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array:24 [ "pii" => "S2387020617303121" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.04.033" "estado" => "S300" "fechaPublicacion" => "2017-06-07" "aid" => "3996" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2017" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2017;148:501-10" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775317301884" "issn" => "00257753" "doi" => "10.1016/j.medcli.2017.02.024" "estado" => "S300" "fechaPublicacion" => "2017-06-07" "aid" => "3996" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2017;148:501-10" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 75 "formatos" => array:2 [ "HTML" => 59 "PDF" => 16 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Revisión</span>" "titulo" => "Utilidad y valor pronóstico de los biomarcadores en los pacientes con neumonía adquirida en la comunidad en los servicios de urgencias" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "501" "paginaFinal" => "510" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Usefulness and prognostic value of biomarkers in patients with community-acquired pneumonia in the emergency department" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2121 "Ancho" => 3347 "Tamanyo" => 427693 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Nuevo algoritmo de clasificación para los pacientes con neumonía adquirida en la comunidad en función de la escala CURB65-A para decidir el lugar de tratamiento.</p> <p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">NAC: neumonía adquirida en la comunidad; CURB65-A: escala que combina la MRproADM con la escala CURB-65, acrónimo de Confusión, Urea plasmática ><span class="elsevierStyleHsp" style=""></span>44<span class="elsevierStyleHsp" style=""></span>mg/dl (BUN ><span class="elsevierStyleHsp" style=""></span>19,4<span class="elsevierStyleHsp" style=""></span>mg/dl o ><span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>mmol/l), Frecuencia respiratoria ≥<span class="elsevierStyleHsp" style=""></span>30, Presión arterial sistólica <<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mmHg o Presión arterial diastólica ≤<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg y Edad ≥<span class="elsevierStyleHsp" style=""></span>65 años; MRproADM: región medial de la proadrenomedulina; UCI: unidad de cuidados intensivos.</p> <p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Fuente: adaptada de Schuetz et al.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">11</span></a> y Huang et al.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">21</span></a>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Agustín Julián-Jiménez, Juan González del Castillo, Francisco Javier Candel" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Agustín" "apellidos" => "Julián-Jiménez" ] 1 => array:2 [ "nombre" => "Juan" "apellidos" => "González del Castillo" ] 2 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "Candel" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020617303121" "doi" => "10.1016/j.medcle.2017.04.033" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617303121?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775317301884?idApp=UINPBA00004N" "url" => "/00257753/0000014800000011/v1_201705140041/S0025775317301884/v1_201705140041/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020617303571" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.05.011" "estado" => "S300" "fechaPublicacion" => "2017-06-07" "aid" => "3998" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2017;148:511-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Cerebral magnetic resonance changes associated with fibromyalgia syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "511" "paginaFinal" => "516" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cambios en la resonancia magnética cerebral asociados al síndrome de fibromialgia" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3016 "Ancho" => 1736 "Tamanyo" => 370836 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging (MRI) indicating whether the values for the referred metabolites are increased (in red) or decreased (in green). Creatinine is in bold as it is used as the reference value. (a) Coronal-slice MRI, indicating the values of the metabolites studied regarding both hippocampus. Note that in the left hippocampus, different authors give opposite values for choline. (b) Horizontal-slice MRI, indicating the values of the studied metabolites referred to the head of the caudate nucleus bilaterally and to the insula (anterior and posterior region). (c) Sagittal-slice MRI, indicating the values of the metabolites studied referred to the ventrolateral prefrontal cortex, and the anterior and posterior cortex of the cingulate gyrus.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Cho: choline; Cr: creatine; GABA: gamma-aminobutyric acid; Gln: glutamine; Glu: glutamate; Glx: glutamate<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>glutamine; Lact: lactate; MI: myo-inositol; NAA: N-acetylaspartate; NAAG: N-acetylaspartate glutamate.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Iñigo Murga, Virginia Guillen, José-Vicente Lafuente" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Iñigo" "apellidos" => "Murga" ] 1 => array:2 [ "nombre" => "Virginia" "apellidos" => "Guillen" ] 2 => array:2 [ "nombre" => "José-Vicente" "apellidos" => "Lafuente" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775317301902" "doi" => "10.1016/j.medcli.2017.01.034" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775317301902?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617303571?idApp=UINPBA00004N" "url" => "/23870206/0000014800000011/v1_201706250038/S2387020617303571/v1_201706250038/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S238702061730342X" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.01.025" "estado" => "S300" "fechaPublicacion" => "2017-06-07" "aid" => "3999" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2017;148:498-500" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "HTML" => 1 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial article</span>" "titulo" => "Birth month, a simple demographic indicator of early environmental exposures and risk of chronic diseases" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "498" "paginaFinal" => "500" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mes de nacimiento, un sencillo indicador demográfico de exposiciones ambientales tempranas y de riesgo de enfermedad crónica" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José R. Banegas" "autores" => array:1 [ 0 => array:2 [ "nombre" => "José R." "apellidos" => "Banegas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775317301914" "doi" => "10.1016/j.medcli.2017.01.035" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775317301914?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702061730342X?idApp=UINPBA00004N" "url" => "/23870206/0000014800000011/v1_201706250038/S238702061730342X/v1_201706250038/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Usefulness and prognostic value of biomarkers in patients with community-acquired pneumonia in the emergency department" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "501" "paginaFinal" => "510" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Agustín Julián-Jiménez, Juan González del Castillo, Francisco Javier Candel" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Agustín" "apellidos" => "Julián-Jiménez" "email" => array:1 [ 0 => "agustinj@sescam.jccm.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Juan" "apellidos" => "González del Castillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Francisco Javier" "apellidos" => "Candel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Urgencias, Complejo Hospitalario Universitario de Toledo, Toledo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Urgencias, Hospital Universitario Clínico San Carlos, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Microbiología Clínica, Hospital Clínico Universitario San Carlos, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad y valor pronóstico de los biomarcadores en los pacientes con neumonía adquirida en la comunidad en los servicios de urgencias" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1661 "Ancho" => 3333 "Tamanyo" => 268058 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">New classification algorithm for patients with community-acquired pneumonia according to CURB65-A score to determine treatment site. CAP: community-acquired pneumonia; CURB65-A: a score that combines MRproADM with CURB-65, acronym for Confusion, Plasma Urea >44<span class="elsevierStyleHsp" style=""></span>mg/dl (BUN<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>19.4<span class="elsevierStyleHsp" style=""></span>mg/dl or >7<span class="elsevierStyleHsp" style=""></span>mmol/l), Respiratory rate ≥30, Systolic blood pressure <90<span class="elsevierStyleHsp" style=""></span>mmHg or diastolic blood pressure ≤60<span class="elsevierStyleHsp" style=""></span>mmHg and Age ≥65 years; MRproADM: mid-regional proadrenomedullin; ICU: intensive care unit. <span class="elsevierStyleItalic">Source</span>: Adapted from Schuetz et al.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">11</span></a> and Huang et al.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">21</span></a></p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The incidence of community-acquired pneumonia (CAP) ranges from 2 to 15 cases/1000 inhabitants/year, depending on the geographic area and the season of the year,<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">1,2</span></a> higher in male subjects, smokers, ≥75 years of age, with comorbidities or immunosuppressed.