• We are sorry, but NCBI web applications do not support your browser and may not function properly. More information
Logo of brjgenpracRCGP homepageJ R Coll Gen Pract at PubMed CentralBJGP at RCGPBJGP at RCGP
Br J Gen Pract. May 2003; 53(490): 358–364.
PMCID: PMC1314594

Contributions of symptoms, signs, erythrocyte sedimentation rate, and C-reactive protein to a diagnosis of pneumonia in acute lower respiratory tract infection.

Abstract

BACKGROUND: Diagnostic tests enabling general practitioners (GPs) to differentiate rapidly between pneumonia and other lower respiratory tract infections (LRTIs) are needed to prevent increase of bacterial resistance by unjustified antibiotic prescribing. AIMS: To assess the diagnostic value of symptoms, signs, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) for pneumonia; to derive a prediction rule for the presence of pneumonia; and to identify a low-risk group of patients who do not require antibiotic treatment. DESIGN OF STUDY: Cross-sectional. SETTING: Fifteen GP surgeries in the southern part of The Netherlands. METHOD: Twenty-five GPs recorded clinical information and diagnosis in 246 adult patients presenting with LRTI. Venous blood samples for CRP and ESR were taken and chest radiographs (reference standard) were made. Odds ratios, describing the relationships between discrete diagnostic variables and reference standard (pneumonia or no pneumonia) were calculated. Receiver operating characteristic analysis of ESR, CRP, and final models for pneumonia was performed. Prediction rules for pneumonia were derived from multiple logistic regression analysis. RESULTS: Dry cough, diarrhoea, and a recorded temperature of > or = 38 degrees C were independent and statistically significant predictors of pneumonia, whereas abnormal pulmonary auscultation and clinical diagnosis of pneumonia by the GPs were not. ESR and CRP had higher diagnostic odds ratios than any of the symptoms and signs. Adding CRP to the final 'symptoms and signs' model significantly increased the probability of correct diagnosis. Applying a prediction rule for low-risk patients, including a CRP of < 20, 80 of the 193 antibiotic prescriptions could have been prevented with a maximum risk of 2.5% of missing a pneumonia case. CONCLUSION: Most symptoms and signs traditionally associated with pneumonia are not predictive of pneumonia in general practice. The prediction rule for low-risk patients presented here, including a CRP of < 20, can considerably reduce unjustified antibiotic prescribing.

