Basis for arranging admission for people that deteriorate on treatment

• People that deteriorate on treatment are at an increased risk of death from pneumonia.
• They require alteration to their treatment and close observation to ensure that these alterations are effective.
• For most people hospital admission is the appropriate way to deliver this care.

Basis for management options for people that are not improving on treatment

• In people who have not responded to an initial course of amoxicillin, switching to, or adding on a macrolide, is recommended by the British Thoracic Society [British Thoracic Society, 2001].
• Empirical treatment with a macrolide and/or amoxicillin is based on clinical experience rather than published studies [SIGN, 2002].
• The rationale is to provide antibiotic coverage for as many pathogens involved in the infection as possible. Up to 10% of community-acquired pneumonia may be caused by two organisms.
• If the person was not initially taking amoxicillin because it was contraindicated, CKS recommends getting expert advice from a microbiologist. Other antibiotics such as fluoroquinolones may be recommended.

The British Thoracic Society recommend a follow-up X-ray at 6 weeks based upon evidence that:

• People with pneumonia who smoke are at high risk of having lung cancer.
• People with pneumonia and persistent or slowly resolving symptoms and signs of pneumonia are at high risk of having an underlying malignancy.
• Chest X-rays taken at presentation will not detect all people with an underlying malignancy.
• A chest X-ray will detect an underlying malignancy in most people after 6 weeks of treatment for pneumonia.

[British Thoracic Society, 2001]

Basis for recommending smoking cessation

• Smoking cessation is widely advocated because:
• Cross-sectional studies show that smoking is a risk factor for chest infections [Gutzwiller et al, 1989]. Smoking cessation reduces the risk of further episodes of chest infections, in addition to conferring many other health benefits.
• Advice and treatment to stop smoking have been shown to have a small but significant effect in reducing smoking.

Basis for recommending pneumococcal vaccination

• Streptococcus pneumoniae is one of the pathogens known to cause acute bronchitis [Macfarlane et al, 2001].
• The effectiveness of pneumococcal vaccination in preventing morbidity and mortality from S. pneumoniae has been demonstrated in a meta-analysis of 14 randomized controlled trials (n = 48,837) [Cornu et al, 2001].

Basis for recommending influenza vaccine

• The influenza virus is one of the pathogens known to cause acute bronchitis [Macfarlane et al, 2001].
• A number of randomized controlled trials and cohort studies have demonstrated that influenza immunization is effective for:
• Reducing the incidence of influenza.
• Reducing morbidity and mortality from secondary bacterial infections following influenza, particularly in at-risk groups.