How to treat
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Treating in and out
PROFESSOR NIGEL STOCKS,
professor and head, discipline of
general practice; director,
primary health care research
evaluation and development
program; director, Australian
sentinel practices research
network, school of population
health and clinical practice;
Community-acquired and assistant dean (student),
medical school, faculty of health
sciences, University of Adelaide,
Pneumonia — a disease of diversity
PNEUMONIA PROFESSOR HASSE MELBYE,
professor of general practice,
THE clinical presentation of pneu- tion of a viral infection. determine the course of an infection, nosed as pneumococcal pneumonia, institute of community
monia depends on several factors. When whole lobes have been con- with some bacteria tending to give mycoplasma pneumonia, legionella medicine, University of
Traditionally the disease has been solidated, the lobar pneumonias are rise to a more severe pneumonia pneumonia, etc. The reason is obvi- Tromso, Norway.
subdivided into lobar pneumonia particularly severe and grave hypoxia than others, for example, through ous — the aetiology directs the
and bronchopneumonia. may develop. developing septic infections. By con- choice of treatment.
Lobar pneumonias develop after Bronchopneumonia may also be trast, pneumonias caused by viruses Pneumonias caused by Myco-
inhalation of infectious agents into severe in small children or when a tend to be milder. plasma pneumoniae, Chlamydia
the alveoli, while a bronchopneumo- patient is weakened by old age or The classification of pneumonias pneumoniae and Legionella species
nia has usually been spread from comorbidity. is nowadays mainly based on the have been called ‘atypical’ because
bronchitis or represents a complica- The aetiological agent can also aetiological agent — they are diag- cont’d next page
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How to Treat – community-acquired pneumonia
from previous page
Common causes of pneumonia in the antibiotic era there is
it was thought that their less reason for a nihilistic
clinical presentation was dif- ■ Streptococcus pneumoniae (pneumococci) — the most therapeutic approach to pneu-
ferent from pneumococcal common cause of CAP and the most common agent in monia in the elderly, although
disease. hospitalised patients. Often sudden onset with high fever. there may be circumstances,
However, there is consid- High mortality when not treated with antibiotics. with patient or carer consent,
erable overlap in signs and ■ Haemophilus Influenzae — similar features to pneumococcal when aggressive treatment is
symptoms and more recently infection. Small children, elderly, and patients with COPD or not pursued.
the emphasis laid on aetiol- chronic bronchitis are most frequently infected.
ogy has led to the sub- ■ Mycoplasma pneumoniae — occurs in outbreaks, with an Incidence and mortality of
division of pneumonias incubation period of 2-3 weeks. Fever headache and cough pneumonia
into community-acquired prominent. Chest signs may be minimal despite radiographic European data indicate that
pneumonia (CAP) and hos- changes. the annual incidence of CAP
pital-acquired pneumonia Sir William ■ Chlamydia pneumoniae — similar features to mycoplasma
in the 18-39 age group is six
(HAP). Osler ... infection but not as frequently in epidemics. per 1000, and in those aged
Pneumonias can also be regarded >75 it is 34 per 1000.
■ Legionella pneumophila — spread via water droplets (potable
caused by chemicals, radio- pneumonia as About 20% of patients
“the captain of water and cooling towers), symptoms include diarrhoea, high
therapy and allergic mecha- require hospitalisation and,
the men of fever, hyponatraemia. Relatively high mortality.
nisms, but these are not cov- of these, 5-10% require
ered in this article. admission to intensive care.
The overall mortality from
CAP versus HAP Other frequent causes are of low virulence and seldom common agents and some of death”, and a frequent CAP is 5-10%. In Australia
CAP is defined as pneumo- M pneumoniae, C pneumo- cause infection in healthy will be multi-resistant hospi- cause of death among the the average GP will see
nia that is acquired outside niae and Legionella species. people may attack the lung tal pathogens. elderly. about two cases of CAP per
hospital in a person who is In contrast, pneumonias tissue, as the host defences, The disease could, accord- 1000 population per year.
not immunocompromised. acquired in hospital often including the cough reflex, “Captain of the men of ing to Osler, also be looked at This figure is similar to the
The aetiological agent is arise after procedures involv- are often poor. death” as the old man’s friend, reliev- situation in the US, with 267
most often Streptococcus ing the respiratory tract, Aerobic Gram-negative Sir William Osler, famous ing him from a distressful end per 100,000 population hos-
pneumoniae. It is also the such as anaesthesia and bacteria such as Klebsiella for his medical textbook of of life. pitalised with CAP in 1991
agent that causes the most assisted respiration. pneumoniae and Pseudo- 1892, regarded pneumonia He had no belief in the and an overall case fatality
severe illness. Bacteria that are usually monas aeruginosa are as “the captain of the men treatments of that time. Now rate of 8.8%.
