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Guideline Summary
Guideline Title
British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009.
Bibliographic Source(s)
Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Le Jeune I, Macfarlane JT, Read RC, Roberts HJ, Levy ML, Wani M, Woodhead MA, Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009 Oct;64(Suppl 3):iii1-55. [502 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: BTS Pneumonia Guidelines Committee. BTS guidelines for the management of community acquired pneumonia in adults - 2004 update. London (UK): British Thoracic Society; 2004. 22 p. [37 references]

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • November 6, 2013 – Low Molecular Weight Heparins External Web Site Policy: The U.S. Food and Drug Administration (FDA) is recommending that health care professionals carefully consider the timing of spinal catheter placement and removal in patients taking anticoagulant drugs, such as enoxaparin, and delay dosing of anticoagulant medications for some time interval after catheter removal to decrease the risk of spinal column bleeding and subsequent paralysis after spinal injections, including epidural procedures and lumbar punctures. These new timing recommendations, which can decrease the risk of epidural or spinal hematoma, will be added to the labels of anticoagulant drugs known as low molecular weight heparins, including Lovenox and generic enoxaparin products and similar products.
  • August 15, 2013 – Fluoroquinolone Antibacterial Drugs External Web Site Policy: The U.S. Food and Drug Administration (FDA) has required the drug labels and Medication Guides for all fluoroquinolone antibacterial drugs be updated to better describe the serious side effect of peripheral neuropathy. This serious nerve damage potentially caused by fluoroquinolones may occur soon after these drugs are taken and may be permanent.
  • August 1, 2013 – Acetaminophen External Web Site Policy: The U.S. Food and Drug Administration (FDA) notified healthcare professionals and patients that acetaminophen has been associated with a risk of rare but serious skin reactions. Acetaminophen is a common active ingredient to treat pain and reduce fever; it is included in many prescription and over-the-counter (OTC) products. These skin reactions, known as Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP), can be fatal. These reactions can occur with first-time use of acetaminophen or at any time while it is being taken. Other drugs used to treat fever and pain/body aches (e.g., non-steroidal anti-inflammatory drugs, or NSAIDS, such as ibuprofen and naproxen) also carry the risk of causing serious skin reactions, which is already described in the warnings section of their drug labels.

Scope

Disease/Condition(s)

Community acquired pneumonia (CAP)

Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Critical Care
Emergency Medicine
Family Practice
Infectious Diseases
Internal Medicine
Pulmonary Medicine
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Respiratory Care Practitioners
Guideline Objective(s)

To provide evidence-based recommendations for the management of community acquired pneumonia in adults

Target Population

Unselected adults with community acquired pneumonia (CAP) who are managed by their general practitioner or admitted to hospital as an emergency

Note: The developers do not consider the management of pneumonia in:

  • Patients where the pneumonia is an expected terminal event or who are known to have lung cancer, pulmonary tuberculosis or cystic fibrosis or primary immune deficiency or secondary immune deficiency related to human immunodeficiency virus (HIV) infection, or drug or systemic disease-induced immunosuppression
  • Patients receiving oral corticosteroid therapy as this is a not uncommon situation for patients admitted on medical take.
  • Patients who have been in hospital within the previous 10 days and may have hospital acquired pneumonia
  • Patients admitted from healthcare facilities such as nursing homes and residential homes will be commented on separately
  • Children with CAP (please refer to the National Guideline Clearinghouse summary: British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011.)
Interventions and Practices Considered

Diagnosis/Evaluation

  1. Chest radiograph
  2. Bronchoscopy
  3. Pulse oximetry
  4. Laboratory testing
    • Oxygenation saturations
    • Arterial blood gases
    • Urea and electrolytes
    • C-reactive protein
    • Full blood count
    • Liver function tests
    • Sputum examination
    • Blood cultures
    • Sensitivity testing
    • Urine antigen investigations
    • Serological investigations
    • Polymerase chain reactions (PCR) of respiratory tract samples
    • Gram staining
  5. Assessment of comorbid conditions
  6. Severity of illness assessment (Confusion, Respiratory rate, Blood pressure, 65 years and older [CRB65] score)

Management/Treatment

  1. Hospital versus community-based management
  2. Hospital admission
  3. Antibiotic therapy (empirical or pathogen-specific therapy), including
    • Amoxicillin
    • Doxycycline
    • Clarithromycin
    • Macrolides
    • Levofloxacin
    • Moxifloxacin
    • Cefuroxime
    • Cefotaxime
    • Ceftriaxone
  4. Transfer to critical care unit
  5. Oxygen therapy
  6. Intravenous fluids
  7. Prophylaxis of venous thromboembolism (low molecular weight heparin)
  8. Nutritional support
  9. Maintenance of mobility
  10. Airway clearance techniques
  11. Specific issues for management of Legionnaire's disease and Panton-Valentine leukocidin-producing Staphylococcus aureus (PVL-SA)
  12. Management of complications
    • Thoracocentesis
    • Pleural fluid drainage
  13. Follow-up plan
  14. Patient education and provision of information
  15. Prevention
    • Influenza immunization
    • Pneumococcal immunization
Major Outcomes Considered
  • Sensitivity and specificity of diagnostic tests
  • Morbidity and mortality associated with community acquired pneumonia (CAP)
  • Symptom improvement including, but not limited to, heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Literature Searches

Systematic electronic database searches were conducted in order to identify potentially relevant studies for inclusion in the community acquired pneumonia (CAP) guidelines. For each topic area the following databases were searched: Ovid MEDLINE (including MEDLINE In Process), Ovid EMBASE, Ovid CINAHL and the Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Cochrane Central Register of Controlled Trials, the Health Technology Assessment database and the NHS Economic Evaluation Database).

