Pneumonia diagnostic algorithm: Difference between revisions
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==Hospital Acquired Pneumonia | ==Hospital Acquired Pneumonia== | ||
Shown below is an algorithm for the diagnostic approach of Healthcare-associated pneumonia (HCAP), Ventilator-associated pneumonia VAP), and Hospital-acquired pneumonia (HAP).<ref>{{cite journal|title=Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia|journal=American Journal of Respiratory and Critical Care Medicine|volume=171|issue=4|year=2005|pages=388–416|issn=1073-449X|doi=10.1164/rccm.200405-644ST}}</ref> | Shown below is an algorithm for the diagnostic approach of Healthcare-associated pneumonia (HCAP), Ventilator-associated pneumonia VAP), and Hospital-acquired pneumonia (HAP).<ref>{{cite journal|title=Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia|journal=American Journal of Respiratory and Critical Care Medicine|volume=171|issue=4|year=2005|pages=388–416|issn=1073-449X|doi=10.1164/rccm.200405-644ST}}</ref> | ||
Revision as of 19:03, 1 March 2018
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2], Alejandro Lemor, M.D. [3]
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Diagnostic Algorithm
Shown below is an algorithm for the diagnostic approach of pneumonia.[1]
[2]
Abbreviations: HCAP: Healthcare-associated pneumonia; CAP: Community-acquired pneumonia; VAP: Ventilator-associated pneumonia; HAP: Hospital-acquired pneumonia; AMT: Abbreviated mental test score
Physical Examination Findings: | |||||||||||||||||||||||||||||||||||||
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:
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❑ Order a chest X-ray if the patient presents with any of the following:[3]
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Does the patient meets any of the following criteria for HCAP?[4]
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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?
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NO The patient has HCAP | |||||||||||||||||||||||||||||||||||||
CURB-65 Clinical Prediction Rule
CURB-65 is a clinical prediction rule that has been validated for predicting mortality in community-acquired pneumonia[5] and infection of any site[6]. The CURB-65 is based on the earlier CURB score[7] and is recommended by the British Thoracic Society for the assessment of severity of pneumonia.[8]
Calculation of CURB-65
The score is an acronym for each of the risk factors measured. Each risk factor scores one point, for a maximum score of 5:
| Criteria | Score |
| Confusion (defined as an AMT of 8 or less) | 1 |
| Urea greater than 7 mmol/l (Blood Urea Nitrogen > 20) | 1 |
| Respiratory rate of 30 breaths per minute or greater | 1 |
| Blood pressure less than 90 systolic or diastolic blood pressure 60 or less | 1 |
| Age 65 or older | 1 |
Interpretation of CURB-65: Risk of Death from Pneumnoia
The risk of death increases as the score increases.
| CURB-65 Score | Risk of death |
|---|---|
| 0 | 0.7% |
| 1 | 3.2% |
| 2 | 13.0% |
| 3 | 17.0% |
| 4 | 41.5% |
| 5 | 57.0% |
The CURB-65 has been compared to the pneumonia severity index in predicting mortality from pneumonia.[9]
Interpretation of CURB-65: Risk of Death from any Infection
A cohort study of patients with any type of infection (half of the patients had pneumonia), the risk of death increases as the score increases[6]:
- 0 to 1 <5% mortality
- 2 to 3 < 10% mortality
- 4 to 5 15-30% mortality
Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation Criteria for Severe Community Acquired Pneumonia in Adults
The IDSA criteria are used to asses if a patient with community-acquired pneumonia requires ICU admission. Patients with at least one major criteria or ≥ 2 minor criteria should be admitted to the ICU.[10]
Major Criteria
- Invasive mechanical ventilation
- Septic shock with the need for vasopressors
Minor Criteria
- Respiratory rate >30 breaths/min
- PaO2/FiO2 ratio <250
- Multilobar infiltrates
- Confusion/disorientation
- Uremia (BUN >20 mg/dL)
- Leukopenia (WBC <4000 cells/mm3)
- Thrombocytopenia (platelets < 100,000 cells/mm3)
- Hypothermia (temperature <36 degrees C)
- Hypotension that requires aggressive fluid resuscitation
Clinical Prediction Rule for Predicting Pulmonary Infiltrates Based on Clinical Findings
A clinical prediction rule found the five following signs from the medical history and physical examination best predicted infiltrates on the chest radiograph of 1134 patients presenting to an emergency room:[11]
- Temperature > 100 degrees F (37.8 degrees C)
- Pulse > 100 beats/min
- Crackles
- Decreased breath sounds
- Absence of asthma
| Number of Findings | Primary Care | Emergency Room |
|---|---|---|
| 5 | 47% | 75% |
| 4 | 27 | 56 |
| 3 | 8 | 22 |
| 2 | 4 | 11 |
| 1 | 1 | 3 |
| 0 | 1 | 2 |
Hospital Acquired Pneumonia
Shown below is an algorithm for the diagnostic approach of Healthcare-associated pneumonia (HCAP), Ventilator-associated pneumonia VAP), and Hospital-acquired pneumonia (HAP).[12]
High suspicion of HAP, VAP or HCAP | |||||||||||||||||||||||||||||||||||
Obtain sputum or respiratory secretions sample for culture and microscopy | |||||||||||||||||||||||||||||||||||
Does the patient has any of the following risk factors for MDR infection?
