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Correspondence to
Dr Ulrich Thiem, Department of
Geriatrics, Marienhospital
Herne, University of Bochum,
Widumer Str 8, Herne D-
44627, Germany;
ulrich.thiem@rub.de
Received 2 June 2014
Revised 6 January 2015
Accepted 8 January 2015
Published Online First
24 January 2015
To cite: Pflug MA, Tiutan T,
Wesemann T, et al. Postgrad
Med J 2015;91:77–82.
Pflug MA, et al. Postgrad Med J 2015;91:77–82. doi:10.1136/postgradmedj-2014-132802
Short-term mortality of adult inpatients with
community-acquired pneumonia: external validation
of a modified CURB-65 score
Marc Andre Pflug,1 Timothy Tiutan,2 Thomas Wesemann,3 Harald Nüllmann,3
Hans Jürgen Heppner,4 Ludger Pientka,3 Ulrich Thiem3,5
ABSTRACT
Objective The management of community-acquired
pneumonia (CAP) continues to be a challenge, especially
in older people. To enable better risk stratification, a
variation of the severity scores CRB-65 and CURB-65,
called CURB-age, has been suggested. We compared the
association between risk groups as defined by the scores
and 30-day mortality for a cohort of mainly older
inpatients with CAP.
Methods We retrospectively analysed data from the
CAP database from the years 2005 to 2009 of a single
centre in Herne, Germany. Patient characteristics, criteria
values within the severity scores CURB-65, CRB-65 and
CURB-age, and 30-day mortality were assessed. We
compared the association between score points and
score-defined risk groups and mortality. Sensitivity and
specificity with corresponding 95% CIs were calculated,
and receiver operating characteristic (ROC) curve analysis
was performed.
Results Data from 559 patients were analysed (mean
age 74.1 years, 55.3% male). Mortality at day 30 was
10.9%. CURB-age included more patients in the low-risk
category than CRB-65 (195 vs 89), and the patient
group had a lower mortality (2.6% vs 3.4%). When
compared with CURB-65, CURB-age included slightly
fewer patients (195 vs 214) with lower mortality (2.6%
vs 4.2%). CURB-age sorted the most patients who died
within 30 days into the high-risk CAP group (CURB-age,
32; CURB-65, 28; CRB-65, 9), which had the highest
mortality (CURB-age, 26.4%; CURB-65, 19.4%; CRB-
65, 21.4%). Advantages of CURB-age categories were
depicted through ROC curve analysis (area under the
curve 0.73 (95% CI 0.67 to 0.79) for CURB-age
categories, 0.67 (95% CI 0.60 to 0.74) for CURB-65
categories, and 0.59 (95% CI 0.52 to 0.66) for CRB-65
categories).
Conclusions In comparison with CRB-65 and CURB-
65, risk stratification as defined by CURB-age showed
the closest association with 30-day mortality in our
sample. Further prospective studies are needed to assess
the potential of CURB-age for better risk prediction,
especially in older patients with CAP.
INTRODUCTION
Management of pneumonia is still a major problem
in developed countries. Along with influenza, it is
one of the ten leading causes of death in both the
USA (2.1% of all deaths or 17.2 per 100 000 citi-
zens annually) and Germany (2.2% of all deaths or
overall 18 889 citizens annually). It is also the
leading cause of death due to infectious disease in
both countries. In patients >85 years old in
Original article
Germany, annual mortality rates due to pneumonia
and influenza reach 3.0%.1 2 This shows the urgent
need for proper management of pneumonia, which
would play an important part in providing
adequate healthcare and reducing overall morbidity
and mortality, especially in older populations.
Pneumonia and influenza also have a major eco-
nomic impact. In 2005, their direct cost amounted
to US$34.2 billion and indirect cost accounted for
US$6 billion in the USA, which have both probably
increased over the last decade.3
Previous studies have shown that physicians who
use a risk-stratified care management approach
along with their clinical expertise are likely to
improve clinical decision-making when encounter-
ing patients with community acquired pneumonia
(CAP). Risk stratification can be used to determine
the need for hospital and intensive care unit admis-
sion as well as to evaluate the use of antibiotic
therapy schemes. The Pneumonia Severity Index
(PSI), developed in the USA, has been shown to
provide good guidance for decision-making in the
clinical management of CAP.4 However, it is difficult
to use in daily clinical practice because of its exten-
sive list of 20 criteria. A recent study by Serisier
et al5 found that many Australian physicians, despite
recommendations to do so, do not use the PSI, nor
do they apply it correctly when choosing to use it. A
simpler score was developed by Lim et al,6 who
altered the modified British Thoracic Society rule
and established the five-point CURB-65 score
(Confusion; Urea >7 mmol/L; Respiratory rate ≥30/
min; low systolic (<90 mm Hg) or diastolic
(≤60 mm Hg) Blood pressure; age ≥65 years) for
use in daily clinical routine. An even simpler
variant, the CRB-65 score, can be used in ambula-
tory settings because of its exclusion of the urea cri-
terion.6 Many studies have confirmed the validity of
these scores. However, several studies have shown
that CURB-65 and CRB-65 perform poorly when
used for older patients. Therefore, efforts have been
made to improve these severity scores.7–14
Myint et al15 proposed a modification to
CURB-65 when used with older patients, extending
the urea criterion to >11 mmol/L and the age cri-
terion to ≥85 years, with each scoring one add-
itional point. This score variant was named
CURB-age. The cut-off for the urea criterion has
recently been confirmed to be significant in deter-
mining prognosis.16 There has only been one valid-
ation study for the CURB-age score, which was
performed by the research group that devised it.8
Although CURB-age was theoretically thought to
77
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Original article
be advantageous, its performance was not considered to be
superior to CURB-65.
The objective of our study was to apply the prognostic tools
