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High Severity Community Acquired Pneumonia Pathway

Symptoms

Patients with high severity community-acquired pneumonia (CAP):

  • are at high risk of death
  • mortality ranges from 15-40%
  • admit patient to hospital
  • diagnosis and initial investigations should have already taken place

Complete standard admission documents

All patients should undergo venous thromboembolism (VTE) risk assessment upon admission and for a second time, within 24 hours of initial assessment

The initial dementia risk assessment should be completed within 72 hours of admission

Use the admission document and nursing assessment document to ensure that all other standard assessments are completed.

Oxygenation management

Oxygen therapy:

all patients should receive appropriate oxygen therapy with monitoring of oxygen saturations and inspired oxygen concentrations with the aim to maintain arterial oxygen tension (PaO2) at greater than 8kPa and oxygen saturation (SpO2) between 94-98%.

high concentrations of oxygen can safely be given in patients who are not at risk of hypercapnic respiratory failure.

oxygen therapy in patients at risk of hypercapnic respiratory failure complicated by ventilatory failure should be guided by repeated arterial blood gas measurements.

Antibiotic management

Administer parenteral antibiotics in all high severity patients as soon as diagnosis of community-acquired pneumonia (CAP) has been confirmed, ie:

  • before they leave the initial assessment area
  • within 4 hours of presentation to hospital for the majority of patients

Antimicrobial Therapy for High Severity CAP (for full guidance see formulary)

First Line: Co-amoxiclav 1.2g IV q8h plus Clarithromycin 500mg IV q12h

Review IV antibiotics no later than 48 hours.

Step down to oral therapy with Co-amoxiclav 625mg PO q8h plus Clarithromycin 500mg PO q12h (Total 7-10 day course) when appropriate

Second Line (Penicillin Allergy): Clarithromycin 500mg IV q12h plus Vancomycin 1g IV q12h

General management Including Smoking Assessment

The following aspects of general management are recommended for all patients with uncomplicated community-acquired pneumonia (CAP):

  • assess the patient for volume depletion they may require intravenous (IV) fluids
  • consider prophylaxis for venous thromboembolism (VTE) for all patients who are not fully mobile
  • consider patient mobility - condition permitting, the patient should:
    • sit out of bed for at least 20 minutes within first 24 hours; and
    • increase mobility each subsequent day of hospitalisation where possible
  • administer analgesia for pleuritic chest pain
  • provide nutritional support in prolonged illness

Airway clearance techniques:

  • are not recommended routinely in patients with uncomplicated pneumonia; but
  • should be considered if the patient has either of the following:
    • difficulty with expectoration
    • a pre-existing lung condition

Microbiological investigations:

Perform the following microbiological investigations for high severity pneumonia:

  • blood cultures – minimum 20mL:
  • two sets of blood cultures should be performed in all patients with community-acquired pneumonia (CAP) who require hospitalisation
  • however, a recent systematic review found they are of very limited use in immunocompetent patients hospitalised with CAP
  • sputum for routine culture and sensitivity tests for those who have not received prior antibiotics:
  • sputum samples may be refrigerated for up to 2-3 hours
  • pleural fluid, if present, for:
    • microscopy
    • culture
    • pneumococcal antigen detection
  • pneumococcal urine antigen test:
    • consider the urinary antigen test for Streptococcus pneumoniae (S. pneumoniae) in patients admitted to the hospital for reasons of illness severity
    • consider a urine antigen test whenever a pleural fluid sample is obtained in the setting of a parapneumonic effusion
    • NB: the S. pneumoniae urinary antigen test in adults has a sensitivity of 65–100% and a specificity of 94%; however, weak positive results should be interpreted with caution
Investigations for Legionella pneumonia:
  • urine for Legionella antigen - if urine antigen positive ensure respiratory samples are sent for Legionella culture
  • sputum or other respiratory sample for Legionella culture and direct immunofluorescence, if available)
investigations for atypical and viral pathogens:
  • sputum or other respiratory sample for polymerase chain reaction (PCR) or direct immunofluorescence for:
    • Mycoplasma pneumoniae
    • Chlamydia spp.
    • influenza A
    • influenza B
    • parainfluenza virus type 1-3
    • adenovirus
    • respiratory syncytial virus
    • Pneumocystis jirovecii, if at risk
  • consider initial and follow-up viral and atypical pathogen serology
  • respiratory samples for polymerase chain reaction (PCR) testing are ideally:
    • induced sputum – when the cough is dry, consider physiotherapy, postural drainage, or inhalation of an aerosol before expectoration
    • bronchoalveolar lavage – washes or brushes, directed or non-directed
    • endo-tracheal aspirate
    • where lower respiratory sampling is not possible, a nose/throat swab is acceptable
Serological tests should not be performed as the only routine diagnostic test.

