Antibiotic Guidelines: Hospital Acquired Pneumonia Reference Number: 144TD(C)25(C6) Version Number: 7 Issue Date: 17/07/2020 Page 1 of 12

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Hospital Acquired Pneumonia Antibiotic Guidelines

Lead Author: Antibiotic Steering Group

Additional author(s) Elizabeth Trautt (Consultant Microbiologist); Sue Wei Chong (Antimicrobial Pharmacist)

Division/ Department:: NCA Diagnostics and Pharmacy Group

Applies to: Salford Royal Care Organisation

Approving Committee Medicines Management Group

Date approved: 2/7/2020

Expiry date: July 2023

Contents

Contents

1. Overview (What is this guideline about?) ....................................................................... 2

2. Scope (Where will this document be used?) .................................................................. 2

3. Background (Why is this document important?) ............................................................. 2

4. What is new in this version? ............................................................................................ 3

5. Guideline. ........................................................................................................................ 3

5.1 Background information .................................................................................................. 3

Criteria for diagnosis of HAP ........................................................................................... 4

5.2 Early Onset Hospital Acquired Pneumonia (within 5 days of admission) ........................ 5

5.3 Late Onset Hospital Acquired Pneumonia (>5days after admission) .............................. 5

5.4 COVID19 ......................................................................................................................... 6

5.5 Aspiration pneumonia - hospital or community acquired ................................................. 7

6. Roles and responsibilities ................................................................................................ 7

7. Monitoring document effectiveness ................................................................................. 8

8. Abbreviations and definitions .......................................................................................... 8

9. References ...................................................................................................................... 8

10. Appendices ..................................................................................................................... 9

Appendix 1 – Fluoroquinolone adverse effects ......................................................................... 9

11. Document Control Information....................................................................................... 10

12. Equality Impact Assessment (EqIA) screening tool ....................................................... 11

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)

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1. Overview (What is this guideline about?)

This policy recommends antibiotic options for adult patients with Hospital Acquired Pneumonia. If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator.

2. Scope (Where will this document be used?)

This policy applies to all clinical staff involved in the prescribing of antimicrobials. This document provides treatment guidelines for the most common situations in which antibiotic treatment is required. The products and regimens listed here have been selected by the Trust's Medicines Management Group on the basis of published evidence. Doses assume a weight of 60-80kg with normal renal and hepatic function. Adjustments may be needed for the treatment of some patients.

This document provides treatment guidelines for the appropriate use of antibiotics. The recommendations that follow are for empirical therapy and do not cover all clinical circumstances. Alternative antimicrobial therapy may be needed in up to 20% of cases. Alternative recommendations will be made by the microbiologist in consultation with the clinical team. This document refers to the treatment of adult patients (unless otherwise stated). Refer to up to date BNF/SPC for information on interactions, side effects, cautions and contraindications for individual drugs. Associated Documents

144TD(C)25(A5) - Issue No 3.1 - Antimicrobial Stewardship Policy

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/topics-

prescriptions/antibiotic/antibiotic-prescribing-principles/144tdc25a5/

163TD(C)(33) – Issue No. 14 - Medicines Policy

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/trust-wide-

clinical/gen/163tdc33/?locale=en

3. Background (Why is this document important?)

Antimicrobial agents are among the most commonly prescribed drugs and account for 20% of the hospital pharmacy budget. Unfortunately, the benefits of antibiotics to individual patients are compromised by the development of bacterial drug resistance. Resistance is a natural and inevitable result of exposing bacteria to antimicrobials. Good antimicrobial prescribing will help to reduce the rate at which antibiotic resistance emerges and spreads. It will also minimise the many side effects associated with antibiotic prescribing, such as Clostridioides difficile infection. It should be borne in mind that antibiotics are not needed for simple coughs and colds. In some clinical situations, where infection is one

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of several possibilities and the patient is not showing signs of systemic sepsis, a wait and see approach to antibiotic prescribing is often justified while relevant cultures are performed. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use NICE guideline [NG15]

4. What is new in this version?

Alternative antibiotic options to oral levofloxacin added for information due to intermittent supply issues with levofloxacin.

Antibiotic recommendation included for mild HAP if NBM

This guideline has been updated for management of suspected or confirmed bacterial pneumonia in adults in hospital during the COVID-19 pandemic

5. Guideline.

5.1 Background information

Pneumonia is classified as “hospital acquired” (HAP) when it develops 48 hours or more after admission. However, the causative organisms of HAP do not consistently change from community to hospital pathogens until 5 days after admission. Hence, for the purposes of antimicrobial treatment:

- Pneumonia developing in the first 5 days of admission should be treated as community-acquired

- Pneumonia should be treated with a HAP regimen if the patient has been in hospital for more than 5 days or has had a hospital stay greater than 5 days within the last 1 month.

