The editorial about recent changes in pneumonia1 addresses treatment as regards early antibiotics and dilemmas regarding steroids. However, there is one early step that needs further attention, and this has not even received a brief mention.

Deciding whether a patient is at high risk and in need of early hospitalization needs further consideration. Several different scales are used to assess risk, such as the PSI, SMARTCOP, CURB-65 and SOAR, but the use of these tools in primary care is considerably hampered by limited access to some parameters (for example urea/blood urea nitrogen, or partial arterial oxygen pressure to FIO2 ratio).

In the case of the PSI, which gives better results in low risk patients,2 step 1 is easy enough to apply, but all patients over age of 50 will need further assessment, and this step alone is not enough. Step 2 can still produce scores up to 185 points (class V needs a score over 130, indicating highest risk), even without including the 110 points from laboratory or radiographic findings.

Community acquired pneumonia is still evaluated differently in primary and secondary care. Therefore, we need to work together to create a tool that can be used in the early stages of the disease, based on more than the patient's history, a clinical examination and bedside tests. This would prevent unnecessary admissions and also provide more input in patients at high risk, thus improving outcomes in these populations.

Clearly, existing guidelines must be updated,1 and better assessment algorithms and tools are needed. There is little point in suggesting, for example, that C-reactive protein (CRP) be measured before considering antibiotics,3 if this test, in the UK, is only available in hospitals, and the time spent awaiting results can delay a critical decision. Risk assessment in patients with community acquired pneumonia is already a challenge in general practice.