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Objective: To describe risk factors of severe pneumococcal community-acquired pneumonia and to study variables influencing outcome. Design: Retrospective (1987–1992) and prospective (1993–1995) study. Setting: Three participating ICUs from primary care hospitals. Patients: Five hundred and five patients (mean age: 63 ± 17 years) with severe community-acquired pneumonia (CAP). Three groups of patients were defined: pneumococcal CAP (group 1), CAP with microbial diagnosis other than Streptococcus pneumoniae(group 2), CAP from group 2 and CAP without microbial diagnosis (group 3). Measurements and results: Admission data and data on the disease's course were recorded. The mean Simplified Acute Physiologic Score (SAPS) was 12.5 ± 5.4. On admission 288 (57 %) patients were mechanically ventilated (mv) and 82 (16.2 %) required inotropic support. A microbial diagnosis was established for 309 (61.2 %) patients.S. pneumoniaewas isolated in 137 (27.1 %) patients. Severe pneumococcal CAP was independently associated with male sex (p= 0.01), lack of antibiotics use before admission (p= 0.0001), non-aspiration pneumonia (p= 0.01) and septic shock (p= 0.0001). The overall mortality rate was 27.5 % (29.2 % in group 1). In patients with severe pneumococcal CAP, multivariate analysis showed that leukopenia less than 3,500/mm3(p= 0.0004), age over 65 years (p= 0.01), septic shock (p= 0.01), sepsis related complications (p= 0.0001), ICU complications (p= 0.001) and inadequacy of antimicrobial therapy (p= 0.002) worsened the prognosis. Conclusions: Few features facilitate the identification of pneumococcal CAP on ICU admission. The prognosis is mostly related to severity of illness (leukopenia, septic shock) while comorbidities do not seem to influence outcome.Sepsis-related disorders, ICU complications and adequate antimicrobial chemotherapy are the major variables affecting the outcome during an ICU stay.

Objective: To determine predictors of intensive care unit (ICU) mortality in patients with community-acquired pneumonia (CAP), to develop a pneumonia-specific prognostic index, and to evaluate this index prospectively. Design: Combined retrospective and prospective clinical study over two periods: January 1987–December 1992 and January 1993–December 1994. Setting: Four medical ICUs in the north of France. Patients: Derivation cohort: 335 patients admitted to one ICU were retrospectively studied to determine prognosis factors and to develop a pneumonia-specific prognostic index. Validation cohort: 125 consecutive patients, admitted to four ICUs, were prospectively enrolled to evaluate this index. Results: In the derivation cohort, 16 predictors of mortality were identified and assigned a value directly proportional to their magnitude in the mortality model: aspiration pneumonia (–0.37), grading of sepsis =11 (–0.2), antimicrobial combination (–0.01), Glasgow score >12+mechanical ventilation (MV) (+0.09), serum creatinine =15?mg/l (+0.22), chest involvement shown by X-ray =3 lobes (+0.28), shock (+0.29), bacteremia (+0.29), initial MV (+0.29), underlying ultimately or rapidly fatal illness (+0.31), Simplified Acute Physiology Score =12 (+0.49), neutrophil count =3500/mm 3 (+0.52), acute organ system failure score =2 (+0.64), delayed MV (+0.67), immunosuppression (+1.38), and ineffective initial antimicrobial therapy (+1.5). An index was obtained by adding each patient‘s points. According to a receiver operating characteristic curve, the cut-off value of this index was 2.5. In the validation cohort, an index of =2.5 could predict death with a positive predictive value of 0.92, sensitivity 0.61, and specificity 0.98. Conclusion: This index, which performs well in classifying patients at high-risk of death, may help physicians in initial patient care (appropriateness of the initial antimicrobial therapy) and guide future clinical research (analysis and design of therapeutic trials).