Community Acquired Pneumonia Antibiotic Guidelines Reference Number: 144TD(C)25(C2) Version Number: 6 Issue Date: 17/07/2020 Page 1 of 13

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Community 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 ..................................................................................................................... 2

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

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

5.1 Community Acquired Pneumonia Investigations ............................................................. 3

5.2 Community Acquired Pneumonia Severity Assessment .................................................. 4

5.3 Empiric antibiotic treatment in patients NOT taking tacrolimus or clclosporin ................. 5

5.4 Empiric antibiotic treatment in patients taking tacrolimus or clclosporin .......................... 6

5.5 COVID-19 ........................................................................................................................ 7

5.6 Legionella pneumonia ..................................................................................................... 8

5.7 Aspiration pneumonia -either hospital or community acquired ........................................ 8

6. Roles and responsibilities ................................................................................................ 8

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

8. Abbreviations and definitions .......................................................................................... 9

9. References ...................................................................................................................... 9

10. Appendices ................................................................................................................... 10

Appendix 1 – Fluoroquinolones adverse effects ..................................................................... 10

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

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

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 guideline provides recommendations on the management of patients with community-acquired pneumonia and empirical antibiotic choices.

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

This policy applies to all clinical staff involved the prescribing of antimicrobials.

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

144TD(C)25(C6) – Issue No. 6.1 – Hospital Acquired Pneumonia – Antibiotic Guidelines

http://intranet/policies-resources/trust-policy-documents/directorate-department-

clinical/ag/144tdc25c6/

144TD(C)25(H3) – Issue No. 5 - IV Vancomycin dosing and monitoring Antibiotic

Guidelines http://intranet/policies-resources/trust-policy-documents/directorate-

department-clinical/ag/144tdc25h3/

3. Background

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 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.

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.

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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). Please refer to up to date BNF/SPC for a full list of cautions, contra-indications, interactions and adverse effects of individual drugs

4. What is new in this version?

Updated guidelines for treatment of community acquired pneumonia during the COVID 19 pandemic in line with new NICE guidelines

Included section on testing and management in COVID19

Included section on CAP investigations

Vancomycin has been removed for CAP CURB4-5 in penicillin allergic patients NOT on tacrolimus/ciclosporin, as levofloxacin as single agent is appropriate

For CAP CURB4-5 in patients on tacrolimus/ciclosporin, treatment has been changed to levofloxacin monotherapy in both penicillin allergy (previously vancomycin + ciprofloxacin) and non-penicillin allergy (previously benzylpenicillin + ciprofloxacin) to simplify regime as single agent levofloxacin is appropriate.

Alternative antibiotic options to oral levofloxacin added for information in case of levofloxacin shortage due to intermittent supply issues

Treatment option for Legionella pneumonia has been included

5. Guideline

Pneumonia has been defined as acute respiratory illness (presumed to be infective) with new pulmonary infiltrate on Chest X-Ray. This guideline has been updated to include management of suspected or confirmed community acquired bacterial pneumonia in adults in hospital during the COVID-19 pandemic If patient is immunocompromised please discuss treatment with the Microbiology Team Community-acquired pneumonia must be distinguished from hospital-acquired pneumonia as the criteria for assessment and treatment protocols are different. Aspiration pneumonia is covered in section 5.4.

5.1 Community Acquired Pneumonia Investigations For patients with low severity CAP, microbiological investigations are not recommended routinely. Moderate/High severity CAP consider the following Investigations:

Respiratory samples for routine culture and sensitivities (eg sputum or tracheal aspirate sample)

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Blood culture (if clinically indicated)

SARS-CoV2 PCR - nasopharyngeal aspirate, nose and throat swabs, or a lower respiratory tract sample if obtainable

Chest imaging (X-ray, CT or ultrasound)

Full blood count, urea and electrolytes

Urine sample for pneumococcal antigen tests

Urine sample for legionella antigen tests (CURB score >/=3). See also Section 5.6

Consider testing for influenza during influenza season, or if there is a history of recent travel.