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">3</span></a> Its diagnosis has increased in the emergency department (ED), going from 0.85% of patients seen in 2001 to 1.35% in 2011.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">3</span></a> 51% correspond to patients ≥70 years of age,<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">3</span></a> a subgroup with more difficult diagnosis,<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">4</span></a> higher clinical severity and mid- to long-term mortality.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">CAP represents the leading cause of death from infectious disease in the Western world (10–14%)<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">1,2</span></a> and the origin of most sepsis and septic shock cases treated in EDs,<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">3</span></a> as well as the first infectious cause (9%) of admission to the intensive care unit (ICU), required by 2.6% of CAP.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">3,5</span></a> Hence the importance of CAP in the EDs, since 75% of them are assessed at some point in these units,<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">6</span></a> also the “ED impact on CAP”, as it is in this department where the initial but essential decisions are made, determining disease progression and patient safety.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">6,7</span></a> There is great variability in the management of the diagnostic-therapeutic aspects of CAP,<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">6,8</span></a> which is one of the reasons for differences in admission rates (22–61%), achievement of microbiological diagnosis, request for complementary studies, choice of antimicrobial regimen or intensity of care offered.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">6,8,9</span></a> Therefore, it is the most relevant infection in the ED. Therefore, correctly determining the need for admission (when), location (where) and intensity of care (how) will determine prognosis, mortality, requests for tests and microbiological studies, antibiotic regimen, intensity of clinical observation and the use of social-health resources (costs).<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">6</span></a> In this sense, the implementation of clinical practice guidelines (CPG)<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">8,9</span></a> together with the use of prognostic severity scores<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">6</span></a> and inflammatory response and infection biomarkers (IRIBM)<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">10,11</span></a> improve treatment and admission adequacy, progression, hospital stay and mortality.<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Recently, the search for help tools has been intensified in order to establish early diagnosis, prognosis, severity, suspicion of bacteraemia and possible bacterial aetiology<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13,14</span></a> when CAP is suspected, even during the first evaluation or targeted triage.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">12</span></a> Multiple studies, reviews and meta-analyses demonstrating the utility of IRIBM in EDs have been recently published,<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> especially on CAP,<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">10,11</span></a> which have included C-reactive protein (CRP), interleukins (IL) 6 and 8, proendothelin-1 (proET1), copeptin, D-dimer, atrial natriuretic propeptide (proANP) or cortisol, among others.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">10,13–17</span></a> Mid-regional proadrenomedullin (MRproADM) stands out among them as a predictor of mortality.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">11,15,18–27</span></a> Procalcitonin (PCT) also stands out as a sensitive and specific marker regarding targeting the pathogen causing the CAP,<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">15,28–30</span></a> its clinical course (severe sepsis and septic shock),<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">30</span></a> the possibility of bacteremia,<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">14,31,32</span></a> mortality<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">33</span></a> and as a guide to antibiotic treatment.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">6,13</span></a> And finally, lactate, the best marker for hypoperfusion and tissue hypoxia, which is included in all the recommendations for assessment of patients with sepsis and septic shock.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This review aims at highlighting recently published scientific evidence, clarifying existing controversies, and comparing the usefulness and prognostic capacity of IRIBM in patients with CAP. And from it, generate different recommendations that can help define the role of these in the assessment of CAP.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Strategy for article review and selection</span><p id="par0025" class="elsevierStylePara elsevierViewall">A systematic search was made in the PubMed, Web of Science, Scopus and EMBASE databases, combining as keywords: (community-acquired pneumonia or pneumonia) and (prognosis or prognostic indices or mortality or bacteraemia) and (biomarkers, adrenomedullin, procalcitonin, lactate). We used filters to select adult patient (>15 years of age) articles related to ED, in English and Spanish, from 1-01-2001 to 30-11-2016. The ones considered relevant were chosen at the discretion of the authors. Articles on patients who were immunosuppressed, neutropenic, with human immunodeficiency virus infection, transplanted, splenectomised, or under immunosuppressive treatment were excluded, as well as articles developed in a hospital ward or intensive care unit. The search was extended manually to other articles that were considered of interest. In this way 4823 results were found, of which 185 articles were initially selected (editorials, scientific letters, originals, short originals, reviews and meta-analyses). Ultimately, 53 articles were selected that met the objectives of the review.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Biomarkers in community-acquired pneumonia</span><p id="par0030" class="elsevierStylePara elsevierViewall">A biomarker is defined as that molecule measurable in a biological sample whose concentrations are indicative of the degree of inflammatory response and help in monitoring response to treatment and as a guide to antibiotic therapy.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> The IRIBM should provide additional information to that obtained with the patient's clinical data and help in decision making.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">6,13</span></a> The main benefits of IRIBM sought in CAP are:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0035" class="elsevierStylePara elsevierViewall">Establish an early diagnosis of bacterial CAP (versus other cardiovascular and inflammatory diseases, viral infections, etc.).<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0040" class="elsevierStylePara elsevierViewall">Identify patients with severe CAP with the highest sensitivity and positive predictive value (PPV),<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> as well as to rule out cases of suspected bacteremia<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">34</span></a> with the greatest specificity and negative predictive value (NPV).<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0045" class="elsevierStylePara elsevierViewall">Stratify the risk of poor outcome, complications and mortality independently or in combination with the severity indices, to indicate hospital admission and the most appropriate department/unit.<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">28,33</span></a></p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">Besides the clinical condition, characteristics and age of the patient, the type of pathogen and the cut-off point adopted, other factors must be taken into account when interpreting the results of each IRIBM. Consideration should be given to whether the patient has taken antibiotics in the previous 72<span class="elsevierStyleHsp" style=""></span>h (may decrease values), duration of symptomatology and possible bacterial aggression and the very kinetics of IRIBM, which will determine their usefulness and which are the most indicated in the ED.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">C-reactive protein</span><p id="par0055" class="elsevierStylePara elsevierViewall">CRP is released in hepatocytes following stimulation of IL-6 and IL-8 in response to any type of inflammation, viral, bacterial or mixed CAP infections.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> It poses limitations due to its slow kinetics, which can lead to false negatives at the beginning of the CAP and a delay in its clearance after adequate treatment and clinical condition resolution.