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

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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "99" "paginaFinal" => "107" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Julián-Jiménez, J. González-Castillo, F.J. Candel González" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Julián-Jiménez" "email" => array:1 [ 0 => "agustinj@sescam.jccm.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "González-Castillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "F.J." "apellidos" => "Candel González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Urgencias-Medicina Interna, Hospital Virgen de la Salud, Toledo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Urgencias-Medicina Interna, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Microbiología Clínica, Hospital Clínico 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" => "¿Cuándo, dónde y cómo ingresar al paciente con neumonía adquirida en la comunidad?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2398 "Ancho" => 2511 "Tamanyo" => 651758 ] ] "descripcion" => array:1 [ "en" => "Prognostic Severity Scales (SCAP and SMART-COP)." ] ] ] "textoCompleto" => "Case reportA 38-year-old male was admitted to the emergency department (ED) with a fever of 39°C, profuse sweating, chills, shivering and chest pain with deep inspiration in the right chest, exertional dyspnea and purulent reddish sputum. The patient presented considerable general impairment. His blood pressure (BP) was 120/70mmHg, respiratory rate 34 breaths per minute, heart rate 116 beats per minute, and oxygen saturation (SatO2) while breathing room air was 90%. Physical examination showed pronounced hypoventilation with crackles in the right lung area. The posteroanterior and lateral chest X-ray revealed an interstitial-linear infiltrate in the upper right lobe (URL) and in the lower right lobe. The analytical study showed 21,300 leucocytes μ/l (70% neutrophils, 16% band neutrophils), urea 42mg/dl, sodium 134mequiv./l, C-reactive protein (CRP) 90mg/l; procalcitonin (PCT) 10ng/ml and a baseline arterial gasometry with pH 7.48, arterial oxygen pressure (PaO2) 58.4mmHg, arterial carbon dioxide partial pressure (PaCO2) 38.6mmHg, HCO3 24.2mmol/l and SatO2 90.8%.Based on a diagnosis of community-acquired pneumonia (CAP), a prognostic assessment according to the Fine index of group II and a score of 1 on the CURB-65 scale (confusion, urea, respiratory rate, systolic BP [SBP] or diastolic BP [DBP] and age ≥65 years), we ask the following questions:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a)Should we hospitalize the patient? If yes, where?</li><li class="elsevierStyleListItem" id="lsti0010">b)What impact should clinical judgment have on our decision?</li><li class="elsevierStyleListItem" id="lsti0015">c)What level of bacteremia is the patient predicted to have?</li><li class="elsevierStyleListItem" id="lsti0020">d)What impact do biomarkers (BM) and a clinical situation of sepsis (S) have on the indication for hospitalization?</li><li class="elsevierStyleListItem" id="lsti0025">e)What additional criteria should we assess along with the prognostic scales?</li><li class="elsevierStyleListItem" id="lsti0030">f)Are there alternatives to conventional hospitalization for patients with CAP?</li></ul>Emergency departments and patients with community-acquired pneumoniaCAP represents the main cause of death due to infectious disease and the sixth overall in Western countries (10–14%, depending on age and associated risk factors). CAP causes a large portion of the cases of sepsis (S), severe sepsis (SS) and septic shock (SSh) treated in EDs.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> In Spain, its incidence is approximately 2–11 cases/1000 inhabitants/year and may increase to 15–35 cases/1000 inhabitants/year during epidemic viral seasons, in winter, in those over 65 years of age and in chronically ill patients or those with toxic habits, among others.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> There is considerable variability among centers and among clinics in the same center in the handling of the diagnostic and therapeutic issues of patients with CAP.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The hospitalization rates (22–61%) differ greatly depending on the center, season and patient characteristics. Between 10 and 20% of patients hospitalized with CAP are admitted to the intensive care unit (ICU), where the mortality may increase by 20–50%.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>At least 75% of those with CAP are treated in EDs, highlighting the transcendental role of the emergency physician in the initial management of these processes, which can determine the patients’ evolution and subsequent morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> The decision to hospitalize patients with CAP (when), the appropriate location (where) and the care they require (how) will determine the patients’ prognosis (morbidity and mortality), the request for laboratory tests, microbiological studies, the initial selection of antimicrobial regimens, the intensity of clinical observation and the use of health center resources.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The final expenditures will depend on all these factors and will increase by 8–25 times in hospitalized patients when compared with those treated at home.