ISSN: 2320-5407 Int. J. Adv. Res.

10(06), 120-130

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/14864
DOI URL: http://dx.doi.org/10.21474/IJAR01/14864

RESEARCH ARTICLE
PNEUMONIA SEVERITY INDEX COMPARED TO CURB-65 IN PREDICTING THE OUTCOME OF
COMMUNITY ACQUIRED PNEUMONIA -A PROSPECTIVE STUDY

Dr. Rishna Ravindran1, Dr. Rajani M.2, Dr. Manoj D.K.3, Dr. Muhammad Shafeek K.4 and Dr.
Padmanabhan K.V4
1. Senior Resident Dept ofRespiratory Medicine Govt Medical College, Kannur.
2. Professor Dept Of Respiratory Medicine Govt Medical College, Kannur.
3. Professor & HOD Dept Of Respiratory MedicineGovt MedicalCollege, Kannur.
4. Assistant Professor Dept Of Respiratory Medicine Govt Medical College, Kannur.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Introduction: Community-acquired pneumonia (CAP) is a leading
Received: 05 April 2022 cause of morbidity and mortality worldwide. Several severity scores
Final Accepted: 08 May 2022 have been proposed to guide initial decision making on hospitalization
Published: June 2022 and to predict the outcome. Pneumonia Severity Index (PSI) and
CURB 65 are the two most widely used scoring systems to
Key words:-
Community Acquired Pneumonia, prognosticate pneumonia.
CURB 65, Pneumonia Severity Index Objectives: Tocompare the efficacy of PSI and CURB 65 scoring
systems in prognosticating the outcome in cases of CAP.
Methods: This is a prospective study conducted over a period of one
year on 150 patients who presented with community acquired
pneumonia on the grounds of their clinical and paraclinical findings in
our institution under the Department of respiratory Medicine, and
fulfilling the inclusion and exclusion criteria. The patients were
classified as per CURB 65 and PSI system and their outcome
compared.
Results: We studied 150 patients with community-acquired pneumonia
(114 men, 36 women). In our study 100 % of patients in CURB 65
class 4 and 5 required ICU admission and death was 84.6% and 100%
respectively. Majority of patients of PSI class 4 and 5 needed ICU
admission 67% and 96% respectively and death was 16% and 58%
respectively. The sensitivity and specificity of CURB-65 class ≥3 in
predicting mortality were 79% and 89%, respectively (AUC 0.92). As
for pneumonia severity index class ≥4, the rates were 79% and 84%,
respectively (AUC 0.86). The mortality rate and need for ICU
admission increased progressively with increasing scores.
Conclusion: CURB-65 seems to be the preferred method to predict
mortality and need for ICU admission in patients with community-
acquired pneumonia.

Copy Right, IJAR, 2022,. All rights reserved.

……………………………………………………………………………………………………....

Corresponding Author:- Dr. Rajani M.

Address:- Professor Dept Of Respiratory Medicine Govt Medical College, Kannur.
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Introduction:-
Infectious disease society of America(IDSA) defines community acquired pneumonia(CAP) as “an acute infection
of pulmonary parenchyma that is associated with at least some symptoms of acute infection , accompanied by the
presence of an acute infiltrate on a chest radiograph or auscultatory findings consistent with pneumonia (such as
altered breath sounds and/or localized roles), in a patient not hospitalized, or residing in a long term care facility for
more than 14 days before onset of symptoms.”1

