Treatment Protocol

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.