Hospital-acquired pneumonia (non COVID-19)

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

severe symptoms/signs or at higher risk of resistance

1st line – intravenous antibiotics

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1st line –

intravenous antibiotics

For the management of patients with suspected or confirmed COVID-19 pneumonia, see Coronavirus disease 2019 (COVID-19). Pneumonia due to COVID-19 is not covered in this topic.

Start intravenous antibiotics within 4 hours of diagnosing HAP.[7] Base your choice of antibiotics on advice from microbiology and local and ward-based resistance data.[7]

Follow your local protocol. However, the UK National Institute for Health and Care Excellence (NICE) recommends the following options:[7]

Piperacillin/tazobactam
Ceftazidime
Ceftriaxone
Cefuroxime
Meropenem
Ceftazidime/avibactam
Levofloxacin (consider the safety issues associated with fluoroquinolone use - see below; consult with a microbiologist and senior colleague first).

More info: EMA and MHRA restrictions on the use of fluoroquinolone antibiotics

In November 2018, the European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with systemic and inhaled fluoroquinolone antibiotics. These adverse effects include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.

As a consequence of this review, the EMA now recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening bacterial infections only. Furthermore, they recommend that fluoroquinolones should not be used for mild to moderate infections unless other appropriate antibiotics for the specific infection cannot be used, and should not be used in non-severe, non-bacterial, or self-limiting infections. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid are at a higher risk of tendon damage. Co-administration of a fluoroquinolone and a corticosteroid should be avoided.[63] The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) supports these recommendations.[64]
NICE recommends that for patients with non-severe symptoms or signs of HAP and not at higher risk of resistance, levofloxacin should be prescribed only if switching from intravenous levofloxacin and with specialist advice.[7]

Be aware of atypical presentations of HAP, such as in a patient with suspected sepsis or delirium.

Practical tip

Think ' Could this be sepsis?' based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[28][29][30] See Sepsis in adults.

Use a systematic approach, alongside your clinical judgement to assess the risk of deterioration due to sepsis.[28][29][31][41]
Consult local guidelines for the recommended approach at your institution for assessment and management of the patient with suspected sepsis.
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[32]
- Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns).
- Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[32][41]
Pneumonia is one of the main sources of sepsis.[33]

Review all patients within 48 hours and if possible switch to the oral route.[7]

Review treatment after a total of 5 days of antibiotics.[7]

Consider stopping antibiotics on an individual basis if the patient is judged to be clinically stable.[7]

Reassess patients if symptoms do not improve as expected or worsen rapidly or significantly.[7]

Primary options

piperacillin/tazobactam: 4.5 g intravenously every 8 hours, may increase to 4.5 g every 6 hours in severe infections

ceftazidime: 2 g intravenously every 8 hours

ceftriaxone: 2 g intravenously every 24 hours

cefuroxime: 750 mg intravenously every 6-8 hours, may increase to 1500 mg every 6-8 hours in severe infections

meropenem: 0.5 to 1 g intravenously every 8 hours

ceftazidime/avibactam: 2.5 g intravenously every 8 hours

Secondary options

levofloxacin: 500 mg intravenously every 12-24 hours

Consider – MRSA antibiotic cover

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Consider –

MRSA antibiotic cover

Additional treatment recommended for SOME patients in selected patient group

In patients with suspected or confirmed MRSA infection, add intravenous vancomycin or teicoplanin.[7]

If vancomycin cannot be used, seek advice from a specialist. An option is to give intravenous linezolid instead, but only if recommended by the specialist.[7]

It is standard practice to continue administration of these antibiotics intravenously in most cases with consultation with microbiology. This is because there are limited antibiotics with MRSA coverage available for oral administration.

Review treatment after a total of 5 days of antibiotics.[7]

Consider stopping antibiotics on an individual basis if the patient is judged to be clinically stable.[7]

Reassess patients if symptoms do not improve as expected or worsen rapidly or significantly.[7]

Primary options

vancomycin: 15-20 mg/kg intravenously every 8-12 hours, maximum 2000 mg/dose

teicoplanin: 6 mg/kg intravenously every 12 hours for 3 doses, followed by 6 mg/kg every 24 hours

Secondary options

linezolid: 600 mg intravenously/orally every 12 hours

Plus – supportive care

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Provide supportive care to all patients with HAP, which may include the following measures.[7]

Oxygen

Assess oxygen requirements. In practice, this is done by measuring oxygen saturations and blood gases (a venous blood gas is preferred to an arterial blood gas). Give oxygen if saturations are <94% (or <88% in patients at risk of hypercapnia) and maintain at target range.[6]Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J. 2017 Sep;50(3):1700582. Early oxygen assessment is associated with improved prognosis.[53]

Monitor controlled oxygen therapy. An upper SpO₂ limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.