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> These decisions will have implications for the safety and quality of the care offered to patients<a class="elsevierStyleCrossRef" href="#bib0025">5</a> and for its cost-effectiveness.<a class="elsevierStyleCrossRefs" href="#bib0020">4,6</a> Improper hospitalization increases the likelihood of experiencing medical malpractice, adverse episodes and nosocomial infections.<a class="elsevierStyleCrossRefs" href="#bib0010">2,4</a> The use of clinical practice guidelines (CPG) decreases the proportion of patients with low-risk CAP, as well as those who are in groups I-III of the Pneumonia Severity Index (PSI), those who are improperly hospitalized (31–49%) and those who are readmitted to the ED. CPG use is also associated with a reduction in mortality.<a class="elsevierStyleCrossRefs" href="#bib0015">3,7</a> Regardless of the prognostic assessment of the patient and the final decision as to where the patient should be treated, the administration of antibiotherapy should not be delayed, especially in the most seriously ill patients (those with severe sepsis and septic shock).<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a>In order to guide these decisions while taking into account new trends in the prognostic assessment of CAP (changing or adapting the traditional scales, new scales, additional criteria, prediction of bacteremia, clinical situation, biomarker assessment, expert professional clinical judgment, etc.) and the current alternatives to conventional hospitalization (early discharge, ED observation, short-stay unit [SSU], outpatient center, home care),<a class="elsevierStyleCrossRef" href="#bib0020">4</a> this study has been prepared for adult patients who are not immunocompromised or hospitalized with CAP.The decision to hospitalizeAn assessment of severity is essential for determining the intensity of the treatment required for the patient with CAP. The majority of prognostic severity scales (PSS) were developed with the idea of converting them into clinical rules that stratified patients into risk groups based on the mortality observed at 30 days.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> These scales were designed according to the presence of various prognostic factors that were dependent on the patient (age, associated diseases, epidemiological aspects, etc.) or dependent on the process (clinical, laboratory and radiological findings).<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Once the decision has been made to hospitalize the patient, other issues should be considered such as the length of the hospital stay, the readmission rates at 30 days and the need to recognize patients who require surveillance in an ICU due to severe CAP (SCAP).<a class="elsevierStyleCrossRefs" href="#bib0015">3,10,11</a> Avoiding both unnecessary admissions and improper discharges constitutes an undeniable objective.<a class="elsevierStyleCrossRefs" href="#bib0005">1,4</a> It is known that 38–62% of patients with low-risk CAP are admitted to the hospital (40% due to a clinical decision) while in contrast, 3–13% of those with high-risk CAP are sent home.<a class="elsevierStyleCrossRefs" href="#bib0020">4–12</a> It is difficult to find simple explanations for these facts. The care of each patient with CAP should be individualized, using PSS as a complementary tool. Other criteria and additional circumstances should also be taken into account (pleural effusion, cavitation, multilobar involvement, hemodynamic instability, sepsis, hyperlactatemia, etc.). We should also consider the epidemiological, personal and societal conditions of each patient that may prevent home care (oral intolerance, hypoxemia, family support, comorbidities, toxic habits, psychological disorders, etc.).<a class="elsevierStyleCrossRefs" href="#bib0005">1–4</a> In addition, we should take into account the healthcare resources available at each center. Clinical judgments made in isolation can be vague and insufficient. PSS have major limitations and are only tools to be used along with CPG. The variability in clinical judgment and in the recommendations of the various CPG, according to the scientific community that endorses them, may become confusing for the clinician.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>FINE scale (Pneumonia Severity Index), CURB-65 and other scalesAlthough there are numerous PSS, the FINE or PSI<a class="elsevierStyleCrossRef" href="#bib0040">8</a> and the CURB-65<a class="elsevierStyleCrossRef" href="#bib0045">9</a> are the most validated and recommended. They have a similar ability to recognize patients at risk of death at 30 days. Capelastegui et al.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> found substantial matching between the predictions achieved with PSI and those achieved with CURB-65, with areas under the curve for the sensitivity of the scales of 0.88 (95% confidence interval [95% CI] 0.86–0.91) and 0.87 (95% CI 0.84–0.89), respectively. Recently, a meta-analysis that included 40 studies confirmed these data.