A combination of IgM antibody detection and PCR may be the most sensitive approach.

Consider urgent referral to critical care unit/respiratory physician

Consider referral to an intensive care unit (ICU) or a high dependency unit (HDU) if:

  • patient has a CURB65 score of 4 or 5
  • hypoxia persists, ie PaO2 less than 8kPa, despite appropriate oxygen management
  • there is evidence of severe acidosis, ie pH less than 7.26
  • hypercapnia is progressing
  • consciousness is depressed
  • hypotension persists despite adequate treatment
  • severe sepsis or septic shock
  • radiographic extension of infiltrates

Consider patient for amber care bundle

Identification: is the patient AMBER?

  • 1. Is the patient deteriorating, clinically unstable, and with limited reversibility?
  • 2. Is the patient at risk of dying within the next 1-2 months?

Monitor and re-assess

Monitor and record the following at least twice daily:

  • temperature
  • respiratory rate
  • pulse
  • blood pressure (BP)
  • mental status
  • oxygen saturation (SpO2)
  • inspired oxygen concentration

Vital signs may be captured by an early warning score and can be used to trigger escalation or de-escalation of management.

Regularly reassess all patients admitted to hospital until shown to be improving:

  • reassess disease severity - the "post take" round provides an early opportunity for this
  • reassess the choice of antibiotic and route of administration on the "post take" round, and daily thereafter

Average time to clinical stability for the following factors is 2-3 days:

  • temperature
  • pulse rate
  • respiratory rate
  • SpO2

Repeat chest radiograph for patients who are not progressing satisfactorily after 3 days of treatment. Remeasure C-reactive protein (CRP) in patients who are not progressing after 3 days of treatment:

  • CRP usually falls by 50% by day 3 of treatment [3]
  • failure of CRP to fall by 50% is associated with [2]:
    • increased 30-day mortality
    • increased need for mechanical ventilation and/or inotropic support
    • increased incidence of complicated pneumonia, eg empyema

Inadequate response or deterioration

For patients who fail to improve as expected, there should be a careful review by an experienced clinician of:

  • clinical history
  • examination
  • prescription chart
  • results of all available investigations

In the light of clinical review, consider further investigations, including:

  • white cell count (WCC)
  • further specimens for microbiological testing

Repeat chest radiograph for patients who are not progressing satisfactorily after 3 days of treatment. Remeasure C-reactive protein (CRP) in patients who are not progressing after 3 days of treatment.

  • CRP usually falls by 50% by day 3 of treatment.
  • failure of CRP to fall by 50% is associated with:
    • increased 30-day mortality
    • increased need for mechanical ventilation and/or inotropic support
    • increased incidence of complicated pneumonia, eg empyema

Reassess diagnosis and look for complications

Common causes of treatment failure include:

  • pulmonary embolism (PE) or infarction
  • pulmonary oedema
  • bronchial carcinoma
  • bronchiectasis
  • slow response in elderly patients
  • complications of pneumonia, eg:
    • empyema
    • abscess
    • pleural effusion
  • unrecognised immunocompromised status
  • resistant causative organism
  • poor absorption of oral antibiotic
  • nosocomial infections

Check results of microbiology for antibiotic resistance or atypical pathogen(s).

