Specific Management

The following management options are recommended:

Antibiotics

Local guidelines should be adhered to but listed below are pragmatic antibiotic regimes that the BTS support.

Patients with low severity pneumonia that are either discharged or admitted (for social reasons or because of significant co-morbidities) and most with moderate severity pneumonia should be prescribed oral antibiotics if they are able to swallow:

• Amoxicillin 500 mg orally, three times per day for 1 week is the preferred regime.
• Clarithromycin 500 mg orally, twice per day for one week is an alternative if the patient is allergic to penicillin.
• Levofloxacin 500mg orally once daily can be used for patients allergic to both drugs mentioned above.

Admitted patients with low and moderate severity pneumonia that are unable to swallow should be given intravenous antibiotics.

Admitted patients with severe pneumonia should be given intravenous antibiotics as soon as possible after the diagnosis made.

The BTS guidelines recommend Co-amoxiclav 1.2 g IV TDS plus Clarithromycin 500 mg IV BD for 7-10 days as an appropriate first-line treatment. However, local resistance patterns and other factors may mean that some hospitals recommend alternative first-line therapy. In this situation local guidelines should be followed.

If penicillin allergic, consider Cefuroxime plus Clarithromycin. If penicillin and clarithromycin allergic, consider Levofloxacin.

Learning bite

Antibiotics should be started in the ED as soon as possible after the diagnosis is made (usually on chest radiography) and within 4 hours of arrival in all cases. Local antibiotic guidelines should be followed.

Oxygen

The BTS oxygen guidelines should be followed [6]. Oxygen should be prescribed and administered if the oxygen saturations are below 94% on air or the arterial oxygen tension PaO₂ is less than 8kPa.

Para-pneumonic effusions

Para-pneumonic effusions are found in up to a half of all patients admitted with CAP. Thoracocentesis is recommended in all cases to identify those that are infected (empyemas).

Where there is evidence that the pleural aspirate is infected (clear but pH<7.2 or cloudy/pus) a pleural drain should be inserted.

The following are not recommended:

• Steroids: Are not recommended in the routine treatment of pneumonia of any severity
• Chest physiotherapy: Classical chest clearance techniques are not routinely recommended for patients admitted with pneumonia but may have a place in patients with pre-existing lung conditions
• NIV: CPAP and NIV have not been demonstrated to improve mortality in patients with respiratory failure secondary to pneumonia and their routine use is not recommended.