Home

Low Severity Community Acquired Pneumonia Pathway

Symptoms

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

  • are at low risk of death
  • mortality is less than 3%
  • most patients will be suitable for discharge and treatment at home

Decide on appropriate care setting

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

Patient Admitted to AMU / Ward

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 antibiotics in all 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
Most patients with low severity CAP can be adequately treated with oral antibiotics, provided there are no contraindications to oral therapy.

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

First Line: Amoxicillin 500mg - Q8h PO for 5 days

Second Line (Penicillin Allergy): Doxycycline 200mg PO stat on day 1, then 100mg PO Q12h for 5 days.

 

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

 

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

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

Refer to Thoraci Medicine

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

Antibiotic management

Administer antibiotics in all 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

Most patients with low severity CAP can be adequately treated with oral antibiotics, provided there are no contraindications to oral therapy.

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

First Line: Amoxicillin 500mg - Q8h PO for 5 days

Second Line (Penicillin Allergy): Doxycycline 200mg PO stat on day 1, then 100mg PO Q12h for 5 days

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.