Pneumoniediagnose in der Praxis auf dem Prüfstand: Wie viel Diagnostik ist erforderlich?

Die Diagnosestellung einer ambulant erworbenen Pneumonie (AEP) bereitet im Krankenhaus in der Regel keine Probleme. Anders sieht die Situation im ambulanten Bereich aus. Hier gehören - insbesonders in den Herbst- und Wintermonaten - Infektionen der unteren Atemwege zu den häufigsten Erkrankungen überhaupt. Der Arzt sieht sich hier vor die Aufgabe gestellt, auf der Grundlage klinischer Kriterien Pneumonien von unteren Atemwegsinfektionen zu unterscheiden. Die wichtigste Methode für die Diagnosestellung einer Pneumonie, das Röntgen-Thoraxbild, steht häufig nicht ohne weiteren Aufwand zur Verfügung. Laborwerte, Blutgasanalysen oder mikrobiologische Untersuchungen (zum Beispiel Gramfärbung und Kultur des Sputums) sind differentialdiagnostisch in der Regel wenig hilfreich. Welches ist in dieser Situation die angemessene diagnostische Strategie?

Literatur

• 1 American Thoracic Society . Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, initial antimicrobial therapy, and prevention.  Am J Respir Crit Care Med. 2001;  163 1730-1754
• 2 Berntsson E, Lagerfeld T, Strannegard Ö, Trollfors B. Etiology pf community-acquired pneumonia in out-patients.  Eur J Clin Microbiol. 1985;  5 446-447
• 3 Deutsche Gesellschaft für Pneumologie . Empfehlungen zur Diagnostik der ambulant erworbenen Pneumonie.  Pneumologie. 1997;  51 69-77
• 4 Diehr P, Wood R W, Bushyhead J, Krueger L, Wolcott B, Tompkins R K. Prediction of pneumonia in outpatients with acute cough: a statistical approach.  J Chronic Dis. 1984;  37 215-225
• 5 Emerman C L, Dawson N, Speroff T. et al . Comparison of physician judgment and decision aids for ordering chest radiographs for pneumonia in outpatients.  Ann Emerg Med. 1991;  20 1215-1219
• 6 Emerman C L, Cydulka R K. Evaluation of high yield criteria for chest radiography in acute exacerbations of chronic obstructive pulmonary disease.  Ann Emerg Med. 1993;  22 680-684
• 7 European Study on Community-acquired pneumonia (ESOCAP) Commitee . Guidelines for management of adult community-acquired lower respiratory tract infections.  Eur Respir J. 1998;  11 986-991
• 8 Ewig S. Community-acquired pneumonia: epidemiology, risk, and prognosis.  Eur Respir Mon. 1996;  2 13-35
• 9 Ewig S. Community-acquired pneumonia: definition, epidemiology, and outcome.  Semin Respir Infect. 1999;  14 94-102
• 10 Ewig S, Soler N, Torres A. Chronic obstructive pulmonary disease (COPD) and infection: from stable patients to pneumonia.  Clin Pulm Med. 1999;  6 1-8
• 11 Fahey T, Stocks N, Thomas T. Quantitative systematic review of randomized controlled trials comparing antibiotic with placebo for acute cough in adults.  BMJ. 1998;  316 906-910
• 12 Farr B M, Kaiser D L, Harrison B DW, Connolly C K. Prediction of microbial etiology at admission to hospital for pneumonia from the presenting clinical features.  Thorax. 1984;  44 1031-1035
• 13 Gennis P, Gallagher J, Falvo C, Baker S, Than W. Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department.  J Emerg Med. 1989;  7 263-268
• 14 Gonzales R, Steiner J F, Sande M A. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians.  JAMA. 1997;  278 901-904
• 15 Guidelines from the Infectious Diseases Society of America . Community-acquired pneumonia in adults: guidelines for management.  Clin Infect Dis. 2000;  26 811-838
• 16 Heckerling P S. The need for chest roentgenogramms in adults with acute respiratory illness: clinical predictors.  Arch Intern Med. 1986;  146 1321-1324