CRB-65, CURB-65 and CURB-age in a cohort of predominantly
older inpatients, in which more patients are likely to meet the
extended urea and age criteria, and to compare the association
between risk groups as defined by the scores and 30-day mortality.
METHODS
We performed a retrospective cohort study using data from a
hospital database of inpatients with CAP (box 1) admitted to
the Marienhospital Herne, Germany (box 2) between 2005 and
2009.
Inclusion and exclusion criteria
The database includes patients ≥18 years old who are admitted
for inpatient treatment of CAP. To ensure that all patients met
the inclusion criteria and no exclusion criteria were present, all
patient records retrieved from the CAP database were checked
by two independent reviewers (MAP and TW).
Patients were considered to have pneumonia when presenting
▸ with at least one classic symptom (new onset of cough, puru-
lent sputum, dyspnoea and/or fever >38.0°C),
▸ without an alternative source of infection and
▸ with either signs of inflammation (elevated C-reactive
protein or leucocytosis)
▸ or typical radiological findings within 48 h of admission.
We excluded patients
▸ with infectious exacerbation of chronic obstructive pulmon-
ary disease,
▸ undergoing chemotherapy and/or radiation,
▸ with primary or secondary immunodeficiency (including
HIV) or
▸ with other types of pneumonia such as aspiration pneumonia.
Further data collection
Comorbidity was assessed with the Charlson Comorbidity Index
(CCI)17 18 by linking the database to the hospital information
system, which provided International Classification of Diseases
10th revision (ICD-10)-coded concomitant diagnoses and dis-
eases. Urea levels on admission, as well as further laboratory
values, were gathered from the central laboratory server, again by
two reviewers (MAP and TW). The central server stores all
values assessed in the laboratory since 2001. Information on sur-
vival status or date of death was provided by the city’s Office of
Box 1 Community-acquired pneumonia (CAP) database
In 2005, a nationwide quality assurance programme was made
mandatory for all German hospitals providing acute medical
care for CAP inpatients. The programme is organised by the
National Institute of Quality in Healthcare which is responsible
for quality assurance for inpatients in Germany. By means of a
predefined report sheet, the hospitals have to assess and report
the following variables for each CAP inpatient: age, sex, referral
mode (from private home, nursing home or another hospital),
respiratory rate, systolic and diastolic blood pressure, presence
of confusion, need of invasive or non-invasive ventilatory
support on admission, clinical condition at discharge and
outcome (death or survival). The data allow calculation of the
CRB-65 severity score. An analysis of the data for the years
2005 and 2006 has been published.8
78
Statistics and Election in Herne, Germany, on 6 September 2012.
Microbiological data were not obtained. They are not part of the
CAP database and have been recommended by national guide-
lines and local policy for only a minority of patients.
Sample size calculation
To calculate the sample size, available data on inpatients with
CAP who were admitted to our institution between 2001 and
2005 were used. For risk groups as defined by CURB-65, we
found a 30-day mortality of 5% for the low-risk group and
>12% mortality for the combined group of intermediate- and
high-risk patients. We assumed that these two proportions
would also apply to our current sample. For detection of at least
this difference, a sample size of 248 patients per group is neces-
sary, or approximately 500 patients in total (χ2 test, significance
level p=0.05, power 0.80).
Data analysis
Baseline characteristics of patients are reported with absolute
and relative frequencies for categorical variables and with mean,
median and range for continuous variables. To assess the associ-
ation between baseline characteristics and 30-day mortality, we
calculated ORs and their corresponding 95% CIs. From the raw
data, we calculated the risk scores CRB-65, CURB-65 and
CURB-age as well as score-defined risk categories. Thirty-day
mortality was compared across the scores. We tested the associ-
ation between the scores and mortality using Pearson’s χ2 test.
In addition, sensitivity, specificity and the corresponding 95%
CI were calculated for each point and risk category of the sever-
ity scores. To evaluate the ability to predict the primary end
point—death due to any cause 30 days after admission—we
compared the different severity scores in a receiver operating
characteristic (ROC) curve analysis. For the area under the
curve (AUC), a 95% CI is provided. For all analyses, a two-sided
p value of <0.05 was considered to be significant.
Data analysis was performed using SPSS for Windows V.21.
The software CI analysis, V.2.2.0 (T. Bryant, 2011), was used to
calculate CIs for sensitivity and specificity.
Ethics
This study was performed in accordance with the Declaration of
Helsinki of the World Medical Association.19 The study was
approved by the institutional review board of the University of
Bochum, Germany, on 6 August 2012.
RESULTS
Patient characteristics
From the CAP database, 587 patients were considered eligible,
and 559 patients met all the inclusion criteria. Twenty-eight
patients were excluded because of one of the following exclu-
sion criteria: advanced healthcare directive such as in palliative
Box 2 Setting
The Marienhospital Herne is a 575-bed hospital of the University of
Bochum, Germany. It operates departments specialising in
cardiology, gastroenterology, nephrology, oncology and geriatrics,
among others. The hospital serves 21 000 inpatients and
approximately 50 000 outpatients annually. Despite being a
university hospital, it provides free, unrestricted and immediate
healthcare to the population of Herne.
Pflug MA, et al. Postgrad Med J 2015;91:77–82. doi:10.1136/postgradmedj-2014-132802
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Original article

