Respiratory System

Microbiological specimens (Where Tuberculosis is not under consideration)

  • Sputum for culture and sensitivity.
  • Urine sample for Pneumococcal antigen for ALL patients with CXR evidence of consolidation.
  • Urinary test for Legionella is performed only for patients with CURB Score of 3, all patients admitted to critical care, or where risk factors for Legionella are present (Epidemiological link to outbreak situation, recent travel/hotel residence, exposure to aerosolised water sources, compost). The reason for test (as above) must be indicated on request while sending the sample.
  • However, if Legionella test is requested for other reasons and following discussion with Microbiologist/ID physician, then this must be indicated on the request.
  • Blood culture.
  • Pleural fluid culture and sensitivity plus a separate sample for TB [since this is sent to reference laboratory].
  • For infections in immune-compromised patients, atypical pneumonia or PCP discuss investigations with Microbiologist or ID Physician during work hours.
  • The choice of agent should take into account the patient’s risk for C. difficile infection.

Tuberculosis (TB)
All suspected cases of TB should be drawn to the attention of Microbiologist/ICTeam and TB Lead

  • If Tuberculosis suspected: 3 separate sputum samples for TB.
  • For miliary TB – EMU x 3 and citrated blood/Bone Marrow for TB culture required.
  • Discuss Quantiferon assay with Microbiologist during working hours.
  • Discuss Mantoux test with TB Health Visitor and TB Lead.

(Non-pneumonic LRTI) NO new CXR infiltrates [consolidation]

Duration of therapy 5 days

Common Pathogen(s)
Haemophilus influenzae; Streptococcus pneumoniae; Moraxella catarrhalisViruses;
Occasionally S. aureus (post viral episode). 20-40% episodes of non-infective aetiology and up to 30% of viral origin.

Antibiotic – 1st line
Doxycycline 100mg q12h PO

 

Antibiotic – 2nd line
Amoxicillin 500mg q8h PO

Comment
Antibiotics ARE indicated in the following:
↑ sputum volume;
↑ purulence of sputum;
Dyspnoea.
Review treatment with culture and sensitivity results and switch to targeted antibiotic therapy. Consider pertussis if non-resolving cough – contact microbiologist

CURB 65:
Confusion (Acute new onset) (AMT<=8); Urea*>7 mmol/L; Resp rate >=30/min; BP <90 systolic or <=60 diastolic; 65Age >=65-yrs.

*No history of renal impairment or known cause for increased urea

Assessing Severity of Community Acquired Pneumonia

  • Calculate CURB-65 score (see above).
  • Caution with CURB-65 scores on the borderline between non-severe and severe pneumonia classifications.
  • Clinical judgment required depending on presence of additional adverse prognostic factors (see below).

Additional adverse prognostic factors

  • Unstable co-morbidities;
  • PaO2 < 8kPa on air;
  • Multilobar or bilateral involvement on CXR;
  • Positive Legionella urine antigen test;

Discuss with On Call Physician / Critical Care Physician / Respiratory Physician any patients with a CURB-65 score > 3.

Microbiological specimens for Community Acquired Pneumonia

  • Blood cultures before antibiotics are given;
  • Sputum cultures if bringing up purulent sputum;
  • Urine for Pneumococcal and Legionella (see above) antigen;
  • If not responding to 1st line treatment, discuss further investigations including serology with Consultant Microbiologist during working hours;
  • The choice of agent should take into account the patient’s risk for C. difficile infection.

Comment
Discuss with On Call Physician / Critical Care Physician / Respiratory Physician any patients with a CURB-65 score > 3
Severe Legionella / MRSA / previous C. diff or MDR Gram negatives – Discuss with Consultant Microbiologist
De-escalate therapy once microbiological results available.
Negative urinary antigen for Legionella  may be used to de-escalate/ or stop Clarithromycin if on duo therapy start treatment as soon as possible (within 4 hours) of admission.

Duration 5 days [guided by the clinical progress]

Antibiotic – 1st line
Amoxicillin 500mg q8h PO.

