Last reviewed: July 2020
Last updated: June  2020
27 Apr 2020

UK guideline provides recommendations for differentiating viral COVID-19 pneumonia from bacterial pneumonia

The National Institute for Health and Care Excellence (NICE) in the UK has published guidance on the management of suspected or confirmed pneumonia in the community during the COVID-19 pandemic.[101]

The guideline provides recommendations for differentiating between a COVID-19 and bacterial cause for community-acquired pneumonia.[101] It recognises that:

  • Signs and symptoms of viral pneumonia caused by COVID-19 and pneumonia caused by bacteria are similar, making it difficult to differentiate between the conditions clinically

  • With COVID-19 becoming more prevalent in the community, patients presenting with pneumonia symptoms are more likely to have a COVID-19 viral pneumonia than a community-acquired bacterial pneumonia.

Recommendations

COVID-19 viral pneumonia may be more likely if the patient presents with:[101]

  • A history of typical COVID-19 symptoms for about a week

  • Severe myalgia

  • Anosmia

  • Breathlessness

  • Absence of pleuritic pain. 

A bacterial cause of pneumonia may be more likely if the patient:[101]

  • Becomes rapidly unwell after only a few days of symptoms

  • Presents with:

    • Pleuritic pain

    • Purulent sputum

    • No history of typical COVID‑19 symptoms. 

This topic covers pneumonia caused by COVID-19 as a differential diagnosis only. For more detail on the diagnosis and management of community-acquired pneumonia caused by COVID-19, see our topic Coronavirus disease 2019 (COVID-19) external link opens in a new window

See Diagnosis: differentials

Original source of updateexternal link opens in a new window

COVID-19 pandemic

During the pandemic, consider all patients with cough and fever or suggestive symptoms to have COVID-19 until proven otherwise. See our topic Coronavirus disease 2019 (COVID-19).

The National Institute for Health and Care Excellence (NICE) in the UK has issued new guidelines on assessment and management of suspected or confirmed CAP during the COVID-19 pandemic.1,2 It has temporarily withdrawn its pre-COVID-19 guideline on diagnosis and management of pneumonia in adults.3

The key changes are that the new guidance:1,2

  • Notes that the CRB-65 tool, recommended for severity assessment in its pre-COVID-19 guidance, is not validated in people with COVID-19, as it requires a blood pressure measurement, which may be ‘difficult or undesirable’ to obtain during the COVID-19 pandemic.1 It recommends using clinical judgement to assess severity and inform decisions on hospital admission during the pandemic.1
    Signs and symptoms of severe illness are:1
    • Severe shortness of breath at rest or difficulty breathing
    • Coughing up blood
    • Blue lips or face
    • Feeling cold and clammy with pale or mottled skin
    • Collapse or fainting (syncope)
    • New confusion
    • Becoming difficult to rouse
    • Little or no urine output.
  • Recommends considering a SARS-CoV2 polymerase chain reaction test in all patients with suspected moderate to severe CAP and in all patients who develop pneumonia while in hospital.2
  • Recommends oral doxycycline first line (in preference to oral amoxicillin) in all non-pregnant patients with suspected bacterial CAP treated in the community with oral amoxicillin as an alternative.1 It includes oral doxycycline as a recommended first-line option in patients with moderate or severe bacterial CAP treated in hospital who can tolerate oral medicines and whose condition is not severe enough to need intravenous antibiotics.2
    • Doxycycline has a broader spectrum of cover than amoxicillin, particularly against Mycoplasma pneumoniae and Staphylococcus aureus, which are more likely to be secondary bacterial causes of pneumonia during the COVID-19 pandemic.1

References

  1. National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community. April 2020 [internet publication].
    Full text
  2. National Institute for Health and Care Excellence. COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital. May 2020 [internet publication].
    Full text
  3. National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic.
    Full text

Summary

Definition

History and exam

Key diagnostic factors

  • cough with increasing sputum production
  • dyspnoea
  • pleuritic chest pain
  • rigors or night sweats
  • fever
  • abnormal auscultatory findings
  • confusion
  • risk factors

Other diagnostic factors

  • myalgia
  • malaise
  • anorexia
  • lethargy
  • worsening of pre-existing conditions
  • sore throat
  • headache
  • nausea
  • abdominal pain
  • diarrhoea

Risk factors

  • age >65 years
  • residence in a healthcare setting
  • COPD
  • exposure to cigarette smoke
  • alcohol abuse
  • poor oral hygiene
  • use of acid-reducing drugs
  • contact with children
  • diabetes mellitus
  • chronic renal disease
  • chronic liver disease
  • use of opioids

Diagnostic investigations

1st investigations to order

  • chest x-ray
  • pulse oximetry
  • arterial blood gas (ABG)
  • urea and electrolytes
  • full blood count
  • C-reactive protein (CRP)
  • liver function tests
Full details

Investigations to consider

  • blood culture
  • sputum culture (± Gram stain)
  • urinary antigen testing for legionella and pneumococcus
  • polymerase chain reaction (PCR) and/or serological tests
  • CT scan of chest
  • chest ultrasound
  • thoracocentesis and pleural fluid culture
  • computer tomographic pulmonary angiography (CTPA)
  • bronchoscopy
Full details

Treatment algorithm

Contributors

Expert advisersVIEW ALL

Honorary Professor of Respiratory Sciences

University of Leicester

Respiratory Consultant

Glenfield Hospital

Leicester

UK

Biography

JB is Chair of the British Thoracic Society.

Disclosures

JB declares that he has no competing interests.

BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:

Catia Cilloniz MSc, PhD

Post-doctoral Research

Pneumology Department

Hospital Clinic of Barcelona

CIBERES

IDIBAPS

Barcelona

Spain

Antoni Torres MD, PhD

Professor of Medicine

Director

Pulmonary Intensive Care Unit

Respiratory Institute

Hospital Clinic of Barcelona

Barcelona

Spain 

Disclosures

CC and AT are each authors of a number of references cited in this topic.

Peer reviewersVIEW ALL

Consultant Respiratory Physician and Honorary Professor of Medicine

Nottingham University Hospitals NHS Trust

Nottingham

UK

Disclosures

WSL was chairman of the British Thoracic Society community-acquired pneumonia guidelines committee and a member of the guideline development group for the National Institute for Health and Care Excellence pneumonia guidelines. His institution has received unrestricted investigator-initiated research funding from Pfizer for a multicentre study of pneumococcal pneumonia in which he was the chief investigator, and research funding from the National Institute for Health Research for studies in pneumonia in which he was the principal investigator. He is also an author of at least one reference cited in the topic.

Section Editor, BMJ Best Practice

Disclosures

HDC declares that she has no competing interests.

Lead Section Editor, BMJ Best Practice

Disclosures

RW declares that she has no competing interests.

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

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