The searches were first run in December 2007 and were updated in August 2008. Searches included a combination of indexing terms and free text terms, and were limited to English language publications only. Full search strategies for each database are available in the web-based supplement.

Appraisal of the Literature

One individual read the title and abstract of each article retrieved by the literature searches and decided whether the paper was definitely relevant, possibly relevant or not relevant to the project. For each unique paper in the first and second category, the full paper was ordered and allocated to the relevant section(s).

Number of Source Documents

A total of 547 papers were retrieved and circulated for critical appraisal.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

See the "Rating Scheme for the Strength of the Recommendations" field.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

The leads for each section independently judged the clinical relevance and scientific rigour of each paper assigned to them using generic study appraisal checklists (see Appendices 1 and 2 in the original guideline document) adapted from published checklists. The reliability of the evidence in each study was graded from Ia to IVb using a generic list of evidence levels (see Appendix 3 in the original guideline document) developed from existing insights and checklists. Disagreements were resolved by discussion with the section partner (see Section 11.2 in the original guideline document). Where relevant, individual references used in this document are followed by an indication of the evidence level in square brackets.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Drafting of the Guidelines

The Guidelines Committee corresponded by email on a regular basis throughout the duration of the guideline development. Meetings of the full group were held in February 2008, July 2008 and November 2008. Each section lead edited the corresponding section in the 2001 guidelines document, incorporating all relevant literature and recommendations from the 2004 update and the current update.

Section leads individually assessed the literature selected and wrote a short document describing study findings and related recommendations. These documents were discussed by the whole committee.

Rating Scheme for the Strength of the Recommendations

Brief Description of the Generic Levels of Evidence and Guideline Statement Grades Used

Evidence Level Definition Guideline Statement Grade
Ia A good recent systematic review of studies designed to answer the question of interest A+
Ib One or more rigorous studies designed to answer the question, but not formally combined A-
II One or more prospective clinical studies which illuminate, but do not rigorously answer, the question B+
III One or more retrospective clinical studies which illuminate, but do not rigorously answer, the question B-
IVa Formal combination of expert views C
IVb Other information D
Cost Analysis

What Are the Economic Consequences of CAP?

A prevalence-based burden of illness study estimated that CAP in the UK incurred a direct healthcare cost of £441 million annually at 1992–3 prices. The average cost for managing pneumonia in the community was estimated at £100 per episode compared with £1700–5100 when the patient required admission to hospital. Hospitalisation accounted for 87% of the total annual cost.

A similar exercise conducted in 1997 in the USA calculated that annual costs of CAP amounted to $8.4 billion, 52% of the costs being for the inpatient care for 1.1 million patients and the remaining costs for the 4.4 million outpatient consultations. The average hospital length of stay varied between 5.8 days for those under 65 years of age and 7.8 days for older patients. A prospective study of costs and outcome of CAP from five hospitals in North America concluded that costs of antibiotic therapy varied widely but had no effect on outcome or mortality. Patients treated in the hospitals with the lowest costs did not have worse medical outcomes.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

In December 2008 the guidelines were discussed at an open plenary session at the British Thoracic Society (BTS) Winter Conference. A revised draft guidelines document was circulated to professional bodies for endorsement in January 2009 and to the BTS Standards of Care Committee in March 2009.

Recommendations

Major Recommendations

The grade of the recommendation (A+, A-, B+, B-, C, D) and the level of evidence (Ia, Ib, II, III, IVa, IVb) are defined at the end of the "Major Recommendations" field.

Investigations

When Should a Chest Radiograph Be Performed in the Community?

  1. It is not necessary to perform a chest radiograph in patients with suspected community acquired pneumonia (CAP) unless:
    • The diagnosis is in doubt and a chest radiograph will help in a differential diagnosis and management of the acute illness. [D]
    • Progress following treatment for suspected CAP is not satisfactory at review. [D]
    • The patient is considered at risk of underlying lung pathology such as lung cancer. [D]

When Should a Chest Radiograph Be Performed in Hospital?

  1. All patients admitted to hospital with suspected CAP should have a chest radiograph performed as soon as possible to confirm or refute the diagnosis. [D] The objective of any service should be for the chest radiograph to be performed in time for antibiotics to be administered within 4 h of presentation to hospital should the diagnosis of CAP be confirmed.  

When Should the Chest Radiograph Be Repeated During Recovery?

