Hospital acquired Pneumonia HAP (NICE 139)
Related Subjects: Asthma
|Acute Severe Asthma
|Exacerbation COPD
|Pulmonary Embolism
|Cardiogenic Pulmonary Oedema
|Pneumothorax
|Tension Pneumothorax
|Respiratory (Chest) infections Pneumonia
|Fat embolism
|Hyperventilation Syndrome
|ARDS
|Respiratory Failure
💊 Start antibiotics within 4 hours of diagnosis.
🔬 Always review when culture/microbiology results return → step down to narrower spectrum if safe.
🚨 If no improvement or clinical deterioration → seek urgent Microbiology advice.
📘 About
- Pneumonia occurring >48 hrs after hospital admission 🏥.
- Usually involves organisms with greater resistance than community-acquired pneumonia (CAP).
- Associated with longer hospital stays, invasive devices (ET tubes, catheters), and immunosuppression.
🦠 Microbiology
- Gram-negative bacilli (>50%): E. coli, Klebsiella, Proteus, Pseudomonas, Acinetobacter, H. influenzae.
- Gram-positive cocci: Staphylococcus aureus (including MRSA), Streptococcus pneumoniae.
- Anaerobes: Bacteroides, Clostridia – especially in aspiration pneumonia overlap.
⚠️ Risk Factors
- Frailty, major surgery, prolonged bedrest, or alcoholism 🍺.
- Neurological conditions (stroke, Parkinson’s, MND, coma, seizures) → dysphagia & aspiration risk 🧠.
- Chronic lung disease, smoking 🚬, immunosuppression 💉, IVDU, trauma.
🔍 Clinical Features
- Respiratory: breathlessness 😮💨, cough with sputum, pleuritic chest pain.
- Systemic: fever 🌡️, rigors 🥶, sweats, delirium/confusion in elderly 👵.
- CV: hypotension, tachycardia, new AF ❤️.
- Hypoxia & cyanosis – may progress to type 1 respiratory failure 🫁.
🧪 Investigations
- Bloods: FBC (raised WCC), CRP ↑, U&E (AKI risk).
- Imaging: CXR (patchy consolidation, often RLL); CT chest if diagnostic uncertainty 📷.
- ABG: assess oxygenation; type 1 failure common.
- ECG: tachycardia, arrhythmias.
- Microbiology: blood cultures, sputum culture, pneumococcal/legionella urine Ag if atypical features.
🔄 Differentials
- PE 🫀 (may coexist with pneumonia).
- Aspiration pneumonia 🌊 (often overlaps with HAP).
- Community Acquired pneumonia 🌊 (often overlaps with HAP).
- Heart failure ❤️ (often overlaps with HAP).
🩺 Management
- Resuscitation: ABC, oxygen (target 94–98%, or 88–92% in COPD) 🫁, IV fluids 💧.
- Early broad-spectrum antibiotics (see below), then tailor once results available 💊.
- Supportive: VTE prophylaxis 🩸, optimise hydration & nutrition, chest physiotherapy, early mobilisation 🚶.
- Escalation planning (severe frailty, poor prognosis) – discuss ceiling of care early 🗨️.
💊 Antibiotic Therapy
- Non-severe HAP (oral, clinically stable, low resistance risk):
- Co-Amoxiclav 500/125 mg TDS PO × 5 days.
- Alternatives (if penicillin-allergic/unsuitable):
• Doxycycline 200 mg stat, then 100 mg OD × 4 days.
• Cefalexin 500 mg BD–QDS (↑ to 1–1.5 g if severe) × 5 days.
• Co-trimoxazole 960 mg BD × 5 days.
• Levofloxacin 500 mg OD/BD (Micro advice only).
- Severe HAP / high resistance risk (initial IV therapy ≥48h):
- Piperacillin–Tazobactam (Tazocin) 4.5 g TDS (↑ QDS if severe).
- Ceftazidime 2 g TDS, or Ceftriaxone 2 g OD.
- Cefuroxime 750 mg TDS–QDS (↑ 1.5 g if severe).
- Meropenem 0.5–1 g TDS (Micro advice only).
- Ceftazidime–Avibactam 2/0.5 g TDS (Micro advice only).
- Levofloxacin 500 mg OD/BD (specialist advice only).
- If MRSA suspected/confirmed (add to IV regimen):
- Vancomycin 15–20 mg/kg BD–TDS (max 2 g/dose; monitor trough levels).
- Linezolid 600 mg BD (if Vancomycin unsuitable; Micro advice only).
📖 References
