Jill is a 64-year-old retired accountant who presents to you with her concerned husband, Michael. Jill is usually fit and well apart from a history of well controlled hypertension on perindopril. Jill developed symptoms of a typical cold about four days previously and since then has been unwell with a worsening cough, fever and shortness of breath. She also complains of lower right sided chest pain when she breathes and coughs. She feels ‘exhausted’.
On examination, Jill has a temperature of 38.6, RR 25, BP 130/90, HR 104, O2 sat 94%. She has crackles in her right lung base on auscultation. You suspect community acquired pneumonia (CAP).
Based on Jill’s clinical presentation, should she be admitted to hospital?
Patients with CAP require careful assessment of disease severity to guide appropriate care. Therapeutic Guidelines provides a list of ‘red flag’ features that can help guide whether a patient needs admission to hospital.1 They state that patients with any of the following features need close observation, and are therefore likely to need inpatient care:
Tachypnoea (RR>22 breaths/min)
Hypotension (sBP<90 mmHg)
Hypoxia (O2 saturation<92% on room air)
Multilobar involvement on CXR
Blood lactate >2mmol/l
Additionally, consideration of comorbidities and the social context of the patient is essential. Ultimately, the decision to admit to hospital should be based on clinical judgement and patient wishes.
Formal pneumonia severity scoring tools can also be used to assess whether to admit a patient with CAP to hospital. While Therapeutic Guidelines recommends the CRB-65 tool as best suited to assessment in primary care settings, a 2010 meta-analysis found that it may over-predict the probability across all strata of predicted risk and should be used with caution.2