situations (18 patients), invasive ventilation on admission (6 dementia, or were 65 years or older. It also increased with CCI
patients), or referral from another hospital (4 patients). In categories (8.5%, 10.7% and 14.7%).
almost 90% of patients included, the CAP diagnosis was radio-
logically confirmed. Restricting the analysis to patients with DISCUSSION
radiologically confirmed CAP did not substantially alter the The main finding of our study is that the new variant of the
results. Therefore, we only present results for the whole sample CURB-65 score called CURB-age showed a closer association
of 559 patients. with 30-day mortality in adult inpatients with CAP than the
Patients included in the study had a mean (median; range) age commonly used CRB-65 and CURB-65 scores. In comparison
of 74.1 years (78.2; 18–104). Female patients (250, 44.7%) had with CRB-65, the low-risk groups defined by CURB-age was
a mean (median; range) age of 77.8 years (81.7; 18–104), twice as large (195 vs 89 patients), but showed lower mortality
whereas male patients (309, 55.3%) had a mean (median; (2.6% vs 3.4%). The low-risk group defined by CURB-age was
range) age of 71.2 years (76.0; 23–95). Baseline characteristics only slightly smaller than that defined by CURB-65 (195 vs 214
are shown in table 1. patients), but again with lower mortality (2.6% vs 4.2%). In
ROC curve analysis, the largest AUC —that is, the best relation
The 30-day mortality with CRB-65, CURB-65 and CURB-age between sensitivity and specificity—corresponded to CURB-age.
The 30-day mortality for this group of patients was 10.9%. The Improvements in the identification of low-risk patients would
association between mortality and the risk assessment scores is have the most clinical impact. Current guidelines recommend
depicted in tables 2 and 3, which are stratified by score points considering ambulatory management when providing care for
or risk categories, respectively. In general, mortality increased low-risk patients with CAP.20 21 Doing so could reduce health-
along with rising score points as well as higher risk categories care costs, save valuable hospital resources, and lower risks asso-
for all three scores. Sensitivity for severe pneumonia (cut-off ciated with hospital stays. Therefore, better identification of
points ≥3 points for CRB-65 and CURB-65, and ≥4 points for low-risk patients would be beneficial to both patients and the
CURB-age) was highest for CURB-age (52.5%). Specificity was healthcare system.
highest for CRB-65 (93.4%). The ROC curve analysis, provided Our findings differ markedly from the validation study of
in figure 1 and table 4, revealed that CURB-age defined risk cat- Myint et al.8 In that study’s 190 inpatient sample, the sensitivity
egories better than the other scores. of both CURB-age and CURB-65 was considerably lower than
that found in our study, namely 50% for CURB-age and 59%
Differentiation of patients with severe/non-severe and
low-risk/non-low-risk CAP in CRB-65, CURB-65 and
CURB-age
Table 2 Mortality stratified by score points of three severity scores
