Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 549–555

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Egyptian Journal of Chest Diseases and Tuberculosis

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Prognostic values of pneumonia severity index, CURB-65 and expanded

CURB-65 scores in community-acquired pneumonia in Zagazig
University Hospitals
Samah M. Shehata a,⇑, Ashraf E. Sileem a, Noha E. Shahien b
a
Chest Department, Faculty of Medicine, Zagazig University, Egypt
b
Tropical Medicine Department, Faculty of Medicine, Zagazig University, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Assessment of severity and site of care decisions for community-acquired pneumonia
Received 3 January 2017 patients (CAP) are very important for patients’ safety and optimal use of resources. Late admission to
Accepted 11 January 2017 the intensive care unit (ICU) leads to increase the rate of mortality in CAP. We aimed to evaluate the effec-
Available online 23 January 2017
tiveness of the new expanded CURB-65 score in comparison with other pneumonia severity scoring sys-
tems (PSI, CURB-65) in predicting CAP patients’ outcomes.
Keywords: Methods: a prospective study included 250 consecutive patients hospitalized for CAP at Chest and
Community-acquired pneumonia
Tropical medicine Departments and ICUs at Zagazig University Hospitals, Egypt in the period between
Expanded CURB-65
CURB-65
May 2016 and November 2016.
Pneumonia severity index Results: The mean age of patients was 59.17 ± 14.04 years, 56% of all patients had comorbid diseases. As
Prognosis regards patients, outcomes (ICU admission rate, the median length of hospital stay, the overall 30-day
mortality rate and need for invasive mechanical ventilation) were 29.6%, 8 days 11.2% and 23.6% respec-
tively. COPD and liver cirrhosis were significantly associated with increased the 30-day mortality in our
CAP patients. Mortality rate increased with the severity of liver cirrhosis. In the multivariate analysis
(age P 65 years, LDH > 230 u/L, Albumin < 3.5 g/dL, Platelet count < 100
109/L, SBP < 90 mmHg or
DBP 6 60 mmHg, septic shock and Confusion) were the independent predictors of the 30-day mortality.
Expanded CURB-65 was correlated with severity of liver disease guided by Child Pugh score (r (0.34), p-
value (0.01). The 30-day mortality was lower in expanded CURB-65 score (1–4) about 4.1% than PSI class
(I–III) and CURB-65 score (0–2). While, the 30-day mortality was higher in expanded CURB-65 score (5–8)
about 25.9% than PSI class (IV–V) 14.2% and lastly CURB-65 score (3–5) 18.4%. Expanded CURB-65 score
(5–8) was associated with more frequent ICU admission about 49.4% than other two scores. The
expanded CURB-65 scoring system was the best predictor of 30-day mortality, ICU admission and need
for mechanical ventilation in CAP patients as it had the highest sensitivity, negative predictive value and
largest area under the ROC curve.
Conclusions: Expanded CURB-65 score is simple, objective and more accurate scoring system for evalua-
tion of CAP severity and can improve the efficiency of predicting the mortality in CAP patients, better than
CURB-65 and PSI scores. Also, Expanded CUEB-65 may generate new therapeutic and prognostic modality
in CAP especially in patients with liver cirrhosis.
Ó 2017 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

Introduction

Community acquired pneumonia (CAP) is one of the most com-

Peer review under responsibility of The Egyptian Society of Chest Diseases and
Tuberculosis.
⇑ Corresponding author at: Chest Department, Faculty of Medicine, Zagazig
University, El-Sharkia, Egypt.
E-mail address: Sama7she7ata2000@yahoo.com (S.M. Shehata).
mon infectious causes of death in the world with a mortality rate of
1% in outpatient settings and higher than 50% in hospitalized
patients. The suboptimal management is one of the most impor-
tant reasons of the high mortality rate, regarding antibiotic treat-
ment, or the identification of individuals who required intensive

