Adult Hospital Acquired Pneumonia (HAP) Severity Assessment and Empirical Antimicrobial Treatment Guidelines

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Guidelines on severity assessment and antimicrobial selection for hospital acquired pneumonia (HAP) th Approved by the Antimicrobial Subcommittee: December 7 2010 Updated: September 2012 Review date: December 2012 Page 1 of 4

Adult Hospital Acquired Pneumonia (HAP) Severity Assessment and Empirical Antimicrobial Treatment Guidelines
Hospital acquired pneumonia is associated with a significant mortality, although mortality may be also a function of a patients co-morbidities. Never the less evidence suggests that prompt treatment with appropriate antibiotics leads to the best outcomes. However it is important that HAP is carefully diagnosed to avoid inappropriate over use of antibiotics. Early review by senior staff and modifying treatment according to microbiological results leads to better management. Definition: Hospital Acquired Pneumonia (HAP) is defined as pneumonia that occurs 48 hours or more after admission to hospital, including transfers, which was not incubating at the time of admission BUT also see under MRSA below. Do not confuse HAP with hospital acquired lower respiratory tract infection, which is non-pneumonic (no infiltrates on chest X-ray), which is NOT included in this guidance. This guidance does not include ventilator associated pneumonia (VAP). Clinical features: Chest X-ray shows new or progressive infiltration plus at least two of the following: Fever > 38oC Leukocytosis or leukopenia (> 11 x109 or <4x109 WBC/ml respectively) Purulent secretions Decline in oxygenation Clinical Assessment of Severity: There is no validated assessment tool available to assess, however the presence of any of the following features may indicate severity. Early review by senior medical staff is required to achieve accurate assessment. New onset of confusion X-ray showing shadowing bilateral or multilobular (preferably taken posteroanterior and lateral if not intubated) Respiratory rate > 30/min Low blood pressure (systolic < 90mmHg and or diastolic < 60 mmHg) Pa O2 <8kPa (normal 10.7-13.3kPa) and or sats O2 < 93% on air These and laboratory studies (FBC, serum electrolytes, renal and liver function) can point to the presence of multiple organ dysfunction and thus help define the severity of illness. Pathogens Likely pathogens include: Streptococcus pneumoniae Haemophilus influenzae

Endogenous flora, should always be considered especially after short hospital stays without additional risk factors. In immunocompromised patients; patients who have Pseudomonas aeruginosa* Multi-resistant Gram negative organisms recently been on ITU/HDU; patients with chronic pulmonary conditions (e.g. bronchiectasis, CF patients). MRSA* Patients known to be colonised with MRSA (e.g. PAS If suspected see antibiotic choice under alert); previously in any hospital in last 3 months, from MRSA nursing/residential home, chronic conditions e.g. haemodialysis, chronic wound care e.g. ulcers. Fungi and Yeasts* These should be considered in high-risk patients, e.g. malignancies esp. haematological, renal and transplant patients. Discuss with Microbiologist. * NOTE sputum culture results may show evidence of colonisation with these organisms. Do not treat unless there is good evidence for pneumonia. Avoid inappropriate prescribing which may lead to acquisition of resistant organisms and C. difficile.

Microbiology investigation: Blood cultures, sputum or tracheal aspirate/broncho-alveolar lavage. NOTE: A sterile culture of respiratory secretions in the absence of a new antibiotic in the past 72 hours virtually rules out the presence of bacterial pneumonia, but viral, legionella and mycobacterial infection is still possible. If these patients have ongoing clinical signs of infection, another site of infection should also be considered.

