PSI/PORT Score: Pneumonia Severity Index for CAP
The PSI/PORT Score can be used in the clinic or emergency department setting to risk stratify a patient’s community acquired pneumonia.
- Since points are assigned by absolute age in the PSI, it may underestimate severe pneumonia in an otherwise young healthy patient.
- Consider sepsis in patients with pneumonia; the PSI was developed prior to aggressive sepsis screening with lactate testing.
- Though a patient may be categorized as appropriate for outpatient treatment, assess potential barriers to treatment such as vomiting, alcohol/drug use, psychosocial conditions, or cognitive impairments.
- Any patient over 50 years of age is automatically classified as risk class 2, even if they otherwise are completely healthy and have no other risk criteria.
The PSI/PORT Score is a useful tool which provides an excellent risk stratification of community acquired pneumonia. For most patients however, the CURB-65 is easier to use and requires fewer inputs.
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While many pneumonias are actually viral in nature, typical practice is to provide a course of antibiotics given the pneumonia may be bacterial.
Disposition (inpatient vs. outpatient) often dictates further care and management -- including lab testing, blood cultures, etc.
- If the patient is >50 years of age, assign to risk class II - V and proceed to step 2.
- If the patient is <50 years of age, but has a history of neoplastic disease, congestive heart failure, cerebrovascular disease, renal disease or liver disease, assign to risk class II - V and proceed to step 2.
- If the patient has an altered mental status, pulse ≥ 125/minute, respiratory rate ≥ 30/minute, systolic blood pressure ≤ 90 mm Hg, or temperature < 35° C or ≥ 40° C, assign to risk class II - V and proceed to step 2
- If none of the above apply, assign to risk class I = low risk.
- Assign points based on age, gender, nursing home residence, co-morbid illness, physical examination findings, and laboratory and radiographic findings as listed above.
- Point distribution:
|≤70||Low risk||Outpatient care|
|71-90||Low risk||Outpatient vs. Observation admission|
|91-130||Moderate risk||Inpatient admission|
|>130||High risk||Inpatient admission|
For patients scoring high on PSI, it would be prudent to ensure initial triage has not missed the presence of sepsis. Evaluation of SIRS criteria would be beneficial.
Addition of selected points, as above.
Facts & Figures
|Risk Class||Risk||Point Value|
|I||Low||None from Comorbidities, PE findings, or Lab findings|
|V||High||>130 total points|
The original study created a five-tier risk stratification based on 14199 inpatients with community acquired pneumonia. This was then validated on 38039 inpatients and additionally another 2287 inpatients and outpatients. Points are assigned based on age, co-morbid disease, abnormal physical findings, and abnormal laboratory results.
In comparison to the PSI score, CURB-65 offers equal sensitivity of mortality prediction due to community acquired pneumonia. Notably, CURB-65 (74.6%) has a higher specificity than PSI (52.2%). However, CURB-65 had a lower sensitivity than PSI in predicting ICU admission.
Original/Primary ReferenceFine MJ. et. al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50.
ValidationShah BA, et. al. Validity of Pneumonia Severity Index and CURB-65 Severity Scoring Systems in Community Acquired Pneumonia in an Indian Setting. The Indian Journal of Chest Diseases & Allied Sciences. 2010;Vol.52.
About the Creator
Michael J. Fine, MD, MSc, is a professor in the Division of General Internal Medicine at the University of Pittsburgh. He is also the director of the Center for Health Equity Research and Promotion (CHERP) at the VA Pittsburgh Healthcare System. Dr. Fine’s research focuses on improving healthcare equity for patients with common medical conditions, such as community-acquired pneumonia, venous thromboembolism, and diabetes, especially in vulnerable patient populations.
To view Dr. Michael J. Fine's publications, visit PubMed