http://dx.doi.org/10.1016/j.ejcdt.2017.01.001
0422-7638/Ó 2017 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
550 S.M. Shehata et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 549–555
care unit admission. Early identification of risk factors in these
patients allows earlier intervention and, thus, improvement of
the outcomes [1,2].
During last decades, several scoring systems as PSI, CURB-65
and SMART-COP have been developed to assess pneumonia sever-
ity. PSI consists of 20 variables and it is accurate in predicting the
30-day mortality, but its complexity decrases its clinical applica-
tion [3]. On the other hand, CURB-65 features are simple [4]. How-
ever, the age and complications of the patient in both PSI and
CURB65 carry heavier weight, underestimating the severity in
young patients and falsely referring the elderly CAP patients as
severe [5]. Moreover, both PSI and CURB-65 cannot detect patients
who need to be referred to the ICU, while SMART-COP can compen-
sate this function [6]. The SMART-COP, (Systolic blood pressure,
Multilobar infiltrates, Albumin, Respiratory rate, Tachycardia, Con-
fusion, Oxygen and pH) can give better accuracy for prediction of
the need for intensive respiratory or vasopressor support, but it
is still a complicated process to calculate multiple points for differ-
ent variables [7].
Liu et al. [8] developed a new simpler and more effective scor-
ing system, named expanded-CURB-65 including: Confusion, Urea
>7 mmol/L, Respiratory rate P30/min, low systolic (<90 mmHg) or
diastolic (660 mmHg) Blood pressure, age P 65 years,
LDH > 230 u/L, Albumin < 3.5 g/dL, Platelet count < 100
109/L. It
expands the independent risk factors into 8 variables in assessing
CAP severity, significantly increases high-risk patients identifica-
tion, through decreasing the relative weight of age and blood pres-
sure, and excluding the use of imaging and comorbid illnesses in
the calculation.
Aim of the work
To evaluate effectiveness of the new expanded CURB-65 score
in comparison with other pneumonia severity scoring systems
(PSI, CURB-65) in predicting CAP patients0 outcomes (ICU admis-
sion, Length of hospital stay, 30-day mortality and need for inva-
sive mechanical ventilation) in Zagazig University Hospitals.
Patients and methods
This was a prospective study included 250 consecutive patients
hospitalized for CAP at Chest and Tropical medicine Departments
and ICUs at Zagazig University Hospitals, Egypt in the period
between May 2016 and November 2016. Informed consent was
taken from all patients before being enrolled in the study.
Inclusion criteria: Patients who were 18 years or more, admitted
from the community, had two or more clinical signs and symptoms
related to pneumonia (fever >38 °C, cough, dyspnea, chest pain or
crackles on auscultation), and presented by new infiltration on
chest radiography were included in the study. CAP was diagnosed
according to Infectious Disease Society of America (IDSA)/Ameri-
can Thoracic Society (ATS) guidelines on the management of
community-acquired pneumonia in adults [9].
Patients were excluded if: they were immunocompromised
(using immunosuppressive drugs, having a human immunodefi-
ciency virus infection, malignancy), had been admitted to hospital
and/or used any antibiotic in last two weeks.
All the data were collected from each subject, including demo-
graphic data, co-morbidity diseases, physical examination, labora-
tory and radiologic findings. The laboratory findings were analyzed
within 24 h after admission including (CBC, Liver and kidney func-
tion tests, ABG, Fasting blood glucose, Serum Na+, Serum LDH and
blood culture).
The diagnosis of comorbid diseases was done: COPD was diag-
nosed by history, clinically, radiologically and spirometry if possi-
ble. Liver cirrhosis was diagnosed clinically, laboratory and
radiologically, cirrhotic patients were classified according to Child
Pugh scores, into grade A, B, C [10]. Congestive heart failure was
confirmed by history, clinically and echocardiogram. Cerebrovas-
cular disease diagnosed by history, clinically, CT and/or MRI.
Direct admission to ICU was done if the patient had one major
or 3 minor of the criteria according to IDSA/ATS guidelines [9]. The
diagnosis of sepsis was done according to the International Con-
sensus Criteria published in 2003 [11].
The scores of PSI, CURB-65, and expanded CURB-65 were calcu-
lated for all patients. Patients were subsequently classified into
two levels of risk groups: (a) PSI: Non-severe risk group (classes
I-III); and severe risk group (class IV, V); (b) CURB-65: Non-
severe risk group (scores 0–2) and severe risk group (scores 3–5)
(c) Expanded CURB-65: Non-severe risk group (score 0–4) and sev-
ere risk group (score 5–8) [12–14].
The final outcomes: Length of stay (LOS) in hospital, ICU admis-
sion, 30-day mortality after hospital admission and need for inva-
sive mechanical ventilation were compared.
Statistical analysis
All data were collected, tabulated and statistically analyzed
using SPSS 20.0 for windows (SPSS Inc., Chicago, IL, USA) and Med-
Calc 13 for windows (MedCalc Software bvba, Ostend, Belgium).
Quantitative data were expressed as median (IQR), and qualitative
data were expressed as absolute frequencies (number) & relative
frequencies (percentage). Percent of categorical variables were
compared using Chi-square test or Fisher’s exact test when appro-
priate. To determine predictors for 30 day-mortality, univariate
logistic regression was done. Multivariate logistic regression anal-
ysis model was done by enter method. Receiver operating charac-
teristic (ROC) curve analysis was used to identify optimal cut-off
values of PSI, CURB-65 and expanded CURB-65 with maximum
sensitivity and specificity for prediction of ICU admission,
30 day-mortality, LOS > 8 days and need for invasive MV. Area
under Curve (AUROC) was also calculated, criteria to qualify for
AUC were as follows: 0.90–1 = excellent, 0.80–0.90 = good, 0.70–
0.80 = fair; 0.60–0.70 = poor; and 0.50–0.6 = fail. The optimal cutoff
point was established at point of maximum accuracy. All tests
were two sided. P < 0.05 was considered statistically significant
(S), p < 0.001 was considered highly statistically significant (HS),
and p P 0.05 was considered non statistically significant (NS).
Results
Patients’ characteristics and outcomes of the CAP patients
enrolled in the study were summarized in (Table 1). The mean
age for overall patients was 59.17 ± 14.04 years, 62.8% of patients
were males and 37.2% were females. 56% of all patients had comor-
bid diseases: COPD (11.6%), congestive heart failure (10%), DM
(16.4%), chronic renal diseases (4.8%), cerebrovascular diseases
(6.4%) and liver cirrhosis patients were 17 (6.8%) who classified
according to child Pugh into Grade A: 4 patients (23%), Grade B:
8 patients (47%), Grade C: 5 patients (30%) (Data not shown).
Some laboratory findings which were done within 24 h of hos-
pital admission: Platelet count <100
103/mm3 was present in 57
patients (32 patients had severe sepsis, 8 patients had known liver
cirrhosis), Albumin < 3.5 g/dl was present in 83 patients (17
patients had known liver cirrhosis), serum LDH > 230 U/L was pre-
sent in 112 patients.
As regards patients0 outcomes: Intensive care unit (ICU) admis-
sion rate was 29.6%, the median length of hospital stay was 8 days
and the overall 30-day mortality rate was 11.2%. 23.6% of patients
needed invasive mechanical ventilation.
 S.M. Shehata et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 549–555 551