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>The PSI combines demographic and morbidity variables and examination, laboratory and radiological findings to define 5 classes of risk (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). According to the assigned risk class, the index recommends outpatient treatment in groups I–II, observation in the ED or SSU for class III and hospitalization for classes IV–V.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Although the PSI properly identifies the low risk of mortality in classes I–III and helps us decide the “discharge”, it may underestimate the severity, especially in young patients with hypoxia and it does not assess additional criteria and circumstances that must be considered. Due to these limitations, the FINE scale or modified PSI (PSIm) was developed as an update to the traditional PSI. This new scale recommends that low-risk (I–III) patients who present respiratory failure be hospitalized. Between 16 and 27% of patients admitted to the ICU for CAP are initially classified as having a PSI of I-III and are frequently classified as such due to the presence of respiratory failure (PaO2<60mmHg and/or SatO2<90%).<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Therefore, it seems advisable to use PSIm in the ED to improve care for those admitted, a recommendation that, to a greater or lesser degree, is stated or insinuated in the recent CPG and by various authors.<a class="elsevierStyleCrossRefs" href="#bib0005">1,4–16</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>The British Thoracic Society (BTS) developed the CURB-659 scale<a class="elsevierStyleCrossRef" href="#bib0045">9</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), defining 6 risk groups. It does a better job of detecting high-risk patients who should be hospitalized but also has major limitations in overestimating the risk in many of those patients over 65 years of age due to the criterion of age, which should not constitute the only indicator for hospitalization, and also does not assess SatO2 or PaO2. A number of authors question the usefulness of these PSS in the elderly and set the new cutoff point for age at 75–80 years as the independent predictor of mortality risk.<a class="elsevierStyleCrossRefs" href="#bib0020">4,10,17</a> Given that CURB-65 and, in particular, CRB-65 (without uremia) are easier to apply than the PSI, there are some that advocate its use in primary care. However, in today's EDs, applying the PSIm should not present any problems.<a class="elsevierStyleCrossRefs" href="#bib0005">1,3</a>In recent years, various PSS have emerged. Among them is the PSS proposed by España et al.,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> known as SCAP (Severity Community Acquired Pneumonia) or PS-CURXO80, which contains 2 major and 6 minor variables (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). This scale will probably be supported by upcoming CPGs because, in addition to predicting mortality as do the PSI and CURB-65 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), it has been validated and is capable of predicting the need for mechanical ventilation (MV) and the evolution to septic shock. The scale defines a CAP as severe (SCAP) if the patient meets at least 1 major or 2 minor criteria.<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Additional criteria to assess in community-acquired pneumoniaIn addition to the factors indicated in the above mentioned PSS, which provide a timely and static assessment of the CAP, and those factors dependent on the actual functional state of the patient, there are other additional independent and dynamic criteria, such as the actual infection and the systemic inflammatory response, which affect and determine the prognosis in the first hours of the patient's stay in the ED.<a class="elsevierStyleCrossRefs" href="#bib0005">1,3</a> Among these criteria are the estimation of the probability for bacteremia,<a class="elsevierStyleCrossRef" href="#bib0090">18</a> the presence of sepsis, severe sepsis and septic shock as stages of a dynamic process or and consideration of the various BM,<a class="elsevierStyleCrossRefs" href="#bib0095">19–22</a> which are of use when deciding on hospitalization and/or the most appropriate location. Many of these additional criteria are commonly used in clinical practice and in all likelihood some of these will be included in the new CPG on CAP that various scientific societies are preparing. Since 1997 when Fine et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> related 20 independent variables with the risk of mortality, a considerable number of articles have been published that associate multiple criteria for patients or the process (some of which have already been mentioned) to a predictive value of mortality and that could prompt the recommendation to hospitalize a patient with CAP.<a class="elsevierStyleCrossRefs" href="#bib0005">1–4</a>Prediction of bacteremiaPSI and CURB-65 do not predict the risk of bacteremia. The scale proposed by Tudela et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> relates clinical (Charlson Comorbidity Index) and laboratory (PCT) variables and achieves a negative predictive value (NPV) greater than 95%. Other authors have conducted studies along the same line. There are discrepancies regarding the PCT cutoff, establishing it at >0.5ng/ml, as proposed by Tudela et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>, or at >2ng/ml, as recommended by other authors.