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Four clinical signs can improve GP pneumonia diagnosis, finds study

GPs may be able to spot pneumonia and therefore avoid unnecessary antibiotics by looking out for four simple clinical signs.

Researchers said these signs could be strong predictors for pneumonia, allowing GPs to spot it more easily.

The study, led by researchers from the University of Southampton, looked at data for 720 patients who were radiographed within a week of an initial consultation for acute cough associated with an LRTI. Of these patients, 115 were marked as having a definite or probable case of pneumonia.

The researchers found that presenting symptoms, such as shortness of breath, were not helpful for making a diagnosis of pneumonia, but clinical examination findings, including raised temperature, crackles on auscultation, oxygen saturation of less than 95% and rapid pulse, were strong positive predictors for pneumonia in those who had the diagnosis confirmed by radiograph.

These four signs held true even when the diagnoses of ‘possible pneumonia’ were removed from the dataset.

Analysis found the positive predictive value for all four signs in those who were radiographed was just over 20%, meaning that around one in five of the patients radiographed who had at least one sign had pneumonia.

They said in the paper: ‘The four variables identified by this analysis are easily measured clinical signs. Although pulse oximetry is not routinely measured, it is a robust and inexpensive technology that is widely available. If antibiotic prescribing was restricted to people who had one or more of these signs, it could substantially reduce antibiotic prescribing for this condition.

‘Clinicians should be aware that the model was derived in those with more severe symptoms referred for radiographs and that effective clinical safety-netting would be needed to cope with missed cases of pneumonia.’

Lead author and professor of primary care health research at the University of Southampton Professor Michael Moore commented: 'It is notoriously difficult to tell one infection from the other. GPs fail to spot two out of every three cases of pneumonia, although those which are missed are the milder ones with less distinctive features. One of the reasons GPs offer antibiotics is that they are rightly concerned about missing a serious illness

'The rise in drug-resistant infections is an international priority and one of the contributors to antibiotic resistance is unnecessary prescribing. Most patients with a lower respiratory tract infection will recover perfectly well without antibiotics but, at the moment, around 60% of patients get a prescription.

‘Finding ways of identifying those at low risk of complications should help reduce this figure. If antibiotic prescribing was restricted to people who had one or more of these signs it could result in a substantial reduction in unnecessary prescriptions for this condition.’

Eur. Respir. J. 2017; available online 23 November


Readers' comments (13)

  • But if they aren't sob or feverish do they need treatment?

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  • AlanAlmond

    Basal creps, a temperature, low sats and fast pulse...sounds like a reasonable set of markers to me and fits with how these folk present. Useful and interesting research. Thanks

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  • Vinci Ho

    My first patient this morning after my two days BMJ Masterclass course in London(BMA house) was 70 years old sarcoid lady on Ling term steroids presenting with three days acute breathlessness:
    Apyrexial(probably effect of prednisolone any way)
    Respiratory rate 30/min
    Oxygen sat in air 88% persistently
    Widespread crackles in chest LR , vocal resonance increased left side
    Pulse 110/min regular
    BP 130/80mm Hg

    I called ambulance and sent her to acute medical assessment unit our local acute hospital query pneumonia

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  • Vinci Ho

    ... crackles in chest L more than R

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  • Vinci Ho

    .....long term steroid....

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  • Tachycardia, fever, low sats and abnormal auscultation, pneumonia likely, who would have thought of that......
    Central crushing chest pain sweating nausea tachycardia, fancy doing a study on this anyone?

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  • Because, like, we don't check those things routinely? Pass me an egg and a straw, please.

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  • ha ha but im surprised significant breathlessness wasn't useful. I wonder if this is because of the asthmatics and of course even the urtis get slight sob or say so until you dig deeper to what they mean but I would think rapid resp rate in non-asthmatic with a cough would be good case for pneumonia even if temp etc ok?

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  • Just Your Average Joe

    Bear Woods

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  • I'm sorry but who are these clinicians going around dishing out antibiotics for patients with a normal pulse, normal sats, clear chest and no fever?

    Conversely, there are many patients with viral urtis who may have a fever or a raised pulse. We wouldn't give them antibiotics either.

    What is the learning point of this study? I am struggling to find one apart from what we already know - which is to take a good history and examination and treat each patient in a holistic manner, rather than rely on protocols and decision making pathways.

    But of course, Noctors will need the latter.

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