Accuracy of Signs and Symptoms for the Diagnosis of Community-acquired Pneumonia: A Meta-analysis.

Abstract

BACKGROUND:

Community-acquired pneumonia (CAP) is an important source of morbidity and mortality. However, overtreatment of acute cough illness with antibiotics is an important problem, so improved diagnosis of CAP could help reduce inappropriate antibiotic use.

METHODS:

This was a meta-analysis of prospective cohort studies of patients with clinically suspected pneumonia or acute cough that used imaging as the reference standard. All studies were reviewed in parallel by two researchers and quality was assessed using the QUADAS-2 criteria. Summary measures of accuracy included sensitivity, specificity, likelihood ratios, the diagnostic odds ratio, and the area under the receiver operating characteristic curve (AUROCC) and were calculated using bivariate meta-analysis.

RESULTS:

We identified 17 studies, of which 12 were judged to be at low risk of bias and the remainder at moderate risk of bias. The prevalence of CAP was 10% in nine primary care studies and was 20% in seven emergency department studies. The probability of CAP is increased most by an abnormal overall clinical impression suggesting CAP (positive likelihood ratio [LR+] = 6.32, 95% CI = 3.58 to 10.5), egophony (LR+ = 6.17, 95% CI = 1.34 to 18.0), dullness to percussion (LR+ = 2.62, 95% CI = 1.14 to 5.30), and measured temperature (LR+ = 2.52, 95% CI = 2.02 to 3.20), while it is decreased most by the absence of abnormal vital signs (LR- = 0.25, 95% CI = 0.11 to 0.48). The overall clinical impression also had the highest AUROCC at 0.741.

CONCLUSIONS:

While most individual signs and symptoms were unhelpful, selected signs and symptoms are of value for diagnosing CAP. Teaching and performing these high value elements of the physical examination should be prioritized, with the goal of better targeting chest radiographs and ultimately antibiotics.

• Authors: Mark H Ebell, Hulme Chupp, Xinyan Cai, Michelle Bentivegna, Maggie Kearney
• Journal: Academic emergency medicine : official journal of the Society for Academic Emergency Medicine (Acad Emerg Med) Vol. 27 Issue 7 Pg. 541-553 (07 2020) ISSN: 1553-2712 [Electronic] United States
• PMID: 32329557 (Publication Type: Journal Article, Meta-Analysis, Systematic Review)
• Copyright: © 2020 by the Society for Academic Emergency Medicine.

Topics

• Community-Acquired Infections (diagnosis)
• Cough (etiology)
• Humans
• Physical Examination (methods, standards)
• Pneumonia (diagnosis)
• Prospective Studies
• ROC Curve
• Radiography (standards)
• Vital Signs (physiology)