Pneumonia: when it has to be fast and when outpatient care is enough

A stubborn cough that has refused to shift for days. Then a sudden fever that leaves the body weak. And that feeling of no longer being able to breathe properly on the stairs, or even while sitting still. When these three signs appear together, pneumonia should be at the back of your mind. Pneumonia is a serious illness in which hours can count, and at the same time it is the most common fatal infectious disease in industrialised countries. You do not have to guess what to do, though. There is a clear rule that lets us estimate whether you can be looked after as an outpatient or whether a hospital setting is needed.

Which symptoms point to pneumonia?

Classic pneumonia does not announce itself subtly. It typically starts suddenly, with chills and high fever, followed by a cough producing yellow-green or rust-coloured sputum. This is often accompanied by pain on one side of the chest that worsens with breathing, because the inflamed lung tissue irritates the pleura as well.

Atypical courses, for instance caused by mycoplasma or chlamydia, develop more gradually. You have a dry cough for weeks, feel run down and develop only moderate fever. This form more often affects younger adults and is regularly classified at first as a stubborn infection in general practice.

In older people, pneumonia frequently takes an atypical course. Instead of fever there is sudden confusion, a feeling of weakness or a fall. This point is often missed in everyday practice. If your mother or father declines noticeably in mental clarity within a few days, pneumonia belongs among the first differential diagnoses.

Outpatient or hospital? The CRB-65 rule

The most important question in the first hour is where you will be treated, ahead of which antibiotic is the right one. This is exactly what the international pneumonia guidelines developed the CRB-65 score for: a simple instrument with four criteria that can be assessed at any practice workstation and even over the telephone.

Each criterion met scores one point. At zero points, 30-day mortality is below one percent and outpatient therapy is generally safe [Bauer et al., J Intern Med 2006]. At one or two points the risk of death rises to roughly five to ten percent, and hospital admission, or at least close outpatient monitoring, is indicated. From three points the work-up belongs on a monitoring or intensive care unit [Lim et al., Thorax 2003].

In your consultation with us we take these four readings within a few minutes. Added to this is the oxygen saturation measured at the finger, which most updated versions of the score include as an additional check. A saturation below 92 percent on room air is a warning sign in its own right and leads to hospital referral independently of the CRB-65.

Diagnostics in the practice: what is really needed

The diagnosis of pneumonia is primarily clinical. Even so, three building blocks belong to the outpatient work-up, ideally on the same day.

The chest X-ray is the imaging standard and confirms the pneumonic infiltrate. In our practice we can arrange this image promptly or organise it through our radiology partners. In a classic course with a CRB-65 of zero points, an X-ray is not mandatory in every case, provided the clinical diagnosis is unambiguous and you are monitored closely [Ewig et al., AWMF S3 guideline 2021].

The laboratory values support the diagnosis and help with monitoring the course. CRP and white blood cell count are the standard parameters. In unclear cases, procalcitonin gives an additional indication of whether a bacterial infection is likely, and it can help to shorten the duration of antibiotics [Metlay et al., Am J Respir Crit Care Med 2019].

Identifying the pathogen is not standard in the outpatient setting. It becomes useful when the course is atypical, when a first course of treatment does not take hold or when certain risk factors are present. If mycoplasma or chlamydia are suspected, PCR tests from a throat swab are available. Pneumococcal antigen in the urine is a point-of-care test used in moderate pneumonia.

Treatment and course

Empirical antibiotic treatment begins as soon as the diagnosis is clinically probable enough. As a rule we do not wait for the result of pathogen identification, because every delay raises the risk of death.

For community-acquired pneumonia without comorbidities, high-dose amoxicillin is the drug of first choice. With a penicillin allergy or suspected atypical pathogens, macrolides or doxycycline are used. Treatment usually lasts five to seven days, provided you improve clearly within 48 to 72 hours [Metlay et al., Am J Respir Crit Care Med 2019].

