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Severity Scores and Community-acquired Pneumonia. Time to Move Forward

Ever since the success of the pneumonia severity index (PSI), a favorite pastime of community-acquired pneumonia (CAP) researchers has been to sort through their databases and try to prove that one score is better than another at predicting an important outcome, typically mortality. Over the past 20 years since the publication of the PSI, more than a dozen scores have been promulgated, some specific to pneumonia and others more generic across all patients with sepsis. Although the addition of a severity score to clinical assessment has been shown to be associated with better patient outcomes, a clear consensus from the dozens of comparative analyses of different scores or even meta-analyses…

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  Pneumonia Severity Scores: Are they Accurate Predictors of Mortality?

More research is needed to determine a valid Pneumonia Severity Score to differentiate patients at risk for mortality from those who are moderately ill. Clinical judgment and frequent reassessments in moderately ill patients is key.

  When should you admit a patient with suspected CAP?

When the patient has 2 or more of the following CURB-65 criteria: respiratory rate ≥30, acute confusion, low blood pressure (systolic blood pressure <90 or diastolic BP ≤60 mm Hg), blood urea nitrogen [BUN] >19.6 mg/dL, and age ≥65 years (strength of recommendation [SOR]: B, based on 3 prospective cohort studies). Alternatively, consider hospitalization for patients presenting with a Pneumonia Severity Index (PSI) class of 4 or 5. There are no studies that test whether using these rules improve outcomes over standard care.

 Community-Acquired Pneumonia in the Emergency Department

The CURB-65 score estimates mortality risk for community-acquired pneumonia and helps guide inpatient versus outpatient treatment decisions. The PSI/PORT score estimates mortality for adult patients with community-acquired pneumonia. The SMART-COP score predicts the need for intensive respiratory or vasopressor support in community-acquired pneumonia. The DRIP score predicts risk for community-acquired pneumonia due to drug-resistant pathogens.

 Pneumonia Scores

A number of pneumonia severity scores have been described in the literature. In Australia CURB and SMART-COP are the most commonly used, however you will also see CURB-65 and PSI referred to in the literature. It is important not to use these scores in isolation as none of these are 100% sensitive. A safer approach is to consider the whole patient, their clinical stability, individual risk factors for severe disease and social factors that could lead to failure of management in the community.

Articles of Interest

Community-Acquired Pneumonia: Determining Safe Treatment in the Outpatient Setting

Some patients with CAP can be treated safely as outpatients. Several clinical prediction rules have been developed to determine the likelihood of mortality in patients with CAP, and the use of these rules is recommended by practice guidelines to support clinician decision-making. For example, the 2007 guidelines from the Infectious Diseases Society of America and American Thoracic Society note that the Pneumonia Severity Index and the CURB-65 (confusion, uremia, respiratory rate, blood pressure, 65 years of age) rule can help identify patients with CAP who are candidates for outpatient therapy

CURB-65 and Long-Term Mortality of Community-Acquired Pneumonia: A Retrospective Study on Hospitalized Patients

Identifying high-risk patients is important for more individualized healthcare and management. The CURB-65 score, only validated for a short-term (30 days) prediction, demonstrates a potential to also predict mortality and rehospitalization in the six-month period after hospitalization, as supported by our findings and previous studies.

EM Cases – Community Acquired Pneumonia: Emergency Management

While community acquired pneumonia (CAP) is ‘bread and butter’ emergency medicine, and the diagnosis is often a ‘slam dunk’, it turns out that up one third of the time, we are wrong about the diagnosis; that x-rays are not perfect; that blood work is seldom helpful; that not all antibiotics are created equal and that deciding who can go home and who needs to go to the ICU isn’t always so clear cut.

Evidence-Based Disposition of Community-Acquired Pneumonia

... it can at times be difficult to determine the appropriate disposition for our patients. In this post we will review the evidence behind determining appropriate dispositions in CAP and hope to provide a clear framework for making these decisions.

