Adult Outpatients with Acute Cough due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report
Adam T. Hill, M et. al., on behalf of the CHEST Expert Cough Panel
DOI: https://doi.org/10.1016/j.chest.2018.09.016
https://journal.chestnet.org/article/S0012-3692(18)32499-1/fulltext
肺炎疑いの急性咳嗽外来成人患者において、以下の臨床徴候・所見で肺炎が疑われる
咳嗽、呼吸困難、胸膜痛、発汗/発熱/震せん、疼痛（aches, pains)、38度以上発熱、多呼吸、新規・限局的胸部診察所見
肺炎疑う場合、Ｘ診断正確性改善のため胸部レントゲン撮影すべき
CRP測定は、肺炎の診断・除外の念押しするが、procalcitonin測定では付加的ベネフィット無し
急性咳嗽・肺炎疑い外来成人患者では、ルーチンの微生物検査必要なし
急性咳嗽外来成人では、画像診断できず画像診断できない場合、empiricな抗生剤使用は地域・グローバルなガイドラインに従い使用示唆。
肺炎の臨床的・画像的エビデンス無い場合、抗生剤のルーチン使用はすべきではないと示唆
非抗生剤症状への対症治療を肯定、否定する十分なエビデンス存在しない
急性咳嗽・インフルエンザ疑いでは、(CDC助言に従い）症状発現48時間以内に初期抗ウィルス治療開始を示唆することで抗生剤使用減少、入院減少、アウトカム改善と相関する可能性
SUMMARY OF RECOMMENDATIONS:
1. We suggest for outpatient adults with acute cough due to suspected pneumonia, the following clinical symptoms and signs are suggestive of pneumonia (cough, dyspnea, pleural pain, sweating/fevers/shivers, aches and pains, temperature 38°C or greater, tachypnea and new and localizing chest examination signs). (Ungraded Consensus Based Statement).
Remark: The quality of evidence is low but the absence of runny nose and presence of breathlessness, crackles and/or diminished breath sounds on auscultation, tachycardia, and fever (38°C or greater) is suggestive of pneumonia.
2. For outpatient adults with acute cough due to suspected pneumonia, we suggest measuring C-reactive protein (CRP) because the addition of CRP to features such as fever (38°C or greater), pleural pain, dyspnea and tachypnoea and signs on physical examination of the chest (tachypnea and new and localizing chest examination signs) strengthens both the diagnosis and exclusion of pneumonia. (Grade 2C).
Remark: The quality of evidence is low but a CRP>30mg/L in addition to suggestive symptoms and signs increases the likelihood that the cough may be related to having pneumonia. Acute cough (i.e., < 3 weeks in duration) is less likely to be caused by a pneumonia when the CRP<10mg 10-50mg="" absence="" and="" between="" daily="" dyspnea="" fever.="" in="" of="" or="" p="" the="">
3. For outpatient adults with acute cough due to suspected pneumonia, we suggest not to routinely measure procalcitonin. (Ungraded Consensus Based Statement)
4. For outpatient adults with acute cough and abnormal vital signs secondary to
suspected pneumonia, we suggest ordering a chest x-ray to improve diagnostic
accuracy. (Grade 2C)
5. We suggest for outpatient adults with acute cough and suspected pneumonia, there is no need for routine microbiologic testing. (Ungraded Consensus Based Statement)
Remark: Microbiologic testing should be considered if the results may result in a change of therapy.
6. For outpatient adults with acute cough, we suggest the use of empiric
antibiotics as per local and national guidelines when pneumonia is suspected in
settings where imaging cannot be obtained. (Ungraded Consensus Based Statement)
7. For outpatient adults with acute cough and no clinical or radiographic evidence
of pneumonia (e.g., when vital signs and lung exams are normal,) we suggest
against the routine use of antibiotics. (Ungraded Consensus-Based Statement)
8. For outpatient adults with acute cough and suspected influenza, we suggest
initiating antiviral treatment (as per CDC advice) within 48 hours of symptom onset.
Anti-viral treatment may be associated with decreased antibiotic usage,
hospitalization and improved outcomes. (Ungraded Consensus Based Statement)
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