Guía de Practica Clínica
Neumonía Adquirida en la Comunidad de manejo ambulatorio en Mayores de 65 años y más
2- Recomendación / Juicio del Panel y Evidencia
En personas de 65 años y más con diagnóstico de Neumonía Adquirida en la comunidad, el Ministerio de Salud SUGIERE NO USAR Índice de gravedad de la neumonía (PSI).
Comentarios generales del panel:
►Es necesario considerar otros factores para definir la conducta a seguir y predecir mortalidad en pacientes mayores de 65 años con neumonía adquirida en la comunidad (decisión de hospitalizar o no)
El Panel de Expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente cuando el panel emitió su juicio sobre todas las preguntas, se emitió la recomendación.
A continuación se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.
1.- ¿El problema es una prioridad?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
El problema ha sido definido como prioritario en el marco de las Garantías Explícitas en Salud (GES), régimen integral de salud que prioriza un grupo de patologías o problemas de salud, garantizando el acceso a tratamiento oportuno y de calidad.
2.- ¿Qué tan precisa es este test?
| Muy imprecisa | Imprecisa | Precisa | Muy precisa | Varía | No lo sé |
|---|
Muy precisa: La prueba PSI es capaz de diferenciar en forma confiable quienes padecen y no padecen la enfermedad o condición.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Resultado de la prueba |
Número de resultados por 1000 pacientes evaluados (IC 95%) |
№ de participantes |
Certainty of the evidence |
|
Prevalencia 7% |
|||
|
verdaderos positivos |
6 (6 a 6) |
16519 |
⨁⨁◯◯ |
|
Falsos negativos |
1 (1 a 1) |
||
|
Verdaderos negativos |
49 (43 a 55) |
16519 |
⨁⨁◯◯ |
|
Falsos positivos |
44 (38 a 50) |
a. Se disminuyó un nivel de certeza de la evidencia por inconsistencia por I2 de 59% para sensibilidad y 98% para especificidad.
b. Se disminuyó un nivel de certeza de evidencia por indirecto, por ser de neumonia en población general y no solo en adulto mayor.
Referencia
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2. Akram AR, Chalmers JD, Hill AT. Predicting mortality with severity assessment tools in out-patients with community-acquired pneumonia. QJM : monthly journal of the Association of Physicians. 2011;104(10):871-9.
3. Chalmers JD, Singanayagam A, Akram AR, Mandal P, Short PM, Choudhury G, Wood V, Hill AT. Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia. Systematic review and meta-analysis. Thorax. 2010;65(10):878-83.
4. Kwok CS, Loke YK, Woo K, Myint PK. Risk prediction models for mortality in community-acquired pneumonia: a systematic review. BioMed research international. 2013;2013(no pagination):504136.
5. Marti C, Garin N, Grosgurin O, Poncet A, Combescure C, Carballo S, Perrier A. Prediction of severe community-acquired pneumonia: a systematic review and meta-analysis. Critical care (London, England). 2012;16(4):R141
6. Chalmers JD, Mandal P, Singanayagam A, Akram AR, Choudhury G, Short PM, Hill AT. Severity assessment tools to guide ICU admission in community-acquired pneumonia: systematic review and meta-analysis. Intensive care medicine. 2011;37(9):1409-20
7. Ananda-Rajah MR, Charles PG, Melvani S, Burrell LL, Johnson PD, Grayson ML. Comparing the pneumonia severity index with CURB-65 in patients admitted with community acquired pneumonia. Scandinavian journal of infectious diseases. 2008;40(4):293-300.
8. Angus DC, Marrie TJ, Obrosky DS, Clermont G, Dremsizov TT, Coley C, Fine MJ, Singer DE, Kapoor WN. Severe community-acquired pneumonia: use of intensive care services and evaluation of American and British Thoracic Society Diagnostic criteria. American journal of respiratory and critical care medicine. 2002;166(5):717-23.
9. Atlas SJ, Benzer TI, Borowsky LH, Chang Y, Burnham DC, Metlay JP, Halm EA, Singer DE. Safely increasing the proportion of patients with community-acquired pneumonia treated as outpatients: an interventional trial. Archives of internal medicine. 1998;158(12):1350-6.
10. Aujesky D, Auble TE, Yealy DM, Stone RA, Obrosky DS, Meehan TP, Graff LG, Fine JM, Fine MJ. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. The American journal of medicine. 2005;118(4):384-92.
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12. Barlow G, Nathwani D, Myers E, Sullivan F, Stevens N, Duffy R, Davey P. Identifying barriers to the rapid administration of appropriate antibiotics in community-acquired pneumonia. The Journal of antimicrobial chemotherapy. 2008;61(2):442-51.
13. British Thoracic Society, Myint PK, Kamath AV, Vowler SL, Maisey DN, Harrison BD. Severity assessment criteria recommended by the British Thoracic Society (BTS) for community-acquired pneumonia (CAP) and older patients. Should SOAR (systolic blood pressure, oxygenation, age and respiratory rate) criteria be used in older people? A compilation study of two prospective cohorts. Age and ageing. 2006;35(3):286-91.
