Community Acquired Pneumonia
Singleton Ambulatory Care and Minor Injuries Unit
(MIU)
Prepared by: Dr Chris Johns-Singleton MIU Lead GP
Background
See ABMU Community Acquired Pneumonia Dr N K Harrison Dr E N Evans
May 2004-(due for review Aug 2011)
http://www.britthoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/CAPGuideli
ne-full.pdf
Singleton Hospital is undergoing transformational change moving towards provision
of services on an ambulatory basis. There are plans to consider adopting a Portsmouth
model with acute GPs from MIU taking calls for admission from Swansea Primary
Care colleagues. Where appropriate patients will be assessed, investigated and
discharged back to the community by the acute GP service. During operational hours
the service would
• Receives community requests (GP and where appropriate downgraded ambulance
service request) for adult medical admissions
• Identifies needs of both patient and carer, and seeks to address them in the most
expedient manner
• Supports the Intermediate Care Team with the development of alternatives to acute
hospital admission
This model promotes choice and ownership within each episode of urgent care. It
provides a responsive service and ensures:
• The patient’s choice is always an informed one,
• Decisions are made with them, rather than for them, about where the most
appropriate care can be provided and,
• Risk management plans are discussed and agreed upon. It also provides an
opportunity for GPs and hospital Physicians to challenge traditional ways of working,
and to build relationships enhanced by mutual respect, trust, and an understanding of
each other’s strengths and weaknesses.
One of the areas of care the Portsmouth model has focused on is risk stratification and
treatment of Community Acquire Pneumonia
Singleton Minor Injuries GP could assess and treat and discharge low risk patients
and arrange appropriate review with colleague GPs or OPD review. Moderate and
high risk patients would be treated and seen in the usual way but there would be
benefits of initial investigations having been completed.
Many GPs will refer patients to SAU in this clinical category with SOB ? cause or ?
PUO or have clinical suspicions on auscultation. Urgent on the day CXR with
reporting and Pathology is often not available for GPs. Simple assessment and straight
forward investigation would allow many patients to be assessed, treated and
discharged by an acute GP unit.
MIU assessment
History, Examination following GP letter of referral
Initial investigations
1. CXR
2. FBC
3. U and E, LFT and glucose
4. CRP
5. Further investigations dependant on history and clinical suspicions
If CXR shows Pneumonic change then progress to. Radiology or General
Medical support to review X ray at Singleton if available
CURB65 and CRB65 Clinical Severity Scoring
Clinical factor
Points
Confusion
1
Blood urea nitrogen > 7mmol/l
1
Respiratory rate > 30 breaths per minute
1
Systolic blood pressure < 90 mm Hg
or
Diastolic blood pressure < 60 mm Hg
Age > 65 years
1
Total points:
1
CURB-65 score
Mortality (%)
Recommendation
0
0.6
1
2.7
2
6.8
Short inpatient hospitalisation or closely
supervised outpatient treatment
3
14.0
4 or 5
27.8
Severe pneumonia; hospitalise and consider
admitting to intensive care
CRB-65 score
Mortality (%)
0
0.9
Very low risk of death; usually does not require
hospitalisation
1
5.2
Increased risk of death; consider hospitalisation
2
12.0
3 or 4
31.2
Low risk; consider home treatment
Recommendation
High risk of death; urgent hospitalisation
CURB-65 = Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of
age and older.
CRB-65 = Confusion, Respiratory rate, Blood pressure, 65 years of age and older.
Additional adverse prognostic features include:
Coexisting disease
Hypoxaemia (SpO2 <92%, PaO2 <8kPa)
Bilateral/multilobe involvement
COMMUNITY AQUIRED PNEUMONIA FLOWCHART
Triage/Initial Assessment suggestive of CAP
Result of CXR reviewed by clinician
No consolidation
Consolidation
Reassess
Does the patient meet Criteria for
CAP?
Yes
No
Treat according to clinical judgement and
CURB65 severity score
0-1
Low severity
(risk of death <3%)
2
Moderate severity
(risk of death 9%)
3-5
High severity
(risk of death 15-40%)
Consider other diagnoses
and treat as appropriate
Other reasons for
admission
(unstable comorbidity, social
No
Hospital
SAU
Hospital
SAU
CURB65 Severity Score
1 point for each feature
present
Yes
Home
Antibiotics
Review in
MIU 24
hours later




Hospital SAU
Aim by 4 hours: diagnosis made and
management including antibiotics
started

Confusion
Urea > 7 mmol/l
Respiratory rate ≥ 30/min
Blood pressure (SBP <90
or DBP ≤ 60mmHg)
Age ≥ 65 years
Low Severity CAP Antibiotic Therapy (ABMU Formulary)
Communityacquired
pneumonia treatment in
the
community2,3
BTS 2009
Guideline
Use CRB65 score to help guide and
review:1 Each scores 1: Confusion
(AMT<8);
Respiratory rate >30/min;
BP systolic <90 or diastolic ≤ 60;
Age ≥65 years
Score 0: suitable for home treatment;
Score 1-2: hospital assessment or
admission
Score 3-4: urgent hospital admission
Give immediate IM benzylpenicillin or
amoxicillin 1G po D if delayed
admission/life threatening
Mycoplasma infection is rare in over
65s 1
IF CRB65=0:
amoxicillinA+ or
clarithromycin Aor doxycycline D
If CRB65=1 & AT
HOME
amoxicillin A+
AND clarithromycin Aor doxycycline alone
500 mg TDS
500 mg BD
200 mg stat/100 mg
OD
7 days
7 days
7 days
500 mg TDS
500 mg BD
200 mg stat/100 mg
OD
7-10 days
7-10 days