The potential severity of pneumonia has led to the development of a number of scoring systems to understand the intensity of the disease in patients. Seven such tools have been listed in this article. The severity score derived from these tools helps clinicians to determine the required next steps in treating the patient.

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CURB-65

It helps estimate the mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment. The score is an acronym for each of the risk factors measured.

Variable	Score
Confusion of new-onset	1
BUN >7 mmol/L (19 mg/dL)	1
Respiratory rate of ≥30 bpm	1
BP < 90 mmHg systolic or diastolic ≤60 mmHg	1
Age 65 or older	1

• Score of 0-1 – Outpatient treatment
• Score of 2 – Admission to the medical ward
• Score of 3 or higher – Admission to intensive care unit (ICU)

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Determining the score for ICU admission

The CURB-65 calculator can be used in the emergency department setting to risk stratify a patient’s community-acquired pneumonia. The percentage of mortality at 30 days associated with the various CURB-65 scores increases with higher scores.

The drastic increase in mortality between scores of 2 and 3 highlights the likely requirement for ICU admission in patients with a score of 3 or higher, as shown below:

CURB-65 score	Mortality risk	Recommendation per derivation study
0	0.60%	Low risk, consider home treatment
1	2.70%	Low risk, consider home treatment
2	6.80%	Short inpatient hospitalisation or closely supervised outpatient treatment
3	14.00%	Severe pneumonia; hospitalise and consider admitting to intensive care
4 or 5	27.80%	Severe pneumonia; hospitalise and consider admitting to intensive care

CURB-65 is fast to compute, requires likely already-available patient information, and provides an excellent risk stratification of community-acquired pneumonia. It can facilitate better utilisation of resources and treatment initiation.

In comparison to the PSI, CURB-65 offers equal sensitivity of mortality prediction due to community-acquired pneumonia. Notably, CURB-65 (74.6%) has a higher specificity than PSI (52.2%).

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SMART-COP

50 years old or less		More than 50 years
Systolic BP <90 mmHg	2	Systolic BP <90 mmHg	2
Multilobar CXR involvement	1	Multilobar CXR involvement	1
Albumin <35 g/L	1	Albumin <35 g/L	1
Respiratory Rate 25 breaths/min or more	1	Respiratory Rate 30 breaths/min or more	1
Tachycardia 125 bpm or more	1	Tachycardia 125 bpm or more	1
Confusion (acute)	1	Confusion (acute)	1
Oxygen low PaO2 <70mmHg, or O2 saturation <93%, or PaO2/FiO2 <333	2	Oxygen low PaO2 <60mmHg, or O2 saturation <90%, or PaO2/FiO2 <250	2
pH <7.35	2	pH <7.35	2

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SMART-COP score	Risk group	Risk*
0–2	Low	Minimal
3–4	Moderate	1 in 8
5–6	High Consider ICU admission	1 in 3
≥7	Very high Consider ICU admission	2 in 3

*Of requiring intensive respiratory or vasopressor support (IRVS)

SMART-COP is used to analyse patients with CAP who may require ICU care. CAP is the single most common cause of sepsis in older patients but can be difficult to recognise due to blunted fever and tachycardic responses to infection. It does not estimate mortality but helps stratify patients who need ICU admission.

Generally used for the population above 18 years of age with clinical and radiographic findings consistent with CAP. It does not apply to patients with significant immunosuppression.

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Pneumonia Severity Index

Parameters	Score
Age in years
Male	Age
Female	10
Nursing home resident	10
Co-morbidity
Neoplasia	30
Liver disease	20
CKD	10
CHD	10
CVD	10
Clinical findings
Altered sensorium	20
RR>30/min	20
SBO<90 %	20
Temp <35°C or >40°C	15
Pulse > 125/min	10
Investigation
pH <7.35	30
BUN >30	20
Sr.Na<130	20
Hematocrit <30%	10
Blood glucose > 250	10
PaO2< 60mmHg	10
Pleural effusion	10

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Class (score)	Mortality rate	Risk	Recommendation
I <50	0.1	Low	Treat at home
II 50-70	0.6	Low	Treat at home
III 71-90	0.9- 2.8	Low	Treat at home or hospitalise
IV 91-130	8.2 -9.3	Moderate	Hospitalise
V >130	27 – 31.1	High	Consider ICU admission

The PSI score can be used in the clinic or emergency department setting to risk stratify a patient’s community-acquired pneumonia. Its purpose is to classify the type of severity of a patient’s type of CAP and allocate medical management and determine the number of resources to be utilised for care. Most commonly, the scoring system has been used to decide whether patients with pneumonia can be treated as outpatients or as inpatients (hospitalised).

