Updated BTS guidelines on community acquired pneumonia will simplify the assessment of disease severity in primary care, as Dr Peter Saul explains
The BTS Guidelines for the Management of Community Acquired Pneumonia in Adults, which underwent a major update in 2001,1 have recently been subject to a number of small but significant revisions. The updated guidelines reflect consideration by the guidelines development group of a further 130 scientific papers as well as feedback from colleagues.
The update is short, but must be read in conjunction with the 2001 version. Each heading is reviewed and modifications indicated where appropriate. Some key elements of the original document are unchanged; these include the diagnostic features, antibiotic treatment in the community and preventive measures (Box 1, below).
Increasing numbers of vulnerable patients are cared for in nursing homes and treated by GPs, and there had been concern about whether the the guidelines were relevant to this special group.
The evidence is reassuring, with studies showing that pathogens are similar to those in other patients in the community, therefore no special assessment or different treatment is required.2
In their review of investigations, the guidelines point out the increasing availability of urinary antigen tests for Legionella and Streptococcus pneumoniae,3,4 but suggest that their use can be confined to individuals who are seriously ill, so they are probably not useful in primary care. Indeed, the guidelines emphasise that the choice of investigations should be based on the setting and clinical features of the patient.
Although sputum cultures are mentioned with respect to hospitalised patients, they can be easily performed by GPs. They are considered useful, particularly in helping to define antimicrobial treatment in patients who fail to improve. The recommendations have been upgraded from D to A-.
The most interesting and helpful part of the guidelines for practising GPs is the further development and simplification of the severity assessment model.
Six prognostic criteria have been identified as affecting clinical outcomes, four of which – confusion, high respiratory rate, low blood pressure and age – are relevant to and measurable in primary care settings.5 Assessment involves identifying and scoring the presence of each criterion (Figure 1, below). The higher the score the greater the risk of death and the need for hospitalisation. These criteria are easy to remember and will help to inform immediate management.
|Figure 1: Severity assessment used to determine the management of CAP in patients in the community (CRB-65 SCORE)|
|* Defined as Mental Test Score of 8 or less, or new disorientation in person, place or time|
The usefulness of pulse oximetry in the community is emphasised, and the recommendation is strengthened, from D to C.6 The document mentions the need for training in this technique but, unfortunately, does not describe how to interpret the measurements. Support in using this clinical tool is something that GP out-of-hours services will need to address.
Many GPs and carers are concerned that pressure on hospital beds all too often means that patients are discharged early, frequently with inadequate support. The latest revision grasps this nettle, identifying evidence that shows that inadequate discharge planning increases the risk of subsequent readmission and death.7
Hospital clinicians are advised to review patients before discharge to ensure that they do not have more than one of the following (unless they represent the usual baseline status for that patient): fever, high respiratory rate, increased heart rate, low blood pressure, reduced oxygen saturation, confusion or inability to maintain hydration.
Much of this advice is common sense, but by making it explicit the guidelines will improve follow up care and help to reduce GP workload.
In summary, this revision does not alter the basic concepts regarding prevention and treatment of community acquired pneumonia, but it does simplify some of the assessment and should point the way to better follow-up care.
BTS Guidelines for the Management of Community Acquired Pneumonia in Adults can be downloaded from the BTS website: www.brit-thoracic.org.uk
- British Thoracic Society Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in adults. Thorax 2001; 56(Suppl 4): IV1-64.
- Lim WS,Macfarlane JT.A prospective comparison of nursing home acquired pneumonia with community acquired pneumonia. Eur Respir J 2001; 18(2): 362-8.
- Murdoch DR, Laing RT, Mills GD et al. Evaluation of a rapid immunochromatographic test for detection of Streptococcus pneumoniae antigen in urine samples from adults with communityacquired pneumonia. J Clin Microbiol 2001; 39: 3495-8.
- Farina C, Arosio M, Vailati F et al. Urinary detection of Streptococcus pneumoniae antigen for diagnosis of pneumonia. New Microbiol 2002; 25: 259-63.
- Lim WS, van der Eerden MM, Laing R et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58: 377-82.
- Levin KP,Hanusa BH,Rotondi A et al.Arterial blood gas and pulse oximetry in initial management of patients with community-acquired pneumonia. J Gen Intern Med 2001; 16: 590-8.
- Halm EA, Fine MJ, Kapoor WN et al. Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia. Arch Intern Med 2002; 162: 1278-84.