CHILD HEALTH INFEC TIONS RESPIR ATORY CONDITIONS

The management of
community-acquired pneumonia
Pneumonia is a significant cause of mortality in children and older people, particularly among Māori and Pacific
peoples. In New Zealand, Māori males are six times more likely to die from pneumonia than non-Māori males.
Prompt identification and treatment will enable patients with initially less severe community-acquired pneumonia
to be managed at home, reducing hospitalisation and mortality.

KEY PR AC TICE POINTS:

Community-acquired pneumonia is usually diagnosed Antibiotic treatment is usually empiric; a short course of
clinically in primary care based on the presence of high dose amoxicillin is first line for most patients. Advise
characteristic symptoms and signs: patients to maintain adequate hydration and to take
– Respiratory, e.g. dyspnoea, tachypnoea, increased paracetamol or ibuprofen as required.
respiratory effort, crackles on auscultation, pleuritic chest Schedule a review two to three days after initiating
pain antibiotic treatment. If there has been inadequate response
– Non-respiratory, e.g. fever, tachycardia, and less typically, to treatment, or clinical deterioration, reassess antibiotic
abdominal pain and vomiting; non-specific symptoms choice and/or suitability for community management.
may also be present such as confusion in older people – A chest X-ray post-treatment may be indicated for select
and poor feeding in infants patients. For example, in patients who had an abnormal
Laboratory tests (including microbiological testing) and X-ray at the time of initial diagnosis (e.g. effusion,
imaging are not usually indicated in primary care for atelectasis) or patients with poor clinical recovery to
patients with suspected community-acquired pneumonia. exclude underlying lung pathology.
Perform a COVID-19 test to rule out SARS-CoV-2 infection. Where possible, advise patients on how to reduce their
– Laboratory testing, e.g. full blood count and CRP, may exposure to modifiable risk factors associated with
be considered for patients with moderate-to-severe pneumonia, e.g. smoking cessation, maintaining a smoke-
symptoms and signs. free home and vehicle, seeking support for improving
– Referral for a chest X-ray may be indicated in some housing quality, vaccination.
clinical situations, e.g. if the diagnosis of pneumonia – Vaccination provides some protection against
is uncertain, underlying respiratory disease, suspected community-acquired pneumonia. Encourage patients to
complications. be up to date with the following vaccines (depending
Once a clinical diagnosis of community-acquired on eligibility): Prevenar 13 (PCV13), Pneumovax 23
pneumonia has been made, determine suitability for (23PPV), Haemophilus influenzae type b (Hib; included as
community-based management. In adults, this decision part of the DTaP-IPV-HepB/Hib [Infanrix-hexa] vaccine
can be guided by the CRB-65 (confusion, respiratory rate, and Hib-PRP-T [Hiberix] vaccine), seasonal influenza,
blood pressure, age ≥ 65 years) severity assessment tool in COVID-19.
addition to clinical judgement.

