![]() ![]() However, there is considerable debate about the accuracy of symptoms and signs alone in the diagnosis of CAP, with many suggesting that clinical features alone are not accurate enough and that a chest radiograph is an absolute requirement without which pneumonia cannot be adequately diagnosed or excluded. Reasons given for this approach include the cost of radiology, the inconvenience for the patient, the potential for delay in diagnosis while awaiting the chest radiograph and the lack of ready availability of routine radiology. However, it has been suggested by some that in the community, milder cases of infection treated as outpatients could be diagnosed on clinical grounds alone without the performance of chest imaging. ![]() In all guidelines there is a recommendation for routine chest radiology for all pneumonia patients admitted to hospital, and this appears to be relatively straightforward. Similarly, the more recent European guideline does not recommend a routine chest radiograph in the community setting but indicates that it could be done in cases in whom, despite c-reactive protein (CRP) testing, there is persistent doubt as to whether the diagnosis is pneumonia or another respiratory tract infection, and also in patients with suspected aspiration pneumonia. However, the British Thoracic Society guideline indicates that while all patients admitted to hospital with suspected CAP need a chest radiograph, in the community it is unnecessary for a chest radiograph to be done unless the diagnosis is in doubt, or clinical progress is not being made on treatment of a patient with suspected CAP, or if the patient is likely to have an underlying pathology, such as lung cancer. The current guideline from North America and the earlier European guideline indicated that if pneumonia was suspected a routine chest radiograph should be performed to confirm the diagnosis. Yet there are discrepancies in the different guideline recommendations with regard to the need for a routine chest radiograph. The argument forwarded is that chest radiology is a relatively inexpensive procedure and is the only way in which pneumonia can be definitely confirmed or excluded. Clearly one of the initial considerations in managing a patient with suspected CAP is to confirm that diagnosis, and to this end, the chest radiograph is universally considered to be the “gold standard” ( 1, 8– 10]. Given the substantial ongoing morbidity and mortality it causes, it is not surprising that a number of guidelines have been developed in the different regions of the world describing what is considered the optimal management of this infection in the hope of improving the patient outcome. Below we debate the diagnostic role of the humble chest radiograph in the context of suspected CAP.ĬAP continues to be associated with a considerable burden of disease throughout the world. Conversely, several studies have demonstrated a lack of agreement in the interpretation of chest radiographs bringing their role as the ultimate arbiter of diagnosis into question. However, there is debate as to whether clinical features alone are sufficiently reliable to support a diagnosis of CAP with some suggesting diagnostic precision is improved by chest radiographs. For these reasons, in mild CAP treated by primary care, guidelines suggest criteria for clinical diagnosis. But, radiographs are not available in the community setting and introduce a delay in diagnosis and treatment. A number of international guidelines recommend a chest radiograph (x-ray) is obtained when pneumonia is suspected the argument forwarded is that chest radiographs are relatively inexpensive and enable pneumonia (lung consolidation) to be confirmed or excluded. Outcome is improved by early recognition and rapid institution of empirical antibiotic therapy. Community-acquired pneumonia (CAP) remains a common condition associated with considerable morbidity and mortality. ![]()
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