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15. Buising KL, Thursky KA, Black JF, MacGregor L, Street AC, Kennedy MP, Brown GV. A prospective comparison of severity scores for identifying patients with severe community acquired pneumonia: reconsidering what is meant by severe pneumonia. Thorax. 2006;61(5):419-24.
16. Buising KL, Thursky KA, Black JF, MacGregor L, Street AC, Kennedy MP, Brown GV. Identifying severe community-acquired pneumonia in the emergency department: a simple clinical prediction tool. Emergency medicine Australasia : EMA. 2007;19(5):418-26.
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42. Garcia-Vidal C, Fernández-Sabé N, Carratalà J, Díaz V, Verdaguer R, Dorca J, Manresa F, Gudiol F. Early mortality in patients with community-acquired pneumonia: causes and risk factors. The European respiratory journal : official journal of the European Society for Clinical Respiratory Physiology. 2008;32(3):733-9.
43. García-Vázquez E, Soto S, Gómez J, Herrero JA. Simple criteria to assess mortality in patients with community-acquired pneumonia. Medicina clínica. 2008;131(6):201-4.
44. Goss CH, Rubenfeld GD, Park DR, Sherbin VL, Goodman MS, Root RK. Cost and incidence of social comorbidities in low-risk patients with community-acquired pneumonia admitted to a public hospital. Chest. 2003;124(6):2148-55.
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2. Akram AR, Chalmers JD, Hill AT. Predicting mortality with severity assessment tools in out-patients with community-acquired pneumonia. QJM : monthly journal of the Association of Physicians. 2011;104(10):871-9.
3. Chalmers JD, Singanayagam A, Akram AR, Mandal P, Short PM, Choudhury G, Wood V, Hill AT. Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia. Systematic review and meta-analysis. Thorax. 2010;65(10):878-83.
4. Kwok CS, Loke YK, Woo K, Myint PK. Risk prediction models for mortality in community-acquired pneumonia: a systematic review. BioMed research international. 2013;2013(no pagination):504136.
5. Marti C, Garin N, Grosgurin O, Poncet A, Combescure C, Carballo S, Perrier A. Prediction of severe community-acquired pneumonia: a systematic review and meta-analysis. Critical care (London, England). 2012;16(4):R141
6. Chalmers JD, Mandal P, Singanayagam A, Akram AR, Choudhury G, Short PM, Hill AT. Severity assessment tools to guide ICU admission in community-acquired pneumonia: systematic review and meta-analysis. Intensive care medicine. 2011;37(9):1409-20
7. Ananda-Rajah MR, Charles PG, Melvani S, Burrell LL, Johnson PD, Grayson ML. Comparing the pneumonia severity index with CURB-65 in patients admitted with community acquired pneumonia. Scandinavian journal of infectious diseases. 2008;40(4):293-300.
8. Angus DC, Marrie TJ, Obrosky DS, Clermont G, Dremsizov TT, Coley C, Fine MJ, Singer DE, Kapoor WN. Severe community-acquired pneumonia: use of intensive care services and evaluation of American and British Thoracic Society Diagnostic criteria. American journal of respiratory and critical care medicine. 2002;166(5):717-23.
9. Atlas SJ, Benzer TI, Borowsky LH, Chang Y, Burnham DC, Metlay JP, Halm EA, Singer DE. Safely increasing the proportion of patients with community-acquired pneumonia treated as outpatients: an interventional trial. Archives of internal medicine. 1998;158(12):1350-6.
10. Aujesky D, Auble TE, Yealy DM, Stone RA, Obrosky DS, Meehan TP, Graff LG, Fine JM, Fine MJ. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. The American journal of medicine. 2005;118(4):384-92.
11. Barlow G, Nathwani D, Davey P. The CURB65 pneumonia severity score outperforms generic sepsis and early warning scores in predicting mortality in community-acquired pneumonia. Thorax. 2007;62(3):253-9.
12. Barlow G, Nathwani D, Myers E, Sullivan F, Stevens N, Duffy R, Davey P. Identifying barriers to the rapid administration of appropriate antibiotics in community-acquired pneumonia. The Journal of antimicrobial chemotherapy. 2008;61(2):442-51.
13. British Thoracic Society, Myint PK, Kamath AV, Vowler SL, Maisey DN, Harrison BD. Severity assessment criteria recommended by the British Thoracic Society (BTS) for community-acquired pneumonia (CAP) and older patients. Should SOAR (systolic blood pressure, oxygenation, age and respiratory rate) criteria be used in older people? A compilation study of two prospective cohorts. Age and ageing. 2006;35(3):286-91.
14. Brown SM, Jones BE, Jephson AR, Dean NC, Infectious Disease Society of America/American Thoracic Society 2007. Validation of the Infectious Disease Society of America/American Thoracic Society 2007 guidelines for severe community-acquired pneumonia. Critical care medicine. 2009;37(12):3010-6.
