Pneumonia diagnostic algorithm
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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
❑ 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:
Does the patient meets any of the following criteria for HCAP?
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?
The patient has HCAP
Admit the patient and administer empiric inpatient antibiotic regimen
Administer empiric outpatient antibiotic regimen
CURB-65 Clinical Prediction Rule
CURB-65 is a clinical prediction rule that has been validated for predicting mortality in community-acquired pneumonia and infection of any site. The CURB-65 is based on the earlier CURB score and is recommended by the British Thoracic Society for the assessment of severity of pneumonia.
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:
|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|
Interpretation of CURB-65: Risk of Death from any Infection
- 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.
- Respiratory rate >30 breaths/min
- PaO2/FiO2 ratio <250
- Multilobar infiltrates
- 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:
- Temperature > 100 degrees F (37.8 degrees C)
- Pulse > 100 beats/min
- Decreased breath sounds
- Absence of asthma
|Number of Findings||Primary Care||Emergency Room|
Pneumonia Severity Index (PSI)
The pneumonia severity index (PSI), also known as PORT score, is a clinical prediction rule that medical practitioners can use to calculate the probability of morbidity and mortality among patients with community acquired pneumonia.
Development of the PSI
The rule uses demographics (whether someone is older, and is male or female), the coexistence of core morbid illnesses, findings on physical examination and vital signs, and essential laboratory findings. This study demonstrated that patients could be stratified into five risk categories, Risk Classes I-V, and that these classes could be used to predict 30-day survival.
Data Source for Derivation and Validation
The rule was derived then validated with data from 38,000 patients from the MedisGroup Cohort Study for 1989, comprising 1 year of data from 257 hospitals across the US who used the MedisGroup patient outcome tracking software built and serviced by Mediqual Systems (Cardinal Health). One significant caveat to the data source was that patients who were discharged home or transferred from the MedisGroup hospitals could not be followed at the 30-day mark, and were therefore assumed to be "alive" at that time. Further validation was performed with the Pneumonia Patient Outcomes Research Team [PORT] (1991) cohort study. This categorization method has been replicated by others and is comparable to the CURB-65 in predicting mortality.
Usage and Application of the PSI
The purpose of the PSI is to classify the severity of a patient's pneumonia to determine the amount of resources to be allocated for care. Most commonly, the PSI scoring system has been used to decide whether patients with pneumonia can be treated as outpatients or as (hospitalized) inpatients. A Risk Class I pneumonia patient can be sent home on oral antibiotics. A Risk Class II-III pneumonia patient may be sent home with IV antibiotics or treated and monitored for 24 hours in hospital. Patients with Risk Class IV-V pneumonia patient should be hospitalized for treatment.
Calculation of PSI
Risk Class I
Assess the following conditions and assign the corresponding scores:
∑ <70 = Risk Class II
∑ 71-90 = Risk Class III
∑ 91-130 = Risk Class IV
∑ >130 = Risk Class V
PSI Derivation and Validation Data
|Medisgroup Study (1989)||PORT Validation Study (1991) Cohort|
|Derivation Cohort||Validation Cohort||Inpatients||Outpatients||All Patients|
|Risk Class||no. of pts||% died||no. of pts||% died||no. of pts||% died||no. of pts||% died||no. of pts||% died|
Note: % Died refers to 30-day mortality.
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).
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?
Start empirical therapy with combined broad spectrum antibiotics
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Start empirical therapy with limited spectrum antibiotics
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After 2-3 days, check cultures and assess the clinical response based on:
Does the patient improved his clinical status after 48-72 hours?
Assess culture results
Assess culture results
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
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- 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.
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