British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Adults Update 2009

It is not necessary to perform a chest radiograph unless: The diagnosis is in doubt and a chest radiograph will help in a differential diagnosis and management of the acute illness; Progress following treatment for suspected CAP is not satisfactory at review; The patient is considered at risk of underlying lung pathology such as lung cancer.

Should have a chest radiograph performed as soon as possible to confirm or refute the diagnosis. The objective of any service should be for the chest radiograph to be performed in time for antibiotics to be administered within 4 hours of presentation to hospital should the diagnosis of CAP be confirmed.

The chest radiograph need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery from CAP.

A chest radiograph should be arranged after about 6 weeks.

Further investigations which may include bronchoscopy should be considered.

It is the responsibility of the hospital team to arrange the follow-up plan with the patient and the general practitioner.

General investigations are not necessary. Pulse oximeters allow for simple assessment of oxygenation. General practitioners, particularly those working in out of hours and emergency assessment centres, should consider their use.

Pulse oximetry should be available in all locations where emergency oxygen is used.

Should have the following tests performed on admission: Oxygenation saturations and, where necessary, arterial blood gases in accordance with the BTS Guideline for Emergency Oxygen Use in Adult Patients; Chest radiograph to allow accurate diagnosis; Urea and electrolytes to inform severity assessment; C-reactive protein to aid diagnosis and as a baseline measure; Full blood count; Liver function tests.

Microbiological tests should be performed on all patients with moderate and high severity CAP. The extent of investigation in these patients being guided by severity.

The extent of microbiological investigations should be guided by clinical factors (age, co-morbid illness, severity indicators), epidemiological factors, and prior antibiotic therapy.

Empirical antibiotics should be changed to the appropriate pathogen-focused agent, unless there are legitimate concerns about dual pathogen infection.

Microbiological investigations are not recommended routinely.

Examination of sputum should be considered.

Examination of sputum for Mycobacterium tuberculosis should be considered.

Urine antigen investigations, PCR of upper (eg. nose and throat swabs) or lower (eg. sputum) respiratory tract samples or serological investigations may be considered.

Blood cultures are recommended, preferably before antibiotic therapy is commenced.

Blood cultures may be omitted.

Sputum samples should be sent for culture and sensitivity tests. Specimens should be transported rapidly to the laboratory.

Culture of sputum or other lower respiratory tract samples should also be performed.

Sputum cultures for Legionella spp should always be attempted in order to provide isolates for epidemiological typing and comparison with isolates from putative environmental sources.

Where sputum Gram stain is available, laboratories should offer a reliable Gram stain as, occasionally, this can give an immediate indicator of the likely pathogen.

Routine performance or reporting of sputum Gram-stain on all patients is unnecessary but can aid the laboratory interpretations of culture results.

Are rarely helpful in establishing a diagnosis.

Should adhere to strict and locally agreed criteria for interpretation and reporting of results.

Pneumococcal urine antigen tests should be performed.

A rapid testing and reporting service for pneumococcal urine antigen should be available to all hospitals admitting patients with CAP.

Investigations for legionella pneumonia are recommended.

Legionella urine antigen tests should be performed.

A rapid testing and reporting service for legionella urine antigen should be available to all hospitals admitting patients with CAP.

Specimens of respiratory secretions, including sputum, should be sent. The clinician should specifically request legionella culture on laboratory request forms.

Legionella cultures should be routinely performed on invasive respiratory samples (eg obtained by bronchoscopy) from patients with CAP.

Clinicians should send respiratory specimens, such as sputum and request legionella culture. This is to aid outbreak and source investigation with the aim of preventing further cases.

Where available, PCR of respiratory tract samples, such as sputum, should be the method of choice.

A throat swab for Mycoplasma pneumoniae PCR is recommended.

Requires considerable caution.

Chlamydophila antigen and/ or PCR detection tests should be available.

The complement fixation test remains the most suitable and practical serological assay. There is no currently available serological test that can reliably detect acute infection due to C pneumoniae.

This is preferred to serological investigations.

Paired serology tests can be considered. The date of onset of symptoms should be clearly indicated on all serological request forms.

Serological tests may be extended to all patients admitted to hospital with CAP. The criteria for performing serology tests in these circumstances should be agreed locally between clinicians, laboratories and public health.

Clinical review should be arranged at around 6 weeks, either with their general practitioner or in a hospital clinic.

Patients should be offered access to information about CAP, such as a patient information leaflet.

It is the responsibility of the hospital team to arrange the follow-up plan with the patient and the general practitioner.

Department of Health guidelines in relation to influenza and pneumococcal immunisation should be followed.

Should receive 23-valent pneumococcal polysaccharide vaccine (23-PPV) at convalescence in line with the Department of Health Guidelines.

Smoking cessation advice should be offered according to smoking cessation guidelines issued by the Health Education Authority.