15. Buising KL, Thursky KA, Black JF, MacGregor L, Street AC, Kennedy MP, Brown GV. A prospective comparison of severity scores for identifying patients with severe community acquired pneumonia: reconsidering what is meant by severe pneumonia. Thorax. 2006;61(5):419-24.
16. Buising KL, Thursky KA, Black JF, MacGregor L, Street AC, Kennedy MP, Brown GV. Identifying severe community-acquired pneumonia in the emergency department: a simple clinical prediction tool. Emergency medicine Australasia : EMA. 2007;19(5):418-26.
17. Calbo E, Ochoa de Echagüen A, Rodríguez-Carballeira M, Ferrer C, Garau J. [Hospital admission, duration of stay and mortality in community-acquired pneumonia in an acute care hospital. Correlation between a pneumonia prognosis index and conventional clinical criteria for assessing severity]. Enfermedades infecciosas y microbiología clínica. 2004;22(2):64-9.
18. Campbell SG, Patrick W, Urquhart DG, Maxwell DM, Ackroyd-Stolarz SA, Murray DD, Hawass A, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. Patients with community acquired pneumonia discharged from the emergency department according to a clinical practice guideline. Emergency Medicine Journal. 2004;21(6):667-669.
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40. Fukuyama H, Ishida T, Tachibana H, Nakagawa H, Iwasaku M, Saigusa M, Yoshioka H, Arita M, Hashimoto T. Validation of scoring systems for predicting severe community-acquired pneumonia. Internal medicine (Tokyo, Japan). 2011;50(18):1917-22.
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43. García-Vázquez E, Soto S, Gómez J, Herrero JA. Simple criteria to assess mortality in patients with community-acquired pneumonia. Medicina clínica. 2008;131(6):201-4.
44. Goss CH, Rubenfeld GD, Park DR, Sherbin VL, Goodman MS, Root RK. Cost and incidence of social comorbidities in low-risk patients with community-acquired pneumonia admitted to a public hospital. Chest. 2003;124(6):2148-55.
45. Gutiérrez F, Masiá M, Rodríguez JC, Mirete C, Soldán B, Padilla S, Hernández I, De Ory F, Royo G, Hidalgo AM. Epidemiology of community-acquired pneumonia in adult patients at the dawn of the 21st century: a prospective study on the Mediterranean coast of Spain. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2005;11(10):788-800.
46. Huang DT, Weissfeld LA, Kellum JA, Yealy DM, Kong L, Martino M, Angus DC, GenIMS Investigators. Risk prediction with procalcitonin and clinical rules in community-acquired pneumonia. Annals of emergency medicine. 2008;52(1):48-58.e2.
47. Johnstone J, Eurich DT, Majumdar SR, Jin Y, Marrie TJ. Long-term morbidity and mortality after hospitalization with community-acquired pneumonia: a population-based cohort study. Medicine. 2008;87(6):329-34.
48. Kontou P, Kuti JL, Nicolau DP. Validation of the Infectious Diseases Society of America/American Thoracic Society criteria to predict severe community-acquired pneumonia caused by Streptococcus pneumoniae. The American journal of emergency medicine. 2009;27(8):968-74.
49. Lamy O, Van Melle G, Cornuz J, Burnand B. Clinical management of immunocompetent hospitalized patients with community-acquired pneumonia. European journal of internal medicine. 2004;15(1):28-34.
50. Liapikou A, Ferrer M, Polverino E, Balasso V, Esperatti M, Piñer R, Mensa J, Luque N, Ewig S, Menendez R, Niederman MS, Torres A. Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2009;48(4):377-85.
51. Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, Lewis SA, Macfarlane JT. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377-82.
52. Man SY, Lee N, Ip M, Antonio GE, Chau SS, Mak P, Graham CA, Zhang M, Lui G, Chan PK, Ahuja AT, Hui DS, Sung JJ, Rainer TH. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax. 2007;62(4):348-53.
53. Marrie TJ, Shariatzadeh MR. Community-acquired pneumonia requiring admission to an intensive care unit: a descriptive study. Medicine. 2007;86(2):103-11.
54. Menéndez R, Martínez R, Reyes S, Mensa J, Filella X, Marcos MA, Martínez A, Esquinas C, Ramirez P, Torres A. Biomarkers improve mortality prediction by prognostic scales in community-acquired pneumonia. Thorax. 2009;64(7):587-91.
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57. 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; author reply 1016.
