Hospital Acquired Pneumonia - Non-ventilated Adult Patients

Publication: 18/12/2008  
Last review: 23/11/2017  
Next review: 01/10/2019  
Clinical Guideline
CURRENT 
ID: 1425 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Hospital Acquired Pneumonia (Non-ventilated Adult Patients)

  • Treatment Algorithm
  • Summary
    Hospital Acquired Pneumonia

    Criteria for use
    Non-ventilated inpatients (≥48hours in hospital) presenting with new or progressive chest x-ray consolidation and symptoms/signs of pneumonia. This guideline does not apply to cystic fibrosis patients, neutropenic patients and post-allogenic SCT recipients.

    Initial investigations

    • Oxygenation assessment and (severe HAP) blood gas analysis
    • Chest X-ray
    • Respiratory secretions for culture e.g. sputum, bronchial washings
    • Blood cultures
    • Respiratory samples for viral PCR, urine for Legionella antigen depending on clinical presentation

    Treatment
    Non-Antimicrobial Management

    • Correct hypoxia
    • Fluid resuscitation
    • Senior review within 24 hours

    Antimicrobial treatment – check previous microbiology to inform empirical treatment regimen according to Table. 1

    Table 1. Empirical antimicrobial regimens for hospital acquired pneumonia* (for directed regimens and oral switch see Table 2)

    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 Acute Respiratory Care Unit (ARCU) 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.

    Situation

    First line (all ages)

    penicillin allergy (all ages)

    MRSA risk (i.e. found in current/recent sputum/screen)

    EARLY ONSET (4 days since admission)

    Non-severe

    Doxycycline electronic Medicines Compendium information on Doxycycline 100mg PO 12-hourly

    100mg PO 12-hourly

    Doxycycline electronic Medicines Compendium information on Doxycycline 100mg PO 12-hourly

    100mg PO 12-hourly

    Doxycycline electronic Medicines Compendium information on Doxycycline 100mg PO 12-hourly

    100mg PO 12-hourly

    Severe

    Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav (Amoxicillin-Clavulanate) (Amoxicillin-Clavulanate) 1.2g IV 8-hourly PLUS Clarithromycin 500mg IV 12-hourly

    Levofloxacin electronic Medicines Compendium information on Levofloxacin 500mg IV 12-hourly

    Linezolid electronic Medicines Compendium information on Linezolid %600mg 12-hourly PO/IV AND Levofloxacinelectronic Medicines Compendium information on Levofloxacin

    LATE ONSET- (≥5 days since admission) – low Pseudomonas aeruginosa risk$

    Non-severe

    Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole @960mg 12-hourly PO

    If trimethoprim/sulphonamide allergy: 1st line Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly PO AND Linezolid electronic Medicines Compendium information on Linezolid %600mg 12-hourly PO.
    or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly PO

    Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole @960mg 12-hourly PO

    If trimethoprim/sulphonamide allergy: Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly PO plus Linezolid electronic Medicines Compendium information on Linezolid %600mg 12-hourly PO.

    Severe

    Amoxicillin electronic Medicines Compendium information on Amoxicillin 1g 8-hourly IV AND Temocillin 2g 12-hourly IV

    1st line Linezolid electronic Medicines Compendium information on Linezolid % 600mg 12-hourly PO/IV  + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly PO (or 400mg IV, 12-hourly if oral unsuitable) or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin   IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly PO (or 400mg IV, 12-hourly if oral unsuitable)

    Replace Amoxicillin electronic Medicines Compendium information on Amoxicillin with Linezolid electronic Medicines Compendium information on Linezolid %600mg 12-hourly PO/IV# if using first line, no change if using regimen for penicillin allergic patient.

    (contact Microbiology [see text] if Linezolid electronic Medicines Compendium information on Linezolid contraindicated.)

    High risk for P. aeruginosa$ = inpatient on respiratory ward (within the last month), admission to ICU this episode, immune-compromised, previous positive respiratory culture for P. aeruginosa (In last 12 months), history of bronchiectasis.

