Open Access Research article

Serum cortisol predicts death and critical disease independently of CRB-65 score in community-acquired pneumonia: a prospective observational cohort study

Martin Kolditz1*, Gert Höffken1, Peter Martus2, Gernot Rohde3, Hartwig Schütte4, Robert Bals5, Norbert Suttorp4, Mathias W Pletz6 and the CAPNETZ study group

Author Affiliations

1 Division of Pulmonology, Medical Department 1, University Hospital Carl Gustav Carus, Fetscherstr. 74, 01307 Dresden, Germany

2 Department of Biostatistics and Clinical Epidemiology, Charité Berlin, Germany

3 Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands

4 Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany

5 Department of Internal Medicine V - Pulmonology, Allergology, Respiratory Intensive Care Medicine, Saarland University Hospital, Homburg, Germany

6 Division of Gastroenterology, Hepatology and Infectious Diseases, Department of Internal Medicine II, Jena University Hospital, Jena, Germany

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BMC Infectious Diseases 2012, 12:90  doi:10.1186/1471-2334-12-90

Published: 13 April 2012



Several biomarkers and prognostic scores have been evaluated to predict prognosis in community-acquired pneumonia (CAP). Optimal risk stratification remains to be evaluated. The aim of this study was to evaluate serum cortisol as biomarker for the prediction of adverse outcomes independently of the CRB-65 score und inflammatory biomarkers in a large cohort of hospitalised patients with CAP.


984 hospitalised CAP-patients were included. Serum cortisol was measured and its prognostic accuracy compared to the CRB-65 score, leucocyte count and C-reactive protein. Predefined endpoints were 30-day mortality and the combined endpoint critical pneumonia, defined as presence of death occurring during antibiotic treatment, mechanical ventilation, catecholamine treatment or ICU admission.


64 patients died (6.5%) and 85 developed critical pneumonia (8.6%). Cortisol levels were significantly elevated in both adverse outcomes (p < 0.001) and predicted mortality (AUC 0.70, cut-off 795 nmol/L) and critical pneumonia (AUC 0.71) independently of all other measured variables after logistic regression analysis (p = 0.005 and 0.001, respectively). Prognostic accuracy of CRB-65 was significantly improved by adding cortisol levels (combined AUC 0.81 for both endpoints). In Kaplan-Meier analysis, cortisol predicted survival within different CRB-65 strata (p = 0.003). In subgroup analyses, cortisol independently predicted critical pneumonia when compared to procalcitonin, the CURB65 score and minor criteria for severe pneumonia according to the 2007 ATS/IDSA-guideline.


Cortisol predicts mortality and critical disease in hospitalised CAP-patients independently of clinical scores and inflammatory biomarkers. It should be incorporated into trials assessing optimal combinations of clinical criteria and biomarkers to improve initial high risk prediction in CAP.

Risk stratification; Prognosis; Biomarker; Mortality; CRB-65 score