Table 1 analysis showed that (age P 65 years, LDH > 230 u/L,
Patients’ characteristics and outcomes of CAP patients enrolled in the study. Albumin < 3.5 g/dL, Platelet count < 100
109/L, SBP < 90 mmHg
CAP patients (N = 250) or DBP 6 60 mmHg, septic shock and Confusion) were the inde-
No. % pendent predictors of the 30-day mortality in the studied patients.
Patients0 outcomes including (ICU admission, LOS, need for
Age
Mean ± SD (years) 59.17 ± 14.04
mechanical ventilation and 30-day mortality) in relation to differ-
Age P 65 years 110 44% ent severity scoring systems were presented in (Table 3): There
Sex
was statistical significant difference between both subgroups of
Male 157 62.8% Expanded CURB-65 score as regards median LOS (P-value 0.001).
Female 93 37.2% The 30-day mortality was lower in expanded CURB-65 score (1–
Comorbidities 140 56% 4) about 4.1% than PSI class (I–III) was 4.9% and lastly CURB-65
Congestive heart failure 25 10% score (0–2) which was 6.1%. While, the 30-day mortality was
COPD 29 11.6% higher in expanded CURB-65 score (5–8) about 25.9% than PSI class
Chronic renal diseases 12 4.8%
(IV–V) was 14.2% and lastly CURB-65 score (3–5) which was 18.4%.
Chronic liver diseases 17 6.8%
Cerebrovascular diseases 16 6.4% Also, there was very high significance difference between both
Diabetes mellitus 41 16.4% subgroups of Expanded CURB-65 score as regards 30-day mortality
Physical and laboratory findings at hospital admission (P-value < 0.001). expanded CURB-65 score (5–8) was associated
Confusion 39 15.6% with more frequent ICU admission about 49.4% than PSI class
Respiratory rate P 30/min 155 62% (IV-V) which was 32.5% and lastly CURB-65 score (3–5) was
Heart rate P 125/min 72 28.8%
39.8%, with statistical significant difference between subgroups
SBP < 90 mmHg or DBP 6 60 mmHg 92 36.8%
LDH > 230 U/L 112 44.8%
of both expanded CURB-65 and PSI scores (P-value < 0.001). Lastly,
Platelet count < 100
103/mm3 57 22.8% as regards the need for mechanical ventilation there was no statis-
Albumin < 3.5 g/dl 83 33.2% tical significance difference between either subgroups of all the
Patients0 outcomes three scores. Expanded CURB-65 was correlated with severity of
LOS: Median (IQR) days 8 (6–12) liver disease guided by child pugh score (r (0.34) p-value (0.01)
30-day mortality 28 11.2% (Data not shown).
ICU admission 74 29.6%
At AUC of ROC curve, Sensitivity and negative predictive values
Need for invasive mechanical ventilation 59 23.6%
for prediction of 30-day mortality in Expanded CURB-65, PSI and
N = Total number of patients; Quantitative data were expressed as mean ± SD; CURB-65 scores were (75%, 60.71% and 53.57%) and (95.9%, 94.4%
Qualitative data were expressed as number (percentage).
and 93.2%) respectively. The expanded CURB-65 scoring system
was the best predictor of 30-day mortality in CAP patients as it
had the largest AUC (0.793) p-value < 0.0001, which was signifi-
Analysis of some Risk factors (measured immediately on hospi- cantly higher than PSI > 3 (AUC 0.740,) and CURB-65 > 3 (AUC
tal admission) and their relation to 30-day mortality using univari- 0.706). (Table 4 and Fig. 1).
ate and multivariate regression analyses (Table 2): univariate At AUC of ROC curve, the sensitivity of the three scoring systems
analysis showed that the following risk factors (age P 65 years, for prediction of ICU admission (expanded CURB-65, PSI and the
LDH > 230 u/L, Albumin < 3.5 g/dL, Platelet count < 100
109/L, CURB-65 score) were 45.45%, 21.21% and 30.30% respectively
Confusion, Respiratory rate P 30/min, SBP < 90 mmHg or (Table 5). AUC of expanded CURB-65 score was 0.631 (p-value
DBP 6 60 mmHg, HR P 125 bpm, septic shock, some comorbid dis- 0.0003), which was significantly higher than PSI (AUC 0.578) and
eases e.g. COPD and liver cirrhosis) were significantly associated CURB-65 score (AUC 0.545) (Fig. 2).
with increased the 30-day mortality in our CAP patients. The num- At AUC of ROC curve, the sensitivity of the three scoring systems
ber of CAP patients died from COPD and liver cirrhosis were (8 for prediction of invasive mechanical ventilation (expanded
patients (27.6%), P-value 0.008) and (7 patients (41.2%), P-value CURB-65, PSI and the CURB-65) were 30.51%, 20.34% and 32.20%
0.001) respectively. Mortality rate increased with the severity of respectively (Table 6). AUC of expanded CURB-65 score was
liver cirrhosis (3 patients and 4 patients) were died in Child Pugh 0.588 (p-value 0.0459), which was significantly higher than PSI
grades B, C respectively (Data not shown). While the multivariate (AUC 0.561) and CURB-65 score (AUC 0.521) (Fig. 3).

