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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SCOPE OF PRACTICE
PRACTITIONER
Nurse Practitioner Aged Care
SCOPE
OUTCOMES
The expected outcome of use of this clinical 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 . Upon failure of treatment, complications of 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.
Medical Practitioner Nurse Practitioner
The NP will refer all Hall & Prior residents outside their scope of practice, to a medical practitioner.
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RESIDENTS ASSESSMENT
RESIDENTS HISTORY
Presenting symptoms
SCOPE
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 . Dysphagia, decreased physical & cognitive function, immunosupression, delirium, malnutrition,COPD,asthma. Relevant medical, surgical and obstetric history Current Medications Allergies, previous respiratory tract infection history, nutrition & hydration, mobility, cognition, behaviour
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 Referrals will be considered in collaboration with residents GP.
Known risk factors for the presenting symptoms Previous medical history Medications Other relevant information
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Community Acquired Pneumonia PHYSICAL Ax

Usual physical examination
SCOPE
Record findings: vital signs, respiratory assessment, cardiovascular assessment, pain assessment
OUTCOMES
Correct diagnosis, provision of effective disease and symptomatic eradication/relief
INVESTIGATIONS
INDICATIONS
Routine investigations
INVESTIGATIONS
Laboratory/diagnostics used in diagnosis and identification of organism: chest x-ray to identify diagnosis and consolidation in lungs and aid in diagnosis, pulse oximetry, sputum MCS to identify pathogen and its sensitivities, blood chemistry and haematology (FBE, U & E, glucose) to help assist defining severity and complications associated with CAP. Sputum MCS,
OUTCOMES
Results from all investigations will be used when determining future management of the residents. Accurate diagnosis will be determined . Refer to GP on result of investigation Correct pharmacotherapy will be prescribed based on sensitivity of organism.
Pathology To determine pathogen, severity & sensitivity of organism. Imaging To determine location, extent and severity of infection Haematology / Biochemistry To confirm diagnosis & to assist in determining severity of infection
Chest x-ray
FBC, U&E.
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SCOPE
INDICATIONS INVESTIGATIONS OUTCOMES
FOLLOW UP AND EDUCATION

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

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FOLLOW UP AND EDUCATION

INTERVENTION
Follow up appointments
INFORMATION
Residents 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. Letter to residents GP
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.
Letters
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 pathogens sensitivities and resistance and the severity of the individuals 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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Non-tropical region benzylpenicillin 1.2g IV 6 hourly or amoxy/ampicillin 1g IV 6 hourly and roxithromycin 300mg PO daily or doxycycline 200mg/100mg PO daily and gentamicin 4-6mg/kg IV daily if gramnegative bacilli isolated
Tropical region gentamicin 4-6mg/kg IV daily and ceftriaxone 2g IV daily
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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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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%
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PHARMACOTHERAPY FORMULARY
amoxycillin trihydrate
Drug (generic name): amoxycillin trihydrate Poisons schedule: schedule 4 Therapeutic class: 8(a) penicillins Dosage range: 250-500mg 8 hourly , In severe infection (pneumonia) 1Gram 8 hourly. Route: oral Frequency of administration: 8 hourly Duration of order: 7 days Actions: intervene in cell wall peptidoglycan synthesis, is bactericidal Indications for use: chronic bronchitis, CAP, acute bacterial otitis media, sinusitis, epididymo-orchitis, acute prostatitis, acute pyelonephritis, UTI, gonococcol inf., prophylaxis: endocarditis, acute cholecystitis, peritonitis, combination therapy for eradication: H. pylori Contraindications for use: allergy to penicillins, cephalosporins, carbapenems Adverse drug reactions: nausea, diarrhoea, rash, allergy Drug (generic name): roxithromycin Poisons schedule: schedule 4 Therapeutic class: 8(d) macrolides Dosage range: 250-500mg Route: oral Frequency of administration: 12hourly Duration of order: 7 days Actions: binds to 50S ribosomal sub-unit, inhibits bacterial protein synthesis, is bacteriostatic Indications for use: upper & lower respiratory tract infections, CAP, recurrent tonsillitis, skin infections Contraindications for use: serious allergy to macrolides, Adverse drug reactions: nausea, vomiting, diarrhoea, abdo. pain/cramps, headache, dyspnoea, cough, candidiasis, taste disturbance.
clarithromycin
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doxycycline
Drug (generic name): doxycycline Poisons schedule: schedule 4 Therapeutic class: 8(c) tetracyclines Dosage range: 100mg-200mg (200mg first dose, followed by 100mg daily) Route: oral Frequency of administration: daily Duration of order: 6 days Actions: reversibly binds to 50S ribosomal sub-unit, inhibits bacterial protein synthesis, is bacteriostatic Indications for use: acne, M. pneumonia, CAP, chronic bronchitis, sinusitis, non-gonococcol genital tract infections, PID, rickettsial infections, prostatitis, prophylaxis and treatment of malaria Contraindications for use: children < 8years, allergy to tetracycline Adverse drug reactions: nausea, vomiting, heartburn, tooth discolouration, enamel dysplasia, reduced bone growth (children), photosensitivity
gentamicin (medical practitioner)