www.bpac.org.nz May 2024 1

 This is a revision of a previously published the community is < 1%.2 Mortality rates are higher for people
article. What’s new for this update: treated in the hospital setting, reaching up to 18% in hospital
General article revision wards or up to 50% in the intensive care unit.2
Antibiotic recommendations updated In New Zealand, hospitalisation rates in children with
Section added on the CRB-65 tool pneumonia have generally decreased since 2008 when
Section added on causes of pneumonia in adults pneumococcal vaccination was included in the childhood
that do not typically respond to empiric treatment Immunisation Schedule (see: “Vaccination can protect against
Pneumococcal vaccine Synflorix (PCV10) is no community-acquired pneumonia”).9, 10 However, between 2016
longer available in New Zealand and 2019 hospitalisation rates increased, before decreasing
significantly in 2020, likely due to the COVID-19 pandemic.9
There are no recent data on hospitalisation rates in adults with
Epidemiology of community-acquired pneumonia in New Zealand.
pneumonia
Pneumonia is caused by inhalation of microorganisms from Ethnic disparities
the upper respiratory tract into the lungs, which subsequently Pneumonia disproportionately affects people of Māori and
induces an inflammatory response in the lower bronchial tree Pacific ethnicity.3, 13 Māori have at least three times the rate of
and alveoli.1, 2 Streptococcus pneumoniae is the most frequently hospitalisations due to pneumonia than non-Māori, and Māori
identified cause, both in New Zealand and internationally.2, 3 males have a mortality rate six times greater than non-Māori
Other causative organisms include Mycoplasma pneumoniae, males.13 Hospital admission rates for Māori and Pacific children
Legionella longbeachae, L. pneumophila, Staphylococcus aureus, are also higher compared to children of other ethnic groups.9, 10
Haemophilus influenzae, Chlamydophila pneumoniae and
viruses, e.g. human rhinovirus, influenza, respiratory syncytial Risk factors for pneumonia
virus (RSV), SARS-CoV-2.4, 5 A range of modifiable and non-modifiable risk factors are
Viral aetiology for community-acquired pneumonia is associated with pneumonia. Young children and older
becoming increasingly more common, likely due to the effects adults, particularly with co-morbidities (see below) are the
of vaccination against S. pneumoniae (see: “Vaccination can populations most at risk of developing community-acquired
protect against community-acquired pneumonia”).6 Since the pneumonia.2, 7 Males are more often affected than females.2, 7
COVID-19 pandemic, SARS-CoV-2 has become a significant
Lifestyle-related risk factors include poor nutrition/
cause of community-acquired pneumonia.
malnutrition, reduced rates of breast feeding,
Although pneumonia can occur at any time throughout
exposure to tobacco smoke (via smoking or second-
year, it is more frequently diagnosed in winter months (except
hand exposure), high alcohol intake, lower housing quality (i.e.
for Legionella pneumonia) and affects younger children, i.e.
lack of insulation and heating, damp, mouldy, overcrowded
aged < 5 years, and older adults, i.e. aged > 65 years, the most
living conditions), low socioeconomic status, incomplete
(see: “Risk factors for pneumonia”).2, 7
vaccination, regular contact with children.2, 10, 14

Hospital- or community-acquired pneumonia? Co-morbid long-term conditions can increase

Community-acquired pneumonia is classified as the risk of community-acquired pneumonia, such
occurring in a person who has not been hospitalised as chronic obstructive pulmonary disease (COPD),
in the month before symptom onset.2 If a person has diabetes, cardiovascular disease and chronic liver disease.2, 14
clinical features that suggest pneumonia after being People who are immunocompromised are also at higher risk.2, 14
hospitalised for at least two days (when there was no
Medicines associated with an increased risk
suspicion of incubation prior to admission), they are
of pneumonia include proton pump inhibitors,
classified as having hospital-acquired pneumonia.2
antipsychotics, inhaled corticosteroids and DPP-4
The threshold for referral of a patient with hospital-
inhibitors (e.g. vildagliptin).7
acquired pneumonia is generally lower than for
community-acquired pneumonia. Where possible, encourage patients to reduce their
exposure to modifiable risk factors associated with pneumonia,
e.g. smoking cessation, maintaining a smoke-free home
Pneumonia incidence and mortality
and vehicle, improving diet/nutrition, seeking support to
The global incidence of pneumonia is estimated to be between improve housing quality, being up to date with vaccinations
1 and 14 cases per 1,000 people each year.2, 8 The global (see: “Vaccination can protect against community-acquired
mortality rate for people with pneumonia who are treated in pneumonia”).2, 10

