Dr Caroline Ward highlights four key learning points from the 2019 NICE guideline on antimicrobial prescribing in community-acquired pneumonia

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Dr Caroline Ward

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Read this article to learn more about:

  • the most common causes of pneumonia in adults and children
  • how to assess the severity of pneumonia
  • when to suspect bacterial pneumonia, and when antibiotics are appropriate
  • when to refer patients with pneumonia to secondary care.

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Community-acquired pneumonia (CAP) is a lower respiratory tract infection most commonly caused by bacteria; however, viruses are thought to cause approximately 13% of cases in adults, and approximately 66% of cases in children and young people. The main bacterial pathogen causing CAP is Streptococcus pneumoniae, followed by Haemophilus influenzae; epidemics of Mycoplasma pneumoniae occur approximately every 4 years in the UK, and mainly affect children.1

Prospective population studies have reported an annual incidence of CAP in the community of between 5 and 11 per 1000 in the adult population.2 This means that the average full-time GP in England, with a list size of 2087 patients,3 can expect to see between 10 and 23 cases of CAP per year. Incidence varies greatly with age, being much higher in the young and the elderly. Increasing age is associated with an increasing likelihood of admission to hospital with CAP.2 Deaths due to CAP in the community are unusual, with a reported mortality in adults of less than 1%.2

Inappropriate prescribing of antibiotics for respiratory tract infections is common in general practice.4 This includes antibiotics prescribed for viral bronchitis, a common differential diagnosis of CAP. Studies have shown that most UK general practices prescribe antibiotics to adults with respiratory infections at rates that are considerably higher than what is clinically indicated; evidence from primary care has shown that the median practice prescribed antibiotics at 48% of consultations for ‘cough and bronchitis’, while the highest prescribing 10% of practices issued antibiotic prescriptions at 67% of consultations for ‘cough’.4 This overuse of antibiotics is a key driver in antibiotic resistance.

In adults, most cases of pneumonia are caused by bacterial infections. Pneumonia caused by viral infection is more common in children than in adults. Therefore, in systemically well children, auscultatory chest findings alone (such as crackles) are not sensitive or specific enough to confirm a diagnosis of bacterial pneumonia.5

In September 2019, NICE published NICE Guideline (NG) 138 on Pneumonia (community-acquired): antimicrobial prescribing. The guideline aims to optimise antibiotic use and reduce antibiotic resistance by encouraging the prescribing of narrow-spectrum antibiotics and a limited course length for the treatment of CAP.1 Previous guidance on the management of pneumonia did not include detailed recommendations on which antibiotics should be used. This article focuses on the recommendations that primary care clinicians need to know from NG138.

1. Assess the severity of CAP

The CRB65 score should be used in primary care to assess the 30-day mortality risk in adult patients diagnosed with CAP. The score is calculated by giving one point for each of the following prognostic features:1

  • c onfusion
  • r espiratory rate ≥30 breaths/minute
  • systolic b lood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg
  • age ≥65 years.

Mortality risk is stratified by CRB65 as follows:1

  • 0: low risk (less than 1% mortality risk)
  • 1 or 2: intermediate risk (1% to 10% mortality risk)
  • 3 or 4: high risk (more than 10% mortality risk).

Features suggesting severe pneumonia in children and young people may include difficulty breathing, oxygen saturation <90%, raised heart rate, grunting, severe chest recession, inability to breastfeed or drink, lethargy, and reduced level of consciousness.1 The severity of symptoms and signs should be assessed by clinical judgement, taking these features into account.

In hospital, the CURB65 score is used to assess 30-day mortality risk in adults.1

2. Use CRB65 and clinical judgement to inform referral decisions

A combination of clinical judgement and CRB65 score should be used to inform decisions about admission to hospital of adult patients. Those with a CRB65 score of 0 can normally be managed in the community; patients with scores of 1 and particularly 2 are at increased mortality risk and should be considered for hospital referral. Those with a score of 3 or more are at high risk of death and require urgent hospital admission.1 However, other factors that should be considered when deciding about hospital admission include the person’s wishes, social circumstances, comorbidity, and pulse oximetry.

Consideration should be given to referring all children and young people with CAP to hospital or seeking specialist paediatric advice.

