Community Acquired Pneumonia 🫁
Guide to recognising and managing community acquired pneumonia (CAP) in adults: interactive CRB65 severity calculator, HSE antibiotic pathways, aspiration pneumonia, and when to escalate.
CRB65 Severity Score
HSE community CAP v2.0 — tick criteria present (each scores 1 point)
CRB65 score
0 / 4
LowNo criteria or prescribing factors ticked yet.
Suitable for home treatment if otherwise well (HSE)
Community oral antibiotics per HSE table. If no response after 48 hours on amoxicillin monotherapy, escalate as per CRB65 1–2 below or consider hospital referral.
HSE community regimen
Amoxicillin 500 mg every 8 hours for 5 days
HSE CRB65 0 — community monotherapy
Prescribing factors
Tailors HSE community oral regimens below. Inpatients still need local IV protocol.
Use clinical judgement — hypoxia, comorbidity, immunosuppression, and multilobar involvement may warrant admission despite a lower score. (CURB-65 adds urea ≥7 mmol/L; HSE Ireland uses CRB65.)
📖 Definition (HSE CAP v2.0)
- CAP = pneumonia acquired outside hospital.
- Clinical definition requires all of: symptoms of acute lower respiratory tract illness (cough + ≥1 other LRT symptom); new focal chest signs on examination; ≥1 systemic feature (sweats, fevers, shivers, aches/pains and/or temperature ≥38°C).
- Consider viral illness (RSV, COVID-19, influenza) in the differential — follow HPSC guidance on assessment and testing where relevant.
- Start antibiotics promptly once CAP is diagnosed; review at 48–72 h if not improving.
📊 CRB65 Severity Score
- Calculate CRB65 using the interactive calculator at the top of this topic — each criterion scores 1 point.
- Use clinical judgement supported by the score; additional risk factors may alter disposition: hypoxia, comorbidity, immunosuppression, multilobar involvement (if CXR available).
- Antibiotic regimens in the sections below align to the HSE CAP v2.0 tables for each CRB65 band.
🔍 Assessment & Investigations
- Vitals: temperature, HR, RR, BP, SpO₂ — consider pulse oximetry per HSE guidance.
- Examine for focal consolidation, bronchial breathing, crackles, effusion signs.
- Bloods: FBC, U&E, CRP, LFTs; consider lactate if unwell.
- CXR to confirm consolidation and assess extent (not always needed before antibiotics in community, but standard on admission).
- Blood cultures and sputum culture if moderate–severe or prior antibiotics.
- Consider COVID/flu/RSV testing per local protocol.
- Screen for sepsis — use HSE sepsis pathway if systemic dysfunction.
💊 Antibiotics — CRB65 score 0 (HSE)
- Suitable for home treatment if clinically appropriate.
- If no response after 48 hours on amoxicillin monotherapy, escalate as per CRB65 1–2 below.
💊 Antibiotics — CRB65 score 1–2 (HSE)
- Suitable for community treatment if clinically appropriate.
- Review if not improving — escalate therapy or consider hospital referral.
- HSE lists dual therapy or doxycycline (penicillin allergy only). No separate macrolide-allergy pathway.
🚨 CRB65 ≥3 — Severe CAP
- Urgent hospital admission.
- If delayed transfer: amoxicillin 1 g PO stat — or benzylpenicillin 1.2 g IV/IM stat if oral not possible (avoid if penicillin allergic).
- Consider sepsis. Ongoing inpatient antibiotics are not specified in this HSE community guideline — follow local protocol.
🫗 Aspiration Pneumonia
- Antibiotics not indicated for aspiration or aspiration pneumonitis without evidence of bacterial infection.
- Empirical aspiration pneumonia treatment does not routinely need anaerobic cover.
- Add anaerobic cover only if high risk: obvious dental/periodontal disease, putrid sputum, suspected lung abscess/empyema — metronidazole 400 mg PO TDS added to amoxicillin, clarithromycin, or doxycycline for 5 days.
- Severe aspiration pneumonia: urgent hospital transfer.
- Prophylactic antibiotics do not prevent aspiration pneumonia.
- Discuss with microbiology if MDR risk, treatment failure, or complications.
🩹 Supportive Care
- Analgesia for pleuritic pain; consider PE in differential if pleuritic features atypical.
- Hydration, smoking cessation advice, and symptom relief (pharmacist/GP follow-up as appropriate).
- Vaccination at convalescence: COVID-19, influenza, and pneumococcal vaccines up to date.
- Advise time off work based on clinical assessment.
- Switch IV to oral when clinically improving — see antibiotic IV-to-PO topic.
🔗 Related Topics
Based on
Note Template
Ready-to-use clinical note structure
🕒 08 / 07 / 2026 — 23:31 ATRP re: community acquired pneumonia (CAP) Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [COPD, heart failure, immunosuppression, malignancy] 🧾 Hx: • Onset: cough, fever, pleuritic pain, breathlessness • Duration and progression • Recent antibiotics or hospital attendance • Vaccination status (COVID, influenza, pneumococcal) • Aspiration risk: dysphagia, reduced GCS, vomiting • Allergies: penicillin [Y/N] macrolide [Y/N] • Pregnant: [Y/N] 🩺 Exam: • Vitals: HR __ BP __ RR __ Temp __ SpO₂ __ • CRB65: Confusion [Y/N] RR≥30 [Y/N] BP≤90/60 [Y/N] Age≥65 [Y/N] → score __ • Chest: focal crackles / bronchial breathing / dullness [site] • Severity markers: hypoxia, multilobar signs, hypotension 🔬 Investigations: • CXR: [consolidation site / effusion / multilobar] • Bloods: FBC, U&E, CRP, lactate [if unwell] • Cultures: blood / sputum [if taken] • Viral testing: [COVID / influenza / RSV per protocol] 📋 Impression: Community acquired pneumonia — CRB65 __ — [mild / moderate / severe] 📌 Plan: • Empirical antibiotics per HSE community CAP v2.0 / local protocol if inpatient: [regimen] • Oxygen to target saturations; fluids if dehydrated • Sepsis screen — Sepsis 6 if indicated • Analgesia for pleuritic pain • Review at 48 h if on amoxicillin monotherapy (CRB65 0); otherwise review if not improving • Vaccination at discharge if not up to date • Escalate to respiratory / ICU if deteriorating 👤 [Your Name], [Role] IMC: _______