GGC Medicines


Adult Therapeutics Handbook

Management of Pneumonia

Management of Pneumonia

Introduction

Pneumonia may be classified as Community Acquired (present on admission to hospital or developing within 48 hours of admission) or Hospital Acquired (developing at least 48 hours after admission or within 10 days of discharge). Pneumonia is defined as features of respiratory infection (cough, purulent sputum, fever, pleurisy, with new focal abnormalities on respiratory examination or CXR).

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 (see page below for flow diagram and the guidance for pneumonia in the infection section for CURB-65 criteria). It should be used in conjunction with SIRS criteria (see Infection management guidelines ) and should aid clinical judgement, not replace it. It is not used for aspiration pneumonia or infective exacerbations of asthma / COPD.

Investigations:

  • Assess Airway, Breathing and Circulation and then resuscitate as appropriate (see 'Sepsis 6').
  • Arterial blood gas if oxygen saturations <95% on air.
  • FBC, U&Es, LFTs, CRP, blood cultures, sputum culture and sensitivity.
  • CXR (lobar / bronchopneumonia)
  • ECG
  • Urine for Legionella and pneumococcal Ag
  • Consider possibility of M. tuberculosis, particularly in upper lobe or cavitating disease - request sputum AFB as emergency.
  • Throat swab in viral transport fluid may be sent (but less useful than samples listed below).
  • Nasopharyngeal aspirates / washings.
  • Broncho-Alveolar Lavage (BAL).
  • Throat swab in viral transport fluid may be sent (but less useful than samples listed above).
  • Ensure travel history and contacts established (including animal and occupational).

General management

  • Oxygen as appropriate to achieve target oxygen saturations as follows:
    • 94-98% for most patients
    • 88-92% for those with COPD or at risk of hypercapnic respiratory failure (e.g. morbid obesity, neuromuscular or chest wall disease).
  • Antibiotics as per flow diagram on next page - start immediately. Consider changing to appropriate antibiotic if specific organism identified.
  • IV fluids if appropriate (fever / excess fluid loss)
  • Analgesia for pleuritic pain (NSAIDs if not contraindicated).
  • Physiotherapy if tenacious sputum or mucus plugging. Consider adding sodium chloride 0.9% nebules up to four times daily and/or carbocisteine oral 750mg three times daily if this is the case. To be discontinued as clincal improvement seen.
  • Consider nursing patient in high dependency unit if severe.
  • Low molecular weight heparin prophylaxis for DVT (see thromboprophylaxis guidance)
  • Repeat CXR and CRP and consider early respiratory referral if not improving within 3 days, atypical features, or effusion / empyema suspected.

Treatment options

Community acquired pneumonia (CAP) studies show increased mortality in young patients when antibiotic treatment is delayed. Prescribe antibiotic for immediate administration. The flow diagram further below outlines the general management of CAP; calculate CURB-65 score first (see pneumonia guidance in infection section) before prescribing.

Pneumonia Management
Hospital acquired See infection section for treatment options (search for HAP)
Suspected Staphylococcus aureus pneumonia (e.g. IVDA, post influenzae or chicken pox) See infection section (search for pneumonia)
Aspiration pneumonia See infection section (search for aspiration pneumonia)
Legionella pneumonia If confirmed, discuss with microbiology to guide antibiotic choice. If severe consider extending treatment up to 14-21 days
Cavitating pneumonia of any type Discuss with local Respiratory Team early on. Consider Staphlyococcus, Streptococcus, tuberculosis, Gram-negative (e.g. Klebsiella) and non-infectious causes (lung cancer,vasculitis).

For oral step down - see IVOST guideline

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 on the ward could be considered as ceiling of treatment.

Discharge planning

  • Consider discharge when off oxygen and on oral antibiotics > 24 hours, 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.

Antibiotic Choice Based on CURB-65 Score

See here to calculate CURB-65 score.

Note: Serious drug interactions with certain antibiotics, see infection section. Further information can be found in Appendix 1 of BNF