5.2 Community Acquired Pneumonia Severity Assessment

It is recommended that Healthcare professionals use clinical judgement along with CURB65 score to assess the severity of community-acquired pneumonia. CURB-65 score for community acquired pneumonia: (See Thorax 2003; 58: 377 for details of this scoring system and mortality rates)

Score 1 point if each of the following risk factors is present- score 0 if absent: New Confusion 0 1 Blood Urea > 7 mmol/l 0 1

Resp Rate >= 30 0 1

BP <90 mm systolic or <60 mm Diastolic 0 1

Age >= 65 0 1 Score 0, Mortality =0.7%, Score 1, Mortality = 2%, Score 2, Mortality = 9%

Score 3, Mortality = 14%, Score 4, Mortality = 40%, Score 5, Mortality =57%

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5.3 Empiric antibiotic treatment in patients NOT taking tacrolimus or clclosporin

First Line

Penicillin Allergy

Low Clinical severity (OR CURB65 0-1) All patients should receive treatment within 4 hours of presentation, ideally within 1 hour

PO Amoxicillin 500mg TDS Add clarithromycin if failure to respond to a course of amoxicillin prior to admission OR if atypical pneumonia is suspected Duration: 5 days

PO Clarithromycin 500mg BD Duration: 5 days

Moderate Clinical severity (OR CURB65 2-3) All patients should receive treatment within 4 hours of presentation, ideally within 1 hour

IV Benzylpenicillin 1.2g QDS PLUS PO Doxycycline 200mg stat followed by 100mg OD (if NBM use IV clarithromycin 500mg BD) ORAL Step-down: PO Amoxicillin 500mg TDS PLUS PO Doxycycline 100mg OD Duration: 7 days

PO Doxycycline 200mg stat followed by 100mg OD (if NBM use IV clarithromycin 500mg BD) Duration: 7 days

High Clinical severity (OR CURB65 4-5) All patients should receive treatment within one hour of diagnosis

IV Co-amoxiclav 1.2g TDS PLUS IV Clarithromycin 500 mg twice daily Oral Step-down: PO Co-amoxiclav 625mg TDS PLUS PO Clarithromycin 500 mg BD Duration: 7 – 10 days

IV/PO Levofloxacin 500mg BD Oral Step-down: PO levofloxacin 500mg BD (if unavailable use PO ciprofloxacin 500mg BD + PO doxycycline 100mg OD) Duration: 7 – 10 days

MRSA pneumonia is not common, but add IV Vancomycin if suspected

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5.4 Empiric antibiotic treatment in patients taking tacrolimus or clclosporin

First Line

Penicillin Allergy

Low Clinical severity (OR CURB65 0-1) All patients should receive treatment within 4 hours of presentation, ideally within 1 hour

PO Amoxicillin 500mg TDS Duration: 5 days

PO Doxycycline 200mg stat, followed by 100mg OD Duration: 5 days

Moderate Clinical severity (OR CURB65 2-3) All patients should receive treatment within 4 hours of presentation, ideally within 1 hour

IV Benzylpenicillin 1.2g QDS PLUS PO Doxycycline 200mg stat followed by 100mg OD (if NBM replace both with IV Levofloxacin 500mg BD) Oral Step-down: PO Amoxicillin 500mg TDS PLUS PO Doxycycline 100mg OD Duration: 7 days

PO Doxycycline 200mg stat followed by 100mg OD (if NBM use IV Levofloxacin 500mg BD) Duration: 7 days

High Clinical severity (OR CURB65 4-5) All patients should receive treatment within one hour of diagnosis

IV/PO Levofloxacin 500mg BD Oral Step-down: PO levofloxacin 500mg BD (if unavailable use PO ciprofloxacin 500mg BD + PO doxycycline 100mg OD) Duration: 7 – 10 days

IV/PO Levofloxacin 500mg BD Oral Step-down: PO levofloxacin 500mg BD (if unavailable use PO ciprofloxacin 500mg BD + PO doxycycline 100mg OD) Duration: 7 – 10 days

MRSA pneumonia is not common, but add IV Vancomycin if suspected

Antibiotic Review Review all antibiotics at 24 to 48 hours or as soon as test results are available and switch to a narrower spectrum antibiotic when appropriate. If no pathogens identified follow empiric antibiotic choice. Follow IV to PO switch criteria in the Antimicrobial Stewardship guideline Comment: If a patient has failed to respond to the treatment regime recommended above, consider and investigate secondary diagnosis or complications of CAP. Discuss with microbiology if a change in treatment regime is required. See Appendix 1 for recent safety alerts on fluoroquinolones including ciprofloxacin and levofloxacin.

