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A. Considerations in Initial Evaluation navigator

  1. Histor
    1. Timing of symptoms: Chronic versus Acute
    2. Comorbid conditions
  2. Potential Organisms
    1. History of pneumonia
    2. Smoking and COPD History
    3. Recent bronchitis, upper respiratory infection (URI)
    4. Community Acquired Pneumonia (CAP)
    5. Hospital or Long-Term Care Institution Acquired Infection
  3. Immune Status of the Patient
    1. HIV infection - CD4 count critical
    2. Underlying neoplasm, recent chemotherapy
    3. Diabetes mellitus
    4. Chronic renal failure
  4. Age: Child versus Adult (<50 or >50 years)
  5. Neurologic function in patient - risk for aspiration syndromes
  6. Symptoms
    1. Cough (>90%)
    2. Sputum production (66%) - often yellow or yellow-green, may be bloody or absent
    3. Shortness of breath / dyspnea (66%)
    4. Chest Pain (50%) - often pleuritic in nature
    5. Fever
    6. Mental status changes - indicates severe disease, possibly sepsis (bacteremia)
  7. History and physical exam do not reliably predict presence of pneumonia [3]
    1. Chest radiograph absolutely required for diagnosis
    2. Pneumonia Severity Index useful for prognosis and inpatient versus outpatient treatment
    3. Careful evaluation of any new infiltrate in mechanically ventilated patients [2,8]
  8. Administration of antibiotics within 8 hours and obtaining blood cultures within 24 hours of hospital arrival were associated with 10-15% reduced 30-day mortality [4]

B. Evaluation of Acute Pneumonia navigator

  1. History as above
  2. Physical Exam
    1. Focus on evidence fo infection and pulmonary disease
    2. Absence of any vital sign or chest auscaltation abnormalities reduce likelihood of pneumonia in many but not all patients [3]
  3. Chest Radiograph (CXR)
    1. Preferably postero-anterior (PA) and lateral
    2. Lateral Decubitus films (both sides) if effusion present
    3. CXR is absolutely required to reliably rule out and rule in pneumonia [3]
  4. Sputum Gram Stain and Culture
    1. Look for neutrophils, epithelial cells and organisms
    2. Predominance of neutrophils with few epithelial cells suggests good specimen
    3. Presence of many epithelial cells suggests saliva - ignore result
    4. Cultures are nonspecific and must be interpreted in light of Gram stain
  5. Additional Laboratory Evaluations
    1. Complete blood count (CBC) with leukocyte differential
    2. Chemistries
    3. Consider blood cultures (particularly if admitted to hospital) - prior to antibiotics
    4. Consider Arterial Blood Gas (ABG)
    5. HIV testing should be considered, particularly in young persons with pneumonia
    6. Suspected pneumonia in mechanically ventillated patients should be evaluated carefully [2]
    7. Early bronchoscopy with sampling for suspected pneumonia in these patients reduces antibiotic use, organ dysfunction, and mortality [7]
  6. Pleural Effusion
    1. Large effusions must be tapped for diagnostic (and therapeutic) purposes
    2. Key issue is ruling out frank empyema (pus in pleural space)
    3. pH, lactate dehydrogenase (LDH), glucose, protein, Gram stain, full cultures
    4. Infection-associated effusions may be transudates or exudates
    5. Exudates defined as Protein >3g/dL or >50% of serum and LDH>200 or >60% of serum
    6. Empyema defined as very high WBC (often >50,000/µL), frank pus and pH <7.2
  7. Evaluation for tuberculosis if appropriate

C. Pneumonia Severity Index (PSI) [1]navigator

  1. Designed for risk stratification and treatment regimen for community acquired pneumonia
  2. Patients in any of the following groups should have PSI Risk Score calculated:
    1. Age >50 years
    2. Coexisting neoplastic, liver, heart failure, cerebrovascular, renal disease
    3. Respiratory rate (RR) >29/min
    4. Systolic blood pressure (SBP) <90 mm Hg
    5. Temperature <35°C or >39.9°C
    6. Pulse >124 beats/minute
    7. Altered mental status
    8. Patients without these characteristics are PSI Risk Class I
  3. PSI Risk Score
    1. Age: points = age (men) or age-10 (women)
    2. Nursing home resident: 10 points
    3. Neoplastic disease: 30 points
    4. Liver disease: 20 points
    5. Heart failure, cerebrovascular disease, renal disease: 10 points each
    6. Altered mental status, RR >29/min, SBP <90 mm Hg: 20 points each
    7. Temperature <35°C or >39.9°C: 15 points
    8. Pulse >124 beats/minute: 10 points
    9. ABG pH <7.35: 30 points
    10. Blood urea nitrogen (BUN) >29mg/dL, Sodium <130 mmol/L: 20 points each
    11. Glucose >249mg/dL, Hematocrit <30%: 10 points each
    12. Partial pressure arterial oxygen <60mm Hg or oxygen saturation <90% room air: 10 points
    13. Pleural effusion: 10 points
  4. Stratification of PSI Risk Score and 30 Day Mortality
    1. Class I (Low Risk): per algorithm, mortality 0.1%
    2. Class II (Low Risk): Score <71, mortality 0.6%
    3. Class III (Borderline Low Risk): Score 71-90, mortality 0.9%
    4. Class IV (Moderate Risk): 91-130, mortality 9.3%
    5. Class V (High Risk): >130, mortality 27.0%
  5. Recommended Hospitalization [6]
    1. Class IV and V patients
    2. Hypoxemia (<90% oxygen saturation on room air)
    3. Hemodynamic instability
    4. Inability to tolerate oral medications
    5. Active coexisting condition requiring hospitalization
    6. Consider brief hospitalization for Class III patients
    7. Frail physical condition, previous no response to oral therapy, consider hospitalization
    8. PSI risk classes II and III with appropriate social setting can be treated safely with oral levofloxacin (Levoquin®) 500mg qd as outpatients [6]

