Community-acquired pneumonia (non COVID-19)
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Give empirical antibiotics to patients presenting in hospital with life-threatening disease based on a presumptive clinical diagnosis of CAP.
Follow your local protocol (e.g., Sepsis Six or Surviving Sepsis Campaign 1-hour care bundle) for investigating and treating all patients with suspected sepsis, or those at risk, within 1 hour.[66]Daniels R, Nutbeam T, McNamara G, et al. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J. 2011 Jun;28(6):507-12. http://www.ncbi.nlm.nih.gov/pubmed/21036796?tool=bestpractice.com [67]Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017 Mar;45(3):486-552. https://journals.lww.com/ccmjournal/Fulltext/2017/03000/Surviving_Sepsis_Campaign___International.15.aspx http://www.ncbi.nlm.nih.gov/pubmed/28098591?tool=bestpractice.com [68]Royal College of Physicians. National early warning score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. Dec 2017 [internet publication]. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2
Immediately order a chest x-ray to confirm the diagnosis.[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
Once a diagnosis of CAP is confirmed, manage these patients as per the protocols below for patients with confirmed CAP on chest x-ray: presenting in hospital.
Treatment recommended for ALL patients in selected patient group
Provide supportive care, which may include the following measures.[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
Oxygen
Prescribe oxygen if oxygen saturation <94% and maintain at target range.[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 For patients at risk of CO2 retention prescribe oxygen if oxygen saturation <88%.
Target oxygen saturation range of:
94% to 96% in acutely ill patients who are not at risk of hypercapnia[72]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com
88% to 92% in patients at risk of hypercapnia.[71]Lim WS, Rodrigo C, Turner AM, et al. British Thoracic Society community-acquired pneumonia care bundle: results of a national implementation project. Thorax. 2016 Mar;71(3):288-90. http://www.ncbi.nlm.nih.gov/pubmed/26197815?tool=bestpractice.com
Measure arterial blood gases in those with SpO2 <94%, those with a risk of hypercapnic ventilatory failure (CO2 retention), and all patients with high-severity CAP.[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
Practical tip
Always record the inspired oxygen concentration clearly as this is essential for interpreting blood gas results.
Fluid resuscitation
Assess all patients for volume depletion and give intravenous fluids if required.[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
Standard intensive care unit (ICU) supportive care
Arrange for patients with an indication for ICU admission to be transferred to ICU and managed by ICU specialists together with respiratory physicians.[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
Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation.
Do not routinely give non-invasive ventilation (NIV) or continuous positive airways pressure (CPAP) support in patients with respiratory failure due to CAP.[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
If indicated, you should conduct a trial of non-invasive support only in a critical care area where immediate expertise is available to allow a rapid transition to invasive ventilation.[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
Vasopressors
Start vasopressors if the patient is hypotensive during or after fluid resuscitation to maintain mean arterial pressure level greater than or equal to 65 mmHg.[117]Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign bundle: 2018 update. Crit Care Med. 2018 Jun;46(6):997-1000. http://www.ncbi.nlm.nih.gov/pubmed/29767636?tool=bestpractice.com See our Sepsis topic for more information.
Analgesia
Give simple analgesia as appropriate (e.g., for pleuritic pain).[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
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
paracetamol
The Renal Handbook
Confirm diagnosis by chest x-ray before starting antibiotic therapy.
In patients presenting in hospital without life-threatening illness, confirm the diagnosis by chest x-ray before starting antibiotics.[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 Once diagnosis is confirmed, patients are managed as per the protocols below for patients with confirmed CAP on chest x-ray: presenting in hospital.
In the meantime, provide supportive care as necessary, which may include the following measures.[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
Oxygen
Prescribe oxygen if oxygen saturation <94% and maintain at target range.[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 For patients at risk of hypercapnia prescribe oxygen if oxygen saturation <88%.
Target oxygen saturation range of:
94% to 96% in acutely ill patients who are not at risk of hypercapnia[72]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com
88% to 92% in patients at risk of hypercapnia.[71]Lim WS, Rodrigo C, Turner AM, et al. British Thoracic Society community-acquired pneumonia care bundle: results of a national implementation project. Thorax. 2016 Mar;71(3):288-90. http://www.ncbi.nlm.nih.gov/pubmed/26197815?tool=bestpractice.com
Measure arterial blood gases in those with SpO2 <94%, those with a risk of hypercapnic ventilatory failure (CO2 retention), and all patients with high-severity CAP.[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
Practical tip
Always record the inspired oxygen concentration clearly as this is essential for interpreting blood gas results.
Fluid resuscitation
Assess all patients for volume depletion and give intravenous fluids if required.[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
Standard intensive care unit (ICU) supportive care
Arrange for patients with an indication for ICU admission to be transferred to ICU and managed by ICU specialists together with respiratory physicians.[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
Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation.