  1. The chest radiograph need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery from CAP. [D]
  2. A chest radiograph should be arranged after about 6 weeks for all those patients who have persistence of symptoms or physical signs or who are at higher risk of underlying malignancy (especially smokers and those aged >50 years) whether or not they have been admitted to hospital. [D]
  3. Further investigations which may include bronchoscopy should be considered in patients with persisting signs, symptoms and radiological abnormalities at around 6 weeks after completing treatment. [D]
  4. It is the responsibility of the hospital team to arrange the follow-up plan with the patient and the general practitioner for those patients admitted to hospital. [D]

What General Investigations Should Be Done in the Community?

  1. General investigations are not necessary for the majority of patients with CAP who are managed in the community. [C] Pulse oximeters allow for simple assessment of oxygenation. General practitioners, particularly those working in out-of-hours and emergency assessment centres, should consider their use. [D]
  2. Pulse oximetry should be available in all locations where emergency oxygen is used. [D]

What General Investigations Should Be Done in a Patient Admitted to Hospital?

  1. All patients should have the following tests performed on admission:
    • Oxygenation saturations and, where necessary, arterial blood gases in accordance with the British Thoracic Society (BTS) guideline for emergency oxygen use in adult patients [B+]
    • Chest radiograph to allow accurate diagnosis [B+]
    • Urea and electrolytes to inform severity assessment [B+]
    • C-reactive protein to aid diagnosis and as a baseline measure [B+]
    • Full blood count [B-]
    • Liver function tests [D]

Why Are Microbiological Investigations Performed?

  1. Microbiological tests should be performed on all patients with moderate and high severity CAP, the extent of investigation in these patients being guided by severity. [D]
  2. For patients with low severity CAP the extent of microbiological investigations should be guided by clinical factors (age, comorbid illness, severity indicators), epidemiological factors and prior antibiotic therapy. [A-]
  3. Where there is clear microbiological evidence of a specific pathogen, empirical antibiotics should be changed to the appropriate pathogen-focused agent unless there are legitimate concerns about dual pathogen infection. [D]

What Microbiological Investigations Should Be Performed in the Community?

  1. For patients managed in the community, microbiological investigations are not recommended routinely. [D]
  2. Examination of sputum should be considered for patients who do not respond to empirical antibiotic therapy. [D]
  3. Examination of sputum for Mycobacterium tuberculosis should be considered for patients with a persistent productive cough, especially if malaise, weight loss or night sweats, or risk factors for tuberculosis (e.g., ethnic origin, social deprivation, elderly) are present. [D]
  4. Urine antigen investigations, polymerase chain reaction (PCR) of upper (e.g., nose and throat swabs) or lower (e.g., sputum) respiratory tract samples or serological investigations may be considered during outbreaks (e.g., Legionnaires' disease) or epidemic mycoplasma years, or when there is a particular clinical or epidemiological reason. [D]

What Microbiological Investigations Should Be Performed in Hospital?

Blood Cultures

  1. Blood cultures are recommended for all patients with moderate and high severity CAP, preferably before antibiotic therapy is commenced. [D]
  2. If a diagnosis of CAP has been definitely confirmed and a patient has low severity pneumonia with no comorbid disease, blood cultures may be omitted. [A-]

Sputum Cultures

  1. Sputum samples should be sent for culture and sensitivity tests from patients with CAP of moderate severity who are able to expectorate purulent samples and have not received prior antibiotic therapy. Specimens should be transported rapidly to the laboratory. [A-]
  2. Culture of sputum or other lower respiratory tract samples should also be performed for all patients with high severity CAP or those who fail to improve. [A-]
  3. Sputum cultures for Legionella spp should always be attempted for patients who are legionella urine antigen positive in order to provide isolates for epidemiological typing and comparison with isolates from putative environmental sources. [D]

Sputum Gram Stain

  1. Clinicians should establish with local laboratories the availability or otherwise of sputum Gram stain. Where this is available, laboratories should offer a reliable Gram stain for patients with high severity CAP or complications as occasionally this can give an immediate indicator of the likely pathogen. Routine performance or reporting of sputum Gram stain on all patients is unnecessary but can aid the laboratory interpretations of culture results. [B-]
  2. Samples from patients already in receipt of antimicrobials are rarely helpful in establishing a diagnosis. [B-]
  3. Laboratories performing sputum Gram stains should adhere to strict and locally agreed criteria for interpretation and reporting of results. [B+]

Other Tests for Streptococcus pneumoniae

  1. Pneumococcal urine antigen tests should be performed for all patients with moderate or high severity CAP. [A-]
  2. A rapid testing and reporting service for pneumococcal urine antigen should be available to all hospitals admitting patients with CAP. [B+]

Tests for Legionnaires' Disease

  1. Investigations for legionella pneumonia are recommended for all patients with high severity CAP, for other patients with specific risk factors and for all patients with CAP during outbreaks. [D]
  2. Legionella urine antigen tests should be performed for all patients with high severity CAP. [B+]
  3. A rapid testing and reporting service for legionella urine antigen should be available to all hospitals admitting patients with CAP. [B+]
  4. As the culture of legionella is very important for clinical reasons and source identification, specimens of respiratory secretions, including sputum, should be sent from patients with high severity CAP or where Legionnaires' disease is suspected on epidemiological or clinical grounds. [D] The clinician should specifically request legionella culture on laboratory request forms.
  5. Legionella cultures should be routinely performed on invasive respiratory samples (e.g., obtained by bronchoscopy) from patients with CAP. [D]
  6. For all patients who are legionella urine antigen positive, clinicians should send respiratory specimens such as sputum and request legionella culture. [D] This is to aid outbreak and source investigation with the aim of preventing further cases.