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After 2-3 days, check cultures and assess the clinical response based on:
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Does the patient improved his clinical status after 48-72 hours? | |||||||||||||||||||||||||||||||||||
Yes Assess culture results | No Assess culture results | ||||||||||||||||||||||||||||||||||
Positive Culture | Negative Culture | Positive Culture | Negative Culture | ||||||||||||||||||||||||||||||||
De-escalate antibiotics, treat for 7-8 more days and re-evaluate | Consider stopping antibiotics | Adjust antibiotic regimen based on culture susceptibility, look for other infection sites and complications | Look for other pathogens, infection sites and complications | ||||||||||||||||||||||||||||||||
References
- ↑ Mandell, L. A.; Wunderink, R. G.; Anzueto, A.; Bartlett, J. G.; Campbell, G. D.; Dean, N. C.; Dowell, S. F.; File, T. M.; Musher, D. M.; Niederman, M. S.; Torres, A.; Whitney, C. G. (2007). "Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults". Clinical Infectious Diseases. 44 (Supplement 2): S27–S72. doi:10.1086/511159. ISSN 1058-4838.
- ↑ Solomon, Caren G.; Wunderink, Richard G.; Waterer, Grant W. (2014). "Community-Acquired Pneumonia". New England Journal of Medicine. 370 (6): 543–551. doi:10.1056/NEJMcp1214869. ISSN 0028-4793.
- ↑ Watkins RR, Lemonovich TL (2011). "Diagnosis and management of community-acquired pneumonia in adults". Am Fam Physician. 83 (11): 1299–306. PMID 21661712.
- ↑ Attridge RT, Frei CR (2011). "Health care-associated pneumonia: an evidence-based review". The American Journal of Medicine. 124 (8): 689–97. doi:10.1016/j.amjmed.2011.01.023. PMID 21663884. Retrieved 2012-09-02. Unknown parameter
|month=ignored (help) - ↑ Lim WS, van der Eerden MM, Laing R; et al. (2003). "Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study". Thorax. 58 (5): 377–82. PMID 12728155.
- ↑ 6.0 6.1 Howell MD, Donnino MW, Talmor D, Clardy P, Ngo L, Shapiro NI (2007). "Performance of severity of illness scoring systems in emergency department patients with infection". Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 14 (8): 709–14. doi:10.1197/j.aem.2007.02.036. PMID 17576773.
- ↑ Lim WS, Macfarlane JT, Boswell TC; et al. (2001). "Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines". Thorax. 56 (4): 296–301. PMID 11254821.
- ↑ "BTS Guidelines for the Management of Community Acquired Pneumonia in Adults". Thorax. 56 Suppl 4: IV1–64. 2001. PMID 11713364.
- ↑ Aujesky D, Auble TE, Yealy DM; et al. (2005). "Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia". Am. J. Med. 118 (4): 384–92. doi:10.1016/j.amjmed.2005.01.006. PMID 15808136.
- ↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083. Retrieved 2012-09-06. Unknown parameter
|month=ignored (help) - ↑ Heckerling PS, Tape TG, Wigton RS; et al. (1990). "Clinical prediction rule for pulmonary infiltrates". Ann. Intern. Med. 113 (9): 664–70. PMID 2221647.
- ↑ "Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia". American Journal of Respiratory and Critical Care Medicine. 171 (4): 388–416. 2005. doi:10.1164/rccm.200405-644ST. ISSN 1073-449X.