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.[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
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.