2 May 2024 www.bpac.org.nz

Community-acquired pneumonia in children
Increasing rates of invasive
Viruses, specifically RSV, are the most common cause of pneumococcal disease reported in
community-acquired pneumonia in children, particularly in recent years
those aged under two years. Purely bacterial pneumonia is
infrequent in the pneumococcal vaccine era but S. pneumoniae People with invasive pneumococcal disease, caused
is still the most commonly identified bacterial cause.15, 16 In a by S. pneumoniae, most often present with pneumonia,
small proportion of cases, a combination of bacterial and viral meningitis or septicaemia. 11 Fewer cases of invasive
aetiology can occur.15 pneumococcal disease may therefore lead to fewer cases
of pneumonia.
Symptoms and signs of pneumonia in children Invasive pneumococcal disease became a notifiable
Diagnosis of pneumonia is usually made clinically, based disease in New Zealand in 2008; a decreasing trend has
on the presence of characteristic symptoms and signs (see generally been observed over time, but case numbers
below).17 Features can vary depending on the age of the child, have fluctuated.11 After a significant decline in cases
aetiology and severity.15 If pneumonia is suspected based on during the 2020/2021 period, likely in part due to the
patient history (including risk factors) and symptoms, perform COVID-19 pandemic public health measures, rates
an age-appropriate examination, e.g. check temperature, heart have been steadily increasing, particularly cases due to
rate, respiratory rate, oxygen saturation, observe and listen to serotype 19A.12 In 2022/2023 there were 692 cases of
the chest. Alternative diagnoses should also be considered, e.g. invasive pneumococcal disease reported in New Zealand;
inhaled foreign body, asthma, bronchiolitis.15 the highest annual incidence rate in the past ten years.12
The change in the childhood Immunisation Schedule
Symptoms and signs of pneumonia in children may in 2022 to include PCV13 (which includes serotype
include:15, 17, 18 19A) is likely to help reverse this increasing trend (see:
Persistent fever (see: “Identifying the risk of serious “Pneumococcal vaccination: PCV13 and 23PPV”). However,
illness in young children with fever”) this will only occur with increasing coverage rates for
infant pneumococcal immunisation, especially in high-risk
Tachypnoea at rest (Table 1)
populations.
Increased respiratory effort (e.g. in-drawing, accessory
muscle use, grunting, nasal flaring)
Irritability
Fatigue/lethargy
Unwell appearance
Poor feeding (infants)
Dyspnoea, wheeze
Cough
Pleuritic chest pain
Hypoxaemia
Crackles, bronchial breathing, decreased or absent
breathing sounds on auscultation
Dullness to percussion

Children may also present with other less typical symptoms,

e.g. abdominal pain, neck stiffness, vomiting.15, 17 In practice,
auscultatory signs are less frequently observed in young
children with pneumonia; non-specific symptoms such as
poor feeding, irritability/restlessness and lethargy may only
be present.15 In school-aged children who present with mild
and non-specific symptoms and signs, consider the possibility
of pneumonia caused by M. pneumoniae (also referred to as
“walking pneumonia”).19

www.bpac.org.nz May 2024 3

 Features more suggestive of bacterial pneumonia include Management of community-acquired pneumonia in
fever > 38.5°C, chills and rigors, unwell appearance, marked children
tachypnoea and localised auscultatory findings, e.g. decreased
breathing sounds, crackles over the affected lobe.15, 19 The Antibiotic treatment is usually appropriate for all children with
presence of low-grade fever, rhinorrhoea, wheeze and diffuse suspected community-acquired pneumonia as differentiating
and bilateral auscultatory signs are more suggestive of viral the cause of pneumonia is difficult, and a bacterial pathogen
pneumonia.15, 19 may still be present even when a virus is the primary causative
agent. 15 However, Starship guidelines recommend that
Table 1. Tachypnoea in children by age.17 children with pneumonia with a likely viral aetiology do not
require antibiotics.17 In practice, antibiotic treatment is empiric,
Age Breaths per minute given that microbiology testing, e.g. viral PCR testing, is not
routinely recommended or available in primary care (viral PCR
< 2 months > 60 testing is usually performed in secondary care).15, 19

2 – 12 months > 50 The first-line antibiotic choice is:17, 20

Amoxicillin 30 mg/kg/dose (maximum 1 g/dose)*, three
> 12 months > 40 times daily, for three to five days

* If aged less than one month, the maximum is 125 mg/dose, but initiation
of oral antibiotics in the community is usually not appropriate in children
Further investigations are not usually required in the
aged less than three months as they should be referred to hospital for
community treatment
Laboratory testing (e.g. full blood count [FBC], C-reactive
protein [CRP]) and microbiological testing are not routinely Amoxicillin is the first-line antibiotic choice for patients with
recommended in primary care for the investigation of community-acquired pneumonia as it is effective against the
suspected pneumonia in children.17, 18 Perform a COVID-19 test most common causes and is generally well tolerated; it is used
to exclude SARS-CoV-2 infection.16 at a high dose to cover potentially resistant S. pneumoniae.15, 21
Referral for a chest X-ray is also not routinely required
but may be considered in some clinical situations, e.g. if the Suitable alternatives to amoxicillin (if penicillin allergic)
diagnosis is uncertain/presentation not typical, underlying include*:
respiratory disease.17 Erythromycin: 10 – 12.5 mg/kg/dose, four times daily,
for seven days (usual maximum 1.6 g/day; up to 4 g/day
When to refer a child with suspected in severe infection)20
pneumonia to hospital Azithromycin: 10 mg/kg, once daily, on day one,
This decision is based on history, clinical features, age followed by 5 mg/kg, once daily on days two to five17
and presence of co-morbidities.17 Hospital referral is
* Doxycycline is also a suitable alternative antibiotic to amoxicillin in
warranted for a child with any of the following:17
children aged over 12 years, however, there is no liquid formulation
Age less than three months available for children unable to swallow tablets17

