Pneumonia diagnostic algorithm

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

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Diagnostic Algorithm

Shown below is an algorithm for the diagnostic approach of pneumonia.
Abbreviations: HCAP: Healthcare-associated pneumonia; CAP: Community-acquired pneumonia; VAP: Ventilator-associated pneumonia; HAP: Hospital-acquired pneumonia; AMT: Abbreviated mental test score

Symptoms that suggest a lower respiratory tract infection: ❑ Fever ❑ Cough with sputum ❑ Dyspnea ❑ Pleuritic chest pain

Physical Examination Findings: ❑ Fever ❑ Tachypnea ❑ Tachycardia ❑ Dullness to percussion on affected side ❑ Bronchial breath sounds ❑ Rales ❑ Increased vocal fremitus ❑ Pleural friction rub

Order Labs: ❑ Complete blood count (CBC) ❑ Blood urea nitrogen (BUN) ❑ Sputum gram stain and culture ❑ Blood culture and ABG if necessary If atypical pneumonia is suspected, obtain: ❑ Urine legionella antigen, rapid influenza test ❑ Enyzme Immunoassay ❑ Immunofluorescence ❑ Polymerase chain reaction (PCR) for atypical and viral including influenza

❑ Order a chest X-ray if the patient presents with any of the following: Fever (>37.8° C / 100° F) Tachypnea (> 20 breaths/min) Tachycardia (> 100 bpm) Decreased breath sounds and crackles in the physical exam

Does the patient meets any of the following criteria for HCAP? Hospitalized in an acute care hospital for 2 or more days within 90 days of the infection; Resided in a nursing home or long-term care facility; Received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection; Attended a hospital or hemodialysis clinic

YES

NO The patient has CAP

Does the infection occurred ≥48 hours after admission and it was not present at admission?

Does the patient has at least 2 of the following CURB65 criteria? Confusion (AMT ≤8) Urea greater than 7 mmol/l (BUN > 20) Respiratory rate ≥ 30 breaths/min Blood pressure ≤ 90 systolic or ≤ 60 diastolic Age 65 or older

YES If the patient had an endotracheal tube placed ≥48 hours ago, suspect VAP. Otherwise, the patient has HAP

NO The patient has HCAP

YES Admit the patient and administer empiric inpatient antibiotic regimen

NO Administer empiric outpatient antibiotic regimen