Do not routinely give non-invasive ventilation (NIV) or continuous positive airways pressure (CPAP) support in patients with respiratory failure due to CAP.[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
If indicated, you should conduct a trial of non-invasive support only in a critical care area where immediate expertise is available to allow a rapid transition to invasive ventilation.[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
Vasopressors
Start vasopressors if the patient is hypotensive during or after fluid resuscitation to maintain mean arterial pressure level greater than or equal to 65 mmHg.[117]Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign bundle: 2018 update. Crit Care Med. 2018 Jun;46(6):997-1000. http://www.ncbi.nlm.nih.gov/pubmed/29767636?tool=bestpractice.com See our Sepsis topic for more information.
Analgesia
Give simple analgesia as appropriate (e.g., for pleuritic pain).[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
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
paracetamol
The Renal Handbook
suspected CAP: presenting in the community
Refer patients presenting in the community with high-severity CAP (CRB-65 score of 3 or 4) for immediate hospital admission (usually by blue-light ambulance in the UK).[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 [64]National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic. https://www.nice.org.uk/guidance/cg191
In hospital, once the diagnosis of CAP is confirmed by chest x-ray and the disease severity has been assessed, patients are managed as per the protocols below for patients with confirmed CAP on chest x-ray: presenting in hospital.
Treatment recommended for SOME patients in selected patient group
Give empirical antibiotics prior to hospital transfer (usually by blue-light ambulance in the UK) to any patients with suspected high-severity CAP considered to be life-threatening, according to your local protocol.[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
British Thoracic Society guidelines recommend intravenous benzylpenicillin or oral amoxicillin. Oral clarithromycin is an alternative for people who are allergic to penicillin.[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
Consider giving empirical antibiotics prior to hospital transfer to patients with suspected high-severity CAP where there are likely to be delays of over 6 hours to hospital admission and treatment.[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
Pre-admission antibiotics can negatively influence the results of subsequent microbiological investigations, but this is not seen as a reason for withholding antibiotics if a general practitioner considers it indicated.[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
Consult your local protocol for guidance on selection of antibiotic regimen.
Refer patients presenting in the community with moderate-severity CAP (CRB-65 score of 1 or 2) to hospital for assessment and management. These patients are at increased risk of death, particularly those with a score of 2.[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 [64]National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic. https://www.nice.org.uk/guidance/cg191
In hospital, once the diagnosis of CAP is confirmed by chest x-ray and the disease severity has been assessed, patients are managed as per the protocols below for patients with confirmed CAP on chest x-ray: presenting in hospital.
Consider managing patients in the community if they prefer to be treated at home and they meet the following criteria:[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 [64]National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic. https://www.nice.org.uk/guidance/cg191
They are able to take oral medication safely and reliably
Their social circumstances make them suitable for treatment at home
They do not have unstable comorbidities.
Take a cautious approach, however, when deciding whether it is safe to treat any patient with moderate-severity CAP in the community. You should refer the majority for management in hospital.[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 [64]National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic. https://www.nice.org.uk/guidance/cg191
If you decide to treat the patient in the community, follow the same treatment recommendations given below for patients with suspected CAP: presenting in the community (low-severity).
Give empirical oral antibiotics and manage people with low-severity CAP (CRB-65 score of 0) in the community.[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 [64]National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic. https://www.nice.org.uk/guidance/cg191
The first-line option is amoxicillin.[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 Alternative options for patients who are allergic to penicillin are a macrolide (e.g., clarithromycin) or a tetracycline (e.g., doxycycline).[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
If the patient does not respond to amoxicillin monotherapy, consider adding, or switching to, a macrolide (e.g., clarithromycin).[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
Advise patients (and their carers) to seek medical advice if their symptoms worsen rapidly or significantly, their symptoms do not start to improve within 3 days, or they become systemically very unwell.[105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138
Admit urgently to hospital any patient on antibiotic treatment with features of moderate- or high-severity infection.[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 Around 10% of patients managed in the community do not respond to antibiotic therapy and require hospitalisation.[122]Niederman M. In the clinic: community-acquired pneumonia. Ann Intern Med. 2009 Oct 6;151(7):ITC42-14. http://www.ncbi.nlm.nih.gov/pubmed/19805767?tool=bestpractice.com
Give antibiotic treatment for 5 days.[105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138 The National Institute for Health and Care Excellence recommends stopping treatment after 5 days unless microbiological results suggest a longer course or the patient is not clinically stable. This should be based on your clinical judgement and the following criteria:[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 [112]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Fever in past 48 hours, or more than one sign of clinical instability:
Systolic blood pressure <90 mmHg
Heart rate >100/minute
Respiratory rate >24/minute
Arterial oxygen saturation <90% or PaO2 <60 mmHg in room air.
Consult local protocols for guidance on selection of antibiotic regimen.
