Q J Med 2009; 102:379–388

doi:10.1093/qjmed/hcp027 Advance Access publication 18 March 2009

Severity assessment in community-acquired pneumonia:

a review
A. SINGANAYAGAM, J.D. CHALMERS and A.T. HILL
From the Department of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh EH16
4SA, UK

Summary
Severity assessment is an important early step in
the management of patients presenting with
community-acquired pneumonia. Various pneumo-
nia-specific scores, generic sepsis scores and pre-
dictive biomarkers have been proposed as tools to
aid clinicians in key management decisions.
However, there is no uniform agreement about
the optimum severity assessment tool to use. This
review provides a summary of current evidence
surrounding severity assessment in adult patients
presenting with community-acquired pneumonia.

Introduction
Community-acquired pneumonia (CAP) is the
leading cause of death from infectious diseases
in the developed world and is a major burden
on healthcare resources.1 Current guidelines
agree that severity assessment is a pivotal
early step in the management of patients
presenting with CAP.2–4 There is, however, no
uniform agreement on the optimum severity assess-
ment tool or an agreed definition of the term ‘severe
pneumonia’.
The aim of this review is to:
 Discuss the advantages and limitations of the
currently available clinical prediction rules for
community-acquired pneumonia
 Explore the definition of ‘severe’ community-acquired
pneumonia
 Discuss the present and future role of biomarkers in
CAP
 Discuss limitations of severity assessment rules and
the implications for clinical practice.
Search criteria
The current review was based on a search of
Pubmed for articles on major MeSH terms ‘Severity
of Illness Index’ and ‘Pneumonia’ between 1981 and
2008. We also performed separate Pubmed searches
for terms ‘CURB65’, ‘pneumonia severity index’ and
a combination of major MeSH terms ‘C-reactive
protein’ and ‘Procalcitonin’ with ‘Pneumonia’. Only
articles in English or English translation were
reviewed. The articles were selected on the basis
of originality and relevance.
What is severity assessment?
Severity assessment is critical for both primary
and secondary care physicians to aid in clinical
decisions such as need for hospital admission,
requirement for intravenous therapy and level of
monitoring if admitted. Routine clinical judgement
alone has been shown to be a poor predictor of
disease severity5,6 and evidence suggests that, in
many cases, clinicians tend to both overestimate
and underestimate the potential severity of CAP.5
This has led to the development of prognostic
scoring systems aimed at assisting in risk stratifica-
tion of patients presenting with CAP. Important
factors to consider in any potential assessment tool

Address correspondence to Aran Singanayagam, Department of Respiratory Medicine, Royal Infirmary of

Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK. email: aransinga@gmail.com
! The Author 2009. Published by Oxford University Press on behalf of the Association of Physicians.
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

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 380 A. Singanayagam et al.

include its accuracy to predict a specific outcome,
its applicability to different healthcare settings and
its simplicity for use in everyday clinical practice.
Existing severity tools incorporate various combina-
tions of co-morbidities, clinical and laboratory
variables that are felt to be important in determining
the clinical course of CAP.
The area under the receiver operating character-
istic curve (AUC) is a measure of the accuracy of a
test to correctly classify patients with and without a
particular outcome and is used frequently in studies
of severity assessment in CAP. A test with no value,
such as a coin toss, would give an AUC of 0.5. With
increasing levels, there is increasing discriminatory
value, up to a ‘perfect test’ score of 1 (Figure 1).
Pneumonia-specific severity scores
The Pneumonia severity index (PSI) was introduced
in 1997 following a study in over 50 000 patients7
and has now been validated in large, independent
populations.8–12 It is based on 20 demographic,
Figure 1. Receiver operator characteristic curve.
co-morbid and clinical variables (Table 1) and
stratifies patients into five risk classes, three with a
low risk of 30-day mortality (class I = 0.1–0.4%;
class II = 0.6–0.7% and class III = 0.9–2.8%), a fourth
with an increased risk (4–10%) and a fifth with a
high risk (27%).7
Although, it has been shown to perform consis-
tently well as a predictor of mortality in CAP with
AUC values for mortality ranging from 0.74 to
0.838–12 and is recommended by the current
American thoracic society (ATS)/Infectious diseases
society of America (IDSA) guidelines,4 PSI is
complex to calculate and therefore difficult to
implement in routine clinical practice.
The British Thoracic Society (BTS) proposes use of
the CURB65 rule,2 a 5-point scoring system with
three risk categories: 0–1 (low risk of mortality; class
0 = 0.7%; class 1 = 3.2%), 2 (intermediate risk of
mortality – 13%) and >3 (high risk of mortality; class
3 = 17%; class 4 = 41.5%; class 5 = 57%).2,13 The
individual components involved are shown in
Table 2. This severity score, introduced in 2003,
has now been extensively validated in over 12 000
patients from several different countries. Studies
assessing CURB65 have shown it to be a robust tool
with moderate to good discriminatory value (AUC
values ranging from 0.73 to 0.83) for prediction of
30-day mortality.8–14
Several studies have prospectively compared the
operating characteristics of these two assessment
tools8,9,11 and most have found no significant
difference in predictive accuracy, except for one
study that found a small but significant difference in
favour of PSI.11 However, given CURB-65 is easier
to remember and calculate, it is perhaps more likely
to gain general acceptance. The ATS recognize the
complexity of the PSI for clinical practice and have
thus taken the step of recommending use of
CURB65 in their latest international CAP guideline.4

