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Management of community-acquired pneumonia

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Pneumonia

About

What is covered

This interactive flowchart covers the diagnosis and management of community-acquired pneumonia and hospital-acquired pneumonia in adults. However, it does not provide recommendations on areas of care where best practice is already established, such as diagnosis using chest X-ray. This flowchart does not cover bronchiectasis complicated by pneumonia, people younger than 18 years, or patients who acquire pneumonia while intubated or in an intensive care unit, who are immunocompromised, or in whom management of pneumonia is an expected part of end-of-life care.

Updates

Updates to this interactive flowchart

23 August 2016 Extracorporeal carbon dioxide removal for acute respiratory failure (NICE interventional procedures guidance 564) added to management of hospital-acquired pneumonia and monitoring in hospital.
9 February 2016 Tests for rapidly identifying bloodstream bacteria and fungi (LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay) (NICE diagnostics guidance 20) added to microbiological tests.
18 January 2016 Pneumonia in adults (NICE quality standard 110) added.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to microbiological tests.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing community- and hospital-acquired pneumonia in adults in an interactive flowchart

What is covered

This interactive flowchart covers the diagnosis and management of community-acquired pneumonia and hospital-acquired pneumonia in adults. However, it does not provide recommendations on areas of care where best practice is already established, such as diagnosis using chest X-ray. This flowchart does not cover bronchiectasis complicated by pneumonia, people younger than 18 years, or patients who acquire pneumonia while intubated or in an intensive care unit, who are immunocompromised, or in whom management of pneumonia is an expected part of end-of-life care.

Updates

Updates to this interactive flowchart

23 August 2016 Extracorporeal carbon dioxide removal for acute respiratory failure (NICE interventional procedures guidance 564) added to management of hospital-acquired pneumonia and monitoring in hospital.
9 February 2016 Tests for rapidly identifying bloodstream bacteria and fungi (LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay) (NICE diagnostics guidance 20) added to microbiological tests.
18 January 2016 Pneumonia in adults (NICE quality standard 110) added.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to microbiological tests.

Quality standards

Quality statements

Mortality risk assessment in primary care using CRB65 score

This quality statement is taken from the pneumonia in adults quality standard. The quality standard defines clinical best practice in pneumonia in adults and should be read in full.

Quality statement

Adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community-acquired pneumonia in primary care.

Rationale

Assessing mortality risk using the CRB65 score in primary care informs clinical judgement and supports decision-making about whether care can be managed in the community or if hospital assessment is needed. This ensures that treatment is based on the severity of the infection and will improve treatment outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community-acquired pneumonia in primary care.
Data source: Local data collection.
Process
Proportion of community-acquired pneumonia diagnoses of adults in primary care at which the adult has a mortality risk assessment using the CRB65 score.
Numerator – the number in the denominator at which the adult has a mortality risk assessment using the CRB65 score.
Denominator – the number of diagnoses of community-acquired pneumonia in adults in primary care.
Data source: Local data collection.
Outcome
Hospital admissions.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care services) ensure that adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community-acquired pneumonia in primary care.
Healthcare professionals (such as GPs and nurse practitioners) carry out a mortality risk assessment using the CRB65 score when an adult is diagnosed with community-acquired pneumonia in primary care. Details of the risk assessment should be shared if the adult is referred to hospital or outpatient care.
Commissioners (NHS England area teams and clinical commissioning groups) commission services in which adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community-acquired pneumonia in primary care.

What the quality statement means for patients, service users and carers

Adults diagnosed with community-acquired pneumonia by their GP have a first assessment to find out how serious the pneumonia is. This includes a ‘CRB65 score’, which uses the person’s age, symptoms and blood pressure to help decide the how serious the risks are for that person and whether they need to go to hospital.

Source guidance

Definitions of terms used in this quality statement

Community-acquired pneumonia
Pneumonia that is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.
[Pneumonia in adults (2014) NICE guideline CG191 and expert opinion]
Mortality risk assessment in primary care
When a clinical diagnosis of community-acquired pneumonia is made in primary care, the healthcare professional should assess whether the person is at low, intermediate or high risk of death by calculating the CRB65 score at the initial assessment (box 1).
Box 1 CRB65 score for mortality risk assessment in primary carea
CRB65 score is calculated by giving 1 point for each of the following prognostic features:
  • confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)b
  • raised respiratory rate (30 breaths per minute or more)
  • low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
  • age 65 years or more.
Patients are stratified for risk of death as follows:
  • 0: low risk (less than 1% mortality risk)
  • 1 or 2: intermediate risk (1–10% mortality risk)
  • 3 or 4: high risk (more than 10% mortality risk).
aLim WS, van der Eerden MM, Laing R et al. (2003) Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58: 377–82.
bFor guidance on delirium, see the NICE guideline on delirium.
[Pneumonia in adults (2014) NICE guideline CG191, recommendation 1.2.1]

Equality and diversity considerations

It is important to be aware of dementia when assessing confusion, and to adapt the assessment approach to meet individual needs.
Healthcare professionals should be aware of the needs of adults at the end of life and agree the approach for managing pneumonia in the context of the person’s overall care plan.

Antibiotic therapy for diagnosed low-severity community-acquired pneumonia

This quality statement is taken from the pneumonia in adults quality standard. The quality standard defines clinical best practice in pneumonia in adults and should be read in full.

Quality statement

Adults with low-severity community-acquired pneumonia are prescribed a 5-day course of a single antibiotic.

Rationale

Pneumonia is usually caused by bacteria and should be treated with antibiotic therapy. A 5-day course of a single antibiotic is usually an effective treatment for diagnosed low-severity community-acquired pneumonia unless symptoms do not improve. Prescribing a 5-day course will ensure that antibiotic therapy is not given for longer than necessary, and will contribute to effective antimicrobial stewardship. Healthcare professionals should give people advice on seeking further help if their symptoms do not show signs of improving after 3 days of antibiotic therapy.

Quality measures

Process
Proportion of adults with low-severity community-acquired pneumonia who receive a 5-day maximum course of a single antibiotic.
Numerator – the number in the denominator who are prescribed a 5-day maximum course of a single antibiotic.
Denominator – the number of adults with low-severity community-acquired pneumonia.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care services and secondary care services) ensure that adults with low-severity community-acquired pneumonia are prescribed a 5-day course of a single antibiotic.
Healthcare professionals (such as GPs, hospital clinicians and nurse practitioners) prescribe a 5-day course of a single antibiotic to adults with low-severity community-acquired pneumonia and give advice on seeking further help if symptoms do not show signs of improving.
Commissioners (NHS England and clinical commissioning groups) ensure that adults with low-severity community-acquired pneumonia are prescribed a 5-day course of a single antibiotic.

What the quality statement means for patients, service users and carers

Adults with mild community-acquired pneumonia (also called low severity) are prescribed a 5-day course of an antibiotic.

Source guidance

  • Pneumonia in adults (2014) NICE guideline CG191, recommendation 1.2.10 (key priority for implementation)

Definition of terms used in this quality statement

Community-acquired pneumonia
Pneumonia that is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.

Chest X-ray and diagnosis within 4 hours of hospital presentation

This quality statement is taken from the pneumonia in adults quality standard. The quality standard defines clinical best practice in pneumonia in adults and should be read in full.

Quality statement

Adults with suspected community-acquired pneumonia in hospital have a chest X-ray and receive a diagnosis within 4 hours of presentation.

Rationale

When community-acquired pneumonia is suspected in adults, it is important that a clinical assessment sequence is carried out. If the person presents at hospital, assessment should include performing and reviewing a chest X-ray, to help make a timely diagnosis in line with the 4-hour patient processing targets in A&E departments. This will ensure that treatment is given to adults with pneumonia as quickly as possible and that those who do not have community-acquired pneumonia are not given inappropriate antibiotic treatment.

Quality measures

Structure
Evidence of local arrangements and processes to ensure that adults with suspected community-acquired pneumonia in hospital have a chest X-ray and receive a diagnosis within 4 hours of presentation at hospital.
Data source: Local data collection.
Process
a) Proportion of diagnoses of community-acquired pneumonia in adults in hospital at which the adult has a chest X-ray within 4 hours of presentation at hospital.
Numerator – the number in the denominator for which a chest X-ray was carried out within 4 hours of presentation at hospital.
Denominator – the number of diagnoses of community-acquired pneumonia in adults.
Data source: Local data collection.
b) Proportion of diagnoses of community-acquired pneumonia in adults in hospital which are made within 4 hours of presentation at hospital.
Numerator – the number in the denominator for which a diagnosis was made within 4 hours of presentation at hospital.
Denominator – the number of diagnoses of community-acquired pneumonia in adults in hospital.
Data source: Local data collection.
Outcome
a) Length of hospital stay.
Data source: Local data collection.
b) Inappropriate antibiotic use.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that adults with suspected community-acquired pneumonia in hospital have a chest X-ray and receive a diagnosis within 4 hours of presentation at hospital.
Healthcare professionals (such as hospital doctors and nurse practitioners) arrange a chest X-ray for adults with suspected community-acquired pneumonia in hospital, and confirm or rule out a diagnosis of community-acquired pneumonia within 4 hours of presentation at hospital.
Commissioners (clinical commissioning groups) commission services in which adults with suspected community-acquired pneumonia in hospital have a chest X-ray and receive a diagnosis within 4 hours of presentation at hospital.

What the quality statement means for patients, service users and carers

Adults with suspected pneumonia who go to hospital have a chest X-ray and are diagnosed within 4 hours of presentation at hospital.

Source guidance

  • Pneumonia in adults (2014) NICE guideline CG191, recommendation 1.2.8 (key priority for implementation)

Definition of terms used in this quality statement

Suspected community-acquired pneumonia
Community-acquired pneumonia is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. It is suspected in adults who have symptoms and signs of lower respiratory tract infection, and diagnosed in adults who, in the opinion of the doctor and in the absence of a chest X-ray, are likely to have community-acquired pneumonia. Symptoms and signs include, but are not limited to, one or more of the following: fever, shortness of breath, cough, pleuritic chest pain, increased respiratory rate or work of breathing, and localised crepitations heard on auscultation of the person’s chest.
Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.
[Pneumonia in adults (2014) NICE guideline CG191 and expert opinion]

Equality and diversity considerations

Adults with pneumonia or their carers who have difficulty speaking or understanding English should have access to an interpreter or advocate if needed to ensure that they understand the diagnosis.

Mortality risk assessment in hospital using CURB65 score

This quality statement is taken from the pneumonia in adults quality standard. The quality standard defines clinical best practice in pneumonia in adults and should be read in full.

Quality statement

Adults have a mortality risk assessment using the CURB65 score when they are diagnosed with community-acquired pneumonia in hospital.

Rationale

Assessing mortality risk using the CURB65 score in hospital informs clinical judgement and supports decision-making about how the infection is treated, whether the person should receive home- or hospital-based care, the choice of microbiological tests and the choice of antibiotic. This will ensure that treatment is based on the severity of the infection and will improve treatment outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults have a mortality risk assessment using the CURB65 score when they are diagnosed with community-acquired pneumonia in hospital.
Data source: Local data collection.
Process
Proportion of diagnoses of community-acquired pneumonia in adults in hospital at which the adult has a mortality risk assessment using the CURB65 score.
Numerator – the number in the denominator at which the adult has a mortality risk assessment using the CURB65 score.
Denominator – the number of diagnoses of community-acquired pneumonia in adults in hospital.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care and ambulatory care services) ensure that adults have a mortality risk assessment using the CURB65 score when they are diagnosed with community-acquired pneumonia in hospital.
Healthcare professionals (such as hospital doctors and nurse practitioners) carry out a mortality risk assessment using the CURB65 score when adults are diagnosed with community-acquired pneumonia in hospital.
Commissioners (clinical commissioning groups) commission services in which adults have a mortality risk assessment using the CURB65 score when they are diagnosed with community-acquired pneumonia in hospital.

What the quality statement means for patients, service users and carers

Adults diagnosed with community-acquired pneumonia in hospital have an assessment to find out how serious the pneumonia is. This includes a CURB65 score, which uses the person’s age, symptoms, blood pressure and a blood test to help decide how serious the risks are for that person, whether they need to stay in hospital and what treatment they should have.

Source guidance

Definitions of terms used in this quality statement

Community-acquired pneumonia
Pneumonia that is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.
[Pneumonia in adults (2014) NICE guideline CG191 and expert opinion]
Mortality risk assessment in hospital
When a diagnosis of community-acquired pneumonia is made at presentation to hospital, the healthcare professional should assess whether the person is at low, intermediate or high risk of death by calculating the CURB65 score (box 2).
Box 2 CURB65 score for mortality risk assessment in hospitala
CURB65 score is calculated by giving 1 point for each of the following prognostic features:
  • confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)b
  • raised blood urea nitrogen (over 7 mmol/litre)
  • raised respiratory rate (30 breaths per minute or more)
  • low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
  • age 65 years or more.
Patients are stratified for risk of death as follows:
  • 0 or 1: low risk (less than 3% mortality risk)
  • 2: intermediate risk (3–15% mortality risk)
  • 3 to 5: high risk (more than 15% mortality risk).
aLim WS, van der Eerden MM, Laing R et al. (2003) Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58: 377–82.
bFor guidance on delirium, see the NICE guideline on delirium.
[Pneumonia in adults (2014) NICE guideline CG191, recommendation 1.2.3]

Equality and diversity considerations

It is important to be aware of dementia when assessing confusion and to adapt the assessment approach to meet individual needs.
Healthcare professionals should be aware of the needs of people at the end of life and agree the approach for managing pneumonia in the context of their overall care plan.

Antibiotic therapy within 4 hours in hospital

This quality statement is taken from the pneumonia in adults quality standard. The quality standard defines clinical best practice in pneumonia in adults and should be read in full.

Quality statement

Adults with community-acquired pneumonia who are admitted to hospital start antibiotic therapy within 4 hours of presentation.

Rationale

Starting appropriate antibiotic therapy as soon as possible (and within 4 hours of presentation) is important for treating adults with community-acquired pneumonia who are admitted to hospital. Evidence shows that early treatment is associated with improved clinical outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with community-acquired pneumonia who are admitted to hospital start antibiotic therapy within 4 hours of presentation.
Data source: Local data collection.
Process
Proportion of hospital admissions of community-acquired pneumonia in adults at which antibiotic therapy is started within 4 hours of presentation.
Numerator – the number in the denominator at which antibiotic therapy is started within 4 hours of presentation.
Denominator – the number of hospital admissions of community-acquired pneumonia in adults.
Data source: Local data collection.
Outcome
Mortality.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that adults who are admitted to hospital and diagnosed with community-acquired pneumonia start antibiotic therapy within 4 hours of presentation.
Healthcare professionals (hospital clinicians) ensure adults who are admitted to hospital and diagnosed with community-acquired pneumonia start antibiotic therapy within 4 hours of presentation.
Commissioners (clinical commissioning groups) commission services in which adults who are admitted to hospital and diagnosed with community-acquired pneumonia start antibiotic therapy within 4 hours of presentation.

What the quality statement means for patients, service users and carers

Adults who are admitted to hospital and diagnosed with community-acquired pneumonia start antibiotic treatment within 4 hours of being seen.

Source guidance

  • Pneumonia in adults (2014) NICE guideline CG191, recommendations 1.2.8 (key priority for implementation) and 1.2.9

Definition of terms used in this quality statement

Community-acquired pneumonia
Pneumonia that is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.
[Pneumonia in adults (2014) NICE guideline CG191 and expert opinion]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Severe acute respiratory failure

NICE has published interventional procedures guidance on the following procedures with special arrangements for consent, audit and clinical governance:

Severity assessment

A judgement by the managing clinician as to the likelihood of adverse outcomes in a patient. This is based on a combination of clinical understanding and knowledge in addition to a mortality risk score. The difference between categories of severity and mortality risk can be important. Typically the mortality risk score will match the severity assessment. However, there may be situations where the mortality score does not accurately predict mortality risk and clinical judgement is needed. An example might be a patient with a low mortality risk score who has an unusually low oxygen level, who would be considered to have a severe illness.

Glossary

diagnosis based on symptoms and signs of lower respiratory tract infection in a patient who, in the opinion of the GP and in the absence of a chest X-ray, is likely to have community-acquired pneumonia. This might be because of the presence of focal chest signs, illness severity or other features
pneumonia that is acquired outside hospital. Pneumonia that develops in a nursing home resident is included in this definition. When managed in hospital the diagnosis is usually confirmed by chest X-ray
treatment with 2 different antibiotics at the same time
pneumonia that develops 48 hours or more after hospital admission and that was not incubating at hospital admission. When managed in hospital the diagnosis is usually confirmed by chest X-ray. For the purpose of this flowchart, pneumonia that develops in hospital after intubation (ventilator-associated pneumonia) is excluded from this definition
an acute illness (present for 21 days or less), usually with cough as the main symptom, and with at least 1 other lower respiratory tract symptom (such as fever, sputum production, breathlessness, wheeze or chest discomfort or pain) and no alternative explanation (such as sinusitis or asthma). Pneumonia, acute bronchitis and exacerbation of chronic obstructive airways disease are included in this definition
the percentage likelihood of death occurring in a patient in the next 30 days

Paths in this pathway

Pathway created: December 2014 Last updated: August 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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