Scandinavian Journal of Infectious Diseases, 2008; 40: 293
300

ORIGINAL ARTICLE

Comparing the pneumonia severity index with CURB-65 in patients

admitted with community acquired pneumonia

MICHELLE R. ANANDA-RAJAH1, PATRICK G. P. CHARLES1,2, SHARMILA MELVANI1,

LAURELLE L. BURRELL1, PAUL D. R. JOHNSON1,2 & M. LINDSAY GRAYSON1
3
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From the 1Department of Infectious Diseases, Austin Health, Heidelberg, 2Department of Medicine, University of Melbourne,
and 3Department of Epidemiology and Preventative Medicine, Monash University, Australia

Abstract
Pneumonia severity assessment systems such as the pneumonia severity index (PSI) and CURB-65 were designed to direct
appropriate site of care based on 30-d mortality. Increasingly they are being used to guide empirical antibiotic therapy and
also possibly to detect patients who will require admission to the intensive care unit (ICU). We retrospectively reviewed the
records of all patients admitted to our institution with confirmed community acquired pneumonia (CAP) for the 12 months
from January 2002. 408 episodes were studied with an overall 30-d mortality of 15.4% and ICU admission of 10.5%. PSI
For personal use only.

classes IV/V were significantly better than CURB-65 score]3 for predicting patients who died within 30 d (94% vs 62%;
pB0.001), and those that needed ICU (86% vs 61%; p0.01). In addition, for the patients identified as ‘low risk’ by PSI
(classes I/II), there was only 1 death and 1 admission to an ICU compared to 8 deaths and 7 ICU admissions with CURB-
65 scores of 0
1. Although easier to use, CURB-65 is neither sensitive nor specific for predicting mortality in CAP patients.
Neither rule was sufficiently accurate for predicting need for an ICU, even when patients with ‘not for resuscitation’ orders
were excluded.

Introduction calculation to stratify patients into 5 severity classes

In this current era of rising health care costs the
decision to hospitalize adults with community ac-
quired pneumonia (CAP) has received considerable
attention. Physicians have been shown to overesti-
mate the risk of death in patients with CAP, leading
to unnecessary admissions [1], and in other patients
have failed to appreciate illness severity at initial
assessment [2]. Pneumonia severity prediction rules
evolved in response to these inconsistencies in an
effort to optimize the initial decision to hospitalize
and to reduce health care expenditure [3].
Pneumonia severity prediction rules were origin-
ally designed to stratify patients with CAP into risk
groups based on short-term mortality. Increasingly,
however, they are being used to guide intensity of
treatment and empirical antibiotic prescribing
[4
6]. The most widely studied of these is the
pneumonia severity index (PSI) [3]. The PSI
uses 20 clinical and investigational variables in its
with 30-d mortality ranging fromB1% for classes I

III to 27% for class V [3]. CURB-65 is an alternative
severity scoring rule that assigns less importance to
the impact of comorbidities and instead uses
5 variables (confusion, elevated blood urea, elevated
respiratory rate, low systolic or diastolic blood
pressure and age]65 y) to assign a 6-point score
(0
5), where scores of 0
1, 2 and ]3 correlate with
low, intermediate and high short-term mortality,
respectively [7]. The PSI has been endorsed by
North American and Australian authorities [4,8

10], while CURB-65 has been endorsed by the
European, Swedish, and British guidelines
[5,11,12]. Guidelines from the Netherlands and
the recent combined Infectious Diseases Society of
America and American Thoracic Society publication
offer the choice of either tool but with a stronger
recommendation for CURB-65 in the latter [6,13].
Each scoring system has strengths and weaknesses.
The PSI is well validated for identifying low-risk

Correspondence: P. Charles, Department of Infectious Diseases, Austin Health, PO Box 5555, Heidelberg VIC 3084, Australia. Tel: 613 9496 6676.
Fax: 613 9496 6677. E-mail: patrick.charles@austin.org.au

(Received 5 April 2007; accepted 3 September 2007)

