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

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 ❑ Sputum culture ❑ Blood culture if necessary ❑ If suspecting atypical pneumonia 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 meets any of the Severity Criteria? Minor Criteria Respiratory rate >30 breaths/min PaO2/FiO2 ratio <250 Multilobar infiltrates Confusion/disorientation Uremia (BUN level, >20 mg/dL) Leukopenia (WBC count, <4000 cells/mm3) Thrombocytopenia (platelet count, < 100,000 cells/mm3) Hypothermia (core temperature, <36 degrees C) Hypotension requiring aggressive fluid resuscitation Major criteria Invasive mechanical ventilation Septic shock with the need for vasopressors

YES

NO The patient has HCAP

YES Admit the patient and administer inpatient antibiotic regimen

NO Administer outpatient antibiotic regimen