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Am Fam Physician. 2019;100(6):375-376

Clinical Question

What signs and symptoms are the most useful for excluding the diagnosis of pneumonia in community-dwelling adults with an acute respiratory infection?

Bottom Line

Community-dwelling adults who present to a primary care office with acute respiratory infection symptoms but normal vital signs and normal findings on a pulmonary examination have only a 0.4% likelihood of community-acquired pneumonia (CAP). (Level of Evidence = 1a)


Identifying signs and symptoms that reliably rule out CAP may help reduce the overuse of radiography and/or laboratory testing. Investigators systematically searched MEDLINE and reference lists of pertinent articles for studies that used a clinical decision rule to diagnose CAP in the outpatient setting. Eligible criteria included the use of chest radiography or computed tomography as the reference standard for all enrolled patients or a random/systematic sample of the enrolled patients. Only studies that recruited adults or adolescents in an outpatient setting, including the emergency department, were included. Two individuals independently reviewed potential studies for inclusion criteria and methodologic quality using standard criteria. The resolution of any disagreements occurred after consensus discussion with a third reviewer.

A total of 12 studies met inclusion criteria, of which six were performed in an emergency department setting and six in a primary care setting. Sample sizes ranged from 246 to 2,820 patients. Six studies were found to be at low risk of bias; the remaining six were at moderate risk of bias. The combination of normal vital signs (temperature, respiratory rate, and heart rate) plus normal findings on the pulmonary examination reliably excluded CAP (sensitivity = 0.96; 95% CI, 0.92 to 0.28; negative likelihood ratio = 0.10; 0.07 to 0.13).

Study design: Systematic review

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Reference: Marchello CS, Ebell MH, Dale AP, et al. Signs and symptoms that rule out community-acquired pneumonia in outpatient adults: A systematic review and meta-analysis. J Am Board Fam Med. 2019;32(2):234–247.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see

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This series is coordinated by Natasha J. Pyzocha, DO, contributing editor.

A collection of POEMs published in AFP is available at

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