Table 2
Univariate and multivariate analyses of some risk factors associated with 30-day mortality in CAP patients.

Univariate analysis Multivariate analysis

b OR (95%CI) p B OR (95%CI) p
Age P 65 years 0.981 3.01 (1.87–4.85) <0.01 0.63 1.88 (1.06–3.32) 0.03
Confusion 2.064 7.87 (3.36–18.42) <0.001 1.553 4.72 (1.50–14.80) 0.008
RR P 30/min. 1.142 3.13 (1.14–8.54) 0.026 0.143 1.15 (0.27–4.77) 0.844
SBP < 90 mmHg or DBP 6 60 mmHg 1.108 3.02 (1.35–6.79) 0.007 0.67 1.95 (1.25–3.03) <0.01
HR P 125/min 1.206 3.34 (1.49–7.44) 0.003 0.036 1.03 (0.24–4.46) 0.962
Septic shock 2.189 8.92 (3.55–22.44) <0.001 1.931 6.89 (1.90–24.94) 0.003
LDH > 230 U/L 3.023 20.55 (4.75–88.81) <0.001 2.527 12.51 (2.49–62.72) 0.002
Platelet count < 100
103/mm3 2.144 8.53 (3.67–19.79) <0.001 1.964 7.12 (1.43–35.34) 0.016
Albumin < 3.5 g/dl 0.659 2.01 1.36–3.06 <0.01 0.82 2.22 0.80–3.90 0.02
Chronic liver diseases 1.683 5.38 (1.24–23.33) 0.025 0.654 1.92 (0.33–10.96) 0.462
COPD 0.861 2.38 (1.48–3.84) <0.01 0.13 0.13 (0.65–2.02) 0.65
Constant 5.503

b: regression coefficient; CI: confidence interval; OR: Odds Ratio, p < 0.05 is significant.
552 S.M. Shehata et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 549–555

Table 3
30 day-mortality rate, ICU admission rate, LOS and need for invasive mechanical ventilation in subgroups of PSI, CURB-65 and expanded CURB-65.