     

    IV Piperacillin/tazobactam 4.5g 8-hourly

    1st line Linezolid electronic Medicines Compendium information on Linezolid % 600mg 12-hourly PO/IV  + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly PO (or 400mg IV, 12-hourly if oral unsuitable) or 2nd line Teicoplanin electronic Medicines Compendium information on Teicoplanin   IV (see dosing guideline) + Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly PO (or 400mg IV, 12-hourly if oral unsuitable)

    Add Linezolid electronic Medicines Compendium information on Linezolid %600mg 12-hourly PO/IV# to Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

    OR ceftobiprole monotherapy if known Pseudomonas colonisation. (see text). No change if using regimen for penicillin allergic patient.

    Treatment to be reviewed daily but a review and clear treatment plan should be documented around day 3 post commencing therapy. MRSA, meticillin resistant S. aureus.

    #Only use IV route where oral absorption is not appropriate (e.g. not absorbing, unsafe swallow).

    $ High risk for P. aeruginosa HAP = inpatient on respiratory ward within the last month, admission to ICU this episode, immune-compromised, previous positive respiratory culture for P. aeruginosa (In last 12 months), history of bronchiectasis.

    @ higher doses of Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole have been used in a recent clinical trial and may be appropriate in selected patients.

    *Note that the suggested doses and frequency assume normal renal and hepatic function, adjust as clinically indicated.

    % Linezolid has a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient.

    Referral criteria:

    • All non-intubated patients with severe HAP should be assessed and treated on an Acute Respiratory Care Unit (ARCU) or appropriate HDU as a minimum (e.g. patients requiring high flow oxygen or non-invasive ventilation (and who do not need inotropic support)
    • Patients with evidence of severe sepsis with hypotension and/or end organ dysfunction should be assessed by the ICU team.
    • Please contact the ICU outreach team in the presence of Respiratory Failure,2 acidosis, or clinical deterioration.

    Respiratory failure is defined as the need for non-invasive ventilation or the need for > 35% oxygen to maintain an arterial oxygen saturation > 90% (in patients who do not have chronic hypoxia).

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    Background

    Pneumonia developing after 48 hours of hospital admission is defined as “hospital acquired’'.2 Ventilator-associated pneumonia (VAP) is pneumonia developing after at least 48 hours of mechanical ventilation and is a subgroup of HAP - see LTHT guideline for VAP. When HAP occurs within four days of admission it is considered to be “early onset” and is most often caused by typical community-acquired pathogens such as Streptococcus pneumoniae and Haemophilus influenzae.3  Late onset HAP, after five or more days in hospital, may still be caused by community-type pathogens but Staphylococcus aureus and Gram negatives, such as Escherichia coli and Pseudomonas aeruginosa, become much more common.2 HAP can be a difficult diagnosis to make and careful clinical assessment is required to avoid giving unnecessary antimicrobial therapy.

    This guideline is intended for:

    • Non-ventilated patients presenting with an acute lower respiratory infection associated with recently developed radiological signs
    • Pneumonia is defined as 'hospital acquired' if it presents after 48 hours of hospital admission.

    Recommendations for ventilator-associated pneumonia (VAP) can be found here.

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    Clinical Diagnosis

    Clinical
    The clinical diagnosis of HAP can be difficult but should be based on the presence of new or progressive infiltrates on chest radiograph (CXR) with any of the following criteria [Evidence level C]:

    • Respiratory symptoms e.g. cough, dyspnoea
    • Temperature <36oC or >38oC.
    • Purulent sputum.2
    • Blood leucocytosis (>12,000 per mm3) or leukopenia (<4,000 per mm3).2
    • Increased inhaled oxygen requirement.2
    • Increased respiratory rate.
    • New confusion (other causes should also be considered).

    NB

    1. Some patients (e.g. immunocompromised, elderly) may not have raised temperature or white cell counts
    2. Patients with HAP usually appear ill. A fever >38oC and a cough for example is not sufficient evidence to make the diagnosis of HAP and start antimicrobial therapy.

