Key learning points

  • Up to 1% of adults in the UK have community-acquired pneumonia in a year
  • Presenting features may be a cough, sputum, fever, shortness of breath, pleuritic chest pain and/or malaise. If a lower lobe pneumonia irritates the diaphragm the patient may report upper abdominal pain1
  • Confusion or a deterioration in condition may be the presenting complaint in an elderly patient, fever may be absent in older patients1
  • The CRB65 score may be used alongside clinical judgement to assess the mortality risk of adults with pneumonia in primary care and to guide referral to hospital
  • A five-day course of antibiotic therapy should be prescribed to patients with community-acquired pneumonia, with the choice of antibiotic guided by the severity of the condition

Introduction

Pneumonia outside of a hospital setting may be classified as community-acquired pneumonia. It is diagnosed in approximately 10% of adults who present to primary care with symptoms of lower respiratory tract infection, and approximately a third of these patients will be admitted to hospital.1 

Case study

Mr Javid, aged 67, presented to the GP with a few days’ history of worsening shortness of breath and a productive cough. He is a non-smoker.

On clinical examination he was speaking in complete sentences. He was tachypnoeic and tachycardic. Pulse oximetry was 99% on air and he was afebrile. There were left-sided crepitations at the lung base. There was equal air entry and resonance.

The CRB65 score was 2 due to age over 65 and tachypnoea. He was treated with a five-day course of amoxicillin and given advice to return should his symptoms persist or worsen.

Discussion

Pneumonia is an infection of the lung where there is inflammation associated with consolidation. This reflects interstitial lung infiltrate composed of fluid, inflammatory cells and micro-organisms. Other causes of consolidation can include pulmonary oedema and blood. 

Pneumonia is a clinical diagnosis in primary care, however consolidation may be seen on chest X-ray, if performed. Causative pathogens include Streptococcus pneumoniae, atypical bacteria such as Mycoplasma pneumoniae, as well as viruses.1,2 The presence of respiratory conditions such as asthma and chronic obstructive pulmonary disease are relevant, as well as other comorbid conditions such as congestive cardiac failure and frailty. Consideration of a patient’s baseline function, such as exercise tolerance, is helpful. Occupation, travel and smoking history are also important to consider.

On clinical examination there may be fever, tachypnoea, tachycardia, crackles or crepitations, bronchial breathing and dullness to percussion. The patient may have a history of cough which is usually productive, with yellow-greenish and sometimes blood-stained mucus. If there are symptoms and signs of lower respiratory tract infection, the clinical diagnosis of pneumonia may be made in primary care, in the absence of a chest X-ray. 

NICE advises a point of care C-reactive protein test may be helpful if a clinical diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed.1 Blood and sputum cultures may be taken for patients with moderate to high-severity community-acquired pneumonia.1,3 

If a clinical diagnosis of community-acquired pneumonia is made, it is important to determine the severity of the pneumonia and whether the patient is at low, intermediate or high risk of death. This may be done using the CRB65 score for mortality risk assessment in combination with clinical judgement (Box 1).1,4 

CRB65 mortality risk assessment score

Give 1 point for each feature in a patient with diagnosis of community-acquired pneumonia:

  • Confusion (abbreviated Mental Test score ≤8, or new disorientation)
  • Increased respiratory rate (≥30 breaths/min)
  • Low blood pressure (diastolic ≤60 mmHg or systolic <90 mmHg)
  • Age ≥65 years

Score: 0 = low risk, 1–2 = intermediate risk, 3–4 = high risk

If the score is 0 this reflects low risk with a less than 1% mortality. If the score is 1 or 2 there is a 1–10% risk of mortality (intermediate risk). A score of 3 or 4 indicates a mortality risk of more than 10% (high risk). Hospital admission may be considered for all patients with a risk score of 1 or above, but particularly for those with a score of 2 or greater.1,4 

Evidence-informed practice should be individualised and the appropriateness of implementing guideline recommendations should be carefully considered as part of the shared decision-making process with patients. Clinical judgement is important and should be influenced by factors such as patient choice, multimorbidity, as well as available social support.

A five-day course of antibiotic therapy should be prescribed to patients with low-severity community-acquired pneumonia and patients should be advised to start treatment as soon as possible. Amoxicillin is first-line therapy for low-severity pneumonia, and clarithromycin may be added to this for moderate severity, in order to cover atypical pathogens. For high severity, co-amoxiclav may be used with clarithromycin.2 

Patients should be advised that by 4 weeks after starting treatment sputum production should have substantially reduced and by 6 weeks cough and shortness of breath should have substantially reduced. If symptoms do not improve as expected or deteriorate clinical re-assessment is necessary.1 

Mr Javid’s condition improved with a five-day course of antibiotics. His observations normalised and his breathing returned to normal.

Dr Suneeta Kochhar, GP, Bexhill-on-Sea, UK

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