Validation of IDSA/ATS Guidelines for ICU Admission in Adults Over 80 Years Old With Community-Acquired Pneumonia

Introduction: The 2007 IDSA/ATS guidelines for community-acquired pneumonia (CAP) recommended intensive care unit (ICU) admission for adults meeting severe CAP criteria. We aimed to validate the accuracy of IDSA/ATS criteria in patients≥80 years old (very elderly patients, VEP) with CAP. Methods: Prospective cohort study of VEP with CAP admitted to three Spanish hospitals between 1996 and 2019. We compared patients who did and did not require ICU admission. We also assessed factors independently associated with ICU admission, as well as the accuracy of severe CAP criteria for ICU admission and mortality. Major criteria include septic shock and invasive mechanical ventilation while minor criteria encompass other variables related to hemodynamics and respiratory insufficiency as well as level of consciousness, renal function, blood parameters indicative of sepsis and body temperature. Results: Of the 2006 VEP with CAP, 519 (26%) met severe CAP criteria, while 204 (10%) required ICU admission. Concordance between severe CAP criteria and the decision to admit the patient to the ICU occurred in 1591 (79%) cases (k coefficient, 0.33), with a sensitivity of 75% and specificity of 80% in predicting ICU admission. All patients with invasive mechanical ventilation received care in ICUs, while 45 (44%) patients with septic shock—previously stabilized in the emergency room—did not. Thirty-day mortality of ICU-admitted patients with septic shock was lower than that of patients in wards (30% vs. 60%, p=0.013). In contrast, patients with severe CAP and only minor criteria had similar mortality. Conclusions: IDSA/ATS criteria for severe CAP predict ICU admission in VEP moderately well. While patients with septic shock and invasive mechanical ventilation warrant ICU admission, severe CAP without major severity criteria in VEP may be acceptably manageable in wards. (AU)

Validation of IDSA/ATS Guidelines for ICU Admission in Adults Over 80 Years Old With Community-Acquired Pneumonia.

INTRODUCTION: The 2007 IDSA/ATS guidelines for community-acquired pneumonia (CAP) recommended intensive care unit (ICU) admission for adults meeting severe CAP criteria. We aimed to validate the accuracy of IDSA/ATS criteria in patients≥80 years old (very elderly patients, VEP) with CAP. METHODS: Prospective cohort study of VEP with CAP admitted to three Spanish hospitals between 1996 and 2019. We compared patients who did and did not require ICU admission. We also assessed factors independently associated with ICU admission, as well as the accuracy of severe CAP criteria for ICU admission and mortality. Major criteria include septic shock and invasive mechanical ventilation while minor criteria encompass other variables related to hemodynamics and respiratory insufficiency as well as level of consciousness, renal function, blood parameters indicative of sepsis and body temperature. RESULTS: Of the 2006 VEP with CAP, 519 (26%) met severe CAP criteria, while 204 (10%) required ICU admission. Concordance between severe CAP criteria and the decision to admit the patient to the ICU occurred in 1591 (79%) cases (k coefficient, 0.33), with a sensitivity of 75% and specificity of 80% in predicting ICU admission. All patients with invasive mechanical ventilation received care in ICUs, while 45 (44%) patients with septic shock-previously stabilized in the emergency room-did not. Thirty-day mortality of ICU-admitted patients with septic shock was lower than that of patients in wards (30% vs. 60%, p=0.013). In contrast, patients with severe CAP and only minor criteria had similar mortality. CONCLUSIONS: IDSA/ATS criteria for severe CAP predict ICU admission in VEP moderately well. While patients with septic shock and invasive mechanical ventilation warrant ICU admission, severe CAP without major severity criteria in VEP may be acceptably manageable in wards.

WITHDRAWN: Validation of IDSA/ATS Guidelines for ICU Admission in Adults Over 80 Years Old With Community-acquired Pneumonia.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.arbres.2022.08.012. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal

Incidence of COVID-19 after pulmonary function tests: a retrospective cohort study.

