Community-acquired pneumonia treated on the ICU

Introduction

Little is known about ICU use in severe community-acquired pneumonia (SCAP). The aim of our study was to examine epidemiological data, prognostic factors and treatment of adult patients admitted to the ICU for SCAP in the industrial region of Western Macedonia.

Methods

Cases of SCAP admitted to the five general hospitals covering the health services needs in the region were identified retrospectively for the period April 2002-February 2005 using the hospital admission forms. Data concerning SCAP treated on the ICU were extracted by ICU records review over the same period. Variables assessed included characteristics at presentation, underlying risk factors, microbiological diagnosis, main therapies and evolution during the ICU stay. Prognostic factors were determined by comparison of the above variables between ICU survivors and nonsurvivors.

Results

Over this 3-year period 839 patients with SCAP were admitted to the hospital, and the mean incidence of SCAP in Western Macedonia was found to be 93 cases per 100,000 population. Of all patients admitted 45 (5.36%) needed intensive care. Thirty-seven (84%) of those patients had comorbidity and 38 (84.9%) received early (<12 hour) intubation. The average age was 60.48 (SD 16.46) years and the average APACHE II score, PSI points and CURB-65 score were 23.1 (SD 8.9), 161.24 (SD 1.1) and 3.75 (SD 41.28), respectively. A microbiological diagnosis was made in 11 patients (24,4%). Mortality was not increased in those in whom a bacterial diagnosis was not made. A total 4.4% of the strains were drug-resistant and the pathogens most frequently identified were Acinetobacter baumanii, Pseudomonas aeruginosa and Klembsiella. ICU mortality was 33.3%. Prognostic factors on and during ICU admission were confusion (P = 0.004), bilateral chest X-ray involvement (P = 0.001), admission through the Emergency Department (P = 0.023), active oral steroid treatment (P = 0.026), ineffective initial antimicrobial therapy (P = 0.01), a longer median mechanical ventilation period (13.66 days vs 6.26, P = 0.01), sepsis-related complications (P = 0.001), ICU-related complications (P = 0.005) and acute renal failure (P = 0.01).

Conclusion

SCAP treated on the ICU carries a high mortality, which is related to underlying diseases, ineffective initial antimicrobial therapy, requirements for mechanical ventilation, bilateral disease and complications during ICU stay. The importance of the admission to ICU at an early time point is underlined. The approach to empirical therapy must take into account local infecting organisms and susceptibility.