Indications for working up a patient with CAP more extensively:
(1) admission to the intensive care unit (ICU)
(2) failure of outpatient antibiotic therapy
(3) cavitary lesion(s) in the lung
(4) leucopenia
(5) active ethanol abuse
(6) severe chronic liver disease
(7) severe COPD and/or interstitial lung disease
(8) asplenia
(9) recent travel
(10) pleural effusion
(11) positive urine antigen test for Legionella or Streptococcus pneumoniae
where:
• Failure of initial antibiotic therapy would be another indication.
• The positive urine antigen statement could be reworded to risk factors for severe pneumonia with Legionalla or Str. pneumoniae.
• Recent travel was defined as within past 2 weeks. Some pathogens may have longer incubation periods. Also travel specifics influence risk, such as foreign travel or to a location with an epidemic outbreak.
Additional testing may include:
(1) specimen collection at bronchoscopy (with avoidance of oropharyngeal flora)
(2) culture for Mycobacteria
(3) culture for fungi
(4) culture for Legionella
(5) culture for virus
(6) thoracentesis (if pleural effusion)
(7) multiple blood cultures