Symptoms and signs of pneumonia
FEVER, cough and dyspnoea have Some of the listed symptoms are Table 1: Frequency (%) of common symptoms and findings in
Symptoms and signs of
been known as the symptoms of not significantly more common in pneumonia in primary care, as found in three clinical studies
pneumonia since the days of Hip- pneumonia than in other lower res-
pocrates. Symptoms piratory tract infections. This is the Frequency (%)
■ Shortness of breath 1 2 3
Chest pain is also often present case for very annoying coughs, Symptom/finding Diehr, et al Melbye, et al Hopstaken, et al
in lobar pneumonia, and may be purulent sputum and wheezes. Very annoying — 65 —
■ Chest pain (pleuritic)
particularly strong when associated cough
with pleuritis. Clinical signs Dry cough — 40 38
■ Rigors or night sweats
However, in most pneumonias The typical signs are rapid breath- Purulent sputum 65 35 59
found in general practice, two or Signs ing, dullness to percussion over an Dyspnoea — 85 72
three of these four cardinal symp- ■ Fever >38ºC involved lung lobe, bronchial Severe dyspnoea — 35 —
toms may be missing or less pro- ■ Raised respiratory rate breathing and localised crackles
Chest pain — 60 66
nounced. ■ Focal chest signs heard on auscultation.
Severe chest pain 17 35 —
This is particularly the case in Wheezes may also be heard,
Chills 31 80 69
pneumonia caused by viruses, alcoholism). either as a sign of a concomitant
C pneumoniae and M pneumoniae, Nausea or diarrhoea may some- bronchitis, or as a localised sign of Crackles (rales) 19 35 32
in which the main symptom is a times be prominent symptoms, and narrowed bronchial branches or Wheezes/rhonchi 15 15 71
persistent dry cough. fever may be absent in infants and mucus plugs in the bronchial tree. Dullness to 4 14 —
Sudden onset of symptoms with the elderly. However, in about half of percussion
chills, or acute worsening of Unsteadiness, as a sign of low- patients with pneumonia diagnosed C-reactive protein — 85 79
influenza or a common cold, may ered blood pressure, tachypnoea, by CXR and encountered in gen- >20mg/L
indicate a pneumonia caused by and mental confusion, are severe eral practice, none of these signs C-reactive protein — 55 60
‘typical’ bacteria, such as pneumo- symptoms that may indicate a need are found, and crackles may also >40mg/L
coccal pneumonia. for hospitalisation. be heard in acute bronchitis, 1. Diehr P, et al. Prediction of pneumonia in outpatients with acute cough: a
Cough may be missing in early- Table 1 shows how often COPD and heart failure. statistical approach. Journal of Chronic Disease 1984; 37:215-25.
2. Melbye H, et al. Diagnosis of pneumonia in adults in general practice.
stage pneumococcal pneumonia and common symptoms and findings Unsteadiness and confusion can Scandinavian Journal of Primary Health Care 1992; 10:226-33.
in patients with insufficient cough occur in primary care patients with be seen in pneumonia among the 3. Hopstaken RM, et al. Contributions of symptoms, signs, erythrocyte sedimentation
reflex (infants, sick elderly, patients pneumonia, revealed by three clin- elderly. Inattentiveness may be rate, and C-reactive protein to a diagnosis of pneumonia in acute lower respiratory
with stroke or those impaired by ical studies. reported by an infant’s parents. tract infection. British Journal of General Practice 2003; 5:358-64.
BECAUSE typical findings are nosed in 32 of these. All pneumonias diagnosed by commonly S pneumoniae in Traditional culture of
frequently missing and the Over-diagnosis is frequently CXRs were also seen on CT. Australia; other important expectorated sputum is of
specificity of crackles is low, made when crackles are You cannot always rely on causes include M pneumoniae, limited value, except when
the diagnosis is seldom clear- heard, while the lack of a negative radiograph when C pneumoniae and Legionella looking for the tubercle
cut. abnormal chest findings is a deciding on antibiotic treat- (see box, above). bacillus. It takes several days
Pneumonia can be over- common reason for under- ment. Although an aetiological to get an answer and cul-
looked when cough is the only diagnosis. CXR should be ordered if agent can be sought, the tures grown do not always
symptom, and no abnormal the patient is severely ill and choice of antibiotics is usu- represent the infectious
chest signs can be found. Chest X-ray there is doubt about the ally based on a presumptive agent.
This was shown in an Although CXR is regarded as diagnosis, and in cases with diagnosis. Rapid tests for agents such
American study of 1819 a diagnostic gold standard for slow recovery. PCR analysis and IgM as M pneumoniae and
adults with acute cough. A pneumonia, you cannot rely A follow-up CXR should tests may allow identifica- Legionella species have been
CXR was ordered by the on radiography in all cases. It be ordered after six weeks tion of some aetiological developed and may be avail-
doctor in 272 cases, and a is well known that radiologists (the resolution of infiltrates agents within a day or two, able in routine general prac-
pneumonic infiltrate was not infrequently disagree in may take this long) in which makes it possible to tice in the future.
found in 16 of the radio- their interpretations. patients with increased risk guide a change of treatment Legionella urinary antigen
graphs. When plain CXR was com- of lung cancer, ie, smokers if the patient shows no sign testing and blood cultures
CXR was later taken in the pared with high-resolution CT older than 40-50. of improvement. should be reserved for
remaining 1547 patients, in in patients with suspected However, PCR analysis of patients admitted to hospi-
whom the doctors had not pneumonia, eight out of 26 Microbiological testing sputum or nasopharynx tal. New tests using throat
Urine tests for Legionella
suspected pneumonia, and a pneumonias diagnosed by CT species are at present usually In Australia, CAP is usually specimens are not always swabs and PCR are being
pneumonic infiltrate was diag- were not diagnosed by CXR. limited to hospitalised patients. caused by one organism, most available. developed.