Tests for Mycoplasma pneumoniae

  1. Where available, PCR of respiratory tract samples such as sputum should be the method of choice for the diagnosis of mycoplasma pneumonia. [D]
  2. In the absence of a sputum or lower respiratory tract sample, and where mycoplasma pneumonia is suspected on clinical and epidemiological grounds, a throat swab for Mycoplasma pneumoniae PCR is recommended. [D]
  3. Serology with the complement fixation test and a range of other assays is widely available, although considerable caution is required in interpretation of results. [C]

Tests for Chlamydophila Species

  1. Chlamydophila antigen and/or PCR detection tests should be available for invasive respiratory samples from patients with high severity CAP or where there is a strong suspicion of psittacosis. [D]
  2. The complement fixation test remains the most suitable and practical serological assay for routine diagnosis of respiratory Chlamydophila infections. [B-] There is no currently available serological test that can reliably detect acute infection due to C pneumoniae.

PCR and Serological Tests for Other Respiratory Pathogens

  1. Where PCR for respiratory viruses and atypical pathogens is readily available or obtainable locally, this is preferred to serological investigations. [D]
  2. Where available, paired serology tests can be considered for patients with high severity CAP where no particular microbiological diagnosis has been made by other means (e.g., culture, urine antigen, PCR) and who fail to improve, and/or where there are particular epidemiological risk factors. [D] The date of onset of symptoms should be clearly indicated on all serological request forms. [D]
  3. Serological tests may be extended to all patients admitted to hospital with CAP during outbreaks and when needed for the purposes of surveillance. The criteria for performing serology tests in these circumstances should be agreed locally between clinicians, laboratories and public health. [D]

Severity Assessment

What Severity Assessment Strategy Is Recommended?

  1. Clinical judgement is essential in disease severity assessment. [D]
  2. The stability of any comorbid illness and a patient's social circumstances should be considered when assessing disease severity. [D]

Severity Assessment of CAP in Patients Seen in the Community

  1. For all patients, clinical judgement supported by the Confusion, Respiratory rate, Blood pressure, 65 years and older (CRB65) score should be applied when deciding whether to treat at home or refer to hospital. [D]
  2. Patients who have a CRB65 score of 0 are at low risk of death and do not normally require hospitalisation for clinical reasons. [B+]
  3. Patients who have a CRB65 score of 1 or 2 are at increased risk of death, particularly with a score of 2, and hospital referral and assessment should be considered. [B+]
  4. Patients who have a CRB65 score of 3 or more are at high risk of death and require urgent hospital admission. [B+]
  5. When deciding on home treatment, the patient's social circumstances and wishes must be taken into account in all instances. [D]

Severity Assessment of CAP in Patients Seen in Hospital

  1. For all patients, the Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older (CURB65) score should be interpreted in conjunction with clinical judgement. [D]
  2. Patients who have a CURB65 score of 3 or more are at high risk of death. These patients should be reviewed by a senior physician at the earliest opportunity to refine disease severity assessment and should usually be managed as having high severity pneumonia. Patients with CURB65 scores of 4 and 5 should be assessed with specific consideration to the need for transfer to a critical care unit (high dependency unit or intensive care unit). [B+]
  3. Patients who have a CURB65 score of 2 are at moderate risk of death. They should be considered for short-stay inpatient treatment or hospital-supervised outpatient treatment. [B+]
  4. Patients who have a CURB65 score of 0 or 1 are at low risk of death. These patients may be suitable for treatment at home. [B+]
  5. When deciding on home treatment, the patient's social circumstances and wishes must be taken into account in all instances. [D]

Reviewing Severity Status after Initial Assessment

  1. Regular assessment of disease severity is recommended for all patients following hospital admission. The 'post take' round by a senior doctor and the medical team provides one early opportunity for this review. [D]
  2. All patients deemed at high risk of death on admission to hospital should be reviewed medically at least 12-hourly until shown to be improving. [D]

General Management

General Management Strategy for Patients Treated in the Community

  1. Patients with suspected CAP should be advised to rest, to drink plenty of fluids and not to smoke. [D]
  2. Pleuritic pain should be relieved using simple analgesia such as paracetamol. [D]
  3. The need for hospital referral should be assessed using the criteria recommended in section 6 in the original guideline document. [C]
  4. Pulse oximetry, with appropriate training, should be available to general practitioners and others responsible for the assessment of patients in the out-of-hours setting for the assessment of severity and oxygen requirement in patients with CAP and other acute respiratory illnesses. [D]

