Share
array:23 [ "pii" => "S2254887412000045" "issn" => "22548874" "doi" => "10.1016/j.rceng.2012.11.003" "estado" => "S300" "fechaPublicacion" => "2013-03-01" "aid" => "574" "copyright" => "Elsevier España, S.L." "copyrightAnyo" => "2012" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Rev Clin Esp. 2013;213:99-107" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1384 "formatos" => array:2 [ "HTML" => 1362 "PDF" => 22 ] ] "itemSiguiente" => array:18 [ "pii" => "S2254887413000131" "issn" => "22548874" "doi" => "10.1016/j.rceng.2012.04.001" "estado" => "S300" "fechaPublicacion" => "2013-03-01" "aid" => "609" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2013;213:108-13" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 254 "formatos" => array:2 [ "HTML" => 240 "PDF" => 14 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Clinical advances of interest in the diagnosis and treatment of patients with antiphospholipid syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "108" "paginaFinal" => "113" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Avances de interés clínico en el diagnóstico y tratamiento de los pacientes con síndrome antifosfolípido" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.L. Rodríguez García, M.A. Khamashta" "autores" => array:2 [ 0 => array:2 [ "nombre" => "J.L." "apellidos" => "Rodríguez García" ] 1 => array:2 [ "nombre" => "M.A." "apellidos" => "Khamashta" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887413000131?idApp=WRCEE" "url" => "/22548874/0000021300000002/v1_201303141351/S2254887413000131/v1_201303141351/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2254887412000094" "issn" => "22548874" "doi" => "10.1016/j.rceng.2012.12.001" "estado" => "S300" "fechaPublicacion" => "2013-03-01" "aid" => "688" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2013;213:88-96" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 284 "formatos" => array:2 [ "HTML" => 278 "PDF" => 6 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Clinical and microbiological aspects of acute community-acquired pneumonia due to <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "88" "paginaFinal" => "96" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aspectos clínicos y microbiológicos de la neumonía aguda comunitaria a <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>" ] ] "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" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1251 "Ancho" => 1635 "Tamanyo" => 122907 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Number of patient cases distributed by age and outcome at day 28 or at hospital discharge.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Cardinal-Fernández, G. García Gabarrot, P. Echeverria, G. Zum, J. Hurtado, G. Rieppi" "autores" => array:6 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Cardinal-Fernández" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "García Gabarrot" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Echeverria" ] 3 => array:2 [ "nombre" => "G." "apellidos" => "Zum" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Hurtado" ] 5 => array:2 [ "nombre" => "G." "apellidos" => "Rieppi" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887412000094?idApp=WRCEE" "url" => "/22548874/0000021300000002/v1_201303141351/S2254887412000094/v1_201303141351/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical up-date</span>" "titulo" => "When, where and how should a patient with community acquired pneumonia be admitted?" "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" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "González-Castillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "F.J." "apellidos" => "Candel González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Urgencias-Medicina Interna, Hospital Virgen de la Salud, Toledo, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Urgencias-Medicina Interna, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Microbiología Clínica, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "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" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Prognostic Severity Scales (SCAP and SMART-COP).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 38-year-old male was admitted to the emergency department (ED) with a fever of 39<span class="elsevierStyleHsp" style=""></span>°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 120/70<span class="elsevierStyleHsp" style=""></span>mmHg, respiratory rate 34 breaths per minute, heart rate 116 beats per minute, and oxygen saturation (SatO<span class="elsevierStyleMonospace"><span class="elsevierStyleInf">2</span></span>) 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 42<span class="elsevierStyleHsp" style=""></span>mg/dl, sodium 134<span class="elsevierStyleHsp" style=""></span>mequiv./l, C-reactive protein (CRP) 90<span class="elsevierStyleHsp" style=""></span>mg/l; procalcitonin (PCT) 10<span class="elsevierStyleHsp" style=""></span>ng/ml and a baseline arterial gasometry with pH 7.48, arterial oxygen pressure (PaO<span class="elsevierStyleInf">2</span>) 58.4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg, arterial carbon dioxide partial pressure (PaCO<span class="elsevierStyleInf">2</span>) 38.6<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg, HCO<span class="elsevierStyleInf">3</span> 24.2<span class="elsevierStyleHsp" style=""></span>mmol/l and SatO<span class="elsevierStyleInf">2</span> 90.8%.</p><p id="par0010" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleLabel">a)</span><p id="par0015" class="elsevierStylePara elsevierViewall">Should we hospitalize the patient? If yes, where?</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0020" class="elsevierStylePara elsevierViewall">What impact should clinical judgment have on our decision?