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> It offers a lower diagnostic and prognostic capacity (prediction of bacteraemia and mortality)<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">6,15,33</span></a> for bacterial CAP<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13,23</span></a> than PCT or MRproADM. In addition, its values depend on age, sex and race, so it would be necessary to adjust and interpret its serum concentrations in each patient.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> Ruiz-González et al.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">35</span></a> published a good CRP performance (with a cut-off point >200<span class="elsevierStyleHsp" style=""></span>mg/l) to detect CAP compared to other respiratory infections, with an area under the curve-<span class="elsevierStyleItalic">receiver operating characteristic</span> (AUC-ROC) of 0.84 (95% CI: 0.82–0.87).</p><p id="par0060" class="elsevierStylePara elsevierViewall">High sensitivity CRP (hsPCR) obtains greater specificity for the diagnosis of bacterial infection. In the elderly, with a cut-off point of 61<span class="elsevierStyleHsp" style=""></span>mg/l, an AUC of 0.76 (95% CI: 0.72–0.79) has been obtained to diagnose CAP in comparison with other acute pulmonary processes, with a relative risk (RR) of 3.59 (95% CI: 2.35–5.48; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001).<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">36</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Procalcitonin</span><p id="par0065" class="elsevierStylePara elsevierViewall">A protein synthesized in the thyroid and lung neuroendocrine cells, although other tissues can produce it in situations of bacterial infection. It is almost undetectable in healthy subjects (<0.05<span class="elsevierStyleHsp" style=""></span>ng/ml).<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> Its concentrations are related to the degree of systemic inflammatory response, bacterial load and/or endotoxin concentration. Its kinetics is considered adequate for use in the ED, as it increases within 2–6<span class="elsevierStyleHsp" style=""></span>h following bacterial stimulation and its peak values are found after 12–36<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The following recognized benefits stand out in the patient with suspected CAP:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Ability to distinguish CAP with a cut-off point >0.10<span class="elsevierStyleHsp" style=""></span>ng/ml in patients with dyspnoea in the ED with the best AUC-ROC of 0.84 (95% CI: 0.77–0.91), a sensitivity of 80%, specificity of 78% and NPV of 96% in comparison with heart failure and other cardiopulmonary diseases.<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">29</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2.</span><p id="par0080" class="elsevierStylePara elsevierViewall">High power to predict bacterial infection versus viral infection, and even to detect bacterial overinfection in patients with viral pneumonia when their values are higher than 0.10–0.25<span class="elsevierStyleHsp" style=""></span>ng/ml.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13,28,29</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3.</span><p id="par0085" class="elsevierStylePara elsevierViewall">Discriminate between atypical bacteria (<span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> or <span class="elsevierStyleItalic">Chlamydophila pneumoniae</span>) and typical bacteria.<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">28,29</span></a> When its values are >0.5<span class="elsevierStyleHsp" style=""></span>ng/ml, it especially points towards <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>.<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">15,30</span></a> Therefore, with a PCT cut-off point ≥0.85<span class="elsevierStyleHsp" style=""></span>ng/ml, a considerable diagnostic yield is obtained to predict the aetiology of pneumococcal CAP, with AUC-ROC of 0.92, a sensitivity of 89%, a specificity of 84%, and a NPV higher than 96%.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4.</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ability to predict poor outcome and risk of severe sepsis and septic shock.<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">15,30,33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">5.</span><p id="par0095" class="elsevierStylePara elsevierViewall">Ability to predict concomitant bacteremia.<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">31,32</span></a> The cut-off point ranges from 0.25 to 1<span class="elsevierStyleHsp" style=""></span>ng/ml according to authors, but always with the best performance of the different IRIBM, and in almost all cases with a NPV higher than 94% and a specificity greater than 90%.<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">14,31,32</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">6.</span><p id="par0100" class="elsevierStylePara elsevierViewall">Classification in mortality risk groups (together with the severity indices or in isolation).<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">33</span></a> Thus, Julián-Jiménez et al.,<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">8,9</span></a> when adding as a criterion of admission a PCT<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>ng/ml to the Pneumonia <span class="elsevierStyleItalic">Severity Index</span> (PSI)<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">37</span></a> in 400 cases of CAP, improves the admission decision in 23% of patients (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01), the mean stay in 2.25 days (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) and mortality from 15 to 5.5% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.003). Multiple studies have shown the relationship between PCT and the PSI and CURB-65 (acronym for Confusion, Urea >44<span class="elsevierStyleHsp" style=""></span>mg/dl, Respiratory rate ≥30, Systolic blood pressure <90<span class="elsevierStyleHsp" style=""></span>mmHg or diastolic blood pressure ≤60<span class="elsevierStyleHsp" style=""></span>mmHg and Age ≥65 years) groups (higher in PSI IV–V and CURB-65 3–5 groups)<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">33</span></a> and a mortality prognosis improvement of both severity scales when combined with PCT.<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">38</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">7.</span><p id="par0105" class="elsevierStylePara elsevierViewall">Clinical and antimicrobial treatment monitoring on PCT serialization (a serum reduction of 30–50% indicates the resolution of the condition).<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">8.</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the elderly, it maintains its diagnostic capacity for CAP, aetiology, bacteraemia and prognosis of mortality, with a performance superior to the rest of IRIBM.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13,27</span></a></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Mid-regional proadrenomedullin</span><p id="par0115" class="elsevierStylePara elsevierViewall">The measurement of proADM is difficult (short half-life and great binding to receptors), that is why MRproADM is used, as it increases in situations of cellular stress and is recognized as IRIBM, marker of sepsis and other cardiovascular diseases.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">11,13–15,18–27</span></a> Able to discriminate between bacterial and viral infection and with the capacity to diagnose sepsis and its progression to septic shock and to predict bacteremia.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13,14</span></a> Its prognostic ability for short term mortality (7–30 days), medium term mortality (90–180 days) and even at one year, stands out above the rest of IRIBM.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">10,11</span></a> This prognostic performance is comparable or superior to the severity scales (PSI and CURB-65).<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13,18,19</span></a> In patients with a PSI of IV–V, Courtais et al.<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">39</span></a> report an AUC-ROC of 0.81 (95% CI: 0.65–0.96) versus a PSI of 0.69 (95% CI: 0.44–0.89), with an OR of 4.61 (95% CI: 1.66–20.22), <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.012. In this sense, a meta-analysis<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">19</span></a> with 8 studies and 4199 patients, with a MRproADM cut-off point of 1.06–1.85<span class="elsevierStyleHsp" style=""></span>nmol/l, determines that to predict mortality at 28–30 days the AUC-ROC is 0.76 (95%: 0.72–0.80). In this review, the lowest OR is 4.61 (95% CI: 2.53–8.43)<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">22</span></a> and the highest OR is 21.60 (95% CI: 2.86–163.09).<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Lactate</span><p id="par0120" class="elsevierStylePara elsevierViewall">It is considered the best marker of hypoperfusion and tissue hypoxia. Its values >2.5<span class="elsevierStyleHsp" style=""></span>mmol/l should be monitored as an independent predictor of severity (sepsis-septic shock), poor outcome and mortality in patients with CAP.