Community-Acquired Pneumonia / Respiratory Sepsis

Antimicrobial prescribing: NHS Fife
NHS Fife

NB: CONSIDER POSSIBILITY OF COVID-19 IN ALL PATIENTS WITH PNEUMONIA

ANTIBIOTIC CHOICES HAVE BEEN ALTERED DURING THE COVID-19 PANDEMIC. USE MACROLIDES AND QUINOLONES WITH CAUTION DUE TO RISK OF QTc PROLONGATION, WHICH MAY COMPLICATE POTENTIAL MYOCARDIAL DISEASE IN THESE PATIENTS

Clinical features
  • Cough
  • Increased sputum production
  • Dyspnoea
  • Haemoptysis
  • Chest pain

CAP is more likely than Hospital-Acquired Pneumonia If the patient has been admitted for less than 5 days, and has not been recently discharged (within the last 7 days).

Consider influenza in a patient with CURB 3 or greater CAP, particularly with high fever. Empirical oseltamivir may be appropriate. During winter peak seasons, rapid testing may be available in A&E / AU1 Adult Treatment of Influenza Guidance

Severity of CAP can be assessed using CURB-65. This must be correlated with clinical judgement. Younger, previously well patients with good physiological reserve may be more unwell than their score suggests.  Use the CURB-65 score to guide treatment.

CURB-65 score

Score 1 point for each of:

  • New or worse confusion
  • Urea > 7mmol / L
  • Respiratory rate ≥ 30
  • BP - Systolic  < 90mmHg OR Diastolic ≤ 60mmHg
  • Age ≥ 65
Investigations
  • Blood culture if starting IV antibiotic therapy
  • Culture of expectorated sputum (NOT saliva)
  • Viral throat swab
  • Chest X-ray
  • For severe CAP (CURB-65 ≥ 3), recent travel abroad or staying somewhere with air-con, consider urine for Legionella antigen. Legionella PCR (induced sputum or BAL only) may be appropriate
  • Consider blood borne virus testing (HIV, Hepatitis B, Hepatitis C) in all adults with pneumonia
Infection Control

Isolation with droplet precautions for all patients

Treatment
CAP should be confirmed by CXR before starting treatment in most patients. Some patients with life-threatening disease (CURB65 ≥3) should be treated immediately based on clinical diagnosis.

Oral clarithromycin is preferred to IV if this route is available due to risk of phlebitis from IV infusion. IV clarithromycin should only be infused through a large vein

Mild (CURB65 = 0-1) 
Oral antibiotics are usually adequate. Consider outpatient management.
1ST CHOICE

DOXYCYCLINE PO 200mg stat then 100mg 24 hourly

2ND CHOICE

AMOXICILLIN PO 1g 8 hourly

IV (only if oral route unavailable):

BENZYLPENICILLIN IV 1.2g 6 hourly

If true penicillin allergy:

CLARITHROMYCIN IV 500mg 12 hourly

Duration: 5 days total
Moderate (CURB65 = 2) 
Most can be managed with oral antibiotics
 
AMOXICILLIN PO 1g 8 hourly  
PLUS
DOXYCYCLINE PO 200mg stat then 100mg 24 hourly

If true penicillin allergy:

DOXYCYCLINE PO 200mg stat then 100mg 24 hourly

IV (if oral route not available):
BENZYLPENICILLIN IV 1.2g 6 hourly 
PLUS
CLARITHROMYCIN IV 500mg 12 hourly

If true penicillin allergy:

VANCOMYCIN IV Dose as per calculator

PLUS

CLARITHROMYCIN IV 500mg 12 hourly

Duration:  5-7 days total 
Severe (CURB65 = 3-5)
 
IV antibiotics initially. Consider oral switch if afebrile >24h, clinically improving and oral route available

CO-AMOXICLAV IV 1.2g 8 hourly 

PLUS

DOXYCYCLINE PO 200mg stat then 100mg 24 hourly

For recent foreign travel consider adding: VANCOMYCIN IV (Dose as per calculator)

If true penicillin allergy:

VANCOMYCIN IV Dose as per calculator 

PLUS

CIPROFLOXACIN IV 400mg 12 hourly (review MHRA Safety Advice before prescribing)

IV to Oral Switch

DOXYCYCLINE PO 200mg stat then 100mg 24 hourly

OR

COTRIMOXAZOLE PO 960mg 12 hourly
Duration: 5-7 days total (IV + oral)