Letter to the Editor
Risk stratification of patients with pneumonia
Estratificación pronóstica de los pacientes con neumonía
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The prognostic stratification of pneumonia patients is crucial for first decision-making, considering that pneumonia is the leading cause of sepsis and the first cause of death within the infectious causes.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Therefore, we would like to discuss some matters about this study and share data from our research studies.</p><p id="par0010" class="elsevierStylePara elsevierViewall">First, we would like to note the discrepancy between the nomenclature used by the authors and the one understood internationally. HCAP is defined as the pneumonia occurring in patients coming from nursing homes, long-stay centers, day hospitals, dialysis centers or their own home, assisted by health professionals within the last 30 days, or if they have been hospitalized for 48<span class="elsevierStyleHsp" style=""></span>h or more in the last 90 days. However, the criteria used by the authors (≥48<span class="elsevierStyleHsp" style=""></span>h after hospital admission or ≤72<span class="elsevierStyleHsp" style=""></span>h after hospital discharge) are those used to define hospital-acquired pneumonia or nosocomial pneumonia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Second, the authors in the methodology indicate that the variables have been gathered within the first 24<span class="elsevierStyleHsp" style=""></span>h after patient admission. In our opinion, since infection is a dynamic process and influenced by the therapeutic attitude, it is important to use the first available variables when assessing the prognostic scales.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Third, and as mentioned by the authors, an area under the curve (AUC) below 0.80 indicates a modest diagnostic accuracy of the tool used. Therefore, we should try to improve the discriminative capacity of these tools since identifying patients at risk of poor results is essential during the first assistance to the infected patient.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> PSI identifies properly the low mortality risk in classes I–III and helps us decide “discharge”, but it can underestimate the severity, especially in young patients with hypoxia. CURB-65 better detects high-risk patients who should be admitted to hospital, but also has significant limitations such as overestimate and therefore indicate hospital admission in many patients aged over 65 only by the criterion of age, which should not be the only indicator of admission. It does not assess oxygen saturation or PaO<span class="elsevierStyleInf">2</span> either.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally, with regard to the classification of severity, we would like to provide the results of an analysis on the prospective cohort of the Infection Group of the Spanish Society of Emergency Medicine (INFURG-SEMES) that included infected patients aged ≥75 years from 10 hospitals where determination of C-reactive protein, procalcitonin, MR-proADM and lactate was available upon arrival at the emergency room.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The results of this cohort of patients showed that the best discriminative capacity to detect patients at risk of death within 30 days was provided by MR-proADM with an AUC 0.886 (95% CI: 0.775–0.997; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, to improve the limitations shown in the PSI and CRB-65 risk scales, we believe that the application of inflammatory biomarkers should be considered, especially in a population with such a high mortality rate as the one studied. In our experience MR-proADM shows the best capacity to identify patients at a high risk of poor short-term results.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González del Castillo J, Clemente C, Núñez Orantos MJ, en representación de INFURG-SEMES. Estratificación pronóstica de los pacientes con neumonía. Med Clin (Barc). 2019;152:e21.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Performance of the PSI and CURB-65 scoring systems in predicting 30-day mortality in healthcare-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E. Murillo-Zamora" 1 => "A. Medina-González" 2 => "L. Zamora-Pérez" 3 => "A. Vázquez-Yáñez" 4 => "J. Guzmán-Esquivel" 5 => "B. 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Martín-Sánchez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Emergencias" "fecha" => "2017" "volumen" => "29" "paginaInicial" => "303" "paginaFinal" => "305" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29077288" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spanish Society of Emergency Medicine and Emergency Care; Spanish Society of Geriatrics and Gerontology; Spanish Society of Chemotherapy; Spanish Society of Pneumology and Thoracic Surgery; Spanish Society of Home Hospitalization" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. González-Castillo" 1 => "F.J. Martín-Sánchez" 2 => "P. Llinares" 3 => "R. Menéndez" 4 => "A. Mujal" 5 => "E. Navas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Quimioter" "fecha" => "2014" "volumen" => "27" "paginaInicial" => "69" "paginaFinal" => "86" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24676248" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nomogram to predict a poor outcome in emergency patients with sepsis and at low risk of organ damage according to Sepsis-related Organ Failure Assessment (SOFA)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. García-Villalba" 1 => "A. Cano-Sánchez" 2 => "A. Alcaraz-García" 3 => "C. Cinesi-Gómez" 4 => "P. Piñera-Salmerón" 5 => "I. Marín" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Emergencias" "fecha" => "2017" "volumen" => "29" "paginaInicial" => "81" "paginaFinal" => "86" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28825248" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognostic power of biomarkers for short-term mortality in the elderly patients seen in Emergency Departments due to infections" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "On behalf of the INFURG-SEMES Group" "etal" => true "autores" => array:6 [ 0 => "A. Julián-Jiménez" 1 => "M.C. Yañez" 2 => "J. González-Del Castillo" 3 => "M. Salido-Mota" 4 => "B. Mora-Ordoñez" 5 => "M.J. Arranz-Nieto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2017.11.017" "Revista" => array:2 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2017" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015200000004/v1_201902100719/S2387020618305874/v1_201902100719/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015200000004/v1_201902100719/S2387020618305874/v1_201902100719/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618305874?idApp=UINPBA00004N" ]
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