Nurse Practitioner CLINICAL PROTOCOL Pneumonia INTRODUCTION • Compared with community dwelling older adults, RACF residents acquire pneumonia at a rate of 10 times higher, and are admitted to hospital 30 times more often. • Pneumonia is the leading cause of death among aged care home residents, • Pneumonia can be hospital acquired or community acquired. Aged care home acquired pneumonia is a recognised variant of community acquired pneumonia. • Aspiration may lead to either pneumonia or non- infectious chemical pneumonitis (which does not require antibiotics). EPIDEMIOLOGY • In RACF, Streptococcus pneumoniae remains the commonest cause, and there are higher rates of gram negative bacilli, Staphylococcus aureus and respiratory viruses, and lower rates of atypical pathogens (legionella, chlamydia and mycoplasma) when compared to the general community. • Aspiration pneumonia may be caused by a wider range of organisms than community acquired pneumonia, including Staphylococcus aureus, Haemophilus influenzae, Gram negative aerobes and anaerobes. Classification Non –infectious chemical pneumonitis • • • • Pneumonia • • • • • • • • Manifestation Cough Difficulty catching breath Abnormal lung sounds (wet, gurgling) +/- chest pain, tightness or burning New cough Increased sputum production Fever Rigors SOB Wheezing Pleuritic pain Sore throat. DIFFERENTIAL DIAGNOSIS • Pulmonary embolism • Pulmonary oedema • Aspiration pneumonitis • Malignancy Additional symptoms • Non-specific symptoms such as; tachypnea, lethargy, incontinence (new), functional decline, loss of appetite, increased confusion, agitation. Nurse Practitioner CLINICAL PROTOCOL Pneumonia CLINICAL PRACTICE GUIDELINE Scope Symptoms suggestive of pneumonia Nurse • Practitioner Medical • Previously treated pneumonia not Practitioner responsive to antibiotics +/Nurse Practitioner Initial Assessment and Interventions Presenting • Fever, rigor, facial flushing, new onset Symptoms cough, dyspnoea, chest discomfort, confusion, sore throat, head cold symptoms, lethargy, tachycardia, increased resp rate, reduced O2 saturation, dullness on percussion 9consolidation), decreased air entry, inspiratory crackles, wheeze, pleural rub (rare). • Atypical symptoms: tachypnoea, functional decline, incontinence, alteration in sleep pattern, loss of appetite, confusion and aggression Known risk factors for presenting symptoms Patient history Physical examination Outcomes Identify patients suitable for NP Clinical Protocol Identify patients not suitable for NP Clinical Protocol and redirect to GP +/- NP in team • • • Outcomes Gaining comprehensive and holistic data in order to prescribe appropriate diagnostic tests and interventions. Ruling out differential diagnosis to specific pathophysiology identified. If known allergy to recommended formulary; NP and GP instigate alternative treatment option to ensure a safe and optimal response to treatment. • Dysphagia decreased cognitive and physical functions, delirium, and immunosuppression. • • • • • Relevant medical and surgical history Onset and duration of symptoms Presence of co-morbidities Known allergies Current medication • Predisposing and associated conditions will be detected and considered when determining diagnosis • • • • Vital signs Pulse oximetry Respiratory and CVS assessment Pain assessment • Correct diagnosis, provision of effective treatment to eradicate disease and provide relief of symptoms. Severe pneumonia is diagnosed in pts. displaying 2 or more of the following: RR >30, P • Nurse Practitioner CLINICAL PROTOCOL Pneumonia > 125, acute altered mental state, systolic BP <90mmHg and /or diastolic <60mmHg, Hx of dementia, CVD, renal failure or liver disease, need for O2 > 3L/min. (RACGP guidelines). Outcomes Identification of causative pathogen and