We thank Evangelatos and Gerlach for their contribution, in which they emphasize again the importance of adequate risk stratification, aiming to identify patients with acute organ dysfunction in pneumonia early on. The case fatality rate they mention—of 40% in inpatients—however, relates to patients with severe pneumonia in intensive care wards, whereas, according to the data of a German nationwide external quality program, inpatients in Germany with CAP still have a case fatality rate of 13% (1).
The example case mentioned by Evangelatos and Gerlach illustrates the problems with arbitrary thresholds of parameters used in scores. It clarifies once again that the clinical assessment of an experienced doctor remains a central element of risk stratification, which should be objectified by applying validated parameters and follow-up assessments.
The qSOFA score was developed as a screening instrument for sepsis and should as such not trigger direct admission to intensive care but extended diagnostic evaluation with regard to acute organ dysfunction (for example, by using the SOFA score or minor criteria). The higher sensitivity of qSOFA compared with the C(U)RB-65 score that the authors described in their contribution has recently been confirmed in the German CAPNETZ cohort in pneumonia, but comes at the cost of a lower specificity (2). The C(U)RB-65 score is much better validated in pneumonia.
Developments in omics technologies to optimize risk stratification, with the aim of implementing individualized therapeutic algorithms, are promising new approaches, also in severe pneumonia (3), but these are currently not available in clinical practice settings. In Germany, the multicenter PROGRES-CAP Study is investigating this research question in pneumonia; initial results are expected in 2018.
PD Dr. med. Martin Kolditz
Abteilung für Pneumologie
Medizinische Klinik und Poliklinik I
Universitätsklinikum Carl Gustav Carus
Conflict of interest statement
PD Dr. Kolditz has served as a paid consultant for Astra-Zeneca, Bayer, and Basilea. He has received third-party funding for a research project from Pfizer, reimbursement of travel expenses from Pfizer und Astra-Zeneca, and lecture honoraria from Pfizer, Astra-Zeneca, Bayer and Roche.
|1.||IQTIG – Institut für Qualitätssicherung und Transparenz im Gesundheitswesen: Bundesauswertung zum Erfassungsjahr 2016: Ambulant erworbene Pneumonie. https://iqtig.org (last accessed on 31 January 2018).|
|2.||Kolditz M, Scherag A, Rohde G, Ewig S, Welte T, Pletz M, CAPNETZ Study Group: Comparison of the qSOFA and CRB-65 for risk prediction in patients with community-acquired pneumonia. Intensive Care Med 2016; 42: 2108–10 CrossRef MEDLINE|
|3.||Davenport EE, Burnham KL, Radhakrishnan J, et al.: Genomic landscape of the individual host response and outcomes in sepsis: a prospective cohort study. Lancet Respir Med 2016; 4: 259–71 CrossRef|
|4.||Kolditz M, Ewig S: Community-acquired pneumonia in adults. Dtsch Arztebl Int 2017; 114: 838–48 VOLLTEXT|