<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">40,41</span></a> A study<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">40</span></a> with 424 patients found that survivors at 30 days had a lactic acidaemia of 1.50<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.91<span class="elsevierStyleHsp" style=""></span>mmol/l versus 3.10<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.17<span class="elsevierStyleHsp" style=""></span>mmol/l in deceased patients (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001), with an excellent mortality prediction, achieving an AUC-ROC of 0.85 (95% CI: 0.78–0.92). The authors conclude that, with/without hypotension, patients with CAP and lactate >2.5<span class="elsevierStyleHsp" style=""></span>mmol/l and/or PCT<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>ng/ml should not be discharged. And patients with lactate >4<span class="elsevierStyleHsp" style=""></span>mmol/l and PCT<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ng/ml should be assessed by the ICU (with a high probability of bacteraemia and progression to septic shock).<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">40</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">On the other hand, Jo et al.<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">41</span></a> compared the ability to predict mortality of CURB-65 and PSI with a new severity index which includes lactate,<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">42</span></a> the <span class="elsevierStyleItalic">National Early Warning Score-Lactate</span> (NEWS-L), which is the adaptation of the <span class="elsevierStyleItalic">VitalPAC Early Warning Score-Lactate</span> (ViEWS-L), for patients with severe CAP. In this study, they observed that mortality increases according to certain selected quartiles of lactate values. Thus, the first quartile, with ≤3<span class="elsevierStyleHsp" style=""></span>mmol/l, presented a 2.2% mortality; the second quartile, with 3.1–5.2<span class="elsevierStyleHsp" style=""></span>mmol/l, presented a 7.9%; the third quartile showed 9.6% if lactate was between 5.3 and 8<span class="elsevierStyleHsp" style=""></span>mmol/l, and the fourth quartile a 23.9% mortality when lactate was ≥8.1<span class="elsevierStyleHsp" style=""></span>mmol/l. The AUC-ROC of the NEWS-L was 0.73 (95% CI: 0.66–0.80), showing no significant difference with that of the PSI, of 0.68 (95% CI: 0.76), nor with that of CURB-65, of 0.66 (95% CI 0.59–0.73). NEWS-L scores systolic blood pressure, respiratory rate, heart rate, temperature, percentage of oxygen saturation, need for supplemental oxygen, level of consciousness and lactate.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Other biomarkers</span><p id="par0130" class="elsevierStylePara elsevierViewall">They are not usually available and do not have the same level of evidence as the ones described above.<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">ProET1</span>. It is related to clinical severity and as a predictor of mortality and ICU admission. In one study, it showed greater ability to predict ICU admission, with an AUC of 0.64 (95% CI: 0.53–0.74) (compared with CRP, PCT and white blood cells).<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">43</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Copeptine</span>. Its concentrations increase in patients with CAP compared to healthy subjects (1–12<span class="elsevierStyleHsp" style=""></span>pmol/l). It is considered a good predictor of ICU admission and mortality in the first 7 days (AUC: 0.81, with a cut-off point >35<span class="elsevierStyleHsp" style=""></span>pmol/l, 78% sensitivity and 79% specificity).<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">10</span></a> The largest published study<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">44</span></a> (1740 patients) which compared copeptin with multiple IRIBMs and CURB-65 to predict mortality at 28 days, with a cut-off point of 29<span class="elsevierStyleHsp" style=""></span>pmol/l, obtained an AUC of 0.84 (similar to MRproADM but higher than CRP, PCT and CURB-65).</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Natriuretic peptides</span>. Both the proatrial natriuretic peptide (proANP)<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">45,46</span></a> and the type B natriuretic peptide (proBNP)<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">47</span></a> have been studied as prognostic factors for mortality in CAP. Perhaps, their greatest contribution is the ability of proBNP to differentiate CAP from acute heart failure, when concentrations ≥200<span class="elsevierStyleHsp" style=""></span>pg/ml are detected, with which it achieves a <span class="elsevierStyleItalic">hazard ratio</span> (HR) of 10.01 (95% CI: 1.32–75.7), with sensitivity of 76.5% and specificity of 60.8% for the diagnosis of acute heart failure.<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">47</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cortisol.</span> It is associated with severity and mortality in CAP and predicts persistent clinical instability, making it a potential IRIBM to identify patients at risk of developing a complicated course CAP.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">10</span></a> Kolditz et al.<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">48</span></a> compared its predictive mortality accuracy in the first 7 days with CRB-65, MRproADM and PCT, showing better results than these, achieving an AUC of 0.70 with a cut-off point <795<span class="elsevierStyleHsp" style=""></span>nmol/l.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Finally, <span class="elsevierStyleItalic">D</span>-<span class="elsevierStyleItalic">dimer</span>,<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">10</span></a> the surface receptor expressed in myeloid cells (sTREM1),<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> the red cell distribution width (RDW),<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">49</span></a> lipid metabolites or IL-6 and IL-8, among others,<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> have been proposed as diagnostic and prognostic markers, although none have been validated in CAP. <span class="elsevierStyleItalic">Neopterin</span> is considered a marker of viral infection; its joint use with PCT can increase its capacity and mutual diagnostic performance, especially in times of viral epidemic or to differentiate viral and bacterial aetiology in the suspicion of CAP.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13,14</span></a></p></li></ul></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Etiological prediction</span><p id="par0160" class="elsevierStylePara elsevierViewall">There is greater systemic inflammation and higher values of IRIBM in bacterial CAP,<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> and especially when the pathogen is <span class="elsevierStyleItalic">S. pneumoniae</span>.<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">28–30</span></a> This fact is important because when the aetiology is pneumococcal there is a greater probability of progression to sepsis-septic shock, bacteraemia and higher mortality.<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">30–32</span></a> The diagnosis of <span class="elsevierStyleItalic">S. pneumoniae</span> increases the possibility of severe sepsis from 18.2 to 25.9% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) and is associated with an OR of 1.59 (95% CI: 1.31–1.95), <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001.<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">50</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The diagnostic capacity of PCT for bacterial CAP is much higher than that of the rest of IRIBM<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a>; the controversy arises when trying to establish the optimal cut-off points that offer an etiological orientation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). When diagnostic doubt exists between bacterial or viral CAP or other pleuropulmonary disease in a patient with dyspnoea, a PCT >0.10<span class="elsevierStyleHsp" style=""></span>ng/ml obtains a sensitivity of 80%, a specificity of 78%, a NPV of 96% and an AUC of 0.84 (95% CI: 0.77–0.91) to diagnose bacterial CAP.<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">29</span></a> In other words, if the PCT is <0.10<span class="elsevierStyleHsp" style=""></span>ng/ml, the probability of bacterial CAP is minimal.<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">51</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Cuquemelle et al.<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">52</span></a> report that PCT<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.8<span class="elsevierStyleHsp" style=""></span>ng/ml distinguishes between viral CAP and viral CAP with bacterial coinfection in situations of influenza epidemic, with an OR of 12.9 (95% CI: 3.2–51.5; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).</p><p id="par0175" class="elsevierStylePara elsevierViewall">España et al.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">28</span></a> found PCT differences between typical bacterial CAP with averages of 1.06 (0.29–10.01)<span class="elsevierStyleHsp" style=""></span>ng/ml versus atypical CAP with 0.09 (0.06–0.17)<span class="elsevierStyleHsp" style=""></span>ng/ml. And with a cut-off point ≥0.15<span class="elsevierStyleHsp" style=""></span>ng/ml, the PCT obtained an OR of 21.67 (95% CI: 7.74–60.67), <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001, with an AUC of 0.81, sensitivity of 88.64%, specificity of 73.53%, PPV of 59.09% and VPN of 93.75% for typical CAP. While CRP, with a cut-off point of CRP ≥125<span class="elsevierStyleHsp" style=""></span>mg/l, obtained a lower performance, with OR of 4.01 (95% CI: 1.85–8.65) and AUC of 0.73.