its sensitivities. • Identify complications associated with disease state. Imaging • CXR • Identify consolidation in lungs and assist in diagnosis. Patient Education / Follow-up Outcomes Follow up Verbal instruction to patient: Ensure patient understands appointment • Review appointment may be indicated problem, treatment and follow by pathology results; NP to contact up patient to schedule follow-up Referral to GP will be appointment. determined on result of • Response to Rx should be reassessed laboratory tests and CXR. in 48 hours. Refer to current GP if no response to Rx within 48 hrs. Patient Verbal instruction and patient information Patient understanding of the Education handout re problem, treatment and • Hygiene and prevention strategies measures which may reduce the risk of pneumonia Medication • Verbal/written instructions from NP/GP Ensure patient understands problem, treatment and follow instructions up Referrals • Unresolved pneumonia Patients with problems outside • Other problems outside of NP scope of the NPs scope of practice are practice referred to appropriate health care providers Ensure appropriate Certificates • Absence from work certificates • Certificate of attendance documentation completed Letter • Copy of notes to GP / Specialist or Ensure continuity of care and acute care facility referral to health care team GP Æ hospital admission Interpretation of results and management decisions Outcome Pathology • • Investigations Sputum (MCS) FBE, U&E, Glucose • All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation Nurse Practitioner CLINICAL PROTOCOL Pneumonia Pharmacotherap eutics (See formulary) Non pharmacological - The use and appropriateness of antibiotic therapy in the treatment of pneumonia depends on the symptoms and likely microbial organisms to be treated. - Refer to the Antibiotic Therapeutic Guidelines for appropriate antibiotic drug administration. • Antibiotic therapy is determined by the causative pathogen, the pathogen’s sensitivities, resistance & the severity of the individual’s clinical presentation and/or PSI. Note that the PSI is only a guide & NPs should consider clinical & social contexts. • Non-pharmacological, supportive nursing and monitoring interventions include: regular observation of vitals’ status (RR, HR, BP, SpO2, and T), 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. Relief of symptoms Eradication of infection Prevention of recurrence Prevention of complications Nurse Practitioner CLINICAL PROTOCOL Pneumonia Goals of Treatment • Relief of symptoms • Eradication of infection • Prevention of recurrence • Prevention of complications Drug Formulary ANTIBIOTIC TREATMENT Amoxycillin 1g PO 8 hourly and clarithromycin 250mg PO 12 hourly or doxycycline 200mg initial dose then 100mg PO daily Hypersensitivity to penicillin: replace amoxycillin: Clarithromycin 250-500mg 12 hourly or doxycycline Non-tropical region benzyl penicillin 1.2g IV 6 hourly or KUB ultrasound, refer amoxy/ampicillin 1g IV 6 hourly to current GP and roxithromycin 300mg PO daily or doxycycline 200mg/100mg PO daily Refer to and current GP gentamicin 4-6mg/kg IV daily if gramnegative bacilli isolated Tropical region gentamicin 4-6mg/kg IV daily and Refer to current GP ceftriaxone 2g IV daily for investigation of other causes for symptoms Hypersensitivity to penicillin: replace penicillin: cefotaxime 1g IV 8 hourly (or ceftriaxone 1g IV daily) until significant improvement then cefuroxime 500mg PO 12 hourly5 Immediate sensitivity to penicillin: replace penicillin: gatifloxacin 400mg PO daily or moxifloxacin 400mg PO daily Nurse Practitioner CLINICAL PROTOCOL Pneumonia ANALGESIA & ANTIPYRETIC TREATMENT 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% FORMULARY AMOXYCILLIN TRIHYDRATE CLARITHROMYCIN Drug (generic