Significant dehydration
If there is a poor response after 48 hours of initial antibiotic
O2 saturation < 93%
treatment, it is likely the child has viral pneumonia (in which
Significant co-morbidity case, consider “watchful waiting”) or a bacterial cause that
Respiratory distress that significantly interferes with does not typically respond to empiric antibiotics. In an
feeding older child, it is appropriate to take a sputum sample for
“Toxic” appearance microbiological testing. The addition of a macrolide antibiotic
(e.g. erythromycin) can be considered in children aged over
Suspected severe pneumonia, e.g. severe
five years, as M. pneumoniae and C. pneumoniae (along with
tachycardia
S. pneumoniae) are common pathogens in school-aged
Suspected complications, e.g. effusion, abscess children,15 but increasing rates of resistance has limited their
Social concerns, e.g. lack of transport if the child effectiveness, including in Mycoplasma infection.22 There is also
deteriorates, communication barriers a lack of clinical trial data that show clear benefit of macrolide
Deterioration despite appropriate oral antibiotics antibiotics in children with pneumonia.22 Legionella infection
rarely occurs in children, even in high incidence regions.23

4 May 2024 www.bpac.org.nz

 Maintaining adequate hydration is important and Sputum production
parents/caregivers should be instructed on how to do this (i.e. Dyspnoea
frequent intake of small amounts of fluid).15, 16 Paracetamol and Pleuritic chest pain
ibuprofen may be given as needed (use ibuprofen with caution Focal signs on auscultation, e.g. crackles, egophony,5
in children who are dehydrated).15, 16 bronchial breathing
Dullness to percussion
Follow-up after treatment
Myalgia
Arrange a follow-up review within a few days of starting
Fatigue
antibiotics (either in person or via phone) to monitor treatment
Chills
progress.15 Children who do not respond adequately within 48 –
Abdominal pain
72 hours, or who clinically deteriorate, should be reassessed and
Headache
severity of illness reviewed to determine ongoing suitability
for community management.15, 16 Consider referral for a chest Older or immunocompromised patients may present with
X-ray in children who have not responded adequately after a subtle or less typical features which can make diagnosis
course of antibiotics.17 Discussion with a paediatric infectious challenging, e.g. lethargy, weakness, falls, changes in mental
diseases physician or paediatrician may also be appropriate for status, absence of fever.4, 14
children with inadequate response to treatment. Consider the possibility of alternative diagnoses, e.g.
Consider scheduling a review six weeks after antibiotic an exacerbation of asthma or COPD, bronchitis, congestive
treatment to assess for any persisting symptoms and signs. heart failure, gastro-oesophageal reflux disease, lung cancer,
Children who had significant abnormalities on chest X-ray pulmonary embolism, tuberculosis.1, 5
at the time of initial diagnosis, e.g. atelectasis, should have a
follow-up X-ray in four to six weeks after completing antibiotic Further investigations are not usually required in the
treatment;19 refer the child to a paediatrician if abnormalities community
have not resolved. Children with recurrent pneumonia Laboratory investigations (e.g. FBC, CRP) or microbiological
affecting the same lobe should also have a follow-up X-ray.19 testing is not routinely required in a primary care setting
for the investigation of suspected pneumonia in adults.6, 25
Perform a COVID-19 test to exclude SARS-CoV-2 infection.4, 5
Community-acquired pneumonia in adults Some guidelines (e.g. United Kingdom NICE guidelines, British
Bacteria, predominantly S. pneumoniae, appear to be the most Thoracic Society guidelines) and regional HealthPathways in
common cause of community-acquired pneumonia in adults.5 New Zealand recommend requesting laboratory testing (e.g.
However, as with children, identifying a causative organism FBC, CRP, creatinine, electrolytes) and considering a sputum
is not possible in most cases.5 Empiric use of antibiotics for sample for culture and microscopy in patients with moderate-
all adults with suspected pneumonia being treated in the to-severe symptoms or signs.25, 26
community is therefore usual practice.5, 24 Referral for a chest X-ray is also not routinely required but
may be considered in some clinical situations such as if the
Symptoms and signs of pneumonia in adults diagnosis is unclear or if there is dullness to percussion or other
A clinical diagnosis of pneumonia in adults is made based on signs of complications, e.g. suspected effusion, consolidation
the presence of characteristic symptoms and signs, which or lung collapse.4, 25
can vary widely.1, 14 Symptoms and signs may be specific to
the chest, but patients can also present with less specific and Management of community-acquired pneumonia in
more varied respiratory and systemic symptoms. If pneumonia adults
is suspected based on patient history (including risk factors) Once a clinical diagnosis of community-acquired pneumonia
and symptoms, perform a physical examination, e.g. check has been made in an adult, determine suitability for community
temperature, heart rate, respiratory rate, oxygen saturation, management.26 Guidelines from NICE (UK), the British Thoracic
examine the chest. Society and the American Thoracic Society and Infectious
Diseases Society of America (and local HealthPathways)
Symptoms and signs of pneumonia in adults may include:1, 4, 14 recommend using a validated pneumonia severity score to
Cough support clinical findings and judgement (see: “Calculating the
Fever (≥ 37.8°C) CRB-65 score for adults”).6, 25, 26 Consider patient characteristics,
Tachypnoea (≥ 20 breaths per minute) e.g. oxygen saturation, hydration status, and co-morbidities
Tachycardia (> 100 beats per minute) along with “gut feeling” when deciding on the appropriate
Oxygen saturation < 95% treatment location (see box).26

