CHAPTER 62

Community-acquired pneumonia
AHMED YOUSUF

Figure 62.1 Management of suspected community-acquired pneumonia.

Acute Medicine: A Practical Guide to the Management of Medical Emergencies, Fifth Edition. Edited by
David Sprigings and John B. Chambers.
© 2018 John Wiley & Sons Ltd. Published 2018 by John Wiley & Sons Ltd.

390
 Community-acquired pneumonia 391

Box 62.1 Definitions.

Community-acquired pneumonia: pneumonia acquired outside hospital (including residency in a care

home or nursing home), or which appears within 48 h of admission to hospital.

Hospital-acquired pneumonia: pneumonia that develops 48 h or longer after hospital admission, and
was not subclinical on admission.

Lower respiratory tract infection: an acute illness with cough and at least one other lower respiratory
tract symptom, presumed to be due to infection. The definition includes pneumonia, acute bronchitis and
infective exacerbation of chronic obstructive pulmonary disease.

Community-acquired pneumonia (CAP) (see Box 62.1 for definition) usually presents with acute respiratory
symptoms, but should always be considered in patients with unexplained sepsis or delirium. Examination of the
chest may be normal and, if you suspect pneumonia, a chest X-ray is need to make the diagnosis.
A broad range of pathogens can cause CAP. Streptococcus pneumoniae (pneumococcus) is the most
common bacterial pathogen, accounting for up to 50% of cases. Other common pathogens are Staph. aureus,
Legionella pneumophila and influenza.

Priorities

Is this pneumonia? How severe is it?

• Suspect pneumonia in the presence of one or more of the following clinical features:
• Fever
• Cough
• Purulent sputum
• Pleuritic chest pain
• Focal lung crackles or bronchial breathing
• Consider the differential diagnosis (Table 62.1). A chest X-ray showing new focal shadowing is essential for the
diagnosis (Table 62.2). Other investigations needed are given in Table 62.3. For low severity (CURB-65 = 0–1)
urine antigen or serological investigations may be considered during outbreaks (e.g. Legionnaires’ disease) or
epidemic mycoplasma years, or when there is a particular clinical or epidemiological reason.
• The severity of CAP can be assessed by the CURB-65 score (Table 62.4).

Choice of initial antibiotic therapy for CAP

• Your initial therapy depends on the clinical setting, severity of pneumonia and local antimicrobial policy
(Table 62.5).
• Start antibiotic therapy as soon as diagnosis of CAP is suspected. Antibiotics should not be withheld if there
is a delay in taking blood for culture.

Further management

Oxygen
Humidified O2 should be continued to keep arterial PaO2 >8.0 kPa, oxygen saturation >92% (>88% in patients
with chronic obstructive pulmonary disease).
392 Acute Medicine

Table 62.1 Differential diagnosis of suspected pneumonia.

Disorder Comment

Cardiovascular disorders
Pulmonary embolism Risk factor(s) for venous thromboembolism
Sudden-onset shortness of breath
See Chapter 57.
Tricuspid valve endocarditis IVDU or indwelling venous cannula e.g. for haemodialysis in blood
cultures.

Neoplastic disorders
Bronchial carcinoma Weight loss, chronic cough, abnormal CXR (nodule or mass,
mediastinal lymphadenopathy)
Alveolar cell carcinoma Similar CXR appearance to pneumonia. If there is no leucocytosis or
fever or if the patient doesn’t respond to antibiotics.

Immune-mediated disorders
Wegener granulomatosis Haematuria, haemoptysis, epistaxis, scleritis, uveitis
Diffuse alveolar haemorrhage in Haematuria, haemoptysis, positive anti-GBM, ANCA antibodies
pulmonary-renal syndromes
Systemic lupus erythematosus Skin rash, sensitivity to sunlight, positive ANA
Acute interstitial pneumonia Ground glass changes and traction bronchiectasis on HRCT
Eosinophilic pneumonia syndromes Peripheral blood eosinophilia, peripheral infiltrate within the outer
two-thirds of the lung fields on X-ray, responds to steroids
Bronchiolitis obliterans – organizing Acute to subacute onset of symptoms, migratory patchy infiltrates on
pneumonia X-ray, responds to steroids
Other disorders
Drug toxicity (e.g. amiodarone Restrictive spirometry, decreased gas transfer, responds to steroids and
pneumonitis) stopping offending drug(s)
Radiation pneumonitis History of recent radiotherapy, responds to steroids

Table 62.2 Chest X-ray findings in pneumonia.

