Hospital-acquired pneumonia: symptoms develop >48hr after hospital admission

Patient clinically unstable:

• Fever in the past 48 hours

• Systolic BP <90 mm Hg

• Heart rate >100/min

• Respiratory rate >24/min

• O2 sat<90% or PaO2 <60 mmHg in room air

Assess severity

No validated severity assessment tools were available for hospital-acquired pneumonia.

Treatment

1. Offer an antibiotic(s) within 4 hours of establishing diagnosis

2. Consider severity and sensitivity assessment when selecting antibiotic(s)

3. Send a sample (sputum, nasopharyngeal swab, tracheal aspirate) for microbiological testing

4. Initiate antibiotic treatment for 5 days, then review (stop or continue or change)

5. Give oral antibiotics first line if possible

6. Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible

Non-severe symptoms/signs
ORAL antibiotics

Co-amoxiclav

+ higher risk of resistance
or penicillin allergy
or co-amoxiclav unsuitable

Doxycycline
Cefalexin
Co-trimoxazole
Levofloxacin
(Clarithromycin preferred if child)

Severe symptoms/signs (e.g. sepsis)
INTRAVENOUS antibiotics

Piperacillin with tazobactam
Ceftazidime
Ceftriaxone
Cefuroxime
Meropenem
Ceftazidime with avibactam
*Levofloxacin (consider safety issues)

Add on therapy if MRSA

Vancomycin
Teicoplanin
Linezolid

*Levofloxacin:
Very rare irreversible side effects affecting musculoskeletal and nervous systems.
Stop treatment if serious adverse reaction (such as tendonitis)
Caution in using antibiotic if age>60y
Avoid co-administration with corticosteroid