Pneumonia: assessment and management

Pneumonia: assessment and management

Primary care setting

NICE recommends that patients should initially be assessed in primary care using the CRB65 criteria:


Patients are stratified for risk of death as follows:

• 0: low risk (less than 1% mortality risk)
  • NICE recommend that treatment at home
    treatment at home
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    should be considered (alongside clinical judgement)
• 1 or 2: intermediate risk (1-10% mortality risk)
  • NICE recommend that ' hospital assessment should be considered (particularly for people with a score of 2)'
• 3 or 4: high risk (more than 10% mortality risk)
  • NICE recommend urgent admission to hospital

NICE also mention point-of-care CRP test. This is currently not widely available but they make the following recommendation with reference to the use of antibiotic therapy:

• CRP < 20 mg/L - do not routinely offer antibiotic therapy
• CRP 20 - 100 mg/L - consider a delayed antibiotic prescription
• CRP > 100 mg/L - offer antibiotic therapy

Secondary care setting

Note that in hospital, once blood tests are available the CURB65, rather than the CRB65, can be used. This adds an extra criterion of urea > 7 mmol/L:


NICE recommend, in conjunction with clinical judgement:

• consider home-based care for patients with a CURB65 score of 0 or 1 - low risk (less than 3% mortality risk)
• consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk (3-15% mortality risk)
• consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk)

Investigations

• chest x-ray
• in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests
• CRP monitoring is recommend for admitted patients to help determine response to treatment

Management of low-severity community acquired pneumonia

• amoxicillin is first-line
  Amoxicillin is the first-line antibiotic for low severity community-acquired pneumonia
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  Importance: 36
• if penicillin allergic then use a macrolide or tetracycline
• NICE now recommend a 5 day course of antibiotics for patients with low severity community acquired pneumonia

Management of moderate and high-severity community acquired pneumonia

• dual antibiotic therapy is recommended with amoxicillin and a macrolide
• a 7-10 day course is recommended
• NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity community acquired pneumonia

Discharge criteria and advice post-discharge

NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings:

• temperature higher than 37.5°C
• respiratory rate 24 breaths per minute or more
• heart rate over 100 beats per minute
• systolic blood pressure 90 mmHg or less
• oxygen saturation under 90% on room air
• abnormal mental status
• inability to eat without assistance.

They also recommend delaying discharge if the temperature is higher than 37.5°C.

NICE recommend that the following information is given to patients with pneumonia in terms of how quickly their symptoms should symptoms should resolve:


All cases of pneumonia should have a repeat chest X-ray at 6 weeks

repeat chest X-ray at 6 weeks

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after clinical resolution to ensure that the consolidation has resolved and there is no underlying secondary abnormalities (e.g. a lung tumour).

+PassMedicine Notes

Primary care setting

NICE recommends that patients should initially be assessed in primary care using the CRB65 criteria:

Criterion _ Marker| C _ Confusion (abbreviated mental test score = 30/min| B _ Blood pressure: systolic 100 mg/L - offer antibiotic therapy

Secondary care setting

Note that in hospital, once blood tests are available the CURB65, rather than the CRB65, can be used. This adds an extra criterion of urea > 7 mmol/L:

Criterion _ Marker| C _ Confusion (abbreviated mental test score 7 mmol/L| R _ Respiration rate >= 30/min| B _ Blood pressure: systolic