It provides an excellent risk stratification of CAP. However, for most patients with clinically diagnosed CAP, the CURB-65 is easier to use and requires fewer inputs to calculate.

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SOAR criteria

Parameters	Value	Score
Systolic BP Or Diastolic BP	<90 mmHg <60 mmHg	1
Oxygenation, PaO2/FiO2	<250	1
Age	≥ 60 years	1
Respiratory rate	≥ 30/min	1

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SOAR Score	Management	30-day mortality
0-1	OP	<8%
>2	IP	33%

It is a modified version of CURB-65, where it excludes “confusion” & “BUN” and adds “PaO2” criteria. Usually used for patients with radiologically or clinically diagnosed pneumonia in a nursing home and helps dispose them as outpatient or inpatient management. The SOAR score also provides 30-day mortality depending on their type of management, that is – outpatient or inpatient (hospitalised).

SOAR is also a superior alternative for better identification of severe nursing home-acquired pneumonia (NHAP).

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ATS/IDSA criteria for severe CAP

Severe CAP is defined as the presence of one major criterion or at least three minor criteria.

Minor criteria

Respiratory rate ≥30 breaths per min

Partial pressure of oxygen/fraction of inspired oxygen ratio [PaO2/FIO2 ratio] ≤250

Multilobar infiltrates

Confusion/disorientation

Uremia (BUN level ≥20 mg per dL)

White blood cell count <4,000 per μL due to infection alone (i.e., not chemotherapy-induced)

Thrombocytopenia (platelet count <100,000 cells per mm3)

Hypothermia - core temperature < 96.8ºF (36ºC)

Hypotension requiring aggressive fluid resuscitation

Major criteria

Respiratory failure requiring mechanical ventilation

Severe shock requiring vasopressors

The Pneumonia Severity Index (PSI) is recommended to determine the need for hospitalisation, whereas the ATS/IDSA criteria for severe CAP are recommended to predict the need for intensive care. Routine treatment of CAP with macrolide monotherapy is no longer recommended unless local resistance is low. Amoxicillin and doxycycline are preferred in low-risk patients. Five-day treatment courses are recommended for all patients with CAP, with reassessment following treatment.

The minor criteria were superior to other prognostic scoring systems (including the PSI, CURB-65 score, and SCAP) for predicting the need for mechanical ventilation, vasopressor support, and ICU admission.

Variable		Points
Arterial pH <7.30	Yes	13
	No	0
Systolic pressure <90 mmHg	Yes	11
	No	0
Respiratory rate >30 breaths/min	Yes	9
	No	0
BUN >30 mg/dL (>10.7 mmol/L)	Yes	5
	No	0
Altered mental status (e.g. confusion)	Yes	5
	No	0
PaO2 <54 mmHg (or PaO2/FiO2 <250 mmHg)	Yes	6
	No	0
Age ≥80 years	Yes	5
	No	0
Multilobar/bilateral X-ray	Yes	5
	No	0

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Severe Community-Acquired Pneumonia (SCAP) Score

SCAP score*	Risk of SCAP**
0	0.27-3.43%
1-9	0.66-3.25%
10-19	9.23-11.24%
20-29	36.62-41.82%
≥30	50%

*Patients with scores ≥10 are classified as having severe community-acquired pneumonia and are recommended for ICU, monitored bed, and/or immediate intervention.

**Defined as in-hospital death, septic shock, and/or need for mechanical ventilation.

In the emergency department, after diagnosis of community-acquired pneumonia is made, calculating SCAP may help predict the chance for “severe CAP”, defined by adverse outcomes including inpatient mortality, septic shock and/or need for mechanical ventilation. It assists with disposition decisions after diagnosing CAP in the emergency department. A high-risk SCAP showed higher rates of adverse outcomes than high-risk PSI and CURB-65, potentially helping choose which patients are at most need for the ICY with higher specificity.

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Clinical Pulmonary infection (CPIS)

Scores ≥ 7 may indicate a higher likelihood of VAP and the need for BAL or mini-BAL.

It assists in diagnosing ventilator-associated pneumonia (VAP) by predicting the benefit of pulmonary (sputum or bronchial-alveolar lavage) cultures. CPIS is utilised in patients being evaluated for potential ventilator-associated pneumonia.

A CPIS value ≥7 reproducibly allowed to differentiate ventilator-associated tracheobronchitis (VAT) from ventilator-associated pneumonia (VAP) with high specificity. The CPIS has been most successfully used in guiding treatment decisions for patients with a low likelihood of VAP, for whom CPIS-guided therapy has resulted in lower costs and reduced development of antimicrobial resistance.

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Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.