What is the diagnosis and treatment for Hospital-Acquired Pneumonia (HAP)?

From the Guidelines

Hospital-acquired pneumonia (HAP) should be treated with broad-spectrum antibiotics, such as piperacillin-tazobactam, cefepime, or meropenem, often combined with vancomycin or linezolid for MRSA coverage, and therapy should be tailored based on local antibiogram data and adjusted once culture results are available, typically continuing for 7 days total. The management of HAP involves early, appropriate antibiotics in adequate doses, while avoiding excessive antibiotics by de-escalation of initial antibiotic therapy, based on microbiologic cultures and the clinical response of the patient, and shortening the duration of therapy to the minimum effective period 1.

Key Considerations

• HAP occurs when pathogens bypass normal respiratory defenses in hospitalized patients whose immune systems may be compromised, and common causative organisms include Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus (including MRSA), and Acinetobacter species, which often have higher resistance rates than community-acquired infections, necessitating broader initial antibiotic coverage 1.
• Prevention strategies include strict hand hygiene, early mobilization of patients, elevating the head of the bed 30-45 degrees, oral care with chlorhexidine, and minimizing sedation 1.
• The selection of initial antibiotic therapy is based on risk factors for specific pathogens, modified by knowledge of local patterns of antibiotic resistance and organism prevalence, and therapy is modified on the basis of the clinical response on Days 2 and 3, and the findings of semiquantitative cultures of lower respiratory tract secretions 1.

Treatment Approach

• Early, appropriate, broad-spectrum, antibiotic therapy should be prescribed with adequate doses to optimize antimicrobial efficacy, and an empiric therapy regimen should include agents that are from a different antibiotic class than the patient has recently received 1.
• Combination therapy for a specific pathogen should be used judiciously in the therapy of HAP, and consideration should be given to short-duration (5 days) aminoglycoside therapy, when used in combination with a -lactam to treat P. aeruginosa pneumonia 1.
• De-escalation of antibiotics should be considered once data are available on the results of lower respiratory tract cultures and the patient’s clinical response, and a shorter duration of antibiotic therapy (7 to 8 days) is recommended for patients with uncomplicated HAP, VAP, or HCAP who have received initially appropriate therapy and have had a good clinical response, with no evidence of infection with nonfermenting gram-negative bacilli 1.

From the FDA Drug Label

Piperacillin and Tazobactam for Injection is a combination of piperacillin, a penicillin-class antibacterial and tazobactam, a beta-lactamase inhibitor, indicated for the treatment of: ... Nosocomial pneumonia in adult and pediatric patients 2 months of age and older (1.2) 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). (2. 2)

Piperacillin and Tazobactam for Injection is indicated for the treatment of nosocomial pneumonia in adult and pediatric patients 2 months of age and older. The recommended dosage for adult patients with nosocomial pneumonia is 4.5 grams every six hours plus an aminoglycoside. 2

From the Research

Hospital-Acquired Pneumonia

• Hospital-acquired pneumonia (HAP) is a significant cause of morbidity and mortality in hospitalized patients 3.
• The pathophysiology of HAP is influenced by various patient- and disease-specific factors, particularly in the surgical population 3.
• Prompt and appropriate antimicrobial therapy is crucial in reducing mortality in patients with HAP 4, 3.

Diagnosis and Treatment

• The diagnosis of HAP can be challenging, especially in the intensive care unit, due to the complexity of critically ill patients 5.
• Early, appropriate, and adequate empiric therapy can increase the chance of survival in HAP patients 6.
• The choice of antibiotic therapy should be based on local patterns of antimicrobial resistance and the patient's risk factors for multidrug-resistant (MDR) organisms 4, 7, 6, 3.

Antibiotic Therapy

• The American Thoracic Society (ATS) guidelines recommend different antibiotic regimens for early and late HAP, based on the patient's risk factors for MDR organisms 4, 6.
• Broad-spectrum antibiotics, such as piperacillin/tazobactam, may be more effective than narrower-spectrum antibiotics, such as ceftriaxone and clindamycin, in the treatment of early HAP 7.
• The use of vancomycin in combination with other antibiotics may be necessary to ensure adequate coverage of MDR gram-positive organisms 4.