PSI/PORT Score: Pneumonia Severity Index for CAP

Why Use

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.

When to Use

The PSI/PORT Score can be used in the clinic or emergency department setting to risk stratify a patient’s community acquired pneumonia.

Formula

Pearls / Pitfalls

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.

Management

Step 1: 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. Step 2: 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: Score Risk Disposition ≤70 Low risk Outpatient care 71-90 Low risk Outpatient vs. Observation admission 91-130 Moderate risk Inpatient admission >130 High risk Inpatient admission

Critical Actions

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.

Advice

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.

More Information

Score interpretation: Risk Class Risk Point Value I Low None from Comorbidities, PE findings, or Lab findings II Low ≤70 points III Low 71-90 IV Moderate 91-130 V High >130 total points