FEATURED PARTNER CONTENT
Reducing admissions and
mortality with pneumonia
decision tools: CURB-65 and PSI
Bottom line: CURB-65 can be calculated with less clinical information than PSI but may sacrifice a small amount of accu-
racy, specifically at predicting 30-day mortality at lower scores.
Clinical outcomes from community-acquired pneu-
monia (CAP) vary widely, from complete recovery to
death, and depend on the patient’s age, comorbidities,
and other underlying risk factors. Not all patients with
CAP need hospitalization, but determining which pa-
tients benefit from inpatient or ICU
care can be difficult. Physicians
overestimate the risk of death in
CAP patients treated either in hospi-
tal or at home1, leading to variations
in care and in admission rates2. The
majority of costs in treating CAP is
incurred from hospital admission3.
This review focuses on the Pneu-
monia Severity Index (PSI) and the
CURB-65, two popular clinical de-
cision tools that calculate expected
mortality rate from CAP and sug-
gest the appropriate level of care
based on validated data, which can
reduce variations in care and sta-
bilize costs. As with all prediction and decision sup-
port tools, clinical judgment should override recom-
mendations when the physician deems it appropriate.
The PSI was initially developed from a database of
more than 14,000 patients with CAP4. The CURB-
65 was developed from an international cohort of
1,068 patients with CAP5. The CURB-65 has also
been validated as shortened versions: the CRB-65
and the CURB. The CRB-65 eliminates the BUN com-
Kate Rowland, MD
ponent, allowing for use of the prediction tool in
the outpatient setting without need for lab testing.
Both scores are validated in diverse clinical settings,
including inpatient6, outpatient, geriatric7 and inter-
national and lower-resource set-
tings8,9. When used as part of an
emergency department pneumonia
protocol, the PSI has been shown
to reduce inpatient admission for
low-risk patients without increas-
ing mortality or affecting quality
of life10. Another study found that
implementation of an ED proto-
col including the PSI reduced in-
patient admission among low-risk
patients and reduced mortality11.
A 2010 meta-analysis of 23 studies12
(22,000 patients) compared pre-
dictive outcomes of the CURB-65
to the PSI. Sensitivity, specificity,
NPV, and PPV for mortality are summarized in Table
1. Pooled sensitivity of the PSI was 90%, compared
with 62% for CURB-65. Pooled specificities were 53%
and 79% for PSI and CURB-65, respectively. The PSI
had a slightly higher negative predictive value, and the
CURB-65 had a slightly higher positive predictive val-
ue. This suggests that higher CURB-65 and PSI scores
both correlate accurately with a high risk of mortal-
ity, but lower CURB-65 scores are less likely to accu-
rately predict 30-day mortality than lower PSI scores.
Table 1. Comparative statistics for PSI vs CURB-65.
Statistic PSI*
90%
Sensitivity (95% CI)
(87-92%)
53%
Specificity (95% CI)
(46-59%)
98%
Negative predictive value (95% CI)
(98-99%)
14%
Positive predictive value (95% CI)
(13-16%)
*16 studies, 16,500 patients
**12 studies, 11,000 patients
The original PSI suggested that patients under age 50
without significant comorbidities could be safely tri-
aged to a low-risk category without further workup.
Patients over age 50 or those with cardiac, hepatic,
renal, or oncologic diseases required x-ray and labs
to determine level of risk and suggested disposition
(outpatient care, inpatient care, or ICU admission).
However, many iterations of the PSI today use all data
from the original study to determine mortality risk,
including lab testing, arterial blood gas, and chest
x-ray data, in addition to history and exam findings.
It should be noted that both the PSI and CURB-
65 were developed prior to aggressive sepsis
screening with lactate testing, and sepsis should
be considered in patients with pneumonia.
CURB-65 has fewer variables and can be implement-
ed with less clinical information than the PSI. It was
developed in an attempt to simplify pneumonia pre-
diction tools for use at the bedside, but both tools
are often built into electronic health records, online
calculators or apps, or emergency department pro-
tocols, making implementation of either feasible.
Both prediction tools have a strong evidence
base to help triage patients with CAP who can
be safely cared for as outpatients and those who
should be monitored at a higher level of care.
K Rowland, Assistant Professor, Department of Family Medicine, Rush Medical
College, Chicago, IL, United States
Correspondence to: kathleen_rowland@rush.edu, 630 S. Hermitage, Room 605,
Chicago IL 60612
Disclosures: None to disclose.
CURB-65**
62%
(54-70%)
79%
(75-83%)
95%
(93-97%)
24%
(19-30%)
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