Canterbury DHB

Aspiration Pneumonia

Empiric treatment of aspiration pneumonia is divided into hospital-acquired and community-acquired disease.

Hospital-acquired

Mild or moderate disease

• Antibiotic treatment may not be necessary.
• Use oral route if possible.
• If need to cover for multidrug-resistant gram-negative bacilli (MDR-GNB), treat as for severe disease hospital-acquired aspiration pneumonia (see below).

  Cover for MDR-GNB organisms if:

  • MDR-GNB positive
  • Current or recent inpatient in a high-risk ward (e.g. ICU, BMTU, SPCU) for 5 days or more
  • Admission to overseas healthcare facility
  • Travel to developing country in previous six months
  • Household contact with MDR-GNB
  • Residence or admission to any facility with high prevalence of MDR-GNB
  • Broad-spectrum antimicrobial treatment.

amoxicillin+clavulanic acid HMLSchedNZFPMLnoids Amoxicillin+Clavulanic Acid F: 0.9 / 0.5 Half life: 2 hours / 1 hour Elimination: renal fe: 0.9 / 0.5

PO 500 mg/125 mg three times a day (or IV 1 g/200 mg every eight hours)

• fe (amoxicillin) = 0.9, fe (clavulanic acid) = 0.5, consider adjusting dose if CrCl reduced.

Mild penicillin allergy

cefuroxime HMLSchedNZFPMLnoids Cefuroxime F: 0.4 Half life: 2 hours Elimination: renal fe: 0.9

PO 500 mg twice a day (or IV 1.5 g every eight hours)

• fe = 0.9, consider adjusting dose if CrCl is reduced.
• Cefuroxime is not funded for this indication on prescription – ask your ward pharmacist to supply on discharge.

Severe penicillin allergy

clindamycin HMLSchedNZFPMLnoids Clindamycin F: 0.9 Half life: 3 hours Elimination: CYP3A fe: 0.1

PO 450 mg three times a day (or IV 600 mg every eight hours)

• Metabolised by CYP3A. (fe < 0.1).

AND EITHER

gentamicin HMLSchedNZFPMLnoids Gentamicin F: n/a Half life: 3 hours Elimination: renal fe: 0.9 Additional points: TDM.

See dosing guidelines

• fe = 0.9, adjust dose if CrCl reduced.

OR

ciprofloxacin HMLSchedNZFPMLnoids Ciprofloxacin F: 0.7 Half life: 4 hours Elimination: renal fe: 0.5 Additional points: Inhibits CYP1A2 and 3A. Antacids, milk, and enteral feeds ↓ absorption.

PO 500 mg twice a day

• Inhibits CYP1A2 (strong) and 3A.
• Subject to OAT and OATP (transporter) inhibition.
• Avoid in pregnancy and breastfeeding.

Severe disease

piperacillin+tazobactam HMLNZFPMLnoids Piperacillin+Tazobactam F: n/a Half life: 1 hour Elimination: renal fe: 0.8/0.6

IV 4 g/500 mg every eight hours

• If still on piperacillin+tazobactam beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
• fe (piperacillin) = 0.8, fe (tazobactam) = 0.6, consider adjusting dose if CrCl reduced.

Mild penicillin allergy

meropenem HMLNZFPMLnoids Meropenem F: n/a Half life: 1 hour Elimination: renal; hydrolysis fe: 0.7

IV 1 g every eight hours

• Meropenem rapidly and significantly reduces sodium valproate concentrations. Concomitant administration may precipitate seizures in patients with a pre-existing seizure disorder. Discuss alternative antibiotic options with Infectious Diseases/Clinical Microbiology.
• If still on meropenem beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
• fe = 0.7, start with full dose initially then consider extending dose interval and/or decreasing dose for subsequent doses if CrCl is reduced (< 30 mL/min). Consult pharmacist.

Severe penicillin allergy

Consult Infectious Diseases/Clinical Microbiology/Respiratory Medicine.

Community-acquired

Mild or moderate disease

• Antibiotic treatment may not be necessary.
• Use oral route if possible.

amoxicillin HMLSchedNZFPMLnoids Amoxicillin F: 0.9 Half life: 2 hours Elimination: renal fe: 0.9

PO 1000 mg three times a day (or IV 1 g  every eight hours)

• fe = 0.9, consider adjusting dose if CrCl is reduced.

Penicillin allergy

• Metabolised by CYP3A. (fe < 0.1).

Severe or life-threatening disease

ceftriaxone HMLSchedNZFPMLnoids Ceftriaxone F: n/a Half life: 8 hours Elimination: 50% renal and 50% biliary excretion fe: 0.5

IV 1 g every 24 hours

• fe = 0.5

AND

metronidazole HMLSchedNZFPMLnoids Metronidazole F: 1 Half life: 8 hours Elimination: oxidation, glucuronidation fe: 0.1

PO 600 mg twice a day (or IV 500 mg every twelve hours if GI absorption is compromised or patient is nil by mouth)

• High oral availability – prescribe orally where able.
• Metabolised by unknown pathways. (fe = 0.1).

Severe penicillin allergy

Start the following and consult Infectious Diseases/Clinical Microbiology:

• Metabolised by CYP3A. (fe < 0.1).

AND EITHER

• fe = 0.9, adjust dose if CrCl reduced.

OR

• Inhibits CYP1A2 (strong) and 3A.
• Subject to OAT and OATP (transporter) inhibition.
• Avoid in pregnancy and breastfeeding.

Pathogens Known

See Community-acquired Pneumonia, pathogens known.

must be prescribed or recommended by a consultant.

Topic Code: 557687