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3.- ¿Qué tan significativos son los efectos deseables anticipados?
| Trivial | Pequeño | Moderado | Grande | Varía | No lo sé |
|---|
Moderado: El uso de la prueba PSI, y las decisiones que se tomen en base a su resultado, probablemente se traduzcan en beneficios moderados para los pacientes.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
PSI para predecir mortalidad en neumonia adquirida en la comunidad |
||||
|
Pacientes |
Pacientes con neumonia adquirida en la comunidad |
|||
|
Intervención |
PSI para predecir mortalidad |
|||
|
Gold standard |
Seguimiento clínico |
|||
|
Desenlaces |
Efecto por 1000 pacientes testeados (IC 95%) Prevalencia* 7% |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|
|
Sensibilidad de 90% (IC 95% de 87 a 92%) — 16 estudios (16.519 pacientes) [10, 19, 24, 33, 35, 45, 46, 47, 52, 54, 61, 64, 65, 67, 70, 74] |
||||
|
Mortalidad correctamente predicha (verdaderos positivos) |
63 por 1000 |
⊕⊕◯◯1,2 Baja |
En este grupo, el PSI probablemente lleva a pocas modificaciones. |
|
|
No mortalidad correctamente descartada (verdaderos negativos) |
493 por 1000 (IC: 375 a 455) |
⊕⊕◯◯1,2 Baja |
En este grupo, el PSI permite evitar cuidados, efectos adversos y gastos innecesarios. |
|
|
Mortalidad incorrectamente predicha (falsos positivos) |
437 por 1000 |
⊕⊕◯◯1,2 Baja |
En este grupo, el PSI considera como de alto riesgo a pacientes que no lo tienen. Esto redunda en cuidados, efectos adversos y gastos innecesarios. |
|
|
Mortalidad incorrectamente descartada (falsos negativos) |
7 por 1000 |
⊕⊕◯◯1,2 Baja |
En este grupo, el PSI considera como de bajo riesgo a pacientes que tienen un riesgo alto. Esto puede llevar a no aplicar los cuidados necesarios, o no hacerlo a tiempo, con el consiguiente aumento en la morbimortalidad. |
|
|
Impacto en desenlaces clínicos |
No se identificaron estudios |
No se encontraron estudios evaluando desenlaces clínicos relevantes. |
||
IC = Intervalo de confianza del 95%.
GRADE: grados de evidencia del GRADE Working Group
* La revisión sistemática [1] estimó una mortalidad en los estudios alrededor de un 7%.
1 Se disminuyó un nivel de certeza de la evidencia por inconsistencia por I2 de 59% para sensibilidad y 98% para especificidad.
2 Se disminuyó un nivel de certeza de evidencia por tratarse de evidencia indirecta, ya que no evalúa a adultos mayores, sino a población general (sin distinguir entre adultos no mayores y mayores).
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30. España PP, Capelastegui A, Gorordo I, Esteban C, Oribe M, Ortega M, Bilbao A, Quintana JM. Development and validation of a clinical prediction rule for severe community-acquired pneumonia. American journal of respiratory and critical care medicine. 2006;174(11):1249-56.
31. España PP, Capelastegui A, Quintana JM, Bilbao A, Diez R, Pascual S, Esteban C, Zalacaín R, Menendez R, Torres A. Validation and comparison of SCAP as a predictive score for identifying low-risk patients in community-acquired pneumonia. The Journal of infection. 2010;60(2):106-13.
32. España PP, Capelastegui A, Quintana JM, Soto A, Gorordo I, García-Urbaneja M, Bilbao A. A prediction rule to identify allocation of inpatient care in community-acquired pneumonia. The European respiratory journal. 2003;21(4):695-701.
33. Etzion O, Novack V, Avnon L, Porath A, Dagan E, Riesenberg K, Avriel A, Schlaeffer F. Characteristics of low-risk patients hospitalized with community-acquired pneumonia. European journal of internal medicine. 2007;18(3):209-14.
34. Ewig S, de Roux A, Bauer T, García E, Mensa J, Niederman M, Torres A. Validation of predictive rules and indices of severity for community acquired pneumonia. Thorax. 2004;59(5):421-7.
35. Ewig S, Seifert K, Kleinfeld T, Göke N, Schäfer H. Management of patients with community-acquired pneumonia in a primary care hospital: a critical evaluation. Respiratory medicine. 2000;94(6):556-63.
36. Feagan BG, Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK. Treatment and outcomes of community-acquired pneumonia at Canadian hospitals. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne. 2000;162(10):1415-20.
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28. Dedier J, Singer DE, Chang Y, Moore M, Atlas SJ. Processes of care, illness severity, and outcomes in the management of community-acquired pneumonia at academic hospitals. Archives of internal medicine. 2001;161(17):2099-104.
29. Escobar GJ, Fireman BH, Palen TE, Gardner MN, Lee JY, Clark MP, Kipnis P. Risk adjusting community-acquired pneumonia hospital outcomes using automated databases. The American journal of managed care. 2008;14(3):158-66.
30. España PP, Capelastegui A, Gorordo I, Esteban C, Oribe M, Ortega M, Bilbao A, Quintana JM. Development and validation of a clinical prediction rule for severe community-acquired pneumonia. American journal of respiratory and critical care medicine. 2006;174(11):1249-56.
31. España PP, Capelastegui A, Quintana JM, Bilbao A, Diez R, Pascual S, Esteban C, Zalacaín R, Menendez R, Torres A. Validation and comparison of SCAP as a predictive score for identifying low-risk patients in community-acquired pneumonia. The Journal of infection. 2010;60(2):106-13.
32. España PP, Capelastegui A, Quintana JM, Soto A, Gorordo I, García-Urbaneja M, Bilbao A. A prediction rule to identify allocation of inpatient care in community-acquired pneumonia. The European respiratory journal. 2003;21(4):695-701.