It is estimated that India together with Bangladesh, Indonesia and Nepal account for 40% of global acute respiratory
infection; 90% of mortality is due to pneumonia, mostly bacterial in origin. 2Though definite statistics are lacking
CAP remains a leading cause of death in India too.3. The mortality in a study of CAP reported by Bansal et al4was
11 percent. In another Indian study5a significantly higher mortality was noticed in patients aged 50 years or above
and in those with underlying comorbid conditions. The mortality of patients with severe CAP requiring admission to
an intensive care unit (ICU) is high. This is likely to be particularly evident in health services where ICU beds are at
a premium such that only critically ill patients in need of assisted ventilation can be admitted. It is hoped that the
knowledge of relevant prognostic factors might be useful for early identification of patients at high risk requiring
intensive care treatment. Prognostic scoring systems for CAP have been developed to address these issues. The two
prominent tools for this purpose are the pneumonia severity index (PSI), developed in the USA after Pneumonia
Outcome Research Trial (PORT), and the BTS rule, which has recently been modified to the CURB-65 rule
“confusion, elevated blood urea nitrogen, elevated respiratory rate, low systolic or diastolic blood pressure (BP), and
age over 65 years (CURB-65)” rule.6,7The two scoring approaches are viewed as being complementary, as each has
different strengths and weaknesses. Even though most of the burden in terms of mortality and morbidity occurs in
the developing world, little has been done to study the factors associated with an adverse prognosis in CAP in this
region. The present study was designed to compare the prognostic value of these two scores for predicting the
outcome of community acquired pneumonia.

Aim of the study was to study and compare pneumonia severity index and CURB 65 (confusion ,blood urea,
respiratory rate, blood pressure, age) in assessing the outcome of community acquired pneumonia.

Relevance of the study: Unnecessary admission to ICU will increase the treatment cost and leads to depletion of
precious hospital resources. It is vital to identify patients at low risk of complications. These scoring systems also
provides meaningful information for physicians to discuss prognosis with patient’s family.

Materials & Methods:-

Study Design:
Hospital based prospective study.

Study Setting:
This observational comparative study was conducted on patients diagnosed with community acquired pneumonia,
admitted in the Department of Respiratory Medicine, Academy of Medical Sciences, Pariyaram.

Study Period:
The study was conducted for a period of 1 year , From 2019 march – 2020 march

Sample Size:
Minimum sample size of the study was calculated as 150 according to the formula

Sample size = 4pq/d2Where p = prevalence

Here p was taken as 10.2 as per study done by bashir ahmed shah8 in the research article entitled “Validity of
pneumonia severity index and CURB 65 severity scoring system in community acquired pneumonia in an indian
setting”
q = 100 – p (here 100 – 10.2 = 89.3)
d = precision, here d = absolute precision fixed at 5%
Hence sample size = (4pq/d2) = ( 4 x 10.2 x 89.3)/(25) = 145.73 ~ 150

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Sampling:
Consecutive sampling

Study Subjects:
Patients aged 18 years or more diagnosed with community acquired pneumonia on the grounds of their clinical and
paraclinical findings were enrolled in the study. Those whose diagnosis changed during treatment was excluded.

Inclusion Criteria:
Patients older than 18 years,No history of hospitalization within the last 2 weeks,Patients found to have infiltration
compatible with pneumonia on chest x-ray at admission,Who has clinical manifestations of pneumonia (fever,
cough, sputum production, clinical signs of consolidation) and new onset focal chest signs.

Exclusion Criteria:
Patients with missing clinical data (according to PSI and CURB 65 scoring criteria),Diagnosed pulmonary
embolism,Who had aspiration pneumonia,Who were diagnosed with pneumonia and were treated for pneumonia in
an external center,Who underwent trauma,Patients with HIV infection, pulmonary tuberculosis,Patients with long
term immunosuppressant or steroid therapy,Pregnant women

Methodology:-
Subjects were selected according to inclusion and exclusion criteria. The written informed consent was obtained
from them and a complete clinical history and physical examination of patients were done. The patients with
clinical diagnosis of pneumonia underwent investigations mentioned below. Investigations done:Arterial blood gas
analysis ,Complete blood count ,Renal function test,Chest radiograph,ECG,Liver function test,Serum
electrolytes,Random blood sugar,Sputum for acid fast bacilli, gram staining & cultureAll patients were assessed
using pneumonia severity index scoring and CURB65 scoring. A questionnaire including the demographic data,
clinical, Para clinicaland imaging findings was completed for each patient. PSI and CURB-65 scores were calculated
for each patient. The CURB-65 is a 5-item index while PSI uses 20 items to predict the patient’s outcome. The need
for ICU stay as well as the risk of mortality was compared according to PSI and CURB-65.