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    Severity Assessment

    There are presently no UK evidence-based scores to predict the severity of hospital acquired pneumonia, severity must therefore be judged clinically. If in doubt consult with a senior colleague. As a guide, patients will have clinical and radiological evidence of HAP and:

    Non-severe HAP: patient well enough for ward care, requiring low flow oxygen (FiO2 < 40%). to maintain saturations and haemodynamically stable AND 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 Acute Respiratory Care Unit (ARCU) 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.

    Evidence/Justification

    The previous version of this guideline did not include severity stratification which has led to over-use of broad-spectrum intravenous antimicrobials. The severity assessment proposed is a pragmatic severity assessment score based on clinical experience of the authors, developed by consensus. Although CURB-65 scoring is in use in LTHT, it has not been validated for hospital acquired pneumonia. A study from Israel  provides some validation for using CURB65 in MRSA pneumonia, but not specifically for HAP.4 They looked at APACHE II and CURB65 and found APACHE II was better which is not surprising as is more complex and looks at more variables.4 A UK study that looked at all-comers with infection into an emergency department5 found that CURB-65 was useful in predicting 28-day mortality. The was anxiety about the reliability of CURB-65 in older patients.

    What is proposed here is a guide only.

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    Investigation

    Oxygenation Assessment
    Recommendation: Oxygen saturation should be measured in patients with signs of hypoxia. [Evidence level C]

    Recommendation: blood gas analysis should be undertaken in patients with severe HAP or suspected Co2 retention. [Evidence level D] 

    Radiology
    Recommendations:

    • A good quality CXR should be performed and compared to previous CXRs if available.2 [Evidence level C]
    • If unsure about the interpretation of a CXR, consult a senior colleague or radiologist. [Evidence level C]
    • A normal CXR excludes HAP. [Evidence level B]
    • The presence of an alveolar infiltrate on the CXR raises the possibility of HAP as well as other differential diagnoses. [Evidence level C]
    • CT scanning may assist in the identification of complications in patients who are not responding to treatment and may aid diagnosis in patients who have a complex CXR. [Evidence level C]

    Specimens
    Recommendations:

    • Blood cultures should be taken before antibiotic treatment is commenced. [Evidence level D]. LTHT blood culture collection method can be found here
    • Respiratory secretions (e.g. sputum or bronchial washings) should be sent for culture, preferably before antibiotic treatment is commenced. [Evidence level C]
    • Other investigations (e.g. respiratory samples for viral PCR, urine for Legionella antigen) should be performed depending on clinical presentation (e.g. send urine for Legionella in patients admitted to ICU or not responding well clinically to routine treatment). [Evidence level C]

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    Treatment
    Non-Antimicrobial Treatment

    Correct hypoxia
    Recommendation: In nearly all cases of HAP, unless complicated by severe chronic obstructive pulmonary disease with ventilatory failure, high concentrations of oxygen of 35% or more are indicated and can be safely used. [Evidence level C]

    Continuous oxygen therapy is indicated for those patients with PaO2 <8 kPa, hypotension with systolic blood pressure <100 mmHg, metabolic acidosis with bicarbonate <18 mmol/L, or respiratory distress with a respiratory rate of >24 breaths/min. The aim of oxygen therapy is to maintain SaO2 of >94% in all patients except those at risk of hypercapnia. In patients at risk of hypercapnia, the target SaO2 is 88 to 92% (e.g. those patients with severe COPD, type 2 respiratory failure, and where increasing oxygen may reduce the drive for breathing). Initial targets saturations in patients with COPD should be 88-92%.