Guidelines on severity assessment and antimicrobial selection for hospital acquired pneumonia (HAP) th Approved by the Antimicrobial Subcommittee: December 7 2010 Updated: September 2012 Review date: December 2012 Page 2 of 4

Adult Hospital Acquired Pneumonia (HAP) Empirical Antimicrobial Treatment Guidelines

See HAP Diagnostic Criteria above. Discuss diagnosis with senior member of team: have you ruled out other infections e.g. urosepsis, Clostridium difficile infection? If source unknown follow Sepsis of Unknown Site guideline The antimicrobial choice indicated in sections below should be modified when results of microbiological investigations are available - Streamline empirical antimicrobials to target significant microbiology results. Use narrowest spectrum of antibiotics possible for minimum period to reduce risk of adverse effects. Review patients daily. Clinical improvement usually takes 4872 hrs. Therapy should not be changed during this time unless there is a rapid clinical decline. If the patient is not responding after 4872 hrs of treatment discuss with a senior respiratory physician or Medical Microbiologist. ONSET EARLY (in-patient <5 days) LATE (in-patient 5 days SEVERITY FIRST LINE SECOND LINE
(if patient allergic to penicillin)

DURATION

Follow CAP guidelines Mild 1st choice: Doxycycline 200mg PO od throughout whole treatment. Review by 3 days Oral treatment not suitable: Follow moderate severe guidance Moderate to severe Initial therapy: Piperacillin & tazobactam (Tazocin ) 4.5g IV tds If high risk MRSA add Vancomycin IV (see Trust Guideline) Oral switch: Doxycycline 200mg PO od 1st choice: Doxycycline 200mg PO od throughout whole treatment. Review by 3 days Oral treatment not suitable: Follow moderate severe guidance Initial therapy: Chloramphenicol 12.5mg/kg IV qds (max 1g qds) If high risk Pseudomonas aeruginosa discuss with Microbiology Oral switch: Doxycycline 200mg PO od Once patient improving switch to oral to complete 5 10 days total If treatment failure by 4872 hrs discuss with microbiology unless under a chest physician Switch to oral at earliest possibility 3-7 days

Special considerations If previous multidrug resistant pathogen isolated note susceptibility and treat as appropriate. Antimicrobial considerations Doses are for guidance only and apply to adults of average size with normal renal and hepatic function. Chloramphenicol: ensure appropriate monitoring including baseline LFTs, U&Es, Cr, & FBC. During therapy monitor FBC a minimum of twice weekly. Reduce dose in hepatic impairment (avoid if severe). Any patient on interacting drugs or with liver impairment will need levels. Stop treatment if LFTs become deranged or if WBCs fall to <2.5x109/L contact Microbiology for advice. Do not prescribe oral chloramphenicol unless specifically recommended by Microbiology. The absorption of doxycycline may be impaired by concurrent administration of antacids containing aluminium, calcium, magnesium (or other drugs containing these cations), oral zinc, iron salts, or bismuth preparations dosages should be maximally separated (ideally withhold oral iron supplements while on doxycycline). Doxycycline should be taken whilst upright with 100mls water & well before bedtime. Counsel patients on risks of photosensitivity. Doxycycline is contraindicated in pregnancy & breastfeeding contact Microbiology for alternative options. Dose vancomycin in accordance with the Trust vancomycin guidelines on the antimicrobial website.

Guidelines on severity assessment and antimicrobial selection for hospital acquired pneumonia (HAP) th Approved by the Antimicrobial Subcommittee: December 7 2010 Updated: September 2012 Review date: December 2012 Page 3 of 4

References American Thoracic Society. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Respir Crit Care Med Vol 171. pp 388416, 2005. http://ajrccm.atsjournals.org/cgi/reprint/171/4/388 Guidelines for the management of hospital-acquired pneumonia in the UK: report of the Working Party on HAP of the BSAC 2008. Journal of Antimicrobial Chemotherapy (2008) 62, 534. http://jac.oxfordjournals.org/cgi/reprint/62/1/5

Guidelines on severity assessment and antimicrobial selection for hospital acquired pneumonia (HAP) th Approved by the Antimicrobial Subcommittee: December 7 2010 Updated: September 2012 Review date: December 2012 Page 4 of 4