At the clinical end points , the following parameters were recorded:

1. Death
2. Need for admission to ICU
3. Need for mechanical ventilation
4. Duration of antibiotics
5. Time taken for defervescence
6. Condition at the time of discharge

Variables Studied -
Age, clinical signs , blood parameters, imaging finding

Data Analysis:
Results were entered into excel sheet and analysed using spss new version.Results were expressed as means and SD
using SPSS. Sensitivity, specificity, and relative risks was calculated for each study outcome using standard
formulas.

Results:-Total 150 patients included in the study

Table 1:- Sociodemographic profile.
Variable Percentage Frequency
AGE
20-30 2.7 4
31-40 9.3 14
41-50 12.7 19
51-60 22.7 34
61-70 29.3 44
71-80 16.0 24

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81-90 7.3 11
GENDER
Male 76.0 114
Female 24.0 36
NURSING HOME RESIDENT
Yes 2.7 4
No 97.3 146

Out of the 150 patients we studied, 114 had cough and shortness of breath (76%), 111 patients had scanty
expectoration (74%), 109 patients had mucoid expectoration. These symptoms were observed in more than 70% of
the population. 96(64%)patients were admitted with fever and 71(47.3%) had chills. 34(22.7%) patients had fatigue,
31(20.7%) patients had complaints of chest pain and night sweats. 10 patients each had Nausea and Myalgia and
only 7 patients had hemoptysis. Majority93(62%) had habit of smoking, alcohol consumption observed in
42(28%) patients and only 8 had other addictions such as chewing tobacco and substance abuse.

The co-morbidities observed in the present study population are, diabetes mellitus (38%), hypertension (32.7%),
COPD (31.3%), other respiratory diseases (6.7%), congestive cardiac failure (16.7%), neoplastic disease (1.3%),
liver disease (4%), renal disease (13.3%), cerebro vascular disease (5.3%).

Table 2:-Distribution of clinical examination among the study population.

Clinical Examination Yes No
Frequency Percentage Frequency Percentage
Altered Mental Status 36 24.0 114 76.0
Pulse Rate > 120 23 15.3 127 84.7
Respiratory Rate >30 89 59.3 61 40.7
Systolic BP < 90 20 13.3 130 86.7
Temperature > 40 38 25.3 112 74.7
Ph<7.35 26 17.3 124 82.7
Urea>7 42 28.0 108 72.0
Sodium<130 10 6.7 140 93.3
Glucose>140 55 36.7 95 63.3
HCT<30% 4 2.7 146 97.3
PAO2<60% 111 74.0 39 26.0

Chest X Ray results among the study population:Out of the 150 patients right upper lobe consolidation was present
among 6 (4%)patients, 12(8%) had right middle lobe consolidation, 18(12%) had right lower lobe consolidation,
26(17.3%) had right multilobar consolidation, 11(7.3%) had left upper lobe consolidation, 9(6%) left middle lobe
consolidation, 10 (6.7%) had left lower lobe consolidation 8(5.3%) had left multilobar consolidation and 46
(30.7%) had bilateral multilobar consolidation.Pleural effusion was present in only 6(4%) patients.

Out of the 150 cases 71 (47.3%) had clearance after 1 week. Next assessment was after three weeks which shows
complete CXR clearance in 112 (74.7%) patients.

Sputum culture & sensitivity showed no growth in 38(25.3%) patients. Klebsiella species were present in
32(21.3%) patients, candida sp were observed in 28 (18.7%)patients, pseudomonas were seen in 18(12%) patients,
16(10.7%) had acinetobacter, staph aureus were present in 9 (6%)cases, non-fermenting gram negative bacilli were
observed in 8 (5.3%)patients and only 1(.7%) patient had streptococci pneumonia.

