SIR,
I read Thiem et al [1] with interest. I am very pleased to see an
article devoted to this important medical condition which is prevalent in
older people and associated with high mortality. We have also made recent
attempts to find a better severity scoring index for older people who are
admitted with community-acquired pneumonia (CAP). The rationale behind
these attempts was that as Thiem and colleagues confirmed our previous
report [2], both sensitivity and specificity of CURB-65, currently
recommended criteria by the British Thoracic Society in the UK, is rather
low in correctly identifying older patients who are likely to die within
30 days of CAP. Therefore, a substantial proportion of older people who
are initially identified as non-severe pneumonia by CURB-65 are also at
risk of dying from CAP.
There are several weak links in the CURB-65 as we pointed out
previously [2]. Simple modification of CURB-65 appears to better identify
severe pneumonia in older people [3], albeit remains controversial [4]. We
suggested recently the usefulness of the shock index, pulse rate divided
by systolic blood pressure, and adjusted shock index, temperature adjusted
pulse rate divided by systolic blood pressure, in the severity assessment
of CAP [5]. It is possible that shock index, which considers both pulse
rate and systolic blood pressure will better perform than blood pressure
criterion in CAP severity assessment because the use of the latter is
questionable in older people [2].
While I agree with the authors [1] that further investigations of the
role of novel markers in the severity assessment of CAP should be
encouraged, it may also be possible to identify other simple clinical
parameters that are associated with mortality in the older people with
pneumonia. These potentially simpler and cheaper alternative means in
better identification of severe pneumonia should not be neglected. In my
opinion, therefore, it is important to explore the determinants of poor
outcomes such as mortality, increased length of stay and ITU admission in
CAP, in those who are initially identified as non-severe pneumonia and
also to examine specific determinants of these poor outcomes in different
age categories, younger (<65 years), older (65-84 years) and the oldest
olds (>85 years) to cover so called “blind spot” in current severity
assessment scales. Larger and well designed pneumonia studies as
multicentre collaboration among the clinicians with interest in CAP should
be the way forward.
Competing interest
None
Dr Phyo Kyaw Myint MRCP MD
Clinical Senior Lecturer and Honorary Consultant Physician
School of Medicine, Health Policy and Practice, University of East Anglia,
Norwich, Norfolk, NR4 7TJ, UK
Academic Department of Medicine for the Eldery, Norfolk and Norwich
University Hospital
Norwich, Norfolk, NR4 7UY, UK
Tel: + 44 (0) 1603 286286
Fax: +44 (0) 1603 286428
Email: phyo.k.myint@uea.ac.uk
References
[1] Thiem U, Niklaus D, Sehlhoff B, Stückle C, Heppner HJ, Endres HG,
Pientka L. C-reactive protein, severity of pneumonia and mortality in
elderly, hospitalised patients with community-acquired pneumonia. Age
Ageing. 2009;38(6):693-7.
[2] Myint PK, Kamath AV, Vowler SL, Maisey DN, Harrison BD. The CURB
(confusion, urea, respiratory rate and blood pressure) criteria in
community-acquired pneumonia (CAP) in hospitalised elderly patients aged
65 years and over: a prospective observational cohort study. Age Ageing.
2005;34(1):75-7.
[3] Myint PK, Kamath AV, Vowler SL, Harrison BD. Simple modification
of CURB-65 better identifies patients including the elderly with severe
CAP. Thorax. 2007;62(11):1015-6;
[4] Myint PK, Sankaran P, Musonda P, Subramanian DN, Ruffell H, Smith
AC, Prentice P, Tariq SM, Kamath AV.Performance of CURB-65 and CURB-age in
community-acquired pneumonia. Int J Clin Pract. 2009;63(9):1345-50.
[5] Myint PK, Bhaniani A, Bradshaw SM, Alobeidi F, Tariq SM.
Usefulness of shock index and adjusted shock index in the severity
assessment of community-acquired pneumonia.
Respiration. 2009;77(4):468-9.
Conflict of Interest:
None declared
