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 has at least 2 of the following CURB65 criteria? Confusion (defined as an AMT of 8 or less) Urea greater than 7 mmol/l (Blood Urea Nitrogen > 20) Respiratory rate of 30 breaths per minute or greater Blood pressure less than 90 systolic or diastolic blood pressure 60 or less Age 65 or older

YES

NO The patient has HCAP

YES Admit the patient and administer empiric inpatient antibiotic regimen

NO Administer empiric outpatient antibiotic regimen