33. Etzion O, Novack V, Avnon L, Porath A, Dagan E, Riesenberg K, Avriel A, Schlaeffer F. Characteristics of low-risk patients hospitalized with community-acquired pneumonia. European journal of internal medicine. 2007;18(3):209-14.
34. Ewig S, de Roux A, Bauer T, García E, Mensa J, Niederman M, Torres A. Validation of predictive rules and indices of severity for community acquired pneumonia. Thorax. 2004;59(5):421-7.
35. Ewig S, Seifert K, Kleinfeld T, Göke N, Schäfer H. Management of patients with community-acquired pneumonia in a primary care hospital: a critical evaluation. Respiratory medicine. 2000;94(6):556-63.
36. Feagan BG, Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK. Treatment and outcomes of community-acquired pneumonia at Canadian hospitals. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne. 2000;162(10):1415-20.
37. Feldman C, Alanee S, Yu VL, Richards GA, Ortqvist A, Rello J, Chiou CC, Chedid MB, Wagener MM, Klugman KP, International Pneumococcal Study Group. Severity of illness scoring systems in patients with bacteraemic pneumococcal pneumonia: implications for the intensive care unit care. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2009;15(9):850-7.
38. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A prediction rule to identify low-risk patients with community-acquired pneumonia. The New England journal of medicine. 1997;336(4):243-50.
39. Flanders WD, Tucker G, Krishnadasan A, Martin D, Honig E, McClellan WM. Validation of the pneumonia severity index. Importance of study-specific recalibration. Journal of general internal medicine. 1999;14(6):333-40.
40. Fukuyama H, Ishida T, Tachibana H, Nakagawa H, Iwasaku M, Saigusa M, Yoshioka H, Arita M, Hashimoto T. Validation of scoring systems for predicting severe community-acquired pneumonia. Internal medicine (Tokyo, Japan). 2011;50(18):1917-22.
41. Garau J, Baquero F, Pérez-Trallero E, Pérez JL, Martín-Sánchez AM, García-Rey C, Martín-Herrero JE, Dal-Ré R, NACER Group. Factors impacting on length of stay and mortality of community-acquired pneumonia. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2008;14(4):322-9.
42. Garcia-Vidal C, Fernández-Sabé N, Carratalà J, Díaz V, Verdaguer R, Dorca J, Manresa F, Gudiol F. Early mortality in patients with community-acquired pneumonia: causes and risk factors. The European respiratory journal : official journal of the European Society for Clinical Respiratory Physiology. 2008;32(3):733-9.
43. García-Vázquez E, Soto S, Gómez J, Herrero JA. Simple criteria to assess mortality in patients with community-acquired pneumonia. Medicina clínica. 2008;131(6):201-4.
44. Goss CH, Rubenfeld GD, Park DR, Sherbin VL, Goodman MS, Root RK. Cost and incidence of social comorbidities in low-risk patients with community-acquired pneumonia admitted to a public hospital. Chest. 2003;124(6):2148-55.
45. Gutiérrez F, Masiá M, Rodríguez JC, Mirete C, Soldán B, Padilla S, Hernández I, De Ory F, Royo G, Hidalgo AM. Epidemiology of community-acquired pneumonia in adult patients at the dawn of the 21st century: a prospective study on the Mediterranean coast of Spain. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2005;11(10):788-800.
46. Huang DT, Weissfeld LA, Kellum JA, Yealy DM, Kong L, Martino M, Angus DC, GenIMS Investigators. Risk prediction with procalcitonin and clinical rules in community-acquired pneumonia. Annals of emergency medicine. 2008;52(1):48-58.e2.
47. Johnstone J, Eurich DT, Majumdar SR, Jin Y, Marrie TJ. Long-term morbidity and mortality after hospitalization with community-acquired pneumonia: a population-based cohort study. Medicine. 2008;87(6):329-34.
48. Kontou P, Kuti JL, Nicolau DP. Validation of the Infectious Diseases Society of America/American Thoracic Society criteria to predict severe community-acquired pneumonia caused by Streptococcus pneumoniae. The American journal of emergency medicine. 2009;27(8):968-74.
49. Lamy O, Van Melle G, Cornuz J, Burnand B. Clinical management of immunocompetent hospitalized patients with community-acquired pneumonia. European journal of internal medicine. 2004;15(1):28-34.
50. Liapikou A, Ferrer M, Polverino E, Balasso V, Esperatti M, Piñer R, Mensa J, Luque N, Ewig S, Menendez R, Niederman MS, Torres A. Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2009;48(4):377-85.
51. Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, Lewis SA, Macfarlane JT. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377-82.
52. Man SY, Lee N, Ip M, Antonio GE, Chau SS, Mak P, Graham CA, Zhang M, Lui G, Chan PK, Ahuja AT, Hui DS, Sung JJ, Rainer TH. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax. 2007;62(4):348-53.
53. Marrie TJ, Shariatzadeh MR. Community-acquired pneumonia requiring admission to an intensive care unit: a descriptive study. Medicine. 2007;86(2):103-11.