    Fluid resuscitation
    Recommendation: Patients admitted with pneumonia should be assessed for volume depletion and may require intravenous fluids. [Evidence level C]

    Clinical review
    Recommendation: All non-ventilated patients with HAP should be reviewed by senior medical staff (SpR or Consultant) within 24 hours. [Evidence level D]

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    Empirical Antimicrobial Treatment

    Recommendation: The route of administration and choice of antimicrobials is influenced by severity of illness (see severity assessment section), which is a clinical judgement. [Evidence level D]

    Recommendation: Empirical antimicrobial regimens for HAP are shown in Table 1. [Evidence level A-D]

    Recommendation: MRSA and MSSA risk should be assessed in patients with HAP and considered in empirical treatment regimens. [Evidence level D]

    Recommendation: Empirical treatment regimens should be reviewed around day 3 of therapy in the light of culture results and clinical progress and amended accordingly.4 [Evidence level C]

    Evidence/justification

    Most early onset HAP is usually caused by community acquired pathogens (e.g. Strep. pneumoniae, H. influenzae) so recommendations for empirical therapy are similar to those for community acquired pneumonia. Once a patient has been in hospital for more than four days, there is an increased risk that the normal oral microbial flora will be replaced with more resistant bacteria, in particular Enterobacteriaceae, commonly called “coliforms”, including E.coli, Klebsiella spp., and Enterobacter spp. species. These microorganisms need to be taken into consideration in empirical treatment regimens. The risk of P. aeruginosa infection should also be considered; P. aeruginosa is an important cause of ventilator-associated pneumonia and a well recognised cause of HAP. Previously reported risk factors for hospital acquired P. aeruginosa infection are: admission to an intensive care unit, mechanical ventilation, chronic obstructive pulmonary disease (COPD) immunocompromise, cystic fibrosis and inpatients with burns.4,5 We add to this list patients with bronchiectasis. Because colonisation with P. aeruginosa is a prerequisite for P. aeruginosa HAP, patients who fulfil clinical criteria for HAP and have recently (in the last 12 months) had a positive respiratory culture for P. aeruginosa should be considered high risk for P. aeruginosa HAP.

    In 1024 sputum samples collected during April 2016 from inpatients in “low risk” areas (i.e excluding ICU, respiratory wards, haematology/oncology wards, cystic fibrosis ward, paediatric/neonates wards) Pseudomonas aeruginosa and Staphylococcus aureus (both MRSA and MSSA) colonisation/infection rates were low i.e <5%. (Appendix 1)

    Changes have therefore been recommended to the antimicrobial treatment of HAP to reduce the use of Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam. This is because:

    1)    we are concerned about over use of Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam;
    2)    increasing resistance to this antimicrobial is being seen nationally;
    3)    it has poor/unreliable activity against coliforms producing extended spectrum beta-lactamase enzymes (ESBL) and AmpC enzymes;
    4)    anecdotally, and in observational studies, it has high rates of diarrhoea and CDI;6
    5)    financial incentives to reduce its use (antimicrobial CQUIN) will offset the cost of agents used in its place, if they can be achieved.

    Temocillin electronic Medicines Compendium information on Temocilin is a narrow spectrum beta-lactam antibacterial active against Enterobacteriaceae (including extended-spectrum beta-lactamase (ESBL) producing organisms) and Haemophilus influenzae, while it does not have clinically important activity against Pseudomonas aeruginosa, Gram-positive aerobes (Staphylococcus aureus, Strep. pneumoniae) and strict anaerobes.7 Temocillin electronic Medicines Compendium information on Temocilin susceptibility testing data in Leeds are biased by the fact that it is usually more resistant pathogens that are currently tested but Temocillin electronic Medicines Compendium information on Temocilin has a low propensity to cause CDI in an animal model.8 Perhaps because of its limited anaerobic activity and minimal effect on the normal anaerobic bowel flora,9 it has a low rate of associated diarrhoea (4%) and CDI.6 Temocillin electronic Medicines Compendium information on Temocilin is therefore an ideal alternative to Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam but it needs to be combined with Gram-positive agents for empirical use and should be avoided where P. aeruginosa is the likely cause of HAP.

