We agree with Buising et al that severity scores for community acquired pneumonia (CAP) that are accurate for predicting 30 day mortality, such as the pneumonia severity index (PSI) and CURB-65, are unlikely to be as useful for predicting the need for admission to the intensive care unit (ICU).¹ In our institution, as their paper describes, the patients who die from CAP are generally older, have unstable co-morbid conditions, and are made “not for resuscitation”, so are not suitable candidates for admission to the ICU. We also agree that the revised American Thoracic Society criteria are of very limited use as a tool for predicting severe CAP as the major criteria (need for mechanical ventilation or inotropic support) identify patients who should already be in the ICU rather than predict those who will need it.²

However, we have some concerns with the methodology used to validate the scoring systems in their study.¹ The entry criteria based on the admission …