<a class="elsevierStyleCrossRefs" href="#bib0095">19,21</a> Falguera et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> established a classification based on 6 variables and divided patients with CAP into 2 groups: one with a low risk of bacteremia (with ≤1 factor) who present positive blood cultures in <8% and another with high risk (≥2 factors) with isolates in 14–63% of the blood cultures. In the latter group, we should perform the same therapeutic management as performed in patients with bacteremic CAP and recommend hospitalization.<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> Adding PCT and the clinical situation (S-SS-SSh) to Shapiro's predictive model improves the prediction of bacteremia (with PCT >2ng/ml predicts worse clinical outcome and a probability of 20% for bacteremia).<a class="elsevierStyleCrossRef" href="#bib0120">24</a>Clinical situation, systemic inflammatory responseThe clinical situation of patients with CAP, according to the S-SS-SSh criteria, is essential and determines whether the patient should be reassessed after a few hours (8–12–24h) and remain under observation by the ED or in the SSU.<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> The frequency of bacteremia increases with the severity of the clinical picture (17–31% in S, 25–35% in SG and 30–45% in SS).<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Several vital signs are individual predictors of mortality (respiratory rate ≥30, heart rate ≥120, body temperature >38.3°C, and SBP<90mmHg and DBP<60mmHg). Chalmers et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> demonstrated that SBP is the best independent predictor of mortality at 30 days (odds ratio [OR]=5.6, 95% CI: 3.4–9.3; p<0.0001; specificity of 89.9%) and need for MV and/or vasopressor support (OR=5.6, 95% CI: 3.4–9.4; p<0.0001; specificity of 90.5%).BiomarkersThe ability of biomarkers to predict mortality has been demonstrated, and they also offer the possibility of predicting bacteremia, the progression to SG-SS, and failure of treatment and can even suggest an etiological orientation. For example, we find greater systemic inflammation and higher levels of BM in patients with CAP with bacteremia due to Streptococcus pneumoniae who progress to SG-SS.<a class="elsevierStyleCrossRefs" href="#bib0095">19–22</a> Numerous studies and recommendations have been published regarding the usefulness of BM in CAP, which have included the CRP, interleukin-6, interleukin-8, tumor necrosis factorα, proendothelin-1, copeptin, D-dimer, proatrial natriuretic peptide and TREM-1 (triggering receptor expressed on myeloid cells-1). Among the recommendations is the one for proadrenomedullin (proADM),<a class="elsevierStyleCrossRefs" href="#bib0100">20,26</a> which offers results that are comparable to PSS in terms of estimating mortality at 28–30 days and at 180 days, and PCT,<a class="elsevierStyleCrossRefs" href="#bib0095">19–22</a> which is highly sensitive and specific for predicting bacterial infection, clinical evolution, the possibility of bacteremia, mortality and even directing the search for the pathogen causing the CAP. The growing accessibility to the determination of PCT in many ED and the speed and ease of the technique has led to its addition as another criterion for PSS to assess severity and for decision making in the ED (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRefs" href="#bib0095">19,21</a> The combination of BM (proADM and PCT) and PSS could increase their predictive ability and improve their use with patients with CAP.<a class="elsevierStyleCrossRefs" href="#bib0135">27–29</a> Currently, several studies are assessing the complementarity of both PCT and proADM and whether their combined use could increase their predictive value,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> especially if they are applied jointly with one or several PSS (especially with PSI or PSIm). This strategy could become the best method for prognostic assessment.<a class="elsevierStyleCrossRef" href="#bib0020">4</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Menendez et al.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> demonstrated that by adding CRP (>25mg/ml) and/or PCT (>0.5ng/ml) as a BM of inflammatory response of the host to PSI (0.81, 95% CI; 0.75–0.87) or to CURB-65 (0.82, 95% CI; 0.76–0.89) the predictive value of these PSS is increased and that it is greater when both BMs are combined with a PSS or both PSS are combined with one of the BMs: PSI+CRP+PCT (0.85, 95% CI; 0.79–0.91) and PSI+CURB-65+PCR (0.88, 95% CI; 0.83–0.93). Krüger et al.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> found that pro-AMD (with a cutoff lower than other authors: 0.95nmol/l) and PCT (>0.48ng/ml), along with the PSS and the proper use of the JC, constitutes the best predictive model for mortality at 28 and 180 days.Recently, Albrich et al.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> released the results of the PSS known as the CURB-65A (adding proADM to CURB-65), which establishes 3 risk groups: class I (CURB-65 0-1 and proADM ≤0.75nmol/l) with low risk of mortality and development of adverse events (0.65 and 3.9%) where discharge is recommended; class II: (CURB-65 2 and proADM ≤1.5nmol/l or CURB-65 0-1 and proADM ≤0.75–1.5nmol/l) with moderate risk (2.6% risk of mortality and 8.6% risk of adverse events) where SSU observation in the ED is recommended; class III: high risk (proADM >1.5nmol/l with any CURB-65) where conventional hospitalization is recommended.We should always consider whether the patient has received prior antibiotic treatment, because this situation alters the interpretation and the predictive value for both the PSS and the BM. Krüger et al.