Treatment recommended for ALL patients in selected patient group
Advise patients to rest, to drink plenty of fluids, and not to smoke.[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
Give simple analgesia as appropriate (e.g., for pleuritic pain).[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
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
paracetamol
The Renal Handbook
Treatment recommended for SOME patients in selected patient group
Consider referring patients to hospital if:[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 [64]National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic. https://www.nice.org.uk/guidance/cg191
They are not able to take oral medication safely and reliably
Their social circumstances do not make them suitable for treatment at home
They have unstable comorbidities
They prefer to be treated in hospital.
In hospital, once the diagnosis of CAP is confirmed by chest x-ray and the disease severity has been assessed, patients are managed as per the protocols below for patients with confirmed CAP on chest x-ray: presenting in hospital.
confirmed CAP on chest x-ray: presenting in hospital
Always manage patients with high-severity CAP in hospital.[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
Give empirical broad-spectrum intravenous antibiotics immediately after diagnosis. This should be within 4 hours of presentation to hospital.[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 [105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138
Prescribe an appropriate antibiotic regimen according to your local protocol to help reduce the development of antibiotic resistance and Clostridium difficile infection. Consult with a microbiologist. The British Thoracic Society (BTS) recommends:[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
A broad-spectrum beta-lactamase-resistant penicillin (e.g., amoxicillin/clavulanate) plus a macrolide (e.g., clarithromycin).[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
For patients who are allergic to penicillin, give a second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) plus a macrolide (e.g., clarithromycin).[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
A small number of patients are allergic to both penicillins and cephalosporins; consult an infectious disease consultant for selection of appropriate antibiotics in these patients.
Review route of administration initially on the ward round following admission and then daily thereafter.[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 De-escalate treatment as soon as appropriate, including switching from intravenous to oral therapy.[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 When making this decision consider response to treatment (see practical tip), change in disease severity, and contraindications to oral administration such as:[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
Patient is unable to swallow (e.g., impaired swallowing reflex, impaired consciousness)
Gastrointestinal malabsorption for functional or anatomical reasons.
Practical tip
Pointers to clinical improvement
The following clinical features should prompt you to consider switching from intravenous to oral antibiotic therapy:[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
Pulse rate <100 beats/minute
Resolution of tachypnoea
Clinically hydrated and taking oral fluids
Resolution of fever for >24 hours
Resolution of hypotension
Absence of hypoxia
Improving white cell count
Non-bacteraemic infection
No microbiological evidence of legionella, staphylococcal, or gram-negative enteric bacilli infection
No concerns over gastrointestinal absorption.
Give antibiotic therapy for 5 days.[105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138 The National Institute for Health and Care Excellence recommends stopping treatment after 5 days unless microbiological results suggest a longer course or the patient is not clinically stable.[105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138 This should be based on your clinical judgement and the following criteria:[105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138 [112]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Fever in past 48 hours, or more than one sign of clinical instability:
Systolic blood pressure <90 mmHg
Heart rate >100/minute
Respiratory rate >24/minute
Arterial oxygen saturation <90% or PaO2 <60 mmHg in room air.
In some people, longer courses might be needed due to individual circumstances. In the UK, some hospitals require consultation with the microbiology team if considering extending the duration of antibiotic treatment beyond 5 days in high-severity CAP. Follow your local protocol.
Consult your local protocol for guidance on selection of antibiotic regimen.
Treatment recommended for SOME patients in selected patient group
Consult with a microbiologist and senior clinician before giving a fluoroquinolone.
Consider safety issues associated with fluoroquinolone use. Fluoroquinolones are known to cause tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[113]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. Mar 2019 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products [114]Medicines and Healthcare products Regulatory Agency. Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects. Mar 2019 [internet publication]. https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-new-restrictions-and-precautions-for-use-due-to-very-rare-reports-of-disabling-and-potentially-long-lasting-or-irreversible-side-effects
The British Thoracic Society guideline recommends adding a fluoroquinolone to the existing empirical regimen (i.e., triple therapy) if the patient does not respond, or if legionella pneumonia is strongly suspected.[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 However, in practice there are concerns about the risk of using a macrolide and a fluoroquinolone together as they can both prolong the QT interval. Therefore, some clinicians may replace the macrolide in the original empirical regimen with a fluoroquinolone instead (i.e., dual therapy).
Treatment recommended for ALL patients in selected patient group
Provide supportive care, which may include the following measures.[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
Oxygen
Prescribe oxygen if oxygen saturation <94% and maintain at target range.[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 For patients at risk of hypercapnia prescribe oxygen if oxygen saturation <88%.