</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0025" class="elsevierStylePara elsevierViewall">What level of bacteremia is the patient predicted to have?</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d)</span><p id="par0030" class="elsevierStylePara elsevierViewall">What impact do biomarkers (BM) and a clinical situation of sepsis (S) have on the indication for hospitalization?</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">e)</span><p id="par0035" class="elsevierStylePara elsevierViewall">What additional criteria should we assess along with the prognostic scales?</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">f)</span><p id="par0040" class="elsevierStylePara elsevierViewall">Are there alternatives to conventional hospitalization for patients with CAP?</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Emergency departments and patients with community-acquired pneumonia</span><p id="par0045" class="elsevierStylePara elsevierViewall">CAP 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"><span class="elsevierStyleSup">1</span></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"><span class="elsevierStyleSup">2</span></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"><span class="elsevierStyleSup">1</span></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"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1–3</span></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"><span class="elsevierStyleSup">4</span></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"><span class="elsevierStyleSup">3</span></a> These decisions will have implications for the safety and quality of the care offered to patients<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and for its cost-effectiveness.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a> Improper hospitalization increases the likelihood of experiencing medical malpractice, adverse episodes and nosocomial infections.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></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"><span class="elsevierStyleSup">3,7</span></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"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">4</span></a> this study has been prepared for adult patients who are not immunocompromised or hospitalized with CAP.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The decision to hospitalize</span><p id="par0060" class="elsevierStylePara elsevierViewall">An 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"><span class="elsevierStyleSup">8,9</span></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"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">3,10,11</span></a> Avoiding both unnecessary admissions and improper discharges constitutes an undeniable objective.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></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"><span class="elsevierStyleSup">4–12</span></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"><span class="elsevierStyleSup">1–4</span></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"><span class="elsevierStyleSup">1</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">FINE scale (Pneumonia Severity Index), CURB-65 and other scales</span><p id="par0070" class="elsevierStylePara elsevierViewall">Although there are numerous PSS, the FINE or PSI<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and the CURB-65<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></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"><span class="elsevierStyleSup">13</span></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"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">8</span></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 (PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg and/or SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>90%).<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></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"><span class="elsevierStyleSup">1,4–16</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The British Thoracic Society (BTS) developed the CURB-659 scale<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></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 SatO<span class="elsevierStyleInf">2</span> or PaO<span class="elsevierStyleInf">2</span>. 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"><span class="elsevierStyleSup">4,10,17</span></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"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In recent years, various PSS have emerged. Among them is the PSS proposed by España et al.,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></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.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional criteria to assess in community-acquired pneumonia</span><p id="par0090" class="elsevierStylePara elsevierViewall">In 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"><span class="elsevierStyleSup">1,3</span></a> Among these criteria are the estimation of the probability for bacteremia,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></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"><span class="elsevierStyleSup">19–22</span></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"><span class="elsevierStyleSup">8</span></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"><span class="elsevierStyleSup">1–4</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prediction of bacteremia</span><p id="par0095" class="elsevierStylePara elsevierViewall">PSI and CURB-65 do not predict the risk of bacteremia. The scale proposed by Tudela et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></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 >0.5<span class="elsevierStyleHsp" style=""></span>ng/ml, as proposed by Tudela et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>, or at >2<span class="elsevierStyleHsp" style=""></span>ng/ml, as recommended by other authors.