Hospital Acquired Pneumonia Pathway

Hospital Acquired Pneumonia

Hospital Acquired Pneumonia (HAP) is defined as pneumonia that occurs 48 hours or more after admission to hospital.

Do not confuse HAP with hospital acquired lower respiratory tract infection, which is non-pneumonic (no infiltrates on chest X-ray).

Clinical features: Chest X-ray shows new or progressive infiltration plus at least two of the following:

• Fever > 38°C
• Leukocytosis or leukopenia (> 11 x109 or < 4x109 WBC/ml respectively)
• Purulent secretions
• Decline in oxygenation

Early review by senior to achieve accurate assessment

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)
• PaO₂ < 8kPa (normal 10.7-13.3kPa) and or sats O2 < 93% on air (this may not be applicable to patients with chronic respiratory disease.

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.

Oxygenation management

Oxygen therapy:

all patients should receive appropriate oxygen therapy with monitoring of oxygen saturations and inspired oxygen concentrations with the aim to maintain arterial oxygen tension (PaO₂) at greater than 8kPa and oxygen saturation (SpO₂) between 94-98%.

high concentrations of oxygen can safely be given in patients who are not at risk of hypercapnic respiratory failure.

oxygen therapy in patients at risk of hypercapnic respiratory failure complicated by ventilatory failure should be guided by repeated arterial blood gas measurements.

Antibiotic management

Administer antibiotics in all patients as soon as diagnosis of hospital-acquired pneumonia (HAP) has been confirmed, ie:

• before they leave the initial assessment area
• within 4 hours of presentation to hospital for the majority of patients

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 48–72 hrs. Therapy should not be changed during this time unless there is a rapid clinical decline. If the patient is not responding after 48–72 hrs of treatment discuss with a senior respiratory physician or Medical Microbiologist.

Antimicrobial Therapy for HAP (for full guidance see formulary)

Non-Severe—Early Onset (2-5d of hospital admission)

First Line: Amoxicillin 2g q8h IV Plus Gentamicin 5mg/kg IV One Stat dose. for 7 days

Second Line: Discuss with Microbiologist

Non-Severe—Late Onset (>5d of hospital admission) OR Severe—No Previous Antibiotics

First Line: Co-amoxiclav 1.2g q8h IV for 7 days

Second Line: Discuss with Microbiologist

Severe—Previous Antibiotic with high risk of CDI

First Line: Piperacillin-tazobactam 4.5g q8h IV for 7 days

Second Line: Discuss with Microbiologist

General management

The following aspects of general management are recommended for all patients with uncomplicated community-acquired pneumonia (CAP):

• assess the patient for volume depletion they may require intravenous (IV) fluids
• consider prophylaxis for venous thromboembolism (VTE) for all patients who are not fully mobile
• consider patient mobility - condition permitting, the patient should:
• sit out of bed for at least 20 minutes within first 24 hours; and
• increase mobility each subsequent day of hospitalisation where possible
• administer analgesia for pleuritic chest pain
• provide nutritional support in prolonged illness

Airway clearance techniques:

• are not recommended routinely in patients with uncomplicated pneumonia; but
• should be considered if the patient has either of the following:
• difficulty with expectoration
• a pre-existing lung condition

Microbiological investigations:

Likely pathogens include:

Streptococcus pneumoniae Haemophilus influenzae	Endogenous flora, should always be considered especially after short hospital stays without additional risk factors.
Pseudomonas aeruginosa* Multi-resistant Gram negative organisms	In immunocompromised patients; patients who have recently been on ITU/HDU; patients with chronic pulmonary conditions (e.g. bronchiectasis, CF patients).
MRSA* If suspected see antibiotic choice under MRSA	Patients known to be colonised with MRSA (e.g. PAS alert); previously in any hospital in last 3 months, from 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.

Consider patient for amber care bundle

Identification: is the patient AMBER?

• 1. Is the patient deteriorating, clinically unstable, and with limited reversibility?
• 2. Is the patient at risk of dying within the next 1-2 months?

Monitor and re-assess

Monitor and record the following at least three times daily:

• temperature
• respiratory rate
• pulse
• blood pressure (BP)
• mental status
• oxygen saturation (SpO₂)
• inspired oxygen concentration

Vital signs may be captured by an early warning score and can be used to trigger escalation or de-escalation of management.