www.bpac.org.nz May 2024 5

 Calculating the CRB-65 score for adults
CRB-65 is a tool for assessing pneumonia in adults, Other pneumonia severity tools are also available
validated for use in primary care. It is used to support The Pneumonia Severity Index (PSI) is preferentially
clinicians in assessing pneumonia severity and guiding recommended in the latest American Thoracic Society
suitability for community management (Table 2).25, 26 and Infectious Diseases Society of America guidelines,6
but it requires input of 20 variables including laboratory
One point is scored for each of the following clinical test results and imaging, so is less practical in a primary
features that are present:25, 26 care setting.5, 8 There is another version of the CRB-65
tool – CURB-65 which contains an additional variable;
Confusion (new onset or score of eight or less on an
serum urea. However, serum urea is now infrequently
abbreviated mental test)
requested in primary care, and the result is unlikely to
Respiratory rate ≥ 30 breaths per minute be readily available to inform management decisions.8, 14
Blood pressure (systolic < 90 mmHg or diastolic ≤ 60 In comparison to the PSI, the CURB-65 does not include
mmHg) information about co-morbidities and is less effective
at guiding the decision of community versus hospital
65 years or older
level care.6, 14 There is no evidence that the CURB-65 is
superior to the CRB-65.25 The CRB-65 is therefore the most
practical tool for use in primary care as it does not require
laboratory testing or imaging.5, 25

Table 2. Pneumonia CRB-65 severity score.25, 26

Score Severity and mortality risk Suggested action

0 Low severity Community management is likely to be suitable

Mortality risk < 1%

1–2 Moderate severity Evaluate possibility of hospital referral, particularly if the score is 2.
Mortality risk 1 – 10% Consider the patients clinical condition, co-morbidities and social
circumstances/home support when deciding whether to refer to
hospital or manage in the community.