Element Comment

Focal shadowing Required to make the diagnosis of pneumonia.

Lobar pneumonia is the result of disease that starts in the periphery and spreads from one alveolus
to another. As the disease reaches a fissure, this will result in a sharp delineation, since
consolidation will not cross a fissure. The alveoli that surround the bronchi become denser and the
bronchi become more visible, resulting in an air-bronchogram.
Bronchopneumonia starts in the airways as acute bronchitis. It will lead to multifocal ill-defined
densities. When it progresses it can produce diffuse consolidation.
Pleural effusion If present, arrange for ultrasound-guided aspiration of effusion and send samples for Gram stain
and culture, pH and biochemistry (LDH, protein, glucose).
Cavitation Associated with tuberculosis and Staphylococcus aureus infection, but may also occur in Gram-
negative and anaerobic infections.
Lung abscess Chest X-ray typically demonstrates an air-fluid level, but chest CT is more sensitive and can confirm
the diagnosis in difficult cases. Most patients with lung abscess do well with conservative
management and a prolonged course of antibiotics.
Pneumothorax May occur in cavitating pneumonia and is particularly associated with Pneumocystis jiroveci
pneumonia (Chapter 34).
 Community-acquired pneumonia 393

Table 62.3 Urgent investigations in suspected community acquired pneumonia.

Test Comment

Chest X-ray See Table 62.2.

Full blood count Leucocytosis or leucopenia are markers of sepsis and severe infection.
Electrolytes, urea and creatinine To assess renal function and disease severity (urea >7.0).
C-reactive protein As biomarker of treatment response.
Liver function tests The identification of underlying or associated hepatic disease.
Arterial blood gases (ABG) If oxygen saturations <92% on air, or in patients with COPD to assess for type 2
respiratory failure.
Urine for Legionella antigen In those with severe CAP or during an outbreak.
Blood culture Identification of pathogens and antibiotic sensitivity patterns allows selection of
optimal antibiotic regimens. Blood for culture must be taken prior to starting
antibiotics.
‘Atypical’ serology For patients with severe CAP or unresponsive to beta lactam antibiotics. ‘Atypical’
pathogens that cause pneumonia are Mycoplasma pneumoniae, Chlamydia
pneumoniae, Chlamydia psittaci and Coxiella burnetii.
Sputum culture For patients with CAP who are able to expectorate sputum. Sputum samples
should be sent for Gram stain, culture and sensitivity tests.
HIV test HIV testing should be offered to all adult patients with community-acquired
pneumonia.

Fluid balance
• Insensible losses are greater than normal due to fever (allow 500 mL/day/°C fever) and tachypnoea.
• Patients with severe pneumonia should receive IV fluids (2–3 L/day), with daily assessment of fluid status and
measurement of renal function. Adequate hydration also helps with expectoration of sputum.

Antibiotic therapy
• Review this after 48 h. If there has been clinical improvement, with a fall in C-reactive protein level, switch to
oral therapy in those patients initially given IV therapy.
• Management of patients who fail to improve after 48 h antibiotic therapy is discussed below (see Problems).

Venous thromboembolism prophylaxis

Give prophylaxis with anti-embolism stockings and low-molecular-weight heparin.

Table 62.4 CURB-65 Score.

Score 1 point each for:

• New Confusion (abbreviated mental test score 8 or less, or new disorientation)

• Blood Urea >7.0 mmol/L
• Respiratory rate >30 breaths/min
• Low Blood pressure (systolic BP <90 mmHg or diastolic BP <60 mmHg)
• Age 65 years).

Score 0–1: low severity (mortality <3%): manage as outpatient.

Score 2: moderate severity (mortality 9%): admit to general or respiratory ward.
Score 3 or more: high severity (mortality of 15–40%): admit to HDU or ICU.
394 Acute Medicine

Table 62.5 Initial empirical treatment regimens for community-acquired pneumonia in adults (source: adapted from
British Thoracic Society guidelines).

