Community-acquired pneumonia

Diagnosis: Community-acquired pneumonia — fever, purulent sputum, pleuritic pain, radiographic consolidation. CURB-65 at least 3: respiratory rate 32 (1), diastolic 58 (≤60, 1), age 68 (1); urea not given in the stem so the score is at least 3. NICE: consider intensive-care assessment at 3 or more. SpO2 91 percent is hypoxaemia.^[1][3]

Assessment: ABCDE. Chest radiograph (consolidation, exclude effusion). Bloods — FBC, CRP, urea (complete CURB-65), LFTs, blood gas. Blood cultures if they will not delay the first dose (severe CAP). Sputum. Urinary pneumococcal and Legionella antigens in severe or suggestive disease. Viral PCR in season. Legionella clues: hyponatraemia, gastrointestinal and neurological features — not LDH as a stand-alone rule.^[1][2]

Management:

1. Oxygen for hypoxaemia (do not apply a COPD controlled target in a patient without chronic CO2 retention).
2. Effective IV antibiotics without delay — cultures are not a reason to wait.
3. Empiric severe-CAP cover: IV beta-lactam plus macrolide (for example ceftriaxone plus azithromycin or clarithromycin) or beta-lactam plus a respiratory fluoroquinolone. Add MRSA or antipseudomonal cover only with locally validated risk factors (HCAP is abandoned).
4. Fluids for hypotension; intensive-care assessment for score 3 or more plus hypoxia.
5. Check for parapneumonic effusion — drain if pH under 7.20, pus, loculation, large size, or positive Gram stain or culture.^[2][3]

Disposition: Admit; consider HDU/ICU. Duration: minimum of 5 days even if earlier stability is reached (ATS/IDSA 2019) — not a default 14-day Legionella course unless the organism and a longer course are confirmed.^[2]