Managing LRTI in adults in the community

When considering a diagnosis of LRTI the main differentiation to make is between pneumonia and non-pneumonic LRTI. It is more difficult to make this distinction in the community because of access constraints to chest radiography and the lack of a quick, simple marker to identify patients with true pneumonia accurately. The diagnosis of pneumonia in the community, without a chest radiograph, is suggested by symptoms that include: cough; (purulent) sputum production; breathlessness; pleurisy; occasional haemoptysis along with new focal signs on chest examination (e.g. crepitations, bronchial breathing, and dullness to percussion); at least one systemic feature (e.g. sweating, fevers, shivers, aches and pains and/or temperature >38 degrees C); and no other explanation for the symptoms. A recent observational study of around 150,000 patients with LRTI in the UK found that the following factors were associated with increased respiratory infection-related mortality: increasing age; smoking; increasing Charlson co-morbidity index; prior antibiotic prescribing; frequent consultation and prior specialist referral or admission. Acute adult LRTI presenting to GPs is a predominantly viral illness most commonly caused by rhinoviruses and influenza viruses. The most common bacterial cause of pneumonia is Streptococcus pneumoniae but frequently no organism is identified. In patients where you suspect non-pneumonic LRTI, the evidence suggests that chest radiography and blood tests for CRP are not helpful in their management in the community. The BTS guidelines recommend that GPs, particularly those working in out-of-hours and emergency assessment centres, should consider using pulse oximeters. The CRB-65 is a helpful tool in the community. Patients scoring 0 or 1 have the lowest mortality risk, however, a score of 2 or more should be a cause for concern and the patient may need to be admitted to hospital for assessment.