Patients admitted from Nursing Homes with pneumonia do not need to be treated as HAP unless they meet these criteria. Diagram 1 The common causative organisms of pneumonia developing after hospital admission, underlying the reason for antimicrobial recommendations.

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The diagnosis of hospital-acquired pneumonia (HAP) is often difficult as there is no national agreement on suitable diagnostic criteria. For this reason, HAP has often been ‘over diagnosed’ in the past and inappropriate therapy commenced. In order to determine whether a patient is likely to have HAP, the following criteria may be applied:

Criteria for diagnosis of HAP

1. New or persistent infiltrates on chest X-ray which are otherwise unexplained and /or purulent tracheal secretions Plus two of either 2. Peripheral blood neutrophils <4,000 or >10,000 per mm3, or 3. Core temperature <36oC or >38.3oC, or 4. Increased oxygen requirements Moderate or Severe Infection For the purpose of this guideline, Moderate or Severe infection is defined as HAP associated with 2 or more new SIRs criteria: 1. Core temperature <36oC or >38.3oC, or 2. Peripheral blood neutrophils <4,000 or >10,000 per mm3, or 3. Respiratory Rate > 20 4. Heart Rate > 90

First 48hrs 2-5 days >5 days

Streptococcus pneumoniae Viruses (Influenza, RSV) Haemophilus influenzae

Mycoplasma Chlamydophila

Moraxella catarrhalis

Coliforms (E coli, Klebsiella) Staph aureus Pseudomonas

Stenotrophomonas Plus community organisms

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Antibiotics are indicated if the patient fulfils the above criteria. A senior clinician may make a clinical decision to prescribe antimicrobial treatment outside the predictions of this scoring system if there is a good reason for deviation from the guidance. This should be documented in the case notes. All patients with pneumonia should receive treatment within one hour of diagnosis. Sputum should be cultured and consideration given to obtaining a lower respiratory tract sample by bronchoscopy, if clinically appropriate. Blood cultures should be collected where clinically indicated.

5.2 Early Onset Hospital Acquired Pneumonia (within 5 days of admission) Treatment: Treat as per Community Acquired Pneumonia Guidelines

5.3 Late Onset Hospital Acquired Pneumonia (>5days after admission) Treatment: NB: Patients admitted from Nursing Homes with pneumonia do not need to be treated as HAP unless they meet the criteria above. Mild infection: Doxycycline orally 200mg stat, then 100mg od If oral route is not available use IV co-trimoxazole 960mg BD Moderate or severe infection (For the purpose of this guideline, Moderate or Severe infection is defined as HAP associated with 2 or more new SIRs criteria): Piperacillin/tazobactam 4.5g IV tds (bd if CrCl <20ml/min, CKD 5). Consider qds if critical care, poor response or Pseudomonas infection. In case of true penicillin hypersensitivity (Piperacillin/tazobactam is a beta-lactam antibiotic), antibiotic choice depends on allergic reaction: Penicillin allergy - Anaphylaxis/angioedema/bronchospasm: Levofloxacin IV/PO 500mg bd. Penicillin allergy - without anaphylaxis/angioedema/bronchospasm: Meropenem IV 1g tds (bd if CrCl <50ml/min, reduce to od if CrCl <10ml/min). Seek specialist microbiological advice during the next working day (microbiology approval required for meropenem). Therapy must be reviewed within 72 hours and a prescribing decision documented. Therapy should be de-escalated according to sensitivities. If no growth: PO co-amoxiclav 625mg tds If penicillin allergy PO Levofloxacin 500mg BD

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Note: There have been intermittent supply issues with oral levofloxacin. If unavailable, a combination of Ciprofloxacin PO 500mg BD + Doxycycline PO 100mg OD will be an appropriate alternative. Total duration of treatment (including IV therapy): 7 days. Comment: 1. If MRSA infection is present add vancomycin (unless patient is on doxycycline for mild infection). Adjust the dose of vancomycin appropriately if the patient is elderly, has impaired renal function or is obese /underweight. This can be discussed with the ward pharmacist. For information or guidance on vancomycin therapeutic drug monitoring refer to Therapeutic Drug Monitoring Section of the Antibiotic Policy. 2. In case of severe illness, or if the patient has received recent courses of broad-spectrum antimicrobial agents, seek specialist microbiological advice and consider referral to a respiratory physician. 3. Consider the possibility of viral or ‘atypical’ pathogens such as Influenza or Legionella (see section on community-acquired pneumonia)

