Community management of pneumonia and suspected COVID-19

Clinical presentation of COVID-19 is that of a respiratory infection and symptoms range in severity from fever, fatigue and persistent cough, to pneumonia – a serious infection of the lungs that occurs owing to inflammation and fluid-filled alveoli^[1],[2],[3]
.

Although the rate of pneumonia among patients with COVID-19 is not yet clear, it is widely understood that it leads to some of the most serious consequences^[4]
.

Recognising pneumonia and suspected COVID-19

It is necessary to distinguish between symptoms that suggest viral infection and those that suggest bacterial or viral pneumonia. However, the overlap in symptom presentation can make it difficult to distinguish and differentiate COVID-19 from pneumonia.

Common symptoms of pneumonia can include:

• Cough;
• Difficulty breathing;
• Rapid heartbeat;
• Fever;
• Sweating and shivering;
• Loss of appetite;
• Chest pain
  ^[3].

Less common symptoms include headache, fatigue, muscle or joint pain, and a general feeling of confusion.

Although a new, persistent cough and a high temperature are the most common symptoms of COVID-19, some patients also develop upper respiratory tract infection, loss of smell and taste, and symptoms such as headache or conjunctivitis ^{[5]
,[6],[7],[8]}
. This helps demonstrate the similarities in symptoms between COVID-19 and pneumonia.

As of 19 May 2020, testing for COVID-19 is carried out in the hospital setting to inform a patient’s clinical diagnosis, but also outside of the hospital setting for:

• All essential workers including NHS and social care workers with symptoms;
• Anyone aged over 65 years with symptoms;
• Anyone with symptoms who cannot work from home;
• Anyone who has symptoms of coronavirus and lives with any of those identified above
  ^[9]
  .

If COVID-19 is suspected, the patient should be advised to self-isolate and implement strict social distancing measures (see Box 1).

Owing to the overlap of presenting symptoms between pneumonia and COVID-19, pharmacists should explain to the patient that they do not have two separate conditions; instead, having COVID-19 has likely led to their respiratory symptoms and pneumonia, or that they could have COVID-19 and community-acquired pneumonia.

Self-isolation with suspected infection

Patients with suspected COVID-19 should be told not to present in person to pharmacies or their GP^[10],[11]
. However, it is possible that a patient, or their carer, can speak to the pharmacy team by phone or, in some cases, via video call (a practice adopted by some community pharmacies in response to the pandemic)^[12]
.

Differentiating between viral and bacterial pneumonia

When a patient is being assessed, it is necessary for the prescriber to distinguish between viral and bacterial pneumonia; however, this is not straightforward and the need for a remote consultation makes this more difficult.

Eliciting a history of symptom presentation will help with differential diagnosis. For example, if a patient describes having a high temperature; a new, continuous cough; and an absence of any other symptoms, they should be referred to the NHS 111 online screening service, which will explain their next steps, and advise them to contact their GP if necessary^[13]
.

On 3 April 2020, the National Institute for Health and Care Excellence (NICE) published a rapid guideline on managing suspected or confirmed pneumonia in adults in the community to ensure best practice treatment during the COVID-19 pandemic^[14]
. These recommendations are subject to change as the knowledge base and expert experience develops. The main differences between bacterial and COVID-19-related pneumonia are summarised in the Table. As of 11 May 2020, no NICE rapid guidelines have been produced on managing children with pneumonia and COVID-19.

Source: Adapted from National Institute for Health and Care Excellence^[14]

Assessing severity and referral

Normally, a patient would receive a physical examination as part of an objective assessment. However, NICE recommends that, during the COVID-19 pandemic, diagnosis of community-acquired pneumonia is informed by symptoms, such as:

• A temperature above 38°C;
• A respiratory rate above 20 breaths per minute;
• A heart rate above 100 beats per minute;
• New confusion^[14]
  .

It may not be possible or may be difficult to determine all these symptoms remotely, but it is important to determine whether the patient has shortness of breath. The Centre for Evidence-Based Medicine suggests asking the patient to describe the problem with their breathing in their own words, and assess the ease and comfort of their speech while they do so^[15]
. This can be achieved by asking questions such as:

• “Are you so breathless that you are unable to speak more than a few words?”;
• “Are you breathing harder or faster than usual when doing nothing at all?”;
• “Are you so ill that you have stopped doing all of your usual daily activities?”^[15]
  .

It is important to understand whether there is a decline in the patient’s ability to breathe, as some, such as those with COPD, may already have existing conditions that affect their breathing. Asking “What could you do yesterday that you cannot do today?” or “What makes you breathless now that did not make you breathless last week?” may reveal the extent of the deterioration^[15]
.

Although prior NICE guidance indicates that the CRB65 mortality prediction tool should be used to aid severity assessment of pneumonia and subsequent treatment, this has not been validated in people with COVID-19 and requires blood pressure measurement, which may be difficult or undesirable^[14]
.

