Pneumonia is an infection of the lung tissue with evidence of changes on the chest x-ray

Typical presentation is with cough, fever, rigors, dyspnoea and pleuritic chest pain. The infecting pathogen is often unidentified.

Every year between 0.5 and 1% of adults in the UK develop community acquired pneumonia (CAP).

Mortality Risk Assessment (CURB65) - must be completed on every patient who has been diagnosed with community acquired pneumonia on initial assessment (it is not a validated tool for other forms of pneumonia)

• New confusion (C)

• Plasma urea >7mmol/L (U)

• Respiratory rate ≥30 (R)

• Systolic BP <90mmHg or diastolic BP ≤60 mmHg (B)

• Age >65 years (65)

Patients are stratified for risk of death as follows:

• 0 or 1: low risk (less than 3% mortality risk)

• 2: intermediate risk (3-15% mortality risk)

• 3 to 5: high risk (more than 15% mortality risk).

Use clinical judgement in conjunction with the CURB65 score to guide the management of community-acquired pneumonia, as follows:

• Consider home-based care for patients with a CURB65 score of 0 or 1

• Consider hospital-based care for patients with a CURB65 score of 2 or more

• Consider intensive care assessment for patients with a CURB65 score of 3 or more.

Other markers of severity:

• Multi-lobar involvement

• Hypoxaemia - PaO2 < 8kPa

• Urine Legionella antigen positive

• Chest x-ray – For a pneumonia diagnosis to be made there must be changes on the chest x-ray that are not explained by an alternative diagnosis

• Blood tests: FBC, U&Es, CRP, LFTs

• ABG if 02 saturation <94% in air

• Microbiology:

• Blood culture

• Sputum culture – if productive

• Pneumococcal and legionella urinary antigen tests

• Consider Mycoplasma serology

• Respiratory viral swabs

General Treatment

• Oxygen to target sats >92%

• Must be given as soon as diagnosis is suspected and at certainly within 4 hours

• Consider IV fluids – assess volume status

• VTE prophylaxis as per Trust guidelines.

• Airway clearance techniques should be considered if the patient has sputum retention and difficulty in expectoration, or in the event of a pre-existing lung condition such as bronchiectasis

• Smoking cessation advice – please ensure patient is referred to smoking cessation team and appropriate nicotine replacement prescribed

• Do not routinely offer a glucocorticosteroid to patients with community-acquired pneumonia unless they have other conditions for which glucocorticosteroid treatment is indicated

Consider ITU/MADU

• If seriously ill and/or exhausted

• Patients with CURB scores of 2 or more

• Oxygen: if patients are needing >40% oxygen to maintain O₂ saturation >92% or PaO₂ >8kPa

• If patients have a high CO2 or low pH on arterial blood gases

Antibiotic therapy:

• Choose antibiotics as per trust guidelines on Eolas, important to consider:

  • The type of pneumonia (eg. CAP, hospital-acquired, aspiration)

  • The severity of the pneumonia (use CURB65 score in CAP)

  • The risk of developing complications, for example if the person has relevant comorbidities such as underlying lung disease or immunosuppression

  • Recent antibiotic use

  • Recent microbiological results, including colonisation with multidrug-resistant bacteria

• If intravenous antibiotics are given, review at 48 hours and consider switching to oral antibiotics if possible

Patient information

All patients should be given a patient information leaflet on pneumonia in adults, which can be found on the intranet

Discharge

Consider discharging patients with pneumonia if in the past 24 hours they have not had 2 or more of the following findings:

• A temperature higher than 37.5°C

• A respiratory rate of ≥24 breaths per minute

• A heart rate >100 beats per minute

• A systolic blood pressure ≤90 mmHg

• An oxygen saturation <90% on room air

• An abnormal mental status

• Inability to eat without assistance.

Explain to patients with community-acquired pneumonia that after starting treatment their symptoms should steadily improve, although the rate of improvement will vary with the severity of the pneumonia, and most people can expect that by:

• 1 week: fever should have resolved

• 4 weeks: chest pain and sputum production should have substantially reduced

• 6 weeks: cough and breathlessness should have substantially reduced

• 3 months: most symptoms should have resolved but fatigue may still be present

• 6 months: most people will feel back to normal.

Follow-up:

• A chest radiograph should be arranged after 6-8 weeks for most patients with pneumonia, particularly those who are at higher risk of underlying malignancy (smokers and those aged >50 years) whether or not they have been admitted to hospital

• In the majority of cases, the GP can be requested to perform the chest x-ray. If patients have pleural effusions, lobar collapse or other concerning x-ray findings, then request an outpatient referral to Respiratory Medicine instead

• It is the responsibility of the hospital team to arrange the follow-up plan, record it on the discharge summary, and let the patient know

• British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Adults Update 2009 A Quick Reference Guide [Internet]. 2009. Available from: https://www.brit-thoracic.org.uk/document-library/guidelines/pneumonia-adults/quick-reference-guide-bts-guidelines-for-the-management-of-community-acquired-pneumonia-in-adults/

• https://gettingitrightfirsttime.co.uk/wp-content/uploads/2021/11/Respiratory-Medicine-Oct21L.pdf (page 72-81)

• Pneumonia in adults: diagnosis and management

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version History

Related Documents