A prediction rule to identify allocation of inpatient care in community-acquired pneumonia

The current authors developed a new prediction rule based on the five risk classes defined by the Pneumonia Severity Index to identify allocation of inpatient care in community-acquired pneumonia. The decision to hospitalise in low-risk classes (I-III) was unquestionable, if the presence of one or more of the following were evident: arterial oxygen tension <8.0 kPa (60 mmHg), shock, decompensated coexisting illnesses, pleural effusion, inability to maintain oral intake, social problem, and lack of response to previous adequate empirical antibiotic therapy. The results at 18 months after implementation of this new prediction rule are reported in a series of 616 patients. The mortality rate was 0.5% in 221 patients treated as outpatients versus 8.9% in 395 patients treated as inpatients. Specific additional criteria for hospitalisation included in the prediction rule were present in 106 of the 178 low-risk patients treated as inpatients, whereas in the remaining 72, the decision to hospitalise was apparently unjustified by the prediction rule. These 72 patients showed a better outcome (significantly shorter hospitalisation, days on intravenous antibiotics, mortality, and complicated course) than high-risk patients and low-risk patients who met the additional specific criteria for deciding hospital admission. Therefore, admission in these low-risk patients might have been avoided by strict adherence to the new prediction rule. Another relevant finding was that the Pneumonia Severity Index alone did not identify all patients who needed to be admitted to the hospital.