Community acquired pneumonia – NICE guidance
ASSESSMENT- patient presents with LRTI symptoms.
Pneumonia is an infection of the lung tissue- air sacs become filled with microorganisms , fluid and inflammatory cells Diagnosis is based on symptoms of an acute LRTI and can be confirmed by a CXR. Management strategies differ – this chart here is focused on CAP ( Community acquired Pneumonia )- which is pneumonia that is acquired outside hospital including people living in a nursing or residential home .
Between 0.5 % to 1 % of adults will have CAP/ yr Diagnosed in 5- 12 % of adults who present with LRTI symptoms to GPs 22- 42 % of them are admitted to hospital where the mortality rate is between 5% to 14 % Risk of death is up to 30 % if patient is managed in intensive care More than 1/2 of pneumonia- related deaths is in people older than 84 yrs.
Symptoms and signs of LRTI –acute illness – present for 21 days or less cough is the main symptom and at-least one other LRTI symptom as ♦ fever ♦ sputum production ♦ breathlessness ♦ wheeze ♦ chest discomfort or pain AND no alternative explanation as sinusitis or asthma.If after clinical assessment a diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed- check CRP
Severity assessment in primary.Confusion which is ♦ abbreviated Mental score of 8 or less ♦ new disorientation in person , place or time Raised resp rate ie 30 or more / min Low BP ♦ diastolic 60 mmHg or less ♦ systolic less than 90 mmHg Age 65 yr or more care-A diagnosis of CAP has been made- use the CRB65 score to determine if patients are at low , intermediate or high risk of death Use clinical judgement + CRB65 score to make a decision if admission is needed.Do not routinely offer microbiological tests to patients with low-severity CAP. Most cases caused by Sreptococcus pneumoniae which is usually sensitive to 1st line antibiotics in UK.
Low severity CAP –Offer a 5 day course of a single antibiotic Consider amoxicillin in preference to a macrolide or a tetracycline Consider a macrolide or a tetracycline if allergic to penicillin Consider extending course for longer than 5 days as a possible management strategy in people with low-severity CAP whose symptoms do not improve as expected after 3 days Safety netting – explain to patient / carers / family that they should seek further medical advice if symptoms do not begin to improve within 3 days of starting Rx or earlier if their symptoms are worsening Do not routinely offer ○ a fluoroquinolone ○ dual antibiotic therapy.
Moderate and high severity CAP –Consider a 7-10 day course of antibiotic therapy Consider dual antibiotic Rx with Amoxicillin + macrolide Consider dual antibiotic Rx with a ○ beta-lactamase stable beta-lactams as co-amoxiclav cefotaxime ceftaroline fosamil ceftriaxone cefuroxime and piperacillin with tazobactam Glucocorticoid Rx – do not routinely offer in patients with CAP unless they have other conditions for which it is indicated
Patient information- 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
FebriDx test- Single-use , portable in vitro diagnostic test Provides qualitative measurement of CRP and Myxovirus resistance protein A ( MxA ) in human peripheral blood FebriDx consists of a test card , buffer solution and an accessory kit which includes a lancet and 2 pipettes. Comes in boxes of 20 with 2 spare accessory kits and buffer sol MxA biomarker is designed to increase specificity compared with CR alone to help differentiate viral and bacterial infections Cost of each single use FebriDx test is $ 14-$ 16 in 2017 NICE has not found many studies to advice on using FebriDx and it mentions ” there was very limited evidence in terms of quantity and quality to assess the FebriDx test “ In plain language more study and research is needed with robust evidence of cost savings to justify use of the FebriDx system
References
- Top tips for GPs : Community-acquired pneumonia Dr Sinan Eccles www.network.nhs.uk
- NICE Pathways Pneumonia Pneumonia in adults : diagnosis and management ( CG 191 ) December 2014
- Pneumonia in adults Quality standard ( QS 110 ) published January 2016
- FebriDx for C-reactive protein and Myxoviris resistance protein A testing in primary care Medtech innovation briefing ( MIB 114 ) Published July 2017