Evidence suggests that liberal use of supplemental oxygen (target SpO₂ >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.
A lower target SpO₂ of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[53]

Evidence: Target oxygen saturation in acutely ill adults

Too much supplemental oxygen increases mortality.

Evidence from a large systematic review and meta-analysis supports conservative/controlled oxygen therapy versus liberal oxygen therapy in acutely ill adults who are not at risk of hypercapnia.

Guidelines differ in their recommendations on target oxygen saturation in acutely unwell adults who are receiving supplemental oxygen. .
- The 2017 British Thoracic Society guideline recommends a target SpO₂ range of 94% to 98% for patients not at risk of hypercapnia, whereas the 2022 Thoracic Society of Australia and New Zealand (TSANZ) guideline recommends 92% to 96%.[53][71]
- The 2022 Global Initiative For Asthma (GINA) guidelines recommend a target SpO₂ range of 93% to 96% in the context of acute asthma exacerbations.[72]
One 2018 systematic review including meta-analysis of data from 25 RCTs found that, in adults with acute illness, liberal oxygen therapy (broadly equivalent to a target saturation >96%) is associated with higher mortality than conservative oxygen therapy (broadly equivalent to a target saturation ≤96%).[70]
- In-hospital mortality was 11 per 1000 higher for the liberal oxygen therapy group versus the conservative therapy group (95% CI 2 to 22 per 1000 more).
- Mortality at 30 days was also higher in the group who had received liberal oxygen (RR 1.14, 95% CI 1.01 to 1.29).
- The trials included adults with sepsis, critical illness, stroke, trauma, myocardial infarction, or cardiac arrest, and patients who had had emergency surgery. The review excluded studies limited to people with chronic respiratory illness or psychiatric illness, or to patients on extracorporeal life support, receiving hyperbaric oxygen therapy, or having elective surgery.
An upper SpO₂ limit of 96% is therefore reasonable when administering supplemental oxygen to patients with acute illness who are not at risk of hypercapnia. However, a higher target may be appropriate for some specific conditions (e.g., pneumothorax, carbon monoxide poisoning, cluster headache, and sickle cell crisis).[73]
In 2019 the BTS reviewed its guidance in response to this systematic review and meta-analysis and decided an interim update was not required.[74]
- The committee noted that the systematic review supported the use of controlled oxygen therapy to a target.
- While the systematic review showed an association between higher oxygen saturations and higher mortality, the BTS committee felt the review was not definitive on what the optimal target range should be. The suggested range of 94% to 96% in the review was based on the lower 95% confidence interval and the median baseline SpO₂ from the liberal oxygen groups, along with the TSANZ guideline recommendation.
Subsequently, experience during the COVID-19 pandemic has also made clinicians more aware of the feasibility of permissive hypoxaemia.[75] The BTS guidance is due for a review in 2022.
Management of oxygen therapy in patients in intensive care is specialised and informed by further evidence (not covered in this summary) that is more specific to this setting.[76][77][78]

Standard ICU supportive care

Arrange for patients with an indication for intensive care unit (ICU) admission to be transferred to ICU and managed by ICU specialists together with respiratory physicians.[34]

Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation.

Intravenous fluids

Assess all patients for volume depletion and give intravenous fluids if required.[34]

Vasopressors

Start vasopressors (according to local protocols) if the patient is hypotensive during or after fluid resuscitation to maintain mean arterial pressure level ≥65 mmHg.[54]

Venous thromboembolism prophylaxis

Consider prophylaxis for venous thromboembolism (VTE) with a low molecular weight heparin according to local protocols for all patients who are not fully mobile.[34] In practice in the UK, prescription of heparin will be prompted if appropriate once you have recorded your VTE risk assessment in the patient’s electronic record.