3. Know when to prescribe antibiotics

NICE Guideline 120 on Cough (acute): antimicrobial prescribing states:6

do not routinely offer an antibiotic to treat an acute cough associated with acute bronchitis in people who are not systemically very unwell or at higher risk of complications

NG120 also emphasises the importance of face-to-face clinical examination in patients with acute cough if prescription of an antibiotic is being considered.6 Clinicians should therefore avoid issuing antibiotics for cough without a face-to-face examination.6 If bacterial pneumonia is suspected, it is important to assess the clinical signs and to determine their severity.1,7 If considering antibiotics for cough or pneumonia via remote consultation, it is important to establish whether the patient is systemically unwell; this usually requires physical examination, so the patient should be offered a face-to-face consultation.

In patients with low-severity pneumonia, evidence shows that there are no significant differences in the clinical effectiveness of narrow- versus broad-spectrum antibiotics, therefore narrow-spectrum antibiotics should be used first-line in order to limit antimicrobial resistance.1

An antibiotic should be offered within 4 hours of establishing a diagnosis of pneumonia, and a 5-day course is considered appropriate in all severity gradings.1 Some computer systems may default it to a 7-day course of the recommended antibiotic and this may need to be overridden manually. Antibiotic course length can be increased if microbiological results suggest a longer course is needed or if the person is not clinically stable (i.e. ongoing fever, low systolic blood pressure, raised heart or respiratory rate, low oxygen saturation). Such patients are usually managed in hospital, so in the community a 5-day course is more common practice.1

In practice, patients often return at the end of the antibiotic course due to concerns that symptoms have not resolved; however, in pneumonia, we should not expect symptom resolution at this stage. When issuing an antibiotic, it is important to explain to patients that their symptoms are highly unlikely to have resolved at the end of the course, but that the infection will have been adequately treated. It may be helpful to bear in mind that chest X-rays are not expected to return to normal for up to 6 weeks after pneumonia, reflecting the ongoing inflammatory rather than infective process. Explain to patients that after starting antibiotics their symptoms should steadily improve (and if they do not, it is important that they return for reassessment), although the rate of improvement will vary with the severity of the infection. Most people can expect:7

  • 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.

In adults, antibiotic choice and dosage for treating pneumonia are defined by severity (see Table 1).1 In children, antibiotic choice and dosage for treating pneumonia are defined by the severity of symptoms or signs (see Table 2).1

Table 1: Antibiotics for adults aged 18 years and over1
AntibioticADosage and course lengthB

First-choice oral antibiotic if low severity (based on clinical judgement and guided by CRB65 score 0, or CURB65 score 0 or 1)C

Amoxicillin

500 mg 3 times a day (higher doses can be used—see BNF) for 5 daysD

Alternative oral antibiotics if low severity, for penicillin allergy or if amoxicillin unsuitable (for example, atypical pathogens suspectedE)C

Doxycycline

200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)D

Clarithromycin

500 mg twice a day for 5 daysD

Erythromycin (in pregnancy)

500 mg 4 times a day for 5 daysD

First-choice oral antibiotics if moderate severity (based on clinical judgement and guided by CRB65 score 1 or 2, or CURB65 score 2); guided by microbiological results when availableC

Amoxicillinwith (if atypical pathogens suspectedE):

500 mg 3 times a day (higher doses can be used—see  BNF) for 5 daysD

ClarithromycinFor

500 mg twice a day for 5 daysD

ErythromycinF (in pregnancy)

500 mg 4 times a day for 5 daysD

Alternative oral antibiotics if moderate severity, for penicillin allergy; guided by microbiological results when availableC

Doxycycline

200 mg on first day, then 100 mg once a day for 4 days

(5-day course in total)D

Clarithromycin

500 mg twice a day for 5 daysD

First-choice antibiotics if high severity (based on clinical judgement and guided by CRB65 score 3 or 4, or CURB65 score 3 to 5); guided by microbiological results when availableC

Co‑amoxiclav with:

500/125 mg 3 times a day orally or 1.2 g 3 times a day IVG for 5 daysD

Clarithromycin or

500 mg twice a day orally or IVG for 5 daysD

Erythromycin (in pregnancy)

500 mg 4 times a day orally for 5 daysD

Alternative antibiotic if high severity, for penicillin allergy; guided by microbiological results when availableC

LevofloxacinH (consider safety issues)

500 mg twice a day orally or IVG for 5 daysE

Consult local microbiologist if fluoroquinolone not appropriate.

A. See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.

B. Oral doses are for immediate-release medicines.

C. Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.

D. Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course is needed or the person is not clinically stable (fever in past 48 hours or more than 1 sign of clinical instability [systolic blood pressure <90 mmHg, heart rate >100/minute, respiratory rate >24/minute, arterial oxygen saturation <90% or PaO2 <60 mmHg in room air]).