3–4 High severity Hospital referral is recommended

Mortality risk > 10%

6 May 2024 www.bpac.org.nz

 When to refer an adult with suspected mg, once daily, for three days; or roxithromycin, 300 mg, once
pneumonia to hospital daily, for five days) as this will also cover other possible causes
This decision is based on clinical features, including of pneumonia, e.g. Legionella.
severity of symptoms, and the presence of co- Patients with certain causes of pneumonia require a longer
morbidities.6, 26 Suitability for community management antibiotic treatment duration or an alternative antibiotic (see:
can also be guided by using validated pneumonia- “Causes of pneumonia that do not typically respond to empiric
specific tools, e.g. the CRB-65, in addition to clinical antibiotic treatment”); discuss a pathogen-specific regimen
judgement (see: “Calculating the CRB-65 score for with an infectious diseases physician or clinical microbiologist.
adults”).6, 26 Consider hospital referral for patients with Advise patients to drink adequate fluids and to take
the following (especially in combination):6, 26 paracetamol or ibuprofen as required, e.g. for chest pain, sore
throat.4, 25
Age ≥ 65 years
Altered mental state (confusion) For information on cough medicines and alternative
Relevant co-morbidities, e.g. heart failure, renal or treatments/remedies for acute cough associated with a viral
hepatic impairment, frailty upper respiratory tract infection, see: bpac.org.nz/2023/
cough-medicines.aspx
Suspected complications, e.g. septicaemia, abscess
Respiratory rate ≥ 30 breaths per minute
For information on the management of other symptoms
Pulse rate > 125 beats per minute associated with respiratory tract infections, see: bpac.org.
O2 saturation ≤ 92% nz/2018/cold-season.aspx and bpac.org.nz/2019/rti.aspx

Systolic blood pressure < 90 mmHg or diastolic Follow-up after treatment

blood pressure ≤ 60 mmHg
Arrange a follow-up review within a few days of starting
Dehydration antibiotics (either in person or via phone) to monitor treatment
Lack of reliable support at home progress, or advise the patient to make contact if they are
not improving.4, 25 Patients who do not show improvement
within 48 – 72 hours of starting antibiotic treatment, or who
Oral antibiotic treatment is appropriate for all adults with clinically deteriorate, should have their antibiotic choice
suspected pneumonia who are managed in the community.5 reassessed (e.g. add a macrolide after taking a sputum sample
for microbiological testing) and severity of illness reviewed to
The first-line antibiotic choice is:28 determine suitability for community management.4, 25 Consider
Amoxicillin 1 g, three times daily, for five days referral for a chest X-ray in patients who have not responded
adequately after a course of antibiotics and there were chest
Practice point. Lower doses of amoxicillin (e.g. 500 mg, signs on examination.
three times daily) may have previously been standard practice
but they are now regarded as inadequate by experts, as the A follow-up chest X-ray four to six weeks after completing
pneumococcal minimum inhibitory concentration to penicillin antibiotic treatment may be appropriate for patients:2, 25
is increasing, i.e. to overcome increasing resistance, higher Who had a chest X-ray at the time of initial diagnosis
doses of amoxicillin are required. However, based on clinical and it was abnormal, e.g. effusion; refer to a respiratory
judgement there may still be some patients for whom 500 mg, specialist if abnormalities have not resolved
three times daily, is an appropriate dose.
With poor clinical recovery (to exclude malignancy)
A suitable alternative to amoxicillin for patients with
Who have recovered from pneumonia but are at high
severe penicillin allergy (e.g. anaphylaxis) is doxycycline 200
risk of underlying lung pathology, e.g. a patient with
mg, twice daily on day one, followed by 100 mg, twice daily,
significant smoking history
on days two to five.28 For patients with mild penicillin allergy
(e.g. rash), cefalexin, 1 g, three times daily, for five days, can
be prescribed. Spirometry testing may be performed in patients who smoke
For patients with more severe symptoms (but who are (or with a history of smoking) to identify underlying COPD,
still suitable for community management), or who have not once they have recovered from pneumonia.
improved after 48 hours of initial antibiotic treatment, consider Offer advice to address modifiable risk factors for
combination treatment with amoxicillin (1 g, three times pneumonia, e.g. vaccination, and encourage smoking
daily, for five days) PLUS a macrolide (e.g. azithromycin, 500 cessation (as appropriate).2, 25