Target oxygen saturation range of:
94% to 96% in acutely ill patients who are not at risk of hypercapnia[72]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com
88% to 92% in patients at risk of hypercapnia.[71]Lim WS, Rodrigo C, Turner AM, et al. British Thoracic Society community-acquired pneumonia care bundle: results of a national implementation project. Thorax. 2016 Mar;71(3):288-90. http://www.ncbi.nlm.nih.gov/pubmed/26197815?tool=bestpractice.com
Measure arterial blood gases in those with SpO2 <94%, those with a risk of hypercapnic ventilatory failure (CO2 retention), and all patients with high-severity CAP.[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
Fluid resuscitation
Assess all patients for volume depletion and give intravenous fluids if required.[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
Standard intensive care unit (ICU) supportive care
Arrange for patients with CURB-65 scores of 4 and 5 and an indication for ICU admission to be transferred to ICU and managed by ICU specialists together with respiratory physicians.[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
Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation.
Do not routinely give non-invasive ventilation (NIV) or continuous positive airways pressure (CPAP) support in patients with respiratory failure due to CAP.[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
If indicated, you should conduct a trial of non-invasive support only in a critical care area where immediate expertise is available to allow a rapid transition to invasive ventilation.[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
Vasopressors
Start vasopressors if the patient is hypotensive during or after fluid resuscitation to maintain mean arterial pressure level greater than or equal to 65 mmHg.[117]Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign bundle: 2018 update. Crit Care Med. 2018 Jun;46(6):997-1000. http://www.ncbi.nlm.nih.gov/pubmed/29767636?tool=bestpractice.com
Venous thromboembolism (VTE) prophylaxis
Consider prophylaxis for VTE with a low molecular weight heparin for all patients who are not fully mobile.[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 In practice in the UK, prescription of heparin will be prompted if appropriate once you have recorded your VTE risk assessment in the patient’s electronic record.
Nutritional support
Arrange nutritional support (whether enteral, parenteral, or via nasogastric feeding) for patients with severe CAP who require a prolonged hospital stay.[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
Airway clearance
Do not treat people with uncomplicated pneumonia with traditional airway clearance techniques routinely. If needed, offer these patients advice regarding expectoration of sputum.[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
Consider airway clearance techniques if the patient has difficulty expectorating sputum or if they have a pre-existing lung condition.[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
Analgesia
Give simple analgesia as appropriate (e.g., for pleuritic pain).[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
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
paracetamol
The Renal Handbook
Treatment recommended for SOME patients in selected patient group
Consult with a microbiologist about appropriate pathogen-targeted antibiotic therapy.[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
Switch from empirical antibiotics to pathogen-targeted antibiotics as soon as specific pathogens are identified (unless there are legitimate concerns about dual-pathogen infection).[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
Only about one third to one quarter of patients with CAP admitted to hospital will have their pneumonia defined microbiologically.[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 Among these patients:
Around 14% have an atypical pathogen, of which:[21]Marchello C, Dale AP, Thai TN, et al. Prevalence of atypical pathogens in patients with cough and community-acquired pneumonia: a meta-analysis. Ann Fam Med. 2016 Nov;14(6):552-66. http://www.annfammed.org/content/14/6/552.long http://www.ncbi.nlm.nih.gov/pubmed/28376442?tool=bestpractice.com
7% have Mycoplasma pneumoniae
4% have Chlamydophila pneumoniae
3% have Legionella pneumophila.
Those with infections due to Mycoplasma, Chlamydophila, and Coxiella burnetii will be diagnosed late in the illness on the basis of seroconversion, reducing the opportunity for early targeted therapy.[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
Consider switching the choice of agent once the results of sensitivity testing are available or following consultation with a microbiologist, intensivist, or respiratory physician.[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
BTS recommendations for pathogen-targeted antibiotics[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
Pathogen | Preferred antibiotic | Alternative antibiotic |
|---|---|---|
Mycoplasma pneumoniae Chlamydophila pneumoniae | Clarithromycin (orally or intravenously) | Doxycycline (orally) or a fluoroquinolone (orally or intravenously) |
Legionella species | Fluoroquinolone (orally or intravenously) | Clarithromycin (orally or intravenously) or azithromycin (in countries where it is used for managing pneumonia) |
Streptococcus pneumoniae | Amoxicillin (orally) or benzylpenicillin (intravenously) | Clarithromycin (orally) or cefuroxime or cefotaxime or ceftriaxone (intravenously) |
Chlamydia psittaci Coxiella burnetii | Doxycycline (orally) | Clarithromycin (orally or intravenously) |
Haemophilus influenzae | Non-beta-lactamase-producing: amoxicillin (orally or intravenously) Beta-lactamase-producing: amoxicillin/clavulanate (orally or intravenously) | Cefuroxime or cefotaxime or ceftriaxone (intravenously) or a fluoroquinolone (orally or intravenously) |
Gram-negative enteric bacilli | Cefuroxime or cefotaxime or ceftriaxone (intravenously) | Fluoroquinolone (intravenously) or imipenem/cilastatin (intravenously) or meropenem (intravenously) |
Pseudomonas aeruginosa | Ceftazidime (intravenously) plus Gentamicin or tobramycin (dose monitoring required) | Ciprofloxacin (intravenously) or piperacillin/tazobactam (intravenously) plus Gentamicin or tobramycin (dose monitoring required) |
Staphylococcus aureus: non-MRSA | Flucloxacillin (intravenously) with or without Rifampicin (orally or intravenously) | |
Staphylococcus aureus: MRSA | Vancomycin (intravenously; dose monitoring required) or linezolid (intravenously) or teicoplanin (intravenously) with or without Rifampicin (orally or intravenously) |
Consider patients with moderate-severity CAP for short-stay inpatient treatment or hospital-supervised outpatient treatment.[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
Give antibiotics as soon as possible after diagnosis. This should be within 4 hours of presentation to hospital.[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 [105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138
Give broad-spectrum empirical oral antibiotics.
