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. See Macrolide warning and check drug interactions. Clarithromycin liquid available: 250mg/5ml or 125mg/5ml
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). See Macrolide warning and check drug interactions. Clarithromycin liquid available as: 250mg/5ml or 125mg/5ml
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

Patient Information

The HSE Health A-Z website provides patient information on many hundreds of conditions and treatments.

HSE Health Care Associated Infection and Antimicrobial Resistance page for leaflets on MRSA, CPE etc

Safe Prescribing (visit the safe prescribing page)

Doses are oral and for adults unless otherwise stated
Clarithromycin and other macrolides warning
Fluoroquinolone warning
Penicillin allergy – tips on prescribing in penicillin allergy
Renal impairment dosing table
Safety in Pregnancy and Lactation
Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed March 2022