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> concluded in their study that the levels of PCT, CRP and leukocytes are predictors of mortality at 28 days in patients with no prior antibiotic treatment, but not if the patient was receiving treatment in the 72h prior to the visit to the ED.Severe community-acquired pneumonia and the decision to hospitalize in an intensive care unitFollowing the decision to hospitalize a patient with CAP, it is also of considerable importance to identify early on the most severe patients or those who may worsen rapidly in order to decide whether they should be treated in an ICU. It is estimated that approximately 45% of patients who are ultimately admitted to the ICU are initially hospitalized conventionally.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>What is meant by SCAP? Although there is no consensus definition, SCAP refers to those cases susceptible to a poorer evolution and/or complications, with hemodynamic and/or respiratory instability, who require substantial monitoring and continuous care and/or who have a greater need for interventions (that are only offered in an ICU) and a greater likelihood of death.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>Although both the PSI and the CURB-65 are useful for assessing the risk of death, neither was designed for assessing the need for ICU admission. In contrast, the 2007 ATS/IDSA (American Thoracic Society/Infectious Diseases Society of America) severity criteria,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> SMART-COP<a class="elsevierStyleCrossRef" href="#bib0055">11</a> and SCAP<a class="elsevierStyleCrossRef" href="#bib0050">10</a> are appropriate for identifying candidates who require inotropic and/or ventilator support and/or admission to the ICU.The majority of CPG<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> recommended the 2007 ATS/IDSA criteria for admission to the ICU in SCAP (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), which recommend admission if the patient meets a major or 3 minor criteria. In addition, the ATS/IDSA reminds us that there are other criteria to consider individually as “minor”, such as hypoglycemia in non-diabetics, hyperglycemia, hyponatremia, metabolic acidosis and hyperlactatemia, and they even identify acute alcohol ingestion and delirium tremens.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> For 60% of patients, the presence of acute respiratory failure is the reason for admission to the ICU; in 28%, hemodynamic instability is the reason. The 2007 ATS/IDSA criteria identify almost 90% of patients who ultimately are admitted to the ICU.<a class="elsevierStyleCrossRef" href="#bib0160">32</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Charles et al.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> have recently developed a severity scale focused on the prediction of the need for intensive respiratory or vasopressor support. This scale, known as SMART-COP (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) comprises 8 clinical and analytical variables with various cutoff points based on age. The SCAP and SMART-COP scales correctly predict admission to the ICU and/or the onset of severe adverse events (mechanical ventilation, shock and/or death). The SMART-COP scale appears to be superior to PSI IV-V and CURB-65,<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a> especially in young patients. However, in contrast to the SCAP scale, the SMART-COP scale has not yet been validated in different cohorts and in distinct geographical environments.<a class="elsevierStyleCrossRef" href="#bib0165">33</a>Other scales (such as APACHE and PIRO-NAC) have attempted to improve the predictive power of the 2007 ATS/IDSA in determining the need for ICU, but the 2007 ATS/IDSA remains the recommended scale due to the sensitivity (71%) and specificity (88%) of its minor criteria (the major one are obvious). PIRO-NAC, the acronym for “predisposition” (chronic diseases, age, comorbidities), “insult” or damage (bacteremia, multilobar impairment), “response” (inflammatory and hemodynamic), “organic” dysfunction (renal failure, ARDS), is only useful in patients admitted to the ICU, identifying candidate patients for an immunomodulatory coadjuvant treatment for septic shock and the systemic inflammatory response.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>Alternatives to conventional hospitalizationIn the search for the optimization of resources and improved management of CAP according to the patient profile, care models have been in place for years as alternatives to conventional hospitalization, including early discharge from the ED in 24–48h,<a class="elsevierStyleCrossRefs" href="#bib0175">35,36</a> observation in the ED,<a class="elsevierStyleCrossRef" href="#bib0180">36</a> the admission to the SSU,<a class="elsevierStyleCrossRefs" href="#bib0185">37,38</a> outpatient center care<a class="elsevierStyleCrossRefs" href="#bib0175">35,36</a> and home care.