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Prediction of bacteraemia</span><p id="par0180" class="elsevierStylePara elsevierViewall">CAP represents the second cause of bacteraemia detected in EDs and <span class="elsevierStyleItalic">S. pneumoniae</span> is the most frequent pathogen (>75%), behind urinary tract infections and <span class="elsevierStyleItalic">Escherichia coli</span>, respectively.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">3</span></a> Bacteraemia is found in 10–25% of patients with CAP, depending on the criteria for collecting blood cultures<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">53</span></a> and patient severity.<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">30–32</span></a> Suspicion and confirmation of bacteraemia has important prognostic significance and determines the decision to request microbiological studies (blood culture and antigenuria),<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> admission or discharge, and the choice of antimicrobial regimen.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">6</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Numerous papers have been published that point to the usefulness of IRIBM, especially PCT, which has demonstrated a much higher ability to predict the existence of bacteremia.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13–15,30–32,54</span></a> Therefore, finding a cut-off point for PCTs that can rule out the existence of bacteraemia in CAP in the ED has been a concern of different authors, although these vary from 0.35 to 2<span class="elsevierStyleHsp" style=""></span>ng/ml.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13,32,33</span></a> In a non-exclusive meta-analysis of patients with CAP, Hoeboer et al.<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">54</span></a> analysed 58 studies (16,514 patients, 3420 with bacteraemia), finding that a cut-off point ≥0.5<span class="elsevierStyleHsp" style=""></span>ng/ml achieved an AUC of 0.79, with a sensitivity of 76% and a specificity of 69%. And this diagnostic yield increases to an AUC of 0.88 with sensitivity of 89% and specificity of 78% in the subgroup of patients being admitted to the ICU. Unlike CRP, PCT maintains this capacity in the elderly, in which, with a cut-off point ≥0.55<span class="elsevierStyleHsp" style=""></span>ng/ml, an AUC of 0.95 was obtained, with sensitivity of 92%, specificity of 88% and NPV of 97%.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Regarding publications comparing PCTs with hsPCR, although the latter increases its specificity and PPV, and there are significant differences between the values of CAPs with/without bacteraemia (9128<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>67.34<span class="elsevierStyleHsp" style=""></span>mg/l versus 180.72<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>98.29<span class="elsevierStyleHsp" style=""></span>mg/l; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01), it remains inferior to PCT.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> Similar results are obtained by Schuetz et al.,<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">43</span></a> where the PCT is superior (AUC: 0.84 [95% CI: 0.74–0.93]) to CRP (AUC: 0.67 [95% CI: 0.56–0.78]) and leukocyte count (AUC: 0.66 [95% CI: 0.55–0.78]). In this line, a Spanish study<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">15</span></a> with 127 patients (23% of them had bacteraemia) found, with PCT<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>0.95<span class="elsevierStyleHsp" style=""></span>ng/ml, an excellent performance (much better than that of CRP, white blood cells, MRproADM and lactate), with an AUC of 0.95 (95% CI: 0.89–1), sensitivity of 93.1%, specificity of 89, 7% and NPV of 97.8%. Similar results were obtained in another study with 474 patients,<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">32</span></a> 85 (17.9%) with bacteraemia and 75 (88.4%) <span class="elsevierStyleItalic">S. pneumoniae</span> isolates; with a cut-off point ≥0.95<span class="elsevierStyleHsp" style=""></span>ng/ml, achieved an AUC of 0.98 (95% CI: 0.91–0.99), sensitivity of 94.1%, specificity of 91%, and NPV<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>98%. When only the cases of CAP with bacteraemia by <span class="elsevierStyleItalic">S. pneumoniae</span> with a cut-off point ≥0.95<span class="elsevierStyleHsp" style=""></span>ng/ml were analysed, an AUC of 0.97 (95% CI: 0.90–0.99), sensitivity of 94.6%, specificity of 91% and NPV of 98.8% was also found.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Risk stratification and mortality</span><p id="par0195" class="elsevierStylePara elsevierViewall">Assessing the severity is essential to estimate the intensity of treatment needed by the patient. The use of CPG with severity indices decreases the proportion of low-risk CAP cases (PSI groups I–III) inadequately admitted (from 49 to 31%), ED re-visits,<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">55</span></a> hospital stays and mortality.<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">8,9</span></a> However, the limitations of the most popular severity indices in EDs (PSI and CURB-65)<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">6</span></a> are well known, but also the fact that the combination of IRIBM with these improves their predictive capacity.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">9</span></a> That is why the IRIBM could improve the adequacy of admissions in CAP.<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">22,23,33,45</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">PSI (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>)<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">37</span></a> identifies the low risk of mortality in PSI groups I–III and helps us regarding “discharge” decisions, but confers excessive weight to age for those over 65, may underestimate the severity, especially in young people with hypoxia, and does not value additional circumstances to consider (sepsis-septic shock criteria, bilaterality, multilobar involvement or radiological cavitation).<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">CURB-65<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">56</span></a> defines 6 risk groups. In relation to PSI, it detects high-risk patients better (groups 3–5) who would be admitted, but also presents major limitations when overestimating the risk in the ≥65 years of age due to the age criterion and neither evaluates PaO<span class="elsevierStyleInf">2</span>, nor comorbidity, nor clinical severity, nor the degree of inflammatory response nor the radiological findings.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">6</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Severity Community Acquired Pneumonia</span> (SCAP)<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">57</span></a> contains 2 major and 6 minor criteria (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>); it is already used in many sites and recommended by different experts because, in addition to predicting mortality (like PSI and CURB-65), it has been validated and is able to predict the need for mechanical ventilation and progression to septic shock.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">After deciding whether to hospitalize a patient, it is also important to identify the most severe early or those who may worsen quickly in order to decide whether they should be treated in an ICU.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">6</span></a> Neither PSI nor CURB-65 were designed to assess the need for ICU admission. On the other hand, the criteria of severity of the <span class="elsevierStyleItalic">American Thoracic Society</span>-<span class="elsevierStyleItalic">Infectious Diseases Society of America</span> (ATS/IDSA) 2007<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">2</span></a> and the SCAP score<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">57</span></a> are appropriate to identify candidates for inotropic and/or ventilatory support.</p><p id="par0220" class="elsevierStylePara elsevierViewall">On the other hand, the accessibility and the speed with which lactate, CRP and PCT are determined in many EDs (MRproADM is also being progressively introduced), has contributed to them being added as criteria to the severity indices and examination to evaluate the severity and improve decision-making.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">6,13</span></a> Thus, their combination may provide additional information to confirm the diagnosis of bacterial CAP, predict bacteraemia and decide the appropriate treatment site for the patient.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">15</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Today, we can consider the combination of severity indices<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>IRIBM as the best strategy for prognostic assessment and prediction of mortality in the patient with CAP<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">6,33,58</span></a> and even to better manage their stay in the ED.<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">59</span></a> Menéndez et al.