Most patients with moderate-severity CAP can be treated with dual oral antibiotic therapy.[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 British Thoracic Society guidelines recommend amoxicillin plus a macrolide (e.g., clarithromycin).[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
For patients who are allergic to penicillin or macrolides, consider oral doxycycline.[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 Alternative choices include oral levofloxacin or moxifloxacin (after considering safety issues associated with fluoroquinolone use).[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
If oral antibiotics are contraindicated (e.g., patient is unable to swallow or has gastrointestinal malabsorption for functional or anatomical reasons) give intravenous amoxicillin or benzylpenicillin plus clarithromycin.[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
For patients who are allergic to penicillin in whom oral antibiotics are contraindicated, give a second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) plus clarithromycin, or intravenous levofloxacin monotherapy.[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
If the patient does not respond to a combination of amoxicillin and clarithromycin, consider changing treatment to doxycycline or a fluoroquinolone with effective pneumococcal cover (e.g., levofloxacin, moxifloxacin).[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
In November 2018, the European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with systemic and inhaled fluoroquinolone antibiotics. These adverse effects include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.
As a consequence of this review, the EMA now recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening bacterial infections only. Furthermore, they recommend that fluoroquinolones should not be used for mild to moderate infections unless other appropriate antibiotics for the specific infection cannot be used, and should not be used in non-severe, non-bacterial, or self-limiting infections. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid are at a higher risk of tendon damage. Co-administration of a fluoroquinolone and a corticosteroid should be avoided.[113]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. Mar 2019 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) supports these recommendations.[114]Medicines and Healthcare products Regulatory Agency. Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects. Mar 2019 [internet publication]. https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-new-restrictions-and-precautions-for-use-due-to-very-rare-reports-of-disabling-and-potentially-long-lasting-or-irreversible-side-effects
For this reason, fluoroquinolones (e.g., levofloxacin, moxifloxacin) should only be considered in moderate-severity CAP when it is considered inappropriate to use other antibiotics that are commonly recommended for the treatment of CAP. Consult with a microbiologist about whether a fluoroquinolone is an appropriate option for your patient.
Consider monotherapy with a macrolide for patients who have been treated in the community and who have not responded to an adequate course of amoxicillin prior to hospital admission.[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
Deciding whether the course of amoxicillin was adequate is tricky and involves clinical judgement. Consult a senior clinician before prescribing monotherapy within the first 24 hours of admission.[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
Review the need for intravenous antibiotics initially on the ward round following admission and then every day thereafter.[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
Switch to oral antibiotics as soon as clinical improvement occurs (see practical tip), and as long as there are no contraindications to oral administration (e.g., patient is unable to swallow or has gastrointestinal malabsorption for functional or anatomical reasons).[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
Practical tip
Pointers to clinical improvement
The following clinical features should prompt you to consider switching from intravenous to oral antibiotic therapy:[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
Pulse rate <100 beats/minute
Resolution of tachypnoea
Clinically hydrated and taking oral fluids
Resolution of fever for >24 hours
Resolution of hypotension
Absence of hypoxia
Improving white cell count
Non-bacteraemic infection
No microbiological evidence of legionella, staphylococcal, or gram-negative enteric bacilli infection
No concerns over gastrointestinal absorption.
Give antibiotic therapy for 5 days.[105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138 The National Institute for Health and Care Excellence recommends stopping treatment after 5 days unless microbiological results suggest a longer course or the patient is not clinically stable.[105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138 This should be based on your clinical judgement and the following criteria:[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 [112]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Fever in past 48 hours, or more than one sign of clinical instability:
Systolic blood pressure <90 mmHg
Heart rate >100/minute
Respiratory rate >24/minute
Arterial oxygen saturation <90% or PaO2 <60 mmHg in room air.
In some people, longer courses might be needed due to individual circumstances. In the UK, some hospitals require consultation with the microbiology team if considering extending the duration of antibiotic treatment beyond 5 days in moderate-severity CAP. Follow your local protocol.
Consult your local protocol for guidance on selection of antibiotic regimen.
