Community Acquired Pneumonia

Community Acquired Pneumonia –

Community acquired pneumonia (CAP) is an acute lower respiratory tract infection in a person who has not been admitted to hospital or a health
care facility in the previous 14 days for 48 hours or more. Residents of residential aged care facilities (RACF) acquire a variant of community
acquired pneumonia. Estimates indicate that approximately 2 in 1000 people in the adult population are diagnosed with CAP, and it accounts for
approximately 2% of all overnight hospital admissions. Residents of RACFs have a risk of acquiring CAP 10 times more than community living
adults, and admissions to hospital at a rate of 30 times more often. CAP accounts for 1/3 – 1/2 of all deaths in RACFs and is responsible for
increased rates in re-hospitalisation, mortality and morbidity.

Streptococcus pneumoniae is the commonest cause of CAP in RACFs Gram negative bacilli, Staphylococcus aureus and respiratory viruses are
predominant, whereas legionella, chlamydia and mycoplasma are uncommon pathogens.
The expected outcome of use of this protocol is rapid and effective relief from symptoms, improve/prevent respiratory distress, prevent
complications, eradicate infection in the respiratory tract, prevention of reoccurrence of infection, prevention of unnecessary hospitalisation, improve
morbidity and decrease the risk and rate of mortality. Alternatively, this clinical guideline may provide guidance in assisting with symptom relief in a
palliative care context for residents with severe complications. May include aspiration pneumonia or palliative care context.

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 Community Acquired Pneumonia

SCOPE OF PRACTICE
PRACTITIONER SCOPE OUTCOMES
Nurse Practitioner – • The expected outcome of use of this clinical
Aged Care guideline is effective relief from symptoms and
eradication of infection from the respiratory
tract, prevention of reoccurrence of infection,
reduction in hospitalisation rates, reduced
mortality or morbidity.
• Improve process of care variables and clinical
outcomes .
Medical Practitioner ± Nurse The NP will refer all Hall & Prior residents outside • Upon failure of treatment, complications of
Practitioner their scope of practice, to a medical practitioner. infection or recurrence of infection, referral to
a GP is required. Nurse practitioners should
consider referral to physiotherapy and a care
plan for nursing staff should be developed
incorporating management plan.

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 Community Acquired Pneumonia

RESIDENT’S ASSESSMENT
RESIDENT’S SCOPE
HISTORY
Presenting symptoms Signs and symptoms of CAP: fever, rigors, flushed,
new-onset cough, change in sputum colour (if cough
chronic), chest discomfort, dyspnoea, confusion, sore
throat, head cold symptoms, lethargy,3 elevated
temperature and heart rate, increased respiratory
rate, decreased oxygen saturation, respiratory
distress, dullness on percussion (if consolidation
present), decreased air entry, inspiratory crackles,
wheeze, bronchial breath sounds and pleural rub
(rare). C riteria/Confusion.Uremia.Respiratory Rate
.Blood Pressure .
OUTCOMES
• Gaining comprehensive and holistic data in
order to prescribe appropriate diagnostics and
interventions related to indicators identified in
assessment.
• Constructing and ruling out related differential
diagnoses to specific pathophysiology
identified.
• Prevent interactions and further complications
with interventions

Known risk factors for the Dysphagia, decreased physical & cognitive function,
presenting symptoms immunosupression, delirium, • Referrals will be considered in collaboration
malnutrition,COPD,asthma. with resident’s GP.

Previous medical history Relevant medical, surgical and obstetric history

Medications Current Medications

Other relevant information Allergies, previous respiratory tract infection history,

nutrition & hydration, mobility, cognition, behaviour

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 Community Acquired Pneumonia

PHYSICAL Ax SCOPE OUTCOMES

Usual physical examination Record findings: vital signs, respiratory assessment, • Correct diagnosis, provision of effective
cardiovascular assessment, pain assessment disease and symptomatic eradication/relief

INVESTIGATIONS
INDICATIONS INVESTIGATIONS OUTCOMES
Routine investigations Laboratory/diagnostics used in diagnosis and • Results from all investigations will be used
identification of organism: chest x-ray to identify when determining future management of the
diagnosis and consolidation in lungs and aid in resident’s.
diagnosis, pulse oximetry, sputum MCS to identify
pathogen and it’s sensitivities, blood chemistry and • Accurate diagnosis will be determined .
haematology (FBE, U & E, glucose) to help assist
defining severity and complications associated with • Refer to GP on result of investigation
CAP.
Pathology • Correct pharmacotherapy will be prescribed
To determine pathogen, Sputum MCS, based on sensitivity of organism.
severity & sensitivity of
organism.
Imaging
To determine location, extent Chest x-ray
and severity of infection