CURB-age (CURB-65/CRB-65) predicted 195 (214/89) patients
to be at low risk (CURB-age ≤1 points, CURB-65 ≤1 points, 30-day
CRB-65 0 points), where 190 (205/86) patients or 97.4% All mortality
Score (n=559), (n=61), n Sensitivity, % Specificity, %
(95.8%/96.6%) survived 30 days of admission. points n (%) (95% CI) (95% CI)
CURB-age (CURB-65/CRB-65) predicted 121 (144/42)
patients to have severe CAP (CURB-age ≥4 points, CURB-65 CRB-65
≥3 points, CRB-65 ≥3 points), of which 32 (28/9) patients or 0 89 3 (3.4) 100 0
26.4% (19.4%/21.4%) died within 30 days of admission. 1 272 24 (8.8) 95.1 (86.5 to 98.3) 17.3 (14.2 to 20.8)
2 156 25 (16.0) 55.7 (43.3 to 67.5) 67.1 (62.8 to 71.1)
Thirty-day mortality and association with patient 3 39 9 (23.1) 14.8 (8.0 to 25.7) 93.4 (90.8 to 95.2)
characteristics 4 3 0 (0) 0 (0 to 5.9) 99.4 (98.2 to 99.8)
The 30-day mortality was significantly higher in the subgroup CURB-65
of patients who were admitted from nursing homes, had 0 74 2 (2.7) 100 0
1 140 7 (5.0) 96.7 (88.8 to 99.1) 14.5 (11.6 to 17.8)
2 201 24 (11.9) 85.2 (74.3 to 92.0) 41.2 (36.9 to 45.5)
3 117 20 (17.1) 45.9 (34.0 to 58.3) 76.7 (72.8 to 80.2)
Table 1 Characteristics of the study cohort
4 26 8 (30.8) 13.1 (6.8 to 23.8) 96.2 (94.1 to 97.5)
Death Survival 5 1 0 (0) 0 (0 to 5.9) 99.8 (98.9 to 99.9)
Risk factor (n=61) (n=498) OR (95% CI)
CURB-age
Female sex 31 (50.8) 219 (44.0) 1.32 (0.77 to 2.24) 0 74 2 (2.7) 100 0
Age ≥65 years 55 (90.2) 379 (76.1) 2.88 (1.21 to 6.85) 1 121 3 (2.5) 96.7 (88.8 to 99.1) 14.5 (11.6 to 17.8)
Nursing home residency 35 (57.4) 111 (22.3) 4.69 (2.71 to 8.13) 2 114 12 (10.5) 91.8 (82.2 to 96.5) 38.2 (34.0 to 42.5)
Congestive heart failure 17 (27.9) 105 (21.1) 1.44 (0.79 to 2.63) 3 129 12 (9.3) 72.1 (59.8 to 81.8) 58.6 (54.3 to 62.9)
Cerebrovascular disease 16 (26.2) 98 (19.7) 1.45 (0.79 to 2.68) 4 73 12 (16.4) 52.5 (40.2 to 64.5) 82.1 (78.5 to 85.2)
Dementia 32 (52.5) 140 (28.1) 2.82 (1.65 to 4.84) 5 42 18 (42.9) 32.8 (22.3 to 45.3) 94.4 (92.0 to 96.1)
Chronic lung disease 14 (23.0) 146 (29.3) 0.72 (0.38 to 1.35) 6 6 2 (33.3) 3.3 (0.9 to 11.2) 99.2 (98.0 to 99.7)
Diabetes mellitus 14 (23.0) 144 (28.9) 0.73 (0.39 to 1.37) 7 0 0 (0) 0 (0 to 0.1) 100 (99.1 to 100)
Renal disease 20 (32.8) 128 (25.7) 1.41 (0.80 to 2.50) CRB-65: 1 point for each characteristic at admission: confusion, respiratory rate ≥30/
Charlson Comorbidity Index min, low blood pressure systolic (<90 mm Hg) or diastolic (≤60 mm Hg), age
≥65 years. CURB-65: 1 point for each characteristic at admission: confusion, urea
0–1 points 18 (29.5) 213 (42.8) 1.00 (reference) >7 mmol/L, respiratory rate ≥30/min, low blood pressure systolic (<90 mm Hg) or
2–3 points 21 (34.4) 196 (39.4) 1.27 (0.66 to 2.45) diastolic (≤60 mm Hg), age ≥65 years. CURB-age: characteristic at admission:
confusion=1, urea >7 mmol/L=1, urea >11 mmol/L=2, respiratory rate ≥30/min=1,
>3 points 22 (36.1) 128 (25.7) 2.03 (1.05 to 3.94) low blood pressure systolic (<90 mm Hg) or diastolic (≤60 mm Hg)=1, age
Values are number (%). ≥65 years=1, age ≥85 years=2.