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>Articles have recently been published that support the efficacy and safety of SSU, on its own or integrated into a multidisciplinary model with early discharge and follow-up in outpatient centers or in home care, offering these as alternatives to conventional hospitalization for some patients with CAP.Llorens et al.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> analyzed the results of a multidisciplinary model (SSU of the ED with discharge and follow-up in an outpatient center of the internal medicine/infectious diseases unit or follow-up through home care through the ED) where the patients with greater age (69 years vs. 62.7 years of age) and functional impairment than in the conventional hospitalization group achieved a shorter hospital stay (2.5 days vs. 9.6 days) and lower mortality at 30 days (3.9% vs. 11.2%), regardless of the PSI or CURB-65 employed. Sempere-Montes et al.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> found that the admission of a number of patients with CAP to the ICU achieved average stays of 3.7±2.2 days versus the 7.8±5.6 days for those who were conventionally hospitalized for internal medicine or versus the 10.8±8.5 days for pulmonology (p<0.001), with similar efficacy and safety. Juan et al.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> demonstrated that the SSU is effective and safe for patients with CAP, reducing the average stay when compared with conventional hospitalization (3.48±1.70 days vs. 7.89±6.12 days) with no differences in the readmission and mortality rates despite the greater mean age of the patients in the SSU group (77.3±12.04 vs. 67.9±15.8). Meanwhile, home care has shown its efficacy in a high percentage (38–48%) of cases secondary to initial conventional hospitalization, as long as there are no criteria or pre-specified concrete circumstances to begin with that contraindicate home care.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>However, there are no well-designed clinical trials that have properly assessed whether patients with CAP with similar severity levels treated in any of these alternative modalities of care evolve similarly or better than those treated according to traditional regimens in conventional hospitalization.Conclusions and recommendationsThe main task of ED physicians should be the correct and early diagnosis of patients with CAP and the establishment of appropriate treatment in terms of time and form. Taking this into account, we can answer the questions concerning the patient described at the start of the report with the following conclusions:Should we hospitalize the patient? If yes, where? Our patient should be hospitalized. Although according to the prognostic scales the initial assessment suggests the opposite (PSI=II and CURB-65=1), the patient has respiratory failure (PaO2<60mmHg), which is already a criterion for hospitalization according to the PSIm and has clinical criteria suggestive of S with substantial systemic clinical involvement.What impact should the clinical judgment have on our decision? Although we know it is insufficient and requires complementary tools, the experience and clinical judgment of the physician should be decisive in cases of diagnostic and prognostic uncertainty and should determine what is safest and most appropriate for the patient.What level of bacteremia is the patient predicted to have? Based on the clinical data (criteria of S) and the PCT value of 10ng/ml (significantly greater than 2ng/ml, the most accepted cutoff for determining a high probability of bacteremia), we can confirm that the patient has a greater than 25% probability of having bacteremia and positive blood cultures.What do biomarkers and the clinical situation of sepsis contribute to the indication for hospitalization? Our patient has a PCT value of 10ng/ml and a PCR value of 90mg/l, which, along with the clinical criteria of sepsis, indicates a greater likelihood of evolving to Sg or septic shock, requiring treatment in the ICU.What additional criteria should we assess along with the prognostic scales? It is essential that each patient be individually assessed, taking into account the additional criteria of the patient's clinical situation (S-SS-SSh), the estimate of the probability of bacteremia, the assessment of the BM, the existence of hypoxemia, hyperlactatemia, pleural effusion and cavitation in the radiology, multilobar and/or bilateral impairment and other particular conditions that prevent home treatment (oral intolerance, absence of family support, psychiatric disorders, comorbidity, baseline situation, etc.).Are there alternatives to conventional hospitalization for patients with CAP? There are alternatives to conventional hospitalization such as early discharge from the ED in 24–48h, observation, SSU admission, outpatient center care and home care. However, given that our patient has clinical and analytical data that indicates a severe condition, the patient should be admitted to the ward under conventional hospitalization." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres61008" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec52380" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres61009" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec52379" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Emergency departments and patients with community-acquired pneumonia" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "The decision to hospitalize" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "FINE scale (Pneumonia Severity Index), CURB-65 and other scales" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Additional criteria to assess in community-acquired pneumonia" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Prediction of bacteremia" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical situation, systemic inflammatory response" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Biomarkers" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Severe community-acquired pneumonia and the decision to hospitalize in an intensive care unit" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Alternatives to conventional hospitalization" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions and recommendations" ] 10 => array:2 [ "identificador" => "xack21673" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-11-27" "fechaAceptado" => "2012-02-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec52380" "palabras" => array:7 [ 0 => "Community-acquired pneumonia" 1 => "Prognostic scales" 2 => "Emergency room" 3 => "Biological markers" 4 => "Procalcitonin" 5 => "Pro-adrenomedullin" 6 => "Short-stay unit" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec52379" "palabras" => array:7 [ 0 => "Neumonía adquirida en la comunidad" 1 => "Escalas pronósticas" 2 => "Urgencias" 3 => "Marcadores biológicos" 4 => "Procalcitonina" 5 => "Proadrenomedulina" 6 => "Unidad de corta estancia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Community-acquired pneumonia is the leading cause of death (10–14%) from infectious disease and the source of many sepsis and septic shock cases attended in the emergency departments. There is great variability in the admission rates (22–61%), and 10–20% of such admissions have to be done in the intensive care unit. The correct determination of need for admission (when), admission site (where) and burden of delivered care (how) will determine the patient's prognosis, request for basic and microbiological studies, antibiotic regimen (via and duration), clinical follow-up intensity and, consequently, the use of socio-health resources (costs). This article aims to orient decision-making, taking into account the new trends in prognostic evaluation tendencies and the current alternatives to the classic hospital admission." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La neumonía adquirida en la comunidad constituye la principal causa de muerte (10–14%) por enfermedad infecciosa y origina gran parte de las sepsis y shock sépticos atendidos en los servicios de urgencias. Existe gran variabilidad en sus tasas de ingreso (22–61%), y de estos, el 10–20% lo hace en una unidad de cuidados intensivos. Determinar correctamente la necesidad de ingreso (el cuándo), la ubicación (el dónde) y la intensidad de cuidados requeridos (el cómo) va a condicionar el pronóstico del paciente, la solicitud de pruebas básicas y estudios microbiológicos, la pauta antibiótica (vía y duración), la intensidad de observación clínica y, a la postre, la utilización de recursos sociosanitarios (costes). Este trabajo pretende orientar en la toma de estas decisiones teniendo en cuenta las nuevas tendencias en valoración pronóstica y las alternativas a la hospitalización convencional." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Julián-Jiménez A, et al. ¿Cuándo, dónde y cómo ingresar al paciente con neumonía adquirida en la comunidad? Rev Clin Esp. 2013;213:99–107." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 4569 "Ancho" => 2923 "Tamanyo" => 1268076 ] ] "descripcion" => array:1 [ "en" => "Prognostic Severity Scales (PSI and CURB-65)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2398 "Ancho" => 2511 "Tamanyo" => 651758 ] ] "descripcion" => array:1 [ "en" => "Prognostic Severity Scales (SCAP and SMART-COP)." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "AUC: area under the curve; CURB-65: confusion, urea, respiratory rate, blood pressure, over 65 years of age. Classes 3–5; Sp: specificity; PSI IV-V: Pneumonia Severity Index, classes IV and V; PSIm: Modified Pneumonia Severity Index (includes variable PaO2<60mmHg); S: sensitivity; SCAP: severity community acquired pneumonia; NPV: negative predictive value; PPV: positive predictive value.When SCAP has a score ≥10 points, it achieves a sensitivity of 92.1% and a specificity of 73.8%, which is higher than that of the CURB-65, although it has less sensitivity than the PSI IV-V and the PSIm.Adapted from: Chalmers et al.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> and España et al.<a class="elsevierStyleCrossRef" href="#bib0165">33</a>" "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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Sp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">PPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">NPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">AUC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SCAP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CURB-65(3–5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PSI IV–V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PSIm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab106090.