Pneumonia - community acquired (CAP)

Prescribing Notes:

The CRB-65 scale can be used in community in conjunction with clinical judgement to help assess the need for hospital admission and risk of death due to pneumonia. One point is given for each indicator; 0 low risk, consider home based care, 1-2 intermediate risk, consider hospital assessment or admission, ≥3 urgent hospital admission.

• Confusion AMT <8
• Respiratory Rate ≥ 30/min
• BP diastolic ≤ 60mmHg or systolic <90mmHg
• 65 years or older

Additional notes:

• The vast majority of respiratory tract illness is self-limiting and it is recommended that the term “infection” is avoided. Purulent sputum alone is not a marker for antibiotic treatment.
• A higher dose of amoxicillin (1g every 8 hours) may be required, please consult any susceptibility reports.
• Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course is needed or the person is not clinically stable (fever in past 48 hours or more than one sign of clinical instability [systolic blood pressure <90 mmHg, heart rate >100/minute, respiratory rate >24/minute, arterial oxygen saturation <90% or PaO2 <60 mmHg in room air]).
• Mycoplasma pneumoniae infection occurs in outbreaks approximately every 4 years.
• CURB-65 is used in hospital to assess the severity of infection and includes the same criteria above and in addition Urea level >7mmol/L.
• May be diagnosed at home (in the absence of chest X-ray) if there are symptoms of lower respiratory tract illness plus systemic features plus focal signs.
• Patients that fail to improve within 48 hours should be considered for hospital admission or chest X-ray.
• If clinically required courses may be extended to 10 days in total.
• Ciprofloxacin has no activity against Streptococcus pneumoniae and should be restricted to the treatment of proven persistent pseudomonal infections on the advice of a specialist i.e. sputum cultures will have grown pseudomonas with demonstrated sensitivity to ciprofloxacin (more often in patients with bronchiectasis). Consider important safety issues and potentially long lasting side-effects prior to prescribing ciprofloxacin.
• See MHRA Drug Safety Update January 2024: Fluoroquinolones must only be used in situations when other antibiotics, that are commonly recommended for the infection, are inappropriate such as: 
  • there is resistance to other first-line antibiotics recommended for the infection
  • other first-line antibiotics are contraindicated in an individual patient 
  • other first-line antibiotics have caused side effects in the patient requiring treatment to be stopped 
  • treatment with other first-line antibiotics has failed.
• In pneumonia following influenza, Staph aureus infection is possible and doxycycline, clarithromycin, co-trimoxazole or co-amoxiclav may be considered. Co-amoxiclav should be avoided in the over 65 age group when possible.

Prescribing Notes:

The CRB-65 scale can be used in community in conjunction with clinical judgement to help assess the need for hospital admission and risk of death due to pneumonia. One point is given for each indicator; 0 low risk, consider home based care, 1-2 intermediate risk, consider hospital assessment or admission, ≥3 urgent hospital admission.

• Confusion AMT <8
• Respiratory Rate ≥ 30/min
• BP diastolic ≤ 60mmHg or systolic <90mmHg
• 65 years or older

Additional notes:

• The vast majority of respiratory tract illness is self-limiting and it is recommended that the term “infection” is avoided. Purulent sputum alone is not a marker for antibiotic treatment.
• A higher dose of amoxicillin (1g every 8 hours) may be required, please consult any susceptibility reports.
• Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course is needed or the person is not clinically stable (fever in past 48 hours or more than one sign of clinical instability [systolic blood pressure <90 mmHg, heart rate >100/minute, respiratory rate >24/minute, arterial oxygen saturation <90% or PaO2 <60 mmHg in room air]).
• Mycoplasma pneumoniae infection occurs in outbreaks approximately every 4 years.
• CURB-65 is used in hospital to assess the severity of infection and includes the same criteria above and in addition Urea level >7mmol/L.
• May be diagnosed at home (in the absence of chest X-ray) if there are symptoms of lower respiratory tract illness plus systemic features plus focal signs.
• Patients that fail to improve within 48 hours should be considered for hospital admission or chest X-ray.
• If clinically required courses may be extended to 10 days in total.
• Ciprofloxacin has no activity against Streptococcus pneumoniae and should be restricted to the treatment of proven persistent pseudomonal infections on the advice of a specialist i.e. sputum cultures will have grown pseudomonas with demonstrated sensitivity to ciprofloxacin (more often in patients with bronchiectasis). Consider important safety issues and potentially long lasting side-effects prior to prescribing ciprofloxacin.
• See MHRA Drug Safety Update January 2024: Fluoroquinolones must only be used in situations when other antibiotics, that are commonly recommended for the infection, are inappropriate such as:  
  • there is resistance to other first-line antibiotics recommended for the infection 
  • other first-line antibiotics are contraindicated in an individual patient 
  • other first-line antibiotics have caused side effects in the patient requiring treatment to be stopped 
  • treatment with other first-line antibiotics has failed.
• In pneumonia following influenza, Staph aureus infection is possible and doxycycline, clarithromycin, co-trimoxazole or co-amoxiclav may be considered. Co-amoxiclav should be avoided in the over 65 age group when possible.

Prescribing Notes:

• MRSA, like other Staphylococcus aureus strains, may be part of normal colonising flora, for example, on skin, on a leg ulcer, in urine in an asymptomatic catheterised patient. The criteria for treating MRSA are the same as for any other pathogen, i.e. clinical evidence of chest infection, soft tissue infection, or systemic illness in a catheterised patient.
• Most MRSA locally is sensitive to doxycycline.
• If severe infection or no response to monotherapy after 24-48 hours, seek advice from Microbiology.

Prescribing Notes:

• May be diagnosed in primary care (in the absence of chest X-ray) if there are symptoms of lower respiratory tract illness plus systemic features plus focal signs.
• Strep pneumoniae is the overall commonest cause of pneumonia at all ages; others include Mycoplasma pneumoniae, Haemophilus influenzae and Staphylococcus aureus.
• If Mycoplasma or an atypical pathogen is suspected choose clarithromycin.
• Most cases of severe pneumonia will require hospitalisation.