26 | Australian Doctor | 16 March 2007 www.australiandoctor.com.au
Over- and under-diagnosing pneumonia
Consequences of over- nosis has been missed, the cations or death. Such cases all pneumonias, regardless values between 10mg/L and
diagnosing pneumonia pneumonia is mild and the sometimes appear on the of aetiology, but it can 100mg/L, the duration of ill-
MAKING a diagnosis of patient recovers without front page of newspapers. take a few days before the ness must be taken into
pneumonia implies prescrib- antimicrobial therapy. This It is worth remembering value exceeds the reference account.
ing of antibiotics. In many will often be the case when that in the pre-antibiotic age range. In uncomplicated viral
cases of over-diagnosis the the aetiological agent is a the mortality of patients with The CRP test has shown infections the CRP value usu-
patient actually has acute virus, C pneumoniae or pneumonia (pneumococci on to be of greatest value, par- ally peaks after 3-4 days of
bronchitis or influenza and M pneumoniae. blood culture) was 90%. ticularly in assessing response illness, and may reach
does not need antibacterial In other cases of over- to treatment. An elevated 100mg/L in the most ‘severe’
treatment. looked pneumonias not Point-of-care testing value is usually seen within cases, for example, in
In some cases the patient treated with antibiotics, the White blood cell count 12 hours, and the extent of influenza.
experiences an exacerbation disease will deteriorate. The (WCC), erythrocyte sedi- the increase reflects the sever- The CRP value then
of COPD, and adequate anti- correct diagnosis will usually mentation rate (ESR), and C- ity of the disease. decreases rapidly and is usu-
asthma treatment may be be made at a later stage, and reactive protein (CRP) tests Most pneumonia patients ally <10mg/L after 7-10 days
neglected. soon enough for recovery, may add valuable informa- admitted to hospital have of illness.
Pneumonia may also be either spontaneously or after tion. CRP values >100mg/L. Pneu- CRP values >100mg/L can
wrongly diagnosed in acute starting an appropriate WCC is usually elevated in monia can usually be ruled support a diagnosis of pneu-
heart failure following MI antibiotic. pneumococcal pneumonia out when CRP is <10mg/L, a monia, as can a persistently
and in pulmonary embolism. In a few cases the mis- but is usually normal in level which is typically found elevated value after one week
diagnosed pneumonia will pneumonias caused by in patients with acute bron- of illness.
Consequences of under- get rapidly worse, and anti- viruses, M pneumoniae and chitis and viral COPD exac- CRP tests for use in GP
diagnosing pneumonia biotics will not be given in C pneumoniae. erbations. surgeries give results within
In most cases when the diag- time to avoid septic compli- The ESR usually rises in When interpreting CRP five minutes.
When is treatment in hospital necessary?
SEVERAL factors are important in
Table 3: Patient classification Table 5: CRB-65 index
deciding where the patient should
using the pneumonia severity
be treated; among them is how One point for each of:
safely the patient can be reviewed ■ C — mental confusion
and managed at home. PSI risk class l (lowest risk) ■ R — respiratory rate
Several scoring systems have Patient has none of the following: ≥30 breaths/min
emerged in recent years to deter- ■ Age >50
■ B — diastolic blood pressure
mine the severity of the disease. ■ History of neoplastic disease,
<60mmHg (or systolic <90mmHg)
The pneumonia severity index congestive cardiac failure, ■ 65 — Age >65
(PSI) (tables 2 and 3) was devel- cerebrovascular, renal or liver
oped in North America and is disease
based on the results of several ■ Clinical signs — altered mental Table 6: Thirty-day mortality
large studies. state, pulse rate ≥125 bpm, according to CRB-65 score in
Patients can be triaged into high, respiratory rate ≥30 breaths/min, 1135 hospitalised patients
moderate and low risk, allowing systolic blood pressure <90mmHg,
GPs to determine who can be safely CRB-65 Mortality (%)
or temperature <35ºC or ≥40ºC.
managed at home. Age and coex- 0 0
isting disease are major contribu- Assessing oxygenation by pulse oximetry. PSI risk classes ll–V 1 4
tors to a high risk ranking. Patients with any of the above 2 11
In Europe, the British Thoracic characteristics are classified
Table 2: Calculation of PSI risk score 3 22.6
Society has recommend the ‘CURB- according to their PSI score,
65’ scoring system (table 4), which calculated according to the table 4 28.6
Factor PSI score
is based on a six-point score, with on the left. Bauer TT, et al: CRB-65 predicts
a range of 0-5, with one point for Patient age Age in years (male)
death from community-acquired
each of: or age –10 (female)
pneumonia. Journal of Internal
■ Mental confusion.
Nursing home resident +10
Table 4: CURB-65 Index Medicine 2006; 260:93-101.
■ A blood urea nitrogen level of
>7mmol/L. Coexisting illnesses One point for each of:
■ A respiratory rate ≥30 breaths/min.
