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How to recognize clinical stability in hospitalized patients with community-acquired pneumonia?

Stefano Aliberti, Tim Wiemken , Annamaria Zanaboni, Ahmed Nahas, Srinivas Uppatla, Chiara Travierso, Fabio Giuliani, Valeria Giunta, Giulia Salomoni, Caterina Conti, Elena Parazzini, Paula Peyrani, Francesco Blasi, Julio Ramirez

University of Milan, Italy; University of Louisville, KY, USA stefano.aliberti@unimib.it

Clinical improvement in CAP

+

1.Clinically Unstable A

Severity of Disease

2. Early Clinical Improvement B 3. Definitive Clinical Improvement

C
Days

Clinical stability
+

1.Clinically Unstable

Point of Clinical Stability

Severity of Disease

2. Early Clinical Improvement

3. Definitive Clinical Improvement

Days

Criteria to define clinical stability

Cough

I feel better Temperature

PCT WBC SpO2

Respiratory Rate
SvO2 TFN alfa

CRP

Lactate SOB Heart Rate PaO2

Criteria to define clinical stability

ATS 2001
1. Cough and shortness of air are improving 2. Patient is afebrile for at least 8 hours 3. White blood cell count is normalizing 4. PO intake and GI absorption are adequate *

Criteria to define clinical stability

ATS 2001
1. Cough and shortness of air are improving 2. Patient is afebrile for at least 8 hours 3. White blood cell count is normalizing 4. PO intake and GI absorption are adequate *

ATS 2007
1. Temperature 37.8 C 2. Heart rate 100 bpm 3. Respiratory rate 24 4. Systolic blood pressure 90 mmHg 5. SaO2 > 90% or PaO2 > 60 on RA 6. Ability to maintain oral intake * 7. Normal mental status

Criteria to define clinical stability

ATS 2001
1. Cough and shortness of air are improving 2. Patient is afebrile for at least 8 hours 3. White blood cell count is normalizing 4. PO intake and GI absorption are adequate *

ATS 2007
1. Temperature 37.8 C 2. Heart rate 100 bpm 3. Respiratory rate 24 4. Systolic blood pressure 90 mmHg 5. SaO2 > 90% or PaO2 > 60 on RA 6. Ability to maintain oral intake * 7. Normal mental status

The aim of the study was to compare the two criteria for clinical stability in hospitalized patients with CAP

Methods
Observational, retrospective study Consecutive patients hospitalized with CAP (including HCAP) Veterans Administration Medical Center of Louisville, Kentucky, US June 2001 and March 2006 Community-Acquired Pneumonia Organization (CAPO) database www.caposite.com Criteria to define clinical stability were evaluated daily during the first 7 days of hospitalization.

Results
487 pts

Results
487 pts

Results
35%
30%

ATS 2001

25%

Patients

20%

15%

10%

5%

0% Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 > Day 7 or not reached

Time to clinical stability

Results
35%
30%

ATS 2001

25%

Patients

20%

15%

10%

5%

0% Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 > Day 7 or not reached

Time to clinical stability

ATS 2001 criteria 429 patients (88%)

Results
35%
30%

ATS 2001 ATS 2007

25%

Patients

20%

15%

10%

5%

0% Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 > Day 7 or not reached

Time to clinical stability

Results
35%
30%

ATS 2001 ATS 2007

25%

Patients

20%

15%

10%

5%

0% Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 > Day 7 or not reached

Time to clinical stability

ATS 2001 criteria 429 patients (88%)

ATS 2007 criteria 410 patients (84%)

Results
35%
30%

ATS 2001 ATS 2007

25%

Patients

20%

15%

10%

5%

0% Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 > Day 7 or not reached

Time to clinical stability

A discrepancy in identifying clinical stability within the first week from admission = 301 pts (62%)

Time to clinical stability

% of pts

ATS 2007

ATS 2001

p = 0.001

>7

>7

Days

Clinical stability and outcomes

Clinical stability and outcomes

Clinical stability and outcomes

Clinical stability and outcomes

ATS 2007 AUC: 0.782

Sensitivity

ATS 2001 AUC: 0.758

1- specificity

Conclusions

1.

ATS 2001 criteria seem to identify clinical stability earlier than ATS 2007 criteria

2.

Both criteria seem to perform similarly with respect to a composite outcome

Some speculations

Some speculations

Severity of Disease

Days

Some speculations

Severity of Disease

Days

Some speculations
Clinical Stability
Severity of Disease
ATS 2001

Days

Some speculations
Clinical Stability
Severity of Disease
ATS 2001 ATS 2007

Clinical Improvement

Days

Clinical stability within 7 days and outcomes

429 patients ATS 2001 criteria Composite outcome: 12.3%
Vs.

410 patients ATS 2007 criteria

Composite outcome: 9%
p = NS