Severity Site Preferred treatment Penicillin allergy

Low (CURB-65 = 0–1, mortality Home Amoxicillin 500 mg TDS orally for Doxycycline 200 mg loading dose
<3%) 5 days. then 100 mg orally or
clarithromycin 500 mg bd orally
for 5 days.
Low severity (CURB-65 = 0–1, Hospital Amoxicillin 500 mg tds orally. If Doxycycline 200 mg loading dose
mortality <3%) but admission oral administration not possible: then 100 mg od orally or
indicated for reasons other than amoxicillin 500 mg tds IV for 5 clarithromycin 500 mg bd orally
pneumonia severity (e.g. social days. for 5 days.
reasons)
Moderate severity (CURB­ Hospital Amoxicillin 500 mg –1.0 g tds Doxycycline 200 mg loading dose
65 = 2, 9% mortality) orally plus clarithromycin 500 mg then 100 mg orally or levofloxacin
bd orally. If oral administration 500 mg od orally or moxifloxacin
not possible: amoxicillin 500 mg 400 mg od orally.
tds IV plus clarithromycin 500 mg
bd IV.
High severity (CURB-65 = 3–5, Hospital Co-amoxiclav 1.2 g tds IV plus Vancomycin 1.g bd IV plus
15–40% mortality) clarithromycin 500 mg bd IV. clarithromycin 500.mg bd IV or
Lower case 500 mg bd IV or
Cefuroxime 1.5 g tds IV or
cefotaxime 1 g tds IV or
ceftriaxone 2 g od IV, plus
clarithromycin 500 mg bd IV

Pain relief
Relieve pleuritic chest pain with paracetamol and/or NSAIDs, to facilitate sputum expectoration.

Chest physiotherapy
• Chest physiotherapy is helpful if the patient is producing sputum but having difficulty expectorating it, and in
bronchiectasis.
• Nebulized hypertonic saline may be helpful when sputum is thick and difficult to expectorate, but tends to
cause a greater degree of bronchoconstriction than normal saline. Give bronchodilator therapy before
nebulized hypertonic saline.

Bronchodilator therapy
Nebulized salbutamol or ipratropium should be prescribed to patients with asthma or COPD if there is wheeze.

Checklist before discharge

Clinically stable for >24 h:

• Normal mental state (or at baseline)
• Temperature <37.5 °C
• Respiratory rate <24/min
• Arterial oxygen saturation breathing air >92% (>88% if COPD)
• Heart rate <100/min
• Systolic BP >90 mmHg
 Community-acquired pneumonia 395

• Able to eat without assistance (or at baseline)

• Able to walk at least short distances unaided (or close to preadmission functional status)
• Social support at home organized if needed
• Advice on smoking cessation given if needed
• General practitioner follow-up arranged within one week
• Follow-up appointment in chest clinic at six weeks, with chest X-ray taken before visit

Problems

Failure to improve after 48 h antibiotic therapy

Address the following points:
• Review the clinical, microbiological and radiological findings.
• Are you confident the diagnosis is pneumonia (consider the diagnoses in Table 62.1), and that the patient’s
current antibiotic therapy is appropriate for the possible pathogens?
• Consider broadening your antibiotic therapy, in case the organism is unusual or resistant: ask advice from a
microbiologist.
• Re-examine the patient, and check for signs of metastatic infection, such as septic arthritis, pericarditis or
infective endocarditis.
• Repeat the chest X-ray. Are there any new findings such as cavitation or pleural effusion? If pleural fluid is now
present, this should be aspirated and sent for Gram stain and culture. If the fluid is cloudy rather than mildly
turbid, drain completely and treat as empyema (discuss with a chest physician). A pH <7.20 also favours
empyema rather than a parapneumonic effusion.
• In an IV drug user or a patient with an indwelling venous cannula consider tricuspid valve endocarditis with
septic pulmonary emboli.
• Consider underlying airways or lung disease, such as chronic obstructive pulmonary disease, bronchiectasis,
bronchial carcinoma and inhaled foreign body.
• Consider pulmonary tuberculosis in patients with risk factors for TB. Send sputum for Ziehl-Neelsen stain. If no
sputum is being produced, consider fibreoptic bronchoscopy. A Mantoux skin test (0.1 mL or 1 in 10,000
intradermally) may be performed, but interpretation can be difficult – a strongly positive test is good evidence
of active infection, but a negative reaction can occur in the presence of active infection.
• Consider HIV/AIDS. Test for HIV if this has not already been done.
• Ask advice from a chest physician. CT or fibreoptic bronchoscopy may be indicated to clarify the diagnosis.

Further reading

National Institute for Health and Care Excellence (2014) Pneumonia in adults: diagnosis and management.
Clinical guideline (CG191). https://www.nice.org.uk/guidance/cg191
Prina E, Ranzani OT, Torres A. (2015) Community-acquired pneumonia. Lancet 386, 1097–1108.