Pneumonia

This information does not replace clinical judgement. Refer to Conditions of use and copyright for further T&Cs.

Pneumonia is a common condition in residents' of aged care facilities with a high rate of associated morbidity and mortality. Early recognition and institution of evidenced based management aligned to the residents goals of care is associated with improved outcomes.

Decision tree

The decision tree (recommended if using a mobile device) will guide you through the questions presented in the flowchart - answer questions by clicking on the relevant answer to progress through the flowchart; health professionals should always remain within their scope of practice; this information should never replace clinical judgement.

Question Id
(Enter as a capital Q
and a number
no spaces)
Question or StatementResponse Go to Question or Outcome
(based on response selected)
Q1

Use this pathway in conjunction with the Acute Respiratory Infection pathway

Resident with suspected pneumonia

(See When to suspect pneumonia - practice point 1)

  1. Immediately isolate the resident and place under standard and transmission-based precautions (PDF 789 kB)
    • Apply appropriate Personal Protective Equipment (PPE) - review QH RACF PPE guidance
    • Where possible, place the resident in a single room with an unshared bathroom and minimise interaction with others
    • Ensure implementation of enhanced environmental hygiene
  2. Check vital signs and assess for
  3. If not immediately life-threatening review Checklist for contact and contact GP. Where feasible, tele-conference or video-conference with GP is preferred.
Stable vitals Q2
   Unstable vitals Outcome1
Q2

Stable vitals

Is there evidence of any of the following risk features?

  • Oxygen saturation < 92 per cent (or if resident has chronic obstructive pulmonary disease (COPD) < 90 per cent)
  • Altered mental state (different from usual)
  • New or increased agitation
  • Respiratory distress
  • Pulse > 100/minute
  • Vomiting
Yes Outcome1
   No Q3
Q3

No evidence of risk features

Is there a history of any of:

  • Immunosupression beyond that caused by older age or diabetes alone e.g. steroids or neutropenia

OR

  • Recent hospital admission
Yes Outcome2
   No Q4
Q4

No history of immunosupression or recent hospital admission

  1. Perform appropriate investigations (practice point 2)
  2. Commence empiric antibiotic therapy (practice point 3)
  3. Implement supportive cares (practice point 4) to reduce risk of complications and undertake regular monitoring of vital signs (four times daily for 72 hours)
  4. Escalate unstable vital signs or development of above risk features
  5. Expect improvement within 48 hours

Does the resident develop risk features or unstable vital signs? Select option 1.

or

Does the resident fails to improve? Select option 2.

or

Does the resident have stable vital signs and clinically improves? Select option 3.

Option 1 Outcome1
   Option 2 Outcome3
   Option 3 Outcome4

Unstable vitals or evidence of risk features

Review Advance Care Plan or Statement of Choices and refer to Management of residents with unstable vital signs 


History of immunosuppression or recent hospital admission

Consider escalation of antibiotics (see practice point 3) and refer to HHS RaSS at GP discretion


Fails to improve

Consider escalation of antibiotics (practice point 6) and refer to HHS RaSS at GP discretion


Continues to have stable vital signs and clinically improves

  1. Continue to monitor until antibiotics complete and resident recovers
  2. Review contributing factors and institute preventive measures (practice point 5)

Practice points

A systemised documentation of expanded relevant information - use only in conjunction with flowchart / decision tree above - note you can access each relevant point from the flowchart / decision tree link.

  • Pneumonia should be considered in any resident who has two or more of the following features:

    1. Fever
    2. New or increased cough
    3. New or increased sputum production
    4. Pleuritic chest pain
    5. Tachypnoea (or elevated respiratory rate)
    6. Pulse rate > 100 beats per minute
    7. New or increased abnormal findings on chest examination, particularly focal crackles
    8. Acute onset confusion or delirium

    Aspiration as the cause of pneumonia should be particularly considered in the following settings:

    1. Resident requires regular suctioning
    2. Presence of a feeding tube
    3. Resident is bed-bound
    4. Altered level of consciousness
    5. Swallowing problem or dysphagia
    6. Thickened fluids or pureed diet
    7. Dependence on feeding
    8. Sedative medications
    9. Hiatus hernia or gastroesophageal reflux disease
    1. Consider viral causes for presentation and, using transmission-based precautions, swab for COVID-19 PCR, influenza PCR and respiratory virus PCR - refer to Acute Respiratory Infection pathway
    2. Urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila
    3. Sputum Gram stain and culture if resident is able to produce a good sputum specimen - caution is advised if sputum is not high quality (high quality sputum is defined as evidence of neutrophils 25 per cent in a x 100 microscopic field and less than 10 squamous epithelial cells present in a x 100 microscopic field)
    4. Consider chest x-ray (mobile where available) and full blood count and electrolytes where: diagnosis is uncertain or if resident fails to respond to therapy
  • Treat with antibiotics for 5 days if response within 48 hours is observed; if response is slow, treat for 7 days:

    If uncomplicated pneumonia and NO penicillin allergy, use:

    Amoxicillin 1g orally every 8 hours

    If resident hypersensitive to penicillin, use:

    Doxycycline 100mg orally every 12 hours Note: Doxycycline can cause oesophagitis, which is more likely in bed-bound residents. Ensure doxycycline is taken with food and a full glass of water, and that the resident remains upright for 1 hour after the dose. If enteral feeding tube, do not open or crush the capsule - see Don't Rush to Crush for advice

    If doxycycline contraindicated or not tolerated and the resident has immediate non-severe or delayed non-severe hypersensitivity to penicillins, use:

    Cefuroxime 500mg orally every 12 hours

    Suspect atypical organisms if any of the following risk factors for Legionella are present:

    1. Chronic lung disease or smoking history
    2. Diabetes
    3. End-stage kidney disease
    4. Malignancy or
    5. Immune compromise

    If atypical organisms suspected, and where doxycycline is not already in use, add:

    Doxycycline 100mg orally every 12 hours

    Note: management of residents within hospital rather than within the facility, in the absence of risk features (see flowchart), does not decrease mortality

    Escalate antibiotic therapy if resident:

    1. Fails to improve within 48 hours, OR
    2. Has had recent hospitalisation, OR
    3. Is immunosuppressed

    Escalation of antibiotics should be guided by clinical assessment for risk of:

    1. Atypical organisms (see above)
    2. Recent hospitalisation or potential for beta-lactamase producing organisms
    3. Clinical risk factors for aspiration pneumonia
    4. Development of risk features or unstable vital signs suggesting parenteral antibiotics are indicated (where consistent with resident's goals of care

    Refer to Therapeutic guidelines: antibiotics for antibiotic guidance if escalation of therapy is indicated

    1. Monitor fluid balance closely:
      • Pneumonia with associated fever and tachypnoea can lead to significant insensible water loss (water loss that is not easily measured)
      • Monitor fluid intake and offer increased oral fluids
      • Consider Subcutaneous fluids if indicated
    2. Analgesics and antipyretics for pain and fever
    3. Review and treat risk factors for pneumonia:
      • Assess swallow - change fluids to those appropriate to swallow where indicated
      • Assess neurological function
      • Attend to oral hygiene
      • Control gastro-oesophageal reflux:
        • Elevate head of bed where safe to do so
        • Ensure resident is fed while sitting upright and sit upright for at least 30 minutes after feeding
      • Review medications and consider withholding or adjusting dose, where appropriate, of sedative medications
    4. Implement supportive care measures outlined in Fever or suspected infection pathway
    1. Ensure immunisations are up-to-date for:
      • Influenza
      • COVID-19 AND
      • Pneumococcus
    2. Review oral care regimen with regular professional oral hygiene care implemented to supplement daily oral regimens where indicated
    3. Review medications and consider whether appropriate to cease or wean, particularly for:
      • Proton pump inhibitors
      • Sedatives
    4. Speech therapy review to assess swallow and modify diet where aspiration pneumonia suspected
    5. For residents with gastrostomy feeds, ensure feeds are administered with the head of the bed elevated to at least 45 degrees and remain elevated for at least 30 minutes after the feed
  • Ensure that any escalation is consistent with resident's goals of care and resident choice

    History:

    • Symptoms:
      • Increasing shortness of breath or respiratory distress
      • Vomiting
    • Comorbidities that require stabilisation or presence of:
      • Immunocompromise
      • Respiratory failure

    Examination:

    • Vital signs: unstable vital signs where consistent with goals of care (refer to Recognition of the deteriorating resident) and / or altered mental status (different to usual)
    • Respiratory distress or new or increasing agitation
    • New or increasing oxygen requirement
    • Altered level of consciousness
    • Failure to respond to oral antibiotics within 72 hours

