EBQ:Pneumonia curb 65

Curb-65

Scoring

Patient gets 1 point for each yes answer. Used to estimate pneumonia mortality to help determine inpatient vs. outpatient treatment.

Risk Factors	Points
Demographic Factors
Confusion?	+1
BUN > 19mg/dl (7 mmol/L)	+1
Respiratory Rate >=30	+1
SBP <90 mmHg or DBP<60 mmHg	+1
Age >=65 mmHg	+1

30 Day Mortality

Points	Mortality	Disposition
5	28% (High Risk)	Consider PCU/ICU
4	28% (High Risk)	Consider PCU/ICU
3	14% (Moderate Risk)	Consider Inpatient
2	7% (Low to Moderate Risk)	Consider Inpatient or Outpatient if good followup
1	2.7% (Low Risk)	Consider Outpatient Treatment

Clinical Question

In adults admitted with community-acquired pneumonia, what risk factors are associated with mortality and determine whether patients should be treated as an outpatient or inpatient?

Conclusion

The CURB-65 score is an easy-to-use scoring system to assess community-acquired pneumonia (CAP) severity and triage patients accordingly.

Major Points

Assessing the risk of CAP and determining whether patients should be treated as out- or inpatients was elusive until several studies demonstrated a method of classifying patients into severe disease. Yet prior to CURB-65, no study had studied the classification of patients into low-risk cohorts; ie, those with mild disease that were suitable for outpatient management. Using a derivation cohort and validating it against a smaller cohort, CURB-65 identified a 6-point system based on the presence of confusion, urea >7 mmol/L (>20 mg/dl), respiratory rate ≥30/min, low blood pressure (systolic <90 mmHg or diastolic ≤60 mmHg), and age ≥65 years. Scores of 0 to 1 were associated with low (<2%) 30-day mortality, a score of 2 was associated with intermediate (9.2%) mortality, and scores of ≥3 were associated with high (22%) mortality.

Design

Review of three prospective studies from multiple centers
N=1068 (80% for derivation, 20% for validation)

Population

Inclusion Criteria

Adults admitted through ED
CAP, defined as
- Acute respiratory tract illness
- New shadowing on admission CXR consistent with infection

Exclusion Criteria

CAP not the primary reason for admission
CAP an expected terminal event
Postobstructive pneumonia
Tuberculosis
Bronchiectasis
Malignancy
HIV
Hospitalization within prior 14 days
Immunocompromised status
Nursing home residents

Interventions

Patients seen by study investigator within 24 hours of admission
Multivariate analysis of derivation cohort, validation against separate cohort

Outcomes

Primary Outcomes

30-day mortality: 1.5% for score of 0 or 1; 9.2% for score of 2; 22% for score ≥3

Funding

Funding provided by Nottingham local trust fund, educational grant from Hoechst Marion Roussel, Health Research Council of New Zealand, and grants from Astra Zeneca BV Netherlands and Pfizer BV Netherlands.

Source

W Lim, M M van der Eerden, R Laing, W Boersma, N Karalus, G Town, S Lewis, and J Macfarlane. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May; 58(5): 377–382. doi: 10.1136/thorax.58.5.377.