 

Antibiotic – 2nd line
Doxycycline 100mg q12h PO.

with no adverse prognostic factors.  If Legionella urine antigen negative, stop Clarithromycin if on dual therapy.  If adverse prognostic factors, treat as severe.

Duration 5 days [guided by the clinical progress]

Antibiotic – 1st line
Amoxicillin 500mg- 1g q8h PO plus Clarithromycin 500mg q12h PO
or
If IV needed, then  Benzyl-penicillin 1.2g q6h IV plus Clarithromycin 500mg q12h IV

 

Antibiotic – 2nd line
Doxycycline 100mg q12h PO
or
If IV needed, then  Clarithromycin 500mg q12h IV

Duration of therapy 7days [guided by clinical progress].

Antibiotic – 1st line
Co-amoxiclav 1.2g q8h (consider C diff risk) IV plus Clarithromycin 500mg q12h IV.

 

Antibiotic – 2nd line
Vancomycin IV (dosed as per trust vancomycin guideline) plus Clarithromycin 500mg q12h IV. Contact Microbiologist during work hours if no response in 48hours

Duration of therapy 7 days [guided by clinical progress].
Comment
All patients with HAP should be entered on HAP Care Bundle.

Severe HAP: RR>30/min;
Hypoxia (PaO2 <8 kPa or <92% on any FiO2); CXR changes;
BP systolic <90 or diastolic <=60;

New mental confusion

Non-severe HAP

A. Early onset [2-5d of hosp. Adm.] & no prev. antibiotic

Antibiotic – 1st line
Amoxicillin 2g q8h IV
plus 
Gentamicin one stat dose (click here for full gentamicin policy) 
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.5mg/kg IV one stat dose  (max 500mg): if <70 years and CrCl≥30mL/minor

3mg/Kg IV one stat dose (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight – use adjusted body weight

 

Antibiotic – 2nd line
Non-serious penicillin allergy (e.g rash) – Cefuroxime 1.5 g IV q8h

B. Late onset [>5d hosp. adm. Or Early onset and received prev. antibiotic].

Antibiotic – 1st line
Co-amoxiclav (Consider C difficile risk)1.2g q8h IV

 

Antibiotic – 2nd line
Non-serious penicillin allergy (e.g rash) – Cefuroxime 1.5 g IV q8h

Severe HAP

A. No previous antibiotic

Antibiotic – 1st line
Co-amoxiclav (consider C diff risk) 1.2g q8h IV

 

Antibiotic – 2nd line
Non-serious penicillin allergy (e.g rash) – Cefuroxime 1.5 g IV q8h

B. Previous antibiotic and not known to be colonised with pseudomonas or other resistant organisms

Antibiotic – 1st line
Non-serious penicillin allergy (e.g. rash) – Cefuroxime 1.5 g IV q8h
Review in 24-48hours

C. Previous antibiotic and patients known to be colonized with at least 2 consecutive pseudomonas in sputum or other relevant samples 

For Late onset HAP severe – 
Piperacillin-tazobactam IV 4.5g q8h

Serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration)

Non severe HAP
Ciprofloxacin PO 500mg q12h

Severe HAP
Ciprofloxacin PO 500mg or IV 400mg q12h plus Vancomycin IV (dosed as per trust vancomycin guideline)

 

Duration of therapy 5 days [guided by clinical progress]

Antibiotic – 1st line
Admission < 5 DAYS:
Amoxicillin 1g q8h IV plus Metronidazole 500mg q8h IV (PO if swallowing assessment is approved)
or
Clindamycin 600mg q6h IV if Penicillin allergyAdmission > 5 DAYS:
Co-amoxiclav IV 1.2g q8h
or
Cefuroxime IV 1.5g q8h plus Metronidazole IV 500mg q8h

Comments
Aspiration pneumonitis is chemical and often self-limiting. Treatment not needed unless major aspiration or if chest x-ray confirms pneumonia (new consolidation).

