Epidemiologic factors:
(1) history of exposure
(2) occupational or environmental risk
Clinical factors – symptoms and signs:
(1) fever with or without chills
(2) sweats, often drenching
(3) fatigue, malaise
(4) cough (usually nonproductive)
(5) shortness of breath
(6) chest discomfort, pleuritic pain
(7) nausea and vomiting
(8) diarrhea
(9) abdominal pain
(10) headache
(11) myalgias
(12) sore throat
(13) low grade fever (temperature > 37.8°C)
Initial triage - order laboratory and imaging studies if both:
(1) either epidemiologic factor is present, AND
(2) there is a 2 – 5 day illness with symptoms and signs
where:
• The number of signs and symptoms required is not specified. I used >= 3 in the implementation.
Laboratory tests:
(1) WBC count
(2) blood cultures
(3) rapid test to exclude influenza
Radiographic imaging:
(1) chest X-ray: mediastinal widening, pleural effusions or pulmonary infiltrates, but often normal
(2) chest CT if chest X-ray is normal: 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
(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) await blood cultures
(3) initiate or continue prophylaxis
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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.