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Original article

Table 3 Mortality stratified by risk categories defined by three severity scores

Risk category All (n=559), n 30-day mortality (n=61), n (%) Sensitivity, % (95% CI) Specificity, % (95% CI)

CRB-65
Low 89 3 (3.4) 100 0
Intermediate 428 49 (11.4) 95.1 (86.5 to 98.3) 17.3 (14.2 to 20.8)
High 42 9 (21.4) 14.8 (8.0 to 25.7) 93.4 (90.8 to 95.2)
CURB-65
Low 214 9 (4.2) 100 0
Intermediate 201 24 (11.9) 85.2 (74.3 to 92.0) 41.2 (36.9 to 45.5)
High 144 28 (19.4) 45.9 (34.0 to 58.3) 76.7 (72.8 to 80.2)
CURB-age
Low 195 5 (2.6) 100 0
Intermediate 243 24 (9.9) 91.8 (82.2 to 96.4) 38.2 (34.0 to 42.5)
High 121 32 (26.4) 52.5 (40.2 to 64.5) 82.1 (78.5 to 85.2)
Risk categories: CRB-65: low risk=0 point, intermediate risk=1–2 points, high risk=3–4 points; CURB-65: low risk=0–1 points, intermediate risk=2 points, high risk=3–5 points;
CURB-age: low risk=0–1 points, intermediate risk=2–3 points, high risk=4–7 points.