ISSN 0036-5548 print/ISSN 1651-1980 online # 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As)
DOI: 10.1080/00365540701663381
 294 M. R. Ananda-Rajah et al.
patients, but may underestimate illness severity in
young, otherwise healthy patients, due to the heavy
weighting it accords to age and comorbidities. On the
other hand, CURB-65 may better identify patients at
the severe end of the spectrum, because it evolved
from prediction rules originally designed to identify
patients with severe CAP [2,7,14]. However, the
CURB-65 rule itself, like the PSI, was derived from
a study of features associated with 30-d mortality [7].
Neither rule is ideal for predicting the need for ICU
admission [15
17].
The PSI was adopted by the Australian Thera-
peutic Guidelines in 2003 with recommendations on
hospitalization and empirical antibiotic therapy
based on disease severity [4]. It has not, however,
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been widely validated in Australia. Therefore, we
undertook a study to evaluate the performance of the
PSI and CURB-65 at our 840-bed, university
affiliated hospital, with particular emphasis on
assessing their accuracy in predicting 30-d mortality,
and need for intensive care unit (ICU) admission.
Patients and methods
We conducted a retrospective review of adults
For personal use only.
admitted to our hospital with a discharge diagnosis
of CAP during a 12-month period from January
2002. Definitions of CAP, as well as inclusion and
exclusion criteria for the study were identical to
those used in the large multi-centre PORT study of
CAP [3], except that where the PORT study
recorded the first results available to emergency
clinicians, we recorded the most abnormal results
identified in the Emergency Department (since these
were considered more practically relevant to clinical
decision-making about disease management). Thus,
inclusion criteria included: patient age 18 y or more,
admission for at least 24 h, principal discharge
diagnosis of pneumonia according to the Interna-
tional Classification of Diseases, 10th Edition,
Australian Modification (ICD-10AM codes: J10-
J18), chest radiograph performed within 24 h of
admission and haematology and serum biochemistry
assessment within 24 h of admission [3].
Medical records were reviewed to confirm the
diagnosis of CAP, which was defined as 1 or more
symptoms suggestive of CAP (cough, sputum pro-
duction and fever) [1], plus chest radiograph evi-
dence of pneumonia confirmed by a radiologist. We
recorded results of temperature, pulse rate, respira-
tory rate, oxygen saturation, arterial blood gas
analyses (if performed), and the number of lobes
involved on chest X-ray. Mental status was assumed
to be normal unless stated otherwise, and missing
results for glucose or arterial pH were assumed to be
normal. If blood gases were not taken, PSI points for
hypoxia could be obtained if pulse oximetry results
were 590%. Patients were excluded if they had
human immunodeficiency virus infection, tubercu-
losis, aspiration pneumonitis or admission to any
hospital within the preceding 14 d.
Primary outcome measures were 30-d mortality
and need for admission to the intensive care unit
(ICU). Mortality was assessed both by a review of
medical records and, if necessary, direct phone
contact with patients. We also recorded need for
mechanical ventilation or inotropic support, patient
length of in-hospital stay and whether patients had a
‘not for resuscitation’ (NFR) recorded within 24 h of
admission. The PSI and CURB-65 scores were
calculated as previously described [3,7].
Statistical analysis was undertaken using Stata
software (Stata 8.2 for Windows; Stata Corporation,
College Station, Texas, USA). Data were analysed
using the x2 test and Fisher’s exact test where
appropriate. p-values of less than 0.05 were consid-
ered statistically significant.
Results
Study population
1299 patient episodes were initially assessed as
having the Emergency Department (ED) diagnosis
of CAP. However, 891 of these episodes were
excluded, most commonly because of a normal chest
X-ray or because of admission to a hospital within
the preceding 14 d. Reasons for exclusion are shown
in Figure 1.
The study comprised 408 episodes of CAP in 390
patients who fulfilled the criteria for a diagnosis of
CAP. The characteristics of these patients are shown
in Table I. Mean patient age was 72 y, with a median
of 76 y. 56.2% were male and 9.3% of patients were
nursing home residents. A NFR was documented in
17.9% (73/408) of admissions, suggesting that these
patients had either a low pre-admission life expec-
tancy or had other clinical features that argued
against aggressive medical intervention.
Assessment of severity criteria for 30-d mortality
Overall 30-d mortality was 15.4% (63/408). The
accuracy of the PSI and CURB-65 for predicting
mortality in this population is shown in Tables II and
III. Results using the PSI were very similar in this
population to those reported by Fine et al. [3]. One
exception was PSI class III, in which mortality was
4.6% in our cohort compared to 0.9%, although
absolute patient numbers in this class were small (see
Table II). In comparison, mortality predictions using
CURB-65 identified similar rates for all scores other