www.bpac.org.nz May 2024 7

 Causes of pneumonia that do not typically respond to empiric antibiotic treatment
If one of the following causes of community-acquired exposure, consider Legionella infection. Azithromycin or
pneumonia is suspected in a patient, it is usually roxithromycin are usually added to empiric treatment and
appropriate to consult with a clinical microbiologist or a longer duration of treatment will be needed; see local
infectious diseases physician on any test(s) to perform and HealthPathways for details.
to inform antibiotic recommendations. The likely cause of
pneumonia cannot usually be accurately predicted based Mycobacterium tuberculosis
on clinical features.23, 25 In practice, the following causes Pneumonia due to M. tuberculosis typically only occurs
of pneumonia may be suspected based on inadequate in people who have immigrated from, or have recently
response to empiric antibiotics and the presence of risk travelled to, an area where M. tuberculosis is endemic, e.g.
factors. India, South Africa.15 People with immunodeficiency, e.g.
HIV infection, are also at increased risk.15, 24
Legionella
Legionella species are a relatively common cause of Pneumocystis jirovecii
community-acquired pneumonia in New Zealand.29 P. jirovecii, a fungus, previously known as P. carinii, is the
Legionella species are often associated with more severe, causative organism of Pneumocystis pneumonia.30, 31
sometimes fatal, cases of pneumonia and symptoms and Infection with P. jirovecii usually occurs only in people
signs can be similar to pneumococcal pneumonia.23, 29 with severe immunodeficiency, e.g. due to advanced
Legionella pneumonia is most common in warmer months HIV infection, organ or bone marrow transplant,
(although it can occur at any time) and is particularly corticosteroid treatment (≥ 20 mg/day for ≥ 2 weeks),
associated with recent use of potting mix or compost chemotherapy.1, 31 Hospital admission for treatment
(usually L. longbeachae) or exposure to a contaminated (usually high dose trimethoprim + sulfamethoxazole) is
water source (usually L. pneumophila), e.g. spa pools, rain generally required.30
water tanks, air conditioning systems.23 People with COPD,
immunocompromise, who smoke or with recent travel to Pseudomonas aeruginosa
an outbreak area are at higher risk.2, 14 Gastrointestinal P. aeruginosa is a relatively common cause of hospital-
effects may be more prominent in people with Legionella acquired pneumonia but is an unusual cause of
pneumonia than with other causes of pneumonia.23 community-acquired pneumonia. 1, 2 Risk factors
for pneumonia caused by P. aeruginosa include
If a patient is not responding to empiric antibiotics immunocompromise, bronchiectasis, cystic fibrosis, lung
and there is recent history of potting mix or compost transplant, COPD and smoking.1, 24

8 May 2024 www.bpac.org.nz

Vaccination can protect against community- implant, premature birth (< 28 weeks), can receive an
acquired pneumonia additional dose at age three months.32 23PPV is not part of the
childhood Immunisation Schedule, but is recommended and
Pneumococcal vaccination can protect against cases of funded for children aged two years and over who are at higher
community-acquired pneumonia caused by S. pneumoniae.1, 14 risk of pneumococcal disease.32
Haemophilus influenzae type b (Hib) vaccines (included as part of An extended pneumococcal vaccination programme is
the DTaP-IPV-HepB/Hib [Infanrix-hexa] and Hib-PRP-T [Hiberix] available for selected groups. Up to four additional doses of
vaccines) can also prevent cases of community-acquired PCV13 and up to three additional doses of 23PPV are funded
pneumonia.1, 15 The seasonal influenza vaccine is recommended for vaccination (or re-vaccination) in children and adults at
to help prevent pneumonia secondary to influenza or high risk of pneumococcal disease or with eligible conditions,
secondary bacterial infection.14, 16 Also encourage patients to e.g. HIV infection, primary immunodeficiency, undergoing
be up to date with COVID-19 vaccination.5 renal dialysis, Down syndrome.32 The vaccination schedule
differs depending on the patient’s age, see the Immunisation
For further information on seasonal influenza and Handbook for details; 23PPV should be administered at least
COVID-19 vaccines, see: bpac.org.nz/2024/vaccinations.aspx eight weeks after PCV13.32