Treatment recommended for ALL patients in selected patient group
Provide supportive care, which may include the following measures.[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
Oxygen
Prescribe oxygen if oxygen saturation <94% and maintain at target range.[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 For patients at risk of hypercapnia prescribe oxygen if oxygen saturation <88%.
Target oxygen saturation range of:
94% to 96% in acutely ill patients who are not at risk of hypercapnia[72]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com
88% to 92% in patients at risk of hypercapnia.[71]Lim WS, Rodrigo C, Turner AM, et al. British Thoracic Society community-acquired pneumonia care bundle: results of a national implementation project. Thorax. 2016 Mar;71(3):288-90. http://www.ncbi.nlm.nih.gov/pubmed/26197815?tool=bestpractice.com
Measure arterial blood gases in those with SpO2 <94%, those with a risk of hypercapnic ventilatory failure (CO2 retention), and all patients with high-severity CAP.[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
Fluid resuscitation
Assess all patients for volume depletion and give intravenous fluids if required.[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
Venous thromboembolism (VTE) prophylaxis
Consider prophylaxis for VTE with a low molecular weight heparin for all patients who are not fully mobile.[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
Airway clearance
Do not treat people with uncomplicated pneumonia with traditional airway clearance techniques routinely. If needed, offer these patients advice regarding expectoration of sputum.[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
Consider airway clearance techniques if the patient has difficulty expectorating sputum or if they have a pre-existing lung condition.[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
Analgesia
Give simple analgesia as appropriate (e.g., for pleuritic pain).[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
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
paracetamol
The Renal Handbook
Treatment recommended for SOME patients in selected patient group
Consult with a microbiologist about appropriate pathogen-targeted antibiotic therapy.[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
Switch from empirical antibiotics to pathogen-targeted antibiotics as soon as specific pathogens are identified (unless there are legitimate concerns about dual-pathogen infection).[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
Only about one third to one quarter of patients with CAP admitted to hospital will have their pneumonia defined microbiologically.[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 Among these patients:
Around 14% have an atypical pathogen, of which[21]Marchello C, Dale AP, Thai TN, et al. Prevalence of atypical pathogens in patients with cough and community-acquired pneumonia: a meta-analysis. Ann Fam Med. 2016 Nov;14(6):552-66. http://www.annfammed.org/content/14/6/552.long http://www.ncbi.nlm.nih.gov/pubmed/28376442?tool=bestpractice.com
7% have Mycoplasma pneumoniae
4% have Chlamydophila pneumoniae
3% have Legionella pneumophila
Those with infections due to Mycoplasma, Chlamydophila, and Coxiella burnetii will be diagnosed late in the illness on the basis of seroconversion, reducing the opportunity for early targeted therapy.[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
Consider switching the choice of agent once the results of sensitivity testing are available or following consultation with a microbiologist, intensivist, or respiratory physician.[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
BTS recommendations for pathogen-targeted antibiotics[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
Pathogen | Preferred antibiotic | Alternative antibiotic |
|---|---|---|
Mycoplasma pneumoniae Chlamydophila pneumoniae | Clarithromycin (orally or intravenously) | Doxycycline (orally) or a fluoroquinolone (orally or intravenously) |
Legionella species | Fluoroquinolone (orally or intravenously) | Clarithromycin (orally or intravenously) or azithromycin (in countries where it is used for managing pneumonia) |
Streptococcus pneumoniae | Amoxicillin (orally) or benzylpenicillin (intravenously) | Clarithromycin (orally) or cefuroxime or cefotaxime or ceftriaxone (intravenously) |
Chlamydia psittaci Coxiella burnetii | Doxycycline (orally) | Clarithromycin (orally or intravenously) |
Haemophilus influenzae | Non-beta-lactamase-producing: amoxicillin (orally or intravenously) Beta-lactamase-producing: amoxicillin/clavulanate (orally or intravenously) | Cefuroxime or cefotaxime or ceftriaxone (intravenously) or a fluoroquinolone (orally or intravenously) |
Gram-negative enteric bacilli | Cefuroxime or cefotaxime or ceftriaxone (intravenously) | Fluoroquinolone (intravenously) or imipenem/cilastatin (intravenously) or meropenem (intravenously) |
Pseudomonas aeruginosa | Ceftazidime (intravenously) plus Gentamicin or tobramycin (dose monitoring required) | Ciprofloxacin (intravenously) or piperacillin/tazobactam (intravenously) plus Gentamicin or tobramycin (dose monitoring required) |
Staphylococcus aureus: non-MRSA | Flucloxacillin (intravenously) with or without Rifampicin (orally or intravenously) | |
Staphylococcus aureus: MRSA | Vancomycin (intravenously; dose monitoring required) or linezolid (intravenously) or teicoplanin (intravenously) with or without Rifampicin (orally or intravenously) |
Most patients with low-severity CAP can be discharged for treatment at home. However, consider admitting patients if:[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 [64]National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic. https://www.nice.org.uk/guidance/cg191
They are not able to take oral medication safely and reliably
Their social circumstances do not make them suitable for treatment at home
They have unstable comorbidities
They prefer to be treated in hospital.
