Community-Acquired Pneumonia: Australian Guidelines
Critical Note on Evidence
The provided evidence consists entirely of British Thoracic Society (BTS) guidelines from 2001, not Australian guidelines. However, I will provide recommendations based on these UK guidelines as they represent the best available evidence in this context, with the understanding that Australian guidelines may differ in specific recommendations 1.
Empirical Antibiotic Treatment by Setting
Community Treatment (Outpatient)
Amoxicillin at high doses is the preferred first-line agent for community-acquired pneumonia treated in the outpatient setting 1.
- First-line: High-dose amoxicillin (higher than previously recommended doses) 1
- Alternative (penicillin allergy): Macrolide monotherapy with erythromycin or clarithromycin 1
- Life-threatening cases or delayed admission (>2 hours): Consider immediate antibiotic administration before hospital transfer 1
- Follow-up: Review all community patients at 48 hours or earlier if clinically deteriorating 1
Hospital Treatment - Non-Severe CAP
Combined oral therapy with amoxicillin plus a macrolide (erythromycin or clarithromycin) is the preferred regimen for hospitalized patients with non-severe CAP 1.
- Preferred regimen: Oral amoxicillin + oral macrolide (erythromycin or clarithromycin) 1
- Amoxicillin monotherapy acceptable for:
- When oral therapy contraindicated: IV ampicillin or benzylpenicillin + IV erythromycin or clarithromycin 1
- Fluoroquinolones (levofloxacin): Alternative for penicillin/macrolide intolerance or Clostridium difficile concerns, but NOT first-line 1
Hospital Treatment - Severe CAP
Patients with severe pneumonia require immediate parenteral combination therapy with a broad-spectrum β-lactam plus a macrolide 1.
- Immediate IV antibiotics required upon diagnosis 1
- Preferred regimens: IV co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone + IV macrolide 1
- ICU management: Requires specialists trained in intensive care and respiratory medicine 1
Supportive Care and Monitoring
Oxygen Therapy
- Target: Maintain SaO₂ >92% and PaO₂ >8 kPa 1, 2
- High-flow oxygen safe in uncomplicated pneumonia 1
- COPD patients: Guide oxygen by repeated arterial blood gases to avoid ventilatory failure 1
Monitoring Parameters
- Frequency: Monitor vital signs (temperature, respiratory rate, pulse, BP, mental status, oxygen saturation) at least twice daily, more frequently in severe cases 1
- Volume status: Assess for dehydration and provide IV fluids as needed 1
- Nutrition: Provide nutritional support in prolonged illness 1
Treatment Response Assessment
- Remeasure CRP in patients not progressing satisfactorily 1
- Repeat chest X-ray only if clinical deterioration occurs 1
- Do NOT repeat imaging solely for radiological lag in clinically improving patients 1
Follow-Up and Discharge Planning
Discharge Criteria
- Chest X-ray NOT required before discharge if satisfactory clinical recovery 1
- Provide patient information about CAP at discharge 1
Post-Discharge Follow-Up
- 6-week clinical review mandatory with GP or hospital clinic 1
- Repeat chest X-ray at 6 weeks for:
- Bronchoscopy consideration for persisting abnormalities at 6 weeks post-treatment 1
Common Pitfalls to Avoid
- Avoid fluoroquinolones as first-line in community or routine hospital settings 1
- Do not delay antibiotics in severe or life-threatening cases 1
- Do not use monotherapy in severe CAP requiring hospitalization 1
- Do not repeat chest X-rays unnecessarily in clinically improving patients 1
- Do not discharge without arranging 6-week follow-up and communicating plan to GP 1
Treatment Duration
Recent evidence suggests 5-7 days of antibiotic therapy is sufficient for uncomplicated CAP, with some studies supporting even shorter 3-day courses in hospitalized patients who meet clinical stability criteria 3, 4, 5.