Severe Pneumonia: Please Request/Send – Samples Sputum/Blood/Urine

BTS Definition of CAP

Signs of acute Lower Respiratory Tract illness (LRTI) [Cough] &:

•  ≥1 other LRTI Symptom [Pleuritic pain, Tachypnea, Dyspnea, etc]
• New Focal Chest Signs [Creps, Bronchial breathing, Red. A/E]
• ≥1 Systemic sign [Fever, Sweats, Chills, Rigors, >38oC]
• New CXR changes [if hospitalized]

Investigations

• Full set Obs; RR, HR, BP, GCS, SaO2
• Bloods; FBC, i-STAT 8 [Urea needed]
• Sputum Sample [if possible]
• Legionella [Urine]
• Sepsis Bundle if any Red Flags

Severity Assessment

CURB-65 – this must be combined with clinical judgment [hypoxia and a low risk score doesn’t mean go home!]

• Confusion: AMTS <8 [Age, Time, 42 west st, Year, Place, recognise 2 people, DOB, Date WWII, Monarch/PM, Count back from 20-1]
• Urea: >7mmol/l
• RR: ≥30 – Red-Flag Sepsis Trigger
• BP: Sys <90mmHg or Dias <60mmHg – Red-Flag Sepsis Trigger
• 65 yrs old or more

Interpretation

• Antibiotic Guidance

Remember Sepsis Bundle

Discharge & FU

If patient is “Low Risk” [CURB-65 0-1], and suitable for treatment at home:

• Ensure patient has appropriate Antibiotic treatment.
• Recommend; Rest, Increase Oral Fluids, Stop Smoking
• Will need 48hr GP review [inform patient and letter to GP]

Follow Up CXR?

BTS recommend FU CXR at 6 weeks if either of:

• Persistent signs/symptoms
• High risk of cancer [>50yrs/Smoker]

Atypical Infections

• Strep. pneumoniea(Amox/Clarythro): Winter, Older, Cardiac Hx, Acute Onset, High Fever, Pleuritic CP
• Haem. influenziea (Amox/Cefuroxime): Winter, Older, Nursing home, COPD
• Staph. aureus(Non-MRSA consider 1-2g Flucloxacillin, MRSA consider Vancomycin): Winter, Severe Illness, Bilat. Infiltrates, Lung Cavitation
• Legionella (Clarythro): Jun-Oct, Mediterranean, Air-Con, Young Male, Encephalitis, Gastro Symps, Inc. LFT’s
• Mycoplasma (Clarythro/Doxy): Winter, Epidemics 3/4 yr, Young, Brown sputum
• Coxiella burnetii (Doxy/Clarytho): Apr-June, Lambing/Calving, Abattoir, Young, Dry-cough, High Fever
• Chlamydia psittaci (Doxy/Clarytho): Bird contact pet/poultry, <20% have bird contact
• Chlamydia pneumoniae (Clarytho/Doxy): Headaches, Prolonged Onset, Non-Specific