Haematology / Biochemistry
To confirm diagnosis & to FBC, U&E.
assist in determining severity
of infection

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 Community Acquired Pneumonia

SCOPE
INDICATIONS INVESTIGATIONS OUTCOMES

FOLLOW UP AND EDUCATION

INTERVENTION INFORMATION OUTCOMES
Pharmacotherapeutics Treatment of CAP involves pharmacological & non- • Eradication of infection
pharmacological treatment. Management of CAP • Prevention of recurrence of infection
involves antibiotic therapy, oxygen, analgesia, • Symptomatic relief
antipyretics & supportive nursing care & monitoring.
Antibiotic therapy is determined by determining the
causative pathogen and sensitivity.

Non-pharmacological Non-pharmacological, supportive nursing and

monitoring interventions include: regular observation
of vitals’ status (RR, HR, BP, SpO2, T ۫C), bed rest,
adequate hydration and nutrition, continuous oxygen
therapy, improving airway (i.e.posture, humidification,
suctioning, deep breathing & coughing exercises) and
assistance with activities of daily living.

Community Acquired Pneumonia

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 FOLLOW UP AND EDUCATION
INTERVENTION INFORMATION
Follow up appointments Resident’s needs to be reviewed daily post
commencing antibiotic therapy to reassess symptoms
and monitor for any complications or adverse
reactions to therapy. A follow up consultation is
required 10 days post therapy for review of signs and
symptoms and repeat sputum MCS approximately 10
days post completion date of antibiotic therapy is
required to validate eradication of infection and
determine if further antimicrobial treatment is
required.
Nurse practitioners are required to follow up on all
referrals they made to allied health and medical
specialists, provide and/or reinforce relevant
education regarding immunisation.
Letters Letter to residents GP
Community Acquired Pneumonia.doc Page 6 of 16
OUTCOMES
• Underlying disease will be detected at follow
up.
• Upon failure of treatment, complications of
infection or recurrence of infection, referral to a
medical specialist is required.1 Referral to an
occupational therapist and/or physiotherapist
should be considered if lack of mobility is a
contributing factor.
• Consider referral to a speech pathologist if
dysphagia an issue.
Review of resident notes
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 Community Acquired Pneumonia -
PHARMACOTHERAPY

Treatment of CAP involves pharmacological and non-pharmacological treatment. Management of CAP involves antibiotic therapy, oxygen,
analgesia, antipyretics and supportive nursing care and monitoring.

Antibiotic therapy is determined by what the causative pathogen is, the pathogen’s sensitivities and resistance and the severity of the individual’s
clinical presentation and/or PSI. Note that the PSI is only a guide and nurse practitioners should consider clinical and social contexts.5
Antibiotic therapy –
First line treatment
amoxycillin 1g PO 8 hourly
and
roxithromycin 300mg PO daily
or
doxycycline 200mg initial dose then 100mg PO daily

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 Community Acquired Pneumonia -
PHARMACOTHERAPY

Non-tropical region Tropical region

benzylpenicillin 1.2g IV 6 hourly gentamicin 4-6mg/kg IV daily
or and
amoxy/ampicillin 1g IV 6 hourly ceftriaxone 2g IV daily
and
roxithromycin 300mg PO daily
or
doxycycline 200mg/100mg PO daily
and
gentamicin 4-6mg/kg IV daily if gram-
negative bacilli isolated

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 Community Acquired Pneumonia -
PHARMACOTHERAPY

Hypersensitivity to penicillin:
replace penicillin: cefotaxime 1g IV 8 hourly (or ceftriaxone 1g IV daily) until
significant improvement then cefuroxime 500mg PO 12 hourly

Immediate sensitivity to penicillin:

replace penicillin: gatifloxacin 400mg PO daily
or
moxifloxacin 400mg PO daily

or
refer to medical practitioner and transfer to hospital if severe

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 Community Acquired Pneumonia -
PHARMACOTHERAPY

