Community Acquired Pneumonia ( CAP ) - treatment in primary care - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  
Last review: 17/09/2017  
Next review: 17/09/2020  
Clinical Guideline
CURRENT 
ID: 2232 
Approved By: LAPC 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

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 (CAP)Treatment in Primary Care

Diagnosis of CAP in community settings. Patients should have:

  • Symptoms of an acute lower respiratory tract illness (cough and at least one other lower respiratory tract symptom : sputum, wheeze, dyspnoea, or pleuritic pain), AND
  • New focal chest signs on examination, AND
  • At least one systemic feature (sweating, fevers, shivers, aches and pains and/or temperature of ≥ 38oC), AND
  • No other explanation for the illness

C‑reactive protein (CRP) test (where available): For people presenting with symptoms of lower respiratory tract infection in primary care, consider a point of care C‑reactive protein (CRP) test if after clinical assessment a diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed.
Use the results of the CRP test to guide antibiotic prescribing in people without a clinical diagnosis of pneumonia as follows:

  • Do not routinely offer antibiotic therapy if the C-reactive protein concentration is less than 20 mg/litre.
  • Consider a delayed antibiotic prescription (a prescription for use at a later date if symptoms worsen) if the C-reactive protein concentration is between 20 mg/litre and 100 mg/litre.
  • Offer antibiotic therapy if the C-reactive protein concentration is greater than 100 mg/litre.

 Microbiological testing:

  • consider sputum cultures and legionella urinary antigen tests in patients with moderate severity community‑acquired pneumonia
  • sputum cultures are not routinely indicated for low severity infections.

Consider

  • sputum culture  if unresponsive to previous empirical antibiotics;
  • sputum culture for AAFB if clinical features consistent with TB are present (includes persistent productive cough, especially if malaise, weight loss or night sweats, or risk factors for tuberculosis )
  • taking specimens  in  known outbreak situations (eg Legionella, mycoplasma) (eg urinary antigens, PCR of sputum/ respiratory swabs, serology) 

Management of CAP: use clinical judgement & CRB-65 score to decide empirical antibiotic therapy and setting of care

CRB-65 (each scores 1):
Confusion (AMT ≤8) or new disorientation in person, place or time
Respiratory rate >30/min
BP systolic <90 or diastolic≤60
Age ≥ 65 years

Score:
Low Severity (0) - suitable for home treatment
Moderate Severity (1-2) - consider hospital referral, particularly if score of 2
High Severity (3-4) urgent hospital admission.

Severity

Preferred Option

Alternative Option

Low Severity
CRB65 = 0

Amoxicillin 500mg 8-hourly for 5 days

Clarithromycin 500mg 12-hourly for 5 days
OR
Doxycycline  200mg stat then 100mg OD for 5 days.

Moderate Severity
CRB65 = 1-2

Amoxicillin 500 mg 8-hourly
AND
Clarithromycin 500 mg 12-hourly
 for 7 days*

Doxycycline 200mg daily for 7days*

 

* Up to 10 days treatment may be required if slow response, patients should re-contact GP if no improvement by day 7. Fever should have settled at least 48hrs before stopping antibiotics.

High Severity
CRB65 >2

Admit for In-Patient Management

Link to secondary Care guideline
NICE 191
For latest recommendations  on prescribing in pregnancy see point 10 below

General Principles for Treating Infections

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  6. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections 1,A+
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  9. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  10. In pregnancy, take specimens to inform treatment, use this guidance alternative or seek expert advice. Penicillins, cephalosporins and erythromycin are not associated with increased risks. If possible, avoid tetracyclines, quinolones, aminoglycosides, azithromycin, clarithromycin, high dose metronidazole (2g stat) unless the benefits outweigh the risks. Short-term use of nitrofurantoin is not expected to cause foetal problems (theoretical risk of neonatal haemolysis). Trimethoprim is also unlikely to cause problems unless poor dietary folate intake, or taking another folate antagonist.
  11. We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily & generic medicines are similar cost. Erythromycin should be used in pregnancy.
  12. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

Provenance

Record: 2232
Objective:
Clinical condition:

Community Acquired Pneumonia (CAP)- treatment in primary care

Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Primary Care Nurses
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Management of Infection guidance for primary care for consultation and local adaptation


Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.


Study design

Recommendation
grade

Good recent systematic review and meta-analysis of studies

A+

One or more rigorous studies; randomised controlled trials

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Non-analytic studies, eg case reports or case series

C

Formal combination of expert opinion

D

Approved By

LAPC

Document history

LHP version 1.0

Related information

Not supplied