12th January 2024

Management

The management of pneumonia depends on the severity of the condition and the causative organism. The CURB-65 score is a predictive score of mortality from CAP, which is commonly used to guide treatment. The score is as follows:

• Confusion (AMTS ≤ 8) – 1 point
• Urea ＞7mmol/L – 1 point
• Respiratory rate ≥ 30 breaths per minute – 1 point
• Blood pressure: systolic ＜90mmHg or diastolic ≤ 60mmHg – 1 point
• Age ≥ 65 years – 1 point

Patients with a score of 0 or 1 are categorised as low severity (less than 3% mortality risk), and these individuals can often be managed as outpatients. A score of 2 is moderate severity (3‑15% mortality risk), which often requires hospital admission, while a score of 3 or above is categorised as severe (more than 15% mortality risk), which should prompt a consideration of discussion with the intensive care team.

Antibiotics are the mainstay of treatment for bacterial pneumonia. If possible, low-severity CAP should be managed with oral amoxicillin, with doxycycline or clarithromycin being alternatives if amoxicillin is unsuitable. Moderate severity CAP is typically treated with amoxicillin and clarithromycin, while severe CAP is managed with a combination of co-amoxiclav (typically IV initially) and clarithromycin.

If specific causative organisms for the pneumonia are identified, the treatment may be modified following discussion with the microbiology team. For instance, the first-line treatment for Legionella pneumophila would typically be a fluoroquinolone such as levofloxacin or a macrolide such as clarithromycin, while Mycoplasma is often managed with a macrolide.

Antibiotic guidelines differ for HAP, with NICE recommending oral co-amoxiclav for patients with non‑severe symptoms or signs and not at higher risk of resistance or a choice of either piperacillin with tazobactam (Tazocin), ceftazidime, ceftriaxone, cefuroxime, meropenem or ceftazidime with avibactam IV for patients with severe symptoms or signs (for example, symptoms or signs of sepsis) or at higher risk of resistance. In patients with aspiration pneumonia, metronidazole is typically added to provide anaerobic cover, and a referral to Speech and Language Therapy should be strongly considered to assess the safety of the swallow.

A follow-up chest X-ray should be arranged after 6 weeks to ensure resolution of consolidation (if it has not resolved, this should raise suspicion for an underlying abnormality, such as a lung tumour) for adults with either symptoms and signs that persist despite treatment, and/or who are at higher risk of underlying malignancy (particularly smokers and people aged more than 50 years). It is important to advise patients that symptoms may persist long beyond the end of their antibiotic course. For instance, it is expected that by three months, most of their symptoms should have resolved, yet fatigue may still be present.