INTRODUCTIONThe identification and management of adults presenting with pneumonia is a major challenge for primary care health professionals. This paper summarises the key recommendations of the British Thoracic Society (BTS) Guidelines for the management of Community Acquired Pneumonia (CAP) in adults.METHODSystematic electronic database searches were conducted in order to identify potentially relevant studies that might inform guideline recommendations. Generic study appraisal checklists and an evidence grading from A+ to D were used to indicate the strength of the evidence upon which recommendations were made.CONCLUSIONSThis paper provides definitions, key messages, and recommendations for handling the uncertainty surrounding the clinical diagnosis, assessing severity, management, and follow-up of patients with CAP in the community setting. Diagnosis and decision on hospital referral in primary care is based on clinical judgement and the CRB-65 score. Unlike some other respiratory infections (e.g. acute bronchitis) an antibiotic is always indicated when a clinical diagnosis of pneumonia is made. Timing of initial review will be determined by disease severity. When there is a delay in symptom or radiographic resolution beyond six weeks, the main concern is whether the CAP was a complication of an underlying condition such as lung cancer.

The authors regret that an error occurred on page 24, Figure 1, which has already been corrected in the online version of the paper: The asterisk under the Abbreviated Mental Test reads '*A score of 6 or less has been used to define mental confusion in the CRB-65 severity score' and should read '*A score of 8 or less has been used to define mental confusion in the CRB-65 severity score'.

Box A CURB-65 score Score 1 point for each feature present: N Confusion (mental test score of (8, or new disorientation in person, place or time) N Urea .7 mmol/l N Respiratory rate >30/min N Blood pressure (SBP ,90 mmHg or DBP (60 mmHg) N Age >65 years i1 www.thoraxjnl.com

Bird flu and pandemic fluWhat's the message for GPs and hospital doctors?T he extensive media coverage of avian influenza (bird flu) over recent weeks has caused confusion and increasing concern that bird flu will imminently cause a human pandemic.This has been fuelled by the report of a parrot infected by the H5N1 strain of avian influenza in the United Kingdom this week.Is such a pandemic a flight of fantasy or a dead cert?The influenza pandemic contingency plan presented by the chief medical officer 1 is clear and comprehensive, but at nearly 450 pages, 11 downloadable documents, and many web links, it may not be ready reading for busy health professionals.Everyone is familiar with seasonal human flu, which typically affects 10-15% of the UK population each winter and leads to around 12 000 excess deaths.Although minor antigenic drift in the human influenza virus A occurs continuously, a major shift in its surface protein antigens H or N can trigger a worldwide influenza pandemic because of absence of population immunity.Fortunately, this happens only rarely-"Spanish" flu in 1918-9 (H1N1 virus) with an estimated 250 000 excess deaths in the UK, "Asian" flu in 1957-8 (H2N2) with 33 000 deaths, and "Hong Kong" flu in 1968-9 (H3N2) with 30 000 deaths.Many scientists believe that another pandemic is overdue.

The incidence of lower respiratory tract infection (LRTI) in women of child-bearing age is approximately 64 per 1000 population. The spectrum of illness ranges from acute bronchitis, which is very common, through influenza virus infection and exacerbations of underlying lung disease, to pneumonia, which, fortunately is uncommon (<1.5% LRTI), but can be severe. Acute bronchitis is generally mild, self-limiting and usually does not require antibacterial therapy. Influenza virus infection in pregnant women has been recently related to increased hospitalization for acute cardiorespiratory conditions. At present, the safety of the newer neuraminidase inhibitors for the treatment of influenza virus infection has not been established in pregnancy and they are not routinely recommended. In influenza virus infection complicated by pneumonia, antibacterial agents active against Staphylococcus aureus and Streptococcus pneumoniae superinfection should be used. There are few data on infective complications of asthma or COPD in pregnancy. The latter is rare, as patients with COPD are usually male and aged over 45 years. Management is the same as for nonpregnant patients. The incidence and mortality of pneumonia in pregnancy is similar to that in nonpregnant patients. Infants born to pregnant patients with pneumonia have been found to be born earlier and weigh less than controls. Risk factors for the development of pneumonia include anemia, asthma and use of antepartum corticosteroids and tocolytic agents. Based on the few available studies, the main pathogens causing pneumonia are S. pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae and viruses. β-Lactam and macrolide antibiotics therefore remain the antibiotics of choice in terms of both pathogen coverage and safety in pregnancy. In HIV-infected pregnant patients, recurrent bacterial pneumonia, but not Pneumocystis carinii pneumonia (PCP), is more common than in nonpregnant patients. Trimethoprim/sulfamethoxazole (cotrimoxazole) has not definitely been associated with adverse clinical outcomes despite theoretical risks. Currently it is still the treatment of choice in PCP, where mortality remains high. In conclusion, there are few data specifically related to pregnant women with different types of LRTI. Where data are available, no significant differences compared with nonpregnant patients have been identified. In considering the use of any therapeutic agent or investigation in pregnant patients with LRTI, safety aspects must be carefully weighed against potential benefit. Otherwise, management strategies should not differ from those for nonpregnant patients. Further research in this area is warranted.

