Pneumonia (CURB-65): Junior Doctor Guide & Clerking Template

Q: What are the red flags for community-acquired pneumonia?

NEWS2 high, lactate raised — think sepsis; SpO₂ below 92% on air, RR ≥30 — think severe pneumonia; Confusion — think CURB-65 point; severe; Effusion + persistent fever — think parapneumonic effusion / empyema; Travel, hot tubs, hyponatraemia, D&V — think Legionella; Weight loss, night sweats, cavity — think TB; Post-influenza, cavitation — think Staph aureus (PVL)

Q: What is the initial management of community-acquired pneumonia?

Oxygen to target (94–98% (88–92% if at risk of hypercapnia)); Chest X-ray (confirms the diagnosis and shows effusion/cavity); Cultures + sputum (blood cultures if moderate–severe; urinary antigens (pneumococcal, Legionella) if moderate–severe); Antibiotics within 4 h (within 1 h if sepsis suspected); Fluids (if hypotensive or dry); Monitor (NEWS2, fluid balance)

Q: What diagnoses must you not miss in community-acquired pneumonia?

Sepsis / septic shock (lactate · hypotension); Respiratory failure (hypoxia · tiring); Parapneumonic effusion / empyema (fever won't settle); Legionella / atypical (hyponatraemia · D&V); TB (cavity · weight loss)

Q: What investigations should a junior doctor order for community-acquired pneumonia?

CXR: Not routine; consider at 6 weeks if persisting symptoms, risk factors or weight loss.; Bloods: FBC, U&E (urea for CURB-65), CRP, LFT, lactate if unwell.; Microbiology: Culture if moderate–severe.; ABG: SpO₂ below 92%, or at risk of hypercapnia.

Q: Admit or discharge: how is the plan decided for community-acquired pneumonia?

Home: CURB-65 0–1, SpO₂ ≥92% on air, able to take oral antibiotics, good support. 5-day course.; Admit / hdu: CURB-65 ≥2, hypoxia, sepsis, effusion, or frailty/social concerns. ITU review at CURB-65 4–5 or with respiratory failure.

Settle them, and check the basics

how sick?

Red flags — what each should make you think

NEWS2 high, lactate raisedsepsis SpO₂ below 92% on air, RR ≥30severe pneumonia ConfusionCURB-65 point; severe Effusion + persistent feverparapneumonic effusion / empyema Travel, hot tubs, hyponatraemia, D&VLegionella Weight loss, night sweats, cavityTB Post-influenza, cavitationStaph aureus (PVL)

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Pearl

CURB-65 helps but doesn't replace judgement. It under-calls risk in young, septic patients and in those with significant comorbidity, frailty or hypoxia (hypoxia isn't in the score). A young patient with SpO₂ of 88% and a normal CURB-65 is still sick.

First actions

O₂Oxygen to target
CXRChest X-ray
cxCultures + sputum
℞Antibiotics within 4 h
IVFluids
UOMonitor

Understand the patient & grade it

CURB-65

CURB-65 (one point each)

Confusion (new)
Urea above 7 mmol/L
Respiratory rate ≥30
Blood pressure: SBP below 90 or DBP ≤60
Age ≥65

0–1: low severity — consider home treatment. 2: moderate — consider short stay or admission. 3–5: high severity — admit, consider HDU/ITU at 4–5. (CRB-65 without urea in the community.)

Antibiotics — typical UK choices (always follow local policy)

Low severity — oral amoxicillin for 5 days (doxycycline or clarithromycin if penicillin allergic)
Moderate — amoxicillin, adding clarithromycin if atypical infection suspected
High severity — co-amoxiclav plus clarithromycin (IV initially)
Aspiration — follow local policy; covers oral anaerobes if lung abscess/empyema
Hospital-acquired — depends on timing, risk of resistance and local policy

Review IV-to-oral switch at 48 h, and stop at 5 days if clinically stable.

