Lower respiratory tract infections

Low doses of penicillins are more likely to select out resistance, amoxicillin doses of 500mg or above are recommended. Do not use quinolones (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms.

Acute cough, bronchitis

Antibiotics are of no benefit in otherwise healthy adults. Symptom resolution can take 3 weeks. Pneumonia is unlikely if there are no new focal chest signs on auscultation in otherwise healthy, non-elderly patients.

Consider no prescription, or delaying a prescription by 7-14 days for the majority of cases.

Sputum samples are generally not useful.

Immediate prescription of antibiotics is recommended in the following patients who are at risk of developing complications (as per NICE CG69):

  1. Pre-existing co-morbidity- including significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis and young children born prematurely
  2. Older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one of more of the following criteria:
    1. Hospitalisation in previous year
    2. Type 1 or type 2 diabetes
    3. History of congestive heart failure
    4. Current use of oral glucocorticoids
  3. If pneumonia suspected, refer to community acquired pneumonia treatment below
Where antibiotics are indicated
Amoxicillin
  • 500mg every 8 hours for 5 days
Penicillin allergy
Doxycycline
  • 200mg single dose on day one, then 100mg once daily, for a total of 5 days
  • For children under 12 years of age who are allergic to penicillin, doxycycline is contraindicated. Give clarithromycin 250mg every 12 hours for 5 days if an antibiotic is required. Reduce dose commensurate with age/ weight.

Acute exacerbation of COPD

See guidance on COPD for information on COPD Rescue packs

Antibiotics are only indicated if there is purulent sputum and increased shortness of breath and/or increased sputum volume.

If clinical evidence of pneumonia, follow community-acquired pneumonia advice below.

Risk factors for antibiotic resistance organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months.

Consider review of COPD management if frequent exacerbations.

Amoxicillin
  • 500mg every 8 hours for 5 days

or

Doxycycline
  • 200mg single dose on day one, then 100mg once daily, for a total of 5 days

Alternative antibiotics: if recent culture, review sensitivities and treat accordingly

If failing on a doxycycline containing regimen consider co-amoxiclav.

Co-amoxiclav
  • 625mg every 8 hours for 5 days

Community-acquired pneumonia (CAP)- treatment in the community

Start antibiotics immediately

Consider using CRB65 score to help guide and review

Each scores 1:

  • Confusion (AMT less than 8, or new disorientation in person, place or time)
  • Respiratory rate 30 breaths per minute or more
  • BP, low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
  • Age 65 years or more

Mortality rates are as follows:

  • CRB65 0 = low risk (less than 1% mortality risk)
  • CRB65 1 or 2 = intermediate risk (1-10% mortality risk)
  • CRB65 3-4 = high risk (more than 10% mortality risk)

CRB-65 score is not a substitute for good clinical judgement; clinicians should take into account other prognostic factors. Care should be taken with younger fit adults, as it is possible that the score may be low in patients who nevertheless have severe illness.

  • Consider home‑based care for patients with a CRB65 score of 0
  • Consider hospital assessment for patients with a CRB65 score of 1-2
  • Urgent hospital admission for all patients with a CRB65 score of 3-4 (unless hospital admission is inappropriate according to patient treatment escalation plans)

The formulary gives dose and duration of treatment for adults unless stated otherwise.

Low severity CAP – treatment at home

Amoxicillin
  • 500mg every 8 hours for 5 days, review at 3 days and extend to 7-10 days if poor response
Penicillin allergy
Doxycycline
  • 200mg single dose on day one, then 100mg once daily for a total of 5 days, review at 3 days and extend to 7-10 days if poor response

Do not routinely offer dual therapy to treat low-severity infection

Patient information (NICE CG191)

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.

Advise patients with community‑acquired pneumonia to consult their healthcare professional if they feel that their condition is deteriorating or not improving as expected.

Moderate severity CAP, managed in community

Doxycycline alone for 7-10 days, or dual therapy adding amoxicillin

Treatment prior to admission

Treatment with an antibiotic in the community is recommended for patients with suspected CAP who are severely ill provided this does not delay transfer to hospital.

Treatment options:

Benzylpenicillin IV 1.2g or oral Amoxicillin 1g (or oral doxycycline 200mg if penicillin sensitivity)

 

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