BREATHLESS PATIENT70 General Medical Emergencies
3 Mild CAP
(i) Young, fit adults with single lobe involvement may well be able to
return home on oral antibiotics:
(a) give amoxicillin 1 g orally 8-hourly for 5–7 days, or if
Mycoplasma pneumoniae, Chlamydophila pneumoniae
or Legionella is suspected, give doxycycline 200 mg orally
first dose then 100 mg orally daily for 5 days instead, or
clarithromycin 250 mg orally 12-hourly for 5–7 days
(b) add doxycycline or clarithromycin to the amoxicillin, if the
patient fails to improve by 48 h, or if review is not going to be
possible
(c) give doxycycline or moxifloxacin 400 mg orally daily, if
the patient has a history of immediate hypersensitivity to
penicillin, depending on local practice.
(ii) Inform the patient’s GP by fax or a letter if the patient is
discharged, and arrange review within 1–2 days.
4 Moderate severity CAP
(i) Most patients need admission to hospital and parenteral
antibiotics:
(a) give benzyl penicillin 1.2 g i.v. 6-hourly until significant
improvement then change to amoxicillin 1 g orally 8-hourly
for 7 days, plus either doxycycline 100 mg orally 12-hourly
for 7 days, or clarithromycin 500 mg orally 12-hourly for 7
days
(b) add gentamicin 5 mg/kg i.v. daily (assuming normal renal
function) if Gram-negative bacilli are identified in blood
or sputum. Alternatively, change the benzyl penicillin to
ceftriaxone 1 g i.v. daily
(c) substitute ceftriaxone 1 g i.v. daily for the penicillin, or
use moxifloxacin 400 mg orally daily as monotherapy, if
the patient has a history of immediate hypersensitivity to
penicillin, depending on local practice
(d) in tropical areas, if the patient has risk factors for melioidosis
(diabetes/alcohol/CRF) give ceftriaxone 2 g i.v. daily i.v. plus
gentamicin 5 mg/kg i.v. as a single dose.
(e) consider adding oseltamivir 75 mg orally b.d. for 5 days
during any ’flu outbreak.
(ii) Refer the patient to the medical team.
5 Severe CAP, usually with a SMART-COP score ≥ 5
(i) Admit these patients with severe CAP to the HDU or ICU:
(a) give ceftriaxone 1 g daily i.v.; or benzyl penicillin 1.2 g
4-hourly i.v. with gentamicin 5 mg/kg daily i.v., plus with
either azithromycin 500 mg daily i.v.