Pneumonia in adults, diagnosis and management. with current guidelines

1. Pneumonia in adults: diagnosis and
management
By Dr. Saad Elfeky
MBBCh
MO (GP) KPC

2. • Pneumonia is an inflammation of the lung tissue. It is usually due
to infection.
• Types of Pneumonia
• Community-acquired pneumonia (CAP)
a new infection of lung parenchyma appearing in the
community or less than 48 hours after admission to the hospital.
• Hospital-acquired Pneumonia (HAP)
a new infection of lung parenchyma appearing more than
48 hours after admission to the hospital.
Terms used in this Presentation

3. Overview
Community-acquired pneumonia (CAP) is diagnosed in 5-12% of
adults who present to GPs with symptoms of lower respiratory tract
infection, and 22-42% of these are admitted to hospital, where the
mortality rate is between 5% and 14%. It is even higher for Hospital-
acquired Pneumonia (HAP).
*This Presentation covers the salient points of the NICE guidelines on the
diagnosis and management of both CAP and HAP. This includes severity
stratification, considerations of point of care testing in the community
other microbiological investigations and recommendations on type and
duration of antibiotic treatment.

4. Introduction
• This Presentation looks at NICE Guideline recommendations on:
• Community Acquired Pneumonia (CAP)
• - Diagnosis
• - Severity stratification
• - Assessment of CAP in hospital
• - Point of care investigationsMicrobiological investigations
• - Antibiotics type and duration
• - Safety netting
• - Recommendations on safe discharge from hospital in CAP
• Hospital Acquired Pneumonia (HAP)
• - Recommendations on time to initiating treatment
• -Antibiotics type and duration

5. Diagnosis
• In the NICE Guidelines, a lower respiratory
tract infection (LRTI) is defined as:-
• An acute illness present for 21 days or less
• Usually with cough as the main symptom
• With at least 1 other lower respirator
tract symptom such as:
- Fever
- Sputum production
- Breathlessness
- Wheeze or Crackles
- Chest discomfort or pain
• With no alternative explanation (such as
sinusitis or asthma)
• Pneumonia, acute bronchitis and
exacerbation of chronic obstructive airways
disease are included in this definition of LRTI
• Diagnosis of CAP is based on clinical
assessment of symptoms and signs of lower
respiratory tract infection with the possible
presence of focal chest signs and illness
severity amongst other features.
• The causes of LRTI in adults may range from
severe and progressive bacterial infection to
mild and self-limiting viral infections.
However, clinical symptoms and signs are not
sensitive discriminators.

6. Severity stratification
• The spectrum of illness severity is wide
for CAP with illness that can be managed
at home with appropriate antibiotic
therapy and at the other extreme,
patients needing hospital admission
• Tools have been devised to predict risk of
death to determine the level of care
required.
• NICE Guidelines recommend the use of
CRB65 risk stratification tool when a
clinical diagnosis of CAP is made.
• The CRB65 score is used to determine
whether patients are at low,
intermediate or high risk of death.
• CRB65 score is calculated by giving 1
point for each of the following
prognostic features:-
• -Confusion (abbreviated Mental Test
score 8 or less, or new disorientation in
person, place or time)
• - Respiratory rate 30 breaths per minut
• - Blood pressure (diastolic 60 mmHg or
less, or systolic less than 90 mmHg)
• -65 years of age or more

7. CRB65 score
⚫ 0: low risk (less than 1% mortality
risk)
⚫ 1 or 2: intermediate risk (1-10%
mortality risk)
⚫ 3 or 4: high risk (more than 10%
mortality risk)
💀 ( Mortality risk= The percentage
likelihood of death occurring in a
patient in the next 30 days).
• Consider home-based care for
patients with a CRB65 score of 0.
• Consider hospital assessment for all
other patients, particularly those
with a CRB65 score of 2 or more
• Clinical judgment should be used in
conjunction with the CRB65 score to
inform decisions about whether
patients need hospital assessment.

8. Assessment of CAP in hospital
• You may send patients to hospital for further assessment of CAP or
they may present there directly. For these patients, NICE guidelines
recommend:
• Put in place processes to allow diagnosis (including x-rays) and
treatment of community-acquired pneumonia within 4 hours of
presentation to hospital
• When a diagnosis of CAP is made, use CURB65 score in hospital to
determine hospital whether patient is at low, intermediate or high
risk of death (see table). Use clinical judgment in conjunction with the
CURB65 score to guide the managementof CAP.