Subgroup All LOS 30 day-mortality ICU admission Invasive Mechanical

ventilation
No. (%) Median (IQR) No. (%) No. (%) No. (%)
PSI class
I–III 81 (32.4%) 7 (5–10) 4 (4.9%) 19 (23.5%) 16 (19.7%)
IV–V 169 (67.6%) 9 (7–13) 24 (14.2%) 55 (32.5%) 43 (25.4%)
P-value 0.385 0.03 <0.001 0.052
CURB-65 score
0–2 147 (58.8%) 9 (6–13) 9 (6.1%) 33 (22.4%) 31 (21.1%)
3–5 103 (41.2%) 8 (7–10) 19 (18.4%) 41 (39.8%) 28 (27.2%)
P-value 0.833 0.002 0.956 0.926
Expanded CURB-65 score
0–4 169 (67.6%) 8 (6.5–12) 7 (4.1%) 34 (20.1%) 26 (15.4%)
5–8 81 (32.4%) 9 (6–12) 21 (25.9%) 40 (49.4%) 33 (40.7%)
P-value 0.001 <0.001 <0.001 0.061

Table 4
The accuracy of different scoring systems in predicting 30-day mortality.

Scoring system Threshold AUC (95% CI) P-value Sensitivity (95% CI) Specificity (95% CI) PPV NPV
PSI >3 0.740 <0.0001 60.71 82.88 30.9 94.4
CURB-65 >3 0.706 0.0005 53.57 80.18 25.4 93.2
Expanded CURB-65 >4 0.793 <0.0001 75.00 72.97 25.9 95.9

predicting CAP patients0 outcomes (ICU admission, Length of hospi-

Fig. 1. The ROC curves for prediction of 30-day mortality for each scoring system.
Discussion
Assessment of severity and site of care decisions for
community-acquired pneumonia patients (CAP) are very impor-
tant for patients’ safety and optimal use of resources. Late admis-
sion to the intensive care unit (ICU) leads to increase the rate of
mortality in CAP [15]. The purpose of our study was to evaluate
effectiveness of the new expanded CURB-65 score in comparison
with other pneumonia severity scoring systems (PSI, CURB-65) in
tal stay, 30-day mortality and need for invasive mechanical
ventilation).
This study revealed that 56% of all CAP patients had comorbid
diseases. Irfan et al. [16] showed that Comorbid illnesses were pre-
sent in 63.5% patients with community acquired pneumonia in a
developing country. Also, Walden et al. [17] concluded that about
62% of patients had one or more co-morbid conditions.
As regards patients0 outcomes, we found that Intensive care unit
(ICU) admission rate of CAP patients was 29.6%, the median length
of hospital stay was 8 days. The overall 30-day mortality rate was
11.2% and 23.6% of patients needed invasive mechanical ventila-
tion. Our results were in accordance with Irfan et al. [16] who
found that the overall mortality in their study population was
11%. On the other hand, Zhang et al. [18] found that the overall
30-day mortality rate was 15.7%, Intensive care unit (ICU) admis-
sion rate was 5.8% and the median length of hospital stay was four
days. Also, Liu et al. [8] concluded that the median length of stay
(LOS) was 10 day and the 30-day mortality was 8.48%. Buising
et al. [5] and Shah et al. [19] stated that ICU admission rates were
6.6% and 23.3%, respectively.
The considerable difference in admission policies, study design,
guidelines compliance, availability of free beds and severity scor-
ing in different studies may be responsible for the wide range of
reported mortality rates. A lot of these studies have used ICU
admission rather than severity scores to indicate severe disease.
Also, the different studies may include wide variety of patients cat-
egories (immunocompetent and immunosuppressed) which could
affect mortality rates [20,21].
Also, our ICU admission rates were higher than previous studies
as many factors play a crucial role in the decision on ICU admis-
sion, patient’s age, unstable comorbid diseases, long-term progno-

Table 5
The accuracy of different scoring systems in predicting ICU admission.

