title: Inflammatory biomarkers and prediction for intensive care unit admission in severe community-acquired pneumonia.
abstract: OBJECTIVE
  Increased inflammatory response is related to severity and outcome in community-acquired pneumonia, but the role of inflammatory biomarkers in deciding intensive care unit admission is unknown. We assessed the relationship between inflammatory response, prediction for intensive care unit admission, delayed intensive care unit admission, and outcome in patients with community-acquired pneumonia.
  
  
  METHODS
  Prospective clinical study.
  
  
  METHODS
  Intensive care units of two university hospitals.
  
  
  METHODS
  We included 627 ward and 58 intensive care unit patients with community-acquired pneumonia, 36 with direct and 22 with delayed intensive care unit admission.
  
  
  METHODS
  Serum levels of C-reactive protein, procalcitonin, tumor necrosis factor-α, interleukin-1, interleukin-6, interleukin-8, and interleukin-10 at admission.
  
  
  RESULTS
  We assessed the prediction for intensive care unit admission of biomarkers and the Infectious Diseases Society of America/American Thoracic Society guidelines minor criteria for severe community-acquired pneumonia. Procalcitonin (p=.001), C-reactive protein (p=.005), tumor necrosis factor-α (p=.042), and interleukin-6 (p=.003) levels were higher in intensive care unit-admitted patients; however, the Infectious Diseases Society of America/American Thoracic Society guidelines minor severity criteria predicted better intensive care unit admission (odds ratio, 12.03; 95% confidence interval, 5.13-28.20; p<.001). No patient with severe community-acquired pneumonia by three or more minor severity criteria and procalcitonin levels below the optimal cutoff (0.35 ng/mL) needed intensive care unit admission compared with 14 (23%) with levels above the cutoff (p=.032). In patients initially admitted to wards, procalcitonin (p=.012) and C-reactive protein (p=.039) were higher in those 22 patients subsequently transferred to the intensive care unit after adjusting for age, comorbidities, and Pneumonia Severity Index risk class. Despite initially admitted to wards, 14 (64%) patients with delayed intensive care unit admission had already criteria for severe community-acquired pneumonia at admission compared with 73 (12%) ward patients (p<.001).
  
  
  CONCLUSIONS
  Inflammatory biomarkers identified patients needing intensive care unit admission, including those with delayed intensive care unit admission. Patients with severe community-acquired pneumonia by minor criteria and low levels of procalcitonin may be safely admitted to wards. Correctly applying the Infectious Diseases Society of America/American Thoracic Society guidelines would reduce substantially delayed intensive care unit admission.
authors.affiliation: Unidad de Cuidados Intensivos and Servicio de Neumologia, Hospital Universitario La Fe, Valencia, Spain.
authors.forename: Paula
authors.initials: P
authors.lastname: Ramírez
authors.forename: Miquel
authors.initials: M
authors.lastname: Ferrer
authors.forename: Verónica
authors.initials: V
authors.lastname: Martí
authors.forename: Soledad
authors.initials: S
authors.lastname: Reyes
authors.forename: Raquel
authors.initials: R
authors.lastname: Martínez
authors.forename: Rosario
authors.initials: R
authors.lastname: Menéndez
authors.forename: Santiago
authors.initials: S
authors.lastname: Ewig
authors.forename: Antoni
authors.initials: A
authors.lastname: Torres
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000032:analysis; D002116:Calcitonin / Q000097:blood; D015740:Calcitonin Gene-Related Peptide; D017714:Community-Acquired Infections / Q000097:blood* / Q000453:epidemiology; D015897:Comorbidity; D016207:Cytokines / Q000097:blood; D005260:Female; D017052:Hospital Mortality; D006785:Hospitals, University; D006801:Humans; D018836:Inflammation Mediators / Q000097:blood*; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000097:blood* / Q000453:epidemiology; D011446:Prospective Studies; D011498:Protein Precursors / Q000097:blood; D012720:Severity of Illness Index; D013997:Time Factors
chemical_list: D015415:Biomarkers; C000606589:CALCA protein, human; D016207:Cytokines; D018836:Inflammation Mediators; D011498:Protein Precursors; D002116:Calcitonin; D002097:C-Reactive Protein; D015740:Calcitonin Gene-Related Peptide