E. Mycoplasma pneumoniaeinfection occurs in outbreaks approximately every 4 years.

F. Consider adding a macrolide to amoxicillin if atypical pathogens suspected. Review when microbiological results available.

G. Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible.

H. See Medicines and Healthcare products Regulatory Agency (MHRA) advice for restrictions and precautions for using fluoroquinolone antibiotics because of very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution for people over 60 years and avoiding coadministration with a corticosteroid (March 2019).

CRB65=c onfusion, r espiratory rate ≥30/minute, low systolic [<90 mmHg] or diastolic [≤60 mmHg] b lood pressure, age ≥65; CURB65=c onfusion, u rea >7 mmol/l, r espiratory rate ≥30/minute, low systolic [<90 mmHg] or diastolic [≤60 mmHg] b lood pressure, age ≥65; BNF=British National Formulary; IV=intravenous; PaO2 =partial pressure of oxygen

© NICE 2019. Pneumonia (community-acquired): antimicrobial prescribing. Available from: www.nice.org.uk/guidance/ng138 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Table 2: Antibiotics for non-severe symptoms or signs in children1
AntibioticADosage and course lengthB

Children under 1 month

Refer to paediatric specialist.

Children aged 1 month and over

First-choice oral antibiotic if non-severe symptoms or signs (based on clinical judgement)C

Amoxicillin

1 month to 11 months, 125 mg 3 times a day for 5 daysD

1 year to 4 years, 250 mg 3 times a day for 5 daysD

5 years to 17 years, 500 mg 3 times a day for 5 daysD (higher doses can be used for all ages—see BNF for children)

Alternative oral antibiotics if non-severe symptoms or signs (based on clinical judgement), for penicillin allergy or if amoxicillin unsuitable (for example, atypical pathogens suspectedE)C

Clarithromycin

1 month to 11 years:

  • Under 8 kg, 7.5 mg/kg twice a day for 5 daysD
  • 8 kg to 11 kg, 62.5 mg twice a day for 5 daysD
  • 12 kg to 19 kg, 125 mg twice a day for 5 daysD
  • 20 kg to 29 kg, 187.5 mg twice a day for 5 daysD
  • 30 kg to 40 kg, 250 mg twice a day for 5 daysD

12 years to 17 years:

  • 250 mg to 500 mg twice a day for 5 daysD

Erythromycin (in pregnancy)

8 years to 17 years, 250 mg to 500 mg 4 times a day for 5 daysD

DoxycyclineF

12 years to 17 years, 200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)D

First-choice antibiotic(s) if severe symptomsor signs (based on clinical judgement); guided by microbiological results when availableC

Co‑amoxiclav

Oral doses:

  • 1 month to 11 months, 0.5 ml/kg of 125/31 suspension 3 times a day for 5 daysD
  • 1 years to 5 years, 10 ml of 125/31 suspension 3 times a day or 0.5 ml/kg of 125/31 suspension 3 times a day for 5 daysD,G
  • 6 years to 11 years, 10 ml of 250/62 suspension 3 times a day or 0.3 ml/kg of 250/62 suspension 3 times a day for 5 daysD
  • 12 years to 17 years, 500/125 mg 3 times a day for 5 daysD

IV dosesH:

  • 1 month to 2 months, 30 mg/kg 2 times a dayD
  • 3 months to 17 years, 30 mg/kg 3 times a day (maximum 1.2 g per dose 3 times a day)D

With (if atypical pathogen suspectedE):

Clarithromycin or

Oral doses: see above for clarithromycin; for 5 daysD

IV dosesH:

  • 1 month to 11 years, 7.5 mg/kg twice a day (maximum 500 mg per dose)D
  • 12 years to 17 years, 500 mg twice a dayD

Erythromycin (in pregnancy)

See oral dose above for erythromycin; for 5 daysD

Alternative antibiotics if severe symptoms or signs (based on clinical judgement), for penicillin allergy; guided by microbiological results when availableC

Consult local microbiologist.

A. See BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.

B. Oral doses are for immediate-release medicines. The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition being treated and the child’s size in relation to the average size of children of the same age.

C. Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.

D. Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course length is needed or the person is not clinically stable.

E. Mycoplasma pneumoniaeinfection occurs in outbreaks approximately every 4 years and is more common in school-aged children.

F.See BNF for children for use of doxycycline in children under 12.

G.Or 5 ml of 250/62 suspension.

H.Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible.

BNFC=British National Formulary for children; IV=intravenous

© NICE 2019. Pneumonia (community-acquired): antimicrobial prescribing. Available from: www.nice.org.uk/guidance/ng138All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licencefor further details.