<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">45</span></a> demonstrated that by adding CRP (>25<span class="elsevierStyleHsp" style=""></span>mg/ml) and/or PCT (>0.5<span class="elsevierStyleHsp" style=""></span>ng/ml) the predictive value of PSI (AUC: 0.81 [95% CI: 0.75–0.87]) and CURB-65 (AUC: 0.82 [95% CI: 0.76–0.89]) improve, and this improvement was greater when both IRIBM were combined with a severity index or both severity indices with a IRIBM.</p><p id="par0230" class="elsevierStylePara elsevierViewall">On the other hand, the prognostic power offered by MRproADM is very significant.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">11,15–28</span></a> Their results were similar or better than the severity indices in the estimation of mortality at 3–7,<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">15,24</span></a> 28–30,<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">15,16,21</span></a> 180<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">16,23</span></a> and 365<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">15</span></a> days. In addition, its combination with different severity indices obtains the best published results for this objective in CAP.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">11–18,22,41</span></a> In a meta-analysis, Cavallazzi et al.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">18</span></a> conclude that high concentrations of MRproADM are associated with an increased risk of mortality at 28–30 days, with an OR of 6.86 (95% CI: 4.64–10.13; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001), and occurrence of complications (need for mechanical ventilation, ICU, death), with an OR of 5.00 (95% CI 3.86–6.49; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the results of different studies evaluating MRproADM in the ED.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">Huang et al.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">21</span></a> show serum concentrations (quartiles) of MRproADM in ED that are related to patient survival: first quartile (<span class="elsevierStyleItalic">Q</span>)<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>0.669<span class="elsevierStyleHsp" style=""></span>nmol/l, 30-day mortality of 1%; second <span class="elsevierStyleItalic">Q</span>, from 0.669 to 0.965<span class="elsevierStyleHsp" style=""></span>nmol/l, 3% mortality; third <span class="elsevierStyleItalic">Q</span>, from 0.966 to 1.45<span class="elsevierStyleHsp" style=""></span>nmol/l, mortality of 6%, and in the fourth <span class="elsevierStyleItalic">Q</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1.45<span class="elsevierStyleHsp" style=""></span>nmol/l, mortality of 15%, with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001 between quartiles.</p><p id="par0240" class="elsevierStylePara elsevierViewall">Albrich et al.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">22</span></a> proposed a new scale (CURB65-A, <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), with 3 risk groups. Class I (CURB-65 0-1 and MRproADM<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.75<span class="elsevierStyleHsp" style=""></span>nmol/l): low risk (0.65% of mortality and 3.9% of adverse events) where discharge is recommended. Class II (CURB-65 2 and MRproADM<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>nmol/lo CURB-65 0-1 and MRproADM between 0.75 and 1.5<span class="elsevierStyleHsp" style=""></span>nmol/l): moderate risk (2.6% mortality and 8.6% adverse events) where admission in the observation or clinical assessment unit (CAU) is indicated. Class III: high risk (MRproADM<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>nmol/l with any CURB-65) in which hospitalization is recommended.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0245" class="elsevierStylePara elsevierViewall">Renaud et al.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">24</span></a> designed a study that analyses the prognostic capacity of MRproADM to detect the early need for ICU admission for severe CAP (those requiring mechanical ventilation or vasopressor agents or death occurs within 3 days from ED consultation).</p><p id="par0250" class="elsevierStylePara elsevierViewall">España et al.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">26</span></a> compared PCT, CRP and MRproADM with different severity indices, as well as their combinations to predict adverse outcome (complications). In addition to PSI and CURB-65, they include SCAP, which is the score with the best AUC, of 0.82, and MRproADM, the IRIBM with the best capacity, with AUC of 0.84, proving that SCAP<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>MRproADM achieves an AUC of 0.899. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows a new classification algorithm for patients with CAP as per SCAP and MRproADM to decide the site of treatment.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions and recommendations</span><p id="par0255" class="elsevierStylePara elsevierViewall">Determining the need for admission and the right site to treat the patient can be difficult, but it is very important. Severity indices have major limitations, as does the physician's clinical assessment. Therefore, today, having an efficient panel of IRIBM in the ED as a complement to the clinical assessment is very relevant. In this sense, nowadays, determining PCT, MRproADM and lactate, independently or associated (“synergism of biomarkers”),<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> or in combination with the severity indices, is the best option. The key will be to know how to choose the IRIBM or the combination that can improve the management of the CAP patient in the ED.<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">60</span></a> PCT has the greatest ability to diagnose CAP, bacterial aetiology and the coexistence of bacteraemia. MRproADM obtains the best results in terms of predicting mortality in the short, medium-long term and combined with the severity indices. In the near future, the new algorithms (CURB65-A or SCAP-MRproADM) will be used routinely and will clearly improve CAP patient care. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents practical recommendations for the use of IRIBM in patients with CAP in the ED.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">Finally, another aspect to consider is related to the cost-benefit ratio and the benefits of EDs having IRIBMs. In our opinion, provided any of the recommendations discussed in this review is applicable, the cost of a lactate determination in a blood gas analysis (1–2<span class="elsevierStyleHsp" style=""></span>€), CRP (3–4<span class="elsevierStyleHsp" style=""></span>€), PCT (8–10<span class="elsevierStyleHsp" style=""></span>€) or in selected cases of MRproADM (12<span class="elsevierStyleHsp" style=""></span>€) (averages of purchase prices reported in our hospitals), should not be an obstacle to their availability in the ED, where the cost of one visit to the same is estimated at 228<span class="elsevierStyleHsp" style=""></span>€, one day of non-indicated admission in 450<span class="elsevierStyleHsp" style=""></span>€ and inadequate treatment decisions, discharge or inappropriate microbiological (blood culture) tests, revisits, etc., can cost thousands of euros to the system and a worse vital prognosis for the patient.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0265" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">AJJ has participated in scientific meetings organized by Roche, Thermo Scientific Biomarkers, BRAHMS AG and Biomerieux.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">JGC has participated in scientific meetings organized by Thermo Scientific Biomarkers.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">FJC declares no conflicts of interest in relation to this article.</p></li></ul></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres856943" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec850989" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres856944" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec850988" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Strategy for article review and selection" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Biomarkers in community-acquired pneumonia" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "C-reactive protein" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Procalcitonin" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Mid-regional proadrenomedullin" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Lactate" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Other biomarkers" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Etiological prediction" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Prediction of bacteraemia" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Risk stratification and mortality" ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusions and recommendations" ] 11 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-29" "fechaAceptado" => "2017-02-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec850989" "palabras" => array:10 [ 0 => "Biomarkers" 1 => "Bacteraemia" 2 => "Community-acquired pneumonia" 3 => "C-reactive protein" 4 => "Emergency department" 5 => "Lactate" 6 => "Mortality" 7 => "Proadrenomedullin" 8 => "Procalcitonin" 9 => "Prognosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec850988" "palabras" => array:10 [ 0 => "Servicio de urgencias" 1 => "Neumonía adquirida en la comunidad" 2 => "Pronóstico" 3 => "Mortalidad" 4 => "Biomarcadores" 5 => "Procalcitonina" 6 => "Proadrenomedulina" 7 => "Proteína C reactiva" 8 => "Lactato" 9 => "Bacteriemia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">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).