Community-acquired pneumonia - Community-acquired

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                                                                                                                                                               Symptoms and

                                                                                                                                                               Over- and

                                                                                                                                                               Treating in and out
                                                                                                                                                               of hospital

                                                                                                                                                               Pneumonia in

                                                                                                                                                               The authors

                                                                                                                                                               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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                                                                                                                    16 March 2007 | Australian Doctor |       25
 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
                                             ■ Cough
 in lobar pneumonia, and may be                                                         purulent sputum and wheezes.               Very annoying            —                    65                     —
                                             ■ Chest pain (pleuritic)
 particularly strong when associated                                                                                               cough
                                             ■ Confusion
 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                                            
 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:
                                                                                                                                       index (PSI)*
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.

                                                                                                                                  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                                  
 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
         in differentiating
         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                                          
 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
                                                                                                                                                                                                                                                                                                                Online resource
 factor. You mentioned in the                                   systolic blood pressure, etc) is                                 may not be readily attainable.                                   ■ All people aged 65 and                                           who have had pneumonia                     ■
 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.

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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
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     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