name): amoxicillin trihydrate Drug (generic name): roxithromycin Poisons schedule: schedule 4 Poisons schedule: schedule 4 Therapeutic class: 8(a) penicillins Therapeutic class: 8(d) macrolides Dosage range: 250-800mg 8 hourly, or in severe infection Dosage range: 250-500mg (pneumonia) 1G 8 hourly Route: oral Route: oral Frequency of administration: 12 hourly Frequency of administration: 8 hourly Duration of order: 7 days Duration of order: 7 days Actions: binds to 50S ribosomal sub-unit, inhibits bacterial Actions: intervene in cell wall peptidoglycan synthesis, is protein synthesis, is bacteriostatic bactericidal Indications for use: upper & lower respiratory tract infections, Indications for use: chronic bronchitis, CAP, acute bacterial Contraindications for use: serious allergy to macrolides otitis media, sinusitis, epididymo-orchitis, acute prostatitis, Adverse drug reactions: taste disturbance. 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. Nurse Practitioner CLINICAL PROTOCOL Pneumonia DOXYCYCLINE GENTAMICIN (GP only) Drug (generic name): doxycycline Drug (generic name): gentamicin Poisons schedule: schedule 4 Poisons schedule: schedule 4 Therapeutic class: 8(c) tetracyclines Therapeutic class: 8(f) aminoglycosides Dosage range: 100mg-200mg (200mg first dose, followed by Dosage range: 4-6mg/kg 100mg daily) Route: intravenous Route: oral Frequency of administration: daily or as single dose depends Frequency of administration: daily on severity. Duration of order: 6 days Duration of order: until significant improvement Actions: reversibly binds to 50S ribosomal sub-unit, inhibits Actions: irreversibly binds to 50S ribosomal sub-unit, inhibits bacterial protein synthesis, is bacteriostatic bacterial protein synthesis, causes cell membrane damage, is Indications for use: acne, M. pneumonia, CAP, chronic bactericidal with concentration dependence bronchitis, sinusitis, non-gonococcol genital tract infections, Indications for use: gram-negative infections (empirical Rx), PID, rickettsial infections, prostatitis, prophylaxis and treatment systemic enterococcal infections, surgical & non-surgical of malaria prophylaxis, cystic fibrosis, bronchiectasis Contraindications for use: children < 8years, allergy to Contraindications for use: serious allergy to aminoglycoside tetracycline Adverse drug reactions: renal impairment, ototoxicity Adverse drug reactions: nausea, vomiting, heartburn, tooth discolouration, enamel dysplasia, reduced bone growth (children), photosensitivity BENZYLPENICILLIN (GP only) AMOXYCILLIN/AMPICILLIN (GP only) Drug (generic name): benzyl penicillin Drug (generic name): amoxy / ampicillin Poisons schedule: schedule 4 Poisons schedule: schedule 4 Therapeutic class: 8(a) penicillins Therapeutic class: 8(a) penicillins Dosage range: 1.2g Dosage range: 1g Route: intravenous Route: intravenous amoxicillin sodium for IV Frequency of administration: 6 hourly Frequency of administration: 6 hourly Duration of order: until significant improvement Duration of order: 5days Actions: intervene in cell wall peptidoglycan synthesis, is Actions: intervene in cell wall peptidoglycan synthesis, is bactericidal bactericidal Indications for use: bacterial endocarditis, meningitis, Indications for use: chronic bronchitis, CAP, acute bacterial aspiration pneumonia, lung abscess, CAP, syphilis, otitis media, sinusitis, epididymo-orchitis, acute prostatitis, Nurse Practitioner CLINICAL PROTOCOL Pneumonia septicaemia in children acute pyelonephritis, UTI, gonococcol infection, prophylaxis of Contraindications for use: allergy to penicillins, endocarditis, acute cholecystitis, peritonitis, combination cephalosporin’s, carbapenems therapy for eradication H. pylori, shigellosis Adverse drug reactions: irritation at injection/IV site, nausea, Contraindications