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Explaining community-acquired pneumonia



Key learning points:

  • Pneumonia is a common and serious condition, it’s one of the leading causes of respiratory admissions and mortality
  • Certain groups are at higher risk of pneumonia – older people and children, smokers and people who are immunosuppressed
  • It is essential to use a severity scoring system to identify which patients can be managed safely in the community and which need to be admitted to hospital

Pneumonia can affect people of any age, but it is more common – and can be more serious – in certain groups, such as the very young or the elderly. People in these groups are more likely to need hospital treatment if they develop pneumonia.1
The condition is an inflammation of one or both lungs, which is usually caused by an infection. The tiny air sacs (alveoli) fill with fluid. This makes the lungs stiffer and harder to inflate and also makes them less able to take up oxygen.2
The inflammation can spread beyond the lungs, causing sepsis.
According to the British Lung Foundation’s Battle for Breath report, published in May 2016, the latest statistics on pneumonia show the scale and incidence of the condition.3 It is useful to see what an impact it has and to confirm who is most susceptible to acquiring it, so that we can be more aware when patients come to see us with lower respiratory tract infections (LRTIs) and breathing difficulties.

Prevalence and incidence
Around 220,000 people receive a diagnosis of pneumonia each year.3 Some receive more than one diagnosis within a year, but for the purposes of this article, we have focused on the number of individuals who receive a diagnosis, rather than the total number of cases.
The number of people diagnosed with pneumonia has remained generally level in recent years. However, the number of cases per 100,000 was 20% higher in 2009 than other years possibly because the winter of 2009-10 was the coldest in over 30 years, or because there was a swine flu pandemic.

Mortality
Pneumonia is the sixth biggest cause of death in the UK. It kills 29,000 people a year and is the third biggest cause of death from lung disease.
Pneumonia and LRTIs combined kill around 30,500 a year. This is more than COPD, which is the second biggest cause of death from lung disease.3

Impact on hospital services
Pneumonia accounts for more hospital admissions and bed days than any other lung disease – over 200,000 admissions and 2.3 million bed days each year. The admissions rise to 325,000 and the bed days to more than 3 million when we combine pneumonia with other LRTIs. LRTIs other than pneumonia have the third highest number of admissions and bed days among all lung diseases.3
It is important for primary care professionals to recognise and treat the symptoms of pneumonia as early as possible and assess whether the patient can be managed safely at home or needs hospital care. Timely treatment can prevent later deterioration and a need for hospital admission.

Gender
Pneumonia kills 40% more women than men. From 2008 to 2012, nearly 87,000 women and more than 61,000 men died of the disease. Between 2004 and 2012, prevalence was also consistently higher in women. The reason is probably that more men die from other conditions and earlier in life.
Women are more likely to live into their 80s, when most cases of pneumonia occur. In the period 2008 to 2012, nearly 12,000 men and more than 8,000 women aged under 75 died from the disease, which is over 40% more men than women. However, this gender difference reverses in over-75s.3

Age
Pneumonia is more common in older people. Out of nearly 225,000 cases in 2012, more than 32,000 (14%) were in people aged 61 to 70; around 38,500 (17%) were in people aged 71 to 80; and nearly 50,000 (over 22%) were in people aged over 80. Older, frailer adults are less able to recover from pneumonia than younger people. Around 95% of the 29,000 people who die from pneumonia each year are over 65 and around 87% are over 75.3
At the other end of the scale, pneumonia and acute LRTIs kill more children under 15 than any other lung disease. These diseases account for 3.5% of all deaths in this age group. In 2012, 58 under-15s died from pneumonia and 25 died from other acute LRTIs. There were also nearly 24,000 cases of pneumonia in children from birth to age five and over 27,000 in children from birth to age 10.3

Regional variation
In 2012, recorded incidence rates were twice as high in both north-east and north-west England than across the south of England, Wales and Northern Ireland. Conversely, relative mortality is highest in areas such as Northern Ireland, Wales, the south east and north west.
We need more research to explain these regional variations and the mismatch between higher incidence and higher mortality. They may relate to how diagnoses and events are coded in healthcare records.

Socio-economic analysis
The social determinants of health are very important in lung disease – smoking (both active and passive), nutrition, adverse early life environment and occupations with greater exposure to dust, fumes and chemicals. Pneumonia is around 45% more common in the most deprived 20% of society than in the most privileged 20%.

