another tool, the PSI. The authors em­phasize its prognostic value but also indicate that the tool has been designed to guide the physician through the decision-making process related to the patient’s management. We should emphasize it is a user-friendly tool, since it is based on clinical and radiological data.

This publication shows the importance of hav­ing tools for evaluating patients with community-acquired pneumonia that allow us to assess the patient’s risk and simplify the decision-making process, and that can be adjusted to local needs.

REFERENCES

1. File TM, Marrie TJ. Burden of community-acquired pneumonia in North American adults. Prostgrad Med 2010;122:130-41. https://doi.org/10.3810/pgm.2010.03.2130

2. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with communityacquired pneumonia. N Engl J Med 1997; 336: 243-50. https://doi.org/10.1056/NEJM199701233360402

3. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58: 377-82. https://doi.org/10.1136/thorax.58.5.377

4. Aujesky D, Auble TE, Yealy DM, et al. Prospective com­parison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med 2005; 118: 384-92. https://doi.org/10.1016/j.amjmed.2005.01.006

5. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treat­ment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Tho­racic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. https://doi.org/10.1164/rccm.201908-1581ST.