Hospital Acquired Pneumonia (HAP) in adults - Secondary Care |
Publication: 18/12/2008 |
Next review: 14/08/2023 |
Clinical Guideline |
CURRENT |
ID: 1425 |
Approved By: Improving Antimicrobial Prescribing Group |
Copyright© Leeds Teaching Hospitals NHS Trust 2020 |
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated. |
Hospital Acquired Pneumonia (HAP) in adults
- Diagnostics
- Empriical Treatment
- Definitions
- Empirical Treatment Choices
- Review by 72 hours
- Directed Therapy
This guideline applies to non-ventilated patients who develop the symptoms of pneumonia ≥48 hours after admission to hospital.
If a patient has been discharged from hospital within the last 28 days, use this guideline to initially guide diagnostics and treatment.
DIAGNOSTICS
For patients with a presumed diagnosis of Hospital Acquired Pneumonia (HAP) the following diagnostic tests should be taken to confirm diagnosis and treatment plan. These should ideally be done before antibiotics are commenced, however if unable to obtain a sputum sample this should not delay treatment:
All patients | Oxygenation assessment |
Chest x-ray |
|
Respiratory secretions for culture: sputum, bronchial washings |
|
Blood cultures |
|
Respiratory samples for viral PCR |
|
Procalcitonin (PCT) |
|
If patient admitted to ICU or not improving to routine treatment |
Urine for Legionella antigen |
Patients with severe HAP |
Blood gas analysis. |
EMPIRICAL TREATMENT
Treatment depends on whether early onset (≤4 days since admission) or late onset (>5 days since admission).
Non-severe HAP should be treated with oral antibiotics where possible.
If PCT is <0.25 antibiotics should only be considered if there is a strong clinical picture of bacterial infection. See PCT guideline for further information.
DEFINITIONS:
- Non-severe HAP: patient well enough for ward care, requiring low flow oxygen (FiO2 < 40%) to maintain saturations and haemodynamically stable, NEWS 6 or less, and not scoring more than 3 in any one parameter.
- Severe HAP: patients with a new requirement for high flow oxygen or non-invasive ventilation (but who do not need inotropic support) – i.e. suitable for Respiratory Care Unit (RCU) or HDU or evidence of severe sepsis with hypotension and/or end organ dysfunction, unsuitable for ward level care, or NEWS 7 or more or scoring more than 3 in any one parameter.
- High risk of P. aeruginosadefined as: inpatient on respiratory ward (within last month), current admission to ICU, immune-compromised, previous positive respiratory culture for P. aeruginosa (in last 12 months), history of bronchiectasis. Antibiotic susceptibility of previous growth of P. Aeruginosa must be checked; if they are resistant to the empirical agent an alternative should be used.
EMPIRICAL TREATMENT CHOICES
Table 1: Patients with Early onset HAP (≤4 days since admission)
- Doses assume normal renal and hepatic function.
EARLY ONSET (≤4 days since admission) |
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Duration |
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Total duration of treatment (IV and PO) should be 5 days. |
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Situation |
First line |
Allergy |
MRSA risk |
Non-severe1 |
Doxycycline |
||
Severe |
Co-amoxiclav |
Levofloxacin
|
1st line: 2nd line: |
Oral switch for severe |
Co-amoxiclav |
Levofloxacin |
Ciprofloxacin |
Table 2: Patients with Late onset HAP (≥5 days since admission)
- Doses assume normal renal and hepatic function.
LATE ONSET (≥ 5 days since admission) |
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Duration |
|||
Total duration of treatment (IV and PO) should be 5 days. |
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Situation |
First line |
Allergy |
MRSA risk |
Non-severe with low risk of P. Aeruginosa |
Co-trimoxazole |
Allergy to Co-trimoxazole 1st line: 2nd line: |
Co-trimoxazole If allergic to Co-trimoxazole 1st line: 2nd line: |
Oral switch for non-severe with low risk of P. Aeruginosa |
N/A |
Teicoplanin |
|
Non-severe with high risk of P. aeruginosa |
Levofloxacin |
Ciprofloxacin |
|
Severe |
Piperacillin/tazobactam |
1st line: 2nd line: |
Low or High risk of P. aeruginosa Piperacillin/tazobactam If the patient is also allergic to penicillin then use |
Oral switch for severe |
Co-amoxiclav |
Ciprofloxacin |
Contact Microbiology for advice. |
REVIEW BY 72 HOURS
By 72 hours of antibacterial treatment (oral or IV), diagnostics should have proven your initial diagnosis or guided to a new diagnosis. Procalcitonin levels should be available within 24 hours and used to guide treatment as soon as available.
Patients on IV antibiotics should be reviewed daily, and can be switched before 72 hours if appropriate.