Neoplastic disease +30 ■ C — mental confusion
■ A diastolic blood pressure Liver disease +20 ■ U — blood urea nitrogen
<60mmHg (or a systolic Congestive cardiac failure +10 >7mmol/L
<90mmHg). Cerebrovascular disease +10 ■ R — respiratory rate
■ Age >65.
Renal disease +10 ≥30 breaths/min
A score of 0-1 has a low mor- ■ B —diastolic blood pressure
tality and the patient can probably Signs on examination <60mmHg (or systolic <90mmHg)
be managed at home. Altered mental state +20 ■ 65 — Age >65
A score of 2 indicates increased Respiratory rate ≥30 breaths/min +20
risk of death (up to 9.2%), and Systolic blood pressure <90mmHg +20 In general, patients younger than
hospital referral and assessment Temperature ≤35ºC or ≥40ºC +15 50 with no coexisting diseases or
should be seriously considered. Pulse rate ≥125 bpm +10 any of the three adverse prognostic
A score of 3 or more indicates features can usually be treated at
high risk (22% mortality), and Results of investigations home.
such patients need to be hospi- Arterial pH <7.35 +30
talised urgently. Serum urea level ≥11mmol/L +20 Pulse oximetry
An even simpler score, omitting Serum sodium level <130mmol/L +10 Assessing oxygenation by pulse
the urea criterion, CRB-65, has Serum glucose level ≥14mmol/L +10 oximetry is recommended in the
recently been introduced (table 5). Haematocrit <30% +10 British Thoracic Society guidelines.
This score has been shown to be PaO2 <60mmHg or O2 saturation <90% +10 Hypoxaemia with oxygen satu-
as valid as the CURB-65 in pre- Pleural effusion +10 ration (SaO2) <92% indicates the
dicting severe outcome and death Class II score 1-70 need for hospitalisation and oxygen
(table 6). Class III score 71-90 treatment during transport.
A CRB-65 score of 1 was most Class IV score 91-130 However, the sensitivity of
frequently encountered among hos- Class V score >130 hypoxaemia as a test for severe
pitalised patients in a German pneumonia is not very high, and
study, and it is always reasonable Fine M, et al. A prediction rule to identify low-risk patients with community- hospitalisation may be needed even
to consider hospitalisation with acquired pneumonia. New England Journal of Medicine 1997; 336:243-50. though the SaO2 is normal.
such a score. The added diagnostic informa-
Patients with a score of 2-4 are tion from measuring oxygenation
at a greatly increased risk of death supports availability of pulse
and usually need to be hospitalised oximeters in practices located far
urgently. from hospital.
www.australiandoctor.com.au 16 March 2007 | Australian Doctor | 27
How to Treat – community-acquired pneumonia
Preventive measures Patients should Treatment of CAP outside hospital
be able to report
clinical TREATMENT of CAP out-
Table 7: Treatment of community-acquired
improvement side hospital is usually
pneumonia according to the PSI
within three days empirical. Acknowledging
this, European guidelines Class I (low risk) or class II - treatment outside hospital
and should stress the importance of Amoxycillin 500-1000mg orally tds for seven days
contact the matching treatment with the (if penicillin allergy, use cefuroxime 500mg orally bd for seven
treating doctor if expected pathogens, sever- days)
ity, microbial resistence and AND if Mycoplasma or Chlamydia are suspected change to, or
the fever persists the tolerability of antimicro- add, either:
for more than bial agents in individual ■ Oral doxycycline 200mg orally for the first dose, followed by
four days, or if patients. 100mg daily for five days
dyspnoea or Practically, in Australia, or alternatively
antibiotic guidelines for the ■ Roxithromycin 300mg orally daily for five days
hydration treatment of CAP outside
worsens. hospital suggest that treat- Class III and IV* — treatment in hospital
ment be based on amoxy- Should be managed as inpatients using IV penicillins (or
cillin 500-1000mg orally tds ceftriaxone/cefotaxime) and oral agents such as doxycycline
for seven days, with the dose or clarithromycin or roxithromycin as per antibiotic guidelines
dependent on local advice
regarding sensitivities. Class V and those requiring ICU management
In addition, because both Azithromycin IV or erythromycin IV in combination with
M pneumoniae and C pneu- ceftriaxone or cefotaxime
moniae are fairly common
*Management in tropical regions of Australia requires different
causes of CAP and, as treat-
antibiotic regimens because of organisms such as Burkholderia
ment in the community is 1
pseudomalleri (see Therapeutic Guidelines: Antibiotic )
empirical, either doxycy-
cline, roxithromycin or clar-
ithromycin can also be pre- otics, hospitalised patients within three days and either
scribed (table 7). may require IV fluids, sup- they or their carers should
While the choice and plementary oxygen, analgesia contact the treating doctor if
FEW preventive measures are available but the use of duration of antibiotic treat- for chest pain and physio- the fever persists for more
influenza and pneumococcal vaccinations in at-risk popula- ment is fairly clear, judging therapy. than four days, or if dyspnoea
tions should be encouraged. the severity of the illness and Although hospitalisation is or hydration worsens.