54. Menéndez R, Martínez R, Reyes S, Mensa J, Filella X, Marcos MA, Martínez A, Esquinas C, Ramirez P, Torres A. Biomarkers improve mortality prediction by prognostic scales in community-acquired pneumonia. Thorax. 2009;64(7):587-91.
55. Migliorati PL, Boccoli E, Bracci LS, Sestini P, Melani AS. A survey on hospitalised community-acquired pneumonia in Italy. Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace / Fondazione clinica del lavoro, IRCCS [and] Istituto di clinica tisiologica e malattie apparato respiratorio, Università di Napoli, Secondo ateneo. 2006;65(2):82-8.
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57. 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; author reply 1016.
58. 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. International journal of clinical practice. 2009;63(9):1345-50.
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60. Phua J, See KC, Chan YH, Widjaja LS, Aung NW, Ngerng WJ, Lim TK. Validation and clinical implications of the IDSA/ATS minor criteria for severe community-acquired pneumonia. Thorax. 2009;64(7):598-603.
61. Pilotto A, Addante F, Ferrucci L, Leandro G, D’Onofrio G, Corritore M, Niro V, Scarcelli C, Dallapiccola B, Franceschi M. The multidimensional prognostic index predicts short- and long-term mortality in hospitalized geriatric patients with pneumonia. The journals of gerontology. Series A, Biological sciences and medical sciences. 2009;64(8):880-7.
62. Putinati S, Ballerin L, Piattella M, Ritrovato L, Zabini F, Potena A. [Clinical policy for management and risk stratification of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria]. Recenti progressi in medicina. 2003;94(5):199-203.
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Consideraciones Adicionales
Detecta adecuadamente los pacientes de alto riesgo de morir.
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
4.- ¿Qué tan significativos son los efectos indeseables anticipados?
| Grande | Moderado | Pequeño | Trivial | Varía | No lo sé |
|---|
Pequeño: El panel de expertos considera que existen potenciales daños pequeños a consecuencia de la aplicación de la prueba PSI o de las decisiones se tomen con su resultado.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
PSI para predecir mortalidad en neumonia adquirida en la comunidad |
||||
|
Pacientes |
Pacientes con neumonia adquirida en la comunidad |
|||
|
Intervención |
PSI para predecir mortalidad |
|||
|
Gold standard |
Seguimiento clínico |
|||
|
Desenlaces |
Efecto por 1000 pacientes testeados (IC 95%) Prevalencia* 7% |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|
|
Sensibilidad de 90% (IC 95% de 87 a 92%) — 16 estudios (16.519 pacientes) [10, 19, 24, 33, 35, 45, 46, 47, 52, 54, 61, 64, 65, 67, 70, 74] |
||||
|
Mortalidad correctamente predicha (verdaderos positivos) |
63 por 1000 |
⊕⊕◯◯1,2 Baja |
En este grupo, el PSI probablemente lleva a pocas modificaciones. |
|
|
No mortalidad correctamente descartada (verdaderos negativos) |
493 por 1000 (IC: 375 a 455) |
⊕⊕◯◯1,2 Baja |
En este grupo, el PSI permite evitar cuidados, efectos adversos y gastos innecesarios. |
|
|
Mortalidad incorrectamente predicha (falsos positivos) |
437 por 1000 |
⊕⊕◯◯1,2 Baja |
En este grupo, el PSI considera como de alto riesgo a pacientes que no lo tienen. Esto redunda en cuidados, efectos adversos y gastos innecesarios. |
|
|
Mortalidad incorrectamente descartada (falsos negativos) |
7 por 1000 |
⊕⊕◯◯1,2 Baja |
En este grupo, el PSI considera como de bajo riesgo a pacientes que tienen un riesgo alto. Esto puede llevar a no aplicar los cuidados necesarios, o no hacerlo a tiempo, con el consiguiente aumento en la morbimortalidad. |
|
|
Impacto en desenlaces clínicos |
No se identificaron estudios |
No se encontraron estudios evaluando desenlaces clínicos relevantes. |
||
IC = Intervalo de confianza del 95%.
GRADE: grados de evidencia del GRADE Working Group
* La revisión sistemática [1] estimó una mortalidad en los estudios alrededor de un 7%.
1 Se disminuyó un nivel de certeza de la evidencia por inconsistencia por I2 de 59% para sensibilidad y 98% para especificidad.
2 Se disminuyó un nivel de certeza de evidencia por tratarse de evidencia indirecta, ya que no evalúa a adultos mayores, sino a población general (sin distinguir entre adultos no mayores y mayores).
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66. Restrepo MI, Mortensen EM, Velez JA, Frei C, Anzueto A. A comparative study of community-acquired pneumonia patients admitted to the ward and the ICU. Chest. 2008;133(3):610-7.
67. Reyes Calzada S, Martínez Tomas R, Cremades Romero MJ, Martínez Moragón E, Soler Cataluña JJ, Menéndez Villanueva R. Empiric treatment in hospitalized community-acquired pneumonia. Impact on mortality, length of stay and re-admission. Respiratory medicine. 2007;101(9):1909-15.
