What are the recommended antibiotics for Hospital-Acquired Pneumonia (HAP)?

From the Guidelines

For hospital-acquired pneumonia (HAP), the recommended initial empiric antibiotic therapy is Piperacillin-tazobactam 4.5g IV every 6 hours, or Cefepime 2g IV every 8 hours, or Levofloxacin 750 mg IV daily, depending on the patient's risk of mortality and likelihood of MRSA. The choice of antibiotic regimen depends on the patient's risk factors, such as mortality risk and previous antibiotic use 1. For patients not at high risk of mortality and without factors increasing the likelihood of MRSA, options include:

• Piperacillin-tazobactam 4.5 g IV q6h
• Cefepime 2 g IV q8h
• Levofloxacin 750 mg IV daily
• Imipenem 500 mg IV q6h
• Meropenem 1 g IV q8h For patients at high risk of mortality or with recent intravenous antibiotic use, a combination of two antibiotics is recommended, including:
• Piperacillin-tazobactam 4.5 g IV q6h
• Cefepime or ceftazidime 2 g IV q8h
• Levofloxacin 750 mg IV daily
• Ciprofloxacin 400 mg IV q8h
• Imipenem 500 mg IV q6h
• Meropenem 1 g IV q8h
• Amikacin 15–20 mg/kg IV daily
• Gentamicin 5–7 mg/kg IV daily
• Tobramycin 5–7 mg/kg IV daily
• Aztreonam 2 g IV q8h Plus vancomycin 15 mg/kg IV q8–12h for MRSA coverage, with a goal to target 15–20 mg/mL trough level 1. It is essential to adjust therapy based on culture results when available and to de-escalate to narrower spectrum antibiotics if possible to reduce the risk of antibiotic resistance. Monitoring renal function and adjusting dosing as needed, particularly for vancomycin, is also crucial. This approach targets the most likely pathogens while balancing the need for broad coverage with the risks of promoting antibiotic resistance, as recommended by the Infectious Diseases Society of America and the American Thoracic Society 1.

From the FDA Drug Label

1. 2 Nosocomial Pneumonia Piperacillin and tazobactam for injection, USP is indicated in adults and pediatric patients (2 months of age and older) for the treatment of nosocomial pneumonia (moderate to severe) caused by beta-lactamase producing isolates of Staphylococcus aureus and by piperacillin and tazobactam-susceptible Acinetobacter baumannii, Haemophilus influenzae, Klebsiella pneumoniae, and Pseudomonas aeruginosa (Nosocomial pneumonia caused by P. aeruginosa should be treated in combination with an aminoglycoside) [see Dosage and Administration (2)]. 2.2 Dosage in Adult Patients with Nosocomial Pneumonia Initial presumptive treatment of adult patients with nosocomial pneumonia should start with piperacillin and tazobactam for injection at a dosage of 4. 5 g every six hours plus an aminoglycoside, [totaling 18 g (16 g piperacillin and 2 g tazobactam)], administered by intravenous infusion over 30 minutes.

The recommended antibiotics for Hospital-Acquired Pneumonia (HAP) are:

• Piperacillin/tazobactam
• Aminoglycoside (in combination with piperacillin/tazobactam for P. aeruginosa) 2

From the Research

Recommended Antibiotics for Hospital-Acquired Pneumonia (HAP)

The following antibiotics are recommended for the treatment of HAP:

• Telavancin, which shows potent activity against Gram-positive bacteria including MRSA 3
• Ceftobiprole medocaril, which exhibits rapid antimicrobial activity against a broad range of both Gram-positive and Gram-negative pathogens, including MRSA 3
• Imipenem/cilastatin plus vancomycin, which can be used as initial broad-spectrum therapy 4
• Ceftazidime-avibactam, imipenem-relebactam, and meropenem-vaborbactam, which have potent activity against some of the carbapenem-resistant Enterobacterales 5
• Ceftolozane-tazobactam, imipenem-relabactam, and cefiderocol, which have potent activity against multidrug-resistant Pseudomonas aeruginosa 5
• Cefiderocol, plazomicin, and eravacycline, which may play an important role in the management of pneumonia caused by Acinetobacter baumannii 5
• Cefepime, imipenem, meropenem, and piperacillin-tazobactam, which are recommended as monotherapy or combination therapy for the treatment of severe CAP, NP, and septicemia 6

Factors to Consider When Selecting Antibiotics

When selecting antibiotics for HAP, the following factors should be considered:

• Knowledge of underlying local risk factors for antimicrobial resistance 3
• Disease staging 3
• Risk factors related to specific pathogens such as Pseudomonas aeruginosa, Acinetobacter spp., and MRSA 3
• Prior use of fluoroquinolones or aminoglycosides 7
• Use of invasive blood pressure monitoring 7
• Bilateral chest X-ray involvement 7

Antibiotic Resistance

The development of antibiotic resistance is a major concern in the treatment of HAP. Factors associated with the emergence of resistant organisms include:

• Prior use of broad-spectrum antibiotics 4, 7
• Inadequate initial antimicrobial therapy 7
• Use of vancomycin 4