During the COVID-19 pandemic, NICE recommends that healthcare professionals are vigilant for red flag symptoms of pneumonia, which indicate that an urgent hospital referral is required:

• Severe shortness of breath at rest or difficulty breathing;
• Coughing up blood;
• Blue lips or face;
• Feeling cold and clammy with pale or mottled skin;
• Collapsing or fainting;
• Becoming difficult to rouse;
• Little or no urine output^[14]
  .

However, even if a patient does not have these red flags they may still require hospital care. Box 2 provides further considerations and criteria for hospital referral and admission^[14],[16]
.

Managing pneumonia at home

The aim of managing symptoms of pneumonia at home is to reduce the impact of symptoms and aid recovery, while reducing admission and consequent pressure on hospital services.

Asking patients to record their symptoms in a diary will help both them and healthcare professionals understand the severity and how they will recover. In addition, assessing the patient’s breathing can help in determining whether their symptoms are worsening, remaining steady or improving. However, patients must understand the need to speak to a healthcare professional if their condition deteriorates or is not improving as expected.

In addition, patients should be advised that drinking plenty of fluids can help prevent dehydration from fever and that there is a need to get plenty of rest, which will aid the time course of recovery^[17]
.

Breathlessness

An important initial step is to help manage a patient’s breathlessness. A patient who is breathless as a result of their chest infection may feel anxious at not being able to breathe normally; this can lead to further anxiety that, in turn, worsens breathlessness. Adopting techniques that reduce the sensation of breathlessness can have the combined effect of improving this symptom and helping the patient relax. Patients can be advised to:

• Adopt pursed-lip breathing (inhaling through the nose for several seconds then exhaling slowly through pursed lips for four to six seconds);
• Relaxing the shoulder and reducing the hunched posture;
• Sitting upright to increase peak ventilation and reduce airway obstruction;
• Leaning forward with arms bracing a chair can increase ventilatory capacity^[18]
  .

Antibiotics

In general, antibiotics should only be used when treating pneumonia with suspected bacterial infection, rather than that of viral origin. They should not be offered to patients when symptoms are mild or there is reason to suspect COVID-19 or viral pneumonia. When the pneumonia is suspected to be bacterial, or if the cause is unknown and the symptoms are concerning, then oral antibiotics will be necessary^[14]
. Regardless of the cause, pharmacists will need to refer these patients to their GP or an NHS prescriber.

The first-line antibiotic is doxycycline 200mg, given immediately then 100mg once per day for a total of five days. Alternatively, the patient can be prescribed amoxicillin, given as 500mg three times per day for five days. If the patient is being managed at home and the medicine has been dispensed from a pharmacy, it should be emphasised that they should take the medicine as soon as possible, regardless of the time of day they collect/receive their medicine^[14]
. For example, if a patient is prescribed amoxicillin and only receives their prescription in the evening then they should take their first dose immediately, followed by the normal dose at the specified intervals until their prescription runs out.

It is important to consider the following consultation points for these antibiotics:

• Doxycycline — patients who have been prescribed doxycycline should be warned to avoid exposure to direct sunlight during their treatment. Although many patients will not feel well enough to leave the house, some individuals may want to sit outside in the sun during their recovery and would be at a higher risk of sun damage as a result of the antibiotic. Doxycycline should also be taken with meals, as studies indicate that, although absorption of doxycycline is not notably influenced by simultaneous ingestion of food or milk, it can cause gastric disturbances which are minimised by the presence of food;
• Amoxicillin — ensure the patient has no known allergy to penicillin
  ^{[19],[20],[21]}
  .

It is important to note that patients who have viral pneumonia, potentially caused by COVID-19, may have a secondary bacterial infection. Although this is more common in those placed on ventilators, it can occur in patients being managed at home^[22]
. This further highlights the need for patients to contact a healthcare professional if their symptoms worsen.

Recovery from pneumonia

Patients with pneumonia of either origin can have a significant recovery period. Although minor symptoms, such as elevated temperature, may disappear after a week, other symptoms can last much longer; for example, it could take:

• Four weeks for chest pain and mucous production to subside;
• Six weeks for a reduction in cough and breathlessness;
• Three to six months for fatigue to pass^[23]
  .

Although the specific timeframe for symptom recovery for COVID-19 is unknown, informing patients of the time periods for pneumonia recovery could be beneficial in helping them cope with their diagnosis and have realistic expectations about their ability to function after the infection resolves.

Patients can become anxious and depressed that they are still feeling fatigued several weeks after infection. Reassure them that slow recovery is normal, particularly after a severe pneumonia, owing to the systemic nature of the illness. Patients should be reminded to contact their GP if they are not seeing any improvement in their symptoms after a week or if they think their symptoms are getting worse.

As recovery can take several months, patients should be advised to rest at first and to not do more than they feel comfortable with. When they feel well enough to do more, they should be advised to do so gradually; for example, starting with moving around for a couple of minutes each day, increasing the duration of activity as their tolerance develops.

The British Lung Foundation also recommends “exercising the lungs” — taking long, slow breaths or blowing into water through a straw can help clear mucous from the lungs^[23]
. More information on breathing techniques are available from the Association of Chartered Physiotherapists in Respiratory Care.