51 were admitted in ward and 99 were admitted to ICU after the assessment of severity of pneumonia.
Non invasive ventilation was given for 34 cases and invasive ventilation given for 19 patients.
Out of the 150 only 19 (12.7%) required long term oxygen therapy.

117 (78%) out of 150 were cured .

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Table 3:-
Severity assessment scores
Pneumonia Severity Index
1 6.7 10
2 13.3 20
3 20.0 30
4 30.0 45
5 30.0 45
CURB 65
0 20.7 31
1 31.3 47
2 22.0 33
3 14.0 21
4 8.7 13
5 3.3 5

Table 4:- Distribution of ICU admission in different CURB-65 classes.

Variable CURB-65 Total
0 1 2 3 4 5
Number of Patients 31(20.67) 47(31.33) 33(22) 21(14) 13(8.67) 5(3.33) 150
ICU Admission 7(7.08) 29(29.29) 25(25.25) 20(20.20) 13(13.13) 5(5.05) 99

Figure 1:- ROC curve for predicting ICU admission using CURB-65 classes.

Area Under the Curve: 0.816 (95% CI: 0.748-0.884)

Table 5:- Distribution of mortality in different CURB-65 classes.

Variable CURB-65 Total
0 1 2 3 4 5
Number of Patients 31(20.67) 47(31.33) 33(22) 21(14) 13(8.67) 5(3.33) 150

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Mortality 0 1(3.03) 6(18.19) 10(30.30) 11(33.33) 5(15.15) 33

Figure 2:- ROC curve for predicting mortality using CURB-65 classes.

Area under the curve: 0.920 (95% CI: 0.872-0.969)

Table 6:- Distribution of ICU admission in different PSI classes.
Variable PSI Total
1 2 3 4 5
Number of Patients 10(6.67) 20(13.33) 30(20) 45(30) 45(30) 150
ICU Admission 2(2.02) 7(7.08) 17(17.17) 30(30.30) 43(43.43) 99

Out of the 150 patients, 99 were referred for ICU admission as per PSI class.

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Figure 3:- ROC curve for predicting ICU admission using PSI classes.

Predictive Area Under the Curve: 0.787 (95% CI: 0.713-0.860)

Table 7:- Distribution of mortality in different PSI classes.

Variable PSI Total
1 2 3 4 5
Number of Patients 10(6.67) 20(13.33) 30(20) 45(30) 45(30) 150
Mortality Admission 0 0 0 7(21.21) 26(78.79) 33

Out of the 150 patients, prevalence of mortality was 33(22%).

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Figure 4:- ROC curve for predicting mortality using PSI classes.

Area under the curve: 0.867(95% CI: 0.809-0.926)

Table 8:- Distribution of duration of ICU stay, total hospital stay, antibiotic and time taken for Defervescence.
Variables Range Mean Standard
Deviation
ICU stay duration 0-12 2.94 2.76
Duration of total hospital stay 1-20 8.38 4.01
Duration of antibiotic 1-20 9.18 3.90
Time taken for Defervescence 0-14 3.24 2.64

The results shows that duration of ICU stay varies from 0-12 days with an average of 2.94±2.76 days, total hospital
stay duration varies from 1-20 days with an average of 8.38±4.01, duration of antibiotic intake range from 1-20 days
with average duration of 9.18±3.90 and time taken for Defervescence ranges from 0-14 days with mean duration of
3.24±2.64.

Table 9:- Correlation between outcome parameters and CURB 65 criteria in the study population.
Outcome Parameters Correlation (R Value) P Value
ICU stay duration 0.575 <0.001
Hospital stay duration -0.156 0.057
Duration of antibiotic -0.108 0.190
Time taken for Defervescence -0.260 0.001

Spearman Rank Correlation, p<0.05 shows significance

There was a significant moderate positive correlation between ICU stay duration and CURB-65 classes (R=0.575,
P<0.001). Hospital stay duration shows a less negative correlation with CURB-65 classes which was not statistically
significant (R=-0.156, P=0.057). Duration of antibiotic also shows a very less negative correlation with CURB-65
classes which was not significant (R=-0.108, P=0.190). Time taken for Defervescence shows a weak negative
correlation with CURB-65 classes which was statistically significant (R=-0.260, P<0.05).

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Table 10:- Correlation between outcome parameters and PSI classes in the study population.
Outcome Parameters Correlation (R Value) P Value
ICU stay duration 0.513 <0.001
Hospital stay duration -0.123 0.135
Duration of antibiotic -0.052 0.525
Time taken for Defervescence -0.222 0.006

Spearman Rank Correlation, p<0.05 shows significance

There was a significant moderate positive correlation between ICU stay duration and PSI classes (R=0.513,
P<0.001). Hospital stay duration shows a less negative correlation with PSI classes which was not statistically
significant (R=-0.123, P=0.135). Duration of antibiotic also shows a very less negative correlation with PSI classes
which was not significant (R=-0.052, P=0.525). Time taken for defervescence shows a weak negative correlation
with PSI classes which was statistically significant (R=-0.222, P<0.05).

Discussion:-
The decision regarding the most appropriate site of care, including whether admission to hospital is warranted, is the
first and single most important decision in the overall management of CAP.It has consequences both for the level of
treatment received by the patient as well as the overall costs of treatment. 9

Majority of the patients in our study group was in age group 61 – 70 years. The median age in our study was 55
years (20 – 90 years). The mean age in the studiesdone by Patil P et al , Babu et al and Dey et al was 54.33±16.87,
53(±17) years and 50.6 years respectively. 10,11,12Majority of patients were male 114 constituting about 76% of the
study population. In our study majority of patients presented with symptoms of cough and shortness of breath.
Similar was seen in the study by ravindranath et al. 13Smoking did not a have any association with ICU admissions &
mortality in our study (P = 0.101, P = 0.826). It was contrary to the study by ravindranath et al where Smoking was
found to have significant association with need for ICU admission. No study till date mentions a direct association
between smoking and mortality in CAP. Of the co morbidities associated, in our study COPD was not significantly
associated with mortality and ICU admission (P = 0.88, P = 0.70). In a study by ravindranath et al COPD was
significantly associated with death & ICU admission.13 The association of COPD and adverse outcome in CAP is
well established as found in study of Restrepo et al and Rello et al. 14,15AcuteRenal Failure was significantly
associated with death in our study (P <0.001), similar to the study done by ravindranath et al. Association of
mortality from CAP with ARF has been reported in a number of studies such as those of Moine P et al and Díaz et
al.16,17

Study included 150 cases of CAP of which 99 patients (66%) needed ICU admission, 19 patients (12.7%) needed
invasive ventilatory support, and 35 patients (23.3%) had non invasive ventilation. Of the 150 patients 33 patients
(22%) succumbed to death and rest were cured (78%). Thirty out of 45 patients (66.6%) in PSI class IV and 43
patients out of 45 (95.5%) in PSI class V were admitted to ICU. Majority of patients admitted to ICU were fro m PSI
class IV and class V. Similarly 13 patients out of 13 (100%) in CURB 65 class IV and 5 patients out of 5 (100%) in
CURB 65 class V were admitted to ICU. Thus in our study 100% of patients in CURB 65 class IV and class V
required ICU admission. This was not similar to study by Shah et al and Mohanty S et alin which ICU admissions
were 23.33% and 25%.6,18

As the severity class of the scoring system increased, the percentage of ICU admission also increased.7 out of 45
patients in PSI class IV (16%) and 26 out of 45 patients (58%) in PSI class V succumbed to death. In CURB 65
class IV 11 out of 13 (84.6%) patients died, and all 5 (100%) patients of CURB 65 class V had died. In the present
study, the overall mortality was 22%. In a study by Patil P et al and Dey et al mortality rates were 18% and 25%
respectively (5,11).The mortality increased as the PSI and CURB 65 severity increased. This finding is similar to that
found by Shah BA et al which showed a linear rise in mortality with severity of CAP in both CURB 65 and PSI
scoring systems.19However, Madhu et al, in their study found that overall mortality was 18% and, the mortality rate
and need for ICU admission increased progressively with increasing scores of PSI but the CURB-65 score did not
show this correlation.20 Mortality was 49.4% in the study by Woodhead et al; this apparently higher mortality was
probably due to delayed admission of the patients into ICU.21

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In comparison of sensitivity, specificity, NPV and PPV for different PSI classes for predicting death as an outcome
we had completely opposite results when compared with results of Shah BA et al19 we had high specificity and low
sensitivity but if we consider class ≥4 as one group and. class 3 and below as another group sensitivity increases.
PSI class ≥4 has 79 % sensitivity, 84% specificity (AUC 0.86). This was similar to the study done by Madhu et
al.20In comparison of sensitivity, specificity, NPV and PPV for different CURB 65 classes for predicting death as an
outcome we had opposite results when compared with results of Shah BA et al and sensitivity was severely
compromised and to compensate this if we consider class ≥3 as one group and class 2 and below as another group
sensitivity increased. CURB 65 class ≥3 sensitivity 79%, specificity 89% (AUC 0.9). Our study had similar results
to the study done by Madhu et al. 20Dividing these groups was consistent with and also previously done in many
studies like Shah BA et al and Mohanty Set al. 18,19 However specificity of CURB-65class ≥3 is higher than that of
PSI class ≥4 because a major limitation of the PSI is the unbalanced impact of age on the score, which results in a
potential underestimation of severe CAP particularly in younger otherwise healthy individuals.

A Brazilian study by Alavi-Moghaddam M et al infers that CURB-65 showed a better predictive value in foreseeing
both the need for ICU admission and mortality than PSI. 22

In our results, however, CURB-65 had better accuracy in predicting mortality and the need for ICU admission
among patients with community-acquired pneumonia. CURB-65 had a high specificity in predicting mortality and
need for ICU admission than PSI score. In our study CURB 65 score ≥2 shows more chance for ICU admission
with 64% sensitivity and 82% specificity (AUC 0.816) and PSI score ≥3 shows more chance for ICU admission with
74% sensitivity and 67% specificity (AUC 0.78).

For predicting ICU admission, however, other indices such as modified ATS, SMART-COP and IDSA/ATS were
reported to perform better than PSI and CURB-65 (23), as these indices were originally designed to assess ICU
admission rather than mortality. Therefore, a poor performance could be found if applied in predicting mortality.

The PSI was developed to identify low mortality risk patients, but this scoring system can occasionally
underestimate the severity of illness, especially in young patients without comorbid illnesses. (19). This is because the
PSI relies more on age and comorbidities, and therefore, the young patients without any comorbidities may be
placed in a lower PSI class and may not receive the care they actually required. In contrast, the CURB-65 approach
may be ideal for identifying high mortality risk patients with severe illness due to CAP. However, the main shortfall
of the CURB-65 approach is that it does not account for comorbid illness, and thus may not be realistic in older
patients who may have considerable mortality risk even with low CURB-65 score.

Limitation
An important limitation of the study was the small number of patients included in the study. Considering the limited
number of ICU beds in our hospital, it is possible that certain patients were admitted to different wards due to
unavailability of ICU beds. Not having an available ICU bed may have affected the final decision on whether the
patient needed ICU admission.

Conclusion:-
In our study we found that CURB-65 is a better indicator for predicting mortality and ICU admissions. Because of
its simplicity and ease of use, CURB-65 may be better suited than PSI as a severity scoring system in CAP in
developing countries with limited resources. We hope that by using the knowledge of relevant prognostic factors, as
obtained from this study, patients of CAP will be better prognosticated as regards severity of their illness with
consequently better triaging of patients, utilization of resources and appropriate treatment to improve the outcome in
this disease

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