Criteria for Hospital Admission in Pneumonia
Patients with pneumonia should be hospitalized if they have a CURB-65 score ≥2 or meet PSI risk class IV-V, with additional consideration for those who cannot safely take oral medications, have decompensated comorbidities (including COPD exacerbations or heart failure), or have hypoxemia (oxygen saturation <90% or PaO2 <60 mmHg). 1
Primary Severity Assessment Tools
Use CURB-65 or PSI as your initial risk stratification:
CURB-65 Scoring System
- Confusion (new-onset disorientation to person, place, or time) 1
- Urea >7 mmol/L (BUN ≥20 mg/dL) 1
- Respiratory rate ≥30 breaths/min 1
- Blood pressure (systolic <90 mmHg or diastolic ≤60 mmHg) 1
- Age ≥65 years 1
Admission recommendations based on CURB-65: 1
- Score 0-1: Outpatient treatment appropriate
- Score ≥2: Hospitalization or intensive home health services warranted
- Score 3-5: Consider ICU admission
Pneumonia Severity Index (PSI)
- Risk classes I-III: Generally suitable for outpatient management 1
- Risk classes IV-V: Hospitalization recommended 1
Critical Admission Criteria Beyond Severity Scores
The following factors mandate hospital admission regardless of low severity scores: 1
Respiratory Compromise
- Oxygen saturation <90% or PaO2 <60 mmHg (this was added as a "margin of safety" even for PSI risk classes I-III) 1
- Respiratory rate >30 breaths/min 1
Hemodynamic Instability
Inability to Maintain Oral Intake
Decompensated Comorbidities
- COPD exacerbation requiring hospitalization 1
- Heart failure decompensation 1
- Diabetes mellitus with poor control 1
- Chronic renal disease 1
Complications of Pneumonia
- Pleural effusion 1
- Multilobar involvement 1
- Radiographic progression (increase in opacity by ≥50% within 48 hours) 1
Social and Functional Factors
- Homelessness 1
- Severe psychiatric illness 1
- Injection drug abuse 1
- Poor functional status or cognitive dysfunction 1
- No available caregiver for dependent patients 1
Immunocompromised States
Failed Outpatient Treatment
- Lack of response to previous adequate empirical antibiotic therapy 1
ICU Admission Criteria
Direct ICU admission is indicated for patients meeting major criteria or ≥3 minor criteria: 1, 3
Major Criteria (Absolute ICU Indications)
Minor Criteria (≥3 Required for ICU)
- Respiratory rate ≥30 breaths/min 1, 3
- PaO2/FiO2 ratio ≤250 (or <200 if COPD present) 1
- Multilobar infiltrates 1, 3
- Confusion/disorientation 1, 3
- BUN ≥20 mg/dL 1, 3
- Leukopenia (WBC <4,000 cells/mm³) from infection alone 1, 3
- Thrombocytopenia (platelets <100,000 cells/mm³) 1, 3
- Hypothermia (core temperature <36°C) 1, 3
- Hypotension requiring aggressive fluid resuscitation 1, 3
Additional ICU Considerations
- Need for vasopressors >4 hours 1
- Urine output <20 mL/hour (without hypovolemia) 1
- Severe acidosis (pH <7.30) 1
- Acute renal failure requiring dialysis 1
Common Pitfalls to Avoid
Do not rely solely on severity scores without clinical judgment: 1
- A healthy 25-year-old with severe hypotension and tachycardia may score PSI class II but clearly requires admission 1
- Elderly patients with minimal comorbidities may score high on PSI but be clinically stable 1
Recognize that CURB-65 may underestimate risk in elderly patients with comorbidities, while PSI may underestimate severity in young patients with acute respiratory failure. 1
Approximately 45% of patients ultimately requiring ICU care are initially undertriaged—maintain high vigilance for clinical deterioration. 4
Dynamic reassessment over several hours is more accurate than a single point-in-time score. 1