Hospital acquired Pneumonia HAP (NICE 139)

Related Subjects: Asthma |Acute Severe Asthma |Exacerbation COPD |Pulmonary Embolism |Cardiogenic Pulmonary Oedema |Pneumothorax |Tension Pneumothorax |Respiratory (Chest) infections Pneumonia |Fat embolism |Hyperventilation Syndrome |ARDS |Respiratory Failure

Offer an antibiotic(s) within 4 hours of establishing a diagnosis. When microbiological results available: review the choice of antibiotic(s), and change the antibiotic(s) according to results, using a narrower spectrum antibiotic, if appropriate. If fails to improve Seek specialist advice from a microbiologist

About

• Pneumonia acquired whilst in Hospital

Microbiology

• Gram-negative bacilli (>50%): Acinetobacter, Escherichia coli, Proteus, Klebsiella, Pseudomonas, Haemophilus influenzae
• Gram-positive cocci: Staphylococcus aureus, Streptococcus pneumoniae
• Anaerobes: Bacteroides, Clostridia

Risks

• Post Operative, Frailty, Alcoholism
• Seizure or coma, Diabetes, Immunosuppressed
• Dysphagia, Stroke, MND, Parkinson's Disease
• Smoker, IVDU, Chronic lung disease, Trauma

Clinical

• Hypotension, Breathless, Cough, Expectoration, Fever
• Tachycardia, New AF, Delirium, Hypoxia, Cyanosis
• Sweating and rigors, chest pain

Investigations

• FBC, High WCC, High CRP
• U&E:AKI
• CXR: patchy opacification right lung base
• ECG: Tachycardia, AF
• ABG: Hypoxia
• CT chest: Consolidation

Differentials

• PE can coexist
• Consider if it may be Aspiration pneumonia

Management

• ABC, High flow O2 target 94-98%, IV fluids
• Appropriate IV antibiotics to cover possible causes - Gram negatives, Gram positives and anaerobes. Follow local guidance
• Ensure VTE prophylaxis. Hydration and Nutrition.
• Early sitting out and mobilisation
• Chest physiotherapy to encourage cough.
• First-choice oral antibiotic for non-severe symptoms or signs and not at higher risk of resistance 3 (guided by microbiological results when available)
  • Co-Amoxiclav: 500/125 mg 3 times a day for 5 days then review
• Alternative oral antibiotics for non-severe symptoms or signs and not at higher risk of resistance, if penicillin allergy or if Co-Amoxiclav unsuitable
  • Doxycycline 200 mg on 1st day, then 100 mg OD for 4 days (5-day course) then review
  • Cefalexin (caution in penicillin allergy) 500 mg BDS/TDS (can be increased to 1 to 1.5 g TDS/QDS) for 5 days then review
  • Co-trimoxazole 960 mg BD for 5 days then review
  • Levofloxacin (only if switching from IV Levofloxacin with specialist advice; consider safety issues 500 mg OD/BD for 5 days then review
• First choice antibiotics (given IV for at least 48 hours) if severe symptoms or signs (for example, symptoms or signs of sepsis) or at higher risk of resistance (guided by microbiological results when available)
  • Tazocin (Piperacillin with Tazobactam) 4.5 g three times a day (increased to 4.5 g QDS if severe infection)
  • Ceftazidime 2 g TDS
  • Ceftriaxone 2 g OD
  • Cefuroxime 750 mg TDS/QDS (increased to 1.5 g three or four times a day if severe infection)
  • Meropenem (specialist advice only) 0.5 to 1 g TDS
  • Ceftazidime with avibactam (specialist advice only) 2/0.5 g TDS
  • Levofloxacin 500 mg OD/BD (use higher dosage if severe infection)
• IV antibiotics to be added if suspected or confirmed MRSA infection (dual therapy with an IV antibiotic listed above)
  • Vancomycin: 15 to 20 mg/kg two or three times a day (maximum 2 g per dose), adjusted according to serum-Vancomycin concentration8
  • Linezolid (if Vancomycin cannot be used; specialist advice only 600 mg twice a day orally or IV

References

• NICE 139 Pneumonia (Hospital-acquired): antimicrobial prescribing