for CURB-65. In several other studies that investigated
CURB-65, sensitivity and specificity were reported to vary
between 80–95% and 50–60%, respectively,6 7 22 23 which are
well in line with our data. An important finding in the Myint
study was the high mortality.8 In total, 54 out of 190 inpatients
(28.4%) died during follow-up. This is much higher than the
mortality of ∼11% in our study, which agrees well with that of
all adult inpatients in Germany.24 There was no significant dif-
ference in age between the Myint study (median age 76 years)
and our study sample (median age 78 years), thus the higher
mortality in the former study may suggest that the patients had
more comorbidities. Comorbidities were also present in our
patient sample, with more than 25% suffering from chronic
lung disease, kidney disease or diabetes. Furthermore, functional
impairment was prevalent, with nearly a quarter of our patients
residing in nursing homes and about a third having dementia.
Advanced comorbidity was present in almost two-thirds of our
inpatients, as indicated by the CCI. However, these
characteristics do not imply that our sample is truly comparable
to that of Myint et al.8
Two prognostically relevant variables, age and urea level on
admission, are potentially undervalued in the established
CURB-65 score, justifying the need for the new CURB-age
score.8 15 In the past, age and urea have only been included in
severity scores as dichotomous variables, scoring 1 point each if
age was ≥65 years and urea ≥7 mmol/L. Two new scoring cat-
egories have since been proposed, extending the age and urea
criteria to ≥85 years and ≥11 mmol/L, respectively, and with
each scoring two points. Both cut-off points are considered to
correlate with mortality.9 16 25 Extending the already adopted
urea and age criteria allows a simple transition towards the use
of the CURB-age score. In addition, the use of both variables
has already been proposed by several guidelines.20 21 The imple-
mentation of the extended criteria would not require much add-
itional work, and doing so has the potential to improve severity
assessment and possibly CAP management.
There are several limitations of our study that should be
acknowledged. First, the data obtained from the patient registry
were initially acquired for the purposes of external quality assur-
ance. In our perspective, this probably does not affect the valid-
ity of the results obtained. In fact, the database contains most of
the variables required for analysis, including all criteria neces-
sary for the calculation of CRB-65. Urea level on admission was
not included, but was available from a central laboratory server
that has stored blood variables obtained for all patient admis-
sions since 2001. Urea values are collected routinely on hospital
admission. Retrieving these values means that our patient
entries do not have any missing values. Finally, vital status to
assess 30-day mortality was obtained from the official local
registration office, which is reliable even when acquired
retrospectively.

Table 4 Receiver operating characteristic curve analysis for risk

categories of three severity scores
Risk category Area under the curve 95% CI

CRB-65 0.591 (0.518 to 0.664)

CURB-65 0.668 (0.600 to 0.736)
Figure 1 Receiver operating characteristic (ROC) curves for risk CURB-age 0.730 (0.666 to 0.794)
categories of three severity scores. For definition of risk categories, see
For definition of risk categories, see tables 2 and 3.
tables 2 and 3.

