Step 1: Decide whether to admit adults with CAP to hospital

Adults without any of the features in Features in adults with community-acquired pneumonia (CAP) that may indicate hospital admission have low-severity CAP and can usually be safely managed in the community with suitable plans for review and management of deterioration. The presence of any of these features indicates patients may benefit from increased support in hospital, not that they require broader-spectrum empirical antibiotic therapy.

Figure 1. Features in adults with community-acquired pneumonia (CAP) that may indicate hospital admission

Adults with CAP and any of the following features need close clinical observation and may need hospital admission [NB1]:

  • tachypnoea (respiratory rate 22 breaths per minute or more)
  • tachycardia (heart rate more than 100 beats per minute)
  • hypotension (systolic blood pressure less than 90 mmHg)
  • acute-onset confusion
  • oxygen saturation less than 92% on room air (or less than baseline in patients with comorbid lung disease)
  • multilobar involvement on chest X-ray (if available)
  • blood lactate concentration more than 2 mmol/L (if available) [NB2].
Note:

NB1: Many of these features are derived from formal pneumonia severity scoring tools. Based on the opinion of the Antibiotic Expert Group, some parameters are more conservative than the scoring tools to enable early identification of patients at risk of deterioration. Also consider if the patient has had a significant change from baseline.

NB2: Blood lactate can be measured using arterial or venous blood gas analysis. Venous blood gas analysis is acceptable for rapid lactate assessment (for further advice, see the Respiratory guidelines).

When deciding whether to admit an adult with CAP to hospital, also assess their:

  • social circumstances (in particular, the availability of home support)
  • age – older patients are at particularly high risk of deterioration
  • comorbidities
  • ability to tolerate and absorb oral therapy
  • need for supportive oxygen therapy
  • functional status.

Always consider the patient’s prognosis and discuss whether hospitalisation aligns with their preferences and goals of care. Reviewing the patient’s advance care plan, if in place, can assist with these decisions. See also Decision-making and ethical challenges in palliative care and Pneumonia in palliative care.