Community acquired Pneumonia

 

Definition of community acquired pneumonia:

Symptoms and signs consistent with an acute lower respiratory tract infection associated with new radiographic shadowing for which there is no other explanation (e.g. pulmonary oedema or infarction)

 Aim to diagnose CAP ( including chest X-ray) and commence antibiotic therapy within 4 hours of admission. Note that antibiotic therapy should be commenced within 1 hour of identifying patients with severe sepsis.

Send urine sample to microbiology for pneumococcal/legionella antigen tests.

 CURB-65 is a BTS recommended severity rating for community acquired pneumonia (CAP) and should not be confused with the ABC criteria defined in the flow diagram. Patients with a CURB-65 score of 3 or more are at highest risk of death and should be managed as having severe pneumonia. Patients with a score of 2 are at increased risk of death and should be considered for short stay inpatient treatment or hospital supervised outpatient treatment. Patients with a score of 0 or 1 are at low risk of death and can be treated as having non-severe pneumonia possibly suitable for home treatment.

CURB-65 Severity rating score for CAP: One point for each below

Initial

Description

C

Mental Confusion

U

Blood Urea > 7 mmol/l

R

Respiratory Rate ≥ 30/min

B

Low Blood Pressure (Diastolic ≤ 60mmHg or Systolic <90mmHg)

65

Age ≥ 65 years

 

Severity
(classification)

1st line oral/iv antibiotics

 

Penicillin allergy
(see explanatory notes)

A

Low severity

CURB-65 = 0 to 1

Review doses in renal impairment

 

AMOXICILLIN 500mg po tds 

 OR

 if atypicals suspected use:

DOXYCYCLINE 200mg po od  

Treatment duration: 5 days

Note: May need to extend to 7 days if symptoms do not improve as expected after 3 days of treatment.

DOXYCYCLINE 200mg po od

 

 Treatment duration: 5 days

Note: May need to extend to 7 days if symptoms do not improve as expected after 3 days of treatment.

 

 

B

Moderate severity

CURB-65 = 2

Review doses in renal impairment

 

Send urine sample to microbiology for pneumococcal/legionella antigen tests

AMOXICILLIN 1g po tds

plus

DOXYCYCLINE 200mg po od

Treatment duration: 7 days

 

 

Send urine sample to microbiology for pneumococcal/legionella antigen tests

LEVOFLOXACIN  500mg po bd monotherapy

 (Consider reducing to 500mg od if patient clearly improving)

Treatment duration: 7 days

 C

High severity

 CURB-65 ≥ 3

Review doses in renal impairment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Send urine sample to microbiology for pneumococcal/legionella antigen tests

 
CO-AMOXICLAV 1.2g iv tds

plus

CLARITHROMYCIN 500mg bd po/iv   (Oral route preferred) 

If suspected MRSA ,ADD:

VANCOMYCIN iv (as per local policy)

 


Send urine sample to microbiology for pneumococcal/legionella antigen tests

 *LEVOFLOXACIN 500mg po/iv bd 
(Oral route preferred. Consider reducing to 500mg od if patient clearly improving).

plus

VANCOMYCIN iv (as per local policy)

*NOTE: if iv levofloxacin is required and there is no stock available, please switch the levofloxacin to:
CIPROFLOXACIN 400mg iv bd

 

                               


 

 

 

 

 

 If laboratory evidence of pneumococci use:

See below  

 

C

High severity

 CURB-65 ≥ 3

Review doses in renal impairment

BENZYLPENICILLIN 2.4g iv qds

plus

CLARITHROMYCIN 500mg po/iv bd                            
(Oral route preferred)

 Non-severe penicillin allergy AND age less than 65 years: 
CEFTRIAXONE 2g iv od

plus

CLARITHROMYCIN 500mg po/iv bd                                 
(Oral route preferred)


Severe penicillin allergy AND / OR age greater than 65 years:

VANCOMYCIN iv (as per local policy)

plus

CLARITHROMYCIN 500mg po/iv bd
(Oral route preferred)

 IV to Oral Switch

(explanatory notes)

 

 

 

CO-AMOXICLAV 625mg po tds 

plus

CLARITHROMYCIN 500mg po bd 

LEVOFLOXACIN 500mg po bd

(Consider reducing to 500mg od if patient clearly improving)

 

Treatment duration should be a minimum of 5 days. Patients with moderate or high severity pneumonia that is microbiologically undefined should be treated for 7-10 days. Note that longer treatment courses may be required for some patients.

If the diagnosis of community acquired pneumonia is not confirmed but the patient is thought to have a respiratory tract infection (i.e. not pneumonia), then a 5 day course of antibiotics may be sufficient.

 

Last Reviewed: 09/05/17

For guidance on the administration of intravenous antibiotics
click here (GHNHSFT intranet only)