80 Pflug MA, et al. Postgrad Med J 2015;91:77–82. doi:10.1136/postgradmedj-2014-132802

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Furthermore, data were retrieved solely from a single centre.
As the hospital is a primary care centre that provides acute
medical care to the population, patient selection as expected
with a tertiary referral centre is unlikely. However, the character-
istics of both the hospital and the population served are likely to
differ in other settings. Therefore, the findings of this study
cannot be transferred to other settings without reservation. In
addition, only inpatients were evaluated. We cannot claim that
low-risk patients as defined in our sample can be treated safely
as outpatients. This conclusion can only be made with rando-
mised controlled trials that adequately investigate this question.
Finally, our findings certainly do not prove superiority of
CURB-age over CURB-65 or CRB-65. Although the sample size
in our study was almost three times larger than that in the study
of Myint et al,8 we still could not perform inference tests—for
example, to detect differences in AUC values from ROC curve
analysis. Therefore, further larger studies assessing the potential
of CURB-age for better identification of low-risk patients are
needed.
Main messages
▸ As common severity scores do not perform optimally in
older inpatients with community-acquired pneumonia (CAP),
a score variant of the standard CURB-65, named CURB-age,
has been proposed.
▸ In a sample of more than 500 inpatients from a single
centre in Germany, CURB-age showed a closer association
with 30-day mortality than standard scores.
▸ The use of CURB-age may improve risk stratification and
hence management of inpatients with CAP.
Current research questions
▸ Can low-risk patients with community-acquired pneumonia
(CAP) be treated safely as outpatients?
▸ Do different risk-based treatment strategies improve the
outcome of high-risk patients?
▸ Are different risk-based treatment strategies able to reduce
side effects in low-risk patients?
Key references
▸ Lim WS, van der Eerden MM, Laing R, et al. Defining
community acquired pneumonia severity on presentation to
hospital: an international derivation and validation study.
Thorax 2003;58:377–82.
▸ Myint PK, Sankaran P, Musonda P, et al. Performance of
CURB-65 and CURB-age in community-acquired pneumonia.
Int J Clin Pract 2009;63:1345–50.
▸ Loke YK, Kwok CS, Niruban A, et al. Value of severity scales in
predicting mortality from community-acquired pneumonia:
systematic review and meta-analysis. Thorax 2010;65:884–90.
▸ Ewig S, Bauer T, Richter K, et al. Prediction of in-hospital
death from community-acquired pneumonia by varying CRB-
age groups. Eur Respir J 2013;41:917–22.
Pflug MA, et al. Postgrad Med J 2015;91:77–82. doi:10.1136/postgradmedj-2014-132802
Original article
Author affiliations
1
School of Medicine, University of Bochum, Bochum, Germany
2
College of Medicine, University of Arizona, Tucson, USA
3
Department of Geriatrics, Marienhospital Herne, University of Bochum, Herne,
Germany
4
Department of Geriatrics, HELIOS Klinikum Schwelm, University of Witten/Herdecke,
Schwelm, Germany
5
Department of Medical Informatics, Biometry and Epidemiology, University of
Bochum, Bochum, Germany
Acknowledgements We sincerely thank Patricia Vierhaus, Department of Medical
Informatics, Biometry and Epidemiology, University of Bochum, Germany, for data
handling and technical assistance. We also thank the staff of the Office of Statistics
and Elections, Herne, Germany, for their cooperation.
Contributors MAP collected, analysed and interpreted the data, performed the
literature review, and drafted the manuscript. TT contributed to data analysis,
interpretation, and drafting of the manuscript. TW contributed to the design of the
study, collected the data, and supported data analysis and interpretation. HN
supported data analysis and interpretation. HJH and LP designed the study and
interpreted the data. UT designed the study, contributed to the collection of data,
performed analysis and interpretation of the data, and assisted in drafting the
manuscript. All authors read and approved the final version of the manuscript.
All authors fulfil the criteria for authorship, as mentioned in the Contributorship
Statement.
Competing interests None.
Ethics approval University of Bochum, Germany (approval given 6 August 2012).
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
1 Hoyert DL, Xu J. Deaths: preliminary data for 2011. Natl Vital Stat Rep
2012;51:1–51.
2 Anonymous. Causes of death in Germany 2012 [Todesursachen in Deutschland].
Fed Stat Office Germany 2013;12.
3 American Lung Association. Lung Disease Data: 2008. 2008.
4 Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients
with community-acquired pneumonia. N Engl J Med 1997;336:243–50.
5 Serisier DJ, Williams S, Bowler SD. Australasian respiratory and emergency
physicians do not use the pneumonia severity index in community-acquired
pneumonia. Respirology 2013;18:291–6.
6 Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired
pneumonia severity on presentation to hospital: an international derivation and
validation study. Thorax 2003;58:377–82.
7 Capelastegui A, Espana PP, Quintana JM, et al. Validation of a predictive rule for
the management of community-acquired pneumonia. Eur Respir J 2006;27:151–7.
8 Myint PK, Sankaran P, Musonda P, et al. Performance of CURB-65 and CURB-age
in community-acquired pneumonia. Int J Clin Pract 2009;63:1345–50.
9 Parsonage M, Nathwani D, Davey P, et al. Evaluation of the performance of
CURB-65 with increasing age. Clin Microbiol Infect 2009;15:858–64.
10 McNally M, Curtain J, O’Brien KK, et al. Validity of British Thoracic Society guidance
(the CRB-65 rule) for predicting the severity of pneumonia in general practice:
systematic review and meta-analysis. Br J Gen Pract 2010;60:e423–33.
11 Chalmers JD, Singanayagam A, Akram AR, et al. Severity assessment tools for
predicting mortality in hospitalised patients with community-acquired pneumonia.
Systematic review and meta-analysis. Thorax 2010;65:878–83.
12 Loke YK, Kwok CS, Niruban A, et al. Value of severity scales in predicting mortality
from community-acquired pneumonia: systematic review and meta-analysis. Thorax
2010;65:884–90.
13 Ochoa-Gondar O, Vila-Corcoles A, Rodriguez-Blanco T, et al. Comparison of three
predictive rules for assessing severity in elderly patients with CAP. Int J Clin Pract
2011;65:1165–72.
14 Myint PK, Kamath AV, Vowler SL, et al. The CURB (confusion, urea, respiratory rate
and blood pressure) criteria in community-acquired pneumonia (CAP) in hospitalised
elderly patients aged 65 years and over: a prospective observational cohort study.
Age Ageing 2005;34:75–7.
15 Myint PK, Kamath AV, Vowler SL, et al. Simple modification of CURB-65 better
identifies patients including the elderly with severe CAP. Thorax 2007;62:1015–16;
author reply 1016.
16 Metersky ML, Waterer G, Nsa W, et al. Predictors of in-hospital vs postdischarge
mortality in pneumonia. Chest 2012;142:476–81.
17 Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic
comorbidity in longitudinal studies: development and validation. J Chronic Dis
1987;40:373–83.
18 Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining
comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care
2005;43:1130–9.
81
 Downloaded from http://pmj.bmj.com/ on September 23, 2017 - Published by group.bmj.com

