Management of Pneumonia
Pneumonia is defined as respiratory infection (features may include cough, purulent sputum, fever, pleurisy) with focal abnormalities on chest x-ray (CXR).
Pneumonia may be classified as:
- Community Acquired Pneumonia (CAP) - present on admission to hospital or developing within 48 hours of admission, or
- Hospital Acquired Pneumonia (HAP) - developing at least 48 hours after admission or within 7 days of discharge, although patients developing HAP <5 days after admission are likely to be infected by organisms similar to CAP and should be treated as CAP.
See the NHSGGC Infection Management Guideline Poster for treatments of choice.
Assessment / monitoring
The CURB-65 score predicts 30 day mortality and is a useful tool to support decisions regarding admission and management of community acquired pneumonia. It should be used in conjunction with Systemic Inflammatory Response Syndrome (SIRS) criteria and should aid clinical judgement, not replace it. It is not used for aspiration pneumonia or infective exacerbations of asthma / chronic obstructive pulmonary disease (COPD).
- Assess Airway, Breathing and Circulation and then resuscitate as appropriate (see 'Sepsis 6' - figure 2).
- Arterial blood gas if oxygen saturations <95% on air.
- FBC, U&Es, LFTs, CRP.
- Sputum culture and sensitivity.
- Blood cultures in all patients with moderate / severe pneumonia.
- Urine for Legionella antigen if atypical features.
- Consider possibility of M. tuberculosis, particularly in upper lobe or cavitating disease - ensure three sputum samples are sent for acid-fast bacillus (AFB) testing.
- Tap water viral gargle may be sent if considering influenza or mycoplasma.
- Ensure travel history and contacts established (including animal and occupational).
- Oxygen as appropriate to achieve target oxygen saturations (see Oxygen and Oximetry guidance):
- 94-98% for most patients
- 88-92% for those at risk of hypercapnic respiratory failure (e.g. some COPD patients, morbid obesity, neuromuscular or chest wall disease).
- Antibiotics as per flow chart Antibiotic choice as Per CURB 65 Score.
- CAP studies show increased mortality in young patients when antibiotic treatment is delayed. Start antibiotics immediately.
- Consider changing to appropriate antibiotic if specific organism identified.
- When improving, consider step down (see IVOST guideline).
- IV fluids if appropriate (fever / excess fluid loss / acute kidney injury / SIRS ≥2).
- Analgesia for pleuritic pain (non steroidal anti-inflammatory drugs if not contraindicated).
- Physiotherapy if tenacious sputum or mucus plugging. Consider adding sodium chloride 0.9% nebules up to four times daily and/or acetylcysteine oral 600mg once daily.
- Move patient to high dependency unit if clinical concern.
- DVT prophylaxis
- Repeat CXR and CRP and consider early respiratory referral if not improving within 3 days, atypical features, or effusion / empyema suspected.
Antibiotic choice is based on CURB-65 score. For oral step down - see IVOST guideline. There are serious drug interactions with certain antibiotics. See Antibiotic Allergy and Interaction guideline for details, with further information available in Appendix 1 of BNF.
NIV / CPAP should not be used for respiratory failure in pneumonia outside of an ITU setting as delayed transition to invasive ventilation (if required) increases mortality. If ITU admission is not appropriate due to comorbidities then NIV / CPAP / high flow nasal oxygen on the ward could be considered as ceiling of treatment.
- Consider discharge when off oxygen and on oral antibiotics, CRP falling and clinical improvement (temperature <37.3oC, RR <24breaths/minute, HR <100bpm, systolic BP >90mmHg).
- Follow up and repeat CXR required at 6-8 weeks post discharge.
- Offer smoking cessation advice if appropriate.
Guideline reviewed: August 2023
Page last updated: November 2023