References

    1. Htun TP, Sun Y, Chua HL, Pang J. Clinical features for diagnosis of pneumonia among adults in primary care setting: A systematic and meta-review. Sci Rep. 2019;9(1):7600.
    2. Langmore SE, Skarupski KA, Park PS, Fries BE. Predictors of aspiration pneumonia in nursing home residents. Dysphagia. 2002;17(4):298-307.
    3. Antibiotic Expert Groups, Therapeutic Guidelines: Antibiotics. Melbourne: Therapeutic Guidelines limited; 2019.
    4. Mehr DR, Binder EF, Kruse RL, Zweig SC, Madsen RW, D'Agostino RB. Clinical findings associated with radiographic pneumonia in nursing home residents. J Fam Pract. 2001;50(11):931-7.
    5. Falcone M, Russo A, Gentiloni Silverj F, Marzorati D, Bagarolo R, Monti M, et al. Predictors of mortality in nursing-home residents with pneumonia: a multicentre study. Clin Microbiol Infect. 2018;24(1):72-7.
    6. Loeb M, Carusone SC, Goeree R, Walter SD, Brazil K, Krueger P, et al. Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial. JAMA. 2006;295(21):2503-10.
    7. Lewis A, Fricker A. Better Oral Health in Residential Care: staff portfolio education and training program. In: Health S, editor. Adelaide: Government of South Australia; 2008.
    8. Khadka S, Khan S, King A, Goldberg LR, Crocombe L, Bettiol S. Poor oral hygiene, oral microorganisms and aspiration pneumonia risk in older people in residential aged care: a systematic review. Age Ageing.
      2021;50(1):81-7.
    9. Del Rio-Pertuz G, Gutierrez JF, Triana AJ, Molinares JL, Robledo-Solano AB, Meza JL, et al. Usefulness of sputum gram stain for etiologic diagnosis in community-acquired pneumonia: a systematic review and meta-analysis. BMC Infect Dis. 2019;19(1):403.
    10. Loeb M, Bentley DW, Bradley S, Crossley K, Garibaldi R, Gantz N, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference. Infect Control Hosp Epidemiol. 2001;22(2):120-4.
    11. Montalto M, Chu MY, Ratnam I, Spelman T, Thursky K. The treatment of nursing home-acquired pneumonia using a medically intensive Hospital in the Home service. Med J Aust. 2015;203(11):441-2.
    12. Dhawan N, Pandya N, Khalili M, Bautista M, Duggal A, Bahl J, et al. Predictors of mortality for nursing home-acquired pneumonia: a systematic review. Biomed Res Int. 2015;2015:285983.
    13. Garin N, Genne D, Carballo S, Chuard C, Eich G, Hugli O, et al. beta-Lactam monotherapy vs beta-lactam-macrolide combination treatment in moderately severe community-acquired pneumonia: a randomized noninferiority trial. JAMA Intern Med. 2014;174(12):1894-901.
    14. El-Solh AA, Niederman MS, Drinka P. Management of pneumonia in the nursing home. Chest. 2010;138(6):1480-5.
  • Pathway Pneumonia
    Document ID CEQ-HIU-FRAIL-00027
    Version no.2.0.0
    Approval date16/03/2022
    Executive sponsorExecutive Director, Healthcare Improvement Unit
    AuthorImproving the quality and choice of care setting for residents of aged care facilities with acute healthcare needs steering committee
    Custodian Queensland Dementia Ageing and Frailty Network
    Supersedes Pneumonia V1.1
    Applicable to Residential aged care facility (RACF) registered nurses and general practitioners in Queensland RACFs, serviced by a RACF acute care Support Service (RaSS)
    Document source Internal (QHEPS) and external
    AuthorisationExecutive Director, Healthcare Improvement Unit
    Keywords Pneumonia, lower respiratory tract infection
    Relevant standards Aged Care Quality Standards:
    Standard 2: ongoing assessments and planning with consumers
    Standard 3: personal care and clinical care, particularly 3(3)
    Standard 8: organisational governance

Flowchart

The flowchart (recommended if using a computer) shows all information at one time.

Click this link to view the full flowchart.

Health professionals should always remain within their scope of practice; these pathways should never replace clinical judgement.

Last updated: 4 July 2023