Review Policy for Patients Managed in the Community

  1. Review of patients in the community with CAP is recommended after 48 h or earlier if clinically indicated. Disease severity assessment should form part of the clinical review. [D]
  2. Those who fail to improve after 48 h of treatment should be considered for hospital admission or chest radiography. [D]

General Management Strategy for Patients Treated in Hospital

  1. All patients should receive appropriate oxygen therapy with monitoring of oxygen saturations and inspired oxygen concentration with the aim to maintain arterial oxygen tension (PaO2) at ≥8 kPa and oxygen saturation (SpO2) 94%–98%. High concentrations of oxygen can safely be given in patients who are not at risk of hypercapnic respiratory failure. [D]
  2. Oxygen therapy in patients at risk of hypercapnic respiratory failure complicated by ventilatory failure should be guided by repeated arterial blood gas measurements. [C]
  3. Patients should be assessed for volume depletion and may require intravenous fluids. [C]
  4. Prophylaxis of venous thromboembolism with low molecular weight heparins should be considered for all patients who are not fully mobile. [A+]
  5. Nutritional support should be given in prolonged illness. [C]
  6. Medical condition permitting, patients admitted to hospital with uncomplicated CAP should sit out of bed for at least 20 min within the first 24 h and mobility should be increased each subsequent day of hospitalisation. [A-]
  7. Patients admitted with uncomplicated pneumonia should not be treated with traditional airway clearance techniques routinely. [B+]
  8. Patients should be offered advice regarding expectoration if there is sputum present. [D]
  9. Airway clearance techniques should be considered if the patient has sputum and difficulty with expectoration or in the event of a pre-existing lung condition. [D]

Monitoring in Hospital

  1. Temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation and inspired oxygen concentration should be monitored and recorded initially at least twice daily and more frequently in those with severe pneumonia or requiring regular oxygen therapy. [C]
  2. C-reactive protein should be remeasured and a chest radiograph repeated in patients who are not progressing satisfactorily after 3 days of treatment. [B+]
  3. Patients should be reviewed within 24 h of planned discharge home, and those suitable for discharge should not have more than one of the following characteristics present (unless they represent the usual baseline status for that patient): temperature >37.8ºC, heart rate >100/min, respiratory rate >24/min, systolic blood pressure <90 mm Hg, oxygen saturation <90%, inability to maintain oral intake and abnormal mental status. [B+]

Critical Care Management of CAP

  1. Patients with CAP admitted to intensive care units (ICUs) should be managed by specialists with appropriate training in intensive care working in close collaboration with specialists in respiratory medicine. [D]
  2. Neither non-invasive ventilation (NIV) nor continuous positive airways pressure (CPAP) support is routinely indicated in the management of patients with respiratory failure due to CAP. [A-]
  3. If a trial of non-invasive support is considered indicated in CAP, it must only be conducted in a critical care area where immediate expertise is available to enable a rapid transition to invasive ventilation. [D]
  4. Steroids are not recommended in the routine treatment of high severity CAP. [A+]
  5. Granulocyte colony stimulating factor is not routinely recommended as an adjunct to antibiotics. [A+]

Follow-up Arrangements

  1. Clinical review should be arranged for all patients at around 6 weeks, either with their general practitioner or in a hospital clinic. [D]
  2. At discharge or at follow-up, patients should be offered access to information about CAP such as a patient information leaflet. [D]
  3. It is the responsibility of the hospital team to arrange the follow-up plan with the patient and the general practitioner. [D]

Antibiotic Management

Empirical Antibiotic Choice for Adults Treated in the Community

  1. For patients treated in the community, amoxicillin remains the preferred agent at a dose of 500 mg three times daily. [A+]
  2. Either doxycycline [D] or clarithromycin [A-] are appropriate as an alternative choice, and for those patients who are hypersensitive to penicillins.
  3. Those with features of moderate or high severity infection should be admitted urgently to hospital. [C]

Should General Practitioners Administer Antibiotics Prior to Hospital Transfer?

  1. For those patients referred to hospital with suspected CAP and where the illness is considered to be life-threatening, general practitioners should administer antibiotics in the community. [D] Penicillin G 1.2 g intravenously or amoxicillin 1 g orally are the preferred agents.
  2. For those patients referred to hospital with suspected high severity CAP and where there are likely to be delays of over 6 h in the patient being admitted and treated in hospital, general practitioners should consider administering antibiotics in the community. [D]

When Should the First Dose of Antibiotics Be Given to Patients Admitted to Hospital?

