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Pneumonia Pathway

Within one hour of arrival:

Symptoms

Patients with pneumonia may present with rapid onset of:

cough
difficulty breathing
sputum
pleuritic chest pain
systemic features, including:

temperature or fever
sweats
myalgia

Elderly patients with CAP more commonly:

present with fewer specific symptoms
display non-specific features, especially confusion
are associated with co-morbid disease and aspiration

History

Take a history, including:

symptoms - the following are common in community-acquired pneumonia (CAP):
cough
difficulty breathing
fever or temperature
sputum
pleuritic chest pain
sweats
myalgia
duration of symptoms - a duration of less than 24 hours is of significant predictive value for CAP
age
habitation in a nursing home - associated with a higher chance of co-morbid disease and aspiration

Measure SpO₂

Assess the patient's oxygen saturation (SpO₂) an SpO₂ of below 94%:

is an adverse prognostic feature for patients with CAP
is an indicator for oxygen therapy
requires urgent referral to hospital

Baseline Observations

Perform an examination, including:

pulse rate
respiratory rate
temperature
blood pressure (BP)
pulse oximetry if available
chest auscultation and percussion
assess mental status
observe for use of accessory muscles of respiration

Signs indicative of community-acquired pneumonia (CAP):

new focal chest signs:
are a defining feature of CAP
in the absence of focal signs, pneumonia is unlikely
fever
pulse more than 100 beats per minute
raised respiratory rate
reduced oxygen saturation (SpO₂)
mental confusion - especially in the elderly

Take Bloods

Full Blood Count
C-reactive protein (CRP): Consider a test for serum-level of CRP in patients with clinical features suggestive of pneumonia:

a CRP level of less than 20 mg/L at presentation, with symptoms for more than 24 hours, makes the presence of pneumonia highly unlikely
a CRP level of more than 100 mg/L makes pneumonia likely

Liver function tests (LFTs)
Urea & Electrolytes (U&Es)
Arterial Blood Gases (ABGs)

Microbiology

sputum: inspection, microscopy culture and sensitivity
blood cultures
in severe pneumonia, serology for atypical organisms (Influenza A and B, Coxiella burnetii, Chlamydia psittaci, Mycoplasma pneumonae, Legionella pneumophila). Indicate date of onset of infection on the request

Consider Sepsis

Sepsis Pathway

Potential sources of infection
Types of infection associated with sepsis / severe sepsis are:

Lung infections (pneumonia).
Appendicitis.
Infection of the lining of the digestive system (peritonitis).
An infection of the bladder, urethra or kidneys (urinary tract infections).
Post surgical (after surgery) infections.
Infections of the nervous system such as meningitis or encephalitis.
Abscesses.

Symptoms of sepsis / severe sepsis
The symptoms of sepsis usually develop quickly and can include:

Generally feeling unwell especially following a recent course of chemotherapy
A fever and shaking chills.
Increased heart beat (greater than 90 beats per minute).
Increased breathing rate (greater than 30 breaths per minute).
Low blood pressure which may result in feeling dizzy on standing.
A change in mental alertness such as confusion or disorientation.
Diarrhoea.
Reduced amount of urine being passed.
Cold, clammy and/or pale skin.
Loss of consciousness.

Diagnosis of sepsis / severe sepsis
To diagnose sepsis several tests may be carried out which could include:

Blood tests.
Urine tests.
Stool sample tests.
A wound culture test - where a small sample of tissue, skin or fluid is taken from the affected area for testing.
Respiratory secretion testing - which involves testing a sample of phlegm or mucus.
Imaging studies such as an X-ray or CT-scan.
Kidney, liver and heart function tests.

Within four hours of arrival:

ECG

The clinical importance of electrocardiogram in pneumonia relates to the differential diagnosis of pneumonia and pulmonary embolism (PE). Findings on electrocardiogram may hint that PE is present when interpreted in the proper context and lead to definitive imaging tests. However, it would be useful to know if electrocardiographic (ECG) abnormalities also occur in patients with pneumonia and whether they are similar to ECG changes with PE. Minor nonspecific ST-segment or T-wave changes were the most prevalent ECG abnormalities other than sinus tachycardia in patients with pneumonia and no previous cardiopulmonary disease.

Legionella and Pneumococcal Antigen Test

Perform the following microbiological investigations:
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 is positive, ensure respiratory samples for Legionella culture are sent, including pleural fluid, if present
sputum or other respiratory sample for Legionella culture and direct immunofluorescence, if available
investigations

Chest X-Ray

All patients admitted with suspected community-acquired pneumonia (CAP) should have a chest X-ray as soon as possible:

a chest X-ray is essential in confirming the diagnosis of CAP in hospital-managed patients
X-ray should be performed in time for antibiotics to be administered within 4 hours of presentation

Cyanosis? Unable to talk in full sentences? Confusion/Reduced GCS?

YES: seek senior / ITU help

Possibility of Aspiration Pneumonia?

YES: follow Aspiration Pneumonia Pathway

Clinical evidence of Pneumonia? Consolidation of CXR?

NO: Consider alternative diagnosis.

Onset more than 48 hours after admission, or admission in last ten days?

YES: follow Hospital Acquired Pneumonia Pathway

NO: Suspected Community Acquired Pneumonia - continue downwards.

Consider Adverse Prognostic Factors?

Unstable Co-morbidities
PaO2 < 8kPa on air
Multilobar OR bilateral involvement on CXR
Positive Legionella Urine Antigen Test

Calculate CURB-65 Score

Assess disease severity for all patients in the secondary care setting, even if the patient was previously assessed in the community:

clinical judgement is essential in the severity assessment of patients with community-acquired pneumonia (CAP)
British Thoracic Society (BTS) guidelines recommend the use of the CURB65 score, in conjunction with clinical judgement, as the severity assessment strategy in hospital or secondary care settings - each relevant factor scores one point:

Confusion - new mental confusion, defined as an Abbreviated Mental Test (AMT) score of 8 or less
Urea - greater than 7mmol/L
Respiratory rate - raised to 30 breaths per minute or more
Blood pressure (BP):

systolic BP lower than 90mmHg; and/or
diastolic BP lower than or equal to 60mmHg

65 - age 65 years and older

Classify the severity of the disease in one of three categories:

high severity [CURB-65 score 3 or more]:

patient is at high risk of death
indicated by a CURB65 score of 3 or more
patient should be reviewed by a senior physician at the earliest opportunity
consider transfer to a critical care unit

High Severity CAP Pathway

moderate severity [CURB-65 score 2]:

patient is at increased risk of death
indicated by a CURB65 score of 2
consider:

short-stay inpatient treatment; or
hospital-supervised outpatient treatment

Medium Severity CAP Pathway

low severity [CURB-65 score 0 or 1]:

patient is at low risk of death
indicated by a CURB65 score of 0 or 1
consider management in the community

Low Severity CAP Pathway

Apart from clinical disease severity, other factors to consider include:

stability of co-morbidities
social circumstances
patient wishes