Original article

19 World Medical Association. WMA Declaration of Helsinki, Ethical Principles for
Medical Research Involving Human Subjects. 55th WMA General Assembly, Tokyo,
Japan 2004.
20 Hoffken G, Lorenz J, Kern W, et al. [Epidemiology, diagnosis, antimicrobial therapy
and management of community-acquired pneumonia and lower respiratory tract
infections in adults. Guidelines of the Paul-Ehrlich-Society for Chemotherapy, the
German Respiratory Society, the German Society for Infectiology and the
Competence Network CAPNETZ Germany]. Pneumologie 2009;63:e1–68.
21 Woodhead M, Blasi F, Ewig S, et al. Guidelines for the management of adult lower
respiratory tract infections—full version. Clin Microbiol Infect 2011;17(Suppl 6):E1–59.
22 Menendez R, Martinez R, Reyes S, et al. Biomarkers improve mortality prediction by
prognostic scales in community-acquired pneumonia. Thorax 2009;64:587–91.
23 Myint PK, Kamath AV, Vowler SL, et al. Severity assessment criteria recommended
by the British Thoracic Society (BTS) for community-acquired pneumonia (CAP) and
older patients. Should SOAR (systolic blood pressure, oxygenation, age and
respiratory rate) criteria be used in older people? A compilation study of two
prospective cohorts. Age Ageing 2006;35:286–91.
24 Ewig S, Birkner N, Strauss R, et al. New perspectives on community-acquired
pneumonia in 388 406 patients. Results from a nationwide mandatory
performance measurement programme in healthcare quality. Thorax
2009;64:1062–9.
25 Ewig S, Bauer T, Richter K, et al. Prediction of in-hospital death from
community-acquired pneumonia by varying CRB-age groups. Eur Respir J
2013;41:917–22.

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82 Pflug MA, et al. Postgrad Med J 2015;91:77–82. doi:10.1136/postgradmedj-2014-132802

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Short-term mortality of adult inpatients with

community-acquired pneumonia: external
validation of a modified CURB-65 score
Marc Andre Pflug, Timothy Tiutan, Thomas Wesemann, Harald Nüllmann,
Hans Jürgen Heppner, Ludger Pientka and Ulrich Thiem

Postgrad Med J 2015 91: 77-82 originally published online January 24,
2015
doi: 10.1136/postgradmedj-2014-132802

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