Community Acquired Pneumonia

Publication: 01/12/2007  --
Last review: 24/01/2018  
Next review: 24/01/2021  
Clinical Guideline
CURRENT 
ID: 1200 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Community Acquired Pneumonia

  • Treatment Algorithm
  • Summary
    Community Acquired Pneumonia

    Please note that these are guidelines. On some occasions you may be advised to manage patients differently, depending on clinical circumstances, microbiology results, etc.
    Criteria for use of guidelines

    • Patients presenting with an acute lower respiratory infection associated with recently developed radiological signs
    • Pneumonia is defined as 'community acquired' if it presents prior to or within the first three days of hospital admission.

    Investigations required

    • Sputum cultures, blood cultures (for moderate to severe CAP), CRP, FBC, U&E, urine sample for legionella/pneumococcal antigen (if required), blood sample for atypical serology (if required), oxygen saturations and arterial blood gases if necessary.
    • Abbreviated Mental Test Score
    • Observations, including blood pressure and respiratory rate
    • Chest x-ray
    • Refer to trust guideline for procalcitonin testing in medical admissions

    Non-Antimicrobial Management

    • Oxygen
    • Fluid resuscitation
    • Thromboprophylaxis

    Antimicrobial treatment
    Table showing empirical therapy

     

    First line

    Penicillin allergy

    Low severity (CURB-65 = 0 or 1)

    ORAL: Amoxicillin electronic Medicines Compendium information on Amoxicillin500mg three times daily
    Add oral Clarithromycin electronic Medicines Compendium information on Clarithromycin500mg twice daily if received Amoxicillin electronic Medicines Compendium information on Amoxicillin in the four weeks prior to admission

    ORAL: Doxycycline electronic Medicines Compendium information on Doxycycline200mg loading dose followed by 100mg twice daily
    OR
    ORAL: Clarithromycin electronic Medicines Compendium information on Clarithromycin500 mg twice daily

    Moderate severity (CURB-65 = 2)

    ORAL: Amoxicillin electronic Medicines Compendium information on Amoxicillin500 mg three times daily plus Clarithromycin electronic Medicines Compendium information on Clarithromycin500 mg twice daily

    ORAL: Doxycycline electronic Medicines Compendium information on Doxycycline200mg loading dose followed by 100mg twice daily
    OR
    ORAL: Levofloxacin electronic Medicines Compendium information on Levofloxacin500 mg twice daily

    High severity (CURB-65 ≥ 3)

    IV Co-Amoxiclav (Amoxicillin-Clavulanate) electronic Medicines Compendium information on Co-Amoxiclav (Amoxicillin-Clavulanate)1.2 g three times daily plus IV Clarithromycin electronic Medicines Compendium information on Clarithromycin500 mg twice daily

    IV: Cefuroxime electronic Medicines Compendium information on Cefuroxime1.5 g three times daily plus Clarithromycin electronic Medicines Compendium information on Clarithromycin500mg twice daily
    (If documented anaphylaxis to penicillins and/or cefalosporins or patient is >65 years of age, use IV Levofloxacin electronic Medicines Compendium information on Levofloxacin500mg twice daily).

    Duration of Treatment

    • Continue IV therapy for at least 24 hours before considering oral switch
    • Mild CAP: 5 days
    • Moderate - Severe CAP: 7-10 days
    • Legionella: at least 14 days

    Switch to oral agent(s) (as recommended by the 2009 BTS guidelines) [B]
    Please follow the LTHT Intravenous to Oral Antimicrobial Therapy Review and Switch (IVOS) guideline

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    Clinical Diagnosis
    Symptoms include: cough, dyspnoea, sputum production, fever, chest pain, fatigue, confusion, myalgia, sweats
    Signs include: pyrexia, tachypnoea, tachycardia, cyanosis, bronchial breathing
    Radiology: consolidation on chest X-ray

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    Severity Assessment

    The severity of CAP can be determined using the CURB-65 score. [B] This should be documented in the notes for all patients presenting with CAP, to identify those individuals with severe pneumonia who should be managed on the acute respiratory wards.

    CURB-65 score

    NB. Patients with CAP who have a CURB-65 score of < 3 may clinically deteriorate and develop severe pneumonia.