Table 1 Variables used to calculate the pneumonia severity index

Demographics Physical examination

Age Altered mental status Temperature <358C or >408C
Male sex Respiratory rate >30/min Pulse >125/min
Nursing home residency Systolic blood pressure <90 mmHg
Co-morbid illnesses Laboratory findings
Neoplastic disease pH <7.35 Haematocrit <30%
Cerebrovascular disease Blood urea >10.7 mmol/l PaO2 <60 mmHg
Congestive cardiac failure Sodium <130 mEq/l Glucose >13.9 mmol/l
Chronic renal disease
Chronic liver disease
Radiographic findings
Pleural effusion

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 Severity assessment in community-acquired pneumonia
Table 2 Variables used to calculate CURB-65 score
New-onset mental confusion
Urea >7 mmol/l
Respiratory rate >30 breaths/min
Systolic blood pressure <90 mmHg or diastolic blood
pressure 660 mmHg
Age >65 years
One disadvantage of both PSI and CURB65 is
their reliance on laboratory investigations for
calculation which limits their use by health care
professionals in the community. This has led to
development of the CRB65 score (CURB65 without
the blood nitrogen urea component), a modified
version of CURB65 that does not rely on the results
of any laboratory tests and is thus better suited to use
in the community. This modified tool appears to
perform equally well compared with both CURB65
and PSI with AUC values ranging from 0.69 to
0.78.8,14–17 However, despite being proposed as a
score for use by general practitioners, most studies
have assessed CRB65 solely in a hospital setting.
Only one study to date has examined the perfor-
mance of CRB65 specifically in a community
setting17 and further validation of this score in
primary-care based populations is therefore war-
ranted. Another important advantage of CRB65 is
increased simplicity, as it relies on fewer compo-
nents, and a recent study has shown it can be
simplified even further without compromising pre-
dictive accuracy by omitting the diastolic blood
pressure and using only systolic blood pressure
<90 mmHg as a criterion of hypotension.15
Other proposed assessment tools include A-
DROP,18 CORB19 and the SCAP prediction rule20
(see Appendix 1 and Table 7). These derived scores
are relatively simple to calculate and differ from
CURB-65 by giving greater weight to markers of
deranged physiology such as assessment of oxyge-
nation. At present, their use is supported by either a
single study or small number of preliminary studies
and further external validation is thus required.
Alternative definitions of ‘Severe’
pneumonia
It is recognized that the majority of mortality in CAP
occurs in the elderly and many patients that die are
treated palliatively.21 In addition, the mortality will
include both pneumonia related and pneumonia
unrelated deaths and up to 50% of deaths from CAP
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381
are unrelated to initial severity.22,23 Therefore, 30-
day mortality may not be the ideal measure to
identify patients requiring the most intensive man-
agement. Other endpoints have been sought to
predict severe pneumonia such as ICU admission
and the need for ventilatory or vasopressor support.
The American Thoracic Society states that ‘severe
community-acquired pneumonia is an entity
described in the literature in reference to patients
with CAP admitted to the intensive care unit (ICU)’.4
Some studies have thus investigated the predictive
value of the commonly used severity scores PSI and
CURB-65 for the outcome of need for admission to
ICU.8,9,24 When considering these outcomes, PSI
and CURB-65 tend to perform less effectively with
studies showing AUC values as low as 0.69 and
0.66, respectively.9
In comparative studies, the modified American
Thoracic society (mATS) rule has been shown to be
the existing score with the best accuracy in
predicting need for ICU admission4,9,12,24,25 with
AUC values as high as 0.90 in one study9 and it is
also recommended by the current ATS guidelines.4
This score was designed specifically to guide
decisions for transfer to ICU, indicated by the
presence on admission of, either a single major
criterion or three minor criteria (Table 3). A major
problem with advocating the mATS rule to guide
clinical decisions is that it uses two outcome
measures (development of septic shock and need
for mechanical ventilation) as its ‘major criteria’
variables. Therefore, any patient that fulfils a
modified ATS major criteria will, by definition,
need ICU care (as this is the site where patients
are transferred to for mechanical ventilation and/or
vasopressors support). Therefore, it is perhaps
unsurprising that this score performs so well for the
outcome of need for ICU admission and raises
questions over its use clinically as it is not truly
