Thorax 2009: another great year!

(10%) within patients presenting co-morbidities and lower than the overall mortality. This finding reopens the debate about the low acute mortality of patients with COPD presenting with CAP. In fact COPD was a protective factor for treatment failure in one study. 15 Although the rate of acute treatment with steroids in patients with COPD is not reported in the study of Ewig et al, it is highly likely that a high percentage of them could have received such treatment, which could have attenuated the lung and systemic inflammatory response leading to a lower mortality. 16 On the other hand, recent information suggests that despite the fact that previous inhaled steroid treatment may increase the risk of hospitalised CAP 17 it may be associated with lower CAP severity and consequently lower mortality. 18 The number of patients requiring mechanical ventilation was lower compared with other studies, particularly in advanced ages. As recognised by the authors, this could be due to treatment limitations such as ''do not resuscitate'' orders, or avoiding intensive care unit admission in older ages and severely disabled strata. This issue could not be analysed in detail by the authors. These are factors that might have influenced the high mortality of German hospitalised patients with CAP in this large study. This is a common error in most retrospective studies of CAP. For future studies it is highly recommended to record these two variables in order to interpret reliable data on mortality more precisely. Finally, this study confirms in a large population the good performance of CRB-65 to predict mortality in CAP in a three-class pattern, a score much easier and less tedious to calculate than the PSI 19 and which further simplifies similar scores such as CURB and CURB-65. The data presented by Ewig et al 4 are currently the most solid and informative data available about hospitalisation rates in patients with CAP. The information reported in this study reminds us that this is an acute illness which occurs particularly in the elderly, a population which is going to increase in the next decades. CAP in this population currently represents an enormous economic and healthcare burden , and this burden will increase substantially in future years. Programmes of prevention are the only effective way to decrease the magnitude of this problem. Funding: Ciber de Enfermedades Respiratorias (Ciberes); el Ciberes es una iniciativa del ISCIII. New evidence of risk factors …