The presence of pneumococcal capsular antigen (PCA) in the oropharynx was sought in subjects without respiratory tract infection. Saliva specimens from 239 subjects were analysed by counter-current immunoelectrophoresis using 'Omni-serum'. 15.5% gave positive reactions but only 24% of positive samples were typable and therefore due to pneumococcal or pneumococcal-like antigens. Given that oropharyngeal production of antigens occurs we investigated whether PCA in expectorated sputum arose from oropharyngeal contamination. Sixteen patients with pneumococcal pneumonia, and with sputum positive for PCA, were investigated in detail. On the basis of serotyping and concentration the PCA in sputum was thought to arise from the lower respiratory tract in all cases. This was confirmed by a simple, novel approach involving the comparison of concentrations in concomitant samples of saliva and sputum. Thus while oropharyngeal production of antigens poses a potential diagnostic problem the latter approach can be used to exclude contamination.

Vaccines exist to protect children and adults from pneumococcal infection. The adult vaccine contains capsular polysaccharides from those pneumococci causing the vast majority of pneumococcal infection around the world. This vaccine is, however, poorly immunogenic and not as protective as would be desired. The vaccine for children is a seven-valent conjugate vaccine, which is highly protective against invasive infection and offers some protection against otitis media and pneumococcal carriage. The capsular types in the vaccine are not all appropriate for the developing world and the vaccine is too expensive for use in the developing world. As a result of these problems there have been extensive efforts to develop pneumococcal vaccines for adults and children based on cross-reactive protein antigens. The molecules used are in general virulence factors and the antibodies to them neutralize their function, thus reducing the virulence of the infecting bacteria. Studies in humans have revealed that the proteins studied are invariably immunogenic in humans, as at least low levels of antibody are seen following colonization or infection. Studies in mice have demonstrated that vaccines containing more than one of these virulence proteins are generally more protective than those involving just one. Proteins that have been studied the most in mice are pneumococcal surface protein A (PspA), PspC, PsaA, and pneumolysin. PspA has been used in human safety trials and was shown to elicit antibodies that can protect mice from otherwise fatal pneumococcal infections.

Throughout the world pneumonia remains an important infectious disease among all age groups, ranking high in terms of mortality, morbidity, and use of medical resources. However, the introduction of antibiotics has had a major impact on the management and mortality of pneumonia. As a clinical syndrome it is constantly changing with the emergence of new pathogens and the rising prominence of opportunistic pathogens in the immunocompromised patient. Developments in science have resulted in a greater understanding of microbial virulence and host defenses as well as new chemotherapeutic agents. However, the single most common pathogen responsible for pneumonia remains Streptococcus pneumoniae, an organism for which there is a vaccine. This review highlights some recent advances in the epidemiology, etiology, pathogenesis, management, and prevention of pneumonia.

The safety and usefulness of fibreoptic bronchoscopy in the elderly was assessed retrospectively in 204 consecutive patients aged 70 and over. One third of patients were examined as day cases. A bronchial tumour was seen in 67% patients, and biopsies showed malignancy in 78% of these cases. Certain knowledge of a diagnosis of bronchial carcinoma helped in the management of the elderly patient. Fibreoptic bronchoscopy proved to be safe in the presence of marked ventilatory impairment. A prospective questionnaire study in 114 patients showed that most patients found the procedure acceptable and would agree to a repeat if necessary and this was largely independent of age.

knowledge of the height and nude weight of the child and ready access to the nomogram itself. These surface area formulae are themselves subject to considerable error and discrepancy. To relate the dose of nalorphine to 1-73 m2 surface area entails further complicated mathematics, since not even the most precocious child is likely to have a surface area approaching that figure. Let us leave mathematics to the mathematicians and allow clinicians faced with res,piratory depression due to Lomotil to ventilate wit-h oxygen and to give the antidote based on the less complicated measurement of body weight.-I am, etc.,