 Clinical Pulmonary Infection Score (CPIS)
 0 points  1 point  2 points
 Tracheal Secretions  Rare  Abundant  Abundant and purulent
 Chest x-ray  No infiltrate  Diffuse  Focal infiltrate
 Temperature  36.0- 38.4  38.5- 38.9  <36 or >39
 White blood cell count  4 to 11  <4 or >11  <4 or >11 plus band >0.5
 PaO2/ FiO2 mmHG  >240 or ARDS  <240 plus no ARDS
 Microbiology  Negative  Positive

 

(> 48 hours of mechanical ventilation. CPIS ≥ 6)

Common Pathogen(s)

Must discuss with Microbiologist during working hours for:
Legionella, MRSA,
ESBL coliforms,
C. difficile,
Pneumocystis,
Neutropenic patients,
Multidrug resistant pathogens, and all haematology patients.

Antibiotic – 1st line
Early VAP (< 5 days on ventilation):
Co-amoxiclav (consider C diff risk) 1.2g q8h IV 5 days [guided by clinical response].

 

Late VAP (>5 days on ventilation)
Cefuroxime 1.5g q8h IV

Previous C. difficile infection:
Piperacillin- tazobactam 4.5g q8h IV

 

Comment
All cases on ITU, HDU and Cardiac ITU should be reviewed regularly with Consultant Microbiologist.

Duration of therapy should be guided by radiological and clinical response.  [4- 6 weeks].
Common Pathogen(s)
Streptococcus milleri;
Anaerobes;
Staphylococcus aureus;
aerobic/ microaerophilic Streptococci.

Antibiotic – 1st line
Community acquired:
Clindamycin 600mg q6h IV.Hospital acquired:
Co-amoxiclav IV 1.2g q8h (contact Microbiologist during working hours for oral switch) – give PO co-amoxiclav option.

 

Antibiotic – 2nd line
Non-serious Penicillin allergy (e.g. mild rash)Cefuroxime IV 1.5g q8h plus metronidazole IV 500mg q8h (contact Microbiologist during working hours for oral switch).

Comment
All cases should be discussed with Microbiologist and a Respiratory Physician during working hours.
De-escalate to appropriate narrow spectrum antibiotic once culture/ sensitivity available

(minimum of 2 weeks depending on radiological/ surgical intervention/ clinical response).

Common Pathogen(s)
Streptococcus milleri;
Anaerobes;
Staphylococcus aureus;
aerobic/ microaerophilic Streptococci.

Antibiotic – 1st line
Co-amoxiclav (consider C diff risk)1.2g q8h IV.

 

Antibiotic – 2nd line
Non-serious penicillin  allergy (e.g. rash) – cefuroxime 1.5g IV q8h plus metronidazole 500mg IV q8h

Comment
All cases should be discussed with Microbiologist and a Respiratory Physician during working hours.
De-escalate to appropriate narrow spectrum antibiotic once culture/ sensitivity available.

Treatment should be individualised for each patient and sputum should be sent for culture before initiating empiric antibiotic therapy – total duration 14 days (IV plus oral de-escalation if possible)

Common Pathogen(s)
Haemophilus
Influenzae;
Streptococcus
pneumoniae;
Moraxella catarrhalis;
Viruses;
Occasionally S. aureus (post viral episode)
Pseudomonas – see below

Antibiotic – 1st line
Doxycycline 100mg q12h PO 14 days (depending on clinical response).

If IV antibiotics indicated, treatment should be guided by previous results.
or

Amoxicillin 1g q8h IV.

 

Antibiotic – 2nd line
Clarithromycin 500mg q12h PO or IV.
If poor therapeutic response, discuss with Microbiologist during working hours.

If Pseudomonas detected and failed 1st line treatment , discuss with Microbiology / Respiratory physician during working hours.

Antibiotic – 1st line
Piperacillin-tazobactam IV q8h 4.5g

 

Serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration)
Ciprofloxacin PO 500-750mg q12h

Comment
IV antibiotics should be considered when patients are particularly unwell, have resistant organisms or have failed to respond to oral therapy.