INTRODUCTION: It has been proposed that exposure to pulmonary function tests (PFT) could be associated with a higher risk of viral transmission. The risk of the Coronavirus Disease 2019 (COVID-19) transmission after performing PFT is unknown. We aimed to assess the incidence  of COVID-19 after a PFT at an academic teaching facility in Buenos Aires, Argentina. MATERIALS AND METHODS: We conducted a retrospective cohort study including all consecutive adult patients that performed PFT between April 1, 2020 and September 30, 2020. Patients with prior COVID-19 were excluded. We defined a 15-day time window to  ascertain PFT related COVID-19. The primary outcome was ascertained by consulting a national database, which has information on all patients with nasopharyngeal swabs for SARS-CoV-2 in Argentina. RESULTS: We included 278 patients who performed a PFT. Fifty percent were women, the mean age was 54 years (SD 18), and the main comorbidities were obesity (31%), smoking (31%), hypertension (29%), and chronic lung disease (28%). The main indication for performing PFT was anesthetic preoperative risk assessment. Swabs were collected from 27 patients (10%). Twenty-two swabs (8%) were taken according to surgical protocols; five swabs (2%) were taken due to clinical suspicion of COVID-19, with only one testing positive. The cumulative incidence of COVID-19 after PFT was 0.36% (95% CI 0.01-20%). None of the technicians developed symptomatic disease. CONCLUSION: Given the right setting and strict adherence to international recommendations, the SARS-CoV-2 infection after having a PFT appears to be low, which follows that these procedures can be performed safely for both patients and staff.

Introducción: Se ha propuesto que las pruebas de función respiratorias (PFR) podrían estar asociadas con un mayor riesgo de transmisión viral. El riesgo de presentar la enfermedad por coronavirus 2019 (COVID-19) después de realizar una PFR es desconocido. El objetivo del estudio fue estimar la incidencia de COVID-19 después de llevar a cabo una PFR, en un Hospital Universitario de la ciudad Autónoma de Buenos Aires, Argentina. Se realizó una cohorte retrospectiva que incluyó a todos los pacientes que realizaron una PFR entre el 1 de abril de 2020 y el 30 de septiembre de 2020. Se excluyeron los pacientes con antecedentes de COVID-19. Definimos una ventana de tiempo de 15 días para determinar la presencia de COVID-19 relacionada con la realización de la PFR. El resultado primario se determinó consultando una base de datos nacional, que contiene información sobre todos los pacientes que se han realizado hisopados nasofaríngeos para detección del SARS-CoV-2 en Argentina. Materiales y métodos: Se incluyeron 278 pacientes, el 50% fueron mujeres, el promedio de edad fue de 54 años (DE 18) y las principales comorbilidades fueron: obesidad (31%), tabaquismo (31%), hipertensión (29%) y enfermedades respiratorias crónicas (28%). La principal indicación de la PFR fue la evaluación pre operatoria o anestésica. A 27 pacientes (10%) se les realizó un hisopado nasofaríngeo para búsqueda de SARS-CoV-2. Veintidós hisopados (8%) se solicitaron por evaluación pre quirúrgica, cinco hisopados (2%) por sospecha clínica de infección y solamente uno fue positivo. La incidencia de COVID-19 fue de 0.36% (IC95% 0.01-20%). Durante el período del estudio ninguno de los operadores que realizaron las PFR presentaron síntomas compatibles con COVID-19. Conclusión: Siguiendo las recomendaciones internacionales, la frecuencia de detección de COVID-19 después de las PFR parece ser bajo, por lo que estos procedimientos se podrían llevar a cabo de forma segura tanto para los pacientes como para el personal.

Lymphopenia Is Associated With Poor Outcomes of Patients With Community-Acquired Pneumonia and Sepsis.