</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">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.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Al 1,35% de los pacientes del servicio de urgencias (SU) se les diagnostica neumonía adquirida en la comunidad (NAC), principal causa infecciosa de muerte en nuestro entorno (10-14%) y origen de la mayoría de sepsis-shock sépticos en los SU. En la última década se ha acentuado la búsqueda de herramientas de ayuda para establecer un diagnóstico precoz, la etiología, la gravedad, la sospecha de bacteriemia y el pronóstico de mortalidad en la NAC. Para ello los biomarcadores han demostrado gran utilidad: procalcitonina (mayor rendimiento diagnóstico de NAC, etiología bacteriana y coexistencia de bacteriemia), lactato (marcador de hipoxia e hipoperfusión tisular) y proadrenomedulina (con la mayor capacidad de predecir mortalidad y combinada con las escalas pronósticas de gravedad obtiene aún mejores resultados). Esta revisión quiere poner de manifiesto las evidencias científicas recientes, aclarar las controversias existentes y comparar la utilidad y capacidad pronóstica de los biomarcadores en los pacientes con NAC en los SU.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Julián-Jiménez A, González del Castillo J, Candel FJ. Utilidad y valor pronóstico de los biomarcadores en los pacientes con neumonía adquirida en la comunidad en los servicios de urgencias. Med Clin (Barc). 2017;148:501–510.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1981 "Ancho" => 3394 "Tamanyo" => 326174 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Mean values of procalcitonin in relation to the aetiology of community acquired pneumonia, clinical status and mortality at 30 days. CAP: community-acquired pneumonia; PCT: procalcitonin. *Atypical bacteria: <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>, <span class="elsevierStyleItalic">Chamydophila pneumoniae</span>. **Typical or pyogenic bacteria: <span class="elsevierStyleItalic">Haemophilus influenzae</span>, <span class="elsevierStyleItalic">Moraxella catarrhalis</span>, <span class="elsevierStyleItalic">Pseudomonas</span> Spp., <span class="elsevierStyleItalic">Staphylococcus aureus</span>, <span class="elsevierStyleItalic">Klebsiella pneumoniae</span>, Gram-negative bacilli. ***Mixed CAP: bacterial (typical, atypical or <span class="elsevierStyleItalic">Legionella</span>) plus (atypical bacterial or viral). <span class="elsevierStyleItalic">Source</span>: prepared by the authors from Julián-Jiménez et al.,<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> Tudela et al.,<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">14</span></a> Julián-Jiménez et al.,<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">15</span></a> España et al.,<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">28</span></a> Alba et al.,<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">29</span></a> Vai et al.,<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">30</span></a> Muller et al.<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">31</span></a> and Julián-Jiménez et al.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">32</span></a></p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3047 "Ancho" => 3259 "Tamanyo" => 740149 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Pneumonia Severity Index</span>. CAP: community-acquired pneumonia; HR: heart rate; RR: respiratory rate; bpm: beats per minute; BP: blood pressure; PSI: <span class="elsevierStyleItalic">Pneumonia Severity Index</span>; bpm: breaths per minute; EDOU: emergency department observation unit; CAU: clinical assessment unit; ICU: intensive care unit. *(Modified PSI criteria) If PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg or criteria for sepsis or isolated hypotension at least observation in the emergency department or clinical assessment unit and re-evaluation at 12–24<span class="elsevierStyleHsp" style=""></span>h is indicated. In addition, any other factor or situation that prevents outpatient treatment should be taken into account (see additional criteria). <span class="elsevierStyleItalic">Source</span>: adapted from Julián-Jiménez et al. and Fine et al.<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">37</span></a></p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2358 "Ancho" => 3450 "Tamanyo" => 592989 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Severity Community Acquired Pneumonia</span> (SCAP) score and new classification algorithm for patients with community-acquired pneumonia as per SCAP and concentrations of MRproADM to decide the site of treatment according to the estimation of expected complications and mortality. CAP: community-acquired pneumonia; SCAP: <span class="elsevierStyleItalic">Severity Community Acquired Pneumonia</span>; MRproADM: mid-regional proadrenomedullin in nmol/l; MV: mechanical ventilation. <span class="elsevierStyleItalic">Source</span>: adapted from Julián-Jiménez et al.,<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">6</span></a> Gordo-Remartínez et al.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">25</span></a> and Schuetz et al.<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">57</span></a></p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1661 "Ancho" => 3333 "Tamanyo" => 268058 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">New classification algorithm for patients with community-acquired pneumonia according to CURB65-A score to determine treatment site. CAP: community-acquired pneumonia; CURB65-A: a score that combines MRproADM with CURB-65, acronym for Confusion, Plasma Urea >44<span class="elsevierStyleHsp" style=""></span>mg/dl (BUN<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>19.4<span class="elsevierStyleHsp" style=""></span>mg/dl or >7<span class="elsevierStyleHsp" style=""></span>mmol/l), Respiratory rate ≥30, Systolic blood pressure <90<span class="elsevierStyleHsp" style=""></span>mmHg or diastolic blood pressure ≤60<span class="elsevierStyleHsp" style=""></span>mmHg and Age ≥65 years; MRproADM: mid-regional proadrenomedullin; ICU: intensive care unit. <span class="elsevierStyleItalic">Source</span>: Adapted from Schuetz et al.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">11</span></a> and Huang et al.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">21</span></a></p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">AUC-ROC: area under the curve-<span class="elsevierStyleItalic">receiver operating characteristic</span>; CURB-65: acronym for Confusion, Plasma Urea<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>44<span class="elsevierStyleHsp" style=""></span>mg/dl (BUN<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>19.4<span class="elsevierStyleHsp" style=""></span>mg/dl or >7<span class="elsevierStyleHsp" style=""></span>mmol/l), Respiratory rate ≥30, Systolic blood pressure <90<span class="elsevierStyleHsp" style=""></span>mmHg or diastolic blood pressure ≤60<span class="elsevierStyleHsp" style=""></span>mmHg and Age ≥65 years; CI: confidence interval; MRproADM: mid-regional proadrenomedullin; CAP: community-acquired pneumonia; OR: odds ratio; CRP: C-reactive protein; PCT: procalcitonin; proANP: natriuretic atrial propeptide; ProET1: proendothelin-1; PSI: <span class="elsevierStyleItalic">Pneumonia Severity Index</span>; REA-ICU: <span class="elsevierStyleItalic">risk of early admission to intensive care unit</span>; ED: emergency department; MV: mechanical ventilation.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>: prepared by the authors.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Term \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MRproADM nmol/l cut-off point \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AUC-ROC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comment in relation to the prognostic value of MRproADM \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Christ-Crain et al.,<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">20</span></a> 2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">302<br>Prospective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 weeks’ mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Superior to CRP and PCT<br>Same as PSI (AUC 0.73)<br>MRproADM<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>PSI: AUC 0.77 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Huang et al.,<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">21</span></a> 2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.653<br>Prospective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Superior to PCT<br>Superior to PSI in high-risk PSI groups IV–V (AUC 0.84) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Krüger et al.,<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">16</span></a> 2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">728<br>Prospective<br>Admitted in ED \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 days<br>180 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.85<br>0.