The initial management of community...

The initial management of community-acquired pneumonia (CAP) in adult patients requires correct diagnosis and a determination of the intensity of treatment required. Because CAP is the simply acute respiratory tract infection in which there is increased mortality if antibiotic therapy is delayed, diagnostic and treatment decisions ne to be made accurately and efficiently. Metlay and Fine reviewed the literature to identify exhibition characteristics of diagnostic and prognostic factors to exhibit a strategy for approaching the initial management of radiographically confirmed CAP.

Symptoms at presentation are not useful in distinguishing CAP from respiratory illnesses with other causes. Consideration of the usefulness of physical examination inferences demonstrated that approximations of the probability of pneumonia based in succession individual findings could be estimated depending upon the cutoff value used to define abnormal findings. Combinations of symptoms and signs have yielded prediction controls The sensitivity of chest radiography hangs greatly on pretest probability. Although chest radiography has been considered the gold standard for diagnosing pneumonia, data upon its sensitivity and specificity are limited. The leukocyte cast up and C-reactive protein level may assist diagnostic accuracy.

one time the diagnosis is established, the short-term prognosis and ne for hospitalization should be considered. Symptoms that significantly influence prognosis include dyspnea and confusion. Predictors of increased mortality include comorbid neurologic disease, renal disease, or congestive heart failure. The risk of death also is increased in patients with passing from hand to hand hypotension, tachypnea, or hypothermia. The three laboratory example abnormalities associated with increased mortality are azotemia, leukocytosis, and leukopenia. Mortality also is increased when a multilobar infiltrate is identified upon the chest radiograph.

The authors determine that combinations of findings from the history and physical examination can accurately identify about 50 percent of patients with CAP and that chest radiography should be performed to confirm the diagnosis in principally patients. Patients with mild illness who do not have vital sign abnormalities and are generally healthy do not require a chest radiograph to shut out CAP. A negative chest radiograph does not government out pneumonia in patients with moderate to exact illness. These patients may benefit from the initiation of empiric antibiotic therapy and repeat radiography several days later. A prognostic scoring tool, of that kind as the Pneumonia Patient consequences Research Team (PORT) Severity Index, can be used to determine the initial site of treatment (see accompanying figure in succession page 730). A stepwise approach includes identifying preexisting conditions that contraindicate family care, collecting data to calculate a patient's risk class, and recommending place of abode care for patients in the three lowest risk categories, unles clinical good sense determines that home care is not appropriate.

Richard Sadovsky, MD

Metlay JP Fine MJ Testing strategies in the initial management of patients with community-acquired pneumonia. Ann Intern M January 21 2003;138:109-18

COPYRIGHT 2003 American Academy of Family Physicians

COPYRIGHT 2003 Gale Group