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,21</span></a> Falguera et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></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"><span class="elsevierStyleSup">1–3</span></a> Adding PCT and the clinical situation (S-SS-SSh) to Shapiro's predictive model improves the prediction of bacteremia (with PCT >2<span class="elsevierStyleHsp" style=""></span>ng/ml predicts worse clinical outcome and a probability of 20% for bacteremia).<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical situation, systemic inflammatory response</span><p id="par0100" class="elsevierStylePara elsevierViewall">The 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 (8–12–24<span class="elsevierStyleHsp" style=""></span>h) and remain under observation by the ED or in the SSU.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></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"><span class="elsevierStyleSup">21</span></a> Several vital signs are individual predictors of mortality (respiratory rate ≥30, heart rate ≥120, body temperature >38.3<span class="elsevierStyleHsp" style=""></span>°C, and SBP<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg and DBP<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg). Chalmers et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> demonstrated that SBP is the best independent predictor of mortality at 30 days (odds ratio [OR]<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.6, 95% CI: 3.4–9.3; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001; specificity of 89.9%) and need for MV and/or vasopressor support (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.6, 95% CI: 3.4–9.4; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001; specificity of 90.5%).</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Biomarkers</span><p id="par0105" class="elsevierStylePara elsevierViewall">The 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 <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> who progress to SG-SS.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19–22</span></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"><span class="elsevierStyleSup">20,26</span></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"><span class="elsevierStyleSup">19–22</span></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"><span class="elsevierStyleSup">19,21</span></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"><span class="elsevierStyleSup">27–29</span></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"><span class="elsevierStyleSup">27</span></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"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Menendez et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</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) 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<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>CRP<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>PCT (0.85, 95% CI; 0.79–0.91) and PSI<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>CURB-65<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>PCR (0.88, 95% CI; 0.83–0.93). Krüger et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> found that pro-AMD (with a cutoff lower than other authors: 0.95<span class="elsevierStyleHsp" style=""></span>nmol/l) and PCT (>0.48<span class="elsevierStyleHsp" style=""></span>ng/ml), along with the PSS and the proper use of the JC, constitutes the best predictive model for mortality at 28 and 180 days.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Recently, Albrich et al.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></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 ≤0.75<span class="elsevierStyleHsp" style=""></span>nmol/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 ≤1.5<span class="elsevierStyleHsp" style=""></span>nmol/l or CURB-65 0-1 and proADM ≤0.75–1.5<span class="elsevierStyleHsp" style=""></span>nmol/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 >1.5<span class="elsevierStyleHsp" style=""></span>nmol/l with any CURB-65) where conventional hospitalization is recommended.</p><p id="par0120" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">28</span></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 72<span class="elsevierStyleHsp" style=""></span>h prior to the visit to the ED.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Severe community-acquired pneumonia and the decision to hospitalize in an intensive care unit</span><p id="par0125" class="elsevierStylePara elsevierViewall">Following 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"><span class="elsevierStyleSup">30</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">31</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">3</span></a> SMART-COP<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and SCAP<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> are appropriate for identifying candidates who require inotropic and/or ventilator support and/or admission to the ICU.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The majority of CPG<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></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"><span class="elsevierStyleSup">3</span></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"><span class="elsevierStyleSup">32</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Charles et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> have recently developed a severity scale focused on the prediction of the need for intensive respiratory or vasopressor support. This scale, known as <span class="elsevierStyleItalic">SMART-COP</span> (<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"><span class="elsevierStyleSup">3–5</span></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"><span class="elsevierStyleSup">33</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">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). <span class="elsevierStyleItalic">PIRO-NAC</span>, 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"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Alternatives to conventional hospitalization</span><p id="par0155" class="elsevierStylePara elsevierViewall">In 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 24–48<span class="elsevierStyleHsp" style=""></span>h,<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,36</span></a> observation in the ED,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> the admission to the SSU,<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37,38</span></a> outpatient center care<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,36</span></a> and home care.