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

From the Guidelines

For hospital-acquired pneumonia (HAP), the recommended empiric antibiotic regimen includes an antipseudomonal beta-lactam (piperacillin-tazobactam 4.5g IV q6h, cefepime 2g IV q8h, meropenem 1g IV q8h, or imipenem 500mg IV q6h) plus either an antipseudomonal fluoroquinolone (ciprofloxacin 400mg IV q8h or levofloxacin 750mg IV daily) or an aminoglycoside (amikacin 15-20mg/kg IV daily, gentamicin 5-7mg/kg IV daily, or tobramycin 5-7mg/kg IV daily), as supported by the most recent guidelines 1. The choice of antibiotic regimen depends on the patient's risk factors for mortality and multidrug-resistant organisms (MDROs) such as MRSA.

• For patients not at high risk of mortality and without risk factors for MRSA, a single antipseudomonal beta-lactam or fluoroquinolone may be sufficient 1.
• For patients with risk factors for MRSA, adding vancomycin (15-20mg/kg IV q8-12h, target trough 15-20 μg/mL) or linezolid (600mg IV q12h) is recommended 1.
• For patients at high risk of mortality or with recent exposure to intravenous antibiotics, empiric double coverage using antibiotics from two different classes with activity against Pseudomonas aeruginosa is recommended 1. The treatment duration is typically 7 days, but may be extended based on clinical response, and de-escalation should occur once culture results are available 1. Key considerations in selecting an antibiotic regimen include the patient's underlying health status, recent antibiotic use, and local antimicrobial resistance patterns. It is essential to note that the most recent and highest quality study 1 provides the most up-to-date recommendations for the treatment of HAP.

From the FDA Drug Label

Levofloxacin tablets are indicated for the treatment of nosocomial pneumonia due to methicillin-susceptible Staphylococcus aureus, Pseudomonas aeruginosa, Serratia marcescens, Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, or Streptococcus pneumoniae. Adjunctive therapy should be used as clinically indicated Where Pseudomonas aeruginosa is a documented or presumptive pathogen, combination therapy with an anti-pseudomonal β-lactam is recommended

The antibiotics of choice for Hospital-Acquired Pneumonia (HAP) include levofloxacin and may require combination therapy with an anti-pseudomonal β-lactam when Pseudomonas aeruginosa is suspected or documented 2.

• Key pathogens for HAP that are susceptible to levofloxacin include:
  • Methicillin-susceptible Staphylococcus aureus
  • Pseudomonas aeruginosa
  • Serratia marcescens
  • Escherichia coli
  • Klebsiella pneumoniae
  • Haemophilus influenzae
  • Streptococcus pneumoniae

From the Research

Antibiotics of Choice for Hospital-Acquired Pneumonia (HAP)

The choice of antibiotics for HAP depends on several factors, including the severity of illness, demographics, specific pathogens involved, and risk factors for antimicrobial resistance.

• For pseudomonal HAP, combination therapy with an antipseudomonal beta-lactam plus an aminoglycoside or a fluoroquinolone (eg, ciprofloxacin) is recommended 3.
• In cases where Pseudomonas aeruginosa is suspected, an anti-pseudomonas beta-lactam (such as piperacillin/tazobactam, carbapenems, cefepime) associated with an anti-pseudomonas fluoroquinolone (high doses ciprofloxacin) can be used 4.
• For early onset HAP and early onset Ventilator Associated Pneumonia (VAP) in patients without risk factors for multi-resistant etiological agents, antibiotics such as ceftriaxone, fluoroquinolones (moxifloxacin or ciprofloxacin or levofloxacin), ampicillin/sulbactam, or ertapenem can be used 4.
• For late onset VAP and HAP in patients with risk factors for multi-resistant, combination therapy with an anti-pseudomonas cephalosporin or an anti-pseudomonas carbapenem or beta-lactam + beta-lactamase inhibitor associated with an anti-pseudomonas fluoroquinolone or an aminoglycoside is recommended 4, 5.
• Ceftazidime, a third-generation cephalosporin, can be used for HAP treatment, but its role has been compromised by increasing resistance rates, especially in P. aeruginosa and Acinetobacter baumannii 6.

Specific Antibiotic Regimens

Some specific antibiotic regimens that can be used for HAP include:

• Combination therapy with an anti-pseudomonal beta-lactam and a fluoroquinolone or an aminoglycoside 3, 5.
• Monotherapy with a broad-spectrum beta-lactam antibiotic, such as cefepime, imipenem, or meropenem 5.
• Combination therapy with a beta-lactam antibiotic and a macrolide or fluoroquinolone 4, 7.

Considerations for Antibiotic Choice

When choosing antibiotics for HAP, it is essential to consider local resistance patterns, the severity of illness, and the presence of risk factors for antimicrobial resistance 4, 5, 6.