Determine disease severity (and therefore mortality risk) in patients with a working diagnosis of pneumonia using the CURB-65 score in hospital or the CRB-65 score in the community together with your clinical judgement. The score allows initiation of appropriate antibiotic therapy and confirms whether the patient can be managed in the community or needs to be admitted to hospital.

CURB-65 score[115]

Recommended by the British Thoracic Society (BTS) and the National Institute for Health and Care Excellence (NICE) in the UK for use in the hospital setting, CURB-65 stratifies patients according to the presence or absence of five prognostic features.[1][63][65]  [ CURB-65 pneumonia severity score ] Mortality at 30 days increases with the number of criteria that are met. Always use the CURB-65 score in conjunction with your clinical judgement.[1][63] [65]

Scoring of the CURB-65 for CAP in hospital

  • Prognostic factors

    • Confusion (e.g., Abbreviated Mental Test score ≤8 Abbreviated Mental Test Score Opens in new window): 1 point

    • Urea >7 mmol/L (>19.6 mg/dL): 1 point

    • Respiratory rate ≥30 breaths/minute: 1 point

    • Blood pressure <90 mmHg systolic or <60 mmHg diastolic: 1 point

    • Age ≥65 years: 1 point

  • Score

    • Score 3-5: high-risk; 30-day mortality >15%

      • Score of 3 or more: discuss with senior colleague at the earliest opportunity and manage as high-severity pneumonia.

      • Score of 4-5: arrange emergency assessment by a critical care specialist.

    • Score 2: moderate-risk; 30-day mortality 3% to 15%

      • Consider for short-stay inpatient treatment or hospital-supervised outpatient treatment.

    • Score 0-1: low-risk; 30-day mortality <3%

      • Consider for outpatient treatment.

CRB-65 score[115]

Recommended by the BTS and NICE in the UK to be used in the community setting, CRB-65 stratifies patients according to the presence or absence of four prognostic features. Always use the CRB-65 score in conjunction with your clinical judgement.[1][63][65]

Scoring of the CRB-65 for CAP in the community[115]

  • Prognostic factors

  • Score

    • Score 3-4: high-risk; 30-day mortality >10%

      • Admit to hospital immediately.

    • Score 1-2: moderate-risk; 30-day mortality 1% to 10%

      • Consider hospital referral and assessment (particularly in those with a score of 2).

    • Score 0: low-risk; 30-day mortality <1%

      • Consider for treatment at home.

Pneumonia severity index (PSI)[116]

The PSI score predicts the risk of 30-day mortality; patients with a high risk are managed in hospital, and those with the highest risk are managed in the intensive care unit. The PSI stratifies patients into 5 categories based on patient age, comorbidities, physical examination, and results of laboratory testing. [ Community-acquired pneumonia severity index (PSI) for adults ] The principal limitation is the high score accorded to variables such as age and comorbidities. In the UK, the BTS and NICE consider the simplicity of the calculation of the CURB-65 score to be an advantage over PSI.[1][63][65]

Scoring of the PSI for CAP[116]

  • Demographics

    • Male: points = age in years

    • Female: points = age in years minus 10

    • Nursing home resident: +10 points

    • Liver disease: +20 points

    • Neoplastic disease: +30 points

    • Congestive heart failure: +10 points

    • Cerebrovascular disease: +10 points

    • Renal failure: +10 points

  • Physical examination findings

    • Altered mental status: +20 points

    • Respiratory rate ≥30 breaths/minute: +20 points

    • Systolic blood pressure <90 mmHg: +20 points

    • Temperature <35°C (<95°F) or ≥40°C (≥104°F): +15 points

    • Pulse rate ≥125 beats/minute: +10 points

  • Laboratory and radiographic findings

    • Arterial pH <7.35: +30 points

    • Urea ≥10.7 mmol/L (≥30 mg/dL): +20 points

    • Sodium <130 mmol/L (<130 mEq/L): +20 points

    • Glucose ≥13.9 mmol/L (≥250 mg/dL): +10 points

    • Haematocrit <30%: +10 points

    • PaO2 <60 mmHg (<90% O2 saturation): +10 points

    • Pleural effusion: +10 points

  • Score

    • Risk class I: 0 to 50 points: outpatients; 0.1% mortality

    • Risk class II: 51 to 70 points: outpatients; 0.6% mortality

    • Risk class III: 71-90 points: short hospital stay for observation; 2.8% mortality

    • Risk class IV: 91-130 points: hospital admission; 8.2% mortality

    • Risk class V: >130 points: hospital admission; 29.2% mortality

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