Pneumonia in Residential Care Facilities

Comments from Expert Advisory Group

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.
Assess severity using clinical judgement supported by the CRB65 score, noting additional risk factors may impact severity e.g. hypoxia, co-morbidities, immunosuppression, multi-lobar involvement (if chest x-ray available).

CRB65 is used to assess 30 day mortality risk in adults with pneumonia. 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

Consider viral respiratory illness, including RSV, COVID-19 and influenza in the differential diagnosis in a patient presenting with a cough. Follow HPSC guidance on assessment and testing for patients presenting with a cough. Particular consideration should be given to RSV, influenza and COVID-19 if these illnesses are known to be circulating in the facility.
Renal impairment is common in elderly patient populations. See renal antibiotic dosing table for more information when considering antibiotic recommendations in this guideline.
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.
There is no validated tool available to assess the severity of signs and symptoms in aspiration pneumonia.
Empirical treatment for aspiration pneumonia does not require coverage for anaerobic organisms. Anaerobic coverage is not suggested for suspected aspiration pneumonia except when patients are at particularly high risk of anaerobic infection, for example in those with obvious dental/periodontal disease, putrid sputum production or those in whom lung abscess/empyema is suspected.
In these specific cases, if anaerobic coverage is deemed necessary:
- Metronidazole 400mg every 8 hours can be added to amoxicillin, doxycycline or levofloxacin (recommended doses outlined in treatment table below).
- Co–amoxiclav does not require extra anaerobic cover.
- Recommended duration of antibiotics is 5 days.
Prophylactic antibiotics do not help prevent the development of aspiration pneumonia and are not recommended.
Discuss antibiotic choice with microbiology or infectious diseases 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.
Ensuring adequate oral hygiene is important in reducing the incidence of aspiration pneumonia among more vulnerable elderly individuals.

Other considerations

At convalescence, ensure COVID-19, influenza and pneumococcal vaccinations are up to date.
Consider analgesia (e.g. paracetamol) for pleuritic pain.
Ensure adequate hydration.
Consider pulse oximetry to assess oxygenation.
Consider sepsis.

Treatment

Pneumonia in Residential Care Facilities: Empiric Treatment Table

Assess using clinical judgement supported by the CRB65 score (each symptom or sign scores one point)
(Confusion, Respiratory rate ≥30/min, BP ≤90/60 mmHg, Age ≥65)

Drug

Dose

Duration

Notes

CRB65 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

CRB65 score 0:
500mg every 8 hours

CRB65 score 1 to 2:
1g every 8 hours

5 days

Avoid in penicillin allergy.
Dose adjustment required in renal impairment.
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. Dose adjustment required in renal impairment.

2nd line option

Doxycycline

(1st line in penicillin allergy)

200mg every 24 hours

100mg every 12 hours

in non-severe infection, doxycycline 200mg stat then 100mg every 24 hours can be considered.

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 and should be separated by at least 3 hours.
Risk of photosensitivity.

Alternatively consider clarithromycin 500mg every 12 hours for 5 days if doxycycline contraindicated. See Macrolide warning and check drug interactions. Dose adjustment required in renal impairment.

CRB65 Score 3 or more : Consider urgent hospital transfer or treat in a nursing home/ residential care facility if not for hospital admission.

CRB65 Score 3 or more : Prior to urgent hospital transfer, if delayed transfer expected, consider administration of:

Amoxicillin

If oral medication is not an option

Benzylpenicillin

1g PO STAT

1.2g IV/IM STAT

N/A

Avoid in penicillin allergy
Urgent hospital admission only

CRB65 Score 3 or more :

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

1st line option

Co-amoxiclav

875/125mg every 8 hours

(500/125mg every 8 hours if 875/125mg unavailable)

5 days

Avoid in penicillin allergy.
Dose adjustment required in renal impairment.
Liquid co-amoxiclav available, see table below*
Consider adding Clarithromycin 500mg every 12 hours if concern of atypical pathogen (e.g. mycoplasma, legionella). See Macrolide warning and check drug interactions. Dose adjustment required in renal impairment.

2nd line option

Levofloxacin

500mg every 12 or 24 hours depending on severity

5 days

Multiple adverse effects associated with fluroroquinolones.
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.
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.

*Co-amoxiclav suspensions available for those with swallowing difficulties:

Co-amoxiclav Solid Dose Form

Suspension Available as

Measured dose

500mg/125mg Tablet

Augmentin^® Paediatric Oral Suspension (125 mg/31.25 mg per 5 mL)

OR Co-amoxiclav paediatric (125 mg/31.25 mg per 5 mL)

20mL = 500mg/125mg

875mg/125mg Tablet

Augmentin^® Duo Oral Suspension (400 mg/57 mg per 5 mL)

11mL = 880mg/125mg (off label use)

Patient Information

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

HSE: Pneumonia

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 tables. 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 September 2024