COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community

Communicating with patients and minimising infection risk

• For patients with COVID-19 symptoms explain:
  • that the typical symptoms are cough, fever and fatigue, but they may also have breathlessness, muscle aches, sore throat, headache and loss of sense of smell
  • that they should follow the UK government guidance on self-isolation and the UK government guidance on protecting vulnerable people
  • that if the symptoms are mild they are likely to feel much better in a week
  • who to contact if their symptoms (such as breathlessness) get worse; see NHS 111 online for details on who to contact
• Support patients’ mental wellbeing, signposting to charities and support groups (including NHS volunteers) where available, to help alleviate any anxiety and fear they may have about COVID-19
• Minimise face-to-face contact by:
  • offering telephone or video consultations (see the BMJ guidance on COVID-19: a remote assessment in primary care for a useful guide, including a visual summary for remote consultations)
  • cutting non-essential face-to-face follow-up
  • using electronic rather than paper prescriptions
  • using different methods to deliver medicines to patients, for example pharmacy deliveries, postal services, NHS volunteers or drive-through pick-up points
• For patients with known or suspected COVID-19, follow appropriate UK government guidance on infection prevention and control. This includes recommendations on patient transfers and on decontaminating reusable equipment between each patient and after patient use
• If a patient shows typical COVID-19 symptoms, follow UK government guidance on investigation and initial clinical management of possible cases. This includes information on testing and isolating patients

Treatment and care planning

• When possible, discuss the risks, benefits and likely outcomes of treatment options with patients with COVID-19, and their families and carers. This will help them make informed decisions about their treatment goals and wishes, including treatment escalation plans where appropriate
• Find out if patients have advance care plans or advance decisions to refuse treatment, including ‘do not attempt cardiopulmonary resuscitation’ decisions
• Use decision support tools (when available). Bear in mind that these discussions may need to take place remotely. Document discussions and decisions clearly and take account of these in planning care

Diagnosis and assessment

Diagnosing pneumonia

• During the COVID-19 pandemic, face-to-face examination of patients may not be possible. Advice on how to conduct a remote consultation can be found in BMJ guidance on COVID-19: a remote assessment in primary care, which includes a visual summary for remote consultations
• Where physical examination and other ways of making an objective diagnosis are not possible, the clinical diagnosis of community-acquired pneumonia of any cause in an adult can be informed by other clinical signs or symptoms such as:
  • temperature above 38°C
  • respiratory rate above 20 breaths per minute
  • heart rate above 100 beats per minute
  • new confusion
    
    (see the CEBM’s rapid diagnosis of community-acquired pneumonia for clinicians)
• Assessing shortness of breath (dyspnoea) is important, but may be difficult via remote consultation. Tools such as the Medical Research Council’s dyspnoea scale or the CEBM’s review of ways of assessing dyspnoea (breathlessness) by telephone or video can be useful

Assessing severity

• Use the following symptoms and signs to help identify patients with more severe illness to help make decisions about hospital admission:
  • severe shortness of breath at rest or difficulty breathing
  • coughing up blood
  • blue lips or face
  • feeling cold and clammy with pale or mottled skin
  • collapse or fainting (syncope)
  • new confusion
  • becoming difficult to rouse
  • little or no urine output

Use of assessment tools

• Although the NICE guideline on pneumonia in adults: diagnosis and management recommends using the CRB65 tool, it has not been validated in people with COVID-19. It also requires blood pressure measurement, which may be difficult or undesirable during the COVID-19 pandemic and risks cross-contamination
• Where pulse oximetry is available use oxygen saturation levels below 92% (below 88% in people with COPD) on room air at rest to identify seriously ill patients. While the Roth tool has been suggested as an alternative where pulse oximetry is not available, its use has not been validated in people with COVID-19 and there are concerns that it may underestimate illness severity (see the CEBM’s rapid review of the use of the Roth score in remote assessment)
• Use of the NEWS2 tool in the community for predicting the risk of clinical deterioration may be useful. However, a face-to-face consultation should not be arranged solely to calculate a NEWS2 score

Differentiating viral COVID-19 pneumonia from bacterial pneumonia

It is difficult to determine whether pneumonia has a COVID-19 viral cause or a bacterial cause (either primary or secondary to COVID-19) in primary care, particularly during remote consultations. However, as COVID-19 becomes more prevalent in the community, patients presenting with pneumonia symptoms are more likely to have a COVID-19 viral pneumonia than a community-acquired bacterial pneumonia

• COVID-19 viral pneumonia may be more likely if the patient:
  • presents with a history of typical COVID-19 symptoms for about a week
  • has severe muscle pain (myalgia)
  • has loss of sense of smell (anosmia)
  • is breathless but has no pleuritic pain
  • has a history of exposure to known or suspected COVID-19, such as a household or workplace contact
• A bacterial cause of pneumonia may be more likely if the patient:
  • becomes rapidly unwell after only a few days of symptoms
  • does not have a history of typical COVID-19 symptoms
  • has pleuritic pain
  • has purulent sputum

Managing suspected or confirmed pneumonia

Deciding about hospital admission

• Be aware that older people, or those with comorbidities, frailty, impaired immunity or a reduced ability to cough and clear secretions, are more likely to develop severe pneumonia. Because this can lead to respiratory failure and death, hospital admission would have been the usual recommendation for these people before the COVID-19 pandemic
• When making decisions about hospital admission, take into account:
  • the severity of the pneumonia, including symptoms and signs of more severe illness
  • the benefits, risks and disadvantages of hospital admission
  • the care that can be offered in hospital compared with at home
  • the patient’s wishes and care plans (see Treatment and care planning)
  • service delivery issues and local NHS resources during the COVID-19 pandemic
• Explain that:
  • the benefits of hospital admission include improved diagnostic tests (chest X-ray, microbiological tests and blood tests) and respiratory support
  • the risks and disadvantages of hospital admission include spreading or catching COVID-19 and loss of contact with families

Managing breathlessness

• Be aware that severe breathlessness often causes anxiety, which can then increase breathlessness further. See the NICE COVID-19 rapid guideline on managing symptoms (including at the end of life) in the community for advice on how to manage breathlessness

Antibiotic treatment

• As COVID-19 pneumonia is caused by a virus, antibiotics are ineffective
• Do not offer an antibiotic for treatment or prevention of pneumonia if:
  • COVID-19 is likely to be the cause and symptoms are mild
    
    Inappropriate antibiotic use may reduce availability if used indiscriminately, and broad-spectrum antibiotics in particular may lead to Clostridioides difficile infection and antimicrobial resistance
• Offer an oral antibiotic for treatment of pneumonia in people who can or wish to be treated in the community if:
  • the likely cause is bacterial or
  • it is unclear whether the cause is bacterial or viral and symptoms are more concerning or
  • they are at high risk of complications because, for example, they are older or frail, or have a pre-existing comorbidity such as immunosuppression or significant heart or lung disease (for example bronchiectasis or COPD), or have a history of severe illness following previous lung infection
• When starting antibiotic treatment, the first-choice oral antibiotic is:
  • doxycycline 200 mg on the first day, then 100 mg once a day for 5 days in total (not in pregnancy)
  • alternative: amoxicillin 500 mg 3 times a day for 5 days

Doxycycline is preferred because it has a broader spectrum of cover than amoxicillin, particularly against Mycoplasma pneumoniae and Staphylococcus aureus, which are more likely to be secondary bacterial causes of pneumonia during the COVID-19 pandemic

• Do not routinely use dual antibiotics
• For choice of antibiotics in penicillin allergy, pregnancy and more severe disease, or if atypical pathogens are likely, see the recommendations on choice of antibiotic in the NICE antimicrobial prescribing guideline on community-acquired pneumonia
• Start antibiotic treatment as soon as possible, taking into account any different methods needed to deliver medicines to patients during the COVID-19 pandemic

Oral corticosteroids

• Do not routinely offer a corticosteroid unless the patient has other conditions for which these are indicated, such as asthma or COPD

Safety netting and review

• Advise patients to seek medical help without delay if their symptoms do not improve as expected or worsen rapidly or significantly, whether they are taking an antibiotic or not
• On reassessment, reconsider whether the patient has symptoms and signs of more severe illness and whether to admit to hospital