predictive of outcome.
There are also significant concerns about the use
of ICU admission as a reliable marker of severity in
CAP as the decision to admit a patient to ICU differs
according to local policies and availability of ICU
resources. Therefore, ICU rates may vary signifi-
cantly between departments, nationally and inter-
nationally and this raises questions over its use as a
standardized definition of severity in CAP. Existing
studies have shown widely varying ICU admission
rates from as low as 4% in some cohorts8 to as high
as 17% in others.24
Other studies have evaluated PSI and CURB65 for
their predictive accuracy for the major ATS criteria
of need for mechanical ventilation, or presence of
septic shock with need for vasopressors.10,12,20,26
These outcomes appear to be more robust measures
 382 A. Singanayagam et al.
Table 3 Variables involved in modified ATS criteria
Major criteria
Presence of septic shock with need for vasopressors
Need for mechanical ventilation
Table 4 AUC values from existing studies for 30-day
mortality and need for mechanical ventilation and/or
inotropic support
Severity score AUC for AUC for need
30-day mortality for mechanical
ventilation and/or
inotropic support
PSI 0.74–0.838–12 0.69–0.7910,12,26
CURB65 0.73–0.838–13 0.59–0.7710,12,26
CRB65 0.69–0.788,14–17 0.7715
Modified ATS 0.63–0.679,12 Not assessed
SMART-COP Not repeated 0.8726
of CAP severity compared with need for ICU
admission, as they are less subjective to interpretive
variability between centres. Studies have shown that
AUC values for PSI and CURB65 range from 0.69 to
0.79 and 0.59 to 0.77 respectively, for prediction of
these outcomes.10,12,26 Table 4 shows AUC values
for 30-day mortality and need for mechanical
ventilation and/or inotropic support in some of the
existing pneumonia-specific scores. The SMART-
COP is an 8-point scoring system that has been
shown to outperform PSI and CURB65 for predicting
need for intensive respiratory or vasopressor support
in preliminary analyses (see Appendix 1 and Table 7).26
Patients with community-acquired pneumonia
may develop infective complications such as
pulmonary abscess, complicated parapneumonic
effusion and empyema. These complications require
admission to hospital and often require prolonged
antibiotic treatment and/or percutaneous drainage
procedures. Such outcomes are not included in any
recognized definition of severe pneumonia but most
physicians would recognize them as indicative of
‘severe’ CAP. One study has evaluated the accuracy
of CURB65 and PSI to predict development of
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Minor criteria
Respiratory rate >30/min
Multilobar infiltrates
Confusion/Disorientation
Uraemia (Blood urea nitrogen >20 mg/dl)
Leucopenia (White cell count <4000 cells/mm3)
Thrombocytopenia (platelet count <100 000 cells/mm3)
Hypothermia (core temperature <368C)
Hypotension requiring aggressive fluid resuscitation
PaO2/FiO2 ratio 6250
complicated pneumonia and/or empyema and
showed they have poor predictive accuracy (AUC
0.54 and 0.60 respectively).10 Admission C-reactive
protein (CRP) levels, however, had a better pre-
dictive accuracy for this outcome (AUC 0.76). In
addition, a CRP level that failed to fall by 50% or
more in 4 days following hospital admission was
associated with increased risk of development of
complicated effusion or empyema.10 Other vari-
ables that have been shown to be predictive of
development of complicated pneumonia or
empyema include hypoalbuminaemia27,28 and
prior alcohol abuse.29,30
Other studies have looked at alternative measures
of severity including need for hospital admission
and length of hospital stay.8,31 However, these
outcomes are likely to be influenced by social
factors and may not solely reflect disease severity.
Therefore, they may be less preferable to more
robust measures such as 30-day mortality and need
for mechanical ventilation and/or inotropic support.
Generic sepsis scores as
assessment tools in CAP
More recently, it has been suggested that
pneumonia-specific severity scores, such as PSI
and CURB65, should be replaced by generic
severity scores as these have been shown to perform
well in populations with sepsis, many of whom have
pneumonia.32–38 This is driven by evidence that
pneumonia specific rules are underutilized in
clinical practice. One study found that only 7% of
junior doctors were able to name the CURB criteria
correctly39 while another found that only a small
proportion (13%) of patients with CAP received
severity assessment, of any kind, on admission.40 An
abundance of severity scores for different conditions
may cause confusion and there is an argument that
 Severity assessment in community-acquired pneumonia 383