1299 episodes from medical records database
841 excluded
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For personal use only.
458 potential CAP episodes for chart review
50 excluded
408 episodes (390 patients) meeting the study criteria
Figure 1. Patient screening and exclusions.
than 1, in which there was a mortality of 8.5% in our
cohort, which was significantly higher (pB0.01)
than the 1.7% in the study by Lim et al. [7]. Overall,
PSI classes IV and V predicted 93.7% (59/63) of
deaths compared to 61.9% (39/63) for CURB-65
scores of 3 or more (pB0.001). Reducing the
Severity assessment rules for CAP 295
CXR normal or not performed (n = 291)
Admitted within previous 14 d (n = 211)
Admitted for < 24 h (n = 123)
Hospital acquired pneumonia (n = 101)
Outside study period (n = 65)
Age < 18 y (n = 40)
Other diagnosis (n = 10)
Other diagnoses (n = 40)
Admitted within previous 14 d (n = 8)
Admitted for < 24 h (n = 1)
Chart missing (n = 1)
CURB-65 score cut-off to 2 or more points im-
proved sensitivity to 87.3% (55/63), but with speci-
ficity falling from 66.4% to 32.5%. Area under the
receiver operating characteristic (ROC) curve was
equivalent for PSI and CURB-65 (0.72 vs 0.69).
There was only 1 death for patients in the ‘low risk’
 296 M. R. Ananda-Rajah et al.
Table I. Baseline characteristics. PSI classes (I and II combined) compared to 8 in
those with CURB-65 scores of 0 or 1 (p0.03).
Characteristic na %a 19 patients died after discharge from their initial
Total CAP episodes 480
CAP admission; 73.7% (14/19) of these died as a
Number of patients 390 result of a terminal event unrelated to CAP, but
Age: instead related to their chronic underlying comor-
Mean9SD 72 y916 bidities.
Median 76 y Of the 44/63 patients who died in hospital, 56.8%
Range 18
100 y
Male 229 56.1
(25/44) had an NFR order, of whom 84.0% (21/25)
Accommodation: died within 7 d of admission. Overall, 30-d mortality
Nursing home residence 38 9.3 among patients with a NFR was 45.9% (34/74). As
Private residence 320 78.4 expected, when NFR patients were excluded from
Patient comorbidities: the analysis, the predictive accuracy for 30-d mor-
Congestive cardiac failure 105 25.7 tality of both the PSI and CURB-65 decreased for
Cerebrovascular disease 56 13.7 patients in higher risk classes: 30-d mortality for PSI
Malignancy 61 15.0
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Renal disease 72 17.6

class V decreased from 31.9% to 18.4%, while in
Liver disease 11 2.7 those with CURB-65 scores ]3, it decreased from
Not for resuscitation order within 73 17.9 25.2% to 12.2%.
24 h If patients with malignancies or those from nur-
CAP characteristics: sing homes were excluded (to make the patients
Antibiotics prior to presentation 120 29.4 more comparable with those in the CURB-65 paper
Altered mental status 51 12.5 [7]), PSI classes IV and V predicted 92.9% of deaths
Pleural effusion 116 28.4
Oxygen saturationB/90% 127 31.1
compared to 71.4% for CURB-65 scores ]3 (26/28
PaO2 B60 mmHg 168/347 48.4 vs 20/28; p 0.08). Specificities were 36.6% and
Arterial pHB7.35 39/347 11.2 64.1%, respectively (pB0.001).
For personal use only.