The NHMRC recommend that influenza vaccine (every whether the patient needs important for those who are Progress CXRs are only
year) and pneumococcal vaccine (two doses five-yearly) be hospitalisation requires sick, the risk of nosocomial required if the patient fails to
used in people aged >65 (>50 for Aboriginal and Torres much clinical experience and infection should be consid- improve or there are persist-
Strait Islanders) and in those with chronic diseases. is guided by either the PSI, ered. ing chest signs that might
Pneumococcal vaccine should also be given to immuno- CURB-65 or CRB-65. Patients should be able to indicate another intercurrent
compromised patients and those with asplenia. In addition to IV antibi- report clinical improvement respiratory disease.
Treatment in hospital
ALTHOUGH this article deals care in older patients not to over- SaO2 of about 90% in those with above, other investigations are of
mainly with the domiciliary care load them with fluids. chronic hypercapnia, and >95% in limited value in assessing progress.
of pneumonia, many GPs will Monitoring of renal function those without. If improvement is delayed, com-
manage patients with pneumonia may be required, with considera- Comorbidities should be care- plications such as empyema or an
in community, private or rural tion that renal impairment may fully assessed and managed, par- effusion should be considered, as
hospitals. affect antibiotic selection. ticularly in those with COPD or should the underlying diagnosis,
As well as IV and oral antibi- Oximetry should be used to asthma. Daily clinical review is presumed aetiological agent (and
otics, these patients should receive monitor hypoxaemia, and oxygen important and, notwithstanding the therefore choice of antibiotic) and
adequate hydration, but taking therapy provided to maintain a potential use of CRP as described specialist referral.
Pneumonia in children
S PNEUMONIAE is the most common after 48 hours.
bacterial cause of pneumonia in child- In the first week of life pneumonia is Severity assessment — indicators for
hood, with M pneumoniae and Chlamy- typically caused by a maternal pathogen admission to hospital
dia trachomatis also being important in such as a group B streptococci, so ben- Infants Older children
older children. zylpenicillin 60mg/kg IV 12-hourly for
SaO2 ≤92%, SaO2 ≤92%, cyanosis
Viruses are common in younger chil- seven days combined with gentamycin 2.5-
dren; however, no pathogen is found in 3mg/kg IV daily for seven days is used.
up to 60% of cases. In children aged <3 For babies aged 1-4 months, treatment Respiratory rate Respiratory rate
>70 breaths/min >50 breaths/min
years, bacterial pneumonia should be for C trachomatis or Bordetella pertussis
considered if there is a fever >38.5ºC should be considered. Difficulty breathing Difficulty breathing
together with chest recession and a res- If the baby is only mildly affected, Intermittent apnoea Grunting
piratory rate >50 breaths/min. azithromycin 10mg/kg daily for five days Not feeding Signs of dehydration
If a child has mild disease, a CXR is is recommended. Alternatives are detailed Family not able Family not able to provide
not required, and only those who have in Therapeutic Guidelines: Antibiotic. to provide appropriate observation or
lobar collapse should have follow-up For children aged four months to five appropriate support
films. years who can be treated in the commu- observation
CRP and ESR are not helpful in chil- nity, oral amoxycillin 25mg/kg tds for or support
dren when determining if the causative seven days is effective.
organism is a virus or bacteria. Similarly amoxycillin is the treatment
Pulse oximetry is useful in determining of choice for mild disease in children
severity of the illness and also for moni- aged 5-15 years in regions where
toring progress in the hospital setting. S pneumoniae is the most common bac-
Microbiological investigation in the terial organism, although M pneumoniae
community is not required, but blood pneumonia does occur in 3-4-yearly
cultures, nasopharyngeal aspirates and cycles.
acute serum samples (paired with a con- For suspected M pneumoniae or
valescent sample) are performed in the C pneumoniae pneumonia, clar-
hospital setting. ithromycin 7.5mg/kg up to 250mg orally
If the child is being managed at home, bd for seven days or roxithromycin
GP review is important, and essential if 4mg/kg up to 150mg orally 12-hourly
they are deteriorating or not improving for five days can be added.
28 | Australian Doctor | 16 March 2007 www.australiandoctor.com.au
How to treat – community-acquired pneumonia
Authors’ case studies
Evidence-based Pneumonia in an elderly patient
recommendations for A GP was on a house call to a 79-
the management of CAP year-old woman with fever and
in the community* fatigue for two days. It was in the
middle of winter, and an influenza
epidemic was occurring.
She had a moderate cough. The
■ In children aged <3 years heart rate and respiratory rate were
bacterial pneumonia moderately increased, as could be
should be considered if expected with a temperature of
there is a fever >38.5ºC 38.5ºC. No adventitious sounds were
together with chest reces- heard on auscultation of the chest.
sion and a respiratory rate The patient was very unsteady when
>50 breaths/min walking around her house. Her condi-
■ CRP and ESR are of tion was diagnosed as influenza, and
limited value in children in she received no treatment.
determining whether the The next day she had deteriorated.
causative organism is a She was unable to stand, was more
virus or bacterium tachypnoeic and confused.