Analgesia and antipyretic

paracetamol 500mg-1g 6 hourly (max. 4g/day) PO/PR

Oxygen therapy

oxygen 6-10 L/min via nasal prongs or Venturi Mask

to maintain oxygen saturation > 97%

Community Acquired Pneumonia -

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 PHARMACOTHERAPY

FORMULARY
amoxycillin trihydrate clarithromycin
Drug (generic name): amoxycillin trihydrate
Poisons schedule: schedule 4 Drug (generic name): roxithromycin
Therapeutic class: 8(a) penicillins Poisons schedule: schedule 4
Dosage range: 250-500mg 8 hourly , In severe infection Therapeutic class: 8(d) macrolides
(pneumonia) 1Gram 8 hourly. Dosage range: 250-500mg
Route: oral Route: oral
Frequency of administration: 8 hourly Frequency of administration: 12hourly
Duration of order: 7 days Duration of order: 7 days
Actions: intervene in cell wall peptidoglycan synthesis, is Actions: binds to 50S ribosomal sub-unit, inhibits bacterial protein
bactericidal synthesis, is bacteriostatic
Indications for use: chronic bronchitis, CAP, acute bacterial otitis Indications for use: upper & lower respiratory tract infections,
media, sinusitis, epididymo-orchitis, acute prostatitis, acute CAP, recurrent tonsillitis, skin infections
pyelonephritis, UTI, gonococcol inf., prophylaxis: endocarditis, Contraindications for use: serious allergy to macrolides,
acute cholecystitis, peritonitis, combination therapy for eradication: Adverse drug reactions: nausea, vomiting, diarrhoea, abdo.
H. pylori pain/cramps, headache, dyspnoea, cough, candidiasis, taste
Contraindications for use: allergy to penicillins, cephalosporins, disturbance.
carbapenems
Adverse drug reactions: nausea, diarrhoea, rash, allergy

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 Community Acquired Pneumonia -
PHARMACOTHERAPY
doxycycline gentamicin (medical practitioner)
Drug (generic name): doxycycline Drug (generic name): gentamicin
Poisons schedule: schedule 4 Poisons schedule: schedule 4
Therapeutic class: 8(c) tetracyclines Therapeutic class: 8(f) aminoglycosides
Dosage range: 100mg-200mg (200mg first dose, followed by Dosage range: 4-6mg/kg
100mg daily) Route: intravenous
Route: oral Frequency of administration: daily or as single dose , depends
Frequency of administration: daily on severity.
Duration of order: 6 days Duration of order: until significant improvement
Actions: reversibly binds to 50S ribosomal sub-unit, inhibits Actions: irreversibly binds to 50S ribosomal sub-unit, inhibits
bacterial protein synthesis, is bacteriostatic bacterial protein synthesis, causes cell membrane damage, is
Indications for use: acne, M. pneumonia, CAP, chronic bactericidal with concentration dependence
bronchitis, sinusitis, non-gonococcol genital tract infections, PID, Indications for use: gram-negative infections (empirical Rx),
rickettsial infections, prostatitis, prophylaxis and treatment of systemic enterococcal infections, surgical & non-surgical
malaria prophylaxis, cystic fibrosis, bronchiectasis
Contraindications for use: children < 8years, allergy to Contraindications for use: serious allergy to aminoglycoside
tetracycline Adverse drug reactions: renal impairment, ototoxicity
Adverse drug reactions: nausea, vomiting, heartburn, tooth
discolouration, enamel dysplasia, reduced bone growth (children),
photosensitivity