For the full list of pneumococcal vaccine eligibility

Pneumococcal vaccination: PCV13 and 23PPV
criteria, see: schedule.pharmac.govt.nz/ScheduleOnline.
There are two pneumococcal vaccines available in New php?edition=&osq=Pneumococcal
Zealand: PCV13 (Prevenar 13) and 23PPV (Pneumovax 23).
PCV10 (Synflorix) is no longer available, as other pneumococcal Pneumococcal vaccination is recommended but not
vaccines provide broader protection against pneumococcal funded for some groups
serotypes. 32 Since the introduction of pneumococcal Pneumococcal vaccination may be considered (not funded)
vaccination in New Zealand in 2008, there have been fewer for people with multiple co-morbidities, e.g. asthma, diabetes,
cases of invasive pneumococcal disease and pneumonia, and and/or exposure to risk factors, e.g. smoking, alcohol
fewer associated hospitalisations.33 dependence.32 The accumulation of co-morbidities and risk
factors increases the risk of invasive pneumococcal disease,
PCV13 is a conjugate vaccine that protects against 13 which can be comparable to the risk in people with a high risk
pneumococcal serotypes.32, 34 Protection is expected to last up condition.32
to five years in children who are vaccinated with PCV13 when
aged ≤ 5 years; if administered to older children/adolescents Vaccination with PCV13 and 23PPV is recommended but not
or adults, protection is expected to last for at least five years funded (unless they meet other eligibility criteria) for people:32
after immunisation.34 Higher valent vaccines PCV15 and PCV20 Aged 65 years and over
have been approved and recommended for use in the USA and At higher risk of pneumococcal disease or its
Europe (in 2021/2022) and may be available in New Zealand in complications, e.g. due to co-morbidities such as
the coming years.35 diabetes, chronic heart, renal or pulmonary disease, or
alcohol dependence
23PPV is a polysaccharide vaccine that provides broader
Who are immunocompromised and at increased risk
coverage than PCV13, protecting against 23 pneumococcal
of pneumococcal disease, e.g. people with nephrotic
serotypes.32, 34 Pure polysaccharide vaccines in general do not
syndrome, multiple myeloma, lymphoma
provide long-lasting protection, especially in young children
Who have had invasive pneumococcal disease in the past
who do not develop good immune responses to these.34 23PPV
should be considered for use only in children and adults who Who smoke
are at increased risk of pneumococcal disease due to certain
underlying medical conditions (see below). 23PPV is also recommended but not funded for people with
intracranial shunts or cerebrospinal fluid leakage (PCV13 is
Who is eligible to receive funded pneumococcal funded for these people).32
vaccination?
All children should receive three funded doses of PCV13 at For further information on Pneumovax 23, see: bpac.org.
ages six weeks, five months and 12 months, as part of the nz/BPJ/2011/april/pneumovax23.aspx (N.B. Article published in
childhood Immunisation Schedule.32 Children at high risk of 2011 so some information may no longer be current.)
pneumococcal disease, e.g. immunosuppressed, cochlear

www.bpac.org.nz May 2024 9

Acknowledgement: Thank you to Professor Tony Walls, 18. The Royal Children’s Hospital Melbourne. Community acquired pneumonia.
2023. Available from: https://www.rch.org.au/clinicalguide/guideline_index/
Paediatric Infectious Diseases Consultant, Canterbury,
Community_acquired_pneumonia/ (Accessed May, 2024).
Head of Department of Paediatrics, University of Otago, 19. Boyd K. Back to the basics: community-acquired pneumonia in children.
Christchurch, and Dr Nick Douglas, Infectious Diseases Pediatr Ann 2017;46. doi:10.3928/19382359-20170616-01
Physician, Christchurch Hospital, Te Whatu Ora Waitaha, 20. New Zealand Formulary for Children (NZFC). Available from: https://www.
nzfchildren.org.nz/nzf_1 (Accessed May, 2024).
Senior Lecturer, Department of Medicine, University of
21. National Institute for Health and Care Excellence (NICE). Pneumonia
Otago, Christchurch, Senior Research Fellow, Menzies (community-acquired): antimicrobial prescribing. 2019. Available from: https://
School of Health Research, Charles Darwin University, Darwin, www.nice.org.uk/guidance/ng138 (Accessed May, 2024).

Australia, for expert review of this article. 22. Blyth CC, Gerber JS. Macrolides in children with community-acquired
pneumonia: panacea or placebo? Journal of the Pediatric Infectious Diseases
South Link Article supported by the South Link Society 2018;7:71–7. doi:10.1093/jpids/pix083
Education Trust
Education Trust 23. Sharma L, Losier A, Tolbert T, et al. Atypical pneumonia: updates on Legionella,
Chlamydophila, and Mycoplasma pneumonia. Clin Chest Med 2017;38:45–58.
N.B. Expert reviewers do not write the articles and are not responsible for
doi:10.1016/j.ccm.2016.11.011
the final content. bpacnz retains editorial oversight of all content.
24. Kaysin A, Viera AJ. Community-acquired pneumonia in adults: diagnosis and
management. Am Fam Physician 2016;94:698–706.
25. British Thoracic Society (BTS). BTS guidelines for the management of
community acquired pneumonia in adults: 2009 update. 2009 (annotated
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10 May 2024 www.bpac.org.nz