Scoring system Threshold AUC (95% CI) P-value Sensitivity (95% CI) Specificity (95% CI) PPV NPV
PSI >4 0.578 0.0222 21.2 97.35 84 65.3
CURB-65 >3 0.545 0.2343 30.3 80.79 50.8 63.9
Expanded CURB-65 >4 0.631 0.0003 45.5 76.16 55.6 68
 S.M. Shehata et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 549–555
Fig. 2. The ROC curves for prediction of ICU admission for each scoring system.
sis and the severity of disease are often the determinant factors
[18].
CAP is associated with high mortality as it is a complex inflam-
matory disease and serious clinical deterioration can occur due to
different processes: respiratory failure, cardiovascular failure, and
destabilization of a preexisting comorbidity, inappropriate initial
antibiotic therapy, or hospital-acquired illnesses. There is no single
clinical rule has sufficient criteria to be useful in this wide range of
evolution profiles [15].
The current study suggested that Hypoalbuminemia on admis-
sion is an independent risk factor of increased mortality among
CAP patients which was agreed with the following studies: Irfan
et al. [16] found that low serum albumin <2.2 g/l and Abnormal
liver function test were significantly associated with increased
mortality. Also, the serum albumin level on admission was a good
predictor of mortality in CAP patients [4] [22]. Physicians should
consider albumin level when evaluating the severity of community
acquired pneumonia. Hypoalbuminemia is a predictor of worse
prognosis in hospitalized and critically ill patients [23].
Low albumin level may relate to high prevalence of undiag-
nosed chronic liver disease or other diseases. Malnutrition, which
is common in elderly hospitalized patients [24]. During acute
infection, decreased albumin levels are also directly caused by
underlying inflammatory process. The endotoxin from Gram nega-
tive bacteria, cytokines like IL-6 inhibits albumin synthesis in the
hepatocytes, as well as increases albumin catabolism and redistri-
bution to the extravascular compartment, the end result is reduced
circulatory albumin level. Also, Cytokines produced during inflam-
mation shift amino acids to increase synthesis of acute phase pro-
tein important to the inflammatory process [25,26].
In this study, Platelet count < 100
103/mm3 was present in 57
patients on admission; thrombocytopenia (platelet count < 105/
mL) was independent risk factors for death. Also, Brogly et al.
[27] concluded that the prognostic impact of platelets in severe
Table 6
The accuracy of different scoring systems in predicting the need for invasive mechanical ventilation.
Scoring system Threshold AUC (95% CI)
PSI >4 0.561
CURB-65 >3 0.521
Expanded CURB-65 >5 0.588
553
CAP patients admitted to ICU was the lower the initial platelet
count; the higher was the mortality rate. Elzey et al. [28] stated
that thrombocytopenia is also a marker of poor outcomes in
patients with pneumonia, as the low platelet counts are associated
with disseminated intravascular coagulation, severe sepsis and
chronic liver diseases.
Platelets play an important role in antimicrobial host defenses
and the coagulation system. An abnormal platelet count may
assess severity of disease in patients with CAP. That is most prob-
ably due to lack of effect of platelets that tend to compartmentalize
the infection so spread of infection occurs with more systemic
complications [29,30]. The mechanisms of thrombocytopenia in
patients with sepsis are secondary to: Platelets activation and their
binding to endothelium, resulting in sequestration and destruction.
Immune-mediated mechanisms as nonspecific platelet-associated
antibodies and cytokine-driven hemophagocytosis of platelets
can also contribute to sepsis-induced thrombocytopenia. Patients
with thrombocytopenia had more attacks of major bleeding,
increased incidence of acute renal injury, and prolonged ICU stay
[31,32].
Elevated serum LDH level (>230 u/L) was independent risk fac-
tors for death in our study which is agreed with Liu et al. [8] study.
Also, Ewig et al. [33] found that the high serum LDH values were
associated with increased mortality in CAP patients. The higher
serum LDH level can indicate severe complications and worse
prognosis.
LDH is a cytoplasmatic enzyme expressed in almost all types of
body cells. It is released into blood when cell injury or death
caused by ischaemia, excess heat or cold, starvation, dehydration,
bacterial toxins, drugs and chemical poisonings. So, the leakage
of LDH from even a small scale of injured tissue can result in a sig-
nificantly elevated serum level [34]. Drent et al. [35] concluded
that the elevated LDH in serum can help determine the extent of
lung tissue damage and inflammation in bacterial pneumonia.
We found also, that some comorbid diseases (COPD and liver