    A combination of Temocillin electronic Medicines Compendium information on Temocilin plus Amoxicillin electronic Medicines Compendium information on Amoxicillin (n=94) produced comparable cures rates (~80%) to Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam (n=98) in a non randomised observational study of treatment for HAP.6 A lower cure rate (64%) were seen in patients treated with Temocillin electronic Medicines Compendium information on Temocilin for lower respiratory tract infection (n=11) during a trial of intermittent dosing vs continuous infusion, but this was an intensive care unit based study.10

    A combination of benzyl penicillin and Temocillin electronic Medicines Compendium information on Temocilin provides good antimicrobial activity against Strep. pneumoniae, Haemophilus influenzae and many Enterobacteriaceae (including AmpC and ESBL producers). This combination would be preferred to the Amoxicillin electronic Medicines Compendium information on Amoxicillin plus Temocillin electronic Medicines Compendium information on Temocilin combination because it should have an even lower propensity to cause diarrhoea and CDI. The frequency of administration of benzylpeniicllin was felt to be currently impractical because of the increased nursing time required for administration, so this option was rejected. Work to explore the possibility of benzylpenicillin infusions will be explored.

    A combination of Linezolid electronic Medicines Compendium information on Linezolid and Temocillin electronic Medicines Compendium information on Temocilin provides good antimicrobial activity against Staphylococcus aureus, (MSSA and MRSA) Strep. pneumoniae, Haemophilus influenzae and Enterobacteriaceae, so in patients with HAP and risk factors for MRSA or MSSA (e.g. known colonisation of the upper respiratory tract/positive screen), it is recommended to replace Amoxicillin electronic Medicines Compendium information on Amoxicillin with Linezolid electronic Medicines Compendium information on Linezolid.

    Assessing the risk of MRSA: If a patient has previous positive respiratory cultures (sputum, throat swab, bronchoalveolar lavage fluid) for MRSA or current positive culture(s) for MRSA at any other site then consider adding antimicrobials active against MRSA (See Table 1). There have been local concerns that empirical treatment has not been added in situations where it would have been appropriate. This is therefore a local consensus recommendation. A systematic review of 12 randomised controlled trials found Linezolid electronic Medicines Compendium information on Linezolid provided an equivalent cure rate to glycopeptides for MRSA nosocomial pneumonia but was associated with less renal dysfunction and fewer rashes.11 Where mixed infection with Pseudomonas aeruginosa and MRSA is suspected/possible based on microbiology results, ceftobiprole may be appropriate (discuss with microbiology consultant).

    Feedback on the first version of this guideline highlighted the lack of an oral option for non-severe HAP. It is challenging to find a single agent with good activity against the majority of potential pathogens. The best available agent is Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole, which is used for HAP in Hull & East Yorkshire Hospitals NHS Trust (Dr Gavin Barlow, personal communication.) Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole failed to reach non-inferiority criteria vs Vancomycin electronic Medicines Compendium information on Vancomycin in a trial of serious MRSA infection,1 and should therefore not usually be used for patients with severe HAP or MRSA bacteraemia.  Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole: use for this indication is off-license. Higher doses (1920mg 12-hourly) may be appropriate according the latest evidence.

    Please note that these are guidelines. On some occasions you may be advised to manage patients differently, depending on clinical circumstances, microbiology results, etc.

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    Directed Antimicrobial Treatment (when microbiology results are known)

    Recommendation: Use the “day 3 review” to check microbiology results, modify therapy if appropriate and document treatment plan and rationale.12 [Evidence level C]

    Recommendation: Use the antimicrobial regimens in Table 2 in situations where both clinical and microbiological findings support a specific causative organism. [Evidence level C]:

    Table 2. Directed Antimicrobial Regimens for Hospital acquired pneumonia.

    Organism

    No known penicillin allergy

    penicillin allergy

    Oral switch

    Meticillin-susceptible
    S. aureus

    IV Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 2g 6-hourly.
    Consider addition of PO Rifampicin electronic Medicines Compendium information on Rifampicin ** 600mg 12-hourly only if response to monotherapy is suboptimal.

    PO/IV #Linezolid electronic Medicines Compendium information on Linezolid % 600mg 12-hourly.

    Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 1g 6-hourly
    OR
    Linezolid electronic Medicines Compendium information on Linezolid % 600mg 12-hourly (if penicillin allergic)

    Meticillin-resistant S. aureus

    1st line
    PO/IV #Linezolid electronic Medicines Compendium information on Linezolid% 600mg 12-hourly
    2nd line
    IV Teicoplanin electronic Medicines Compendium information on 

Teicoplanin (see dosing guideline) plus PO Rifampicin electronic Medicines Compendium information on Rifampicin ** 600mg 12-hourly

    No change required

    Linezolid electronic Medicines Compendium information on Linezolid % 600mg 12-hourly.

    P. aeruginosa1

    IV Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam * 4.5g 8-hourly (age >65),

    OR

    IV Ceftazidime electronic Medicines Compendium information on Ceftazidime 2g 8-hourly (age <65)

    **On-going supply problems with ceftazidime please see link for alternatives**

    If severe HAP, consider adding Tobramycin (dosed according to Hartford regimen link) to Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam

    or Ceftazidime electronic Medicines Compendium information on Ceftazidime .

    IV Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin * 400mg 12-hourly

    Ciprofloxacin Description: electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly

    Legionellosis

    IV Levofloxacin electronic Medicines Compendium information on Levofloxacin ** 500mg 12-hourly

    No change required

    Levofloxacin electronic Medicines Compendium information on Levofloxacin ** 500mg 12-hourly

    Other Gram negative bacilli e.g coliforms, Acinetobacter spp, Stenotrophomonas maltophilia

    Therapy should be targeted on a case-by-case basis, dependent on the susceptibilities of the causative organism. Please discuss these cases with the duty Microbiologist for further advice and approval

    As for no allergy

    As for no allergy 

    IV =intravenous; PO = oral
    *The addition of a second agent (e.g. gentamicin) in severe cases or poor clinical response may be of value2 - please contact the duty Microbiologist for further advice. Please also Discuss with Microbiology if resistance reported or susceptibilities not available.
    **Prior to commencing Levofloxacin electronic Medicines Compendium information on Levofloxacin or Rifampicin electronic Medicines Compendium information on Rifampicin , the possibility of tuberculosis should be considered, and, if appropriate, sputum sent for tuberculosis culture (AAFBs).

    #Only use IV route where oral absorption is not appropriate (e.g. not absorbing, unsafe swallow).

    % Linezolid electronic Medicines Compendium information on 

Linezolid has a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient.

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    Duration of Treatment

    Recommendations [Evidence level C]

    • Continue IV therapy for at least 24 hours before considering oral switch in severe HAP.
    • In most instances a total of 5-7 days of therapy should be sufficient, depending on clinical response.
    • HAP caused by Pseudomonas aeruginosa or legionellosis may require longer therapy – review at 7 days consider 10-14 days in total

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    Switch to oral agent(s)

    Recommendation: Intravenous therapy should be discontinued as soon as clinically indicated.3 The following criteria may be considered when deciding to switch from intravenous to oral therapy [Evidence level D]:

    • Resolution of fever.
    • Pulse rate <100 beats/min.
    • Resolution of tachypnoea.
    • Clinically hydrated and taking oral fluids.
    • Resolution of hypotension.
    • Absence of hypoxia.
    • Improving white cell count.
    • Non-bacteraemic infection.
    • No microbiological evidence of Staphylococcus aureus or Gram negative enteric bacilli infection.
    • No concerns over gastrointestinal absorption.

    NB. Patients who are commenced on empirical IV Amoxicillin electronic Medicines Compendium information on Amoxicillin plus Temocillin electronic Medicines Compendium information on Temocilin or Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam can be switched to oral co-amoxiclav 625mg 8-hourly if no P. aeruginosa or resistant coliforms are isolated.

    The choice of oral agent can be determined by a number of factors, including susceptibility of isolated pathogen(s), drug allergy, tolerability, etc. Some oral switch options are given in Table 2. If no obvious alternative is apparent, please contact Microbiology for further advice.

