Community-acquired pneumonia

Patients with community-acquired pneumonia (CAP) typically present with symptoms and signs consistent with a lower respiratory tract infection (i.e., cough, dyspnoea, pleuritic chest pain, mucopurulent sputum, myalgia, fever) and no other explanation for the illness. Older people present more frequently with confusion or worsening of pre-existing conditions, and without chest signs or fever.

Diagnostic confirmation in all patients presenting to hospital requires evidence of consolidation (new shadowing that is not due to any other cause) on chest x-ray. A chest x-ray should not be requested routinely for patients managed in the community.

The CURB-65 mortality risk score (hospital setting) or CRB-65 severity score (community setting) are the basis, together with clinical judgement, for deciding whether to manage the patient in hospital or at home and determining appropriate therapy.

Initial treatment is with empirical antibiotics, following national/international guidelines and local epidemiology. In hospital, antibiotics should be administered within 4 hours of presentation. 

Sputum and blood samples should be sent for culture in people with moderate- or high-severity CAP, ideally before antibiotics are started, and legionella and pneumococcal urine antigen testing should be considered.

Patients with oxygen saturation <94% (or <88% in patients at risk of CO₂ retention) should receive supplemental oxygen.

Sepsis should be considered whenever an acutely unwell person presents with likely infection, even if their temperature is normal. Local protocols (e.g., Sepsis Six or Surviving Sepsis Campaign 1 hour care bundle) should be followed for investigation and treatment of all patients with suspected sepsis, or those at risk, within 1 hour.

Community-acquired pneumonia (CAP) is defined as pneumonia acquired outside hospital or healthcare facilities. Clinical diagnosis is based on a group of signs and symptoms related to lower respiratory tract infection with presence of fever >38ºC (>100ºF), cough, mucopurulent sputum, pleuritic chest pain, dyspnoea, and new focal chest signs on examination such as crackles or bronchial breathing. Older patients present more frequently with confusion or worsening of pre-existing conditions, and without chest signs or fever.[1]Lim WS, Baudouin SV, George RC, et al; Pneumonia Guidelines Committee of the BTS Standards of Care Committee. British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009 Oct;64(suppl 3):iii1-55. https://thorax.bmj.com/content/64/Suppl_3/iii1.long http://www.ncbi.nlm.nih.gov/pubmed/19783532?tool=bestpractice.com This topic focuses on the diagnosis and management of CAP in adults.