Work A–E — assess and act as you go

AAirway. Usually patent.—

BBreathing. RR, SpO₂, focal crackles, bronchial breathing, dullness (effusion).oxygen, CXR, ABG if hypoxic

CCirculation. HR, BP, CRT, hydration.fluids, lactate, cultures

DDisability. Confusion (CURB-65), glucose.delirium screen

EExposure. Temperature, rash, legs (PE as differential).—

The diagnoses you must not miss

tap to open each

What points toward it, what would rule it in, and how to manage it.

points toward it

Hypotension, high lactate, organ dysfunction.

rule in

NEWS2, lactate, bloods.

manage it

Sepsis bundle, antibiotics within 1 h, fluids, critical care if not responding.

Source: Septic patient page

points toward it

SpO₂ below 92% despite oxygen, rising RR, exhaustion, rising CO₂.

rule in

ABG.

manage it

Senior and ITU early; high-flow nasal oxygen, CPAP or ventilation.

Source: BTS oxygen guideline

points toward it

Persistent fever, rising CRP, effusion on CXR, pleuritic pain.

rule in

Ultrasound-guided pleural tap: pus, positive Gram stain/culture, or pH below 7.2 → empyema/complicated effusion.

manage it

Chest drain plus antibiotics with anaerobic cover; respiratory team; surgery if not resolving.

Source: BTS pleural guideline 2023

points toward it

Travel, hotels, hot tubs, hyponatraemia, deranged LFTs, diarrhoea, confusion.

rule in

Urinary Legionella antigen, PCR.

manage it

Macrolide (clarithromycin) or as per microbiology; notify public health.

Source: UKHSA

points toward it

Chronic cough, weight loss, night sweats, haemoptysis, upper-lobe cavity; risk groups.

rule in

Sputum smear, culture and PCR x3; isolate.

manage it

Airborne isolation, respiratory/ID team, notify.

Source: NICE NG33 — tuberculosis

Investigate — what to order, when, and what it tells you

test with a question in mind

CXR

When

In hospital, aim to diagnose (including CXR) within 4 h of presentation; lung ultrasound is an alternative.

Repeat

Not routine; consider at 6 weeks if persisting symptoms, risk factors or weight loss.

Bloods

Routine

FBC, U&E (urea for CURB-65), CRP, LFT, lactate if unwell.

Cultures

Moderate–high severity.

Microbiology

Sputum

Culture if moderate–severe.

Urinary antigens

Pneumococcal and Legionella in moderate–high severity.

Viral PCR

Influenza / COVID-19 in season.

ABG

When

SpO₂ below 92%, or at risk of hypercapnia.

How the plan comes together

disposition · handover

home

CURB-65 0–1, SpO₂ ≥92% on air, able to take oral antibiotics, good support. 5-day course.

Safety-net: worsening breathlessness, confusion, not improving within 3 days → return. Cough may last weeks.

admit / HDU

CURB-65 ≥2, hypoxia, sepsis, effusion, or frailty/social concerns. ITU review at CURB-65 4–5 or with respiratory failure.

Hand over: score, oxygen requirement, antibiotic and time given, cultures sent.

🩺

Pearl

Score it, give the antibiotic on time, and use your judgement, because CURB-65 misses hypoxia. If the fever won't settle, look for pus in the pleura. Nicely done getting here.

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Clerking template

copy or download

Pneumonia — documentation structure

A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.

PNEUMONIA — CLERKING TEMPLATE PRESENTING COMPLAINT: HISTORY OF PRESENTING COMPLAINT Cough / sputum / breathlessness / pleuritic pain — onset: Fever / rigors / confusion: Travel / contacts / aspiration risk / recent hospital: TB risk factors / weight loss / night sweats: Smoking / COPD / immunosuppression: RED FLAGS ASKED (record present or absent) [ ] NEWS2 high, lactate raised -> sepsis [ ] SpO₂ below 92% on air, RR ≥30 -> severe pneumonia [ ] Confusion -> CURB-65 point; severe [ ] Effusion + persistent fever -> parapneumonic effusion / empyema [ ] Travel, hot tubs, hyponatraemia, D&V -> Legionella [ ] Weight loss, night sweats, cavity -> TB [ ] Post-influenza, cavitation -> Staph aureus (PVL) SCORES / KEY CHECKS CURB-65: C U R B 65 = SpO2 on air: CXR: Antibiotic (drug / dose / route / time): Cultures / urinary antigens sent: PAST MEDICAL HISTORY: DRUG HISTORY: ALLERGIES: SOCIAL HISTORY (smoking / alcohol / function / who's at home): FAMILY HISTORY: OBSERVATIONS: RR SpO2 ( % O2) HR BP Temp GCS NEWS2 EXAMINATION A - B - C - D - (GCS pupils glucose ) E - INVESTIGATIONS ORDERED: IMPRESSION: DIFFERENTIALS CONSIDERED: [ ] Sepsis / septic shock [ ] Respiratory failure [ ] Parapneumonic effusion / empyema [ ] Legionella / atypical [ ] TB [ ] Acute exacerbation COPD / asthma [ ] PE [ ] Heart failure [ ] Lung cancer PLAN: 1. 2. 3. ESCALATION / SENIOR DISCUSSION: Discussed with: Time: Advice: SAFETY NET / IF DETERIORATES: Documented by: Grade: Date/Time:

Test yourself

active recall

Cover the answer, say it out loud, then reveal. Retrieval beats re-reading.

0 / 12 known

Red flag

NEWS2 high, lactate raised — what should it make you think?

sepsis

Red flag

SpO₂ below 92% on air, RR ≥30 — what should it make you think?

severe pneumonia

Red flag

Confusion — what should it make you think?

CURB-65 point; severe

Red flag

Effusion + persistent fever — what should it make you think?

parapneumonic effusion / empyema

Red flag

Travel, hot tubs, hyponatraemia, D&V — what should it make you think?

Legionella

Red flag

Weight loss, night sweats, cavity — what should it make you think?

Red flag

Post-influenza, cavitation — what should it make you think?

Staph aureus (PVL)

Must not miss

How do you rule in sepsis / septic shock?

NEWS2, lactate, bloods.

Must not miss

How do you rule in respiratory failure?

ABG.

Must not miss

How do you rule in parapneumonic effusion / empyema?

Ultrasound-guided pleural tap: pus, positive Gram stain/culture, or pH below 7.2 → empyema/complicated effusion.

Must not miss

How do you rule in legionella / atypical?

Urinary Legionella antigen, PCR.

Must not miss

How do you rule in TB?

Sputum smear, culture and PCR x3; isolate.

Frequently asked questions

quick answers

What are the red flags for community-acquired pneumonia?

NEWS2 high, lactate raised — think sepsis
SpO₂ below 92% on air, RR ≥30 — think severe pneumonia
Confusion — think CURB-65 point; severe
Effusion + persistent fever — think parapneumonic effusion / empyema
Travel, hot tubs, hyponatraemia, D&V — think Legionella
Weight loss, night sweats, cavity — think TB
Post-influenza, cavitation — think Staph aureus (PVL)

What is the initial management of community-acquired pneumonia?

Oxygen to target — 94–98% (88–92% if at risk of hypercapnia)
Chest X-ray — confirms the diagnosis and shows effusion/cavity
Cultures + sputum — blood cultures if moderate–severe; urinary antigens (pneumococcal, Legionella) if moderate–severe
Antibiotics within 4 h — within 1 h if sepsis suspected
Fluids — if hypotensive or dry
Monitor — NEWS2, fluid balance

Always alongside senior support and your local guideline.

What diagnoses must you not miss in community-acquired pneumonia?

Sepsis / septic shock — lactate · hypotension
Respiratory failure — hypoxia · tiring
Parapneumonic effusion / empyema — fever won't settle
Legionella / atypical — hyponatraemia · D&V
TB — cavity · weight loss

Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.

What investigations should a junior doctor order for community-acquired pneumonia?

CXR — Not routine; consider at 6 weeks if persisting symptoms, risk factors or weight loss.
Bloods — FBC, U&E (urea for CURB-65), CRP, LFT, lactate if unwell.
Microbiology — Culture if moderate–severe.
ABG — SpO₂ below 92%, or at risk of hypercapnia.

Admit or discharge: how is the plan decided for community-acquired pneumonia?

Home — CURB-65 0–1, SpO₂ ≥92% on air, able to take oral antibiotics, good support. 5-day course.
Admit / hdu — CURB-65 ≥2, hypoxia, sepsis, effusion, or frailty/social concerns. ITU review at CURB-65 4–5 or with respiratory failure.

Is there a clerking template for community-acquired pneumonia?

Yes — there is a clerking template for community-acquired pneumonia on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.

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