cirrhosis) were associated with death in CAP patients, (P-value
0.008 and 0.001) respectively. Mortality rate increased with the
severity of liver cirrhosis. These results were in agreement with
Viasus et al. [36] who concluded that early and overall mortality
rates were higher in cirrhotic patients than in those without cir-
rhosis, and increased with the severity of liver dysfunction. Hung
et al. [37] found that pneumonia had about 3-fold increased mor-
tality among cirrhotic patients with ascites, compared to the mor-
tality of cirrhotic patients without pneumonia.
CAP is one of the most common bacterial infections in patients
with cirrhosis, and about 13%–20% of bacterial infections in cir-
rhotic patients are caused by pneumonia [38]. High mortality of
pneumonia in cirrhotic patients may be due to significant
immunologic disturbance with abnormal cytokine level, decrease
macrophage activation, decrease bactericidal activity of polymorph
nuclear leukocyte and low complement levels. So, cirrhotic
patients are more liable to mortality during CAP than general pop-
ulation, even if they receive antibiotics [39,40].
Braeken et al. [41] concluded that COPD is a common comorbid-
ity of CAP and associated with increased short- and long-term mor-
tality. The risk of death due to CAP in COPD patients was twice high
than CAP-only patients. Other studies observed no differences in
P-value Sensitivity (95% CI) Specificity (95% CI) PPV NPV
0.1350 20.34 93.19 48.0 79.1
0.6563 32.20 79.06 32.2 79.1
0.0459 30.51 86.39 40.9 80.1
554 S.M. Shehata et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 549–555
Fig. 3. The ROC curves for prediction of need for Invasive MV for each scoring
system.
short-term mortality comparing CAP-COPD patients with CAP-
only. The discrepancies found can be due to inclusion of ICU
patients with very severe pneumonia, differences in severity of
COPD patients, variability in other patients’ characteristics, such
as age, comorbidities and the initiated therapy [42,43].
As regards, patients0 outcomes including (ICU admission, LOS,
30-day mortality and need for invasive mechanical ventilation) in
relation to different severity scoring systems in the current study:
There was statistical significant difference between both sub-
groups of Expanded CURB-65 score as regards median LOS (P-
value 0.001). This result was in agreement with the previous study
done by Liu et al. [8] in which Expanded-CURB-65 scores were pos-
itively associated with median LOS.
The comparison between 30-day mortality rates in different
risk classes in this study and that of the previous studies Fine
et al. [3], Ewig et al. [44] and Liu et al. [8] showed that the mortality
rates progressively increase with increasing risk scores in different
scoring systems.
In the current study, the mortality rates in the different risk
classes of the three scoring systems (Expanded CURB-65 score,
CURB-65 and PSI) nearly were lower compared to the study by
liu et al. [8]. This discrepancy may be due to Low ICU admission
rate in the other study, as a portion of patients died before reaching
the ICU due to the shortage of ICU resources and financial support,
other factor that may contribute to higher mortality in the other
study was older patients who included in that study (mean age
64 ± 19 years and incidence of patients older than 65 years was
53.7%, while in our study the mean age was 59.17 ± 14.04 years,
and only 44% of patients were older than 65 years.
This study revealed that Expanded CURB-65 score (0–4) had
lower mortality rates than other two scoring systems. Also, the
Expanded CURB-65 score (5–8) had higher mortality rates than
CURB-65 and PSI. There was very high significance difference
between both subgroups of Expanded CURB-65 score as regards
30-day mortality (P-value < 0.001). So, in our study the expanded
CURB-65 approach may be ideal for identifying both low mortality
and high mortality risk patients with severe illness.
CURB-65 had higher mortality rates than PSI in all severity
levels, in the current study which was in accordance with the fol-
lowing studies: Shah et al. [19] and Zhang et al. [18] demonstrated
that CURB-65 had higher mortality rates than PSI in all severity
levels. So, CURB-65 underestimated the severity and misclassified
some patients with high risk of death into the low risk classes.
Expanded CURB-65 score (5–8) was associated with more fre-
quent ICU admission about 49.4% than PSI class (IV-V) and CURB-
65 score (3–5), with statistical significant difference between sub-
groups of both expanded CURB-65 and PSI scores (P-value < 0.001).
So both expanded CURB-65 and PSI scores can identify the severe
CAP patients who need ICU admission, better than CURB-65 score.
Man et al. [45] concluded that all three predictive rules (PSI, CURB-