If you feel no improvement after three days, if the fever persists or if the breathlessness increases, a re-evaluation is mandatory. In that case we think of a resistant pathogen, a complication such as a pleural effusion, or a different diagnosis. This is exactly where quick access to our practice pays off. A repeat examination, a follow-up X-ray and an adjustment of the treatment are often possible on the same day.

The cough can persist for weeks after the pneumonia has healed. That is not unusual. A follow-up after about six weeks, including a follow-up X-ray, is important in people over 50 and in smokers, to rule out an underlying disease such as bronchial carcinoma [Ewig et al., AWMF S3 guideline 2021].

Risk groups: who should be particularly careful

Not every pneumonia is equally dangerous. Several groups carry an increased risk of a severe course and, with the symptoms described above, should seek medical assessment earlier than others.

The classic risk groups include people aged 65 and over, patients with chronic lung or heart disease (COPD, heart failure), with diabetes mellitus, on immunosuppressive therapy after transplantation or under oncological treatment. Pneumonia also takes a severe course more often in people with poorly controlled diabetes or with alcohol dependence [Woodhead et al., ERS/ESCMID 2011].

For these groups the rule is: with the triad of cough, fever and breathlessness described above, do not hesitate to contact the practice, often on the very first day of illness. In this constellation, early assessment frequently changes the course.

When you should contact us

If you have had a cough and fever for more than two days together with shortness of breath or chest pain on breathing, get in touch with us the same day. We can usually find you an appointment in the Dein Team fürs Leben consultation within 24 hours. We examine you clinically, measure oxygen saturation, CRP and, where appropriate, procalcitonin, arrange an X-ray if needed and, once pneumonia is confirmed, start treatment immediately. With a CRB-65 of one point or more, or an oxygen saturation below 92 percent, we organise the referral to hospital.

For acute severe breathlessness, blue lips, sudden confusion or clouding of consciousness, a different rule applies. Dial 144 directly. In this situation the practice is the wrong route, because initial care begins at the scene and the transport must be accompanied by a physician. This applies in particular to older people and to those with pre-existing conditions.

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How does pneumonia differ from severe bronchitis?

In acute bronchitis, the large airways are inflamed. Cough and sputum dominate, fever usually stays moderate, and breathlessness at rest is not part of the typical picture. In pneumonia the lung tissue itself is affected. Fever is more often high, the general condition markedly worse, and breathlessness can occur even at rest. In case of doubt, certainty comes from the clinical picture together with auscultation, oxygen saturation and, where appropriate, an X-ray.

When is treatment at home enough?

With a CRB-65 score of zero, an oxygen saturation above 92 percent on room air and a stable general condition, outpatient treatment is generally safe. The prerequisite is that you have someone who can react quickly if you deteriorate, and that a medical follow-up within 48 to 72 hours is guaranteed.

Does every pneumonia need an antibiotic?

In bacterial pneumonia, empirical antibiotic treatment is standard and should start promptly. Viral pneumonias (for instance from influenza or SARS-CoV-2) are different. Here the treatment depends on the pathogen, the severity and the risk profile. A bacterial superinfection frequently develops on top of it, however, which is why the decision is made individually.

How long does full recovery take?

The fever should fall markedly within 48 to 72 hours of starting treatment. The cough can persist for another two to four weeks. Full energy and fitness often only return after six to eight weeks. In people over 65 or with pre-existing conditions, recovery can take considerably longer.

When is vaccination against pneumococci advisable?

The Swiss vaccination recommendation provides for pneumococcal vaccination for people aged 65 and over, for those with chronic lung, heart or kidney disease, and in cases of immunosuppression. The annual flu vaccination also lowers the risk of pneumonia markedly, because bacterial pneumonia frequently occurs as a consequence of influenza.

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Written by Prof. Dr. C.K. Fritz M.Sc., Physician Associate for General Internal Medicine, Pain Medicine, Practice Lead Dein Team fürs Leben.