Give antibiotics as soon as possible. This should be within 4 hours of presentation to hospital.[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 [64]National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic. https://www.nice.org.uk/guidance/cg191
Most patients with low-severity CAP managed in hospital can be treated with oral antibiotics.[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
The preferred choice is amoxicillin.[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 Consider a macrolide (e.g., clarithromycin) or a tetracycline (e.g., doxycycline) for patients who are allergic to penicillin.[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
If the patient does not respond to amoxicillin monotherapy, consider adding, or switching to, a macrolide (e.g., clarithromycin).[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
If the oral route is contraindicated (e.g., impaired swallowing reflex, impaired consciousness, gastrointestinal malabsorption) consider intravenous amoxicillin, benzylpenicillin, or clarithromycin.[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
Review the need for intravenous antibiotics initially during the ward round following admission and then every day after.[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
Switch to oral antibiotics as soon as clinical improvement occurs (see practical tip), and as long as there are no contraindications to oral administration.
Practical tip
Pointers to clinical improvement
The following clinical features should prompt you to consider switching from intravenous to oral antibiotic therapy:[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
Pulse rate <100 beats/minute
Resolution of tachypnoea
Clinically hydrated and taking oral fluids
Resolution of fever for >24 hours
Resolution of hypotension
Absence of hypoxia
Improving white cell count
Non-bacteraemic infection
No microbiological evidence of legionella, staphylococcal, or gram-negative enteric bacilli infection
No concerns over gastrointestinal absorption.
Give antibiotic therapy for 5 days.[105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138 The National Institute for Health and Care Excellence recommends stopping treatment after 5 days unless microbiological results suggest a longer course or the patient is not clinically stable.[105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138 This should be based on your clinical judgement and the following criteria:[105]National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng138 [112]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Fever in past 48 hours, or more than one sign of clinical instability:
Systolic blood pressure <90 mmHg
Heart rate >100/minute
Respiratory rate >24/minute
Arterial oxygen saturation <90% or PaO2 <60 mmHg in room air.
Consult local protocols for guidance on selection of antibiotic regimen.
Treatment recommended for ALL patients in selected patient group
Provide supportive care, which may include the following measures.[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
Oxygen
Prescribe oxygen if oxygen saturation <94% and maintain at target range.[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 For patients at risk of hypercapnia prescribe oxygen if oxygen saturation <88%.
Target oxygen saturation range of:
94% to 96% in acutely ill patients who are not at risk of hypercapnia[72]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com
88% to 92% in patients at risk of hypercapnia.[71]Lim WS, Rodrigo C, Turner AM, et al. British Thoracic Society community-acquired pneumonia care bundle: results of a national implementation project. Thorax. 2016 Mar;71(3):288-90. http://www.ncbi.nlm.nih.gov/pubmed/26197815?tool=bestpractice.com
Measure arterial blood gases in those with SpO2 <94%, those with a risk of hypercapnic ventilatory failure (CO2 retention), and all patients with high-severity CAP.[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
Fluid resuscitation
Assess all patients for volume depletion and give intravenous fluids if required.[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
Venous thromboembolism (VTE) prophylaxis
Consider prophylaxis for VTE with a low molecular weight heparin for all patients who are not fully mobile.[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
Airway clearance
Do not treat people with uncomplicated pneumonia with traditional airway clearance techniques routinely. If needed, offer these patients advice regarding expectoration of sputum.[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
Consider airway clearance techniques if the patient has difficulty expectorating sputum or if they have a pre-existing lung condition.[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
Analgesia
Give simple analgesia as appropriate (e.g., for pleuritic pain).[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
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Primary options
paracetamol
The Renal Handbook
Treatment recommended for SOME patients in selected patient group
Consult with a microbiologist about appropriate pathogen-targeted antibiotic therapy.[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
Switch from empirical antibiotics to pathogen-targeted antibiotics as soon as specific pathogens are identified (unless there are legitimate concerns about dual-pathogen infection).[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
Only about one third to one quarter of patients with CAP admitted to hospital will have their pneumonia defined microbiologically.[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 Among these patients:
