Questionnaire/history:

Age 65+?

Cough?

Pleuritic pain (typical for pneumonia)?

Sputum?

Wheeze?

Sputum?

Raised temperature?

Sweats (typical for pneumonia)?

Myalgia (typical for pneumonia)?

Past medical history?

Current medication?

Known drug allergies:

Social history?

Examination:

Confusion?

Blood pressure?

- Systolic blood pressure (SBP) < 90 mmHg?

- Diastolic blood pressure (DBP) < 60 mmHg?

Temperature?

- > 38°C (typical for pneumonia)?

SpO2?

Respiratory rate (RR)?

- > 30?

Chest auscultation?

Wheeze?

Focal chest signs (eg dullness to percussion, coarse crepitations, vocal fremitus (typical for pneumonia)?

CRB65 score (confusion, RR > 30, SBP < 90, DBP < 60, age: 65+):

Investigations:

CRP?

If community acquired pneumonia (CAP) suspected:

Chest X-ray (not routinely needed in primary care but to be considered if diagnostic uncertainty or at risk of underlying lung pathology (eg lung cancer)?

Sputum cultures (not routinely needed in low-risk pneumonia but should be sent in moderate severity pneumonia if community management appropriate)?

Management:

CRB65 score:

0 = low risk (< 1% mortality risk): management in the community

1-2 = intermediate risk (1-10% mortality): consideration for hospital assessment (clinical judgement depending on other factors e.g. comorbidity/frailty, SpO2, pregnancy, social support)

Score ≥ 3 = high risk (> 10% mortality risk): urgent hospital admission

(Note: CRB65 can underestimate risk particularly in adults <65 years even though it is recommended by NICE)

Acute bronchitis:

Do not offer antibiotics to people who are otherwise well

Offer immediate or backup antibiotics in high-risk groups (based on clinical judgement) (eg heart, lung, kidney, liver or neuromuscular disease, immunosuppression or cystic fibrosis, young people born prematurely, > 65 years old with ≥ 2 of the following, or > 80 years old with ≥1 of the following:

Hospital admission in the previous year

Type 1 or type 2 diabetes mellitus

Known congestive heart failure

Concurrent use of oral corticosteroids

Offer immediate antibiotics if systemically very unwell

CRP:

No treatment if CRP 20mg/L or less

Delayed script if CRP 20-100mg/L

Immediate antibiotics if CRP >100mg/L

Antibiotic choice:

Adult: first choice Doxycycline 200mg stat then 100mg OD, alternative first choices amoxicillin 500mg TDS or clarithromycin 250-500mg BD or erythromycin 250-500mg QDS. All 5/7 courses

Child: first choice amoxicillin, alternative first choice clarithromycin or erythromycin or doxycycline (>12yrs only). All 5/7 courses

But note latest evidence above that for children (not in high-risk groups) antibiotics in uncomplicated LRTI does not improve outcomes

Delayed antibiotic prescription:

Reassured that antibiotics are not currently needed as they are unlikely to make a difference to symptoms, and may have adverse effects eg diarrhoea, vomiting and rash

Advised to use the delayed prescription if symptoms get significantly worse at any time

Advised to seek medical advice if symptoms fail to resolve at 3 weeks or get significantly worse despite taking the antibiotics 

Community-acquired pneumonia:

Offer all patients immediate antibiotics and aim to start within 4 hours if treating in the community:

Adults:

CRB65 = 0/Absence of amber flags:

Amoxicillin 500mg TDS first choice

Alternative (eg penicillin allergy) Clarithromycin 500mg BD or doxycycline 200mg stat then 100mg OD

CRB65 = 1-2/Amber flag and safe to treat at home:

Amoxicillin 500mg TDS (PLUS clarithromycin 500mg BD if atypical pathogens suspected) OR

Alternative monotherapy (eg penicillin allergy) Clarithromycin 500mg BD OR Doxycycline 200mg stat then 100mg OD

CRB65 ≥ 3/Red flag

Urgent secondary care admission for IV therapy

Occasionally patients will refuse referral and PO therapy is required (send sputum culture):

Co-Amoxiclav 500/125mg TID AND either Clarithromycin 500mg BD or Erythromycin 500mg QID for 5/7

Alternative monotherapy: Levofloxacin 500mg BD for 5/7

Aim for course length of 5 days if treating in the community - if not improving as expected after 5 days antibiotics consider other causes (eg flu) and send sputum culture (if not already done so)

Advised to seek further advice if symptoms do not begin to improve within 3 days of starting an antibiotic, or sooner if they worsen

Children (doses as per children's BNF)

To consider referring children with community-acquired pneumonia to hospital, or seek specialist paediatric advice on further investigation and management, but if treating in the community: 

Amoxicillin is the first line

Alternative first line (e.g. penicillin allergy, atypical pathogen suspected) - clarithromycin, erythromycin or doxycycline (if >12 years old)

Co-Amoxiclav is reserved for those with severe symptoms (essentially red flag symptoms/signs so these children should have been admitted)

Course length 5 days 

Advised on safety net including information on managing fever/hydration and identifying increasing work of breathing, apnoea, cyanosis, fluid intake reduced to 50-75% normal, no urine output for 12 hours, less responsive/difficult to rouse, persistent worsening fever), to call 111 or take child to hospital if new or worsening symptoms and to read Sepsis Trust info ‘Spotting sepsis in children’

Explained that the resolution of pneumonia takes times:

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

Resource(s):

CKS 2021

NICE Acute cough 2019 

NICE pneumonia antimicrobials 2019 

NICE pneumonia in adults updated 2019

NICE/PHE Antimicrobial guidelines

Information for patient/carer(s):

Sepsis Trust: Spotting sepsis in children