Proadrenomedullin improves Risk of Early Admission to ICU score for predicting early severe community-acquired pneumonia.
BACKGROUND
Whether proadrenomedullin (ProADM) improves the performance of the Risk of Early Admission to ICU (REA-ICU) score in predicting early, severe community-acquired pneumonia (ESCAP) has not been demonstrated.


METHODS
Secondary analysis was completed of the original data from 877 consecutive patients with community-acquired pneumonia (CAP) enrolled in the Procalcitonin-Guided Antibiotic Therapy and Hospitalization in Patients With Lower Respiratory Tract Infections (ProHOSP) study, a multicenter trial in EDs of six tertiary-care hospitals in Switzerland. ESCAP was defined by either the requirement for mechanical ventilation or vasopressive drugs or occurrence of death within 3 days of ED presentation.


RESULTS
Eighty patients (9.1%) developed ESCAP (47 required mechanical ventilation, 19 vasopressive drugs, and 16 died) within 3 days of ED presentation. They had a higher median ProADM value (2.18 nmol/L vs 1.15 nmol/L, P < .001). Combining ProADM testing with the REA-ICU score improved the area under the curve (0.81) compared with either parameter (ProADM [0.73] or REA-ICU score [0.76], P < .001) and resulted in a net reclassification improvement of 0.20 (P < .001). A ProADM value ≥ 1.8 nmol/L or assignment to REA-ICU risk classes III-IV predicted ESCAP with a sensitivity of 76.3% and a negative predictive value of 96.7%. Excluding 21 patients with major criteria of severe CAP on presentation showed similar results.


CONCLUSIONS
These study findings demonstrate that the addition of ProADM to the REA-ICU score improves the classification of a substantial proportion of patients in the ED at intermediate or high risk for ESCAP, which may translate into better triage decisions.
Service d'urgence, Assistance Publique des Hôpitaux de Paris, Groupe Hospitalier Henri Mondor-Albert Chenevier, Créteil, France; Université Paris Est Créteil, Faculté de Médecine, Créteil, France. Electronic address: bertrand.renaud@hmn.aphp.fr.
Bertrand
B
Renaud
Harvard School of Public Health, Boston, MA.
Philipp
P
Schuetz
Department of Emergency Medicine, Centre Hospitalier Princesse Grace, Monaco.
Yann-Erick
YE
Claessens
Techniques de l'Ingénierie Médicale et de la Complexité, Unité Mixte de Recherche 5525 Centre National de Recherche Scientifique Université Joseph Fourier-Grenoble 1, Grenoble, France.
José
J
Labarère
Medical University Clinic, Kantonsspital Aarau, Switzerland.
Werner
W
Albrich
Medical University Clinic, Kantonsspital Aarau, Switzerland.
Beat
B
Mueller
D053607:Adrenomedullin / Q000097:blood*; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D017714:Community-Acquired Infections / Q000097:blood / Q000145:classification* / Q000175:diagnosis*; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010343:Patient Admission; D011237:Predictive Value of Tests; D011379:Prognosis; D000091402:Prohibitins; D011498:Protein Precursors / Q000097:blood*; D012372:ROC Curve; D012307:Risk Factors; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013557:Switzerland; D062606:Tertiary Care Centers; D014218:Triage / Q000379:methods*
D015415:Biomarkers; C000717331:PHB2 protein, human; D000091402:Prohibitins; D011498:Protein Precursors; C088633:proadrenomedullin; D053607:Adrenomedullin