Nutritional support

Arrange nutritional support (enteral, parenteral, or via nasogastric feeding) for patients with severe HAP who require a prolonged hospital stay.[34]

Airway clearance

Do not routinely treat people with uncomplicated pneumonia with traditional airway clearance techniques. If needed, offer these patients advice regarding expectoration of sputum.[34]

Consider airway clearance techniques if the patient has difficulty expectorating sputum or if they have a pre-existing lung condition.[34]

Analgesia

Give simple analgesia (e.g., paracetamol) as appropriate (e.g., for chest pain).[34]

Practical tip

Encourage patients with uncomplicated pneumonia (i.e., not complicated by the presence of parapneumonic effusion, empyema, abscess, pneumothorax, necrotising pneumonia [pneumonia associated with cavitation], or bronchopleural fistula), whose medical condition allows them, to sit out of bed. Initially aim for at least 20 minutes in the first 24 hours, and then increase mobility each subsequent day of hospitalisation.

Consider – switch to pathogen-targeted therapy

mild to moderate symptoms/signs and not at higher risk of resistance

1st line – oral antibiotics

Back

1st line –

oral antibiotics

For the management of patients with suspected or confirmed COVID-19 pneumonia, see Coronavirus disease 2019 (COVID-19). Pneumonia due to COVID-19 is not covered in this topic.

Start oral antibiotics, where possible, within 4 hours of diagnosing HAP.[7] Base your choice of antibiotics on advice from microbiology and local and ward-based resistance data.[7]

Follow your local protocol. However, NICE recommends amoxicillin/clavulanate first line.[7]

Consider amoxicillin alone for patients with symptoms or signs of pneumonia starting on days 3 to 5 after hospital admission who are not at high risk of resistance.[7][65]

Give alternative oral antibiotics in patients with penicillin allergy or if amoxicillin/clavulanate is unsuitable (e.g., because of local resistance data). NICE recommends the following options:[7]

Doxycycline
Cefalexin (use caution in penicillin allergy)
Trimethoprim/sulfamethoxazole
Levofloxacin

NICE recommends that for patients with mild to moderate symptoms or signs of HAP and not at higher risk of resistance, levofloxacin should be prescribed only if switching from intravenous levofloxacin and following specialist advice.[7]

More info: EMA and MHRA restrictions on the use of fluoroquinolone antibiotics

As a consequence of this review, the EMA now recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening bacterial infections only. Furthermore, they recommend that fluoroquinolones should not be used for mild to moderate infections unless other appropriate antibiotics for the specific infection cannot be used, and should not be used in non-severe, non-bacterial, or self-limiting infections. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid are at a higher risk of tendon damage. Co-administration of a fluoroquinolone and a corticosteroid should be avoided.[63] The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) supports these recommendations.[64]
NICE recommends that for patients with non-severe symptoms or signs of HAP and not at higher risk of resistance, levofloxacin should be prescribed only if switching from intravenous levofloxacin and with specialist advice.[7]

Give intravenous antibiotics to patients unable to take oral antibiotics (e.g., impaired swallowing reflex, impaired consciousness, gastrointestinal malabsorption).[7]

Review within 48 hours and if possible switch to the oral route.[7]

Review treatment after a total of 5 days of antibiotics.[7] Consider stopping antibiotics on an individual basis if the patient is judged to be clinically stable.[7]

Reassess patients if symptoms do not improve as expected or worsen rapidly or significantly.[7]

Primary options

amoxicillin/clavulanate: 500/125 mg orally three times daily

amoxicillin: 500 mg orally three times daily

Secondary options

doxycycline: 200 mg orally on the first day, followed by 100 mg once daily thereafter

cefalexin: 500 mg orally two to three times daily, may increase to 1000-1500 mg three to four times daily in severe infections

trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily

Tertiary options

levofloxacin: 500 mg orally once or twice daily

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Provide supportive care to all patients with HAP, which may include the following measures.[7]

Oxygen

Monitor controlled oxygen therapy. An upper SpO₂ limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.

Evidence suggests that liberal use of supplemental oxygen (target SpO₂ >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[70]
A lower target SpO₂ of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[53]

Evidence: Target oxygen saturation in acutely ill adults

Too much supplemental oxygen increases mortality.

Evidence from a large systematic review and meta-analysis supports conservative/controlled oxygen therapy versus liberal oxygen therapy in acutely ill adults who are not at risk of hypercapnia.