BACKGROUND: Lymphopenia is a marker of poor prognosis in patients with community-acquired pneumonia (CAP), yet its impact on outcomes in patients with CAP and sepsis remains unknown. We aim to investigate the impact of lymphopenia on outcomes, risk of intensive care unit (ICU) admission, and mortality in CAP patients with sepsis. METHODS: This was a retrospective, observational study of prospectively collected data from an 800-bed tertiary teaching hospital (2005-2019). RESULTS: Of the 2203 patients with CAP and sepsis, 1347 (61%) did not have lymphopenia, while 856 (39%) did. When compared with the nonlymphopenic group, patients with sepsis and lymphopenia more frequently required ICU admission (P = .001), had a longer hospital length of stay (P ˂ .001), and presented with a higher rate of in-hospital (P ˂ .001) and 30-day mortality (P = .001). Multivariable analysis showed that C-reactive protein ≥15 mg/dL, lymphopenia, pleural effusion, and acute respiratory distress syndrome within 24 hours of admission were risk factors for ICU admission; age ≥80 years was independently associated with decreased ICU admission. In addition, age ≥80 years, chronic renal disease, chronic neurologic disease, being a nursing home resident, lymphopenia, and pleural effusion were independently associated with increased 30-day mortality, whereas pneumococcal vaccination, diabetes mellitus, and fever were independently associated with reduced 30-day mortality. CONCLUSIONS: Lymphopenia was independently associated with risk of ICU admission and higher in-hospital and 30-day mortality in patients with CAP and sepsis. Early identification of lymphopenia could help identify septic patients with CAP who require or will shortly require critical care.

[Analysis of Crowding in an Adult Emergency Department of a tertiary university hospital]. / Descripción de las características del fenómeno Crowding en la Central de Emergencia de Adultos, en un hospital universitario de alta complejidad: estudio de cohorte retrospectiva.

BACKGROUND: Crowding in Emergency Departments (ED), results from the imbalance between the simultaneous demand for health care and the ability of the system to respond. The NEDOCS scale (National Emergency Department Crowding Scale) measures the degree of crowding in an ED. AIM: To describe ED Crowding characteristics, using the NEDOCS scale, in an Argentinean hospital. MATERIAL AND METHODS: A retrospective cohort study was conducted with all adult patient consultations between July 2013 and July 2014 at the ED of Hospital Italiano de Buenos Aires. We included all hours in the analysis period (365 days x 24 h = 8,760). The NEDOCS value was calculated for each hour using an automatic algorithm and was quantified in a six points score. Levels 4 (overcrowded), 5 (severely overcrowded) and 6 (dangerously overcrowded) were defined as overcrowding. Contour plots analysis was applied to identify patterns. RESULTS: During the study period, 124,758 visits to the ED were registered. Overcrowding was present in 57.7% (5,055) of the analyzed hours. A predominance of scores between four and five was observed between 10:00 and 24:00 hours. The months with predominance of overcrowding were June, July and August (southern winter). CONCLUSIONS: The calculation of the NEDOCS score and the analysis of its temporal distribution are highly relevant to identify opportunities for improvement and to develop mechanisms to prevent the highest categories of overcrowding.

Descripción de las características del fenómeno Crowding en la Central de Emergencia de Adultos, en un hospital universitario de alta complejidad: estudio de cohorte retrospectiva / Analysis of Crowding in an Adult Emergency Department of a tertiary university hospital

Background: Crowding in Emergency Departments (ED), results from the imbalance between the simultaneous demand for health care and the ability of the system to respond. The NEDOCS scale (National Emergency Department Crowding Scale) measures the degree of crowding in an ED. Aim: To describe ED Crowding characteristics, using the NEDOCS scale, in an Argentinean hospital. Material and Methods: A retrospective cohort study was conducted with all adult patient consultations between July 2013 and July 2014 at the ED of Hospital Italiano de Buenos Aires. We included all hours in the analysis period (365 days x 24 h = 8,760). The NEDOCS value was calculated for each hour using an automatic algorithm and was quantified in a six points score. Levels 4 (overcrowded), 5 (severely overcrowded) and 6 (dangerously overcrowded) were defined as overcrowding. Contour plots analysis was applied to identify patterns. Results: During the study period, 124,758 visits to the ED were registered. Overcrowding was present in 57.7% (5,055) of the analyzed hours. A predominance of scores between four and five was observed between 10:00 and 24:00 hours. The months with predominance of overcrowding were June, July and August (southern winter). Conclusions: The calculation of the NEDOCS score and the analysis of its temporal distribution are highly relevant to identify opportunities for improvement and to develop mechanisms to prevent the highest categories of overcrowding.