Refer to rispiratory physician

Consider urgent referral to critical care unit

Consider referral to an intensive care unit (ICU) or a high dependency unit (HDU) if:

  • patient has a CURB65 score of 4 or 5
  • hypoxia persists, ie PaO2 less than 8kPa, despite appropriate oxygen management
  • there is evidence of severe acidosis, ie pH less than 7.26
  • hypercapnia is progressing
  • consciousness is depressed
  • hypotension persists despite adequate treatment
  • severe sepsis or septic shock
  • radiographic extension of infiltrates

Consider care of the dieing patient plan if patient fits criterea

Satisfactory Improvement

If on IV Antibiotics consider switch to oral

If the patient has been initially treated with intravenous (IV) antibiotics and there are no contraindications to oral therapy, consider switching to oral antibiotics:

  • most patients with moderate severity community-acquired pneumonia (CAP) can be adequately treated with oral antibiotics
  • the antibiotic choices for the switch from IV to oral are straightforward where there are effective and equivalent oral and parenteral formulations:
    • if parenteral cephalosporins are being used, a switch to oral co-amoxiclav is recommended rather than to oral cephalosporins for those treated with parenteral benzylpenicillin and levofloxacin, oral levofloxacin with or without oral amoxicillin is recommended

The following features indicate a response to parenteral therapy permitting consideration of oral antibiotic substitution:

  • resolution of fever for longer than 24 hours
  • pulse rate less than 100 beats per minute
  • tachypnoea resolved
  • clinically hydrated and taking oral fluids
  • hypotension has resolved
  • absence of hypoxia
  • improving white cell count (WCC)
  • non-bacteraemic infection
  • no microbiological evidence of legionella, staphylococcal, or Gram-negative enteric bacilli infection
  • no concerns over gastrointestinal (GI) absorption

Reassess diagnosis and look for complications

Common causes of treatment failure include:

  • pulmonary embolism (PE) or infarction
  • pulmonary oedema
  • bronchial carcinoma
  • bronchiectasis
  • slow response in elderly patients
  • complications of pneumonia, eg:
    • empyema
    • abscess
    • pleural effusion
  • unrecognised immunocompromised status
  • resistant causative organism
  • poor absorption of oral antibiotic
  • nosocomial infections

Check results of microbiology for antibiotic resistance or atypical pathogen(s).

Discharge and advise on secondary prevention

Consider discharge:

  • patients should be reviewed within 24 hours of planned discharge home
  • those suitable for discharge should not have more than one of the following clinical instabilities:
    • temperature above 37.8°C
    • heart rate above 100 beats per minute
    • respiratory rate above 24 breaths per minute
    • systolic blood pressure (BP) less than 90mmHg
    • oxygen saturation (SpO2) less than 90%
    • inability to maintain oral intake
    • abnormal mental status

Advise on measures for secondary prevention of community-acquired pneumonia (CAP):

  • ensure immunisation is up to date, following Department of Health (DH) guidelines for the following vaccines:
    • influenza vaccine – recommended for those aged 65 years or older and for people of any age with underlying chronic disease, or living in long-stay residential care
    • pneumococcal vaccine (PPV) – should be given to all people over the age of 65 years, on a one-off basis
  • reinforce smoking cessation advice if relevant

Arrange a clinical review for all patients after 6 weeks, either with their GP or in a hospital clinic:

  • it is the responsibility of the hospital team to arrange the follow-up plan with the patient and GP
  • at discharge or follow-up, patients should be offered written information about CAP

Reassess in outpatient clinic as appropriate

Arrange a clinical review after 6 weeks, as an outpatient in secondary care if appropriate:

  • it is the responsibility of the hospital team to arrange the follow-up plan with the patient and GP
  • at discharge or follow-up, patients should be offered written information about community-acquired pneumonia (CAP)
Arrange a chest radiograph after 6 weeks for patients with:
  • persistence of symptoms
  • physical signs of illness
  • a high risk of underlying malignancy - this especially includes all those who smoke and are age 50 years or older

Arrange follow-up with GP

Arrange a clinical review after 6 weeks, with patient's GP if appropriate:

  • it is the responsibility of the hospital team to arrange the follow-up plan with the patient and GP
  • at discharge or follow-up, patients should be offered written information about community-acquired pneumonia (CAP)

Arrange a chest radiograph after 6 weeks for patients with:

  • persistence of symptoms
  • physical signs of illness
  • a high risk of underlying malignancy - this especially includes all those who smoke and are age 50 years or older.