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Testing strategies in the initial management of patients with community-acquired pneumonia.
Autor – Metlay JP; Fine MJ
Zeitschrift/Erscheinungsdatum – Ann Intern Med 2003 Jan 21;138(2):109-18.
STUDY OBJECTIVES:
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.