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Statistical significance at p<0.05." ] ] ] "descripcion" => array:1 [ "en" => "Comparison of the ability to predict mortality in the SCAP, modified PSI, high-risk PSI group and CURB-65 scales." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "PSS: prognostic severity scales; CRP: C-reactive protein; PCT: procalcitonin; ProADM: proadrenomedullin; SIR: systemic inflammatory response; ED: emergency department; ICU: intensive care unit.Source: Our own preparation according to references in this article; the cutoff points are directed to the ED in lieu of validation and consensus among the various authors." "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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Cutoff points \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical significance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Values/limitations \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25–0.5 (bacterial infection)0.5ng/ml (clinical severity)2ng/ml (possibility of bacteremia)10ng/ml (evolution to septic shock) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Mortality at 30 days- Prediction of bacteremia- Relationship with clinical situation and evolution to sepsis/severe sepsis/septic shock- Correlation demonstrated with PSS and usefulness in combination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Differentiating acute bacterial infection from other viral and non-infectious processes- Highly specific of SIR- Accessibility from ED- Early- Lower predictive value if previous antibiotic treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ProADM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.75nmol/l (possibility for home treatment)0.75–1.5nmol/l (hospital observation)>1.5nmol/l (requires hospitalization and increases mortality) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Mortality at 30 and 180 days- Prediction of bacteremia- Severity of the process- Evolution to septic shock- Requires ICU- Demonstrated correlation with PSS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Better predictor of mortality- Non-specific for bacterial infection, it is related to cardiac comorbidity and shock- Accessibility from ED- Early \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CRP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥60mg/ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Severity of the process- Mortality at 30 days- Prediction of bacteremia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Relationship to SIR- Little specificity in relation to bacterial infection- Accessibility from ED- Not very early \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab106088.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Biomarkers in the prognostic assessment of community-acquired pneumonia." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Must meet one major or three minor criteria to indicate admission to an intensive care unit.ATS/IDSA: American Thoracic Society-Infectious Diseases Society of America; SCAP: severe community-acquired pneumonia; ICU: intensive care unit.Adapted from Mandell et al.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>" "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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Major criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Minor criteria \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Need for mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• SBP <90mmHg (requiring aggressive fluid therapy) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Multilobar (≥2 lobes) or bilateral impairment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Respiratory rate ≥30rpm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Confusion/disorientation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Urea ≥45mg/dl (BUN ≥20mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Septic shock with vasopressors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• PaO2/FiO2 ≤250 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Leukopenia <4000/mm3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Thrombocytopenia <100,000/mm3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Hypothermia (temperature <36°C) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab106089.png" ] ] ] ] "descripcion" => array:1 [ "en" => "2007 ATS/IDSA criteria for ICU admission of SCAP." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recomendaciones INFURG-SEMES: manejo de la infección respiratoria de vías bajas en urgencias" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. 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Dean" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/511159" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2007" "volumen" => "44" "paginaInicial" => "S27" "paginaFinal" => "S72" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17278083" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "¿Cuándo y dónde ingresar las neumonías adquiridas en la comunidad" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. 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