NICE releases guideline on diagnosis and management of Pneumonia in adults

Written by Hina Zahid Published On 2019-10-01T19:00:12+05:30 | Updated On 1 Oct 2019 7:00 PM IST

NICE has released its new guideline on diagnosis and management of pneumonia in adults. The guideline provides recommendations for the management of suspected and confirmed community-and hospital‑acquired pneumonia in adults.

Pneumonia is an infection of the lung tissue. When a person has pneumonia the air sacs in their lungs become filled with microorganisms, fluid and inflammatory cells and their lungs are not able to work properly. Every year between 0.5% and 1% of adults in the UK will have community‑acquired pneumonia. It is diagnosed in 5–12% of adults who present to GPs with symptoms of lower respiratory tract infection, and 22–42% of these are admitted to hospital, where the mortality rate is between 5% and 14%.

Key Recommendations are-

1. Presentation with lower respiratory tract infection

For people presenting with symptoms of lower respiratory tract infection in primary care, consider a point of care C‑reactive protein test if after clinical assessment a diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed. Use the results of the C‑reactive protein test to guide antibiotic prescribing in people without a clinical diagnosis of pneumonia as follows:

- Do not routinely offer antibiotic therapy if the C‑reactive protein concentration is less than 20 mg/litre.
- Consider a delayed antibiotic prescription (a prescription for use at a later date if symptoms worsen) if the C‑reactive protein concentration is between 20 mg/litre and 100 mg/litre.
- Offer antibiotic therapy if the C‑reactive protein concentration is greater than 100 mg/litre.

2. Community-acquired pneumonia

Severity assessment in primary care

When a clinical diagnosis of community-acquired pneumonia is made in primary care, determine whether patients are at low, intermediate or high risk of death using the CRB65 score.

Box 1 CRB65 score for mortality risk assessment in primary care

CRB65 score is calculated by giving 1 point for each of the following prognostic features:

confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)

raised respiratory rate (30 breaths per minute or more)

low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)

age 65 years or more.

Patients are stratified for risk of death as follows:

0: low risk (less than 1% mortality risk)

1 or 2: intermediate risk (1‑10% mortality risk)

3 or 4: high risk (more than 10% mortality risk).

Use clinical judgement in conjunction with the CRB65 score to inform decisions about whether patients need hospital assessment as follows:

- consider home‑based care for patients with a CRB65 score of 0
- consider hospital assessment for all other patients, particularly those with a CRB65 score of 2 or more.

Severity assessment in hospital

When a diagnosis of community-acquired pneumonia is made at presentation to hospital, determine whether patients are at low, intermediate or high risk of death using the CURB65 score.

Box 2 CURB65 score for mortality risk assessment in hospital

CURB65 score is calculated by giving 1 point for each of the following prognostic features:

confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)

raised blood urea nitrogen (over 7 mmol/litre)

raised respiratory rate (30 breaths per minute or more)

low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)

age 65 years or more.

Patients are stratified for risk of death as follows:

0 or 1: low risk (less than 3% mortality risk)

2: intermediate risk (3‑15% mortality risk)

3 to 5: high risk (more than 15% mortality risk).

Use clinical judgement in conjunction with the CURB65 score to guide the management of community‑acquired pneumonia, as follows:

- consider home‑based care for patients with a CURB65 score of 0 or 1
- consider hospital‑based care for patients with a CURB65 score of 2 or more
- consider intensive care assessment for patients with a CURB65 score of 3 or more.

Stratify patients presenting with community‑acquired pneumonia into those with low‑, moderate‑ or high‑severity disease. The grade of severity will usually correspond to the risk of death.

Microbiological tests

Do not routinely offer microbiological tests to patients with low‑severity community‑acquired pneumonia.

For patients with moderate‑ or high‑severity community‑acquired pneumonia:

- take blood and sputum cultures and
- consider pneumococcal and legionella urinary antigen tests.

Timely diagnosis and treatment

Put in place processes to allow diagnosis (including X‑rays) and treatment of community‑acquired pneumonia within 4 hours of presentation to hospital.

This recommendation has been withdrawn. See the NICE guideline on pneumonia (community-acquired): antimicrobial prescribing for updated recommendations on antibiotic therapy.

Antibiotic therapy

Low-severity community-acquired pneumonia

This recommendation has been withdrawn. See the NICE guideline on pneumonia (community-acquired): antimicrobial prescribing for updated recommendations on antibiotic therapy.

Glucocorticoid treatment

Do not routinely offer a glucocorticoid to patients with community‑acquired pneumonia unless they have other conditions for which glucocorticoid treatment is indicated.

Monitoring in hospital

Consider measuring a baseline C‑reactive protein concentration in patients with community‑acquired pneumonia on admission to hospital, and repeat the test if clinical progress is uncertain after 48 to 72 hours.

Safe discharge from hospital

Do not routinely discharge patients with community‑acquired pneumonia if in the past 24 hours they have had 2 or more of the following findings:

- temperature higher than 37.5°C
- respiratory rate 24 breaths per minute or more
- heart rate over 100 beats per minute
- systolic blood pressure 90 mmHg or less
- oxygen saturation under 90% on room air
- abnormal mental status
- inability to eat without assistance.

Consider delaying discharge for patients with community‑acquired pneumonia if their temperature is higher than 37.5°C.

Patient information

Explain to patients with community‑acquired pneumonia that after starting treatment their symptoms should steadily improve, although the rate of improvement will vary with the severity of pneumonia, and most people can expect that by:

- 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.

Advise patients with community‑acquired pneumonia to consult their healthcare professional if they feel that their condition is deteriorating or not improving as expected.

3. Hospital-acquired pneumonia

Antibiotic therapy

This recommendation has been withdrawn. See the NICE guideline on pneumonia (hospital-acquired): antimicrobial prescribing for updated recommendations on antibiotic therapy.

For more details click on the link: nice.org.uk

antibiotic therapyC‑reactive protein testGlucocorticoid treatmentlow blood pressureLower Respiratory Tract InfectionMental TestMicrobiological testsNICE guidelinepneumococcalpneumoniaPneumonia in adultssputum culturesurea nitrogenX‐rays

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Hina Zahid