Diagnostic approach

The initial diagnostic approach for severe pneumonias should include sputum Gram stain and cultures (including a-BCYE for Legionella), two serial blood cultures, acute phase serology for Legionella and atypical agents, and pleural fluid stains and cultures (aerobic and anaerobic) if pleural effusion is present ( Table.3). If there are no contraindications, transthoracic needle aspiration could be considered in non-ventilated pneumonia (Gram stain, direct fluorescence antigen for Legionella, latex agglutination for pneumococcus, and cultures). If the patient is already receiving assisted ventilation, a sample of respiratory secretions for Gram stain should be obtained. Bronchoscopy could be carried out for protected specimen brush. Proceed to bronchoalveolar lavage if opportunistic organisms are suspected.

EpjuT*- Gmm hdF n=*1 oAutn («KfuAng i-OCT r mrewrni ihu.in Mid**

iprmogy h* irrpp-ou c-qjarHvn* (neue pf-n ¡w-.i h"'Mfi¡■ bJ IIhI t'liWi ñJiHis'i JfcM¡i>il i'li. I A M fMMW^tl urn* LIBB >H [siMWiuai AHigH- itiAA, rcf CJ^uh jWyi MH^Hkfk I"

EpjuT*- Gmm hdF n=*1 oAutn («KfuAng i-OCT r mrewrni ihu.in Mid**

iprmogy h* irrpp-ou c-qjarHvn* (neue pf-n ¡w-.i h"'Mfi¡■ bJ IIhI t'liWi ñJiHis'i JfcM¡i>il i'li. I A M fMMW^tl urn* LIBB >H [siMWiuai AHigH- itiAA, rcf CJ^uh jWyi MH^Hkfk I"

Tfu-ui

Table 3 Diagnostic approach to severe community-acquired pneumonia

Finally, there is substantial debate about the best timing for the performance of invasive procedures. Some authors consider these diagnostic tools as the last step in non-responding cases. In contrast, others prefer to use them earlier, on the basis of determined prognostic factors, when the patient is not yet in a critical condition and could benefit from their result. The latter approach would have a greater impact on the outcome of pneumonia.

Bibliography

Campbell, G.D., et al. (1995). Hospital-acquired pneumonia in adults: diagnosis, assessement of severity, initial antimicrobial therapy and preventive strategies. American Journal of Respiratory Care Medicine, 153, 1711-25.

Meduri, G.U. and Johanson, W.G. (ed.) (1992). International Consensus Conference on Clinical Investigation of Ventilator-associated Pneumonia. Chest, 102 (Supplement 1).

Niederman, M.S., et al. (1993). Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity and initial antimicrobial treatment. American

Review of Respiratory Disease, 148, 1418-26.

Torres, A. (1996). Severe pulmonary infections, Vols I and II. W.B. Saunders, Philadelphia, PA.

Torres, A. and Woodhead, M. (1996). Pneumonia. European Respiratory Monograph 3, Vol. 2. European Respiratory Society, Sheffield.

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