The updated Hunter New England guideline, Adult Community Acquired Pneumonia: Initial Investigation and Empiric Antibiotic Therapy has now been released.
Community acquired pneumonia (CAP) is a common cause of hospital admission, carrying a significant risk of morbidity and mortality. Approximately 1/3 of patients require admission to hospital. Streptococcus pneumoniae remains the commonest pathogen ( see here for local epidemiology).
Studies show that the use of clinical pathways for CAP treatment can reduce mortality, length of stay and ultimately cost. Explicit assessment of severity is important. Severe cases should receive broad spectrum empiric therapy (usually intravenous) as soon as possible.
The HNE clinical pathway utilises CORB scoring, derived from a prospective, observational study from Melbourne published in 2007 that demonstrated that the independent predictors of death and/or mechanical ventilation or inotropic support were:
C – confusion (which could be acute or worsening of pre-existing confusion)
O – oxygen saturations </= 90%
R – respiratory rate >/= 30/min
B – systolic blood pressure < 90mmHg or diastolic </= 60mmHg
The CORB score is collated by assigning one point for each of the above four items if met. Severe cases are defined as a score of >/= 2. All patients managed in ED with pneumonia should have the score assessed. The scale needs to be performed on all patients seen in the Emergency Department (ED) with CAP and on admitted cases after 24 hours. This tool is simple, does not require invasive testing and is not biased by a patient’s age, sex or comorbidities.
Of course, clinical pathways are never a substitute for clinical acumen and must be used as an adjunct in decision making. Furthermore a patient’s co-morbidities should be taken into account as this may alter antibiotic management.