Severity assessment in hospital

When a diagnosis of community-acquired pneumonia is made at presentation to hospital, determine whether patients are at low, intermediate or high risk of death using the CURB65 score ..

CURB65 score for mortality risk assessment in hospita

CURB65 score is calculated by giving 1 point for each of the following prognostic features:

confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)

raised blood urea nitrogen (over 7 mmol/litre)

raised respiratory rate (30 breaths per minute or more)

low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)

age 65 years or more.
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).

Timely diagnosis and treatment
Put in place processes to allow diagnosis (including X rays) and treatment of community acquired pneumonia within 4 hours of presentation to hospital.
Offer antibiotic therapy as soon as possible after diagnosis, and certainly within 4 hours to all patients with community acquired pneumonia who are admitted to hospital.

Antibiotic therapy
Low-severity community-acquired pneumonia

Offer a 5 day course of a single antibiotic to patients with low severity community acquired pneumonia.
Consider amoxicillin in preference to a macrolide or a tetracycline for patients with low severity community acquired pneumonia.
Consider a macrolide or a tetracycline for patients who are allergic to penicillin.

Consider extending the course of the antibiotic for longer than 5 days as a possible management strategy for patients with low severity community acquired pneumonia whose symptoms do not improve as expected after 3 days.

Explain to patients with low severity community acquired pneumonia treated in the community, and when appropriate their families or carers, that they should seek further medical advice if their symptoms do not begin to improve within 3 days of starting the antibiotic, or earlier if their symptoms are worsening.

Moderate- and high-severity community-acquired pneumonia

Consider a 7 to 10 day course of antibiotic therapy for patients with moderate or high severity community acquired pneumonia.

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. ] Available beta-lactamase stable beta lactams include: co amoxiclav, cefotaxime, ceftaroline fosamil, ceftriaxone, cefuroxime and piperacillin with tazobactam.

Glucocorticosteroid treatment
Do not routinely offer a glucocorticosteroid to patients with community acquired pneumonia unless they have other conditions for which glucocorticosteroid treatment is indicated.

Monitoring in hospital
Consider measuring a baseline C reactive protein concentration in patients with community acquired pneumonia on admission to hospital, and repeat the test if clinical progress is uncertain after 48 to 72 hours.

Safe discharge from hospital
Do not routinely discharge patients with community acquired pneumonia if in the past 24 hours they have had 2 or more of the following findings:

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.

G Mohan.