Guidelines differ in their recommendations on target oxygen saturation in acutely unwell adults who are receiving supplemental oxygen.
- The 2017 British Thoracic Society guideline recommends a target SpO₂ range of 94% to 98% for patients not at risk of hypercapnia, whereas the 2022 Thoracic Society of Australia and New Zealand (TSANZ) guideline recommends 92% to 96%.[53][71]
- The 2022 Global Initiative For Asthma (GINA) guidelines recommend a target SpO₂ range of 93% to 96% in the context of acute asthma exacerbations.[72]
One 2018 systematic review including meta-analysis of data from 25 RCTs found that, in adults with acute illness, liberal oxygen therapy (broadly equivalent to a target saturation >96%) is associated with higher mortality than conservative oxygen therapy (broadly equivalent to a target saturation ≤96%).[70]
- In-hospital mortality was 11 per 1000 higher for the liberal oxygen therapy group versus the conservative therapy group (95% CI 2 to 22 per 1000 more).
- Mortality at 30 days was also higher in the group who had received liberal oxygen (RR 1.14, 95% CI 1.01 to 1.29).
- The trials included adults with sepsis, critical illness, stroke, trauma, myocardial infarction, or cardiac arrest, and patients who had had emergency surgery. The review excluded studies limited to people with chronic respiratory illness or psychiatric illness, or to patients on extracorporeal life support, receiving hyperbaric oxygen therapy, or having elective surgery.
An upper SpO₂ limit of 96% is therefore reasonable when administering supplemental oxygen to patients with acute illness who are not at risk of hypercapnia. However, a higher target may be appropriate for some specific conditions (e.g., pneumothorax, carbon monoxide poisoning, cluster headache, and sickle cell crisis).[73]
In 2019 the BTS reviewed its guidance in response to this systematic review and meta-analysis and decided an interim update was not required.[74]
- The committee noted that the systematic review supported the use of controlled oxygen therapy to a target.
- While the systematic review showed an association between higher oxygen saturations and higher mortality, the BTS committee felt the review was not definitive on what the optimal target range should be. The suggested range of 94% to 96% in the review was based on the lower 95% confidence interval and the median baseline SpO₂ from the liberal oxygen groups, along with the TSANZ guideline recommendation.
Subsequently, experience during the COVID-19 pandemic has also made clinicians more aware of the feasibility of permissive hypoxaemia.[75] The BTS guidance is due for a review in 2022.
Management of oxygen therapy in patients in intensive care is specialised and informed by further evidence (not covered in this summary) that is more specific to this setting.[76][77][78]

Intravenous fluids

Assess all patients for volume depletion and give intravenous fluids if required.[34]

Vasopressors

Start vasopressors (according to local protocols) if the patient is hypotensive during or after fluid resuscitation to maintain mean arterial pressure level ≥65 mmHg.[54]

Venous thromboembolism prophylaxis

Airway clearance

Do not routinely treat people with uncomplicated pneumonia with traditional airway clearance techniques. If needed, offer these patients advice regarding expectoration of sputum.[34]

Consider airway clearance techniques if the patient has difficulty expectorating sputum or if they have a pre-existing lung condition.[34]

Analgesia

Give simple analgesia (e.g., paracetamol) as appropriate (e.g., for chest pain).[34]

Practical tip

Consider – switch to pathogen-targeted therapy

Use of this content is subject to our disclaimer

Hospital-acquired pneumonia (non COVID-19)

Treatment algorithm

severe symptoms/signs or at higher risk of resistance

intravenous antibiotics

More info: EMA and MHRA restrictions on the use of fluoroquinolone antibiotics

Practical tip

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

MRSA antibiotic cover

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

supportive care

Oxygen

Evidence: Target oxygen saturation in acutely ill adults

Standard ICU supportive care

Intravenous fluids

Vasopressors

Venous thromboembolism prophylaxis

Nutritional support

Airway clearance

Analgesia

Practical tip

switch to pathogen-targeted therapy

Consult with a microbiologist

mild to moderate symptoms/signs and not at higher risk of resistance

oral antibiotics

More info: EMA and MHRA restrictions on the use of fluoroquinolone antibiotics

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

Tertiary options

supportive care

Oxygen

Evidence: Target oxygen saturation in acutely ill adults

Intravenous fluids

Vasopressors

Venous thromboembolism prophylaxis

Airway clearance

Analgesia

Practical tip

switch to pathogen-targeted therapy

Consult with a microbiologist