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Superior to CRP, PCT, copeptin, proANP, proET1 and white blood cells<br>Independent of CURB-65<br>30 days MRproADM<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>CURB-65: AUC 0.85<br>180 days MRproADM<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>CURB-65: AUC 0.81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Schuetz et al.,<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">58</span></a> 2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">925<br>Prospective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Death combined with ICU admission and empyema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.75–1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MRproADM<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>PSI (AUC 0.75) and CURB-65<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>MRproADM (AUC 0.73) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Albrich et al.,<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">22</span></a> 2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.359 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AUC of the CURB65-A model (AUC 0.81) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bello et al.,<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">23</span></a> 2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">228<br>Prospective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 days<br>1 year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.07<br>0.646 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.86<br>0.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Superior to PSI and CURB-65<br>Regardless of the aetiology of CAP (bacterial, viral, atypical or mixed)<br>PSI<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>MRproADM (AUC 0.91)<br>CURB-65<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>MRproADM (AUC 0.90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renaud et al.,<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">24</span></a> 2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">877<br>Prospective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3-Day mortality combined use of MV and vasopressors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Improves the REA-ICU <span class="elsevierStyleItalic">Score</span> with AUC 0.81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Courtais et al.,<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">39</span></a> 2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">109<br>Prospective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In patients with PSI IV–<span class="elsevierStyleSmallCaps">V</span>, proADM predicts risk of death at 30 days better than PSI (OR 4.61 [95% CI: 1.66–20.22], <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.012) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Julián-Jiménez et al.,<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">15</span></a> 2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">127<br>Prospective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 days<br>180 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.86<br>1.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.89<br>0.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 days: the best performing combination is MRproADM<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>PSI, with AUC-ROC of 0.94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bello et al.,<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">49</span></a> 2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">265 Prospective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 days<br>1 year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.913 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.82<br>0.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PSI<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>MRproADM (AUC 0.91)<br>CURB-65<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>MRproADM (AUC 0.88)<br>OR 4.229 (1.690–10.585) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gordo-Remartínez et al.,<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">25</span></a> 2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">226<br>Prospective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PSI<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>MRproADM (AUC 0.75) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1447600.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Studies evaluating mid-regional proadrenomedullin in emergency department patients as a prognostic factor in community-acquired pneumonia.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Estimated cut-off points chosen by consensus for the ED.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">IRIBM: inflammatory response and infection biomarkers; SI: severity indices; hsCRP: high sensitivity CRP; MRproADM: mid-regional proadrenomedullin; CAP: community-acquired pneumonia; CRP: C-reactive protein; PCT: procalcitonin; SS: septic shock; ED: emergency department; ICU: intensive care unit.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>: prepared by the authors.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Biomarker \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cutt-off points \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical significance or utility \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Values/limitations \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="6" align="left" valign="top">PCT (ng/ml)</td><td class="td" title="table-entry " align="char" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prediction of other processes or viral CAP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="6" align="left" valign="top">To determine diagnosis, aetiology, rule out bacteraemia, adequate indication of admission or discharge in the ED<br>Quantitative sample with high sensitivity. In its absence, semiquantitative<br>Higher performance than CRP and rest of IRIBM for diagnosis of CAP, aetiology and bacteraemia<br>Lower performance than MRproADM in predicting mortality with/without severity index</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">0.10–0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Suspicion of atypical CAP versus typical CAP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>0.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Suspicion of <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prediction of bacteraemia. Indication of admission and higher mortality. Progression to sepsis-SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Greater mortality at 30 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU admission assessment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">MRproADM (nmol/l)</td><td class="td" title="table-entry " align="char" valign="top"><0.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Possibility of home treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Determine in the ED prognosis of complications and mortality and adequate indication of admission or discharge<br>Quantitative sample with high sensitivity<br>Higher performance than the rest of IRIBM in predicting mortality with/without severity index</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">0.75–1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hospital observation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Need for admission. Higher mortality. Progression to sepsis-SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">CRP (mg/ml)</td><td class="td" title="table-entry " align="char" valign="top">≥60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prediction of CAP vs other processes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Best to use hsPCR (gains in sensitivity, specificity and predictive value) with ultrasensitive quantitative techniques<br>Lower performance than PCT for aetiology, bacteraemia and prognosis<br>Lower performance than lactate, PCT and MRproADM in predicting mortality alone or with a severity index<br>Use only if PCT or MRproADM is not available</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">≥125 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Typical CAP suspicion versus atypical CAP, higher mortality at 30 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">≥200 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prediction of bacteraemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Lactate (mmol/l)</td><td class="td" title="table-entry " align="char" valign="top">>2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Monitor arterial lactate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Determine in the ED if criteria for clinical severity (sepsis-SS) are met<br>Seriation at 8–12<span class="elsevierStyleHsp" style=""></span>h to check for clearance in patients with initial lactate >2<span class="elsevierStyleHsp" style=""></span>mmol/l upon arrival at ED</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher mortality. Monitor to see response to treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>3.5–4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Very high mortality at 7 and 30 days, independent of the haemodynamic situation \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1447601.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Practical recommendations for the use of biomarkers in patients with community-acquired pneumonia in emergency departments.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:60 [ 0 => array:3 [ "identificador" => "bib0305" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "223.e1–2319.e" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guía multidisciplinar para la valoración pronóstica, diagnóstico y tratamiento de la neumonía adquirida en la comunidad" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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