Outcomes of community-acquired pneumonia using the Pneumonia Severity Index versus the CURB-65 in routine practice of emergency departments

In this study, using the CURB-65 in CAP patients at the ED in the Netherlands is associated with similar and possibly even better clinical outcomes compared to the PSI. After further confirmation, the CURB-65 may be recommended over the use of the PSI.

The Battle of the Pneumonia Predictors

Both severity scores have identical sensitivity, but the CURB-65 score was more specific than the PSI. Moreover, the CURB-65 score showed more sensitivity (89.3%) in ICU prediction than PSI (78.8%). It was seen that the two severity scores are the most preferred tools in the prediction of ICU admission and mortality. However, despite having comparable mortality, CURB-65 is highly preferred as it is easier to implement apart from everything else. Finally, even though these two scores are helpful tools, they cannot and should not be used in place of clinical judgment and medical examination. Ideally, the best strategy depends on doctors' experience and how well they apply their knowledge to the individual patients' scores to make the appropriate decision for ICU admission.

The Clinical Impact of the Pneumonia Severity Index and the CURB-65 for Making Admission Decisions

The PSI and CURB-65 had unacceptably low positive predictive values and this was due to the comorbid conditions that required in-hospital care for the patients with low risk CAP. These indices did not supersede clinical judgment for making the decision to hospitalize low risk patients with CAP.

The Pneumonia Severity Index: A Decade after the Initial Derivation and Validation

The pneumonia severity index was derived and validated with data on >50,000 patients with community-acquired pneumonia by use of well-accepted methodological standards and is the only pneumonia decision aid that has been empirically shown to safely increase the proportion of patients given treatment in the outpatient setting. Because of its prognostic accuracy, methodological rigor, and effectiveness and safety as a decision aid, the pneumonia severity index has become the reference standard for risk stratification of community-acquired pneumonia.

Using Pneumonia Severity Index and CURB-65 to Predict COVID-19 Pneumonia Deaths

The pneumonia severity index (PSI) and CURB-65 (confusion, uremia, respiratory rate, BP, age 65 years and older) criteria, established predictors of mortality in patients hospitalized with community-acquired pneumonia (CAP), may have even greater value for predicting mortality in patients with SARS-CoV-2 CAP, according to research.

Utility of pneumonia severity assessment tools for mortality prediction in healthcare-associated pneumonia: a systematic review and meta-analysis

Accurate prognostic tools for mortality in patients with healthcare-associated pneumonia (HCAP) are needed to provide appropriate medical care, but the efficacy for mortality prediction of tools like PSI, A-DROP, I-ROAD, and CURB-65, widely used for predicting mortality in community-acquired and hospital-acquired pneumonia cases, remains controversial.

Utility of pneumonia severity assessment tools for mortality prediction in healthcare-associated pneumonia: a systematic review and meta-analysis

Accurate prognostic tools for mortality in patients with healthcare-associated pneumonia (HCAP) are needed to provide appropriate medical care, but the efficacy for mortality prediction of tools like PSI, A-DROP, I-ROAD, and CURB-65, widely used for predicting mortality in community-acquired and hospital-acquired pneumonia cases, remains controversial.

Yeah, it's Pneumonia, But How Bad is it Really?

In October 2019, the Infectious Diseases Society of America (IDSA) in conjunction with the ATS published recommendations for the assessment, treatment and disposition of immunocompetent adult patients with community acquired pneumonia which included several clinical decision rules also known as pneumonia severity scores

Resources

CRB-65

A modified version of the score, known as CRB-65 is often performed in general practice to assess the need for hospital admission. This omits ht urea measurement

CURB-65 Score

Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment.

PSI/PORT Score: Pneumonia Severity Index for CAP

Estimates mortality for adult patients with community-acquired pneumonia.

SMART-COP Score for Pneumonia Severity

Predicts need for intensive respiratory or vasopressor support (IRVS) in community-acquired pneumonia (CAP).