Pneumonia Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The diagnosis and management of community-acquired pneumonia in adults in primary care.
  • Adults 18+

This guidance does not cover:

  • Bronchiectasis complicated by pneumonia
  • People younger than 18 years
  • Patients who acquire pneumonia while intubated or in an intensive care unit, who are immunocompromised, or in whom management of pneumonia is an expected part of end-of-life care.

Assessment

History and Examination

The following features support a diagnosis of pneumonia

  • Symptoms of an acute lower respiratory tract illness (cough, sputum production and symptoms)
  • Evidence of systemic illness (temperature >38°C and/or the symptom complex of sweating, fevers, shivers, aches and pains)
  • The presence of abnormal vital signs (fever >38°C, tachycardia >100/min and tachypnoea >20/min)
  • An abnormal chest examination (crackles, decreased breath sounds, dullness to percussion, wheeze). This identifies patients with radiographically confirmed CAP with a sensitivity of 95%, negative predictive value of 92% and specificity of 56%.
  • No other explanation for the illness

These features are likely to result in a clinical decision that the condition should be treated as community acquired pneumonia with antibiotics

Stratification of severity

  • Stratify patients presenting with community-acquired pneumonia into those with low-, moderate- or high-severity disease using CRB 65
  • CRB65 score is calculated by giving 1 point for each of the following prognostic features:
    • Confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)
    • Raised respiratory rate (30 breaths per minute or more)
    • Low Blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
    • Age 65 years or more.
  • Patients are stratified as follows:
    • 0: low risk (less than 1% mortality risk)
    • 1 or 2: intermediate risk (1–10% mortality risk)
    • 3 or 4: high risk (more than 10% mortality risk)
  • Consider home treatment for those with a score of 0, and hospital treatment for those with a score of 2 or more

However, CRB-65 score is NOT a substitute for good clinical judgement and clinicians should take into account other prognostic factors such as oxygen saturation. Care should be taken with younger fit adults, as it is possible that the score may be low in patients who nevertheless have severe illness

Red Flags

Consider immediate hospital admission if:

  • Patients without pre-existing co-morbid medical conditions have an oxygen saturation <94% should be considered for hospital referral and oxygen supplementation
  • The grade of severity of CRB65 Score will usually correspond to the risk of death.
  • CRB65 score for mortality risk assessment in primary care
  • Patients are stratified for risk of death as follows:
    • 0: low risk (less than 1% mortality risk)
    • 1 or 2: intermediate risk (1–10% mortality risk)
    • 3 or 4: high risk (more than 10% mortality risk).
    • CRB65 score of 2 or more consider hospital admission

Investigations

Pulse oximetry

  • Patients without pre-existing co-morbid medical conditions who have an oxygen saturation <94% should be considered for hospital referral and oxygen supplementation

Chest X Ray

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

Management

Use clinical judgement in conjunction with the CRB65 score to inform decisions about whether patients need hospital assessment as follows:

  • Consider home-based care for patients with a CRB65 score of 0
  • Consider hospital assessment for all other patients, particularly those with a CRB65 score of 2 or more

No other explanation for the illness, and a clinical decision that it should be treated as community acquired pneumonia with antibiotics as soon as possible after diagnosis

IF CRB65=0

Amoxicillin

500mg TDS

7 Days

or

Clarithromycin

500mg BD

7 Days

or

Doxycycline

200 mgstat/100mg OD

7 Days

If CRB65=1 & AT HOME

Amoxicillin

500mg TDS

7-10 days

and

clarithromycin

500mg BD

7-10 days

Or

Doxycycline alone

200mg stat/ 100mg OD

7-10 days

Explain to patients with low-severity community-acquired pneumonia treated in the community, and when appropriate their families or carers that they should seek further medical advice if their symptoms do not begin to improve within 3 days of starting the antibiotic, or earlier if their symptoms are worsening.

Do not routinely offer patients with low-severity community-acquired pneumonia:

  • a fluoroquinolone
  • dual antibiotic therapy.

Full guidance available at: https://www.swyapc.org/primary-care-antibiotics/

Note: doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.

Manage patient Expectations

  • Explain to patients with community-acquired pneumonia that after starting treatment their symptoms should steadily improve, although the rate of improvement will vary with the severity of the pneumonia, and most people can expect that by:
    • 1 week: fever should have resolved
    • 4 weeks: chest pain and sputum production should have substantially reduced
    • 6 weeks: cough and breathlessness should have substantially reduced
    • 3 months: most symptoms should have resolved but fatigue may still be present
    • 6 months: most people will feel back to normal.
  • Advise patients with community-acquired pneumonia to consult their healthcare professional if they feel that their condition is deteriorating or not improving as expected.
  • Give Patient - 'Information for Patients Diagnosed with Mild Pneumonia' leaflet

Referral

Referral Criteria

  • Red Flags
  • Use clinical judgement in conjunction with the CRB65 score to inform decisions about whether patients need hospital assessment as follows:
    • Consider home-based care for patients with a CRB65 score of 0
    • Consider hospital assessment for all other patients, particularly those with a CRB65 score of 2 or more
      • Refer patient to ambulatory care if CRB score 1 Pneumonia and saturation's of >93% on air and no history of chronic lung disease
      • Patient requires 999 if CRB 2 and above or saturations <93% irrespective of pre-existing lung disease

Referral Instructions

  • e-Consultation is available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 08.2017
  • Publication Date: 08.2017
  • Review Date: 03.2019
  • Ref No: RS8 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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