Nice | Diagnosis and management of pneumonia

pneumoniaNice's latest guideline looks at the diagnosis and management of pneumonia. I was surprised by the stats here, so I'm including those. The 2 new things here are the use of CRP in deciding when to use antibiotics and use of the CRB65 score to give an idea of severity. Another useful aspect of this guideline is that it advises how long it takes to get better - again I found this surprising.

The scale of the problem.

  • 0.5 to 1% of adults are affected each year
  • 5 to 12% of patients seen in GP with LRTI have pneumonia
  • 22 to 42% of patients diagnosed are admitted to hospital
  • 5 to 14% in hospital mortality
  • 1.2 to 10% of those admitted end up on ITU
  • More than half of deaths occur in those aged 84 and older

CRP

Where pneumonia is diagnosed clinically, then treat it. If you are in doubt about whether antibiotics are needed, they advise a point of care CRP test. I haven't seen these used anywhere and would be interested to know if others have. Presumably a normal CRP could be done, but the time scales would make it less useful.

  • 19 or less - do not routinely use antibiotics
  • 20 to 100 - consider delayed antibiotics
  • 100 or more - give antibiotics

CRB65 score

This gives a risk of mortality associated with the pneumonia. Score 1 for each of:

  • Confusion (mmt 8 or less, or new confusion in time, person or place)
  • RR 30 or more
  • Low BP (90/60)
  • 65 or more

0 low risk (1% mortality); consider home care
1 or 2 - intermediate risk (1 to 10% mortality)
3 or 4 - high risk ( > 10% mortality)
Consider admission if 2 or more

What antibiotics are advised?

  • Low risk - amoxicillin for 5d (longer if they're not improving by d3)
  • Intermediate risk - consider amoxicillin + macrolide for 7 to 10d
  • High risk - consider co-amoxiclav + macrolide

What should you advise patients about recovery times?

  • 1w - fever should have resolved
  • 4w - chest pain and sputum should have substantially reduced
  • 6w - cough and breathlessness should have substantially reduced
  • 3m - most symptoms should have resolved, though may have fatigue
  • 6m - most will be back to normal

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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