  1. A diagnosis of CAP should be confirmed by chest radiography before the commencement of antibiotics in the majority of patients. Selected patients with life-threatening disease should be treated based on a presumptive clinical diagnosis of CAP. In such instances, an immediate chest radiograph to confirm the diagnosis or to indicate an alternative diagnosis is indicated. [D]
  2. All patients should receive antibiotics as soon as the diagnosis of CAP is confirmed. [D] This should be before they leave the initial assessment area (emergency department or acute medical unit). The objective for any service should be to confirm a diagnosis of pneumonia with chest radiography and initiate antibiotic therapy for the majority of patients with CAP within 4 h of presentation to hospital. [B-]

Empirical Antibiotic Choice for Adults Hospitalised with Low Severity CAP

  1. Most patients with low severity CAP can be adequately treated with oral antibiotics. [C]
  2. Oral therapy with amoxicillin is preferred for patients with low severity CAP who require hospital admission for other reasons such as unstable comorbid illnesses or social needs. [D]
  3. When oral therapy is contraindicated, recommended parenteral choices include intravenous amoxicillin or benzylpenicillin, or clarithromycin. [D]

Empirical Antibiotic Choice for Adults Hospitalised with Moderate Severity CAP

  1. Most patients with moderate severity CAP can be adequately treated with oral antibiotics. [C]
  2. Oral therapy with amoxicillin and a macrolide is preferred for patients with moderate severity CAP who require hospital admission. [D]
    • Monotherapy with a macrolide may be suitable for patients who have failed to respond to an adequate course of amoxicillin before admission. Deciding on the adequacy of prior therapy is difficult and is a matter of individual clinical judgement. It is therefore recommended that combination antibiotic therapy is the preferred choice in this situation and that the decision to adopt monotherapy is reviewed on the 'post take' round within the first 24 h of admission. [D]
  3. When oral therapy is contraindicated, the preferred parenteral choices include intravenous amoxicillin or benzylpenicillin, together with clarithromycin. [D]
  4. For those intolerant of penicillins or macrolides, oral doxycycline is the main alternative agent. Oral levofloxacin and oral moxifloxacin are other alternative choices. [D]
  5. When oral therapy is contraindicated in those intolerant of penicillins, recommended parenteral choices include levofloxacin monotherapy or a second-generation (e.g., cefuroxime) or third-generation (e.g., cefotaxime or ceftriaxone) cephalosporin together with clarithromycin. [D]

Empirical Antibiotic Choice for Adults Hospitalised with High Severity CAP

  1. Patients with high severity pneumonia should be treated immediately after diagnosis with parenteral antibiotics. [B-]
  2. An intravenous combination of a broad-spectrum β-lactamase stable antibiotic such as co-amoxiclav together with a macrolide such as clarithromycin is preferred. [C]
  3. In patients allergic to penicillin, a second-generation (e.g., cefuroxime) or third-generation (e.g., cefotaxime or ceftriaxone) cephalosporin can be used instead of co-amoxiclav, together with clarithromycin. [C]

When Should the Intravenous or the Oral Route Be Chosen?

  1. The oral route is recommended in those with low and moderate severity CAP admitted to hospital provided there are no contraindications to oral therapy. [B+]

When Should the Intravenous Route Be Changed to Oral?

  1. Patients treated initially with parenteral antibiotics should be transferred to an oral regimen as soon as clinical improvement occurs and the temperature has been normal for 24 h, providing there is no contraindication to the oral route. Pointers to clinical improvement are given in box 4 in the original guideline document. [B+]
  2. The choice of route of administration should be reviewed initially on the 'post take' round and then daily. [D]
  3. Ward pharmacists could play an important role in facilitating this review by highlighting prescription charts where parenteral antibiotic therapy continues. [D]

Which Oral Antibiotics are Recommended on Completion of Intravenous Therapy?

  1. The antibiotic choices for the switch from intravenous to oral are straightforward where there are effective and equivalent oral and parenteral formulations. [C]
  2. In the case of parenteral cephalosporins, the oral switch to co-amoxiclav 625 mg three times daily is recommended rather than to oral cephalosporins. [D]
  3. For those treated with benzylpenicillin + levofloxacin, oral levofloxacin with or without oral amoxicillin 500 mg–1.0 g three times daily is recommended. [D]

How Long Should Antibiotics Be Given for?

  1. For patients managed in the community and for most patients admitted to hospital with low or moderate severity and uncomplicated pneumonia, 7 days of appropriate antibiotics is recommended. [C]
  2. For those with high severity microbiologically-undefined pneumonia, 7–10 days of treatment is proposed. This may need to be extended to 14 or 21 days according to clinical judgement; for example, where Staphylococcus aureus or Gram-negative enteric bacilli pneumonia is suspected or confirmed. [C]

Failure of Initial Empirical Therapy

  1. When a change in empirical antibiotic therapy is considered necessary, a macrolide could be substituted for or added to the treatment for those with low severity pneumonia treated with amoxicillin monotherapy in the community or in hospital. [D]
  2. For those with moderate severity pneumonia in hospital on combination therapy, changing to doxycycline or a fluoroquinolone with effective pneumococcal cover are alternative options. [D]
  3. Adding a fluoroquinolone is an option for those with high severity pneumonia not responding to a β-lactam/macrolide combination antibiotic regimen. [D]

Avoiding Inappropriate Antibiotic Prescribing

  1. The diagnosis of CAP and the decision to start antibiotics should be reviewed by a senior clinician at the earliest opportunity. There should be no barrier to discontinuing antibiotics if they are not indicated. [D]
  2. The indication for antibiotics should be clearly documented in the medical notes. [D]
  3. The need for intravenous antibiotics should be reviewed daily. [D]
  4. De-escalation of therapy, including the switch from intravenous to oral antibiotics, should be considered as soon as is appropriate, taking into account response to treatment and changing illness severity. [D]
  5. Strong consideration should be given to narrowing the spectrum of antibiotic therapy when specific pathogens are identified or when the patient's condition improves. [D]
  6. Where appropriate, stop dates should be specified for antibiotic prescriptions. [D]

