NICE has urged GPs to consider the risks as well as the benefits of referring patients with pneumonia for hospital admission during the coronavirus (Covid-19) outbreak.
In new a rapid guideline published last weekend, NICE said GPs should consider the ‘benefits, risks and disadvantages of hospital admission’ during the crisis, as well as ‘service delivery issues and local NHS resources’.
GPs should also consider how the care that can be offered in hospital compares with that possible at home, alongside the patient’s wishes and any care plan.
The guidance said: ‘Explain that the benefits of hospital admission include improved diagnostic tests (chest X-ray, microbiological tests and blood tests) and respiratory support, [while] the risks and disadvantages of hospital admission include spreading or catching Covid‑19 and loss of contact with families.’
These considerations also apply to the most vulnerable patients who would usually have been admitted for severe pneumonia ‘before the Covid-19 pandemic’.
NICE said: ‘Be aware that older people, or those with comorbidities, frailty, impaired immunity or a reduced ability to cough and clear secretions, are more likely to develop severe pneumonia.
‘Because this can lead to respiratory failure and death, hospital admission would have been the usual recommendation for these people before the Covid‑19 pandemic.’
GPs should ‘take into account’ the severity of symptoms and ‘signs of more severe illness’ upon reaching their decision.
If deciding the patient should stay at home, they should be advised to seek medical help ‘without delay’ if their symptoms worsen ‘rapidly or significantly’ or do not improve ‘as expected’.
The guideline further said that antibiotics should not be prescribed to treat or prevent pneumonia if coronavirus is ‘likely’ to be the cause and symptoms are mild.
It said: ‘As Covid‑19 pneumonia is caused by a virus, antibiotics are ineffective. Inappropriate antibiotic use may reduce availability if used indiscriminately, and broad-spectrum antibiotics in particular may lead to Clostridioides difficile infection and antimicrobial resistance.’
However, GPs should prescribe antibiotics for those who can be treated in the community if it’s ‘unclear’ whether the cause is viral or bacterial or they are ‘at high risk of complications’, NICE said.
Oral corticosteroids should not ‘routinely’ be prescribed unless the patient has ‘other conditions for which these are indicated’ such as COPD or asthma.
NICE told Pulse that ‘pneumonia risk’ is ‘one of the main factors’ a clinician should consider when deciding whether someone with suspected or confirmed Covid-19 should be admitted to hospital.
However, there may be ‘other reasons for admission’ to be considered, for example if a patient has an underlying health condition that may be ‘worsened’ by coronavirus but may not necessarily increase their risk of pneumonia, it added.
It comes as NICE also produced rapid guidelines on the treatment of patients with severe asthma during the coronavirus pandemic, those with Covid-19 who also have rheumatological autoimmune, inflammatory and metabolic bone disorders, as well as managing coronavirus symptoms in the community.
NICE rapid guideline on pneumona management during Covid-19 pandemic
When making decisions about hospital admission, take into account:
- the severity of the pneumonia, including symptoms and signs of more severe illness (see recommendation 3.4)
- the benefits, risks and disadvantages of hospital admission
- the care that can be offered in hospital compared with at home
- the patient’s wishes and care plans (see the section on treatment and care planning)
- service delivery issues and local NHS resources during the COVID‑19 pandemic.
- the benefits of hospital admission include improved diagnostic tests (chest X-ray, microbiological tests and blood tests) and respiratory support
- the risks and disadvantages of hospital admission include spreading or catching COVID‑19 and loss of contact with families.