4. Consider testing respiratory samples

Sputum samples do not need to be routinely sent for patients with CAP treated in primary care.7 However, they can be useful if signs or symptoms have not improved as expected after antibiotic treatment,1 or in people who have previously had frequent courses of antibiotics, as this increases the likelihood of resistant organisms.

If a sample has been sent for microbiological testing, the choice of antibiotic should be reviewed when results are available, and consideration should be given to changing antibiotic according to the results, using a narrower-spectrum antibiotic if appropriate.1

Respiratory sampling in children is not usually required in primary care; however, NG138 recommends sending a sputum sample for microbiological testing if symptoms or signs have not improved following antibiotic treatment.1 Sputum samples can also be considered for children and young people in hospital with community-acquired pneumonia and severe symptoms or signs or a co-morbidity.1

Dr Caroline Ward

GP and member of the NG138 guideline development group

Key points

  • Assess and record the CRB65 score when diagnosing pneumonia in adult patients
  • In adult patients, use the CRB65 score and clinical judgement to decide if hospital admission is required
  • Use narrow-spectrum antibiotics as first-line treatment for low-severity pneumonia in adults
  • Antibiotic course length is 5 days for adults and children, regardless of severity grading
  • Consider sputum sampling if symptoms are not improving as expected
  • Advise patients on the expected natural course of symptom improvement.

CRB65=confusion, respiratory rate ≥30/minute, low systolic [<90 mmHg] or diastolic [≤60 mmHg] blood pressure, age ≥65

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources. 

  • Publicise and disseminate this guidance among all health service providers but especially GPs, out-of-hours providers, pharmacies, and walk-in centres
  • Emphasise the need for face-to-face assessment of patients, in an era that now often provides digital first contacts with health services
  • Challenge the ingrained perception, in both patients and prescribers, that 7-day courses of antibiotics are needed for community-acquired pneumonia
  • Educate the public about the likely duration of symptoms even after successful treatment of pneumonia, to avoid repeat attendance and antibiotic prescription
  • Identify antibiotic choices and alternatives, where patients have sensitivities, in local formularies.

STP=sustainability and transformation partnership; ICS=integrated care system

Implementation actions for clinical pharmacists in general practice

written by Gupinder Syan, Training and Clinical Outcomes Manager, Soar Beyond Ltd

The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level.

  • Identify acutely unwell patients during medication or respiratory reviews, or minor illness clinics
  • Define inclusion and exclusion criteria for acute assessment of patients by the practice pharmacist
  • Ensure training and development is in place to allow the practice pharmacist to conduct physical examinations competently and within their scope of practice. This includes appropriate GP support and supervision with examinations, clinical decision making, and for prescribing or referral
  • Prepare for clinics and ensure that all necessary equipment is available to carry out clinical assessments and the pharmacist is competent in using it
  • Review patients in clinic: use CRB65 to assess severity; take a detailed history; use clinical judgement to make decisions on prescribing an antibiotic or referring the patient; counsel the patient and manage expectations regarding symptom resolution 
  • Evaluate outcomes by auditing antibiotic use, choice, dose, and course length for pneumonia to assess how the practice is performing with regards to antibiotic stewardship and appropriate prescribing. 

CRB65=confusion, respiratory rate ≥30/minute, low systolic [<90 mmHg] or diastolic [≤60 mmHg] blood pressure, age ≥65 years

References

  1. NICE. Pneumonia (community-acquired): antimicrobial prescribing. NICE guideline 138. NICE, 2019. Available at: www.nice.org.uk/ng138
  2. Lim W, Baudouin S, George R et al. BTS guidelines for the management of community-acquired pneumonia in adults: update 2009. Thorax 2009; 64 (Suppl 3): iii1–iii55.
  3. Gault B. Number of registered patients per GP rises to almost 2,100. www.pulsetoday.co.uk/news/all-news/number-of-registered-patients-per-gp-rises-to-almost-2100/20039037.article (accessed 27 November 2019).
  4. Gulliford M, Dregan A, Moore M et al. Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices. BMJ Open 2014; 4 (10): e006245.
  5. Lakhanpaul M, Atkinson M, Stephenson T. Community acquired pneumonia in children: a clinical update. Arch Dis Child Ed Pract 2004; 89 (2): 29–34.
  6. NICE. Cough (acute): antimicrobial prescribing. NICE Guideline 120. NICE, 2019. Available at: www.nice.org.uk/ng120
  7. NICE. Pneumonia in adults: diagnosis and management. Clinical Guideline 191. NICE, 2019. Available at: www.nice.org.uk/cg191