68. Riley PD, Aronsky D, Dean NC. Validation of the 2001 American Thoracic Society criteria for severe community-acquired pneumonia. Critical care medicine. 2004;32(12):2398-402.
69. Rosón B, Carratalà J, Dorca J, Casanova A, Manresa F, Gudiol F. Etiology, reasons for hospitalization, risk classes, and outcomes of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2001;33(2):158-65.
70. Schuetz P, Koller M, Christ-Crain M, Steyerberg E, Stolz D, Müller C, Bucher HC, Bingisser R, Tamm M, Müller B. Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings. Epidemiology and infection. 2008;136(12):1628-37.
71. Shah BA, Ahmed W, Dhobi GN, Shah NN, Khursheed SQ, Haq I. Validity of pneumonia severity index and CURB-65 severity scoring systems in community acquired pneumonia in an Indian setting. The Indian journal of chest diseases & allied sciences. 2010;52(1):9-17.
72. Spindler C, Ortqvist A. Prognostic score systems and community-acquired bacteraemic pneumococcal pneumonia. The European respiratory journal : official journal of the European Society for Clinical Respiratory Physiology. 2006;28(4):816-23.
73. Tejera A, Santolaria F, Diez ML, Alemán-Valls MR, González-Reimers E, Martínez-Riera A, Milena-Abril A. Prognosis of community acquired pneumonia (CAP): value of triggering receptor expressed on myeloid cells-1 (TREM-1) and other mediators of the inflammatory response. Cytokine. 2007;38(3):117-23.
74. van der Eerden MM, de Graaff CS, Bronsveld W, Jansen HM, Boersma WG. Prospective evaluation of pneumonia severity index in hospitalised patients with community-acquired pneumonia. Respiratory medicine. 2004;98(9):872-8.
75. Yandiola PP, Capelastegui A, Quintana J, Diez R, Gorordo I, Bilbao A, Zalacain R, Menendez R, Torres A. Prospective comparison of severity scores for predicting clinically relevant outcomes for patients hospitalized with community-acquired pneumonia. Chest. 2009;135(6):1572-9.
76. Yealy DM, Auble TE, Stone RA, Lave JR, Meehan TP, Graff LG, Fine JM, Obrosky DS, Mor MK, Whittle J, Fine MJ. Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial. Annals of internal medicine. 2005;143(12):881-94.
77. Zuberi FF, Khan JA. Prospective comparison of prediction rules of mortality risk for CAP in a developing country. The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease. 2008;12(4):447-52.
2. Akram AR, Chalmers JD, Hill AT. Predicting mortality with severity assessment tools in out-patients with community-acquired pneumonia. QJM : monthly journal of the Association of Physicians. 2011;104(10):871-9.
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65. Renaud B, Coma E, Labarere J, Hayon J, Roy PM, Boureaux H, Moritz F, Cibien JF, Guérin T, Carré E, Lafontaine A, Bertrand MP, Santin A, Brun-Buisson C, Fine MJ, Roupie E, Pneumocom Study Investigators. Routine use of the Pneumonia Severity Index for guiding the site-of-treatment decision of patients with pneumonia in the emergency department: a multicenter, prospective, observational, controlled cohort study. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2007;44(1):41-9.
66. Restrepo MI, Mortensen EM, Velez JA, Frei C, Anzueto A. A comparative study of community-acquired pneumonia patients admitted to the ward and the ICU. Chest. 2008;133(3):610-7.
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69. Rosón B, Carratalà J, Dorca J, Casanova A, Manresa F, Gudiol F. Etiology, reasons for hospitalization, risk classes, and outcomes of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2001;33(2):158-65.
70. Schuetz P, Koller M, Christ-Crain M, Steyerberg E, Stolz D, Müller C, Bucher HC, Bingisser R, Tamm M, Müller B. Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings. Epidemiology and infection. 2008;136(12):1628-37.
71. Shah BA, Ahmed W, Dhobi GN, Shah NN, Khursheed SQ, Haq I. Validity of pneumonia severity index and CURB-65 severity scoring systems in community acquired pneumonia in an Indian setting. The Indian journal of chest diseases & allied sciences. 2010;52(1):9-17.
72. Spindler C, Ortqvist A. Prognostic score systems and community-acquired bacteraemic pneumococcal pneumonia. The European respiratory journal : official journal of the European Society for Clinical Respiratory Physiology. 2006;28(4):816-23.
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76. Yealy DM, Auble TE, Stone RA, Lave JR, Meehan TP, Graff LG, Fine JM, Obrosky DS, Mor MK, Whittle J, Fine MJ. Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial. Annals of internal medicine. 2005;143(12):881-94.
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Consideraciones Adicionales
Prueba adecuada para personas mayores
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
5.- ¿Cuál es la certeza general de la evidencia sobre la precisión de la prueba?
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluído |
|---|
Baja: Existe cierta incertidumbre respecto de la precisión de la prueba «PSI».
