Community acquired pneumonia

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Severity assessment

CURB65 score is calculated by giving 1 point for each of the following prognostic features:

  • Confusion: abbreviated Mental Test score 8 or less, or new disorientation in person, place or time
  • Urea: >7 mmol/L
  • Respiratory rate: 30 breaths per minute or more
  • Blood pressure: diastolic 60 mmHg or less, or systolic less than 90 mmHg
  • 65 years of age or more

CURB65 0-1, low severity pneumonia

Required investigations

  • CXR
  • Viral throat swab if being admitted (Swab throat and nose at same time with single swab, send in viral transport medium)

Antibiotic Recommendation

Recommended total duration: 5 days

Recommended Antibiotic Amoxicillin 500mg every 8 hours orally
Penicillin allergy Doxycycline 200mg on first day, then 100mg daily for 4 days orally

CURB65 2, moderate severity pneumonia

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)
  • Sputum for culture

Antibiotic recommendation

Recommended total duration: 5 days (total duration = IV + oral)

Recommended Antibiotic

Amoxicillin 500mg every 8 hours orally

If oral route unavailable: Amoxicillin 1g every 8 hours IV

If atypical pathogens suspected see atypical pneumonias
Penicillin allergy

Doxycycline 200mg on first day and then 100mg daily orally

If oral route unavailable: Clarithromycin 500mg every 12 hours IV - risk of phlebitis

 

CURB65 3-5, high severity pneumonia

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)
  • Sputum for culture and
  • Legionella PCR on sputum – document on TRAK request “CAP CURB 3-5/severe”.
    • 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”)

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 fluruoquinolones 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

Amoxicillin 500mg every 8 hours orally

OR

Co-amoxiclav 625mg every 8 hours orally

PLUS

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]).

Severe pneumonia in the frail elderly

This guidance avoids the use of coamoxiclav and ciprofloxacin in frail elderly patients to reduce the risk of C.diff infection.

Severity: CURB65 3-5

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)
  • Sputum for culture (NB: also ask for Legionella PCR – document on request form “CAP CURB 3-5/severe”.
    • 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”)

Antibiotic Recommendation

Total duration: 5 days (total duration = IV + oral)

Recommended Antibiotic

Amoxicillin   1g every 8 hours IV

PLUS

Gentamicin  IV (use NHS Lothian Calculator located on AMT intranet page)
Penicillin allergy

Vancomycin  IV (use NHS Lothian Calculator located on AMT intranet page)

PLUS

Gentamicin IV (use NHS Lothian Calculator located on AMT intranet page)

 

IV-to-ORAL switch

IV-to-Oral switch Recommended Antibiotic Amoxicillin 500mg every 8 hours orally
Penicillin allergy Doxycycline 200mg on first day and then 100mg daily orally

 

 

Atypical pneumonia

Clarithromycin,   Doxycycline,  Ciprofloxacin all cover atypical pneumonia organisms.

  • Moderate severity CAP - CURB 2 ADD Clarithromycin 500mg every 12 hours orally ONLY if patient has risk factors or clinical features of atypical pneumonia 
  • High severity CAP – CURB 3-5 atypical cover is embedded into the recommendations for high severity CAP - do not add additional antimicrobial (unless advised to by an infection specialist).

STOP Clarithromycin  at 72 hours if lower respiratory tract samples are negative for atypical pathogens.

Atypical pneumonia risk factors Include:

  • Smokers
  • Returning travellers
  • Bird or animal exposure

Clinical features:

  • 7-10 day prodrome of upper respiratory tract symptoms prior to developing cough & fever
  • Non-respiratory features:
    • Diarrhoea
    • Abnormal LFTs
    • Low sodium
    • Rash (Mycoplasma pneumoniae is associated with erythema multiforme)
    • Neurological symptoms

Investigations only recommended in high severity CAP or where there is a high suspicion of atypical pneumonia

Specific investigations for atypical pneumonias in addition to investigations based on severity of CAP

Sputum or lower respiratory tract samples available
  • Sputum or other lower respiratory tract sample for respiratory PCR (includes Legionella)
  • Sputum or other lower respiratory tract sample for bacterial culture

Sputum or lower respiratory tract samples not available
  • Viral Throat Swab (Swab throat and nose at same time with single swab, send in viral transport medium) for respiratory PCR 
  • Urine for Legionella antigen test (Indicate on request “CAP CURB 3-5/severe, unable to produce sputum”)

Consider serum for Q fever if animal exposure risk.

HIV serology is recommended for patients with bacterial pneumonia.

In immunocompromised patients review Pneumonia in the immunocompromised (including PCP)

Notes

Atypical organisms:

    • Legionella pneumophila
    • Mycoplasma pneumoniae
    • Chlamydophila pneumoniae
    • Chlamydophila psittacci