for use: allergy to penicillins, cephalosporins, diarrhoea, urticaria, rash, super infection, allergy (fever, chills, carbapenems headache and exacerbation of lesions when used in Adverse drug reactions: irritation at injection/IV site, nausea, syphilis/spirochete infections Jarisch-Herxheimer reaction) diarrhoea, urticaria, rash, super infection, allergy CEFTRIAXONE (GP only) PARACETAMOL Drug (generic name): ceftriaxone Drug (generic name): paracetamol Poisons schedule: schedule 4 Poisons schedule: unscheduled Therapeutic class: 8(b) cephalosporins Therapeutic class: 4(b) simple analgesics and antipyretics, Dosage range: 2g non-opioid analgesic. Route: intravenous Dosage range: 500mg-1g Frequency of administration: daily Route: oral/rectal Duration of order: until significant improvement Frequency of administration: 4- 6 hourly Actions: intervenes in bacteria cell wall peptidoglycan Duration of order: as required max 4g daily synthesis Actions: inhibition of prostaglandin synthesis Indications for use: severe pneumonia, orbital cellulitis, Indications for use: mild-moderate pain, migraine, headache, bacterial meningitis, gonococcal infection, PID, epiglottitis, fever, muscular pain septicaemia, prophylaxis: meningococcal disease, H. Contraindications for use: nil –caution for resident with liver influenzae, cholecystitis, peritonitis, Salmonella, typhoid, disease. sexually transmitted epididymo-orchitis Adverse drug reactions: (rare) rash, drug fever, mucosal Contraindications for use: allergy to penicillins, cephalosporins, lesions, neutro/pancyto/thrombocytopenia carbapenems Adverse drug reactions: nausea, diarrhoea, electrolyte imbalance, rash, pancreatitis, cholecystitis, psuedolithiasis, nephrolithiasis. Nurse Practitioner CLINICAL PROTOCOL Pneumonia Unexpected representation NP Clinical Practice Evaluative strategies Review Patient Notes. Full audit of clinical events. NP Clinical Practice/Medical Report Audit Key Terms NP – Nurse Practitioner CPG – Clinical Practice Guideline GP – General Practitioner S4 – Schedule of the drug administration act 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. 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. 3. Dartnell JG, editor. Therapeutic guidelines: antibiotic. 12th ed. Victoria: Therapeutic Guidelines Limited; 2003. 4. Rossi S, editor. Australian medicines handbook. Adelaide SA: Australian Medicines Handbook Pty Ltd; 2006. 5. eMIMS MIMS. MIMS medicine information [standard online]. c2005 [cited 2006 Oct 20]. Available from: eMIMS MIMS Online. 6. Johnson PD, Irving LB, Turnidge JD. 3: Community-acquired pneumonia. Medical Journal of Australia. 2002; 176: 341-347. 7. Maxwell DJ, McIntosh KA, Pulver LK, Easton KL. Emperic management of communityacquired pneumonia in Australian emergency departments. Medical Journal of Australia. 2005; 183(10): 520-524. 8. Kennedy M L, Fletcher KR, Plank LM. Management guidelines for nurse practitioners working with older adults. 2nd ed. Philadelphia: F. A. Davis; 2004. 9. etg complete (internet). Melbourne: Therapeutic Guidelines Limited; 2011 Nov. Accessed 2001 Nov 25 at http://etg.tg.com.au/ref/ref Nurse Practitioner CLINICAL PROTOCOL Pneumonia Authorship, Endorsement and acknowledgement This CP was originally written by: Reviewed and authorised by: Carol Jones Nurse Practitioner Dr. Frank Reedman Jones Murray Medical Centre Mandurah MBBCh, DCH, DRCOG, FRACGP, FACRRM Murray Medical Centre: Primary Care Physician We acknowledge the authorship and input of : Hall and Prior Residential health and Aged Care Organisation: CPG Pneumonia. Dr. Eileen Bristol MBChB,MRCGP,DRCOG,FRACGP Murray Medical Centre: Primary Care Physician Carol Jones RN, RM, PGradDipNursePractitioner, NP Nurse Practitioner Date Written: November 2011 Review Date: November 2013