Around 14% have an atypical pathogen, of which:[21]Marchello C, Dale AP, Thai TN, et al. Prevalence of atypical pathogens in patients with cough and community-acquired pneumonia: a meta-analysis. Ann Fam Med. 2016 Nov;14(6):552-66. http://www.annfammed.org/content/14/6/552.long http://www.ncbi.nlm.nih.gov/pubmed/28376442?tool=bestpractice.com
7% have Mycoplasma pneumoniae
4% have Chlamydophila pneumoniae
3% have Legionella pneumophila
Those with infections due to Mycoplasma, Chlamydophila, and Coxiella burnetii will be diagnosed late in the illness on the basis of seroconversion, reducing the opportunity for early targeted therapy.[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
Consider switching the choice of agent once the results of sensitivity testing are available or following consultation with a microbiologist, intensivist, or respiratory physician.[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
BTS recommendations for pathogen-targeted antibiotics[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
Pathogen | Preferred antibiotic | Alternative antibiotic |
|---|---|---|
Mycoplasma pneumoniae Chlamydophila pneumoniae | Clarithromycin (orally or intravenously) | Doxycycline (orally) or a fluoroquinolone (orally or intravenously) |
Legionella species | Fluoroquinolone (orally or intravenously) | Clarithromycin (orally or intravenously) or azithromycin (in countries where it is used for managing pneumonia) |
Streptococcus pneumoniae | Amoxicillin (orally) or benzylpenicillin (intravenously) | Clarithromycin (orally) or cefuroxime or cefotaxime or ceftriaxone (intravenously) |
Chlamydia psittaci Coxiella burnetii | Doxycycline (orally) | Clarithromycin (orally or intravenously) |
Haemophilus influenzae | Non-beta-lactamase-producing: amoxicillin (orally or intravenously) Beta-lactamase-producing: amoxicillin/clavulanate (orally or intravenously) | Cefuroxime or cefotaxime or ceftriaxone (intravenously) or a fluoroquinolone (orally or intravenously) |
Gram-negative enteric bacilli | Cefuroxime or cefotaxime or ceftriaxone (intravenously) | Fluoroquinolone (intravenously) or imipenem/cilastatin (intravenously) or meropenem (intravenously) |
Pseudomonas aeruginosa | Ceftazidime (intravenously) plus Gentamicin or tobramycin (dose monitoring required) | Ciprofloxacin (intravenously) or piperacillin/tazobactam (intravenously) plus Gentamicin or tobramycin (dose monitoring required) |
Staphylococcus aureus: non-MRSA | Flucloxacillin (intravenously) with or without Rifampicin (orally or intravenously) | |
Staphylococcus aureus: MRSA | Vancomycin (intravenously; dose monitoring required) or linezolid (intravenously) or teicoplanin (intravenously) with or without Rifampicin (orally or intravenously) |
Continue empirical antibiotics in patients with CAP confirmed by chest x-ray in the community. However, where a pathogen has been identified, follow your local antibiotic protocol for the identified organism(s).[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
BTS recommendations for pathogen-targeted antibiotics[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
Pathogen | Preferred antibiotic | Alternative antibiotic |
|---|---|---|
Mycoplasma pneumoniae Chlamydophila pneumoniae | Clarithromycin (orally or intravenously) | Doxycycline (orally) or a fluoroquinolone (orally or intravenously) |
Legionella species | Fluoroquinolone (orally or intravenously) | Clarithromycin (orally or intravenously) or azithromycin (in countries where it is used for managing pneumonia) |
Streptococcus pneumoniae | Amoxicillin (orally) or benzylpenicillin (intravenously) | Clarithromycin (orally) or cefuroxime or cefotaxime or ceftriaxone (intravenously) |
Chlamydia psittaci Coxiella burnetii | Doxycycline (orally) | Clarithromycin (orally or intravenously) |
Haemophilus influenzae | Non-beta-lactamase-producing: amoxicillin (orally or intravenously) Beta-lactamase-producing: amoxicillin/clavulanate (orally or intravenously) | Cefuroxime or cefotaxime or ceftriaxone (intravenously) or a fluoroquinolone (orally or intravenously) |
Gram-negative enteric bacilli | Cefuroxime or cefotaxime or ceftriaxone (intravenously) | Fluoroquinolone (intravenously) or imipenem/cilastatin (intravenously) or meropenem (intravenously) |
Pseudomonas aeruginosa | Ceftazidime (intravenously) plus Gentamicin or tobramycin (dose monitoring required) | Ciprofloxacin (intravenously) or piperacillin/tazobactam (intravenously) plus Gentamicin or tobramycin (dose monitoring required) |
Staphylococcus aureus: non-MRSA | Flucloxacillin (intravenously) with or without Rifampicin (orally or intravenously) | |
Staphylococcus aureus: MRSA | Vancomycin (intravenously; dose monitoring required) or linezolid (intravenously) or teicoplanin (intravenously) with or without Rifampicin (orally or intravenously) |
In community settings, the diagnosis of CAP is based on signs and symptoms of lower respiratory tract infection, focal chest signs, and illness severity, and management is based on a suspected diagnosis.[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 [64]National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic. https://www.nice.org.uk/guidance/cg191 However, a chest x-ray is indicated in the community if:[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 [64]National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic. https://www.nice.org.uk/guidance/cg191
There is diagnostic doubt
The patient is deemed to be at risk of underlying lung pathology (e.g., they have risk factors for lung cancer)
Progress following treatment is not satisfactory at review.
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