Choice of route of administration and antibiotic therapy for CAP in residents of an aged-care facility
The antibiotic regimens in this topic are for management of residents of an aged-care facility who are treated in the facility. If the resident is managed in hospital, see Management of adults with community-acquired pneumonia.
Oral therapy for CAP in residents of an aged-care facility is suitable when the following clinical parameters are metLoeb, 2006:
- heart rate less than 100 beats per minute
- systolic blood pressure more than 90 mmHg
- respiratory rate less than 25 breaths per minute
- oxygen saturation more than 92%
- no evidence of acute-onset confusion.
For residents who do not meet the above criteria or who require supportive oxygen therapy, consider transfer to hospital. Functional status and goals of care should be reviewed when making decisions about location of care.
Check the resident’s ability to swallow or absorb medication. Even if the resident does not have impaired swallowing, some antibiotics are difficult to administer (eg regimens with a high pill burden, the resident must remain upright after a dose of doxycycline). Ask whether the resident or carer prefer alternative dose forms or methods of administration. If the resident cannot swallow, consider enteral administration if they already have a percutaneous endoscopic gastrostomy (PEG) tube in situ1 (see Choice of route of drug administration in palliative care).
If treatment with oral or enteral antibiotics is indicated but not possible, parenteral therapy (eg through an organised Residential In-Reach Program or ambulatory antimicrobial therapy) can be used in the aged-care facility to avoid hospitalisation. Ceftriaxone is a practical choice because of its once-daily administration but it can cause bacterial resistance; only use such broad-spectrum antibiotic therapy in this setting if there is no alternative. Intravenous ceftriaxone is preferred to intramuscular to avoid painful administration and variable absorption in frail residents. The intravenous ceftriaxone dosage recommended in this topic is lower than the dosage recommended for adults with high-severity CAP because the lower dosages have been shown to reach adequate concentrations in frail patients and are easier to administer in the aged-care facilityTan, 2020.
Ceftriaxone does not treat atypical pathogens2 (eg Legionella species). If the resident cannot tolerate or absorb oral therapy and there is clinical suspicion of these pathogens (eg in residents with risk factors for Legionella pneumonia3), seek expert advice. For dosage regimens, see Parenteral therapy for CAP in residents of an aged-care facility.
If the resident has had an aspiration event, try to exclude aspiration pneumonitis before starting antibiotic therapy – see Management of a patient who has had an aspiration event. If aspiration pneumonia is suspected (eg pneumonia in a resident with recurrent aspiration), and treatment aligns with the resident’s preferences and goals of care, start empirical therapy for CAP.
Residents of an aged-care facility with comorbid lung disease (eg chronic obstructive pulmonary disease [COPD]) usually do not require adjustment to empirical therapy for CAP. For further information, see Considerations in managing CAP in adults with COPD or bronchiectasis.