Pneumonia (CAP)Emergency

Diabetic 60-year-old, 3 days of fever, cough with rusty sputum, right pleuritic pain; RR 28, BP 100/60, urea 50 mg/dL, confused — CURB-65 = 4; right lower lobe consolidation

• Septic shock
• RR ≥30 or SpO₂ <90%
• Confusion
• Multilobar consolidation
• Empyema

• Heart failure
• Pulmonary embolism with infarct
• TB
• Melioidosis, scrub typhus, leptospirosis
• Lung cancer with post-obstructive pneumonia

• Admit: CURB-65 ≥2, hypoxia, unable to take oral, comorbidity
• ICU: Septic shock, invasive ventilation, or ≥3 minor criteria (RR ≥30, PaO₂/FiO₂ ≤250, multilobar, confusion, urea ≥20 mg/dL, WBC <4000, platelets <100k, T <36 °C, hypotension needing aggressive fluids)
• Intubate: Refractory hypoxaemia, exhaustion, ↓GCS
• Vasopressors: Septic shock after fluids — noradrenaline

• Commonest bacterial cause is still Streptococcus pneumoniae; atypicals (Mycoplasma, Legionella) are covered by the macrolide.
• Non-resolving pneumonia at 6 weeks, especially in smokers >50, needs repeat CXR ± CT (cancer, TB).
• Vaccination: pneumococcal and influenza for all adults ≥50 y and at-risk groups.

• Delay antibiotics for cultures in septic CAP
• Use fluoroquinolone monotherapy as first choice where TB is common without sending sputum for TB
• Give broad MRSA/Pseudomonas cover without risk factors
• Give steroids in influenza pneumonia

• Wrong severity triage
• FQ masking TB
• Missing tropical mimics
• No follow-up CXR in smokers

CURB-65-guided site of care; ICU for severe criteria; review at 48–72 h and CXR at 6 weeks if risk factors.