    Confusion assessed by Abbreviated mental test score:

    • Age
    • Date of birth
    • Time (to nearest hour)
    • Year
    • Hospital name
    • Recognition of two persons
    • Recall address
    • Date of first World War
    • Name of monarch
    • Count backwards from 20 to 1

    Other risk factors include:

    • Presence of co-existing disease
    • Hypoxia (SaO2 < 92% or PaO2 <8kPa regardless of concentration of oxygen administered
    • Bilateral or multi-lobar involvement on chest x-ray
    • Respiratory Rate >40/min

    The presence of one or more of these risk factors during the initial assessment may lead to re-classification of severity into a higher risk group.

    • Specimens
      • blood cultures should be taken for patients with moderate to high severity CAP, preferably before antibiotic treatment is commenced. [D]
      • If a patient has low severity pneumonia with no co-morbid disease, then blood cultures maybe omitted. [A]
      • Antibiotics should not be delayed whilst trying to get sputum for culture. [C]
      • Refer to trust guideline for procalcitonin testing
      • Microbiological sampling on basis of CURB-65 score in patients with CAP admitted to hospital [A]:

    Notes

    • May be considered, depending on clinical factors (age, co-morbid illness, severity indicators) or epidemiological factors (such as during outbreaks e.g. legionella, mycoplasma).
    • Please send urine for Legionella antigen testing in a plain, white-topped universal.
    • Send these if there are clinical/epidemiological factors supporting a diagnosis of viral infection or legionellosis or another atypical pathogen [B].
    • Consider Broncho-alveolar lavage (BAL), especially if immuno-compromised patient.

    Oxygenation Assessment

    • Oxygen saturation should be measured on admission. Patients with pre-existing lung disease (e.g. COPD) and those with SaO2 <92%, those likely to retain CO2, and those with features of severe pneumonia should have an arterial blood gas measurement. [C]

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    Investigation
    • Radiology
      • A chest x-ray should be performed for every patient. [D]
      • CXR resolution may take many weeks to occur and not every patient will require a pre-discharge radiograph. [D]
      • A CXR should be undertaken on follow up in clinic after about 6 weeks to ensure full radiological resolution. (CXR resolution: 51% at 2 weeks, 64% at 4 weeks, 73% at 6 weeks). [D]
      • A repeat CXR is required for patients who are not progressing satisfactorily after 3 days of treatment, or in the presence of persistently elevated CRP and slow clinical resolution, or any persisting clinical signs.

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    Treatment
    Non-Antimicrobial Treatment
    • Correct hypoxia
      • All patients should receive appropriate oxygen therapy with monitoring of oxygen saturations and inspired oxygen concentration. (See also the LTH ‘Guideline on the Prescribing and Administration of Oxygen in Adults’)
        • The aim of oxygen therapy is to maintain PaO2≥8kPa and SpO2 94-98%. High concentrations of oxygen can safely be given in patients who are not at risk of hypercapnic respiratory failure. [D]
        • In patients at risk of hypercapnic respiratory failure, the aim of oxygen therapy is to maintain SpO2 88-92%, and should also be guided by repeated arterial blood gas measurements. [C]
      • In nearly all cases of CAP, unless complicated by severe chronic obstructive pulmonary disease with ventilatory failure, high concentrations of oxygen of 35% or more are indicated and can be safely used. [C]
    • Fluid resuscitation
      Patients admitted with pneumonia should be assessed for volume depletion and may require intravenous fluids. [C]
      All patients with CAP should be assessed for their nutritional and physiotherapy requirements [D]
    • Prophylaxis of venous thromboembolism with low molecular weight heparins should be considered for all patients who are not fully mobile. [A]
    • All patients with CAP should be reviewed by senior medical staff (SpR or Consultant) within 24 hours [C].
    • Bacterial pneumonia may be the first presentation of HIV. Recommendations regarding HIV testing are available HERE

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    Empirical Antimicrobial Treatment

    Empirical therapy
    Low severity (CURB-65 = 0 or 1) [C]
    ORAL: Amoxicillin electronic Medicines Compendium information on Amoxicillin500mg three times daily daily.1,2
    Most patients with low severity CAP can be adequately treated with oral antibiotics [C].