■ Children with an oxygen She was admitted immediately to
saturation of <92% when hospital, where pneumonia was diag-
breathing air should be nosed by CXR. Fortunately, she recov-
given oxygen by nasal ered with antibacterial treatment.
cannula, face mask or
head box to maintain Comment
saturation >92%. This patient’s unsteadiness should
have been regarded as a possible sign bilateral back pain. He had a past further management. pneumonia that he had parapro-
■ There is no evidence that
of pneumonia and her blood pres- history of asthma and pneumonia On presentation his CRP was teinaemia at very low levels.
chest physiotherapy is
sure should have been measured. six years ago and used a ventolin 208mg/L, O2 saturation 93%, WCC His specialist initiated further
beneficial in children with 9
The absence of adventitious lung inhaler occasionally. 16.7 × 10 /mL, ECG showed no assessment of his immune status to
sounds should not have excluded On examination he was distressed, acute changes and CXR unequivo- check for any potential underlying
■ Amoxycillin orally is consideration of pneumonia. pale, temperature 38ºC, respiratory cal right lower-lobe consolidation. lymphoproliferative disorder, and
effective for treating CAP A diagnosis of pneumonia could rate 35 breaths/min, blood pressure He was given fluids intravenously these results are still awaited.
in children (> six months) have been supported by an elevated 135/65mmHg, pulse 100 bpm and and O2 via nasal cannula, admitted,
who are well enough not C-reactive protein level, which could regular, not cyanosed and was mod- started on ceftriaxone 1g IV and Comment
to be treated with hospital have been measured in her home or erately dehydrated. He had bilateral azithromycin 500mg daily, and given Although a PSI risk score, CURB-65
admission at the nearest emergency unit. chest crackles to the mid zones, right some analgesia to make him com- or CRB-65 index was not formally
An ambulatory CXR would have greater than left, but no evidence of fortable. calculated, a quick scan of the crite-
Adults been a sensible approach. consolidation. The azithromycin upset his stom- ria indicates that he was at increased
Because the local radiology service ach so he was switched to cefaclor, risk of death and was appropriately
■ Severity of illness should
Pneumonia in a 69-year-old man had just closed, a CXR could not which was continued for another 10 admitted. Intolerance to medication
be assessed (using the
MR Smith presented to a general be arranged and he was referred, days. He recovered gradually, but should be monitored because alter-
CURB-65, PSI or
practice with a one-day history of with a presumptive diagnosis of further testing revealed a potential natives are usually available. Recur-
CRB-65) and the results
fever, cough, rigors and vomiting. pneumonia, to a private hospital for IgG deficiency, and it was noted that rent pneumonia should prompt a
used as a guide to
He also complained of non-localised assessment, physician review and during his previous admission for search for an underlying cause.
managing patients in the
community or hospital.
■ The CRP test is valuable
pneumonia from other GP’s contribution
respiratory tract infections,
but its clinical utility is not Case study ence) and lives with his wife. ment of John? amoxycillin 500-1000mg tds
yet settled. JOHN, 67, attends complain- On examination his vital It would be very important for seven days. If I suspected
*Supported by evidence from ing of seven days of produc- signs were blood pressure to confirm the presumptive M pneumoniae or C Pneu-
RCTs or one or more tive cough and mild dyspnoea. 138/86mmHg, pulse 110 diagnosis of left lower lobe moniae I would add doxy-
descriptive studies He reports having purulent bpm, temperature 38.3ºC, res- pneumonia before initiating cycline.
green sputum and intermittent piratory rate 25 breaths/min. treatment. Although the find- I would ensure that John
fevers. He appeared comfortable ings from clinical examination had support at home and
John thought his symptoms despite his dyspnoea, and are very suggestive of pneu- that the family knew he
DR WINSTON LO were the result of “the flu coughed up thick green monia, a CXR would be the should seek further help if
Kings Cross and going around this winter” and sputum during the consulta- gold standard. his symptoms were worse
Newtown, NSW did not seek review until tion. Blood should be collected over the weekend. I would
today. He has been taking Auscultation of his chest for pathology testing even ask him to return in one
over-the-counter ‘cold and flu’ revealed soft crackles in his though the results will not be week, or earlier if necessary,
preparations, with minimal left lower lung, which was known for three days, as they and would phone him on
benefit and admits his illness is dull on percussion. John had will provide important base- Monday with the pathology
getting worse. reduced chest expansion. Car- line information. Sputum cul- results (and assess his
John is a current smoker, diac examination was unre- ture at this stage would also progress).
having smoked on average a markable. be helpful if treatment failure Clearly in the short term
half a pack of cigarettes a day You do not have a pulse occurs. he should stop smoking and
for 20 years. Spirometry 12 oximeter or point-of-care test An ECG may be useful to as he recovered I would take
months ago showed normal devices (as mentioned in the rule out an underlying cardiac the opportunity to maximise
lung function. article) in your surgery. It is problem, but otherwise you his chances of quitting per-
His medical records show Friday afternoon — John can could make a diagnosis of manently.
