Community Acquired Pneumonia

Micro-organism

Streptococcus pneumoniae (lobar pneumonia)

Mycoplasma pneumoniae (atypical pneumonia)

Chlamydia pneumoniae (atypical pneumonia)

Duration

Low severity 5 days - consider extending if symptoms not improved after 3 days.

Moderate severity 5 - 7 days - consider extending if symptoms not improved after 3 days

High severity 7 - 10 days

Notes

Assess CURB65 score

  • Confusion
  • Urea > 7mmol/L
  • Respiratory rate ≥30/min
  • BP systolic <90mmHg or BP diastolic <60mmHg
  • 65 years of age

Also treat as high severity if multilobar consolidation or cavitation on chest X-ray

Avoid co-amoxiclav and levofloxacin in frail elderly patients where possible due to CDI risk.

  • Collect sputum (AND blood cultures in pneumonia)
  • For patients with pneumonia, send urine for legionella antigen and a viral throat swab.
  • Consider diagnosis of influenza and isolate patient according to Patient Placement Tool [intranet link only]
  • Always consider prior therapy; patients who have not responded to a recent course of antibiotics should receive an alternative agent

Oral therapy must be considered the norm except in SEVERE pneumonia or in patients unable to take oral therapy

Consider immune deficiency and testing for HIV

Low severity (CURB65 0-1)

Amoxicillin oral 1g 8 hourly

OR 

Doxycycline 200mg oral stat then 100mg once daily

Moderate Severity (CURB65=2)

Amoxicillin oral or IV 1g 8 hourly

+

Clarithromycin oral 500mg 12 hourly (until atypical excluded)

Moderate Severity (CURB65=2) Penicillin Allergy

Doxycycline monotherapy oral 100mg 12 hourly

If IV therapy required treat as high severity

High Severity (CURB65 3-5)

No previous antibiotics

Amoxicillin IV 1g 8 hourly

+ Clarithromycin oral 500mg 12 hourly (until atypical excluded)

 

Switch to oral:

Doxycycline monotherapy 100mg 12 hourly

OR

Amoxicillin 1g 8 hourly

+ Clarithromycin 500mg 12 hourly (until atypical excluded)

 

Previous antibiotics in community:

Co-amoxiclav* IV 1.2g 8 hourly

+ Clarithromycin 500mg oral/IV 12 hourly (until atypical excluded).

 

Switch to oral:

Doxycycline monotherapy 100mg 12 hourly

*Avoid co-amoxiclav in frail elderly patients where possible due to CDI risk

If preceding influenza illness consider possibility of staphylococcal pneumonia

Risk assess for resistant organisms prior to therapy (previous microbiology sensitivities) and rationalise choice once sensitivities on current samples available

High Severity (CURB65 3-5) - Penicillin Allergy

Co-trimoxazole IV 960mg 12 hourly

OR

Levofloxacin* IV 500mg 12 hourly

 

Switch to oral:

Doxycycline monotherapy 100mg 12 hourly

OR

Co-trimoxazole 960mg 12 hourly

*Avoid levofloxacin in frail elderly patients where possible due to CDI risk

If preceding influenza illness consider possibility of staphylococcal pneumonia

Risk assess for resistant organisms prior to therapy (previous microbiology sensitivities) and rationalise choice once sensitivities on current samples available