Evidencia de investigación
|
Resultado de la prueba |
Número de resultados por 1000 pacientes evaluados (IC 95%) |
№ de participantes |
Certainty of the evidence |
|
Prevalencia 7% |
|||
|
verdaderos positivos |
6 (6 a 6) |
16519 |
⨁⨁◯◯ |
|
Falsos negativos |
1 (1 a 1) |
||
|
Verdaderos negativos |
49 (43 a 55) |
16519 |
⨁⨁◯◯ |
|
Falsos positivos |
44 (38 a 50) |
a. Se disminuyó un nivel de certeza de la evidencia por inconsistencia por I2 de 59% para sensibilidad y 98% para especificidad.
b. Se disminuyó un nivel de certeza de evidencia por indirecto, por ser de neumonía en población general y no solo en adulto mayor.
6.- ¿Cuál es certeza general de la evidencia para desenlaces críticos o importantes al tratarse de beneficios directos, efectos adversos o carga de la prueba?
| Muy baja | Bajo | Moderado | Alto | Ningún estudio incluído |
|---|
Baja: Existe cierta incertidumbre respecto del efecto de la prueba PSI para desenlaces críticos o importantes al tratarse de beneficios directos, efectos adversos o carga de la prueba?
Consideraciones Adicionales
Se sugiere bajar nivel de evidencia por evidencia indirecta, porque existirían terceras variables que incidirían en la muerte por neumonía adquirida en la comunidad.
7.- ¿Cuál es certeza general de la evidencia sobre efectos de la prueba?
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluído |
|---|
Baja: Existe cierta incertidumbre respecto del efecto de la intervención.
8.- ¿Hay incertidumbre importante o variabilidad sobre qué tanto valora la gente los desenlaces principales?
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
|---|
Incertidumbre o variabilidad importantes: El panel de expertos consideró que existe incertidumbre o variabilidad respecto a lo que la mayoría de los pacientes podrían llegar a elegir, en función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
No se realizó búsqueda de valores y preferencias de los pacientes
Consideraciones Adicionales
La prueba considera múltiples exámenes
9.- El balance entre efectos deseables e indeseables favorece la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | No lo sé |
|---|
No favorece la prueba ni la comparación: Considerando que la prueba es «realizar PSI» y la comparación es «no realizar PSI «, el panel de experto opinó que el balance entre efectos deseables e indeseables no favorece ni realizar PSI ni tampoco realizar .
Evidencia de investigación
Incertidumbre en efectos y alta carga para el paciente y equipo.
10.- ¿Qué tan grandes son los recursos necesarios (costos)?
| Costos extensos | Costos moderados | Costos y ahorros despreciables | Ahorros moderados | Ahorros extensos | Varía | No lo sé |
|---|
Costos extensos: El panel de expertos consideró que para implementar la prueba realizar PSI se requieren recursos no significativos, en función de los antecedentes recolectados, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
NITROGENO UREICO Y/O UREA, EN SANGRE
Nivel 1 Total$1060; Beneficiario $530
Nivel 2 Total $1380; Beneficiario $850
Nivel 3 Total $1700; Beneficiario $1170
PROCEDIMIENTO PARA DETERMINAR GASOMETRIA ARTERIAL EN REPOSO Y EJERCICIO
Nivel 1 Total$3710; Beneficiario $1860
Nivel 2 Total $4820; Beneficiario $2970
Nivel 3 Total $5940; Beneficiario $4090
ELECTROLITOS PLASMATICOS (SODIO, POTASIO, CLORO) C/U
Nivel 1 Total$980; Beneficiario $490
Nivel 2 Total $1270; Beneficiario $780
Nivel 3 Total $1570; Beneficiario $1080
GLUCOSA EN SANGRE
Nivel 1 Total$1050; Beneficiario $530
Nivel 2 Total $1370; Beneficiario $850
Nivel 3 Total $1680; Beneficiario $1160
HEMATOCRITO
Nivel 1 Total$540; Beneficiario $270
Nivel 2 Total $700; Beneficiario $430
Nivel 3 Total $860; Beneficiario $590
11.- ¿La costo-efectividad de la intervención beneficia la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | Ningún estudio incluído |
|---|
Ningún estudio incluído: No se encontraron estudios que respondieran la preguntan de interés.
Evidencia de investigación
No se realizó búsqueda de evidencia de estudios de costo efectividad de las intervenciones
12.- ¿Cuál sería el impacto en equidad en salud?
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
No lo sé: El panel de expertos consideró que no contaba con suficiente información para emitir un juicio respecto al impacto en equidad en salud de realizar PSI.
13.- ¿La intervención es aceptable para las partes interesadas?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente no: El panel de expertos consideró que realizar PSI probablemente NO es aceptable para las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos servicios de salud, pacientes, cuidadores, seguros de salud, otros).
14.- ¿Es factible implementar la intervención?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente no: El panel de expertos consideró que realizar PSI probablemente NO es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, preferencias de los pacientes, etc.
Consideraciones Adicionales
Uso de tiempo y recursos importantes en servicios de urgencia