he has had bronchitis or probably be squeezed in for a community-acquired pneu- Although he is not a heavy
URTIs annually for five years. CXR at a nearby radiology monia and treat accordingly. smoker I would repeat his
He has no past history of practice if needed, but results spirometry, when he was
pneumonia and has had two of any pathology testing Could you outline your over- fully recovered, especially if
previous attempts at smoking ordered won’t be received all management plan for John, spirometry had been per-
cessation for short periods. until Monday morning (the including your management formed in general practice,
John has well-controlled surgery does not open on of the acute and longer-term because results can be mis-
hypertension, with no past weekends). issues? leading because of patient
history of heart disease. He is John would score 1 on the effort and incorrectly cali-
taking Coversyl 5mg daily, Questions for the author CRB-65 index (indicating a brated or maintained
has no drug allergies and Given the limitations outlined, 4% chance of mortality), he spirometers.
drinks alcohol occasionally. what specific investigations is not particularly distressed
He has not received any would you consider ordering? and he appears to be coping John returns to see you in a
influenza or pneumococcal Would these investigations at home. I would treat him week to report he has experi-
vaccinations (personal prefer- change your overall manage- at home initially with cont’d page 32
30 | Australian Doctor | 16 March 2007 www.australiandoctor.com.au
How to treat – community-acquired pneumonia
from page 30 its use in general practice? as recommended by the
enced minimal improvement We acknowledge the dif- NHMRC. References
in his symptoms despite fol- ficulties of applying these ■ People with asplenia, either
1. Antibiotic Expert Group.
lowing your management scoring systems in general functional or anatomical, Therapeutic Guidelines:
plan. Would you order any practice, particularly the including sickle-cell disease Antibiotic. Version 13.
additional investigations, blood urea nitrogen. in anyone aged over two Therapeutic Guidelines
and what treatment plan However, we explicitly years. Limited, Melbourne, 2006.
would you now institute? indicated that they should ■ Immunocompromised
2. Woodhead M, et al.
I would assess him clini- act as a guide and, clearly, patients at increased risk of ERS Task Forces in
cally and review the need for if a patient scores 2 or above pneumococcal disease (eg, Collaboration with
hospitalisation and further on the CURB-65 index, patients with HIV infection ESCMID. Guidelines for
investigation. If I had not without inclusion of the before the development of the management of adult
added doxycyline, rox- blood urea nitrogen score, AIDS, acute nephrosis, mul- lower respiratory tract
ithromycin or clarithromycin that patient is at moderate tiple myeloma, lymphoma, infections. European
to his treatment regimen I to high risk of mortality and Hodgkin’s disease and Respiratory Journal 2005;
would do so now. much weight do you place on severity of these conditions in should be hospitalised. organ transplantation). 26:1138-80.
I would also be concerned the patient’s coexisting respi- patients and therefore the It is also why we included ■ Aboriginal and Torres
about antibiotic resistance to ratory illnesses or smoking effect they could potentially the more recently developed Strait Islander people aged Further reading
amoxycillin and would history when managing CAP have. CRB-65 index — because it ≥50 and those aged 15-49 ■ Marston B, et al. Incidence
therefore check the sensitivi- patients? can be used in general prac- who are at high risk, of community acquired
ties from his sputum culture The PSI is a classification of You mention in the article tice. according to NHMRC rec- pneumonia requiring
and adjust his treatment as the risk of mortality and that the clinical decision as to ommendations. hospitalisation. Results of
necessary. It is important to therefore where and how who needs hospitalisation Given the NHMRC recom- ■ Immunocompetent persons
a population based active
note that laboratory resistance someone should be managed. requires clinical experience mendations and the health at increased risk of compli- surveillence study in Ohio.
does not automatically corre- Although COPD, asthma and is guided by either the department’s strict criteria for cations from pneumococ- the Community-Based
late with treatment failure. or other respiratory conditions PSI, CURB-65 or CRB-65. ‘free’ pneumococcal vaccina- cal disease because of Pneumonia Incidence
are not explicitly listed as However, only the latter scor- tions, which groups of patients chronic illness (eg, chronic Study Group. Archives of
General questions for the comorbidities, the clinical ing system is feasible for use in do you recommend receive cardiac, renal or pulmonary Internal Medicine 1997;
author effect of these conditions on general practice, given the pneumococcal vaccinations disease, diabetes and alco- 157:1709-18.
The PSI does not list coexist- a patient’s vitals signs (eg, res- inclusion of various pathology (even if this means the patient hol-related problems).
ing respiratory illnesses as a piratory rate, pulse rate, SaO2 test results in the others that bears the vaccine cost)? ■ I would include patients
factor. You mentioned in the systolic blood pressure, etc) is may not be readily attainable. ■ All people aged 65 and who have had pneumonia ■ www.brit-thoracic.org.
article that “comorbidities taken into consideration by Also, you mentioned that clin- over, newborn babies previously, depending on the uk/iqs/dlsfa.view/
should be carefully assessed the PSI scoring system. ical utility is not yet proved under the new vaccination aetiology and severity of the dldbitemid.311/dlcpti.
and managed — particularly This makes sense because for the CRP point-of-care test. schedule, and children in pneumonia, their age and 175/page269.html
COPD or asthma.” How of marked variation in the Could you please comment on specific high-risk groups, comorbidities.
