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Community acquired


Type and extent of investigations depend on

severity of the patient.
Investigations are done to diagnose and
asses the severity

Low risk patients Chest x ray , FBC , ESR,

Moderate risk above Ix and blood culture ,
sputum culture and Gram stain ,
pneumococcal urine antigen. Legionella
urine antigen and sputum culture and
High risk all above and investigations for
atypical organism and virus ,SaO2

Chest radiograph AP and

Not necessary in all patients Help in confirming diagnosis , follow up , ruling
out other etiology , identifying etiology
Indicated if patient is unwell , diagnosis not clear ,
unexpected progression with not improving after
48 72 hours of treatment , recurrent
Must be done in all patients referred to hospital
with suspected pneumonia.
Findings are - consolidation with air bronchogram
, cavitations , parapneumonic effusion

Chest x ray findings depending

on organism
Streptococcus pneumonia - consolidation ,
effusion more common, collapse . Multilobe
Mycoplasma usually one lobe involved
( can be bilateral and extensive)
Legionella lobar and multilobar
( occational small effusion)

Possible aetiology with chest x

ray appearance

Possible diagnosis


S. pneumonia, klebsiella, H influenza , Gram neg


Atypical , viral , Legionella


Viral, PCP , Legionella


Anaerobes , klebsiella , Tb , S. aureus, fungi

Large effusion

Staph , klebsiella, anaerobes

Full blood count and

inflammatory markers
WCC > 15x 109 bacterial ( particularly
WCC >20x 109 or <4x109 indicates severe
CRP correlate with the clinical progression.
Serial measures help to asses response to
treatment. More sensitive marker of
infection than WCC.

Full blood count and inflammatory

markers depending on organism
Streptococcus pneumoniea WBC is > 15
X109 ( 90% polymophonuclear leucocytosis) ,
ESR > 100mm/hr , CRP >100mg/l
Mycoplasma WBC usually normal , if
anaemia is present haemolysis is ruled out by
direct coombs test and cold agglutinin test
Legionella lymphopenia without marked
leucocytosis. Hyponatraemia ,
hypoalbuminaemia , increased liver

Full range of microbiological tests done in severe
Bacterial cultures are considered as the gold
standard to diagnose Pneumonia
1. blood culture and sputum gram stain and
2. urinary antigen tests for pneumococcus and
legionella infections.
3. Other atypical pneumonia microbes can be
investigated by PCR or direct
immunofluorescence (or other antigen detection
4. Serology during epidemics of Mycoplasma.

5. AFB tests if symptoms of malaise , LOW ,night
sweats no response to initial antibiotics.

Treating without aetiology in severe
Pneumonia leads to
irrational use of antibiotics
unnessasary cost
SE and interactions of drugs
developing resistance to antibiotics

Conventional microbilogical
These are done to identify typical organism
and not for atypical organism
Help to differentiate bacterial cause from
non bacterial cause
Useful for monitoring treatment and to
decide on antibiotic therapy and sensitivity.

Routine microbiological test to

identify typical organism
Gram stain of sputum and other fluids
Special stain of sputum and other fluids
Culture blood , sputum , pleural fluid ,
tracheal aspirate , BAL

Sputum Gram stain and culture

and ABST

Not routinely done in patients treated in community

Useful in
patients fail to respond to empirical antibiotics
Non severe Pneumonia admitted to hospital with purulent
sputum and has not received antibiotics previously
Severe Pneumonia

AFB direct stain and culture can be done if suspected to

have TB

Blood culture
Ideally recommended for all patients with
CAP before treatment because this has a
prognostic value
But low sensitivity Only 10% have positive

Pleural fluid

Culture and ABST and PH to exclude


Serological tests for

Pneumococcal Pneumonia

Urinary antigen 100% sensitive , 60% 90% specific in invasive disease.

Routine investigations for

atypical organism
Routine Gram stain is not useful and need
special stains
Cultures are difficult and require long time
and need specific methods . Not done
No common specific test to differentiate
atypical pathogens.
Direct antigen tests not routinely available
Tests are available for Mycoplasma and

Tests for Mycoplasma

Specific test
CFT gold standard
Non specific Cold agglutinin ( titre >1:64 is
PCR from throat swab and sputum culture

Tests for Legionella

Urinary antigen 70% sensitive , 90%
specific for serogroup A only.
Direct immunofluorescence (DIF) in
bronchial aspirates a rapid test
Antibody and PCR also available
BAL - culture 100% specific ( can use
sputum , pleural fluid , endotracheal

Tests for Chlamydia

Antigen by DIF in respiratory samples

Investigations that predict

increase mortality and severity
For risk assessment different predictive
assessment models are used adjunct to
clinical assessment . There should be
regular reassessment.(ex: Pneumonia
outcome Research team score, Pneumonia
Severity Index, CURB 65 , Ewigs score)
Generally two or more adverse prognostic
factors are at increased risk of mortality

Investigations that predict

increase mortality and severity
Age >65years
Co-existing disease
RR> 30/min
SBP<90mmHg and or DBP<60mmHg
Respiratory failiure with PaO2 <8kPa
BU > 7mmol/L
Albumin < 35g/L
WCC > 20x109 or < 4x109/L
Radiology bilateral or multi lobe involvement,
progression of chest xray
Microbiology positive blood culture

SaO2 and ABG

Done when SaO2 is <92% or patient has
features of severe pneumonia .
Metabolic acidocis is associated with severe

Renal and Liver function

If dearranged can indicate severe disease
with organ invovement or presence of
underlying disease
Raised BU is a marker of severe pneumonia

When to do CT chest
Not indicated unless;
diagnosis is in doubt
severely ill patient with failing to respond
to treatment to exclude underlying
abscess , empyma, malignancy and other
interstitial involvement

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