Table 5 Summary of generic scores assessed in CAP and evidence for their use

Generic score Evidence for use in CAP AUC (30-day mortality)

Standardized early warning score (SEWS)
Systemic inflammatory response syndrome
(SIRS)
Acute Physiology and chronic health
evaluation II (APACHE II)
Single study14—less favourable than 0.6414
CURB65/PSI
Two studies14,42—both show less 0.6814
favourable than CURB65/PSI
Two studies—outperformed CURB65 0.8143
in MRSA pneumonia43 and comparable
with PSI/CURB65 in pneumococcal
pneumonia44

pneumonia-specific tools should be supplanted by a
generic ‘one size fits all’ illness scoring tool. It has
been proposed that a generic predictive tool
applicable to all forms of sepsis including pneumo-
nia may be easier to remember and thus more useful
in clinical practice.38
Scoring systems such as SIRS (systemic inflamma-
tory response syndrome) criteria and SEWS (stan-
dardized early warning score) have been extensively
studied in acutely unwell patients and are relatively
simple to calculate.32–33,36,41 The results of one
study comparing CURB65/CRB65 against the gen-
eric sepsis scores SIRS and SEWS, suggested that
pneumonia-specific scores should not be sup-
planted by generic scores for severity assessment
in CAP with AUC values of 0.68 and 0.64 for SIRS/
SEWS compared with 0.78 for CURB65.14 However,
notable limitations of this study included incon-
sistencies in the definition of CAP with only 52%
having radiographically confirmed disease. Other
studies have shown that SIRS performs less favour-
ably than PSI for prediction of progression to sepsis
in severe CAP.42 However, one potential advantage
of generic scores such as SEWS is that it can be
measured daily and allows monitoring over time,
unlike most other prediction rules which have been
designed solely for use on admission.
Studies have compared the more complicated
generic sepsis score APACHE II (Acute physiology
and chronic health evaluation) with pneumonia-
specific scores. APACHE is a severity score calcu-
lated from 12 physiological measurements,
designed for use in ICU admitted patients.33,34 It
has been shown to outperform CURB65/CRB65 as a
predictor of outcome in patients specifically with
Methicillin Resistant Staphylococcus Aureus (MRSA)
pneumonia43 and showed equal performance to
CURB65 and PSI in pneumococcal pneumonia.44
However, it remains to be seen if this holds true for
all forms of CAP, regardless of microbiological
cause.
Overall, the limited numbers of studies to date do
not support use of generic sepsis scores over
pneumonia-specific scores in CAP (summarized in
Table 5). The absence of methologically sound
research in this area means this issue is largely
unresolved and further comparison in independent
populations is therefore warranted.
Predictive biomarkers in severity
assessment
As existing scoring systems may be too complicated
for use in everyday practice, it would be appealing
to have a single blood test that would provide rapid
prognostic information equivalent to these scores.
This has led to increasing interest in the use of serum
biomarkers as potential predictors of outcome in
CAP. Several biomarkers have been evaluated to
date, such as C-reactive protein (CRP),10,45–49
procalcitonin,49–53 proadrenomedullin,54 pro-atrial
natriuetic peptide,55 pro-vasopressin55 and
56
copeptin.
CRP is an acute phase protein synthesized by the
liver in response to tissue damage. Initial small
studies suggested that it did not appear to correlate
with severity in CAP46,47 and, on the basis of this
evidence, CRP was not recommended as a reliable
admission severity marker in national guidelines.2
However, a more recent larger study demonstrated
that a low CRP (<100 mg/l) has similar negative
predictive values to CURB 65 and PSI for predicting
30-day mortality and need for mechanical ventila-
tion and/or inotropic support in CAP.10 The authors
concluded that CRP may be a useful adjunct to
clinical judgement in identifying low-risk patients.
Furthermore, failure of CRP to fall by 50% or more
on repeat measurement at Day 4, independent of
admission CRP level, was shown to be associated
with increased 30-day mortality and need for
mechanical ventilation and/or inotropic support
and complicated pneumonia.10 These findings

