CURB-65

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Lim WS, et al. "Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study". Thorax. 2003. 58(5):377-382.
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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?

Bottom Line

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.