B-Quick: Community-acquired pneumonia

B-QuiCK: Community-acquired pneumonia

Assessment and diagnosis

• Community-acquired pneumonia is diagnosed clinically, based on the presence of characteristic symptoms and signs:
  • Respiratory, e.g. dyspnoea, tachypnoea, increased respiratory effort, crackles on auscultation, pleuritic chest pain
  • Non-respiratory, e.g. fever, tachycardia, and less typically, abdominal pain and vomiting; non-specific symptoms may also be present such as confusion in older people and poor feeding in infants
• Perform a physical examination based on patient history (including risk factors) and symptoms, e.g. check temperature, heart rate, respiratory rate, oxygen saturation, examine the chest
• Consider alternative diagnoses, e.g. inhaled foreign body, asthma, bronchiolitis, congestive heart failure, gastro-oesophageal reflux disease, lung cancer
• Perform a COVID-19 test to exclude SARS-CoV-2 infection
  • Laboratory testing, e.g. FBC, CRP, and microbiological testing, may be considered for adults with moderate-to-severe symptoms and signs, but is not routinely required
• Referral for chest X-ray is not routinely required but may be considered in some clinical situations, e.g. if the diagnosis is uncertain/presentation not typical, underlying respiratory disease, suspected complications
• Once a clinical diagnosis of community-acquired pneumonia has been made, determine suitability for community-based management. In adults, this decision can be guided by the CRB-65 (confusion, respiratory rate, blood pressure, age ≥ 65 years) severity assessment tool in addition to clinical judgement.

When to refer a child or an adult with suspected pneumonia to hospital.

Management

Antibiotic treatment is usually empiric: high dose amoxicillin is first line for most patients. Advise patients to maintain adequate hydration and to take paracetamol or ibuprofen as required (use ibuprofen with caution in children who are dehydrated).

	First line	Alternatives (if penicillin allergic)	Additional treatment
Child	Amoxicillin: 30 mg/kg/dose (maximum 1 g/dose)*, three times daily, for three to five days *If aged less than one month, the maximum is 125 mg/dose, but initiation of oral antibiotics in the community is usually not appropriate in children aged less than three months as they should be referred to hospital for treatment	Erythromycin: 10 – 12.5 mg/kg/dose, four times daily, for seven days (usual maximum 1.6 g/day; up to 4 g/day in severe infection) Azithromycin: 10 mg/kg, once daily, on day one, followed by 5 mg/kg, once daily on days two to five N.B. Doxycycline is also a suitable alternative antibiotic to amoxicillin in children aged over 12 years, however, there is no liquid formulation available for children unable to swallow tablets.	If there is a poor response after 48 hours of initial antibiotic treatment, it is likely the child has viral pneumonia (in which case, consider “watchful waiting”) or a bacterial cause that does not typically respond to empiric antibiotics. In an older child, take a sputum sample for microbiological testing. Consider adding a macrolide antibiotic (e.g. erythromycin) in children aged over five years.
Adult	Amoxicillin: 1 g, three times daily, for five days N.B. The higher dose of amoxicillin is recommended to overcome increasing resistance, but lower doses (e.g. 500 mg, three times daily) may still be appropriate for some patients based on clinical judgement.	Doxycycline: (severe penicillin allergy, e.g. anaphylaxis): 200 mg, twice daily on day one, followed by 100 mg, twice daily, on days two to five Cefalexin: (mild penicillin allergy, e.g. rash): 1 g, three times daily, for five days	For patients with more severe symptoms (but who are still suitable for community management), or who have not improved after 48 hours of initial antibiotic treatment, consider combination treatment with amoxicillin (1 g, three times daily, for five days) PLUS a macrolide (e.g. azithromycin, 500 mg, once daily, for three days; or roxithromycin, 300 mg, once daily, for five days). Certain causes of pneumonia, e.g. Legionella, require a longer antibiotic treatment duration or an alternative antibiotic; discuss a pathogen-specific regimen with an infectious diseases physician or clinical microbiologist.

Follow-up

Review two to three days after initiating antibiotic treatment (either in person or via phone). If there has been inadequate response to treatment, or clinical deterioration, reassess antibiotic choice and/or suitability for community management. Ideally review children again six weeks after antibiotic treatment to assess for any persisting symptoms and signs.

Indications for follow-up chest X-ray:

Consider referral for a chest X-ray in patients who have not responded adequately to antibiotic treatment and/or discussion with an appropriate specialist.

• Children. Children who had significant abnormalities on chest X-ray at the time of initial diagnosis, e.g. atelectasis, or recurrent pneumonia affecting the same lobe, should have a follow-up X-ray four to six weeks after completing antibiotic treatment.
• Adults. A follow-up chest X-ray four to six weeks after completing antibiotic treatment is recommended for patients:
  • Who had an abnormal chest X-ray (e.g. effusion) at the time of initial diagnosis
  • With poor clinical recovery (to exclude malignancy)
  • Who have recovered from pneumonia but are at high risk of underlying lung pathology, e.g. significant smoking history

Additional follow-up:

• Consider spirometry testing in adults who smoke (or with a history of smoking) to identify underlying COPD, once they have recovered from pneumonia
• Provide advice on reducing exposure to modifiable risk factors associated with pneumonia, e.g. smoking cessation, maintaining a smoke-free home and vehicle, seeking support for improving housing quality
  • Vaccination provides some protection against community-acquired pneumonia. Encourage patients to be up to date with the following vaccines (depending on eligibility): Prevenar 13 (PCV13), Pneumovax 23 (23PPV), Haemophilus influenzae type b (Hib; included as part of the DTaP-IPV-HepB/Hib [Infanrix-hexa] vaccine and Hib-PRP-T [Hiberix] vaccine), seasonal influenza, COVID-19