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 384 A. Singanayagam et al.
were supported by a large Spanish study that found
a high CRP on admission and at Day 3 to be
predictive of treatment failure in CAP.49
Another biomarker gaining interest is procalcito-
nin (PCT), a precursor of the hormone calcitonin
produced by the C cells of the thyroid gland. Blood
levels of procalcitonin rise in response to systemic
inflammation associated with infection and several
studies have shown that serum PCT levels correlate
with pneumonia severity.50–53 A recent large study
showed that a low PCT (<0.228 ng/ml) has a high
negative predictive value for mortality from CAP and
similar receiver operating characteristics for survival
when compared with the CRB65 score.51 Other
studies however, have shown little advantage for the
use of procalcitonin over the cheaper and more
widely available alternative biomarker CRP.49
If simplicity is the key to acceptance and integra-
tion of a severity assessment tool into clinical
practice, there may be an argument for advocating
the use of these serum biomarkers as potential
predictors of outcome in CAP. However, they have
not been extensively studied and further validation
studies are required to investigate the safety of using a
single blood test to guide placement and manage-
ment of patients with CAP. The incorporation of
Table 6 Advantages and disadvantages of existing severity tools
Assessment Strengths
tool
PSI Well validated and shown to improve outcome
Useful research tool
CURB65 Well validated and simple to calculate
CRB65 Well validated, simple and suitable for use in
community
SMART-COP Superior accuracy for prediction of need
for ventilatory/vasopressor support
Modified ATS Performs well for predicting ICU admission
C-Reactive Cheap, simple and widely available
protein
Serial measurements can detect treatment failure
Procalcitonin Simple
Serial measurements can detect treatment failure
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biomarkers into existing scores may further improve
their accuracy and also warrants investigation. Other
markers including pro-adrenomedullin, pro-atrial
natriuetic peptide, pro-vasopression and copeptin
have been investigated with remarkably high AUC
values for mortality in pilot studies.54–56 Larger
confirmatory studies will be required before any of
these tests can be recommended for routine use.
One major advantage that biomarkers offer is that
serial measurements can be taken as a marker of
treatment response. Measurement of CRP on Day 3
or 410,45,49 of admission has been shown to be a
reliable marker of treatment failure in patients with
CAP. There is no reason why severity assessment
should end at the hospital ‘front door’ and this is a
genuine advantage that biomarkers offer over
traditional severity scores such as PSI and
CURB65, which are designed only for use on
admission. This potential use is acknowledged by
national guidelines.2
Limitations to severity assessment
Although severity assessment scores are a useful aid
to clinical decision making for patients with CAP,
they have important limitations to their use. Table 6
Weaknesses
Complex to calculate
Performs less well for need for ICU/ventilatory or
vasopressor support
Underestimates severity in young patients
Performs less well for need for ICU/ventilatory or
vasopressor support
Underestimates severity in young patients
As for CURB65
Complex to calculate with multiple points for
different variables and age-adjusted cut-offs
Need for ICU is a less accurate measure of
severity due to inter-center variability
Questionable clinical use
Not extensively validated
May be affected by factors other than pneumonia
severity
Not routinely available
Relatively expensive
Not extensively validated
May be affected by factors other than pneumonia
severity
 Severity assessment in community-acquired pneumonia
shows strengths and weaknesses for some of the
existing scores.
Severity criteria have been used to guide clin-
icians about need for hospital admission and to
determine site of care. Low admission severity
scores (CRB65 0, CURB65 0 or 1 or PSI 1-3) are
regarded as low risk and can potentially be
managed at home. However, PSI or CURB65
cannot be used solely by the clinician to define
site of care as they do not consider social factors that
often dictate need for hospitalization. Studies have
revealed that a large proportion of patients with low
risk pneumonia according to severity scoring still
require hospitalization for concomitant social fac-
tors such as acute alcohol intoxication, lack of a
stable home environment57,58 or other factors such
as intolerance of oral therapy or occurrence of
medical conditions other than CAP.58
Studies have also shown that both PSI and
CURB65 can also underestimate the potential
severity of CAP in young patients, who may be at
risk of death or serious complications such as need
for mechanical ventilation and/or inotropic support,
despite being classified in a ‘low risk’ category. A
recent study has shown that CURB65 and PSI have
sensitivities as low as 54% for prediction of need for
mechanical ventilation and/or inotropic support in
patients under the age of 50 years59 and this
reinforces the fact that severity scores should only
be used in conjunction with clinical judgement.
The United Kingdom department of health has
recognized this limitation by specifically advising
that CURB65 may underestimate severity of pneu-
monia in young adults.60
Conclusion
Severity assessment is a crucial component in the
management of patients presenting with CAP to
guide physicians in clinical decisions. There are
large numbers of pneumonia-specific severity and
generic sepsis scores available for this purpose. The
pneumonia severity index is regarded as the ‘gold
standard test’ but complexity limits its use in routine
clinical practice. Given that simplicity is critical to
acceptance for general use, CRB65 is the most
useful clinical score currently available. Severity
assessment tools are evolving, but at present have
major limitations and should be used with caution
and only in conjunction with clinical judgment.
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Appendix 1: Alternative pneumonia
specific severity scores
SMART-COP
SMART-COP26 is a recently described tool designed
to predict patients admitted with community-
acquired pneumonia likely to require intensive
respiratory or vasopressor support (IRVS). The
score was retrospectively calculated from prospec-
tively collected data. Factors involved are shown in
Table 7.
The authors recommend the following
interpretation:
0–2 points Low risk of needing IRVS
3–4 points Moderate risk (one in eight)
of needing IRVS