• 17 Heckerling P S, Tape T G, Wigton R S. et al . Clinical prediction rule for pulmonary infiltrates.  Ann Intern Med. 1990;  113 664-670
• 18 Heckerling P S, Tape T G, Wigton R S. Relation of physicians’ predicted probabilities of pneumonia to their utilities for ordering chest x-rays to detect pneumonia.  Med Decis Making. 1992;  12 32-38
• 19 Huchon G, Woodhead M. Management of adult community-acquired lower respiratory tract infections.  Eur Respir Rev. 1998;  8 391-426
• 20 Lode H, Schaberg T. Pneumonie. Weißbuch Lunge.  Pneumologie. 1996;  50 592-594
• 21 Macfarlane J T, Colville A, Guion A, Macfarlane R M, Rose D H. Prospective study of aetiology of adult lower-respiratory-tract infections in the community.  Lancet. 1993;  341 511-514
• 22 Macfarlane J, Holmes W, Macfarlane R. et al . Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community.  Thorax. 2001;  56 109-114
• 23 Meehan T P, Fine M J, Krmholz H M. et al . Quality of care, process, and outcomes in elderly patients with pneumonia.  JAMA. 1997;  278 2080-2084
• 24 Melbye H, Straume B, Aasebo U, Dale K. Diagnosis of pneumonia in adults in general practice: relative importance of typical symptoms and abnormal chest signs evaluated against a radiographic reference standard.  Scand J Prim Health Care. 1992;  10 226-233
• 25 Melbye H, Dale K. Interobserver variability in the radiographic diagnosis of adult outpatient pneumonia.  Acta Radiol. 1992;  33 79-81
• 26 Metlay J P, Kapoor W N, Fine M J. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination.  JAMA. 1997;  278 1440-1445
• 27 Metlay J P, Schulz R, Li Y H. et al . Influence of age on symptoms at presentation in patients with community-acquired pneumonia.  Arch Intern Med. 1997;  157 1453-1459
• 28 Owen N. Clinical prediction of pneumonia (letter).  Ann Intern Med. 1991;  114 428-429
• 29 Ruiz M, Ewig S, Marcos M A. et al . Etiology of community-acquired pneumonia - impact of age, comorbidity, and severity.  Am J Respir Crit Care Med. 1999;  160 397-405
• 30 Ruiz M, Ewig S, Torres A. et al . Severe community-acquired pneumonia: risk factors and follow-up epidemiology.  Am J Respir Crit Care Med. 1999;  160 923-929
• 31 Schilling R SF, Hughes J PW, Dingwall-Fordyce I. Disagreement between observers in an epidemiological study of respiratory disease.  BMJ. 1955;  1 65-68
• 32 Simpson J CG, Hulse P, Taylor P M, Woodhead M. Do radiographic features of acute infection influence management of lower respiratory tract infections in the community?.  Eur Respir J. 1998;  12 1384-1387
• 33 Singal B M, Hedges J R, Radack K L. Decision rules and clinical prediction of pneumonia: evaluation of low-yield criteria.  Ann Emerg Med. 1989;  18 13-20
• 34 Spiteri M A, Cook D G, Clarke S W. Reliability of eliciting physical signs in examination of the chest.  Lancet. 1988;  1 873-875
• 35 Wipf J E, Lipsky B A, Hirschmann J V. et al . Diagnosing pneumonia by physical examination: relevant or relic?.  Arch Intern Med. 1999;  159 1082-1087
• 36 Woodhead M A, Gialdroni-Grassi G, Huchon G, Leophonte P, Manresa F, Schaberg T. Use of investigations of lower respiratory tract infection in the community: a European survey.  Eur Respir J. 1996;  9 1596-1600
• 37 Young M, Marrie T J. Interobserver variability in the interpretation of chest roentgenogramms of patients with positive pneumonia.  Arch Intern Med. 1994;  154 2729-2732

Korrespondenz