Reassess all patients deemed to be at high risk of death at least every 12 hours until shown to be improving:

• reassess disease severity - the "post take" round provides an early opportunity for this
• reassess the choice of antibiotic and route of administration on the "post take" round, and daily thereafter

Average time to clinical stability for the following factors is 2-3 days:

• temperature
• pulse rate
• respiratory rate
• SpO₂

Repeat chest radiograph for patients who are not progressing satisfactorily after 3 days of treatment. Remeasure C-reactive protein (CRP) in patients who are not progressing after 3 days of treatment:

• CRP usually falls by 50% by day 3 of treatment [3]
• failure of CRP to fall by 50% is associated with [2]:
• increased 30-day mortality
• increased need for mechanical ventilation and/or inotropic support
• increased incidence of complicated pneumonia, eg empyema

Inadequate response or deteriotation

For patients who fail to improve as expected, there should be a careful review by an experienced clinician of:

• clinical history
• examination
• prescription chart
• results of all available investigations

In the light of clinical review, consider further investigations, including:

• white cell count (WCC)
• further specimens for microbiological testing

Repeat chest radiograph for patients who are not progressing satisfactorily after 3 days of treatment.

Remeasure C-reactive protein (CRP) in patients who are not progressing after 3 days of treatment:

• CRP usually falls by 50% by day 3 of treatment.
• failure of CRP to fall by 50% is associated with:
• increased 30-day mortality
• increased need for mechanical ventilation and/or inotropic support
• increased incidence of complicated pneumonia, eg empyema

Consider care of the dieing patient plan if patient fits criterea

Reassess diagnosis and look for complications

Common causes of treatment failure include:

• pulmonary embolism (PE) or infarction
• pulmonary oedema
• bronchial carcinoma
• bronchiectasis
• slow response in elderly patients
• complications of pneumonia, eg:
• empyema
• abscess
• pleural effusion
• unrecognised immunocompromised status
• resistant causative organism
• poor absorption of oral antibiotic
• nosocomial infections

Check results of microbiology for antibiotic resistance or atypical pathogen(s).

Consider referral to Thoracic Medicine

Symptoms Improving

Reconfirm by completing the swallowing assessment.

If on IV antibiotics consider switch to oral.

If the patient has been initially treated with intravenous (IV) antibiotics and there are no contraindications to oral therapy, consider switching to oral antibiotics:

• Perform a swallowing assessment to reconfirm diagnosis
• reassess the route of administration on the "post take" round, and daily thereafter

The antibiotic choices for the switch from IV to oral are straightforward where there are effective and equivalent oral and parenteral formulations:

• if parenteral cephalosporins are being used, a switch to oral co-amoxiclav is recommended rather than to oral cephalosporins for those treated with parenteral benzylpenicillin and levofloxacin, oral levofloxacin with or without oral amoxicillin is recommended

The following features indicate a response to parenteral therapy permitting consideration of oral antibiotic substitution:

• resolution of fever for longer than 24 hours
• pulse rate less than 100 beats per minute
• tachypnoea resolved
• clinically hydrated and taking oral fluids
• hypotension has resolved
• absence of hypoxia
• improving white cell count (WCC)
• non-bacteraemic infection
• no microbiological evidence of legionella, staphylococcal, or Gram-negative enteric bacilli infection
• no concerns over gastrointestinal (GI) absorption

Discharge and advise on secondary prevention

Consider discharge:

• patients should be reviewed within 24 hours of planned discharge home
• those suitable for discharge should not have more than one of the following clinical instabilities:
• temperature above 37.8°C
• heart rate above 100 beats per minute
• respiratory rate above 24 breaths per minute
• systolic blood pressure (BP) less than 90mmHg
• oxygen saturation (SpO₂) less than 90%
• inability to maintain oral intake
• abnormal mental status

Advise on measures for secondary prevention of community-acquired pneumonia (CAP):

• ensure immunisation is up to date, following Department of Health (DH) guidelines for the following vaccines:
• influenza vaccine – recommended for those aged 65 years or older and for people of any age with underlying chronic disease, or living in long-stay residential care
• pneumococcal vaccine (PPV) – should be given to all people over the age of 65 years, on a one-off basis
• reinforce smoking cessation advice if relevant
• Arrange a clinical review for all patients after 6 weeks, either with their GP or in a hospital clinic:
• it is the responsibility of the hospital team to arrange the follow-up plan with the patient and GP
• at discharge or follow-up, patients should be offered written information about CAP

Reassess in outpatient clinic as appropriate

Arrange a clinical review after 6 weeks, as an outpatient in secondary care if appropriate:

• it is the responsibility of the hospital team to arrange the follow-up plan with the patient and GP
• at discharge or follow-up, patients should be offered written information about community-acquired pneumonia (CAP)

Arrange a chest radiograph after 6 weeks for patients with:

• persistence of symptoms
• physical signs of illness
• a high risk of underlying malignancy - this especially includes all those who smoke and are age 50 years or older

Arrange follow-up with GP

Arrange a clinical review after 6 weeks, with patient's GP if appropriate:

• it is the responsibility of the hospital team to arrange the follow-up plan with the patient and GP
• at discharge or follow-up, patients should be offered written information about community-acquired pneumonia (CAP)

Arrange a chest radiograph after 6 weeks for patients with:

• persistence of symptoms
• physical signs of illness
• a high risk of underlying malignancy - this especially includes all those who smoke and are age 50 years or older