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    Treatment Algorithm

    To be revised when content agreed

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    Treatment Failure

    Consider the following explanations and investigate as appropriate:

    • Incorrect diagnosis (e.g. review possibility of heart failure or pulmonary embolsation)
    • Non-susceptible organism (includes Mycobacterium tuberculosis, viruses and fungi)
    • Complication e.g. empyema, abscess
    • Underlying lung disease e.g. lung cancer
    • Immunosuppression (known or unexpected)

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    Referral Criteria

    Recommendation:

    • All non-intubated patients with severe HAP should be treated on an Acute Respiratory Care Unit (ARCU) or appropriate HDU as a minimum (e.g. patients requiring high flow oxygen or non-invasive ventilation (and who do not need inotropic support)
    • Patients with evidence of severe sepsis with hypotension and or end organ dysfunction should be managed on ICU.
    • Please contact the ICU outreach team in the presence of Respiratory Failure1, acidosis, or clinical deterioration.

    Respiratory failure is defined as the need for non-invasive ventilation or the need for > 35% oxygen to maintain an arterial oxygen saturation > 90% (in patients who do not have chronic hypoxia).

    See also Severe Sepsis Screening Tool and Resuscitation Care Bundle (Adults)

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    Provenance

    Record: 1425
    Objective:

    Aims

    • To improve the diagnosis and management of Hospital-Acquired Pneumonia (HAP) in non-ventilated patients.

    Objectives

    • To provide evidence-based recommendations for appropriate diagnosis and investigation of HAP in non-ventilated patients.
    • To provide evidence-based recommendations for appropriate empirical or directed antimicrobial therapy of HAP in non-ventilated patients.
    • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
    • To advise in the event of antimicrobial allergy.
    • To set-out criteria for referral to specialists.
    Clinical condition:

    Hospital acquired pneumonia (HAP)

    Target patient group: Patients with HAP
    Target professional group(s): Pharmacists
    Secondary Care Doctors
    Secondary Care Nurses
    Adapted from:

    Evidence base

    Evidence base

    Evidence levels:
    A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
    B. Robust experimental or observational studies
    C. Expert consensus.
    D. LTH consensus

    References

    1. 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.

    2. Anon. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. American journal of respiratory and critical care medicine 2005; 171(4): 388-416.

    3. 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.

    4. 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.

    5. 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.

    6. Habayeb H, Sajin B, Patel K, Grundy C, Al-Dujaili A, Van de Velde S. Amoxicillin plus temocillin as an alternative empiric therapy for the treatment of severe hospital-acquired pneumonia: results from a retrospective audit. Eur J Clin Microbiol Infect Dis 2015; 34(8): 1693-9.

    7. Livermore DM, Tulkens PM. Temocillin revived. J Antimicrob Chemother 2009; 63(2): 243-5.

    8. Boon RJ, Beale AS. Studies with temocillin in a hamster model of antibiotic-associated colitis. Antimicrobial agents and chemotherapy 1985; 27(6): 980-1.

    9. Mittermayer HW. Influence of temocillin on human bowel flora. Drugs 1985; 29 Suppl 5: 43-8.

    10. Laterre PF, Wittebole X, Van de Velde S, et al. Temocillin (6 g daily) in critically ill patients: continuous infusion versus three times daily administration. J Antimicrob Chemother 2015; 70(3): 891-8.

    11. Jiang H, Tang RN, Wang J. Linezolid versus vancomycin or teicoplanin for nosocomial pneumonia: meta-analysis of randomised controlled trials. Eur J Clin Microbiol Infect Dis 2013; 32(9): 1121-8.

    12. Public_Health_England. Start Smart - Then Focus: Antimicrobial Stewardship Toolkit for English Hospitals. In: ESPAUR, editor. London; 2015.

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    Related information

    Appendix 1. Colonisation/infection rates with different pathogens in hospital inpatients

    Background
    To inform the empirical choice of treatment of suspected HAP a pragmatic assessment of the prevalence of different pathogens/pathogen groups was undertaken. Key questions in term of empirical treatment are the need to cover Pseudomonas aeruginosa or Staphylococcus aureus (MRSA/MSSA)

    For inpatients on non-acute wards, this approximates to patients with a suspected diagnosis of HAP. Sputum samples are often contaminated with bacteria from the oropharyngeal flora – so the culture results may represent either the cause of an episode of HAP or the colonising flora with potential to cause HAP (because the aetiology is usually micro-aspiration). The sample therefore provides useful information about potential causes of HAP.

    Methods
    A data gather of culture results from samples was undertaken from the microbiology laboratory results database (telepath) for the period 1st April 2015 to 31st March 2016. The population of patients was all inpatients from whom a sputum or bronchoalveolar lavage (BAL) was taken. The dataset was deduplicated with 2 weeks from an index sputum sample as the definition of an episode.

    Culture results were divided into organism categories as shown in Tables 3. Wards were divided by specialty including wards deemed to be potentally “high risk” for Pseudomonas aeruginosa colonisation or representing vulnerable patient groups and the remainder were grouped as ”low risk areas”. Haematology wards were not included as there is no plan to change empirical treatment in this area. Table 3 presents culture results expressed as a percentage of the total sampled.

    Table 3

     

     

     

     

     

     

     


    "low risk areas" (1024)

    Thoracic (151)

    Oncology
    (182)

    Respir-atory (627)

    Paed/ neonate
    (78)

    CF (132)

    ICU (976)

    Acinetobacter spp.

    0.2

    0.0

    0.0

    0.5

    0.0

    0.0

    0.0

    Burkholderia spp.

    0.1

    0.0

    0.0

    0.0

    0.0

    0.0

    0.0

    Enterobacteriaceae (coliforms)

    10.8

    12.6

    16.5

    17.4

    10.3

    3.8

    21.1

    Haemophilus influenzae

    9.5

    17.9

    1.6

    7.5

    12.8

    16.7

    7.5

    Moraxella catarrhalis

    1.3

    1.3

    1.1

    1.0

    1.3

    2.3

    0.6

    Neisseria meningitidis

    0.1

    0.0

    0.0

    0.0

    0.0

    0.0

    0.0

    Pseudomonas aeruginosa

    3.7

    1.3

    3.3

    9.7

    11.5

    6.8

    3.1

    Stenotrophomonas maltophilia

    0.6

    0.7

    0.5

    2.4

    1.3

    0.0

    0.8

    Pseudomonas spp.

    0.6

    0.0

    0.0

    3.2

    1.3

    3.0

    0.8

    S. aureus (MSSA)

    4.2

    1.3

    4.9

    4.5

    15.4

    6.1

    8.1

    S. aureus (MRSA)

    0.9

    2.0

    0.0

    1.0

    0.0

    0.0

    0.3

    Streptococcus NOT pneumoniae

    1.8

    2.6

    0.5

    0.8

    0.0

    2.3

    2.2

    Streptococcus pneumoniae

    0.8

    0.7

    0.5

    1.0

    5.1

    9.1

    2.4

    Enterococcus spp.

    0.9

    2.0

    1.1

    0.6

    1.3

    1.5

    1.2

    no pathogens

    64.6

    57.6

    69.8

    50.6

    39.7

    48.5

    51.9

    Total

    100.0

    100.0

    100.0

    100.0

    100.0

    100.0

    100.0

     

    Table 4. Co-trimoxazole susceptibility in selected microorganism groups from respiratory samples 2015/6

    microorganism/group

    I

    R

    S

    total tested

    %resistant

    Coliforms

    1

    27

    188

    216

    12.5

    Streptococci (other)

    0

    0

    45

    45

    0.0

    beta haemolytic streptococci

    0

    0

    32

    32

    0.0

    Streptococcus pneumoniae

    2

    4

    79

    85

    4.7

    Staphylococcus aureus (MRSA)

    0

    0

    27

    27

    0.0

    Staphylococcus aureus (MSSA)

    0

    0

    7

    7

    0.0

    Stenotrophomonas maltophilia

    0

    0

    47

    47

    0.0

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