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">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.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Llorens et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></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"><span class="elsevierStyleSup">37</span></a> found that the admission of a number of patients with CAP to the ICU achieved average stays of 3.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.2 days versus the 7.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.6 days for those who were conventionally hospitalized for internal medicine or versus the 10.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8.5 days for pulmonology (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001), with similar efficacy and safety. Juan et al.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> demonstrated that the SSU is effective and safe for patients with CAP, reducing the average stay when compared with conventional hospitalization (3.48<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.70 days vs. 7.89<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>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<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.04 vs. 67.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>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"><span class="elsevierStyleSup">39</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">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.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions and recommendations</span><p id="par0175" class="elsevierStylePara elsevierViewall">The 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:</p><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Should we hospitalize the patient? If yes, where?</span> Our patient should be hospitalized. Although according to the prognostic scales the initial assessment suggests the opposite (PSI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>II and CURB-65<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1), the patient has respiratory failure (PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg), which is already a criterion for hospitalization according to the PSIm and has clinical criteria suggestive of S with substantial systemic clinical involvement.</p><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">What impact should the clinical judgment have on our decision?</span> 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.</p><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">What level of bacteremia is the patient predicted to have?</span> Based on the clinical data (criteria of S) and the PCT value of 10<span class="elsevierStyleHsp" style=""></span>ng/ml (significantly greater than 2<span class="elsevierStyleHsp" style=""></span>ng/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.</p><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">What do biomarkers and the clinical situation of sepsis contribute to the indication for hospitalization?</span> Our patient has a PCT value of 10<span class="elsevierStyleHsp" style=""></span>ng/ml and a PCR value of 90<span class="elsevierStyleHsp" style=""></span>mg/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.</p><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">What additional criteria should we assess along with the prognostic scales?</span> 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.).</p><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Are there alternatives to conventional hospitalization for patients with CAP?</span> There are alternatives to conventional hospitalization such as early discharge from the ED in 24–48<span class="elsevierStyleHsp" style=""></span>h, 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.</p></span></span>" "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" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">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.</p>" ] ] "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" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Prognostic Severity Scales (PSI and CURB-65).</p>" ] ] 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" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Prognostic Severity Scales (SCAP and SMART-COP).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">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 PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg); S: sensitivity; SCAP: severity community acquired pneumonia; NPV: negative predictive value; PPV: positive predictive value.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">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.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Adapted from: Chalmers et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and España et al.