title: Physician judgement is a crucial adjunct to pneumonia severity scores in low-risk patients.
abstract: This study investigates the reasons for hospitalisation in patients with low-risk (CURB-65 score 0-1) community-acquired pneumonia (CAP), with a view to identifying the potential for improving outpatient management. As part of a prospective observational study of CAP, we evaluated reasons for hospitalisation in these low-risk patients. 565 patients had low-risk CAP and 420 of these were admitted (for >12 h). 39.3% had additional markers of severity justifying admission, 29.5% of the admissions were required for further management that could not be provided rapidly in the community, 11.9% had unsafe social circumstances and 19.3% had no clinical reason justifying hospitalisation. 30-day mortality was increased in patients with additional severity markers (6.7%), which was significantly higher compared with 0% for patients awaiting investigations (p=0.009) and 0% without a clear indication for hospitalisation (p=0.04). In a logistic regression analysis, parameters associated with 30-day mortality were chronic cardiac comorbidity (adjusted odds ratio (aOR) 5.73, 95% CI 1.52-21.6; p=0.01), acidosis (aOR 5.14, 95% CI 1.44-18.3; p=0.01), hypoxia (aOR 9.86, 95% CI 2.39-40.7; p=0.002) and multilobar chest radiograph shadowing (aOR 4.54, 95% CI 1.21-17.1; p=0.03). This study supports recommendations from international guidelines that pneumonia severity scores should be used as an adjunct to clinical judgement, when deciding on hospitalisation.
authors.affiliation: Dept of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK. gourab19@hotmail.com
authors.forename: G
authors.initials: G
authors.lastname: Choudhury
authors.forename: J D
authors.initials: JD
authors.lastname: Chalmers
authors.forename: P
authors.initials: P
authors.lastname: Mandal
authors.forename: A R
authors.initials: AR
authors.lastname: Akram
authors.forename: M P
authors.initials: MP
authors.lastname: Murray
authors.forename: P
authors.initials: P
authors.lastname: Short
authors.forename: A
authors.initials: A
authors.lastname: Singanayagam
authors.forename: A T
authors.initials: AT
authors.lastname: Hill
mesh_terms: D000328:Adult; D000368:Aged; D017714:Community-Acquired Infections / Q000628:therapy; D003657:Decision Making; D005260:Female; D017408:Guidelines as Topic; D006760:Hospitalization; D006801:Humans; D007239:Infections; D008168:Lung / Q000473:pathology; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000175:diagnosis* / Q000628:therapy; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D015272:Pulmonary Medicine / Q000379:methods*; D012044:Regression Analysis; D012189:Retrospective Studies; D012306:Risk; D012720:Severity of Illness Index; D016896:Treatment Outcome; D006113:United Kingdom