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    SMART-COP Score for Pneumonia Severity

    Predicts need for intensive respiratory or vasopressor support (IRVS) in community-acquired pneumonia (CAP).
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    INSTRUCTIONS

    Use in patients ≥18 years with clinical and radiographic findings consistent with community acquired pneumonia (CAP). Does not apply to patients with significant immunosuppression.

    When to Use
    Pearls/Pitfalls
    Why Use

    Patients with CAP who may require ICU care.

    • The SMART-COP Score for Pneumonia Severity was developed to identify patients at increased risk for intensive respiratory or vasopressor support (IRVS).
    • Can help stratify which patients need ICU admission.
    • Does not estimate mortality.
    • Includes age-adjusted cutoffs for respiratory rate and oxygen levels, but otherwise does not explicitly include patient age as a variable, in contrast with PSI or CURB-65 scores. This may preserve the positive predictive value with advancing age.
    • CAP is the single most common cause of sepsis in older patients, but can be difficult to recognize due to blunted fever and tachycardic responses to infection.
    • Consideration of other variables not included in the SMART-COP Score, such as comorbidities, functional status, frailty, and physician gestalt, may still recommend ICU admission.
    • Uses readily available patient information.
    • Can help identify which patients need ICU admission, with 92.3% sensitivity, 62.3% specificity, and an AUC of 0.87, leading to better utilization of resources and treatment initiation.
    • Delayed admission to the ICU is associated with higher 30-day mortality in patients with CAP (Restrepo 2010).
    • Performs comparably well with the 2007 IDSA/ATS guidelines’ minor criteria.
    ≤50
    >50

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • Patients who do not meet criteria for ICU admission using the SMART-COP Score should still be evaluated for the need for inpatient admission.
    • They should also receive timely and appropriate empiric antibiotics for CAP, generally a beta-lactam plus a macrolide, or a fluoroquinolone.
    • Goals of care and other variables may recommend against ICU admission even if the SMART-COP Score is high.

    Critical Actions

    For patients with high SMART-COP Scores, consider broadening antibiotic regimen to include MRSA coverage (for ICU admission, necrotizing or cavitary infiltrates, or empyema, previous MRSA infection) and/or to include antipseudomonal coverage (for history of structural lung disease, immunocompromise, or previous Pseudomonas infection). Also, consider if the patient has associated sepsis and treat accordingly.

    Formula

    Addition of the selected points:

     

    0 points

    1 point

    2 points

    Systolic BP <90

    No

    --

    Yes

    Multilobar CXR involvement

    No

    Yes

    --

    Albumin <3.5 g/dL

    No

    Yes

    --

    Respiratory rate

    <25, if age ≤50

    <30, if age >50

    ≥25, if age ≤50

    ≥30, if age >50

    --

    Tachycardia ≥125

    No

    Yes

    --

    Confusion (new onset)

    No

    Yes

    --

    Oxygen low

    PaO2 ≥60 (or SaO2 >90% or P/F ratio ≥250), if age >50

    PaO2 ≥70 (or SaO2 >93% or P/F ratio ≥333), if age ≤50

    --

    PaO2 <60 (or SaO2 ≤90% or P/F ratio <250), if age >50

    PaO2 <70 (or SaO2 ≤93% or P/F ratio <333), if age ≤50

    Arterial pH <7.35

    No

    --

    Yes

    Facts & Figures

    Interpretation:

    SMART-COP Score

    Risk Group

    Risk*

    0–2

    Low

    Minimal

    3–4

    Moderate

    1 in 8

    5–6

    High

    Consider ICU admission

    1 in 3

    ≥7

    Very high

    Consider ICU admission

    2 in 3

    *Of requiring intensive respiratory or vasopressor support (IRVS).

    Evidence Appraisal

    The original SMART-COP study by Charles et al in 2008 prospectively examined patients with CAP at six hospitals in Australia over a 28 month period. It included 865 CAP episodes, with a mean patient age of 65.1 years. The SMART-COP Score was developed to stratify patients into need for ICU admission based on risk for intensive respiratory or vasopressor support (IRVS).

    The study cohort had a 13.4% ICU admission rate, a 10.3% IRVS rate, and a 5.7% 30-day mortality rate. In the derivation study, the SMART-COP Score demonstrated 92.3% sensitivity and 62.3% specificity (AUC 0.87) for accurately predicting need for IRVS, compared with 73.6% sensitivity for PSI classes IV and V, and 38.5% sensitivity for CURB-65 group 3 patients.

    The original study also then validated the SMART-COP Score using 5 existing databases (including the PORT database) with a total of 7,464 patients. When applied to these five external databases, the SMART-COP Score had an AUC 0.72-0.87.

    One database analysis study (Valley 2015) found that among hospitalized Medicare patients with pneumonia, ICU admission of patients for whom the decision appeared to be discretionary was associated a 5.7% absolute survival advantage at 30 days compared with patients admitted to general wards.

    Dr. Patrick Charles

    About the Creator

    Patrick Charles, MBBS, FRACP, Ph.D, is a practicing infectious disease physician at Austin Health in Victoria, Australia. He is also the head of the general medicine unit and an honorary lecturer at the University of Melbourne. Dr. Charles researches the emergence of antibiotic-resistant pathogens, community-acquired pneumonia, and urinary bacteriotherapy, among other infectious disease topics.

    To view Dr. Patrick Charles's publications, visit PubMed

    Content Contributors
    • Jennifer Chen, MD
    About the Creator
    Dr. Patrick Charles
    Content Contributors
    • Jennifer Chen, MD