D. Common Organisms [5] navigator

  1. Acute Viral
    1. Influenza A: usually protracted "flu-like" like syndrome, rarely causes severe pneumonia
    2. Influenza B: more common in children; linked to Reye Syndrome
    3. Parainfluenza Virus
    4. Adenoviruses
    5. RSV, especially in children
    6. Varicella Zoster Virus
    7. Measles
    8. Metapneumovirus - ~25% of lower respiratory infections in infants and children [9]
  2. Acute Bacterial
    1. Streptococcus pneumoniae (pneumococcus): community acquired, often with bacteremia
    2. Haemophilus influenzae : common in smokers, COPD, elderly and very young persons
    3. Mycoplasma pneumoniae : community acquired, nonproductive cough, little sputum
    4. Klebsiella pneumoniae : Gram - organism, more frequent as superinfection (aspiration)
    5. Chlamydia pneumoniae : young adults, little sputum, variable radiographic findings
    6. Legionella pneumophilia : nonproductive cough, little sputum, multilobar, smokers
    7. Staphylococcus aureus : hospital acquired, alcoholics, post-influenza
    8. Other Streptococci: rare community acquired organism
    9. Anaerobic Oral Flora: aspiration pneumonia (alcoholics, comatose, stroke, poor gag
    10. Nearly 40% of patients with community acquired pneumonia (CAP) have >1 bacterium
  3. Chronic Infectious
    1. Mycobacterial
    2. Fungi: Cryptococcus, Histoplasmosis, Aspergillus
    3. Nocardia asteroides : more common in immunosuppressed including diabetics
    4. Pneumocystis carinii : immunocompromised patients
  4. Chemical: Aspiration / Inhalation
  5. Unusual Organisms - consider if standard evaluation is negative
    1. Pasteurella multocida
    2. Coxiella burnetti
    3. Francisella tularensis
    4. Neisseria meningitidus
    5. Hantavirus
  6. Frequency of common organisms varies depending on setting of disease
    1. Community Acquired
    2. Hospital Acquired
    3. Long-term Care Insitution Acquired

E. Recommendations for Determining Appropriate Discharge [1]navigator

  1. Vital signs stable for 24 hours
    1. Temperature <37.8°C (100°F)
    2. Respiratory rate <25/min
    3. Pulse <100/min
    4. SBP >90 mm Hg
    5. Oxgen saturation >90% breathing room air
  2. Patient able to tolerate oral medications
    1. Tailored to infectious agent
    2. Antipneumococcal fluoroquinolone or advanced generation macrolide usually acceptable
  3. Patient able to tolerate adequate hydration and nutrition
  4. Normal or baseline mental status
  5. No other active clinical or psychosocial problems requiring hospitalization

Resources navigator

calcAbsolute Neutrophil Count

References navigator

  1. Halm EA and Teirstein AS. 2002. NEJM. 347(25):2039 abstract
  2. Klompas M. 2007. JAMA. 297(14):1583 abstract
  3. Metlay JP, Kapoor WN, Fine MJ. 1997. JAMA. 278(17):1440 abstract
  4. Meehan TP, Fine MJ, Krumholz HM, et al. 1997. JAMA. 277(24):2080
  5. Brown PD and Lerner SA. 1998. Lancet. 352(9136):1295 abstract
  6. Carratala J, Fernandez-Sabe N, Ortega L, et al. 2005. Ann Intern Med. 142(3):165 abstract
  7. Fagon JY, Chastre J, Wolff M, et al. 2000. Ann Intern Med. 132(8):621 abstract
  8. Gibot S, Cravoisy A, Levy B, et al. 2004. NEJM. 350(5):451 abstract
  9. Williams JV, Harris PA, Tollefson SJ, et al. 2004. NEJM. 350(5):443 abstract