Community acquired pneumonia & LRTIs

 

Chest infections in primary care can be split into acute bronchitispneumonia, and infective exacerbations of chronic obstructive pulmonary disease (COPD) or asthma.  Acute bronchitis is a transient inflammation of the trachea and major bronchi associated with oedema and mucus production that leads to cough and phlegm production lasting for up to 3 weeks.  It is usually caused by a viral infection, but may be caused by a bacterial infection. The annual incidence of acute bronchitis is 44 per 1000 adult population.  Community-acquired pneumonia (CAP) is an acute infection of the lung parenchyma acquired in the community, most commonly caused by Streptococcus pneumonia.  Most episodes occur during autumn or winter.  The annual incidence of community-acquired pneumonia (CAP) is 5-10 per 1000 adult population.  CAP accounts for 5-12% of all lower respiratory tract infections managed by GPs in the community

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Lower respiratory tract infection (LRTI)

Definition

A lower respiratory tract infection can be defined as:

  • Acute illness, duration 21 days or less, with cough as predominant symptom and one additional symptom:
    • fever
    • sputum
    • breathlessness
    • wheeze
    • chest discomfort or pain

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Investigation

If a patient has symptoms of lower respiratory tract infection, and pneumonia has not been diagnosed and it is not clear if antibiotics should be prescribed, consider a point of care C-reactive protein (CRP) testing to aid decision making - prescribing guidance is available in the HPA management guidance for infection in primary care

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Use the results of the CRP test to guide antibiotic prescribing in people without a clinical diagnosis of pneumonia as follows:

  1. Do not routinely antibiotic therapy if the CRP concentration is < 20 mg/l
  2. Consider a delayed antibiotic prescription (a prescription for use at a later stage if symptoms worsen) if the CRP concentration is between 20 mg/l and 100 mg/l
  3. Offer antibiotic therapy if the CRP concentration is > 100 mg/l

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Community-acquired pneumonia

Diagnosis

NOTE:  A diagnosis should be based on symptoms and signs of lower respiratory tract infection in a patient who, in the opinion of the GP and in the absence of a chest X‑ray, is likely to have community‑acquired pneumonia

This might be because of the presence of:

  • New focal chest signs on examination
  • At least one systemic feature (either a symptom complex of sweating, fevers, shivers, aches and pains and/or temperature of 38°C or more)

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Severity assessment

When a diagnosis of community acquired pneumonia is made, use the CRB-65 score in conjunction with clinical judgement to assess the severity of pneumonia (i.e. whether the patients is at low, medium, or high risk of mortality), in order to determine the need for hospital assessment

CRB65 score for mortality risk assessment in primary care

  1. Consider home-based care for patients with a CRB-65 score of 0
  2. Consider hospital assessment for all other patients, particularly those with a CRB-65 score of 2 or more

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Management of low-severity pneumonia in primary care

Antibiotic therapy

  1. Offer a 5 day course of a single antibiotic
  2. Use amoxicillin in preference to a macrolide or tetracycline except for patients who are allergic to penicillin
  3. Consider extending the course of the antibiotic for longer than 5 days for patients with low‑severity community‑acquired pneumonia whose symptoms do not improve as expected after 3 days
  4. Do not routinely offer microbiological tests to patients with low‑severity community‑acquired pneumonia

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Ongoing review

  1. It is not necessary to perform a chest x-ray in patients with suspected CAP unless:
    1. The diagnosis is in doubt and a chest radiograph will help in a differential diagnosis and management of the acute illness
    2. Progress following treatment for suspected CAP is not satisfactory at review
    3. The patient is considered at risk of underlying lung pathology such as lung cancer
  2. Explain to patients with low‑severity community‑acquired pneumonia treated in the community, and when appropriate their families or carers, that they should seek further medical advice if their symptoms do not begin to improve within 48-72 hours of starting the antibiotic, or earlier if their symptoms are worsening
  3. BTS guidelines recommend a review of patients with CAP at 48 hours or earlier if clinically indicated

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Patient information

Explain to patients with community‑acquired pneumonia that after starting treatment their symptoms should steadily improve, although the rate of improvement will vary with the severity of the pneumonia, and most people can expect that by:

1 week:  fever should have resolved

4 weeks:  chest pain and sputum production should have substantially reduced

6 weeks:  cough and breathlessness should have substantially reduced

3 months:  most symptoms should have resolved but fatigue may still be present

6 months:  most people will feel back to normal

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Further management

A chest x-ray should be arranged after about 6 weeks for all those patients who have persistence of symptoms or physical signs or who are at higher risk of underlying malignancy (especially smokers and those aged > 50 years) whether or not they have been admitted to hospital

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Severity assessment

Use the CRB score to assess the severity of the pneumonia in order to determine if the patient requires hospitalisation

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Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

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Chest radiography

For chest x-rays, you can refer the patient to the Radiology Department at East Kent Hospitals (find details here)

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

 

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