    Notes:
    1Add Clarithromycin electronic Medicines Compendium information on Clarithromycin500mg twice daily if patient has previously received Amoxicillin electronic Medicines Compendium information on Amoxicillin in the community in the previous 28 days.
    2Intravenous therapy should only be considered when oral medication can’t be administered.

    Moderate severity (CURB-65 = 2) [C]
    ORAL: Amoxicillin electronic Medicines Compendium information on Amoxicillin500 mg three times daily plus Clarithromycin electronic Medicines Compendium information on Clarithromycin500 mg twice daily
    Most patients with moderate severity CAP can be adequately treated with oral antibiotics [C]. If oral medication can’t be administered then use the following:
    IV: Amoxicillin electronic Medicines Compendium information on Amoxicillin500 mg three times daily plus Clarithromycin electronic Medicines Compendium information on Clarithromycin500 mg twice daily

    High severity (CURB-65 ≥ 3) [C]
    IV: Co-Amoxiclav (Amoxicillin-Clavulanate) electronic Medicines Compendium information on Co-Amoxiclav (Amoxicillin-Clavulanate)1.2 g three times daily plus Clarithromycin electronic Medicines Compendium information on Clarithromycin500 mg twice daily
    Specific CAP recommendations for microbiologically- confirmed organisms [C]:

    Streptococcus pneumoniae
    IV: Benzyl penicillin electronic Medicines Compendium information on Benzyl penicillin1.2 g four times daily.1
    Oral: Amoxicillin electronic Medicines Compendium information on Amoxicillin500mg three times daily.
    Most patients with low and moderate severity CAP can be adequately treated with oral antibiotics [C].

    Notes:
    1Higher doses may be considered in certain situations (e.g. poorly responding pneumococcal parapneumonic effusion) - please Discuss with Microbiology.
    Any case of lobar pneumonia believed to be due to S. pneumoniae should prompt a review of the patient’s medical history to establish whether they are in a recognised risk group for invasive pneumococcal infection and whether they have been vaccinated. Patients with risk factors who have not previously been vaccinated should be given vaccination on discharge from hospital. (Immunisation Against Infectious Disease, Department of Health 2006)

    Meticillin-susceptible Staphylococcus aureus
    E.g. post-influenza during epidemics and cavitation seen on CXR. If MSSA confirmed switch to IV Flucloxacillin electronic Medicines Compendium information on Flucloxacillin2g four times daily (adjust dose in cases of renal impairment). The addition of Rifampicin electronic Medicines Compendium information on Rifampicin600mg once or twice daily PO may be considered if clinically indicated (subject to an approval code from Microbiology).
    NB: Cases of necrotising pneumonia may be caused by PVL+ strains of S. aureus. These require different treatment regimens and advice can be sought from Microbiology/Infectious Diseases

    Meticillin-resistant Staphylococcus aureus
    1st line Linezolid electronic Medicines Compendium information on Linezolid* 600mg 12-hourly PO/IV or 2nd line Teicoplanin electronic Medicines Compendium information on TeicoplaninIV (see dosing guideline). The addition of Rifampicin electronic Medicines Compendium information on Rifampicin600mg once or twice daily PO may be considered if clinically indicated.
    NB: Cases of necrotising pneumonia may be caused by PVL+ strains of S. aureus. These require different treatment regimens and advice can be sought from Microbiology/Infectious Diseases
    *Linezolid electronic Medicines Compendium information on Linezolidhas a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient.

    Recent travel
    Please contact Microbiology or Infectious Diseases for advice.

    Legionellosis
    ORAL or IV: Levofloxacin electronic Medicines Compendium information on Levofloxacin500mg twice daily1
    The addition of ORAL Rifampicin electronic Medicines Compendium information on Rifampicin600mg once or twice daily may be considered in severe infections.

    In the presence of an adverse reaction to quinolones, ORAL or IV Clarithromycin electronic Medicines Compendium information on Clarithromycin500mg twice daily can be considered.

    Notes
    1Prior to commencing Levofloxacin electronic Medicines Compendium information on Levofloxacin, the possibility of tuberculosis should be considered, and, if appropriate, sputum sent for AAFBs.