Review antibiotics once culture results are available.

Pulmonary exacerbations of cystic fibrosis (CF) can be treated with oral or intravenous antibiotics. When IV therapy is needed patients are usually managed with a combination of two or more IV antibiotics. Common organisms in the sputum of CF patients are Pseudomonas aeruginosa and Burkholderia cepacia.
Ideally an aminoglycoside in combination with an anti-pseudomonal beta-lactam should be used first line. For those colonised with Burkholderia species, a third IV antibiotic should normally be prescribed. IV treatment is normally continued for 14 days depending on response.
Patients with CF have a high prevalance of antibiotic intolerance (check the allergy card in the medical notes) and alternative antibiotic regimens may be needed; if in doubt discuss with the CF doctors or the CF specialist pharmacist in normal working hours, or the CF consultant on call out of hours.
If the patient uses a maintenance nebulised antibiotic (e.g. tobramycin) and the same antibiotic is also being used for IV treatment, the nebulised form of the antibiotic would usually be withheld.
If you need information on how to administer a particular IV antibiotic for a patient with CF please contact the CF specialist pharmacist.
See the CF Trust’s ‘Antibiotic Treatment for Cystic Fibrosis’ consensus document for further information.

Antibiotic – 1st line
Tobramycin IV 5mg/kg q24h
If patient is obese (20% over ideal body weight), use adjusted body weight to calculate dose – see below for detailsplusCeftazidime IV 3g q6h (unlicensed dose)or 

Meropenem IV 2g q8h

or

Piperacillin/Tazobactam IV 4.5g q6h (max 14 days)

If colonised with Burkholderia add a 3rd IV antibiotic, preferably:

Co-trimoxazole IV 960mg q12h

Alternatives
In those with allergy, intolerance or previous failure on the above first line agents alternatives may be needed.

Other agents sometimes used for CF exacerbation
All doses assume normal renal and hepatic function – discuss with the CF pharmacist in hours, or the on call pharmacist out of hours if there is concern regarding renal or hepatic clearance of antibiotics. The list below is in alphabetical order, not order of preference.

Amikacin IV 15mg/kg q24h (do NOT use in combination with other aminoglycosides) – If patient is obese (20% over ideal body weight), use adjusted body weight to calculate dose – see below for details

Aztreonam IV 3g q6h (or 4g q8h) – both doses are unlicensed

Chloramphenicol 
IV 1g q6h (with alternate day FBC monitoring)

Ciprofloxacin 
IV 400mg q12h or q8h

Colistimethate Sodium (Colistin) IV 2MU q8h

Flucloxacillin IV 1-2g q6h

Fosfomycin 
IV 4g q8h (can give higher doses on discussion with consultant)

Teicoplanin IV 12mg/kg kg q12h for 3 doses then continue q24h (round to nearest 200mg or 400mg vial)

Temocillin 
IV 2g q12h

Ticarcillin with Clavulanic Acid 
(Timentin) IV 3.2g q6h

Tigecycline 100mg stat dose followed by 50mg q12h (12 hours after initial dose)

Vancomycin IV as per Trust guidance

Pregnancy and breastfeeding
If a patient is pregnant or breastfeeding and requires IV antibiotics please discuss treatment options with a CF consultant or the CF specialist pharmacist before commencing treatment.

Antibiotic desensitisations
These can be arranged by contacting the CF specialist pharmacist during working hours. Desensitisations should not be attempted outside of normal working hours.
Following a successful desensitisation, the patient must receive the antibiotic regularly. If the antibiotic is withheld for more than 24 hours a repeat desensitisation will be required and it must be given by intravenous infusion (not bolus).

Calculating Ideal and Adjusted Body Weight
Calculate the ideal body weight (IBW) first and then use this to calculate the adjusted body weight (AdjBW).

IBW men (kg) = 50 + (2.3 x every inch over 5 feet)
IBW women (kg) = 45.5 + (2.3 x every inch over 5 feet)

AdjBW = IBW + 0.4 x (actual body weight – IBW)