Pneumonia Risk Stratification Tools

Author: Michelle Lin, MD
Updated: 2/25/2011

Pneumonia: Risk Stratification Scoring Tools

Pneumonia Severity Index (PSI)

Fine et al., JAMA 1997

  • Pneumonia Patient Outcomes Research Team (PORT)
  • A large derivation and validation study with >50,000 patients
  • Best identifies low-risk/ low-mortality patients
  • Tends to miss higher-risk pneumonia in younger patients because score is based on age
  • Does not factor in immunosuppression (eg. HIV) and poor social support
Risk factors Points
Men Age (years)
Women Age (years)-10
Nursing home resident +10
History of neoplasm +30
History of liver disease +20
History of heart failure +10
History of stroke +10
History of renal failure +10
Altered mental status +20
RR ≥ 30 breaths/ min +20
SBP < 90 mmHg +20
Temp < 95F (35C) or ≥104F (40C) +15
HR ≥ 125 bpm +10
Arterial pH < 7.35 +30
BUN > 30 mg/dL +20
Na < 130 mmol/L +20
Glucose ≥250 mg/dL +10
Hematocrit < 30% +10
PaO2 < 60 mmHg +10
Pleural effusion +10
PSI Class Total Points 30-Day Mortality Disposition
I < 51 0.1% Outpatient
II 51-70 0.6% Outpatient
III 71-90 0.9% Outpatient vs short-stay inpatient
IV 91-130 9.3% Inpatient
V > 130 27.0% Inpatient ICU

CURB-65 Severity Score

Supported by (British Thoracic Society Standards of Care Committee & Aujesky et al, Am J Med, 2005)

  • Best identifies high-risk/ high-mortality patients
  • Tends to misclassify moderate-risk pneumonia patients (as low-risk)
  • Does not account for co-morbidities and hypoxemia

| | Risk Factor | Points | | ------ | ----------------------------------------------- | -----: | | C** | **Confusion | 1 | | U** | Uremia (BUN >19 mg/dL) | 1 | | **R | R*R ≥ 30 breaths/min | 1 | | *B | B*P low (SBP <90 mmHg or DBP <60 mmHg) | 1 | | *65 | Age ≥ 65 years | 1 |

Total Points 30-Day Mortality Disposition
0 0.6% Outpatient
1 3.2% Outpatient
2 13.0% Outpatient or short-stay inpatient
3 17.0% Inpatient
4 41.5% Inpatient, likely ICU
5 57.0% Inpatient ICU

SMART-COP

Supported by Australian CAP Study (Charles et al., Clin Infect Dis, 2008)

  • Tool to predict need for intensive respiratory or vasopressor support (IRVS)

Risk factor Points
S Systolic BP < 90 mmHg 2
M Multilobar CXR involvement 1
A Albumin < 3.5 g/dL 1
R If age ≤ 50 years: RR ≥ 25 breaths/min
If age > 50 years: RR ≥ 30 breaths min
1
T Tachycardia HR ≥ 125 bpm 1
C Confusion (new onset) 1
O Oxygen low

If age ≤50 years:

  • PaO2 < 70 mmHg, or
  • O2 sat ≤ 93%, or
  • PaO2/FiO2 < 333

If age >50 years:

  • PaO2 < 60 mmHg, or
  • O2 sat ≤ 90%, or
  • PaO2/FiO2 < 250
2
P Arterial pH < 7.35 2
Total points Risk of needing IRVS
0-2 Low
3-4 Moderate (1 in 8)
5-6 High (1 in 3)
≥ 7 Very high (2 in 3)

References

  • Aujesky D et. al. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med. 2005 Apr;118(4):384-92. [PubMed]
  • Fine MJ et. al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50. [PubMed]
  • Charles PG et. al. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis. 2008 Aug 1;47(3):375-84. [PubMed]
  • British Thoracic Society Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Adults. Thorax. 2001 Dec;56 Suppl 4:IV1-64. [PubMed]