    Antibiotic prescribing in the Emergency Department
    Patients with CAP who present to the Emergency Department should be started on antibiotic therapy immediately after blood cultures have been taken and before transfer to the ward. The first dose should be written up as a stat dose in order to prevent delays in treatment that may occur if antibiotics are only prescribed on the regular section of the drug chart. [B]

    Antimicrobial allergy

    • Penicillin allergy

    Low severity (CURB-65 = 0 or 1):
    ORAL: Doxycycline electronic Medicines Compendium information on Doxycycline200mg loading dose followed by 100mg twice daily
    OR
    ORAL: Clarithromycin electronic Medicines Compendium information on Clarithromycin500 mg twice daily

    Moderate severity (CURB-65 = 2):
    ORAL: Doxycycline electronic Medicines Compendium information on Doxycycline200mg loading dose followed by 100mg twice daily
    OR
    ORAL: Levofloxacin electronic Medicines Compendium information on Levofloxacin500 mg twice daily1

    High severity (CURB-65 ≥ 3):
    IV: Cefuroxime electronic Medicines Compendium information on Cefuroxime1.5 g three times daily plus Clarithromycin electronic Medicines Compendium information on Clarithromycin500mg twice daily
    (If documented anaphylaxis to penicillins and/or cefalosporins or patient is >65 years of age, use IV Levofloxacin electronic Medicines Compendium information on Levofloxacin500mg BD1)

    Notes:
    1Prior to commencing Levofloxacin electronic Medicines Compendium information on Levofloxacin, the possibility of tuberculosis should be considered, and, if appropriate, sputum sent for AAFBs.

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    Duration of Treatment

    Duration of treatment (as recommended by the BTS guidelines) [C]

    • Continue IV therapy for at least 24 hours before considering oral switch
    • Low severity CAP: 5 days
    • Moderate - High severity CAP (microbiologically undefined): 7 to 10 days
    • High severity CAP (microbiologically defined): treatment may be extended to 14-21 days according to the causative organism and clinical judgement e.g. legionellosis, S. aureus

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    Switch to oral agent(s)

    Switch to oral agent(s) (as recommended by the BTS guidelines) [B]
    Please follow the LTHT Intravenous to Oral Antimicrobial Therapy Review and Switch (IVOS) guideline

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    Treatment Algorithm

    Description: http://nww.lhp.leedsth.nhs.uk/images/1200Algorithm.jpg

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    Treatment Failure

    Consider the following explanations:

    • Incorrect diagnosis
    • Resistant organism (including Mycobacterium tuberculosis)
    • Antibiotic hypersensitivity reaction
    • Complication e.g. empyema, abscess
    • Underlying lung disease e.g. lung cancer, CCF
    • Immunosuppresion (known or unexpected)

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    Provenance

    Record: 1200
    Objective:
    • To provide evidence-based recommendations for appropriate investigation of Community Acquired Pneumonia
    • To provide evidence-based recommendations for appropriate empirical or directed antimicrobial therapy of Community Acquired Pneumonia
    • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
    • To advise in the event of antimicrobial allergy.
    • To set-out criteria for referral to specialists.
    Clinical condition: Community Acquired Pneumonia
    Target patient group:
    • Patients presenting with an acute lower respiratory infection associated with recently developed radiological signs
    • Pneumonia is defined as 'community acquired' if it presents prior to or within the first three days of hospital admission.
    Target professional group(s): Secondary Care Doctors
    Secondary Care Nurses
    Pharmacists
    Adapted from:

    Evidence base

    Evidence base
    Lim WS, Baudouin SV, George RC et al. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009;64(Suppl 3):iii1-iii55. 
    O’Driscoll BR, Howard LS, Davison AG on behalf of the British Thoracic Society Emergency Oxygen Guideline Development Group. British Thoracic Society Guideline for emergency oxygen use in adult patients. Thorax 2008;63(Suppl VI):vi1-vi73. 
    Department of Health: Immunisation Against Infectious Disease (2006).
    UK National Guidelines for HIV testing (2008). Access at http://www.bhiva.org/documents/Guidelines/Testing/GlinesHIVTest08.pdf

    Evidence levels:
    A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
    B. Robust experimental or observational studies
    C. Expert consensus.
    D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

    Approved By

    Improving Antimicrobial Prescribing Group

    Document history

    LHP version 1.0

    Related information

    Not supplied

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