Hospital Acquired Pneumonia (HAP) in adults - Secondary Care

Publication: 18/12/2008  --
Last review: 24/08/2020  
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.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Hospital Acquired Pneumonia (HAP) in adults

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.

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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.

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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.

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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)

Duration

Total duration of treatment (IV and PO) should be 5 days.
This can be extended to 7 days in patients who are slow to respond to treatment.
In severe HAP IV therapy should be given for a minimum of 24 hours.

Situation

First line

Allergy

MRSA risk
(found in current/recent sputum/sample)

Non-severe1

Doxycycline electronic Medicines Compendium information on Doxycycline PO 200mg loading dose followed by 100mg 24-hourly

Severe

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav
1.2g IV 8-hourly AND
Clarithromycin electronic Medicines Compendium information on Clarithromycin 500mg IV 12-hourly

Levofloxacin electronic Medicines Compendium information on Levofloxacin4,5 500mg IV2 12-hourly

 

1st line:
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin4 500mg PO2 12-hourly AND Linezolid 600mg PO2 12-hourly

2nd line:
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin4 500mg PO2 12-hourly AND Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 6mg/kg (see prescribing guidance)

Oral switch for severe

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav
625mg PO 8-hourly AND
Clarithromycin electronic Medicines Compendium information on Clarithromycin 500mg PO 12-hourly

Levofloxacin electronic Medicines Compendium information on Levofloxacin4,5 500mg PO2 12-hourly

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin4 500mg PO2 12-hourly AND Linezolid 600mg PO2 12-hourly

Table 2: Patients with Late onset HAP (≥5 days since admission)

  • Doses assume normal renal and hepatic function.

LATE ONSET (≥ 5 days since admission)
See definitions above for definitions of high/low risk of P. Aeruginosa

Duration

Total duration of treatment (IV and PO) should be 5 days.
This can be extended to 7 days in patients who are slow to respond to treatment.
In severe HAP IV therapy should be given for a minimum of 24 hours.

Situation

First line

Allergy

MRSA risk
(found in current/recent sputum/sample)

Non-severe with low risk of P. Aeruginosa

Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole3 960mg PO 12-hourly

Allergy to Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole

1st line:
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin4 500mg PO2 12-hourly AND Linezolid 600mg PO2 12-hourly

2nd line:
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin4 500mg PO2 12-hourly AND Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 6mg/kg (see prescribing guidance)

Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole3 960mg PO 12-hourly

If allergic to Co-trimoxazole

1st line:
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin4 500mg PO2 12-hourly AND Linezolid 600mg PO2 12-hourly

2nd line:
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin4 500mg PO2 12-hourly AND Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 6mg/kg (see prescribing guidance)

Oral switch for non-severe with low risk of P. Aeruginosa

N/A

Teicoplanin electronic Medicines Compendium information on Teicoplanin should be switched
to Linezolid 600mg PO 12-hourly.

Non-severe with high risk of P. aeruginosa

Levofloxacin electronic Medicines Compendium information on Levofloxacin3,4,5 500mg PO2 12-hourly

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin4 750mg PO2, 7 12-hourly AND Linezolid 600mg PO2 12-hourly
OR Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 6mg/kg (see prescribing guidance) if unable to have Linezolid

Severe

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam IV 4.5g 8-hourly

1st line:
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750mg PO2,4,7 12-hourly AND Linezolid 600mg PO2 12-hourly

2nd line:
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750mg PO2,4,7 12-hourly AND Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 6mg/kg (see prescribing guidance)

Low or High risk of P. aeruginosa

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam IV 4.5g 8-hourly AND Linezolid 600mg PO 12-hourly
OR Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 6mg/kg (see prescribing guidance) if unable to have Linezolid

If the patient is also allergic to penicillin then use
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750mg PO2,4,7 12-hourly AND Linezolid 600mg PO2 12-hourly
OR Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 6mg/kg (see prescribing guidance) if unable to have Linezolid

Oral switch for severe

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav
625mg PO 8-hourly

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750mg PO4,7 12-hourly AND Linezolid 600mg PO 12-hourly

Contact Microbiology for advice.

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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. 
Afebrile for 24 hours
Clinically improving
Eating and drinking
Not Deep seated infection

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.

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DIRECTED THERAPY

  • Doses assume normal renal and hepatic function.

Organism

No known penicillin allergy

Penicillin allergy

Duration

Meticillin-susceptible S. aureus

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin IV 2g 6-hourly.

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.
This can be extended to 7 days in patients who are slow to respond to treatment.
In severe HAP IV therapy should be given for a minimum of 24 hours.

Oral switch

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin PO 1g 6-hourly

Consider adding Rifampicin PO 600mg 12-hourly if response to mono-therapy is suboptimal.

N/A

Meticillin-resistant S. aureus

1st line:
Linezolid 600mg PO2 12-hourly

2nd line:
Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 6mg/kg (see prescribing guidance) AND Rifampicin PO 600mg 12-hourly

N/A

Total duration of treatment (IV and PO) should be 5 days.
This can be extended to 7 days in patients who are slow to respond to treatment.
In severe HAP IV therapy should be given for a minimum of 24 hours.

Oral switch

Linezolid PO 600mg 12-hourly

N/A

P. aeruginosa

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

OR

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam IV 4.5g 6-hourly6 (age ≥65).

In severe HAP consider adding Tobramycin IV.  See Guideline for dosage and monitoring information.

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO2,4,7 750mg 12-hourly

Total duration of treatment (IV and PO) should be 7 days.
This can be extended to 10 days in patients who are slow to respond to treatment.
In severe HAP IV therapy should be given for a minimum of 24 hours.

Oral switch

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin PO4,7 750mg 12-hourly unless sensitivities suggest otherwise

Legionellosis

Levofloxacin electronic Medicines Compendium information on Levofloxacin4,5 500mg PO2 12-hourly

N/A

Total duration of treatment should be 7 days.
This can be extended to 10 days in patients who are slow to respond to treatment.

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

Discuss with microbiology.

Discuss with microbiology.

FOOT NOTES

  1. Divergence from NICE guidance is based on local susceptibility data
  2. 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.
  3. Off-license indication for both co-trimoxazole and levofloxacin - however, both agents are in widespread use for respiratory infections.
  4. 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).
  5. Before prescribing levofloxacin, consider the possibility of tuberculosis, to reduce risk of promoting quinolone resistance in tuberculosis.
  6. For directed P. aeruginosa therapy, piperacillin-tazobactam is prescribed at the maximum dose of four times a day due to increased risk of mortality.
  7. 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

LHP version 2.0

Related information

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