CT Scan Within 6 Hours of Admission Versus Plain X-ray of The Chest For Immunocompetent Patient

Admitted With Community Acquired Pneumonia, A Retrospective Observational Study

M Chadi Alraies M.D., Samer Alhindi M.D., Abdul Hamid Alraiyes M.D., Joseph Sopko MD, FCCP
Department of Internal Medicine - St. Vincent Charity Hospital / Case Western Reserve University - Cleveland, Ohio

Introduction Statistical Analysis Discussion

 Clinical suspicion for pneumonia is one of the most common Patient and control groups were compared using Fisher exact and paired  Study patients were sicker than control group.
indications for chest imaging1. Student’s t tests.  Clinical presentation not radiological report should guide further
 According to the guidelines from the American Thoracic Society, workup.
postero-anterior and if possible lateral chest radiographs should be  Future criteria for CT use in immunocompetent CAP patients.
obtained if pneumonia is suspected in adults2. Results  Importance of:
 The chest radiograph (CXR) continues to be the initial imaging tool 1. Radiation safety.
Clinical history, presentation, and management variables for cases (n=37) and controls (n=37)
to assess the lung parenchyma because its yield in relation to cost, 2. Cost effectiveness.
radiation dose, availability, and ease of performance is unmatched by Variables Cases (%) Controls (%) p value 3. Identify the group of patients who will benefit from CT
other modalities. Age (years) 56 55.4 0.497 4. Identify the group of patients in whom chest CT is not required.
 In immunocompromised patients with suspected pneumonia, CT has Smoking history 28 (78%) 26 (72%) 0.999
been shown to improve pretest probability when forming a Study Limitations
Fever 17 (46%) 7 (18%) 0.086
differential diagnosis and strengthen clinical decision making3. Chest pain 14 (38%) 5 (13%) 0.103 •Small population
 There is a paucity of literature regarding the utility of chest CT in Cough 31 (84%) 33 (89%) 0.834 •Teaching hospital
immunocompetent patients with chest radiographic findings of Hypoxemia 21 (57%) 11 (29%) 0.004 •Observational retrospective study
pneumonia4. Weight loss 4 (11%) 0 (0) 0.088 •Majority of low socioeconomic African American population.
Hypothesis Night sweats 8 (22%) 1 (2%) 0.006
Leukocytosis 19 (54%) 2 (5.4%) 0.093 Conclusion
Chest CT scan in immunocompetent patient will make no change in Auscultation abnormalities 35 (95%) 25 (67%) 0.044
diagnosis and clinical management comparing to plain chest x-ray for We conclude that chest CT was of minimal value in a group of clinically
Abnormal sputum 15 (41%) 0 (0) <0.001
patient admitted with pneumonia. ill, immunocompetent patients with chest radiographic findings of
Initiation of antibiotics 37 (100%) 18 (47%) <0.001
pneumonia. Physician experience and clinical skills play a major role in
Change of antibiotics based on CT
Method findings
3 (8%) 0 (0) 0.094 ordering CT of the chest as a further work up of CAP (community-
 acquired pneumonia) which might help guiding therapy, or providing an
Study type: Observational retrospective case-controlled study Procedures 5 (14%) 2 (6%) 0.467
Additional/alternative diagnosis
alternative diagnosis in only (11%) percent of cases.
4 (11%) 0 (0) 0.03
 Inclusion criteria: based on CT findings

1. Immunocompetent patients with chest radiographic findings of Mean length of stay 6.5 days <1 day <0.005 References
pneumonia. 1. Adams PF, Marano MA (1995) Current estimates from the National Health Interview Survey, 1994.
Vital Health Stat 10 1995:1–260.
2. Subsequent evaluation by chest CT within 24 hours. 2. Niderman MS, Bass JB Jr, Campbell GD (1993) Guidelines for the initial management of adults with
community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy.
American Thoracic Society. Medical Section of the American Lung Association. Am Rev Respir Dis 148
 Exclusion criteria: (5):1418–1426
1. Immunocompromised patients. 3. Pulmonary complications in immunocompromised non-AIDS patients: comparison of diagnostic
accuracy of CT and chest radiography. Clin Radiol 47(3):159–165, Mar
2. Further imaging was recommended by radiologist. 4. Syrjala H, Broas M, Suramo I et al (1998) High-resolution computed tomography for the diagnosis of
3. CT chest done to role out pulmonary embolism. community-acquired pneumonia. Clin Infect Dis 27:358.
5. Dimarco AF, Briones B (1993) Is chest CT performed too often? Chest 103:985–986.
6. Reittner P, Ward S, Heyneman L, Johkoh T, Muller NL (2003) Pneumonia: high-resolution CT findings
 538 patients from our admissions that underwent chest CT between in 114 patients. Eur Radiol 13(3):515–521, Ma
7. Kang EY, Staples CA, McGuinness G, Primack SL, Muller NL (1996) Detection and differential
1/05 and 1/07. 37 patient matched our inclusion criteria. Age and sex- diagnosis of pulmonary infections and tumors in patients with AIDS: value of chest radiography versus
matched controls from the floor admissions with pneumonia that did Study patients’ clinical presentation
CT. Am J Roentgenol 166(1):15–19, Ja
8. Diehl SJ, Lehmann KJ, Thienel F, Georgi M (1997) Value of highresolution CT of the lungs in acute
not undergo CT were identified. pulmonary symptoms of patients with HIV infections. Rofo 167(3):227–233, Sep.