Clinical judgement is essential. The stability of any co-morbid illness and a patient’s social circumstances should be considered.

Clinical judgement supported by the CRB65 score should be applied when deciding whether to treat at home or refer to hospital.

Are at low risk of death and do not normally require hospitalisation for clinical reasons.

Are at increased risk of death, particularly with a score of 2, and hospital referral and assessment should be considered.

Are at high risk of death and require urgent hospital admission.

The patient’s social circumstances and wishes must be taken into account in all instances.

The CURB65 score should be interpreted in conjunction with clinical judgement.

Are at high risk of death. These patients should be reviewed by a senior physician at the earliest opportunity to refine disease severity assessment and should usually be managed as having high severity pneumonia.

Should be assessed with specific consideration to the need for transfer to a critical care unit (high dependency unit or intensive care unit).

Are at moderate risk of death. They should be considered for short-stay inpatient treatment or hospital supervised outpatient treatment.

Are at low risk of death. These patients may be suitable for treatment at home.

Regular assessment of disease severity is recommended. The ‘post take’ round by a senior doctor and the medical team provides one early opportunity for this review.

Should be reviewed medically at least 12 hourly until shown to be improving.

Should be advised to rest, to drink plenty of fluids and not to smoke.

Pain should be relieved using simple analgesia such as paracetamol.

Pulse oximetry, with appropriate training, should be available for the assessment of severity and oxygen requirement in patients with CAP and other acute respiratory illnesses.

Review is recommended after 48 hours or earlier if clinically indicated. Disease severity assessment should form part of the clinical review.

Should be considered for hospital admission or chest radiograph.

All patients should receive appropriate oxygen therapy with monitoring of oxygen saturations and inspired oxygen concentration with the aim to maintain (PaO2) ≥ 8 kPa and oxygen saturation (SpO2) 94–98%. High concentrations of oxygen can safely be given in patients who are not at risk of hypercapnic respiratory failure.

Oxygen therapy should be guided by repeated arterial blood gas measurements.

Patients should be assessed for volume depletion and may require intravenous fluids.

Prophylaxis of venous thromboembolism with low molecular weight heparins should be considered.

Nutritional support should be given.

Medical condition permitting, patients should sit out of bed for at least 20 minutes within the first 24 hours and mobility should be increased each subsequent day of hospitalisation.

Should not be treated with traditional airway clearance techniques routinely.

Patients should be offered advice regarding expectoration.

Airway clearance techniques should be considered.

Temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation and inspired oxygen concentration should be monitored and recorded initially at least twice daily and more frequently in those with severe pneumonia or requiring regular oxygen therapy.

C-reactive protein should be remeasured and a chest radiograph repeated.

Those suitable for discharge should not have more than one of the following characteristics present (unless they represent the usual baseline status for that patient): temperature > 37.8°C, heart rate > 100/min, respiratory rate > 24/min, systolic blood pressure < 90mmHg, oxygen saturation < 90%, inability to maintain oral intake and abnormal mental status.

Amoxicillin remains the preferred agent at a dose of 500mg three times daily.

Either doxycycline or clarithromycin are appropriate.

Should be admitted urgently to hospital.

General practitioners should administer antibiotics in the community. Penicillin G 1.2 g intravenously or amoxicillin 1 g orally are the preferred agents.

General practitioners should consider administering antibiotics in the community.

A diagnosis of CAP should be confirmed by chest radiography before the commencement of antibiotics.

Should be treated based on a presumptive clinical diagnosis of CAP. In such instances, an immediate chest radiograph to confirm the diagnosis, or indicate an alternative diagnosis, is indicated.

All patients should receive antibiotics as soon as the diagnosis of CAP is confirmed. This should be before they leave the initial assessment area (emergency department or acute medical unit). The objective for any service should be to confirm a diagnosis of pneumonia with chest radiography and initiate antibiotic therapy for the majority of patients with CAP within 4 hours of presentation to hospital.

Can be adequately treated with oral antibiotics.

Oral therapy with amoxicillin is preferred.

Recommended parenteral choices include intravenous amoxicillin or benzylpenicillin, or clarithromycin.

Can be adequately treated with oral antibiotics.

Oral therapy with amoxicillin and a macrolide is preferred.

Monotherapy with a macrolide may be suitable. Deciding on the adequacy of prior therapy is difficult and is a matter of individual clinical judgement. Therefore it is recommended that combination antibiotic therapy is the preferred choice in this situation and that the decision to adopt monotherapy is reviewed on the “post take” round within the first 24 hours of admission.

The preferred parenteral choices include intravenous amoxicillin or benzylpenicillin, together with clarithromycin.

Oral doxycyline is the main alternative agent. Oral levofloxacin and oral moxifloxacin are other alternative choices.

