How should I manage a patient on bed rest after community‑acquired pneumonia, including antibiotic duration, venous thromboembolism prophylaxis, respiratory physiotherapy, pressure‑ulcer prevention, nutrition, and follow‑up?

Management of Bed Rest After Community-Acquired Pneumonia

For patients on bed rest after community-acquired pneumonia, complete a minimum 5-day antibiotic course (discontinue after 48-72 hours of clinical stability), implement VTE prophylaxis for all hospitalized patients, initiate early mobilization and respiratory physiotherapy within 24-48 hours of stability, assess pressure ulcer risk daily with preventive measures, ensure adequate nutrition with protein supplementation, and schedule 6-week follow-up with chest radiograph for high-risk patients. 1

Antibiotic Duration

Complete the antibiotic course based on clinical stability criteria, not arbitrary calendar days. 1

• Minimum 5 days of treatment required, even if patient improves earlier 1, 2
• Discontinue antibiotics after patient is afebrile for 48-72 hours AND has no more than one sign of clinical instability 1, 2
• Clinical stability criteria include: temperature ≤37.8°C, heart rate ≤100 bpm, respiratory rate ≤24 breaths/min, systolic BP ≥90 mmHg, oxygen saturation ≥90% on room air, ability to maintain oral intake, and normal mental status 2
• Total duration typically 5-7 days for uncomplicated CAP 1, 2
• Extend to 14-21 days ONLY for specific pathogens: Legionella pneumophila, Staphylococcus aureus, or Gram-negative enteric bacilli 1, 2

The 2007 IDSA/ATS guidelines provide the foundational recommendation for 5-day minimum treatment 1, which has been validated by multiple subsequent meta-analyses showing non-inferiority of short-course therapy 3, 4. Recent 2025 guidelines support even shorter 3-day courses for patients achieving clinical stability by day 3 3.

Venous Thromboembolism Prophylaxis

All hospitalized pneumonia patients on bed rest require pharmacologic VTE prophylaxis unless contraindicated. While the provided guidelines focus primarily on antibiotic management, standard medical practice mandates VTE prophylaxis for immobilized hospitalized patients.

• Initiate low-molecular-weight heparin (enoxaparin 40 mg subcutaneously daily) or unfractionated heparin (5,000 units subcutaneously every 8-12 hours) immediately upon admission
• Continue prophylaxis until patient is fully ambulatory
• Use mechanical prophylaxis (sequential compression devices) if pharmacologic prophylaxis is contraindicated due to bleeding risk
• Reassess daily for contraindications and need for continued prophylaxis

Respiratory Physiotherapy and Early Mobilization

Begin respiratory physiotherapy and mobilization within 24-48 hours of achieving hemodynamic stability. 1

• Switch from IV to oral antibiotics when patient is hemodynamically stable, clinically improving, able to ingest medications, and has normally functioning GI tract 1—this signals readiness for mobilization
• Initiate incentive spirometry every 1-2 hours while awake
• Begin chest physiotherapy with percussion and postural drainage if secretions are present
• Progress from sitting at bedside to ambulation as tolerated
• Discharge as soon as clinically stable with no other active medical problems—inpatient observation while receiving oral therapy is unnecessary 1

The ERS guidelines emphasize that fever should resolve within 2-3 days of appropriate antibiotic therapy 1, which marks the appropriate time to begin aggressive mobilization efforts.

Pressure Ulcer Prevention

Implement comprehensive pressure ulcer prevention protocol immediately upon admission for all bed-bound patients.

• Assess pressure ulcer risk using Braden Scale within 8 hours of admission and daily thereafter
• Reposition patient every 2 hours with documentation
• Use pressure-redistributing mattress or overlay for high-risk patients
• Keep skin clean and dry; apply barrier cream to vulnerable areas
• Ensure adequate nutrition (see below) as malnutrition significantly increases pressure ulcer risk
• Inspect skin daily, particularly over bony prominences (sacrum, heels, elbows, occiput)

Nutrition

Ensure adequate caloric and protein intake to support recovery and prevent complications.

• Assess nutritional status within 24 hours of admission
• Provide 25-30 kcal/kg/day and 1.2-1.5 g protein/kg/day for recovery
• Ensure ability to maintain oral intake before discharge 1—this is a clinical stability criterion
• Consider nutritional supplementation if oral intake is inadequate
• Monitor for aspiration risk, particularly in elderly patients or those with altered mental status
• Maintain hydration with goal urine output >0.5 mL/kg/hour

Follow-Up Care

Schedule structured follow-up to ensure complete resolution and identify complications. 1

• Clinical review at 48-72 hours or sooner if not improving as expected 1
• 6-week follow-up with repeat chest radiograph for patients who are smokers, have persistent symptoms, or are at high risk for underlying malignancy 1
• Instruct patient to return immediately if symptoms persist beyond 3 weeks, fever exceeds 4 days, dyspnea worsens, or consciousness decreases 1
• Administer pneumococcal vaccination to patients aged ≥65 years or those with chronic lung, heart, renal, or liver disease, diabetes, or immunosuppression 1
• Administer influenza vaccination to high-risk groups (same criteria as pneumococcal vaccine) 1

Common Pitfalls to Avoid

• Do NOT continue antibiotics beyond 7-8 days without specific indication (identified resistant pathogen, complicated infection, or failure to achieve clinical stability) 1, 2
• Do NOT delay mobilization waiting for complete radiographic resolution—radiographic improvement lags behind clinical improvement by weeks 2
• Do NOT fail to assess clinical stability criteria daily—this drives antibiotic discontinuation decisions 1, 2
• Do NOT discharge patients who cannot maintain oral intake or have persistent vital sign abnormalities 1
• Do NOT skip follow-up chest radiograph in high-risk patients—underlying malignancy must be excluded 1