Open Access Research article

Diagnostic aid to rule out pneumonia in adults with cough and feeling of fever. A validation study in the primary care setting

Ulrike Held1, Claudia Steurer-Stey23, Felix Huber3, Sergio Dallafior4 and Johann Steurer1*

Author Affiliations

1 Horten Center for Patient-oriented Research and Knowledge Transfer, University of Zurich, Postfach Nord, Pestalozzistrasse 24, Zurich CH-8091, Switzerland

2 Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland

3 Medix Gruppenpraxis, Rotbuchstrasse 46, Zurich, CH-8037, Switzerland

4 Praxisgemeinschaft Altstetten, Eugen Huber-Strasse 16, 8048, Zürich, Switzerland

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BMC Infectious Diseases 2012, 12:355  doi:10.1186/1471-2334-12-355

Published: 17 December 2012



We recently reported the derivation of a diagnostic aid to rule out pneumonia in adults presenting with new onset of cough or worsening of chronic cough and increased body temperature. The aim of the present investigation was to validate the diagnostic aid in a new sample of primary care patients.


From two group practices in Zurich, we included 110 patients with the main symptoms of cough and subjective feeling of increased body temperature, and C-reactive protein levels below 50 μg/ml, no dyspnea, and not daily feeling of increased body temperature since the onset of cough. We excluded patients who were prescribed antibiotics at their first consultation. Approximately two weeks after inclusion, practice assistants contacted the participants by phone and asked four questions regarding the course of their complaints. In particular, they asked whether a prescription of antibiotics or hospitalization had been necessary within the last two weeks.


In 107 of 110 patients, pneumonia could be ruled out with a high degree of certainty, and no prescription of antibiotics was necessary. Three patients were prescribed antibiotics between the time of inclusion in the study and the phone interview two weeks later. Acute rhinosinusitis was diagnosed in one patient, and antibiotics were prescribed to the other two patients because their symptoms had worsened and their CRP levels increased. Use of the diagnostic aid could have missed these two possible cases of pneumonia. These observations correspond to a false negative rate of 1.8% (95% confidence interval: 0.50%-6.4%).


This diagnostic aid is helpful to rule out pneumonia in patients from a primary care setting. After further validation application of this aid in daily practice may help to reduce the prescription rate of unnecessary antibiotics in patients with respiratory tract infections.

Pneumonia; Primary care; Decision tree; Prescription of antibiotics; Validation study