Recommended parenteral choices include levofloxacin monotherapy, or a second generation (eg cefuroxime) or third generation (eg cefotaxime or ceftriaxone) cephalosporin together with clarithromycin.

Should be treated immediately after diagnosis with parenteral antibiotics.

An intravenous combination of a broad spectrum ß-lactamase stable antibiotic such co-amoxiclav together with a macrolide such as clarithromycin is preferred.

A second-generation (eg, cefuroxime) or third-generation (eg, cefotaxime or ceftriaxone) cephalosporin can be used instead of co-amoxiclav, together with clarithromycin.

The oral route is recommended provided there are no contraindications to oral therapy.

Should be transferred to an oral regimen as soon as clinical improvement occurs and the temperature has been normal for 24 hours, providing there is no contra-indication to the oral route.

The choice of route of administration should be reviewed initially on the “post take” round and then daily. Ward pharmacists could play an important role in facilitating this review by highlighting prescription charts where parenteral antibiotic therapy continues.

The oral switch to co-amoxiclav 625mg three times daily is recommended rather than to oral cephalosporins.

Oral levofloxacin with or without oral amoxicillin 500 mg–1.0 g three times daily is recommended.

7 days of appropriate antibiotics is recommended.

7 to 10 days treatment is proposed. This may need to be extended to 14 or 21 days according to clinical judgement; for example, where Staphylococcus aureus or Gram negative enteric bacilli pneumonia is suspected or confirmed.

A macrolide could be substituted for or added to the therapy.

Changing to doxycycline or a fluoroquinolone with effective pneumococcal cover are alternative options.

Adding a fluoroquinolone is an option.

The diagnosis of CAP and the decision to start antibiotics should be reviewed by a senior clinician at the earliest opportunity. There should be no barrier to discontinuing antibiotics if they are not indicated.

The indication for antibiotics should be clearly documented in the medical notes. The need for intravenous antibiotics should be reviewed daily.

De-escalation of therapy, including the switch from intravenous to oral antibiotics, should be considered as soon as is appropriate, taking into account response to treatment and changing illness severity. Strong consideration should be given to narrowing the spectrum of antibiotic therapy when specific pathogens are identified, or when the patient’s condition improves.

Stop dates should be specified for antibiotic prescriptions.

The clinician should liaise with the clinical microbiologist to confirm that the local Health Protection Unit has been informed. The clinician should assist, where appropriate, in the gathering of clinical and epidemiological information from the patient and their relatives to aid the source investigation. Sputum or respiratory secretions should be sent off specifically for legionella culture in proven cases, even after appropriate antibiotics have started.

An oral fluoroquinolone is recommended. In the unusual case when this is not possible due to patient intolerance, a macrolide is an alternative.

Antibiotics are not required.

A fluoroquinolone is recommended. For the first few days this can be combined with a macrolide (azithromycin is an option in countries where it is used for pneumonia), or rifampicin as an alternative. Clinicians should be alert to the potential small risk of cardiac electrophysiological abnormalities with quinolone-macrolide combinations.

Duration of therapy should be as for microbiologically-undefined CAP (for those with low to moderate severity pneumonia, 7 days treatment is proposed; for those with high severity pneumonia, 7 to 10 days treatment is proposed - this may need to be extended to 14 or 21 days) and should be guided by clinical judgement.

Such patients should be considered for critical care admission. Clinicians should liaise urgently with microbiology in relation to further antibiotic management, and consider referral to the respiratory medicine department for clinical management advice.

Current recommendations include the addition of a combination of intravenous linezolid 600mg twice daily, intravenous clindamycin 1.2g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic regimen. As soon as PVL-SA infection is either confirmed or excluded, antibiotic therapy should be narrowed accordingly.

There should be a careful review by an experienced clinician of the clinical history, examination, prescription chart and results of all available investigation results. Further investigations, including a repeat chest radiograph, C-reactive protein and white cell count and further specimens for microbiological testing should be considered. Referral to a respiratory physician should be considered.

Early thoracocentesis is indicated.

Early and effective pleural fluid drainage should be provided. The British Thoracic Society Guidelines for the Management of Pleural Infection should be followed.

Less usual respiratory pathogens including anaerobes, S aureus, Gram-negative enteric bacilli and S milleri should be considered.

Prolonged antibiotic therapy of up to 6 weeks depending on clinical response, and occasionally surgical drainage should be considered.

Should be managed by specialists with appropriate training in intensive care working in close collaboration with specialists in respiratory medicine.

Neither non-invasive ventilation (NIV) nor continuous positive airways pressure (CPAP) support is routinely indicated.

It must only be conducted in a critical care area where immediate expertise is available to enable a rapid transition to invasive ventilation.

Steroids are not recommended in the routine treatment.

Granulocyte colony stimulating factor is not routinely recommended.