Lower Respiratory Tract Infection (H@H)

Antimicrobial prescribing: NHS Lothian
NHS Lothian

Organisms:

  • Respiratory viruses including influenza and SARS-CoV-2
  • Bacteria: Streptococcus pneumoniae, Haemophilus influenzae
  • Atypical organisms: Legionella, Mycoplasma, Chlamydia pneumoniae/psittaci – less commonly detected in elderly population
  • Underlying lung disease will affect bacteria involved (especially bronchiectasis, COPD)

Investigations:

  • Sputum culture
  • Viral throat swab

LRTI/pneumonia (H@H)

Length of treatment: 5 days

Amoxicillin 500mg orally every 8 hours

OR

Doxycycline 200mg orally on day 1, then 100mg daily every 24 hours

Penicillin allergy:

Doxycycline 200mg orally on day 1, then 100mg daily every 24 hours

Alternative for frail elderly patients where patient has already received one of the above and further antibiotic treatment is deemed essential:

Co-trimoxazole 960mg orally every 12 hours

(see Appendix 1 for dose reduction in renal impairment)

 

During influenza season consider antiviral treatment when use in primary care, based on symptoms alone, has been authorised by HPS

Aspiration Pneumonia (H@H)

This can reflect chemical injury and does not always indicate antibiotic treatment

Only treat patients with evidence of pneumonia. Do not treat prophylactically.

BTS have removed indications for routine additional anaerobic cover if mild/moderate aspiration pneumonia follow guidance for pneumonia. For severe aspiration pneumonia please following guidance under severe pneumonia. 

Severe Pneumonia including severe aspiration pneumonia (H@H)

Length of treatment: 5 days

Severity: CURB65 3-5, or other signs of organ dysfunction including low oxygen saturations.

  • Arrange chest x-ray (CXR) if feasible.
  • Blood cultures
  • Viral throat swab (if for admission) (swab throat and nose at same time with single swab, send in viral transport medium)
  • Sputum for culture
  • Sputum for "sputum respiratory PCR (including atypicals)
  • Consider hospital admission.
  • Discuss goals of care.
  • Senior review.

Consider

Amoxicillin 1g orally every 8 hours,

OR

If oral route unavailable: Amoxicillin 2g intravenously every 12 hours (see comments below)

PLUS

Gentamicin intravenous: dose as per NHS Lothian online calculator

If severe aspiration pneumonia ADD Metronidazole 400mg orally every 8 hours

OR

If oral route unavailable: Metronidazole 1g by rectum every 8 hours for 3 days then 1g by rectum every 12 hours

Penicillin allergy:

Teicoplanin intravenous (see Appendix 2 for protocol)

PLUS

Gentamicin intravenous: dose as per NHS Lothian online calculator

If severe aspiration pneumonia ADD Metronidazole 400mg orally every 8 hours

OR

If oral route unavailable: Metronidazole 1g by rectum every 8 hours for 3 days then 1g by rectum every 12 hours

  • If oral route unavailable there are limited options in community, consider need for hospital admission. Initial dose of amoxicillin 2g can be given intravenously and can be continued as amoxicillin 2g intravenous every 12 hours until oral route becomes available. Patient should then be switched to amoxicillin 1g orally every 8 hours.
  • Review after 48 hours of IV therapy and switch to oral antibiotic therapy (co-trimoxazole/ doxycycline/ amoxicillin (plus metronidazole if aspiration pneumonia) if symptomatic improvement
  • Gentamicin should not be extended for more than 72 hours in H@H patients without advice from an infection specialist, consideration of toxicities and monitoring. (Note this differs from advice for patients in acute care settings where up to 5 days may be given).
  • Teicoplanin should not be extended past the 72-hour loading period without discussion with an infection specialist.
  • Please note updated BTS guidance has removed metronidazole from routine management of non-severe aspiration pneumonia.

Infective exacerbation of COPD (H@H)

Investigations:

  • Sputum culture
  • Viral throat swab

 

Length of treatment: 5 days

Doxycycline 200mg orally on day 1, then 100mg daily every 24 hours (also in penicillin allergy)

OR

Amoxicillin 500mg orally every 8 hours

Exacerbation of Bronchiectasis (H@H)

Investigations:

  • Sputum culture
  • Viral throat swab 

Length of treatment: 10-14 days

Send sputum for culture and review last bronchiectasis clinic letter to guide initial empiric antibiotic choice.

If no clinic letter base choice on latest sputum result.

  • Only alter antibiotic therapy based on culture result if there is no clinical response to the empiric therapy -regardless of what is grown.
  • Contact the respiratory team (SPR on call via switchboard) for further advice if repeated exacerbations, poor response or if Pseudomonas aeruginosa is grown for the first time as this may require eradication therapy.
  • Good chest clearance and hydration are an essential part of managing bronchiectasis exacerbations. Optimise this alongside antibiotic therapy.
  • Treatment with ciprofloxacin carries a high risk of C.difficile infection and has risk of disabling and potentially long-lasting or irreversible side effects. Fluoroquinolones should only be used when there is no alternative- see the MHRA safety warnings 2024. 
  • Should the patient require multiple courses of antibiotics in succession please discuss with an infection specialist or respiratory physician.

If there are no previous microbiology results treat empirically with:

Amoxicillin 500mg orally every 8 hours

OR

Doxycycline 100mg orally every 12 hours. (also in penicillin allergy)