Joshua P. Metlay, MD, PhD; Michael J. Fine, MD, MSc
Grant Support: Dr. Metlay is supported by a Research Career Development Award from the Department of Veterans Affairs and a Generalist Physician Faculty Scholar Award from the Robert Wood Johnson Foundation. Data collected for the development of the Pneumonia Severity Index was supported through the Pneumonia Patient Outcomes Research Team (PORT) Project funded by grant R01 HS06468 from the Agency for Healthcare Research and Quality.
Requests for Single Reprints: Joshua P. Metlay, MD, PhD, Center for Health Equity Research and Promotion, Veterans Affairs Medical Center, 9th floor, University and Woodland Avenues, Philadelphia, PA 19104.
Current Author Addresses: Dr. Metlay: Center for Health Equity Research and Promotion, VA Medical Center, 9th floor, University and Woodland Avenues, Philadelphia, PA 19104.
Dr. Fine: Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240.
The initial management of patients suspected of having community-acquired pneumonia is challenging because of the broad range of clinical presentations, potential life-threatening nature of the illness, and associated high costs of care. The initial testing strategies should accurately establish a diagnosis and prognosis in order to determine the optimal treatment strategy. The diagnosis is important in determining the need for antibiotic therapy, and the prognosis is important in determining the site of care.
This paper reviews the test characteristics of the history, physical examination, and laboratory findings, individually and in combination, in diagnosing community-acquired pneumonia and predicting short-term risk for death from the infection. In addition, we consider the implications of these test characteristics from the perspective of decision thresholds. The history and physical examination cannot provide a high level of certainty in the diagnosis of community-acquired pneumonia, but the absence of vital sign abnormalities substantially reduces the probability of the infection. Chest radiography is considered the gold standard for pneumonia diagnosis; however, we do not know its sensitivity and specificity, and we have limited data on the costs of false-positive and false-negative results. In the absence of empirical evidence, the decision to order a chest radiograph needs to rely on expert opinion in seeking strategies to optimize the balance between harms and benefits. Once community-acquired pneumonia is diagnosed, a combination of history, physical examination, and laboratory items can help estimate the short-term risk for death and, along with the patient's psychosocial characteristics, determine the appropriate site of treatment.
Table 1. Accuracy of History, Physical Examination, and Laboratory Findings for the Diagnosis of Community-Acquired Pneumonia
Revised pneumonia probabilities based on history and physical examination findings.
Table 2. History, Physical Examination, and Laboratory Findings Significantly Associated with Death in Patients with Community-Acquired Pneumonia
Application of the Pneumonia Patient Outcomes Research Team Severity Index to determine initial site of treatment..
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Metlay JP, Fine MJ. Testing Strategies in the Initial Management of Patients with Community-Acquired Pneumonia. Ann Intern Med. 2003;138:109-118. doi: 10.7326/0003-4819-138-2-200301210-00012
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Published: Ann Intern Med. 2003;138(2):109-118.
Infectious Disease, Pneumonia, Pulmonary/Critical Care.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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