Community-Acquired Pneumonia

(the Stanly Cup, pictured left)

Community-acquired pneumonia is extremely common. When patients present with this condition, we are often faced with a situation in the ER where we either admit pateints to hospital, or decide to treat in an out-patient setting. How do we decide? There are two major ways to do this.....

• "Gestalt": take a careful history and physical exam, look at the bloodwork and chest x-ray, think about the patients' social situation and the time of day (or night), and put all the information into context and make a decision.

• Clinical Prediction Rules: There are a few of these, however the Pneumonia Severity Index (derived from PORT score) and CURB65 score are most widely used.

Pneumonia Severity Index: Here is a link to the original article from NEJM. Points are given for various clinical/historical feaures and patients are categorized into one of 5 classes. Class I, II, have very low all-cause mortality rates at 30 days and can usually be treated as outpatients. Class IV, and V have higher rates of morbidity and 30-day all cause mortality - these patients should be admitted to hospital.

CURB65: This is a much simpler scale requiring only 5 pieces of information. Here is a link to the original article in Thorax. Each feature is worth 1 point...then just add them up.

• C: confusion- disorientation to person, place, time
• U: urea >7 mmol/L
• R: respiration rate >30 breaths per minute
• B: Blood pressure- systolic <90 or diastolic <60 mmHg
  
• 65: age >65 years

30-day mortality rates are 0.6% with a score of 0, and 1.7% with a score of 1. Scores of 4 have roughly 15% 30-day mortality rates - oy vey (come find me if you don't know what that means). Patients with scores of 0 or 1 can most likely be treated as outpatients. 3 points or more should be brought into hospital, and 4 or more points should likely be evaluated by the ICU.

Remember, these scales are helpful tools meant to assist you - they are not substitutions for good clinical judgment.