Volume 181 - Issue 9
Are the Australian guidelines asking too much of the Pneumonia Severity Index (PSI)?
Authors: Kirsty L Buising, Karin A Thursky, James F Black and Graham V Brown
Med J Aust 2004; 181 (9): 515-516. || doi: 10.5694/j.1326-5377.2004.tb06418.x
Published online: 1 November 2004
Published online: 1 November 2004
Kirsty L Buising,* Karin A Thursky,† James F Black,‡ Graham V Brown§
* Clinical Research Fellow, † Physician, ‡ Head of Epidemiology, § Head, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Grattan Street, Parkville, Melbourne, VIC 3050. Kirsty.buisingATmh.org.au
In reply: We thank Charles and colleagues for their comments. The modified British Thoracic Society (mBTS) severity score for patients with community-acquired pneumonia (CAP) has been validated in more than one study (the largest involving 1068 patients from three countries1) and is recommended by the British and American thoracic societies. It predicts requirement for intensive care with comparable sensitivity to the Pneumonia Severity Index (PSI) score (using classes IV and V)2 (unpublished data), and is easy to use, requiring four variables rather than 21. The study cited by Charles and colleagues showing that the BTS severity score was less sensitive used an older version of the tool. We believe the mBTS score represents a reasonable, simple alternative tool to identify severe pneumonia, although neither score should replace clinical judgement.
Caution is needed when relying on a scoring system that may give false reassurance about patients not recognised to be at risk. Early recognition of severe illness enables early intensive-care intervention, which is associated with better outcome.3 The major guidelines for management of CAP recognise the entity of severe pneumonia and recommend broader-spectrum antibiotic therapy.4-6 Whether the spectrum of pathogens in severe pneumonia differs from that in mild pneumonia is not yet clear, as data are conflicting.7,8 However, a percentage of patients with severe pneumonia will have more resistant or unusual pathogens. Inadequate antibiotic therapy for patients with severe pneumonia is associated with higher mortality. For intensive-care patients, where there is less perceived “room for error”, a strategy of broad empirical antibiotic therapy and early narrowing to directed therapy is usually promoted.
References
- Lim WS, Van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58: 377-382. BABDFCIB
- Neill AM, Martin IR, Weir R, et al. Community acquired pneumonia: aetiology and usefulness of severity criteria on admission. Thorax 1996; 51: 1010-1016. BABCHFBH
- Rivers E, Nguyen B, Havstad S, et al. Early goal directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377. BABGBGDG
- British Thoracic Society. Guidelines for the management of community acquired pneumonia in adults. Thorax 2001; 56 Suppl 4; 1-64. BABEEDCF
- Niederman MS, Mandell LA, Anzueto A, et al: American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001; 163: 1730-1754.
- Therapeutic Guidelines Writing Group. Therapeutic guidelines: antibiotic. Version 12. Melbourne: Therapeutic Guidelines Ltd, 2003. BABHHHFE
- Wilkinson M, Woodhead M. Guidelines for community acquired pneumonia in the ICU. Curr Opin Crit Care 2004; 10: 59-64. BABBBEEJ
- Oosterheert JJ, Bonten MJ, Hak E, et al. Severe community acquired pneumonia: what’s in a name? Curr Opin Infect Dis 2003; 16: 153-159. i1085640