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Communicating with patients and minimising infection risk

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

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

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

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

© NICE 2020. COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community. Available from: www.nice.org.uk/guidance/NG165. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published date: 03 April 2020.

Last updated: 23 April 2020.