See separate guidance for severe pneumonia in the frail elderly to avoid harms of 4C antibiotics.
Required investigations
- CXR
- Blood cultures
- Viral throat swab if being admitted (swab throat and nose at same time with single swab, send in viral transport medium); TRAK as 'Resp Virus Screen'
- Sputum for culture; TRAK as 'C&S-Respiratory (Routine Bacteriology)'
- Sputum for atypicals; TRAK as 'Respiratory Sputum (Inc Atypicals)
- Do not routinely send urine for Legionella urinary antigen. If patient unable to produce sputum, send urine for Legionella antigen (Document on request form “CAP CURB 3-5/severe, unable to produce sputum”) TRAK as 'Legionella Urinary Ag Profile'
Antibiotic Recommendation
Recommended total duration: 5 days (total duration = IV + oral)
Recommended Antibiotic |
Co-amoxiclav 1.2g every 8 hours IV
PLUS
Clarithromycin 500mg every 12 hours orally, IV only if oral route unavailable.
Risk of phlebitis with IV, oral formulation has very good bioavailability.
|
Penicillin allergy |
Vancomycin (use NHS Lothian Calculator located on AMT intranet page, choose trough levels 10-15 mg/L)
PLUS
Ciprofloxacin 500mg every 12 hours orally (if oral route unavailable: 400mg every 12 hours IV)
Avoid fluoroquinolones if taking steroids and the elderly.
Review MHRA Quinolone Warning before prescribing.
|
DO NOT ADD CLARITHROMYCIN IF CIPROFLOXACIN USED AS BOTH COVER ATYPICALS (SEE SECTION BELOW), AS DOES DOXYCYCLINE.
IV-to-ORAL switch |
Co-amoxiclav 625mg every 8 hours orally
Consider need for ongoing atypical pneumonia cover see atypical pneumonia section below.
|
Penicillin allergy |
Doxycycline 200mg on first day and then 100mg daily orally |
Notes
Stop antibiotic treatment after 5 days unless
- microbiological results suggest a longer course is needed or
- the patient is not clinically stable (fever in past 48 hours or more than 1 sign of clinical instability [systolic blood pressure <90 mmHg, heart rate >100/minute, respiratory rate >24/minute, arterial oxygen saturation <90% or PaO2 <60 mmHg in room air]).
In all patients consider:
- Repeat CXR in 6 weeks for all those with consolidation on CXR
- Smoking cessation advice
- Influenza/pneumococcal vaccination for those >65 years or with chronic illness.