From the Guidelines
Hospital-acquired pneumonia (HAP) should be treated with empiric broad-spectrum antibiotics initiated promptly after obtaining appropriate cultures, with the choice of antibiotics guided by the patient's risk factors for mortality and methicillin-resistant Staphylococcus aureus (MRSA) as outlined in the 2016 guidelines by the Infectious Diseases Society of America and the American Thoracic Society 1.
Recommended Empiric Antibiotic Therapy
For non-ventilated patients with HAP, recommended regimens include:
- Cefepime 2g IV every 8 hours
- Piperacillin-tazobactam 4.5g IV every 6 hours
- Meropenem 1g IV every 8 hours
- Levofloxacin 750 mg IV daily For patients with risk factors for MRSA, add:
- Vancomycin 15-20 mg/kg IV every 8-12 hours
- Linezolid 600mg IV every 12 hours
Considerations for Ventilator-Associated Pneumonia (VAP)
For VAP, use similar regimens but consider double coverage for Pseudomonas with the addition of an aminoglycoside or fluoroquinolone.
Prevention Strategies
Prevention strategies include:
- Elevation of the head of the bed to 30-45 degrees
- Oral care with chlorhexidine
- Maintaining endotracheal cuff pressure
- Minimizing sedation with daily sedation interruptions for ventilated patients
Treatment Duration and De-escalation
Treatment duration should typically be 7 days, with adjustments based on clinical response and culture results. De-escalate therapy once culture results are available.
Recent Guidelines
The 2024 guidelines by the World Health Organization's Essential Medicines and Aware recommend similar approaches, emphasizing the importance of local antimicrobial stewardship and the use of antibiograms to guide antibiotic treatments 1. The 2017 guidelines by the European Respiratory Society, European Society of Intensive Care Medicine, European Society of Clinical Microbiology and Infectious Diseases, and Asociación Latinoamericana del Tórax also support these recommendations, highlighting the need for a European perspective on HAP and VAP management 1.
From the FDA Drug Label
Adult Patients with Nosocomial Pneumonia: Initial presumptive treatment of patients with nosocomial pneumonia should start with piperacillin and tazobactam for injection at a dosage of 4.5 grams every six hours plus an aminoglycoside, totaling 18.0 grams (16.0 grams piperacillin and 2.0 grams tazobactam).
In clinically and microbiologically evaluable patients with documented Pseudomonas aeruginosa infection, 15 of 17 (88.2%) received ceftazidime (N = 11) or piperacillin/tazobactam (N = 4) in the levofloxacin arm and 16 of 17 (94. 1%) received an aminoglycoside in the comparator arm.
The guidelines for hospital-acquired pneumonia treatment include:
- Initial presumptive treatment: Piperacillin and tazobactam for injection at a dosage of 4.5 grams every six hours plus an aminoglycoside.
- Pseudomonas aeruginosa infection: Consider adding ceftazidime or piperacillin/tazobactam to the treatment regimen.
- Adjunctive therapy: May be empirically initiated at study entry, with an average duration of 7 days.
- Vancomycin: May be added to the treatment regimen for suspected methicillin-resistant S. aureus infection. 2 3
From the Research
Guidelines for Hospital-Acquired Pneumonia
- The treatment of hospital-acquired pneumonia (HAP) should be guided by local microbiological data and awareness of the risk factors for multidrug-resistant (MDR) bacteria 4.
- Broad-spectrum antibiotics are recommended in the treatment of HAP, especially in patients with risk factors for MDR pathogens 4.
- The American guidelines recommend broader spectrum therapy than the European guidelines, but recent studies support the idea that not all HAP patients need antipseudomonal therapy 5.
- An algorithm, modified from the European guideline, proposes an approach to therapy that necessitates dual antipseudomonal therapy in less than 25% of all HAP patients 5.
Antibiotic Treatment
- Piperacillin/tazobactam has shown comparable efficacy and tolerability to ceftazidime in the treatment of ICU patients with nosocomial pneumonia 6.
- Treatment with piperacillin/tazobactam was more effective than that with ceftriaxone plus clindamycin in patients with early non-ventilator HAP 7.
- Vancomycin with ciprofloxacin, cefepime, or piperacillin-tazobactam had predicted coverage of 95%, 94%, and 93%, respectively, for late HAP/VAP 8.
Risk Factors for MDR Pathogens
- Prior hospitalization for at least 5 days, prior use of broad-spectrum antibiotics, prior colonization with resistant pathogens, admission to hospital settings with high rates of MDR pathogens, and septic shock at the time of diagnosis with nosocomial pneumonia are risk factors for MDR pathogens 4.
- The ATS guidelines define patients at risk for MDR organisms on the basis of standardized criteria and time since admission (early <5 days; late ≥5 days) 8.