5.4 COVID19 COVID-19 pneumonia is caused by a virus, so antibiotics are ineffective unless there is a bacterial co-infection. If there is confidence that the clinical features are typical for COVID-19, it is reasonable not to start empirical antibiotics. Evidence so far suggests that bacterial co-infection occurs in less than about 10% of patients with COVID-19. But patients in critical care have an increased likelihood of bacterial infection compared with patients in other hospital wards or settings. Empirical antibiotics, as per HAP recommendations outlined in this document, should be started if there is clinical suspicion of bacterial infection, including characteristic symptoms and localised chest findings. Severity should be based on clinical judgement. Antibiotic Review Review all antibiotics at 24 to 48 hours or as soon as test results are available Use the following to help inform the overall clinical assessment and decision about when to safely stop antibiotics:

no evidence of bacterial infection in blood, urine or sputum samples

a positive SARS-CoV2 PCR test

fever resolved or resolving

symptoms and blood test results (particularly lymphopenia) consistent with COVID-19 pneumonia

chest imaging (plain X-ray, CT scan or lung ultrasound) consistent with COVID-19 pneumonia

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Continuing Antibiotics Continue antibiotics if there is clinical or microbiological evidence of bacterial infection, regardless of SARS-CoV2 PCR test results or if the SARS-CoV2 PCR test is positive but clinical features are not typical for COVID-19 pneumonia. Review antibiotic choice based on microbiological test results and switch to a narrower spectrum antibiotic when appropriate. Follow empiric guideline if no pathogens identified. Review antibiotics at 5 days Antiviral Treatment - Remdesivir Remdesivir is now available on application to treat patients with a severe COVID-19 infection. See the links below. Quick Reference Guide: Early Access to Medicines Scheme for Remdesivir in the treatment of COVID-19 - Guidance for Prescribers Dexamethasone Clinicians should consider dexamethasone for the management of hospitalised patients with COVID-19 who require oxygen or ventilation. See Dexamethasone in COVID-19

5.5 Aspiration pneumonia - hospital or community acquired All patients with pneumonia should receive treatment within one hour of diagnosis. All first doses of antibiotics MUST be prescribed on the STAT section of the drug chart. Blood and sputum should be cultured. Follow treatment protocol above for hospital or community acquired pneumonia as appropriate Metronidazole is ONLY indicated if patient has one of the following (ref: Primary Care: Aspiration Pneumonitis and Aspiration Pneumonia. New England Journal of medicine Mar 2001;344:665-671)

periodontal disease putrid sputum lung abscess

Initial treatment: To the treatment listed above ADD IV metronidazole 500 mg tds OR, if the enteral route is not compromised, prescribe oral metronidazole 400mg tds Oral continuation treatment: To the treatment listed above ADD Metronidazole 400mg tds

6. Roles and responsibilities

All clinical staff involved in the prescribing of antimicrobials to adhere to this policy including full documentation on EPMAR as detailed.

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7. Monitoring document effectiveness

Key standards:

Document the Indication/rationale for antimicrobial therapy.

Review and document the patient’s allergy status.

Ensure the choice of antibiotic complies with the antibiotic guidelines.

Method(s): Audits of compliance with the guideline will be conducted on a regular basis as part of the Antibiotic stewardship monthly audit. . Team responsible for monitoring: Ward Pharmacists Frequency of monitoring: Once every three years. Process for reviewing results and ensuring improvements in performance: Monthly compliance dashboards will be shared with the divisional leads, Antibiotic Steering Group and Infection Control Committee.

8. Abbreviations and definitions

BNF – British National Formulary CAP – Community-acquired pneumonia HAP – Hospital acquired pneumonia SPC – Summary of Product Characteristics

9. References

References 1. National Institute for health and Clinical Excellence COVID-19 rapid guideline: antibiotics

for pneumonia in adults in hospital.NG173. 1 May 2020

2. Masterton et al., Guidelines for the management of hospital-acquired pneumonia in the

UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society

for Antimicrobial Chemotherapy. J Antimicrob Chemother 2008, 62: 5–343. Pugin et al.,

Amer Rev Resp Dis 1991; 143: 1121

Acknowledgement of sources None

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10. Appendices

Appendix 1 – Fluoroquinolone adverse effects

*Fluoroquinolones warning

Please note that serious adverse events affecting musculoskeletal and nervous systems have

been reported very rarely with fluoroquinolone antibiotics (ciprofloxacin, levofloxacin,

moxifloxacin, ofloxacin). Fluoroquinolone treatment should be discontinued at the first signs of a

serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness,

joint pain, joint swelling, peripheral neuropathy, and central nervous system effects. Prescribe

with special caution for people older than 60 years, with renal impairment, or solid-organ

transplants as they are at a higher risk of tendon injury. The MHRA recommends avoiding use

of a corticosteroid with a fluoroquinolone since co-administration could exacerbate

fluoroquinolone-induced tendinitis and tendon rupture

Fluoroquinolones may be associated with a small increased risk of aortic aneurysm and

dissection, particularly in older patients. They should only be used after careful benefit-risk

assessment and after consideration of other therapeutic options in patients with, or at risk for,

aortic aneurysm and dissection.

