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The clinical heterogeneity of CAP means that no severity scoring system will ever be able consistently to separate all patients into correct management subgroups, but the recently developed CURB-65 prediction tool appears to be an advance.
Illness severity might usefully guide a number of management decisions in the care pathway of a patient with community acquired pneumonia (CAP). Whether to refer to hospital by the primary care physician, whether to admit by the hospital junior doctor, what investigations to perform, what antibiotic(s) to give, and whether to admit to the intensive care unit (ICU) are just some examples. This approach is captured to a varying extent in a number of the published management guidelines for CAP.1–5 While a clinical prediction tool to assess severity might therefore be helpful, there is no agreement on what constitutes the best approach to this. Additional caveats are that such a tool would need to be better than current practice, would need to accurately do what it sets out to do (that is, predict outcome), would need to be simple to use in a variety of settings, would need to have been shown to alter outcomes, and would need to actually be usable in clinical practice.
That current practice is inadequate is suggested by a number of studies. The mortality rate of 5–10% of adults admitted to hospital is well recognised—some of these deaths might be preventable. Routine clinical judgement was found to underestimate illness severity in one study6 and another found illness severity assessment to be the most common failing in the management of young adults dying from CAP.7 Severity assessment before ICU admission has been found to be suboptimal for a wide variety of conditions,8 and the variation in hospital9–13 and ICU14 admission rates for …