14 October 2009
What’s new in the area of CAP?
The guidelines note the following developments:
- There are ever-increasing concerns about health-care associated infections, especially MRSA and C difficile. We should take steps to ensure their prudent and careful use, and, in particular, limit the use of levofloxacin and moxifloxacin in favour of other classes of antibiotics where appropriate.
- A reversal in the trend for increasing resistance of S pneumoniae, with rates of penicillin-resistance in the UK remaining below 4%.
- Increases in admissions to hospital and intensive care units.
- Changes in processes for managing acutely ill patients in hospitals.
- Enlarged priorities regarding timeliness of treatment, including the 4-hour admission target.
- Changes in practice regarding microbiological investigations.
These are reflected in the guidance, where most of the changes relate to hospital care.
Key messages for community-based health professionals
- Clinical judgement, supported by the CRB65 score, should be used to decide whether to treat patients at home or in hospital. When deciding on home treatment, the patient’s social circumstances and wishes must be taken into account in all instances.
- Patients in the community should be reviewed after 48 hours, or earlier if clinically indicated.
- Patients with suspected CAP should be advised to rest, drink plenty of fluids and not to smoke.
- Pleuritic pain should be managed with simple analgesia such as paracetamol.
- Pulse oximetry, should be considered, and should be available in the out-of-hours setting and in all locations where emergency oxygen is used.
- Amoxicillin 500mg three times daily is the preferred antibiotic, with doxycycline or clarithromycin as alternatives, for example in those patients hypersensitive to penicillins.
- Microbiological investigations are not recommended routinely but may be appropriate in certain circumstances. For example Examination of sputum should be considered for patients who do not respond to empirical antibiotic therapy.
- In patients with suspected severe, life-threatening CAP referred to hospital, GPs should administer antibiotics in the community: either benzylpenicillin 1.2g intravenously or amoxicillin 1g orally.
More information on CAP and bronchitis can be found on the common infections — respiratory tract section of NPC.
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