Respiratory
A 65 year old patient presents with suspected community acquired pneumonia. You are assessing her CURB65 score. Which of the following is NOT a criterion of the CURB65 severity score?
Answer:
If an adult has clinical symptoms and signs suggestive of community-acquired pneumonia, assess the severity of the illness using clinical judgement and the CURB-65 score for mortality risk. CURB65 is used in hospital to assess 30‑day mortality risk in adults with pneumonia. The score is calculated by giving 1 point for each of the following prognostic features:- Confusion (new disorientation in person, place, or time; or abbreviated mental test score 8 or less)
- Urea (> 7 mmol/L)
- Respiratory rate (≥ 30 breaths/min)
- Blood pressure (< 90 systolic or ≤ 60 diastolic)
- 65 (age ≥ 65 years)
Community Acquired Pneumonia
Respiratory
Last Updated: 12th February 2021
Pneumonia is an infection of the lung tissue in which the air sacs in the lungs become filled with microorganisms, fluid and inflammatory cells, affecting the function of the lungs.
Causes
Community-acquired pneumonia is usually caused by bacterial infection. Usually the causative organism is not identified. The likely microbial causes of community-acquired pneumonia depend on factors such as local epidemiology, severity of disease, and the person’s sex, age, and comorbidities.
Pathogens in community acquired pneumonia:
- Bacterial
- Streptococcus pneumoniae (most common cause)
- Haemophilus influenzae
- Staphylococcus aureus
- Klebsiella spp.
- Moraxella catarrhalis
- Viral
- Influenza A and B
- Respiratory syncytial virus
- Adenovirus
- Coronavirus
- Atypical organisms
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
- Chlamydia psittaci
- Legionella pneumophila
- Coxiella burnetii
Clinical features
Clinical judgement must always be used to diagnose community-acquired pneumonia because no combination of symptoms or signs is clearly diagnostic.
- History
- Cough
- Dyspnoea
- Sputum production
- Pleural pain
- Sweating, fever, shivers, aches and pains
- Examination
- Moderately to severely ill
- Focal chest signs such as decreased or asymmetric breath sounds, bronchial breath sounds, dullness to percussion, coarse crepitations, vocal fremitus
- Typically tachypnoea, tachycardia, dyspnoea
- Temperature 38°C, or above
- May be hypoxia
- Confusion (uncommon, but may be seen in older people)
Investigations
- Pulse oximetry
- Arterial blood gas (ABG) if indicated by oxygen saturations (< 92%)
- Chest x-ray - consolidation +/- pleural effusion
- Bloods – U&Es, FBC, LFTs, CRP
- Microbiology
- Do not routinely recommend microbiological tests for people with low-severity community-acquired pneumonia.
- Blood cultures (in moderate or high severity CAP)
- Sputum culture (in moderate or high severity CAP)
- Urine antigen investigations, PCR of respiratory secretions, or serological investigation if atypical pneumonia is being considered (or in high severity CAP)
Severity assessment
If an adult has clinical symptoms and signs suggestive of community-acquired pneumonia, assess the severity of the illness using clinical judgement and the CURB-65 score for mortality risk. CURB65 is used in hospital to assess 30‑day mortality risk in adults with pneumonia. The score is calculated by giving 1 point for each of the following prognostic features:
- Confusion (new disorientation in person, place, or time; or abbreviated mental test score 8 or less)
- Urea (> 7 mmol/L)
- Respiratory rate (≥ 30 breaths/min)
- Blood pressure (< 90 systolic or ≤ 60 diastolic)
- 65 (age ≥ 65 years)
Patients are stratified for risk of death as follows:
- 0 or 1: low risk (less than 3% mortality risk)
- 2: intermediate risk (3‑15% mortality risk)
- 3 to 5: high risk (more than 15% mortality risk).
Management
Use clinical judgement in conjunction with the CURB65 score to guide the management of community‑acquired pneumonia, as follows:
- consider home‑based care for patients with a CURB65 score of 0 or 1
- consider hospital‑based care for patients with a CURB65 score of 2 or more
- consider intensive care assessment for patients with a CURB65 score of 3 or more.
Start antibiotic treatment as soon as possible after establishing a diagnosis of community-acquired pneumonia, and certainly within 4 hours (within 1 hour if the person has suspected sepsis and meets any of the high risk criteria for this). Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics. If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible.
Antibiotic Choice:
| Infection | First Choice Antibiotic |
|---|---|
| Low-severity community acquired pneumonia |
|
| Moderate-severity community acquired pneumonia |
|
| High-severity community acquired pneumonia |
|
Additional Considerations:
- Patient should receive oxygen as per BTS guidelines.
- Pleuritic pain should be relieved using simple analgesia such as paracetamol.
- Patients should be assessed for volume depletion and may require intravenous fluids.
- Prophylaxis of venous thromboembolism with low molecular weight heparin should be considered for all patients who are not fully mobile.
- Nutritional support should be given in prolonged illness.
Complications
- Pleural effusion
- Empyema
- Lung abscess
- Pneumothorax
- Acute respiratory distress syndrome
- Septic shock
- Disseminated infection
- Postinfectious bronchiectasis
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
