Pneumonia is infection of the lung tissue. It is characterised by signs and symptoms of a lower respiratory tract infection and diagnosis is confirmed by a chest radiograph.


Cough- productive or unproductive
Pleuritic chest pain
General malaise

Less common symptoms include:
Confusion (especially in elderly patients)
Nausea and vomiting


How long have the symptoms been going on for? Have they been getting worse/better/stayed the same?
Have they been taking any medications for their symptoms? If so what and have they helped?
Has the patient been in contact with anyone known to have a chest infection recently?
Have they travelled abroad recently?- Identify TB risk
Does the patient have any risk factors for pneumonia?- Age >65 years, smoking, alcoholism, immunosuppressive conditions, and conditions such as COPD, cardiovascular disease, cerebrovascular disease, chronic liver or renal disease, diabetes mellitus and dementia
What is the patient's occupation?- Farm work
Does the patient work with birds or have a bird as a pet?- Exposure to atypical bacteria causing pneumonia


Dyspnoea- laboured breathing/use of accessory muscles
Low oxygen sats/signs of hypoxia
Signs of consolidation- dull percussion, coarse crepitations, increased vocal resonance

Be aware of sepsis:
Reduced consciousness
Reduced urine output
Hypotension- septic shock


Oxygen saturations- ABG if considered necessary
Blood tests:

  • FBC
  • CRP
  • U+E's
  • LFT's
  • Blood Cultures

Chest Radiograph
Sputum culture
If Legionella suspected- urine antigen test for Legionella


Community acquired Pneumonia (CAP) is contracted out of hospital or less than 48 hours of being in hospital
Pneumonia is deemed hospital acquired (HAP) if the patient has been in hospital for over 48 hours.
The causative organisms differ between the two and therefore the management of patients will also be slightly different


Used to assess severity of Community-Acquired Pneumonia (CAP) patients:
C onfusion =1
U rea >7mmol/L =1
R espiratory rate ≥30/min =1
B lood pressure- systolic BP <90mmHg or diastolic BP ≤60mmHg =1
65 - patient aged ≥65 =1

CRB 65 is used to assess patients in the primary care setting

Score Risk of Mortality Management
1 Low (<3%) May be suitable for outpatient management
2 Increased (3-15%) Short stay in-patient treatment or hospital supervised outpatient treatment depending on clinical judgment
≥3 High (>15%) Admit patient and consider intensive care assessment

Causes of CAP

Most common causes:
Streptococcus pneumonia
Haemophillus influenzae
Moraxella catarrhalis- common in patients with COPD

Klebsiella pneumoniae- Alcoholics and those at risk of aspiration e.g. stroke patients
Chlamydia psticacci- 'bird fanciers lung'
Coxiella burnetti- Patients who work with farm animals

Approximately 1/3 of pneumonia in adults is caused by a virus
The most common viruses that cause pneumonia are: influenza, parainfluenza, human respiratory syncytial virus (RSV) and adenovirus

Causes of HAP

Usually bacterial not viral
It is the second most common nosocomial infection (after UTI's) and the leading cause of death from a nosocomial infection

Gram negative bacilli- e.g. pseudomonas aeruginosa
Staph. aureus- including MRSA
Klebsiella pneumoniae


Appropriate oxygen therapy

Assess for volume depletion and treat with IV fluids if present

Monitor and record at least twice daily: Temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation and inspired oxygen concentration
Monitor more frequently in those with severe pneumonia or requiring regular oxygen therapy

Low Severity CAP
Outpatient Antibiotic Therapy
Amoxicillin 500mg three times a day for 5 days
Tetracycline (e.g. Doxycyline) or Macrolide (e.g. Clarithromycin) suitable alternatives if patient is hypersensitive to Penicillin
Consider extending course if no improvement within 3 days
Advise patients to consult healthcare professional if they feel that they are getting worse or not improving as expected

Moderate and High Severity CAP
7-10 day course of antibiotics
Consider dual antibiotic therapy with amoxicillin and a macrolide for patients with moderate‑severity community‑acquired pneumonia

Consider dual antibiotic therapy with a beta‑lactamase stable beta‑lactam and a macrolide for patients with high‑severity community‑acquired pneumonia.

Offer antibiotic therapy within 4 hours
Consider a 5‑ to 10‑day course of antibiotic therapy in accordance with local hospital policy and clinical circumstances

Repeat CRP and chest radiograph in patients who are not progressing satisfactorily within 3 days of treatment

Prior to discharge

Review patients 24 hours before discharge. If they have 2 or more of the following findings then delay discharge:

  • temperature higher than 37.5°C
  • respiratory rate 24 breaths per minute or more
  • heart rate over 100 beats per minute
  • systolic blood pressure 90 mmHg or less
  • oxygen saturation under 90% on room air
  • abnormal mental status
  • inability to eat without assistance.

Consider delaying discharge for patients with community‑acquired pneumonia if their temperature is higher than 37.5°C.

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