International comparison
Pneumonia mortality in the UK is the third highest in Europe. World Health Organization data also suggest that the UK has the sixth highest number of deaths from acute LTRIs. Some of this may be due to variations in how these diseases are recorded.
The British Lung Foundation’s publication, Pneumonia, provides an overview of the condition, which is a useful reference for primary care nurses.4  

What causes pneumonia?
Many kinds of bacteria, viruses and, occasionally, fungi can cause pneumonia. The most common cause is the bacterium Streptococcus pneumoniae, but in individual cases the cause can be unknown. In winter, the number of cases rises. This is because of infection spreading from person to person, and because other infections are more common in the winter, such as influenza (flu). An infection with flu or other viruses can impair immune defences, increasing the risk of a secondary pneumonia.4

What are the symptoms?
Primary care nurses should look out for symptoms that are similar to flu or a chest infection. These usually develop gradually over days, but sometimes they can progress much faster. Key features include cough, breathlessness and chest discomfort.
Guidelines from the National Institute for Health and Care Excellence (NICE) recommend that when a clinical diagnosis of community-acquired pneumonia is made in primary care, patients should be graded as low, intermediate or high risk of death using the CRB65 score.5
CRB65 score is calculated by giving one point for each of the following prognostic features:5

  • Confusion (abbreviated mental test score eight or less, or new disorientation in person, place or time).†
  • Raised respiratory rate (30 breaths per minute or more).
  • Low blood pressure (diastolic 60mmHg or less, or systolic less than 90mmHg).
  • Age 65 years or more.
  • Patients are stratified for risk of death as follows:5
  • 0: low risk (less than 1% mortality risk).
  • 1 or 2: intermediate risk (1–10% mortality risk).
  • 3 or 4: high risk (more than 10% mortality risk).

People with pneumonia will typically have a high temperature. This can sometimes be very high and they might also sweat and shiver. Another symptom is a cough producing brings up phlegm (mucus).4  
If the patient’s breathing is quick, this suggests the pneumonia is likely to be severe. Confusion is also a serious sign.
The severity of pneumonia may be multifaceted, but the British Thoracic Society guidelines (2015) advise:
‘The diagnosis in hospital will be made with the benefit of a chest radiograph. In the community, the recognition and definition of community-acquired pneumonia by GPs in the UK, without the benefit of investigations or radiology, poses greater challenges and the diagnosis will often be based only on clinical features.’6
A sharp pain in the side of the chest that is worse when the patient breathes in suggests that pleurisy has developed with inflammation of the lining of the lung, which moves as the person breathes.

Who is at risk?
Anyone of any age can get pneumonia. In adults, five to 11 people out of every 1,000 develop the condition each year in the UK. Health professionals should be more vigilant for pneumonia in two groups:

  • Those who are more susceptible, such as:

    – the immunosuppressed
    – chronic disease patients
    – elderly patients – over 65 years
    – Infants – under five years
    – those with lifestyle risk factors such as smoking and alcohol

  • Secondly, people who are not at extra risk of developing pneumonia, but may experience worse effects if they do develop it. This group includes:

    –  people with heart or lung disease and other medical conditions
    –  babies and infants
    –  older people
    –  people with kidney conditions
    –  patients with diabetes
    –  People with cancer, especially those having chemotherapy or who have leukaemia or lymphoma
    –  people who smoke or drink alcohol to excess
    –  people receiving drugs that suppress the immune system, and those with HIV/AIDS

Preventing pneumonia

  • Advising patients to stop smoking is an essential tool in reducing the risk of pneumonia. Smokers have an increased risk of developing pneumonia and other chest infections – as do children whose parents smoke. All smokers should be offered assistance to quit, including counselling through NHS stop-smoking services and pharmacotherapy such as varenicline or dual nicotine replacement therapy (NRT) – dual therapy is patches combined with a rapid onset preparation for cravings.
  • Infections that are common in winter can increase the risk of pneumonia. Therefore, patients should be advised to practise good hygiene to reduce the spread of germs. For example, if they use a tissue when coughing or sneezing, they should throw it away immediately. Hand hygiene is also important.
  • Pneumonia can be caused by aspiration, so this needs to be considered in people who have difficulty swallowing.
  • You may be able to offer a vaccine. There are two available, but they only protect against the most serious cases caused by the commonest bacterium, Streptococcus pneumoniae. These vaccines are intended to protect people who are vulnerable to pneumonia or at greater risk if they develop it, including young babies and older people.