For further information see November 2018 & March 2019 MHRA alerts.

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11. Document Control Information

All sections must be completed by the author prior to submission for approval

Lead Author: Sue Wei Chong (on behalf of Antibiotic Steering Group)

Lead author contact details:

0161 20 65819 Suewei.chong@srft.nhs.uk

Consultation List the persons or groups who have contributed to this guideline. (please state which Care Organisation)

Name of person or group

Role / Department / Committee (Care Org)

Date

Consultant Microbiologists

SCO June 2020

Antibiotic Steering Group SCO June 2020

Endorsement List the persons or groups who have seen given their support to this guideline. (please state which Care Organisation)

Name of person or group

Role / Department / Committee (Care Org)

Date

Elizabeth Trautt Antibiotic Steering Group Chair SCO 01/07/20

Richard Cooper Medicines Management Group Chair

SCO 18/11/2019

Keywords / phrases: Pneumonia, hospital-acquired, HAP, antibiotic, infection

Communication plan:

The guideline will form part of the Trust Antibiotic Policy and thus can be accessed via the Antibiotic and Infection Control hotlinks area on the front page of Synapse. Information about the policy will be sent to all ward managers, medical staff and pharmacists. In addition, adherence to the policy will be encouraged through FY1 and FY2 teaching sessions. The policy will be implemented in all areas with electronic prescribing.

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

This section will be completed following committee approval

Guideline Approval: Name of Approving Committee: Medicines Management Group

Chairperson: Dr Richard Cooper

Approval date: 2/7/2020

Formal Committee decision

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12. Equality Impact Assessment (EqIA) screening tool

Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/

involvement with service users, staff or other

groups in relation to this document?

Yes

Please state: Consulted critical care

teams. Email distribution to consultant

staff for comments. Discussions at

Antibiotic Steering Group and Medicines

Management Group. Discussion at ENT

directorate meeting.

1b) Have any amendments been made as a

result?

Yes – see changes to policy section

2) Does this guideline have the potential to affect any of the groups below differently or

negatively? This may be linked to access, how the process/procedure is experienced, and/or

intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure Reasons for decision

Age (e.g. are specific age groups excluded? Would the same

process affect age groups in different ways?) X

Sex (e.g. is gender neutral language used in the way the

guideline or information leaflet is written?) X

Race (e.g. any specific needs identified for certain groups such

as dress, diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

X

Religion & Belief (e.g. Jehovah Witness stance on blood

transfusions; dietary needs that may conflict with medication offered.)

X

Sexual orientation (e.g. is inclusive language used? Are

there different access/prevalence rates?) X

Pregnancy & Maternity (e.g. are procedures suitable for

pregnant and/or breastfeeding women?) X

Marital status/civil partnership (e.g. would there be any

difference because the individual is/is not married/in a civil partnership?)

X

Gender Reassignment (e.g. are there particular tests related

to gender? Is confidentiality of the patient or staff member maintained?)

X

Human Rights (e.g. does it uphold the principles of Fairness,

Respect, Equality, Dignity and Autonomy?) X

Carers (e.g. is sufficient notice built in so can take time off work

to attend appointment?) X

Socio/economic (e.g. would there be any requirement or

expectation that may not be able to be met by those on low or

x

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limited income, such as costs incurred?) Disability (e.g. are information/questionnaires/consent forms

available in different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

x

Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

x

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? Not applicable

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? Not applicable

5) Where the policy, procedure, guidelines, patient information leaflet or project impacts on patients how have you ensured that you have met the Accessible Information Standard – please state below: Not applicable ……………………………………………………………………………………………………………… EDI Team/Champion only: does the above ensure compliance with Accessible Information Standard

o Yes

o No

If no what additional mitigation is required:

Will this guideline require a full impact assessment? No Please state your rationale for the decision: Minor update to existing policy (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or

if you believe there is a potential for it to affect a group differently and do not know how to mitigate

against this - Please contact the Inclusion and Equality team for advice on equality@pat.nhs.uk) Author: Sue Wei Chong Date: 01/07/20 Sign off from Equality Champion: Date: