Mono and amoxicillin

Score 1 or 2: intermediate risk (1?10% mortality risk).

Score 3 or 4: high risk (more than 10% mortality risk). NICE recommends that anyone with a score of 2 should be admitted to hospital. NICE’s approach, however, doesn’t account for the high risk in very elderly people.

The mortality rate from COVID-19 approaches 15% at age 80 (Figure 1).

Current NICE guidance requires starting antibiotic treatment as soon as possible after establishing a diagnosis of community-acquired pneumonia, and certainly within 4 hours. This strategy is supported by the results of a US multicenter retrospective cohort study, a medical record review of 14,069 patients aged over 65 years and hospitalized with pneumonia.

A lower 30-day mortality was associated with antibiotic administration within 8 hours of hospital arrival (odds ratio = 0.85; 95% CI = 0.75-0.96). However, this may not be possible within the constraints of an overstretched service in a pandemic.

If antibiotics have to be taken within 4 hours of onset, there needs to be in place a self-management strategy that permits rapid access to the right antimicrobial treatment. Nursing homes could hold stocks of antibiotics

for

The ‘eyeball’ test, incorporating information on temperature, oxygen saturation, and pulse rate, should be sufficient to assess severity and cut down significantly on contact time. The absence of any individual chest examination finding has little effect on the probability of diagnosing pneumonia. Assessing blood pressure significantly increases contact time and should be considered only in those in whom it contributes to the decision to admit or not. We recommend documenting that a ‘limited examination’ was performed.

In assessing patients, carry antibiotics in a pre-sealed bag, to cut down entry and exit times from the person’s home or nursing home. COVID Monitoring Service (CMS) Patients at high risk deemed to be managed at home require monitoring, to ensure that they do not deteriorate. This is essential for nursing homes, where the potential for further spread in their patient population is significant.

Telephone monitoring services can follow up patients to determine whether deterioration occurs, and to detect spread in nursing homes .

Based on evolving NHS England guidance we recommend the following pathways.

Category 1: May require admission When it is uncertain that safe care can be provided in the community and the patient is deteriorating.

Clinical pathway: Start antibiotics immediately; discuss management with a designated hospital admitting consultant.

Category 2: Home isolation with active health monitoring Higher risk group for severe COVID-19, with stable illness that can be managed in the community.

Clinical pathway: Signs of bacterial pneumonia–start antibiotics; active health monitoring (every other day calls and symptom monitoring) and point of contact if deteriorates. Nursing homes with active cases–daily calls to monitor individuals and case progression; patients should remain in isolation until 5 days after resolution of symptoms.

Category 3: Home isolation with health advice Mild illness in a patient who can be managed safely in the community AND who is not in a higher risk group for complications. Clinical pathway: Self isolate at home; health advice on how to identify deterioration; call CMS if more

unwell

Gov.UK on those at increased risk of severe illness from coronavirus (COVID-19) includes: aged 70 or older (regardless of medical conditions) under 70 with an underlying health condition listed below (ie anyone instructed to get a flu jab as an adult each year on medical grounds): chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis chronic heart disease, such as heart failure chronic kidney disease chronic liver disease, such as hepatitis chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy diabetes problems with your spleen – for example, sickle cell disease or if you have had your spleen removed a weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid tablets or chemotherapy being seriously overweight (a body mass index (BMI) of 40 or above) those who are pregnant. Oxygen The use of oxygen in pneumonia is based on expert opinion. A Cochrane systematic review of the effectiveness of oxygen in adults with pneumonia highlights that the evidence is weak and limited owing to a small number of studies. The British Thoracic Society suggests that for patients with pneumonia not at risk of hypercapnic respiratory failure, it is appropriate to aim for an oxygen saturation of 94–98%.

Very elderly patients may tolerate an abnormally low SaO2 at rest when clinically stable; however, COVID-19 pneumonia may significantly worsen SaO2.

