Excerpt

The microbial causes of pneumonia vary according to its origin and the immune constitution of the patient. Pneumonia is classified into community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and pneumonia in the immunocompromised. The guideline development process is guided by its scope - published after stakeholder consultation. This guideline does not cover all aspects of pneumonia, but focuses on areas of uncertainty or variable practice and those considered of greatest clinical importance. Best practice guidance on the diagnosis and management of CAP and HAP is offered, based on systematic analysis of clinical and economic evidence with the aim of reducing mortality and morbidity from pneumonia and maximising resources.

Contents

• Guideline Development Group members
• NCGC technical team members
• Acknowledgements
• 1. Introduction
• 2. Foreword
• 3. Navigating this guideline
  • 3.1. Terms used
  • 3.2. Finding information relevant to you
• 4. Development of the guideline
  • 4.1. What is a NICE clinical guideline?
  • 4.2. Remit
  • 4.3. Who developed this guideline?
  • 4.4. What this guideline covers
  • 4.5. What this guideline does not cover
  • 4.6. Relationships between the guideline and other NICE guidance
• 5. Methods
  • 5.1. Developing the review questions and outcomes
  • 5.2. Searching for evidence
  • 5.3. Evidence of effectiveness
  • 5.4. Evidence of cost effectiveness
  • 5.5. Developing recommendations
• 6. Guideline summary
  • 6.1. Key priorities for implementation
  • 6.2. Full list of recommendations
  • 6.3. Key research recommendations
• 7. Diagnostic tests
  • 7.1. Review question: In adults with lower respiratory tract infection in the community, what is the clinical value and cost effectiveness of testing C-reactive protein, procalcitonin or performing a chest X-ray over clinical assessment to inform antibiotic prescribing decisions and need for hospital admission?
  • 7.2. Clinical evidence
  • 7.3. Economic evidence
  • 7.4. Evidence statements
  • 7.5. Recommendations and link to evidence
• 8. Severity assessment tools
  • 8.1. Review question: In adults presenting with a lower respiratory tract infection or suspected community-acquired pneumonia in the community, what is the most accurate and cost-effective severity assessment tool to identify patients whose outcome will be improved by referral to hospital?
  • 8.2. Clinical evidence
  • 8.3. Economic evidence
  • 8.4. Evidence statements
  • 8.5. Recommendations and link to evidence
  • 8.6. Review question: In adults with community-acquired pneumonia (presenting to Accident & Emergency) what is the most accurate and cost-effective severity assessment tool to stratify patients at first presentation according to who would benefit from: a) hospital admission? b) ITU assessment?
  • 8.7. Clinical Evidence
  • 8.8. Economic evidence
  • 8.9. Evidence statements
  • 8.10. Recommendations and link to evidence
  • 8.11. Disease severity
• 9. Microbiological tests
  • 9.1. Review question: In adults with community-acquired pneumonia or hospital-acquired pneumonia in a hospital setting, what microbiological test or combination of tests at presentation (including urinary pneumococcal and urinary legionella antigen, blood culture and sputum culture) is most likely to be clinically and cost effective?
  • 9.2. Clinical evidence
  • 9.3. Economic evidence
  • 9.4. Evidence statements for patients with community acquired pneumonia
  • 9.5. Recommendations and link to evidence
  • 9.6. Research recommendation
• 10. Antibiotic therapy
  • 10.1. Timing of antibiotic therapy
  • 10.2. Review question: In adults with suspected community-acquired pneumonia is earlier rather than later antibiotic administration more clinically and cost effective?
  • 10.3. Review question: In adults with community-acquired pneumonia what is the most clinically- and cost-effective empirical antibiotic choice?
  • Low-severity community-acquired pneumonia
  • 10.4. Single-compared with other single-antibiotic therapy for low-severity community-acquired pneumonia
  • 10.5. Single- compared with dual-antibiotic therapy for low-severity community-acquired pneumonia
  • 10.6. Dual- compared with other dual-antibiotic therapy for low-severity community-acquired pneumonia
  • Moderate- to high-severity community-acquired pneumonia
  • 10.7. Single- compared with other single-antibiotic therapy for moderate- to high-severity community-acquired pneumonia
  • 10.8. Single- compared with dual-antibiotic therapy for moderate-to high-severity community-acquired pneumonia
  • 10.9. Dual- compared with other dual-antibiotic therapy for moderate- to high-severity community-acquired pneumonia
  • 10.10. Review question: In adults with community-acquired pneumonia what is the clinical and cost effectiveness of short- compared with longer-course antibiotics?
  • 10.11. Low-severity community-acquired pneumonia
  • 10.12. Moderate- and high-severity community-acquired pneumonia
  • 10.13. Recommendation summary
• 11. Glucocorticosteroid treatment
  • 11.1. Review question: In adults with community-acquired pneumonia or hospital-acquired pneumonia requiring management in hospital, what is the clinical and cost effectiveness of initial glucocorticosteroid treatment in addition to antibiotic treatment compared with antibiotic treatment alone?
  • 11.2. Clinical evidence
  • 11.3. Economic evidence
  • 11.4. Evidence statements
  • 11.5. Recommendations and link to evidence
• 12. Gas exchange
  • 12.1. Review question: In adults with community-acquired pneumonia or hospital-acquired pneumonia managed in hospital, what is the clinical and cost effectiveness of non-invasive ventilation compared with continuous positive airways pressure or usual care?
  • 12.2. Clinical evidence
  • 12.3. Review question: In adults with pneumonia managed in hospital, what is the clinical and cost effectiveness of NIV, CPAP or usual care compared with elective intubation?
  • 12.4. Clinical evidence
  • 12.5. Economic evidence
  • 12.6. Evidence statements
  • 12.7. Recommendations and link to evidence
  • 12.8. Research recommendation
• 13. Monitoring
  • 13.1. Review question: In adults with community-acquired pneumonia or hospital-acquired pneumonia managed in hospital, what is the clinical and cost effectiveness of C-reactive protein or procalcitonin monitoring in addition to clinical observation in helping to determine when to stop or change treatment and when to discharge?
  • 13.2. Clinical evidence
  • 13.3. Economic evidence
  • 13.4. Evidence statements
  • 13.5. Recommendations and link to evidence
  • 13.6. Research recommendation
• 14. Safe discharge
  • 14.1. Introduction
  • 14.2. Review question: What is the prognostic value, clinical and cost effectiveness of various factors for assessing whether it is safe to discharge adults with community-acquired pneumonia or hospital-acquired pneumonia requiring management in hospital?
  • 14.3. Clinical evidence
  • 14.4. Economic evidence
  • 14.5. Evidence statements
  • 14.6. Recommendations and link to evidence
• 15. Patient information
  • 15.1. Review question: What advice should be given to adults about what symptoms and duration of symptoms can be expected following treatment for community-acquired or hospital-acquired pneumonia, and when should patients be advised to consult or re-consult a GP?
  • 15.2. Clinical evidence
  • 15.3. Economic evidence
  • 15.4. Evidence statements
  • 15.5. Recommendations and link to evidence
  • Hospital-acquired pneumonia
• 16. Severity assessment
  • 16.1. Review question: In adults with hospital-acquired pneumonia what is the most accurate and cost-effective severity assessment tool to stratify patients at first presentation according to who would benefit from ITU assessment?
• 17. Microbiological tests
  • 17.1. In adults with community-acquired pneumonia or hospital-acquired pneumonia in a hospital setting, what microbiological test or combination of tests at presentation (including urinary pneumococcal and urinary legionella antigen, blood culture and sputum culture) is most likely to be clinically and cost effective?
• 18. Antibiotic therapy
  • 18.1. Timing of antibiotic therapy for hospital-acquired pneumonia
  • 18.2. Review question: In adults with hospital-acquired pneumonia is earlier rather than later antibiotic administration more clinically and cost effective?
  • 18.3. Review question: In adults with hospital-acquired pneumonia what is the most clinically- and cost-effective empirical antibiotic choice?
  • 18.4. Single-compared with other single-antibiotic therapy for hospital-acquired pneumonia
  • 18.5. Single-compared with dual-antibiotic therapy for hospital-acquired pneumonia
  • 18.6. Dual- compared with other dual-antibiotic therapy for hospital-acquired pneumonia
  • 18.7. Recommendations and link to the evidence
  • 18.8. Research recommendation
  • 18.9. Duration of antibiotic therapy for hospital-acquired pneumonia
  • 18.10. In adults with hospital-acquired pneumonia what is the clinical and cost effectiveness of short- compared with longer-course antibiotics?
• 19. Glucocorticosteroid treatment
  • 19.1. In adults with community-acquired pneumonia or hospital-acquired pneumonia requiring management in hospital, what is the clinical and cost effectiveness of initial glucocorticosteroid treatment in addition to antibiotic treatment compared with antibiotic treatment alone?
• 20. Reference list
• 21. Acronyms and abbreviations
• 22. Glossary
• Appendices
  • Appendix A. SCOPE
  • Appendix B. Declarations of interest
  • Appendix C. Review protocols
  • Appendix D. Clinical article selection
  • Appendix E. Economic article selection
  • Appendix F. Literature search strategies
  • Appendix G. Clinical evidence tables
  • Appendix H. Economic evidence tables
  • Appendix I. Forest plots
  • Appendix J. Excluded clinical studies
  • Appendix K. Excluded economic studies
  • Appendix L. Cost-effectiveness analysis: microbiological investigations
  • Appendix M. Research recommendations
  • Appendix N. Antibiotic classifications
  • Appendix O. Unit costs
  • Appendix P. Supplementary evidence

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.