Drug (generic name): gentamicin Poisons schedule: schedule 4 Therapeutic class: 8(f) aminoglycosides Dosage range: 4-6mg/kg Route: intravenous Frequency of administration: daily or as single dose , depends on severity. Duration of order: until significant improvement Actions: irreversibly binds to 50S ribosomal sub-unit, inhibits bacterial protein synthesis, causes cell membrane damage, is bactericidal with concentration dependence Indications for use: gram-negative infections (empirical Rx), systemic enterococcal infections, surgical & non-surgical prophylaxis, cystic fibrosis, bronchiectasis Contraindications for use: serious allergy to aminoglycoside Adverse drug reactions: renal impairment, ototoxicity
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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)
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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ceftriaxone (medical practitioner)

Drug (generic name): ceftriaxone Poisons schedule: schedule 4 Therapeutic class: 8(b) cephalosporins Dosage range: 2g Route: intravenous Frequency of administration: daily Duration of order: until significant improvement Actions: intervenes in bacteria cell wall peptidoglycan synthesis Indications for use: severe pneumonia, orbital cellulitis, bacterial meningitis, gonococcal infection, PID, epiglottitis, septicaemia, prophylaxis: meningococcal disease, H. influenzae, cholecystitis, peritonitis, Salmonella, typhoid, sexually transmitted epididymoorchitis Contraindications for use: allergy to penicillins, cephalosporins, carbapenems Adverse drug reactions: nausea, diarrhoea, electrolyte imbalance, rash, pancreatitis, cholecystitis, pseudolithiasis, nephrolithiasis
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paracetamol
Drug (generic name): paracetamol Poisons schedule: unscheduled Therapeutic class: 4(b) simple analgesics and antipyretics, nonopiod analgesic. Dosage range: 500mg-1g Route: oral/rectal Frequency of administration: 4- 6 hourly Duration of order: as required max 4g daily Actions: inhibition of prostaglandin synthesis Indications for use: mild-moderate pain, migraine, headache, fever, muscular pain Contraindications for use: nil caution for resident with liver disease. Adverse drug reactions: (rare) rash, drug fever, mucosal lesions, neutro/pancyto/thrombocytopenia
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moxifloxacin
Drug (generic name): moxifloxacin Poisons schedule: schedule 4 Therapeutic class: 8(e) quinolones Dosage range: 400mg Route: oral Frequency of administration: daily Duration of order: 7 days Actions: blocks DNA gyrase & topoisomerase IV, thus inhibiting DNA synthesis, is bactericidal Indications for use: severe CAP, acute bacterial chronic bronchitis & sinusitis (where other Rx failed or contraindicated), gonorrhoea, severe mixed aerobic & anaerobic infections, resistant tuberculosis Contraindications for use: allergy to quinolones, prolongation of QT interval, or Rx with drugs that prolong QT interval. Adverse drug reactions: nausea, vomiting diarrhoea, abdo. pain, dyspepsia, rash, itch, dizziness, taste change
cefotaxime (medical practitioner)