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5.5 COVID-19

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. Antibiotics Empirical antibiotics should be started if there is clinical suspicion of bacterial infection, including characteristic symptoms and localised chest findings.

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

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

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5.6 Legionella pneumonia

Discuss with a respiratory physician or a medical microbiologist Indications for Legionella urinary antigen testing in a patient with pneumonia are: travel within 2 weeks of onset of symptoms, ICU admission, failure to respond to therapy, active alcohol abuse, pleural effusion and severe infection Paired serology for atypical pneumonia (‘respiratory screen’) is no longer available. Respiratory virus detection by PCR of tracheal secretions may be helpful in ICU and paediatric patients (bronchiolitis) and must be approved by a microbiologist, paediatrician or respiratory physician. Specific treatment: Levofloxacin 500mg BD IV/PO. Advice on treatment duration should be obtained from discussion with microbiology.

5.7 Aspiration pneumonia -either hospital or community acquired

Follow treatment protocol above for hospital or community acquired pneumonia as appropriate Metronidazole is ONLY indicated if patient has one of the following (ref: NEJM 2019;380(70):651-663)

periodontal disease putrid sputum lung abscess

If any of these are present ADD IV metronidazole 500mg tds OR if enteral route not compromised prescribe PO metronidazole 400mg tds If already on co-amoxiclav no need for additional metronidazole

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.

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.

Prescribe single dose antibiotics for surgical prophylaxis, unless policy states otherwise.

Administer antibiotic prophylaxis within 60 minutes prior to surgical incision (administration must be complete before the incision, and before inflation of the tourniquet when used)

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Audits of compliance with the guideline will be conducted on a regular basis as part of the Antibiotic Point Prevalence study. Compliance with guidelines is also one of the elements of the Antibiotic prescribing bundle which is audited monthly

8. Abbreviations and definitions

BNF – British National Formulary CAP – Community-acquired pneumonia COVID-19 – Coronavirus disease 2019 EPMAR – Electronic prescribing medication administration record

IV - Intravenous

MHRA - Medicines and Healthcare products Regulatory Agency

PO - oral

SPC – Summary of Product Characteristics

9. 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. National Institute for health and Clinical Excellence COVID-19 rapid guideline: managing

suspected or confirmed pneumonia in adults in the community NICE guideline [NG165]

Updated 23 April 2020

3. British Thoracic Society community acquired pneumonia in adults guideline group.

Guidelines for the management of community acquired pneumonia in adults: update 2009.

Thorax October 2009, 64: Supp III pages iii1-iii55

4. National Institute for health and Clinical Excellence. Pneumonia: Diagnosis and

management of community- and hospital-acquired pneumonia in adults.December 2014.

5. Longo DL. Aspiration pneumonia. NEJM 2019;380(70):651-663

6. IDSA/ATS consensus guidelines on the management of CAP in adults. CID 2007; 44 Suppl. 2: S27-S72

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10. Appendices

Appendix 1 – Fluoroquinolones 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 Antimicrobial Pharmacist

Lead author contact details:

Suewei.chong@srft.nhs.uk 01612 065819

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

Microbiologists SCO June 2020

Dr Graham Wood Renal consultant, SCO June 2020

Antibiotic Steering Group SCO June 2020

Respiratory consultants SCO June 2019

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

Dr Elizabeth Trautt Antibiotic Steering Group July 2020

Dr Richard Cooper Medicines Management Group Chair

SCO July 2019

Dr Alex Peel Antibiotic Steering Group Chair SCO June 2019

Keywords / phrases: Antibiotics, infection, pneumonia, COVID-19, remdesivir, CAP, community-acquired pneumonia

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. In addition, adherence to the policy will be encouraged through FY1 and FY2 teaching sessions.

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: 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 renal and critical

care teams. Circulated to medical

microbiologists and respiratory

physicians, discussed at ASG

1b) Have any amendments been made as a

result?

Yes

Please Comment: as above in changes

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 limited income, such as costs incurred?)

x

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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: Update to existing version of guideline and none of the changes made are identified as likely to affect equality or diversity outcomes (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:01/07/2020 Sign off from Equality Champion: Date: