Clinical Knowledge Summaries CKS Chest infections - adults Primary care management of acute...

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 (August 2012), and guidelines published by the British Thoracic Society (2009): BTS guidelines for the management of community acquired pneumonia in adults.

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 (August 2012), and guidelines published by the British Thoracic Society (2009); BTS guidelines for the management of community acquired pneumonia in adults.

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.


Usual pathogens• Acute bronchitis:

o Viral infections account for most cases, buto 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%.


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.


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.


Diagnosis

• Cough is the predominant symptom for acute bronchitis and community-acquired pneumonia (CAP).

• Difficult to distinguish CAP from acute bronchitis.


Differentiating featuresFactor Acute bronchitis Community acquired

pneumoniaHistory Cough Cough

May or may not have sputum, wheeze, or dyspnoea

At least one other symptom of sputum, wheeze, dyspnoea, or pleuritic pain

Examination Wheeze often present, but no other focal chest signs

Focal chest signs presentIncludes dullness to percussion, course crepitations, vocal fremitus

May have systemic features with or without a raised temperatureFeatures include sweats, fevers, myalgia

At least one systemic feature present with or without a temperature above 38°CFeatures include sweats, fevers, myalgia

Investigations (not usually considered necessary in general practice)

Chest X–ray clear Chest X–ray diagnostic


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).


Investigations• Chest X-ray

oMay not be necessary for people with suspected CAP who are managed in community.

• Microbiological investigationso 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.


Differential diagnosis• If acute bronchitis and cough persists longer

than 3 weeks rule out:o Asthma/chronic obstructive pulmonary disease.o Post-infectious cough.oWhooping cough.o Post-nasal drip.o Gastro-oesophageal reflux.o Tuberculosis.o An underlying malignancy in people who smoke.


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 (August 2012).

Acute bronchitis – management

http://cks.nice.org.uk/chest-infections-adult

Acute bronchitis – management • 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 alternativelyo Doxycycline.o Clarithromycin if amoxicillin or doxycycline is

unsuitable.

• Encourage smoking cessation.Based on the CKS topic Chest infections – adults (August 2012), and guidelines published by the British Thoracic Society (2009); BTS guidelines for the management of community acquired pneumonia in adults.

http://cks.nice.org.uk/chest-infections-adult

Antibiotics for acute bronchitis?• Only prescribe an antibiotic if the person has a

pre-existing condition that impairs their ability to deal with infection or is likely to deteriorate with acute bronchitis, for example:o Over 75 years of age, with fever.o Chronic obstructive pulmonary disease (COPD).o Heart failure.o Immunocompromised, including people with cancer

or insulin dependant diabetes.• Give a delayed antibiotic prescription if it is felt

safe not to prescribe antibiotics immediately.Based on the CKS topic Chest infections – adults (August 2012), and guidelines published by the British Thoracic Society (2009); BTS guidelines for the management of community acquired pneumonia in adults.

Why are antibiotics not usually prescribed for acute bronchitis?• Evidence from a Cochrane review shows that:

o Antibiotics have a modest effect in reducing the duration of cough in some people.

• Some studies estimate that:o The adverse effects of antibiotics are as frequent as

beneficial effects.

• Most experts agree that:o Antibiotics are not recommended for people with acute

bronchitis who do not have any significant pre-existing conditions.


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, oro 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 (August 2012), and guidelines published by the British Thoracic Society (2009); BTS guidelines for the management of community acquired pneumonia in adults.

Managing community acquired pneumonia (CAP)

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 (August 2012), and guidelines published by the British Thoracic Society (2009); BTS guidelines for the management of community acquired pneumonia in adults.

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.


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 (August 2012), and guidelines published by the British Thoracic Society (2009); BTS guidelines for the management of community acquired pneumonia in adults.

Managing CAP• If admission/referral not required:

o Arrange a chest X-ray for people over 50 years of age who smoke.

o Advise using analgesia and keeping hydrated.o Treat with an antibiotic:• Amoxicillin first-line.• Erythromycin, clarithromycin, or azithromycin if

amoxicillin is contraindicated.• Doxycycline can be used if Mycoplasma pneumoniae is

suspected.o Encourage smoking cessation.


Antibiotics for CAP• Immediate empirical treatment with antibiotics is

essential to reduce:o Mortality, o Length of illness,o Severity of symptoms, and o The likelihood of complications.

• The trial evidence to support antibiotics is limited, but the benefit of antibiotics is beyond doubt in this group. o Placebo controlled trials are considered unethical.

• Antibiotics may not be appropriate during the terminal phase of life.


Follow up of CAP• Follow up all cases of pneumonia.• 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.


Follow up of CAP• Arrange a chest X-ray after 6 weeks for all

people:oWith symptoms and signs that are slow to resolve

or persist despite treatment.oWho smoke and are over 50 years of age.

• Reinforce smoking cessation advice.• Once the person has recovered consider

pneumococcal and influenza vaccine.


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.• Erythromycin, clarithromycin, or azithromycin if amoxicillin is contraindicated.• Doxycycline can be used if Mycoplasma pneumoniae is suspected.

o 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 50 years of age.

• Ensure smoking cessation advice is given and reinforced (where appropriate).

Clinical Knowledge Summaries CKS Chest infections - adults Primary care management of acute...

Documents

Transcript of Clinical Knowledge Summaries CKS Chest infections - adults Primary care management of acute...