Pneumonia.

Pneumonia is an infection of the lung tissue. When a person has pneumonia the air sacs in their lungs become filled with microorganisms, fluid and inflammatory cells and their lungs are not able to work properly.

Diagnosis of pneumonia is based on symptoms and signs of an acute lower respiratory tract infection, and can be confirmed by a chest X ray showing new shadowing that is not due to any other cause (such as pulmonary oedema or infarction).

In this guideline pneumonia is classified as community acquired or hospital acquired, based on different microbial causes and patient factors, which need different management strategies.

It is diagnosed in 5–12% of adults who present to GPs with symptoms of lower respiratory tract infection, and 22–42% of these are admitted to hospital, where the mortality rate is between 5% and 14%.
Between 1.2% and 10% of adults admitted to hospital with community acquired pneumonia are managed in an intensive care unit, and for these patients the risk of dying is more than 30%. More than half of pneumonia related deaths occur in people older than 84 years.

The following recommendations have been identified as priorities for implementation.

Presentation with lower respiratory tract infection
For people presenting with symptoms of lower respiratory tract infection in primary care, consider a point of care C reactive protein test if after clinical assessment a diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed.

Use the results of the C reactive protein test to guide antibiotic prescribing in people without a clinical diagnosis of pneumonia as follows:
Do not routinely offer antibiotic therapy if the C reactive protein concentration is less than 20 mg/litre.
Consider a delayed antibiotic prescription (a prescription for use at a later date if symptoms worsen) if the C reactive protein concentration is between 20 mg/litre and 100 mg/litre.
Offer antibiotic therapy if the C reactive protein concentration is greater than 100 mg/litre.
CRP recommendation is a 2014 advance, and may not be feasible or practical in common practice.

Community-acquired pneumonia
Microbiological tests
For patients with moderate or high severity community acquired pneumonia:
take blood and sputum cultures and
consider pneumococcal and legionella urinary antigen tests.

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.

Antibiotic therapy
Low-severity community-acquired pneumonia
Offer a 5 day course of a single antibiotic to patients with low severity community acquired pneumonia.

Do not routinely offer patients with low severity community acquired pneumonia:
a fluoroquinolone
dual antibiotic therapy.

Patient information
Explain to patients with community acquired pneumonia that after starting treatment their symptoms should steadily improve, although the rate of improvement will vary with the severity of the pneumonia, and most people can expect that by:
1 week: fever should have resolved
4 weeks: chest pain and sputum production should have substantially reduced
6 weeks: cough and breathlessness should have substantially reduced
3 months: most symptoms should have resolved but fatigue may still be present
6 months: most people will feel back to normal.

Part 2 , to follow- Severity assessment , and treatment schedules .

G Mohan.