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
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