Access to oxygen therapy will be challenging at the height of a pandemic. Corticosteroids In the initial phase of pneumonia, elderly patients can present with wheezing and respiratory distress. It is not uncommon to consider corticosteroids at this stage, because of their anti-inflammatory effects. Corticosteroids were widely used during the 2002-3 SARS outbreak.

However, in a subsequent systematic review, including 29 low-quality studies of steroid use, 25 studies were inconclusive and four reported possible harm from steroid use. A further evidence review did not support corticosteroid treatment, reporting no evidence of net benefit with corticosteroids in “respiratory infection due to RSV, influenza, SARS-CoV, or MERS-CoV”, and that corticosteroids probably impair clearance of SARS-CoV. In contrast to pneumonia, corticosteroids show much clearer benefit in patients with sepsis.

Potential harms of rapid deployment of antibiotics for pneumonia The main disadvantage of this proposed strategy is that it would tend to drive increased bacterial resistance. However, in a pandemic with a high mortality rate in a specific subpopulation, in this case very elderly people, this needs to be weighed against the benefits of the policy. Apart from penicillin allergy, adverse reactions to the recommended antibiotics, e.g. Conclusions Interventions that affect mortality in pneumonia

are

For example, in the current context, it may be entirely appropriate for

nursing

Strategies should also plan to ensure that all those eligible at risk, eg COPD and immuno-compromised as well as the elderly, were up to date with preventive immunisation (influenza and pneumococcal). And also consider rescue medication for those aged 70 or older (regardless of medical conditions), and under 70 with an underlying health condition instructed to get a flu

jab

The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the

NHS

We welcome feedback on this page and if there are errors or omissions then please let us know at cebm@phc.ox.ac.uk.

Please note there was an error with the prescribing strategy the original version stated doxycycline plus clarithromycin, which is incorrect.

The article should have stated doxycycline or clarithromycin as per NICE recommendations. Please Check NICE guidance for all recommendations. ‘Alternatively, if there is a penicillin allergy, or amoxicillin is unsuitable (for example atypical pathogens are suspected) options are oral doxycycline 200 mg on the first day then 100 mg once a day for 4 days (total course of 5 days), or oral clarithromycin 500 mg twice a day for 5 days, or oral erythromycin (in pregnancy) 500 mg four times a day for 5 days.’ Authors. Carl Heneghan is the Editor in Chief BMJ EBM, Professor of Evidence-Based Medicine, Director of

the

(Full bio and disclosure statement here) Jeffrey K. Aronson is a physician and clinical pharmacologist working in the Centre for Evidence-Based Medicine in the Nuffield Department of Primary Care Health Sciences, University of Oxford.

He is an Associate Editor of

BMJ

Mahtani is a GP, Associate Professor and Deputy Director of the Centre for Evidence-Based Medicine,

Nuffield

He is also an Associate Editor at the BMJ Evidence-Based Medicine journal and Director of The Evidence-based Healthcare MSc in Systematic Reviews. Infection with human coronavirus NL63 enhances streptococcal adherence to epithelial cells.

14 WHO guidelines

for

15 BTS GUIDELINE FOR OXYGEN USE IN ADULTS IN HEALTHCARE AND EMERGENCY SETTINGS British Thoracic Society Emergency Oxygen Guideline Development Group https://www.brit-thoracic.org.uk/document-library/guidelines/emergency-oxygen/bts-guideline-for-oxygen-use-in-healthcare-and-emergency-settings/ 16 Metlay JP, Kapoor WN, Fine MJ.

Does This Patient Have Community-Acquired Pneumonia?

Diagnosing Pneumonia by History and Physical Examination. Cochrane Database of Systematic Reviews 2012, Issue 3.

Chances are, you or someone you know is one of the 10% of Americans with a documented penicillin allergy. But just because you were told you had a penicillin allergy, or had one in the past, does not mean you have one now.

People with a penicillin allergy history have their allergy disproved with allergy testing more than 90% of the time. Penicillin is part of a larger drug class called beta-lactam

antibiotics