Bacterial Pneumonia Differential Diagnoses

  • Author: Nader Kamangar, MD, FACP, FCCP, FCCM; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Jan 3, 2012
 
 

Diagnostic Considerations

Remember that the most prevalent causative organism in bacterial pneumonia is pneumococcus regardless of the host; empiric therapy must be selected with this in mind.

Because the episode of aspiration is usually not witnessed, the diagnosis is inferred when a patient at risk of aspiration develops evidence of a radiographic infiltrate in characteristic anatomic pulmonary locations or bronchopulmonary segments.

Always consider the possibility of Legionella infection, because delayed treatment significantly increases mortality.

Despite the frequency of pneumonia and the large body of research and literature surrounding it, controversy remains regarding certain aspects of the evaluation and management of pneumonia. Much emphasis has been placed on the utility of diagnostic testing versus the role of empiric treatment. The following 3 aspects of disease are important in the management of pneumonia, in which diagnostic testing can play a pivotal role:

  • Determining the presence of pneumonia
  • Assessing disease severity at the time of presentation
  • Identifying the causative agent

Distinguishing pneumonia from other pulmonary pathologies, such as acute COPD or asthma exacerbation, can often present a significant challenge, particularly in patients with these underlying lung diseases. C-reactive protein (CRP) and procalcitonin values may help in distinguishing infectious pneumonia from noninfectious underlying disease exacerbations.[45]

Differentiation between CAP, healthcare-associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and other pulmonary pathology at presentation is important for several reasons, but primarily because the varying pathogens implicated in each category dictate the empiric therapy likely to be most useful.[16]

In children, the following conditions should also be taken into consideration:

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Nader Kamangar, MD, FACP, FCCP, FCCM  Associate Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, Los Angeles, David Geffen School of Medicine, Olive View-UCLA Medical Center; Associate Program Director, Pulmonary and Critical Care Multi-Campus Fellowship Program, Cedars-Sinai/West Los Angeles Veterans Affairs/Los Angeles Kaiser Permanente/Olive View-UCLA Medical Center; Site Director, Pulmonary/Critical Care Fellowship Program, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: American Academy of Sleep Medicine, American Association of Bronchology, American College of Chest Physicians, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Annie Harrington, MD  Fellow in Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center

Annie Harrington, MD is a member of the following medical societies: Alpha Omega Alpha and American College of Chest Physicians

Disclosure: Nothing to disclose.

Christina Rager, MD  Resident Physician, Internal and Emergency Medicine, Olive View-University of California at Los Angeles Medical Center

Christina Rager, MD is a member of the following medical societies: American College of Physicians, American Medical Student Association/Foundation, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Dana A Stearns, MD  Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital

Dana A Stearns, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

James M Stephen, MD, FAAEM, FACEP  Assistant Professor, Tufts University School of Medicine; Attending Physician, Director of Medical Informatics and Graduate Education, Department of Emergency Medicine, Tufts Medical Center

James M Stephen, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Ryland P Byrd Jr, MD  Professor, Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, Program Director of Pulmonary Diseases and Critical Care Medicine Fellowship, East Tennessee State University, James H Quillen College of Medicine; Medical Director of Respiratory Therapy, James H Quillen Veterans Affairs Medical Center

Ryland P Byrd Jr, MD is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Paul Blackburn, DO, FACOEP, FACEP  Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Sat Sharma, MD, FRCPC,to the development and writing of a source article.

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Bacterial pneumonia. Radiographic images in a patient with right upper lobe pneumonia. Note the increased anteroposterior chest diameter, which is suggestive of chronic obstructive pulmonary disease (COPD).
Bacterial pneumonia. Radiographic images in a patient with bilateral lower lobe pneumonia. Note the spine sign, or loss of progression of radiolucency of the vertebral bodies
Bacterial pneumonia. Radiographic images in a patient with early right middle lobe pneumonia.
Table. Pathogen-Driven Antibiotic Choices[16]
OrganismFirst-Line AntimicrobialsAlternative Antimicrobials
Streptococcus pneumoniae
Penicillin susceptible



(MIC < 2 mcg/mL)



Penicillin G, amoxicillinMacrolide, cephalosporin (oral or parenteral), clindamycin, doxycycline, respiratory fluoroquinolone
Penicillin resistant



(MIC ≥2 mcg/mL)



Agents chosen on the basis of sensitivityVancomycin, linezolid, high-dose amoxicillin (3 g/d with MIC ≤4 mcg/mL
Staphylococcus aureus
Methicillin susceptibleAntistaphylococcal penicillinCefazolin, clindamycin
Methicillin resistantVancomycin, linezolidTrimethoprim- sulfamethoxazole
Haemophilus influenzae
Non–beta-lactamase producingAmoxicillinFluoroquinolone, doxycycline, azithromycin, clarithromycin
Beta-lactamase producingSecond- or third-generation cephalosporin, amoxicillin/clavulanateFluoroquinolone, doxycycline, azithromycin, clarithromycin
Mycoplasma pneumoniaeMacrolide, tetracyclineFluoroquinolone
Chlamydophila pneumoniaeMacrolide, tetracyclineFluoroquinolone
Legionella speciesFluoroquinolone, azithromycinDoxycycline
Chlamydophila psittaciTetracyclineMacrolide
Coxiella burnetiiTetracyclineMacrolide
Francisella tularensisDoxycyclineGentamicin, streptomycin
Yersinia pestisStreptomycin, gentamicinDoxycycline, fluoroquinolone
Bacillus anthracis (inhalational)Ciprofloxacin, levofloxacin, doxycyclineOther fluoroquinolones, beta-lactam (if susceptible), rifampin, clindamycin, chloramphenicol
EnterobacteriaceaeThird-generation cephalosporin, carbapenemBeta-lactam/beta-lactamase inhibitor, fluoroquinolone
Pseudomonas aeruginosaAntipseudomonal beta-lactam plus ciprofloxacin, levofloxacin, or aminoglycosideAminoglycoside plus ciprofloxacin or levofloxacin
Bordetella pertussisMacrolideTrimethoprim- sulfamethoxazole
Anaerobe (aspiration)Beta-lactam/beta-lactamase inhibitor, clindamycinCarbapenem
MIC = Minimal inhibitory concentration.
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