Education And Debate

Fortnightly Review: Management of community acquired lower respiratory tract infection

BMJ 1994; 308 doi: (Published 12 March 1994) Cite this as: BMJ 1994;308:701
  1. H S R Hosker,
  2. G M Jones,
  3. P Hawkey
  1. Department of Respiratory Medicine, General Infirmary at Leeds, Leeds LS1 3EX
  2. Department of Microbiology, University of Leeds, Leeds LS2 9JT Wenlock Terrace Surgery, Fulford, York YO1 4DU
  1. Correspondence to: Dr Hosker.
  • Accepted 29 November 1993

Lower respiratory tract infection incorporates a spectrum of disease from acute bronchitis to pneumonia. The division between bronchitis and pneumonia is not always clear, but patients with focal signs on clinical examination should be regarded as suffering from clinical pneumonia even if the chest radiograph is normal.

In otherwise healthy individuals, acute bronchitis is usually associated with a speedy recovery and few sequelae, but pneumonia remains a leading cause of death throughout the world. Infective exacerbations of chronic obstructive pulmonary disease lead to considerable morbidity, time off work, and days in hospital. This article reviews the diagnosis and management of community acquired lower respiratory tract infection. The management of patients with underlying diseases such as cystic fibrosis and bronchiectasis, and of immunocompromised patients, is not considered here.


Infections of the lower respiratory tract are responsible for 6% of all general practitioner consultations and form 4.4% of all hospital admissions.1 They account for 3-5% of deaths in adults up to the age of 60. The best estimate from available data suggests that around 25 million prescriptions for antibiotics are written each year by general practitioners to treat respiratory infections.2

As with most diseases, the less severe types predominate. Acute bronchitis is common and usually self limiting, although the associated cough and sleep disturbance can be distressing. Children who develop croup or stridor during a viral respiratory infection may need to be admitted to hospital.

Community acquired pneumonia is potentially more serious, with elderly people and those with pre-existing illness at greatest risk of dying. Community acquired pneumonia is distinct from other types (box 1) in terms of epidemiology, causative organisms, management, and outcome. It occurs more commonly in those over 65, smokers, and those with other non-respiratory illnesses (particularly alcoholism), and the incidence doubles during the winter months. Most …

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