9. Box 1 CURB65 score
for mortality risk
assessment in
hospital
NICE Clinical
Guideline CG191
⚫ consider home-based care for patients
with a CURB65 score of 0 or 1
⚫ consider hospital-based care for patients
with a CURB65 score of 2 or more
⚫ consider intensive care assessment for
patients with a CURB65 score of 3 or more.
Assessment of CAP in hospital

10. Investigations in CAP
• Research has been conducted to examine whether diagnostic accuracy and clinical
management can be improved by the use of simple investigations
• Point of care (POC) C-reactive Protein (CRP)
• New shadowing on a CXR is deemed'gold standard' for diagnosis.
• As this is not available in most practices, NICE Guidelines recommend the use of point
of care (POC)* CRP testing for people presenting with symptoms of LRTI in primary
care, if after clinical assessment a diagnosis of pneumonia has not been made and it
is not clear whether antibiotics should be prescribed.
• *POC test is a test taken on site providing a quick result which does not involve sending a blood sample
to the lab.

11. CRP testing
🔵If available and clinically indicated
NICE recommends using the results of
the point of care C-reactive protein test
to guide antibiotic prescribing in
people without aclinical diagnosis of
pneumonia (see table to right).
🔵Review of evidence by NICE suggests
that CRP may be more accurate for
predicting cases with CXR-confirmed
pneumonia than an alternative marker
called Procalcitonin.
C-reactive protein
concentration
Antibiotics
< 20 mg/itre Do not routinely
offer antibiotic
therapy
Low frequency of
CXRconfirmed
pneumonia can
befound in this
group
20 mg/litre to 100
mg/litre
Consider a delayed
antibiotic
prescription (a
prescription for use
at a later date if
symptoms worsen)
> 100 mg/litre Offer antibiotic
therapy
High frequency of
CXR confirmed
pneumonia can be
found in this group
📑Please note: elderly patients or
those with cirrhotic liver disease
may not mount a high CRP
responses.

12. Investigations in CAP
• Studies reviewed by NICE Guidelines varied from low to moderate quality.
They indicated that:-
• -Using CRP to assist antibiotic prescribing decisions for people presenting in
primary care with LRTI can reduce antibiotic treatment at index consultation
and 28 days (203 per 1000 fewer prescriptions)
• - No significant differences were found between the CRP and usual care
groups for the outcomes of mortality, re-consultation, symptom resolution
and quality-of-life
• - There was a trend towards more hospital admissions in the CRP compared
with the usual care group although the difference in terms of absolute effect
was small and there was no data available to see whether these hospital
admissions were appropriate or not.

13. Chest x-ray in CAP
• BTS 2015 guidelines recommend that it is not essential to perform a CXR
in patients with suspected CAP unless:
• The diagnosis is in doubt
• Progress following treatment is not satisfactory
• Patient is at risk of other underlying pathology such as Lung Cancer
• A CXR should be arranged after about 6 weeks if symptoms or physical
signs persist or for those who are at higher risk of malignancy e.g
Smokers aged >50 years.

14. Chest x-ray in CAP

15. Chest x-ray in CAP

16. Chest x-ray in CAP

17. Microbiological testing
• For patients with moderate-or high-severity CAP, NICE Guidelines
recommend:-
• Take blood and sputum culture
• Consider pneumococcal and legionella urinary antigen tests
• Do not routinely offer microbiological tests to patients with low-
severity CAP

18. • Patients with suspected CAP should be advised not to smoke
and to rest and drink plenty of fluids. Other general measures
include:
• Oxygen for hypoxia; ventilation if there is severe hypoxia.
• Fluids for dehydration.
• Analgesics: non-steroidal anti-inflammatory drugs (NSAIDs) and
paracetamol - for mild pleuritic pain; more severe pain may
require opiate analgesia but care is needed not to aggravate
CO2retention.
• Nebulised saline may help expectoration.
• Chest physiotherapy has doubtful benefit. Physiotherapy may
be more important in helping to mobilise the patient.
Management of CAP

19. Management of CAP
• NICE Guidelines recommend:-
• Amoxicillin in preference to a macrolide or tetracycline as the first-choice antibiotic
for low-severity CAP
• -Explain to patients with low-severity CAP can be treated in the community, but that
they should seek further medical advice if their symptoms do not begin toimprove
within 3 days of starting the antibiotic, or earlier if their symptoms are worsening
• - Do not routinely offer a fluoroquinolone to patients with low-severity CAP
• - Do not routinely offer a glucocorticosteroid to patients with CAP unless they have
conditions for which glucocorticosteroid treatment is indicated
• Dual antibiotics therapy is recommended for moderate and severe CAP (seeI table
on next slide)
• Clarithromycin is the most commonly used macrolide for this purpose, it is relatively
better tolerated and there is good experience of its use.

