Diagnosis

• Note: HAP develops >48 hrs after admission
• Symptoms of LRTI: fever, sputum, SOB, wheeze, chest pain if no other explanation present
• Clinical diagnosis: symptoms and signs w/o chest X-ray
• When managed in hospital diagnosis usually confirmed by chest X-ray

Investigation

Primary care

• CRP: if <20 do not offer Antibiotics; if >20 delayed script; >100 offer antibiotics
• CRB65 (i.e no Urea): Confusion AMTS <8; RR >30; Systolic <90 Diastolic <60
  • 0 = Home care
  • 2 = Hospital care

Secondary care

• CURB65: Urea >7 mmol/l
  • 0-1 = low risk
  • 2 = Intermediate
  • 3-4 = Severe hence ITU consideration
• Microbiology should only be offered for intermediate risk and above
• Microbiology: Blood & sputum cultures + Legionella & Pneumococcal urinary antigen tests

Management

• Antibiotics as soon as possible after diagnosis
• (Xray) usually within 4 hrs
• CAP Low severity
  • Amoxicllin favoured, Macrolide or tetracycline if penicillin allergic
  • Consider extending course beyond 5 days if no response in 3 days
• CAP Moderate & High severity
  • Consider dual therapy Amoxicillin and a macrolide
  • 7-10 day course
  • Add beta-lactamase for high severity
• CAP Do not discharge if within 24 hrs have had:
  • 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
• HAP antibiotic in line with local policy, 5-10 day course

NICE Source: CG191 Pneumonia in adults: diagnosis and management. Summary compiled by Dr D P Sheppard MBBS.