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></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"><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"><span class="elsevierStyleItalic">p</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></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" => "<p class="elsevierStyleNotepara">Statistical significance at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comparison of the ability to predict mortality in the SCAP, modified PSI, high-risk PSI group and CURB-65 scales.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">PSS: prognostic severity scales; CRP: C-reactive protein; PCT: procalcitonin; ProADM: proadrenomedullin; SIR: systemic inflammatory response; ED: emergency department; ICU: intensive care unit.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>: 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.</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"><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)0.5<span class="elsevierStyleHsp" style=""></span>ng/ml (clinical severity)2<span class="elsevierStyleHsp" style=""></span>ng/ml (possibility of bacteremia)10<span class="elsevierStyleHsp" style=""></span>ng/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"><span class="elsevierStyleVsp" style="height:0.5px"></span></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"><0.75<span class="elsevierStyleHsp" style=""></span>nmol/l (possibility for home treatment)0.75–1.5<span class="elsevierStyleHsp" style=""></span>nmol/l (hospital observation)>1.5<span class="elsevierStyleHsp" style=""></span>nmol/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"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">≥60<span class="elsevierStyleHsp" style=""></span>mg/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" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Biomarkers in the prognostic assessment of community-acquired pneumonia.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Must meet one major or three minor criteria to indicate admission to an intensive care unit.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ATS/IDSA: American Thoracic Society-Infectious Diseases Society of America; SCAP: severe community-acquired pneumonia; ICU: intensive care unit.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Adapted from Mandell et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></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"><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 <90<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg (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 ≥30<span class="elsevierStyleHsp" style=""></span>rpm \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 ≥45<span class="elsevierStyleHsp" style=""></span>mg/dl (BUN ≥20<span class="elsevierStyleHsp" style=""></span>mg/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"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">• PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ≤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/mm<span class="elsevierStyleSup">3</span> \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/mm<span class="elsevierStyleSup">3</span> \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<span class="elsevierStyleHsp" style=""></span>°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" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">2007 ATS/IDSA criteria for ICU admission of SCAP.</p>" ] ] ] "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. Julián-Jiménez" 1 => "F.J. Candel" 2 => "P. Piñera" 3 => "J. González del Castillo" 4 => "M.S. Moya" 5 => "M. Martínez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emergencias" "fecha" => "2009" "volumen" => "3" "paginaInicial" => "1" "paginaFinal" => "21" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neumonía adquirida en la comunidad. Nueva normativa de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Menéndez" 1 => "A. Torres" 2 => "J. Aspa" 3 => "A. Capelastegui" 4 => "C. Prat" 5 => "F. Rodríguez de Castro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2010.06.014" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2010" "volumen" => "46" "paginaInicial" => "543" "paginaFinal" => "558" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20832928" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.A. Mandell" 1 => "R.G. Wunderink" 2 => "A. Anzueto" 3 => "J.G. Bartlett" 4 => "D. Campbell" 5 => "N.C. 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. Julián Jiménez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Emergencias" "fecha" => "2011" "volumen" => "23" "paginaInicial" => "161" "paginaFinal" => "163" "itemHostRev" => array:3 [ "pii" => "S0049017210000739" "estado" => "S300" "issn" => "00490172" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Grupo de trabajo EVADUR-SEMES. EVADUR: eventos adversos ligados a la asistencia en los servicios de urgencias de hospitales españoles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Tomás" 1 => "M. Chanovas" 2 => "F. Roqueta" 3 => "J. Alcaraz" 4 => "T. Toranzo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emergencias" "fecha" => "2010" "volumen" => "22" "paginaInicial" => "415" "paginaFinal" => "428" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "¿Cuál es el coste de las neumonías que ingresamos inadecuadamente" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. González Moraleja" 1 => "P. Sesma" 2 => "C. González" 3 => "M.E. López" 4 => "J.F. García" 5 => "J.L. Álvarez-Sala" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "1999" "volumen" => "35" "paginaInicial" => "312" "paginaFinal" => "316" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10439127" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Improvement of process-of-care and outcomes after implementing a guideline for the management of community-acquired pneumonia: a controlled before-and-after design" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Capelastegui" 1 => "P.E. España" 2 => "J.M. Quintana" 3 => "I. Gorordo" 4 => "M. Ortega" 5 => "I. Idoiaga" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/423960" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2004" "volumen" => "39" "paginaInicial" => "955" "paginaFinal" => "963" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15472846" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A prediction rule to identify low-risk patients with community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.J. Fine" 1 => "T.E. Auble" 2 => "D.M. Yealy" 3 => "B.H. Hanusa" 4 => "L.A. Weissfeld" 5 => "D.E. Singer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199701233360402" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "1997" "volumen" => "336" "paginaInicial" => "243" "paginaFinal" => "250" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8995086" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W.S. Lim" 1 => "M.M. Van der Eerden" 2 => "R. Laing" 3 => "W.G. Boersma" 4 => "N. Karalus" 5 => "G.I. Town" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2003" "volumen" => "58" "paginaInicial" => "377" "paginaFinal" => "382" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12728155" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development and validation of a clinical prediction rule for severe community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "EspañaF P.P." 1 => "A. Capelastegui" 2 => "I. Gorordo" 3 => "C. Esteban" 4 => "M. Oribe" 5 => "M. Ortega" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200602-177OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2006" "volumen" => "174" "paginaInicial" => "1249" "paginaFinal" => "1256" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16973986" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.G. Charles" 1 => "R. Wolfe" 2 => "M. Whitby" 3 => "M.J. Fine" 4 => "A.J. Fuller" 5 => "R. Stirling" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/589754" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2008" "volumen" => "47" "paginaInicial" => "375" "paginaFinal" => "384" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18558884" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estudio de una cohorte de pacientes con neumonía adquirida en la comunidad de bajo riesgo ingresados en un hospital universitario" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E. García" 1 => "S. Soto" 2 => "A. Hernández-Torres" 3 => "J.A. Herrero" 4 => "J. Gómez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emergencias" "fecha" => "2010" "volumen" => "22" "paginaInicial" => "275" "paginaFinal" => "281" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Validation of a predictive rule for the management of community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Capelastegui" 1 => "P.P. España" 2 => "J.M. Quintana" 3 => "I. Areitio" 4 => "I. Gorordo" 5 => "M. Egurrola" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.06.00062505" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2006" "volumen" => "27" "paginaInicial" => "151" "paginaFinal" => "157" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16387948" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severity assessment tools for predicting mortality in hospitalized patients with community-acquired pneumonia. Systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.D. Chalmers" 1 => "A. Singanayagam" 2 => "A.R. Akram" 3 => "P. Mandal" 4 => "P.M. Short" 5 => "G. Choudhury" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2009.133280" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2010" "volumen" => "65" "paginaInicial" => "878" "paginaFinal" => "883" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20729231" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Routine use of the Pneumonia Severity Index for guiding the site-of-treatment decision of patients with pneumonia in the emergency department: a multicenter, prospective, observational, controlled cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Renaud" 1 => "E. Coma" 2 => "J. Labarere" 3 => "J. Hayon" 4 => "P.M. Roy" 5 => "H. Boureaux" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/509331" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2007" "volumen" => "44" "paginaInicial" => "41" "paginaFinal" => "49" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17143813" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adecuación de los ingresos y de la asistencia facilitada a los pacientes con neumonía adquirida en la comunidad" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Hinojosa Mena-Bernal" 1 => "C. Hinojosa Mena-Bernal" 2 => "E. González Sarmiento" 3 => "A. Almaraz Gómez" 4 => "S. Martín Santos" 5 => "A. Zapatero Gaviria" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rce.2009.06.019" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2011" "volumen" => "211" "paginaInicial" => "179" "paginaFinal" => "186" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21420665" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Utilidad de la escala CRB-65 en la evaluación pronóstica de los pacientes mayores de 65 años con neumonía adquirida en la comunidad" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Vila" 1 => "O. Ochoa" 2 => "T. Rodríguez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2010" "volumen" => "135" "paginaInicial" => "97" "paginaFinal" => "102" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A prediction rule for estimating the risk of bacteremia in patients with community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Falguera" 1 => "J. Trujillano" 2 => "S. Caro" 3 => "R. Menéndez" 4 => "J. Carratalá" 5 => "A. Ruiz-González" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/600291" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2009" "volumen" => "49" "paginaInicial" => "409" "paginaFinal" => "416" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19555286" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Utilidad de la procalcitonina y la proteína C reactiva en la neumonía adquirida en la comunidad en urgencias" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Julián-Jiménez" 