IVOS | If your initial diagnosis is correct and the patient is prescribed IV antibiotics, review whether an oral switch is appropriate using the ACED criteria (see below). If they meet all 4 criteria (note HAP is not a deep seated infection) consider switching using the oral options listed in the table above. |
Stop |
If no signs of infection and diagnostics support this decision e.g. Procalcitonin <0.25. |
Change |
If the patient is not clinically responding, check microbiology results to see if directed therapy is required or you may need to consider an alternative diagnosis (including tuberculosis, malignancy or other obstructing lesion, or complications including parapneumonic effusion/empyema). |
Continue |
If the patient is improving but does not fully meet ACED criteria. Review daily until ready to switch. |
DIRECTED THERAPY
- Doses assume normal renal and hepatic function.
Organism |
No known penicillin allergy |
Penicillin allergy |
Duration |
Meticillin-susceptible S. aureus |
Flucloxacillin Consider adding Rifampicin PO 600mg 12-hourly if response to mono-therapy is suboptimal. |
Linezolid PO2 600mg 12-hourly
|
Total duration of treatment (IV and PO) should be 5 days. |
Oral switch |
Flucloxacillin Consider adding Rifampicin PO 600mg 12-hourly if response to mono-therapy is suboptimal. |
N/A |
|
Meticillin-resistant S. aureus |
1st line: 2nd line: |
N/A |
Total duration of treatment (IV and PO) should be 5 days. |
Oral switch |
Linezolid PO 600mg 12-hourly |
N/A |
|
P. aeruginosa |
Ceftazidime OR Piperacillin/tazobactam In severe HAP consider adding Tobramycin IV. See Guideline for dosage and monitoring information. |
Ciprofloxacin |
Total duration of treatment (IV and PO) should be 7 days. |
Oral switch |
Ciprofloxacin |
||
Legionellosis |
Levofloxacin |
N/A |
Total duration of treatment should be 7 days. |
Other Gram negative bacilli e.g. coliforms, Acinetobacter spp, Stenotrophomonas maltophilia |
Discuss with microbiology. |
Discuss with microbiology. |
FOOT NOTES
- Divergence from NICE guidance is based on local susceptibility data
- For ciprofloxacin, levofloxacin and linezolid PO is preferred route of administration due to excellent bioavailability. IV can be considered if oral route not available. Where ciprofloxacin is prescribed 500mg PO 12-hourly the IV dose would be 400mg 12-hourly, where ciprofloxacin is prescribed 750mg PO 12-hourly the IV dose would be 400mg 8-hourly. There is no change in dose for levofloxacin and linezolid.
- Off-license indication for both co-trimoxazole and levofloxacin - however, both agents are in widespread use for respiratory infections.
- See MHRA advice for restrictions and precautions for using fluoroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding co-administration with a corticosteroid (March 2019).
- Before prescribing levofloxacin, consider the possibility of tuberculosis, to reduce risk of promoting quinolone resistance in tuberculosis.
- For directed P. aeruginosa therapy, piperacillin-tazobactam is prescribed at the maximum dose of four times a day due to increased risk of mortality.
- Ciprofloxacin is prescribed at a higher dose (750mg 12-hourly orally or 400mg 8-hourly IV) where there is an increased risk or confirmed case of P. aeruginosa due to increased risk of mortality.
|
Provenance
Record: | 1425 |
Objective: | |
Clinical condition: | Hospital acquired pneumonia (HAP) |
Target patient group: | Adult patients with HAP |
Target professional group(s): | Pharmacists Secondary Care Doctors Secondary Care Nurses |
Adapted from: |
Evidence base
- NICE guideline 139: Pneumonia (hospital-acquired): antimicrobial prescribing. Published Sept 2019. Accessed April 1st 2020
Note: this was used for initial peer review copy. It was subsequently archived by NICE and replaced with NG173 which guided change in antibacterial choices for final update. - NICE COVID-19 Rapid guideline: antibiotics for pneumonia in adults in hospital (NG173. Published 1st May 2020. Accessed July 2020
- Vardakos KZ, Voulgaris GL, Maliaros M, Samonis G, Falagas ME. Prolonged versus short-term intravenous infusion of antipseudomonal β-lacatams for patients with sepsis: a systematic review and meta-analysis of randomised trials. Lancet 2018;18:108-120
- Paul M, Bishara J, Yahav D, et al. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin resistant Staphylococcus aureus: randomised controlled trial. BMJ 2015; 350: h2219.
- Masterton RG, Galloway A, French G, et al. Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy. 2008. p. 5-34.
- D’Agata E. Chapter 221 Pseudomonas aeruginosa and Other Pseudomonas Species. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia: Churchill Livingstone; 2015: 2518-31.
- Montero M, Sala M, Riu M, et al. Risk factors for multidrug-resistant Pseudomonas aeruginosa acquisition. Impact of antibiotic use in a double case-control study. Eur J Clin Microbiol 2010; 29(3): 335-9.
Approved By
Improving Antimicrobial Prescribing Group
Document history
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