Optimum Antibiotic Choices When Specific Pathogens Have Been Identified

  1. If a specific pathogen has been identified, the antibiotic recommendations are as summarised in table 6 in the original guideline document. [C]

Specific Issues Regarding the Management of Legionnaires' Disease

  1. As soon as a diagnosis of legionella pneumonia has been made, the clinician should liaise with the clinical microbiologist to confirm that the local Health Protection Unit has been informed. The Health Protection Unit is responsible for promptly investigating the potential sources of infection. [D]
  2. The clinician should assist, where appropriate, in the gathering of clinical and epidemiological information from the patient and their relatives to aid the source investigation. [D]
  3. Sputum or respiratory secretions should be sent off specifically for legionella culture in proven cases, even after appropriate antibiotics have started. [D]
  4. For low and moderate severity community acquired legionella pneumonia, an oral fluoroquinolone is recommended. In the unusual case when this is not possible due to patient intolerance, a macrolide is an alternative. [D] Antibiotics are not required for the non-pneumonic self-limiting form of legionellosis—Pontiac fever. [D]
  5. For the management of high severity or life-threatening legionella pneumonia, a fluoroquinolone is recommended. For the first few days this can be combined with a macrolide (azithromycin is an option in countries where it is used for pneumonia) or rifampicin as an alternative. [D] Clinicians should be alert to the potential small risk of cardiac electrophysiological abnormalities with quinolone-macrolide combinations.
  6. Duration of therapy should be as for microbiologically-undefined CAP (for those with low to moderate severity pneumonia, 7 days treatment is proposed; for those with high severity pneumonia, 7–10 days treatment is proposed—this may need to be extended to 14 or 21 days) and should be guided by clinical judgement. [D]

Specific Issues Regarding Panton-Valentine Leukocidin-Producing Staphylococcus aureus (PVL-SA)

  1. PVL-SA infection is a rare cause of high severity pneumonia and can be associated with rapid lung cavitation and multiorgan failure. Such patients should be considered for critical care admission. [D]
  2. If PVL-SA necrotising pneumonia is strongly suspected or confirmed, clinicians should liaise urgently with the microbiology department in relation to further antibiotic management and consider referral to the respiratory medicine department for clinical management advice. [D]
  3. Current recommendations for the antibiotic management of strongly suspected necrotising pneumonia include the addition of a combination of intravenous linezolid 600 mg twice daily, intravenous clindamycin 1.2 g four times a day and intravenous rifampicin 600 mg twice daily to the initial empirical antibiotic regimen. As soon as PVL-SA infection is either confirmed or excluded, antibiotic therapy should be narrowed accordingly. [D]

Complications and Failure to Improve

Failure to Improve in Hospital

  1. For patients who fail to improve as expected, there should be a careful review by an experienced clinician of the clinical history, examination, prescription chart and results of all available investigation results. [D]
  2. Further investigations including a repeat chest radiograph, C-reactive protein and white cell count and further specimens for microbiological testing should be considered in the light of any new information after the clinical review. [D]
  3. Referral to a respiratory physician should be considered. [D]

Common Complications of CAP

  1. Early thoracocentesis is indicated for all patients with a parapneumonic effusion. [D]
  2. Those found to have an empyema or clear pleural fluid with pH <7.2 should have early and effective pleural fluid drainage. [C]
  3. The British Thoracic Society guidelines for the management of pleural infection should be followed. [D]
  4. Less usual respiratory pathogens including anaerobes, S aureus, Gram-negative enteric bacilli and S milleri should be considered in the presence of lung abscess. [D]
  5. Prolonged antibiotic therapy of up to 6 weeks depending on clinical response and occasionally surgical drainage should be considered. [D]

Prevention and Vaccination

Influenza and Pneumococcal Vaccination

  1. Department of Health guidelines in relation to influenza and pneumococcal immunisation of at-risk individuals should be followed. [C]
  2. All patients aged >65 years or at risk of invasive pneumococcal disease who are admitted with CAP and who have not previously received pneumococcal vaccine should receive 23-valent pneumococcal polysaccharide vaccine (23-PPV) at convalescence in line with the Department of Health guidelines. [C]

Smoking Cessation

  1. Smoking cessation advice should be offered to all patients with CAP who are current smokers according to smoking cessation guidelines issued by the Health Education Authority. [B+]

Definitions:

Brief Description of the Generic Levels of Evidence and Guideline Statement Grades Used

Evidence Level Definition Guideline Statement Grade
Ia A good recent systematic review of studies designed to answer the question of interest A+
Ib One or more rigorous studies designed to answer the question, but not formally combined A-
II One or more prospective clinical studies which illuminate, but do not rigorously answer, the question B+
III One or more retrospective clinical studies which illuminate, but do not rigorously answer, the question B-
IVa Formal combination of expert views C
IVb Other information D
Clinical Algorithm(s)