1 => "M.J. Palomo" 2 => "J.G. Sentenac" 3 => "J. Aguilar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2009.10.007" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2010" "volumen" => "28" "paginaInicial" => "661" "paginaFinal" => "667" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20430482" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiovascular and inflammatory biomarkers to predict short- and long-term survival in community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Krüger" 1 => "S. Ewig" 2 => "S. Giersdorf" 3 => "O. Hartmann" 4 => "N. Suttorp" 5 => "T. Welte" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201003-0415OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2010" "volumen" => "182" "paginaInicial" => "1426" "paginaFinal" => "1434" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20639437" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Utilidad de la procalcitonina y la proteína C reactiva en el paciente con sepsis en urgencias" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Julián" 1 => "M.J. Palomo" 2 => "R. Ortiz" 3 => "A. Pedrosa" 4 => "R. Parejo" 5 => "R. Salcedo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emergencias" "fecha" => "2009" "volumen" => "21" "paginaInicial" => "23" "paginaFinal" => "27" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biomarkers of thrombosis, fibrinolysis, and inflammation in patients with severe sepsis due to community-acquired pneumonia with and without <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.M. Vail" 1 => "Y.J. Xie" 2 => "D.J. Haney" 3 => "C.J. Barnes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s15010-008-8128-6" "Revista" => array:6 [ "tituloSerie" => "Infection" "fecha" => "2009" "volumen" => "37" "paginaInicial" => "358" "paginaFinal" => "364" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19169631" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predicción de bacteriemia en los pacientes con sospecha de infección en urgencias" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Tudela" 1 => "A. Lacoma" 2 => "C. Prat" 3 => "J.M. Mòdol" 4 => "M. Giménez" 5 => "J. Barallat" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2010" "volumen" => "135" "paginaInicial" => "685" "paginaFinal" => "690" ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Importancia de la sospecha clínica y confirmación de bacteriemia en los servicios de urgencias" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Julián-Jiménez" 1 => "E.J. Laserna-Mendieta" 2 => "J. Timón-Zapata" 3 => "A. Cabezas-Martínez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2011" "volumen" => "137" "paginaInicial" => "424" "paginaFinal" => "429" ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systolic blood pressure is superior to other haemodynamic predictors of outcome in community acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.D. Chalmers" 1 => "A. Singanayagam" 2 => "A.T. Hill" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2008.095562" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2008" "volumen" => "63" "paginaInicial" => "698" "paginaFinal" => "702" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18492742" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Midregional proadrenomedullin as a prognostic tool in community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.T. Huang" 1 => "D.C. Angus" 2 => "J.A. Kellum" 3 => "N.A. Pugh" 4 => "L.A. Weissfeld" 5 => "J. Struck" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.08-1981" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2009" "volumen" => "136" "paginaInicial" => "823" "paginaFinal" => "831" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19363212" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biomarkers improve mortality prediction by prognostic scales in community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Menéndez" 1 => "R. Martínez" 2 => "S. Reyes" 3 => "J. Mensa" 4 => "X. Filella" 5 => "M.A. Marcos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2008.105312" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2009" "volumen" => "64" "paginaInicial" => "587" "paginaFinal" => "591" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19131448" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assessment of inflammatory markers in patients with community-acquired pneumonia – influence of antimicrobial pre-treatment. Results from the German competence network CAPNETZ" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Krüger" 1 => "S. Ewig" 2 => "J. Kunde" 3 => "O. Hartmann" 4 => "R. Marre" 5 => "N. Suttorp" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cca.2010.08.004" "Revista" => array:6 [ "tituloSerie" => "Clin Chim Acta" "fecha" => "2010" "volumen" => "411" "paginaInicial" => "1929" "paginaFinal" => "1934" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20699094" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Enhancement of CURB65 score with proadrenomedullin (CURB65-A) for outcome prediction in lower respiratory tract infections: derivation of a clinical algorithm" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W.C. Albrich" 1 => "F. Dusemund" 2 => "K. Rüegger" 3 => "M. Christ-Crain" 4 => "W. Zimmerli" 5 => "T. Bregenzer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-2334-11-112" "Revista" => array:5 [ "tituloSerie" => "BMC Infect Dis" "fecha" => "2011" "volumen" => "11" "paginaInicial" => "112" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21539743" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association between timing of intensive care unit admission and outcomes for emergency department patients with community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Renaud" 1 => "A. Santin" 2 => "E. Coma" 3 => "N. Camus" 4 => "D. Van Pelt" 5 => "J. Hayon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/CCM.0b013e3181b02dbb" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2009" "volumen" => "37" "paginaInicial" => "2867" "paginaFinal" => "2874" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19770748" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.I. Restrepo" 1 => "A. Anzueto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.idc.2009.04.003" "Revista" => array:6 [ "tituloSerie" => "Infect Dis Clin North Am" "fecha" => "2009" "volumen" => "23" "paginaInicial" => "503" "paginaFinal" => "520" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19665080" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neumonía comunitaria grave. Estudio descriptivo de 7 años y utilidad de los criterios de la <span class="elsevierStyleItalic">Infectious Diseases Society of America</span> y la <span class="elsevierStyleItalic">Americam Thoracic Society</span> 2007 en la identificación de los pacientes que requieren ingreso en una unidad de cuidados intensivos" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Sabatier" 1 => "R. Peredo" 2 => "A. Villagrá" 3 => "N. Bacelat" 4 => "D. Mariscal" 5 => "R. Ferrer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2009.11.008" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2010" "volumen" => "34" "paginaInicial" => "237" "paginaFinal" => "245" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20116135" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prospective comparison of severity scores for predicting clinically relevant outcomes for patients hospitalized with community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.P. España" 1 => "A. Capelastegui" 2 => "J. Quintana" 3 => "R. Diez" 4 => "I. Gorordo" 5 => "A. Bilbao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.08-2179" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2009" "volumen" => "135" "paginaInicial" => "1572" "paginaFinal" => "1579" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19141524" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "PIRO score for community-acquired pneumonia: a new prediction rule for assessment of severity in intensive care unit patients with community-acquired pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Rello" 1 => "A. Rodríguez" 2 => "T. Lisboa" 3 => "M. Gallego" 4 => "M. Lujan" 5 => "R. Wunderink" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/CCM.0b013e318194b021" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2009" "volumen" => "37" "paginaInicial" => "456" "paginaFinal" => "462" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19114916" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0175" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluación de un modelo de atención coordinada entre alternativas a la hospitalización convencional en la neumonía adquirida en la comunidad" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Llorens" 1 => "J. Murcia-Zaragoza" 2 => "J. Sánchez-Paya" 3 => "F. Laghzaoui" 4 => "S. Reus" 5 => "J.M. Carratalá-Perales" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emergencias" "fecha" => "2011" "volumen" => "23" "paginaInicial" => "167" "paginaFinal" => "174" ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0180" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Resultado de un proceso para la mejora de las altas hospitalarias precoces" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. García" 1 => "N. Enguix" 2 => "L. Valverde" 3 => "M. Castells" 4 => "I. Pascual" 5 => "A. Esquerda" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emergencias" "fecha" => "2011" "volumen" => "23" "paginaInicial" => "29" "paginaFinal" => "34" ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0185" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impacto de una unidad de corta estancia en un hospital de tercer nivel" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Sempere-Montes" 1 => "M. Morales-Suarez-Varela" 2 => "E. Garijo-Gómez" 3 => "M.D. Illa-Gómez" 4 => "P. Palau-Muñoz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rce.2009.11.016" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2010" "volumen" => "210" "paginaInicial" => "279" "paginaFinal" => "283" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20416866" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Análisis de la seguridad y la eficacia de la unidad de corta estancia en el tratamiento de la neumonía adquirida en la comunidad" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Juan" 1 => "J. Jacob" 2 => "F. Llopis" 3 => "C. Gómez-Vaquero" 4 => "C. Ferré" 5 => "J.R. Pérez-Mas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emergencias" "fecha" => "2011" "volumen" => "23" "paginaInicial" => "175" "paginaFinal" => "182" ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0195" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento de la neumonía adquirida en la comunidad en hospitalización a domicilio: resultado clínico en casos con diferente nivel de gravedad" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Regalado" 1 => "F. Aizpuru" 2 => "E. Oceja" 3 => "M. de Juan" 4 => "L. Apraiz" 5 => "E. Altuna" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2010" "volumen" => "135" "paginaInicial" => "47" "paginaFinal" => "51" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "identificador" => "xack21673" "titulo" => "Acknowledgements" "texto" => "<p id="par0210" class="elsevierStylePara elsevierViewall">We would like to thank Rodríguez Villa and Oscar Miró i Andreu for their collaboration and help in preparing this manuscript.</p>" ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000021300000002/v1_201303141351/S2254887412000045/v1_201303141351/en/main.assets" "Apartado" => array:4 [ "identificador" => "1904" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Clinical Up-Date" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021300000002/v1_201303141351/S2254887412000045/v1_201303141351/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887412000045?idApp=WRCEE" ]