20. Antibiotics in CAP
CRB65 score Which antibiotic(s) Alternatives (e.g if allergic
to 1st line)
Duration Further information
0 (Low severity) Amoxicillin Macrolide or Tetacycline 5 days * Consider extending the
course of theantibiotic for
longer than 5 days
forpatients with low-
severity CAP
whosesymptoms do not
improve as expectedafter
3 days
1-2(Moderate severity) Consider dual
therapy with
Amoxicillin+Macrolide
Liaise with microbiologist 7-10 days Clarithromycin is the most
commonlyI used
macrolide for this purpose
3-4 (High severity) Consider dual therapy
with abeta-lactamase
stable beta-lactam
Macrolide **
Liaise with microbiologist 7-10 day Co-amoxiclav was deemed
by the NICE guidelines as
the most suitable choice
of beta-lactamase stable
beta-lactam
*British Thoracic Society guidelines recommendations differ (see further reading)
**Available beta-lactamase stable beta-lactams include: co-amoxiclav, cefotaxime, ceftaroline, fosamil, ceftriaxone,cefuroxime
and piperacillin with tazobactam

21. Safety netting
• Most people can expect that by:-
• 1 week: fever should have resolved
• 4 weeks: chest pain and sputum
production should have substantially
reduced
• 6 weeks: cough and breathlessness
should have substantially reduced
• 3 months: most symptoms should have
resolved but fatigue may still be
present
• 6 months: most people will feel back to
normal.
• Explain to patients with CAP that
after starting treatment their
symptoms should steadily
improve, although the rate of
improvement will vary with
theseverity of the pneumonia
• Advise patients CAP to consult
their healthcare professional if
they feel that their condition is
deteriorating or not improving as
expected

22. Safe discharge of patients with CAP
• NICE Guidelines recommend the following for safe discharge in patients with
CAP(but do not make specific recommendations for Hospital acquired
pneumonia).
• -Do not routinely discharge patients with CAP if in the past 24 hours they
have had 2 or more of the following findings:-
• - Temperature higher than 37.5° C
• - Respiratory rate more than/equal to 24 breaths per minute
• - Heart rate over 100 beats per minute
• - Systolic blood pressure 90 mmHg or less
• oxygen saturation under 90% on room air
• - Abnormal mental status
• - Inability to eat without assistance

23. Recommendations for Hospital AcquiredPneumonia
• Hospital-acquired pneumonia (HAP) is pneumonia that develops 48 hours
or more after hospital admission and that was not incubating at hospital
admission
• When managed in hospital the diagnosis is usually confirmed by chest x-
ray.
• For HAP, NICE guidelines recommend:(-Offer antibiotic therapy as soon as
possible after diagnosis, and certainly within 4 hours, to patients with
hospital-acquired pneumonia
• Choose antibiotic therapy in accordance with local hospital policy (which
should take into account knowledge of local microbial pathogens) and
clinical circumstances for patients with hospital-acquired pneumonia-
• Consider a 5-10 day course of antibiotic therapy for patients with hospital-
acquired pneumonia

24. Practical tips
• Record CRB65 severity in notes to help
justify next steps in investigations and
managemen
• Document clearly if you deviate
management from guidelines based on
clinical judgement
• In patients with low severity CAP,consider
extending the course of antibiotics as a
management option for those not
improving as expected
• Use microbiological investigations
to move from broad spectrum
antibiotics cover to targeted therap
• CRP testing via hospital labs, may
be useful for some cases to
determine the need for antibiotics
and offer a delayed prescription
• Certain groups of patients may not
mount a CRP response and to
consider these factors in planning
management e.g. elderly patients
or those with Liver cirrhosis

25. Thank you