The following clinical algorithms are provided in the original guideline document:

  • Synopsis of the management of adult patients seen in the community with suspected community acquired pneumonia, with cross reference to relevant sections in the document text
  • Synopsis of the management of adult patients seen in hospital with suspected community acquired pneumonia, with cross reference to relevant sections in the document text
  • Suggested algorithm for serological testing for patients with high severity community acquired pneumonia (CAP)
  • Severity assessment of community acquired pneumonia (CAP) in patients seen in the community (CRB65 severity score plus clinical judgement)
  • Hospital management of community acquired pneumonia (CAP) in the first 4 h

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Accurate diagnosis and appropriate treatment of community acquired pneumonia (CAP) to improve symptoms, decrease complication rates and improve outcomes
  • Appropriate utilization of antibiotic therapy for community acquired pneumonia to decrease morbidity and mortality and prevent antibiotic overuse
  • Prevention of CAP by immunisation
Potential Harms
  • Antibiotic resistance of respiratory pathogens
  • In view of the increased risk of adverse hepatic reactions associated with moxifloxacin, the European Medicines Agency recommended in July 2008 that moxifloxacin should only be given in community acquired pneumonia (CAP) when treatment with other antibiotics cannot be used. Similar advice is given in the British National Formulary (http://www.bnf.org/bnf/ External Web Site Policy).
  • A small minority of patients will be allergic to both penicillins and cephalosporins.
  • Parenteral administration of antibiotics causes discomfort to the patient due to the insertion of the intravenous devices and there are significant complications, notably infection.

Implementation of the Guideline

Description of Implementation Strategy

Implementation of the Guidelines

The developers expect that these guidelines will act as a framework for local development or modification of protocols after discussion with local clinicians and management. The subsequent dissemination, implementation and evaluation of these guidelines should be undertaken by the hospital Quality and Clinical Effectiveness Group in conjunction with relevant committees such as those responsible for therapeutics, antibiotic prescribing or protocol development. Countries with similar health service systems will also find the framework of value, adapting the guidelines to take into account any relevant national differences in disease presentation and the availability of investigations and antimicrobial agents.

Implementation Tools
Audit Criteria/Indicators
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Le Jeune I, Macfarlane JT, Read RC, Roberts HJ, Levy ML, Wani M, Woodhead MA, Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009 Oct;64(Suppl 3):iii1-55. [502 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2004 (revised 2009 Oct)
Guideline Developer(s)
British Thoracic Society - Medical Specialty Society
Source(s) of Funding

British Thoracic Society

Guideline Committee

Pneumonia Guidelines Committee

Composition of Group That Authored the Guideline

Committee Members: Wei Shen Lim (Chairman), Consultant Respiratory Physician, Nottingham University Hospitals; Simon Baudouin, Senior Lecturer in Critical Care Medicine, Royal Victoria Infirmary and Intensive Care Society; Robert George, Director Respiratory and Systemic Infections Department, Health Protection Agency Centre for Infections, Colindale; Adam Hill, Consultant Respiratory Physician, Edinburgh Royal Infirmary; Conor Jamieson, Principal Pharmacist – Anti-infectives, Heart of England NHS Trust and British Society of Antimicrobial Chemotherapy; Ivan Le Jeune, Consultant in Acute Medicine, Nottingham University Hospitals and Society for Acute Medicine; John Macfarlane, Professor of Respiratory Medicine, University of Nottingham and Consultant Respiratory Physician, Nottingham University Hospitals; Robert Read, Professor in Infectious Diseases, University of Sheffield and British Infection Society; Helen Roberts, Specialist Registrar in Respiratory Medicine, Mid-Trent rotation, Nottingham University Hospitals; Mark Levy, General Practitioner, Royal College of General Practitioners and General Practice Airways Group (GPIAG); Mushtaq Wani, Health Care of the Elderly Consultant, Swansea NHS Trust and British Geriatrics Society; Mark Woodhead, Consultant Respiratory Physician, Manchester Royal Infirmary

Financial Disclosures/Conflicts of Interest

The committee members fulfilled the requirements of the British Thoracic Society (BTS) regarding personal declaration of interests. Declaration of interest forms were updated annually by committee members and the contents submitted to the BTS Standards of Care Committee. These are available for inspection on request from the Chairman of this Committee.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: BTS Pneumonia Guidelines Committee. BTS guidelines for the management of community acquired pneumonia in adults - 2004 update. London (UK): British Thoracic Society; 2004. 22 p. [37 references]

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the British Thoracic Society Web site External Web Site Policy.

Availability of Companion Documents

An audit tool is available to registered users from the British Thoracic Society (BTS) Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on August 17, 2012. The information was verified by the guideline developer on October 4, 2012. This summary was updated by ECRI Institute on October 25, 2013 following the U.S. Food and Drug Administration advisory on Fluoroquinolone Antibacterial Drugs. This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen. This summary was updated by ECRI Institute on March 10, 2014 following the U.S. Food and Drug Administration advisory on Low Molecular Weight Heparins.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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