How to Treat Quiz Complete this quiz to earn 2 CPD points and/or 1 PDP point by marking the correct answer(s)
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1. Which TWO statements about community- ❏ a) Crackles heard in her lung bases are a ❏ c) A CXR should be ordered to confirm the treatment?
acquired pneumonia (CAP) are correct? reliable marker of pneumonia diagnosis in all cases ❏ a) His respiratory rate is 40 breaths/min
❏ a) About 50% of patients with CAP require ❏ b) Sorrell has a 25% chance of having a ❏ d) The white cell count is likely to be raised in ❏ b) His pulse oximetry reading is 95% on
admission to hospital for treatment completely normal chest examination both bacterial and atypical pneumonia room air
❏ b) The most common pathogen causing CAP ❏ c) A raised respiratory rate is a typical sign of ❏ c) He has some grunting on respiration
is Streptococcus pneumoniae pneumonia 6. Mavis is an independent 81-year-old ❏ d) He has signs of dehydration on
❏ c) Common pathogens causing atypical CAP ❏ d) Breath sounds with a prolonged expiratory woman who presents with a cough, examination
are Gram-negative bacteria, such as phase and a blowing quality are indicative of shortness of breath and lethargy. After
Klebsiella pneumoniae pneumonia history and examination you make a 9. Which TWO statements about pneumonia
❏ d) Patients older than 75 have a 5-6-fold provisional diagnosis of CAP. Which TWO in children are correct?
increase in incidence of CAP compared with 4. After history and examination you decide features would be significant in indicating ❏ a) CRP is helpful in determining the likely
young adults that clinically Sorrell has CAP. She is well that Mavis may need hospital admission? aetiology
enough to be treated in the community and ❏ a) Her temperature is 34.9ºC ❏ b) Viruses more commonly cause pneumonia
2. Sorrell, 28, has had symptoms of an URTI you wish to start empirical treatment. She ❏ b) Her respiratory rate is 26 breaths/min in young children than older children
for one week. She has felt worse over the has no known allergies. Which ONE antibiotic ❏ c) Her blood pressure is 85/60mmHg ❏ c) Mild disease in babies aged 1-4 months
last 48 hours, with fevers and chills, regimen would you choose? ❏ d) Her serum creatinine level is 110µmol/L may be treated with azithromycin
increased cough and shortness of breath. ❏ a) Amoxycillin 250mg tds ❏ d) Chest physiotherapy is helpful to clear
From this history, you think that she may ❏ b) Amoxycillin-clavulanic acid 875/125mg 7. Jamal, nine, presents with a dry irritating secretions in children with pneumonia
have CAP. In considering Sorrell’s history bd cough, intermittent fevers and headache. He
which TWO statements are correct? ❏ c) Amoxycillin 1000mg tds, plus roxithromycin has a normal chest examination but a CXR 10. Which THREE statements about
❏ a) The history given is more suggestive of a 300mg daily reveals bilateral patchy changes in the lungs. pneumonia in the elderly are correct?
‘typical’ bacterial pneumonia than an atypical ❏ d) Doxycycline 100mg daily plus cefaclor Several children in Jamal’s class have ❏ a) Pneumonia prevention includes annual
pneumonia 250mg tds recently been sick with respiratory illnesses. pneumococcal vaccination for all people
❏ b) If Sorrell reports chest pain, this is likely to This clinical picture is MOST consistent with over 65
indicate a bronchopneumonia 5. In addition to starting treatment you arrange pneumonia caused by which ONE organism? ❏ b) Unsteadiness is an important feature to
❏ c) If Sorrell did not have a cough, CAP could some investigations for Sorrell to support your ❏ a) S pneumoniae recognise in the elderly patient with CAP
be excluded diagnosis. Which TWO statements about ❏ b) Mycoplasma pneumoniae ❏ c) Fever may be absent
❏ d) Other symptoms Sorrell may have include investigations in CAP are correct? ❏ c) Haemophilus influenzae ❏ d) A 68-year-old patient with CAP who has a
nausea and diarrhoea ❏ a) Pneumonia is unlikely if the C-reactive pro- ❏ d) Staphylococcus aureus respiratory rate >30 breaths/min and mental
tein (CRP) value is <10mg/L confusion but normal blood pressure has a
3. Which TWO statements about your ❏ b) The ESR rises in all pneumonias, usually 8. Which TWO factors would make you one-month mortality rate of 22%
examination of Sorrell are correct? after a few days of illness consider admitting Jamal to hospital for
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HOW TO TREAT Editor: Dr Marcela Cox
Co-ordinator: Julian McAllan
Quiz: Dr Marcela Cox
Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.
NEXT WEEK While nausea and vomiting are common and distressing, with myriad underlying causes, in practice a systematic approach to treatment leads to a clear diagnosis in most cases. See how in
next week’s How to Treat on managing nausea and vomiting. The authors are Professor Anne Duggan, senior staff specialist, department of gastroenterology, John Hunter Hospital; consultant, clinical
governance, Hunter New England Area Health Service; conjoint associate professor, school of medical practice and population health, the University of Newcastle, NSW, and Dr Sam Al-Sohaily, senior
gastroenterology registrar, department of gastroenterology, John Hunter Hospital, Newcastle, NSW.
32 | Australian Doctor | 16 March 2007 www.australiandoctor.com.au