Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study

Background: In the assessment of severity in community acquired pneumonia ( CAP), the modified British Thoracic Society (mBTS) rule identifies patients with severe pneumonia but not patients who might be suitable for home management. A multicentre study was conducted to derive and validate a practical severity assessment model for stratifying adults hospitalised with CAP into different management groups. Methods: Data from three prospective studies of CAP conducted in the UK, New Zealand, and the Netherlands were combined. A derivation cohort comprising 80% of the data was used to develop the model. Prognostic variables were identified using multiple logistic regression with 30 day mortality as the outcome measure. The final model was tested against the validation cohort. Results: 1068 patients were studied ( mean age 64 years, 51.5% male, 30 day mortality 9%). Age greater than or equal to 65 years ( OR 3.5, 95% CI 1.6 to 8.0) and albumin < 30 g/dl ( OR 4.7, 95% CI 2.5 to 8.7) were independently associated with mortality over and above the mBTS rule ( OR 5.2, 95% CI 2.7 to 10). A six point score, one point for each of Confusion, Urea > 7 mmol/l, Respiratory rate greater than or equal to30/min, low systolic(< 90 mm Hg) or diastolic (<= 60 mm Hg) Blood pressure), age >= 65 years ( CURB- 65 score) based on information available at initial hospital assessment, enabled patients to be stratified according to increasing risk of mortality: score 0, 0.7%; score 1, 3.2%; score 2, 3%; score 3, 17%; score 4, 41.5% and score 5, 57%. The validation cohort confirmed a similar pattern. Conclusions: A simple six point score based on confusion, urea, respiratory rate, blood pressure, and age can be used to stratify patients with CAP into different management groups.