From the Guidelines
When evaluating a patient with suspected pneumonia presenting with cough and chest pain, it is crucial to rule out several negative history elements to ensure accurate diagnosis and appropriate treatment, including recent travel to endemic areas for specific pathogens, immunocompromising conditions, recent hospitalization, antibiotic use in the past 3 months, and history of structural lung disease, as suggested by the guidelines for outpatient adults with acute cough due to suspected pneumonia or influenza 1. To ensure accurate diagnosis and appropriate treatment, the clinician should specifically inquire about:
- Absence of recent travel to endemic areas for specific pathogens
- Lack of immunocompromising conditions (HIV, organ transplantation, chemotherapy)
- No recent hospitalization or healthcare facility exposure (which might suggest hospital-acquired pneumonia)
- Absence of antibiotic use in the past 3 months (which could affect pathogen resistance patterns)
- No history of structural lung disease like COPD or bronchiectasis Additionally, it's essential to confirm the patient has no allergies to common antibiotics used for pneumonia treatment, such as beta-lactams, macrolides, or fluoroquinolones, as well as establish the absence of risk factors for aspiration (dysphagia, altered mental status, poor dentition) 1. These negative history elements help narrow the differential diagnosis, guide appropriate empiric antibiotic selection, and identify patients who might need specialized treatment approaches, as recommended by the guidelines for outpatient adults with acute cough due to suspected pneumonia or influenza 1. Ruling out these factors allows for more targeted therapy and potentially shorter treatment duration in otherwise healthy individuals with community-acquired pneumonia.
From the FDA Drug Label
NOTE: Azithromycin should not be used in patients with pneumonia who are judged to be inappropriate for oral therapy because of moderate to severe illness or risk factors such as any of the following: patients with cystic fibrosis, patients with nosocomially acquired infections, patients with known or suspected bacteremia, patients requiring hospitalization, elderly or debilitated patients, or patients with significant underlying health problems that may compromise their ability to respond to their illness (including immunodeficiency or functional asplenia).
The negative history that should be ruled out in a case of pneumonia presenting with cough and chest pain includes:
- Cystic fibrosis
- Nosocomially acquired infections
- Known or suspected bacteremia
- Need for hospitalization
- Elderly or debilitated state
- Significant underlying health problems, such as:
- Immunodeficiency
- Functional asplenia 2
From the Research
Negative History to be Ruled Out in Pneumonia
In a case of pneumonia presenting with cough and chest pain, several negative histories should be ruled out to ensure accurate diagnosis and treatment. These include:
- Pulmonary embolism (PE) 3, as pneumonia may occasionally mask PE, particularly in patients with predominant systemic symptoms such as fever, and with no evidence of deep vein thrombosis (DVT) or trauma.
- Other pulmonary causes of chest pain, such as acute pleurisy, primary spontaneous pneumothorax, pulmonary hypertension, lung cancer, and mesothelioma 4.
- Acute myocardial infarction, especially in patients with active pulmonary tuberculosis 5, as Mycobacterium tuberculosis may act in the coronary vessels by activating the inflammatory mechanism of atherosclerosis.
- Cardiac comorbidity, such as acute coronary syndrome (ACS), in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) 4.
Diagnostic Considerations
When evaluating a patient with pneumonia, it is essential to consider the clinical features, such as cough, fever, and pleuritic chest pain, as well as lung imaging, usually an infiltrate seen on chest radiography 6. The decision aid developed by 7 can help rule out pneumonia and reduce unnecessary antibiotic prescriptions in primary care patients with cough and fever. This aid suggests that pneumonia can be ruled out in patients with C-reactive protein values below 10 μg/ml or patients presenting with C-reactive protein between 11 and 50 μg/ml, but without dyspnoea and daily fever.