Drug (generic name): cefotaxime Poisons schedule: schedule 4 Therapeutic class: 8(b) cephalosporins Dosage range: 1g Route: intravenous Frequency of administration: 8 hourly Duration of order: until significant improvement Actions: intervenes in bacteria cell wall peptidoglycan synthesis Indications for use: severe pneumonia, orbital cellulitis, bacterial meningitis, gonococcal infection, PID, epiglottitis, septicaemia, acute cholecystitis, acute peritonitis Contraindications for use: allergy to penicillins, cephalosporins, carbapenems Adverse drug reactions: nausea, diarrhoea, electrolyte imbalance, irritation at injection/IV site
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REFERENCES
1. Clinical Practice Guidelines for Nurses in Primary Care [monograph online]. 2000 [cited 2006 Apr 12]. Available from: http://www.hc-sc.gc.ca/msb/fnihp. 2. Tal S, Guller V, Levi S, Bardenstein R, Berger D, Gurevich I, Gurevich A. Profile and prognosis of febrile elderly residents with bacteremic urinary tract infection. Journal of Infection [serial online]. 2005 [cited 2006 Oct 20]; 50:296-305. Available from: ScienceDirect. 3. The Royal Australian College of General Practitioners. Medical Care of Older Persons in Residential Aged Care Facilities. 4th ed. South Melbourne: The Royal Australian College of General Practitioners; 2005. 4. Wagenlehner FM, Naber KG. Treatment of bacterial urinary tract infections: presence and future. European Urology [serial online]. 2006 [cited 2006 Oct 20]; 49:235-244. Available from: ScienceDirect. 5. Dartnell JG, editor. Therapeutic guidelines: antibiotic. 12th ed. Victoria: Therapeutic Guidelines Limited; 2003. 6. Rossi S, editor. Australian medicines handbook. Adelaide SA: Australian Medicines Handbook Pty Ltd; 2011. 7. eMIMS MIMS. MIMS medicine information [standard online]. c2005 [cited 2006 Oct 20]. Available from: eMIMS MIMS Online. 8. Hughes J. Urinary tract infections. Proceedings from The Infectious Diseases Module Lectures; 2006 Oct 9-16; Bentley, Perth: Curtin University of Technology; n.d. 9. McMurdo M, Bissett L, Price R, Phillips G, Crombie I. Does ingestion of cranberry juice reduce symptomatic urinary tract infections in older people in hospital? A double-blind, placebo-controlled trial. Age and Ageing. 2005; 34: 256-261. 10. etg complete( internet ). Melbourne : Therapeutic Guidelines Limited; 2011 Nov Accessed 2001at http://etg.com.au/ref/re 11. Grayson ML, McDonald M, Gibson K, Athan E, Munckhof WJ, Paull P, et al. Once-daily intravenous cefazolin plus oral probenecid is equivalent to once-daily intravenous ceftriaxone plus oral placebo for the treatment of moderate-to-severe cellulitis in adults. Clinical Infectious Diseases. 2002; 34(11): 1440-1448. 12. Ginsberg MB. Cellulitis: analysis of 101 cases and review of the literature. Southern Medical Journal. 1981; 74(5): 530-533. 13. Fleisher G, Ludwig S. Cellulitis: a prospective study. Annals of Emergency Medicine. 1980; 9(5): 246-249. 14. Kennedy M L, Fletcher KR, Plank LM. Management guidelines for nurse practitioners working with older adults. 2nd ed. Philadelphia: F. A. Davis; 2004. 15. Reuben DB, Herr KA, Pacala JT. Geriatrics at your fingertips. 6th ed. Malden, MA: Blackwell; 2004. 16. McKinnon PS, Paladino JA, Grayson ML, Gibbons GW, Karchmer AW. Cost-effectiveness of ampicillin/su;bactam versus imipenum/cilastatin in the treatment of limb-threatening foot infections in diabetic residents. Clinical Infection Diseases. 1997; 24(1): 57-63. 17. Friedlaender MH. A review of the causes and treatment of bacterial and allergic conjunctivitis. Clinical Therapeutics. 1995; 17(5): 800-810. 18. Wan W L, Farkas GC, May WN, Robin JB. The clinical characteristics and course of adult gonococcal conjunctivitis. American Journal of Ophthalmology. 1986; 102(5): 575-583.
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