Diagnosis of the Month: Respiratory Infections - Mercy Medical Center
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Diagnosis of the Month: Respiratory Infections

Posted on: March 13, 2018

Follow these guidelines when diagnosing respiratory infections:

  1. The more specificity that you can provide for any respiratory diagnosis, the better.
  2. Avoid “lower respiratory tract infection” (LRTI) when at all possible. Instead, indicate a bronchitis or pneumonia diagnosis if you are able. Also, indicate acute bronchitis if that is the case, in order to differentiate it from a chronic bronchitis/COPD diagnosis.
  3. Indicate a specific etiology for a bronchitis or pneumonia if it is known or even suspected, probable, or likely. If there is evidence for a specific pathogen, link it specifically to the bronchitis or pneumonia. Only saying that the sputum culture is positive for a particular organism, a urine antigen is positive, or the respiratory PCR is positive for an organism is not sufficient documentation re: causation. e.g. “probable Pneumococcal pneumonia” rather than “pneumonia, urine antigen positive for Pneumococcus.”
  4. Avoid using an “HCAP” diagnosis. There is no code for this, and it will go to a simple, unspecified pneumonia, which is usually not the case. If a gram negative, MRSA, or other etiology is known, suspected, probable, or likely, please indicate that in your documentation. It might be helpful to think about what antibiotics the patient is on, and therefore what known or suspected organisms are being treated in someone with recent or ongoing exposure to a healthcare setting.
  5. If more than one pathogen is known or suspected, please indicate all of them in your diagnosis. A common scenario is an initial viral infection followed by a bacterial superinfection, e.g. influenza followed by a bacterial pneumonia such as S. pneumoniae or Staph aureus.
  6. The use of the respiratory PCR panel has greatly improved our ability to detect specific viral and bacterial/atypical pathogens. Sometimes it is difficult to know what the significance of a positive result is.

In general, any of the viral organisms on the respiratory PCR panel can cause a significant lower respiratory infection (even rhinovirus, though uncommon). This is especially the case in patients who are older, have chronic lung disease, or are immunosuppressed.

Pertussis identification is important for isolation, prophylaxis of patient contacts, and treatment of the index patient.

Mycoplasma pneumoniae and Chlamydia pneumoniae, especially the former, are relatively common causes of atypical pneumonia/CAP. PCR testing has enabled more rapid diagnosis of these, rather than waiting for results of serologic testing.

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