Pneumonia and Aspiration Pneumonia in Residential Care Facilities

Comments from Expert Advisory Committee

  • Nursing home-acquired pneumonia is defined as pneumonia occurring in a resident of a residential care facility or nursing home and more closely resembles community-acquired pneumonia than hospital-acquired pneumonia.
  • Empiric antibiotic treatment approach is dependent on severity and should be selected using the CRB-65 score below.

CRB65 is used to assess 30 day mortality risk in adults with pneumonia and is a useful scoring tool to help guide the selection of empiric antibiotic therapy. The score is calculated by giving 1 point for each of the following prognostic features:

  • Confusion (defined as a Mental Test Score of 8 or less, or new disorientation in person, place or time)
  • Respiratory rate ≥30/minute
  • Low blood pressure systolic [< 90 mmHg] or diastolic [≤ 60 mmHg]
  • Age 65 or more
  • There is no validated tool available to assess the severity of signs and symptoms in aspiration pneumonia, however in practice the CRB-65 score is also used.
  • Antibiotic recommendations in this guideline have been selected taking into account older age, polypharmacy, dysphagia and renal impairment which are common in patient populations in residential care facilities.
  • Where dysphagia is an issue, doxycycline capsules should not be opened as contents can cause oesophageal irritation. Doxycycline dispersible tablets are available as an unlicensed medicine. For pharmacies that provide a service to residential care facilities, it is recommended a small quantity of dispersible doxycycline is kept in stock to avoid a delay in supply.

Aspiration Pneumonia

  • Antibiotics are not indicated for aspiration or aspiration pneumonitis without evidence of bacterial infection.
  • Empirical treatment for aspiration pneumonia does not require coverage for anaerobic organisms.
  • Prophylactic antibiotics do not help prevent the development of aspiration pneumonia and are not recommended.
  • Discuss antibiotic choice with microbiology or infection specialist if risk factors for multi-drug resistant pathogens, failure to respond to empirical treatment or concerns of complications such as lung abscess or empyema.

Other considerations

  • Consider all individuals with cough, fever or suggestive symptoms to have COVID-19 until proven otherwise.
  • During the influenza season, always consider influenza and other seasonal respiratory viruses.
  • At convalescence, ensure COVID-19, influenza and pneumococcal vaccinations are up to date.

Treatment

Pneumonia / Aspiration Pneumonia: Antibiotic Treatment Table​
Assess using the CRB-65 score (each symptom or sign scores one point)
(Confusion, Respiratory rate ≥ 30/min, BP ≤ 90/60 mmHg, Age ≥ 65) ​
Drug Dose Duration Notes
CRB-65 Score 0-2 and assessed suitable for treatment in the residential care facility/ nursing home
Review if symptoms are not improving within 48-72 hours as expected with antibiotics and escalate therapy, or consider hospital referral.

1st line option

Amoxicillin

CRB-65 score 0:
500mg every 8 hours

CRB-65 score 1-2:
500mg-1g every 8 hours

5 days
  • Avoid in penicillin allergy.
  • Amoxicillin liquid available: 250mg/5ml or 125mg/5ml
  • Consider adding Clarithromycin 500mg every 12 hours for 5 days if concern of atypical pathogen (e.g. mycoplasma, legionella).
  • See Macrolide warning and check drug interactions.
  • Clarithromycin liquid available: 250mg/5ml or 125mg/5ml.

2nd line option

Doxycycline

(1st line in penicillin allergy)

200mg every 24 hours

or 100mg every 12 hours
5 days
  • If dysphagia is a concern, do not open capsules as the contents can cause oesophageal irritation. Doxycycline is available as 100mg dispersible tablet (ULM) - see expert advisory comments.
  • Advise to take with a glass of water and sit upright for 30 minutes after taking. Can take with food or milk.
  • Absorption is significantly impaired by antacids, iron/calcium/magnesium/zinc-containing products.

Alternatively consider clarithromycin 500mg every 12 hours for 5 days if doxycycline contraindicated.

CRB-65 Score 3 or more : Consider urgent hospital transfer or treat in a nursing home/ residential care facility if not for hospital admission

Prior to urgent hospital transfer administer:

Benzylpenicillin

OR 

Amoxicillin

1.2g IV/IM STAT

 

1g PO STAT

N/A

  • Avoid in penicillin allergy
  • Urgent hospital admission only

CRB-65 Score 3 or more :

Treatment in a nursing home/ residential care facility if not for hospital admission

1st line option

Co-amoxiclav

625mg every 8 hours

5 days
  • Avoid in penicillin allergy.
  • Liquid co-amoxiclav available as:
    Augmentin Paediatric® suspension 125mg/31.25mg/5ml 
    Dose 625mg = 20ml suspension
    (Augmentin Duo® Suspension not recommended in adults)

Consider adding Clarithromycin 500mg every 12 hours if concern of atypical pathogen (e.g. mycoplasma, legionella).  

2nd line option

Levofloxacin

(1st line in penicillin allergy)
500mg every 12 or 24 hours depending on severity 5 days
  • If dysphagia is a concern, tablets will not disperse in water and crushing tablets in not recommended. Liquid preparation not available. Contact microbiologist for advice. May need to consider IV therapy / hospital admission.  
  • Consider Fluoroquinolone warning
  • Dose adjustment required in renal impairment
  • Check for drug interactions
  • Absorption is significantly impaired by antacids, iron/calcium/magnesium/zinc-containing products.
  • Increased risk of tendon damage with concomitant use of steroids.
  • Lowers seizure threshold and is contraindicated in epilepsy

Pneumonia Aspiration Pneumonia: Antibiotic Treatment Table March 2022.pdf (size 464.7 KB)

Patient Information

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Reviewed March 2022

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