Systolic BP B90 mmHg 26 6.6

Diastolic BP 560 mmHg 171 41.9
Pulse]125 bpm 68 16.7 Assessment of severity criteria for predicting ICU
Respiratory rate ]30 br/min 118 28.9
HaematocritB30% 23 5.6
admission
SodiumB130 mmol/l 23 5.6 Rates of admission to ICU by severity assessment are
Urea7 mmol/l 234 57.4
Urea]11 mmol/l 120 29.4
given in Table II. In general, need for ICU admission
Glucose]14 mmol/l 28/327 8.6 rose with increasing PSI class although with no
ICU characteristics:
difference between classes IV and V. For CURB-
ICU admissions 43 10.5 65, no patients with a score of 0 required ICU, but
Age: high rates were seen for all other scores. Surprisingly,
Mean 64 y rates were highest for the patients with a score of 3.
Range 37
87 y Notably, 16.3% (7/43) of patients admitted to an
ICU admission within 24 h of 35 81.4
presentation
ICU were classed as ‘low risk’ by CURB-65 (scores
Admitted from emergency 29 67.4 of 0 or 1) and 5.8% (7/120) of patients in this group
department required ICU admission. In contrast, only 1 patient
Admitted from ward 14 32.6 from PSI classes I and II required ICU care.
Mechanical ventilation (invasive 30 69.8 The accuracy of the PSI and CURB-65 at
and non-invasive)
Invasive ventilation 20 46.5
predicting need for ICU in this cohort is shown in
Inotropes required for]4 h 28 65.1 Table IV. PSI classes IV/V predicted 86.1% of ICU
Mechanical ventilation and/or 37 86.0 admissions, while PSI class V alone predicted
inotropes for]4 h 32.6%. In comparison, CURB-65 scores ]3 pre-
Multilobar infiltrates on chest 11 dicted 60.5% of admissions. PSI classes IV/V had a
radiography
significantly higher sensitivity than CURB-65 group
Patient outcomes: 3 (37/43 vs 26/43; p 0.01) although specificity was
Hospital length of stay (d)
Mean 10.7
better for CURB-65 (pB0.001). Positive predictive
Range 2
91 values were poor for both PSI and CURB-65, even
30-d mortality 63 15.4 after exclusion of patients with NFR orders. As with
Readmission within 30 d 64 15.7 mortality, area under the ROC curve was equivalent
a
Denominators are 408 unless otherwise specified.
but moderate for both PSI and CURB-65 (0.58 vs
0.63). In comparison, exclusion from analysis of
patients from nursing homes or those with malig-
 Severity assessment rules for CAP 297
Table II. Correlation between CAP severity assessments and both 30-d mortality and need for ICU.

30-d mortality

Severity score No. episodes All patients n (%) Patients without NFRb n (%) Published results,% [Refs 3,7] ICU admissiona n (%)

PSI
Class I/II 49 1 (2.0) 0/46 0.1
0.6 1 (2.0)
Class III 65 3 (4.6) 2/60 (3.3) 0.9 5 (7.7)
Class IV 181 23 (12.7) 13/150 (8.7) 9.3 23 (12.7)
Class V 113 36 (31.9) 14/76 (18.4) 27.0 14 (12.4)
CURB-65
0 points 26 0 0/26 0.6 0
1 point 94 8 (8.5) 4/81 (4.9) 1.7 7 (7.4)
2 points 133 16 (12.0) 11/112 (9.8) 9.0 10 (7.5)
3 points 107 20 (18.7) 11/88 (12.5) 20.7 20 (18.7)
4
5 pointsc 48 19 (39.6) 3/26 (11.5) 35.1 6 (12.5)
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Total 408 63 (15.4) 29/332 43a (10.5)

a
In 6 episodes, patients did not require mechanical ventilation or inotropes; 3 of these were in PSI classes IV and V, 1 in CURB-65 group 1,
and 5 in CURB-65 group 3.
b
Not for resuscitation order within 24 h of admission.
c
There were only 3 people with a CURB-65 score of 5.

nancies resulted in higher sensitivity for PSI classes
IV/V at 85.0% versus 62.5% for CURB-65 group
3 (34/40 vs 25/40; pB0.05). Again, specificity was
significantly better for CURB-65 (p B0.001).
For personal use only.
with CURB-65 scores 0
1. This is of concern as
patients with CURB-65 scores 0
1, like those in PSI
classes I/II, are regarded as potentially suitable for
home-based treatment [3,7]. Area under ROC curve

results are similar for the 2 tools because of the

Discussion
This large study of CAP in Australia suggests that of
the available pneumonia severity scoring rules the
PSI is superior to CURB-65 in predicting 30-d
mortality and the need for ICU admission. PSI
classes IV/V predicted 93.7% of deaths and 86.0% of
ICU admissions, while there was only 1 death and 1
ICU admission from PSI classes I/II. In comparison,
CURB-65 scores ]3 predicted 61.9% of deaths and
60.5% of ICU admissions. Dropping the CURB-65
cut-off to 2 points improved sensitivity at the
expense of specificity for both outcomes, but this is
problematic as it means that the same cut-off is used
for consideration of both hospital admission
and ICU admission. 12.7% of the deaths and
16.3% of the ICU admissions came from those
better specificity for CURB-65.
The majority of the patients who died had active
treatment withdrawn because of advanced age,
significant comorbidities, NFR status, or patient
and family wishes, meaning that they were not
considered appropriate candidates for admission to
an ICU. When patients with NFR orders were
excluded from the analysis, mortality for each risk
group fell, suggesting that patients with a short life
expectancy heavily influence published mortality
figures
an observation which has been noted by
others [16]. Only 7 of the patients who died went to
an ICU, so it is not surprising that tools designed to
predict mortality performed poorly at identifying
patients who required care in an ICU. In addition,
many of those who received high severity scores with
either PSI or CURB-65 did not have clinically severe

Table III. Accuracy for predicting mortality.

Pneumonia scoring rule Sensitivity% (95% CI) Specificity% (95% CI) PPV% (95% CI) NPV% (95% CI)

PSI class IV/V 93.7 31.9 20.1 96.5

All patients 84.5
98.2 27.0
37.1 15.6
25.1 91.2
99.0
CURB-65]3 points 61.9 66.4 25.2 90.5
All patients 48.8
73.9 61.1
71.3 25.1
43.0 86.2
93.8
CURB-65]2 points 87.3 32.5 19.1 93.3
All patients 76.5
94.4 27.5
37.7 14.7
24.1 87.3
97.1

Abbreviations: CI: confidence interval; PPV: positive predictive value; NPV: negative predictive value.
 298 M. R. Ananda-Rajah et al.
Table IV. Accuracy for predicting need for ICU, with and without NFRa patients.

Pneumonia scoring rule Sensitivity% (95% CI) Specificity% (95% CI) PPV% (95% CI) NPV% (95% CI)

PSI class IV/V 86.0 29.6 12.6 94.7

All patientsb (72.1
94.7) (25.0
34.6) (9.0
16.9) (88.9
98.0)
PSI class IV/V 86.0 34.6 16.1 94.4
Without NFRc (72.1
94.7) (29.2
40.3) (11.6
21.5) (88.3
97.9)
CURB-65]3 pts 60.5 64.7 16.8 93.3
All patientsb (44.4
75.0) (59.5
69.9) (11.3
23.6) (89.5
96.0)
CURB-65]3 pts 60.5 69.2 22.2 92.3
Without NFRc (44.4
75.0) (44.4
75.0) (15.1
30.8) (88.0
95.5)
CURB-65]2 pts 83.7 31.0 12.5 94.2
All patientsb 69.3
93.2 26.3
36.0 8.9
16.9 88.4
97.6
CURB-65]2 pts 83.7 35.0 15.5 96.3
Without NFRc 69.3
93.2 29.6
40.8 11.0
20.9 90.7
99.0
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Abbreviations: CI: confidence interval; PPV: positive predictive value; NPV: negative predictive value.
a
Not for resuscitation order within 24 h of admission.
b
n408.
c
n335.

CAP, contributing to the low positive predictive
values for this outcome.
Since admission to an ICU can be an imprecise
surrogate marker of severe CAP (given differing
criteria for ICU admission between hospitals), the
For personal use only.
Several other studies have compared these pneu-
monia severity scoring rules. A large US study of
inpatients and ambulatory patients found that the
PSI was slightly better at identifying low risk (PSI
classes I
III) patients than CURB (age criterion

need for ventilatory and/or inotropic support was
assessed among these patients. 86.0% of patients
who were admitted to an ICU required such
support, suggesting that most had severe CAP.
Both PSI and CURB-65 correlated moderately
with this outcome, but similar to results for 30-d
mortality, CURB-65 misidentified 7 patients with
severe CAP as being ‘low risk’.
The demographic characteristics of the cohort in
this study may have affected the performance of
CURB-65, since the included patients were older
(mean age 72 y) and more sick (30-d mortality,
15.6%; ICU admission, 10.5%) than those originally
described by Lim et al. (mean age, 64 y; 30-d
mortality, 9%; ICU admission, 5%) [7]. Also, unlike
Lim et al., this study included residents from care
facilities for the aged and those with active malig-
nancies, although results for CURB-65 only im-
proved marginally when we excluded these patients.
Others have also questioned the usefulness of
CURB-65 in the elderly, because it does not assess
the impact of many comorbid illnesses on mortality
[18
20]. In addition, a minimally elevated urea, a
key element of CURB-65 which was present in 57%
of all patients in this cohort, may not be a good
discriminator in the elderly as it is subject to multiple
confounders [18,19,21]. Diastolic blood pressure of
60 mmHg or less was also a poor discriminator,
being present in 42% of our patient population and
thus contributing to the poor positive predictive
value of CURB-65.
omitted) or CURB-65 [22]. A study comparing
CURB-65, CRB-65 (urea result omitted) and the
PSI found that they were all similar in terms of their
area under the receiver operator curve graph for
predicting 30-d mortality. However, the authors
neglected to mention that CURB-65 scores ]3
only predicted 67% of deaths compared to 94% for
PSI classes IV/V (pB0.001) [17]. CURB-65 was
also poor for predicting the need for mechanical
ventilation with a sensitivity of only 39%, and this
study was further limited by the small number of
patients who required an ICU (only 4.3%) [17]. An
Australian study of CURB, CURB-65, the modified
British Thoracic Study (mBTS) rule, the modified
American Thoracic Society criteria, and the PSI
found that PSI classes IV and V and CURB were
equivalent and performed better than CURB-65 for
30-d mortality and ICU admission, but that the
rarely used mBTS rule was superior [16]. However,
similar to Capelastegui et al. [17], conclusions were
based on a small number (6.6%) of ICU admissions
compared to 10
15% generally reported in the
literature [13]. A Swedish study compared these
tools in patients with bacteraemic pneumococcal
infections and showed improved sensitivities for PSI
classes IV/V compared to CURB-65 scores ]3 for
predicting both 30-d mortality and need for ICU
[23]. A recent study from Hong Kong also demon-
strated better results for PSI for both predicting
deaths and need for ICU for classes IV/V compared
to CURB-65 scores ]3, as well as a lower risk of

these in PSI classes I/II compared to CURB-65
scores 0 or 1 [24]. Despite these findings, the
authors of 3 of these studies that showed better
results for the PSI all concluded that CURB-65 was
the preferred tool because of its simplicity
[17,23,24]. The common theme in these papers is
that areas under ROC curve results are similar, due
to better specificity and poorer sensitivity for CURB-
65. However, such ROC calculations weight sensi-
tivity and specificity equally, whereas for the identi-
fication of severe CAP, higher sensitivity is preferable
because it is more important that such patients are
detected.
Our study has some limitations. In particular, the
retrospective design meant that variables such as
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confusion might have been under-reported in the
medical charts, thereby lowering scores for both
CURB-65 and the PSI. In addition, not all patients
had glucose levels or arterial blood gas analysis
performed and we used the worst results of observa-
tions taken in the ED rather than the first results
available. However, by using stringent case defini-
tions based on principal discharge diagnoses as well
as review of medical records and chest radiograph
reports, the likelihood that the studied patients did
For personal use only.
have CAP was increased. This method is more
robust than relying on ED diagnoses, since previous
studies have shown that the discrepancy between ED
clinicians’ interpretation of the chest radiograph and
radiologist opinion is high, with 20
50% not con-
firmed as consistent with pneumonia, despite clin-
icians’ interpretation as such [25
27].
In a predominantly elderly population such as
these, CURB-65 did not safely identify low risk
patients and was inferior to the PSI for predicting
severe illness and short-term mortality. PSI classes
IV/V better correlated with ICU admission than
class V alone because a substantial proportion of PSI
class V patients was not considered suitable for
aggressive interventions due to non-severe CAP,
advanced age, or comorbidities. Neither rule, how-
ever, was ideal for predicting the need for an ICU. As
a result, we are undertaking a large prospective study
with 1 of its aims being to develop a more useful and
accurate tool for this purpose.
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