Epidemiologic factors:
(1) history of exposure
(2) occupational or environmental risk
Clinical factors – symptoms:
(1) fever
(2) sweats, often drenching
(3) fatigue
(4) cough
(5) chest discomfort, pleuritic pain
(6) nausea and vomiting
(7) headache
(8) dyspnea
(9) myalgias
(10) abdominal pain
(11) confusion
Clinical factors – signs:
(1) low grade fever (temperature > 37.8°C; mean temperature 38°C)
(2) tachycardia (resting heart rate > 100 beats per minute; mean heart rate 121 beats per minute)
Initial triage - order laboratory and imaging studies if one of the following is present:
(1) either epidemiologic factor is present, OR
(2) >= 5 symptoms AND fever AND tachycardia present
Laboratory tests:
(1) WBC count (phase 1 counts are 9,600 per µL; phase 2 are 26,800 per µL with neutrophilia and bands)
(2) blood cultures (8 of 8 patients positive if taken prior to blood cultures)
Radiographic imaging:
(1) chest X-ray: mediastinal widening, pleural effusions or pulmonary infiltrates, but often normal
(2) chest CT: performed if chest X-ray normal; look for mediastinal adenopathy, pleural effusions, variable pulmonary infiltrates
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Clinical Group
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Management
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negative initial triage
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(1) observe closely with definite followup
(2) provide antimicrobial prophylaxis if exposure is confirmed
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positive initial triage, mildly ill, normal laboratory tests and imaging studies
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(1) consider hospitalization or close followup
(2) initiate presumptive antibiotic therapy pending blood cultures and clinical progression
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positive initial triage, moderately or severely ill, any laboratory test or imaging study abnormal
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(1) begin antimicrobial therapy
(2) if pleural effusions present, obtain sample with Gram stain, PCR and/or cell block for immunohistochemistry
(3) if meningeal signs or altered mental status, perform lumbar puncture
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Other actions: Notify public health agency if suspected or definite infection diagnosed.
