Lower respiratory tract infections

Low doses of penicillins are more likely to select out resistance, 500mg of amoxicillin is recommended. Do not use early generation quinolones for pneumonia e.g. ciprofloxacin, ofloxacin due to poor pneumococcal activity. Reserve the respiratory quinolone levofloxacin for proven resistant organisms.

Acute cough, acute 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

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

Where antibiotics are indicated
Amoxicillin
  • 500mg every 8 hours for 5 days
Penicillin allergy
Doxycycline
  • 200mg single dose on first day; 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. Clarithromycin 250mg every 12 hours for 5 days may be considered. 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 or twice daily, depending prescriber preference and disease severity, for a total of 5 days

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

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

Community acquired pneumonia - treatment in the community

Start antibiotics immediately

Consider using CRB65 score to help assess severity and to guide treatment.

Each scores 1:

  • Confusion (AMT less than 8 or new disorientation in person, place or time)
  • Respiratory rate greater than 30/min
  • BP systolic less than 90 or Diastolic BP 60 or lower
  • Age 65 years or over

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 and 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 all other patients, particularly those with a CRB65 score of 2 or more

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

Low severity CAP - treatment at home
Amoxicillin
  • 500-1000mg every 8 hours for 5 days, review at 3 days and extend to 7-10 days if poor response
Penicillin allergy
Doxycycline
  • 200mg single on the first day, 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: Pneumonia in adults: diagnosis and management) (December 2014)

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
Amoxicillin
  • 500-1000mg every 8 hours for 5 days, review at 3 days and extend to 7-10 days if poor response

AND

Doxycycline
  • 200mg single on the first day, then 100mg once daily for a total of 5 days, review at 3 days and extend to 7-10 days if poor response

OR

Amoxicillin
  • 500-1000mg every 8 hours for 5 days, review at 3 days and extend to 7-10 days if poor response

AND

Clarithromycin
  • 500mg every 12 hours for 5 days, review at 3 days and extend to 7-10 days if poor response

 

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