Full Text

The Full Text of this article is available as a PDF (109K).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Smucny JJ, Becker LA, Glazier RH, McIsaac W. Are antibiotics effective treatment for acute bronchitis? A meta-analysis. J Fam Pract. 1998 Dec;47(6):453–460. [PubMed]
  • Macfarlane J, Holmes W, Gard P, Macfarlane R, Rose D, Weston V, Leinonen M, Saikku P, Myint S. Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community. Thorax. 2001 Feb;56(2):109–114. [PMC free article] [PubMed]
  • Felmingham D, Grüneberg RN. The Alexander Project 1996-1997: latest susceptibility data from this international study of bacterial pathogens from community-acquired lower respiratory tract infections. J Antimicrob Chemother. 2000 Feb;45(2):191–203. [PubMed]
  • Friedland IR, McCracken GH., Jr Management of infections caused by antibiotic-resistant Streptococcus pneumoniae. N Engl J Med. 1994 Aug 11;331(6):377–382. [PubMed]
  • Jacoby GA. Prevalence and resistance mechanisms of common bacterial respiratory pathogens. Clin Infect Dis. 1994 Jun;18(6):951–957. [PubMed]
  • Schwartz B, Bell DM, Hughes JM. Preventing the emergence of antimicrobial resistance. A call for action by clinicians, public health officials, and patients. JAMA. 1997 Sep 17;278(11):944–945. [PubMed]
  • Seppälä H, Klaukka T, Vuopio-Varkila J, Muotiala A, Helenius H, Lager K, Huovinen P. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. Finnish Study Group for Antimicrobial Resistance. N Engl J Med. 1997 Aug 14;337(7):441–446. [PubMed]
  • Swartz MN. Use of antimicrobial agents and drug resistance. N Engl J Med. 1997 Aug 14;337(7):491–492. [PubMed]
  • Magee JT, Pritchard EL, Fitzgerald KA, Dunstan FD, Howard AJ. Antibiotic prescribing and antibiotic resistance in community practice: retrospective study, 1996-8. BMJ. 1999 Nov 6;319(7219):1239–1240. [PMC free article] [PubMed]
  • Priest P, Yudkin P, McNulty C, Mant D. Antibacterial prescribing and antibacterial resistance in English general practice: cross sectional study. BMJ. 2001 Nov 3;323(7320):1037–1041. [PMC free article] [PubMed]
  • Keeley Duncan. Guidelines for managing community acquired pneumonia in adults. BMJ. 2002 Feb 23;324(7335):436–437. [PMC free article] [PubMed]
  • Knottnerus JA. Interpretation of diagnostic data: an unexplored field in general practice. J R Coll Gen Pract. 1985 Jun;35(275):270–274. [PMC free article] [PubMed]
  • Knottnerus JA. Medical decision making by general practitioners and specialists. Fam Pract. 1991 Dec;8(4):305–307. [PubMed]
  • Knottnerus JA, Leffers P. The influence of referral patterns on the characteristics of diagnostic tests. J Clin Epidemiol. 1992 Oct;45(10):1143–1154. [PubMed]
  • Dinant GJ, de Kock CA, van Wersch JW. Diagnostic value of C-reactive protein measurement does not justify replacement of the erythrocyte sedimentation rate in daily general practice. Eur J Clin Invest. 1995 May;25(5):353–359. [PubMed]
  • Dinant GJ, Knottnerus JA, Van Wersch JW. Discriminating ability of the erythrocyte sedimentation rate: a prospective study in general practice. Br J Gen Pract. 1991 Sep;41(350):365–370. [PMC free article] [PubMed]
  • Hjortdahl P, Landaas S, Urdal P, Steinbakk M, Fuglerud P, Nygaard B. C-reactive protein: a new rapid assay for managing infectious disease in primary health care. Scand J Prim Health Care. 1991 Mar;9(1):3–10. [PubMed]
  • Woodhead MA, Macfarlane JT, McCracken JS, Rose DH, Finch RG. Prospective study of the aetiology and outcome of pneumonia in the community. Lancet. 1987 Mar 21;1(8534):671–674. [PubMed]
  • Jokinen C, Heiskanen L, Juvonen H, Kallinen S, Karkola K, Korppi M, Kurki S, Rönnberg PR, Seppä A, Soimakallio S, et al. Incidence of community-acquired pneumonia in the population of four municipalities in eastern Finland. Am J Epidemiol. 1993 May 1;137(9):977–988. [PubMed]
  • Hopstaken RM, Nelemans P, Stobberingh EE, Muris JWM, Rinkens PELM, Dinant GJ. Is roxithromycin better than amoxicillin in the treatment of acute lower respiratory tract infections in primary care? A double-blind randomized controlled trial. J Fam Pract. 2002 Apr;51(4):329–336. [PubMed]
  • Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl J Med. 1995 Dec 14;333(24):1618–1624. [PubMed]
  • DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988 Sep;44(3):837–845. [PubMed]
  • Harrell FE, Jr, Lee KL, Mark DB. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med. 1996 Feb 28;15(4):361–387. [PubMed]
  • Melbye H, Straume B, Aasebø U, Dale K. Diagnosis of pneumonia in adults in general practice. Relative importance of typical symptoms and abnormal chest signs evaluated against a radiographic reference standard. Scand J Prim Health Care. 1992 Sep;10(3):226–233. [PubMed]
  • Marrie TJ. Community-acquired pneumonia. Clin Infect Dis. 1994 Apr;18(4):501–515. [PubMed]
  • Marrie TJ, Peeling RW, Fine MJ, Singer DE, Coley CM, Kapoor WN. Ambulatory patients with community-acquired pneumonia: the frequency of atypical agents and clinical course. Am J Med. 1996 Nov;101(5):508–515. [PubMed]
  • Helms CM, Viner JP, Sturm RH, Renner ED, Johnson W. Comparative features of pneumococcal, mycoplasmal, and Legionnaires' disease pneumonias. Ann Intern Med. 1979 Apr;90(4):543–547. [PubMed]
  • Melbye H, Straume B, Aasebø U, Brox J. The diagnosis of adult pneumonia in general practice. The diagnostic value of history, physical examination and some blood tests. Scand J Prim Health Care. 1988 May;6(2):111–117. [PubMed]
  • Diehr P, Wood RW, Bushyhead J, Krueger L, Wolcott B, Tompkins RK. Prediction of pneumonia in outpatients with acute cough--a statistical approach. J Chronic Dis. 1984;37(3):215–225. [PubMed]
  • Singal BM, Hedges JR, Radack KL. Decision rules and clinical prediction of pneumonia: evaluation of low-yield criteria. Ann Emerg Med. 1989 Jan;18(1):13–20. [PubMed]
  • González Ortiz MA, Carnicero Bujarrabal M, Varela Entrecanales M. Predicción de la presencia de neumonía en el adulto con fiebre. Med Clin (Barc) 1995 Oct 28;105(14):521–524. [PubMed]
  • Heckerling PS, Tape TG, Wigton RS, Hissong KK, Leikin JB, Ornato JP, Cameron JL, Racht EM. Clinical prediction rule for pulmonary infiltrates. Ann Intern Med. 1990 Nov 1;113(9):664–670. [PubMed]
  • Gennis P, Gallagher J, Falvo C, Baker S, Than W. Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department. J Emerg Med. 1989 May-Jun;7(3):263–268. [PubMed]
  • Melbye H, Straume B, Brox J. Laboratory tests for pneumonia in general practice: the diagnostic values depend on the duration of illness. Scand J Prim Health Care. 1992 Sep;10(3):234–240. [PubMed]
  • Kuyvenhoven MM, Verheij TJ, de Melker RA, van der Velden J. Antimicrobial agents in lower respiratory tract infections in Dutch general practice. Br J Gen Pract. 2000 Feb;50(451):133–134. [PMC free article] [PubMed]
  • Oeffinger KC, Snell LM, Foster BM, Panico KG, Archer RK. Treatment of acute bronchitis in adults. A national survey of family physicians. J Fam Pract. 1998 Jun;46(6):469–475. [PubMed]
  • Macfarlane J, Lewis SA, Macfarlane R, Holmes W. Contemporary use of antibiotics in 1089 adults presenting with acute lower respiratory tract illness in general practice in the U.K.: implications for developing management guidelines. Respir Med. 1997 Aug;91(7):427–434. [PubMed]
  • Coenen S, Van Royen P, Vermeire E, Hermann I, Denekens J. Antibiotics for coughing in general practice: a qualitative decision analysis. Fam Pract. 2000 Oct;17(5):380–385. [PubMed]
  • Knottnerus J André, van Weel Chris, Muris Jean W M. Evaluation of diagnostic procedures. BMJ. 2002 Feb 23;324(7335):477–480. [PMC free article] [PubMed]
  • Dahler-Eriksen BS, Lassen JF, Petersen PH, Lund ED, Lauritzen T, Brandslund I. Evaluation of a near-patient test for C-reactive protein used in daily routine in primary healthcare by use of difference plots. Clin Chem. 1997 Nov;43(11):2064–2075. [PubMed]
  • Dahler-Eriksen BS, Lauritzen T, Lassen JF, Lund ED, Brandslund I. Near-patient test for C-reactive protein in general practice: assessment of clinical, organizational, and economic outcomes. Clin Chem. 1999 Apr;45(4):478–485. [PubMed]

Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners

Formats:

Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...

Links

  • MedGen
    MedGen
    Related information in MedGen
  • PubMed
    PubMed
    PubMed citations for these articles
  • Substance
    Substance
    PubChem Substance links