1. Clinical Knowledge Summaries CKS Chest infections - adults Primary care management of acute bronchitis and community-acquired pneumonia in adults. Infective exacerbations of chronic obstructive pulmonary disease (COPD) are not covered. Educational slides based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015): BTS guidelines for the management of community acquired pneumonia in adults.

2. Key learning points and objectives To be able to: o Distinguish between acute bronchitis and community acquired pneumonia. o Outline the management of acute bronchitis and describe when antibiotics should be prescribed. o Outline the management of community acquired pneumonia (CAP) and describe which antibiotics should be prescribed. o Describe when people with CAP should be admitted or referred for specialist investigation. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

3. Definition Chest infections in primary care can be broadly split into: o Acute bronchitis – acute inflammation of the bronchial tree associated with oedema and mucus production leading to cough and phlegm production that lasts for up to 3 weeks. o Community acquired pneumonia (CAP) – acute infection of the lung parenchyma. o Infective exacerbations of chronic obstructive pulmonary disease (COPD) – discussed in another slide set. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

4. Usual pathogens Acute bronchitis: o Viral infections account for most cases, but o A significant minority are bacterial e.g. o Streptococcus pneumoniae and Haemophilus influenzae. Community acquired pneumonia (CAP): o In around 45% of cases no pathogen is found. o Streptococcus pneumoniae found in 36%. o Haemophilus influenzae found in 10%. o Staphylococcus aureus found in 0.8%. o Viruses found in 13%. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

5. Prevalence Acute respiratory infections account for 17% of all GP consultations. For acute bronchitis the annual incidence is 44 per 1000 adult population. For CAP: o The annual incidence is 5–11 per 1000 adult population. o Accounts for 5–12% of all lower respiratory tract infections managed by GPs. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

6. Complications and prognosis Acute bronchitis is usually mild and self-limiting. o Cough usually lasts 7–10 days but can last for up to 3 weeks. CAP – complications include: o Pleural effusion, empyema, lung abscess, septicaemia and metastatic infection (e.g. meningitis). The mortality associated with pneumonia: o Is less than 1% if well enough to be managed in the community. o Ranges from 6–12% if hospital admission is required. o More than 50% if patient needs intensive care. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

7. Diagnosis Cough is the predominant symptom for acute bronchitis and community-acquired pneumonia (CAP). Difficult to distinguish CAP from acute bronchitis. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

8. Differentiating features FactorAcute bronchitisCommunity acquired pneumonia HistoryCough May or may not have sputum, wheeze, or dyspnoea At least one other symptom of sputum, wheeze, dyspnoea, or pleuritic pain ExaminationWheeze often present, but no other focal chest signs Focal chest signs present Includes dullness to percussion, course crepitations, vocal fremitus May have systemic features with or without a raised temperature Features include sweats, fevers, myalgia At least one systemic feature present with or without a temperature above 38°C Features include sweats, fevers, myalgia Investigations (not usually considered necessary in general practice) Chest X–ray clearChest X–ray diagnostic Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

9. Diagnosis No combination of symptoms or signs are clearly diagnostic for CAP. Always use clinical judgement. Elderly people with CAP: o Present more frequently with non-specific symptoms, and o Are less likely to have a fever (compared with younger people). Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

10. Investigations Chest X-ray o May not be necessary for people with suspected CAP who are managed in community. Microbiological investigations o Usually not necessary to diagnose CAP or acute bronchitis managed in community. o Sputum samples for culture and/or sensitivity may be useful in people with: Recurrent episodes of acute bronchitis who may have become colonized with bacteria resistant to first-line antibiotics. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

11. Differential diagnosis If acute bronchitis and cough persists longer than 3 weeks rule out: o Asthma/chronic obstructive pulmonary disease. o Post-infectious cough. o Whooping cough. o Post-nasal drip. o Gastro-oesophageal reflux. o Tuberculosis. o An underlying malignancy in people who smoke. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

12. Differential diagnosis For people with chest signs, other conditions to rule out include: o Pneumonia with underlying malignancy. o Heart failure. o Pulmonary embolism. o Asthma. Based on the CKS topic Chest infections – adults ( November 2015 ).

13. Acute bronchitis – management

14. Adequate analgesia and hydration is all that is usually necessary. Antibiotics are not routinely indicated. If necessary use empirical treatment with: o Amoxicillin (first-line), or alternatively o Doxycycline. o Clarithromycin if amoxicillin or doxycycline is unsuitable. Encourage smoking cessation. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

15. Antibiotics for acute bronchitis? Consider prescribing antibiotics if the person: – Is systemically very unwell. – Is at high risk of serious complications because of a pre-existing comorbid condition such as heart, lung, kidney, liver or neuromuscular disease, or immunosuppression. – Is older than 65 years of age with two or more of the following, or older than 80 years with one or more of the following: Hospital admission in the previous year. Type 1 or type 2 diabetes mellitus. Known congestive heart failure. Concurrent use of oral corticosteroids. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

16. Why are antibiotics not usually prescribed for acute bronchitis? Evidence from a Cochrane review shows that: oAntibiotics have a modest effect in reducing the duration of cough in some people. Some studies estimate that: oThe adverse effects of antibiotics are as frequent as beneficial effects. Most experts agree that: oAntibiotics are not recommended for people with acute bronchitis who do not have any significant pre-existing conditions. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

17. Follow up for acute bronchitis Follow up not usually required. Advise the person to seek advice if: o Their condition deteriorates significantly, or o Symptoms last longer than 3 weeks. People who have deteriorated should be re- examined to exclude pneumonia. For people with a pre-existing condition that has deteriorated on treatment, consider: o Admission, or o A second-line antibiotic (co-amoxiclav or doxycycline). o Seeking advice from a microbiologist if either of these are unsuitable. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

18. Managing community acquired pneumonia (CAP)

19. Managing CAP – admit or refer? Use the CRB 65 score as well as clinical judgement to help decide if referral or admission is required. Also take social circumstances into account: o Does the person live alone? Are they socially isolated? Have a higher index of suspicion in certain groups such as: o The elderly, those with rapid deterioration, pre- existing lung conditions. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

20. Using the CRB 65 score When using the CRB 65 score — score one point for each of the following: o Confusion — recent. o Respiratory rate of 30 breaths/min or greater. o Blood pressure — systolic of 90 mmHg or less or diastolic of 60 mmHg or less. o 65 years old or older. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

21. Managing CAP — admit or refer? Admit if oxygen saturation is less than 92% (as measured by pulse oximetry). If CRB-65 score is: o 3 or 4 — urgently admit to hospital. o 2 — refer for same-day assessment (secondary care). o 1 — consider same-day assessment (secondary care). o 0 — treat at home (depending on clinical judgement and available social support). Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

22. Managing CAP If admission/referral not required: o Arrange a chest X-ray for people over 60 years of age who smoke to rule out lung cancer. o Advise using analgesia and keeping hydrated. o Treat with an antibiotic: Amoxicillin first-line. Doxycycline if there is a true penicillin allergy Alternatively clarithromycin Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

23. Antibiotics for CAP Immediate empirical treatment with antibiotics is essential to reduce: oMortality, oLength of illness, oSeverity of symptoms, and oThe likelihood of complications. The trial evidence to support antibiotics is limited, but the benefit of antibiotics is beyond doubt in this group. oPlacebo controlled trials are considered unethical. Antibiotics may not be appropriate during the terminal phase of life. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

24. Follow up of CAP Follow up all cases of pneumonia within 3 days If there is no clinical improvement, or worsening on treatment: o Reconsider admission, or o Consider a second line antibiotic. If already taking amoxicillin, switch to, or add on, a macrolide (erythromycin or clarithromycin). If these are not suitable, seek advice from a microbiologist. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

25. Follow up of CAP Arrange a chest X-ray after 6 weeks for all people: o With symptoms and signs that are slow to resolve or persist despite treatment. o Who smoke and are over 60 years of age. Reinforce smoking cessation advice. Once the person has recovered consider pneumococcal and influenza vaccine. Based on the CKS topic Chest infections – adults (November 2015), and guidelines published by the British Thoracic Society (2015); BTS guidelines for the management of community acquired pneumonia in adults.

26. Summary Difficult to distinguish CAP from acute bronchitis. Acute bronchitis: o Viral infections account for most cases. o Antibiotics are not usually required – only needed if the person is immunocompromised or has an existing condition likely to significantly worsen. CAP: o Use clinical judgement and the CRB 65 score to help decide if referral or admission is required. o If managing in community start empirical treatment with an antibiotic. Amoxicillin first-line. Doxycycline can be used if there is true penicillin allergy Clarithromycin is an alternative Arrange chest X-ray after 6 weeks for all people: With symptoms and signs that are slow to resolve or persist despite treatment. Who smoke and are over 60 years of age. Ensure smoking cessation advice is given and reinforced (where appropriate).