65 and CRB-65) had a similar performance in predicting the sever-
ity of CAP, but CURB-65 was more applicable than the other two for
use in the emergency department as it is simple and can identify
low-risk patients. Liu et al. [8] didn’t assess the ICU admission as
a patient outcome in different scoring systems as some patients
died before reaching the ICU due to the shortage of ICU resources
and financial support. Charles et al. [6] suggested that neither PSI
nor CURB-65 was designed to identify patients who need ICU
referral.
In current study demonstrated that the Expanded CURB-65
score gave the most sensitive prediction of mortality (75%) with
the highest NPV (95.9%). The expanded CURB-65 scoring system
was the best predictor of 30-day mortality in CAP patients as it
had the largest AUC (0.793) p-value < 0.0001). These results were
comparable with Liu et al. [8] study in which the overall sensitivity
and specificity of expanded-CURB-65 were superior (AUC = 0.826)
to other score systems, of which the AUCs were 0.801, 0.756 for
PSI, CURB-65 respectively in predicting the 30-day mortality.
PSI which consists of 20 variables and it is accurate in predicting
the 30-day mortality, but its complexity decreases its clinical
application. Contrarily, CURB-65 is simple score. However, the
age and complications of patients carry heavier weight, underesti-
mating the potential severity in young patients and falsely refer-
ring the elderly CAP patients as severe [5]. The new expanded-
CURB-65 score significantly improves the identification of high-
risk patients, through decreasing the relative weight of age and
blood pressure, and eliminating the use of imaging and comorbid
diseases in the calculation [8].
In this study, At AUC of ROC curve, the sensitivity of the
expanded CURB-65 score for prediction of ICU admission was
higher than other two scores and AUC of expanded CURB-65 score
was 0.631 (p-value 0.0003) So, the expanded CURB-65 score was
better than the other two scores in predicting the severe patients
who needed the ICU admission. But, the sensitivity of expanded
CURB-65 score in our study was still lower than the previous stud-
ies and the AUC was also, smaller than other studies, so larger
number of studied patients and multicenter research were needed
to improve our sensitivity and AUC.
Previous studies assessed only PSI and CURB-65 as predictors of
ICU admission, but there were great debates in those studies. Shah
et al. [19] concluded that the PSI class PIV is more sensitive in pre-
dicting ICU admission than CURB-65 class PIII; as CURB-65 class
PIII has a higher specificity (84.4%) than PSI class PIV (60.9%).
Buising et al. [5] suggested that CURB-65 had a sensitivity of only
57.7% for ICU admission. PSI classes IV + V had a sensitivity of 84%,
with this tool, younger patients were less likely to be identified as
‘‘severe’’ as they needed to qualify for three of the remaining four
criteria (after excluding age). The PSI is a well validated tool and
performed well for the different outcomes of interest. CURB is a
simple tool which showed comparable performance to the PSI.
Lastly, At AUC of ROC curve, the sensitivity of the expanded
CURB-65 score for prediction of invasive mechanical ventilation
was better than the other two scores. AUC of expanded CURB-65
score was 0.588 (p-value 0.0459), which was significantly higher
than PSI (AUC 0.561) and CURB-65 score (AUC 0.521). But, these
low sensitivity and very small AUC were poorly predict the need
for invasive mechanical ventilation in CAP patients. Chalmers
 S.M. Shehata et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 549–555
et al. [46] reported that both CURB65 and PSI had high specificity
but low sensitivity (89.6% and 54.5%) and (82.8% and 54.5%)
respectively in predicting the requirement for mechanical ventila-
tion and/or inotropic support. These scores should be used only in
conjunction with a formal clinical assessment.
The current study had some limitations. First, relatively small
number of studied patients compared to other studies. Second, this
work did not study etiologic diagnosis of CAP in the studied
patients to identify causative organisms & their relation to risk fac-
tors of mortality. Third, multicenter research was needed to
improve the sensitivity and the negative predictive values of the
new expanded CURB-65 score in predicting the ICU admission
and need for mechanical ventilation.
Conclusions
Expanded CURB-65 score is simple, objective and more accurate
scoring system for evaluation of CAP severity and can improve the
efficiency of predicting the mortality in CAP patients, better than
CURB-65 and PSI scores.
Expanded CUEB-65 may generate new therapeutic and prog-
nostic modality in CAP especially in patients with liver cirrhosis.
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