Table 7 Alternative pneumonia-specific severity scores

SMART-COP A-DROP CORB SCAP rule

Systolic BP <90 mmHg Age (male >70 years, Confusion Arterial pH <7.30
(2 points) female >75 years)
Multilobar Chest X-ray involvement Dehydration (blood urea Oxygen saturations Systolic blood pressure
(1 point) nitrogen >210 mg/l) 690% <90 mmHg
Albumin <35 g/l Respiratory failure Respiratory rate Respiratory rate
(1 point) (SaO2 690% or >30/min >30/min
Respiratory rate (age-adjusted PaO2 660 mmHg) Blood pressure Altered mental status
cut-offs) Orientation disturbance (systolic 690 mmHg) Blood urea nitrogen
Age 650 years:>25 br/min (confusion) >30 mg/dl
(1 point) Blood pressure (Systolic Oxygen arterial pressure
Age >50 years:>30 br/min 690 mmHg) <54 mmHg or ratio of
(1 point) arterial oxygen
Tachycardia >125 b.p.m. (1 point) tension to fraction of
Confusion of new onset (1 point) inspired oxygen
Oxygenation (Age-adjusted cut-offs) <250 mmHg
Age 650 years: <70 mmHg or O2 Age >80 years
sat 693% (2 points) Multilobar/bilateral lung
Age >50 years: <60 mmHg or O2 affectation
sat 690% (2 points)
pH (arterial) <7.35 (2 points)

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 388 A. Singanayagam et al.

5–6 points High risk (one in three) mortality and need for ventilatory/inotropic support
of needing IRVS in derivation and validation cohorts.19 Table 7
>7 points Very high risk (two in three) illustrates the parameters involved.
of needing IRVS
SCAP prediction rule
A-DROP A clinical prediction rule consisting of eight
A recently described modified version of CURB-65, variables (Table 7) identified on multivariate analy-
showing similar predictive accuracy in a retro- sis of data collected in 1057 patients with CAP.20
spective observational study of 329 patients.18 It The rule showed superior predictive accuracy to
comprises of five separate variables (Table 7). CURB65, PSI and modified ATS scores for a
combined endpoint of in hospital death, mechanical
CORB ventilation and septic shock.
A modified version of CURB-65 which showed
similar accuracy to existing tools for prediction of

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