Skip to main content

Main menu

  • Home
  • Articles
    • Current Issue
    • COVID-19
    • Ahead of Print
    • Archives
    • Abstracts In Press
    • Editors' Blog
    • Email Alerts
  • Info For
    • Authors
    • Reviewers
    • Subscribers
    • Advertisers
  • SUBMIT
    • Manuscript
    • Peer Review
  • About
    • The JABFM
    • Editorial Board
    • Indexing
  • Classifieds
  • More
    • Email Alerts
    • Feedback
    • ABFM News
    • Folders
    • Help
  • Other Publications
    • abfm

User menu

Search

  • Advanced search
American Board of Family Medicine
  • Other Publications
    • abfm
American Board of Family Medicine

American Board of Family Medicine

Advanced Search

  • Home
  • Articles
    • Current Issue
    • COVID-19
    • Ahead of Print
    • Archives
    • Abstracts In Press
    • Editors' Blog
    • Email Alerts
  • Info For
    • Authors
    • Reviewers
    • Subscribers
    • Advertisers
  • SUBMIT
    • Manuscript
    • Peer Review
  • About
    • The JABFM
    • Editorial Board
    • Indexing
  • Classifieds
  • More
    • Email Alerts
    • Feedback
    • ABFM News
    • Folders
    • Help
  • JABFM On Twitter
  • JABFM On YouTube
  • JABFM On Facebook
Research ArticleOriginal Research

Signs and Symptoms That Rule out Community-Acquired Pneumonia in Outpatient Adults: A Systematic Review and Meta-Analysis

Christian S. Marchello, Mark H. Ebell, Ariella P. Dale, Eric T. Harvill, Ye Shen and Christopher C. Whalen
The Journal of the American Board of Family Medicine March 2019, 32 (2) 234-247; DOI: https://doi.org/10.3122/jabfm.2019.02.180219
Christian S. Marchello
the Department of Epidemiology and Biostatistics, College of Public Health, (CSM, MHE, APD, YS, CCW), Department of Infectious Diseases, College of Veterinary Medicine (EH), University of Georgia, Athens, GA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Mark H. Ebell
the Department of Epidemiology and Biostatistics, College of Public Health, (CSM, MHE, APD, YS, CCW), Department of Infectious Diseases, College of Veterinary Medicine (EH), University of Georgia, Athens, GA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ariella P. Dale
the Department of Epidemiology and Biostatistics, College of Public Health, (CSM, MHE, APD, YS, CCW), Department of Infectious Diseases, College of Veterinary Medicine (EH), University of Georgia, Athens, GA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Eric T. Harvill
the Department of Epidemiology and Biostatistics, College of Public Health, (CSM, MHE, APD, YS, CCW), Department of Infectious Diseases, College of Veterinary Medicine (EH), University of Georgia, Athens, GA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ye Shen
the Department of Epidemiology and Biostatistics, College of Public Health, (CSM, MHE, APD, YS, CCW), Department of Infectious Diseases, College of Veterinary Medicine (EH), University of Georgia, Athens, GA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Christopher C. Whalen
the Department of Epidemiology and Biostatistics, College of Public Health, (CSM, MHE, APD, YS, CCW), Department of Infectious Diseases, College of Veterinary Medicine (EH), University of Georgia, Athens, GA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
Loading

Article Figures & Data

Figures

  • Tables
  • Figure 1.
    • Download figure
    • Open in new tab
    Figure 1.

    PRISMA flow diagram of search strategy and selection of articles.

  • Appendix B4.
    • Download figure
    • Open in new tab
    Appendix B4.

    Summary Receiver Operating Characteristic Curves for Clinical Decision Rules Using any Abnormal Vital Signs (A), and Any Abnormal Vital Sign and Abnormal Pulmonary Exam (B) to Diagnose (Rule in) Community Acquired Pneumonia.

Tables

  • Figures
    • View popup
    Table 1.

    Characteristics of Included Studies

    Author, YearCountryDesignSettingYear RecruitedSample SizeInclusion AgeMean or Median Age
    Diehr, 19847United StatesProspectiveEDNot reported1758AdultsNot reported
    Gennis, 198920United StatesProspectiveED1984 to 1985308≥16 years53.6 years (mean)
    Singal, 198914United StatesProspectiveED1986 to 1987255≥18 yearsNot reported
    Heckerling, 19907United StatesProspectiveED1987 to 19881436≥16 years45.4 years (mean): Illinois/Nebraska; 41.4 years (mean): Virginia
    Melbye, 199217NorwayProspectiveED1988 to 1989581≥18 years32.1 (mean)
    Hopstaken, 200318The NetherlandsCross-sectional/prospectivePrimary care1998 to 1999246≥18 years52 years (mean)
    O'Brien, 200616United StatesCase-control/prospectiveOutpatient/ED2004 to 2005700≥18 years65 years (mean): cases; 66 years (mean): controls
    Holm, 200719DenmarkProspectivePrimary care2002 to 2003364≥18 years50 years (median)
    Saldias, 200715ChileProspectiveED2005325>15 years53.4 years (mean)
    Steurer, 20118SwitzerlandProspectivePrimary care2006 to 2009621≥18 years46.8 years (mean)
    van Vugt, 2013912 European countriesProspectivePrimary care2007 to 20102820Adults50 years (mean)
    Ebrahimzadeh, 201521IranCase-control/prospectiveOutpatient/ED2008 to 2009840≥18 years60 years (mean): cases; 63 years (mean): controls
    • ED, emergency department.

    • View popup
    Table 2.

    Clinical Decision Rules That Used a Point Score to Diagnose Pneumonia

    Author, Year (Signs, Symptoms, Tests Used in CDR)CDR ScoreCAPNo CAPPVLR
    Diehr, 19847−301400.0%0.00
        (>37.8°C,−245520.7%0.27
        >25 breath/min,−185041.6%0.59
        myalgia, night073162.2%0.82
        sweats, sputum,1121248.8%3.60
        sore throat,265210.3%4.29
        rhinorrhea)341225.0%12.41
    43827.3%13.96
    51420.0%9.30
    610100.0%†
    Total461712
    Low: −3 to −2*415120.3%0.10
    Mod: −1 to 1*2717613.3%5.7
    High: 2 to 6*152438.5%23.3
    Heckerling, 19906Derivation: Illinois
        (>37.8°C,01482.0%0.12
        HR >100/min,1113163.4%0.20
        rales, absence of22823210.8%0.70
        asthma, decrease34214922.0%1.64
        breath sounds)4373055.2%7.18
    515575.0%17.5
    Total134780
    Low: 0 to 1*123643.2%0.19
    Mod: 2 to 3*7038115.5%1.07
    High: 4 to 5*523559.8%8.6
    Validation: Nebraska
    0050.0%0.000
    13289.7%0.20
    2112629.7%0.78
    3121642.9%1.38
    411284.6%10.1
    550100.0%†
    Total4277
    Low: 0 to 1*3338.3%0.17
    Mod: 2 to 3*234235.4%1.00
    High: 4 to 5*16288.9%14.7
    Validation: Virginia
    01712.5%0.51
    12306.3%0.24
    284415.4%0.65
    361627.3%1.35
    411857.9%4.93
    510100.0%†
    Total29104
    Low: 0 to 1*3377.5%0.29
    Mod: 2 to 3*146018.9%0.84
    High: 4 to 5*12860.0%54
    Pooled
    02603.2%0.16
    1163744.1%0.20
    24730213.5%0.73
    36018124.9%1.55
    4594059.6%6.92
    521580.8%19.7
    Total60205
    Low: 0 to 1*184344.0%0.19
    Mod: 2 to 3*10748318.1%1.04
    High: 4 to 5*804564.0%8.33
    van Vugt, 20139 (decreased breath sounds, crackles, breathlessness, vesicular breath sounds, absence of runny nose, >37.8C, HR >100/min, CRP >30)    CDR w/out CRP
    Low: <2.5%116541.7%0.32
    Mod: 2.5% to 20%10519875.0%1.01
    High: >20%243938.1%11.8
    Total1402680
    CDR and CRP >30
    Low: 045680.7%0.14
    Mod: 1 to 27318293.8%0.76
    High: ≥36328318.2%4.26
    Total1402680
    • CAP, community-acquired pneumonia; CDR, clinical decision rule; CRP, c-reactive protein; HR, heart rate; NR, not reported; LR, likelihood ratio; PV, predictive value.

    • ↵* Risk groups calculated post hoc and were not in original publication.

    • ↵† Unable to calculate due to zero value for no CAP.

    • View popup
    Table 3.

    Summary Estimates of Meta-Analysis for the Diagnostic Accuracy of Clinical Decision Rules that Diagnose (Rule in) CAP

    CDR Used to Diagnose CAP (Rule in)Sensitivity (95% CI)Specificity (95% CI)LR+ (95% CI)LR− (95% CI)AUROCC
    Any abnormal vital signs0.89 (0.79 to 0.94)0.49 (0.25 to 0.73)1.84 (1.25 to 3.03)0.24 (0.17 to 0.34)0.83
    Any abnormal signs or any abnormal pulmonary exam finding0.96 (0.92 to 0.98)0.43 (0.20 to 0.69)1.79 (1.22 to 3.01)0.10 (0.07 to 0.13)0.92
    • AUROCC, area under the receiver operating characteristic curve; CAP, community-acquired pneumonia; CDR, clinical decision rule; CI, confidential interval; LR, likelihood ratio.

    • View popup
    Table 4.

    Simulated Primary Care (4%) and Emergency Department (20%) Prevalence Rates for Selected CDRs

    LR% CAP Given Baseline Prevalence of
    Score or CDR4%20%
        Normal signs and no pulmonary finding15,16,210.100.4%2.4%
        Normal vital signs15,16,20,210.241.0%5.7%
    Diehr, 19847
        Low (−3 to −2)*0.100.4%2.4%
        Mod (−1 to 1)*5.719.2%58.8%
        High (2 to 6)*23.349.2%85.3%
    Heckerling, 19906
        Pooled (all 3 states)
        Low (0 to 1)*0.190.8%4.6%
        Mod (2 to 3)*1.044.1%20.6%
        High (4 to 5)*8.3325.8%67.6%
    van Vugt, 20139
        Low (0)0.140.6%3.3%
        Interm (1 to 2)0.763.1%16.0%
        High (≥3)4.2615.1%51.6%
    • ↵* Risk groups calculated post hoc and were not in original publication.

    • CAP, community-acquired pneumonia; CDR, clinical decision rule.

    • View popup
    Appendix B1.

    Assessment of Study Quality Using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) Framework

    Author, YearConsecutive or random sample enrolled? (Y/N/U)Case-control design avoided? (Y/N/U)Avoided inappropriate exclusion criteria? (Y/N/U)Likelihood that patient selection could have introduced bias? (H/L/U)Concerns that included patients and setting do not match the review question? (Y/N/U)CDR results interpreted without knowledge of reference standard? (Y/N/U)Likelihood that conduct or interpretation of the CDR have introduced bias? (H/L/U)Concerns that the CDR differs from the review question? (Y/N/U)Reference standard likely to correctly classify patients as pneumonia? (Y/N/U)Reference standard interpreted without knowledge of index test? (Y/N/U)Likelihood that conduct or interpretation of reference standard introduced bias? (H/L/U)Conditions defined by the reference standard do not match the review question? (Y/N/U)All patients receive a reference standard? (Y/N/U)Did all patients receive the same reference standard? (Y/N/U)Were all patients included in the analysis? (Y/N/U)Patient flow have introduced bias? (H/L/U)Overall assessment of risk of bias (H/M/L)
    Diehr, 1984YYYLNYLNYYLNYYYLL
    Ebrahimzadeh, 2015UNYHNYLNYYLNYYYLM
    Gennis, 1989YYNHNYLNYYLNYYYLM
    Heckerling, 1990YYNHNYLNYYLNYYYLM
    Holm, 2007YYYLNYLNYYLNYYYLL
    Hopstaken, 2003YYYLNYLNYYLNYYYLL
    Melbye, 1992YYYLNYLNYYLNNYYHM
    Obrien, 2006UNYHNYLNYYLNYYYLM
    Saldias, 2007YYYLNYLNYYLNYYYLL
    Singal, 1989YYNHNYLNYYLNYYYLM
    Steurer, 2011YYYLNYLNYYLNYYYLL
    van Vugt, 2013YYYLNYLNYYLNYYYLL
    • Y: yes; N: No; U: unknown; H; high, M: moderate; L: low; CDR: clinical decision rule.

    • View popup
    Appendix B2.

    Individual Signs, Symptoms, and Point Care Tests Used in Clinical Decision Rules (CDRs) to Diagnose or Rule Out Pneumonia

    Author, YearTemp (C)Pulse (per min)CracklesDecreased breath soundsResp (per min)Other signs, symptoms or point of care tests
    Diehr, 1984>37.8>25sore throatnight sweatsmyalgiarhinorrheasputum
    Ebrahimzadeh, 2015≥38≥100XX≥20CRPdullness on percussionrhonchiESRWBC
    Gennis, 1989>37.8>100X>20raleswheezesrhonchi
    Heckerling, 1990>37.8>100Xralesabsence of asthma
    Holm, 2007CRPclinical pneumoniaSATO2
    Hopstaken, 2003≥38CRP<20diarrheaESR <20dry cough
    Melbye, 1992XXpleural rubsdullness on percussion
    Obrien, 2006≥38≥100XX>20rhonchidullness on percussion
    Saldias, 2007≥38≥100X≥20orthopneadullness on percussionabnormal auscultation
    Singal, 1989XXcough
    Steurer, 2011XCRP >11dyspnea
    van Vugt, 2013>37.8>100XXCRP >30breathlessnessVesicular soundsabsence of runny nose
    • Boxes in gray indicate not used in study. X: used in study but did not give specific value; Temp: temperature in Celsius.

    • Resp: respiratory rate; CRP: c-reactive protein ESR: erythrocyte sedimentation rate; WBC: white blood cell count; SATO2: oxygen saturation.

    • View popup
    Appendix B3.

    Diagnostic Accuracy of Clinical Decision Rules Using Signs, Symptoms, and Point of Care Tests to Diagnose (Rule In) Pneumonia

    Author, YearCDR used to diagnose CAP (rule in)CDR expressed as low yield criteria (rule out)Sensitivity (TP/TP+FN)Specificity (TN/TN+FP)LR+LR−
    Ebrahimzadeh, 2015Any abnormal VSNormal VS0.86 (361/420)0.72 (302/420)3.060.20
    Any abnormal VS or PE findingNormal VS and no PE findings0.94 (395/420)0.57 (241/420)2.210.10
    Any abnormal lab (CRP, ESR, WBC)Normal labs0.60 (254/420)0.74 (310/420)2.310.54
    Gennis, 1989Any abnormal VSNormal VS0.97 (114/118)0.19 (36/190)1.190.18
    Any abnormal auscultatory findingsNormal auscultatory findings0.78 (92/118)0.38 (73/190)1.270.57
    Holm, 2007GP diagnosis of CAP and CRP ≥ 20GP diagnosis of CAP or CRP < 200.49 (23/47)0.84 (249/297)3.030.61
    GP diagnosis of CAP and SATO2 ≤ 95%GP diagnosis of CAP or SATO2 > 95%0.32 (15/47)0.92 (268/291)4.040.74
    GP diagnosis of CAP or CRP ≥ 20GP diagnosis of CAP and CRP < 200.83 (39/47)0.48 (144/297)1.610.35
    GP diagnosis of CAP or SATO2 ≤ 95%GP diagnosis of CAP and SATO2 > 95%0.79 (37/47)0.56 (164/291)1.800.38
    Hopstaken, 2003>1 (diarrhea, dry cough, ≥ 38C) or CRP ≥ 20<=1 of 3 sign/symptom + CRP <200.91 (29/32)0.49 (104/211)1.790.19
    >1 (diarrhea, dry cough, ≥ 38C) or ESR ≥ 20<=1 of 3 sign/symptom + ESR <200.81 (26/32)0.55 (115/211)1.790.34
    Melbye, 1992Abnormal auscultatory signsNormal auscultatory signs0.40 (8/12)0.88 (336/382)3.320.68
    O'Brien, 2006Any abnormal VSNormal VS0.81 (282/350)0.64 (225/350)2.260.30
    Any abnormal VS or PE findingNormal VS and no PE findings0.95 (333/350)0.56 (196/350)2.160.09
    Saldias, 2007Any abnormal VSNormal VS0.86 (89/103)0.44 (85/193)1.540.31
    Abnormal VS or PE findingNormal VS and no PE findings0.98 (101/103)0.19 (37/193)1.210.10
    Singal, 1989Fever, cough, cracklesAbsence of fever, cough, crackles0.93 (37/40)0.27 (57/215)1.260.28
    Steurer, 2011CRP>50 or CRP 11–50 and dyspnea or daily feverCRP < 10 or CRP 11–50, no dyspnea, and no daily fever1.00 (127/127)0.38 (190/494)1.630.00
    • CDR: clinical decision rule; CAP; community-acquired pneumonia; VS: vital signs; PE: pulmonary exam; GP: general practitioner; CRP: c-reactive protein; ESR: erythrocyte sedimentation rate; WBC: white blood cell count; SATO2: oxygen saturation; Sensitivity and specificity calculated using ruling in criteria.

  • Dier, 1984

    SymptomPoints/Score assigned
    Rhinorrhea−2
    Sore throat−1
    Night sweats1
    Myalgia1
    Sputum all day1
    Respiratory rate >252
    Temp. 100F or more2
  • Heckerling, 1990

    SymptomLogistic coefficient
    Temp. > 37.8C0.494
    Pulse ?100 beats/min0.428
    Rales0.658
    Decreased breath sounds0.638
    Absence of asthma0.691
    Intercept−1.705
  • Van Vugt, 2013

    SymptomPoints/Score assigned
    Absence of running nose1
    Breathlessness1
    Crackles1
    Diminished vesicular breathing1
    Raised pulse (>100/min)1
    Fever (temp. >37.8C)1
    Raised CRP (>30 mg/L)1
    • CRP, c-reactive protein.

PreviousNext
Back to top

In this issue

The Journal of the American Board of Family     Medicine: 32 (2)
The Journal of the American Board of Family Medicine
Vol. 32, Issue 2
March-April 2019
  • Table of Contents
  • Table of Contents (PDF)
  • Cover (PDF)
  • Index by author
  • Back Matter (PDF)
  • Front Matter (PDF)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on American Board of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Signs and Symptoms That Rule out Community-Acquired Pneumonia in Outpatient Adults: A Systematic Review and Meta-Analysis
(Your Name) has sent you a message from American Board of Family Medicine
(Your Name) thought you would like to see the American Board of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
3 + 17 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
Signs and Symptoms That Rule out Community-Acquired Pneumonia in Outpatient Adults: A Systematic Review and Meta-Analysis
Christian S. Marchello, Mark H. Ebell, Ariella P. Dale, Eric T. Harvill, Ye Shen, Christopher C. Whalen
The Journal of the American Board of Family Medicine Mar 2019, 32 (2) 234-247; DOI: 10.3122/jabfm.2019.02.180219

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Signs and Symptoms That Rule out Community-Acquired Pneumonia in Outpatient Adults: A Systematic Review and Meta-Analysis
Christian S. Marchello, Mark H. Ebell, Ariella P. Dale, Eric T. Harvill, Ye Shen, Christopher C. Whalen
The Journal of the American Board of Family Medicine Mar 2019, 32 (2) 234-247; DOI: 10.3122/jabfm.2019.02.180219
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Appendix A
    • Appendix
    • Appendix C
    • Notes
    • References
  • Figures & Data
  • Info & Metrics
  • References
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • The Most Frequently Read Articles of 2019
  • Response: Re: Signs and Symptoms That Rule Out Community-Acquired Pneumonia in Outpatient Adults: A Systematic Review and Meta-Analysis
  • Multiple Research Methodologies Can Advance the Science of Family Medicine
  • Google Scholar

More in this TOC Section

  • Documenting New Ways of Delivering Care Under Oregon’s Alternative Payment and Advanced Care Model
  • Barriers to Follow-Up Colonoscopy After Positive FIT or Multitarget Stool DNA Testing
  • A Cross-Sectional Study of Factors Associated With Pediatric Scope of Care in Family Medicine
Show more Original Research

Similar Articles

Keywords

  • Community-Acquired Infections
  • Meta-Analysis
  • Outpatients
  • Pneumonia
  • Prospective Studies
  • Systematic Review

Navigate

  • Home
  • Current Issue
  • Past Issues

Authors & Reviewers

  • Info For Authors
  • Info For Reviewers
  • Submit A Manuscript/Review

Other Services

  • Get Email Alerts
  • Classifieds
  • Reprints and Permissions

Other Resources

  • Forms
  • Contact Us

© 2021 American Board of Family Medicine

Powered by HighWire