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 Community Acquired Pneumonia -
PHARMACOTHERAPY
benzylpenicillin (medical practitioner)
Drug (generic name): benzylpenicillin
Poisons schedule: schedule 4
Therapeutic class: 8(a) penicillins
Dosage range: 1.2g
Route: intravenous
Frequency of administration: 6 hourly
Duration of order: until significant improvement
Actions: intervene in cell wall peptidoglycan synthesis, is
bactericidal
Indications for use: bacterial endocarditis, meningitis, aspiration
pneumonia, lung abscess, CAP, syphilis, septicaemia in children
Contraindications for use: allergy to penicillins, cephalosporins,
carbapenems
Adverse drug reactions: irritation at injection/IV site, nausea,
diarrhoea, urticaria, rash, superinfection, allergy (fever, chills,
headache and exacerbation of lesions when used in
syphilis/spirochete infections Jarisch-Herxheimer reaction)
Community Acquired Pneumonia.doc
amoxy / ampicillin (medical practitioner)
Drug (generic name): amoxy / ampicillin
Poisons schedule: schedule 4
Therapeutic class: 8(a) penicillins
Dosage range: 1g
Route: intravenous amoxicillin sodium for IV
Frequency of administration: 6 hourly
Duration of order: 5days
Actions: intervene in cell wall peptidoglycan synthesis, is
bactericidal
Indications for use: chromic bronchitis, CAP, acute bacterial
otitis media, sinusitis, epididymo-orchitis, acute prostatitis, acute
pyelonephritis, UTI, gonococcol infection, prophylaxis of
endocarditis, acute cholecystitis, peritonitis, combination therapy
for eradication H. pylori, shigellosis
Contraindications for use: allergy to penicillins, cephalosporins,
carbapenems
Adverse drug reactions: irritation at injection/IV site, nausea,
diarrhoea, urticaria, rash, superinfection, allergy
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 Community Acquired Pneumonia -
PHARMACOTHERAPY

ceftriaxone (medical practitioner) paracetamol

Drug (generic name): ceftriaxone Drug (generic name): paracetamol
Poisons schedule: schedule 4 Poisons schedule: unscheduled
Therapeutic class: 8(b) cephalosporins Therapeutic class: 4(b) simple analgesics and antipyretics, non-
Dosage range: 2g opiod analgesic.
Route: intravenous Dosage range: 500mg-1g
Frequency of administration: daily Route: oral/rectal
Duration of order: until significant improvement Frequency of administration: 4- 6 hourly
Actions: intervenes in bacteria cell wall peptidoglycan synthesis Duration of order: as required max 4g daily
Indications for use: severe pneumonia, orbital cellulitis, bacterial Actions: inhibition of prostaglandin synthesis
meningitis, gonococcal infection, PID, epiglottitis, septicaemia, Indications for use: mild-moderate pain, migraine, headache,
prophylaxis: meningococcal disease, H. influenzae, cholecystitis, fever, muscular pain
peritonitis, Salmonella, typhoid, sexually transmitted epididymo- Contraindications for use: nil –caution for resident with liver
orchitis disease.
Contraindications for use: allergy to penicillins, cephalosporins, Adverse drug reactions: (rare) rash, drug fever, mucosal lesions,
carbapenems neutro/pancyto/thrombocytopenia
Adverse drug reactions: nausea, diarrhoea, electrolyte
imbalance, rash, pancreatitis, cholecystitis, pseudolithiasis,
nephrolithiasis

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 Community Acquired Pneumonia -
PHARMACOTHERAPY

moxifloxacin cefotaxime (medical practitioner)

Drug (generic name): moxifloxacin Drug (generic name): cefotaxime
Poisons schedule: schedule 4 Poisons schedule: schedule 4
Therapeutic class: 8(e) quinolones Therapeutic class: 8(b) cephalosporins
Dosage range: 400mg Dosage range: 1g
Route: oral Route: intravenous
Frequency of administration: daily Frequency of administration: 8 hourly
Duration of order: 7 days Duration of order: until significant improvement
Actions: blocks DNA gyrase & topoisomerase IV, thus inhibiting Actions: intervenes in bacteria cell wall peptidoglycan synthesis
DNA synthesis, is bactericidal Indications for use: severe pneumonia, orbital cellulitis, bacterial
Indications for use: severe CAP, acute bacterial chronic meningitis, gonococcal infection, PID, epiglottitis, septicaemia,
bronchitis & sinusitis (where other Rx failed or contraindicated), acute cholecystitis, acute peritonitis
gonorrhoea, severe mixed aerobic & anaerobic infections, Contraindications for use: allergy to penicillins, cephalosporins,
resistant tuberculosis carbapenems
Contraindications for use: allergy to quinolones, prolongation of Adverse drug reactions: nausea, diarrhoea, electrolyte
QT interval, or Rx with drugs that prolong QT interval. imbalance, irritation at injection/IV site
Adverse drug reactions: nausea, vomiting diarrhoea, abdo. pain,
dyspepsia, rash, itch, dizziness, taste change

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