Vaccinations
The pneumococcal conjugate vaccine (PCV) is provided to infants by the NHS in a three-dose schedule as part of the national immunisation programme in the UK. The first dose is given at eight weeks, followed by doses at 16 weeks and one year.
The pneumococcal polysaccharide vaccine (PPV) is available for adults over the age of 65 and anyone over the age of two who falls into a high-risk category. Most adults only need to have it once.
Flu vaccination is recommended for everyone over the age of 65 and people with long-term conditions and is an important preventive measure. It has to be given each winter and patients can get it from many high-street chemists as well as at primary care practices. Some people are not eligible to receive the vaccine free of charge on the NHS.

Diagnosis and treatment
Pneumonia can often be diagnosed by the symptoms and by examining the patient’s chest. A chest X-ray may be required to confirm the diagnosis, or if progress with treatment is unsatisfactory, or if pneumonia recurs.
A key question is to establish how severe the pneumonia is and if it can be managed safely at home. The CURB-65 score, as described earlier, is used to assess severity. If the score is 0 the person can usually be managed safely at home with antibiotics, rest and adequate hydration. If the score is 1 or 2, hospital admission should be considered. A score of 3 or 4 implies a higher risk of death and urgent admission should be considered. A low temperature ( Hospital admission allows treatment with intravenous antibiotics, though most patients respond to oral antibiotics. Hospital treatment also allows assistance with fluids, oxygen and if necessary, intensive care input such as ventilation.
Immunosuppressed patients (eg those on long-term steroids) are at a higher risk.
For community-acquired pneumonia, amoxicillin is a usual first line antibiotic.7 Doxycycline and clarithromycin can be used in people who are allergic.7 It is important to be aware that patients who develop pneumonia after previously being admitted to hospital have a high risk of becoming very ill and need broader-spectrum antiobiotic therapy – seek local advice or refer to the British National Formulary.
Recovery
If a patient has milder pneumonia, they will usually be unwell for a week or two, then steadily return to normal activity. After severe pneumonia, which needs hospital admission, recovery to full fitness can take months.
The vast majority of patients with pneumonia will recover and return to good health. However, it is important that support and guidance is offered to them as they will worry about their chest even if they have a simple common cold. They will be anxious and need advice for a considerable time post recovery.
If a patient is not improving, the possibility of a complication should be considered. If fluid collects around the lung (a pleural effusion), this can delay recovery. The fluid may need to be drained, especially if it becomes infected.
Chest X-ray changes can take several months to resolve, long after the patient has recovered.

Online breath test
Some people with pneumonia will report feeling breathless after their usual recovery time. This may be a sign of more serious lung disease.
The British Lung Foundation has launched the Listen to your lungs public health campaign to find the millions of people who are living with undiagnosed lung disease.
The campaign encourages people not to ignore if they are feeling breathless doing everyday tasks and to take a simple online test to find out if they should see a health professional. They are asked 10 questions based on the Medical Research Council breathlessness scale. The aim is to reassure people who don’t have a problem and guide those with significant breathlessness to make an appointment with their doctor or nurse. To take the breath test visit the British Lung Foundation website.

Further help and information
For more advice and information about pneumonia, call the British Lung Foundation Helpline on 03000 030 555. Lines are open Monday to Friday, from 9am–5pm.

Resources
British Lung Foundation breath test – blf.org.uk/breathtest

References
1. NHS Choices. Pneumonia. nhs.uk/Conditions/Pneumonia/Pages/Introduction.aspx (accessed 17 August 2016)
2. The British Lung Foundation. Pneumonia, 2014. blf.org.uk/support-for-you/pneumonia/what-is-it (accessed 17 August 2016)
3.  The British Lung Foundation. The battle for breath – the impact of lung disease in the UK, 2016. blf.org.uk/what-we-do/our-research/the-battle-for-breath-2016 (accessed 17 August 2016), p57-58
4. The British Lung Foundation. Pneumonia PDF (Code FL15. Version 3). blf.org.uk/support-for-you/pneumonia/what-is-it (accessed 19 September 2016).
5. NICE. Pneumonia in adults: diagnosis and management [CG191], 2014. guidelines.co.uk/nice/pneumonia (accessed 22 August 2016).
6. British Thoracic Society. Guidelines for the Management of Community Acquired Pneumonia in Adults Update 2009 – A Quick Reference Guide.
7. British National Formulary. Respiratory system. evidence.nhs.uk/formulary/bnf/current/5-infections/51-antibacterial-drugs/table-1-summary-of-antibacterial-therapy/respiratory-system (accessed 17 August 2016).